Underreporting puts HCWs at risk of the unknown
Underreporting puts HCWs at risk of the unknown
Occ illnesses are poorly understood, tough to track
Hospital workers are far more likely than employees in any other industry to develop an occupational illness. In 2010, the U.S. Bureau of Labor Statistics logged about 17,000 such illnesses in hospitals. Yet safety experts say it’s still just the tip of the iceberg. No one knows just how big that iceberg is.
“Occupational illness” is a catch-all category of events that develop over time. It includes work-related dermatitis that requires medical treatment, asthma triggered at work, and even carpal tunnel syndrome.
But here are a few things that often aren’t captured in the data as work-related illnesses in hospitals: Seroconversions that are detected months after an exposure, respiratory ailments such as pertussis or influenza, latent tuberculosis infections that aren’t treated.
Even when the link between an exposure and an illness is clear-cut, a lack of urgency in reporting puts employees at risk for serious illness. In a 2009 incident in Oakland, CA, first responders and emergency department personnel didn’t receive prophylaxis because they didn’t know they were exposed to a patient with meningitis. The hospital, Alta Bates Summit Medical Center, waited three days to report a suspected case and seven days to conduct an exposure analysis and contact potentially exposed employees, according to the California Department of Industrial Relations Occupational Safety and Health Division (Cal-OSHA). A respiratory therapist and police officer contracted meningitis and are now unable to work due to a resulting disability. (See related article below.)
“There was an assumption made that people were all using PPE [personal protective equipment] and therefore they didn’t need to do anything further,” says Deborah Gold, CIH, MPH, deputy chief of health and engineering services for the California Department of Industrial Relations (Cal-OSHA) in Oakland, which fined the hospital $84,450. “Almost no one was actually using PPE.”
Ken Rosenman, MD, an expert on occupational injury reporting, has analyzed emergency room records and other data sources to detect work-related amputations, burns and skull fractures. Only one-third of the amputations and burns are being captured by the U.S. Bureau of Labor Statistics reporting system, which is based on OSHA logs, he says.
Underreporting is almost certainly much greater in the more subtle area of occupational illness, says Rosenman, who is chief of the Division of Occupational and Environmental Medicine in the Michigan State University College of Human Medicine in Lansing.
“The basic premise of prevention is knowing where and how adverse events occur. Once you know that, you can intervene. You can prioritize,” he says.
“If you have inadequate reporting at a national level, it means there are not enough resources given to occupational injuries and illnesses. You may be targeting the wrong things. At an individual employer or hospital, the CEO may say, ‘What’s the big deal? We’ve got such low rates this is not a problem.’”
Nurses died of SARS, H1N1
It has been 9 years since SARS (Severe Acute Respiratory Syndrome) revealed just how vulnerable health care workers are to unrecognized or newly emerging infectious diseases. In hospital-based outbreaks in Toronto, China, Hong Kong and Singapore, 378 health care workers became ill, which was 57% of all hospital-acquired SARS cases.1 Two Toronto nurses died of SARS.
Hospital workers need to be protected from infectious agents even when the nature of the risk is not fully known, the SARS Commission of Ontario declared in a 2007 report. “[R]easonable steps to reduce risk should not await scientific certainty,” it said.2
That “precautionary principle” is still not being followed in Canada or the United States, says Gabor Lantos, MD, P.Eng, MBA, president of Occupational Health Management Services in Toronto and a consultant to hospitals. The policy seems to be “if [the risk] is not proven, don’t do anything or do next to nothing. Do something that someone thinks would suffice,” says Lantos. “Overall, I would say even if there is a respirator program, the rigor is lacking. It’s simply lacking.”
Four nurses died of H1N1 in the early months of the pandemic. One, a California nurse who had been a triathlete and marathon runner, developed pneumonia and a severe respiratory illness related to H1N1, with methicillin-resistant Staphylococcus aureus (MRSA) infection as a contributing factor.
Cal-OSHA tried to investigate H1N1-related deaths among nurses but struggled to establish the clear occupational link. “If there’s an exposure that’s potentially both in the community and in the workplace, the question is whether you can meet the threshold of causation,” says Gold. “We didn’t find that we could prove transmission.”
A study of 63 health care workers exposed to six of the first eight cases of lab-confirmed pandemic H1N1 in the United States found that nine (14%) health care workers were serologically positive but only three developed influenza symptoms.3
“Use of either a mask or a N95 respirator appeared to be effective in mitigating healthcare-associated H1N1 transmission,” the researchers found. But only 10% of the health care workers consistently wore a mask or N95 respirator during pandemic H1N1 patient encounters. In fact, 68% of outpatient health care workers and 9% of inpatient health care workers reported using no PPE during contact with pandemic H1N1.
Health care workers need better infection prevention training and N95 readiness, the authors concluded.
Infections are a top worry
Nurses are worried about acquiring an infection at work. It is their third-greatest health and safety concern, according to a 2011 survey of 4,614 nurses by the American Nurses Association. (Stress/overwork and disabling musculoskeletal injuries were the top concerns.)4
Almost one in five of the nurses had taken days off from work in the past year due to an occupational illness, the survey found — about twice as many as reported lost work time for occupational injuries.
Yet according to the U.S. Bureau of Labor Statistics, there were 14,190 occupational injuries among nurses that required time away from work but just about 750 occupational illnesses that resulted in lost workdays.
There are other indications that occupational illnesses are underreported. A Congressional report noted that it is particularly difficult to connect occupational illnesses to work exposures.5
In a National Emphasis Program, the U.S. Occupational Safety and Health Administration (OSHA) found errors in half of all injury and illness reports. Most of them were minor, but some were cases that employers had failed to document, an OSHA spokesperson told HEH.
The National Institute for Occupational Safety and Health (NIOSH) has just begun an investigation of reporting, with an emphasis on occupational illness. Researchers will conduct surveillance at 60 emergency departments across the country and seeks to interview about 3,000 workers.
There are a myriad of reasons that occupational illnesses are underreported, says Larry L. Jackson, PhD, chief of the Injury Surveillance Team of NIOSH’s Surveillance and Field Investigations Branch in Morgantown, WV.
If the disorder develops over time or it’s an exacerbation of a chronic condition, the employee may not report it as work-related. Or the employer may fail to place it on the OSHA 300 log.
Yet understanding the problem of occupational illness is a critical first step toward prevention, he says. “You may be applying the wrong infection control if you do not understand the true magnitude or exposure routes,” he says.
References
1. Sepkowitz KA and Eisenberg L. Occupational deaths among healthcare workers. Emerg Infect Dis 2005; 11:1003-1008.
2. Campbell JA. Spring of Fear: The SARS Commission Final Report, Toronto, 2006. Available at http://www.ontla.on.ca/library/repository/mon/16000/268478.pdf. Accessed on August 15, 2012.
3. Jaeger JL, Patel M, Dharan N, et al. Transmission of 2009 pandemic influenza A (H1N1) virus among healthcare personnel – Southern California,2009 Infect Control Hosp Epidemiol 2011; 32:1149-1157.
4. American Nurses Association. 2011 ANA Health & Safety Survey: Hazards of the RN Work Environment. Available at http://nursingworld.org/FunctionalMenuCategories/MediaResources/MediaBackgrounders/The-Nurse-Work-Environment-2011-Health-Safety-Survey.pdf. Accessed on August 15, 2012.
5. Hidden tragedy: Underreporting of workplace injuries and illnesses. A majority staff report by the House Committee on Education and Labor, 110th Congress, June 2008. Available from http://www.cste.org/dnn/Portals/0/House%20Ed%20Labor%20Comm%20Report%20061908.pdf. Accessed on August 15, 2012.
Occ illness? It's in the eyes of employer What defines an occupational illness? It's up to the employer to make that decision. The U.S. Occupational Safety and Health Administration has a specific reporting category for certain illnesses: skin disorders, respiratory conditions, poisoning, and hearing loss. Anything that is not in one of those categories would be recorded as "other illness." An OSHA spokesperson offered some advice about recording illnesses: Record all needlesticks but not all splashes. Any sharps injury that involves a needle or object that was contaminated with a patient's blood or other potentially infectious material must be reported on a sharps log and the OSHA 300 log, even if the patient does not have a bloodborne pathogen. (The OSHA 300 log can serve as the sharps injury log if the sharps injuries can be segregated easily from other injuries. They are privacy cases so the employee's name should not appear on the log.) A needlestick is considered to be a puncture (injury) unless an infection develops. If an employee develops an infection and receives medical treatment, the log should be updated. Splashes of blood and body fluid do not need to be reported unless the employee develops an infection and requires medical treatment. Record positive TB tests as a "respiratory condition" even if there is no treatment. For a positive TB test to be work-related, there needs to be an exposure at work. That could occur if there was someone in the work environment with tuberculosis, even if the employee didn't have direct contact with them. It is not recordable if the worker lives in a household with someone who has active TB, if public health authorities identify the employee as a contact of someone with active TB outside of work, or if a medical investigation demonstrated that the TB infection was caused by an exposure outside of work. Record pertussis but not the common cold or flu. OSHA specifically excludes the common cold or flu from recordkeeping. However, employers were required to record confirmed cases of pandemic H1N1 if it was related to a work exposure and required treatment or days away from work. Employers also must report other infectious diseases linked to work exposures that require treatment or days away from work, such as pertussis even if the illness also exists in the community. Record a work-related asthma attack as a "respiratory condition." If the employee has a pre-existing condition, such as asthma, but it is triggered by a work exposure, such as cleaning or disinfecting chemicals, and it requires medical treatment, that is a recordable case. Work does not have to be the sole cause. |
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