Managing Hospital Hazardous Exposure as an Occupational Health Risk
The environmental health of a hospital evaluates the impact of this setting on the health and well-being not only of the patients but also of workers spending long hours at the hospital. The focus of the discussion is health care workers because the health and well-being of hospital workers indicates two things. One is the soundness of the hospital environment as a workplace. The other is the implication on the state of the hospital environment as conducive to the betterment and recovery of patients. Moreover, the quality of the hospital environment as the workplace of health care workers concurrently affects the quality of health care delivery to patients. This means that achieving and maintaining a good hospital work environment for health care workers has positive effect on health care delivery to patients.
Occupational health has close relations to environmental health by describing the interaction of health care workers with the hospital environment. An excellent occupational health is a reflection of environmental health of the hospital as a workplace and environmental health is the outcome of conscious concerns and effective management strategies on occupational health. As such, occupation health policies are important aspects of ensuring the environmental health of hospitals.
Hazardous exposure comprises an occupational health risk in hospitals. This refers to the contact of health care workers with substances classified as hazardous in the course of their work in hospitals. Hazardous exposure could lead to disease infection, illness or injury. (Burgess et al., 1997) This calls for the development of hazardous exposure management strategies to prevent and control this occupation health risk.
Hospital Hazardous Exposure as an Occupational Risk for Health Care Workers
Hazardous exposure comprises an occupational risk for health care workers because of the nature and requirements of their work. The Centers for Disease Control and Prevention (2001) described health care workers as employees, volunteers and students engaged in activities necessitating contact with patients or the blood or fluids from the body of patients that are potentially infectious, whether this happens in the laboratory or health care delivery context. This means that in the course of work, health care workers are facing the risk of contamination in dealing with infectious matter or substances. This is the reason for the classification of health care workers, especially those working in the emergency response, as high-risk groups in terms of exposure to transmittable and toxic substances.
However, this description of hazardous exposure is limited. The hospital setting also involves not only biological hazards but also other hazards such as exposure to chemical, radioactive, and other substances used in the hospital care setting (Burgess et al., 1997). Although, health care workers in hospitals may not directly use chemical substances in cleaning and sterilizing the facility, exposure to dangerous levels could still happen. A more encompassing definition of hazardous exposure in the hospital setting considers the risk from a wide range of hazardous materials.
Hazardous materials are diverse. The classification of materials or substances as hazardous depends on the quantity or volume and form that present a significant threat to the health of individuals or the safety of a given environment such as hospitals with improper storing, transportation, and disposal. The nature of the materials or substances determines the classification as a hazard. (Burgess et al., 1997)
In the hospital setting, the occupational risks from hazardous material or substances could fall under the three classifications, which are physical and radioactive, chemical and biological hazards. These hazards exert risk for all health care workers employed in hospitals.
Physical and radioactive hazards refer to the diverse materials and substances that could lead to physical harm due to exposure. One physical hazard is exposure to radiation. Although ionizing radiation comprises a means of imaging and treatment for conditions such as cancer, excessive exposure is harmful. This calls for the handling of ionizing radiation equipment by trained professionals as well as the implementation of the necessary precautionary levels to control exposure of the personnel as well as patients and non-trained personnel handling radiation imaging and treatment. The use of protective equipment or shielding, restricted access to radiation facilities, and proper storage of equipment are risk aversion methods. Another physical hazard is laser burns. A number of procedures utilize laser in surgery and treatment. The beam of the laser could pose a physical hazard when used without care or caution. The most common measure implemented is the use of eye protection or shield to prevent possible retinal burns. (Sadleir, 2000)
Chemical hazards refer to the wide range of toxic substances utilized in hospitals that could pose a hazard to health care workers, when improper storage or usage leading to excessive and repetitive exposure. The toxic chemical substances found in hospitals could include industrial cleaners, chemical sterilizers, tissue preservatives particularly formaldehyde, chemical reagents, processing chemicals for the development of x-ray films, anesthetic gases applied during operations or surgery, and cytotoxic drugs that need preparation before administering to cancer patients. Exposure to these health hazards could cause injury or illness and even death in severe cases. The risk from chemical substances gives rise to the need for control and preventive processes including proper disposal, use of the least hazardous chemical with the same effect, isolation of toxic compounds, enclosure of chemical substances, proper and sufficient ventilation, exercise of personal hygiene and protection, and overall cleanliness in hospital facilities. (Sadleir, 2000)
Actual cases of chemical hazardous exposure have been reported in hospitals in the Washington State. A survey of hospitals showed that a number have previously undergone evacuations because of hazardous substance incidents. Three hospitals experienced threat of chemical exposure. Eight hospitals actually experienced chemical exposure. Of this incident, the common issue was exposure to irritant gases through the mixing of cleaning chemicals. There was failure to determine the exact nature of the chemical substance in one incident. Seven incidents led to the evacuation of the emergency department. Two incidents also showed contamination of emergency department personnel through transfer from patients. (Burgess, 1999) These instances reflect the likelihood of chemical hazard exposure in hospitals putting health care workers at risk.
Another incident involved the exposure of eleven laboratory technicians working in a hospital to very high levels of aerosolized sulfuric acid. This incident was uncovered through the history taking of one of the technicians seeking medical care. The technician went to the emergency department on complaints of itching and rashes on his hands and face. The elimination of possible causes led to further investigation. Interview of the technician led to recollection of faint irritating odor and corroborated by the other technicians. Six of the laboratory technicians received treatment. The hospital laboratory closed temporarily for de-fumigation. (Winslow, 2005) This exemplifies another actual case of hazardous exposure by health care workers in the hospital setting. This requires the development of hazardous materials preventive and contingency planning by hospitals.
Reports also warn of exposure to hazardous drugs classifies as such because exposure could lead to cancer, toxicity in the reproductive system, or other injury to organs. Drugs administered to cancer patients constitute the most pervasive hazardous drug. Statistical estimates indicate that the risk of drug exposure covers 5.5 million health care workers possibly exposed through the handling, transportation, storage, administration and disposal of hazardous drugs. (Polovich, 2007) Even drugs for treatment could pose occupational risk to health care workers when improperly handled, stored or disposed as well as through accidents.
Biological hazards refer to the substances as well as the means that could lead to the infection of health care workers. There are three modes of transmission. First is aerial or aerosol exposure to illness such as viral respiratory infections, tuberculosis, or measles. This form of hazard requires control measures such as maintaining appropriate distance, preventing frontal coughing, frequent hand washing, non-rubbing of eyes, use of facemasks, and isolation of patients inside a negative air pressure enclosure. Second is skin contact with illness causing viruses and bacteria. This requires protective gear such as gloves and laboratory gowns. Third is exposure to infected blood or fluids through skin cuts and burns, eyes, nose, and infusion. This means of infection requires use of protective gear as well as the proper handling and disposal of contaminated waste. (Sadleir, 2000)
An important concern in biological hazardous exposure in health care practice is skin exposure. While care against dermal exposure is important, there is tendency to overlook this practice because of limited techniques for assessment and lack of identified limits of exposure. Statistical reports from the National Institute for Occupational Safety and Health showed that around 13 million health care workers, including health care workers, experience exposure to hazardous contaminants through the skin every year. The Bureau of Labor Statistics added that 12 percent of incidents of occupational illness are due to skin diseases. Prevention is important since some skin infections could manifest months or years later. (Geer et al., 2007) This explains skin exposure as an actual means of biological hazardous exposure of health care workers. The lack of preventive standards for skin exposure as well as non-identification of the exposure levels deemed hazardous pose a challenge to hospitals to consider these matters as a challenge in ensuring the occupational health and safety of hospital employees.
As venues of potential hazardous exposure, which affects occupational risk of health care workers, hospitals need to incorporate hazardous exposure into their management planning and practices to secure an environment that prevents or controls occupations risks of health care workers.
Hospital Hazardous Exposure Management Strategies
The development of strategies in managing hazardous exposure in hospitals is inevitably an organizational issue for two reasons. One, planning should be at an organizational level because hazardous exposure as a risk or threat occurs hospital-wide. Another, control and management practices requires organization-wide or concerted implementation to significantly achieve results. (Gimeno et al., 2005)
Occupational risk has a direct relationship to organizational management. In the case of a public hospital, the health care workers reporting exposure to chemical and physical hazards represented higher work related injuries ratio when compared to health care workers without previous exposure. Of the health care workers reporting previous hazardous exposure, the performance of tasks without meeting safety precautions and limited safety training constitute the reasons for work related injuries. At the individual level, the safety climate of the hospital and the implementation of safety practices contributed to the increased risk. (Gimeno et al., 2005) At the individual and organizational level, awareness, safety training, safety atmosphere, and precautionary practices affect the incidence of hazardous exposure. These factors operate at the organizational level and a responsibility of hospital management.
Awareness of hazardous materials and exposure comprise an important organizational practice of hospitals. This is the initial process before expecting the development of hazardous exposure management policies and compliance by health care workers. (Fuller, Bain & Sperrazza, 2007)
As early as 2004, the Centers for Disease Control and Prevention together with the National Institute for Occupational Safety and Health developed guidelines on “Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Health Care Setting”. The introduction of these guidelines was to develop the awareness of health care workers and hospitals towards the risks posed by hazardous drugs and recommend preventive practices. However, a survey of nurses in Massachusetts showed limitations in hospital implementation of the guidelines. Hazardous risk still comprise significant risks to health care workers because of the lack of consciousness regarding the policies or programs of the hospital on hazardous exposure, lack of hazardous materials training, and absence of equipment use and job completion controls. Of basic concern is the diverse understanding by nurses of hazardous material that affects their ability to identify or recognize risk. (Fuller, Bain & Sperrazza, 2007) Building awareness over hazardous materials and exposure requires improvement in hospitals.
Detection and assessment of hazardous exposure is another sound management practice of hospitals. These processes involve the regular monitoring of the work environment of hospital workers in terms of hazardous materials and symptoms observed in health care workers. (Koda, Kumagi & Ohara, 1999; Budnik & Baur, 2009)
Regular monitoring of the breathing environment of hospital employees focused on the detection of ethylene oxide, formaldehyde, and glutaraldehyde that comes about during the sterilization process. The results showed these chemicals as hazards for hospital workers. Practice of ventilation is not sufficient to alleviate the risk. There is need to implement other protective measures such as information drives about these chemical hazards, use of protective equipment, and engineering controls. (Koda, Kumagi & Ohara, 1999) This shows limitations in the safety practices of hospitals and stresses on the importance of regular monitoring for hazardous exposure in hospitals.
Apart from air or ambient monitoring for occupational risks of hospital workers, biomonitoring also developed as the means of detecting and assessing internal exposure. These measures complement each other and ambient monitoring usually done prior to biomonitoring to have an idea over the possible internal exposure of health care workers and the likely means of exposure such as through the skin, inhalation or other means. Biomonitoring involves the measurement of body fluids such as blood and urine for possible exposure. Tests done could include toxicology as well as other tests on the subcellular level to identify accurately if there is exposure, the nature of exposure, and the extent of exposure. (Budnik & Baur, 2009) Hospitals should develop biomonitoring capabilities and measures as part of hazardous exposure management. Moreover, the measures should be integrative by combining different processes of hazardous exposure.
Management planning and policies are significant preventive and responsive solutions to hazardous exposure risks in hospitals. Hospitals can implement a number of activities in averting or managing occupational risks, particularly hazardous exposure, of health care workers.
One hazardous exposure management activity is the formalization of occupational health concerns or policies of hospitals. This could be through the establishment of a team or group specifically in charge of ensuring occupational health and safety of hospital workers particularly against hazardous exposure. Another practice is the implementation of a formal education, learning, or information sharing on hazardous exposure and best practices. Still another practice is the enforcement of measures and standards of practice related to hazardous exposure. (Massoomi et al., 2008) The formalization of hazardous exposure management practices also implies the allocation of the necessary resources as well as influence on the health and safety in work practice of the hospital.
Another hazardous exposure management activity for hospitals is the development of contractual relations with suppliers of hazardous substances and agencies providing contracted labor in the hospital handling matters such as utility and maintenance work that covers hazardous management practice awareness in hospitals. Hospitals should also establish resource-sharing partnerships with other health and safety institutions such as other hospitals and health care institutions, the fire department, and other similar organizations. (Winslow, 2005) These partnerships are important in ensuring that preparedness of hospitals through information and resource sharing as well as collaborative practice. Open communication lines with partners also ensure immediate response in case of emergency, severe, or large-scale hazardous exposure in hospitals. Contracts and partners also support liability sharing and responsibility for occupational health and safety of hospital workers.
Still another hazardous exposure management practice is the provision of the necessary equipment to hospital workers and the training of hospital personnel. One way of doing this is the training of a group of personnel charged with handling quarantine and decontamination in case of hazardous exposure incidents. Another way could be the implementation of hazardous exposure drills to provide hospital workers with a simulated experience of incidents to develop practice-based awareness. Seminars covering most of not all employees done organization-wide or in the different departments could also be way of training. (Winslow, 2005) These imply the allocation of the necessary resources by the hospital.
Another hazardous exposure practice for hospitals is effective waste management. This is a key area of occupational health and safety of hospital workers because the improper management of hospital waste could lead to chemical, biological, physical and radioactive hazardous exposure of hospital personnel. In addition, poor waste management could also contribute to environmental problems including land, water and air pollution as well as the possible infection of the surrounding community. To ensure against occupational risk from hazardous infection, hospitals need to implement thoroughly effective waste control measures for infectious materials and substances commencing from the generation of the waste, to its treatment, and until disposal. (Manyele, 2004) Effective waste control measures include segregation, isolation, containment, and decontamination.
Hospital hazardous exposure comprises an occupational health risk for health care workers. This is because of their exposure to physical, chemical, biological and even radioactive hazards in the workplace. The issue of hazardous exposure needs to form part of the occupational health and safety policies of hospitals. However, despite this need and policy guidance from the concerned government agencies, compliance and implementation in many hospitals appear to be wanting. These limitations and loopholes need resolution to provide a healthy and safe hospital environment for health care workers. A number of hazardous exposure management strategies exist for hospitals to control occupational risks of hospital workers including the formalization of hazardous exposure management standards and practices, awareness building, detection and assessment of hospital environment for hazardous exposure, collaboration and partnership with external entities, and hospital management practices.
Budnik, L. T., & Baur, X. (2009). The assessment of environmental and occupational exposure to hazardous substances by biomonitoring. Deutsches Ärzteblatt International, 106(6). Retrieved April 13, 2009, from http://web.ebscohost.com.
Burgess, J. L., Keifer, M. C., Barnhart, S., Richardson, M., & Robertson, W. O. (1997). Hazardous materials exposure information service: Development, analysis, and medical implications. Annals of Emergency Medicine, 29(2), 248-254.
Burgess, J. L. (1999). Hospital evacuations due to hazardous materials incidents. American Journal of Emergency Medicine, 17(1), 50-52.
Centers for Disease Control and Prevention. (2001). Updated US public health services guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for post-exposure prophylaxis. Morbidity and Mortality Weekly Report, 50, 11.
Fuller, T. P., Bain, E. I., & Sperrazza, K. (2007). A survey of the status of hazardous drug awareness and control in a sample Massachusetts nursing population 2007. Journal of Occupational and Environmental Hygiene, 4, D113–D119.
Geer, L. A., Anna, D., Curbow, B., Diener-West, M., van Wendel de Joode, B., Mitchell, C., & Buckley, T. J. (2007). Survey assessment of worker dermal exposure and underlying behavioral determinants. Journal of Occupational and Environmental Hygiene, 4, 809–820.
Gimeno, D., Felknor, S., Burau, K. D., & Delclos, D. L. (2005). Organizational and occupational risk factors associated with work related injuries among public hospital employees in Costa Rica. Occupational and Environmental Medicine, 62(5), 337-343.
Koda, S., Kumagi, S., & Ohara, H. (1999). Environmental monitoring and assessment of short-term exposures to hazardous chemicals of a sterilization process in hospital wing working environments. Acta Medica Okayama, 53(5), 217-223.
Manyele, S. V. (2004). Effects of improper hospital-waste management on occupational health and safety. African Newsletter on Occupational Health and Safety, 14, 30–33.
Massoomi, F., Neff, B., Pick, A., & Danekas, P. (2008). Implementation of a safety program for handling hazardous drugs in a community hospital. American Journal of Health-System Pharmacy, 65(9), 861-865.
Polovich, M. (2007). Advisory issued on hazardous drug exposure. Same-Day Surgery, July 2007, 85-86.
Sadleir, B. (2000). Environmental and occupational health issues in hospitals. Retrieved April 13, 2009, from http://www.tropmed.org/rreh/vol1_2.htm.
Winslow, J. A. (2005). Exposure to sulfuric acid: A hazardous materials incident on hospital property. American College of Emergency Physicians. Retrieved April 13, 2009, from http://www.acep.org/ACEPmembership.aspx?id=39408