OSHA Compliance in the Ophthalmic ASC

By Jolynn Dobson Cook, RN, COE, CASC

While we busy ourselves with preparations for the annual state licensing survey, Medicare surveys or accreditation surveys, we should plan a yearly review to check where the ASC stands in regard to Occupational Safety & Health Administration (OSHA) compliance. As medical directors or managers, with multiple responsibilities, it's easy to keep the OSHA manual sitting on the shelf. After all, what are the chances of an OSHA inspector stopping by? We do a great job and are compliant with the OSHA regulations that pertain to our ASC — or are we? If it's been a while since you took a real look at your OSHA manual and safety policies, it would be a beneficial exercise to carve out time to do so.

Your best option, particularly with OSHA, is to be prepared. Let's start with some basic questions to see how your ASC measures up:

1. When did your team last sit down and conduct a sharps safety review and document how you evaluated and selected sharps devices (needles, scalpels, butterfly or winged needles, angiocaths, and so on)? If you've done this, did you document it? If so, how and where is the documentation? Did you train staff members on how to properly use new sharps? Is the training documented?

2. What would you do if an employee sustained an injury with a contaminated sharp? Where would he go to receive medical care and more importantly, the professional counseling that follows?

3. Do you know what steps to take if the employee tests positive for a disease caused by a bloodborne pathogen?

4. Do you know what chemicals within your ASC are considered to be hazardous? Do you have material safety data sheets (MSDS) and are they accessible to your staff? Do you have the correct items in your spill kit to contain a toxic or hazardous chemical spill in the ASC in order to protect employees and patients?

5. Do you have eye wash stations in your ASC?

6. Do you provide, at no charge to your employees, the necessary personal protective equipment (PPE) to perform their job duties? Have you examined the equipment to be sure it is in good condition? How recently was it checked and how often do you perform these checks?

7. Do you annually post workplace injuries (via the OSHA 300 Workplace Injury Log) for all employees to see?

Our ASC team recently had the opportunity to work with an agency that assists facilities to ensure compliance with OSHA regulations. During this voluntary visit sponsored by a local university, we found that we had several areas of concern regarding OSHA compliance. The regulations are challenging for any physician, nurse or manager in an ASC. The information that follows is intended to share a few pearls we learned and to assist you with OSHA compliance in your ASC. Perhaps it will reveal issues in your ASC that could help you prevent a serious injury or illness.

Bloodborne Pathogens and Sharps Safety

OSHA defines bloodborne pathogens as pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV) and others. Any worker handling sharp devices such as scalpels, sutures, hypodermic needles and blood collection devices is at risk for a workplace injury. According to OSHA, nursing staff are most frequently injured and needlestick injuries most frequently occur in the operating room. The Centers for Disease Control report that the occupational exposure to bloodborne pathogens from needlesticks and other sharps injuries is a serious problem, resulting in approximately 385,000 needlesticks and other sharps-related injuries to hospital-based healthcare personnel each year. Sharps injuries are primarily associated with occupational transmission of HBV, HCV and HIV, but they have been implicated in the transmission of more than 20 other pathogens.

The Bloodborne Pathogens Standard is available to ASC managers online at www.osha.gov. This site contains useful tools available at no charge.

A significant amount of information exists on the website regarding “engineering and work practice controls” that must be the primary means used to eliminate or minimize exposure of your ASC employees to bloodborne pathogens. This information must be documented in every ASC's Exposure Control Plan (ECP).

Engineering controls are measures that isolate or remove the bloodborne pathogens hazard from the workplace (e.g. sharps disposal containers, self-sheathing needles, safer medical devices such as sharps injury protections and needleless systems). The ECP must document consideration and implementation of appropriate commercially available and effective engineering controls designed to eliminate or minimize exposure. Work practice controls are measures that reduce the likelihood of exposure by altering the manner in which a task is performed (for example, prohibiting recapping of needles by a two-handed technique.) An annual documented review of the ECP must reflect changes in technology that eliminate or reduce exposure to bloodborne pathogens and document consideration and implementation of appropriate, commercially available and effective safer medical and surgical devices designed to eliminate or minimize occupational exposure to contaminated blood. It is essential that ASC managers document the evaluation of safe sharps each year. Additionally, employers are required by OSHA to annually review, identify, evaluate and select engineering and workplace controls and solicit help and input from employees who are responsible for direct patient care. Managers must then document employee input.

Another OSHA regulation applicable to the ASC is the requirement that an employer must maintain a log of injuries from contaminated sharps. This log, called the OSHA 300 Log, can be downloaded from the OSHA website. The OSHA 300 log sheet contains all work related to needlestick injuries and cuts from sharp objects that are contaminated with another person's blood or other potentially infectious material (OPIM.) In the event that the injured employee is later diagnosed with an infectious bloodborne disease, the OSHA 300 log must be updated.

Other Bloodborne Pathogens Standard requirements include:
• Compliance with Universal or Standard Precautions (an infection control principle that treats all human blood and other OPIM as infectious)
• Use of PPE. Engineering and work practice controls shall be used to eliminate or to minimize employee exposure. Where occupational exposure remains after institution of these controls, PPE shall also be used.
• Employee training in appropriate use of personal protective equipment and work practices, to eliminate or to minimize employee exposure to bloodborne pathogens
• Proper handling and proper use of sharps containers
• Hepatitis B vaccine (at no cost to the employee) and the vaccination series made available within 10 days of assignment to a job or work area where risk of exposure exists
• Post-exposure evaluation and follow-up, including post-prophylaxis when appropriate.

Should the ASC have access to an occupational medicine specialist or department, it is recommended that the medical director and/or the RN clinical director seek guidance from a physician with training in occupational medicine. These specialists can assist your ASC if an employee is exposed to a bloodborne pathogen. Because the ASC is responsible for providing continued counseling to affected employees, it is best to utilize the services of a physician skilled in this area.

Effective Employee Health and Safety Program

The following are the basic elements that OSHA requires in an effective employee safety and health program in the ASC:

Management leadership and employee involvement will be evaluated if OSHA visits your ASC. The OSHA inspector will evaluate your center's safety programs to be certain that the Governing Body assigns safety and health responsibility and authority to managers and employees and holds them accountable to follow the safety policies and procedures established by the Governing Body of the ASC. Additionally, this area of responsibility includes policy formulation, program review and encouragement of employee involvement. Documentation of safety programs should reflect this information.

A worksite analysis will be conducted to identify current and potential hazards. The OSHA inspector will perform a thorough baseline survey to review work processes and identify potential hazards. A job analysis is a review of written safe operating procedures for major tasks. In addition, checklists will be used by the OSHA inspector to determine whether facilities and equipment are hazardous. Documentation of employee training is vital to demonstrate that good systems are in place within the ASC. All materials used that are toxic or hazardous must have an MSDS sheet describing how to manage a spill involving the product as well as how to treat an exposure to the chemicals contained within the solution or powder.

A clearly stated worksite policy on safe and healthful work and working conditions should be readily available. Personnel responsible for each particular work area must understand that safety and health protection are of utmost importance. Establish and communicate a goal for the safety and health program of your center that includes detailed objectives to help you and your staff meet the goals. All members of the ASC team must understand the results desired and the measures planned for achieving them. Goals should be clear, measurable and achievable within an appropriate and reasonable amount of time for each goal.

Ensure that those in leadership positions in your ASC lead by example — obeying all safety rules and engaging in safe practices, written or not, such as wearing proper protective equipment whenever and wherever necessary and refraining from operating equipment without current training. Management should avoid permitting the use of defective equipment and ensure that effective housekeeping is done at all times.

The prudent management team in the ASC will take advantage of the wide variety of resources available to ensure appropriate measures for protecting employees and patients alike. It's a good rule to consistently review:
• Manufacturer's guidelines for indications and/or use
• Industry journals
• Data from national and local meetings
• National Institute for Occupational Safety and Health (NIOSH) guidelines
• Occupational Safety and Health Administration (OSHA) guidelines
• Occupational Safety and Health Administration's Safety and Health Achievement Recognition Program (SHARP) guidelines
• Database searches on key words and phrases
• New technology to improve health and safety in the ASC

As we begin a new year, it's crucial that you make the time to conduct a thorough review and evaluate your past success in meeting the goals, objectives and regulatory requirements for your ASC. In doing so, deficiencies can be identified and programs and/or objectives can be revised as needed.◊