A Survey on Health and Chemical Exposures
Nurses' Health: Are Nurses Protected?
Occupational Safety and Health Regulations and Nurses' Health
Employing over 12 million people, health care is the second-fastest-growing sector of the U.S. economy (NIOSH 2006). Hospitals and other health care facilities provide jobs for 1.6 million workers at 21,000 work sites (OSHA 2006). Yet while caring for the health of their communities, every health care worker may be exposed to numerous occupational hazards every day. Unfortunately, many of the regulations aimed at protecting these workers are obsolete, and enforcement of existing requirements is inadequate.
Table 1: Few regulations limit nurses' exposures to hazards in the workplace
|Chemical or hazardous agent and key health concerns||Mandatory limits for nurses' exposures?||Does the gov't product approval consider nurses' exposures and safety?|
|Anesthetic gases (miscarriage, birth defects)||No||No|
|Antiretroviral medications (unknown health effects)||No||No|
|Chemotherapeutic agents (birth defects, cancer)||Only for platinum- and arsenic-based drugs; rarely monitored or enforced||No|
|Ethylene oxide (miscarriage, cancer)||Yes (OSHA Permissible Exposure Limit)||No|
|Glutaraldehyde (skin and eye problems)||No||No|
|Hand and skin disinfection (skin allergies, asthma)||Only for isopropyl alcohol (OSHA Permissible Exposure Limit)||No|
|Housekeeping chemicals (asthma, allergies)||No||No (no approval process for most products)|
|Ionizing radiation (cancer)||Yes (maximum exposure limit)||No|
|Latex (asthma, allergies, anaphylaxis)||No||No|
|Mercury-containing devices (neurological effects)||Yes (OSHA Permissible Exposure Limit)||No|
|Medications (birth defects, miscarriage)||No||No|
|Personal care products (dermatitis, cancer)||No||No (no approval process)|
The U.S. Department of Labor's Occupational Safety and Health Administration (OSHA) is charged with developing and enforcing regulations designed to protect workers. Though OSHA has devoted rigorous attention to regulations concerning bloodborne pathogens, many hazards commonly found in health care settings have received far less scrutiny. In fact, of 12 key hazardous exposures examined, OSHA has set health-based exposure limits for just three (ethylene oxide, ionizing radiation, and mercury), and has set limits that cover just a small fraction of chemicals in two other exposure categories (cancer drugs and skin disinfectants). None of these limits have been updated within the last two decades.
Government enforcement of existing occupational safety and health regulations within health care settings is disturbingly inadequate. Over one full year, from October 2000 to September 2001, OSHA performed just 103 hospital inspections while overseeing more than 5,800 hospitals nationwide (NCHS 2005, OSHA 2006). By inspecting a tiny fraction of health care facilities for violations of regulations designed to protect nurses and other health care workers, OSHA is failing to protect millions of Americans from occupational hazards.
Federal regulations and guidelines
OSHA has established exposure limits (Permissible Exposure Limits, or PELs) for a few specific exposures relevant to the hospital environment, including ionizing radiation (29 CFR 1910.1096), used for diagnostic imaging, radiotherapy, or produced by radioactive medicines; ethylene oxide (29 CFR 1910.1047), a powerful cold sterilant; mercury (29 CFR 1910.1000), a component in a variety of medical devices; isopropyl alcohol, (29 CFR 1910.1000) an important disinfectant; and a few other chemicals. These exposure limits, however, were set over 20 years ago, and have not been tightened despite recent scientific evidence that has led to increasing concern regarding the potential health effects of chronic, low-dose occupational exposures to these hazards.
Further regulations relevant to health care settings include those regarding hazard communication, involving the labeling of hazardous chemicals, training of employees on proper use of chemicals, and maintaining available chemical safety and health information in the form of a collection of material safety data sheets (MSDS) (29 CFR 1910.1200). Health care facilities are obligated to provide appropriate personal protective equipment to their staff (29 CFR 1910 Subpart I), and to provide alternatives to latex for staff with latex allergy (29 CFR 1910.1030(d)(3)(iii)). Facilities employing mercury-containing devices must also provide spill kits for the safe cleanup of mercury spills (29 CFR 1910.132 and 1910.134). Staff exposure to ionizing radiation must be monitored and recorded (29 CFR 1910.1096). In addition, EPA evaluation and registration of pesticides, especially antimicrobial disinfectants used in health care settings, prevents some harmful chemicals from being used in hospitals.
There are many chemicals in common use in health care settings, however, that are not regulated by OSHA or EPA standards. For these chemical hazards, any exposure is legal, and the burden falls on individual health care facilities to establish safe workplace practices for employees. For example, while OSHA has announced plans for over ten years to develop exposure limits for glutaraldehyde (SH 2006), a high level disinfecting agent known to trigger asthma and contact dermatitis, no deadline has been set. As well, established concerns regarding cancer and reproductive problems linked to the exposure of health care workers to trace amounts of multiple, powerful hazardous medications have resulted in no new regulatory efforts by OSHA (NIOSH 2004).
The National Institute of Occupational Safety and Health (NIOSH), an agency within the Centers for Disease Control and Prevention (CDC), studies a variety of occupational issues relevant to health care, and formulates guidelines concerning handling of hospital hazards. These guidelines, however, are not enforceable, and studies indicate adherence to them within medical centers is often sporadic. For example, concentrations of the anesthetic gas nitrous oxide in dental operatories often exceed the limits recommended by NIOSH, even when appropriate scavenging equipment is in use (NIOSH 1994). Many nurses and other health care workers who prepare and administer hazardous medications, or care for patients treated with these medications, do not use the recommended personal protective equipment outlined by NIOSH (Valanis et al. 1991 & 1992, Mahon et al. 1994, Nieweg et al. 1994, Martin and Larson 2003).
At this time, primary responsibility for many aspects of health care worker health and safety lies with the administration of individual hospitals and other health care facilities. Caring, motivated staff can use resources from NIOSH, as well as nongovernmental organizations such as Health Care Without Harm, Hospitals for a Healthy Environment (H2E) and ANA's Center for Occupational and Environmental Health, to create programs that reduce employee exposures to hazards above and beyond OSHA requirements. These programs may facilitate use of less hazardous substitute chemicals, encourage more efficient use of hazardous chemicals, implement engineering solutions that reduce or prevent exposures to health care workers, or improve training, documentation, and investigation of exposure incidents.
OSHA has implemented a Voluntary Protection Program that encourages medical centers to establish their own internal regulations regarding hazardous exposures and other occupational health and safety concerns (OSHA 2000). The Administration has concluded that effectively managing safety and health protection programs improves employee morale and productivity, and significantly reduces workers' compensation costs and other less obvious costs of work-related injuries and illnesses (OSHA 2006). Despite the clear benefits of these measures to health care personnel and hospital efficiency, there has been no effort to require such plans for all health care facilities.
Perhaps the best drivers of efforts to improve the safety and health of occupational environments are careful epidemiological studies of worker health and exposures to a variety of hazards. Unfortunately, in recent years neither OSHA nor any other U.S. agency has performed an epidemiological study of nurses and other health care workers with respect to exposures to hazardous chemicals. In 2001, the Centers for Disease Control and Prevention announced plans to implement a National Exposures at Work Survey within the health care industry. This survey would provide much needed data on nurses' exposures to hospital hazards, a first step towards identifying those hazards most in need of new or updated safety standards. After extensive preparation, funding for the survey has finally been secured. We ask that further governmental approval of the study be expedited, so that it can be conducted as soon as possible.
Lacking this data, it is difficult to prioritize health-based improvements to existing hazardous exposure limits, or identify new concerns regarding any of the broad range of exposures present in the hospital setting. Thus, well-designed studies that probe the effects of hazards on the health of health care personnel would generate information that could guide future efforts to ensure the occupational safety and health of this vital segment of the population.
Health care workers spend their lives healing the ill and the injured. They deserve to work in an environment that is safe and healthy. To foster an environment free of hazards, OSHA must:
- update existing regulations concerning well-established hazardous exposures;
- mandate development and implementation of hospital and health care worker protection plans that include many of the guidelines and best practices outlined by NIOSH;
- increase enforcement efforts;
- conduct epidemiological research on the effects of hazardous exposures on health care workers' health.