OSHA ramps up action on bloodborne risks in health care settings

Reach extends to clinics, nursing homes

Some health care employers are failing to take even the most basic steps to protect against bloodborne pathogen exposures, and the U.S. Occupational Safety and Health Administration is beginning to take notice.

In 85 inspections last year of doctors’ offices, OSHA issued more than $235,000 in fines for violations of the Bloodborne Pathogen Standard. Hospitals are cited more often for violations of that standard than for any other violation. And OSHA has targeted bloodborne pathogen compliance in its National Emphasis Program on nursing homes. In 2012, 47 nursing homes received $132,000 in fines.

“We really are looking at these issues and we will cite people who are not complying,” says Dionne Williams, MPH, director of OSHA’s Office of Health Enforcement.

The number of OSHA inspections is small compared to the scope of the health care workforce. There are about 5,700 hospitals, 16,000 nursing homes and about 50,000 multi-physician offices in the United States. But when inspectors target health care, they often find that employers fail to adequately train employees or update their exposure control plans. In some cases, they aren’t even providing safety-engineered devices.

The Pittsburgh area office of OSHA conducted 10 special inspections in a year-long local emphasis program on health care that ended in September 2012. Inspectors cited a hospital and an allergy clinic for failing to offer the hepatitis B vaccine to all employees at risk. An ambulatory surgery center and a doctor’s office weren’t using safety-engineered devices. Sharps containers were overfilled or unsafe, OSHA said.

“It’s very difficult to believe that anyone running a hospital or a clinic would not have these [bloodborne pathogen] rules well-documented and have familiarity with them,” says Janine Jagger, PhD, MPH, director of the International Health Care Worker Safety Center at the University of Virginia in Charlottesville. “I think it’s just a question of doing the easiest thing if no one is looking.”

Jagger and other sharps safety experts have long expressed concern about compliance with the Bloodborne Pathogen Standard in non-hospital settings. “OSHA is well aware that there are risks that are not being properly addressed in doctors’ offices and non-hospital facilities, and they’re turning their attention in that direction,” she says.

Risk without protection or follow-up

Inspections in Pittsburgh provide a window into some of the problems occurring in health care facilities.

Jefferson Allergy & Family Associates, OSHA noted, “completely lacked an Exposure Control Program and no employee had been offered the hepatitis B vaccination. One worker had received a needlestick injury and she had been expected to pay for her own post-exposure evaluation and follow-up.”

OSHA also cited the allergy clinic for using open buckets to dispose of sharps. “[O]nce every few days an employee would gather all of these open buckets of sharps and manually pour the used needles into a larger, approved sharps disposal container,” OSHA said in a summary report.

A supervising physician at the clinic said the citations mischaracterized the practices at the clinic. The employees had all previously received the hepatitis B vaccine and the employee with the needlestick had not followed instructions about how to receive post-exposure follow-up. But the physician said the clinic is now working with a consultant to improve training, the Exposure Control Plan, documentation and other practices.

In Conemaugh Memorial Medical Center, a regional hospital in Johnstown, PA, OSHA inspectors found overfilled sharps containers and employees who had not been offered hepatitis B vaccination or provided annual bloodborne pathogen training.

“Problems were found in the soiled linen area, where employees emptied a suction canister of blood,” OSHA said. “No procedures had been developed for the emptying and cleaning of this canister, and employees were subsequently not wearing appropriate PPE and gross contamination of the work area was allowed to accumulate.”

Conemaugh has since created a SafetyNet Committee to reduce bloodborne pathogen hazards and has implemented new bloodborne pathogen training.

Other OSHA regions also have focused on bloodborne pathogen concerns. Region 2 issued a news release after citing Health East Ambulatory Surgery Center in Englewood, NJ, for failing to provide post-exposure counseling and prophylaxis after a needlestick. The surgery center contested the citations and reached a settlement with OSHA.

“The alleged written policy violations were self-corrected by Health East on our own initiative during the investigative process and long before OSHA issued its proposed penalties,” a spokesperson said in an emailed statement. In fact, Health East is now pursuing the rigorous process of becoming a Voluntary Protection Program (VPP) site, she said.

National tracking is lacking

More than 10 years after the Needlestick Safety and Prevention Act, why are needlesticks still occurring? That question is best answered by surveillance, but national data have been lacking. The Centers for Disease Control and Prevention included a bloodborne pathogen module on its National Healthcare Safety Network (NHSN) but has not reported any data.

The best surveillance has come from Massachusetts, where all hospitals are required to report bloodborne pathogen exposures, and EPINet, a network based at the University of Virginia that collects data from 32 hospitals and health care facilities, many of them from South Carolina.

Those tracking systems point to lingering gaps in sharps injury prevention. In 2010, more needlesticks were linked to hypodermic needles than any other device, the Massachusetts data showed. About one-fourth of those hypodermic needles (24%) lacked safety features.

Suture needles cause almost one in five (18.6%) sharps injuries, according to 2011 EPINet data, which reveals the continuing risk in operating rooms.

National information would help employee health professionals target their sharps injury prevention and provide some benchmarks, says Linda Good, PhD, RN, COHN-S, director of Employee Health Services for Scripps Health in La Jolla, CA.

The Association of Occupational Health Professionals in Healthcare (AOHP) is collecting sharps injury information from members to provide some basic data while they wait for a national reporting system, says Good, who is chair of the AOHP Research Committee. (See related article below.)

“If we can identify some best practices, we can share those with our membership and the community at large to try to make a safer workplace,” she says.

Employers are required to update their Exposure Control Plan annually, including a review of new safety technology. But they also should be reviewing procedures to look for ways to redesign them for safety, says Jagger.

“The elimination of a sharp, whenever possible, is always the Number 1 goal,” she says.

Health care facilities need to recognize the inextricable link between patient safety and worker safety, says Williams. “Health care workers in general have a very high regard for patient care,” she says. “Their own protection also is a benefit to their patients.”

Employers who need some help with compliance should contact their area OSHA office for free consultation — a program that won’t trigger enforcement action, Williams says.

AOHP to track national needlestick trends

Employee health professionals who want more information about needlesticks are taking matters into their own hands. The Association for Occupational Health Professionals in Healthcare (AOHP) has begun to collect data in a national survey and will report the first results this fall at the AOHP conference in Orlando.

“We saw a gap in the knowledge,” says Linda Good, PhD, RN, COHN-S, director of Employee Health Services for Scripps Health in La Jolla, CA, and chair of the AOHP Research Committee. “With our AOHP membership spanning the United States, we had an opportunity to collect data from our members and come up with some good numbers.”

Expo-S.T.O.P, or Exposure Survey of Trends in Occupational Practice, could eventually gather data on other health care hazards, such as patient handling injuries, says executive president Dee Tyler, RN, COHN-S, FAAOHN, who is director of Medical Management for Coverys Insurance Services in Lansing, MI.

About 115 occupational health professionals have participated in the survey so far, providing information about needlesticks and mucocutaneous exposures. They also report some hospital characteristics, such as bed size, average daily inpatient census, number of employees, and whether it is a teaching or non-teaching hospital.

While hospitals track their own needlesticks, they also like to know how they compare to similar hospitals, Good says. AOHP also plans to share information about best practices. “The membership has expressed a lot of interest in what we find,” she says.

Bloodborne pathogen exposure is one of five “health and safety initiatives” that AOHP targeted in its recent public policy statement. AOHP also is advocating for: “evidence-based best practices” on influenza vaccination of health care workers; safe patient handling “regulations, legislation, education, training, research and prevention activities;” “increased research, training and education” on respiratory protection; and comprehensive workplace violence prevention programs.

The priorities will guide AOHP’s strategies as it designs education programs and collaborates with other organizations, says Tyler.