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Bane or boon? OSHA makes bold move to regulate infection prevention
OSHA: 'The lack of adherence to voluntary infection control procedures is of particular interest.'
By Gary Evans, Senior Managing Editor
The Occupational Safety and Health Administration is setting the stage for regulatory action on occupational infection prevention in hospitals and other heath care settings. Moreover, by expanding its previous interest in airborne diseases to include a request for comment on those transmitted via droplet and contact, OSHA is essentially considering regulating the full gamut of health care infection prevention.
"Infection control programs are currently the primary means of controlling occupational exposure to infectious agents," OSHA states in a request for comment recently published in the Federal Register.1 "However, these programs are largely voluntary. OSHA is particularly interested in case studies that highlight experience in the implementation and effectiveness of IC programs in protecting workers against infectious diseases (e.g., the extent to which employers are fully implementing and consistently following their written IC programs). For example, has your workplace had instances where a significant increase in infections (among either patients or workers) required more rigorous implementation of your IC program?"
In addition, OSHA is asking for any studies that "demonstrate the difference in infection rates between situations where the IC program had lapsed and situations where rigorous implementation of control measures was instituted."
OSHA is requesting information and comment on occupational exposure to infectious agents in settings where healthcare is provided, including hospitals, outpatient clinics, clinics in schools and correctional facilities. In addition, it is interested in hearing from health care related settings, including laboratories that handle potentially infectious biological materials, medical examiner offices and mortuaries. The agency is soliciting information on a variety of topics related to infectious diseases including:
"OSHA is interested in strategies that are being used in healthcare and other healthcare-related work settings to mitigate the risk of occupationally-acquired infectious diseases," the agency states. "OSHA would like to collect information and data on the facilities and the tasks potentially exposing workers to this risk; successful employee infection control programs; control methodologies being utilized (including engineering, work practice, and administrative controls and personal protective equipment); medical surveillance programs; and training. OSHA will use the information received in response to this request to determine what action, if any, the agency may take to further limit the spread of occupationally-acquired infectious diseases in these types of settings."
The key question, if any of this comes to pass, is whether patient safety will be improved or compromised by new regulations designed to protect workers, which by regulatory mandate are the sole purview of OSHA's power. While federal regulation is often characterized as burdensome and counterproductive, there is also the intriguing possibility that OSHA could empower infection preventionists by putting its considerable clout behind heretofore voluntary guidelines.
Though citing the existing guidelines by the Centers for Disease Control and Prevention and groups like the Association for Professionals in Infection Control and Epidemiology, OSHA expressed a somewhat cryptic interest in "any other strategies that might be applied within healthcare or healthcare related work settings to mitigate the risk of occupationally transmitted infectious diseases. While the CDC/HICPAC guidelines present the recommended practices for reducing the risk of infectious disease transmission to patients and HCWs, the guidelines are non-mandatory. The lack of adherence to voluntary infection control procedures is of particular interest to OSHA. What are the potential benefits of more widespread compliance with infection control guidelines? How can OSHA best assure such compliance takes place?"
An acrimonious history
IPs and infectious disease groups have historically been at odds with OSHA, primarily over its emphasis on respirators which many feel are more suited for industry than healthcare. The most recent iteration of that issue was the requirement for N95s to protect workers against H1N1 pandemic influenza A. However, the conflict between occupational health and infection control goes back many years, including the protracted battle over OSHA's attempt to issue a federal tuberculosis regulation for health care. It may be recalled that the TB donnybrook was imbued with a certain bitterness on both sides, particularly when OSHA folded some of the provisions of the defeated TB standard into its existing respiratory protection regs at almost literally the last minute. Indeed, the timing was particularly infuriating to IPs, coming as it did on New Year's Eve of 2003. (See Hospital Infection Control & Prevention, Feb. 2004, cover story in the HIC archives at http://www.ahcpub.com)
Will similar troubles ensue? Well, for starters, the blood pressure of many an infection preventionist may spike upon reading this statement in an OSHA fact sheet accompanying the notice of rule making: "Most current infection control efforts are intended primarily for patient protection and not for worker protection." One could argue that point, and no doubt someone will, possibly emphasizing the irony that some of OSHA's more stringent requirements (e.g., N95 respirators) could actually increase worker risk because they are well nigh impossible to consistently apply in the real world of clinical care. Still, OSHA has some points to make as well, including the vanishing incidence of hepatitis B virus in health care workers after it required HBV vaccination as part of its bloodborne pathogen standard.
"While OSHA has a Bloodborne Pathogens standard (§ 1910.1030), the Agency does not have a comprehensive standard that addresses occupational exposure to contact, droplet, and airborne transmissible diseases. OSHA is interested in commenters' insights regarding the adequacy of existing OSHA requirements to protect workers against occupational exposure to infectious agents," the agency states. " In most cases, an IC program is managed by an infection control preventionist or other designated person. For example, the CDC/HICPAC guidelines recommend that the IC program be managed by individuals with training in infection control. Who manages your program? What percentage of this individual's time is spent managing the IC program?"
Furthermore, OSHA requests "in detail, the resource requirements and associated costs, if available, expended to initiate the [infection control] program(s) and conduct the program(s) annually. Please estimate, in percentage terms where possible, the extent to which the components or elements in your program(s) are typical of those practiced throughout your industry. Please describe how your workplace or industry evaluates the effectiveness of its IC program, including the methods and criteria used. How often does your workplace evaluate its program? Please describe the results your program has achieved (e.g., if there has been a decrease in patient and/or worker infections). Please describe any specific problems and/or successes that have been encountered in the implementation and operation of the program."
A decision whether to promulgate infection control regulations may ultimately depend on the cost-benefit equation, which would likely weigh the cost of compliance against the projected infections prevented in workers and presumably, patients.
"As the Agency considers possible actions to address the prevention and control of infectious diseases (e.g., prospective standards or guidelines), what are the potential economic impacts associated with the promulgation of a standard specific to the hazards of infectious diseases?" OSHA asks. "Describe these impacts in terms of benefits from the reduction of incidents and illnesses; effects on revenue and profit; and any other relevant impact measure. If you have any estimates of the costs of controlling infectious disease hazards, please provide them."