OSHA hearings over; final rule a year away
AHA says most hospitals follow CDC guidelines
After holding its third public hearing in Chicago in early June, the Occupational Health and Safety Administration (OSHA) has completed the public-input stage of its proposed tuberculosis standard. However, the standard is more than a year away from becoming a rule, say OSHA officials.
"We do not have a date for when it will come out, but it will be at least a year," says Susan Fleming, OSHA spokeswoman.
Following the last of three public hearings, OSHA will allow up to 60 days for follow-up comments from hearing participants. The intention is to clear up issues raised and provide data supporting or refuting claims made during the hearings, she explains.
Presentations at the June 2 hearing in Chicago included comments from the American Association of Homes & Services for the Aging, the American Federation of Teachers, the American Ambulance Association, and the National Coalition for the Homeless. All three groups would be in the OSHA compliance net under the proposed rule, and they have concerns about meeting its requirements.
The American Hospital Association also presented its position, as it did at the Washington, DC, public hearing in April, which was followed by a hearing in Los Angeles in May. Based on surveys of its 5,000 facilities, the AHA told OSHA it believes the majority of hospitals will incur no significant burden complying with the OSHA requirements that follow the CDC guidelines.
"I think hospitals are probably the farthest ahead in meeting the standard because it is based very much on the CDC guidelines," says AHA spokeswoman Gina Pugliese. "So of all the groups, hospitals are the most ready." A 1996 AHA survey of hospitals found 96% had isolation rooms meeting CDC criteria, and 98% had TB skin testing programs for health care workers.
Although the Association for Professionals in Infection Control remains opposed to the standard, the AHA has taken a more moderate position by emphasizing that OSHA shouldn't sway from CDC guidelines. "We support efforts to ensure that the control measures based on science are implemented to reduce risk, and for the most part hospitals have done that," Pugliese says.
So far, OSHA officials have suggested they will modify several requirements, such as the frequency of skin testing, use of UV lights, and compliance by homeless shelters. (See TB Monitor, June 1998, p. 61.) "That is about the only idea we have about what might change," Pugliese says.
In step-by-step fashion, AHA outlined areas for which it believes OSHA has proposed requirements that surpass the scope of CDC guidelines.1 They include:
o Exempted facilities.
The AHA says using the countywide incidence of TB to determine whether a facility must comply with the standard is troublesome. Because levels of risk can differ significantly throughout a county, AHA recommends criteria include incidence of TB in a facility's "community" rather than county.
o Skin testing.
The AHA recommends OSHA testing standards: "Require no baseline skin testing for those facilities that have not encountered a TB patient in intake areas in the past year and have a policy to transfer them out; and require baseline testing only for workers in intake areas of those facilities that have encountered a patient with TB in the intake area in the past year." Also, the AHA says testing low-risk facilities could increase the number of false-positive test results. As for two-step skin testing, the AHA notes that providing it for all workers without a documented negative skin test in the past year "goes beyond the CDC guidelines and is unnecessary for all work sites."
o Respiratory protection.
The AHA says respirator training and fit-testing "be portable so that they need not be duplicated when there is evidence from a previous employer that worker: (1) has been fit-tested for a particular type of respirator and the same type is being used; (2) has received appropriate training on respirator use as outlined in the standard; (3) and can demonstrate specific knowledge and skills for respirator use." While saying fit-testing should be evaluated each time a respirator is donned, fit-checking methods for the N-95 respirator haven't been studied adequately. Therefore, a requirement should not be mandated yet.
o Work practices.
The OSHA rule requires that a minimal number of workers be allowed to enter and spend time in an isolation room - a proposal the AHA considers overly intrusive in hospital operations and threatening to the quality of care. "Hospitals and other health care facilities should determine how many workers are needed to care for patients in isolation and then provide those workers with proper training on risks and methods to reduce risk," the AHA states.
o Engineering controls.
Because of new data on the efficacy of UV lights and portable HEPA units, the AHA states that these secondary control measures should be allowed in some situations. The need for airing an AFB isolation room vacated by known or suspected TB patients for an established period is excessive, it notes. Also, it recommends OSHA's requirements for inspections and performance monitoring of HEPA filters be changed to match CDC recommendations.
o Hazard communication.
The AHA argues that OSHA's requirement to post caution signs on isolation room doors is "excessive and overly prescriptive." As for labeling on ventilation units, the AHA says OSHA has put too much emphasis on labeling rather than on procedures that reduce the risk to workers entering ventilation systems, such as shutting off fans before working on vents.
o Clinical and research laboratories.
OSHA's requirements for eliminating wastes contaminated with TB should be made only to follow local, state, and federal regulations, the AHA says.
1. American Hospital Association. Letter to Charles Jeffress, OSHA's assistant secretary of labor, from Richard Pollack, AHA executive vice president. Submitted to OSHA docket Feb. 6, 1998.