No OSHA Hazcom Training in Healthcare

The last two blog entries described a survey of low temperature sterilization and liquid sterilants and high level disinfectants. The survey was conducted at the recent IAHCSMM show where we invited attendees to complete a short information card in exchange for being entered into a competition to win some prizes.

We had about 175 respondents and eliminated entries that did not list the chemicals and equipment, and multiple people from the same institution. For this analysis non-US facilities were also excluded, leaving 117 US based facilities that use low temperature sterilization and in most cases liquid sterilants/high level disinfectants

The most startling answer we received on our survey was to the question "Have you ever received OSHA HAZCOM Training?" Of the 89 people who answered this question, 45 (51%) said YES and 44 (49%) said NO.

OSHA's Hazard Communication (Hazcom) Standard 29 CFR 1910.1200 applies to any work location where chemicals are used and requires training about the chemicals used (safe use, how to recognize leaks, safety data sheets, and labels; and of course training about the standard itself.

Our survey was shocking since it is a federal law that everyone who uses chemicals in the workplace be trained on the HazCom standard. The International Association of Healthcare Central Service Materiel Management (IAHCSMM) show is for primarily for people who work in sterile processing departments in healthcare. Additionally, all of the people included in this survey had identified the chemical used for low temperature sterilization and so presumably are working with or near potentially hazardous chemicals.

However, the percentage of people who have not had Hazcom training may be conservative. ChemDAQ's President & CEO, David Hilliker, frequently gives talks about the HazCom standard to people from hospital sterile processing departments and he estimated that about 80% audience members that he talked to individually have never had HazCom training. Our survey was voluntary and perhaps a disproportionate fraction of the 28 people who did not answer this question in the survey would have selected NO had they checked a box. For information about ChemDAQ's Hazcom training program contact Kevin Vaughn at kvaughn@chemdaq.com.

In 2009 the NIOSH-NORA State of the Sector Healthcare and Social Assistance report stated in the Executive Summary that

"The HCSA sector is burdened by the historical and entrenched belief that patient care issues supersede the personal safety and health of workers and that it is acceptable for HCSA workers to have less than optimal protections against the risks of hazardous exposures or injuries."

If our survey is representative across healthcare in the US, then it suggests that healthcare can make significant improvement in workplace safety, at least with respect to exposure to hazardous chemicals, by improving training and ensuring at a minimum that everyone has the training they are required to receive by law.

Survey of Liquid Sterilants and High Level Disinfectants

As discussed in the previous blog article, ChemDAQ was pleased to see many new and familiar faces at the recent IAHCSMM show. This show is almost exclusively attended by people who are responsible for or who work in sterile processing departments. As part of the show we asked attendees to complete a short information card in exchange for being entered into a competition to win some prizes. This survey is not a scientific random sample, but it probably shows a reasonable snap-shot of low temperature chemical sterilization in the US today.

The survey asked which chemicals were used for high level disinfection and sterilization and which manufacturers equipment was used, but the survey did not ask about specific models. We had about 175 respondents and eliminated entries that did not list the chemicals and equipment, and multiple people from the same institution. There were not enough responses from outside the US to be able to draw any conclusions and so non-US facilities were also excluded.

Some of the numbers may not add up exactly because of rounding errors. In the end we had responses from 117 institutions from people who used low temperature sterilants (ethylene oxide and hydrogen peroxide) but of these responses only 69 (59%) indicated that they performed liquid sterilization or high level disinfection. It is not clear why more responses were not completed for the liquid sterilants and high level disinfectants. The statistics below therefore are based on a population of 69.

Of the chemicals used, 54 (78%) used peracetic acid (PAA), 26 (38%) used o-phthalaldehdye (OPA) and 14 (20%) used glutaraldehyde. These results indicate that PAA is the dominant liquid sterilant/high level disinfectant in use today. Glutaraldehyde which used to be the dominant high level disinfectant in the past is now relegated to third place behind OPA.

Among the PAA users 27 (50%) use Steris, 21 (39%) use Medivator, 9 (17%) use Custom Ultrasonics and 8 (15%) use Olympus equipment.

For OPA use, the equipment is evenly split between Steris and Custom Ultrasonics with 11 users each and four unspecified.

For glutaraldehyde, with 14 users, the two manufacturers again are Steris and Custom Ultrasonics with 7 (50%) and 5 (36%) users each, with two users unspecified.

We hope you found the results of this survey interesting and would like to thank everyone who completed their survey cards at the IAHCSMM show. Whether you agree or disagree with these findings, we welcome your comments below.

Survey of Low Temperature Gas/Vapor Sterilant Use in Healthcare

ChemDAQ was pleased to see many new and familiar faces at the recent IAHCSMM show. This show is almost exclusively attended by people who are responsible for or who work in sterile processing departments. As part of the show we asked attendees to complete a short information card in exchange for being entered into a competition to win some prizes. This survey is not a scientific random sample, but it probably shows a reasonable snap shot of low temperature chemical sterilization in the US today.

The survey asked which chemicals were used for high level disinfection and sterilization and which manufacturers equipment was used, but the survey did not ask about specific models. We had about 175 respondents and eliminated entries that did not list the chemicals and equipment, and multiple people from the same institution. There were not enough responses from outside the US to be able to draw any conclusions and so non-US facilities were also excluded.

Some of the numbers may not add up exactly because of rounding errors and because a few entrants said that they used a particular without specifying the manufacturer. These responses were included in the totals for each sterilant gas/vapor but were excluded from the statistics by manufacturer. In the end we had responses from 117 institutions. There are 5,724 hospitals in the US and so our sample represents about 2% of US hospitals.

All of the institutions in our survey did some kind of gas/vapor sterilization. Of the 117 institutions, 109 (93%) used hydrogen peroxide and 43 (37%) used ethylene oxide and 35 (30%) that used both EtO and H2O2.

Of the hydrogen peroxide users, 100 (86%) had a Sterrad (Advanced Sterilization Products (ASP)) and 32 (27%) used a Steris sterilizer. The market dominance of ASP was expected, but we were surprised at how many Steris hydrogen peroxide vapor sterilizers were in use (presumably the Steris V-Pros). The vast majority of the Steris hydrogen peroxide sterilizers (26/32 = 81%) were used along side Sterrad sterilizers; perhaps a reflection of the more recent entry of the Steris V-Pro sterilizers to the US market.

People have been claiming the demise of ethylene oxide (EtO) for several years now, in part because of the confusion between ethylene oxide and the CFC/HCFC carrier gases that were phased out under the Montreal Protocol. This survey indicates that EtO sterilization is still widely used. Out of the survey, 43 (37%) facilities are using EtO, and of these 23 (53%) and 18 (41%) use 3M and Steris sterilizers respectively. Most (39 out of 43, 91%) of the facilities that use EtO also use hydrogen peroxide, presumably because of the faster cycle times available with hydrogen peroxide sterilizers.

We hope you found the results of this survey interesting and would like to thank everyone who completed their survey cards at the IAHCSMM show. The next entry in this blog will summarize the findings for liquid sterilants and high level disinfectants.

Tragedy in Poultry Plants

The Washington Post, Seattle Times, Daily Herald and other news papers ran a story on April 25th about the tragic story of Jose Navarro a USDA inspector at the Murray's Chicken poultry processing plant in South Fallsburg, in upstate New York who died at age 37 because of lung damage caused by exposure to antimicrobial chemicals (primarily chlorine and peracetic acid) that were used to sanitize the birds. According the Daily Herald

"Several months before he died, he coughed up blood, but it "self-resolved," according to the autopsy report. Then on Nov. 19, 2011, he began coughing up blood and went to the hospital, where his lungs continued to hemorrhage. He died a week later after his lungs and kidneys failed, the autopsy report said."

While Mr Navarro was an extreme case, chemical exposure in the poultry plant was not uncommon. The article went on to say that

"more than two dozen USDA inspectors and poultry-industry employees described a range of ailments they attributed to chemical exposure, including asthma and other severe respiratory problems, burns, rashes, irritated eyes, sinus ulcers and other sinus problems."

According to the Daily Herald, Murray's denied that chemical exposure was the cause of the death, but the OSHA report cited chemicals as the suspected cause of the workers' ailments. During the investigation at the plant, inspectors and plant workers offered a raft of complaints. They said they suffered from irritation to their respiratory system, two reported "coughing up blood," and still others had "various skin diseases."

OSHA was apparently unable to provide direct cause and effect between inhalation of the chlorine and peracetic acid vapors since the concentrations were low on the day that OSHA inspected the plant, but OSHA officials issued a hazard alert letter, showing they had concerns about the use of chemicals and made a series of recommendations to improve conditions at the plant. OSHA placed the following summary on its website:

The U.S. Department of Labor's Occupational Safety and Health Administration has cited MB Consultants Ltd., doing business as Murray's Chickens, for eight alleged violations of workplace safety and health standards at the company's South Fallsburg chicken processing facility. Proposed fines total $67,600 following a November 2011 inspection by OSHA's Albany Area Office. OSHA found ... the company failed to ... provide workers with information and training on specific hazards involving disinfectants and other chemicals used in work areas. These conditions resulted in citations for six serious violations. A serious violation occurs when there is substantial probability that death or serious physical harm could result from a hazard about which the employer knew or should have known. The citations carry $32,600 in proposed fines. ...

The chlorine and peracetic acid were used as antimicrobials and they perform an essential function. The overriding concern in the food industry is food safety from pathogens in the food that potentially can cause food poisoning, death. The statistics for food poisoning in the US are startling:

• Salmonella poisoning is the most common type of food poisoning. It causes 40 percent of food poisoning cases. There were 7,800 reported cases of Salmonella poisoning in 2012, with 33 deaths.
• Campylobacter, a type of bacteria that is spread through chicken and unpasteurized milk and cheese, is becoming more common. In 2012, 7,000 people were sickened by Campylobacter, and six died.
• Vibrio infections – caused by contaminated seafood spread via warm sea water – have increased 43 percent. In 2012, there were 193 cases of Vibrio infections and six deaths.
• Approximately one in six Americans (48 million people) is sickened by foodborne illnesses every year, and about 3,000 die.
• Roughly 128,000 people are hospitalized annually for foodborne illnesses.
• There are two major groups of foodborne illnesses — 31 known pathogens were predicted to cause 9.4 million illnesses in 2011. About 55,961 people would be hospitalized, and 1,351 would die due to one of these known pathogens.
• “Unspecified pathogens” were predicted to cause 38.4 million illnesses, hospitalize 71,878, and kill 1,686 people in 2011.

Sometimes food poisoning reaches the headlines. We remember the two children who died and over 400 people sickened from e-coli tainted hamburgers from a Jack-in the Box restaurant in Tacoma, Washington and the three people died and over 500 were sickened with hepatitis A after an outbreak at a Chi-chis's restaurant in Pennsylvania.

The healthcare industry faces many of the same issues as food. In healthcare, hospital acquired infections are major problem for the healthcare industry where every year nearly two million hospital-acquired infections claim roughly 100,000 lives and add $45 billion in costs. Unfortunately, in their efforts to make patient care paramount, employee health and safety has not always been a priority, as the NIOSH NORA Report recently stated

The HCSA sector is burdened by the historical and entrenched belief that patient care issues supersede the personal safety and health of workers and that it is acceptable for HCSA workers to have less than optimal protections against the risks of hazardous exposures or injuries.

The food processing industry, especially animal slaughter has historically been a dangerous place to work, but the industry has made great progress in recent years to reduce its accident rate. For example, the Poultry processing’s 2011 rate of 5.8 non-fatal injuries and illnesses per 100 full time workers per year represents a 74 percent decrease from 1994 (the oldest data available on the BLS website), when the recorded rate was 22.7. Though greatly improved, animal slaughter still represents a hazardous workplace, compared to 3.5 for all industry.

In both healthcare and the food industry, antimicrobial chemicals are one of the most effective means to reduce the risk of infection. These chemicals are used to destroy a broad range of pathogens and so exposure of these chemicals to workers is potentially hazardous and can lead to serious injury or as in the case of Mr. Navaro, death. The chemicals provide an essential function preventing infections in healthcare and food poisoning in the food supply, but the danger they present to workers is real and they must be used safely.

Safe use means that there must be sufficient engineering controls and PPE in place to prevent exposure, continuous gas monitoring to ensure that airborne concentrations are at safe levels and employee training to know what to do in the case of a chemical leak or other exposure. Several studies have shown that worker safety improves patient safety and that investing in workplace safety helps the bottom line several times over. Improving safety in healthcare and the food industry not only helps meet the legal duty of employers to provide a safe work environment under the 1970 Occupational Safety and Health Act (section 5), but it will also improve both food safety and patient safety.