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A surprise visit from OSHA.

A surprise visit from OSHA

OSHA's here!" No two words could have a more chilling effect on a lab manager. That's certainly how I felt when I heard them on Oct. 25, 1988.

A technologist had filed a complaint with the Occupational Safety and Health Administration a couple of months earlier. Now this division of the U.S. Department of Labor was on our doorstep to investigate the lab's alleged safety and health hazards.

AtlantiCare Medical Center is a two-campus, 300-bed tertiary trauma center located on Boston's North Shore. I had signed on as lab manager just three months earlier and was still in the process of orienting myself. That unusually hot summer was overwhelming the hospital's cooling system. On one occassion, an analyzer had refused to run when the temperature in an isolated corner of the lab hit 90 F. The extremely elevated ambient temperature had caused the instrument to fail.

Working conditions continued to deteriorate. The blood storage refrigerator alarm began to blare intermittently as its internal temperature climbed. The technologists weren't happy, either. One day they arrived at work in shorts to protest. In an attempt to make the workplace more tolerable, we brought in several area fans. This was a major mistake.

The searing summer heat persisted; tempers flared; and a frustrated technologist - acting as spokesperson - placed the infamous call to OSHA. (The staff later acknowledged that it was nothing personal but merely a desperate attempt to alleviate intolerable conditions.)

That's how I came to hold in my hands a notice citing violations such as the use of area fans, which "blew blood and blood products" on lab workers. Other allegations included our failure to designate "clean areas" by labeling keyboards and telephones for "contaminated" and "non-contaminated" use, to enforce handwashing rules, to provide sufficient eye protection, and to document adequately the hospital's formal training programs in universal precautions and hazard communication.

If that weren't bad enough, the two OSHA investigators informed us that they had the authority to review the safety status of the entire hospital - and fully intended to do so. AtlantiCare was to have the dubious honor of being the first hospital in the commonwealth of Massachusetts to undergo such a thorough inspection. The entire process would take five months to complete. Our two inspectors would see it all the way through.

The OSHA team began right away with employee interviews. The investigators intended to question supervisory and technical staff members at separate times and locations. I was asked to deliver six non-supervisory "volunteers." I quickly reviewed the day's work assignments and pulled two technologists, two technicians, and two phlebotomists from workstations, creating absences that would cause the least disruption to the lab.

Participants were told they had the right to refuse to answer any questions. Union laboratorians were advised to have a union representative on hand during questioning.

When the supervisors were interviewed, as a group, management and administrative personnel were permitted to attend. I sat in, along with the lab's pathologist director and the director of human resources, who also served as the official OSHA escort. The technical staff was questioned (en masse) behind closed doors.

The initial focus of the supervisors' sessions was the extent of their ability to train staff members properly. All were questioned at length about their familiarity with Material Safety Data Sheets (MSDS), hazard communication, and infection control policies. They were also asked about their professional training and about any continuing education they had taken that qualified them to train others. The inspectors tested our supervisors' knowledge of the Hazard Communication Standard and an employee's right to know.

The inquisition then turned to infection control. The supervisors were asked when the hospital's universal precautions policy took effect and how this information was passed along to the staff. The investigators asked to see documentation that appropriate training had actually taken place.

Next, the supervisors were quizzed on waste disposal. The OSHA team wanted to assess the consistency of the supervisors' knowledge of our institution's infection control policy. Did the supervisors clearly understand, for example, which items were "red bagged" (as infectious waste) versus "brown bagged" (as non-infectious waste)?

Finally, there was the matter of adequate ventilation. Ironically, the original problem had been resolved months before, in August, when we had installed a new airconditioning system.

I spent a great deal of "quality time" with the OSHA team members. They posed endless questions about our policies, perused our safety manual, asked how we shared important lab information with the staff, and requested mountains of documentation.

Part of the OSHA strategy was to see whether our rank-and-file laboratorians actually knew what management claimed to have told them. Sometimes our perceptions jibed; often, they did not. For example, I knew the lab encouraged staff members to be inoculated with hepatitis B vaccine. Yet they told OSHA we had never discussed it. I think these staff members had simply forgotten. Unfortunately, we lacked the proper documentation and thus were docked for having failed to do something we had actually done.

The remainder of the OSHA investigation that day dealt with bloodborne diseases. Since OSHA had not yet developed its own regulations, the inspectors relied on CDC guidelines for universal precautions. (OSHA published instructional guidelines regarding occupational exposure to HBV and HIV, in August 1988,(1) and proposed regulations, in May 1989.(2) Final regulations have not yet been issued.)

Acting on the CDC guidelines, the OSHA inspectors made recommendations. To begin with, we would have to designate telephones, keyboards, desks, and doorknobs as non-contaminated zones and ban gloves and specimens from these areas. The goal was clearly to eliminate cross-contamination in the workplace.

The supervisors' interview concluded with a barrage of unrelated questions: Were gloves readily available? Was their quality acceptable? Did the lab have a written policy detailing when phlebotomists must wear gloves? Did any bacteriology procedures require a hood? Should blood bankers wear eye protection when cutting segments?

These queries seemed to point to a certain lack of savvy about the laboratory. My suspicions were later confirmed when I learned that the inspectors had visited only one other lab and that we represented their first hospitalwide assignment.

To verify our supervisors' comments on infection control and follow-up, the inspection team subsequently interviewed a phlebotomist who had once reported an accidental needlestick. OSHA asked how it had happened, what he had been instructed to do immediately afterward, and how the hospital had followed up. The team wanted to ascertain whether our employee health department had tried to identify the source patient and to secure his or her consent for HBV and HIV testing. Last, the OSHA inspectors asked the phlebotomist whether he had been told about the hepatitis vaccine and had been encouraged to receive it.

The point of all this questioning was to see whether proper infection control training had taken place. If the phlebotomist had known nothing about the vaccine, the inspectors would have assumed there had been no training at all. He said there hadn't; we knew there had, but again had no documentation to prove it. Needless to say, prudent record keeping is essential to protect employers in such cases. Unfortunately, many individuals forget even the existence of training programs shortly after attending them.

The investigators moved on to histology, where formalin is poured for sectioning the surgical path specimens. OSHA wanted to know how much formalin was used, where it was used, and how large the containers were. They asked one of our two histotechnologists whether she knew the symptoms of acute and chronic exposure and how she would clean up an accidental spill. The team reviewed our documentation of employee training for pouring and tested our ability to produce formalin MSDS on demand.

The exhaustive two-campus inspection spanned nearly six months. The inspectors returned to the hospital periodically to assess the other departments and dropped in on the lab once or twice. At the summation meeting last March, the inspectors finally shared their findings, including the probable citations. There were a few surprises.

We learned, for example, that centrifuges were considered reusable equipment and we therefore had to keep the paperwork documenting scheduled cleaning and sterilization on hand. This revelation fostered a lengthy debate on the classification of equipment as reusable. OSHA won the debate.

Gloves were deemed mandatory for handling blood and other body fluids but not for routine phlebotomy. The phlebotomists, we were told, should have a list noting the few occassions when gloves are considered mandatory for specimen procurement. These exceptions might typically include the presence of cuts, scratches, or other breaks on the phlebotomist's skin; draws on uncooperative patients; the need to perform finger or heel sticks on infants and children; and on-the-job phlebotomy training. (Incidentally, with regard to venipuncture, employers can be cited only if they fail to supply gloves or if they discourage their use under such "special" circumstances.)

I find the rationale behind this mandate extremely curious. Basically, OSHA says gloves are not necessary when procuring a specimen but must be worn when processing blood and other body fluids. As soon as a patient's blood is removed from the evacuated tube, it graduates to specimen status - and the person holding it must be gloved. Such questionable distinctions must be addressed.

The inspectors reiterated the need to eliminate the possibility of contamination transfer by laboratorians who use telephones and computer terminals while wearing soiled gloves. OSHA suggested that we clearly identify equipment as "clean" or "contaminated" and strictly enforce a ban on cross-contamination. (Everything in our lab - including my office door - is now duly labeled.)

The histology department garnered two citations. The first stated that we had to develop an emergency procedure for cleaning accidental formalin spills, including a cutoff volume limit above which we would notify the fire department. We were also cited for deficient documentation of training lab personnel in the proper handling of formalin.

We were told that the Code of Federal Regulations, Title 29, offers a detailed description of what must be incorporated into a formalin training procedure. This code requires that all records related to training personnel and monitoring formalin levels be kept for 30 years following an employee's termination of service. Having learned the hard way, I strongly recommend consulting a copy of this part of the code before implementing any training or emergency spill plan.

The OSHA citations arrived nearly six months after the initial investigation. The paperwork specified the standards or regulations that had been violated and noted the site of the violation. It also listed the abatement dates and monetary penalties for failure to comply. Employers have the right to object to any abatement date believed to be unreasonable. This didn't apply in our case, since we had already corrected virtually all of the deficiencies.

The law requires that copies of all citations be posted immediately and prominently - at or near the site of the infraction. The citation must remain posted until the violations have been corrected, or for at least three working days. Acting on the information presented at the summation conference, we began to make amends immediately and were in good shape by the time the official citations arrived. In some cases, compliance was merely a matter of ordering a case of goggles or absorbent pads for cleaning up spills.

Throughout our six-month acquaintance, I had several opportunities to discuss OSHA objectives and philosophies with the investigators. Although these people were not experts on how labs run, they were well read and reasonably knowledgeable about the laboratory's function. In retrospect, I think the investigation was often a mutual learning experience.

I do take issue with the investigators' deliberate separation of management and staff. This made us feel that OSHA was there to represent the rights of only the technical and support staff. The inspectors seemed unconcerned about the safety and general rights of management. OSHA should address the situations or attitudes that led us to this perception.

While OSHA's intentions are good, its bureaucratic approach can be frustrating. For example, the inspectors kept belaboring us about the "poor" quality of our gloves. The problem: Adhesive labels stuck to the gloves and inevitably tore them. We tried brand after brand of gloves to no avail but could not convince OSHA that they couldn't all be defective. We finally solved the problem by switching to a different brand of labels.

Having survived an OSHA inspection, my institution has painfully acquired the wisdom that documentation is everything. All efforts related to equipment maintenance, employee training, hazard communication, and infection control education must be carefully planned, written, implemented, and documented. A record of every phase of training must be filed and updated annually. Employees must sign and date all records.

The additional work and expense are considerable, but necessary. Today our lab provides the entire staff with a safer working environment than before. Our duty and our goal are to maintain this hard-won condition. (1.) Enforcement procedures for occupational exposure to hepatitis B virus (HBV) and human immunodeficiency virus (HIV). Washington, D.C., OSHA Instruction CPL 2-2.44A, Aug. 15, 1988. (2.) Occupational exposure to bloodborne pathogens (OSHA proposed regulations). Washington, D.C., Federal Register, Vol. 54, No. 102, May 30, 1989, pp. 23041-23139.

General references:

Code of Federal Regulations, Title 29, Parts 1900-1910. Washington, D.C., U.S. Government Printing Office, 1988.

Rules and Regulations. Hepatitis B virus and human immunodeficiency virus (HIV or AIDS); occupational exposure. Washington, D.C., Federal Register, Vol. 52, No. 233, Dec. 4, 1987, p. 45438 ff.
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Title Annotation:Occupational Safety and Health Administration
Author:Daigneault, Robert
Publication:Medical Laboratory Observer
Date:Jan 1, 1990
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