HEH Roundtable: The proposed OSHA tuberculosis standard
Practitioners, occupational health leaders discuss controversial provisions
Editor's note: This is the first in a series of periodic roundtable discussions Hospital Employee Health will bring to you on timely issues of concern to hospital occupational health practitioners, enabling you to share your opinions and learn what your colleagues think of important matters affecting your practice.
On Oct. 17, 1997, the U.S. Occupational Safety and Health Administration released the long-awaited proposed standard to control occupational exposure to tuberculosis,1 unleashing a torrent of concerns from HEH readers. Presented here in a roundtable format are participants' comments on several aspects of the proposed standard that are of particular concern for hospital employee health practitioners. (For additional information and comments from OSHA, see HEH, January 1998, pp. 1-4; February 1998, pp. 13-17.) Also, see a related story on p. 72 of this issue on attempts to change the wording of the proposed standard that could limit the licensed scope of practice of occupational health practitioners.
To find out how you can participate in the next HEH roundtable discussion, see note at end of article.
TB Proposal Roundtable Participants:
Kathleen F. Gordon, RN, MS, MSN, director, employee risk management and occupational health, Beth Israel Deaconess Medical Center (9,400 employees), Boston
Kae Livsey, RN, MPH, governmental affairs manager, American Association of Occupational Health Nurses (AAOHN), Atlanta
JoAnn Shea, RN, MSN, ARNP, manager, employee health service, Tampa General Healthcare (3,500 employees), Tampa, FL
Kathleen VanDoren, RN, BSN, COHN-S, paralegal, executive president, Association of Occupational Health Professionals in Healthcare (AOHP), Reston, VA
HEH: When the proposed tuberculosis standard was published last fall, many members of the occupational health and infection control communities protested that a standard was not necessary because the U.S. Centers for Disease Control and Prevention had issued guidelines for health care institutions to follow in controlling the spread of TB.2 Do you think a federal OSHA standard is necessary?
Livsey: We are generally supportive of a standard. It's important that employees are protected, but while a standard is necessary, it must be something that is reasonable for employers to implement. It can't be onerous. It's a matter of weighing the cost vs. the benefit. The inherent risk that health care workers face [of occupational TB infection] is in question; there are little data to show what the risk is. We're looking at it from the point of view of feasibility in the real world because our members are the ones who must implement all the provisions. They're the ones who have to make it happen.
VanDoren: Most hospitals already have enforced many components of the CDC guidelines, so I don't think the cost of adding one or two more would be prohibitive. But guidelines are only recommendations. When standards are published by a government agency that is empowered to institute law, they carry far more weight than guidelines. Even when guidelines are coupled with hospital administrative policies, they do not guarantee that health care facilities have programs in place that will protect health care workers, patients, and their families. An OSHA standard will guarantee that health care facilities have a written and implemented TB program, and that employee/occupational health personnel will have a standard to cite when enforcing administrative policy.
Many health care institutions are focused on the bottom line. That doesn't mean they don't want to provide a good place to work for employees, but it means that if they can substitute or eliminate parts of guidelines that will, in their eyes, cost too much, they will do so. Being able to cite an OSHA standard gives hospital employee/occupational health professionals the push necessary to implement programs.
Gordon: I support OSHA's decision to develop a proposed rule to protect the estimated five million persons who work in settings where there is a recognized risk for TB transmission. Some might argue that the standard is not necessary because we're now seeing a decline in the number of TB cases, but it's my observation that this decline is a direct result of the attention and implementation of aggressive programs to control TB transmission. I get calls from colleagues locally and nationally who are still struggling with what portions of the CDC guidelines they need to comply with. If everybody is in good compliance with the CDC guidelines, it's not going to be that much of a burden. A standard will be impetus for those not in good compliance to protect their employees.
Shea: Without a standard, you'll find health care facilities not taking any precautions. From an employee health perspective, our priority is to be an advocate for employees, to promote their health and safety. I agree that a standard is necessary, but I do have some problems with this one.
HEH: One problem that many people have with the proposal is the requirement for annual respirator fit-testing. Do you think annual fit-testing is necessary?
VanDoren: [As an employee health manager,] I have done spot-checking and found that employees who previously had been fit-tested did not remember how to put on a respirator or how to properly do negative-positive fit checks, so what I've found is needed is ongoing education and review of the procedure. When I examined health questionnaires filled out at the time of original fitting, I found little had changed to indicate that employees needed a different size or type of respirator. So I recommend ongoing education, not a yearly medical evaluation. Most hospitals hold yearly safety inservices, and a repeat demonstration of how to put on a respirator can be done at that time.
Gordon: I don't think it's necessary to re-fit everyone annually unless there's been some change that would require it, such as weight gain or facial surgery. Employees can be given a questionnaire at the time of annual PPDs to assess the need for re-fitting. It can be done face-to-face by whomever is reading the PPD.
Shea: I don't think you'll find any health care facility that agrees with that. In most cases, it's burdensome, expensive, requires a lot of staff, and just doing a fit-check generally is adequate. It's putting a burden on employers that is unreasonable and unnecessary in terms of time, expense, and follow-up. Is it necessary if you're complying with [other parts of] the standard, identifying patients, educating staff when to wear a mask, and you have no problems with PPD conversions? Everyone needs to look at their own facility. For example, we do monthly tracking of reported and actual exposures. We have a conversion rate of 5% on pre-employment, but this year on annual skin tests, the conversion rate was .8%. We have a very low conversion rate and a low rate of exposures to TB.
We've already fit-tested everyone, and it was very time-consuming. Now we do it monthly at new employee orientation. It takes about five hours, and we use a minimum of 10 people - educators, nurses, employee health staff, and infection control staff - to fit-test anywhere from 60 to 120 new employees each time. It's very difficult to get enough staff to do it.
Livsey: Employees need to be protected, but identification of potentially infected [patients] needs to be stressed as the primary mechanism for prevention of transmission. Employee exposures occur primarily as a result of failure to identify an infected individual, not from personal protective equipment failure. Personal protective equipment is important; it needs to fit, and people need to know how to use it right, but it has to be weighed against the resources that have to be used. Can the energy and resources be better spent in identifying [infected] people when they come in the door? This is the biggest concern for occupational health nurses in the hospital environment. Even [AAOHN] members in large university hospitals are concerned about getting all of these provisions done with the amount of resources they have. Most of our member feedback is that fit-checking is adequate.
HEH: OSHA also proposes that many employees with potential for occupational exposure to TB be skin-tested every six months, compared with the CDC's recommendation for annual retesting of employees in low-risk categories and every six to 12 months for those in intermediate-risk categories. What do you think of OSHA's proposed six-month retesting mandate?
Gordon: OSHA is suggesting that anyone who enters an AFB negative-pressure isolation room should have six-month testing, but this requirement will erode the predictive value of the screening tool. Required respiratory protection for those employees should lower or eliminate their exposure risk. Where the risk for TB is low, the value of TB testing declines, leading to an increased risk of false positives. This in turn causes the administration of unnecessary diagnostic procedures or therapy. Repeat testing should be based on the prevalence of TB and the population's exposure risks.
Shea: The way OSHA is proposing this means you would do six-month testing on anyone who walks into a patient's room who is on AFB isolation. That's very broad, and it would include employees such as dietary workers. We've identified departments that do high-risk procedures; about 10 departments right now are classified as intermediate risk. We're doing six-month testing on about 300 employees in those departments.
Livsey: Many of our members are sole providers, and they say they're lucky if they can get everybody tested annually. Many occupational health programs have limited human resources. Six-month testing should be limited to those employees who regularly engage in high-hazard procedures such as bronchoscopy, unless there is an unusually high prevalence of tuberculosis within the client population.
VanDoren: Six-month testing is unnecessary if an effective TB program is in place. Employees would be safeguarded by respiratory protection and the fact that a patient is undergoing treatment and is presumably less infectious. If employees wear personal protective equipment properly, there should be no reason to feel they are unnecessarily exposed, nor should there be a need to skin-test more than once a year.
HEH: Some practitioners find the medical removal clause confusing because it seems to conflict with workers' compensation requirements, and because it does not specify whether medical removal applies to all employees who develop active TB, even if the exposure is not work-related. What do you think of the proposed standard's medical removal provisions in these regards?
Livsey: OSHA needs to re-evaluate this clause because it produces a number of complexities for employers. It has the potential to provide compensation above that set by a state workers' compensation system, so it would create additional liabilities for employers and remove the exclusive remedy of workers' compensation.
While it's important to remove infected employees from the work setting, many employers feel it is an unfair burden to have to cover 18 months of salaries and benefits to employees who may have developed TB from social exposure or from activation of an old infection due to a change in the individual's immune system. The clause also may be construed as overriding states' rights to determine what is a work-related, compensable medical condition.
Shea: The requirement for workers to maintain earnings, seniority, and benefits for up to 18 months when off work with infectious TB is beyond all workers' compensation requirements. A determination needs to be made as to whether or not the employee acquired the disease at work before compensation can be issued.
No one will agree with this. You can't say if you get TB, you get these benefits, but if you get hepatitis B or C, you don't get those benefits. That's inequitable and definitely not appropriate. Anything you consider a compensable illness should be treated the same. In Florida, with the no-fault system, you would have to assume that as a compensable claim, and it would fall under the workers' comp system. We can't give benefits over and above what workers' comp gives.
VanDoren: In my experience, if active TB is determined to be occupationally acquired, employees are taken off work, and workers' compensation is provided. If TB is not occupationally acquired - there has been no documented exposure, nor has the employee cared for a known TB patient - the employee is taken off work and can use any sick time or paid time off hours accrued.
Most health care institutions have benefits allowing employees to accrue paid sick time and personal time in the form of an extended illness bank or paid time off, along with short- or long-term disability insurance that can be used while an employee is unable to work. Facilities with effective TB control programs should have few removals necessary.
Gordon: I understand OSHA's intent is to encourage reporting of suspected exposures or symptoms, but I'm concerned with the inconsistent remedy this section imposes. However, given the decline in the number of occupational TB cases and the continued protection this standard will afford, the need to place individuals out on medical removal will soon be negligible. Given that this language does protect employees from lost wages, this requirement would only serve to encourage employees to report TB symptoms and minimize efforts involved for postexposure follow-up.
References
1. Department of Labor, U.S. Occupational Safety and Health Administration. Occupational exposure to tuberculosis; proposed rule. 62 Fed Reg 54,159-54,307 (Oct. 17, 1997).
2. Centers for Disease Control and Prevention. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care facilities, 1994. MMWR 1994; 43 (No. RR-13): 1-132.
[Editor's note: The topic for the next HEH Roundtable will be the structure and function of an employee health service. Questions to be considered will include: What is an appropriate ratio of practitioners to employees? In what department should the employee health service be located? To whom should the manager report? What services should an employee health department provide? How important is an employee health service in health care institutions today?
We invite your participation. Mail or fax a short response by June 29 to: Editor, Hospital Employee Health, P.O. Box 740056, Atlanta, GA 30374; fax (770) 664-7103. Please keep your comments brief and indicate a convenient time for us to call you for a short interview.]
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