OSHA’S FINAL WORD ON BLOODBORNE PATHOGENS
On December 6, 1991. the Occupational Safety and Health Administration (OSHA) issued the final rule on the protection of workers from bloodborne pathogens. These regulations will have a dramatic impact on fire and rescue services nationwide. Although not all states fall under the federal OSHA regulations, most departments will be affected. States that do not fall under the federal regulations must develop “state plans”— which follow the federal regulations but may go beyond them. (See box on page 83 for a list of states that have developed their own plans. If your state is listed, be sure to obtain a copy of the plan for review by your department’s infection control officer to ensure that your department is in compliance with the current rcgulations.) Since the federal OSHA regulations do not apply to state and local employees, departments may have to turn to NFPA 1581, Standard on Fire Department Infection Control Program, for guidance in developing an overall plan for infection control.
The final regulations are not significantly different from the proposed regulations that were issued on May .30. 1989. Major changes did not appear in the final regulations. The two documents, however, are not identical. There are some terminology changes, the requirements for education and training have some additional guidelines, and the hepatitis B vaccine issue has a much stronger focus.
WORKER COVERAGE UNDER THE LAW
Many have questioned whether these regulations apply to fire and rescue personnel. This question is answered in part one of the document. While it does not name fire and rescue personnel in print, it goes beyond that by stating “a single exposure incident may result in infection and subsequent illness and in some cases, death. The hazard affects employees in many different types of employ ment and is not restricted to the healthcare industry.” OSHA, therefore, relates coverage to occupational exposure to blood and other body fluids, not a specific occupation. The regulation also states: “…all workers with reasonably anticipated occupational exposure to blood and other potentially infectious body fluids should be included in this rule.” Thus, fire and rescue personnel clearly are under this rule. This rule now wall be the major driving force for developing and implementing infection-control procedures. To maintain consistency, state plans have to reflect this and other changes—and must do so by May 5, 1992.
CHANGES IN THE PLAN
In the proposed regulations published in May 1989, the need for developing an infection-control plan was cited. Now, in the final rule, the new term used for this plan is the “exposure control plan.”
The exposure control plan shall include sections that address the following:
Exposure determined ion. Employers who have employees at occupational risk for exposure must establish a written list of all job classifications and specific tasks/procedures that may lead to occupational exposure. This may sound like an enormous task; OSHA. however, permits identitying employees at risk by groups at risk. For example, paramedics would be a group identified as being at risk. In contrast, a firefighter who is not an EMT but who may be in a position at some point to assist an injured person would be in the “gray” area. This is the area in which time must be spent listing the specific tasks that would place that individual at risk. It should be noted that this determination must be done “without regard to the use of personal protective equipment [PPE].” This is the first step in developing a comprehensive exposure control plan. This task might best be handled by the groups’ supervisors, who have an established course of day-to-day activities of their personnel, which might help to reduce the time spent on this requirement. Department members also should have input in this process, and this is best done by having the members appoint a representative to work with the supervisor. service would be more costly, and the time involved in exchange would require more uniforms to be available.
Engineering ancl work practice controls. Many important issues must be addressed here, including hand washing, sharps disposal and handling, and personal protective equipment.
Hand washing is addressed at length, as it again is stated that this is one of the major ways to reduce the risk of infection —not only for you, the care provider, but also for the patient. The final regulation also makes very clear that when handwash facilities are not available, employers are to furnish antiseptic hand cleaners or antiseptic towelettes. Employers are asked to monitor employee compliance with hand washing following removal of their gloves and personal protective equipment.
The handling and disposal of sharps also is addressed, as improper handling and disposal can result in an injury, and a contaminated needlestick injury presents the greatest risk to personnel.
In this section there is new wording, which may be important when developing protocols in your department. The regulation on recapping has been changed. The final regulation states, “Contaminated needles and other contaminated sharps shall not be bent, recapped, or removed unless the employer can demonstrate that no alternative is feasible or that such action is required by a specific medical procedure.” If recapping is to be done in a specific instance, then it must be done using a one-handed technique or a mechanical device.
States That Developed Their Own Plans
Alaska
Arizona
California
Hawaii
Indiana
Iowa
Kentucky
Maryland
Michigan
Minnesota
Nevada
New Mexico
New York
North Carolina
Oregon
South Carolina
Tennessee
Utah
Vermont
Virginia
Washington
Wyoming
Territories
Puerto Rico
Virgin Islands
Other key points are that the device for needle collection and disposal must be easily accessible to personnel and located as close as is feasible to the immediate area where sharps are used or can reasonably be found. They also must be maintained in an upright position throughout use and replaced before they become overfilled. The type of container and the requirements for it have not been changed in this final document. All containers must meet the recommended standard of being closable, leakproof on the sides and bottom, puncture-resistant, and color-coded—or they must have the universal biohazard symbol clearly visible. Also, some new wording has appeared with regard to reusable containers: The containers shall not be opened, emptied, or cleaned manually or in any other manner that would expose employees to the risk of injury.
The employer must furnish personal protective equipment, and it must be available in sizes to fit all personnel. Personnel with allergies to certain types of personal protective equipment must be accommodated, The equipment to be made available includes gloves, gowns, eye protection, resuscitation bags, and pocket masks and other ventilation devices. Again, employers are responsible to ensure that employees use the PPE made available to them. The document also contains a “waiver” that is important to fire/rescue personnel and their supervisors, stating that “…unless the employer shows that the employee temporarily and briefly declined to use personal protective equipment when under rare and extraordinary circumstances, it was the employee’s professional judgment that in the specific instance its use would have prevented the delivery of health care or public safety services or would have posed an increased hazard to the safety of the worker or co-worker.” This clause is important when developing department policies and procedures, and the wording should be added to any existing policy Laundry. As part of the furnishing personal protective equipment requirement, employers are required to clean, launder, and dispose of PPE at no cost to the employee. The employer also is responsible for the repair and replacement of PPE. None of this shall be at any cost to the employee Adding a washer and dryer at the fire station will make life easier for all concerned. Using a contract laundry
Housekeeping/cleaning. Housekeeping is the term used in the regulation to address issues of cleaning the workplace and equipment. The regulations are very straightforward and are not as specific as those contained in NFPA 1581. The only new requirement under this section is that there be a written schedule for cleaning.
Hepatitis B vaccine program. This section has one significant change: Having received the necessary training. employees at risk must be offered vaccines within 10 days of initial assignment. This is a strong and important requirement. Also, employers may not make pretesting a requirement for the vaccine program. If an employee requests pretesting, the employer is obligated to do the testing. Another addition, if employees decline to receive the vaccine, they are required to sign a document so stating. (The box on this page gives the required wording for the denial statement.) Vaccines are to be at no cost to the employee, and employees must be compensated if they come in for education and training or immunizations on their own time. Records documenting participation or nonparticipation in the program must be maintained on each individual.
Fxposure notification, reporting, medical follow-up, and documentation requirements are contained in the section addressing the vaccine program. All records must be kept for the duration of employment, plus 30 years
Education and training. The additions listed under education and training are of particular importance and require special note.
- It is clearly stated that in the education and training programs there must be an opportunity of “interactive questions and answers with the person conducting the training session.”
- The person conducting the train-
Hepatitis B Vaccine Delineation (Mandatory)
I understand that due to my occupational exposure to blood and other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. 1 have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. 1 understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future 1 continue to have occupational exposure to blood and other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.
Source: Appendix A, Section 1910.1030, “Occupational Exposure to Bloodborne Pathogens, Final Rule, ’’ Department of Labor.
- ing “shall be knowledgeable in the subject matter covered.” OSHA has defined “knowledgeable” as having “education and experience in infection control and communicable diseases.” This requirement is important to ensure proper answers to any questions regarding bloodborne disease, states James Johnston, OSHA industrial hygienist. Region III. This requirement affects many department training sections.
- The name and qualifications of the person conducting the training sessions must be recorded on the training record. The training records must be maintained for three years, a reduction from the original five-year requirement.
IMPLEMENTATION TIMETABLES
The OSHA final ruling clearly lists specific time frames for various portions of the standard. The effective date of the final rule is March 6, 1992. The exposure control plan must be completed before May 5. 1992. Information and recordkeeping requirements shall be in effect on or before June 4, 1992, and signs and labels requirements on July 6, 1992. In speaking with OSHA representatives in Washington, however, it was made clear that sections previously addressed in the Compliance Directive (CPL 2-2.44B), issued February 27, 1990, are still in effect. This means that some sections already are in effect and that your department could be subject to citations and fines now.
Departments that have put off developing a program waiting for the final ruling to be published have much work to do. Many departments have been cited and fined by OSF1A in the past year for failing to begin an infection-control program and to provide hepatitis B vaccines to personnel. Under the new budget, OSHA was granted permission to increase its fine structure sevenfold. Thus, the lowest fine is S7,000 and the highest for a single violation is S70,000. Fines can have a bigger impact on a department budget than implementing the program over time. Remember, infection control is a cost-benefit proposition. Exposure follow-up costs and employee worker compensation claims will be reduced. In the current days of budget cuts and documentation of need for funding, this is an easy program to justify’.*
Endnotes
1. “Occupational Exposure to Bloodborne Pathogens. Final Rule,” 29 CFR 1910.1030; Federal Register, Dept, of Labor, Washington, D.C.; Dec. 6, 1991.
2. NFPA 1581, Standard on Fire Department Infection Control Program; National Fire Protection Association, Quincy, MA; 1991.
3. Conversation with James Johnston, industrial hygienist, Occupational Safety and Health Administration, Region III.
