Course 171 Hospital Hazards and Solutions: Hazardous Chemicals

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Hazardous Chemicals in Healthcare

Introduction

Healthcare workers who prepare or administer hazardous drugs or who work in areas where these drugs are used may be exposed to these agents in the workplace. Some examples of hazardous drugs include those used for cancer therapy, some antiviral drugs, hormone agents, and bioengineered drugs.

Healthcare employees are also exposed to hazardous chemicals, such as pesticides and disinfectants.

About 8 million U.S. healthcare workers are potentially exposed to these hazardous drugs and chemicals. At-risk workers include:

  • pharmacy and nursing personnel
  • physicians
  • operating room personnel
  • environmental services workers
  • workers in research laboratories
  • veterinary care workers
  • shipping and receiving personnel
  • janitorial staff
hazardous chemicals
Exposure to hazardous drugs can result in adverse health effects in healthcare workers.

Exposure to hazardous drugs can result in adverse health effects in healthcare workers. In fact, published studies have shown that workplace exposures to hazardous drugs can cause a variety of health effects, such as:

As the graphic to the right shows, acute health effects usually occur rapidly as a result of short-term exposures, whereas chronic health effects generally occur as a result of long-term exposure and last longer.

Here are some examples of health effects from hazardous drugs:

  • skin rashes
  • adverse reproductive outcomes, including:
    • infertility
    • spontaneous abortions
    • congenital malformations
  • possibly leukemia and other cancers

The health risk depends on how much exposure a worker has to these drugs and how toxic they are.

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1. The health risk of hazardous drugs depends on how much _______ a worker has to these drugs and how ______ they are.

a. allergies, exposure
b. exposure, risky
c. risk, allergic
d. exposure, toxic

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Hazardous Drug Safety and Health Plan

safety and health plan
OSHA has identified worker exposure to hazardous drugs as a problem of increasing health concern.
Click to Enlarge

OSHA has identified worker exposure to hazardous drugs as a problem of increasing health concern. When hazardous drugs are used in a healthcare facility, employers are required to implement a written program that meets the requirements of the Hazard Communication Standard (HCS). This standard provides for worker training, warning labels, and access to Safety Data Sheets (SDSs).

The HCS ensures employee awareness of the hazardous chemicals they are exposed to in the workplace.

  • Agents with any of the following characteristics are considered hazardous: carcinogens, corrosives, toxic or highly toxic, irritants, sensitizers, or target organ effectors.
  • Provide readily available Safety Data Sheets (SDSs) for all hazardous chemicals.
  • Clearly label all hazardous chemicals, such as those found in some soaps, disinfectants, and pesticides, as hazardous. [29 CFR 1910.1200(f)]
  • Train workers in potential chemical hazards and controls (engineering controls, work practices, and PPE) necessary to prevent hazards in the work area. [29 CFR 1910.1200(h)(3)]

2. Which of these must be included as part of an employer's written health and safety program?

a. Safety Data Sheet
b. Chemical Locator Sheet
c. Notebook of Hazards
d. Chemicals and the Worker

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hierarchy of controls
Workers can be protected from hazardous drug exposures using hierarchy of controls.

Hierarchy of Controls

Workers can be protected from exposures to hazardous drugs through engineering controls, administrative controls, and personal protective equipment.

  • Engineering Controls: Engineering controls include biological safety cabinets (BSC), compounding aseptic containment isolators, closed system transfer devices, and needleless systems. Engineering controls are the most effective way to control exposure to hazardous chemicals by preventing exposure from occurring.
  • Administrative Controls: Administrative controls include implementing work practices, management policies, and training programs to reduce worker risk. A medical monitoring program serves as a form of secondary prevention by identifying indicators of exposure or early disease.
  • Personal Protective Equipment: Employers are required to provide appropriate PPE, such as gloves, goggles, and splash aprons when employees are handling hazardous chemicals. [29 CFR 1910.132] PPE is the least effective control method because it relies on employee behaviors to prevent exposure.

Medical Services and First Aid

If the eyes or body of any person may be exposed to harmful corrosive materials, suitable facilities for quick drenching or flushing of the eyes and body must be provided within the immediate area for emergency use. [29 CFR 1910.151(c)]

3. Where should a suitable facility be located for quick flushing of the eyes and body after exposure to harmful corrosive materials in a healthcare facility?

a. Outside the building
b. In the immediate work area
c. In another location to protect other workers
d. Close to the bathroom

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Engineering and Adminstrative Controls

engineering controls
Engineering controls, such as an appropriate anesthetic gas scavenging system, help protect healthcare workers.

Engineering and administrative controls such as an appropriate anesthetic gas scavenging system are the first line of defense and the preferred method of control to protect employees from exposure to anesthetic gases. A recent report from the Centers for Disease Control and Prevention found there is widespread use of these scavenging systems to control anesthetic gases during medical procedures. However, many other recommended controls are lacking in many facilities. Here are the results of the study:

  • 3% did not always use anesthesia machines equipped with a waste gas scavenging system
  • 35% started anesthetic gas flow before mask was applied to pediatric patient and 14% did the same for adult patients.
  • 19% reported safe handling procedures were unavailable.
  • 18% never received training on safe handling of anesthetic gases.
  • 17% used a funnel-fill (open-air) system instead of a key-filler or other closed system to fill anesthesia vaporizers.
  • 17% used high (fresh gas) flow anesthesia only for pediatric patients and 6% did the same for adult patients.
  • 5% did not routinely check anesthesia equipment for leaks.

When precautionary practices are not followed, anesthesia care providers and bystanders are at risk of exposure. Ensuring proper precautionary measures are followed requires diligence on the part of both employers and healthcare workers.

Employers need to ensure the following:

  • anesthesia care providers are initially and periodically trained
  • safe-handling procedures reflecting recommended practices are in place
  • anesthesia machines with scavenging systems are used (including regular inspection of anesthesia delivery equipment for leaks, periodic air and exposure monitoring prompt elimination of spills and leaks)
  • medical surveillance, exposure monitoring, and other administrative controls are in place

Anesthesia care providers should seek out training, understand and follow facility procedures, ask questions, and report any safety concerns.

4. In a recent CDC study, what percentage of healthcare workers didn’t receive training on safe handling of anesthetic gases?

a. 10%
b. 18%
c. 25%
d. 50%

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Chemicals

What is Ethylene Oxide?

Ethylene Oxide

Ethylene oxide (EtO) is used extensively by hospitals and other industries as a sterilizing agent.

EtO is a colorless, odorless gas which is both flammable and highly reactive. Most importantly, you cannot smell EtO until it reaches a temperature of 51.3 degrees Fahrenheit (10.7 degrees Celsius), the gas smells like ether.

It can be found in fumigants and sterilants and presents an opportunity for healthcare worker exposure during operations such as EtO sterilization of surgical equipment.

Human and animal studies consistently show that EtO can be hazardous to human health.

Short-term (acute) exposures to EtO can cause the following health issues:

acute vs. chronic
Short and long term exposure to ethylene oxide can cause several health issues.
  • respiratory irritation and lung injury
  • shortness of breath
  • headache
  • nausea
  • vomiting
  • diarrhea
  • cyanosis (bluish or grayish color of the skin, nails, lips, or around the eyes)

Long-term (chronic) exposure over many years may cause the following:

  • cancer
  • reproductive effects
  • genetic changes
  • damage to the nervous system
  • sensitization

5. Acute exposure to Ethylene Oxide can cause which of the following health issues?

a. Damage to the nervous system
b. Genetic changes
c. Shortness of breath
d. Cancer

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Formaldehyde
Healthcare workers may be harmed by exposure to formaldehyde.
Click to Enlarge

Formaldehyde

Formaldehyde is used as a disinfectant or sterilant. It is commonly used as a preservative in medical laboratories and mortuaries. Formaldehyde is also used to prepare viral vaccines, as an embalming agent, a tissue fixative, and in the sterilization of medical equipment. Paraformaldehyde, a solid polymer of formaldehyde, can be heat vaporized for the gaseous decontamination of laminar flow biologic safety cabinets. Additionally, formaldehyde is often found mixed in water and referred to as formalin.

Healthcare workers may be harmed by exposure to formaldehyde. It can irritate the skin, throat, lungs, and eyes. Repeated exposure to formaldehyde can possibly lead to cancer. The level of exposure depends on the dose, duration, and the work being done.

6. Allison has been working in a morgue for several years and has had repeated exposure to formaldehyde. What health issue may she experience?

a. Cancer
b. Immediate death
c. Skin rashes
d. Fatigue

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Glutaraldehyde

Glutaraldehyde is a toxic chemical that is used as a cold sterilant to disinfect and clean heat-sensitive medical, surgical, and dental equipment. Glutaraldehyde is also used as a tissue fixative in histology and pathology labs and as a hardening agent in the development of x-rays.

Glutaraldehyde is used in a limited number of applications, rather than just as a general disinfectant. Specific applications include:

  • use as a disinfecting agent for respiratory therapy equipment
  • bronchoscopes
  • physical therapy whirlpool tubs
  • surgical instruments
  • anesthesia equipment parts
  • x-ray tabletops
  • dialyzers
  • dialysis treatment equipment
Glutaraldehyde
Exposure to glutaraldehyde has both short and long term health effects.

Health Effects

  • Short term (acute) effects: Contact with glutaraldehyde liquid and vapor can severely irritate the eyes, and at higher concentrations burns the skin. Breathing glutaraldehyde can irritate the nose, throat, and respiratory tract, causing coughing and wheezing, nausea, headaches, drowsiness, nosebleeds, and dizziness.
  • Long term (chronic) effects: Glutaraldehyde is a sensitizer. This means some workers will become very sensitive to glutaraldehyde and have strong reactions if they are exposed to even small amounts. Workers may get sudden asthma attacks with difficulty breathing, wheezing, coughing, and tightness in the chest. Prolonged exposure can cause a skin allergy and chronic eczema, and afterwards, exposure to small amounts produces severe itching and skin rashes. Glutaraldehyde has been implicated as a possible cause of occupational asthma.

7. _____ is the main use of Glutaraldehyde.

a. An alternative to anesthesia
b. Disinfectant for medical gloves
c. Disinfecting and cleaning heat-sensitive medical equipment
d. Cleaning patient wounds during surgery

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Mercury

Mercury Spill Cleanup: Health Effects

Mercury is naturally occurring and exists in several forms. High mercury exposure results in permanent nervous system and kidney damage.

Employee exposure to mercury from accidental spills can occur during repair of broken thermometers, sphygmomanometers, or during sterilization and centrifugation of thermometers in maintenance areas. Mercury can also be found in some pressure-sensing instruments (e.g., barometers and sensors in machine rooms), as well as electronic equipment, and some older, medical devices. When mercury is exposed to the air, as in the case of a spill, it slowly vaporizes.

If spills are not promptly cleaned up, mercury may accumulate on surfaces and then vaporize and be inhaled by unaware workers. Mercury can also be absorbed through the skin.

Case Report

A wall-mounted blood pressure unit in a doctor's office examination room failed spilling mercury on the tiled floor. The facility closed the room and hired a contractor to clean up the mercury. After cleanup, air sampling results indicated that mercury was still present. When facility staff called the State Health Department for advice, the Department conducted further air sampling and located additional beads of mercury. In all, it took the contractor several days and three cleaning cycles to completely remove all the mercury and decontaminate the office.

8. High mercury exposure can cause which of the following health issues?

a. Heart attacks
b. Nervous system/kidney damage
c. Imminent death
d. Cancer

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Mercury Health Effects

Mercury
Long and short term exposure to mercury can cause health issues.

Acute (short term) exposure: Acute exposure to high levels of mercury can cause severe respiratory irritation, digestive disturbances, and marked renal damage. Acute inhalation of mercury vapor may also result in health issues, including:

  • chills
  • nausea
  • general malaise (feeling of discomfort, illness, or uneasiness)
  • tightness in the chest
  • chest pains
  • dyspnea (difficulty breathing or shortness of breath)
  • cough
  • stomatitis (inflammation of the mouth and lips)
  • gingivitis
  • salivation
  • diarrhea

Chronic (long term) exposure: Chronic exposure to mercury may result in the following:

  • weakness
  • fatigue
  • anorexia
  • weight loss
  • disturbance of gastrointestinal function

9. Which of the following is listed as an acute health effect of mercury?

a. Weight loss
b. Chest tightness
c. Weakness
d. Fatigue

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Waste Anesthetic Gases

Waste Anesthetic Gases
The anesthetic gases and vapors that leak into the surrounding room during medical procedures are considered waste anesthetic gases.

The anesthetic gases and vapors that leak into the surrounding room during medical procedures are considered waste anesthetic gases. Healthcare professionals who work in hospitals, operating rooms, dental offices, and veterinary clinics, are potentially exposed to waste anesthetic gases and are at risk of occupational illness.

The waste anesthetic gases and vapors of concern are:

  • nitrous oxide and halogenated agents (vapors) such as:
    • halothane
    • enflurane
    • isoflurane
    • desflurane

Exposure to these gases can occur through leakage of the patient's anesthetic breathing circuit during the delivery of anesthetic and through exhalations of patients recovering from anesthesia.

Some potential effects of exposure to waste anesthetic gases include the following:

  • nausea
  • dizziness
  • headaches
  • fatigue and irritability
  • sterility
  • miscarriages
  • birth defects
  • cancer
  • liver and kidney disease

Employers and employees should be aware of the potential effects and be advised to take appropriate precautions.

10. Which of the following is a potential health effect after exposure to anesthetic gases?

a. Sneezing
b. Chest tightness
c. Coughing
d. Fatigue/irritability

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