OSHA readies TB, ergonomics rules despite mounting opposition
Congressional foes won’t derail standards, agency vows
Ignoring the grenades lobbed into their camp by congressional factions and politically savvy professional associations, officials of the Occupa tional Safety and Health Administration (OSHA) pledge to forge ahead and release two long-awaited, controversial regulations on time.
OSHA is in the final stages of drafting a proposed ergonomics standard that could be issued as soon as this fall and is putting the finishing touches on the final rule regulating occupational exposure to tuberculosis, which is scheduled to become law next year. Both regulations have met with significant political and professional opposition during their years of development.
Nevertheless, OSHA remains steadfast in its resolve to promulgate both standards. "Right now, this agency continues to go forward," says spokesman Bill Wright. "As of now, nothing has changed. This agency’s intent is to issue a proposed ergonomics standard this fall, and a final TB rule is planned for spring 2000. That’s the schedule. It’s a priority of the agency."
Most recently, the TB standard, which was reopened this summer for public comment (see related story, p. 124), has been threatened with a strategic attempt to block its release. The Association for Professionals in Infection Control and Epidemiology (APIC) is calling on Congress to withhold funding unless OSHA submits the TB rule to a scientific review by the Institute of Medicine (IOM) in Washington, DC.
A similar tactic could prove successful in delaying the ergonomics proposal. HR 987, the "Workplace Preservation Act," narrowly passed the House of Representatives this summer. It requires OSHA to wait for the Washington, DC-based National Academy of Sciences (NAS) — an organization affiliated with the IOM — to complete and submit to Congress a study on the cause-and-effect relationship between repetitive tasks in the workplace and repetitive stress injuries before issuing an ergonomics standard.
The Workplace Preservation Act was introduced in the House by Rep. Roy Blunt (R-MO) and passed 217-209, mostly on the strength of Republican support. Efforts to develop an ergo nomics rule have been plagued by political opposition, largely along partisan lines. Proposed rulemaking for a standard was announced in 1992, with a proposal slated for release in 1994.
However, that plan crashed due to congressional actions that weakened OSHA’s regulatory authority. A draft proposal released in 1995 encouraged employers not to wait for a standard to implement workplace ergonomics programs.1 Again, that proposal was squelched, along with any other plans to issue a standard, this time by a rider attached to a federal appropriations bill adopted by Congress. The rider prohibited OSHA from developing a rule before Sept. 30, 1998.
Prescriptive approach scrapped
When the ban was lifted last fall, OSHA once again resumed work toward a standard, although town hall-type meetings on ergonomics had been held around the country during most of 1998 in preparation for a federal rule. Earlier versions of an ergonomics proposal generally viewed as too prescriptive were scrapped in favor of a more "programmatic, flexible" approach, says David Cochran, PhD, PE, CPE, a special assistant for ergonomics at OSHA and a lead author of the standard.
Earlier this year, Cochran told Hospital Employee Health that the chances of OSHA’s proposed rule gaining the support of both employer and labor groups looked good, based on responses at recent stakeholder meetings.
"It was surprising how much agreement there was," he says. "They agreed that a good [ergonomics] program is necessary to deal with these problems, and they agreed on the components of a good program. The key is trying to get the right amount of information [in a standard] without overdoing it."
OSHA head defends need for rule
Nevertheless, the working draft proposal released on OSHA’s Internet Web site earlier this year did nothing to placate critics. In a speech last spring to the National Coalition on Ergo nom ics — a group of 200 diverse organizations including truckers, farmers, and convenience store owners who are the main opposition to a federal law and the main supporters of Blunt’s legislation — Charles N. Jeffress, OSHA’s assistant secretary of labor for occupational safety and health, defended the standard.
Noting that a 1998 NAS study found "substantial sound scientific evidence" linking back injuries and other musculoskeletal disorders (MSDs) to work activities (see Hospital Employee Health, January 1999, pp. 1-3),2 Jeffress denounced the coalition’s support for another NAS review of the same subject.
"What different conclusions do you expect from yet another literature review by the aca demy? What will you say if the findings are identical to the last review? More research is always welcome, but we already know enough to begin addressing these problems," Jeffress stated.
Dan Wadlington, a spokesman for Rep. Blunt, argues that the 1998 NAS review was not a scientific study of the connection between MSDs and work, but just "some documents that hinted at it." The study called for in the legislation would be "the only scientific study of its kind," he says.
Having passed the House, the bill has been referred to the Senate for action there. President Clinton has said he will veto the measure if both sides of Congress approve it. Other supporters include the American Association of Occupational Health Nurses (AAOHN), the American Nurses Association (ANA), the Service Employees Inter national Union (SEIU), and the American College of Occupational and Environmental Medicine (ACOEM).
Noting that ergonomics is "a very hot topic in Washington" now, Jeffress maintains that ergo nomics programs have been shown to reduce the risk of injury. More than 600,000 occupational MSDs occur annually, he says, costing businesses $15 billion to $20 billion each year in workers’ compensation costs alone.
Following publication of the proposal this fall, OSHA will hold public hearings in early 2000 and will issue a final rule by the end of the year, Jeffress vows.
Some call proposal ambiguous’
While most critics fear being over-regulated by an ergonomics standard, others have the opposite concern. Geoff Kelafant, MD, MSPH, FACOEM, medical director of the occupational health department at Sarah Bush Lincoln Health Center in Mattoon, IL, says the draft proposal is too vague.
"From looking at this, I’m not really sure what a work-related musculoskeletal injury is," he observes. "I don’t think companies do well when given a whole lot of latitude. I think they do better when beaten over the head."
Kelafant says an ergonomics standard should be more prescriptive, leaving less open to interpretation by employers.
"It’s great that OSHA thinks it should have these [standards], but I’m not sure another ambiguous standard is going to clear things up," he states.
Guy Fragala, PhD, PE, CSP, a health care ergonomics expert and director of environmental health and safety at the University of Massachu setts Medical Center in Worcester, sees the standard as flexible rather than ambiguous. He says efforts to block the standard are "unfortunate."
"I don’t know if the people who are voting on the issue really understand how effective ergo nomics management can result in cost savings," Fragala says. "Many people think it would add a lot of cost, but it’s changed quite a bit since the original proposal came out, so it’s much less prescriptive. The program aspect of the standard is good — requiring a program but giving a lot of flexibility. Many health care providers have realized the value of reducing occupational injuries, especially those associated with patient lifting and handling."
Similar attempts to derail the TB standard have not gone as far yet, but APIC members hope their legislative strategy will be successful in delaying the rule’s finalization. The TB standard proposed in 1997 met with an onslaught of criticism from the health care community over a number of controversial provisions, including the risk assessment and frequency of respirator fit-testing and employee skin-testing.3 (See HEH, January 1998, pp. 1-4; February 1998, pp. 13-17; June 1998, pp. 69-72; and February 1999, pp. 13-16.)
Many critics, most prominently APIC, have argued for enforcement of the 1994 Centers for Disease Control and Prevention guidelines,4 which they say have worked to control the risk of occupational TB infection. This would be preferable to an OSHA rule, they contend.
APIC has taken its case to Congress, where the organization’s government affairs representatives have gained support from Rep. Roger Wicker (R-MS) and Rep. John Porter (R-IL) in introducing a bill that would require third-party review of the rule to determine whether there is a need for it, says Jennifer Thomas, APIC’s government and public affairs director.
While APIC tried to stop the standard for several years, those efforts were unsuccessful, she says. Now the organization is taking a "compromise approach."
"When it came right down to it, we had to do something this year because the rule is due out next year, but we don’t want it to be so political as the thwarting of a regulation," Thomas says. "We feel that the science can speak for itself, so by asking for an IOM review, we hope that it’s a more objective approach to proving that there is no need for this rule."
Viewing TB as a public health issue
To prove its point, APIC says the rate of TB disease in health care workers is lower than that in the general population (5.3 per 100,000 vs. 8.0), "so that tells you it’s a public health issue, not a health care worker issue," Thomas states.
The problem, she says, is that undiagnosed patients are "unwittingly" spreading TB to HCWs. "They are not symptomatic at all, which tells us that if 73% of transmissions come from undiagnosed patients, that’s a public health issue."
The solution is to target populations in the community at risk for TB and to tailor TB prevention and treatment efforts to those groups before they enter health care facilities with undiagnosed TB.
"That’s going to curb the problem for everybody, including health care workers," she says. (See related story, p. 124.)
That opinion is not shared by the American Nurses Association (ANA), which supports both the TB and ergonomics standards. Susan Wilburn, RN, MPH, occupational safety and health specialist for the Washington, DC-based organization, says the TB standard is a "long overdue" and necessary protection.
"Although the rates of TB in this country have declined over the last couple of years, the international rates have increased. We need to protect nurses and other health care workers from a completely preventable exposure and infection," she states.
Those protections are threatened even in hospitals that enforce the CDC’s TB recommendations, Wilburn says.
A shield against the budgetary axe
"I’ve been told by employee health nurses and physicians over and over that [policies not based] on the requirements of a standard go on the cutting table when there’s a budget crunch. I think APIC sees this as a resource allocation issue, that when resources are being spent on preventing TB, it means they’re going to miss catching some new bug. I think the opposite is true," she states. "If there is an OSHA standard, they are going to be provided with the resources to do their job. If there’s not a standard, they won’t be."
APIC’s position is an "extension of management," Wilburn says, whose aim is to cut costs, so "any regulation is a bad regulation," no matter how significant the risk.
"Hospitals may say in good faith they’re going to do the right thing, but it’s not true for TB and it’s not true for ergonomics," she says.
References
1. Occupational Safety and Health Administration. OSHA’s Proposed Ergonomics Protection Standard: Draft. Washington, DC: OSHA; March 13, 1995.
2. Steering Committee for the Workshop on Work-Related Musculoskeletal Injuries: The Research Base, Committee on Human Factors, National Research Council. Work-Related Musculoskeletal Disorders: A Review of the Evidence. Washington, DC: National Academy Press; 1998.
3. Occupational Safety and Health Administration. Occu pational exposure to tuberculosis; proposed rule. 62 Fed Reg 54,159-54,307 (Oct. 17, 1997).
4. Centers for Disease Control and Prevention. Guide lines for preventing the transmission of Mycobacterium tuberculosis in health care facilities, 1994. MMWR 1994; 43 (No. RR-13):1-133.
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