OSHA PROGRAM. MANUAL for Medical Facilities

Transcription

1 OSHA PROGRAM MANUAL for Medical Facilities About the Author Sheila Dunn, DA, MT (ASCP), holds a doctoral degree in clinical laboratory science from the Catholic University of America in Washington, DC. She has helped thousands of outpatient medical facilities comply with federal regulations such as CLIA and OSHA through her presentations at a nationwide seminar series. She has written more than 150 articles about regulatory issues and healthcare delivery systems and serves as an advisor to numerous companies. 13K HCPro, Inc. 75 Sylvan Street, Suite A-101 Danvers, MA Tel: 800/ Fax: 800/ HCPro, Inc. All rights reserved, including right of reproduction. The author(s) and their agent(s) have made every reasonable effort in the preparation of this publication to ensure the accuracy of the information. However, the information in this book is sold without warranty, either expressed or implied. The authors, the editors, their agents, and the publishers will not be liable for any damages caused or alleged to be caused directly, indirectly, incidentally, or consequentially by the information in this publication. This publication cannot and does not provide specific information for a user s exact situation. Users of this publication should exercise their own judgment and, where appropriate, seek the assistance of legal counsel regarding their particular situation.

2 is published by HCPro, Inc. Copyright 2013 HCPro, Inc. All rights reserved. Printed in the United States of America ISBN: No part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center ( ). Please notify us immediately if you have received an unauthorized copy. HCPro, Inc., provides information resources for the healthcare industry. HCPro, Inc., is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks. Sheila Dunn, DA, MT (ASCP), Author Jay Kumar, Senior Managing Editor Marge McFarlane, PhD, CHSP, CHFM, HEM, MEP, CHEP, Reviewer Mike Mirabello, Senior Graphic Artist Matt Sharpe, Senior Manager of Production Elizabeth Petersen, Vice President Advice given is general. Readers should consult professional counsel for specific legal, ethical, or clinical questions. Arrangements can be made for quantity discounts. For more information, contact: HCPro, Inc. 75 Sylvan Street, Suite A-101 Danvers, MA Telephone: or Fax: customerservice@hcpro.com Visit HCPro online at: and 12/

3 OSHA PROGRAM MANUAL Contents Front Pocket OSHA Poster 3165: IT S THE LAW! Laminated Eyewash Station Sign 4 Sample Biohazard Self-Adhesive Labels CD-ROM (MS Word for Windows 2000) with Master Record Forms (Tab 11) from this Manual for Customization. Introduction Page Important Information About the Use of This Program... i How to Customize This Program... ii What Is Included in This Program... vi TAB 1: What Is OSHA? A Quick Look at OSHA States with OSHA-Approved Plans OSHA Consultative Services Division OSHA s Jurisdiction OSHA s General Duty Clause Employee or Employer? Employers Responsibility Under OSHA Overview of OSHA Standards OSHA Inspections Employee Complaints If an On-site OSHA Inspection Occurs During the Inspection What OSHA Inspectors May Ask Employees The Typical OSHA Inspection The Closing Conference OSHA Sanctions Whistleblower Protection Students and Volunteers ix

4 Contents TAB 2: OSHA Program Administration Injury and Illness Prevention Plan Flowchart... Reverse Side of TOC Injury and Illness Prevention Plan Management Leadership and Employee Involvement Key Contacts for the OSHA Program Manual Location of the OSHA Manual Program Duties of the OSHA Safety Officer Accident/Incident Investigation & Reporting Procedure Definition of an Accident and/or Incident When to Investigate an Accident and/or Incident How to Document an Accident and/or Incident Recording Accidents or Injuries for OSHA Correcting Unsafe or At-Risk Conditions Recordkeeping Requirements Workplace Hazard Analysis Practical Ideas for Involving Employees Organizing OSHA Compliance Duties Weekly Facility Review Checklist Monthly Facility Review Checklist Annual Facility Review Checklist Annual OSHA Safety Program Review TAB 3: General Facility Safety Keeping Employees Safe Important Phone Numbers & Contacts Emergency Phone List Fire Safety Automatic Sprinkler Systems Fire Alarms Fire Procedures: Immediate Actions Building Evacuation Fire Extinguishers Purchase the Right Extinguisher How Many Fire Extinguishers to Have & Where to Put Them To Use a Fire Extinguisher: Think PASS When to Extinguish Fires with a Portable Fire Extinguisher When NOT to Extinguish Fires and to Evacuate Fire Extinguisher Inspections Fire Extinguisher Maintenance Fire Risks During Surgery Fire Extinguisher Supplement... Supplement Fire Drills x

5 Contents Electrical Safety Physical Characteristics of a Safe Medical Facility Automated External Defibrillators Air Quality Mold Mold Remediation Aisles Emergency Lighting Employee Dress Code Exits, Means of Egress Exit Doors Exit Signs Floors Lighting Noise Portable Space Heaters Restricted Access Areas Sinks Storage Systems Failure Evacuation Plan Evacuation Procedures Methods for Carrying Patients During an Evacuation Evacuation Floor Plan Example Evacuation Floor Plan Emergency Preparedness Supplies Emergency Action Procedures Bioterrorism: Suspicious Letters or Packages What Is a Suspicious Package? Bomb Threat If You Discover a Bomb or a Suspicious Item Explosion Civil Disturbance Earthquake If a Tremor Occurs when You Are Inside After the Tremor Is Over Severe Weather Flood Hurricane Severe Thunderstorm or Tornado Warning Tornado Safety Tips Severe Thunderstorm or Tornado Watch Toxic External Atmosphere Violence Violence Prevention Plan Introduction Overview of Violence Prevention Plan Components Violence Prevention Plan; Part xi

6 Contents Violence Prevention Plan; Part More Sources for Prevention of Workplace Violence First Aid Crash Kit/Cart Components Drug-Free Workplace Program Service Animals Holiday Decorations Sample Checklist: Spot Check Your Facility s Holiday Decorations Safe Decorations and Displays Policy Slip, Trip, and Fall Prevention Contaminants on the Floor Poor Drainage: Pipes and Drains Indoor Walking Surface Irregularities Outdoor Walking Surface Irregularities Weather Conditions: Ice and Snow Inadequate Lighting Stairs and Handrails Stepstools and Ladders Tripping Hazards: Clutter, Including Loose Cords, Hoses, Wires, Medical Tubing Improper Use of Floor Mats and Runners Healthcare Facility Slip, Trip, and Fall Hazard Checklist TAB 4: Ergonomics in the Medical Workplace A Quick Look at Ergonomics Common Musculoskeletal Disorders Back Injuries Techniques to Reduce Injury Fatigue Repetitive Stress Injuries/Wrist Injuries Wrist and Hand Exercises Eye Strain Why Prevent CVS? Symptoms of CVS Other Suggestions for Relieving Eye Strain Selecting Equipment TAB 5: Bloodborne Pathogens Exposure Control Plan Exposure Control Plan Introduction Overview of Bloodborne Pathogens Standard Components A Quick Look at Occupational Exposure Industries Subject to the Bloodborne Pathogens Standard xii

7 Contents Interactive Safety Training Exercises General Safety Fire Safety Bloodborne Pathogens Safety Chemical Safety TB Safety Annual Employee Retraining Bloodborne Pathogens Annual Training Contents Respiratory Protection Annual Training Contents Hazard Communication Annual Training Contents New Employee Orientation New Employee OSHA Orientation Checklist (Form 26) Sample Tests with Answer Keys OSHA Annual Retraining: Sample Essay Test Questions (Form 28) OSHA Annual Retraining: Sample Essay Test Answer Key OSHA Annual Retraining: Sample Multiple Choice Test Questions (Form 29) OSHA Annual Retraining: Sample Multiple Choice Test Answer Key OSHA Annual Retraining: Sample True/False Test Questions (Form 30) OSHA Annual Retraining: Sample True/False Test Answer Key Documenting Employee Training Annual Safety Training Record (Form 27) TAB 11: Master Record Forms General Equipment and Facility Records Safety Report...Form 1 Autoclave Log...Form 2 Eyewash Station Weekly Check Log...Form 2-A Annual OSHA Program (Exposure Control Plan) Review...Form 3 Weekly Facility Review Checklist...Form 4-A Monthly Facility Review Checklist...Form 4-B Annual Facility Review Checklist...Form 5 Fire Drill Evaluation Form...Form 5-A Employee Fire Drill Participation Sign-up Sheet...Form 5-B Risk Assessment for Workplace Violence...Form 6 Housekeeping Schedule...Form 7 Emergency Telephone List...Form 7-A Healthcare Facility Slip, Trip, and Fall Hazard Checklist...Form 7-B Bloodborne Pathogens Records Bloodborne Pathogens Exposure Determination List #1...Form 8 Bloodborne Pathogens Exposure Determination List #2...Form 9 Bloodborne Pathogens PPE Compliance Checklist...Form 9-A Failure to Use PPE...Form 9-A-1 Bloodborne Pathogens Compliance Checklist: ECP, Training, and Records...Form 9-B Safety Needle/Syringe Evaluation...Form 10 Phlebotomy Device Evaluation...Form 11 Generic Safety Device Evaluation...Form 12 xix

8 Contents Sharps Disposal Container Locations...Form 12-A Sharps Evaluation Results...Form 13 Exposure Prevention Checklist...Form 13-A Bloodborne Pathogens Employee Medical Records Accident Report/Sharps Injury...Form 14 Sharps Injury Log...Form 14-A HBV Vaccination Declination Form...Form 15 HBV Employee Vaccination Form...Form 16 Post-exposure Checklist...Form 17 Post-exposure Medical Evaluation Declination Form...Form 18 Source Patient Testing Consent Form...Form 18-A Hazard Communication Records Hazardous Substances List...Form 19 TB/Infection Control Records TB Risk Assessment Results Form...Form 20 TST Record...Form 21 TST Declination Form...Form 22 TB Exposure Log...Form 23 Influenza Vaccine Log...Form 24 Influenza Vaccine Declination Form (Seasonal and H1N1)...Form 25-A Checklist for Infection Prevention for Outpatient Settings...Form 25-B List of Infection Prevention Contact Persons and Roles/Responsibilities...Form 25-C Training Records New Employee OSHA Orientation Checklist...Form 26 Annual Employee Training Record...Form 27 OSHA Annual Retraining (Sample Essay Test)...Form 28 OSHA Annual Retraining (Sample Multiple Choice Test)...Form 29 OSHA Annual Retraining (Sample True/False Test)...Form 30 Respiratory Protection Training Record...Form 31 Qualitative Respirator Fit Test Report...Form 31-A Checklist for Decreasing Surgical Fire Risks...Form 32 TAB 12: OSHA Regulations & Key Contacts OSHA Regulations Bloodborne Pathogens Standard Amended Bloodborne Pathogens Standard (Sharps Safety) Hazard Communication Standard Exit Routes, Emergency Action Plans, and Fire Prevention Plans Ionizing Radiation Table of Other OSHA Standards for Outpatient Medical Facilities Additional OSHA Resources Healthcare Worker Vaccination Recommendations (Revised 2011) Suggested Work Restrictions for Employees Key Contacts State OSHA Consultative Services Directory Directory of States with Approved OSHA Plans Acronyms used in the OSHA Program Manual xx

9 TAB 2: OSHA PROGRAM ADMINISTRATION Contents Page Injury & Illness Prevention Plan Flowchart... Reverse Side of TOC Injury & Illness Prevention Plan Management Leadership and Employee Involvement Key Contacts for the OSHA Safety Program Location of the OSHA Manual Program Duties of the OSHA Safety Officer Accident/Incident Investigation & Reporting Procedure Definition of an Accident and/or Incident When to Investigate an Accident and/or Incident How to Document an Accident and/or Incident Recording Accidents or Injuries for OSHA Correcting Unsafe or At-Risk Conditions Recordkeeping Requirements Workplace Hazard Analysis Practical Ideas for Involving Employees Organizing OSHA Compliance Duties Weekly Facility Review Checklist Monthly Facility Review Checklist Annual Facility Review Checklist Annual OSHA Safety Program Review

10 Tab 2: Program Administration Tab 3: General Facility Safety Tab 3: Fire Tab 3: Emergency Tab 10: Employee Training Tab 4: Ergonomics INJURY AND ILLNESS PREVENTION PLAN FOR MEDICAL PRACTICES Safety Plans Tab 5: Bloodborne Pathogens Exposure Control Plan Tab 2: Accident Investigation Tab 2: Recordkeeping Tab 7: Hazardous Chemicals Safety Infection Control Tab 6: Respiratory Pathogens Tab 8: Waste Disposal Tab 8: Instrument & Surface Disinfection

11 for doing this the best part is that they don t cost a penny. Try some or all of them to reduce your real or perceived liability: During staff meetings, encourage employees to bring up any concerns about their safety on the job. Listen to their responses and encourage discussion. When an employee states a concern, show interest and ask for more details. Regardless of whether that concern is high on your priority list or not, address it and resolve either to fix the problem or allay the employee s fears. Bring this OSHA Program Manual for to staff meetings to reinforce the fact that your practice has a tangible program that contains policies to ensure staff safety. Take five minutes at these same meetings to do a safety-related demonstration, such as showing how to remove exam gloves without splashing your colleagues, how to clean up a biohazardous spill, how to locate and read an MSDS (SDS), etc. These short exercises reinforce the commitment to safety. One approach is to have different employees demonstrate a safety topic to their peers each month. Practice evacuation drills for fire, violent behavior, and other emergencies that could potentially occur. After the drill, critique the staff s performance and amend the emergency plan, if necessary. Finally, the ultimate goal of an OSHA Safety Officer should be zero non-compliance and minimal exposure incidents. Make sure that employees know exactly what safety measures to take. Employees should know that using appropriate work practices and wearing appropriate protective gear is not optional. Employees should expect consistent enforcement of safety policies and know what happens if there is non-compliance. Disciplinary actions should be fair and consistent: Follow an unheeded verbal warning with a written warning. If no corrective action follows, take further disciplinary action and/or termination. Organizing OSHA Compliance Duties To help organize a busy OSHA Safety Officer s efforts to get a facility in compliance and keep it there, HCPro, Inc., offers four useful tools: 1. A Weekly Facility Review Checklist (highly recommended). 2. A Monthly Facility Review Checklist (highly recommended). 3. An Annual Facility Review Checklist (highly recommended to assist in the annual assessment of the facility safety program). 4. An Annual OSHA Program Manual Review Form (mandatory and includes the Exposure Control Plan, the Hazard Communications Plan and the Respiratory Protection Plan). These forms are located on the following pages, as well as behind Tab 11: Master Record Forms. These forms document and organize compliance duties. If it is determined that revisions need to be made, the OSHA Safety Officer ensures implementation of the recommendations and makes changes to the OSHA Program Manual. For this purpose, use the Annual OSHA Program Manual Review Form located on the following pages and behind Tab 11: Master Record Forms (Form 3). 2-9

12 WEEKLY FACILITY REVIEW CHECKLIST Mark Yes (Y), No (N), or Not Applicable (NA) for the following OSHA requirements. If you answered No to any question, explain on the reverse of this form. Facility Are all secondary containers, such as spray bottles and chemical bottles, properly labeled and readable? Are all sharps containers filled below the fill line (or 2/3 full) and positioned firmly so that they cannot be casually knocked over? Are biohazard waste bags/storage bins in the proper locations (in every area where blood or OPIM is encountered) and functioning properly? Is the biohazard storage area clean and orderly? Is the autoclave working properly? Are weekly biological indicator test records complete? (Reference Form 2.) Are scavenging systems for waste anesthetic gas (hoses, bags, masks, and connections) inspected for cracks and leaks? Is the eyewash station functioning properly? (Run water for several minutes and disinfect eyepieces; see Tab 8 for details.) Are exit signs visible and illuminated where required? Administration Have hepatitis B vaccinations been made available to unvaccinated new hires with occupational exposure to bloodborne pathogens after training and within 10 working days of initial assignment? Have tuberculin skin tests (TST) been made available to new hires before exposures to patients with TB or within 10 working days of initial assignment? Is the exam/treatment room set-up and clean-up procedure consistently followed? (Reference Form 7.) Date: OSHA Safety Officer: 2-10

13 MONTHLY FACILITY REVIEW CHECKLIST Mark Yes (Y), No (N), or Not Applicable (NA) for the following OSHA requirements. If you answered No to any question, explain on the reverse of this form. Facility Are compressed gas cylinders securely fastened in an upright condition? Are empty or unused gas cylinders capped and properly labeled? Are exit doors free of blockage, clearly marked and unlocked? Are fire extinguishers fully charged, accessible, and in their designated places? Are all floors and carpets dry and free of tripping hazards? Are stored items not stacked higher than 5 feet (unless a stepstool is available), stable, and located more than 3 feet from any heat source? Are PPE (gowns, face shields, gloves, shoe covers, etc.) and respirators (N95s) in the proper location, available in the correct sizes and amounts, and functioning properly? Are hand cleansers available and in the proper locations? Are all chemicals labeled legibly so contents and hazards are clearly identified? Are chemical and biohazard spill kits available and within their expiration date? Are all first aid kit/crash cart components within their expiration dates? Administration Have all new employees completed a New Employee OSHA Orientation checklist? (Reference Form 26.) Is the MSDS binder and the Master Hazardous Substances List up to date, reflecting any new chemicals brought into use this month? (Reference Form 19, MSDS Binder.) Do the Exposure Determination Lists #1 and #2 reflect new employees with occupational exposure? Have employees who left the facility been removed? Have employees whose job duties changed been added/deleted? (Reference Form 8, 9.) Has a new clinical procedure been implemented which requires face, body, or hand protection? If so, has the PPE table (Tab 5) been updated? Date: OSHA Safety Officer: 2-11

14 ANNUAL FACILITY REVIEW CHECKLIST Mark Yes (Y), No (N), or Not Applicable (NA) for the following OSHA requirements. If you answered No to any question, explain in the space provided below or on the reverse of this form. General Facility Safety The OSHA poster, It s the Law (or state equivalent poster) is visible to all employees. Exit doors are free of blockage, clearly marked, and unlocked. Exit signs are properly lit and backup lights/batteries are functioning. If your facility has 10 or more employees, a written evacuation plan/route is posted. Medical equipment cords have grounded 3-pronged plugs. Extension cords are being used properly (not as permanent wiring). Electrical cords are managed to prevent tripping hazards (not placed under rugs or across doorways). Electrical cords are in good condition (no frays, defects, etc.). The fire alarm is in proper working order. An appropriate number of fire extinguishers are present/accessible. The fire extinguishers have been inspected and tagged within the last 12 months and are fully charged. Panic buttons, or public address systems, are in working order. The worksite is maintained in a clean and sanitary condition. Restricted areas (lab, decontamination room, etc.) are designated with signage. Break Room The break area is free of contamination from blood and other potentially infectious materials (OPIM). Employees discard PPE before entering the break area. The break area is free from hazardous chemicals. Check-in/Reception An up-to-date emergency contact list is posted or present. (Reference Form 7-A.) The reception area is free of contamination from blood and OPIMs. Employees discard PPE before entering the reception area. The reception area is free from hazardous chemicals. Administration Area All employees have undergone OSHA annual retraining on bloodborne pathogens, hazard communication, and TB in the last 12 months and this training is documented. (Reference Form 27.) All new employees received initial OSHA training (if not previously trained) or completed a New Employee Orientation Checklist (if previously trained) and this training is documented. (Reference Form 26.) 2-12

15 (Annual Facility Review Checklist, page 2 of 3) Employees are trained on the proper precautions, and how to properly don and use, the PPE necessary for their job duties. (Reference Forms 26, 27) All employees participated in at least one fire drill this year. (Reference Forms 5-A, 5-B) Employees have been trained on how to respond in the event of a fire (R.A.C.E. or A.R.A.C.E.). (Reference Forms 26, 27) Employees have been properly trained on how to use a fire extinguisher (P.A.S.S.)? (Reference Forms 26, 27) All OSHA training records from the last three (3) years are available? (Reference Forms 26, 27) Exposure Determination Lists #1 and #2 document all employees with risk for exposure. (Reference Forms 8, 9) The facility has documented all needlesticks and other sharps injuries which occurred this year using the Accident/Sharps Injury Log? (Reference Form 14 ) All employee accidents, near-misses, injuries and complaints (check Safety Report and Accident/Sharps Injury Logs) were examined for trends. The need to change engineering controls, policies or procedures was evaluated. (Reference Forms 1, 14) In areas where trends were noted above or safer sharps have not yet been implemented frontline employees have evaluated new safety devices for possible future implementation. Evaluations have been documented, and evaluation forms are retained. (Reference Forms 10, 11, 12, 13) Hepatitis B vaccination records (or declination forms) are available for all employees. (Reference Forms 15, 16) Employee post-exposure medical records (for all employees who sustained a needlestick or other BBP or chemical exposure) are complete and located in a confidential area. Records are available from the last 30 years. (Reference Forms 14, 17, 18, 18-A) Engineering controls are functioning effectively (protective shields have not been removed or broken, and all parts are functioning as intended). The Hazardous Substances List contains all hazardous chemicals in the facility (check for new chemicals recently brought into use). (Reference Form 19) MSDS binder(s) are in the proper location (accessible to employees). MSDS are present for all hazardous chemicals in the facility, including fire extinguishing chemicals. (Reference MSDS (SDS) binder) TB skin test (TST) records are on file for all employees. (Reference Forms 22, 23) The annual TB risk assessment has been performed. (Reference Form 21) The contents (type and number of items) of the first aid kit have been reviewed and are considered adequate for emergencies anticipated in the facility. Storage Area Hazardous chemicals are stored properly (e.g., combustibles away from outlets, large volumes of flammables in a flammable cabinet etc.) and are disposed of properly. Chemicals are labeled legibly with contents and hazards clearly identified. Labels match the identity on the corresponding MSDS. (Reference Form 19, MSDS (SDS) binder) Appropriate PPE (gloves, respirators, goggles/face-shields, aprons) is available/ accessible for handling hazardous chemicals. (Reference MSDS (SDS) binder) All items are stored at least 18 inches from the ceiling. 2-13

16 (Annual Facility Review Checklist, page 3 of 3) Exam Rooms/Clinical Areas All eyewash stations are in proper working order. Universal Precautions are used when handling all blood and Other Potentially Infectious Materials (OPIMs). Handwashing facilities (sinks with soap or alcohol gels) are available in all areas where biohazards and patients are encountered. The biohazard symbol/label is used to indicate the potential presence of BBPs for all blood & OPIMs. Contaminated items and regulated waste are placed into approved biohazard bags and containers displaying the biohazard symbol. Biohazard waste bags/storage bins are located in every area where blood or OPIM are encountered and functioning properly (i.e. they seal). PPE (gloves, gowns, masks, goggles/face shields) is in the proper location. It is available in the correct sizes and amounts, and functions properly. Sharps containers are in the proper locations and positioned firmly so that they cannot be knocked over. Sharps containers are replaced as soon as they reach the fill line and not filled past 2/3 full. The most effective engineering controls are available and functioning correctly? (i.e. safety needles, sharps containers, fume hoods, splash shields) Employees decontaminate and clean work surfaces as soon as contaminated and at the end of every shift with an appropriate disinfectant? Cleaning/Decontamination Room PPE (gloves, gowns, masks, goggles/face shields) is in the proper location. It is available in the correct sizes and amounts, and functions properly? Is appropriate PPE (rubber or vinyl gloves, respirators, goggles/face shields, aprons) available and accessible for handling hazardous chemicals in the workplace? Employees decontaminate and clean work surfaces as soon as contaminated and at the end of every shift with an appropriate disinfectant? Chemicals are labeled legibly with contents and hazards clearly identified. Labels match the identity on the corresponding MSDS. (Reference Form 19, MSDS binder) Hazardous chemicals are stored properly (e.g., combustibles away from outlets, large volumes of flammables in an explosion-proof flammable cabinet etc.) and are disposed of properly. Soaking basins or reservoirs used for decontamination of instruments have tight fitting covers to reduce evaporation of hazardous vapors? Comments (explain any No answer): Date: OSHA Safety Officer*: * Note: Also document this annual OSHA Program Manual review on Form

17 ANNUAL OSHA SAFETY PROGRAM (INCLUDES EXPOSURE CONTROL PLAN, HAZARD COMMUNICATION PROGRAM AND RESPIRATORY PROTECTION PLAN) REVIEW Date Reviewed By Page # of Changes Summary of Revisions* *Include evaluations of sharps containers, safety needles and protective equipment 2-15

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19 TAB 4: ERGONOMICS IN THE MEDICAL WORKPLACE Contents Page A Quick Look at Ergonomics Common Musculoskeletal Disorders Back Injuries Techniques to Reduce Injury Fatigue Repetitive Stress Injuries/Wrist Injuries Wrist and Hand Exercises Eye Strain Why Prevent CVS? Symptoms of CVS Other Suggestions for Relieving Eye Strain Selecting Equipment

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21 ERGONOMICS IN THE MEDICAL WORKPLACE A Quick Look at Ergonomics Ergonomics is the science of fitting the job to the worker. Workers who repeat the same motion throughout their workday, or perform their work in an awkward position, or need to use a great deal of force to perform their jobs (e.g., repeatedly lifting heavy objects), are most likely to develop musculoskeletal disorders (MSDs). Ergonomics is the process to design work to the worker to reduce injury and illness so that employees are more comfortable and therefore more productive. Many different tasks are performed in a clinical setting: sitting and standing at different work-stations, computers, and benches using different instruments and equipment using different movements to perform tasks assisting with patient movement and transfer All of these tasks put different demands on our bodies. Some of these demands may lead to strain or injury. Work-related musculoskeletal disorders account for 34% of all lost workday injuries and illnesses, accounting for $15 to $20 billion in workers compensation costs each year. Indirect costs may run as high as $45 to $60 billion. Ergonomics examines the demands put on our bodies and focuses on the safest and most efficient way to perform a task. Ergonomics is dependent on the physical needs and demands of each individual employee such as height as well as arm and leg length. Physical size and shape is important in designing work areas and equipment. Ergonomics minimizes the amount of stress put on our bodies. Work areas should be customized in accordance to the individual employee whenever possible. More importantly than saving employers money, ergonomics keeps employees safe and comfortable in their work environment. Practicing ergonomics can help prevent a serious injury that could be painful, debilitating or permanent. The Occupational Safety and Health Administration (OSHA) currently has no specific standard for ergonomic hazards. Rather OSHA will use the General Duty Clause as a basis for employer citations. Before issuing any citation alleging ergonomic hazards, OSHA will consider the evidence and relevant factors for each case. The basic criteria OSHA will use in deciding whether to cite are those imposed by the General Duty Clause itself: whether there exists an ergonomic hazard, whether that hazard is recognized, 4-1

22 whether the hazard is causing, or is likely to cause, serious physical harm to employees, and whether a feasible means exists to reduce the hazard. State OSHA plans may have adopted specific ergonomic guidelines from various industries. California OSHA (CalOSHA) requires a repetitive motion injury prevention program when at least two employees, performing the same job or work activity, develop repetitive motion injuries, but exempts employers with fewer than ten employees. Many ergonomic-related injuries are avoidable and preventable. Some steps to take toward this goal are to: Review injury and illness records to see where problems have occurred. Interview employees to identify tasks that may be contributing to workplace musculoskeletal disorders. Get input from employees on suggested improvements. Investigate ways to reduce repeated motions, forceful hand exertions, prolonged bending, or working above shoulder height. Common Musculoskeletal Disorders These ergonomic stressors are typically experienced by healthcare workers: Stressor Force Repetition Awkward Postures Vibration Contact Stress Examples Lifting more than 75 pounds at any one time; more than 55 pounds more than 10 times per day; or more than 25 pounds below the knees, above the shoulders, or at arm s length more than 25 times per day. Repeating the same motions every few seconds or repeating a cycle of motions involving the affected body part more than twice per minute for more than two consecutive hours in a workday. Repeatedly raising or working with the hands above the head or the elbows above the shoulders for more than two hours per day. Kneeling or squatting for more than two hours per day. Working with the back, neck or wrists bent or twisted for more than two hours per day. Using vibrating tools or equipment for more than two hours per day. Using the hand or knee as a hammer more than 10 times per hour for more than two hours total per day. 4-2

23 Exposure to these stressors in the workplace can result in a variety of disorders, including muscle strains and tears, ligament sprains, joint and tendon inflammation, pinched nerves, and herniated spinal discs. These MSDs may develop gradually over time or may result from instantaneous events such as a single heavy lift. To identify where and how job requirements exceed the physical capabilities of employees, OSHA suggests doing a worksite analysis. Such an analysis looks at the conditions of the job and the aspects of work activities that result in increased risk to employees. Begin by reviewing illness and injury logs, compensation records, and reports of problems. Have discussions with affected employees, or just walk around your workplace to find tasks that warrant analysis. Another option is to use employee questionnaires or checklists to better identify problems. OSHA suggests using algorithms to train staff about appropriate options or control methods for specified tasks. To create an algorithm, begin by listing the activity with a description explaining the type of equipment or handling methods used and when they are to be used. Provide points to remember to remind users about proper safety and effective use. If your workplace has ergonomic stressors, consider developing controls to minimize them. The stressors most likely to exist in outpatient medical facilities are back injuries, fatigue, repetitive stress injuries/wrist injuries and eye strain. Back Injuries Back injuries are a common occurrence among healthcare workers, especially if patients are moved or lifted. To avoid back injuries in the workplace: 1. Use proper techniques for lifts and transfers: Bend at the hips and knees. Lift with your leg muscles, not your back or arm muscles. Avoid any twisting motion. Never lift a load higher than your waist. Keep the load close to your body. Ask for help when necessary. 2. Provide and use lifting devices when employees are expected to assist patients in ways that could result in ergonomic injuries. OSHA provides guidance on when mechanical means may be necessary (see flowchart next page). 4-3

24 Techniques to Reduce Injury When lifting a box: Photo from CalOSHA. Photo from CalOSHA. Photo from CalOSHA. Incorrect technique when lifting box. Correct technique when lifting a box. Ask for help with heavy lifts. Deciding to use mechanical help when transferring patients: 4-4

25 When assisting a patient: Photo from CalOSHA. Incorrect technique, pulling patient onto exam table. Photo from CalOSHA. Correct way to assist patient onto exam table. When working with medical records: Incorrect to overreach when retrieving patient records. Incorrect, record too large and cumbersome. Photo from CalOSHA. Photo from CalOSHA. Correct, use a step stool to get to records easily. Correct, split large records into smaller, more manageable volumes. Photo from CalOSHA. Photo from CalOSHA. Fatigue Because of the sedentary nature of computer tasks, employees often get fatigued. Sitting too long can cause neck and back pain. Circulation problems can occur in the legs. 4-5

26 To avoid fatigue: 1. Take breaks for a few minutes each day, stretching and moving about the office. 2. Engage in exercises like these, right at the desk: Deep breathing Head rotations Shoulder rolls Stretches Elbow presses Repetitive Stress Injuries/Wrist Injuries Carpal Tunnel Syndrome (CTS) from prolonged computer use is becoming one of the most common employee medical problems. Claims for CTS have been increasing by 50% annually. The following safety tips and guidelines can help prevent employees from developing injuries due to repetitive stress: 1. Adjust chairs to a comfortable height for computer work. 2. Keep the height and angle of the keyboard at a comfortable level for wrists and hands. Elbow height is best. 3. Keep wrists moderately straight and relaxed whenever possible. 4. Use wrist pads across the bottom of the keyboard. 5. Take a break to do some wrist and hand exercises (below) that will prevent CTS. Wrist and Hand Exercises There are many exercises that can be performed in your work area to increase the circulation in your muscles. Pain and stiffness comes from sitting still or working in one position for an extended period of time. A. While standing straight extend both arms out in front of you. Extend your wrists and fingers acutely as if they were in a hand-stand position. Hold this position for 5 seconds. 4-6

27 B. Next, keeping your arms extended in front of your body, flatten your wrists and relax your fingers so they droop towards the ground. C. Keeping your arms extended in front of your body and your wrists straight make a fist and squeeze it tightly. Hold for 5 seconds. D. Keeping your arms extended in front of your body and your fists tightly clenched, bend your wrists down towards the ground. Hold the position for 5 seconds. E. Straighten both wrists and relax your fingers once again so they droop towards the ground. F. Repeat steps A-E 10 times, then while standing relax your arms, wrists and hands, letting them fall to your sides. 4-7

28 Eye Strain Computer Vision Syndrome (CVS) is the most common repetitive stress injury brought about by video display terminal (VDT) work, despite the fact that it is not as well known as some other computer-related conditions such as carpal tunnel syndrome. According to NIOSH, nearly 80% of those working at a computer for more than two hours a day suffer from the symptoms of CVS. But while less than one in four regular computer users suffer from carpal tunnel syndrome, three times as many experience CVS. Why Prevent CVS Workers with computer-related vision problems are usually less efficient on the job and experience higher error rates as the day goes on. The Journal of the American Optometric Association reports that just a small amount of visual interference, such as glare, causes a reduction in employee efficiency of 4% to 19%. Poor contrast, poor resolution, glare and reflections on the screen can all exacerbate CVS symptoms. Symptoms of CVS Tired, burning, itching eyes. Dry eyes or watery eyes or both. Headaches. Double vision and after-images. Sensitivity to light. Pain in the eyes. Development of excessive blinking or squinting. The following problems are characteristic of working in front of computer screens: Problem: Reflections from surrounding light sources. Glare from lights reflecting off the screen lowers the contrast, thus forcing the eyes to work harder. Solutions: Typical office lighting is twice as bright as the optimal lighting conditions for computer work. Workstation lighting should be shaded to avoid reflections on the monitor. Use a glare reduction filter approved by the American Optometric Association. Problem: Unclear or flickering images on VDT screen. Solutions: Select monitors with higher hertz, or frequency. These have a lower amount of perceptible flickering. A monitor with a higher pixel (at least 110 pixels per inch) has better resolution and readability. Problem: Continuous, uninterrupted activity at a computer station. This causes the eyes focusing mechanisms to tire. Solutions: Proper eyeglass prescriptions. Take frequent breaks at least 10 minutes every hour. Problem: Focal distance is farther than normal reading distance. People normally hold reading materials 12 to 18 inches from their eyes. Eye doctors typically prescribe reading or near vision prescriptions for that range, but computer screens are usually situated 18 to 30 inches from the user (see Figure 4-1, next page). 4-8

29 Solutions: Move screen closer. Get a special lens prescription to focus clearly at these distances for extended periods. Problem: Screen height. For wearers of bifocals and trifocals, the prescription for close tasks is set into the lower portion of the lens, but VDTs are set relatively high, near eye level or higher. Solutions: Bifocal and trifocal wearers may require special lenses to function effectively at computers. Adjust computer screens 5 to 20 degrees below eye level for these users (see Figure 4-1, below). Other Suggestions for Relieving Eye Strain 1. Consciously increase your blink rate while using the computer. 2. Position the computer screen directly in front of you, slightly below eye level. Routinely clean the screen to eliminate dust that can dim the display. 3. Arrange your workstation to keep your eyes at a natural focusing distance from the screen, 18 to 30 inches (see Figure 4-1, below). 4. Reduce intense color contrasts between the background and printed text. 5. Get a larger computer monitor. 6. Arrange reference material close to your monitor and at the same level to reduce the amount of refocusing. 7. Exercise your eyes by rolling them clockwise then counter clockwise. Blink frequently. Palm (massage) your eye area. Figure

30 Selecting Equipment One of the largest factors to keep in mind when purchasing equipment is: Is it adjustable? Money thought to be saved up-front by purchasing cheaper items often creates additional expenses later on due to extra purchases needed to make nonadjustable equipment/furniture fit the next user. Carts Carts are helpful as they reduce physical stress when moving medications, cleaning supplies, equipment, and maintenance tools. Position items on the cart to keep the most frequently used and heavy items within easy reach between hip and shoulder height. Carts should have full-bearing wheels of a material designed for the floor surface in your facility. Cart handles that are vertical, with some horizontal adjustability will allow all employees to push at elbow height and shoulder width. Carts should have locking wheels. Handles that can swing out of the way may be useful for saving space or reducing reach. Heavy carts should have brakes. Balance loads and keep loads under cart weight restrictions. Ensure stack height does not block vision. Low profile medication carts with easy-open side drawers are recommended to accommodate hand height of shorter users. Chairs Consider having vendors provide a trial period for all new chairs of at least one week. Have vendors provide a documented ergonomic assessment listing the anthropometric data (i.e. lower leg length, hip to knee length, seated width, upper torso height, and elbow height) while seated of the user and use these measurements to select a chair that will adjust to meet the users needs. All chairs should meet following guidelines: Have five replaceable casters. Be height adjustable with a single hand movement. Have a height adjustable back with lumbar support. Have an adjustable seat pan depth. Use breathable, cleanable fabric. Have moderate density foam cushioning with a waterfall front edge. (Seats with low-density foam will break down quicker and require re foaming or replacement sooner than a moderate to high-density foam cushion) 4-10

31 If a chair is purchased with arms, consider adjustable arms (both horizontally & vertically) as well as the ability for the arms to be removed if necessary. Consider specialty chairs for ultrasound technicians and others whose tasks require prolonged forward leaning postures. Desks and Work Stations Some considerations for desks and workstations are: 1. Is it adjustable? Workstations should have the ability to adjust up or down. 2. Does the job require work to be performed in a seated as well as a standing position? If so, seek a seated to standing workstation. The acceptable range for work surface height in a seated position: 5 10 cm above elbow height for precision work (i.e. drawing up meds, pipetting). At elbow height for most writing tasks and general office work. No more than 5 cm below the elbows for coarse work (pre-cleaning instruments). The acceptable range for work surface height in a standing position: 10 cm above elbow height for precision work. At elbow height for general office work. 10 cm below elbow height for heavy work. Footrests Footrests should be used if the user s feet do not touch the floor (flat footed) when seated at the workstation. Legs, if allowed to dangle unsupported from the front edge of the seat, will place static pressure on the thighs causing eventual discomfort. The opposite (knees too high) can also place static pressure on the leg muscles causing discomfort as well. Footrest should be large enough to support both feet at a height that allows the knees to be positioned approximately equal to 90 degrees while seated. Keyboard Trays Seek a vendor that offers a free change service if at a later date the keyboard tray needs to be changed due to a different user or setup. Desirable characteristics for keyboard trays: Height adjustable. Articulating (rotate 360 degrees). 4-11

32 Allow for positive and negative tilt. Capable of being locked in place. Operate on ball bearing slides. Sized to support the keyboard and mouse as desired by the user. Large enough to accept a wrist rest. Mobile Medical Equipment Use small cylinders with handles for medical gases (i.e. oxygen tanks) to reduce weight and allow for easier gripping. Secure oxygen tanks to transport devices. Use stands on wheels for medication pumps. Push equipment, rather than pull, when possible. Keep arms close to the body and push with whole body and not just arms. Remove unnecessary objects to minimize weight. Avoid obstacles that could cause abrupt stops. Place equipment on a rolling device if possible. Perform routine maintenance on all equipment. Take defective equipment out of service. Ensure that if transporting patients, additional equipment such as oxygen tanks and IV/ medication poles are attached to wheelchairs or gurneys or moved by another person to avoid awkwardly pushing with one hand and holding freestanding equipment with the other hand. Monitor Stands and Arms Monitors need to be positioned in front of the user while typing. Ask the questions below before selecting a monitor-positioning device. Ensure the item adequately addresses all that apply. At what height does the monitor need to be placed for the user? Does the user wear multi-prescription glasses (bi or tri focal or reading)? Where will the monitor be placed? Does it need to be moved frequently? Does the monitor need to hang over the back of the desk (space issue)? Are there multiple users using the computer? Does the monitor need to be swiveled/ rotated while on the stand? 4-12

33 Monitor devices need to have the following features: Support the weight and size of a large monitor (40 pounds). Allow for quick and easy adjustment. Secure with a clamp, or rest on the desk surface (avoid screw mounted and wall mounted devices if damage left behind when repositioning is required is a concern). Fixed monitor devices can be used but keep in mind that they may not adjust to the proper height for the next user. Avoid monitor arms, rests or stands that require the insertion of spacers or additional pieces, which can be lost. Personal Protective Equipment Exam gloves, masks, eye protection and fluid resistant gowns should be offered in various sizes to fit the workers assigned tasks for which these types of PPE are required. X-ray technicians and others who wear lead aprons for extended periods (the majority of their day) may experience prolonged stress on the shoulders and spine. In this situation consider lighter aprons, lead-free options, and PPE that is sized as opposed to one size fits all. The amount of strain reported by employees is greatly reduced when the lead apron fits closely to the employee s body. Sinks Choose sinks that prevent excessive bending and reaching during cleaning tasks. Modify a deep sink when it s needed for cleaning small items by placing an object, such as a plastic basin, in the bottom of the sink to raise the work surface. Note: if this method is used when cleaning objects contaminated with bloodborne pathogens, the bin needs to be decontaminated with a hospital level disinfectant. 4-13

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35 TAB 10: EMPLOYEE TRAINING Contents Page A Quick Look at the Employee Training Program Training Format Checklist for an Effective Safety Training Session Interactive Safety Training Exercises General Safety Fire Safety Bloodborne Pathogens Safety Chemical Safety TB Safety Annual Employee Retraining Bloodborne Pathogens Annual Training Contents Respiratory Protection Annual Training Contents Hazard Communication Annual Training Contents New Employee Orientation New Employee OSHA Orientation Checklist (Form 26) Sample Tests with Answer Keys OSHA Annual Retraining: Sample Essay Test Questions (Form 28) OSHA Annual Retraining: Sample Essay Test Answer Key OSHA Annual Retraining: Sample Multiple Choice Test Questions (Form 29) OSHA Annual Retraining: Sample Multiple Choice Test Answer Key OSHA Annual Retraining: Sample True/False Test Questions (Form 30) OSHA Annual Retraining: Sample True/False Test Answer Key Documenting Employee Training Annual Employee Training Record (Form 27)