For Development of Home Care Specific Occupational Hazard Training

**Document for Review***

for Development of Home Care Specific Occupational Hazard Training

Occupational Hazard Assessment and Standards of Concern

for Workers Who provide Healthcare in Non-acute care settings

Sections:

1. Hazard Communication

2. Personal Protective Equipment

3. Universal Precautions

4. Infection Control

5. Blood-borne Pathogens

6. Safe Patient Handling

7. Respiratory Diseases

8. Respiratory Protection

1. Hazard Communication (1910.1200) - The Hazard Communication standard protects employees who may be exposed to hazardous chemicals. Both standards require employers to develop written documents to explain how they will implement each standard, provide training to employees, and protect the health and safety of their workers. Every facility must have a written Hazard Communication program that includes:

Model Hazard Communication Program
Company Policy
To ensure that information about the dangers of all hazardous chemicals used by (Name of Company) is known by all affected employees, the following hazardous information program has been established. Under this program, you will be informed of the contents of the OSHA Hazard Communications standard, the hazardous properties of chemicals with which you work, safe handling procedures and measures to take to protect yourself from these chemicals.
This program applies to all work operations in our company where you may be exposed to hazardous chemicals under normal working conditions or during an emergency situation. All work units of this company will participate in the Hazard Communication Program. Copies of the Hazard Communication Program are available in the (location) for review by any interested employee.
(Name of responsible person and/or position) is the program coordinator, with overall responsibility for the program, including reviewing and updating this plan as necessary.
Container Labeling
(Name of responsible person and/or position) will verify that all containers received for use will be clearly labeled as to the contents, note the appropriate hazard warning, and list the manufacturer's name and address.
The (name of responsible person and/or position) in each section will ensure that all secondary containers are labeled with either an extra copy of the original manufacturer's label or with labels marked with the identity and the appropriate hazard warning. For help with labeling, see (name of responsible person and/or position).
Material Safety Data Sheets (MSDSs)
The (name of responsible person and/or position) is responsible for establishing and monitoring the company MSDS program. He/she will ensure that procedures are developed to obtain the necessary MSDSs and will review incoming MSDSs for new or significant health and safety information. He/she will see that any new information is communicated to affected employees. The procedure below will be followed when an MSDS is not received at the time of initial shipment: (Describe procedure to be followed here) Copies of MSDSs for all hazardous chemicals to which employees are exposed or are potentially exposed will be kept in (identify location).
MSDSs will be readily available to all employees during each work shift. If an MSDS is not available, contact (name of responsible person and/or position).

Employee Training and Information
(Name of responsible person and/or position) is responsible for the Hazard Communication Program and will ensure that all program elements are carried out.
Everyone who works with or is potentially exposed to hazardous chemicals will receive initial training on the hazard communication standard and this plan before starting work. Each new employee will attend a health and safety orientation that includes the following information and training:

• An overview of the OSHA hazard communication standard
• The hazardous chemicals present at his/her work area
• The physical and health risks of the hazardous chemicals
• Symptoms of overexposure
• How to determine the presence or release of hazardous chemicals in the work area
• How to reduce or prevent exposure to hazardous chemicals through use of control procedures, work practices and personal protective equipment
• Steps the company has taken to reduce or prevent exposure to hazardous chemicals
• Procedures to follow if employees are overexposed to hazardous chemicals
• How to read labels and MSDSs to obtain hazard information
• Location of the MSDS file and written Hazard Communication program

Prior to introducing a new chemical hazard into any section of this company, each employee in that section will be given information and training as outlined above for the new chemical hazard. The training format will be as follows:

Hazardous Non-routine Tasks
Periodically, employees are required to perform non-routine tasks that are hazardous. Examples of non-routine tasks are: confined space entry, tank cleaning, and painting reactor vessels. Prior to starting work on such projects, each affected employee will be given information by (Name of responsible person and/or position) about the hazardous chemicals he or she may encounter during such activity. This information will include specific chemical hazards, protective and safety measures the employee should use, and steps the company is taking to reduce the hazards, including ventilation, respirators, the presence of another employee (buddy systems), and emergency procedures.
Examples of non-routine tasks performed by employees of this company are:

Informing Other Employers/Contractors
It is the responsibility of (Name of responsible person and/or position) to provide other employers and contractors with information about hazardous chemicals that their employees may be exposed to on a job site and suggested precautions for employees. It is the responsibility of (Name of responsible person and/or position) to obtain information about hazardous chemicals used by other employers to which employees of this company may be exposed.
Other employers and contractors will be provided with MSDSs for hazardous chemicals generated by this company's operations in the following manner:

(Describe company policy here)

In addition to providing a copy of an MSDS to other employers, other employers will be informed of necessary precautionary measures to protect employees exposed to operations performed by this company.
Also, other employers will be informed of the hazard labels used by the company. If symbolic or numerical labeling systems are used, the other employees will be provided with information to understand the labels used for hazardous chemicals for which their employees may have exposure.
List of Hazardous Chemicals
A list of all known hazardous chemicals used by our employees is attached to this plan. This list includes the name of the chemical, the manufacturer, the work area in which the chemical is used, dates of use, and quantity used. Further information on each chemical may be obtained from the MSDSs, located in (identify location).

2.Personal Protective Equipment (PPE) - When engineering controls, work practices, and administrative controls are infeasible or do not provide sufficient protection, employers must provide appropriate personal protective equipment (PPE) and ensure its proper use. PPE is worn to minimize exposure to a variety of workplace hazards. PPE can include protection for eyes, face, head, and extremities. Gowns, face shields, gloves, and respirators (addressed in Section 7) are examples of commonly used PPE within healthcare facilities.
Employers must conduct a workplace hazard assessment to determine if hazards are present that necessitate the use of PPE. The employer must verify that the required workplace hazard assessment has been performed through a written certification that identifies the workplace evaluated; the person certifying that the evaluation has been performed; the date(s) of the hazard assessment; and, which identifies the document as a certification of hazard assessment. Based on the hazard assessment, employers are to select PPE that will protect employees from the identified hazards. Employees are to receive training to ensure that they understand the hazards present, the necessity of the PPE, and its limitations. In addition, they must learn how to properly put on, take off, adjust, and wear PPE. Finally, employees must understand the proper care, maintenance, and disposal of PPE.

Gloves - Gloves should be made of latex, vinyl, nitrile, or other synthetic materials as appropriate, when there is contact with blood and other bodily fluids, including respiratory secretions.

• There is no need to double-glove.
• Gloves should be removed and discarded after patient care.
• Gloves should not be washed or reused.
• Hand hygiene should be done after glove removal.

Goggles and Face Protection - Goggles or face shields for routine contact with patients is not necessary; however, if sprays or splatters of infectious material are likely, goggles or a face shield should be worn as recommended for standard precautions.

Gowns -

• Healthcare workers should wear an isolation gown when it is anticipated that soiling of clothes or uniform with blood or other bodily fluids, including respiratory secretions, may occur. Examples of when a gown may be needed include procedures such as intubation or when closely holding a pediatric patient.

• Isolation gowns can be disposable and made of synthetic material or reusable and made of washable cloth.
• Gowns should be the appropriate size to fully cover the areas requiring protection.
• After patient care is performed, the gown should be removed and placed in a laundry receptacle or waste container, as appropriate. Hand hygiene should follow.

3. Universal Precautions - Standard precautions are designed for the care of all patients, regardless of their diagnosis or presumed infection status. Transmission-based precautions are used for patients known or suspected to be infected or colonized with epidemiologically important pathogens that can be transmitted by airborne, droplet, or contact transmission (See Section 6). Standard precautions and transmission-based precautions can be applied to all healthcare settings, including Adult Homes, Home Care and Long Term Care facilities.

Standard Precautions - Standard precautions should be used for all patients receiving care, regardless of their diagnosis or presumed infection status. Standard precautions apply to (1) blood; (2) all body fluids, secretions, and excretions except sweat, regardless of whether or not they contain visible blood; (3) non-intact skin; and (4) mucous membranes. Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in healthcare settings.
A risk assessment to determine necessary PPE and work practices to avoid contact with blood, body fluids, excretions, and secretions will help to customize standard precautions to the healthcare setting of interest. Standard precautions include:

• The use of gloves and facial (nose, mouth, and eye) protection by healthcare workers when providing care to coughing/sneezing patients.
• Hand hygiene before and after patient contact, and after removing gloves or other PPE. Routine hand hygiene is performed either by using an alcohol-based hand rub (preferably) or by washing hands with soap and water and using a single-use towel for drying hands. If hands are visibly dirty or soiled with blood or other body fluids, or if broken skin might have been exposed to infectious material, healthcare workers should wash their hands thoroughly with soap and water.
• Standard operating procedures to handle and disinfect patient care equipment, patient rooms, and soiled linen; prevent needlestick/sharp injuries; and address environmental cleaning, spills-management, and handling of waste.

Poor compliance with standard precautions among healthcare workers has been well described in the scientific literature. Additionally, it has not been the routine practice of healthcare workers in many healthcare facilities to wear facial protection or to encourage respiratory hygiene among patients.

Contact Precautions - Droplet precautions are indicated for patients known or suspected to have serious illnesses transmitted by large particle droplets, such as seasonal influenza, invasive Haemophilus influenzae type b disease and invasive Neisseria meningitidis. In addition to standard precautions, droplet precautions include the use of a surgical mask when working within 3 feet of the patient and the placement of the patient in a private room or with patients who have an active infection with the same microorganism but with no other infection (cohorting).
Although human seasonal influenza virus is transmitted primarily by contact with infectious droplets, some degree of airborne transmission occurs. Additionally, droplet precautions do not protect healthcare workers from infections resulting from aerosol transmission or during patient care activities that are likely to generate infectious aerosols, such as sputum induction or bronchoscopy.

4. Infection Control - Healthcare administrators should emphasize those aspects of infection control already identified as "weak links" in the chain of infectious precautions- adherence to hand hygiene, consistent and proper use of PPE, and influenza vaccination of healthcare workers. The following section describes factors influencing compliance with infection control measures.

Hand Hygiene Compliance - Although handwashing is well known as a critical factor for infection control, low rates of healthcare worker compliance have been well documented.
Several factors influence adherence to hand hygiene practices, including

• Being a physician or a nursing assistant, rather than a nurse
• Wearing gowns/gloves
• Understaffing and overcrowding
• Handwashing agents that cause irritation and dryness
• Lack of knowledge of guidelines
• Perceived lack of institutional priority for hand hygiene

It is important to recognize that healthcare workers report compliance with hand hygiene recommendations despite observations to the contrary. Recognition of the factors that influence compliance to hand hygiene practices is important in order to enable healthcare employers to prioritize and customize compliance strategies. These strategies should be implemented to promote hand hygiene and may include staff education, reminders in the workplace and routine observation and feedback.

Organizational Factors that Affect Adherence to Infection Control - Lessons from the SARS outbreak showed that the most important factors affecting healthcare worker perceptions of risk and adherence to infection control practices were healthcare workers' perception that their facilities had clear policies and protocols, having adequate training in infection control procedures, and having specialists available.
In a study among healthcare workers it was found that employees who perceived a strong commitment to safety at their workplace were over 2.5 times more likely to comply with universal precautions. The safety climate in a facility and regard for adhering to it, was found to have the greatest association with proper infection control behaviors of the staff.
A good safety climate includes:

• Senior management support for safety programs
• Absence of workplace barriers to safe work practices
• Cleanliness and orderliness of the worksite
• Minimal conflict and good communications among staff
• Frequent safety-related feedback and training by supervisors
• Availability of PPE and engineering controls

5. Bloodborne Pathogens (1910.1030)- OSHA's Bloodborne Pathogens standard is a regulation that protects employees against health hazards related to the occupational exposure to blood-borne pathogens, including Hepatitis B, Hepatitis C, and HIV/AIDS. The standard applies to any employee who is occupationally exposed to human blood or certain other potentially infectious materials (e.g., pleural fluid, any body fluids visibly contaminated with blood, any unfixed human tissue or organ). The Bloodborne Pathogens standard has provisions requiring exposure control plans, engineering and work practice controls, PPE, hepatitis B vaccination, hazard communication, training, and recordkeeping. Each facility must have an Exposure Control Plan that includes:

• Determination of employee exposure,
• Implementation of various methods of exposure control, including:
  - Universal precautions
  - Engineering and work practice controls
  - Personal protective equipment
  - Housekeeping
• Hepatitis B vaccination
• Post-exposure evaluation and follow-up
• Communication of hazards to employees and training
• Recordkeeping
• Procedures for evaluating circumstances surrounding exposure incidents

6. Safe Patient Handling -

• administering medications,
• turning and lifting residents,
• changing linens and clothing, and
• transferring residents to chairs and other devices.

7. Respiratory Diseases

• Droplet Transmission (Seasonal Influenza) - Susceptible individuals are subject to infection by large particle droplets from infected patients. Droplets are produced by coughing, sneezing, or talking, or by therapeutic manipulations such as suctioning or bronchoscopy. Infected droplets may enter the susceptible individual through the conjunctiva of the eye or the mucus membranes of the mouth or nose. Droplets travel only about 3 feet and do not remain in the air, so special ventilation procedures and advanced respiratory protection is not required to prevent this type of transmission.
• Aerosol (Airborne) Transmission (Tuberculosis) - Airborne transmission, as occurs in tuberculosis, is spread through small infectious particles such as droplet nuclei. Unlike the larger droplets, these very small airborne droplet nuclei can be readily disseminated by air currents to susceptible individuals. They can travel significant distances and can penetrate deep into the lung to the alveoli where they can establish an infection.

• Airborne Precautions are designed to reduce the risk of airborne transmission of infectious agents. In addition to standard precautions, airborne precautions are used for patients known or suspected to have serious illnesses. Current clinical guidelines recommend that airborne precautions be used for such illnesses as H5N1 avian influenza, severe acute respiratory syndrome (SARS), measles, varicella, and tuberculosis.

◦Airborne precautions include: