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Occupational health and safety risks in the healthcare sector Guide to prevention and good practice
This publication is supported by the European Union Programme for Employment and Social Solidarity PROGRESS (2007-2013). This programme is implemented by the European Commission. It was established to financially support the implementation of the objectives of the European Union in the employment, social affairs and equal opportunities area, and thereby contribute to the achievement of the Europe 2020 Strategy goals in these fields. The seven-year Programme targets all stakeholders who can help shape the development of appropriate and effective employment and social legislation and policies, across the EU-27, EFTA-EEA and EU candidate and pre-candidate countries. For more information see: http://ec.europa.eu/progress
Occupational health and safety risks in the healthcare sector
European Commission Directorate-General for Employment, Social Affairs and Inclusion Unit B.3 Manuscript completed in December 2010
Neither the European Commission nor any person acting on behalf of the Commission may be held responsible for the use that may be made of the information contained in this publication. © Cover photos: iStock For any use or reproduction of photos which are not under European Union copyright, permission must be sought directly from the copyright holder(s). This guide has been produced by the Bundesanstalt für Arbeitsschutz und Arbeitsmedizin (BAuA), Berufsgenossenschaft für Gesundheitsdienst und Wohlfahrtspflege (BGW), contec Gesellschaft für Organisationsentwicklung mbH, Deutsches Netz Gesundheitsfördernder Krankenhäuser (DNGfK) and BAD/ Team Prevent GmbH.
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Luxembourg: Publications Office of the European Union, 2011
ISBN 978-92-79-19454-2 doi:10.2767/27263
© European Union, 2011 Reproduction is authorised provided the source is acknowledged. Printed in Luxembourg Printed on elemental chlorine-free bleached paper (ecf)
Contents Preamble 7 Introduction and vision
11
1. Prevention and health promotion as a management task 13
Description of good company practice
21
2. How to carry out a risk assessment
23
2.1. Introduction
24
2.2. Roles and responsibilities
24
2.3. What should be considered before I start the risk assessment
28
2.4. How do I get started with the risk assessment?
28
2.5. Inclusion of gender aspects in the risk assessment
34
2.6. Description of good company practice
35
2.7. Links
40
2.8. Relevant European Union directives
43
2.9. OiRA: Online risk assessment tool, EU-OSHA
43
2.10. Literature
43
2.11. Example of a risk assessment based on the task of manually handling patients
44
2.12. Example of a risk assessment based on the task of surface disinfection
45
3. Biological risks
49
3.1. Introduction
50
3.2. General risk assessment of potential occupational exposure to infection
51
3.3. Special risk assessment of biological risks
69
3.3.1.
Risk of blood-borne infections
69
3.3.2.
Risk of airborne infection
80
3.3.3.
Risk of direct and indirect contact infection
84
3.3.4.
Description of good company practice:
88
- handling contact infections - preventive measures in the ambulance service
90
3.3.5.
Special infections
92 3
3.4. Pregnancy
101
3.5. Relevant European Union directives
102
3.6. Links
103
3.7. Literature
105
4. Musculoskeletal risks 4.1. Risks for the development of musculoskeletal disorders
107 108
4.1.1. Introduction
108
4.1.2.
Nature of the risk
109
4.1.3.
Basic criteria for a specific risk assessment for the prevention of MSDs
111
4.1.4.
Work situations with the greatest exposure
116
4.1.5.
Effects on health and safety
121
4.1.6.
Preventive and protective measures
124
4.1.7.
Behaviour in critical situations — Recommendations for workers
132
4.1.8.
Main messages and conclusions
136
4.1.9.
Relevant European Union directives
137
4.1.10. Description of good company practice
139
4.1.11. Links
151
4.1.12. Literature
156
4.2. Prevention of accidents due to slips, trips and falls (85) 157 4.2.1. Introduction
157
4.2.2.
Nature of the risk
158
4.2.3.
Basic criteria for a specific risk assessment for the prevention of slip, trip and fall accidents
159
4.2.4.
Work situations with the greatest exposure
160
4.2.5.
Effects on health and safety
161
4.2.6.
Preventive and protective measures
161
4.2.7.
Personal protective equipment
164
4.2.8.
Behaviour in critical situations — Recommendations for workers
166
4.2.9.
Main messages and conclusion
166
4.2.10. Relevant European Union directives
166
4.2.11. Links
168
4.2.12. Literature
170
5. Psychosocial risks
171
5.1. Introduction
172
5.2. Stress and burnout
176
5.2.1.
Nature of risk dealt with
176
5.2.2.
Basic criteria for a specific risk assessment
176
5.2.3.
Work situations with the greatest exposure
182
4
5.2.4.
Effects on health and safety
182
5.2.5.
General preventive and protective measures
183
5.2.6.
Description of specific preventive techniques and procedures
184
5.3. Prevention and monitoring of violence and mobbing (bullying and harassment) at the workplace
186
5.3.1.
Nature of the risk dealt with
186
5.3.2.
Basic criteria for a specific risk assessment
188
5.3.3.
Work situations with the greatest exposure
192
5.3.4.
Effects on health and safety
192
5.3.5.
General preventive and protective measures
193
5.3.6.
Description of the specific preventive techniques and procedures
194
5.3.7.
Examples of good corporate practice
194
5.3.8.
Appropriate modes of behaviour in critical situations
194
5.3.9.
Most important knowledge and conclusions
195
5.4. Working hours
196
5.4.1.
Nature of risk dealt with
196
5.4.2.
Basic criteria for a specific risk assessment
196
5.4.3.
Description of the work situations with the greatest exposure
198
5.4.4.
Descriptions of the effects on health and safety
198
5.4.5.
General preventive and protective measures
200
5.4.6.
Description of the specific preventive techniques and procedures
201
5.4.7.
Examples of good corporate practice
201
5.4.8.
Appropriate modes of behaviour in critical situations 202
5.4.9.
Most important knowledge and conclusion
5.5. Drug abuse
202
203
5.5.1.
Nature of the risk dealt with
203
5.5.2.
Basic criteria for a specific risk assessment
203
5.5.3.
Work situations with the greatest exposure
205
5.5.4.
Effects on health and safety
205
5.5.5.
General preventive and protective measures
205
5.5.6.
Specific preventive techniques and procedures
205
5.5.7.
Appropriate modes of behaviour in critical situations 206
5.5.8.
Most important knowledge and conclusions
207
5.6. Relevant European Union directives
208
5.7. Description of good company practice
209
5.7.1.
Interview with Havelland Clinics, Nauen, on psychosocial risks
209
5.7.2.
Interview with St Elisabeth Hospital, Tilburg, on psychosocial risks
211
5.8. Links
213
5.9. Literature
215
Annex
217
5
6. Chemical risks
219
6.1. Introduction
220
6.2. Nature of the risk dealt with: Special risks attributed to dangerous substances and preparations
221
6.3. Basic criteria for assessing chemical risks
221
6.3.1.
Risk assessment
6.4. General preventive and protective measures (135)(136): Implementation of protective measures taking into account the risk assessment 6.4.1.
225
227
Protective measures (137)(138) 227
6.4.2.
Provision of information/instruction to workers
229
6.4.3.
Monitoring the effectiveness of measures
230
6.5. Cleaning and disinfection work
230
6.5.1.
Descriptions of the work situations with the greatest exposure
231
6.5.2.
Description of the effect on health and safety
232
6.5.3.
Specific preventive techniques and procedures
233
6.6. Cytostatic/cytotoxic drugs
234
6.6.1.
Description of the work situations with the greatest exposure
234
6.6.2.
Description of the effect on health and safety
236
6.6.3.
Specific prevention techniques and procedures
236
6.7. Activities involving anaesthetic gases
241
6.7.1.
Description of work with maximum exposure
242
6.7.2.
Description of the effect on health and safety
242
6.7.3.
Specific prevention techniques and procedures
244
6.8. Activities involving substances which endanger reproduction
247
6.9. Relevant European Union directives
250
6.10. Description of good company practice
251
6.10.1. Interview with General Hospital Vienna (AKH Vienna) on safe working in disinfection activities
251
6.10.2. Working safely with cytostatic drugs
254
6.11. Links
258
6.12. Literature
263
Imprint 265 Annexes 269
6
Preamble
Occupational health and safety risks in the healthcare sector
About 10 % of workers in the European Union belong to the health and welfare sector, and many of them work in hospitals. These workers may be exposed to a very wide variety of risks. EU legislation on health and safety at work currently covers most of these risks — nevertheless, the combination of such diverse risks arising at the same time and the fact that this is clearly a high-risk sector have given rise to a debate on the need for a specific approach in order to improve the protection of the health and safety of hospital personnel at Union level. All the considerations and any measures designed to improve the health and safety of hospital personnel can be extended to workers in the health sector in general.
Background In November 2001, a first meeting was held with the representatives of the Member States’ governments to discuss the situation in their countries and the initial positions on the question of possible Community measures aimed at improving occupational health and safety in the hospital sector. It was considered appropriate to start with contacts with government representatives because it was felt important to have an overview of the particular situation concerning occupational health and safety in healthcare establishments in the EU and the implementation of the Community provisions in force in this area. During the meeting, the participants particularly welcomed the Commission’s initiative to launch a debate on the situation in a sector which employs a high percentage of the EU’s working population and where the workers are exposed to a large number of different types of concomitant risks (infections, chemical agents, carcinogens, musculoskeletal disorders, accidents, radiation, etc.). The participants were unanimous in their view that, although new specific Community legislation for the hospital sector does not seem necessary at present, the adoption of other, non-legislative measures, such as a recommendation and the production at Community level of guides to good practice for this sector, would be a very positive and necessary step. Particular importance was also attached to the dissemination of information and the exchange of experience in this area, especially via the European Agency for Health and Safety at Work (EU-OSHA), based in Bilbao. It was also felt that the creation of an ad hoc group on ‘Health and safety in the hospital sector’ within the Advisory Committee would make it possible to continue the analysis of possible Community measures within a tripartite context. The ad hoc group was also tasked with preparing a draft opinion for the consideration of the Advisory Committee on possible Community measures to improve protection of the health and safety of workers in the hospital sector.
(1) OJ L 183, 29.6.1989, pp. 1–8.
8
The working party adopted a draft opinion which was presented for discussion and later adopted by the committee. The committee was of the opinion that there are a number of possible initiatives that could be taken at Community level. Having discussed the various options available, the committee agreed that all occupational health and safety risks within the healthcare sector are already adequately covered by the framework directive, Council Directive 89/391/EEC of 12 June 1989 on the introduction of measures to encourage improvements in the safety and health of workers at work (1), and other health and safety at work directives.
Preamble
Furthermore, the Committee agreed that priority should be given to the production, at Community level, of a guide to prevention and good practice for hospital workers, focusing on the most significant risks in the sector, especially: a) biological agents b) musculoskeletal disorders c) psychosocial disorders, and d) chemical agents. These risk groups are being targeted from the occupational health and safety perspective, and exclude all public health considerations except where these impinge on health and safety. Other potential risks have been excluded from the guide since they already fall within the scope of other European Union legislation in force. The guide to prevention and good practice has been designed and produced as a very practical, easily understood tool that can be used as the basis for initial and periodic training measures for hospital personnel. The guide takes account, in particular, of the latest technical and scientific knowledge available in the field of prevention, as well as the guides and good-quality materials already existing at national level, together with the information available via EU-OSHA. When describing the applicable measures, the guide follows the hierarchical methods of prevention outlined in Council Directive 89/391/EEC. Special attention is given to vulnerable groups working within the sector — pregnant workers, the young, the old and migrant workers, and where appropriate, specific preventive and protective measures are mentioned in respect of these groups.
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Introduction and vision
Occupational health and safety risks in the healthcare sector
This guide to prevention and good practice in the healthcare sector aims at improving health and safety standards in health institutions in the EU. Occupational health and safety (OSH) issues are an important part of quality management, risk management and corporate social responsibility (CSR). In this sense, OSH aspects must be an integrated element of all managerial development processes, i.e. corporate strategy, human resources and organisational development. The basis of the vision regarding better, healthier and more competitive workplaces is to create a corporate culture where managers and workers (as experts on their workplaces) discuss work processes together in a continuous improvement process including all related risks and possible measures for improvements. Such a positive corporate culture is the core for the sustainable development and success of health institutions. This guide introduces the foundation on which appropriate health and safety systems may be built. It offers orientation to non-specialists in this field about the scope of action. However, it does not provide in-depth knowledge about certain measures and methods of prevention. A list of Internet links at the end of each chapter refers to further and more detailed information as well as specific instruments. The guide addresses both employers and healthcare workers about occupational risks which occur in the healthcare sector. The user will find information on the nature of risks and the methods of risk assessment, and recommendations on measures and training options to prevent adverse health effects. Furthermore, this guide gives workers and employers clear information about good practices aimed at preventing the risks covered. The guide is based on the European Union directives obligatory for all Member States. Therefore, the user has to bear in mind that there may be stricter regulations at national level which also have to be taken into account.
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1 Prevention and health promotion as a management task
Occupational health and safety risks in the healthcare sector
Workplace-related health impairments, injuries and illnesses cause great human suffering and incur high costs, both for those affected and for society as a whole. Occupational health and safety measures and health promotion in workplaces are aimed at preventing this. But, in addition to protecting workers from harm, this guide wants to show managers in the healthcare system how to achieve a health-promoting hospital or facility according to the World Health Organisation (WHO) definition of health. This defines health as a state of complete physical, mental and social well-being, as well as the empowerment of individuals to use their own health potential and to deal successfully with the demands of their environment. Such pronounced health competence among workers can only be achieved if a prevention culture prevails in the company which systematically allows for health-related aspects in all company matters. Management is not only responsible for the implementation of health-promoting measures in the company in the sense of circumstantial prevention. Above all, it also has to set an example in terms of its own conduct. As a result, it has a crucial impact on the corporate culture and initiates changes at the behaviour level among the workers. Therefore, occupational health and safety must be seen as an important corporate goal of the organisation, like quality, customer satisfaction, productivity, growth and profitability. Safe and healthy working conditions for workers can be achieved more efficiently if the implementation of occupational health and safety is integrated into a quality management system. Risk assessment is an ongoing process and has to be repeated frequently, and the results have to be documented and integrated into the strategic planning by the management. Definition of occupational health and safety (2) In 1950, the Joint ILO/WHO Committee on Occupational Health stated that “Occupational health should aim at the promotion and maintenance of the highest degree of physical, mental and social well-being of workers in all occupations; the prevention amongst workers of departures from health caused by their working conditions; the protection of workers in their employment from risks resulting from factors adverse to health; the placing and maintenance of the worker in an occupational environment adapted to his physiological and psychological capabilities”. In summary: “the adaptation of work to man, and of each man to his job.”
Statutory European Union specifications According to Article 153 of the Treaty on the Functioning of the European Union, the Union shall support and complement the activities of the Member States in the following fields: a) improvement in particular of the working environment to protect workers’ health and safety; b) working conditions; (2) Stellman, J. M. (ed.), ILO Encyclopaedia of Occupational Health and Safety, Vol. 1:16.1–16.62, International Labour Organisation, Geneva, 1998.
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c) social security and social protection of workers; d) protection of workers where their employment contract is terminated; e) informing and consulting workers.
1 Prevention and health promotion as a management task
Council Directive 89/391/EEC on the introduction of measures to encourage improvements in health and safety of workers at work laid down minimum regulations which promote the improvement of, in particular, the working environment in order to give greater protection to the health and safety of workers(3). The specific requirements of the directive will be referred to in detail later in the guide. The directive has been implemented in national legislation that may include additional requirements. Employers are required to assess risks and take practical measures to protect the health and safety of their workers, keep accident records, provide information and training, consult employees and cooperate and coordinate measures with contractors. Preventive and protective measures should be implemented in the following order of priority:(4) • elimination of the hazard/risk; • control of the hazard/risk at source, through the use of engineering controls or organisational measures; • minimisation of the hazard/risk by the design of safe work systems, which include administrative control measures; • where residual hazards/risks cannot be controlled by collective measures, provision by the employer of appropriate personal protective equipment, including clothing, at no cost, and implementation of measures to ensure its use and maintenance. Obligations to implement occupational health and safety measures do not only exist on the employers’ side. There is also an obligation for the workers to cooperate in this matter (i.e. taking part in training courses offered, the cooperation of workers and safety representatives). Paragraph 1 of Article 13 of Directive 89/391/EEC states: ‘It shall be the responsibility of each worker to take care as far as possible of his own health and safety and that of other persons affected by his acts or omissions at work in accordance with his training and the instructions given by his employer.’
(3)
Council Directive 89/391/EEC of 12 June 1989 on the introduction of measures to encourage improvements in health and safety of workers at work, OJ C, 29.6.1989, pp. 1–8.
(4) ‘Guidelines on occupational health and safety management systems’, ILO-OSH, Geneva, 2001, p. 11.
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Occupational health and safety risks in the healthcare sector
A structured approach to management ensures that risks are fully assessed and that safe methods of work are introduced and followed. Periodic reviews ensure that these measures remain appropriate. A typical management model is described below (5). • Policy: sets a clear commitment and objectives, responsibilities and procedures for the organisation. • Planning: identifies and assesses the risks arising from work activities and how they can be controlled. Activities in the planning process include: »» risk assessment and identification of preventive measures; »» identifying the management arrangements and organisation needed to exercise control; »» identifying training needs; »» ensuring that occupational health and safety knowledge, skills and expertise are available. • Implementation and operation: involves putting plans into practice. This may mean: making changes to the organisation and working procedures, working environment, equipment and products used; training management and staff, and improving communication. • Checking and corrective action: performance should be monitored. This can be reactive — for example, using accident records — or proactive, for example, through feedback from inspections and audits and from staff surveys. Accident investigations should identify the immediate and underlying causes, including management failings. The aim is to ensure that systems and procedures are working and to immediately take any corrective action needed. • Management review and audit: allows checking of the management system’s overall performance. External circumstances may have changed — for example, new legislation may have been introduced. There is also an opportunity to look forward, for example, to changes in business structure, development of new products or the introduction of new technology. Review of accidents should include learning lessons at management level. Auditing examines whether the policy, organisation and systems are actually achieving the right results.
Occupational health and safety management systems must have the following components • Constant participation of the workers in determining objectives and measures of occupational health and safety — the employees are the experts for their own workplaces! • Consultation concerning workers’ experience with existing health risks. • Ideas for improving the assignment of duties, the procedural sequences and the concrete working conditions in the activities and at the workplaces.
(5) http://osha.europa.eu/ en/topics/accident_ prevention
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Occupational health and safety objectives must be measurable and must be scheduled, and they must conform to the principles mentioned above. The organisation must provide the resources required for implementation — this applies in particular to the naming of individuals with occupational health and safety functions (including release from other duties).
1 Prevention and health promotion as a management task
Every organisation should record the following in writing: a) the factors triggering a hazard determination and identification; b) how hazards are determined and risks assessed; c) how results are evaluated; d) how necessary measures are laid down and implemented; e) how the effectiveness of the measures taken is checked. It is not only in-house factors that play a role in occupational health and safety — it must also be ensured that products purchased and used by the company meet the occupational health and safety requirements laid down. Furthermore, it must be recorded in writing how any hazardous substances must be handled in everyday routines in the company. The organisation must collect, record and evaluate appropriate data in order to establish the suitability and effectiveness of occupational health and safety and to be able to initiate improvement measures at an appropriate point. Occupational health and safety – an integral part of all managerial tasks and functions Health and safety comprise – protection against injuries and work-related illnesses – health promotion
Health and safety include all – physical – chemical – biological – mental – physical – social factors of the work process
Holistic view of health and safety
Health and safety require – work system design (T-O-P) – integrated occupational health and safety management – participation of the employees
Health and safety are targeted at all employees in different ways according to – gender – age – performance potential/disability and allow for all activities
Source: Department of Trade and Industry BadenWuerttemberg, Information centre for environmental protection at company level (IBU)
Any assessment of occupational health and safety measures should take into account the following information: a) feedback from workers and external occupational health and safety partners; b) results of communication with workers; c) ways of dealing with changes which may have an impact on the integration of occupational health and safety in quality management; d) results of hazard determinations and assessments; e) evaluations of accident reports, first aid book entries, suspicion notifications and occupational diseases
17
Occupational health and safety risks in the healthcare sector
Economic benefit and value of occupational health and safety for the competitiveness of facilities Improvement of health and safety at work is important not only in human terms to reduce workers’ pain and suffering but also as a way of ensuring that enterprises are successful and sustainable and that economies thrive in the long term. According to EU-OSHA, every year 142 400 people in the EU die from occupational diseases and 8 900 from work-related accidents. Eurostat data from 2000 show that about 150 million days are lost each year due to accidents at work and 350 million due to other health problems caused by work in the EU-15 Member States (6). In the healthcare sector, the number of accidents at work is rather high compared to other activities:
Fishing (estimated) Construction Agriculture, hunting and forestry Health and social work (estimated) Transport, storage and communication Manufacturing Hotels and restaurants Wholesale and retail trade; repairs Source: Eurostat – European Statistics on Accidents at Work (ESAW).
Systematic information on the costs of accidents at work and other work-related health problems is not available. Therefore, Eurostat carried out a study to develop a pilot model to estimate the costs of accidents at work. These were estimated to have caused costs of EUR 55 billion in the EU-15 in 2000. These are only the costs specified by the companies and most of them (88 %) were due to lost working time (labour costs). The costs relating to the victims are not included (7).
(6) The social situation in the European Union 2005–06, p 114, http:// bookshop.europa.eu/ en/the-social-situationin-the-europeanunion-2005-2006pbKEAG06001/ (7) Statistical analysis of socio-economic costs of accidents at work in the European Union, http:// epp.eurostat.ec.europa. eu/cache/ITY_OFFPUB/ KS-CC-04-006/EN/KSCC-04-006-EN.PDF
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1 Prevention and health promotion as a management task
A study in Germany came to the conclusion that the costs of work-induced illnesses could be estimated at a minimum of EUR 28 billion per annum (estimate based on data for 1998). These costs were at the lower limit on the basis of physical loads and comprised direct costs of EUR 15 billion (treatment of illnesses) and indirect costs of EUR 13 billion (loss of working years due to incapacity to work). The most significant load factors are the difficulty of work/lifting loads and little latitude for action. The highest costs are attributable to diseases of the musculoskeletal system and the digestive organs, as well as accidents at work (8). Studies subsequently made available, particularly from the USA, examine the commercial efficiency of health promotion and prevention at the workplace. The most significant savings for companies are recorded for illness costs and illness-related absenteeism. In the literature, a return on investment of 1:2.3 to 1:1.59 is given for illness costs (i.e. for each dollar invested in company health protection USD 2.3 to USD 5.9 flows back into the company) (9). Studies by Chapman ( ) showed that workplace health promotion measures result in an average reduction in the illness costs of 26.1 %. Illness-related absenteeism is reduced by an average of 26.8 %. 10
Not all workplace health promotion measures prove to be equally effective. Preventive measures which are merely aimed at the communication of knowledge and information in the form of instruction make hardly any contribution towards reducing health complaints and therefore absenteeism. There is strong evidence that multicomponent programmes that prove to be effective combine both behavioural prevention measures (training courses, exercise programmes) with ergonomic intervention (circumstantial prevention), e.g. technical aids for lifting and carrying or changes in work organisation (11). Special programmes for stopping smoking, alcohol prevention and the prevention of psychosocial risks also proved to be particularly cost-effective with regard to the problem of absenteeism. The results of a survey of companies with many years of experience with workplace health promotion in Germany clearly showed that ‘a sustained corporate health management system not only improves the health situation of the workers but, in addition, also has a positive impact on the cost-efficiency and competitiveness of a company. Here, the key to success … is the improvement in in-house information, participation and multi-level cooperation, the core process of a company health management system.’ (12)
(8) Bödeker, W., H. Friedel, Chr. Röttger and A. Schröer, Kosten arbeitsbedingter Erkrankungen in Deutschland, Wirtschaftsverlag NW Verlag für neue Wissenschaft, Bremerhaven, 2002 (Publication series of the Federal Institute for Occupational Safety and Health: Research Report, Fb 946), ISBN: 3-89701-806-3. (9) Kreis, J. and W. Bödeker, Gesundheitlicher und ökonomischer Nutzen betrieblicher Gesundheitsförderung und Prävention. Zusammenstellung der wissenschaftlichen Evidenz, IGA- Report 3, in: Kramer, I. et. al. (2008). (10) Chapman, L. S., ‘Metaevaluation of worksite health promotion economic return studies: 2005 update’, The Art of Health Promotion 6 (6): 1–10, in: Kramer, I. et. al. (2008). (11) See Kramer, I. (2008), pp. 70–72. (12) Lueck, P., G. Eberle and D. Bonitz, Der Nutzen des betrieblichenGesundheitsmanagements aus der Sicht von Unternehmen, in Badura, B. et. al. (2008), pp. 77–84.
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Occupational health and safety risks in the healthcare sector
Important to note
Conclusion: In a modern company, an occupational health policy is indispensable not only for reasons relating to labour law but also from the aspect of competition and must become an integral element in company management.
Literature Badura, B., H. Schröder and C. Vetter (eds), Fehlzeiten-Report 2008 — Betriebliches Gesundheitsmanagement: Kosten und Nutzen, Springer Medizin Verlag, Heidelberg, 2008, pp. 65–76) (ISBN 978-3-540-69212-6). European Commission, The social situation in the European Union 2005–06, Office for Official Publications of the European Communities, Luxembourg, 2007. European Commission, Statistical analysis of socioeconomic costs of accidents at work in the European Union, Office for Official Publications of the European Communities, Luxembourg, 2004 (ISBN: 92-894-8168-4). European Commission, Work and health in the EU — A statistical portrait, Office for Official Publications of the European Communities, Luxembourg, 2004 (ISBN: 92-894-7006-2). Kramer, I., I. Sockell, and W. Boedeker, Die Evidenzbasis für betriebliche Gesundheitsförderung und Prävention — Eine Synopse des wissenschaftlichen Kenntnisstandes, in Badura, B. et al. 2008, pp. 65–76.
Further links: Website on occupational safety and health) and corporate social responsibility (references to many national websites and sources): http://osha.europa.eu/en/topics/business/csr/initiatives.stm/
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1 Prevention and health promotion as a management task
Description of good company practice Safety and health has gained a central position in the policy operations of St Elisabeth Hospital In the 1990s, St Elisabeth Hospital (the EZ) in Tilburg, the Netherlands, aimed to profile itself as a good employer and to offer safe and healthy working conditions to its employees. As a result of changes in the law, in the mid-1990s the EZ therefore decided to embed health and safety in its business policy.
Best practice
A new position was created and a health and safety coordinator was appointed to systematically develop operations management, the responsibility for which would devolve to this new position. In 1998, the whole hospital was reorganised: overall responsibility for the entire business operations was given to the managers (integrated management). This gave an extra stimulus to the responsibility and position which health and safety held in operational management.
For years, the management had been aware of the importance of preventing absenteeism. In comparison to other top clinical hospitals, the EZ already performed well, having had an average absenteeism of around 5 % (while the national average was 6 to 8 %). To keep this absenteeism rate low, the focus on prevention increased. Some costly investments were made which produced positive results. The absenteeism rate decreased further and, at the same time, the employees were more satisfied. In nationwide research on the satisfaction of employees, EZ employees valued their working conditions as favourable. Line management more frequently requested advice and support to improve health and safety in the hospital departments. This is why, in 2002, the hospital chose to take the responsibility for occupational health and safety management into its own hands. Previously, all the obligatory services were hired externally but, from that moment on, the EZ added more and more health and safety-related positions to its staff establishment. Currently the EZ has in its employ an occupational physician, an occupational therapist, a safety expert, an occupational welfare officer and medical assistants (who carry out examinations, give vaccinations and offer support regarding absenteeism). This internal occupational health and safety service meets the need for the provision of advice and support to managers and employees at strategic, tactical and operational levels. In recent years, health and safety has gained a strong position in the hospital’s operations. Health and safety considerations are now explicitly included, not only in purchase procedures, reconstruction and new construction, but also at strategic policy level. This has resulted, for example, in ergonomic desks, safe working stations in laboratories and the use of ergonomic furniture. Investments go before costs; the EZ is fully aware of this and shows it too. The EZ has been accredited since 2006. Quality audits are organised annually in which matters concerning health and safety and working conditions are explicitly included. For example, tests are regularly made to check whether policy developments have been implemented across the departments.
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Best practice
Health and safety measures are continuing to improve. In consultation with an external research agency and Tilburg University, the EZ has worked on the development of a new method of researching the satisfaction and fitness of its employees. From 2009, the EZ is, for the first time, conducting systematic and combined research into the levels of employee satisfaction and fitness (lifetime employment). In this research study, working conditions are tested and figures are provided about the effects on the physical and psychological health of employees. This research is embedded in the policy cycles and so the implementation of measures facilitating improvement is also guaranteed.
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Since 2008, it has been compulsory in the Netherlands to systematically care for the safety of patients. The EZ is one of the few Dutch hospitals to include its employees in its commitment to care. This was done because safe working conditions and patient safety overlap, for example, as regards cytostatics or lifting. In 2009, the EZ planned to research and expand the theme of humane care. The EZ believes that a healthy, fit and content employee contributes to the humane care of patients. St Elisabeth Hospital is a medium-sized training hospital which provides highly specialised medical care. This top clinical hospital offers education and educational programmes in a broad sense, advancing high-quality care for patients and fulfilling an important role in applied medical scientific research. It offers the opportunity for PhD research to specialists and trainee specialists. The hospital services 435 000 inhabitants of its area. Each year, 347 000 patients visit the outpatient clinics and 44 000 patients are admitted. In the emergency care department, about 30 000 patients register annually. The hospital has 3 100 employees and 559 beds. For further information see: http://www.elisabeth.nl
2 How to carry out a risk assessment 2.1. Introduction 2.2. Roles and responsibilities 2.3. What should be considered before I start the risk assessment 2.4. How do I get started with the risk assessment? 2.5. Inclusion of gender aspects in the risk assessment 2.6. Description of good company practice 2.7. Links 2.8. Relevant European Union directives 2.9. OiRA: Online risk assessment tool, EU-OSHA 2.10. Literature 2.11. Example of a risk assessment based on the task of manually
handling patients
2.12. Example of a risk assessment based on the task of surface disinfection
Occupational health and safety risks in the healthcare sector
2.1. Introduction This guide to prevention and good practice in hospitals and the healthcare sector focuses on the most significant risks in the sector, especially: –– biological agents –– musculoskeletal disorders –– psychosocial disorders, and –– chemical agents. Other potential risks have been excluded from the guide since they already fall within the scope of other European Union legislation in force. For each of the four groups, the different types of risk will be presented for carrying out different tasks at work. To facilitate a sound understanding of the significance of these risks, the effects on the health and safety of workers are described. The application of the relevant EU regulations for hospitals and the healthcare sector is explained for the risk groups and specified for the sector. In each risk group, specific aspects for the risk assessment and measures of prevention are highlighted. The readers will able, with the help of instruments and recommendations, to identify risks in their own healthcare facility. Up-to-date technical and organisational knowledge as well as good practice examples from healthcare facilities in Europe will show how a good and healthy quality of work can be established.
2.2. Roles and responsibilities Occupational health and safety is a management task! Under Article 6 of Council Directive 89/391/EEC, employers are obliged to take the measures necessary for the health and safety protection of workers. The necessary measures of occupational health and safety include the prevention of occupational risks, the provision of information and training and the provision of the necessary organisation and means.
01 A database can help to collect and organise information for the risk assessment.
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The overall responsibility for determining and assessing risks at the workplace lies with employers. They must ensure that these activities are properly implemented. If they do not have the relevant knowledge themselves, they must obtain expert advice internally, through occupational health and safety specialists and occupational physicians, or externally, through the use of external services.
Risk assessment — Employers’ roles and responsibilities Under Articles 5 to 12 of Council Directive 89/391/EEC, employers are obliged to: • ensure the health and safety of workers in every aspect related to work; • be in possession of an assessment of the risks to health and safety at work, including those facing groups of workers exposed to particular risks; • take appropriate measures so that workers and/or their representatives receive all the necessary information in accordance with national laws and/or practices; • consult workers and/or their representatives and allow them to take part in discussions on all questions relating to health and safety at work; • decide on the protective measures to be taken and, if necessary, the protective equipment to be used; • take the measures necessary for the health and safety protection of workers; • implement the necessary measures on the basis of the following general principles of prevention, see the text box ‘Framework Directive 89/391/EEC, Article 6, Paragraph 2’, page 26; • ensure that each worker receives adequate health and safety training, in particular in the form of information and instructions specific to their workplace or job (on recruitment, in the event of transfer, if new work equipment or any new technology is used); • take appropriate measures so that employers of workers from any outside establishments engaged in work in their establishment receive adequate information in accordance with national laws and/or practices, and have in fact received appropriate instructions regarding health and safety risks during their activities in their establishment; • document, monitor and review the risk assessment and the measures taken. For additional obligations of the employer, see Council Directive 89/391/EEC.
Risk assessment — Workers’ roles and responsibilities Workers’ participation is not only a right, it is fundamental to make the employers’ occupational health and safety management effective and efficient. Workers know not only the problems but also the resources when they perform their tasks or activities. Their participation also greatly increases the acceptance and long-lasting effectiveness of the preventive measures taken.
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Framework Directive 89/391/EEC, Article 6, Paragraph 2 2. The employer shall implement the measures referred to in the first subparagraph of paragraph 1 on the basis of the following general principles of prevention: a) avoiding risks b) evaluating the risks which cannot be avoided c) combating the risks at source d) adapting the work to the individual, especially as regards the design of workplaces, the choice of work equipment and the choice of working and production methods, with a view, in particular, to alleviating monotonous work and work at a predetermined work-rate and to reducing their effect on health e) adapting to technical progress f ) replacing the dangerous by the non-dangerous or the less dangerous g) developing a coherent overall prevention policy which covers technology, organisation of work, working conditions, social relationships and the influence of factors related to the working environment h) giving collective protective measures priority over individual protective measures i) giving appropriate instructions to the workers. Under Article 6 of Council Directive 89/391/EEC, workers and or/their representatives have the following rights and obligations: • to be consulted in the risk assessment and to take part in discussions on all questions relating to health and safety at work.; this also means that the risk assessment should take account of particularly sensitive risk groups. They must be protected against the dangers which specifically affect them. This relates, among other things, to specific risks of male and female workers, younger and older workers, pregnant workers and workers who have recently given birth or are breastfeeding, workers with different nationalities and languages and specific risks of workers from outside establishments or undertakings; • to make proposals; • t o have balanced participation in accordance with national laws and/or practices; • t o be informed of the risks to their health and safety and of the measures necessary to eliminate or reduce these risks; 02 The risk assessment should address particularly sensitive groups.
• to be involved in the process of deciding on the preventive and protective measures to be put in place; • to receive adequate health and safety information and training, in particular in the form of information and instructions specific to their workplace.
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Workers are obliged to: • take care, as far as possible, of their own health and safety and that of other persons affected by their acts or commissions at work in accordance with their training and the instructions given by their employer. • in accordance with their training and the instructions given by their employer: »» make correct use of machinery, apparatus, tools, dangerous substances, transport equipment and other means of production; »» make correct use of the personal protective equipment supplied to them and, after use, return it to its proper place; »» refrain from disconnecting, changing or removing arbitrarily safety devices fitted, e.g. to machinery, apparatus, tools, plant and buildings, and use such safety devices correctly; »» immediately inform the employer and/or the workers with specific responsibility for the health and safety of workers of any work situation they have reasonable grounds for considering to be a serious and immediate danger to health and safety and of any shortcomings in the protection arrangements; »» cooperate, in accordance with national practice, for as long as may be necessary to enable the employer to ensure that the working environment and working conditions are safe and pose no risk to health and safety within their field of activity.
03 Workers are obliged to work in accordance with instructions given by the employer.
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2.3. What should be considered before I start the risk assessment Before the potential risks and hazards at the workplace are identified, employers should first carefully prepare the complete risk assessment process. This includes the definition of who should be included, what the different roles and responsibilities are and what the different steps of the assessment will be. According to the information provided by EU-OSHA, employers can do this through an action plan for the elimination or control of risks. The action plan should include: • commissioning, organising and coordinating the assessment; • appointing competent people to make the assessments; the persons carrying out the risk assessment can be the employers themselves, employees designated by the employers, external assessors and service providers; • consulting workers’ representatives on arrangements for the appointment of those who will make the assessments in accordance with national laws and practices; • providing the necessary information, training, resources and support to assessors who are the employer’s own employees; • involving management and encouraging the participation of the workforce; • ensuring that the risk assessment is documented; • informing and consulting workers and/or their representatives on the results of the risk assessment and on the measures to be introduced; • ensuring that the preventive and protective measures take account of the results of the assessment; • monitoring and reviewing the protective and preventive measures to ensure that their effectiveness is maintained.
2.4. How do I get started with the risk assessment? If you have an organisational chart for your facility, start with an overview of all working areas within it. Write down which tasks, such as moving patients or cleaning surfaces, are performed in the different working areas. The same tasks from different working areas can be described together to avoid writing them down twice. The tasks which are performed in your facility are the starting point for the identification of hazards or risks which are connected with performing the task and the identification of the employees who are potentially exposed to the hazards or risks.
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Step 1 — Identifying hazards and those at risk Step 2 — Evaluating and prioritising risks
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According to the information provided by EU-OSHA, employers can take the appropriate action for the risk assessment following the five steps below.
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Why carry out a risk assessment?
Step 4 — Taking action Step 5 — Documentation, monitoring and review
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How to assess the risks?
Ever y few minutes somebody in the EU dies from work-related causes. Furthermore, every year hundreds of thousands of employees are injured at work; others take sickness leave to deal with stress, work overload, musculoskeletal disorders or other illnesses related to the workplace. And, as well as the human cost for workers and their families of accidents and illnesses, they also stretch the resources of healthcare systems and affect business productivity. Risk assessment is the basis for successful safety and health management, and the key to reducing work-related accidents and occupational diseases. If it is implemented well, it can improve workplace safety and health — and business performance in general.
Step 3 — Deciding on preventive action — T-O-P
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Risk assessment — the key to healthy workplaces For most businesses, a straightforward five-step (4) approach to risk assessment should work well. However, there are other methods that work equally well, particularly for more complex risks and circumstances.
The five-step approach to risk assessment Step 1. Identifying hazards and those at risk Remember: a hazard can be anything — whether work materials, equipment, work methods or practices — that has the potential to cause harm. Here are some tips to help identify the hazards that matter: ■
■
■
■ ■
What is risk assessment? Risk assessment is the process of evaluating risks to workers’ safety and health from workplace hazards. It is a systematic examination of all aspects of work that considers: ■ what could cause injury or harm, ■ whether the hazards could be eliminated and, if not, ■ what preventive or protective measures are, or should be, in place to control the risks (1). Employers have a general duty to ensure the safety and health of workers in every aspect related to work and to carry out a risk assessment. The EU framework directive (2) highlights the key role played by risk assessment and sets out basic provisions that must be followed by every employer. Member States, however, have the right to enact more stringent provisions to protect their workers (please check the specific legislation of your country) (3).
walk around the workplace and looking at what could cause harm; consult workers and/or their representatives about problems they have encountered; consider long-term hazards to health, such as high levels of noise or exposure to harmful substances, as well as more complex or less obvious risks such as psychosocial or work organisational risk factors; look at company accident and ill-health records; seek information from other sources such as: — manufacturers’ and suppliers’ instruction manuals or data sheets; — occupational safety and health websites; — national bodies, trade associations or trade unions; — legal regulations and technical standards.
For each hazard it is important to be clear about who could be harmed; it will help in identifying the best way of managing the risk. This doesn’t mean listing everyone by name, but identifying groups of people such as ‘people working in the storeroom’ or ‘passers-by’. Cleaners, contractors and members of the public may also be at risk. Particular attention should be paid to gender issues (5) and to groups of workers who may be at increased risk or have particular requirements (see box). In each case, it is important to identify how they might be harmed, i.e. what type of injury or ill health may occur.
(1) Guidance on risk assessment at work, Luxembourg: Office for Official Publications of the European Communities, 1996. (2) Council Directive 89/391/EEC of 12 June 1989 on the introduction of measures to encourage improvements in the safety and health of workers at work. (3) Ireland: www.hsa.ie; Malta: www.ohsa.org.mt; United Kingdom: www.hse.gov.uk/risk/index.htm (4) Whether the risk assessment process in your country is divided into more or fewer steps, or even if some of the five steps are different, the guiding principles should be the same. (5) Factsheet 43, including gender issues in risk assessment: http://osha.europa.eu/publications/factsheets
HEALTHY WORKPLACES
Step 1 — Identifying hazards and those at risk As mentioned above, the basis for the risk assessment is the tasks which are performed in the different working areas. Documents regarding dangerous substances, the duty roster, job profiles, working appliances and so forth provide a first impression about potential risks and hazards connected to the tasks. Besides these documents, the most important information can be provided by the workers. Ask your employees about their health and safety at work and visit their workplace to get a first hand impression of their working conditions. Ask them what can be improved for a better, safer and healthier work organisation.
Well-known occupational risks and hazards in the healthcare sector include biological, musculoskeletal, psychosocial and chemical risks. Specific risks that should be addressed are, for example:
GOOD FOR YOU. GOOD FOR BUSINESS.
http://hw.osha.europa.eu
04 The five steps of a risk assessment are described in EU-OSHA’s Factsheet 81.
Important to note
• the handling of blood and blood products, including the handling of needles and other sharp objects; • exposure to chemical agents/hazardous substances, including cleaning agents and disinfectants; • time pressure, high workload and interpersonal conflicts; • bullying or violence at the workplace; • shift, weekend and night work; • manual patient handling, lifting, pushing and pulling of weights; • the ergonomic design of workplaces.
Tools and instruments for the risk assessment Checklists, screening instruments or other tools and recommendations provided by different associations and liability insurances can be used to get an overall impression of potential risks and hazards. For example, psychosocial risks at work can be analysed with a mental workload screening. However, the use of a checklist or screening can only be a part of analysing the hazards and risks at work. It should not be used exclusively: always use other sources of information as well.
Step 2 — Evaluating and prioritising risks Not all of the identified risks and hazards will have the same importance nor can they all be addressed at the same time. It is recommended to prioritise within the risks and hazards and to agree which ones should be tackled first. Improving the working conditions should be seen as a continuous improvement process of your facility, which starts with more urgent risks and hazards and continuously moves on to other related topics to establish a safe, healthy and productive work environment.
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05 Ergonomically designed workplaces help to prevent musculoskeletal disorders.
How do I evaluate risks? Look at each individual risk you identified for the tasks performed and determine if measures have to be taken. You can categorise, for example, risks into three categories. Are they: a) negligible? b) acceptable for a short time? c) not acceptable? This depends on the probability and severity of potential accidents or health problems caused by the risk. If a risk is not acceptable you will have to take immediate measures. On the other hand, if a risk is acceptable for a short time, it can be addressed at a later date.
Step 3 — Deciding on preventive action — T-O-P After identifying and prioritising the risks in your facility, the next step is the identification of the appropriate measures to eliminate or control the risks. Under Framework Directive 89/391/EEC, Article 6, paragraph 2, preventive measures follow a hierarchy (see page 26). If possible, a risk should be avoided rather than being reduced, e.g. a dangerous chemical substance should be replaced by a less dangerous one. Additionally, the following hierarchy should be considered regarding preventive measures: first technical solutions should be considered, followed by organisational and finally personal/individual measures.
Technical measures Organisational measures Personal/individual measures
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Example
It is better to provide employees with height-adjustable tables than to train them to relax their back muscles which are cramped from sitting all day at a desk which is too high or low.
Technical measures
Organisational measures
Personal/individual measures
If possible, risks should be reduced with technical appliances, technical aids or construction measures.
A good work organisation and written organisational agreements on working sequences can avoid or reduce risks.
Individual instructions as well as training and most importantly retraining measures are necessary for sustainable effects on workers’ health and safety.
Consider how technical, organisational and personal/individual measures can work together.
Important to note
Step 4 — Taking action Implement the preventive and protective measures according to the prioritisation plan. Employees have to be informed about the results of the risk assessment and the planned improvements. The long-term implementation of measures within the daily work depends greatly on the participation of the workers and their acceptance of the measures. Specialists in occupational health and safety and quality management should compare and coordinate their activities and establish an integrated quality, as well as health and safety, management system.
The necessary improvements derived from the risk assessment should be planned regarding what should be done by whom and by when to eliminate or control the risks. A time schedule should be established together with everybody involved.
Important to note
Prioritisation plan Priority
Task performed Identified risk
Appropriate measures (T-O-P)
Who is responsible?
Timeline
Monitoring/ Review date
1. 2. 3. 4.
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06 It is important that workers participate in the decision-making as well as the implementation process.
Step 5 — Documentation, monitoring and review Documentation The risk assessment has to be documented. The documentation should include the results of the risk analysis, the improvements implemented and the results of the evaluation of the improvements. What risks were identified for the workers? How high is the risk of being exposed to those risks? Is the risk negligible, acceptable for a short time or not acceptable? Which measures have been taken and which ones planned for the future? Who is responsible for the implementation of the measures? By when should the measures have been taken and how will their effectiveness be evaluated?
Monitoring The preventive measures taken have to be monitored and evaluated. Additional modifications might be necessary if the measures do not produce the expected results. Additionally, changes in the work organisation or work environment may also change the level of risk. The risk assessment will have to be updated in such cases. Important to note
The implemented measures must also be monitored and reviewed to ensure that they are effective and do not create additional risks, e.g. on the one hand, the use of disinfectants protects the workers from biological risks such as bacteria, but on the other it increases the risk of skin problems. Additional measures will be necessary, e.g. appropriate skin protection.
Managers, such as group leaders and the head of departments, are responsible for monitoring and reviewing risk assessments in consultation with workers and their representatives. They are also responsible for the documentation of the review process.
Review The assessment should be reviewed at regular intervals. A set date to review the measures taken and a reevaluation of the risks at work should be included into the documentation of the risk assessment. The risk assessment has to be revised whenever significant changes occur, such as: 1. changes in the work organisation or work sequences; 2. use of new technology; 3. using a new chemical product such as cleaning agents or disinfectants;
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4. an increase in the number of sick days; 5. an increase in the number of accidents; 6. new or modified laws or regulations. •
The review process should determine whether: • the chosen preventive measures have been implemented as planned; • the chosen preventive measures are being used and being used correctly, e.g. lifting aids; • the preventive measures are being accepted by workers and included in their daily work; • the assessed risks have been eliminated or reduced by the measures; • the preventive measures have resulted in any new problems; • any new problems have occurred. •
Occupational risks and hazards should be updated yearly. Occupational health and safety is a continuous improvement process within a facility. As part of the company strategy and quality management system, it contributes to corporate success. Discussing the measures taken in frequent team meetings helps to integrate them into daily work. The workers know best why something does or does not work and can provide immediate feedback. Combining occupational health and safety (OSH) measures with quality management and strategy supports the hospital’s or healthcare facility’s success. To show a positive effect of OSH measures on the quality of care and economic situation of the hospital, criteria described in quality management have to be combined with OSH data. Preventive measures to reduce trips and falls will potentially also reduce the number of falls from patients, and improved hygiene measures will result in a lower number of bacterial infections and so forth.
Important to note
Reporting the results of the preventive measures taken to the higher management is the last step of a risk assessment which is integrated into the strategy of the hospital or healthcare facility. As mentioned above, the results can be reported in the context of data referring to the quality of care and the economic situation of the hospital or healthcare facility.
07 The use of technology can improve the working conditions; but does it also cause any new problems?
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2.5. Inclusion of gender aspects in the risk assessment Step 1 — Identifying hazards and those at risk • Asking both female and male workers what problems they have in their work • Avoiding making initial assumptions about what might be ‘trivial’ • Encouraging women to report issues that they think may affect their health and safety at work as well as problems that may be related to work • Considering the entire workforce including cleaners, receptionists and part-time workers
Step 2 — Evaluating and prioritising risks • Involving female workers in risk assessment; considering using health circles with members from different occupational groups, hierarchies, age groups etc. • Providing sufficient information about gender and diversity issues • Making sure instruments and tools used for the assessment include issues relevant to both male and female workers • Informing external assessors that they should take a gender-sensitive approach • Including harassment, emotional stressors and reproductive risks • Looking critically at weights of loads that have to be handled and how often
Step 3 — Deciding on preventive action — T-O-P • Selecting protective equipment according to individual needs • Involving female workers in decision-making
Step 4 — Taking action • Involving female workers in the implementation of solutions
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• Making sure male and female workers are provided with occupational health and safety information and training
Including gender issues in risk assessment Continuous efforts are needed to improve the working conditions of both women and men. However, taking a ‘gender-neutral’ approach to risk assessment and prevention can result in risks to female workers being underestimated or even ignored altogether. When we think about hazards at work, we are more likely to think of men working in high accident risk areas such as a building site or a fishing vessel than of women working in health and social care or in new areas such as call centres. A careful examination of
real work circumstances shows that both women and men can face significant risks at work. In addition, making jobs easier for women will make them easier for men too. So it is important to include gender issues in workplace risk assessments, and ‘mainstreaming’ gender issues into risk prevention is now an objective of the European Community ( 1). Table shows some examples of hazards and risks found in female-dominated work areas.
Table 1. Examples of hazards and risks found in female-dominated work Work area
Step 5 — Documentation, monitoring and review 08 Factsheet 43 ‘Including gender aspects in risk assessment’, EU-OSHA, 2003 (http://osha.europa. eu/en/publications/ factsheets/43/).
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Biological
Physical
Chemical
Psychosocial
Infectious diseases, e.g. bloodborne, respiratory, etc.
Manual handling and strenuous postures; ionising radiation
Cleaning, sterilising and disinfecting agents; drugs; anaesthetic gases
‘Emotionally demanding work’; shift and night work; violence from clients and the public
Nursery workers
Infectious diseases, e.g. particularly respiratory
Manual handling, strenuous postures
Cleaning
Infectious diseases; dermatitis
Manual handling, strenuous postures; slips and falls; wet hands
Food production
Infectious diseases, e.g. animal borne and from mould, spores, organic dusts
Repetitive movements, e.g. Pesticide residues; sterilising in packing jobs or agents; sensitising spices and slaughterhouses; knife wounds; additives cold temperatures; noise
Stress associated with repetitive assembly line work
Catering and restaurant work
Dermatitis
Manual handling; repetitive chopping; cuts from knives and burns; slips and falls; heat; cleaning agents
Passive smoking; cleaning agents
Stress from hectic work, dealing with the public, violence and harassment
Textiles and clothing
Organic dusts
Noise; repetitive movements and awkward postures; needle injuries
Dyes and other chemicals, including formaldehyde in permanent presses and stain removal solvents; dust
Stress associated with repetitive assembly line work
Laundries
Infected linen, e.g. in hospitals
Manual handling and strenuous postures; heat
Dry cleaning solvents
Stress associated with repetitive and fast pace work
Ceramics sector
Repetitive movements; manual handling
Glazes, lead, silica dust
Stress associated with repetitive assembly line work
‘Light’ manufacturing
Repetitive movements, e.g. in assembly work; awkward postures; manual handling
Chemicals in microelectronics
Stress associated with repetitive assembly line work
Call centres
Voice problems associated with talking; awkward postures; excessive sitting
Poor indoor air quality
Stress associated with dealing with clients, pace of work and repetitive work
Prolonged standing; voice problems
Poor indoor air quality
‘Emotionally demanding work’, violence
Hairdressing
Strenuous postures, repetitive movements, prolonged standing; wet hands; cuts
Chemical sprays, dyes, etc.
Stress associated with dealing with clients; fast paced work
Clerical work
Repetitive movements, awkward postures, backpain from sitting
Poor indoor air quality; photocopier fumes
Stress, e.g. associated with lack of control over work, frequent interruptions, monotonous work
Manual handling, strenuous postures; unsuitable work equipment and protective clothing; hot, cold, wet conditions
Pesticides
Education
• Being aware of new information about gender-related occupational health issues
Risk factors and health problems include:
Healthcare
Agriculture
Infectious diseases, e.g. respiratory, measles
Infectious diseases, e.g. animal borne and from mould, spores, organic dusts
‘Emotional work’ Cleaning agents
Unsocial hours; violence, e.g. if working in isolation or late
(1) ‘Adapting to change in work and society: A new Community strategy on health and safety at work, 2002–06’. Communication from the European Commission, COM(2002) 118 final
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2.6. Description of good company practice The St Elisabeth Hospital in Tilburg, the Netherlands, is a hospital with a 180-year history. It was started as a nursing home, and now has 3 100 employees and 4 000 inpatients per year. In addition, 347 000 patients are treated yearly in the polyclinic. In this interview, Ms Christel van Neerven, the head of the occupational health and safety department, and Ms Monique Pullen, adviser on occupational health and safety, describe the hospital’s risk assessment process.
Ms van Neerven: We had a method for the frequent risk assessment which was performed every few years. But this year, we will be starting a new system, with a new kind of survey. Besides risks at work, we will also be asking about health, loyalty and how content our employees are at work. The new survey also includes questions about private and family demands. This is going to take place every two years in every department. In this way, we will obtain a frequent evaluation of the risks at work including the work setting and the environment.
Christel van Neerven, head of the occupational health and safety department.
Best practice
Interviewer: How do you assess risks at work? Do you perform a risk assessment every year or frequently?
Monique Pullen, adviser on occupational health and safety.
Interviewer: Who is taking part in it? Is the management involved?
Ms van Neerven: We organise the risk assessment and ensure that good instruments are used. The management, the human resources department and employees from the different departments work with us. The team leaders in the departments are the owners of the risk assessment. They have to take action once they receive a report. It’s their responsibility. Before we start a risk assessment, we draw up a project plan. What are we going to do? Why are we doing it? Who is responsible for what? And top management has to give its ‘OK’ before we start. I present the project plan to the management and the workers’ representatives. And when they all agree, we can start. Afterwards, we address the heads of the departments and the team leaders to make the appointment for the survey. We inform them about the goal and the means. They have to say ‘Go, you can do it!’ and ‘We think it’s important that you perform this risk assessment for us so that we have information to improve the workplace for our staff’. Health and safety management is included in the hospital’s strategy. Health and safety is part of the quality of care. The management sees it as their responsibility to take good care of the employees. The health and safety management is included in the management strategy. It’s one of the main points of the strategic policy of the hospital. Interviewer: Who has to approve the preventive measures?
Ms van Neerven: It’s the responsibility of the team leaders and the heads of the departments to take action. They have to write it down in CEO plans. Such plans include a follow-up schedule with the board of the hospital. After one year, they have to report on what they did and did not do with the plans.
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Best practice
Interviewer: Do you include employees in the risk assessment?
36
Ms Pullen: Employees participate in two ways. Firstly, we ask them to fill out a questionnaire, our survey. Secondly, we perform an inspection on the work floor and speak to them directly. Ms van Neerven: When we make a policy on a subject, we also always ask the employees who have to work with it to observe certain rules. Their feedback is important to us. Ms Pullen: We depend on their information. They are on the work floor and are faced with the risks. They can provide us with the right information. A lot of times they have very good suggestions. After the risk assessment, we prepare a report and discuss it with the team leader or head of the floor. We always suggest talking about it with all employees. It’s actually obligatory but we also suggest it. Sometimes we come to explain the results after we have performed the risk assessment. Ms van Neerven: For special risks, such as musculoskeletal or chemical risks, we also conduct interviews for two hours with two employees in each group. We ask all the team leaders to name two employees we can talk to. There is a great variety of functions and specialisation. So you have to talk to each one of them to gain a good impression of the risks. Interviewer: Is it an open conversation or do you have special questions? Ms Pullen: It’s a specific method. We ask what kind of activities they pursue, for example a nurse washes the patient or helps him to shower, sometimes they have to do some administration work. Interviewer: So it’s task-oriented. Do you have a list of risks relating to the tasks? Ms Pullen: Yes. Firstly, we have the interview and afterwards we go with them and observe them at the workplace to see how long they have to perform the different activities. We evaluate the duration of the activity, the frequency and if they have any complaints. Interviewer: Where does the list of risks come from? Is a list provided by the hospital or an external agency? Who provides the method? Ms Pullen: They are guidelines from the government. This method gives us a lot of insight into where the real problems are: what loads they have to handle and whether they also have a high mental workload, for example whether they report that they have a lot of things to think about.
2 How to carry out a risk assessment
Interviewer: Do you pay special attention to gender differences?
Interviewer: Do you write down these policies?
Best practice
Ms Pullen: We look more at different age groups. Older workers are more likely to have back problems or to need more time to recuperate. Our employees are getting older. The average age is above 40. We use the results of the risk assessment to work out a policy for older employees, for example to ensure that they don’t have to work night shifts. They also don’t have to work alone and shouldn’t work too many consecutive shifts. We also pay attention to achieving a balance between late and early shifts and to not make the work too difficult. Employees don’t have to transfer the patients alone. We encourage them to use lifts and other technical aids. We invest more in those things. Also in the reconstruction of the hospital. We are currently rebuilding parts of it so that employees have more space to work with the patients.
Ms Pullen: Yes, and we advise employees. But it is also the responsibility of the employee him or herself to talk to the team leader. Based on our risk assessment, we also address what the greatest risks are and discuss them. How can you prevent them? We also have specially trained employees, the ergo coaches, on the floor who deal with the prevention of musculoskeletal risks. They coach their colleagues, for example on how to transfer patients in the right way. The workload is very high for the employees and they want to do a lot but sometimes it is better to ask a colleague to assist. Interviewer: Can you describe an example of successful preventive action in your hospital?
Ms van Neerven: We are rebuilding a lot and have all kinds of companies coming here to do work. We frequently observe that they don’t take enough precautions and then they can have accidents. We then make agreements with the facility department on what we have to provide so that they can work in a safe environment. We also had a lot of accidental falls in the kitchen because of a new floor. We have a very big kitchen and the floor was very slippery. We tried to find out the cause and what we could do about it. Did we have to change the floor or maybe the cleaning method? If all those things are done and there is still a risk, we provide people with good safety shoes. Another example is an accident with cytostatics. We have a policy for cytostatics but two years ago we had a few accidents with the cytostatic pump and we had a few incidents where the cytostatics exploded. The cytostatics went everywhere, even over the nurse. The pumps were too old. We researched the entire matter and this resulted in new pumps for the whole hospital. That’s a good example of accidents but also of the establishment we have, our advice is taken seriously.
37
Best practice
Occupational health and safety risks in the healthcare sector
38
Interviewer: What has been your experience with the implementation of measures? Did you have support from top management or did you have any difficulties? Ms van Neerven: The management participates in the survey and the recommendations. So what we advise never comes as a surprise to them. Interviewer: Did you ever have any resistance from the team leaders or the employees? Ms Pullen: No. It’s also because of the way we did it. There were often things which were already very good. So we told them to keep it that way, it’s already very good. And we also gained more insight by talking to them about what additional measures they could take. We advised them on which activities they could improve. Interviewer: Did you do that intentionally, i.e. gave them feedback first about what they are doing well? Because it’s a very good method to gain higher acceptance. Ms van Neerven: Yes, we are very focused on communication. Interviewer: What do you think is the basis for a good relationship in which you respect one another? Ms van Neerven: Our strong point is communication. We focus on communication. Not only on the subject matter but how to get the message across. Our goal is to change people’s attitude or behaviour. On that level we make contact. I think this is what makes our work good. Interviewer: How did you establish good communication? How did you start? Ms van Neerven: It took us a few years to get this far. Ms Pullen: You have to listen to what the problems are when you talk to the team leaders. You take an interest in what they do. What are they doing? What is their main task? Where do they have problems? What are the good aspects? Ms van Neerven: We want to be a good partner in communication. There was some prejudice about occupational health and safety: ‘It costs a lot of money but it doesn’t get us anywhere.’ So we made an effort to let them see the results constantly, to make it positive. And the mood changed. We wanted to give occupational health and safety a face that everyone knew so that they could talk to the office of occupational health and safety if they had questions or problems. To give it a face and show results. And give small results priority over policymaking. Policy is also important but at that stage concrete results were more important. That was our goal and it worked out.
2 How to carry out a risk assessment
Interviewer: Do you remember one of those small results? Ms van Neerven: They were small things. Doors which didn’t close well. Problems with the floor. Problems with the computer. It took a lot of hard work but after one year I heard somebody say ‘I called the office of occupational health and safety because my colleague told me that you have to call there if you want to see results’. And I thought ‘That’s what I wanted’. It has to grow from there. That was the first phase.
Best practice
Interviewer: That’s very interesting. That is a different approach to what a lot of people do — and that’s probably why it works so well for you. People often start with the strategy and don’t go directly to the people. You can write down a lot of things on paper but nobody really ever understands what you are doing. How do you check the effectiveness of the measures you have taken? Ms van Neerven: With the internal audits of the quality management. Every few years we have an external audit. The internal audit is conducted every year. Ms Pullen: We also evaluate effectiveness by talking to the team leaders informally. Have things changed? Can you manage? Do you need more assistance from us? Can we do anything?
Interviewer: How do you update the risk assessment or how do you ensure the sustainability of the measures taken? You already mentioned the follow-up two years after measures are taken and you also talk to the team leaders. Ms van Neerven: And observe the work on the floor ourselves.
Interviewer: How do you modify measures? Based on the conversations with the team leaders? Ms Pullen: Yes. Also together with the employees. We ask about the reasons why they don’t use something and try to find out which measures suit the floor. Otherwise they might never implement them, so we try to take that into consideration. Ms van Neerven: We also organise internal networking meetings, for example for the ergo coaches, twice a year.
Ms Pullen: They can network and ask questions. Sometimes they develop something on one floor and it is useful for another floor. We also have trial periods with tools. The employees also have to evaluate the tools. We can advise them but they also have a responsibility.
39
Occupational health and safety risks in the healthcare sector
2.7. Links No
Title
Country/Region
Contents/Source
1.
E-fact 18 -– Risk assessment in healthcare
EU-OSHA
This article outlines the risk factors specific to the healthcare sector and describes practical steps of risk assessment. http://osha.europa.eu/en/publications/e-facts/efact18
Factsheet 43 — Including gender issues in risk assessments
EU-OSHA
Factsheet 80 — Risk assessment — roles and responsibilities
EU-OSHA
2.
3.
4.
5.
6.
7.
Factsheet 81 — Risk assessment — the key to healthy workplaces Risk assessment essentials
Council Directive 89/391/EEC
E-fact 20 — Checklist for the prevention of accidents in laboratories
(European Agency for Safety and Health at Work) (European Agency for Safety and Health at Work) (European Agency for Safety and Health at Work) EU-OSHA (European Agency for Safety and Health at Work) EU-OSHA (European Agency for Safety and Health at Work) EU-OSHA (European Agency for Safety and Health at Work) EU-OSHA (European Agency for Safety and Health at Work)
Taking a ‘gender-neutral’ approach to risk assessment and prevention can result in risks to female workers being underestimated or even ignored altogether. A table shows some examples of hazards and risks found in female-dominated work areas. http://osha.europa.eu/en/publications/factsheets/43 Workers’ health and safety is protected in Europe by an approach based on assessing and managing risks. In order to carry out effective workplace risk assessment, all those involved require a clear understanding of the legal context, concepts, the process of assessing the risks and the role to be played by the main actors involved in the process. http://osha.europa.eu/en/publications/factsheets/80 Risk assessment is the basis for successful health and safety management, and the key to reducing work-related accidents and occupational diseases. If it is implemented well, it can improve workplace health and safety — and business performance in general. http://osha.europa.eu/en/publications/factsheets/81 This publication contains checklists related to a wide range of hazards to help to assess the risk at the workplace. It contains checklists for risk assessment of chemical substances, stress and slippery surface. http://osha.europa.eu/en/campaigns/hwi/about/material/rat2007 Council Directive 89/391/EEC of 12 June 1989 on the introduction of measures to encourage improvements in the safety and health of workers at work. http://eur-lex.europa.eu/Result.do?T1=V1&T2=1989&T3=391&RechType= RECH_naturel&Submit=Search Laboratories involve a greater variety of hazards than most workplaces. This e-factsheet focuses on safety in chemical and biological laboratories in particular. It outlines EU legislation on laboratory safety, particularly as it relates to chemical and biological hazards, and pregnant and young workers. It summarises hazards that the lab worker can encounter and gives examples of serious lab accidents that could have been prevented if proper safety measures had been taken. It concludes with a set of checklists to help workers in laboratories assess possible risks and to monitor safety processes. http://osha.europa.eu/en/publications/e-facts/efact20
8.
40
E-fact 28 — Patient handling techniques to prevent MSDs in healthcare
EU-OSHA (European Agency for Safety and Health at Work)
Muskuloskeletal disorders (MSDs) are a serious problem among hospital personnel, and in particular the nursing staff. Of primary concern are back injuries and shoulder strains, which can both be severely debilitating. The nursing profession has been shown to be one of the most at risk occupations for low back pain. The primary cause of MSDs is patient handling tasks such as lifting, transferring and repositioning of patients. This article provides recommendations and examples for nursing staff to help reducing the number and severity of MSDs due to patient handling. http://osha.europa.eu/en/publications/e-facts/efact28
2 How to carry out a risk assessment
No
Title
Country/Region
Contents/Source
9.
Report —Mainstreaming gender into occupational safety and health
EU-OSHA
This report summarises a workshop held on 15 June 2004 in Brussels. The objectives of the seminar were, first, the exchange of information on issues specific to gender, including an approach sensitive to gender and how it can be integrated into health and safety. The goal of promoting discussion and exchange of views on the further development of gender-specific issues between the EU and national authorities and social partners and experts is also pursued. The report contains proposals for the development of gender issues in the field of safety and health at work
Safety and health at work is everyone’s concern: Good practice for enterprises, social partners and organisations
EU-OSHA
Report — Gender issues in health and safety at work
EU-OSHA
10.
11.
(European Agency for Safety and Health at Work)
(European Agency for Safety and Health at Work)
(European Agency for Safety and Health at Work)
Good practice for enterprises, social partners and organisations. Introducing the healthy workplace initiative, to provide employers and employees with easy access to quality information about health and safety. http://osha.europa.eu/en/publications/other/brochure2007
Achieving gender equality in all aspects of employment is now a key European priority. It is a matter of rights, but also of sound economic policy. The report highlights the dual importance of considering gender in risk prevention and including occupational health and safety in gender equality employment activities. Cooperation between these two policy areas is crucial, from the European level, down to the workplace, to promote improved workplace risk prevention for both women and men. http://osha.europa.eu/en/publications/reports/209
12.
Factsheet 42 — Gender issues in health and safety at work
EU-OSHA (European Agency for Safety and Health at Work)
There are substantial differences in the working lives of women and men and this affects their occupational health and safety (OSH). ‘The Community strategy on health and safety at work’ has ‘mainstreaming’, or integrating gender into occupational health and safety activities, as an objective. To support this, the Agency has produced a report examining gender differences in workplace injury and illness, gaps in knowledge and the implications for improving risk prevention. http://osha.europa.eu/en/publications/factsheets/42
13.
Factsheet 29 — Safety and health good practice online for the healthcare sector
EU-OSHA (European Agency for Safety and Health at Work)
According to European data the work-related accident rate in the healthcare sector is 34 % higher than the EU average. In addition, the sector has the second highest incidence rate of work-related musculoskeletal disorders (MSDs), after construction. This factsheet provides a basic introduction to occupational health and safety in the healthcare sector and how to find information for the sector on the Agency’s website. http://osha.europa.eu/en/publications/factsheets/29
14.
Factsheet 53 — Ensuring the health and safety of workers with disabilities
EU-OSHA (European Agency for Safety and Health at Work)
People with disabilities should receive equal treatment at work. This includes equality regarding health and safety at work. People with disabilities are covered by both European anti-discrimination legislation and occupational health and safety legislation. This legislation, which the Member States implement in national legislation and arrangements, should be applied to facilitate the employment of people with disabilities, not to exclude them. http://osha.europa.eu/en/publications/factsheets/53
15 .
Europe’s ageing workforce
EU-OSHA (European Agency for Safety and Health at Work)
Specific occupational health and safety issues of particular concern to older workers include musculoskeletal disorders (MSDs), psychosocial job characteristics and work organisation arrangements (e.g. shift patterns). http://osha.europa.eu/en/priority_groups/ageingworkers
41
Occupational health and safety risks in the healthcare sector
No
Title
Country/Region
Contents/Source
16.
Migrant workers
EU-OSHA
Occupational health and safety (OSH) issues relating to migrant workers include the high employment rates of migrant workers in high-risk sectors, language and cultural barriers to communication and training in OSH, and the fact that migrant workers often work a lot of overtime and/ or are in poor health and thus are more prone to occupational injuries and diseases.
(European Agency for Safety and Health at Work)
http://osha.europa.eu/en/priority_groups/migrant_workers 17.
18.
People with disabilities
Young people
EU-OSHA (European Agency for Safety and Health at Work) EU-OSHA (European Agency for Safety and Health at Work)
19.
Factsheet 69 — Young Workers
EU-OSHA (European Agency for Safety and Health at Work)
EU-OSHA has compiled various resources related to occupational health and safety and people with disabilities. This website aims to provide links to practical information regarding workplace health and safety issues relating to the integration and retention of people with disabilities in employment. http://osha.europa.eu/en/good_practice/priority_groups/disability The Agency has compiled resources and links to sources of information related to young people and occupational health and safety at work. http://osha.europa.eu/en/good_practice/priority_groups/young_people
The factsheet gives an overview of the employment situation of young workers and the jobs they are employed in, mainly in service professions and low-skilled manual jobs. This distribution has important implications for the occupational health and safety of young people because of the specific set of potentially harmful conditions (including low pay, temporary seasonal work, poor employment conditions, atypical working time, shift, night and weekend work and physically demanding work). http://osha.europa.eu/en/publications/factsheets/69
20.
Factsheet 70 — Young Workers
EU-OSHA (European Agency for Safety and Health at Work)
This publication aims to provide a review of the hazards young workers are exposed to at work and what the consequences of this exposure are both in the short term and in the long term. Many of the sectors and occupations young people are employed in are characterised by high accident risks and exposure to many workplace hazards. Specific targeted measures need to be taken in education and training as well as in daily workplace practice http://osha.europa.eu/en/publications/factsheets/70
42
2 How to carry out a risk assessment
2.8. Relevant European Union directives 1. Council Directive 89/391/EEC of 12 June 1989 on the introduction of measures to encourage improvements in the safety and health of workers at work (13) 2. Council Directive 89/654/EEC of 30 November 1989 concerning the minimum safety and health requirements for the workplace (14) 3. Council Directive 92/85/EEC of 19 October 1992 on the introduction of measures to encourage improvements in the safety and health at work of pregnant workers and workers who have recently given birth or women who are breastfeeding (15)
2.9. OiRA: Online risk assessment tool, EU-OSHA The European Agency for Safety and Health at Work (EU-OSHA) is developing an online risk assessment tool that will be available for users by 2011 (http://osha.europa.eu/). This consists of web pages on risk assessment that can help micro and small organisations to put in place a risk assessment process — starting with the identification and evaluation of workplace risks, through decision-making on preventive actions and the taking of action, to monitoring and reporting.
2.10. Literature Berufsgenossenschaft für Gesundheitsdienst und Wohlfahrtspflege (BGW), Germany, 8 July 2009 (www.bgw-online.de). Berufsgenossenschaft für Gesundheit und Wohlfahrtspflege, Germany. Gefährdungsbeurteilung in Kliniken, 2005 (http://www.bgw-online.de/internet/generator/Inhalt/OnlineInhalt/Medientypen/bgw__check/TP-4GB__ Gefaehrdungsbeurteilung__in__Kliniken,property=pdfDownload.pdf ). Council Directive 89/391/EEC of 12 June 1989 on the introduction of measures to encourage improvements in the safety and health of workers at work (http://eur-lex.europa.eu/Result.do?T1=V1&T2=1989&T3=391&RechType=R ECH_naturel&Submit=Search). European Agency for Safety and Health at Work, ‘Factsheet — 80 Risk Assessment — roles and responsibilities’ (http://osha.europa.eu/en/publications/factsheets/80/). European Agency for Safety and Health at Work, ‘Factsheet 43 — Including gender issues in risk assessment’ (http://osha.europa.eu/en/publications/factsheets/43/). European Agency for Safety and Health at Work, Risk assessment (http://osha.europa. eu/en/topics/riskassessment).
(13) OJ L 183, 29.6.1989, pp. 1–8. (14) OJ L 393, 30.12.1989, pp. 1–12. (15) OJ L 348, 28.11.1992, pp. 1–8.
43
44
Hazard and those at risk
Physical strain of the spine, shoulder and neck areas and the hand and arm joints for all caregivers who are involved, triggered by the weight and the functional ability of the patient as well at the insufficient space to move around the bed
Task
Help a patient to sit up in the bed and lie down again
2
Risk classification
Preventive actions (T-O-P)
Information on safe conduct
Elimination Training in the handling of electriof the physi- cal beds cal load for Training in back-friendly and the carer patient resources- orientated working ways
Information about hazards
Enough space in the patients’ rooms: e.g. removal of unnecessary furniture, rearrangement of the furniture
No supplementary beds in the patients’ rooms
Review of the organisation of the workflow
Reduction Sufficient people in the shift to of the physi- work with two colleagues cal load for Sufficient time to work in a backthe carer friendly and patient resourcesorientated working way
Elimination Electrical powered adjustable of the physi- beds cal load for the carer
Target
Working area: Care Unit 2B Professional group: All workers involved in taking care of patients Task: Moving patients
Within the next four years, follow up for the entire workforce
Within the next two years, basic training for the entire workforce,
The person responsible for medical devices
Within eight weeks
Head nurse, security officer
Within the next six weeks for the entire staff of all care units
All members of the care unit
Immediately
Medical management and head nurse
Immediately
Head nurse
Immediately
Management and head nurse
Within six months
Management, purchase department
Within the next two years for all care units
By when and by whom
2.11. Example of a risk assessment based on the task of manually handling patients
Monitoring/ Review date
Occupational health and safety risks in the healthcare sector
2 How to carry out a risk assessment
2.12. Example of a risk assessment based on the task of surface disinfection Working area: Internal medicine Professional group: Nursing staff Task: Surface disinfection as routine disinfection (scrubbing/wiping disinfection) of large surfaces
Step 1 — Identifying hazards and those at risk Example: Information provided by safety data sheets, the duty roster, working appliances — How can information be collected including who might be harmed and how? Routine surface disinfection is performed as scrubbing/wiping disinfection with a diluted, aqueous disinfection solution which may contain dangerous substances. Surface disinfectant concentrates are normally diluted in water to an approx. 0.25 % to approx. 3 % application solution, depending on the type and concentration of the active substances. Consumption of the application solution is more than 50 ml/m2 and less than 100 ml/m2 of basic floor area but may amount to a total of several litres depending on the extent of disinfection. The activity frequently occurs on the wards, and may take minutes (e.g. with nurses) or hours (with assistant nurses or cleaning staff ). Fixtures, work surfaces, beds, equipment and machines etc. are disinfected. The workers are exposed to various risks, in particular: • musculoskeletal risks due to prolonged or awkward postures or heavy lifting and carrying (e.g. mattresses, fixtures); • risks of infection (infection risk typical of hospitals); • chemical risks due to the action of various substances for cleaning and disinfecting as well as prolonged wet work which may result in swelling of the skin, wear-related dermatoses and sensitisation. The labelling of dangerous substances normally gives the user sufficient information on the risks arising from the product. The standard dilutions produced by the users from disinfectant concentrates frequently contain active substances of less than 0.1g/100g and therefore less than 0.1 % in the working solutions. Labelling of these working solutions can usually be dispensed with. However, risks may still remain for the workers even from diluted disinfectants.
Step 2 — Evaluating and prioritising risks Example: Not all identified risks have the same importance — How can I evaluate which risks should be prioritised and tackled first? Dermal risks arise from direct contact with the disinfectant or from splashes. This must be allowed for, in particular with certain critical ingredients which, for example, cause sensitisation by skin contact (R43). The risk phrases for the ingredients can be found in Section 2 of the safety data sheet. Inhalation risks arise due to the evaporation of the ingredients. Fire and the risk of explosion are possible with inflammable products. Standard application solutions, however, are not inflammable.
45
Occupational health and safety risks in the healthcare sector
Reaction products do not arise if the disinfectant is used in accordance with the instructions. One speciality is products with formaldehyde splitters such as, for example, 1.6-dihydroxy-2.5-dioxahexane (CAS No 3586-55-8). In the case of these products, formaldehyde is not added as an ingredient during production but arises in a chemical reaction in the concentrate. The user is therefore confronted with a formaldehydecontaining disinfectant although this is not directly apparent. Dermal risk The dermal exposure can be avoided with all disinfection activities, regardless of the ingredients of the disinfectants, by wearing appropriate protective gloves. The wearing of liquid-tight protective gloves, especially for more than two hours per shift, represents a special risk from ‘wet work’. Inhalation risk It can be stated in summary for the inhalation risk that it is normally negligible, apart from aldehydes. The disinfectants are classified into product groups which are distinguished according to ingredients. Product group: Quaternary ammonium compounds and biguanides The inhalation exposure is insubstantial for products with quaternary ammonium compounds and biguanides as long as no aerosols form.
Evaluating and prioritising risks Product group: Aldehyde-containing products Aldehydes normally have a sensitising potential; in addition, formaldehyde even has a carcinogenic potential (C3 acc. to EU; C1 acc. to IARC). Even if the limit values are undershot, a health risk cannot be excluded with sensitising substances if they sensitise the respiratory tract (R42). Product group: Alcohols The inhalation alcohol exposure is negligible with alcohol-containing products with maximum concentrations of up to 10g/100g in the concentrate and therefore normally 50 mg/100g in the 0.5 % application solution. Product group: Other ingredients (phenol derivatives) Surface disinfectants may also contain other active substances in addition to the abovementioned ingredients, e.g. phenol derivatives. The substance-specific risk must be determined on a case-by-case basis if these products are used. Risk of fire/explosion A risk of fire or explosion (conflagration) only exists if the concentrates are labelled with a flame symbol or with R10 (flammable). There is no risk of fire or explosion for the other diluted application concentrations. Products with a higher alcohol content are unsuitable as disinfectants for large surfaces owing to the risk of fire/explosion.
46
2 How to carry out a risk assessment
Step 3 — Deciding on preventive action T -O -P Examples of appropriate measures to certain risks (Technical prior to Organisational prior to Personal measures) Substitution A regular check must be made to determine whether cleaning is sufficient instead of disinfection. The necessary disinfection work is stipulated in the hygiene plan. Many products are offered for surface disinfection which have no volatile ingredients or which contain substances with fewer critical properties. The suitability for use of a less critical product must be examined. The following risks are to be allowed for, in particular when disinfectants are replaced: • The sensitisation potential of the ingredients (R42, R43) • Products containing aldehydes, in particular formaldehyde and glutaraldehyde, should only be used in justified cases in view of their volatility and the risk potential which remains even if diluted solutions are used. • Wiping procedures are to be used, not spray methods with a fine mist, for the disinfection of large surfaces.
Technical • With application concentrations of over 1 % and volatile ingredients (apart from alcohols) it must be assumed that technical ventilation is required. The ventilation must ensure an adequate number of air changes. • Handling of the disinfectant with aids to minimise skin contact • Aerosols are to be avoided as far as possible. For example, with a lower pressure, aerosol formation at the discharge opening and the impact speed of liquid particles and therefore the volume of aerosol produced there can be reduced. (This is relevant, for example, in the disinfection of baths for hospitals and nursing homes with showers.)
Organisational • Necessary disinfection work is stipulated and employees are instructed in how to work properly prior to starting these activities. Specifications on the production of the application concentration and contact time are observed. • Good ventilation, if possible cross ventilation, during disinfection must be ensured by opening doors and windows. • If technical ventilation facilities are present, they must be put into operation during disinfection. • The application of disinfectants to hot surfaces must be avoided as the disinfecting action is no longer produced owing to the faster evaporation of the active substances (missing contact time). Moreover, there is also a major risk due to evaporating substances which would normally be negligible at room temperature (e.g. heat disinfection).
47
Occupational health and safety risks in the healthcare sector
Personal/individual • As regards personal protective measures, always observe Section 8 of the relevant safety data sheet. • Use appropriate gloves; gloves made of nitrile rubber are usually suitable. In view of the variety of products used, no definitive information can be provided here on protective gloves. Section 8 of the relevant safety data sheet always contains notes. • Wear appropriate body protection when it is expected that clothing or shoes can become wet through.
Step 4 — Taking action Employees have to be informed about the results of the risk assessment. For the implementation of the measures, it has to be planned what should be done by whom and by when. A time schedule has to be established with everybody involved. The involvement of workers from different occupational groups and with different needs, such as younger and older workers, male and female workers and other groups of workers, in the implementation of measures supports the acceptance of measures and their longterm success.
Step 5 — Documentation, monitoring and review Documentation The risk assessment has to be documented. The documentation should involve the results of the risk analysis, the implemented measures and the results of the evaluation of the measures. Monitoring The results of the measures have to be monitored and evaluated. Additional modifications might be necessary if the improvements do not produce the expected results. The implemented measures will be monitored by one or more employees. They report to the responsible manager in their department and/or the hospital. The group leader or the head of the department is responsible for monitoring and reviewing the risk assessment. Review The assessment should be reviewed at regular intervals. It has to be revised whenever significant changes occur. The occupational risks and hazards should be updated yearly and a continuous improvement process established. A set date to review the measures taken and to reevaluate the risks is included in the documentation. Ideally, the managers responsible report to the higher management if the goal of preventing or reducing a risk was achieved or not.
48
3 Biological risks 3.1. Introduction 3.2. General risk assessment of potential occupational exposure to infection 3.3. Special risk assessment of biological risks 3.3.1. 3.3.2. 3.3.3. 3.3.4. 3.3.5.
Risk of blood-borne infections Risk of airborne infection Risk of direct and indirect contact infection Description of good company practice: handling contact infections Special infections
3.4. Pregnancy 3.5. Relevant European Union directives 3.6. Links 3.7. Literature
Occupational health and safety risks in the healthcare sector
3.1. Introduction Health sector personnel face an increased risk of contracting an infection, for which numerous and to some extent quite disparate pathogens play a significant role. As a rule, the risk is either unexpected or not immediately apparent, which makes risk assessment particularly difficult.
A new way to assess risk A risk assessment is crucial to the prevention of infection among personnel working in areas of high risk. Any assessment of risk potential must take account of: 1. the natural virulence of the pathogen; 2. its capacity to survive in the environment; 3. the severity of the disease; 4. the dose or exposure level necessary to cause illness or infection; 5. the mode of transmission; 6. epidemiological factors.
The classification of Directive 2000/54/EC of the European Parliament and of the Council on the protection of workers from risks related to exposure to biological agents at work Four risk groups, according to their level of risk of infection: • Group 1 Biological agent means one that is unlikely to cause human disease. • Group 2 Biological agent means one that can cause human disease and might be a hazard to workers; it is unlikely to spread to the community and there is usually effective prophylaxis or treatment available.
(16) See Article 2 of Directive 2000/54/EC of the European Parliament and of the Council of 18 September 2000 on the protection of workers from risks related to exposure to biological agents at work (seventh individual directive within the meaning of Article 16(1) of Directive 89/391/EEC) (OJ L 262, 17.10.2000, pp. 21–45.). Annex III contains a list of Community classified biological agents.
50
• Group 3 Biological agent means one that can cause severe human disease and present a serious hazard to workers; it may present a risk of spreading to the community, but there is usually effective prophylaxis or treatment available. • Group 4 Biological agent means one that causes severe human disease and is a serious hazard to workers; it may present a high risk of spreading to the community; there is usually no effective prophylaxis or treatment available (16). •
Connected with the risk groups is a classified bundle of protective measures that allows a general reaction on different levels of hazard. Nevertheless, a specific response on a current situation is not easy with this system, as hazard in healthcare can change rapidly.
3 Biological risks
The European system of risk assessment requires an evaluation of the risk potential of every pathogen likely to be encountered, the allocation of pathogens into risk groups and the drawing up of precautions based on this risk analysis and risk grouping. If pathogens of different risk groups are present, the set of precautions for the highest risk category should be implemented. Although this approach is effective, it is also time consuming and complex and the determination of the protective measures to be employed is abstract.
01 T he employer is responsible for the risk assessment.
For the purpose of meaningful risk assessment, it is strategically more sensible to bundle pathogens into groups rather than consider every pathogen individually. Categorisation according to the mode of transmission offers an appropriate solution, because protective measures are directly connected to the mode of transmission. In the context of the health sector three modes of transmission are of relevance: 1. blood-borne infections 2. airborne infections 3. contact infections. Faecal-oral infections also present a risk but can be prevented in the same manner as contact infections. Risk analysis and assessment procedures should be developed separately for each of the defined modes of transmission and the protective measures stipulated respectively. In some instances, special attention needs to be paid to special aspects or questions that arise in connection with particular pathogens or health sector activities. These are referred to below.
3.2. General risk assessment of potential occupational exposure to infection Health service workers engaged in different areas or activities are exposed to quite different types of risk from infection.
Step 1 — Identifying hazards and those at risk Information on the risk from biological agents can also be found in books on occupational medicine (see literature). Instructions concerning the current risk situation can be obtained from national databases, for example in Germany epidemiological studies on outbreak situations by the Robert Koch Institute. The employer should utilise the expertise of a physician who specialises in occupational medicine and conduct the risk analysis together with him or her.
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Occupational health and safety risks in the healthcare sector
Risk areas include (non-exhaustive list) • Operating theatres • Acute medicine • Intensive care units • Emergency and ambulance services • Dialysis • Laboratories • Geriatrics, especially where there is exposure to blood and blood products, potentially hazardous devices and instruments, or handling of aggressive patients • Pathology, anatomy and forensic medicine (excluding laboratories) • Blood and plasma donor banks and centres.
Activities with potential risk of infection • Clinical examination of humans • Taking specimens of blood, body fluids or other clinical specimens e. g. smears • Surgical procedures • Dressing/treatment of wounds • Care of patients incapable of looking after themselves • Attending humans or animals at risk from others or themselves • Working with animals.
In addition, the following activities can also present a risk of infection: • cleaning, disinfection, repair and maintenance work as well as transport and disposal work in contaminated areas and/or with contaminated equipment and objects; • contact with areas where infection is suspected, e.g. contaminated materials in laundries (soiled laundry zone); • handling/moving of cleaning or disinfection apparatus; • handling pointed or sharp instruments or equipment.
Step 2 — Evaluating and prioritising risks Specific risk assessment for biological risks This is based on empirical knowledge, i.e. of which pathogens usually occur. In addition, epidemiological studies provide details of the frequency of infections and hence instructions concerning the risk assessment. Information about sud-
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3 Biological risks
denly changing situations (under certain circumstances pandemic outbreaks such as SARS or swine flu) is passed on in the public media. It should include: • consideration of which pathogens are commonly encountered (epidemiological situation); • consideration of which pathogens present a risk or possible exposure (risk group); • consideration of which means of transmission are encountered; • consideration of whether the work situation involve pressures of time and responsibility or high stress levels; • assessment of which risks require a risk minimisation plan; • determination of concrete measures to minimise risk; • implementation of health and safety measures. 02 There is a high risk from blood in operating theatres.
Step 3 — Deciding on preventive action — T-O-P General precautions — Standard measures of hygiene These are measures that have to be taken with contact to all patients to avoid a transmission of pathogens to the patients and to healthcare workers to reduce the risk of nosocomial infections. These include mainly the hygienic disinfection of the hands, but also the correct use of barrier precautions, according to the circumstances: • use of gloves (see below); • use of protective clothing (see below); • use of filtering face masks (see below); • the disinfecting and cleaning of visibly contaminated surfaces and objects and regular maintenance of medical products, as an important standard hygiene measure.
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Occupational health and safety risks in the healthcare sector
Technical measures and building installations
03 Example of a technical measure: safe equipment should be used.
The following preventive methods relate to general, basic methods of patient hygiene and care. They are, however, equally relevant to the health and safety of workers and should therefore be mentioned. In order to avoid potential risk, the employer is obliged to ensure that the necessary technical and hygienic measures are put in place. In certain situations the use of personal/individual protection methods is also appropriate and should be implemented. The specific methods prescribed depend on the actual situation or working conditions and, where necessary, should be extended or altered to take account of materials and workplace criteria.
Measures of hand hygiene Hygienic hand disinfection If there is an actual or even possible microbial contamination of the hands, hygienic hand disinfection is essential. In the case of a suspected or probable contamination use must be made of a reliable bactericidal, fungicidal and virucidal preparation, provided valid test results are available for it (e.g. isolation unit, children’s ward, suspected or definitely transmittable infection). Hygienic hand disinfection must be carried out in such a way that the contamination flora still on the hands are largely killed off. The alcoholic preparation is rubbed in over all the areas of the dry hands, paying special attention to the inner and outer surfaces including the wrists, the areas between the fingers, the finger tips, the nail folds and thumbs, and these are to be kept moist for the entire exposure time. Hygienic hand disinfection is necessary: • before the individual concerned enters the clean side of the personnel sluice of operating departments, sterilisation departments and other clean room areas; • prior to invasive measures, even if gloves (sterilised or unsterilised) are worn (e.g. installing a vein or bladder catheter, before angiography, bronchoscopy, endoscopy, injections, puncturing); 04 Hand disinfection has priority over hand washing. Hands should only be washed first and then disinfected if they are visibly dirty.
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3 Biological risks
• prior to contact with patients who are subject to a particularly high degree to the risk of infection (e.g. leukaemia patients, polytraumatised patients, patients who have been exposed to radiation or are otherwise seriously ill, patients with burns); • prior to activities involving a risk of contamination (e.g. provision of infusions, production of mixed infusions, charging medications); • before and after any contact with wounds; • before and after contact with the area of insertion points for catheters, drain tubes etc. • after contact with potentially or definitively infectious material (blood, secretion or excrement) or infected areas of the body. • after contact with potentially contaminated objects, liquids or surfaces (urine collection systems, evacuation units, respirators, respiration masks, tracheal tubes, drain tubes, dirty washing, waste etc.). • after contact with patients who may be a source of infections or who carry pathogens which are of special significance in terms of hospital hygiene (e.g. Methicillinresistant Staphylococcus aureus (MRSA)). • after removing protective gloves where there has been or probably has been pathogen contact or major soiling. Before aseptic measures (e.g. when dealing with patients with burns) it may be necessary to wash the hands prior to hand disinfection as with surgical hand disinfection. In the following situations a decision must be taken regarding hygienic hand disinfection or hand washing, according to the risk involved: • before preparing and distributing food; • before and after nursing or attending to patients where the indications mentioned with respect to hygienic hand disinfection do not apply; • after visiting the toilet (if the individual is suffering form diarrhoea, it is highly probable that there will be a major discharge of viral, bacterial or parasitic pathogens with extremely low infection dose — rotavirus, SRSV, EHEC, Clostridium difficile and Cryptosporidia — and so hands should be disinfected first); • after blowing one’s nose (in the presence of rhinitis there is a high probability of a viral infection with consecutive increased discharge of Staphylococcus aureus, and so hands should be disinfected first). Hygienic hand disinfection is a frequently repeated activity and mistakes are often made when it is being done. Such mistakes contribute both to a difficult to determine (but not inconsiderable) proportion of nosocomial infections and to work-related diseases (occupational diseases) among workers in the health service. It is the employer’s job to strengthen compliance, in particular with respect to hand disinfection. This can
05 The use of a brush to wash hands can be dispensed with because the brush may damage the skin.
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Occupational health and safety risks in the healthcare sector
be achieved by taking part in campaigns (e.g. clean hands campaigns) or by means of inspections — measurement of the consumption of disinfectants or (unnoticed) observation of workers as they perform duties involving compulsory disinfection. Hand washing Before the start and after the end of work it is sufficient to wash one’s hands once. Mainly owing to its limited effectiveness, hygienic hand washing is no alternative to hygienic hand disinfection. If, in addition to hygienic hand disinfection, cleaning is required, this should only be carried out after disinfection, with the following exceptions. Heavily soiled hands are first carefully rinsed off and then washed, and care must be taken to ensure that the surrounding area and clothing are not splashed (e.g. in the case of soiling by blood). Where necessary, the contaminated area must be disinfected subsequently and the overalls changed. Then the hands must be disinfected. Where the soiling is limited to certain spots, it can be removed using a paper handkerchief, cellulose or similar soaked in hand disinfectant and then the hand can be disinfected. 06 Hand washing before and after work, and when the hands are dirty.
Skin protection and skin care Skin care for hands and underarms is an occupational duty since even the smallest cracks or microtraumas are potential pathogen reservoirs and it is not possible to reliably disinfect uncared for skin. It is important when providing skin care products and for hand disinfection and washing agents that they are not only demonstrably effective and available at an acceptable price, but also that they are acceptable to the personnel, which will be reflected in the degree of compliance with all measures of hand hygiene. Skin care products should be taken from dispensers or tubes and are best used in work breaks or after work, given the impaired effectiveness of hand disinfection demonstrated as a function of the preparation; this applies where the manufacturer does not give well-founded instructions for use. Where the skin is at risk from working in a wet environment, moisture-proof gloves must be worn, controlled precautionary occupational healthcare must be ensured, an operating manual must be produced and a skin protection plan drawn up. Jobs performed with liquid-proof gloves for more than two hours are also deemed to be wet work.
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Basically the following applies: Where hands are severely or visibly soiled they must first be washed. Where it is suspected or definitely known that the hands are contaminated, priority must be given to hand disinfection. This is because disinfection is more effective in reducing germs and frequent hand washing damages the skin barrier. All workers must have access to hand-washing stations with hot and cold running water, hand disinfectant dispensers, appropriate skin protection and skin care products, and disposable towels. Workers must also have separate toilet facilities that are inaccessible to patients. This does not apply to the domestic sector. Surfaces (e.g. floors, worktops and surfaces, surfaces of apparatus, equipment) should be easy to clean and must be resistant to damage from the cleaning agent(s) and disinfectants used. In work areas where activities are carried out which present an increased risk of infection, hand basins should be fitted with taps that do not require hand contact to be operated.
Organisational measures The employer should only delegate work to persons who are suitably qualified in a health sector occupation unless they work under the instruction and supervision of an appropriately qualified member of staff whose training and experience make it possible to identify risks of infection and implement the correct preventive measures (e.g. doctors, nurses, medical assistant technicians, midwives and disinfectant specialists, as well as trained medical, dental and veterinary staff, ambulance staff, paramedics and care personnel). The requirement for supervision is deemed to be fulfilled when the person supervising the personnel is convinced that further monitoring is not necessary and that the designated task or function can be fulfilled without further supervision and includes the provision that spot checks should be carried out to make sure that the work is being carried out properly and safely. The employer may not delegate tasks where there is a potential risk of infection to juveniles or expectant and nursing mothers unless precautions are taken to ensure that they are not exposed to a health risk. The employer is responsible for preparing a list of written measures (hygiene plan) geared to the specific area of work and risk of infection, including disinfection, cleaning and sterilisation, and supplies and disposal. Personnel should not consume or store any food or drink in workplace areas where there is danger of contamination through biological agents. Employers should therefore provide staff lounges/separate rest areas for this purpose. In the case of activities where hygiene considerations dictate hand disinfection, personnel should be informed that no jewellery or watches may be worn on the hands or lower arms and that no earrings and other jewellery are permitted. Following contact with patients and exposure to infectious or potentially contaminated materials, personnel must disinfect and/or wash their hands taking into account the risk assessment of the specific cases.
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Personal/individual protection Protective wear is any clothing specifically intended to protect workers from the potential hazards and risks of the work situation or to protect their ordinary work clothes or personal clothing from becoming contaminated with pathogens. Used protective clothing must be kept separate from all other clothing. To this end, the employer must provide separate cloakrooms and changing facilities. Employers should provide personnel with sufficient quantities of the appropriate protective clothing and all other personal protective gear and equipment (PPE), especially fine, impermeable, hypoallergenic gloves. They must also ensure that these materials are regularly disinfected, cleaned and, where indicated, mended or repaired. Workers’ representatives shall be consulted before a decision on the use of protective equipment is made (Article 8 of Council Directive 89/656/EEC (17). If work clothes become contaminated they should be changed and then disinfected and cleaned by the employer. Personnel are obliged to use the protective wear and equipment provided. Personnel should not be allowed to take protective wear home for the purpose of washing. Admission to staff lounges, rest areas and canteens is not permitted to personnel wearing protective wear. 07 Adequate face protection is absolutely essential for operations involving a risk of splashing. 08 Face visors can prevent contamination of the eyes.
The employer should also provide staff with the following additional personal/individual protection:
(17) Council Directive 89/656/EEC of 30 November 1989 on the minimum health and safety requirements for the use by workers of personal protective equipment at the workplace (third individual Directive within the meaning of Article 16(1) of Directive 89/391/EEC), OJ L 393, 30.12.1989, pp. 18–28.
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• durable, impermeable, hypoallergenic gloves to be worn when disinfecting and cleaning used instruments, equipment and surfaces; gloves should not be affected by the disinfectants used; • impermeable, hypoallergenic gloves for cleaning work with long arms (gauntlet gloves) that can be tucked in to prevent contaminated fluids from running back under the glove; • cotton inner gloves for activities that involve prolonged use; • waterproof aprons or gowns where there is a possibility that clothing could get wet; • waterproof footwear for working conditions where it could be wet underfoot.
3 Biological risks
Eye and face protection should be provided against aerosol droplets and splashes of contaminated or potentially contaminated materials or fluids if technical measures do not otherwise afford sufficient protection. This could occur in the following situations: • surgical procedures, e.g. in vascular surgery, orthopaedic procedures (sawing bone); • endoscopic examinations; • diagnostic and therapeutic punctation; • intubation, extubation and management of endotracheal tubes; • insertion, cleaning and removal of in-dwelling catheters. • dental procedures, e.g. ultrasound removal of dental calculi; • caring for patients where there is coughing or expectoration; • cleaning contaminated instruments by hand or ultrasound; • work in mortuaries, e.g. when using hand-held devices or in the event of compression of the chest cavity of bodies when lifting and moving. Suitable equipment for protecting eyes and face includes: • safety glasses with side protection, including corrective glasses; • fit-over safety goggles; • safety glasses — disposable with side shields; • mouth protection and visor combination (disposable). Personnel are obliged to wear the prescribed personal protective gear. 09 Eye protection for dental procedures.
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Occupational health and safety risks in the healthcare sector
Medical gloves: requirements for medical gloves Qualitative minimum requirements for disposable medical gloves in the health service These must be manufactured in compliance with EN 455, i.e. with its stipulated thickness (accepted quality norm: AQL > 1.5) and other criteria. In view of the relatively high number of health sector workers with latex allergies, disposable gloves made of natural latex must comply with the guidelines on hazardous materials and should therefore be non-powdered and hypoallergenic. Use of protective gloves The so-called glove plan, which sets down guidelines regarding which type of glove should be worn by whom and for which purpose, often proves a valuable decisionmaking aid. The glove plan not only reduces the possibility of mistakes about the suitability for use but also serves cost reduction. Ideally, the decision about which gloves to select should be made in the works’ health and safety committee, which would, in all probability, ensure greater acceptance among personnel (see Table 3.1, page 62). In the operating theatre, non-powdered surgical gloves made of natural latex are advisable as currently no other material equals them in terms of comfort, fit, grip and wear. Surgical departments must decide internally when it is necessary to wear double gloves or gloves with a perforation indication system. The latter may be useful in the case of long surgical procedures lasting several hours as well as in procedures where there is an increased risk of perforation (e.g. in trauma surgery or orthopaedic procedures) or a specific risk of infection (e.g. HIV/AIDS). With respect to the use of non-sterile protective gloves, there are at least three different types that recommend themselves and should be made available. • In non-clinical activities, such as kitchens, technical services or cleaning (as long as infectious or potentially contaminated material is not involved), PVC or polyethylene (PE) gloves may be used; however, medical protective gloves (tested to EN 455 standards) are not necessary. • For simple tasks in patient care where grip control or sensitivity to touch are not particularly important, gloves made of synthetic materials such as PVC or PE are generally sufficient. • By contrast, latex gloves are preferable for all activities that involve exceptional mechanical strain or where gloves need to be worn for longer periods of time. For tasks requiring a high degree of sensitivity to touch and strong grip control, it is essential that latex gloves are worn. It is advisable to store gloves at all workplaces because the route to finding the gloves prevents the wearing of them. For the user, this means the end of a thoughtless, careless attitude towards gloves. In future, more consideration should be given to the importance and function of gloves. Management must ensure that the importance of wearing gloves forms part of workplace instruction, which should be included in basic training, refresher courses and further training.
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3 Biological risks
If workers report allergic reactions or sensitivity following contact with medical gloves a decision should be made (in cooperation with the works physician or health and safety expert) regarding the choice of alternative products. Following consultation with all departments it is generally possible to put together a selection of gloves that meets all the different sets of requirements. Allergies or adverse reactions associated with the wearing of medical gloves need to be taken seriously and diagnostic procedures (including dermatological diagnosis if necessary) should be initiated. Mistakes relating to the use of medical gloves • Disinfectants are usually concentrates that are diluted in solution. When using solutions made up from concentrates it is necessary to wear the appropriate chemical gloves in order to provide effective skin protection (higher membrane strength, compliant with EN 374). Medical gloves (made of latex, PVC or polyethylene) are not suitable wear for this type of work. • Work in the emergency and rescue services requires especially tough gloves that are strong, durable and do not tear easily. This is often not given sufficient attention (see PVC). • Incorrect storage of packs of gloves, for example involving exposure to heat or ultraviolet rays (fluorescent lamps, sunlight), has been observed in many ambulances (and doctors’ surgeries). Light and heat cause oxidisation, which effectively reduces the strength and elasticity of natural latex products. • Gloves are put on although the hands are still wet from residual hand disinfectant. Once covered, alcohol-based hand rubs cannot evaporate. This may cause burnlike symptoms. It has yet to be determined whether disinfectants with additional extracts cause after-effects. • Surgical gloves are frequently worn for aseptic tasks and procedures, although sterile examination gloves (which are usually much less expensive) are entirely suited for such purposes. According to the task or activity, individually packed sterile gloves are perfectly sufficient, e.g. for endotracheal suction of patients on respirators. As a basic principle the selection of personal protective equipment must take full account of the risk and the activity involved (the protective goal). Below are three tables containing instructions for the use of protective gloves and protective clothing.
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Occupational health and safety risks in the healthcare sector
Glove
Material
Use
Examples
Unsterile
Disposable glove (polyethylene (PE))
Working with low mechanical load
Discharging urine
Household glove
Working with high mechanical load
On contact with dirt
Latex examination glove
For medical activities
Removing dressings, disposing of soiled material Working with tactile sensation
Examination glove (latex-free e.g. PVC)
Working with disinfectant/cleaning solutions and in case of allergies against latex
Working with tactile sensation
Protective glove of nitrile or similar
Broad use spectrum with exposure to hazardous substances (cytostatica)
With skin irritations, incompatibility, for big operations, good tactile properties
Cloth glove When protective gloves are worn (e,g. seamless cotton yarn gloves) for long periods
Working with surface and instrument disinfectant solutions
With skin irritations, incompatibilities
Where relevant also acceptable to use sterile Sterile operating gloves
Disposable glove (polyethylene (PE))
When working under sterile With indwelling catheter, tracheal conditions and with low mechani- evacuation glove liner in the case cal load of possible latex intolerance
Latex glove (sterile use operating gloves)
When working under sterile con- Wound care, insertion of cathditions with high mechanical load eters, operations
Latex-free glove
See above
See above
Where allergy has been determined in patient or personnel Table 3.1: Glove materials, special uses for these gloves and examples of the application of protective gloves in the health service Source: Deutsche Gesellschaft für Krankenhaushygiene.
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Clothing
Use
Frequency of change
Work clothing
In working areas with low hygienic requirements (e.g. psychiatry, old people’s residential facilities)
The frequency of change depends on the individual circumstances at the workplace; in the case of contamination immediately
Where there is the risk of contamination, protective clothing from employer
Normally daily change
Area clothing Allocation to a certain working area Protective clothing
In defined areas, such as operating/functional areas
To be taken off when leaving the area
Over working, area or personal clothing
Immediately after visible soiling
Apron overall Protection of working/service clothing Hair protection
Eye protection
Mouth-nose protection (mask)
After completion of activity To be taken off for eating and in breaks Protection of head from contamination by infectious material (e.g. during invasive measures)
Disposable product, direct disposal after use
Protection of eyes against contamination from infectious material or chemical hazardous substances/operations
Disposal of single-use material
Protection of patient against contamination, exhaled and spat-out aerosols
Direct disposal of single-use products
Subsequent hygienic hand disinfection
Disinfection/cleaning of reprocessable material in the case of contamination To be taken off after completion of work Subsequent hygienic hand disinfection
Respiratory protection
Where infectious aerosols arise, or where there Disposable product, with subsequent hygienic hand disinfection Filters the respiration air in order are airborne infections to retain infectious aerosols No reuse Table 3.2: Protective equipment — use and change requirement Source: Deutsche Gesellschaft für Krankenhaushygiene.
10 Area clothing does not meet the requirements of protective clothing; the protective clothing must be worn over the area clothing.
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Occupational health and safety risks in the healthcare sector
Work clothing Protective clothing Hospital
Rehabilitation clinics
Work clothing to be provided by company/ employer.
Work clothing to be provided by company/ employer
Hair protection
Sterile protective cloth- Operating/funcing, e.g. for invasive tional departments measures Sterile protective clothing where there is a risk of contamination and for isolation
In the case of operative interventions where there is a risk of contamination
Sterile protective cloth- In the case of ing for operative/inva- invasive meassive interventions ures Unsterile protective clothing where there is a risk of contamination
Eye protection
Mouth-nose protection
Where there is a risk of splashing when handling body fluids and disinfectant/cleaning concentrates and other chemical substances
Operating/functional areas Risk of contamination for patients –– where relevant in the case of isolation –– in the case of immunitysuppressed patients Respiratory mask as protection for personnel when dealing with airborne diseases
Where there is a risk of contamination
For example, in the case of defined invasive measures
When handling disinfectant/cleaning concentrates and other chemical substances
–– where there is a risk of contamination –– where relevant in the case of isolation –– where relevant with immunity-suppressed patients Respiration mask Isolation/dealing with highly contagious diseases
Nursing facilities
Outpatient care
Work clothing to be provided by company/ employer
Work clothing
Unsterile protective clothing in the case of invasive measures
In the case of invasive measures
Sterile protective clothing where there is a risk of contamination and in cases of isolation
Sterile protective cloth- Not applicable ing for defined invasive measures Unsterile protective clothing (apron) where there is a risk of contamination for shortsleeved clothing Covering overall where there is a risk of contamination to the lower arm/when clothing is drawn back
Where there is a risk of contamination
When handling disinfectant/cleaning concentrates, including chemical substances Not applicable
As patient protection with invasive measures Where there is a risk of contamination for infectious patients to reduce infectious aerosols In cases of isolation For defined invasive measures
Where there is a risk of contamination
Where relevant in the case of immunity-suppressed patients see ‘Nursing facilities’
Table 3.3: Use of different protective clothing in various areas of the health service Source: Deutsche Gesellschaft für Krankenhaushygiene.
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Cleaning, disinfection, sterilisation When cleaning used instruments additional protective measures in keeping with the respective mode of transmission should be adopted. Special protective measures are required when personnel are engaged in the cleaning and sterilisation of instruments that have been in contact with patients with Creutzfeldt-Jakob disease (CJD) or new variant Creutzfeldt-Jakob disease or comparable spongiform encephalopathy or suspected cases. The greatest risk of infection occurs when preparing instruments for cleaning as they are still contaminated by blood, body fluids or body tissues and the risk of injury is relatively high. Disinfectants effectively reduce the bacteria count and hence the risk of infection is much lower after disinfection. But there is also a clear risk of injury during the manual cleaning of instruments. At the same time, attention should be paid to the effects of the potentially allergenic and hazardous chemical materials employed in such procedures. If infectious or potentially contaminated instrumentation, devices, equipment or materials are handled at one central unit, it is essential that the incoming (unclean or contaminated) zone and the outgoing (clean/sterile) zone be strictly separated both in terms of organisation and actual location. The incoming zone should be spacious enough to be able to store the soiled incoming items for a brief period before they can be dealt with effectively. Prior to leaving the contaminated zone personnel must remove all personal protective equipment (PPE) and disinfect their hands. If instruments are cleaned and sterilised in one central unit any risk assessment must take account of all the potential pathogens generally encountered. When cleaning instruments from high-risk medical situations, particular care and attention should be paid to the increased incidence of microorganisms specific to that situation and the special risks anticipated. The disinfection and cleaning of instruments should preferably be carried out in a closed automated system in order to minimise the risk of injury or contamination and to protect workers from contact with disinfectants. Technical and organisational steps should be taken so that the soiled instruments do not need to be re-packed in advance of cleaning. 11 The personal protective equipment must be put on before the activity involving the risk of infection.
Manual cleaning of contaminated instruments should be kept to an absolute minimum. However, if manual preparation of the instruments is unavoidable, this should be done in a separate, well-ventilated room that is not used for other purposes, especially not for the storage of open items, such as a changing room or recreational or rest area.
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Whilst cleaning instruments manually, personnel must wear long protective gloves, mouth-nose protectors and protective glasses, as well as a waterproof apron or gown to protect skin and mucous membranes against contact with infectious material. If the staff member carrying out manual cleaning operates behind a screen and is effectively protected, the mouth-nose protector and protective eyewear may be dispensed with. The protective gloves chosen must be suitable for working with disinfectants and afford protection against potentially infectious material. It is important to avoid producing aerosols or airborne droplets during the initial cleaning of instruments, especially if sticky, dried-on material needs to be removed. For this reason, the instruments should not be placed under a strong jet of water or sprayed. If contaminated instruments are placed in an ultrasonic cleaning bath, the bath should be covered during use and the aerosols extracted by suction. Every precaution should be taken to avoid injury when handling sharp, pointed and cutting instruments designated for manual cleaning. To this end, various precautionary steps should be taken beforehand, for example in the operating theatre or treatment room. • All items which are not designated for processing, such as single use instruments, swabs, compresses, wipes and towels, should be removed from the sieve or container using tongs or a similar tool. • Scalpel blades, needles and canulae should — wherever possible — also be handled using tongs or a similar tool. Sharp or pointed instruments or instrument parts should be laid out separately in a sieve or on a kidney dish. 12 Care must be taken to select sturdy protective gloves for cleaning work.
• A ll machines and equipment that need to be processed by hand must be handled separately with caution. Attachments such as drills and cutting devices, should be removed. • M inimally invasive surgical (MIS) instruments, which need to be taken apart prior to processing, should be kept separate and — if possible — placed on an MIS sterilisation trolley at the same time as they are disassembled. • T angled hoses, pipes and cables should be avoided by keeping them separate from the outset.
Handling soiled linen Linen used where there is a high risk of contamination from pathogens and infectious materials must be discarded and disposed of immediately at the site of use in sufficiently sturdy, closed containers ready for collection. Laundry should be transported so that personnel are not exposed to biological agents. The containers must be clearly labelled. The following precautions apply to linen collection: • separate handling of infectious linen; • separate handling of wet linen (heavily soiled with body excretions); • separation according to the method of laundering and cleaning.
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3 Biological risks
A suitable laundry collection system uses: • textile bags made of a fabric which is so closely woven and dense that it is virtually impenetrable; • plastic bags, e.g. polyethylene sacks, to bag the soiled linen; For the purpose of infection control, the following points should be observed regarding the handling and transport of full laundry bags. • They should be closed during transportation, should not be thrown, stacked high or rammed together. • It should be possible to put the contents in the washing machine or in the laundry system. Precautionary measures In occupations where there is a high risk of infection the workers should be examined regularly with respect to the work they carry out. It is particularly important that occupational health checks and examinations are carried out if there is an occupational exposure to microorganisms which could cause infectious disease. Medical check-ups and health and safety reviews should help identify problems at an early stage and ideally prevent health problems resulting from transmissible infection. The employer, usually in consultation with the medical officer or designated health and safety officer, chooses the persons and groups of workers selected for medicals. In the health sector, a medical check-up is a condition of employment for all new workers. In addition to medical check-ups, occupational healthcare embraces the assessment and management of occupational health risks (including recommendations on suitable precautions and protective measures). It also entails the submission of health and safety recommendations about workplace conditions and the continual improvement of occupational health and safety standards by applying the lessons gained through experience and through ongoing instruction and advice for staff and management. Vaccinations carried out during the course of medicals may prove necessary if risk assessment indicates vaccination as a suitable control of infectious pathogens. One of the key tasks of occupational healthcare is the delivery of information and advice. Where workers are at risk from biological agents (pathogens) medical aspects are of great importance to occupational health. For example, if there is a history of a particular disease that might result in weakened immunity, there could be an increased risk of infection. A knowledge of modes of transmission, symptoms and post-exposure prophylaxis is also required, firstly to determine the precautions needed to prevent and control infection and secondly to ensure a prompt, correct response to critical exposures (e.g. needlestick injuries). In view of the aforementioned, advice on occupational health and risk control must address both management and personnel. Workers are generally advised on occupational health at the same time as they undergo their medical check-up and the advice and information should be geared to the individual health status of the individual. However, as the intervals between medical check-ups tend to be quite long, it is advisable to provide all workers with general instruction and advice on occupational health and safety issues at least once a year. Here the aim is to remind personnel of the health risks associated with their work, especially when immunity is weakened, and to encourage them to accept the help available.
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Vaccination Vaccinations are an important link in the chain of preventive measures. An indicative list of diseases which can be prevented by vaccination can be found below. Directives 2000/54/EC (18) and 2010/32/EU (19) contain provisions regarding vaccinations. Vaccination is not compulsory. 13 It is advisable to provide all workers with general instruction and advice on occupational health and safety issues at least once a year.
Directive 2000/54/EC (18), Article 14, paragraph 3: ‘The assessment referred to in Article 3 should identify those workers for whom special protective measures may be required. When necessary, effective vaccines should be made available for those workers who are not already immune to the biological agent to which they are exposed or are likely to be exposed. When employers make vaccines available, they should take account of the recommended code of practice set out in Annex VII.’ Annex VII. (3): ‘Vaccination must be offered free of charge to workers.’ Directive 2010/32/EU of 10 May 2010 implementing the Framework Agreement on prevention from sharp injuries in the hospital and healthcare sector concluded by HOSPEEM and EPSU (19) states, in Clause 6 of the annex to the directive: ‘3. If the assessment referred to in Clause 5 (20) reveals that there is a risk to the safety and health of workers due to their exposure to biological agents for which effective vaccines exist, workers shall be offered vaccination.’
(18) Directive 2000/54/ EC of the European Parliament and of the Council of 18 September 2000 on the protection of workers from risks related to exposure to biological agents at work (seventh individual directive within the meaning of Article 16(1) of Directive 89/391/EEC), OJ L 262, 17.10.2000, pp. 21–45. (19) Council Directive 2010/32/EU of 10 May 2010 implementing the Framework Agreement on prevention from sharp injuries in the hospital and healthcare sector concluded by HOSPEEM and EPSU (Text with EEA relevance), OJ L 134, 1.6.2010, pp. 66–72. (20) Clause 5 concerns risk assessment.
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Indicative list of illnesses that can be prevented by immunisation Diphtheria
Influenza
Pneumococci
Hepatitis A
Measles
Rubella
Hepatitis B
Mumps
Tetanus
Human papilloma virus
Pertussis
Step 4 — Taking action Infection prevention measures must be implemented in consultation with the hygiene commission (a physician responsible for matters of hygiene) and a physician with expertise in occupational medicine. Bacteriological checks must be conducted to preclude any risk to workers.
Step 5 — Monitoring and review Infection monitoring measures must be inspected regularly. If an outbreak occurs, special, more extensive investigations are required. The integration of a quality management system can give effective support when implementing infection monitoring measures.
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3.3. Special risk assessment of biological risks 3.3.1. Risk of blood-borne infections Blood-borne infections: Hepatitis virus B, C and D Human immune deficiency virus (HIV) Handling blood These viruses are transmitted parenterally (through blood-to-blood transmission). They enter the blood stream of the healthcare worker via contact with the infected body fluids of a virus carrier (predominately blood and blood products) and are transmitted through the mucous membrane or broken skin of the healthcare professional. Occupational health risks are posed by: • injuries from contaminated canulae, lancets or similar implements; • broken skin — often unnoticed — when blood plasma, serum or similar fluids enter via broken skin despite the absence of any sharps or needlestick injury. Areas of special exposure These include: health services; mental health institutes and the prison service; care of the elderly; and ambulant care services, especially where personnel handle blood and blood products or potentially hazardous implements or equipment, or attend aggressive patients, such as: • operating theatres and anaesthesia units; • intensive care units; • emergency and ambulance services; • blood and plasma donor banks and centres;
14 Installing an infusion is a critical moment with a high risk of injury.
• the supply and disposal side or other areas which serve the operation and maintenance of the areas listed above; • dental units. Activities with potential risk of infection include: • clinical examination humans;
of
• taking specimens of blood, body fluids or other clinical specimens, such as smears; 69
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• surgical procedures; • dressing/treatment of wounds; • care of patients incapable of looking after themselves; • attending humans at risk from others or themselves. In addition, the following activities can also present a risk of infection: • cleaning, disinfection, repair and maintenance work, and transport and disposal work in contaminated areas and/or with contaminated equipment and objects; • handling infectious materials or where contamination is anticipated or suspected (soiled laundry zone); • setting up cleaning or disinfection apparatus; • handling pointed or sharp instruments or equipment; • handling healthcare waste. Blood is the body fluid that presents the greatest risk of infection to healthcare personnel. Basic hygiene rules Body fluids, excretions and secretions must always be handled as if they were infectious. Therefore the most effective precautions must always be stringently and consistently applied to protect patients and personnel.
15 16 Sharps containers of an appropriate size must be available at the workplace.
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Technical precautions Risk assessment and needlestick injuries: safe sharps In order to minimise the risk of workers injuring themselves with sharp medical instruments traditional instruments should be replaced — on the basis of the results if a risk assessment dictates and insofar as this is technically possible — with safer, modern equipment that presents a lower risk of resultant injury. Safe equipment and utensils should be used in areas that present a high risk of infection and/or injury, such as: • care and treatment of patients with blood-borne infections; • attending patients who pose a threat to others; • ambulance and emergency services and casualty departments • hospital prison service Safe equipment should be used as a matter of routine in all activities where there is a possibility of transmitting relevant amounts of infectious matter via body fluids, in particular when • taking blood specimens; • collecting other body fluids (minimally invasive punctures). The selection of safe equipment must take account of various criteria, including: whether it is fit for the purpose; easy to operate and handle; and acceptable among the personnel for whom it is intended. Work practices and methods should be adapted to incorporate safe systems and best practice. Management has a responsibility to ensure that workers are capable of using safe equipment correctly. This can be achieved by informing workers about safe equipment and how it should be used. 17 There are very different technical solutions to prevent cannula injuries.
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The success of the new measures should be monitored. Safe equipment and utensils designed to protect staff from needlestick and cut injuries must not present any risk to patients. Furthermore, they should fulfil the following criteria. • The safety mechanism is integral to the system and compatible with other tools and accessories. • It requires only one hand to activate. • Activation can proceed immediately after use. • The safety mechanism excludes further use. • The safety product does not necessitate any changes to the application procedure. • The safety mechanism must emit a clear signal (tactile or audible). The use of safe equipment is accorded the same importance as procedures which facilitate putting syringes back in protective sheaths using just one hand, as exemplified by local anaesthesia in dental medicine or pens to inject medicine. 18 Needlestick injuries can be avoided with the use of safe products. After the injection, a protective cap remains at the end of the hollow needle to prevent puncture injuries.
Disposal of pointed and sharp instruments As sharp, blood-contaminated objects present probably the greatest risk to personnel, it is essential that items such as syringes and canulae are immediately disposed of at the site of use in impenetrable, unbreakable containers. Staff should take such a container with them every time they carry out any invasive procedure — irrespective of how minimal — and containers should be placed in every work area where such instruments and objects are frequently used.
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Waste containers Personnel must have access to and use pierce-proof/puncture-proof, unbreakable containers for the collection of sharp and pointed instruments. Such containers should have the following characteristics: • Closable, single-use containers • Ability to retain contents even if knocked, placed under pressure or tipped over • Impermeable and impenetrable • Moisture does not adversely affect their solidity • Suitable for the waste product in question in terms of size/capacity and the size of the opening • The safety mechanism is not deactivated by disposal • Clearly identifiable as waste containers through their colour, shape and labelling. 19 Sharp and pointed objects must be disposed of immediately after use.
Organisational measures should include: • immediate disposal of sharp instruments in unbreakable, impenetrable containers directly at the site of use; • routine, regular hand hygiene and skin care;. • disinfection, cleaning and sterilisation of blood contaminated instruments and work surfaces; • regularly issued information bulletin on work health and safety regulations.
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Personal/individual protection Protective gloves and other protective equipment must be worn: • when performing tasks where contact with blood, blood components, body fluids, excretions or secretions can be expected; • including protective apparel (over uniform or work clothes) and — where necessary — waterproof aprons; • during all tasks where contamination of clothing through blood, body fluids, excretions or secretions can be expected; • to protect the respiratory tract and eyes (with filtering face pieces (FFP2) and protective eyewear) when the formation of aerosols or droplets or splashing with blood, body fluids or excretions/secretions can be expected, for example by the intubation of bronchioscopes, suction, dental treatment and transurethral procedures. Occupational health precautions: immunisation (vaccination) Hepatitis B is the only form of hepatitis for which there is an effective vaccine. The employer should offer immunisation free of charge and urge all workers exposed to risk to agree to active immunisation. The anti-hepatitis B vaccine also affords protection against the hepatitis D virus. Prior to primary immunisation, the immune status of the worker should be ascertained to establish if hepatitis B (HB) antibodies already present. If there is a negative finding (no immunity), is active immunisation indicated? If tests for anti-HBc are positive, then tests should establish whether HBs Ag and antiHBs are present. (Further advice should be sought from a general practitioner or medical specialists.) Non-responders Approximately 5 % of vaccinated persons either do not develop an HB immunity or exhibit insufficient immunity following the first vaccination. When this occurs, a repeat intramuscular vaccination, perhaps even a double dose administered in both upper arms (m. deltoideus) can result in the desired protection. This also applies to combination vaccine with other vaccines (e.g. hepatitis A or influenza). Healthcare professionals who are considered non-responders, i.e. who have no immunity and remain unprotected following vaccination, should be informed that they are susceptible to an increased occupational risk and told about post-exposure prophylaxis (passive immunisation). It is advisable to secure written documentation in cases where a worker refuses vaccination. Course of hepatitis B vaccine Initial immunisation should be given at intervals of 0.1 and six months: four weeks after primary immunisation, a test should be done for vaccination efficacy. Given antiHBs value > 100 IE/litre, a booster vaccine (one dose) should be administered as a rule 10 years after the complete course of primary immunisation. Given anti-HBs values below 100 IE/L, vaccinate again (one dose) within a year and conduct antibody screening after four weeks. Given anti-HBs values below 10 IE/L, there should be immediate repeat vaccination. With additional vaccinations 60–75 % of non-responders or low responders will produce an adequate antibody count. Therefore, serum testing would be necessary in some specific cases.
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Immediate measures following contact with infectious material It is possible for pathogens to enter the blood stream through percutaneous injury (e.g. cuts, needlestick injuries). Action should be taken even if the contaminated skin appears to be intact. • Clean off the blood as soon as possible. Rinse the skin with water and disinfect the area using a skin disinfectant. • For splashes and droplets of blood/body fluids on intact skin, wash with soap and water. Disinfect the area using a skin disinfectant. • For contamination of mucous membranes (mouth, nose, eyes), rinse thoroughly with water or a physiological liquid (Aquadest or sterile NaCl 0.9 %) or 1:4 diluted iodine to water solution (mouth, nose). • For blood/body fluids splashed on broken skin, clean off blood/body fluid disinfect with a skin disinfectant plus PVP iodine. • The event should be well documented. Vaccination post exposure? Determining whether to vaccinate against hepatitis B post exposure: • If the worker is immune (has been infected with hepatitis B in the past) or is adequately protected by earlier vaccination (anti-HBs > 100 IE/L within the last 12 months or has had a successful vaccination within the past five years), further measures are not required. • If the donor (source of infection) is HBsAg negative, further measures are unnecessary although the worker should be vaccinated against hepatitis B (in order to safeguard against a similar incident in the future) unless he or she is immune or already sufficiently protected by vaccination
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Directive 2010/32/EU implementing the Framework Agreement on prevention from sharp injuries in the hospital and healthcare sector concluded by HOSPEEM and EPSU (21) In November 2008, the European social partner organisations HOSPEEM (the European Hospital and Healthcare Employers’ Association, a sectoral organisation representing employers) and EPSU (the European Federation of Public Services Unions, a European trade union organisation) informed the Commission of their wish to enter into negotiations in accordance with Article 138(4) and Article 139 of the Treaty establishing the European Community (the EC Treaty) with a view to concluding a framework agreement on prevention from sharp injuries in the hospital and healthcare sector. On 17 July 2009 the European social partners signed the text of the framework agreement on prevention from sharp injuries in the hospital and healthcare sector, and informed the Commission of their request to submit the agreement to the Council for a Council directive. The framework agreement aims to protect workers at risk of injury from all medical sharps (including needlesticks) and to prevent the risk of injuries and infections caused by medical sharps. It provides for an integrated approach to risk assessment, risk prevention, training, information, awareness-raising and monitoring and for response and follow-up procedures. The agreement will contribute to achieving the safest possible working environment in the hospital and healthcare sector. The European Parliament adopted on 11 February 2010 a resolution supporting the proposal for a Council directive presented by the Commission in October 2009. Directive 2010/32/EU implementing the framework agreement was adopted by the Council on 10 May 2010. The Member States shall bring into force the laws, regulations and administrative provisions necessary to comply with this directive or shall ensure that the social partners have introduced the necessary measures by agreement by 11 May 2013 at the latest. The framework agreement, which is implemented by the above directive, is composed by a preamble and eleven clauses. The main points are the following: Clause 1: Purpose This clause lays down out the overall objective of the agreement (to achieve the safest possible working environment by preventing injuries to workers caused by all medical sharps, including needlesticks, and protecting workers at risk). To this end, it provides for an integrated approach, establishing policies in risk assessment, risk prevention, training, information, awareness-raising and monitoring, and for response and followup procedures. Clause 2: Scope This clause makes it clear that the agreement applies to all workers in the hospital and healthcare sector and to all who are under the managerial authority and supervision of the employers. Clause 3: Definitions
(21) OJ L 134, 1.6.2010, pp. 66–72.
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The agreement employs various terms: workers, workplaces, employers, sharps, hierarchy of measures, specific preventative measures, workers’ representatives, workers’ health and safety representatives and subcontractors. Clause 3 sets out the meanings of these terms for the purpose of this agreement.
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Clause 4: Principles This clause lays down the principles which must be observed when taking action under the agreement. Paragraph 1 points to the vital role of a well-trained, adequately resourced and secure health service workforce in preventing risks. It also states that preventing exposure is the key strategy for eliminating and minimising the risk of injuries and infections. Paragraph 2 concerns the role of health and safety representatives in risk prevention and protection. Paragraph 3 sets out the duty of the employer to ensure the health and safety of workers in every aspect relating to the work. Paragraph 4 makes it the responsibility of each worker to take care of his or her own safety and that of other persons affected by their actions at work. Paragraph 5 deals with the participation of workers and their representatives in the development of health and safety policy and practice. Paragraph 6 explains that the principle of the specific preventative measures is never assuming that no risk exists. It also points to the hierarchy of measures concerning the safety and health protection of workers as set out in the relevant Community directive, i.e. to avoid risks, to evaluate remaining risks which cannot be avoided, to combat risks at source and to reduce risks to a minimum. Paragraph 7 concerns collaboration between employers and workers’ representatives with a view to eliminating and preventing risks, to protecting workers’ health and safety and to creating a safe working environment. Paragraph 8 recognises the need for action involving information and consultation in accordance with national law and/or collective agreements. Paragraph 9 deals with the effectiveness of awareness-raising measures. Paragraph 10 stresses the importance of a combination of several measures for achieving the safest possible workplace environment. Paragraph 11 states that incident reporting procedures should focus on systemic factors rather than individual mistakes and that systematic reporting must be considered as accepted procedure. Clause 5: Risk assessment Paragraph 1 states that risk assessment procedures are to be conducted in compliance with the relevant provisions of Directives 2000/54/EC and 89/391/EEC. Paragraph 2 stipulates what is to be included in risk assessments and specifies potentially hazardous situations to be covered by them. Paragraph 3 lists the factors to be taken into account in risk assessments with a view to identifying how exposure can be eliminated and considering possible alternative systems. Clause 6: Elimination, prevention and protection Paragraphs 1 and 2 list several measures to be taken to eliminate the risk of injuries with a sharp and/or infection and to reduce the risk of exposure. 77
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Paragraphs 3 and 4 address situations where there is a risk to the safety and health of workers owing to their exposure to biological agents for which effective vaccines exist. Under these circumstances workers are to be offered vaccination, which is to be carried out in accordance with national law and/or practice. Furthermore, workers are to receive information on the benefits and drawbacks of vaccination and non-vaccination. Vaccination must be free of charge. Clause 7: Information and awareness-raising As medical sharps are considered work equipment in accordance with Directive 89/655/EEC, this clause lays down several information and awareness-raising measures to be taken by the employer, in addition to the provision of information and written instructions in accordance with Article 6 of that directive. Clause 8: Training This clause stipulates that workers are to receive training in certain policies and procedures associated with injuries caused by sharps, including those listed. This training is in addition to measures laid down in Article 9 (‘Information and training of workers’) of Directive 2000/54/EC on the protection of workers from risks related to exposure to biological agents at work (22). The clause also imposes various obligations on employers with regard to training and stipulates that the training is mandatory for workers. Clause 9: Reporting Paragraph 1 stipulates that the existing procedures for accident reporting involving injuries are to be adapted and should be revised in conjunction with health and safety representatives and/or appropriate employers and workers’ representatives. Reporting procedures should include technical details with a view to improving data collection on this type of hazard (which is underestimated) at local, national and European levels. Paragraph 2 imposes an obligation on workers to report any accident or incident involving medical sharps immediately. Clause 10: Response and Follow-up This clause deals with policies and procedures that are to be in place where an injury involving a sharp occurs. In particular, it specifies several steps that are to be taken, such as the provision of post-exposure prophylaxis and the necessary medical tests, appropriate health surveillance, the investigation of the causes and circumstances of the accident, the recording of the accident and the counselling of the workers. It states that confidentiality of injury, diagnosis and treatment must be respected. Clause 11: Implementation This clause lays down several provisions regarding the implementation of the agreement. It lays down a ‘minimum standards’ clause, which states that the agreement is without prejudice to existing or future national and European Union provisions which are more favourable to workers’ protection from injuries caused by medical sharps.
( ) OJ L 262, 17.10.2000, pp. 21–45. 22
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It states that the Commission could refer the interpretation of the sgreement to the signatory parties, who will give their opinion, without prejudice to the roles of the Commission, the national courts and the Court of Justice of the European Union.
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Programme of tests and examinations following needlestick and sharps injuries Risk analysis The basis for further action is the assessment that a real risk exists. Before reaching this conclusion, it is necessary to evaluate key factors such as the immune status of the injured person, the type and gravity of the sharps or needlestick injury and the contaminated quantity of blood. Blood tests If risk analysis cannot exclude a risk of infection, the following tests should be carried out: anti-HBs, anti-HBc, anti-HCV and anti-HIV. These tests should be repeated six, 12 and 26 weeks after the first test. If the index patient is known and suspected of exhibiting infection, it is possible to obtain further information on the basis of an immediate single test for antiHBs, anti-HBc, anti-HCV and anti-HIV. Hepatitis B — Precautions If the exposed person has not been rendered sufficiently immune by previous immunisation, the response should be immediate active anti-hepatitis B vaccination. If an injury involves proven contamination with blood that is hepatitis-B positive, this should be followed within six hours by passive immunisation. Hepatitis C — Precautions Two to four weeks after contact with blood from a person identified as being hepatitis C positive, HCV-PCR is recommended to facilitate early diagnosis and treatment. Irrespective of this, testing for anti-HCV must be carried out at the intervals given in the schedule above. HIV — Measures and precautions Following contact with blood that is from a person who is potentially infected with HIV, the infectiousness of the index patient can be determined with a quick HIV test (an antibody test). If the blood contact is from a person clinically proven to be HIV positive, medical postexposure prophylaxis (PEP) is indicated. PEP is at its most effective if commenced within two hours of the injury and it can prevent infection even if the virus has entered the bloodstream. However, due to the severe side-effects of the medication, the decision whether to embark on PEP should be made by a specialist. Documentation of the injury and an account of the accident Injuries should be well documented so that accidents can be analysed and preventive measures recorded.
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3.3.2. Risk of airborne infection Aerogen transmitted infection, including: • mumps
• tuberculosis
• influenza
• measles
• rubella
• SARS.
Introduction Airborne pathogens are transmitted almost exclusively from one person to the next (human-to-human transmission). Aerosols are formed when patients with an infection of the respiratory organs (lungs, bronchi or larynx) cough, sneeze or speak. Thus, miniscule droplets and droplet nuclei are released as a fine mist in the exhaled air. The size of these aerosols varies as they are subject to diverse aerodynamic factors.
Risk assessment The infectiousness of the aerosols depends on particle size and density, the density of the pathogens within the particle, as well as the time required for inhalation and the volume inhaled. Small particles (droplet nuclei