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Health care unions call for OSHA standard on infectious diseases
SEIU, ANA cite need for infection control enforcement
By Gary Evans, Senior Managing Editor
Squaring off with the nation's leading infection prevention groups, health care worker unions and associations are urging the Occupational Safety and Health Administration (OSHA) to develop an infectious disease standard that would essentially regulate and enforce infection control programs in hospitals.
The Service Employees International Union, (SEIU), which counts some 1 million health care workers among its members, strongly encouraged OSHA to promulgate an Infectious Disease Standard.
"We believe that the most effective approach for OSHA to assure compliance with infection control measures to protect workers from these diseases is through a comprehensive enforceable standard," the SEIU stated in comments to OSHA. "[We need a standard] that covers a wide range of infectious agents and protects healthcare workers from dangerous and potentially deadly diseases so they can provide their patients with the quality care they need and deserve without jeopardizing their own health and safety."
OSHA set the stage for regulatory action on occupational infection prevention in hospitals and other heath care settings with a recent request for information on the need for an infectious disease standard.1 The comment period is closed, but the docket submissions by key stakeholders suggest a tumultuous debate is only just beginning. Noting that infection prevention programs are largely "voluntary," the agency went beyond its longstanding interest in airborne infections to include a request for comment on those transmitted via droplet and contact. As a result, OSHA is essentially considering regulating the full gamut of health care infection prevention.
The Association for Professionals in Infection Control and Epidemiology (APIC) argues that an OSHA standard on infectious diseases would unnecessarily duplicate existing guidelines, standards and regulations such as those already in respective effect by the Centers for Disease Control and Prevention, the Joint Commission and the Center for Medicare and Medicaid Services (CMS).
"We are currently following national guidelines by CDC and other entities such as the Joint Commission. We feel that there are agencies like CMS that are enforcing those guidelines," says Susan Dolan, RN, MS, CIC, APIC public policy chair. "If they identify problem areas, that may be something we can take a look at, but until that time I don't think we can pinpoint something they have identified as an issue. We may learn things that we didn't realize were there, but our sense from what we are hearing from members is that they don't seem to understand why this is needed."
The SEIU said it was "a false perception that the industry is self-regulated. "The Joint Commission, which accredits hospitals with a primary focus on patient care, conducts pre-announced inspections of most hospitals every 3 years," the union argued. "[There has been an] historic lack of attention by governmental agencies responsible for health and safety. Only relatively recently has OSHA begun to issue standards and guidance for hazards that cause injuries and illnesses to health care workers."
ANA says expand California reg
A lack of enforcement of infection control recommendations was also cited as an issue by the American Nurses Association (ANA), a group with considerable political clout that represents some 3 million registered nurses.
"Much of the evidence on infection transmission and prevention is not new information, however the shortcoming lies in the capacity to enforce programs," the ANA said in comments to OSHA. "Healthcare employers are responsible to provide an aggressive infection control program. The California-OSHA Aerosol Transmissible Diseases standard may be a model for future OSHA standard which could incorporate contact transmission as well."
Indeed, many observers think the Cal-OSHA airborne standard is the most likely template for a national standard, though OSHA is now talking about going beyond its traditional respiratory infection focus to include other modes of transmission. (See related story, p. 100.) In that regard, the ANA cited the need for clarity around disease transmission by contact, droplet and airborne transmission in the wake of the pandemic.
"The 2009 H1N1 pandemic resulted in much uncertainty and mixed messages that caused confusion around transmission even when more information became known about the H1N1 virus," the ANA told OSHA. "The highest level of respiratory protection must occur to provide healthcare workers with appropriate protection. ANA supports the development of a more protective respirator which is user-friendly and ideally does not require fit testing so nurses and other healthcare workers experience an optimal level of respiratory protection when exposed to airborne or droplet infectious agents. In the interim, there is a strong need to enforce the annual fit testing requirement in order for healthcare workers to be prepared to achieve the highest level of respiratory protection."
Quantifiable knowledge of occupationally acquired infections of healthcare workers is hampered by a lack of systematic tracking and reporting, the ANA noted. "ANA recommends that an improved reporting and tracking methodology be developed and utilized to expand the knowledge of the prevalence of infectious disease exposure and incidence of healthcare workers to benefit both the healthcare worker and the patients who they serve," the nurses group stated. "This will allow data for infection control planning and prevention."
Sinking in a sea of data
More data collection is not exactly music to the ears of an infection preventionist. APIC expressed concern about any "increased burden of reporting infectious agents (e.g., MRSA) when it is very difficult to distinguish occupational versus community acquisition." Instead of adding additional reporting requirements, the focus within facilities should be on timely post-exposure prophylaxis for targeted diseases to protect the health of employees, APIC argued.
"There are already a lot of requirements for documentation and data collection," Dolan says. "Having another agency coming in requiring different documentation, a different method of submission, and being subject to more surveys seems like a duplication to us. It would be an added burden that would take us away [from key duties]. We encouraged our members to submit [comments] to show all of the things that they are currently doing."
In its submitted comments to OSHA, APIC said it "does not see any additional gain from a highly redundant standard and the burden of documenting elements of infection prevention efforts for yet another government agency." APIC also rejected OSHA's contention that infection prevention programs are voluntary efforts designed primarily to protect patients.
"We believe that OSHA has mischaracterized IPC programs as "voluntary," APIC stated. "Hospitals, ambulatory care centers, other care-delivery sites and related entities understand that in order to receive Medicare and Medicaid funds, these programs are mandated by CMS and any agency which has received deemed status from CMS. Beyond reducing reimbursement, CMS hospitals not complying with its standards risk loss of certification or even their license if CMS determines the facility has unsafe conditions related to life safety codes and infection control standards. Therefore CMS and other accrediting agencies' enforcement affect both patients and health care workers."
In addition, infection prevention programs are designed to protect both patients and workers APIC emphasized. "Hospitals are concerned about the health and safety of all occupants, whether patients, health care workers, or visitors," APIC stated. "Therefore elements of the infection prevention programs must include airborne, droplet and contact assessments, as well as attention to environmental/engineering controls for the environment affecting ALL occupants."
APIC reminded OSHA that programs typically develop a risk assessment for the specific population served and for the types of communicable diseases likely to be seen in the specific facility. For this purpose, hospitals and other settings use reportable communicable disease entries published weekly from local and state and federal agencies, APIC explained.
"Therefore, specific issues may vary by locale," APIC said. "The best example is TB, for which CDC guidelines indicate that some areas may have minimal risk and need not carry out TB testing nor develop respiratory protection programs."
TB battle resonates
The OSHA initiative could reopen some old wounds from the protracted debate between infection control and occupational health over a national tuberculosis standard. Indeed, some commentors recalled that specific situation, reminding OSHA that its contention that health care workers were at greater risk of TB was never borne out in data.
"[We have] a concern that with this regulation, OSHA may be singling out healthcare workers (HCW) without good documentation that additional regulations will reduce the infection rate of HCW's exposed to infected patients, or patients to infected HCW's," commented Bruce Cunha, RN, MS, COHN-S, manager of employee health and safety at the Marshfield (WI) Clinic. "This is similar to what occurred with the tuberculosis standard that OSHA proposed back in 1997. We are not sure that OSHA is correctly identifying the potential for work exposure to infectious diseases. This is not restricted to just health care settings. The probability is that HCW's are actually better protected than workers in other industries in that they have had training and are more aware of signs and symptoms that may indicate a person has an infectious disease. The HCW is also educated and proficient in the use of personal protective equipment (PPE) and other IC measures such as hand washing."
On the contrary, the SEIU comments argued that health care workers face a host of occupational infectious disease risks not covered under the current OSHA bloodborne pathogen standard.
"Our healthcare members experience on a daily basis the inadequacy of existing OSHA requirements to protect them from non-blood borne infectious disease," the union comments continued. "While existing standards such as for respiratory protection are important, without a comprehensive standard healthcare workers work within a confusing system of mandatory requirements and voluntary guidelines. The confusion extends beyond just front-line workers to supervisors, upper management and local and state health departments which provide advice to most health care institutions. There is an important need for OSHA to provide clarity with a comprehensive standard to protect healthcare workers from exposure to and risk of infectious disease."
In any case, regulations are a poor tool to address the unpredictable nature of infectious diseases, Cunha noted. "[E]xposure to most cases of infectious disease occur prior to the disease being diagnosed and protective measures being implemented," he told OSHA. "In this situation, additional regulations will not reduce the incidents of disease."
Still, the SEIU pointed to the success of OSHA's 1991 bloodborne pathogen standard in reducing the rate of occupationally acquired hepatitis B. "Later when the [bloodborne] standard was amended to require the use of safer needles, the number of accidental needlesticks were slashed as well," the SEIU told OSHA.
APIC cautiously conceded some positive aspects of that standard, but reiterated that more OSHA regulations are not needed.
"Although hospitals and other entities follow the OSHA bloodborne pathogen standard carefully, we believe the high level of efficacy of the HBV vaccine had an enormous impact on the reduction of HBV," APIC stated in its comments. "We acknowledge the impact of OSHA's standard but believe its impact was felt in many areas in which accessibility to HBV vaccination was less feasible. We also acknowledge the value of OSHA's attention to regular review of current safety devices, but also believe the current attention by CDC and CMS to increase focus on injection safety in all care settings is an important focus today."
An OSHA Infectious Disease Standard would result in "unnecessary increased costs that would take resources from other programs designed to protect workers and patients," APIC emphasized. "Because these efforts are already well-guided by other government agencies, they do not require additional monitoring by another government agency and represent a redundant and unnecessary cost burden for employers and taxpayers. APIC does not believe OSHA has demonstrated a specific problem that would permit development of a measure that would provide specific improvements over existing employee health and infection prevention programs."