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Insufficient training or inadequate exposure control plans are deficiencies that most frequently result in citations by the U.S. Occupational Safety and Health Administration (OSHA) under the bloodborne pathogens standard. In the 16 months after OSHA issued a compliance directive on needle safety in 1999, only 48 hospitals received inspections. Of the resulting 144 citations, 20% involved training deficiencies, such as the failure of hospitals to include all the necessary elements specified by the standard. For example, three citations stemmed from training programs that didn’t include an opportunity to ask questions, such as video-only instruction. (See table, below.)
|OSHA Bloodborne Pathogens Citations|
|Inadequate exposure control plan||19|
|Lack of engineering controls||18|
|Sharps containers overfilled or not easily accessible||12|
|Violations related to HBV vaccination||8|
|Failure to ensure employees use personal protection equipment||6|
|Source: Occupational Safety and Health Administration, Washington, DC.|
The numbers of such citations are likely to increase substantially in the coming year, in light of the revised bloodborne pathogens standard and the inclusion of hospitals in OSHA’s targeted inspection program. The Joint Commission on Accreditation of Healthcare Organizations also looks for compliance with OSHA regulations in its survey process.
Employee concerns can lead to complaint-related inspections as well. "A number of these inspections were initiated due to employee complaints rather than as a scheduled inspection," notes Craig Moulton, an OSHA industrial hygienist who works with compliance.
Deficient training programs and exposure-control plans are long-standing problems. Those issues emerged in the two years before the compliance directive, according to an analysis by Katherine West, MSEd, CIC, an infection control consultant with Infection Control/Emerging Concepts in Manassas, VA. From Aug. 1, 1998, to July 30, 2000, OSHA issued 410 citations at health care facilities for having no exposure control plan and 273 citations for having no training programs. The data include hospitals as well as other types of health care facilities, such as clinics and long-term care centers.
West says she was shocked to discover how many facilities didn’t even have an exposure control plan. "What some people think is an exposure control plan isn’t," says West, noting that a collection of policy and procedure manuals doesn’t constitute an exposure control plan. "Most of the plans are missing the specifics."
A single exposure control plan isn’t adequate for a multisite facility, notes Sandra Elias, RN, occupational health consultant with St. Jude Heritage Occupational and Environmental Health Services in Fullerton, CA. For example, details such as the location of personal protective equipment would be different from site to site, she says.
After all, the exposure control plan is supposed to be a working tool, not just a document that sits on a shelf, says West. "I think people are missing the great things that this document can do for them," she says. "Once they’ve created it and it’s a useful document, then the update on an annual basis is very simple."
Training is an area of frequent lapses — not only in content, but also in the scope of employees who receive the training. "There is a misconception that unless you’re in a medical field you don’t need this," says Elias. Clinical staff aren’t the only ones who have the potential for bloodborne exposures, she notes. For example, housekeepers may be stuck by needles left in dirty linens, or security personnel may be at risk when helping to deal with a combative patient. Yet nonclinical staff shouldn’t have the exact same course as clinical employees, says Elias. "The training should be task-specific," she says.
OSHA regulations are very specific about what must be included in bloodborne pathogen training. But West notes, "Most facilities are not complying with what OSHA states about education and training and what has to be accomplished and what needs to be included. They’re trying to short cut it every way they can."
After training, employees should have a full understanding of the bloodborne diseases that can be transmitted through needlesticks, the details of the facility’s exposure control plan, and the steps to take for post-exposure treatment and follow-up. "If [employees] understand the diseases and how they work, we can bring down the apprehension level," says West.
Meanwhile, the revised bloodborne pathogens standard contains new requirements for recordkeeping and the involvement of frontline health care workers in the evaluation of safety devices. The new language requiring the use of safety devices also may lead to an increase in citations in that area. From November 1999 to February 2000, OSHA issued only 18 citations at hospitals for lack of engineering controls.