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94. Education and Training Services

94. Education and Training Services (7)

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94. Education and Training Services

Chapter Editor: Michael McCann


Table of Contents

Tables and Figures

E. Gelpi
 
Michael McCann
 
Gary Gibson
 
Susan Magor
 
Ted Rickard
 
Steven D. Stellman and Joshua E. Muscat
 
Susan Magor

Tables 

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1. Diseases affecting day-care workers & teachers
2. Hazards & precautions for particular classes
3. Summary of hazards in colleges & universities

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95. Emergency and Security Services

95. Emergency and Security Services (9)

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95. Emergency and Security Services

Chapter Editor: Tee L. Guidotti


Table of Contents

Tables and Figures

Tee L. Guidotti
 
Alan D. Jones
 
Tee L. Guidotti
 
Jeremy Brown
 
Manfred Fischer
 
Joel C. Gaydos, Richard J. Thomas,David M. Sack and Relford Patterson
 
Timothy J. Ungs
 
John D. Meyer
 
M. Joseph Fedoruk

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1. Recommendations & criteria for compensation

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96. Entertainment and the Arts

96. Entertainment and the Arts (31)

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96. Entertainment and the Arts

Chapter Editor: Michael McCann


Table of Contents

Tables and Figures

Arts and Crafts

Michael McCann 
Jack W. Snyder
Giuseppe Battista
David Richardson
Angela Babin
William E. Irwin
Gail Coningsby Barazani
Monona Rossol
Michael McCann
Tsun-Jen Cheng and Jung-Der Wang
Stephanie Knopp

Performing and Media Arts 

Itzhak Siev-Ner 
 
     Susan Harman
John P. Chong
Anat Keidar
    
     Jacqueline Nubé
Sandra Karen Richman
Clëes W. Englund
     Michael McCann
Michael McCann
Nancy Clark
Aidan White

Entertainment

Kathryn A. Makos
Ken Sims
Paul V. Lynch
William Avery
Michael McCann
Gordon Huie, Peter J. Bruno and W. Norman Scott
Priscilla Alexander
Angela Babin
Michael McCann
 

Tables

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1. Precautions associated with hazards
2. Hazards of art techniques
3. Hazards of common stones
4. Main risks associated with sculpture material
5. Description of fibre & textile crafts
6. Description of fibre & textile processes
7. Ingredients of ceramic bodies & glazes
8. Hazards & precautions of collection management
9. Hazards of collection objects

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97. Health Care Facilities and Services

97. Health Care Facilities and Services (25)

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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

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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

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98. Hotels and Restaurants

98. Hotels and Restaurants (4)

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98. Hotels and Restaurants

Chapter Editor: Pam Tau Lee


Table of Contents

Pam Tau Lee
 
 
Neil Dalhouse
 
 
Pam Tau Lee
 
 
Leon J. Warshaw
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99. Office and Retail Trades

99. Office and Retail Trades (7)

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99. Office and Retail Trades

Chapter Editor: Jonathan Rosen


Table of Contents

Tables and Figures

The Nature of Office and Clerical Work
Charles Levenstein, Beth Rosenberg and Ninica Howard

Professionals and Managers
Nona McQuay

Offices: A Hazard Summary
Wendy Horde

Bank Teller Safety: The Situation in Germany
Manfred Fischer

Telework
Jamie Tessler

The Retail Industry
Adrienne Markowitz

     Case Study: Outdoor Markets
     John G. Rodwan, Jr.

Tables 

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1. Standard professional jobs
2. Standard clerical jobs
3. Indoor air pollutants in office buildings
4. Labour statistics in the retail industry

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100. Personal and Community Services

100. Personal and Community Services (6)

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100. Personal and Community Services

Chapter Editor: Angela Babin


Table of Contents

Tables and Figures

Indoor Cleaning Services
Karen Messing

Barbering and Cosmetology
Laura Stock and James Cone

Laundries, Garment and Dry Cleaning
Gary S. Earnest, Lynda M. Ewers and Avima M. Ruder

Funeral Services
Mary O. Brophy and Jonathan T. Haney

Domestic Workers
Angela Babin

     Case Study: Environmental Issues
     Michael McCann

Tables

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1. Postures observed during dusting in a hospital
2. Dangerous chemicals used in cleaning

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101. Public and Government Services

101. Public and Government Services (12)

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101. Public and Government Services

Chapter Editor: David LeGrande


Table of Contents

Tables and Figurs

Occupational Health and Safety Hazards in Public and Governmental Services
David LeGrande

     Case Report: Violence and Urban Park Rangers in Ireland
     Daniel Murphy

Inspection Services
Jonathan Rosen

Postal Services
Roxanne Cabral

Telecommunications
David LeGrande

Hazards in Sewage (Waste) Treatment Plants
Mary O. Brophy

Domestic Waste Collection
Madeleine Bourdouxhe

Street Cleaning
J.C. Gunther, Jr.

Sewage Treatment
M. Agamennone

Municipal Recycling Industry
David E. Malter

Waste Disposal Operations
James W. Platner

The Generation and Transport of Hazardous Wastes: Social and Ethical Issues
Colin L. Soskolne

Tables

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1. Hazards of inspection services
2. Hazardous objects found in domestic waste
3. Accidents in domestic waste collection (Canada)
4. Injuries in the recycling industry

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102. Transport Industry and Warehousing

102. Transport Industry and Warehousing (18)

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102. Transport Industry and Warehousing

Chapter Editor: LaMont Byrd


Table of Contents

Tables and Figures

General Profile
LaMont Byrd  

     Case Study: Challenges to Workers’ Health and Safety in the Transportation and Warehousing Industry
     Leon J. Warshaw

Air Transport

Airport and Flight Control Operations
Christine Proctor, Edward A. Olmsted and E. Evrard

     Case Studies of Air Traffic Controllers in the United States and Italy
     Paul A. Landsbergis

Aircraft Maintenance Operations
Buck Cameron

Aircraft Flight Operations
Nancy Garcia and H. Gartmann

Aerospace Medicine: Effects of Gravity, Acceleration and Microgravity in the Aerospace Environment
Relford Patterson and Russell B. Rayman

Helicopters
David L. Huntzinger

Road Transport

Truck and Bus Driving
Bruce A. Millies

Ergonomics of Bus Driving
Alfons Grösbrink and Andreas Mahr

Motor Vehicle Fuelling and Servicing Operations
Richard S. Kraus

     Case Study: Violence in Gasoline Stations
     Leon J. Warshaw

Rail Transport

Rail Operations
Neil McManus

     Case Study: Subways
     George J. McDonald

Water Transport

Water Transportation and the Maritime Industries
Timothy J. Ungs and Michael Adess

Storage

Storage and Transportation of Crude Oil, Natural Gas, Liquid Petroleum Products and Other Chemicals
Richard S. Kraus

Warehousing
John Lund

     Case Study: US NIOSH Studies of Injuries among Grocery Order Selectors

Tables

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1. Bus driver seat measurements
2. Illumination levels for service stations
3. Hazardous conditions & administration
4. Hazardous conditions & maintenance
5. Hazardous conditions & right of way
6. Hazard control in the Railway industry
7. Merchant vessel types
8. Health hazards common across vessel types
9. Notable hazards for specific vessel types
10. Vessel hazard control & risk-reduction
11. Typical approximate combustion properties
12. Comparison of compressed & liquified gas
13. Hazards involving order selectors
14. Job safety analysis: Fork-lift operator
15. Job safety analysis: Order selector

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Wednesday, 02 March 2011 16:17

Overview of Chemical Hazards in Health Care

Written by

Exposure to potentially hazardous chemicals is a fact of life for health care workers. They are encountered in the course of diagnostic and therapeutic procedures, in laboratory work, in preparation and clean-up activities and even in emanations from patients, to say nothing of the “infrastructure” activities common to all worksites such as cleaning and housekeeping, laundry, painting, plumbing and maintenance work. Despite the constant threat of such exposures and the large numbers of workers involved—in most countries, health care invariably is one of the most labour-intensive industries—this problem has received scant attention from those involved in occupational health and safety research and regulation. The great majority of chemicals in common use in hospitals and other health care settings are not specifically covered under national and international occupational exposure standards. In fact, very little effort has been made to date to identify the chemicals most frequently used, much less to study the mechanisms and intensity of exposures to them and the epidemiology of the effects on the health care workers involved.

This may be changing in the many jurisdictions in which right-to-know laws, such as the Canadian Workplace Hazardous Materials Information Systems (WHMIS) are being legislated and enforced. These laws require that workers be informed of the name and nature of the chemicals to which they may be exposed on the job. They have introduced a daunting challenge to administrators in the health care industry who must now turn to occupational health and safety professionals to undertake a de novo inventory of the identity and location of the thousands of chemicals to which their workers may be exposed.

The wide range of professions and jobs and the complexity of their interplay in the health care workplace require unique diligence and astuteness on the part of those charged with such occupational safety and health responsibilities. A significant complication is the traditional altruistic focus on the care and well-being of the patients, even at the expense of the health and well-being of those providing the services. Another complication is the fact that these services are often required at times of great urgency when important preventive and protective measures may be forgotten or deliberately disregarded.

Categories of Chemical Exposures in the Health Care Setting

Table 1 lists the categories of chemicals encountered in the health care workplace. Laboratory workers are exposed to the broad range of chemical reagents they employ, histology technicians to dyes and stains, pathologists to fixative and preservative solutions (formaldeyde is a potent sensitizer), and asbestos is a hazard to workers making repairs or renovations in older health care facilities.

Table 1. Categories of chemicals used in health care

Types of chemicals

Locations most likely to be found

Disinfectants

Patient areas

Sterilants

Central supply
Operating theatres
Physician offices
Rehabilitation centres

Medicines

Patient areas
Pharmacy

Laboratory reagents

Laboratories

Housekeeping/maintenance chemicals

Hospital-wide

Food ingredients and products

Kitchen
Cafeteria

Pesticides

Hospital-wide

 

Even when liberally applied in combating and preventing the spread of infectious agents, detergents, disinfectants and sterilants offer relatively little danger to patients whose exposure is usually of brief duration. Even though individual doses at any one time may be relatively low, their cumulative effect over the course of a working lifetime may, however, constitute a significant risk to health care workers.

Occupational exposures to drugs can cause allergic reactions, such as have been reported over many years among workers administering penicillin and other antibiotics, or much more serious problems with such highly carcinogenic agents as the antineoplastic drugs. The contacts may occur during the preparation or administration of the dose for injection or in cleaning up after it has been administered. Although the danger of this mechanism of exposure had been known for many years, it was fully appreciated only after mutagenic activity was detected in the urine of nurses administering antineoplastic agents.

Another mechanism of exposure is the administration of drugs as aerosols for inhalation. The use of antineoplastic agents, pentamidine and ribavarin by this route has been studied in some detail, but there has been, as of this writing, no report of a systematic study of aerosols as a source of toxicity among health care workers.

Anaesthetic gases represent another class of drugs to which many health care workers are exposed. These chemicals are associated with a variety of biological effects, the most obvious of which are on the nervous system. Recently, there have been reports suggesting that repeated exposures to anaesthetic gases may, over time, have adverse reproductive effects among both male and female workers. It should be recognized that appreciable amounts of waste anaesthetic gases may accumulate in the air in recovery rooms as the gases retained in the blood and other tissues of patients are eliminated by exhalation.

Chemical disinfecting and sterilizing agents are another important category of potentially hazardous chemical exposures for health care workers. Used primarily in the sterilization of non-disposable equipment, such as surgical instruments and respiratory therapy apparatus, chemical sterilants such as ethylene oxide are effective because they interact with infectious agents and destroy them. Alkylation, whereby methyl or other alkyl groups bind chemically with protein-rich entities such as the amino groups in haemoglobiin and DNA, is a powerful biological effect. In intact organisms, this may not cause direct toxicity but should be considered potentially carcinogenic until proven otherwise. Ethylene oxide itself, however, is a known carcinogen and is associated with a variety of adverse health effects, as discussed elsewhere in the Encyclopaedia. The potent alkylation capability of ethylene oxide, probably the most widely-used sterilant for heat-sensitive materials, has led to its use as a classic probe in studying molecular structure.

For years, the methods used in the chemical sterilization of instruments and other surgical materials have carelessly and needlessly put many health care workers at risk. Not even rudimentary precautions were taken to prevent or limit exposures. For example, it was the common practice to leave the door of the sterilizer partially open to allow the escape of excess ethylene oxide, or to leave freshly-sterilized materials uncovered and open to the room air until enough had been assembled to make efficient use of the aerator unit.

The fixation of metallic or ceramic replacement parts so common in dentistry and orthopaedic surgery may be a source of potentially hazardous chemical exposure such as silica. These and the acrylic resins often used to glue them in place are usually biologically inert, but health care workers may be exposed to the monomers and other chemical reactants used during the preparation and application process. These chemicals are often sensitizing agents and have been associated with chronic effects in animals. The preparation of mercury amalgam fillings can lead to mercury exposure. Spills and the spread of mercury droplets is a particular concern since these may linger unnoticed in the work environment for many years. The acute exposure of patients to them appears to be entirely safe, but the long-term health implications of the repeated exposure of health care workers have not been adequately studied.

Finally, such medical techniques as laser surgery, electro-cauterization and use of other radiofrequency and high-energy devices can lead to the thermal degradation of tissues and other substances resulting in the formation of potentially toxic smoke and fumes. For example, the cutting of “plaster” casts made of polyester resin impregnated bandages has been shown to release potentially toxic fumes.

The hospital as a “mini-municipality”

A listing of the varied jobs and tasks performed by the personnel of hospitals and other large health care facilities might well serve as a table of contents for the commercial listings of a telephone directory for a sizeable municipality. All of these entail chemical exposures intrinsic to the particular work activity in addition to those that are peculiar to the health care environment. Thus, painters and maintenance workers are exposed to solvents and lubricants. Plumbers and others engaged in soldering are exposed to fumes of lead and flux. Housekeeping workers are exposed to soaps, detergents and other cleansing agents, pesticides and other household chemicals. Cooks may be exposed to potentially carcinogenic fumes in broiling or frying foods and to oxides of nitrogen from the use of natural gas as fuel. Even clerical workers may be exposed to the toners used in copiers and printers. The occurrence and effects of such chemical exposures are detailed elsewhere in this Encyclopaedia.

One chemical exposure that is diminishing in importance as more and more HCWs quit smoking and more health care facilities become “smoke-free” is “second hand” tobacco smoke.

Unusual chemical exposures in health care

Table 2 presents a partial listing of the chemicals most commonly encountered in health care workplaces. Whether or not they will be toxic will depend on the nature of the chemical and its biological proclivities, the manner, intensity and duration of the exposure, the susceptibilities of the exposed worker, and the speed and effectiveness of any countermeasures that may have been attempted. Unfortunately, a compendium of the nature, mechanisms, effects and treatment of chemical exposures of health care workers has not yet been published.

There are some unique exposures in the health care workplace that substantiate the dictum that a high level of vigilance is necessary to protect workers fully from such risks. For example, it was recently reported that health care workers had been overcome by toxic fumes emanating from a patient under treatment from a massive chemical exposure. Cases of cyanide poisoning arising from patient emissions have also been reported. In addition to the direct toxicity of waste anaesthetic gases to anaesthetists and other personnel in operating theatres, there is the often unrecognized problem created by the frequent use in such areas of high-energy sources which can transform the anaesthetic gases to free radicals, a form in which they are potentially carcinogenic.

Table 2. Chemicals cited Hazardous Substances Database (HSDB)

The following chemicals are listed in the HSDB as being used in some area of the health care environment. The HSDB is produced by the US National Library of Medicine and is a compilation of more than 4,200 chemicals with known toxic effects in commercial use. Absence of a chemical from the list does not imply that it is not toxic, but that it is not present in the HSDB.

Use list in the HSDB

Chemical name

CAS number*

Disinfectants; antiseptics

benzylalkonium chloride
borax
boric acid
cetyl pyridinium chloride
m-cresol
2-chlorophenol
4-chlorophenol
hexachlorophene
methyl ethyl ketone
phenol
tri-m-cresyl phosphate (lysol)

0001-54-5
1303-96-4
10043-35-3
123-03-5
95-57-8
106-48-9
70-30-4
108-39-4
78-93-3
108-95-2
563-04-2

Sterilants

beta-propiolactone
crotonaldehyde
ethylene oxide
formaldehyde
glutaraldehyde

57-57-8
4170-30-3
75-21-8
50-00-0
111-30-8

Laboratory reagents:
Biological stains

2,4-xylidine (magenta-base)
acridine-red
basic parafuchsine
basic-magenta
CI-acid-blue-9
CI-acid-green-3
CI-acid-red-14
CI-direct-blue-1
CI-direct-red-28
CI-direct-yellow-11
CI-acid-green-3
curcumin
Heamtoxylin
hexamethyl-p-rosaniline
chloride (violet)
malachite green
osmiun tetroxide
ponceau 3R

3248-93-9
2465-29-4
569-61-9
3248-93-9
129-17-9
4680-78-8
3567-69-9
2429-74-5
573-58-0
1325-37-7
4680-78-8
458-37-7
517-28-2

548-62-9
569-64-2
20816-12-0
3564-09-8

* Chemical Abstracts identification number.

 

Back

The very definition of the maritime setting is work and life that takes place in or around a watery world (e.g., ships and barges, docks and terminals). Work and life activities must first accommodate the macro-environmental conditions of the oceans, lakes or waterways in which they take place. Vessels serve as both workplace and home, so most habitat and work exposures are coexistent and inseparable.

The maritime industry comprises a number of sub-industries, including freight transportation, passenger and ferry service, commercial fishing, tankships and barge shipping. Individual maritime sub-industries consist of a set of merchant or commercial activities that are characterized by the type of vessel, targeted goods and services, typical practices and area of operations, and community of owners, operators and workers. In turn, these activities and the context in which they take place define the occupational and environmental hazards and exposures experienced by maritime workers.

Organized merchant maritime activities date back to the earliest days of civilized history. The ancient Greek, Egyptian and Japanese societies are examples of great civilizations where the development of power and influence was closely associated with having an extensive maritime presence. The importance of maritime industries to development of national power and prosperity has continued into the modern era.

The dominant maritime industry is water transportation, which remains the primary mode of international trade. The economies of most countries with ocean borders are heavily influenced by the receipt and export of goods and services by water. However, national and regional economies heavily dependent on the transport of goods by water are not limited to those which border oceans. Many countries removed from the sea have extensive networks of inland waterways.

Modern merchant vessels may process materials or produce goods as well as transport them. Globalized economies, restrictive land use, favourable tax laws and technology are among the factors which have spurred the growth of vessels that serve as both factory and means of transportation. Catcher-processor fishing vessels are a good example of this trend. These factory ships are capable of catching, processing, packaging and delivering finished sea food products to regional markets, as discussed in the chapter Fishing industry.

Merchant Transport Vessels

Similar to other transport vehicles, the structure, form and function of vessels closely parallel the vessel’s purpose and major environmental circumstances. For example, craft that transport liquids short distances on inland waterways will differ substantially in form and crew from those that carry dry bulk on trans-oceanic voyages. Vessels can be free moving, semi-mobile or permanently fixed structures (e.g., offshore oil-drilling rigs) and be self-propelled or towed. At any given time, existing fleets are comprised of a spectrum of vessels with a wide range of original construction dates, materials and degrees of sophistication.

Crew size will depend on the typical duration of trip, vessel purpose and technology, expected environmental conditions and sophistication of shore facilities. Larger crew size entails more extensive needs and elaborate planning for berthing, dining, sanitation, health care and personnel support. The international trend is toward vessels of increasing size and complexity, smaller crews and expanding reliance on automation, mechanization and containerization. Table 1 provides a categorization and descriptive summary of merchant vessel types.

Table 1. Merchant vessel types.

Vessel types

Description

Crew size

Freight ships

 

Bulk carrier

 

 

 

Break bulk

 

 

 

Container

 

 

 

Ore, bulk, oil  (OBO)

 

 

Vehicle

 

 

Roll-on roll- off (RORO)

Large vessel (200-600 feet (61-183 m)) typified by large open cargo holds and many voids; carry bulk cargoes such as grain and ore; cargo is loaded by chute, conveyor or shovel

 

Large vessel (200-600 feet (61-183 m)); cargo carried in bales, pallets, bags or boxes; expansive holds with between decks; may have tunnels

 

 

Large vessel (200-600 (61-183 m)) with open holds; may or may not have booms or cranes to handle cargo; containers are 20-40 feet (6.1-12.2 m) and stackable

 

 

Large vessel (200-600 feet (61-183 m)); holds are expansive and shaped to hold bulk ore or oil; holds are water tight, may have pumps and piping; many voids

 

 

Large vessel (200-600 feet (61-183 m)) with big sail area; many levels; vehicles can be self loading or boomed aboard

 

 

Large vessel (200-600 feet (61-183 m)) with big sail area; many levels; can carry other cargo in addition to vehicles

25-50

 

 

25-60

 

 

 

25-45

 

 

 

25-55

 

 

25-40

 

 

 

25-40

Tank ships

Oil

 

 

 

Chemical

 

 

 

Pressurized

Large vessel (200-1000 feet (61-305 m)) typified by stern house piping on deck; may have hose handling booms and large ullages with many tanks; can carry crude or processed oil, solvents and other petroleum products

 

Large vessel (200-1000 feet (61-305 m)) similar to oil tankship, but may have additional piping and pumps to handle multiple cargoes simultaneously; cargoes can be liquid, gas, powders or compressed solids

 

Usually smaller (200-700 feet (61-213.4 m)) than typical tankship, having fewer tanks, and tanks which are pressurized or cooled; can be chemical or petroleum products such as liquid natural gas; tanks are usually covered and insulated; many voids, pipes and pumps

25-50

 

 

25-50

 

 

15-30

 

Tug boats

Small to mid-size vessel (80-200 feet (24.4-61 m));  harbour, push boats, ocean going

3-15

Barge

Mid-size vessel (100-350 feet (30.5-106.7 m)); can be tank, deck, freight or vehicle; usually not manned or self-propelled; many voids

 

Drillships and rigs

Large, similar profile to bulk carrier; typified by large derrick; many voids, machinery, hazardous cargo and large crew; some are towed, others self propelled

40-120

Passenger

All sizes (50-700 feet (15.2-213.4 m)); typified by large number of crew and passengers (up to 1000+)

20-200

 

Morbidity and Mortality in the Maritime Industries

Health care providers and epidemiologists are often challenged to distinguish adverse health states due to work-related exposures from those due to exposures outside the workplace. This difficulty is compounded in the maritime industries because vessels serve as both workplace and home, and both exist in the greater environment of the maritime milieu itself. The physical boundaries found on most vessels result in close confinement and sharing of workspaces, engine-room, storage areas, passageways and other compartments with living spaces. Vessels often have a single water, ventilation or sanitation system that serves both work and living quarters.

The social structure aboard vessels is typically stratified into vessel officers or operators (ship’s master, first mate and so on) and remaining crew. Ship officers or operators are generally relatively more educated, affluent and occupationally stable. It is not uncommon to find vessels with crew members of an entirely different national or ethnic background from that of the officers or operators. Historically, maritime communities are more transient, heterogeneous and somewhat more independent than non-maritime communities. Work schedules aboard ship are often more fragmented and intermingled with non-work time than are land-based employment situations.

These are some reasons why it is difficult to describe or quantify health problems in the maritime industries, or to correctly associate problems with exposures. Data on maritime worker morbidity and mortality suffer from being incomplete and not representative of entire crews or sub-industries. Another shortfall of many data sets or information systems that report on the maritime industries is the inability to distinguish among health problems due to work, vessel or macro-environmental exposures. As with other occupations, difficulties in capturing morbidity and mortality information is most obvious with chronic disease conditions (e.g., cardiovascular disease), particularly those with a long latency (e.g., cancer).

Review of 11 years (1983 to 1993) of US maritime data demonstrated that half of all fatalities due to maritime injuries, but only 12% of non-fatal injuries, are attributed to the vessel (i.e., collision or capsizing). The remaining fatalities and non-fatal injuries are attributed to personnel (e.g., mishaps to an individual while aboard ship). Reported causes of such mortality and morbidity are described in figure 1 and figure 2 respectively. Comparable information on non-injury-related mortality and morbidity is not available.

Figure 1. Causes of leading fatal unintentional injuries attributed to personal reasons (US maritime industries 1983-1993).

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Figure 2. Causes of leading non-fatal unintentional injuries attributed to personal reasons (US maritime industries 1983-1993).

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Combined vessel and personal US maritime casualty data reveal that the highest proportion (42%) of all maritime fatalities (N = 2,559), occurred among commercial fishing vessels. The next highest were among towboats/barges (11%), freight ships (10%) and passenger vessels (10%).

Analysis of reported work-related injuries for the maritime industries shows similarities to patterns reported for the manufacturing and construction industries. Commonalities are that most injuries are due to falls, being struck, cuts and bruises or muscular strains and overuse. Caution is needed when interpreting these data, however, as there is reporting bias: acute injuries are likely to be over-represented and chronic/latent injuries, which are less obviously connected to work, under-reported.

Occupational and Environmental Hazards

Most health hazards found in the maritime setting have land-based analogs in the manufacturing, construction and agricultural industries. The difference is that the maritime environment constricts and compresses available space, forcing close proximity of potential hazards and the intermingling of living quarters and workspaces with fuel tanks, engine and propulsion areas, cargo and storage spaces.

Table 2 summaries health hazards common across different vessel types. Health hazards of particular concern with specific vessel types are highlighted in table 3. The following paragraphs of this section expand discussion of selected environmental, physical and chemical, and sanitation health hazards.

Table 2. Health hazards common across vessel types.

Hazards

Description

Examples

Mechanical

Unguarded or exposed moving objects or their parts, which strike, pinch, crush or entangle. Objects can be mechanized (e.g., fork-lift) or simple (hinged door).

Winches, pumps, fans, drive shafts, compressors, propellers, hatches, doors, booms, cranes, mooring lines, moving cargo

Electrical

Static (e.g., batteries) or active (e.g., generators) sources of electricity, their distribution system (e.g., wiring) and powered devices (e.g., motors), all of which can cause direct electrical-induced physical injury

Batteries, vessel generators, dockside electrical sources, unprotected or ungrounded electric motors (pumps, fans, etc.), exposed wiring, navigation and communication electronics

Thermal

Heat- or cold-induced injury

Steam pipes, cold storage spaces, power plant exhaust, cold- or warm-weather exposure above deck

Noise

Adverse auditory and other physiological problems due to excessive and prolonged sound energy

Vessel propulsion system, pumps, ventilation fans, winches, steam-powered devices, conveyor belts

Fall

Slips, trips and falls resulting in kinetic-energy-induced injuries

Steep ladders, deep vessel holds, missing railings, narrow gangways, elevated platforms

Chemical

Acute and chronic disease or injury resulting from exposure to organic or inorganic chemicals and heavy metals

Cleaning solvents, cargo, detergents, welding, rusting/corrosion processes, refrigerants, pesticides, fumigants

Sanitation

Disease related to unsafe water, poor food practices or improper waste disposal

Contaminated potable water, food spoilage, deteriorated vessel waste system

Biologic

Disease or illness causes by exposure to living organisms or their products

Grain dust, raw wood products, cotton bales, bulk fruit or meat, seafood products, communicable disease agents

Radiation

Injury due to non-ionizing radiation

Intense sunlight, arc welding, radar, microwave communications

Violence

Interpersonal violence

Assault, homicide, violent conflict among crew

Confined space

Toxic or anoxic injury resulting from entering an enclosed space with limited entry

Cargo holds, ballast tanks, crawl spaces, fuel tanks, boilers, storage rooms, refrigerated holds

Physical work

Health problems due to overuse, disuse or unsuitable work practices

Shovelling ice in fish tanks, moving awkward cargo in restricted spaces, handling heavy mooring lines, prolonged stationary watch standing

 

Table 3. Notable physical and chemical hazards for specific vessel types.

Vessel Types

Hazards

Tank vessels

Benzene and various hydrocarbon vapours, hydrogen sulphide off-gassing from crude oil, inert gases used in tanks to create oxygen-deficient atmosphere for explosion control, fire and explosion due to combustion of hydrocarbon products

Bulk cargo vessels

Pocketing of fumigants used on agricultural products, personnel entrapment/suffocation in loose or shifting cargo, confined space risks in conveyor or man tunnels deep in vessel, oxygen deficiency due to oxidation or fermentation of cargo

Chemical carriers

Venting of toxic gases or dusts, pressurized air or gas release, leakage of hazardous substances from cargo holds or transfer pipes, fire and explosion due to combustion of chemical cargoes

Container ships

Exposure to spills or leakage due to failed or improperly stored hazardous substances; release of agricultural inerting gases; venting from chemical or gas containers; exposure to mislabeled substances that are hazardous; explosions, fire or toxic exposures due to mixing of separate substances to form a dangerous agent (e.g., acid and sodium cyanide)

Break bulk vessels

Unsafe conditions due to shifting of cargo or improper storage; fire, explosion or toxic exposures due to mixing of incompatible cargoes; oxygen deficiency due to oxidation or fermentation of cargoes; release of refrigerant gases

Passenger ships

Contaminated potable water, unsafe food preparation and storage practices, mass evacuation concerns, acute health problems of individual passengers

Fishing vessels

Thermal hazards from refrigerated holds, oxygen deficiency due to decomposition of seafood products or use of antioxidant preservatives, release of refrigerant gases, entanglement in netting or lines, contact with dangerous or toxic fish or sea animals

 

Environmentalhazards

Arguably the most characteristic exposure defining the maritime industries is the pervasive presence of the water itself. The most variable and challenging of water environments is the open ocean. Oceans present constantly undulating surfaces, extremes of weather and hostile travel conditions, which combine to cause constant motion, turbulence and shifting surfaces and can result in vestibular disturbances (motion sickness), object instability (e.g., swinging latches and sliding gear) and the propensity to fall.

Humans have limited capability to survive unaided in open water; drowning and hypothermia are immediate threats upon immersion. Vessels serve as platforms that permit the human presence at sea. Ships and other water craft generally operate at some distance from other resources. For these reasons, vessels must dedicate a large proportion of total space to life support, fuel, structural integrity and propulsion, often at the expense of habitability, personnel safety and human factor considerations. Modern supertankers, which provide more generous human space and liveability, are an exception.

Excessive noise exposure is a prevalent problem because sound energy is readily transmitted through a vessel’s metallic structure to nearly all spaces, and limited noise attenuation materials are used. Excessive noise can be nearly continuous, with no available quiet areas. Sources of noise include the engine, propulsion system, machinery, fans, pumps and the pounding of waves on the vessel hull.

Mariners are an identified risk group for developing skin cancers, including malignant melanoma, squamous cell carcinoma and basal cell carcinoma. The increased risk is due to excess exposure to direct and water-surface-reflected ultraviolet solar radiation. Body areas of particular risk are exposed parts of the face, neck, ears and forearms.

Limited insulation, inadequate ventilation, internal sources of heat or cold (e.g., engine rooms or refrigerated spaces) and metallic surfaces all account for potential thermal stress. Thermal stress compounds physiological stress from other sources, resulting in reduced physical and cognitive performance. Thermal stress that is not adequately controlled or protected against can result in heat- or cold-induced injury.

Physical and chemical hazards

Table 3 highlights hazards unique or of particular concern to specific vessel types. Physical hazards are the most common and pervasive hazard aboard vessels of any type. Space limitations result in narrow passageways, limited clearance, steep ladders and low overheads. Confined vessel spaces means that machinery, piping, vents, conduits, tanks and so forth are squeezed in, with limited physical separation. Vessels commonly have openings that allow direct vertical access to all levels. Inner spaces below the surface deck are characterized by a combination of large holds, compact spaces and hidden compartments. Such physical structure places crew members at risk for slips, trips and falls, cuts and bruises, and being struck by moving or falling objects.

Constricted conditions result in being in close proximity to machinery, electrical lines, high-pressure tanks and hoses, and dangerously hot or cold surfaces. If unguarded or energized, contact can result in burns, abrasions, lacerations, eye damage, crushing or more serious injury.

Since vessels are basically a composite of spaces housed within a water-tight envelope, ventilation can be marginal or deficient in some spaces, creating a hazardous confined space situation. If oxygen levels are depleted or air is displaced, or if toxic gases enter these confined spaces, entry can be life threatening.

Refrigerants, fuels, solvents, cleaning agents, paints, inert gases and other chemical substances are likely to be found on any vessel. Normal ship activities, such as welding, painting and trash burning can have toxic effects. Transport vessels (e.g., freight ships, container ships and tank ships) can carry a host of biological or chemical products, many of which are toxic if inhaled, ingested or touched with the bare skin. Others can become toxic if allowed to degrade, become contaminated or mix with other agents.

Toxicity can be acute, as evidenced by dermal rashes and ocular burns, or chronic, as evidenced by neurobehavioural disorders and fertility problems or even carcinogenic. Some exposures can be immediately life-threatening. Examples of toxic chemicals carried by vessels are benzene-containing petrochemicals, acrylonitrile, butadiene, liquefied natural gas, carbon tetrachloride, chloroform, ethylene dibromide, ethylene oxide, formaldehyde solutions, nitropropane, o-toluidine and vinyl chloride.

Asbestos remains a hazard on some vessels, principally those constructed prior to the early 1970s. The thermal insulation, fire protection, durability and low cost of asbestos made this a preferred material in ship building. The primary hazard of asbestos occurs when the material becomes airborne when it is disturbed during renovations, construction or repair activities.

Sanitation and communicable disease hazards

One of the realities aboard ship is that the crew is often in close contact. In the work, recreation and living environments, crowding is often a fact of life that heightens the requirement for maintaining an effective sanitation programme. Critical areas include: berthing spaces, including toilet and shower facilities; food service and storage areas; laundry; recreation areas; and, if present, the barbershop. Pest and vermin control is also of critical importance; many of these animals can transmit disease. There are many opportunities for insects and rodents to infest a vessel, and once entrenched they are very difficult to control or eradicate, especially while underway. All vessels must have a safe and effective pest control programme. This requires training of individuals for this task, including annual refresher training.

Berthing areas must be kept free of debris, soiled laundry and perishable food. Bedding should be changed at least weekly (more often if soiled), and adequate laundry facilities for the size of the crew should be available. Food service areas must be rigorously maintained in a sanitary manner. The food service staff must receive training in proper techniques of food preparation, storage and galley sanitation, and adequate storage facilities must be provided aboard ship. The staff must adhere to recommended standards to ensure that food is prepared in a wholesome manner and is free of chemical and biological contamination. The occurrence of a food-borne disease outbreak aboard a vessel can be serious. A debilitated crew cannot carry out its duties. There may be insufficient medication to treat the crew, especially underway, and there may not be competent medical staff to care for the ill. In addition, if the ship is forced to change its destination, there may be significant economic loss to the shipping company.

The integrity and maintenance of a vessel’s potable water system is also of vital importance. Historically, water-borne outbreaks aboard ship have been the most common cause of acute disability and death among crews. Therefore, the potable water supply must come from an approved source (wherever possible) and be free from chemical and biological contamination. Where this is not possible, the vessel must have the means to effectively decontaminate the water and render it potable. A potable water system must be protected against contamination by every known source, including cross-contaminations with any non-potable liquids. The system also must be protected from chemical contamination. It must be cleaned and disinfected periodically. Filling the system with clean water containing at least 100 parts per million (ppm) of chlorine for several hours and then flushing the entire system with water containing 100 ppm chlorine is effective disinfection. The system should then be flushed with fresh potable water. A potable water supply must have at least 2 ppm residual of chlorine at all times, as documented by periodic testing.

Communicable disease transmission aboard ship is a serious potential problem. Lost work time, the cost of medical treatment and the possibility of having to evacuate crew members make this an important consideration. Besides the more common disease agents (e.g., those that cause gastroenteritis, such as Salmonella, and those that cause upper respiratory disease, such as the influenza virus), there has been a re-emergence of disease agents that were thought to be under control or eliminated from the general population. Tuberculosis, highly pathogenic strains of Escherichia coli and Streptococcus, and syphilis and gonorrhoea have reappeared in increasing incidence and/or virulence.

In addition, previously unknown or uncommon disease agents such as the HIV virus and the Ebola virus, which are not only highly resistant to treatment, but highly lethal, have appeared. It is therefore important that assessment be made of appropriate crew immunization for such diseases as polio, diphtheria, tetanus, measles, and hepatitis A and B. Additional immunizations may be required for specific potential or unique exposures, since crew members may have occasion to visit a wide variety of ports around the world and at the same time come in contact with a number of disease agents.

It is vital that crew members receive periodic training in the avoidance of contact with disease agents. The topic should include blood-borne pathogens, sexually transmitted diseases (STDs), food- and water-borne diseases, personal hygiene, symptoms of the more common communicable diseases and appropriate action by the individual on discovering these symptoms. Communicable disease outbreaks aboard ship can have a devastating effect on the vessel’s operation; they can result in a high level of illness among the crew, with the possibility of serious debilitating disease and in some cases death. In some instances, vessel diversion has been required with resultant heavy economic losses. It is in the best interest of the vessel owner to have an effective and efficient communicable disease programme.

Hazard Control and Risk Reduction

Conceptually, the principles of hazard control and risk reduction are similar to other occupational settings, and include:

  • hazard identification and characterization
  • inventory and analysis of exposures and at-risk populations
  • hazard elimination or control
  • personnel monitoring and surveillance
  • disease/injury prevention and intervention
  • programme evaluation and adjustment (see table 4).

 

Table 4. Vessel hazard control & risk-reduction.

Topics

Activities

Programme development and evaluation

Identify hazards, shipboard and dockside.
Assess nature, extent and magnitude of potential exposures.
Identify crew members at risk.
Determine suitable methods for hazard elimination or control and protection of personnel.
Develop health surveillance and reporting system.
Evaluate and follow at-risk members’ health status.
Measure programme effectiveness.
Adapt and modify programme.

Hazard identification

Inventory shipboard chemical, physical, biological, and environmental hazards, in both work and living spaces (e.g., broken railings, use and storage of cleaning agents, presence of asbestos).
Investigate hazards of cargo and those dockside.

Assessment of exposure

Understand work practices and job tasks (prescribed as well as those actually done).
Qualify and quantify exposure levels (e.g., number of hours in hazardous cargo hold areas, ambient H2S levels due to off-gassing, type of organisms in potable water, sound levels in ship’s spaces).

Personnel at risk

Review work logs, employment records and monitoring data of entire ship’s complement, both seasonal and permanent.

Hazard control and
personnel protection

Know established and recommended exposure standards (e.g., NIOSH, ILO, EU).
Eliminate hazards where possible (replace live watches in hazardous holds with remote electronic monitoring).
Control hazards that cannot be eliminated (e.g., enclose and isolate winches rather than leave exposed, and post warning signs).
Provide necessary personal protective equipment (wear toxic gas and O2 detectors when entering confined spaces).

Health surveillance

Develop health information gathering and reporting system for all injuries and illnesses (e.g., maintain a ship’s daily binnacle).

Monitor crew health

Establish occupational medical monitoring, determine performance standards, and establish fitness-for-work criteria (e.g., pre-placement and periodic pulmonary testing of crew handling grain).

Hazard control and risk reduction effectiveness

Devise and set priorities for goals (e.g., reduce shipboard falls).
Set and measure outcomes toward goals (reduce annual number of days crew members not able to work due to falls aboard ship).
Determine effectiveness of efforts in achieving goals.

Programme evolution

Modify prevention and control activities based on changing circumstances and prioritization.

 

To be effective, however, the means and methods to implement these principles must be tailored to the specific maritime arena of interest. Occupational activities are complex and take place in integrated systems (e.g., vessel operations, employee/employer associations, commerce and trade determinants). The key to prevention is to understand these systems and the context in which they take place, which requires close cooperation and interaction between all organizational levels of the maritime community, from general deck hand through vessel operators and company upper management. There are many government and regulatory interests that impact the maritime industries. Partnerships between government, regulators, management and workers are essential for meaningful programmes for improving the health and safety status of the maritime industries.

The ILO has established a number of Conventions and Recommendations relating to shipboard work, such as the Prevention of Accidents (Seafarers) Convention, 1970 (No. 134), and Recommendation, 1970 (No. 142), the Merchant Shipping (Minimum Standards) Convention, 1976 (No. 147), the Merchant Shipping (Improvement of Standards) Recommendation, 1976 (No. 155), and the Health Protection and Medical Care (Seafarers) Convention, 1987 (No. 164). The ILO has also published a Code of Practice regarding the prevention of accidents at sea (ILO 1996).

Approximately 80% of vessel casualties are attributed to human factors. Similarly, the majority of reported injury-related morbidity and mortality have human factor causes. Reduction in maritime injury and death requires successful application of principles of human factors to work and life activities aboard vessels. Successful application of human factors principles means that vessel operations, vessel engineering and design, work activities, systems and management policies are developed that integrate human anthropometrics, performance, cognition and behaviours. For example, cargo loading/unloading presents potential hazards. Human factor considerations would highlight the need for clear communication and visibility, ergonomic matching of worker to task, safe separation of workers from moving machinery and cargo and a trained workforce, well acquainted with work processes.

Prevention of chronic diseases and adverse health states with long latency periods is more problematic than injury prevention and control. Acute injury events generally have readily recognized cause-effect relationships. Also, the association of injury cause and effect with work practices and conditions is usually less complicated than for chronic diseases. Hazards, exposures and health data specific to the maritime industries are limited. In general, health surveillance systems, reporting and analyses for the maritime industries are less developed than those for many of their land-based counterparts. The limited availability of chronic or latent disease health data specific to maritime industries hinders development and application of targeted prevention and control programmes.

 

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Wednesday, 02 March 2011 15:02

Are They Health Care Workers, Too?

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Often overlooked when considering the safety and well-being of health care workers are students attending medical, dental, nursing and other schools for health professionals and volunteers serving pro bono in healthcare facilities. Since they are not “employees” in the technical or legal sense of the term, they are ineligible for workers’ compensation and employment-based health insurance in many jurisdictions. Health care administrators have only a moral obligation to be concerned about their health and safety.

The clinical segments of their training bring medical, nursing and dental students into direct contact with patients who may have infectious diseases. They perform or assist in a variety of invasive procedures, including taking blood samples, and often do laboratory work involving body fluids and specimens of urine and faeces. They are usually free to wander about the facility, entering areas containing potential hazards often, since such hazards are rarely posted, without an awareness of their presence. They are usually supervised very loosely, if at all, while their instructors are often not very knowledgeable, or even interested, in matters of safety and health protection.

Volunteers are rarely permitted to participate in clinical care but they do have social contacts with patients and they usually have few restrictions with respect to areas of the facility they may visit.

Under normal circumstances, students and volunteers share with health care workers the risks of exposure to potentially harmful hazards. These risks are exacerbated at times of crisis and in emergencies when they step into or are ordered into the breech. Clearly, even though it may not be spelled out in laws and regulations or in organizational procedure manuals, they are more than entitled to the concern and protection extended to “regular” health care workers.

 

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Wednesday, 02 March 2011 16:21

Managing Chemical Hazards in Hospitals

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The vast array of chemicals in hospitals, and the multitude of settings in which they occur, call for a systematic approach to their control. A chemical-by-chemical approach to prevention of exposures and their deleterious outcome is simply too inefficient to handle a problem of this scope. Moreover, as noted in the article “Overview of chemical hazards in health care”, many chemicals in the hospital environment have been inadequately studied; new chemicals are constantly being introduced and for others, even some that have become quite familiar (e.g., gloves made of latex), new hazardous effects are only now becoming manifest. Thus, while it is useful to follow chemical-specific control guidelines, a more comprehensive approach is needed whereby individual chemical control policies and practices are superimposed on a strong foundation of general chemical hazard control.

The control of chemical hazards in hospitals must be based on classic principles of good occupational health practice. Because health care facilities are accustomed to approaching health through the medical model, which focuses on the individual patient and treatment rather than on prevention, special effort is required to ensure that the orientation for handling chemicals is indeed preventive and that measures are principally focused on the workplace rather than on the worker.

Environmental (or engineering) control measures are the key to prevention of deleterious exposures. However, it is necessary to train each worker correctly in appropriate exposure prevention techniques. In fact, right-to-know legislation, as described below, requires that workers be informed of the hazards with which they work, as well as of the appropriate safety precautions. Secondary prevention at the level of the worker is the domain of medical services, which may include medical monitoring to ascertain whether health effects of exposure can be medically detected; it also consists of prompt and appropriate medical intervention in the event of accidental exposure. Chemicals that are less toxic must replace more toxic ones, processes should be enclosed wherever possible and good ventilation is essential.

While all means to prevent or minimize exposures should be implemented, if exposure does occur (e.g., a chemical is spilled), procedures must be in place to ensure prompt and appropriate response to prevent further exposure.

Applying the General Principles of Chemical Hazard Control in the Hospital Environment

The first step in hazard control is hazard identification. This, in turn, requires a knowledge of the physical properties, chemical constituents and toxicological properties of the chemicals in question. Material safety data sheets (MSDSs), which are becoming increasingly available by legal requirement in many countries, list such properties. The vigilant occupational health practitioner, however, should recognize that the MSDS may be incomplete, particularly with respect to long-term effects or effects of low-dose chronic exposure. Hence, a literature search may be contemplated to supplement the MSDS material, when appropriate.

The second step in controlling a hazard is characterizing the risk. Does the chemical pose a carcinogenic risk? Is it an allergen? A teratogen? Is it mainly short-term irritancy effects that are of concern? The answer to these questions will influence the way in which exposure is assessed.

The third step in chemical hazard control is to assess the actual exposure. Discussion with the health care workers who use the product in question is the most important element in this endeavour. Monitoring methods are necessary in some situations to ascertain that exposure controls are functioning properly. These may be area sampling, either grab sample or integrated, depending on the nature of the exposure; it may be personal sampling; in some cases, as discussed below, medical monitoring may be contemplated, but usually as a last resort and only as back-up to other means of exposure assessment.

Once the properties of the chemical product in question are known, and the nature and extent of exposure are assessed, a determination could be made as to the degree of risk. This generally requires that at least some dose-response information be available.

After evaluating the risk, the next series of steps is, of course, to control the exposure, so as to eliminate or at least minimize the risk. This, first and foremost, involves applying the general principles of exposure control.

Organizing a Chemical Control Programme in Hospitals

The traditional obstacles

The implementation of adequate occupational health programmes in health care facilities has lagged behind the recognition of the hazards. Labour relations are increasingly forcing hospital management to look at all aspects of their benefits and services to employees, as hospitals are no longer tacitly exempt by custom or privilege. Legislative changes are now compelling hospitals in many jurisdictions to implement control programmes.

However, obstacles remain. The preoccupation of the hospital with patient care, emphasizing treatment rather than prevention, and the staff’s ready access to informal “corridor consultation”, have hindered the rapid implementation of control programmes. The fact that laboratory chemists, pharmacists and a host of medical scientists with considerable toxicological expertise are heavily represented in management has, in general, not served to hasten the development of programmes. The question may be asked, “Why do we need an occupational hygienist when we have all these toxicology experts?” To the extent that changes in procedures threaten to have an impact on the tasks and services provided by these highly skilled personnel, the situation may be made worse: “We cannot eliminate the use of Substance X as it is the best bactericide around.” Or, “If we follow the procedure that you are recommending, patient care will suffer.” Moreover, the “we don’t need training” attitude is commonplace among the health care professions and hinders the implementation of the essential components of chemical hazard control. Internationally, the climate of cost constraint in health care is clearly also an obstacle.

Another problem of particular concern in hospitals is preserving the confidentiality of personal information about health care workers. While occupational health professionals should need only to indicate that Ms. X cannot work with chemical Z and needs to be transferred, curious clinicians are often more prone to push for the clinical explanation than their non-health care counterparts. Ms. X may have liver disease and the substance is a liver toxin; she may be allergic to the chemical; or she may be pregnant and the substance has potential teratogenic properties. While the need to alter the work assignment of particular individuals should not be routine, the confidentiality of the medical details should be protected if it is necessary.

Right-to-know legislation

Many jurisdictions around the world have implemented right-to-know legislation. In Canada, for example, WHMIS has revolutionized the handling of chemicals in industry. This country-wide system has three components: (1) the labelling of all hazardous substances with standardized labels indicating the nature of the hazard; (2) the provision of MSDSs with the constituents, hazards and control measures for each substance; and (3) the training of workers to understand the labels and the MSDSs and to use the product safely.

Under WHMIS in Canada and OSHA’s Hazard Communications requirements in the United States, hospitals have been required to construct inventories of all chemicals on the premises so that those that are “controlled substances” can be identified and addressed according to the legislation. In the process of complying with the training requirements of these regulations, hospitals have had to engage occupational health professionals with appropriate expertise and the spin-off benefits, particularly when bipartite train-the-trainer programmes were conducted, have included a new spirit to work cooperatively to address other health and safety concerns.

Corporate commitment and the role of joint health and safety committees

The most important element in the success of any occupational health and safety programme is corporate commitment to ensure its successful implementation. Policies and procedures regarding the safe handling of chemicals in hospitals must be written, discussed at all levels within the organization and adopted and enforced as corporate policy. Chemical hazard control in hospitals should be addressed by general as well as specific policies. For example, there should be a policy on responsibility for the implementation of right-to-know legislation that clearly outlines each party’s obligations and the procedures to be followed by individuals at each level of the organization (e.g., who chooses the trainers, how much work time is allowed for preparation and provision of training, to whom should communication regarding non-attendance be communicated and so on). There should be a generic spill clean-up policy indicating the responsibility of the worker and the department where the spill occurred, the indications and protocol for notifying the emergency response team, including the appropriate in-hospital and external authorities and experts, follow-up provisions for exposed workers and so on. Specific policies should also exist regarding the handling, storage and disposal of specific classes of toxic chemicals.

Not only is it essential that management be strongly committed to these programmes; the workforce, through its representatives, must also be actively involved in the development and implementation of policies and procedures. Some jurisdictions have legislatively mandated joint (labour-management) health and safety committees that meet at a minimum prescribed interval (bimonthly in the case of Manitoba hospitals), have written operating procedures and keep detailed minutes. Indeed in recognizing the importance of these committees, the Manitoba Workers’ Compensation Board (WCB) provides a rebate on WCB premiums paid by employers based on the successful functioning of these committees. To be effective, the members must be appropriately chosen—specifically, they must be elected by their peers, knowledgeable about the legislation, have appropriate education and training and be allotted sufficient time to conduct not only incident investigations but regular inspections. With respect to chemical control, the joint committee has both a pro-active and a re-active role: assisting in setting priorities and developing preventive policies, as well as serving as a sounding board for workers who are not satisfied that all appropriate controls are being implemented.

The multidisciplinary team

As noted above, the control of chemical hazards in hospitals requires a multidisciplinary endeavour. At a minimum, it requires occupational hygiene expertise. Generally hospitals have maintenance departments that have within them the engineering and physical plant expertise to assist a hygienist in determining whether workplace alterations are necessary. Occupational health nurses also play a prominent role in evaluating the nature of concerns and complaints, and in assisting an occupational physician in ascertaining whether clinical intervention is warranted. In hospitals, it is important to recognize that numerous health care professionals have expertise that is quite relevant to the control of chemical hazards. It would be unthinkable to develop policies and procedures for the control of laboratory chemicals without the involvement of lab chemists, for example, or procedures for handling anti-neoplastic drugs without the involvement of the oncology and pharmacology staff. While it is wise for occupational health professionals in all industries to consult with line staff prior to implementing control measures, it would be an unforgivable error to fail to do so in health care settings.

Data collection

As in all industries, and with all hazards, data need to be compiled both to help in priority setting and in evaluating the success of programmes. With respect to data collection on chemical hazards in hospitals, minimally, data need to be kept regarding accidental exposures and spills (so that these areas can receive special attention to prevent recurrences); the nature of concerns and complaints should be recorded (e.g., unusual odours); and clinical cases need to be tabulated, so that, for example, an increase in dermatitis from a given area or occupational group could be identified.

Cradle-to-grave approach

Increasingly, hospitals are becoming cognizant of their obligation to protect the environment. Not only the workplace hazardous properties, but the environmental properties of chemicals are being taken into consideration. Moreover, it is no longer acceptable to pour hazardous chemicals down the drain or release noxious fumes into the air. A chemical control programme in hospitals must, therefore, be capable of tracking chemicals from their purchase and acquisition (or, in some cases, synthesis on site), through the work handling, safe storage and finally to their ultimate disposal.

Conclusion

It is now recognized that there are thousands of potentially very toxic chemicals in the work environment of health care facilities; all occupational groups may be exposed; and the nature of the exposures are varied and complex. Nonetheless, with a systematic and comprehensive approach, with strong corporate commitment and a fully informed and involved workforce, chemical hazards can be managed and the risks associated with these chemicals controlled.

 

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Wednesday, 02 March 2011 15:03

Social Services

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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.

 

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Wednesday, 02 March 2011 16:24

Waste Anaesthetic Gases

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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.

 

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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


 

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Wednesday, 02 March 2011 16:27

Health Care Workers and Latex Allergy

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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.

 

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Wednesday, 02 March 2011 15:06

Case Study: Violence in Health Care Work

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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.

 

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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.

 

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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