Occupational Safety and Health

A hospital is not necessarily a safer environment than the general community. The major causes of staff injury in the hospital are sharps injury, slips and falls, sprains and crush injuries. During epidemics, health care workers may be at higher risk of becoming infected than the general communit.

Reporting of injuries

Because of the medical culture of not reporting injuries, problems affecting the health of doctors may not be addressed due to a lack of evidence that they are occurring. Staff should follow the relevant reporting procedure if they are injured whilst at work.

Infectious hazards

In general the pathogens of greatest concern to medical staff are blood borne and respiratory pathogens.

Blood borne pathogens

Blood borne pathogens (including viruses, bacteria, fungi, rickettsiae, protozoa and probably prions) can be transmitted via:

• sharps injuries
• mucosal exposure
• skin contact - mostly a problem if the skin integrity is impaired, for example by dermatitis.

Sharps injury

The most dangerous sharps injuries are those in which a large amount of heavily infectious blood is injected. In general this involves deep injuries with hollow core needles with an attached reservoir of blood, such as IV cannula trochars and needles used in blood taking. Injuries from scalpels also appear to be relatively high risk. Suture needle injuries inject a lower volume of blood, and as such carry a lower risk of transmission.

Although the risk of HIV transmission is low, there is a substantial risk of transmission of both hepatitis B and C.

To minimize the risk of needle-stick injury:

• Sharps should be disposed of in rigid sharps bins. With the exception of areas where there are protocols for checking and disposal of sharps (eg the operating theatre) it is the responsibility of the user of the sharps to dispose of them safely
• Bring the sharps bin to the point at which the sharps are used
• Avoid picking up used sharps with your hands if possible
• Avoid disconnecting used sharps from used syringes with your hands
• Double glove whilst suturing and use blunt taper suture needles
• Use safety cannulae for intravenous access

Mucosal exposure

HIV, Hepatitis B and C have all been transmitted after mucosal splash. Conjunctival splash is surprisingly common during many surgical procedures. Measures which might be expected to protect against splashes (eg the use of cameras rather than eyepieces in urological surgery and wearing corrective glasses) may not prevent splashes. It is, therefore, important to wear protective eyewear in areas where splash is likely, such as the operating theatre, or when performing invasive procedures.

Skin exposure

Cases of HIV have occurred in health care workers following skin exposure. These may be prevented by the appropriate use of gloves and gowns. Gloves should be worn whenever there is a risk of contact with the patient’s body fluids. Latex gloves are perforated at least 10% of the time, so hands must be washed after removal of gloves.

Management of exposure to blood

Initial management is outlined in table 1. Staff should report the injury to their supervisor (filling out an Injury on Duty form) and then report to the A&E department.

Post exposure prophylaxis is available for hepatitis B and HIV. If prophylaxis is indicated it should be given as soon as possible and not later than 24 h.

Occupational dermatitis

Occupational dermatitis increases the risk of transmission of blood borne pathogens through the damaged skin. The risk of developing occupational dermatitis can be reduced by washing all of the soap off when washing hands, drying hands thoroughly before putting on gloves, and the use of a moisturiser.

Latex allergy develops in a substantial proportion of staff. There are two forms:

• Contact dermatitis due to the accelerants used in the latex curing process. Often resolves with changing the brand of glove, particularly changing to powder free gloves
• IgE mediated reactions to latex proteins. These may include systemic symptoms as well as local rash and itching. Affected staff should use latex free gloves (eg nitrile or neoprene gloves) and be aware that latex particles may be present in the air in areas where large amounts of latex are used, such as the operating theatre. If respiratory symptoms develop, it may be necessary to transfer to a different area of work.

Latex allergy can be prevented by minimising exposure to latex. Therefore, gloves should only be worn when actually contacting an infectious substance, and should be removed immediately when finished. After removal, hands should be washed to remove residual latex particles. These are also good infection control practices.

If latex allergy develops, it should be reported. Skin testing can be performed to detect IgE mediated reactions, although it may give false positive and negative results.

Respiratory pathogens

Most respiratory pathogens are spread by droplets. This usually involves an infected subject coughing onto a surface. The droplets remain infective on the surface for a period of time, during which a second person may touch the surface, and then infect themselves by rubbing the eyes or nose. Some pathogens are spread by the airborne route. When a patient coughs, they bring up small droplets of sputum, which rapidly dry to form droplet nuclei, which can remain suspended in the atmosphere, and are then inhaled.

The primary means of preventing droplet spread is handwashing, and avoiding rubbing the eyes and nose whilst at work. Auxiliary methods include the use of gloves, gowns, eye protection, and some form of mask (table 2).

Negative pressure respirators (eg N95 respirators) require a tight seal to be effective. There is a wide variation between brands in terms of fit. For this reason the wearer should be fit tested to ensure that a particular model of mask is appropriate for them, before using it in a contaminated area. These respirators do not work in the presence of facial hair. Not shaving for more than 24 hours may be enough to cause a significant leak.

Staff who are immunosuppressed or who have had a splenectomy may be at increased risk of contracting respiratory pathogens, including meningococcus.

Chemical hazards

The most common chemical hazards in the hospital are chemical disinfectants and anaesthetic agents.

The common chemical disinfectant hazards likely to be encountered are (Cidex™) and formaldehyde. Glutaraldehyde can cause skin rashes, conjunctival injury, respiratory irritation, and occupational asthma.

Formaldehyde is used as a chemical disinfectant, and also for fixing of specimens in the operating theatre and pathology departments. It has been classified as a known carcinogen, causing squamous cell carcinoma of the nasal cavity. It also causes respiratory and eye irritation.

These hazards are best controlled by changing to different agents, and containment of the agents within fume cabinets or sealed washers. If necessary, chemical respirators are available for use with these chemicals.

It is possible that nitrous oxide may cause problems with fertility and miscarriage, although the evidence is not strong and problems are unlikely to occur in a properly scavenged and ventilated operating theatre. In addition to the operating theatre, nitrous oxide may also be used in the labour ward, the accident and emergency department and the burns unit.

Physical hazards

Slips and falls in the hospital are relatively common, at least partly because hospital floors are commonly wet. Some of these injuries can be serious. Sprains and other soft tissue injuries are also common, and result in prolonged sick leave. Doctors are not immune to this type of injury and should ensure that they comply with good lifting practices.

Electrical hazards

All hospital power outlets should be protected with at least a ground fault interrupter. Care needs to be taken that electrical outlets do not become wet, and that the use of extension boards is minimised.

Fire safety

Fires also occur commonly in hospitals. Fire plans are posted prominently in all areas. It is easier to familiarise oneself with the fire plan electively, rather than to try and read it in a hot and smoke filled environment. The factor most strongly correlated with death in hospital fires is failure to call the fire department early. Therefore, the first action on finding a fire should be to break the glass of the nearest fire alarm.

Physical safety

Hospitals are public places, and not necessarily safer than any other public place. Staff should take precautions appropriate to the area in which their hospital is located.

Doctors have a higher risk of being stalked than the general population and should avoid disclosing personal data. The address given to the Medical Council is freely available. It is advisable not to use one’s home address on such public documents. Other precautions include using an unlisted telephone number, not leaving personal documents lying around, and ensuring that patients are clear about the terms of their relationships.

Other safety issues

Certain departments in the hospital use high-powered lasers, X-ray or gamma ray generating devices. Staff should follow the protocols of these departments to avoid dangerous exposure.

Health issues

Doctors often work in high stress environments with significant sleep deprivation, and do not have enough time to exercise. They are not immune to diseases caused by this type of lifestyle. Sleep deprivation causes mood changes, poor performance on vigilance tasks, and an increase in error rate. Call rosters should be adjusted to minimise this problem.

Some doctor groups are known to engage in chronic verbal abuse of junior medical staff and other health care workers. This is known to

Exercise is known to improve mood, reduce stress, and improve cardiovascular risk. Current guidelines are that everyone should exercise for at least one hour per day.