The vast array of chemicals in hospitals, and the multitude of settings in which they occur, call for a systematic approach to their control. A chemical-by-chemical approach to prevention of exposures and their deleterious outcome is simply too inefficient to handle a problem of this scope. Moreover, as noted in the article “Overview of chemical hazards in health care”, many chemicals in the hospital environment have been inadequately studied; new chemicals are constantly being introduced and for others, even some that have become quite familiar (e.g., gloves made of latex), new hazardous effects are only now becoming manifest. Thus, while it is useful to follow chemical-specific control guidelines, a more comprehensive approach is needed whereby individual chemical control policies and practices are superimposed on a strong foundation of general chemical hazard control.
The control of chemical hazards in hospitals must be based on classic principles of good occupational health practice. Because health care facilities are accustomed to approaching health through the medical model, which focuses on the individual patient and treatment rather than on prevention, special effort is required to ensure that the orientation for handling chemicals is indeed preventive and that measures are principally focused on the workplace rather than on the worker.
Environmental (or engineering) control measures are the key to prevention of deleterious exposures. However, it is necessary to train each worker correctly in appropriate exposure prevention techniques. In fact, right-to-know legislation, as described below, requires that workers be informed of the hazards with which they work, as well as of the appropriate safety precautions. Secondary prevention at the level of the worker is the domain of medical services, which may include medical monitoring to ascertain whether health effects of exposure can be medically detected; it also consists of prompt and appropriate medical intervention in the event of accidental exposure. Chemicals that are less toxic must replace more toxic ones, processes should be enclosed wherever possible and good ventilation is essential.
While all means to prevent or minimize exposures should be implemented, if exposure does occur (e.g., a chemical is spilled), procedures must be in place to ensure prompt and appropriate response to prevent further exposure.
Applying the General Principles of Chemical Hazard Control in the Hospital Environment
The first step in hazard control is hazard identification. This, in turn, requires a knowledge of the physical properties, chemical constituents and toxicological properties of the chemicals in question. Material safety data sheets (MSDSs), which are becoming increasingly available by legal requirement in many countries, list such properties. The vigilant occupational health practitioner, however, should recognize that the MSDS may be incomplete, particularly with respect to long-term effects or effects of low-dose chronic exposure. Hence, a literature search may be contemplated to supplement the MSDS material, when appropriate.
The second step in controlling a hazard is characterizing the risk. Does the chemical pose a carcinogenic risk? Is it an allergen? A teratogen? Is it mainly short-term irritancy effects that are of concern? The answer to these questions will influence the way in which exposure is assessed.
The third step in chemical hazard control is to assess the actual exposure. Discussion with the health care workers who use the product in question is the most important element in this endeavour. Monitoring methods are necessary in some situations to ascertain that exposure controls are functioning properly. These may be area sampling, either grab sample or integrated, depending on the nature of the exposure; it may be personal sampling; in some cases, as discussed below, medical monitoring may be contemplated, but usually as a last resort and only as back-up to other means of exposure assessment.
Once the properties of the chemical product in question are known, and the nature and extent of exposure are assessed, a determination could be made as to the degree of risk. This generally requires that at least some dose-response information be available.
After evaluating the risk, the next series of steps is, of course, to control the exposure, so as to eliminate or at least minimize the risk. This, first and foremost, involves applying the general principles of exposure control.
Organizing a Chemical Control Programme in Hospitals
The traditional obstacles
The implementation of adequate occupational health programmes in health care facilities has lagged behind the recognition of the hazards. Labour relations are increasingly forcing hospital management to look at all aspects of their benefits and services to employees, as hospitals are no longer tacitly exempt by custom or privilege. Legislative changes are now compelling hospitals in many jurisdictions to implement control programmes.
However, obstacles remain. The preoccupation of the hospital with patient care, emphasizing treatment rather than prevention, and the staff’s ready access to informal “corridor consultation”, have hindered the rapid implementation of control programmes. The fact that laboratory chemists, pharmacists and a host of medical scientists with considerable toxicological expertise are heavily represented in management has, in general, not served to hasten the development of programmes. The question may be asked, “Why do we need an occupational hygienist when we have all these toxicology experts?” To the extent that changes in procedures threaten to have an impact on the tasks and services provided by these highly skilled personnel, the situation may be made worse: “We cannot eliminate the use of Substance X as it is the best bactericide around.” Or, “If we follow the procedure that you are recommending, patient care will suffer.” Moreover, the “we don’t need training” attitude is commonplace among the health care professions and hinders the implementation of the essential components of chemical hazard control. Internationally, the climate of cost constraint in health care is clearly also an obstacle.
Another problem of particular concern in hospitals is preserving the confidentiality of personal information about health care workers. While occupational health professionals should need only to indicate that Ms. X cannot work with chemical Z and needs to be transferred, curious clinicians are often more prone to push for the clinical explanation than their non-health care counterparts. Ms. X may have liver disease and the substance is a liver toxin; she may be allergic to the chemical; or she may be pregnant and the substance has potential teratogenic properties. While the need to alter the work assignment of particular individuals should not be routine, the confidentiality of the medical details should be protected if it is necessary.
Many jurisdictions around the world have implemented right-to-know legislation. In Canada, for example, WHMIS has revolutionized the handling of chemicals in industry. This country-wide system has three components: (1) the labelling of all hazardous substances with standardized labels indicating the nature of the hazard; (2) the provision of MSDSs with the constituents, hazards and control measures for each substance; and (3) the training of workers to understand the labels and the MSDSs and to use the product safely.
Under WHMIS in Canada and OSHA’s Hazard Communications requirements in the United States, hospitals have been required to construct inventories of all chemicals on the premises so that those that are “controlled substances” can be identified and addressed according to the legislation. In the process of complying with the training requirements of these regulations, hospitals have had to engage occupational health professionals with appropriate expertise and the spin-off benefits, particularly when bipartite train-the-trainer programmes were conducted, have included a new spirit to work cooperatively to address other health and safety concerns.
Corporate commitment and the role of joint health and safety committees
The most important element in the success of any occupational health and safety programme is corporate commitment to ensure its successful implementation. Policies and procedures regarding the safe handling of chemicals in hospitals must be written, discussed at all levels within the organization and adopted and enforced as corporate policy. Chemical hazard control in hospitals should be addressed by general as well as specific policies. For example, there should be a policy on responsibility for the implementation of right-to-know legislation that clearly outlines each party’s obligations and the procedures to be followed by individuals at each level of the organization (e.g., who chooses the trainers, how much work time is allowed for preparation and provision of training, to whom should communication regarding non-attendance be communicated and so on). There should be a generic spill clean-up policy indicating the responsibility of the worker and the department where the spill occurred, the indications and protocol for notifying the emergency response team, including the appropriate in-hospital and external authorities and experts, follow-up provisions for exposed workers and so on. Specific policies should also exist regarding the handling, storage and disposal of specific classes of toxic chemicals.
Not only is it essential that management be strongly committed to these programmes; the workforce, through its representatives, must also be actively involved in the development and implementation of policies and procedures. Some jurisdictions have legislatively mandated joint (labour-management) health and safety committees that meet at a minimum prescribed interval (bimonthly in the case of Manitoba hospitals), have written operating procedures and keep detailed minutes. Indeed in recognizing the importance of these committees, the Manitoba Workers’ Compensation Board (WCB) provides a rebate on WCB premiums paid by employers based on the successful functioning of these committees. To be effective, the members must be appropriately chosen—specifically, they must be elected by their peers, knowledgeable about the legislation, have appropriate education and training and be allotted sufficient time to conduct not only incident investigations but regular inspections. With respect to chemical control, the joint committee has both a pro-active and a re-active role: assisting in setting priorities and developing preventive policies, as well as serving as a sounding board for workers who are not satisfied that all appropriate controls are being implemented.
The multidisciplinary team
As noted above, the control of chemical hazards in hospitals requires a multidisciplinary endeavour. At a minimum, it requires occupational hygiene expertise. Generally hospitals have maintenance departments that have within them the engineering and physical plant expertise to assist a hygienist in determining whether workplace alterations are necessary. Occupational health nurses also play a prominent role in evaluating the nature of concerns and complaints, and in assisting an occupational physician in ascertaining whether clinical intervention is warranted. In hospitals, it is important to recognize that numerous health care professionals have expertise that is quite relevant to the control of chemical hazards. It would be unthinkable to develop policies and procedures for the control of laboratory chemicals without the involvement of lab chemists, for example, or procedures for handling anti-neoplastic drugs without the involvement of the oncology and pharmacology staff. While it is wise for occupational health professionals in all industries to consult with line staff prior to implementing control measures, it would be an unforgivable error to fail to do so in health care settings.
As in all industries, and with all hazards, data need to be compiled both to help in priority setting and in evaluating the success of programmes. With respect to data collection on chemical hazards in hospitals, minimally, data need to be kept regarding accidental exposures and spills (so that these areas can receive special attention to prevent recurrences); the nature of concerns and complaints should be recorded (e.g., unusual odours); and clinical cases need to be tabulated, so that, for example, an increase in dermatitis from a given area or occupational group could be identified.
Increasingly, hospitals are becoming cognizant of their obligation to protect the environment. Not only the workplace hazardous properties, but the environmental properties of chemicals are being taken into consideration. Moreover, it is no longer acceptable to pour hazardous chemicals down the drain or release noxious fumes into the air. A chemical control programme in hospitals must, therefore, be capable of tracking chemicals from their purchase and acquisition (or, in some cases, synthesis on site), through the work handling, safe storage and finally to their ultimate disposal.
It is now recognized that there are thousands of potentially very toxic chemicals in the work environment of health care facilities; all occupational groups may be exposed; and the nature of the exposures are varied and complex. Nonetheless, with a systematic and comprehensive approach, with strong corporate commitment and a fully informed and involved workforce, chemical hazards can be managed and the risks associated with these chemicals controlled.