Safety and health workers: Rethinking old assumptions

(Editor's note: This column by John Howard, MD, director of the National Institute for Occupational Safety and Health, is reprinted from the NIOSH online newsletter, enews.)

It is no easy task to be an occupational safety and health practitioner in the health care industry. Longstanding and deeply embedded assumptions are always difficult to shake, even when the need to do so becomes increasingly apparent.

People in health care — including me — often take offense when we are said to belong to an "industry." In my career as a physician in an acute care hospital setting, I have heard the words "profession" or even "calling" used to describe people who work in health care. And, depending on how remote, or how dangerous the part of the world where you deliver health care, health care workers are sometimes described as "noble" or "self-sacrificing."

Indeed, these descriptions are flattering and are, in some cases, accurate, but we must be careful when society characterizes routine work in any industry as "self-sacrificing." This characterization places workers engaged in such work outside the protections of the governmental worker safety and health paradigm that we apply to other all other industrial sectors where labor is exchanged for wages.

Providing occupational safety and health protections for health care workers is complex. In health care, some people have described a tension between caring for the patient and caring for the worker who cares for the patient. Health care has a long history of resolving that conflict entirely to the advantage of the patient without a rigorous consideration of all alternative ways to protect both the patient and the worker. The adoption of the Bloodborne Pathogens Standard http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051 in 1991 marked a real turning point in efforts to protect health care workers and patients.

Hazards in the Work Setting

We have known for years about the hazards that health care workers face every day:

• Exposures to formaldehyde, anesthetic gases, and other potentially toxic chemicals;

• Risks for acute or chronic injuries from physical exertion such as turning and lifting patients, or standing for hours at a time in the operating room;

• Potential for work-related assault and injury from human agents in stressful situations or in public-access work areas, such as belligerent psychiatric patients, irate family members, or even gang members who engage in "shoot-outs" in hospital emergency rooms.

All of these hazards, and more, characterize the risks associated with working in the industrial sector called health care.

Health care workers themselves have become more aware of these hazards. As awareness, education and research on preventing these hazards from maturing into injuries and illnesses have increased, so have the demands of health care workers for less "self-sacrifice" rhetoric and more straight talk about hazard identification, risk assessment, and risk management. Self-sacrifice is indeed admirable and many health care workers often go far beyond the duties of their job to help patients and their loved ones.

However, on a routine basis in a $2 trillion industry, it should not be the operating principle if we are to create a sustainable health care workforce for the 21st century.

Lessons from 2009 H1N1 Influenza

And it is important that we use the opportunity of the first influenza pandemic of the 21st century to figure out what attitudes, what policies, what programs and what practical decisions we need to employ to guarantee a sustainable health care work force. To do that successfully, we must confront the last frontier of occupational safety and health in the health care industry — the frontier associated with biological hazards.

Biological hazards include those that are transmissible from patient to health care worker, and from health care worker to the health care worker's unborn child, spouse, partner, children, friends, and others. Transmissible diseases are new to the lexicon of all occupational safety and health professionals, but I encourage all occupational safety and health practitioners to learn about transmissible diseases not only in the health care workplace, but also in nonhealth care workplaces.

The list of such agents is long and growing, and yet we in occupational safety and health know very little about such agents. In fact, we have often been led to believe that understanding the transmission of such transmissible agents requires a medical degree. That simply is not the case in the context of carrying out our duties as safety and health professionals.

Influenza — that virus that has plagued mankind since the dawn of the human race — that highly changeable virus with an 8-gene team that frequently trades and acquires new gene players—that virus that has outwitted the smartest virologists in the world — to survive through thousands of years — is upon us again. A fourth-generation relative of the virus that caused the terrible 1918 global pandemic appeared in the spring of 2009 and is now spreading throughout the world. In June, the World Health Organization declared the H1N1 influenza a pandemic.

Pivotal Documents

On Oct. 14, 2009, the U.S. Centers for Disease Control and Prevention (CDC) updated its Interim Guidance on Infection Control in Healthcare Settings. The Guidance recommends that a robust hierarchy of controls — engineering, administrative, and personal protective equipment — be used to protect health care workers from the biological hazards associated with exposure to influenza (www.cdc.gov/h1n1flu/guidelines_infection_control.htm). Regarding personal protective equipment, the guidance continues to recommend that health care workers in close contact with patients suspected or confirmed to have H1N1 influenza wear fit-tested disposable N95 respirators.

The recommendation is based on scientific findings that the influenza virus can be spread by small particles or aerosols generated by an infected patient that can remain suspended in the air and that a surgical mask does not provide equivalent protection for the health care worker to a fit-tested respirator. The CDC Guidance, together with the recently adopted California Aerosol Transmissible Disease Standard www.dir.ca.gov/dosh/SwineFlu/Interim_enforcement_H1N1.pdf, are pivotal documents in the effort to promote a sustainable 21st-century health care work force.

Currently, it is anticipated that there may be a shortage in the supply of disposable N95 respirators for health care settings trying their best to follow the CDC Guidance. NIOSH has developed a Respirator Information Clearinghouse to connect those who need to obtain respirators with those suppliers who have respirators available. As new information is obtained, NIOSH will update the clearinghouse site. I encourage you to visit this site and mark the page for ongoing reference. (www.cdc.gov/niosh/npptl/topics/respirators/disp_part/RespSource.html.)

Where occupational safety and health practice in the health care industry goes from here when the current pandemic has passed us by, remains to be seen. A far more virulent influenza, so-called "avian" influenza or H5N1 influenza, may present us with even greater challenges. For this reason, I do not think we can return to an era when a health care worker's exposure to transmissible diseases such as influenza can be merely considered "diseases of life" for which a health care worker "assumes the risk" when he or she offers their labor to a health care employer.

We need to care for the sick and, at the same time, we need to care for those who care for the sick. Our attitudes, our policies, our laws, and our practices need to more clearly and emphatically reflect this duality in the 21st century delivery of health care. For further information, I invite you to use our resources for preventing work-related injuries and illnesses in health care (www.cdc.gov/niosh/topics/healthcare/), and to become familiar with NIOSH's research program portfolio in health care and social assistance (www.cdc.gov/niosh/programs/hcsa/).

As always, we invite your partnership under the National Occupational Research Agenda (NORA) to stimulate, plan, conduct, and support the research necessary for meeting the challenges of the 21st century.