Landmark CA rule sets stage for airborne regs
Employers must provide respirators for novel virus
Amid the backdrop of a worldwide influenza pandemic, hospitals received a new model for protecting health care workers from airborne diseases: Landmark regulation from California that provides a comprehensive approach to the hazards of airborne infectious diseases.
The Aerosol Transmissible Diseases standard, adopted by the California Division of Occupational Safety and Health (Cal-OSHA), is patterned after the Bloodborne Pathogens Standard, requiring risk assessment, an exposure control plan, and annual training. It incorporates practices that have been longstanding recommendations from the Centers for Disease Control and Prevention, such as respiratory hygiene and isolation of patients suspected to have an airborne infectious disease.
The California standard also sets new ground by allowing hospitals to conduct fit-testing every other year rather than on an annual basis, as required by the U.S. Occupational Safety and Health Administration's Respiratory Protection Standard. Cal-OSHA asserts that because the new standard is comprehensive and includes requirements beyond those of OSHA it is "at least as effective" as the federal standard. (States with their own occupational safety and health programs must promulgate standards at least as effective as the federal ones.)
This combination of tougher requirements with more flexibility on fit-testing won widespread support in California. The standard passed the Board of Standards unanimously.
"It's really a victory for health care workers not only in California, but it sets the stage to protect health care workers nationwide," says Bill Borwegen, MPH, health and safety director of the Service Employees International Union. "We hope that California's regulation will provide the foundation for a discussion at the national level for a federal OSHA regulation."
Meanwhile, the California Hospital Association lauded the clarity and uniformity that the standard brings to airborne infectious disease hazards. "Best practices vary from facility to facility. This really sets one standard for the state," says Roger Richter, senior vice president for professional services. He notes that the standard evolved over five years of public meetings that allowed input from many stakeholders.
For many hospitals, the new standard simply requires tweaking their current programs, including some new requirements for documentation. Others will need to switch their employees from surgical masks to N95 respirators when they have an "elevated risk" of exposure to patients with the novel H1N1 virus.
In fact, some local health departments in California had issued advice contrary to the CDC and Cal-OSHA and advised hospitals to use droplet precautions (surgical masks) with the novel flu virus rather than airborne precautions (respirators).
"As long as it remains a novel pathogen that hasn't been fully characterized, it would require airborne [precautions]," says Deborah Gold, MPH, CIH, senior safety engineer in the research and standards health unit at Cal-OSHA in Oakland. "If you're going to provide treatment or perform aerosol-generating procedures on those patients, then you have to have a full program including respirators."
The standard is explicit about how to handle novel pathogens that could be transmitted by aerosols. There must be "credible evidence" of airborne transmission and the novel disease is "a newly recognized pathogen; a newly recognized variant of a known pathogen and there is reason to believe that the variant differs significantly from the known pathogen in virulence or transmissibility; a recognized pathogen that has been recently introduced into the human population, or a not-yet-identified pathogen.
"Variants of the human influenza virus that typically occur from season to season are not considered novel or unknown [aerosol transmissible pathogens] if they do not differ significantly in virulence or transmissibility from existing seasonal variants. Pandemic influenza strains that have not been fully characterized are novel pathogens," the standard says.
The standard also covers diseases known to be airborne, such as tuberculosis, severe acute respiratory syndrome, varicella, and measles. It requires signed declination statements from employees who do not accept recommended vaccinations, such as the influenza vaccine. Surveillance of airborne-transmissible diseases will improve with the standard, says Borwegen. The regulation requires the reporting of aerosol-transmissible disease cases to the local health officer, post-exposure follow-up of employees who have been exposed, and recordkeeping of exposures similar to the log for bloodborne pathogen exposures. Frontline employees must be involved in the annual reviews of the exposure control plan.
As California hospitals adapt to the new standard, they also are evaluating their response to the novel H1N1. "Hopefully, this summer as we're gearing up this standard, we're also helping people assess what went right and what went wrong with the H1N1 responses," says Gold.
The standard will encourage hospitals to boost resources for employee health, much as the Bloodborne Pathogens Standard created a ongoing emphasis on using safer sharps devices, predicts Sandra Domeracki Prickitt, RN, FNP, COHN-S, executive president of the Association of Occupational Health Professionals in Healthcare and coordinator of Employee Health Services at Marin General Hospital/Novato Community hospitals in California. "[Hospitals] can quantify things a little bit more because of the standard," she says.
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At-a-glance: California's new rules on airborne diseases California's proposed Aerosol Transmissible Diseases standard covers a range of issues, including the minimum air exchanges per hour in negative pressure rooms (12, although they can be six if HEPA filtration is used), vaccination and fit-testing. The standard would require employers to: implement "source control measures" such as a respiratory hygiene/cough etiquette program, as recommended by the Centers for Disease Control and Prevention. identify patients needing airborne infection isolation in a timely manner. If the facility doesn't treat patients with airborne infectious diseases, it must transfer the patient within five hours (or by 11 a.m., if the initial patient encounter occurs after 3:30 p.m.). Exceptions are provided when rooms are not available, and when a transfer is medically contraindicated. maintain an exposure control plan that outlines the job classifications that may involve aerosol transmissible disease exposure, high-hazard procedures, tasks requiring respiratory protection, and the control measures. The plan also must address medical surveillance, reporting of exposures, and evaluation of exposure incidents. It must be reviewed annually, and employees must be involved in that review. have a system of communicating the infectious disease status of patients to which employees may be exposed that complies with medical confidentiality requirements. If employees are not sick but must be removed from their normal assignment because an evaluating physician determines they have been exposed or may be infectious, they must be provided with an appropriate alternate assignment or be paid if they are furloughed. This "precautionary removal" period ends when either the person has passed the incubation period or if the employee gets sick or is otherwise unable to work. provide annual training to employees with potential exposure to patients with aerosol-transmissible diseases. have adequate supplies of personal protective equipment. provide fit-tests biannually for employees who do not perform high-hazard procedures and at least annual fit-tests for those in areas where high hazard procedures are performed. Additional fit-tests would be required for employees who have a physical change, such as significant weight gain or loss, dental changes, or cosmetic surgery. provide powered air-purifying respirators (PAPRs) to employees performing high-hazard procedures "unless the employer determines that this use would interfere with the successful performance of the required task or tasks." provide vaccines for susceptible health care workers with the potential for exposure. Employees who decline a recommended vaccine must sign a declination statement. conduct TB tests at least annually for employees with occupational exposure (or perform annual symptoms screens for employees who are baseline positive for latent tuberculosis infection). - Employers would be able to use a streamlined version of the respirator medical evaluation questionnaire, which would potentially reduce the number of employees who are referred to a physician for further evaluation. - As with existing regulations, the proposed rule establishes a fit factor of 100 as the minimum acceptable fit factor for quantitative testing. |
Linda Good, PhD, RN, COHN-S, manager of employee occupational health services at Scripps Memorial Hospital in La Jolla, CA, welcomes the clarity of the standard. "We were already doing everything this standard has in it and maybe even more. In this case, it just validates that we were on the right track," she says.
The biannual fit-testing provision for non-high-hazard procedures is due to expire in 2014. At that time, Cal-OSHA anticipates that research sponsored by the National Institute for Occupational Safety and Health will provide additional information on fit-testing. Meanwhile, employees must be provided with training each year, and they must answer questions as to whether they had major dental work, facial injury, facial surgery, or significant weight gain or loss. Employers must provide a fit-test if an employee requests one.
"I thought it was encouraging that Cal-OSHA seemed willing to relax the annual fit-testing requirement," says Good. "That's a wise, reasonable move."
(Editor's note: A copy of the California Aerosol Transmissible Diseases standard is available at www.dir.ca.gov/oshsb/atd0.html.)
Amid the backdrop of a worldwide influenza pandemic, hospitals received a new model for protecting health care workers from airborne diseases: Landmark regulation from California that provides a comprehensive approach to the hazards of airborne infectious diseases.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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