Will Cal-OSHA airborne standard go national?
State plan may be expanded by national office
With the Occupational Safety and Health Administration (OSHA) opening preliminary rulemaking on a national infectious disease standard, infection preventionists pondering the end result of the effort may follow the old admonition, "look to California."
Just as it did with the first versions of the bloodborne pathogen standard years ago, Cal-OSHA enacted an Aerosol Transmissible Diseases standard that became effective in August 2009. With health care worker unions already expressing support for a national version of the standard, it appears OSHA may use the regulation as a template.
Cal-OSHA was able to achieve support for the standard from both the California Hospital Association and labor unions representing health care workers. While it requires fit-tested N95 respirators (or greater protection) for health care workers caring for patients infected with a novel pathogen, it also temporarily allows fit-testing to occur biannually rather than every year. That provision was based on the premise that future research will clarify fit-testing issues and it automatically expires in 2014.
However, some IPs in California ran into problems trying to comply with the standard during the H1N1 pandemic, when fit-testing and respirator supply issues were an overwhelming problem.
"The standard didn't allow for any flexibility in the event of a lack of supplies, such as during a pandemic," says Susan Dolan, RN, MS, CIC, public policy chair of the Association for Professionals in Infection Control and Epidemiology (APIC). "[Infection preventionists] found that very challenging in addition to the cost issues. Anecdotally, our members were just really concerned that there wasn't enough evidence or justification for having such a standard. That was the piece that seemed to be a disconnect for our members."
In that regard, APIC is not likely to support a national version of a standard it resisted at the state level. "We did not understand the need or justification for California's aerosol transmissible disease standard, given the studies that were examined by OSHA and stakeholders that did not demonstrate that the TB rate in HCWs was any higher than the general population," APIC stated in its comments submitted to OSHA.
California's airborne 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), vaccinations and fit-testing. The standard also calls for 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 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).
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