Prepare now: OSHA gearing up its inspectors

By Katherine West, BSN, MSEd, CIC

Infection Control Consultant

Infection Control/Emerging Concepts

Manassas, VA

[Editor’s note: The Occupational Safety and Health Administration (OSHA) has notified 2,600 hospitals and nursing homes that they may be the subject of a future inspection due to their level of reported needlesticks and other injuries and illnesses in health care workers, OSHA chief Charles Jeffress announced recently. The American Nurses Association also is urging members to call OSHA if needle safety devices are not in use at their facilities. Hospital Infection Control editorial board member Katherine West assesses the situation for infection control professionals who may be facing an OSHA inspection.]

OSHA will be watching hospitals and long-term care facilities (LTC) more closely in the coming year. Previously, hospitals and LTC facilities have not been high on OSHA’s list for inspections. However, with the current focus on the need to reduce sharps injuries, that has changed. In the new compliance directive for the bloodborne pathogens standard (CPL 2-2.44D) published Nov. 5, 1999, it is clear that hospitals and LTCs must switch over to needle-safe systems. This is not an option. OSHA has clearly recognized sharps as the major risk to health care worker safety. OSHA has set limits for sharps injuries for facilities based on the number of full-time-equivalent employees. If that number is exceeded, an inspection may result. How will those limits be monitored? One source of information will be the number of sharps-related injuries reported on the OSHA 200 Log.

Now that OSHA’s attention will be focused more directly on the hospital and LTC settings, it is essential that the ICP be ready to assist the facility should an inspection occur. Here are some tips to ensure that you and your facility are ready:

• Read the preface to the original OSHA standard published in December 1991. This is important because information there offers a more complete understanding of what is being asked in the standard. For example, it was very clear back in 1991 that education and training were to include hepatitis C and syphilis as well as hepatitis B and HIV/AIDS.

• Reference and read the OSHA regulations cited in the standard. For every OSHA regulation, there is a published listing of other OSHA regulations that must be reviewed and applied for compliance. For example, when you look at the bloodborne pathogens standard, it references the personal protection standard. If you read that standard/regulation, you note that heavy-duty utility gloves must be worn for cleaning activities.

• Get a copy of the compliance directive. A compliance directive is issued for every OSHA standard. This document is written for inspectors and serves as a guide for conducting inspections. The directives are written in easy-to-read language and give clear explanations for each area addressed in the standard. For example, if you read the new compliance directive with regard to needle-safe systems, it states that device selection needs to include employee input, and training should be "hands-on."

• Check interpretations on the Internet. OSHA’s home page (http://www.osha.gov) offers a section under interpretations called "Quips," which often can be a useful source of information to answer questions. When someone has a question and writes it as a formal letter to OSHA, the answer is published in Quips. There is a menu of headings to click onto, and many letters to review. The answers published are formal and official OSHA responses. When this document review is completed, you will have a comprehensive review of what OSHA is truly asking.

Review your exposure control plan

Your next step is to review your facility’s exposure control plan to ensure it is comprehensive. The exposure control plan needs to be facility-specific, not a generic "fill-in-the-blank." The listing of components to be addressed specifically for your facility includes:

• Exposure determination should include a clear listing of "at-risk" staff and staff who are not at risk.

• Education and training should cover the five diseases (four bloodborne, plus TB), adding latex allergy/sensitivity, post-exposure prophylaxis for HIV, work restriction guidelines, and needle-safe devices.

• The hepatitis B vaccine and titer testing programs need to be clearly laid out, along with the TB skin-testing program.

• Engineering controls should include hand washing, sharps devices, and sharps containers, and personal protective equipment should indicate when those controls are used for each risk procedure identified in your plan.

• Post-exposure medical follow-up should include how to notify, what paperwork to complete, where to go for treatment, and who will counsel and monitor follow-up.

• Medical waste management should be specific to the laws of the state in which you work. OSHA monitors compliance based on Environmental Protection Agency and state and local laws.

• Record keeping should define who keeps the records, how confidentiality is maintained, and how staff can obtain a copy.

• Compliance monitoring should include how the facility will ensure staff are complying with the program outlined in the plan. Include what will be done if noncompliance is identified.

Those are the components that are required and will ensure a comprehensive plan is in place. Once a plan is written and incorporated into the training program for staff, the plan must be updated and reviewed each year. That update and review should be noted on the implementation sheet in the plan to document the process. The ICP with all of that information is then ready to assist the facility by identifying any areas of noncompliance.

The role of education and training

The ICP needs to maintain a role in the education and training of staff. The ICP has the knowledge base to answer questions relating to the diseases, infection control techniques, and post-exposure follow-up. Delegating the training to human resources or staff development can and often does result in staff confusion, unanswered questions, and noncompliant training sessions. Remember, the sole use of videos or computer-training programs is not considered compliance. There must be a knowledgeable instructor available to answer questions, and the program needs to reflect the specifics for that workplace. There is no short cut to meeting that requirement.

The ICP should have an active role in conducting compliance monitoring to identify noncompliance and training needs relative to the diseases and infection control. There is no one more suited to that task than the ICP. When monitoring compliance, don’t forget to look at proper post-exposure medical follow-up. Evaluate follow-up not just for in-house staff but also for pre-hospital personnel. OSHA states that the employer is responsible for ensuring proper post-exposure follow- up is conducted according to guidelines from the Centers for Disease Control and Prevention. Therefore, ensuring proper care is rendered is a risk management tool.

The ICP also needs to monitor regulatory or legal changes that occur. Do not always count on risk management or legal affairs to identify what is important for infection control. The Internet makes tracking state legislation and laws less cumbersome. Bookmark sites on state laws and check them once a month. The ICP needs to keep up to date on all those issues. Frequently check the CDC (http://www.cdc.gov), OSHA, and the National Institute of Occupational Health and Safety (http://www.cdc.gov/niosh/homepage.html) home page sites. Knowledge will permit you to take action.

Another document to become familiar with is OSHA’s Field Instruction Reference Manual (FIRM). FIRM, CPL 2.115, was updated in 1996 and outlines the process for an inspection. For example, if an employee files a complaint that is not "life-threatening," OSHA will address that by phone and fax; the facility will be notified by phone and faxed information regarding the complaint.

Employers will have five days to investigate and respond. They must post the complaint for employees to see. They can fax OSHA the response and proof such as photos. That process is termed an "investigation," not an inspection, which means OSHA will not come to the facility for an inspection unless the corrections needed do not take place in the time frame assigned. It should be noted that employees now can file a complaint on-line directly to OSHA. Since that process was started a few months ago, the number of complaints has increased.

The FIRM document also outlines the process for handling any disagreement regarding an OSHA finding or citation. An employer can request an informal meeting with the inspector and the inspector’s supervisor to review the issue. The ICP can pull together data that will support the facility and participate in the presentation of the data. Often, issues can be resolved easily during this informal process. Remain active, visible, and knowledgeable, and you as an ICP will be a great asset to the facility in any inspection or investigation process.