Banner 17

 

97. Health Care Facilities and Services

Chapter Editor: Annelee Yassi


Table of Contents

Tables and Figures

Health Care: Its Nature and Its Occupational Health Problems
Annalee Yassi and Leon J. Warshaw

Social Services
Susan Nobel

Home Care Workers: The New York City Experience
Lenora Colbert

Occupational Health and Safety Practice: The Russian Experience
Valery P. Kaptsov and Lyudmila P. Korotich

Ergonomics and Health Care

Hospital Ergonomics: A Review
Madeleine R. Estryn-Béhar

Strain in Health Care Work
Madeleine R. Estryn-Béhar

     Case Study: Human Error and Critical Tasks: Approaches for Improved System Performance

Work Schedules and Night Work in Health Care
Madeleine R. Estryn-Béhar

The Physical Environment and Health Care

Exposure to Physical Agents
Robert M. Lewy

Ergonomics of the Physical Work Environment
Madeleine R. Estryn-Béhar

Prevention and Management of Back Pain in Nurses
Ulrich Stössel

     Case Study: Treatment of Back Pain
     Leon J. Warshaw

Health Care Workers and Infectious Disease

Overview of Infectious Diseases
Friedrich Hofmann

Prevention of Occupational Transmission of Bloodborne Pathogens
Linda S. Martin, Robert J. Mullan and David M. Bell 

Tuberculosis Prevention, Control and Surveillance
Robert  J. Mullan

Chemicals in the Health Care Environment

Overview of Chemical Hazards in Health Care
Jeanne Mager Stellman 

Managing Chemical Hazards in Hospitals
Annalee Yassi

Waste Anaesthetic Gases
Xavier Guardino Solá

Health Care Workers and Latex Allergy
Leon J. Warshaw

The Hospital Environment

Buildings for Health Care Facilities
Cesare Catananti, Gianfranco Damiani and Giovanni Capelli

Hospitals: Environmental and Public Health Issues
M.P. Arias

Hospital Waste Management
M.P. Arias

Managing Hazardous Waste Disposal Under ISO 14000
Jerry Spiegel and John Reimer

Tables

Click a link below to view table in article context.

1. Examples of health care functions
2. 1995 integrated sound levels
3. Ergonomic noise reduction options
4. Total number of injuries (one hospital)
5. Distribution of nurses’ time
6. Number of separate nursing tasks
7. Distribution of nurses' time
8. Cognitive & affective strain & burn-out
9. Prevalence of work complaints by shift
10. Congenital abnormalities following rubella
11. Indications for vaccinations
12. Post-exposure prophylaxis
13. US Public Health Service recommendations
14. Chemicals’ categories used in health care
15. Chemicals cited HSDB
16. Properties of inhaled anaesthetics
17. Choice of materials: criteria & variables
18. Ventilation requirements
19. Infectious diseases & Group III wastes
20. HSC EMS documentation hierarchy
21. Role & responsibilities
22. Process inputs
23. List of activities

Figures

Point to a thumbnail to see figure caption, click to see the figure in the article context.

HCF020F1HCF020F2HCF020F3HCF020F4HCF020F5HCF020F6HCF020F7HCF020F8HCF020F9HCF20F10HCF060F5HCF060F4


Click to return to top of page

Children categories

The Physical Environment and Health Care

The Physical Environment and Health Care (4)

Banner 17

 

The Physical Environment and Health Care

View items...
Healthcare Workers and Infectious Diseases

Healthcare Workers and Infectious Diseases (3)

Banner 17

 

Healthcare Workers and Infectious Diseases

View items...
Chemicals in the Health Care Environment

Chemicals in the Health Care Environment (4)

Banner 17

 

Chemicals in the Health Care Environment

View items...
Wednesday, 02 March 2011 15:03

Social Services

Written by

Overview of the Social Work Profession

Social workers function in a wide variety of settings and work with many different kinds of people. They work in community health centres, hospitals, residential treatment centres, substance-abuse programmes, schools, family service agencies, adoption and foster care agencies, day-care facilities and public and private child welfare organizations. Social workers often visit homes for interviews or inspections of home conditions. They are employed by businesses, labour unions, international aid organizations, human rights agencies, prisons and probation departments, agencies for the ageing, advocacy organizations, colleges and universities. They are increasingly entering politics. Many social workers have full- or part-time private practices as psychotherapists. It is a profession that seeks to “improve social functioning by the provision of practical and psychological help to people in need” (Payne and Firth-Cozens 1987).

Generally, social workers with doctorates work in community organization, planning, research, teaching or combined areas. Those with bachelor’s degrees in social work tend to work in public assistance and with the elderly, mentally retarded and developmentally disabled; social workers with master’s degrees are usually found in mental health, occupational social work and medical clinics (Hopps and Collins 1995).

Hazards and Precautions

Stress

Studies have shown that stress in the workplace is caused, or contributed to, by job insecurity, poor pay, work overload and lack of autonomy. All of these factors are features of the work life of social workers in the late 1990s. It is now accepted that stress is often a contributing factor to illness. One study has shown that 50 to 70% of all medical complaints among social workers are linked to stress (Graham, Hawkins and Blau 1983).

As the social work profession has attained vendorship privileges, managerial responsibilities and increased numbers in private practice, it has become more vulnerable to professional liability and malpractice suits in countries such as the United States which permit such legal actions, a fact which contributes to stress. Social workers are also increasingly dealing with bioethical issues—those of life and death, of research protocols, of organ transplantation and of resource allocation. Often there is inadequate support for the psychological toll confronting these issues can take on involved social workers. Increased pressures of high caseloads as well as increased reliance on technology makes for less human contact, a fact which is likely true for most professions, but particularly difficult for social workers whose choice of work is so related to having face to face contact.

In many countries, there has been a shift away from government-funded social programmes. This policy trend directly affects the social work profession. The values and goals generally held by social workers—full employment, a “safety net” for the poor, equal opportunity for advancement—are not supported by these current trends.

The movement away from spending on programmes for the poor has produced what has been called an “upside-down welfare state” (Walz, Askerooth and Lynch 1983). One result of this, among others, has been increased stress for social workers. As resources decline, demand for services is on the rise; as the safety net frays, frustration and anger must rise, both for clients and for social workers themselves. Social workers may increasingly find themselves in conflict over respecting the values of the profession versus meeting statutory requirements. The code of ethics of the US National Association of Social Workers, for example, mandates confidentiality for clients which may be broken only when it is for “compelling professional reasons”. Further, social workers are to promote access to resources in the interest of “securing or retaining social justice”. The ambiguity of this could be quite problematic for the profession and a source of stress.

Violence

Work-related violence is a major concern for the profession. Social workers as problem-solvers on the most personal level are particularly vulnerable. They work with powerful emotions, and it is the relationship with their clients which becomes the focal point for expression of these emotions. Often, an underlying implication is that the client is unable to manage his or her own problems and needs the help of social workers to do so. The client may, in fact, be seeing social workers involuntarily, as, for example, in a child welfare setting where parental abilities are being evaluated. Cultural mores might also interfere with accepting offers of help from someone of another cultural background or sex (the preponderence of social workers are women) or outside of the immediate family. There may be language barriers, necessitating the use of translators. This can be distracting at least or even totally disruptive and may present a skewed picture of the situation at hand. These language barriers certainly affect the ease of communication, which is essential in this field. Further, social workers may work in locations which are in high-crime areas, or the work might take them into the “field” to visit clients who live in those areas.

Application of safety procedures is uneven in social agencies, and, in general, insufficient attention has been paid to this area. Prevention of violence in the workplace implies training, managerial procedures and modifications of the physical environment and/or communication systems (Breakwell 1989).

A curriculum for safety has been suggested (Griffin 1995) which would include:

  • training in constructive use of authority
  • crisis intervention
  • field and office safety
  • physical plant set-up
  • general prevention techniques
  • ways to predict potential violence.

 

Other Hazards

Because social workers are employed in such a variety of settings, they are exposed to many of the hazards of the workplace discussed elsewhere in this Encyclopaedia. Mention should be made, however, that these hazards include buildings with poor or unclean air flow (“sick buildings”) and exposures to infection. When funding is scarce, maintenance of physical plants suffers and risk of exposure increases. The high percentage of social workers in hospital and out-patient medical settings suggests vulnerability to infection exposure. Social workers see patients with conditions like hepatitis, tuberculosis and other highly contagious diseases as well as human immunodeficiency virus (HIV) infection. In response to this risk for all health workers, training and measures for infection control are necessary and have been mandated in many countries. The risk, however, persists.

It is evident that some of the problems faced by social workers are inherent in a profession which is so centred on lessening human suffering as well as one which is so affected by changing social and political climates. At the end of the twentieth century, the profession of social work finds itself in a state of flux. The values, ideals and rewards of the profession are also at the heart of the hazards it presents to its practitioners.

 

Back

Wednesday, 02 March 2011 16:24

Waste Anaesthetic Gases

Written by

The use of inhaled anaesthetics was introduced in the decade of 1840 to 1850. The first compounds to be used were diethyl ether, nitrous oxide and chloroform. Cyclopropane and trichloroethylene were introduced many years later (circa 1930-1940), and the use of fluoroxene, halothane and methoxiflurane began in the decade of the 1950s. By the end of the 1960s enflurane was being used and, finally, isoflurane was introduced in the 1980s. Isoflurane is now considered the most widely used inhalation anaesthetic even though it is more expensive than the others. A summary of the physical and chemical characteristics of methoxiflurane, enflurane, halothane, isoflurane and nitrous oxide, the most commonly used anaesthetics, is shown in table 1 (Wade and Stevens 1981).

Table 1. Properties of inhaled anaesthetics

 

Isoflurane,
Forane

Enflurane,
Ethrane

Halothane,
Fluothane

Methoxyflurane,
Penthrane

Dinitrogen oxide,
Nitrous oxide

Molecular weight

184.0

184.5

197.4

165.0

44.0

Boiling point

48.5°C

56.5°C

50.2°C

104.7°C

Density

1.50

1.52 (25°C)

1.86 (22°C)

1.41 (25°C)

Vapour pressure at 20 °C

250.0

175.0 (20°C)

243.0 (20°C)

25.0 (20°C)

Smell

Pleasant, sharp

Pleasant, like ether

Pleasant, sweet

Pleasant, fruity

Pleasant, sweet

Separation coefficients:

Blood/gas

1.40

1.9

2.3

13.0

0.47

Brain/gas

3.65

2.6

4.1

22.1

0.50

Fat/gas

94.50

105.0

185.0

890.0

1.22

Liver/gas

3.50

3.8

7.2

24.8

0.38

Muscle/gas

5.60

3.0

6.0

20.0

0.54

Oil/gas

97.80

98.5

224.0

930.0

1.4

Water/gas

0.61

0.8

0.7

4.5

0.47

Rubber/gas

0.62

74.0

120.0

630.0

1.2

Metabolic rate

0.20

2.4

15–20

50.0

 

All of them, with the exception of nitrous oxide (N2O), are hydrocarbons or chlorofluorinated liquid ethers that are applied by vapourization. Isoflurane is the most volatile of these compounds; it is the one that is metabolized at the lowest rate and the one that is least soluble in blood, in fats and in the liver.

Normally, N2O, a gas, is mixed with a halogenated anaesthetic, although they are sometimes used separately, depending on the type of anaesthesia that is required, the characteristics of the patient and the work habits of the anaesthetist. The normally used concentrations are 50 to 66% N2O and up to 2 or 3% of the halogenated anaesthetic (the rest is usually oxygen).

The anaesthesia of the patient is usually started by the injection of a sedative drug followed by an inhaled anaesthetic. The volumes given to the patient are in the order of 4 or 5 litres/minute. Parts of the oxygen and of the anaesthetic gases in the mixture are retained by the patient while the remainder is exhaled directly into the atmosphere or is recycled into the respirator, depending among other things on the type of mask used, on whether the patient is intubated and on whether or not a recycling system is available. If recycling is available, exhaled air can be recycled after it is cleaned or it can be vented to the atmosphere, expelled from the operating room or aspirated by a vacuum. Recycling (closed circuit) is not a common procedure and many respirators do not have exhaust systems; all the air exhaled by the patient, including the waste anaesthetic gases, therefore, ends up in the air of the operating room.

The number of workers occupationally exposed to waste anaesthetic gases is high, because it is not only the anaesthetists and their assistants who are exposed, but all the other people who spend time in operating rooms (surgeons, nurses and support staff), the dentists who perform odontological surgery, the personnel in delivery rooms and intensive care units where patients may be under inhaled anaesthesia and veterinary surgeons. Similarly, the presence of waste anaesthetic gases is detected in recovery rooms, where they are exhaled by patients who are recovering from surgery. They are also detected in other areas adjacent to operating rooms because, for reasons of asepsis, operating rooms are kept at positive pressure and this favours the contamination of surrounding areas.

Health Effects

Problems due to the toxicity of anaesthetic gases were not seriously studied until the 1960s, even though a few years after the use of inhaled anaesthetics became common, the relationship between the illnesses (asthma, nephritis) that affected some of the first professional anaesthetists and their work as such was already suspected (Ginesta 1989). In this regard the appearance of an epidemiological study of more than 300 anaesthetists in the Soviet Union, the Vaisman (1967) survey, was the starting point for several other epidemiological and toxicological studies. These studies—mostly during the 1970s and the first half of the 1980s—focused on the effects of anaesthetic gases, in most cases nitrous oxide and halothane, on people occupationally exposed to them.

The effects observed in most of these studies were an increase in spontaneous abortions among women exposed during or before pregnancy, and among women partners of exposed men; an increase in congenital malformations in children of exposed mothers; and the occurrence of hepatic, renal and neurological problems and of some types of cancer in both men and women (Bruce et al. 1968, 1974; Bruce and Bach 1976). Even though the toxic effects of nitrous oxide and of halothane (and probably its substitutes as well) on the body are not exactly the same, they are commonly studied together, given that exposure generally occurs simultaneously.

It appears likely that there is a correlation between these exposures and an increased risk, particularly for spontaneous abortions and congenital malformations in children of women exposed during pregnancy (Stoklov et al. 1983; Spence 1987; Johnson, Buchan and Reif 1987). As a result, many of the people exposed have expressed great concern. Rigorous statistical analysis of these data, however, casts doubt on the existence of such a relationship. More recent studies reinforce these doubts while chromosomal studies yield ambiguous results.

The works published by Cohen and colleagues (1971, 1974, 1975, 1980), who carried out extensive studies for the American Society of Anaesthetists (ASA), constitute a fairly extensive series of observations. Follow-up publications criticized some of the technical aspects of the earlier studies, particularly with respect to the sampling methodology and, especially, the proper selection of a control group. Other deficiencies included lack of reliable information on the concentrations to which the subjects had been exposed, the methodology for dealing with false positives and the lack of controls for factors such as tobacco and alcohol use, prior reproductive histories and voluntary infertility. Consequently, some of the studies are now even considered invalid (Edling 1980; Buring et al. 1985; Tannenbaum and Goldberg 1985).

Laboratory studies have shown that exposure of animals to ambient concentrations of anaesthetic gases equivalent to those found in operating rooms does cause deterioration in their development, growth and adaptive behaviour (Ferstandig 1978; ACGIH 1991). These are not conclusive, however, since some of these experimental exposures involved anaesthetic or subanaesthetic levels, concentrations significantly higher than the levels of waste gases usually found in operating room air (Saurel-Cubizolles et al. 1994; Tran et al. 1994).

Nevertheless, even acknowledging that a relationship between the deleterious effects and exposures to waste anaesthetic gases has not been definitively established, the fact is that the presence of these gases and their metabolites is readily detected in the air of operating rooms, in exhaled air and in biological fluids. Accordingly, since there is concern about their potential toxicity, and because it is technically feasible to do so without inordinate effort or expense, it would be prudent to take steps to eliminate or reduce to a minimum the concentrations of waste anaesthetic gases in operating rooms and nearby areas (Rosell, Luna and Guardino 1989; NIOSH 1994).

Maximum Allowable Exposure Levels

The American Conference of Governmental Industrial Hygienists (ACGIH) has adopted a threshold limit value-time weighted average (TLV-TWA) of 50 ppm for nitrous oxide and halothane (ACGIH 1994). The TLV-TWA is the guideline for the production of the compound, and the recommendations for operating rooms are that its concentration be kept lower, at a level below 1 ppm (ACGIH 1991). NIOSH sets a limit of 25 ppm for nitrous oxide and of 1 ppm for halogenated anaesthetics, with the additional recommendation that when they are used together, the concentration of halogenated compounds be reduced to a limit of 0.5 ppm (NIOSH 1977b).

With regard to values in biological fluids, the recommended limit for nitrous oxide in urine after 4 hours of exposure at average ambient concentrations of 25 ppm ranges from 13 to 19 μg/L, and for 4 hours of exposure at average ambient concentrations of 50 ppm, the range is 21 to 39 μg/L (Guardino and Rosell 1995). If exposure is to a mixture of a halogenated anaesthetic and nitrous oxide, the measurement of the values from nitrous oxide is used as the basis for controlling exposure, because as higher concentrations are used, quantification becomes easier.

Analytical Measurement

Most of the procedures described for measuring residual anaesthetics in air are based on the capture of these compounds by adsorption or in an inert bag or container, later to be analysed by gas chromatography or infrared spectroscopy (Guardino and Rosell 1985). Gas chromatography is also employed to measure nitrous oxide in urine (Rosell, Luna and Guardino 1989), while isoflurane is not readily metabolized and is therefore seldom measured.

Common Levels of Residual Concentrations in the Air of Operating Rooms

In the absence of preventive measures, such as the extraction of residual gases and/or introducing an adequate supply of new air into the operating suite, personal concentrations of more than 6,000 ppm of nitrous oxide and 85 ppm of halothane have been measured (NIOSH 1977). Concentrations of up to 3,500 ppm and 20 ppm, respectively, in the ambient air of operating rooms, have been measured. The implementation of corrective measures can reduce these concentrations to values below the environmental limits cited earlier (Rosell, Luna and Guardino 1989).

Factors that Affect the Concentration of Waste Anaesthetic Gases

The factors which most directly affect the presence of waste anaesthetic gases in the environment of the operating room are the following.

Method of anaesthesia. The first question to consider is the method of anaesthesia, for example, whether or not the patient is intubated and the type of face mask being used. In dental, laryngeal or other forms of surgery in which intubation is precluded, the patient’s expired air would be an important source of emissions of waste gases, unless equipment specifically designed to trap these exhalations is properly placed near the patient’s breathing zone. Accordingly, dental and oral surgeons are considered to be particularly at risk (Cohen, Belville and Brown 1975; NIOSH 1977a), as are veterinary surgeons (Cohen, Belville and Brown 1974; Moore, Davis and Kaczmarek 1993).

Proximity to the focus of emission. As is usual in industrial hygiene, when the known point of emission of a contaminant exists, proximity to the source is the first factor to consider when dealing with personal exposure. In this case, the anaesthetists and their assistants are the persons most directly affected by the emission of waste anaesthetic gases, and personal concentrations have been measured in the order of two times the average levels found in the air of operating rooms (Guardino and Rosell 1985).

Type of circuit. It goes without saying that in the few cases in which closed circuits are used, with reinspiration after the cleansing of the air and the resupply of oxygen and the necessary anaesthetics, there will be no emissions except in the case of equipment malfunction or if a leak exists. In other cases, it will depend on the characteristics of the system used, as well as on whether or not it is possible to add an extraction system to the circuit.

The concentration of anaesthetic gases. Another factor to take into account is the concentrations of the anaesthetics used since, obviously, those concentrations and the amounts found in the air of the operating room are directly related (Guardino and Rosell 1985). This factor is especially important when it comes to surgical procedures of long duration.

Type of surgical procedures. The duration of the operations, the time elapsed between procedures done in the same operating room and the specific characteristics of each procedure—which often determine which anaesthetics are used—are other factors to consider. The duration of the operation directly affects the residual concentration of anaesthetics in the air. In operating rooms where procedures are scheduled successively, the time elapsed between them also affects the presence of residual gases. Studies done in large hospitals with uninterrupted use of the operating rooms or with emergency operating rooms that are used beyond standard work schedules, or in operating rooms used for prolonged procedures (transplants, laryngotomies), show that substantial levels of waste gases are detected even before the first procedure of the day. This contributes to increased levels of waste gases in subsequent procedures. On the other hand, there are procedures that require temporary interruptions of inhalation anaesthesia (where extracorporeal circulation is needed, for example), and this also interrupts the emission of waste anaesthetic gases into the environment (Guardino and Rosell 1985).

Characteristics specific to the operating room. Studies done in operating rooms of different sizes, design and ventilation (Rosell, Luna and Guardino 1989) have demonstrated that these characteristics greatly influence the concentration of waste anaesthetic gases in the room. Large and non-partitioned operating rooms tend to have the lowest measured concentrations of waste anaesthetic gases, while in small operating rooms (e.g., paediatric operating rooms) the measured concentrations of waste gases are usually higher. The general ventilation system of the operating room and its proper operation is a fundamental factor for the reduction of the concentration of waste anaesthetics; the design of the ventilation system also affects the circulation of waste gases within the operating room and the concentrations in different locations and at various heights, something that can be easily verified by carefully taking samples.

Characteristics specific to the anaesthesia equipment. The emission of gases into the environment of the operating room depends directly on the characteristics of the anaesthesia equipment used. The design of the system, whether it includes a system for the return of excess gases, whether it can be attached to a vacuum or vented out of the operating room, whether it has leaks, disconnected lines and so on are always to be considered when determining the presence of waste anaesthetic gases in the operating room.

Factors specific to the anaesthetist and his or her team. The anaesthetist and his or her team are the last element to consider, but not necessarily the least important. Knowledge of the anaesthesia equipment, of its potential problems and the level of maintenance it receives—both by the team and by the maintenance staff in the hospital—are factors that affect very directly the emission of waste gases into the air of the operating room (Guardino and Rosell 1995). It has been clearly shown that, even when using adequate technology, the reduction of the ambient concentrations of anaesthetic gases cannot be achieved if a preventive philosophy is absent from the work routines of anaesthetists and their assistants (Guardino and Rosell 1992).

Preventive Measures

The basic preventive actions required to reduce occupational exposure to waste anaesthetic gases effectively can be summarized in the following six points:

  1. Anaesthetic gases should be thought of as occupational hazards. Even if from a scientific standpoint it has not been conclusively shown that anaesthetic gases have a serious deleterious effect on the health of people who are occupationally exposed, there is a high probability that some of the effects mentioned here are directly related to the exposure to waste anaesthetic gases. For that reason it is a good idea to consider them toxic occupational hazards.
  2. Scavenger systems should be used for waste gases. Scavenger systems are the most effective technical hardware for the reduction of waste gases in the air of the operating room (NIOSH 1975). These systems must fulfil two basic principles: they must store and/or adequately eliminate the whole volume of air expired by the patient, and they must be designed to guarantee that neither the respiration of the patient nor the proper functioning of the anaesthesia equipment will be affected—with separate safety devices for each function. The techniques most commonly employed are: a direct connection to a vacuum outlet with a flexible regulating chamber that allows for the discontinuous emission of gases of the respiratory cycle; directing the flow of the gases exhaled by the patient to the vacuum without a direct connection; and directing the flow of gases coming from the patient to the return of the ventilation system installed in the operating room and expelling these gases from the operating room and from the building. All these systems are technically easy to implement and very cost-efficient; the use of installed respirators as part of the design is recommended. In cases where systems that eliminate waste gases directly cannot be used because of the special characteristics of a procedure, localized extraction can be employed near the source of emission as long as it does not affect the general ventilation system or the positive pressure in the operating room.
  3. General ventilation with a minimum of 15 renewals/hour in the operating room should be guaranteed. The general ventilation of the operating room should be perfectly regulated. It should not only maintain positive pressure and respond to the thermohygrometric characteristics of the ambient air, but should also provide a minimum of 15 to 18 renewals per hour. Also, a monitoring procedure should be in place to ensure its proper functioning.
  4. Preventive maintenance of the anaesthesia circuit should be planned and regular. Preventive maintenance procedures should be set up that include regular inspections of the respirators. Verifying that no gases are being emitted to the ambient air should be part of the protocol followed when the equipment is first turned on, and its proper functioning with regard to the safety of the patient should be checked. The proper functioning of the anaesthesia circuit should be verified by checking for leaks, periodically replacing filters and checking the safety valves.
  5. Environmental and biological controls should be used. The implementation of environmental and biological controls provides information not only about the correct functioning of the various technical elements (extraction of gases, general ventilation) but also about whether the working procedures are adequate for curtailing the emission of waste gases into the air. Today these controls do not present technical problems and they can be implemented economically, which is why they are recommended.
  6. Education and training of the exposed personnel is crucial. Achieving an effective reduction of occupational exposure to waste anaesthetic gases requires educating all operating room personnel about the potential risks and training them in the required procedures. This is particularly applicable to anaesthetists and their assistants who are most directly involved and those responsible for the maintenance of the anaesthesia and air-conditioning equipment.

 

Conclusion

Although not definitively proven, there is enough evidence to suggest that exposures to waste anaesthetic gases may be harmful to HCWs. Stillbirths and congenital malformations in infants born to female workers and to the spouses of male workers represent the major forms of toxicity. Since it is technically feasible at a low cost, it is desirable to reduce the concentration of these gases in the ambient air in operating rooms and adjacent areas to a minimum. This requires not only the use and correct maintenance of anaesthesia equipment and ventilation/air conditioning systems but also the education and training of all personnel involved, especially anaesthetists and their assistants, who generally are exposed to higher concentrations. Given the work conditions peculiar to operating rooms, indoctrination in the correct work habits and procedures is very important in trying to reduce the amounts of anaesthetic waste gases in the air to a minimum.

 

Back

Massive use of home care workers in New York City began in 1975 as a response to the needs of the growing population of chronically ill and frail elderly and as an alternative to more expensive care in nursing homes, many of which had long lists of such people waiting for admission. Additionally, it allowed for more personal assistance at a time when nursing homes were perceived as impersonal and uncaring. It also provided entry-level employment to unskilled individuals, mostly women, many of whom were recipients of welfare.

Initially, these workers were employees of the City’s Department of Human Resources but, in 1980, this service was “privatized” and they were recruited, trained and employed by non-profit, community-based social agencies and traditional health care organizations such as hospitals which had to be certified by the State of New York as providers of home care services. The workers are categorized as home makers, personal care workers, health aides, home care attendants and housekeepers, depending on their levels of skills and the kinds of services they provide. Which of these services a particular client uses depends on an evaluation of that person’s health status and needs which is conducted by a licensed health professional, such as a physician, nurse or social worker.

The Home Care Workforce

Home care workers in New York City present a conglomerate of characteristics that provide a unique profile. A recent survey by Donovan, Kurzman and Rotman (1993) found that 94% are female with an average age of 45. About 56% were not born within the continental US and about 51% never completed high school. Only 32% were identified as married, 33% were separated or divorced and 26% were single, while 86% have children, 44% with children under 18 years of age. According to the survey, 63% live with their children and 26% live with a spouse.

The median family income for this group in 1991 was $12,000 per year. In 81% of these families, the home care worker was the primary breadwinner. In 1996, the annual salary of full-time home care workers’ ranged between $16,000 and $28,000; part-time workers earned less.

Such low earnings represent significant economic hardship to the survey respondents: 56% said they could not afford adequate housing; 61% reported being unable to afford furniture or household equipment; 35% said they lacked funds to purchase enough food for their families; and 36% were ineligible for Medicare and unable to afford needed medical care for themselves and their families. As a group, their financial status will inevitably worsen as cuts in government funding force curtailment of the amount and intensity of home care services being provided.

Home Care Services

The services provided by home care workers depend on the needs of the clients being served. Those with greater disability require assistance with the “basic activities of daily living”, which consist of bathing, dressing, toileting, transferring (moving in or out of bed and chairs) and feeding. Those with higher levels of functional capacity need help with the “instrumental activities of daily living”, which comprise housekeeping (cleaning, bed making, dishwashing, and so forth), shopping, food preparation and serving, laundry, using public or private transportation and managing finances. Home care workers may give injections, dispense medications and provide such treatments as passive exercise and massage as prescribed by the client’s physician. A most appreciated service is companionship and assisting the client to participate in recreational activities.

The difficulty of the home care worker’s job is directly related to the home environment and, in addition to physical status, the behaviour of the client and any family members who may be on the scene. Many clients (and the workers as well) live in poor neighbourhoods where crime rates are high, public transportation often marginal and public services substandard. Many live in deteriorated housing with no or non-functioning elevators, dark and dirty stairwells and hallways, lack of heat and hot water, dilapidated plumbing and poorly functioning household appliances. Commuting to and from the client’s home may be arduous and time-consuming.

Many of the clients may have very low levels of functional capacity and require assistance at every turn. Clients’ muscle weakness and lack of coordination, loss of vision and hearing and incontinence of bladder and/or bowels add to the burden of care. Mental difficulties such as senile dementia, anxiety and depression and difficulties in communication because of memory loss and language barriers may also magnify the difficulty. Finally, abusive and demanding behaviour on the part of both clients and their family members may sometimes escalate into acts of violence.

Home Care Work Hazards

Work hazards commonly encountered by home care workers include:

  • working alone without assistance
  • lack of education and training and remote, if any, supervision
  • working in substandard housing in high risk neighbourhoods
  • back pain and musculoskeletal injuries incurred while lifting, transferring and supporting clients who may be heavy, weak and poorly coordinated
  • violence in the home and in the neighbourhood
  • infectious diseases (the health care worker may not have been fully informed of the client’s medical status; recommended gloves, gowns and masks may not be available)
  • household chemicals and cleaning supplies (often incorrectly labelled and stored)
  • sexual harassment
  • work stress.

 

Stress is probably the most ubiquitous hazard. It is compounded by the fact the worker is usually alone in the home with the client with no simple way to report trouble or summon assistance. Stress is being exacerbated as cost-containment efforts are reducing the hours of service allowed for individual clients.

Prevention Strategies

A number of strategies have been suggested to promote occupational health and safety for home care workers and to improve their lot. They include:

  • development and promulgation of standards of practice for home care accompanied by improved education and training so that home care workers can meet them
  • education and training in the recognition and avoidance of chemical and other hazards in the home
  • training in lifting, carrying and giving physical support to clients as needed in the course of providing services
  • preliminary needs assessment of clients supplemented by inspections of their homes so that potential hazards can be identified and eliminated or controlled and needed materials and equipment can be procured
  • periodic meetings with supervisors and other home care workers to compare notes and receive instruction. Videotapes may be developed and used for skills demonstrations. The meetings may be supplemented by telephone networks through which workers may communicate with each other to exchange information and alleviate any feelings of isolation.
  • establishment of a health and safety committee within each agency to review work-related accidents and problems and develop appropriate preventive interventions
  • establishment of an Employee Assistance Programme (EAP) through which the workers may receive counselling for their own psychosocial problems both on- and off-the-job.

 

Educational and training sessions should be conducted during working hours at a place and time convenient for the workers. They should be supplemented by the distribution of instructional materials designed for the low educational levels of most of the workers and, when necessary, they should be multilingual.


Case study: Violence in health care work

A psychotic patient in his thirties had been forcibly committed to a large psychiatric hospital in the suburbs of a city. He was not regarded as having violent tendencies. After a few days he escaped from his secure ward. The hospital authorities were informed by his relatives that he had returned to his own house. As was routine an escort of three male psychiatric nurses set out with an ambulance to bring the patient back. En route they stopped to pick up a police escort as was routine in such cases. When they arrived at the house, the police escort waited outside, in case a violent incident developed. The three nurses entered and were informed by the relatives that the patient was sitting in an upstairs bedroom. When approached and quietly invited to come back to hospital for treatment the patient produced a kitchen knife which he had hidden. One nurse was stabbed in the chest, another a number of times in the back and the third in the hand and the arm. All three nurses survived but had to spend time in hospital. When the police escort entered the bedroom the patient quietly surrendered the knife.

Daniel Murphy


 

Back

Wednesday, 02 March 2011 16:27

Health Care Workers and Latex Allergy

Written by

With the advent of the universal precautions against bloodborne infections which dictate the use of gloves whenever HCWs are exposed to patients or materials that might be infected with hepatitis B or HIV, the frequency and severity of allergic reactions to natural rubber latex (NRL) have zoomed upward. For example, the Department of Dermatology at the Erlangen-Nuremberg University in Germany reported a 12-fold increase in the number of patients with latex allergy between 1989 and 1995. More serious systemic manifestations increased from 10.7% in 1989 to 44% in 1994-1995 (Hesse et al. 1996).

It seems ironic that so much difficulty is attributable to rubber gloves when they were intended to protect the hands of nurses and other HCWs when they were originally introduced toward the end of the nineteenth century. This was the era of antiseptic surgery in which instruments and operative sites were bathed in caustic solutions of carbolic acid and bichloride of mercury. These not only killed germs but they also macerated the hands of the surgical team. According to what has become a romantic legend, William Stewart Halsted, one of the surgical “giants” of the time who is credited with a host of contributions to the techniques of surgery, is said to have “invented” rubber gloves around 1890 to make it more pleasant to hold hands with Caroline Hampton, his scrub nurse, whom he later married (Townsend 1994). Although Halsted may be credited with introducing and popularizing the use of rubber surgical gloves in the United States, many others had a hand in it, according to Miller (1982) who cited a report of their use in the United Kingdom published a half century earlier (Acton 1848).

Latex Allergy

Allergy to NRL is succinctly described by Taylor and Leow (see the article “Rubber contact dermatitis and latex allergy” in the chapter Rubber industry) as “an immunoglobulin E-mediated, immediate, Type I allergic reaction, most always due to NRL proteins present in medical and non-medical latex devices. The spectrum of clinical signs ranges from contact urticaria, generalized urticaria, allergic rhinitis, allergic conjunctivitis, angioedema (severe swelling) and asthma (wheezing) to anaphylaxis (severe, life-threatening allergic reaction)”. Symptoms may result from direct contact of normal or inflamed skin with gloves or other latex-containing materials or indirectly by mucosal contact with or inhalation of aerosolized NRL proteins or talcum powder particles to which NRL proteins have adhered. Such indirect contact can cause a Type IV reaction to the rubber accelerators. (Approximately 80% of “latex glove allergy” is actually a Type IV reaction to the accelerators.) The diagnosis is confirmed by patch, prick, scratch or other skin sensitivity tests or by serological studies for the immune globulin. In some individuals, the latex allergy is associated with allergy to certain foods (e.g., banana, chestnuts, avocado, kiwi and papaya).

While most common among health care workers, latex allergy is also found among employees in rubber manufacturing plants, other workers who habitually use rubber gloves (e.g., greenhouse workers (Carillo et al. 1995)) and in patients with a history of multiple surgical procedures (e.g., spina bifida, congenital urogenital abnormalities, etc.) (Blaycock 1995). Cases of allergic reactions after the use of latex condoms have been reported (Jonasson, Holm and Leegard 1993), and in one case, a potential reaction was averted by eliciting a history of an allergic reaction to a rubber swimming cap (Burke, Wilson and McCord 1995). Reactions have occurred in sensitive patients when hypodermic needles used to prepare doses of parenteral medications picked up NRL protein as they were pushed through the rubber caps on the vials.

According to a recent study of 63 patients with NRL allergy, it took an average of 5 years of working with latex products for the first symptoms, usually a contact urticaria, to develop. Some also had rhinitis or dyspnoea. It took, on average, an additional 2 years for the appearance of lower respiratory tract symptoms (Allmeers et al. 1996).

Frequency of latex allergy

To determine the frequency of NRL allergy, allergy tests were performed on 224 employees at the University of Cincinnati College of Medicine, including nurses, laboratory technicians, physicians, respiratory therapists, housekeeping and clerical workers (Yassin et al. 1994). Of these, 38 (17%) tested positive to latex extracts; the incidence ranged from 0% among housekeeping workers to 38% among dental staff. Exposure of these sensitized individuals to latex caused itching in 84%, a skin rash in 68%, urticaria in 55%, lachrymation and ocular itching in 45%, nasal congestion in 39% and sneezing in 34%. Anaphylaxis occurred in 10.5%.

In a similar study at the University of Oulo in Finland, 56% of 534 hospital employees who used protective latex or vinyl gloves on a daily basis had skin disorders related to the usage of the gloves (Kujala and Reilula 1995). Rhinorrhoea or nasal congestion was present in 13% of workers who used powdered gloves. The prevalence of both skin and respiratory symptoms was significantly higher among those who used the gloves for more than 2 hours a day.

Valentino and colleagues (1994) reported latex induced asthma in four health care workers in an Italian regional hospital, and the Mayo Medical Center in Rochester Minnesota, where 342 employees who reported symptoms suggestive of latex allergy were evaluated, recorded 16 episodes of latex-related anaphylaxis in 12 subjects (six episodes occurred after skin testing) (Hunt et al. 1995). The Mayo researchers also reported respiratory symptoms in workers who did not wear gloves but worked in areas where large numbers of gloves were being used, presumably due to air-borne talcum powder/latex protein particles.

Control and Prevention

The most effective preventive measure is modification of standard procedures to replace the use of gloves and equipment made with NRL with similar items made of vinyl or other non-rubber materials. This requires involvement of the purchasing and supply departments, which should also mandate the labelling of all latex-containing items so that they may be avoided by individuals with latex sensitivity. This is important not only to the staff but also to patients who may have a history suggestive of latex allergy. Aerosolized latex, from latex powder, is also problematic. HCWs who are allergic to latex and who do not use latex gloves may still be affected by the powdered latex gloves used by co-workers. A significant problem is presented by the wide variation in content of latex allergen among gloves from different manufacturers and, indeed, among different lots of gloves from the same manufacturer.

Glove manufacturers are experimenting with gloves using formulations with smaller amounts of NRL as well as coatings that will obviate the need for talcum powder to make the gloves easy to put on and take off. The goal is to provide comfortable, easy to wear, non-allergenic gloves that still provide effective barriers to the transmission of the hepatitis B virus, HIV and other pathogens.

A careful medical history with a particular emphasis on prior latex exposures should be elicited from all health care workers who present symptoms suggestive of latex allergy. In suspect cases, evidence of latex sensitivity may be confirmed by skin or serological testing. Since there is evidently a risk of provoking an anaphylactic reaction, the skin testing should only be performed by experienced medical personnel.

At the present time, allergens for desensitization are not available so that the only remedy is avoidance of exposure to products containing NRL. In some instances, this may require a change of job. Weido and Sim (1995) at the University of Texas Medical Branch at Galveston suggest advising individuals in high-risk groups to carry self-injectable epinephrine to use in the event of a systemic reaction.

Following the appearance of several clusters of latex allergy cases in 1990, the Mayo Medical Center in Rochester, Minnesota, formed a multidisciplinary work group to address the problem (Hunt et al. 1996). Subsequently, this was formalized in a Latex Allergy Task Force with members from the departments of allergy, preventive medicine, dermatology and surgery as well as the Director of Purchasing, the Surgical Nursing Clinical Director and the Director of Employee Health. Articles on latex allergy were published in staff newsletters and information bulletins to educate the 20,000 member workforce to the problem and to encourage those with suggestive symptoms to seek medical consultation. A standardized approach to testing for latex sensitivity and techniques for quantifying the amount of latex allergen in manufactured products and the amount and particle size of air-borne latex allergen were developed. The latter proved to be sufficiently sensitive to measure the exposure of individual workers while performing particular high-risk tasks. Steps were initiated to monitor a gradual transition to low-allergen gloves (an incidental effect was a lowering of their cost by concentrating glove purchases among the fewer vendors who could meet the low allergen requirements) and to minimize exposures of staff and patients with known sensitivity to NLR.

To alert the public to the risks of NLR allergy, a consumer group, the Delaware Valley Latex Allergy Support Network has been formed. This group has created an Internet website (http://www.latex.org) and maintains a toll-free telephone line (1-800 LATEXNO) to provide up-to-date factual information about latex allergy to persons with this problem and those who care for them. This organization, which has a Medical Advisory Group, maintains a Literature Library and a Product Center and encourages the exchange of experiences among those who have had allergic reactions.

Conclusion

Latex allergies are becoming an increasingly important problem among health care workers. The solution lies in minimizing contact with latex allergen in their work environment, especially by substituting non-latex surgical gloves and appliances.

 

Back

Wednesday, 02 March 2011 15:06

Case Study: Violence in Health Care Work

Written by

A psychotic patient in his thirties had been forcibly committed to a large psychiatric hospital in the suburbs of a city. He was not regarded as having violent tendencies. After a few days he escaped from his secure ward. The hospital authorities were informed by his relatives that he had returned to his own house. As was routine an escort of three male psychiatric nurses set out with an ambulance to bring the patient back. En route they stopped to pick up a police escort as was routine in such cases. When they arrived at the house, the police escort waited outside, in case a violent incident developed. The three nurses entered and were informed by the relatives that the patient was sitting in an upstairs bedroom. When approached and quietly invited to come back to hospital for treatment the patient produced a kitchen knife which he had hidden. One nurse was stabbed in the chest, another a number of times in the back and the third in the hand and the arm. All three nurses survived but had to spend time in hospital. When the police escort entered the bedroom the patient quietly surrendered the knife.

 

Back

The work of people in the medical profession has great social value, and in recent years the urgent problem of the labour conditions and the state of health of HCWs has been studied actively. However, the nature of this work is such that any preventive and ameliorating measures cannot eliminate or reduce the main source of the hazards in the work of physicians and other HCWs: contact with a sick patient. In this respect the problem of prevention of occupational illness in medical workers is rather complicated.

In many cases the diagnostic and medical equipment and the methods of treatment used in medical institutions can affect the health of HCWs. Therefore, it is necessary to follow hygienic standards and precautionary measures to control the levels of exposure to unfavourable factors. Studies carried out in a number of Russian medical institutions have revealed that the labour conditions at many workplaces were not optimum and could induce the deterioration of the health of medical and support personnel, and sometimes cause the development of occupational diseases.

Among the physical factors that can substantially affect the health of medical personnel in the Russian Federation, ionizing radiation should be ranked as one of the first. Tens of thousands of Russian medical workers encounter sources of ionizing radiation at work. In the past, special laws were adopted to limit the doses and levels of irradiation at which specialists could work for a long period without health risk. In recent years x-ray control procedures were extended to cover not only radiologists, but surgeons, anaesthetists, traumatologists, rehabilitation specialists and mid-level personnel. The levels of radiation at worksites and the x-ray doses received by these individuals sometimes are even higher than the doses received by the radiologists and radiology laboratory assistants.

Instruments and equipment generating non-ionizing radiation and ultrasound are also widespread in modern medicine. Since many physiotherapy procedures are used precisely because of the therapeutic benefits of such treatment, the same biological effects may be hazardous to those involved in administering them. Persons encountering instruments and machines generating non-ionizing radiation are often reported to have functional disturbances in the nervous and cardiovascular systems.

Studies of working conditions where ultrasound is used for diagnostic or therapeutic procedures revealed that the personnel were exposed during as much as 85 to 95% of their working day to levels of high frequency, low intensity ultrasound comparable to the exposures experienced by operators of industrial ultrasonic defectoscopy. They experienced such impairments of the peripheral neuro-vascular system as angiodistonic syndrome, vegetative polyneuritis, vegetative vascular malfunction and so on.

Noise is rarely reported as a substantial factor of occupational risk in the work of Russian medical personnel, except at dental institutions. When using high-speed drills (200,000 to 400,000 rev/min) the maximum energy of the sound falls at a frequency of 800 Hz. The noise levels at a distance of 30 cm from the drill placed in the mouth of the patient vary from 80 to 90 dBA. One-third of the whole sound spectrum falls within the range most harmful to the ear (i.e., between 1000 and 2000 Hz).

Many noise sources gathered in one place can generate levels exceeding permissible limits. To create optimum conditions it is recommended that anaesthetizing machines, respiratory equipment and artificial blood circulation pumps be taken out of operating rooms.

In surgery departments, especially in operating rooms and in rehabilitation and intensive care departments, as well as in some other special rooms, it is necessary to maintain the required parameters of temperature, humidity and air circulation. The optimal layout of modern medical institutions and the installation of ventilation and air-conditioning plants provide the favourable microclimate.

However, in operating suites built without optimal planning, occlusive clothing (i.e., gowns, masks, caps and gloves) and exposure to heat from lighting and other equipment lead many surgeons and other members of the operating teams to complain of “overheating”. Perspiration is mopped from surgeons’ brows lest it interfere with their vision or contaminate the tissues in the surgical field.

As a result of the introduction into medical practice of treatment in hyperbaric chambers, physicians and nurses now are often exposed to heightened atmospheric pressure. In most cases this affects surgical teams performing operations in such chambers. Exposure to conditions of increased atmospheric pressure is believed to lead to unfavourable changes in a number of body functions, depending on the level of the pressure and the duration of the exposure.

Working posture is also of great importance for physicians. Although most tasks are performed in sitting or standing positions, some activities require long periods in awkward and uncomfortable positions. This is particularly the case with dentists, otologists, surgeons (especially microsurgeons), obstetricians, gynaecologists and physiotherapists. Work requiring long periods of standing in one position has been associated with the development of varicose veins in the legs and haemorrhoids.

Continual, intermittent or casual exposure to potentially hazardous chemicals used in medical institutions also can affect medical personnel. Among these chemicals, inhalation anaesthetics are considered to have the most unfavourable influence on humans. These gases can accumulate in large amounts not only in operating and delivery rooms but also in pre-op areas where anaesthesia is induced and in recovery rooms where they are exhaled by patients coming out of anaesthesia. Their concentration depends on the content of the gas mixtures being administered, the type of equipment being used and the duration of the procedure. Concentrations of anaesthetic gases in the breathing zones of surgeons and anaesthetists in the operating room have been found ranging from 2 to 14 times the maximum allowable concentration (MAC). Exposure to anaesthetic gases has been associated with impaired reproductive capacity of both male and female anaesthetists and abnormalities in the foetuses of pregnant female anaesthetists and the spouses of male anaesthetists (see chapter Reproductive system and the article “Waste anaesthetic gases" in this chapter).

In the treatment rooms where many injections are performed, the concentration of a medicine in the respiration zone of nurses can exceed permissible levels. Airborne drug exposure can happen when washing and sterilizing syringes, removing air bubbles from a syringe, and while dispensing aerosol therapy.

Among chemicals which could affect the health of medical personnel are hexachlorophene (possibly causing teratogenic effects), formalin (an irritant, sensitizer and carcinogen), ethylene oxide (which has toxic, mutagenic and carcinogenic characteristics), antibiotics that cause allergies and suppressed immune response, vitamins and hormones. There is also the possibility of exposure to industrial chemicals used in cleaning and maintenance work and as insecticides.

Many of the drugs used in the treatment of cancer are themselves mutagenic and carcinogenic. Special training programmes have been developed to prevent workers involved in preparing and administering them from exposure to such cytotoxic agents.

One of the features of job assignments of medical workers of many specialties is contact with infected patients. Any infectious disease incurred as a result of such contact is considered to be an occupational one. Viral serum hepatitis has proved to be the most dangerous for the staff of medical institutions. Viral hepatitis infections of laboratory assistants (from examining blood samples), staff members of haemodialysis departments, pathologists, surgeons, anaesthetists and other specialists who had occupational contact with the blood of infected patients have been reported (see the article “Prevention of occupational transmission of bloodborne pathogens” in this chapter).

There has apparently been no recent improvement in the health status of HCWs in the Russian Federation. The proportion of cases of work-related, temporary disability remained at the level of 80 to 96 per 100 working doctors and 65 to 75 per 100 mid-level medical workers. Although this measure of work loss is quite high, it should also be noted that self-treatment and informal, unreported treatment are widespread among HCWs, which means that many cases are not captured by the official statistics. This was confirmed by a survey among physicians which found that 40% of the respondents were ill four times a year or more but did not apply to a practising physician for medical care and did not submit a disability form. These data were corroborated by medical examinations which found evidence of disability in 127.35 cases per 100 workers examined.

Morbidity also increases with age. In these examinations, it was six times more frequent among HCWs with 25 years of service than among those with less than 5 years of service. The most common diseases included circulatory impairments (27.9%), diseases of the digestive organs (20.0%) and musculoskeletal disorders (20.72%). Except for the last, most of the cases were non-occupational in origin.

Sixty per cent of doctors and 46% of mid-level personnel were found to have chronic diseases. Many of these were directly associated with job assignments.

Many of the observed diseases were directly associated with job assignments of those examined. Thus, microsurgeons working in an awkward posture were found to have frequent osteochondroses; chemotherapists were found to suffer frequently from chromosome abnormalities and anaemia; nurses who were in contact with a large variety of medicines suffered various allergic diseases, ranging from dermatoses to bronchial asthma and immunodeficiency.

In Russia, health problems of medical workers were first addressed in the 1920s. In 1923 a special scientific-consultative bureau was founded in Moscow; the results of its studies were published in five collections entitled Labour and Life of Medical Workers of Moscow and Moscow Province. Since that time other studies have appeared devoted to this problem. But this work has been carried on in the most fruitful way only since 1975, when the Laboratory of Labour Hygiene of Medical Workers was established in the RAMS Institute of Occupational Health, which coordinated all the studies of this problem. After analysis of the then-current situation, research was directed at:

  • studies of the features of labour processes in the main medical specialties
  • assessment of the factors of the occupational environment
  • analysis of the morbidity of medical workers
  • elaboration of measures for optimization of labour conditions, reduction of fatigue and prevention of morbidity.

 

Based on the studies carried out by the Laboratory and other institutions, a number of recommendations and suggestions were prepared, aimed at reduction and prevention of the occupational diseases of medical workers.

Instructions were established for pre-employment and periodic medical examinations of health care workers. The aim of these examinations was to determine the fitness of the worker for the job and to prevent common and occupational diseases as well as occupational accidents. A list of hazardous and dangerous factors in the work of medical personnel was prepared which included recommendations for frequency of examinations, the range of specialists to take part in the examinations, the number of laboratory and functional studies as well as a list of medical contra-indications for work with a specific hazardous occupational factor. For every studied group there was a list of occupational diseases, enumerating the nosological forms, approximate list of job assignments and hazardous factors which can cause the respective occupational conditions.

In order to control the working conditions in treatment and prevention institutions, a Certificate of Sanitary and Technical Conditions of Labour in the health care institutions was developed. The certificate can be used as a guide for conducting sanitary measures and improvement of labour safety. For an institution to complete the certificate, it is necessary to carry out a study, with the help of specialists in sanitary service and other respective organizations, of the general situation in the departments, rooms and wards, to measure the levels of health and safety hazards.

Departments of hygiene of the preventive medicine institutions have been established in the modern centres of sanitary-epidemic inspections. The mission of these departments includes perfecting measures for the prevention of nosocomial infections and their complications in hospitals, creating optimal conditions for treatment and protecting the safety and health of HCWs. Public health doctors and their assistants conduct the preventive monitoring of design and construction of buildings for health care institutions. They see to the compliance of the new premises with the climate conditions, required arrangement of worksites, comfortable labour conditions and systems of rest and nutrition during the work shifts (see the article “Buildings for health care facilities” in this chapter). They also control technical documentation for the new equipment, technological procedures and chemicals. The routine sanitary inspection includes the monitoring of the occupational factors at the worksites and accumulation of the received data in the above-mentioned Certificate of Sanitary and Technical Conditions of Labour. Quantitative measurement of working conditions and prioritization of health improvement measures are established according to hygienic criteria for assessments of labour conditions which are based on indicators of the hazard and danger of labour environment factors and the heaviness and intensity of the working process. The frequency of laboratory studies is determined by the specific needs of each case. Each study usually includes measurement and analysis of microclimate parameters; measurement of indicators of air environment (e.g., content of bacteria and hazardous substances); assessment of the effectiveness of ventilation systems; assessment of the levels of natural and artificial illumination; and measurement of noise levels, ultrasound, ionizing radiation and so on. It is also recommended that time-keeping monitoring of the exposures of the unfavourable factors be conducted, based on the guideline documents.

According to instructions of the Russian government, and in keeping with current existing practice, the hygienic and medical standards should be revised following the accumulation of new data.

 

Back

Health error and critical tasks in remote afterloading brachytherapy: Approaches for improved system performance

Remote afterloading btachytherapy (RAB) is a medical process used in the treatment of cancer. RAB uses a computer-controlled device to remotely insert and remove radioactive sources, close to a target (or tumour) in the body. Problems related to the dose delivered during RAB have been reported and attributed to human error (Swann-D'Emilia, Chu and Daywalt 1990). Callan et al. (1995) evaluated human error and critical tasks associated with RAB in 23 sites in the United States. Evaluation included six phases:

Phase 1: Functions and tasks. Preparation for treatment was considered to be the most difficult task, as it was responsible for the greatest cognitive strain. In addition, distractions had the greatest effect on preparation.

Phase 2: Human-system interferences. Personnel were often unfamiliar with interfaces they used infrequently. Operators were unable to see control signals or essential information from their workstations. In many cases, information on the state of the system was not given to the operator.

Phase 3: Procedures and practices. Because procedures used to move from one operation to the next, and those used to transmit information and equipment between tasks, were not well defined, essential information could be lost. Verification procedures were often absent, poorly constructed or inconsistent.

Phase 4: Training policies. The study revealed the absence of formal training programmes at most sites.

Phase 5: Organizational support structures. Communication during RAB was particularly subject to error. Quality-control procedures were inadequate.

Phase 6: Identification and classification or circumstances favouring human error. In all, 76 factors favouring human error were identified and categorized. Alternative approaches were identified and evaluated.

Ten critical tasks were subject to error:

  • patient scheduling, identification and tracking
  • applicator placement stabilization
  • large volume localization
  • dwell position localization
  • dosimetry
  • treatment set-up
  • treatment plan entry
  • source exchange
  • source calibration
  • record-keeping and routine quality assurance

 

Treatment was the function associated with the greatest number of errors. Thirty treatment-related errors were analysed and errors were found to occur during four or five treatment sub-tasks. The majority of errors occurred during treatment delivery. The second-highest number of errors were associated with the planning of treatment and were related to the calculation of dose. Improvements of eqiupment and documentation are under way, in collaboration with manufacturers.

 

Back

Wednesday, 02 March 2011 16:30

Buildings for Health Care Facilities

Written by

The health maintenance and enhancement, the safety and the comfort of people in health care facilities are seriously affected if specific building requirements are not met. Health care facilities are rather unique buildings, in which heterogeneous environments coexist. Different people, several activities in each environment and many risk factors are involved in the pathogenesis of a broad spectrum of diseases. Functional organization criteria classify health care facility environments as follows: nursing units, operating theatres, diagnostic facilities (radiology unit, laboratory units and so on), outpatients’ departments, administration area (offices), dietary facilities, linen services, engineering services and equipment areas, corridors and passages. The group of people which attends a hospital is composed of health personnel, staff personnel, patients (long-stay inpatients, acute inpatients and outpatients) and visitors. The processes include health care specific activities—diagnostic activities, therapeutic activities, nursing activities—and activities common to many public buildings—office work, technological maintenance, food preparation and so on. The risk factors are physical agents (ionizing and non-ionizing radiation, noise, lighting and microclimatic factors), chemicals (e.g., organic solvents and disinfectants), biological agents (viruses, bacteria, fungi and so on), ergonomics (postures, lifting and so on) and psychological and organizational factors (e.g., environmental perceptions and work hours). The illnesses related to the above-mentioned factors range from environmental annoyance or discomfort (e.g., thermal discomfort or irritative symptoms) to severe diseases (e.g., hospital-acquired infections and traumatic accidents). In this perspective, the risk assessment and control require an interdisciplinary approach involving physicians, hygienists, engineers, architects, economists and so on and fulfilment of preventive measures in the building planning, design, construction and management tasks. Specific building requirements are extremely important among these preventive measures, and, according to the guidelines for healthy buildings introduced by Levin (1992), they should be classified as follows:

  • site planning requirements
  • architectural design requirements
  • requirements for building materials and furnishings
  • requirements for heating, ventilation and air-conditioning systems and for microclimatic conditions.

 

This article focuses on general hospital buildings. Obviously, adaptations would be required for specialty hospitals (e.g., orthopaedic centres, eye and ear hospitals, maternity centres, psychiatric institutions, long-term care facilities and rehabilitation institutes), for ambulatory care clinics, emergency/urgent care facilities and offices for individual and group practices. These will be determined by the numbers and types of patients (including their physical and mental status) and by the number of HCWs and the tasks they perform. Considerations promoting the safety and well-being of both patients and staff that are common to all health care facilities include:

  • ambience, including not only decoration, lighting and noise control but also partitioning and placement of furniture and equipment that avoid entrapment of workers with potentially violent patients and visitors
  • ventilation systems that minimize exposure to infectious agents and potentially toxic chemicals and gases
  • storage facilities for clothing and effects of patients and their visitors that minimize potential contamination
  • lockers, changing rooms, wash-up facilities and rest rooms for staff
  • conveniently-located hand-washing facilities in each room and treatment area
  • doorways, elevators and toilets that accommodate wheel chairs and stretchers
  • storage and filing areas designed to minimize workers’ stooping, bending, reaching and heavy lifting
  • automatic and worker-controlled communication and alarm systems
  • mechanisms for collection, storage and disposition of toxic wastes, contaminated linens and clothing and so on.

 

Site Planning Requirements

The health care facility site must be chosen following four main criteria (Catananti and Cambieri 1990; Klein and Platt 1989; Decree of the President of Ministers Council 1986; Commission of the European Communities 1990; NHS 1991a, 1991b):

  1. Environmental factors. The terrain should be as level as possible. Ramps, escalators and elevators can offset sides of hills, but they hinder the access of elderly and handicapped people, adding both a higher cost to the project and an extra burden to fire departments and evacuation teams. Heavy wind sites should be avoided, and the area should be far from sources which create pollution and noise (especially factories and landfills). Radon and radon daughters levels should be assessed, and measures to reduce exposure should be taken. In colder climates, consideration should be given to embedding snow-melting coils in sidewalks, entrance ways and parking areas to minimize falls and other accidents. 
  2. Geological configuration. Earthquake-prone areas should be avoided, or at least anti-seismic construction criteria must be followed. The site must be chosen following an hydrogeological assessment, to avoid water infiltrations into the foundations. 
  3. Urbanistic factors. The site should be easily accessible to potential users, ambulances and service vehicles for goods supply and waste disposal. Public transportation and utilities (water, gas, electricity and sewers) should be available. Fire departments should be nearby, and fire-fighters and their apparatus should find ready access to all parts of the facility. 
  4. Space availability. The site should allow some scope for expansion and provision of adequate car parking.

 

Architectural Design

Health care facilities architectural design usually follows several criteria:

  • class of the health care facility: hospital (acute-care hospital, community hospital, rural hospital), large or small health care centre, nursing homes (extended care facilities, skilled nursing homes, residential care homes), general medical practice premise (NHS 1991a; NHS 1991b; Kleczkowski, Montoya-Aguilar and Nilsson 1985; ASHRAE 1987)
  • catchment area dimensions
  • management issues: costs, flexibility (susceptibility to adaptation)
  • ventilation provided: an air-conditioned building is compact and deep with as small an amount of external walls as possible, to reduce the heat transfer between outside and inside; a naturally ventilated building is long and thin, to maximize exposure to breezes and to minimize internal distances from windows (Llewelyn-Davies and Wecks 1979)
  • building/area ratio
  • environmental quality: safety and comfort are extremely relevant targets.

 

The listed criteria lead health care facilities planners to choose the best building shape for each situation, ranging essentially from an extended horizontal hospital with scattered buildings to a monolithic vertical or horizontal building (Llewelyn-Davies and Wecks 1979). The first case (a preferable format for low-density buildings) is normally used for hospitals up to 300 beds, because of its low costs in construction and management. It is particularly considered for small rural hospitals and community hospitals (Llewelyn-Davies and Wecks 1979). The second case (usually preferred for high-density buildings) becomes cost-effective for hospitals with more than 300 beds, and it is advisable for acute-care hospitals (Llewelyn-Davies and Wecks 1979). The internal space dimensions and distribution have to cope with many variables, among which one can consider: functions, processes, circulation and connections to other areas, equipment, predicted workload, costs, and flexibility, convertibility and susceptibility of shared use. Compartments, exits, fire alarms, automatic extinction systems and other fire prevention and protection measures should follow local regulations. Furthermore, several specific requirements have been defined for each area in health care facilities:

1.       Nursing units. Internal layout of nursing units usually follows one of the following three basic models (Llewelyn-Davies and Wecks 1979): an open ward (or “Nightingale” ward)—a broad room with 20 to 30 beds, heads to the windows, ranged along both walls; the “Rigs” layout—in this model beds were placed parallel to the windows, and, at first, they were in open bays on either side of a central corridor (as at Rigs Hospital in Copenhagen), and in later hospitals the bays were often enclosed, so that they became rooms with 6 to 10 beds; small rooms, with 1 to 4 beds. Four variables should lead the planner to choose the best layout: bed need (if high, an open ward is advisable), budget (if low, an open ward is the cheapest one), privacy needs (if considered high, small rooms are unavoidable) and intensive care level (if high, the open ward or Rigs layout with 6 to 10 beds are advisable). The space requirements should be at least: 6 to 8 square metres (sqm) per bed for open wards, inclusive of circulation and ancillary rooms (Llewelyn-Davies and Wecks 1979); 5 to 7 sqm/bed for multiple bedrooms and 9 sqm for single bedrooms (Decree of the President of Ministers Council 1986; American Institute of Architects Committee on Architecture for Health 1987). In open wards, toilet facilities should be close to patients’ beds (Llewelyn-Davies and Wecks 1979). For single and multiple bedrooms, handwashing facilities should be provided in each room; lavatories may be omitted where a toilet room is provided to serve one single-bed room or one two-bed room (American Institute of Architects Committee on Architecture for Health 1987). Nursing stations should be large enough to accommodate desks and chairs for record keeping, tables and cabinets for preparation of drugs, instruments and supplies, chairs for sit-down conferences with physicians and other staff members, a wash-up sink and access to a staff toilet.

2.       Operating theatres. Two main classes of elements should be considered: operating rooms and service areas (American Institute of Architects Committee on Architecture for Health 1987). Operating rooms should be classified as follows:

  • general operating room, needing a minimum clear area of 33.5 sqm.
  • room for orthopaedic surgery (optional), needing enclosed storage space for splints and traction equipment
  • room for cardiovascular surgery (optional), needing a minimum clear area of 44 sqm. In the clear area of the surgical suite, nearby the operating room, an additional pump room should be designed, where extracorporeal pump supplies and accessories are stored and serviced.
  • room for endoscope procedures, needing a minimum clear area of 23 sqm
  • rooms for waiting patients, induction of anaesthesia and recovery from anaesthesia.

 

Service areas should include: sterilizing facility with high-speed autoclave, scrub facilities, medical gas storage facilities and staff clothing change areas.

3.       Diagnostic facilities: Each radiology unit should include (Llewelyn-Davies and Wecks 1979; American Institute of Architects Committee on Architecture for Health 1987):

  • appointment desk and waiting areas
  • diagnostic radiographic rooms, needing 23 sqm for fluoroscopic procedures and about 16 sqm for radiographic ones, plus a shielded control area, and rigid support structures for ceiling-mounted equipment (where necessary)
  • dark room (where necessary), needing almost 5 sqm and appropriate ventilation for the developer
  • contrast media preparation area, clean-up facilities, film quality control area, computer area and film storage area
  • viewing area where films can be read and reports dictated.

 

The wall thickness in a radiology unit should be 8 to 12 cm (poured concrete) or 12 to 15 cm (cinder block or bricks). The diagnostic activities in health care facilities may require tests in haematology, clinical chemistry, microbiology, pathology and cytology. Each laboratory area should be provided with work areas, sample and material storage facilities (refrigerated or not), specimen collection facilities, facilities and equipment for terminal sterilization and waste disposal, and a special facility for radioactive material storage (where necessary) (American Institute of Architects Committee on Architecture for Health 1987).

4.       Outpatient departments. Clinical facilities should include (American Institute of Architects Committee on Architecture for Health 1987): general-purpose examination rooms (7.4 sqm), special-purpose examination rooms (varying with the specific equipment needed) and treatment rooms (11 sqm). In addition, administrative facilities are needed for the admittance of outpatients.

5.       Administration area (offices). Facilities such as common office building areas are needed. These include a loading dock and storage areas for receiving supplies and equipment and dispatching materials not disposed of by the separate waste removal system.

6.       Dietary facilities (optional). Where present, these should provide the following elements (American Institute of Architects Committee on Architecture for Health 1987): a control station for receiving and controlling food supplies, storage spaces (including cold storage), food preparation facilities, handwashing facilities, facility for assembling and distributing patients’ meals, dining space, dishwashing space (located in a room or an alcove separated from the food preparation and serving area), waste storage facilities and toilets for dietary staff.

7.       Linen services (optional). Where present, these should provide the following elements: a room for receiving and holding soiled linen, a clean-linen storage area, a clean-linen inspection and mending area and handwashing facilities (American Institute of Architects Committee on Architecture for Health 1987).

8.       Engineering services and equipment areas. Adequate areas, varying in size and characteristics for each health care facility, have to be provided for: boiler plant (and fuel storage, if necessary), electrical supply, emergency generator, maintenance workshops and stores, cold-water storage, plant rooms (for centralized or local ventilation) and medical gases (NHS 1991a).

9.       Corridors and passages. These have to be organized to avoid confusion for visitors and disruptions in the work of hospital personnel; circulation of clean and dirty goods should be strictly separated. Minimum corridor width should be 2 m (Decree of the President of Ministers Council 1986). Doorways and elevators must be large enough to allow easy passage of stretchers and wheelchairs.

Requirements for Building Materials and Furnishings

The choice of materials in modern health care facilities is often aimed to reduce the risk in accidents and fire occurrence: materials must be non-inflammable and must not produce noxious gases or smokes when burnt (American Institute of Architects Committee on Architecture for Health 1987). Trends in hospital floor-covering materials have shown a shift from stone materials and linoleum to polyvinyl chloride (PVC). In operating rooms, in particular, PVC is considered the best choice to avoid electrostatic effects that may cause explosion of anaesthetic flammable gases. Up to some years ago, walls were painted; today, PVC coverings and fibreglass wallpaper are the most used wall finishes. False ceilings are today built mainly from mineral fibres instead of gypsum board; a new trend appears to be that of using stainless steel ceilings (Catananti et al. 1993). However, a more complete approach should consider that each material and furnishing may cause effects in the outdoor and indoor environmental systems. Accurately chosen building materials may reduce environmental pollution and high social costs and improve the safety and comfort of building occupants. At the same time, internal materials and finishes may influence the functional performance of the building and its management. Besides, the choice of materials in hospitals should also consider specific criteria, such as ease of cleaning, washing and disinfecting procedures and susceptibility to becoming a habitat for living beings. A more detailed classification of criteria to be considered in this task, derived from the European Community Council Directive No. 89/106 (Council of the European Communities 1988), is shown in table 1 .

Table 1. Criteria and variables to be considered in the choice of materials

Criteria

Variables

Functional performance

Static load, transit load, impact load, durability, construction requirements

Safety

Collapse risk, fire risk (reaction to fire, fire resistance, flammability), static electric charge (explosion risk), disperse electric power (electric shock risk), sharp surface (wound risk), poisoning risk (hazardous chemical emission), slip risk, radioactivity

Comfort and pleasantness

Acoustic comfort (features related to noise), optical and visual comfort (features related to light), tactile comfort (consistence, surface), hygrothermal comfort (features related to heat), aesthetics, odour emissions, indoor air quality perception

Hygienicity

Living beings habitat (insects, moulds, bacteria), susceptibility to stains, susceptibility to dust, easiness in cleaning, washing and disinfecting, maintenance procedures

Flexibility

Susceptibility to modifications, conformational factors (tile or panel dimensions and morphology)

Environmental impact

Raw material, industrial manufacturing, waste management

Cost

Material cost, installation cost, maintenance cost

Source: Catananti et al. 1994.

On the matter of odour emissions, it should be observed that a correct ventilation after floor or wall-coverings installation or renovation work reduces exposure of personnel and patients to indoor pollutants (especially volatile organic compounds (VOCs)) emitted by building materials and furnishings.

Requirements for Heating, Ventilation and Air-Conditioning Systems and for Microclimatic Conditions

The control of microclimatic conditions in health care facilities areas may be carried out by heating, ventilation and/or air-conditioning systems (Catananti and Cambieri 1990). Heating systems (e.g., radiators) permit only temperature regulation and may be sufficient for common nursing units. Ventilation, which induces changes of air speed, may be natural (e.g., by porous building materials), supplementary (by windows) or artificial (by mechanical systems). The artificial ventilation is especially recommended for kitchens, laundries and engineering services. Air-conditioning systems, particularly recommended for some health care facility areas such as operating rooms and intensive-care units, should guarantee:

  • the control of all microclimatic factors (temperature, relative humidity and air speed)
  • the control of air purity and concentration of micro-organisms and chemicals (e.g., anaesthetic gases, volatile solvents, odours and so on). This target may be achieved by adequate air filtration and air changes, right pressure relationships among adjacent areas and laminar airflow.

 

General requirements of air-conditioning systems include outdoor intake locations, air filter features and air supply outlets (ASHRAE 1987). Outdoor intake locations should be far enough, at least 9.1 m, from pollution sources such as exhaust outlets of combustion equipment stacks, medical-surgical vacuum systems, ventilation exhaust outlets from the hospital or adjoining buildings, areas that may collect vehicular exhaust and other noxious fumes, or plumbing vent stacks. Besides, their distance from ground level should be at least 1.8 m. Where these components are installed above the roof, their distance from roof level should be at least 0.9 m.

Number and efficiency of filters should be adequate for the specific areas supplied by air conditioning systems. For example, two filter beds of 25 and 90% efficiency should be used in operating rooms, intensive-care units and transplant organ rooms. Installation and maintenance of filters follow several criteria: lack of leakage between filter segments and between the filter bed and its supporting frame, installation of a manometer in the filter system in order to provide a reading of the pressure so that filters can be identified as expired and provision of adequate facilities for maintenance without introducing contamination into the air flow. Air supply outlets should be located on the ceiling with perimeter or several exhaust inlets near the floor (ASHRAE 1987).

Ventilation rates for health care facility areas permitting air purity and comfort of occupants are listed in table 2 .

Table 2. Ventilation requirements in health care facilities areas

Areas

Pressure relationships to adjacent areas

Minimum air changes of outdoor air per hour supplied to room

Minimum total air changes per hour supplied to room

All air exhausted directly to outdoors

Recirculated within room units

Nursing units

         

Patient room

+/–

2

2

Optional

Optional

Intensive care

P

2

6

Optional

No

Patient corridor

+/–

2

4

Optional

Optional

Operating theatres

         

Operating room (all outdoor system)

P

15

15

Yes1

No

Operating room (recirculating system)

P

5

25

Optional

No2

Diagnostic facilities

         

X ray

+/–

2

6

Optional

Optional

Laboratories

         

Bacteriology

N

2

6

Yes

No

Clinical chemistry

P

2

6

Optional

No

Pathology

N

2

6

Yes

No

Serology

P

2

6

Optional

No

Sterilizing

N

Optional

10

Yes

No

Glasswashing

N

2

10

Yes

Optional

Dietary facilities

         

Food preparation centres3

+/–

2

10

Yes

No

Dishwashing

N

Optional

10

Yes

No

Linen service

         

Laundry (general)

+/–

2

10

Yes

No

Soiled linen sorting and storage

N

Optional

10

Yes

No

Clean linen storage

P

2 (Optional)

2

Optional

Optional

P = Positive. N = Negative. +/– = Continuous directional control not required.

1 For operating rooms, use of 100% outside air should be limited to these cases where local codes require it, only if heat recovery devices are used; 2 recirculating room units meeting the filtering requirement for the space may be used; 3 food preparation centres shall have ventilation systems that have an excess of air supply for positive pressure when hoods are not in operation. The number of air changes may be varied to any extent required for odour control when the space is not in use.

Source: ASHRAE 1987.

Specific requirements of air-conditioning systems and microclimatic conditions regarding several hospital areas are reported as follows (ASHRAE 1987):

Nursing units. In common patient rooms a temperature (T) of 24 °C and a 30% relative humidity (RH) for winter and a T of 24 °C with 50% RH for summer are recommended. In intensive-care units a variable range temperature capability of 24 to 27 °C and a RH of 30% minimum and 60% maximum with a positive air pressure are recommended. In immunosuppressed patient units a positive pressure should be maintained between patient room and adjacent area and HEPA filters should be used.

In full-term nursery a T of 24 °C with RH from 30% minimum to 60% maximum is recommended. The same microclimatic conditions of intensive-care units are required in special-care nursery.

Operating theatres. Variable temperature range capability of 20 to 24 °C with RH of 50% minimum and 60% maximum and positive air pressure are recommended in operating rooms. A separate air-exhaust system or special vacuum system should be provided in order to remove anaesthetic gas traces (see “Waste anaesthetic gases” in this chapter).

Diagnostic facilities. In the radiology unit, fluoroscopic and radiographic rooms require T of 24 to 27 °C and RH of 40 to 50%. Laboratory units should be supplied with adequate hood exhaust systems to remove dangerous fumes, vapours and bioaerosols. The exhaust air from the hoods of the units of clinical chemistry, bacteriology and pathology should be discharged to the outdoors with no recirculation. Also, the exhaust air from infectious disease and virology laboratories requires sterilization before being exhausted to the outdoors.

Dietary facilities. These should be provided with hoods over the cooking equipment for removal of heat, odours and vapours.

Linen services. The sorting room should be maintained at a negative pressure in relation to adjoining areas. In the laundry processing area, washers, flatwork ironers, tumblers, and so on should have direct overhead exhaust to reduce humidity.

Engineering services and equipment areas. At work stations, the ventilation system should limit temperature to 32 °C.

Conclusion

The essence of specific building requirements for health care facilities is the accommodation of external standard-based regulations to subjective index-based guidelines. In fact, subjective indices, such as Predicted Mean Vote (PMV) (Fanger 1973) and olf, a measure of odour (Fanger 1992), are able to make predictions of the comfort levels of patients and personnel without neglecting the differences related to their clothing, metabolism and physical status. Finally, the planners and architects of hospitals should follow the theory of “building ecology” (Levin 1992) which describes dwellings as a complex series of interactions among buildings, their occupants and the environment. Health facilities, accordingly, should be planned and built focusing on the whole “system” rather than any particular partial frames of reference.

 

Back

A hospital is not an isolated social environment; it has, given its mission, very serious intrinsic social responsibilities. A hospital needs to be integrated with its surroundings and should minimize its impact upon them, thus contributing to the welfare of the people who live near it.

From a regulatory perspective, the health industry has never been considered to be on the same level as other industries when they are ranked according to the health risks they pose. The result is that specific legislation in this sphere has been non-existent until recently, although in the last few years this deficiency has been addressed. While in many other kinds of industrial activities, health and safety is an integral part of the organization, most health centres still pay little or no attention to it.

One reason for this could be the attitudes of HCWs themselves, who may be preoccupied more with research and the acquisition of the latest technologies and diagnostic and treatment techniques than with looking into the effects that these advances could have on their own health and on the environment.

New developments in science and health care must be combined with environmental protection, because environmental policies in a hospital affect the quality of life of HCWs within the hospital and those who live outside it.

Integrated Health, Safety and Environmental Programmes

HCWs represent a major group, comparable in size to the large enterprises of the private sector. The number of people who pass through a hospital every day is very large: visitors, inpatients, outpatients, medical and commercial representatives, subcontractors and so on. All of them, to a greater or lesser degree, are exposed to the potential risks posed by the activities of the medical centre and, at the same time, contribute on a certain level to the improvement or the worsening of the safety and the care of the centre’s surroundings.

Strict measures are needed in order to safeguard HCWs, the general public and the surrounding environment from the deleterious effects that may stem from hospital activities. These activities include the use of ever more sophisticated technology, the more frequent use of extremely powerful drugs (the effects of which can have a profound and irreparable impact on the people who prepare or administer them), the too-often uncontrolled use of chemical products and the incidence of infectious diseases, some of which are incurable.

The risks of working in a hospital are many. Some are easy to identify, while others are very hard to detect; the measures to be taken should therefore always be rigorous.

Different groups of health professionals are particularly exposed to risks common to the health care industry in general, as well as to specific risks related to their profession and/or to the activities they perform in the course of their work.

The concept of prevention, therefore, must of necessity be incorporated to the health care field and encompass:

  • safety in the broadest sense, including psychosociology and ergonomics as part of the programmes to improve the quality of life in the workplace
  • hygiene, minimizing as much as possible any physical, chemical or biological factor that may affect the health of people in the work environment
  • environment, following policies to protect nature and people in the surrounding community and decreasing the impact on the environment.

 

We should be aware that the environment is directly and intimately related to the safety and hygiene in the workplace, because natural resources are consumed at work, and because these resources are later reincorporated into our surroundings. Our quality of life will be good or bad depending on whether we make correct use of these resources and use appropriate technologies.

Everyone’s involvement is necessary in order to contribute to further:

  • nature conservancy policies, designed to guarantee the survival of the natural heritage that surrounds us
  • environmental improvement policies as well as policies to control indoor and environmental pollution in order to integrate human activity with the environment
  • environmental research and training policies to improve working conditions as well as to reduce environmental impact
  • planning organizational policies designed to set goals and develop norms and methodology for workers’ health and the environment.

 

Goals

Such a programme should endeavour to:

  • change the culture and habits of health professionals in order to stimulate behaviour more conducive to safeguarding their health
  • set goals and develop internal safety, hygiene and environmental guidelines through adequate planning and organization
  • improve the methods of work to avoid a negative impact on health and the environment through environmental research and education
  • increase the involvement of all personnel and have them take responsibility for health in the workplace
  • create an adequate programme to establish and publicize the guidelines as well as to monitor their continued implementation
  • correctly classify and manage the waste generated
  • optimize costs, avoiding added expenditures that cannot be justified by the increased levels of safety and health or environmental quality.

 

Plan

A hospital should be conceived as a system that, through a number of processes, generates services. These services are the main goal of the activities performed in a hospital.

For the process to begin, certain commitments of energy, investments and technology are needed, which in turn will generate their own emissions and wastes. Their only aim is to provide service.

In addition to these prerequisites, consideration should be given to the conditions of the areas of the building where these activities will take place, since they have been designed a certain way and built with basic construction materials.

Control, planning and coordination are all necessary for an integrated safety, health and environmental project to succeed.

Methodology

Because of the complexity and the variety of risks in the health care field, multidisciplinary groups are required if solutions to each particular problem are to be found.

It is important for health care workers to be able to collaborate with safety studies, participating in the decisions that will be made to improve their working conditions. This way changes will be seen with a better attitude and the guidelines will be more readily accepted.

The safety, hygiene and environmental service should advise, stimulate and coordinate the programmes developed at the health centre. Responsibility for their implementation should fall upon whoever heads up the service where this programme will be followed. This is the only way to involve the entire organization.

In each particular case, the following will be selected:

  • the system involved
  • the parameters of the study
  • the time needed to carry it out.

 

The study will consist of:

  • an initial diagnosis
  • analysis of the risk
  • deciding on the course of action.

 

In order to implement the plan successfully it will always be necessary to:

  • educate and inform people of the risks
  • improve the management of human resources
  • improve the channels of communication.

 

This type of study may be a global one encompassing the centre as a whole (e.g., internal plan for the disposal of hospital wastes) or partial, encompassing only one concrete area (e.g., where cancer chemotherapeutic drugs are prepared).

The study of these factors will give an idea of the degree to which safety measures are disregarded, as much from the legal as from the scientific point of view. The concept of “legal” here encompasses advances in science and technology as they occur, which requires the constant revision and modification of established norms and guidelines.

It would be convenient indeed if the regulations and the laws by which safety, hygiene and the environment are regulated were the same in all countries, something that would make the installation, management and use of technology or products from other countries much easier.

Results

The following examples show some of the measures that can be taken while following the aforementioned methodology.

Laboratories

An advisory service can be developed involving professionals of the various laboratories and coordinated by the safety and hygiene service of the medical centre. The main goal would be to improve the safety and health of the occupants of all the labs, involving and giving responsibility to the entire professional staff of each and trying at the same time to make sure that these activities do not have a negative impact on public health and the environment.

The measures taken should include:

  • instituting the sharing of materials, products and equipment among the different laboratories, in order to optimize resources
  • reducing the stocks of chemical products in laboratories
  • creating a manual of basic norms of safety and hygiene
  • planning courses to educate all laboratory workers on these matters
  • training for emergencies.

 

Mercury

Thermometers, when broken, release mercury into the environment. A pilot project has been started with “unbreakable” thermometers to consider eventually substituting them for the glass thermometers. In some countries, such as the United States, electronic thermometers have replaced mercury thermometers to a very great extent.

Training the workers

The training and the commitment of the workers is the most important part of an integrated safety, health and environment programme. Given enough resources and time, the technicalities of almost any problem can be solved, but a complete solution will not be achieved without informing the workers of the risks and training them to avoid or control them. The training and education must be continuous, integrating health and safety techniques into all the other training programmes in the hospital.

Conclusions

The results that have been achieved so far in applying this work model allow us so far to be optimistic. They have shown that when people are informed about the whys and wherefores, their attitude toward change is very positive.

The response of health care personnel has been very good. They feel more motivated in their work and more valued when they have participated directly in the study and in the decision-making process. This participation, in turn, helps to educate the individual health care worker and to increase the degree of responsibility he or she is willing to accept.

The attainment of the goals of this project is a long-term objective, but the positive effects it generates more than compensate for the effort and the energy invested in it.

 

Back

Wednesday, 02 March 2011 16:38

Hospital Waste Management

Written by

An adaptation of current guidelines on the disposal of hospital wastes, as well as improvements in internal safety and hygiene, must be part of an overall plan of hospital waste management that establishes the procedures to follow. This should be done through properly coordinating internal and external services, as well as defining responsibilities in each of the management phases. The main goal of this plan is to protect the health of health care personnel, patients, visitors and the general public both in the hospital and beyond.

At the same time, the health of the people who come in contact with the waste once it leaves the medical centre should not be overlooked, and the risks to them should also be minimized.

Such a plan should be campaigned for and applied according to a global strategy that always keeps in mind the realities of the workplace, as well as the knowledge and the training of the personnel involved.

Stages followed in the implementation of a waste management plan are:

  • informing the management of the medical centre
  • designating those responsible at the executive level
  • creating a committee on hospital wastes made up of personnel from the general services, nursing and medical departments that is chaired by the medical centre’s waste manager.

 

The group should include personnel from the general services department, personnel from the nursing department and personnel from the medical department. The medical centre’s waste manager should coordinate the committee by:

  • putting together a report on the present performance of the centre’s waste management
  • putting together an internal plan for advanced management
  • creating a training programme for the entire staff of the medical centre, with the collaboration of the human resources department
  • launching the plan, with follow-up and control by the waste management committee.

 

Classification of hospital wastes

Until 1992, following the classical waste management system, the practice was to classify most hospital wastes as hazardous. Since then, applying an advanced management technique, only a very small proportion of the large volume of these wastes is considered hazardous.

The tendency has been to adopt an advanced management technique. This technique classifies wastes starting from the baseline assumption that only a very small percentage of the volume of wastes generated is hazardous.

Wastes should always be classified at the point where they are generated. According to the nature of the wastes and their source, they are classified as follows:

  • Group I: those wastes that can be assimilated into urban refuse
  • Group II: non-specific hospital wastes
  • Group III: specific hospital wastes or hazardous wastes
  • Group IV: cytostatic wastes (surplus antineoplastic drugs that are not fit for therapeutic use, as well as the single-use materials that have been in contact with them, e.g., needles, syringes, catheters, gloves and IV set-ups).

 

According to their physical state, wastes can be classified as follows:

  • solids: wastes that contain less than 10% liquid
  • liquids: wastes that contain more than 10% liquid

 

Gaseous wastes, such as CFCs from freezers and refrigerators, are not normally captured (see article “Waste anaesthetic gases”).

By definition, the following wastes are not considered sanitary wastes:

  • radioactive wastes that, because of their very nature, are already managed in a specific way by the radiological protection service
  • human cadavers and large anatomical parts which are cremated or incinerated according to regulations
  • waste water.

 

Group I Wastes

All wastes generated within the medical centre that are not directly related to sanitary activities are considered solid urban wastes (SUW). According to the local ordinances in Cataluna, Spain, as in most communities, the municipalities must remove these wastes selectively, and it is therefore convenient to facilitate this task for them. The following are considered wastes that can be assimilated to urban refuse according to their point of origin:

Kitchen wastes:

  • food wastes
  • wastes from leftovers or single-use items
  • containers.

 

Wastes generated by people treated in the hospital and non-medical personnel:

  • wastes from cleaning products
  • wastes left behind in the rooms (e.g., newspapers, magazines and flowers)
  • wastes from gardening and renovations.

 

Wastes from administrative activities:

  • paper and cardboard
  • plastics.

 

Other wastes:

  • glass containers
  • plastic containers
  • packing cartons and other packaging materials
  • dated single-use items.

 

So long as they are not included on other selective removal plans, SUW will be placed in white polyethylene bags that will be removed by janitorial personnel.

Group II Wastes

Group II wastes include all those wastes generated as a by-product of medical activities that do not pose a risk to health or the environment. For reasons of safety and industrial hygiene the type of internal management recommended for this group is different from that recommended for Group I wastes. Depending on where they originate, Group II wastes include:

Wastes derived from hospital activities, such as:

  • blood-stained materials
  • gauze and materials used in treating non-infectious patients
  • used medical equipment
  • mattresses
  • dead animals or parts thereof, from rearing stables or experimental laboratories, so long as they have not been inoculated with infectious agents.

 

Group II wastes will be deposited in yellow polyethylene bags that will be removed by janitorial personnel.

Group III Wastes

Group III includes hospital wastes which, due to their nature or their point of origin, could pose risks to health or the environment if several special precautions are not observed during handling and removal.

Group III wastes can be classified in the following way:

Sharp and pointed instruments:

  • needles
  • scalpels.

 

Infectious wastes. Group III wastes (including single-use items) generated by the diagnosis and treatment of patients who suffer from one of the infectious diseases are listed in table 1.

Table 1. Infectious diseases and Group III wastes

Infections

Wastes contaminated with

Viral haemorrhagic fevers
Congo-Crimean fever
Lassa fever
Marburg virus
Ebola
Junin fever
Machupo fever
Arbovirus
Absettarow
Hanzalova
Hypr
Kumlinge
Kiasanur Forest Disease
Omsk fever
Russian spring-summer
encephalitis

All wastes

Brucellosis

Pus

Diphtheria

Pharyngeal diphtheria: respiratory secretions
Cutaneous diphtheria: secretions from skin
lesions

Cholera

Stools

Creutzfelt-Jakob encephalitis

Stools

Borm

Secretions from skin lesions

Tularaemia

Pulmonary tularaemia: respiratory secretions
Cutaneous tularaemia: pus

Anthrax

Cutaneous anthrax: pus
Respiratory anthrax: respiratory secretions

Plague

Bubonic plague: pus
Pneumonic plague: respiratory secretions

Rabies

Respiratory secretions

Q Fever

Respiratory secretions

Active tuberculosis

Respiratory secretions

 

Laboratory wastes:

  • material contaminated with biological wastes
  • waste from work with animals inoculated with biohazardous substances.

 

Wastes of the Group III type will be placed in single-use, rigid, colour-coded polyethylene containers and hermetically sealed (in Cataluna, black containers are required). The containers should be clearly labelled as “Hazardous hospital wastes” and kept in the room until collected by janitorial personnel. Group III wastes should never be compacted.

To facilitate their removal and reduce risks to a minimum, containers should not be filled to capacity so that they can be closed easily. Wastes should never be handled once they are placed in these rigid containers. It is forbidden to dispose of biohazardous wastes by dumping them into the drainage system.

Group IV Wastes

Group IV wastes are surplus antineoplastic drugs that are not fit for therapeutic use, as well as all single-use material that has been in contact with the same (needles, syringes, catheters, gloves, IV set-ups and so on).

Given the danger they pose to persons and the environment, Group IV hospital wastes must be collected in rigid, watertight, sealable single-use, colour-coded containers (in Cataluna, they are blue) which should be clearly labelled “Chemically contaminated material: Cytostatic agents”.

Other Wastes

Guided by environmental concerns and the need to enhance waste management for the community, medical centres, with the cooperation of all personnel, staff and visitors, should encourage and facilitate the selective disposal (i.e., in special containers designated for specific materials) of recyclable materials such as:

  • paper and cardboard
  • glass
  • used oils
  • batteries and power cells
  • toner cartridges for laser printers
  • plastic containers.

 

The protocol established by the local sanitation department for the collection, transport and disposal of each of these types of materials should be followed.

Disposal of large pieces of equipment, furniture and other materials not covered in these guidelines should follow the directions recommended by the appropriate environmental authorities.

Internal transport and storage of wastes

Internal transport of all the wastes generated within the hospital building should be done by the janitorial personnel, according to established schedules. It is important that the following recommendations be observed when transporting wastes within the hospital:

  • The containers and the bags will always be closed during transport.
  • The carts used for this purpose will have smooth surfaces and be easy to clean.
  • The carts will be used exclusively for transporting waste.
  • The carts will be washed daily with water, soap and lye.
  • The waste bags or containers should never be dragged on the floor.
  • Waste should never be transferred from one receptacle to another.

 

The hospital must have an area specifically for the storage of wastes; it should conform to current guidelines and fulfil, in particular, the following conditions:

  • It should be covered.
  • It should be clearly marked by signs.
  • It should be built with smooth surfaces that are easy to clean.
  • It should have running water.
  • It should have drains to remove the possible spillage of waste liquids and the water used for cleaning the storage area.
  • It should be provided with a system to protect it against animal pests.
  • It should be located far away from windows and from the intake ducts of the ventilation system.
  • It should be provided with fire extinguishing systems.
  • It should have restricted access.
  • It should be used exclusively for the storage of wastes.

 

All the transport and storage operations that involve hospital wastes must be conducted under conditions of maximum safety and hygiene. In particular, one must remember:

  • Direct contact with the wastes must be avoided.
  • Bags should not be overfilled so that they may be closed easily.
  • Bags should not be emptied into other bags.

 

Liquid Wastes: Biological and Chemical

Liquid wastes can be classified as biological or chemical.

Liquid biological wastes

Liquid biological wastes can usually be poured directly into the hospital’s drainage system since they do not require any treatment before disposal. The exceptions are the liquid wastes of patients with infectious diseases and the liquid cultures of microbiology laboratories. These should be collected in specific containers and treated before being dumped.

It is important that the waste be dumped directly into the drainage system with no splashing or spraying. If this is not possible and wastes are gathered in disposable containers that are difficult to open, the containers should not be forced open. Instead, the entire container should be disposed of, as with Group III solid wastes. When liquid waste is eliminated like Group III solid waste, it should be taken into consideration that the conditions of work differ for the disinfection of solid and liquid wastes. This must be kept in mind in order to ensure the effectiveness of the treatment.

Liquid chemical wastes

Liquid wastes generated in the hospital (generally in the laboratories) can be classified in three groups:

  • liquid wastes that should not be dumped into the drains
  • liquid wastes that can be dumped into the drains after being treated
  • liquid wastes that can be dumped into the drains without being previously treated.

 

This classification is based on considerations related to the health and quality of life of the entire community. These include:

  • protection of the water supply
  • protection of the sewer system
  • protection of the waste water purification stations.

 

Liquid wastes that can pose a serious threat to people or to the environment because they are toxic, noxious, flammable, corrosive or carcinogenic should be separated and collected so that they can subsequently be recovered or destroyed. They should be collected as follows:

  • Each type of liquid waste should go into a separate container.
  • The container should be labelled with the name of the product or the major component of the waste, by volume.
  • Each laboratory, except the pathological anatomy laboratory, should provide its own individual receptacles to collect liquid wastes that are correctly labelled with the material or family of materials it contains. Periodically (at the end of each work day would be most desirable), these should be emptied into specifically labelled containers which are held in the room until collected at appropriate intervals by the assigned waste removal subcontractor.
  • Once each receptacle is correctly labelled with the product or the family of products it contains, it should be placed in specific containers in the labs.
  • The person responsible for the laboratory, or someone directly delegated by that person, will sign and stamp a control ticket. The subcontractor will then be responsible for delivering the control ticket to the department that supervises safety, hygiene and the environment.

 

Mixtures of chemical and biological liquid wastes

Treatment of chemical wastes is more aggressive than treatment of biological wastes. Mixtures of these two wastes should be treated using the steps indicated for liquid chemical wastes. Labels on containers should note the presence of biological wastes.

Any liquid or solid materials that are carcinogenic, mutagenic or teratogenic should be disposed of in rigid colour-coded containers specifically designed and labelled for this type of waste.

Dead animals that have been inoculated with biohazardous substances will be disposed of in closed rigid containers, which will be sterilized before being reused.

Disposal of Sharp and Pointed Instruments

Sharp and pointed instruments (e.g., needles and lancets), once used, must be placed in specifically designed, rigid “sharps” containers that have been strategically placed throughout the hospital. These wastes will be disposed of as hazardous wastes even if used on uninfected patients. They must never be disposed of except in the rigid sharps container.

All HCWs must be repeatedly reminded of the danger of accidental cuts or punctures with this type of material, and instructed to report them when they occur, so that appropriate preventive measures may be instituted. They should be specifically instructed not to attempt to recap used hypodermic needles before dropping them into the sharps container.

Whenever possible, needles to be placed in the sharps container without recapping may be separated from the syringes which, without the needle, can generally be disposed of as Group II waste. Many sharps containers have a special fitting for separating the syringe without risk of a needlestick to the worker; this saves space in the sharps containers for more needles. The sharps containers, which should never be opened by hospital personnel, should be removed by designated janitorial personnel and forwarded for appropriate disposal of their contents.

If it is not possible to separate the needle in adequately safe conditions, the whole needle-syringe combination must be considered as biohazardous and must be placed in the rigid sharps containers.

These sharps containers will be removed by the janitorial personnel.

Staff Training

There must be an ongoing training programme in waste management for all hospital personnel aimed at indoctrinating the staff on all levels with the imperative of always following the established guidelines for collecting, storing and disposing wastes of all kinds. It is particularly important that the housekeeping and janitorial staffs be trained in the details of the protocols for recognizing and dealing with the various categories of hazardous waste. The janitorial, security and fire-fighting staff must also be drilled in the correct course of action in the event of an emergency.

It is also important for the janitorial personnel to be informed and trained on the correct course of action in case of an accident.

Particularly when the programme is first launched, the janitorial staff should be instructed to report any problems that may hinder their performance of these assigned duties. They may be given special cards or forms on which to record such findings.

Waste Management Committee

To monitor the performance of the waste management programme and resolve any problems that may arise as it is implemented, a permanent waste management committee should be created and meet regularly, quarterly at a minimum. The committee should be accessible to any member of the hospital staff with a waste disposal problem or concern and should have access as needed to top management.

Implementing the Plan

The way the waste management programme is implemented may well determine whether it succeeds or not.

Since the support and cooperation of the various hospital committees and departments is essential, details of the programme should be presented to such groups as the administrative teams of the hospital, the health and safety committee and the infection control committee. It is necessary also to obtain validation of the programme from such community agencies as the departments of health, environmental protection and sanitation. Each of these may have helpful modifications to suggest, particularly with respect to the way the programme impinges on their areas of responsibility.

Once the programme design has been finalized, a pilot test in a selected area or department should permit rough edges to be polished and any unforeseen problems resolved. When this has been completed and its results analysed, the programme may be implemented progressively throughout the entire medical centre. A presentation, with audio-visual supports and distribution of descriptive literature, can be delivered in each unit or department, followed by delivery of bags and/or containers as required. Following the start-up of the programme, the department or unit should be visited so that any needed revisions may be instituted. In this manner, the participation and support of the entire hospital staff, without which the programme would never succeed, can be earned.

 

Back

Page 2 of 2

" DISCLAIMER: The ILO does not take responsibility for content presented on this web portal that is presented in any language other than English, which is the language used for the initial production and peer-review of original content. Certain statistics have not been updated since the production of the 4th edition of the Encyclopaedia (1998)."

Contents

Preface
Part I. The Body
Part II. Health Care
Part III. Management & Policy
Part IV. Tools and Approaches
Part V. Psychosocial and Organizational Factors
Part VI. General Hazards
Part VII. The Environment
Part VIII. Accidents and Safety Management
Part IX. Chemicals
Part X. Industries Based on Biological Resources
Part XI. Industries Based on Natural Resources
Part XII. Chemical Industries
Part XIII. Manufacturing Industries
Part XIV. Textile and Apparel Industries
Part XV. Transport Industries
Part XVI. Construction
Part XVII. Services and Trade
Part XVIII. Guides