Occupational and Environmental Risks in Nursing

Hospitals and other healthcare settings have long been thought to be different than other workplaces - cleaner, safer, healthier. Yet, many healthcare professionals are becoming alerted to the risks posed within their workplace settings, risks to their own health and to the health of the communities they serve. This chapter will provide an overview of environmental health and safety risks in the healthcare industry and focus on two prevalent risks: 1) an occupational health risk - latex exposure, and 2) an environmental risk - hospital waste. Both risks can affect nurses and the clients they care for.

An Overview

The delivery of health care with the approach of the Year 2000 would be unrecognizable to the healthcare providers at the beginning of the Century. Lasers, X-rays, radiation therapy, modem anesthetic methods, even intravenous administration of drugs would have been unimaginable to nursing's collegial predecessors. While healthcare providers have made huge strides in preventing and curing illnesses and in improving the prognosis in those whose illnesses remain incurable, many of the new technologies have created occupational hazards for nurses and other healthcare workers. Some of the anti-neoplastic drugs are carcinogens; many of them pose reproductive hazards for nurses. If these drugs are not prepared and administered carefully, there can be risk of exposure to the carcinogenic properties of the medication.

Anesthetic gases such as nitrous oxide and halogenated anesthetics have been linked to such health problems as impaired fertility; spontaneous abortions; congenital anomalies; hepatic, renal and neurological diseases; depressed immune responses, and increased susceptibility to neo-plastic diseases (Allen, 1996). Interestingly, the room-air levels of anesthetic gases are higher in the recovery room where extubated patients "off-gas," or exhale the anesthetic gases they received during surgery, than in the operating room. Exposure to anesthetic gases may occur in the operating room when there are leaks in endotracheal tubes, poorly fitting patient facial masks, or failure to properly connect the anesthetic waste lines (Rogers, 1991).

Some of the dangers of infectious diseases that existed at the turn of the last century, before antibiotic therapy, are reemerging. Healthcare workers may be at risk of infection when they work with patients who have infectious diseases such as multiple drug-resistant tuberculosis, drug-resistant staphylococcus, and hepatitis. In addition to the biological and chemical hazards to which healthcare workers may be exposed, risks of injury from lifting patients and from workplace violence are at unacceptable levels in the healthcare industry. These workplace hazards put the nurse at.risk. Managing these risks is an important component of a workplace occupational health and safety program.

Latex Risk

Allergies to latex have become a significant occupational health issue. Latex allergy is frequently underestimated and not seriously considered as a risk by many healthcare professionals (Smith, 1993). However, allergic responses can range from the merely irritating runny nose and itchy eyes to life-threatening conditions such as full blown anaphylaxis. In 1987, the Center for Disease Control recommended universal precautions for the prevention of the spread of Hepatitis and Human Immuno-deficiency Virus (HIV). The Occupational Safety and Health Administration's (OSHNs) Blood-borne Pathogens Standard reflects these recommendations. Since the primary universal precaution is the use of gloves, an increased exposure to the latex allergen in healthcare workers has occurred (Susman, 1995). Latex proteins compose about 1.7% of rubber (Yunginger, 1994). Latex proteins leach from rubber gloves into the powder within the gloves and into the hands of the wearer as a result of normal skin moisture. When rubber gloves are donned or removed, latex proteins are discharged into the air exposing those present. Routes of exposure are primarily through cutaneous contact or inspiration.

The American College of Allergy and Immunology has identified healthcare workers who wear latex gloves on a regular basis as being at high risk for developing latex allergy. The predicted percentages for healthcare workers with latex allergy in an early study ranged from three to seventeen percent (Sussman and Beezhold, 1995). In a more recent study, 24% of healthcare workers with a history of atrophy, had a positive skin prick test to latex extract (Sussman and Beezhold, 1995). Of the 24%, approximately one-half were clinically asymptomatic for latex allergy at the time of testing. This represents a large population at risk for latex allergy-related disease and raises the importance of developing comprehensive approaches to risk reduction before severe allergic responses arise.

Some groups of healthcare workers are at greater risk than others. For instance, operating room personnel are at high risk as there is constant glove wearing by multiple people in the operating suite. Patients and healthcare workers can become sensitized to latex through repeated skin or mucous membrane contact, or by inhaling aerosolized glove allergens. Continued exposure to latex allergens increases sensitization and worsens allergic reactions. Contact dermatitis can occur from six to 48 hours after exposure to latex and is characterized by localized redness, swelling, itching, cracking, and fissures of the skin with scaling, vesicles, and open lesions (Gliniecki, 1998). The most dramatic form of latex allergy is immediate and systemic anaphylactic reaction. Symptoms are unmistakable and include a severe generalized skin reaction, upper respiratory symptoms which can escalate to airway obstruction, and a drop in blood pressure. Medical management of anyone who has experienced systernic reactions must include removal of the allergen. Accommodations must be made for allergic employees. For example, the unit to which the employee is assigned could be converted to a latex-free unit. Nurse managers must clearly communicate the accommodations made for the allergic employee to co-workers.

The management of latex allergic employees is an issue in every healthcare institution. Nurses need to know the risks of latex in the healthcare setting to protect themselves, patients, and colleagues.

The American Nurses Association (1996) created the following list of precautions for latex sensitive nurses:

• Avoid all forms of exposure to latex, (i.e., latex sensitive persons must never wear latex gloves)
• Alert physicians, colleagues, and employers of the diagnosis and the need to avoid latex
• Wear a medical alert bracelet and carry emergency medical instructions
• Carry auto-injectable epinephrine
• Carry non-latex gloves
• Make preparations for latex-safe medical care with providers and healthcare facilities

A latex risk assessment should be implemented in all healthcare settings and should include an identification of all places in which latex exposure may occur. Managers should assess employees' perceptions of risk and provide education related to latex allergies and the management of these allergies.

Nurses can be involved in planning education programs related to latex allergy. Education programs should include glove selection, gloving practices, symptoms of latex allergy, and the importance of hand washing (Culver, 1995). Nurses' roles in developing policies for those healthcare workers who are known to be latex sensitive should include assistance with environmental source control, management of symptoms through appropriate referral, and education and communication about workplace accommodation for allergic employees. Finally, nurses should be involved in monitoring latex allergy trends in the workforce (Culver, 1995).

Patients can be exposed to latex through a number of products. Catheters, tubing, drains, intravenous ports, and anesthesia equipment contain latex. Nurses should ask patients about latex allergies, document the allergy in a visible place on the patient record, and alert other healthcare personnel to the allergy. Nurses should monitor patients for latex allergies when using equipment known to contain latex. Nurses can also be instrumental in developing institutional policies for the care of patients with latex allergies.

Latex allergy is a relatively new hazard in the healthcare field. The occupational health team has the most responsibility and the greatest opportunity to influence the health and safety of workers. The occupational health team should be active in developing and implementing comprehensive approaches to hazard identification and elimination. The American Nurses Association has been very active in developing and promoting sound policies regarding latex exposures and is an important source of information for nurses. In addition, two other organizations can provide vital information: ALERT (Allergy to Latex Education and Resource Team, Inc.) and ELASTIC (Education for Latex Allergy Support Team and Information Coalition).

Hospital Waste

While latex exposure is an example of an occupational hazard associated with health care, dioxin and mercury exposures are two environmental hazards related to the healthcare industry. These two hazards are associated with the waste generated by healthcare institutions (Health Care Without Harm, 1998). Dioxin is a known human carcinogen and has been associated with a host of health problems including birth defects, decreased fertility, immune system suppression, and other hormonal disruption. Mercury is a poison that can interfere with the development of the fetal brain, and is directly toxic to the central nervous system, kidneys, and liver in people of all ages.

Dioxin is the common name for a host of similar chemicals that are formed when chlorine -containing products are combusted. Polyvinyl Chloride plastic (PVC) is a major source of the chlorine in medical waste. Plastics comprise 10-15% of the medical waste stream, twice as much as household waste. Once emitted into the air, dioxins become a threat to humans through the food chain. Dioxins can be found in some meats, dairy products, eggs, and fish. Dioxin bioaccumulates in fatty tissue, and can accumulate in human breast milk thereby putting nursing infants at risk of receiving as much as 50 times an adult's exposure dose. Two aspects of dioxin's toxicity are particularly insidious to the public's health: 1) the wide array of health effects including reduced sperm counts, endometriosis, and breast cancer, and 2) the low dosage required to cause adverse effects on health. Additionally, dioxin is extremely persistent in the environment resulting in an ongoing accumulation for current and future generations.

The increase in dioxin risk is associated with HIV/AIDS and Hepatitis infection prevention measures. Universal precautions require that all body fluids be regarded as potentially infectious. This definition encourages the generation of massive amounts of what is believed to be infectious waste. "Red bagging" is the practice of discarding contaminated, infectious waste in red bags earmarked for disposal as regulated medical waste most often in medical waste incinerators. The Environmental Protection Agency (EPA) estimates that there are approximately 2,400 medical waste incinerators in the United States which combust approximately 846 thousand tons of hospital and medical/infectious waste annually (Health Care Without Hann, 1998). The Centers for Disease Control has identified two percent or less of a typical hospital waste stream as pathological waste, (i.e., organs or tissues), which require some form of treatment to protect the public's health. Without a clear understanding of what truly belongs in the category of contaminated medical waste, "red bagging" has been overused in many institutions. Some healthcare institutions place all waste in red bags and incinerate it. The amount of medical waste generated per hospital patient has more than doubled since 1955 (Health Care Without Hann, 1998). This is due, in part, to the use of more plastic and disposable products.

The creation of dioxins can be reduced by not combusting products that contain chlorine including products such as PVC and white paper which is bleached with chlorine to achieve whiteness. Such pollution prevention can be attained through several activities, in many of which nurses can play a vital role. Shaner (1997) suggested that at the point of purchase, many decisions can be made that will ultimately impact on the environment. Shaner (1997) referred to a new set of three R's - reduce, reuse, and recycle. Selecting products that are mercury and PVC free, eliminating unnecessary plastic packaging, buying reusable products, and recycling waste products such as paper can make a huge difference in the environment.

In the clinical setting nurses can play an important part in pollution prevention by properly segregating waste materials, In a New England hospital operating room, two nurses spearheaded a waste reduction project that decreased the volume of regulated waste by 75%. This project resulted in a savings of $30,000 per year in medical waste disposal fees (Shaner, 1997). The nurses worked with infection control staff to ensure safety and appropriate segregation of waste. The Recommended Practices Committee of the Association of Operating Room Nurses (AORN)(1998) developed "Recommended Practices for Environmental Responsibility in the Practice Setting," which can serve as a model for the development of model practices in other clinical settings.

Mercury is the other significant environmental offender associated with hospital waste. Mercury is a heavy metal which is a bioaccumulative and persistent pollutant that is poisonous to humans and wildlife. Once emitted into the environment, it does not break down. In the healthcare setting, mercury can be found in thermometers, blood pressure devices, dilation and feeding tubes, batteries, and fluorescent lamps. Because of the widespread use of these items, mercury may account for 20% of the waste in solid waste streams (Health Care Without Harm, 1998).

Mercury is a potent neurotoxin. Mercury is not destroyed nor changed by incineration. Once emitted by incinerator smokestacks, mercury is deposited on land and surface water. Bacteria can convert elemental mercury to a more biologically available form, methyl mercury. Methyl mercury crosses the placenta, placing the fetus at risk for neurologic damage including psychornotor retardation. Thirty-seven states have some waterways that are so contaminated with mercury that they have been declared unsafe: fish from these lakes, rivers, and streams are unsafe for human consumption.

It is important to note that alternative products exist for all mercury containing products such as light fixtures, for example. A mercury-free healthcare setting would significantly reduce the risks posed by the disposal of mercury. In general, the amount of medical waste can be reduced through the adoption of a pollution prevention approach that integrates healthcare product purchasing and disposal decisions with an emphasis on the use of non-toxic, recyclable, and reusable materials. Waste reduction activities should include the housekeeping and environmental services, purchasing, warehouse and materials management, infectious disease departments, and recycling coordinators (American Society for Healthcare Environmental Services, 1993). Training of all staff in waste recycling and reduction is essential. Nurses, housekeepers, and all members of the healthcare team must know their roles in assigning waste products to the appropriate level of disposal.

Environmentally sound practices are cost effective for hospitals. The Beth Israel Medical Center in New York saves $600,000 per year through product purchasing and disposal modifications, including reducing, reusing and recycling. Guidance for planning such a comprehensive approach is provided by such organizations as the American Society for Health Care Environmental Sciences of the American Hospital Association and the Health Care Without Harm Campaign, a coalition of organizations including the American Nurses Association, the Association of Operating Room Nurses, and other nursing specialty groups. The following nine-step approach adopted by the Health Care Without Harm Campaign (1998) can provide a framework to plan pollution reduction activities in healthcare facilities:

1. Establish a "green team" including administrators, housekeepers, engineers, and those handling waste to identify the waste stream of the facility and how it is disposed, and to identify a waste management strategy that includes waste reduction, reuse, and recycling measures
2. Assign a full-time person to be in charge of the waste management program.
3. Train staff about the environmental consequences of medical waste incineration and better waste management practices.
4. Explore fully the recycling of products and do not incinerate what can be recycled. Communicate with suppliers about the need for recyclable and reusable products and packaging materials.
5. Use reusable products over disposable ones and do not incinerate what can be reused.
6. Use other, safer disposal methods such as autoclaving and microwaving when possible in lieu of incineration.
7. Begin a program to eliminate products containing mercury.
8. Create a plan to reduce chlorine-containing products such as PVCs.
9. Assign materials management staff to communicate with suppliers concerning the need to buy environmentally preferable products, including cleaning products, biocides, and other chemicals that help reduce the overall use of toxic chemicals.

Summary

The public will come to better understand the environment and its impact on health. Nurses and other healthcare workers are increasingly aware of the personal health and safety risks in the employment setting. As a result, the healthcare industry and healthcare practitioners will be held accountable to reduce the risks posed to the people they employ and the communities they serve.

The registered nurse will become an ever more vital link in limiting occupational and environmental risks in the practice setting. Appropriate education, thoughtful precautions in practice, and careful management of health and safety risks in the workplace can ensure that healthcare settings are cleaner, safer, and healthier places for the nurse and the populations they care for.

References

Allen, A., & Badgewell, M.J. (1996). The post anesthesia care unit: Unique contribution, unique risk. Journal of Perianesthesia Nursing, 2 (4), 248-258.

American Nurses Association. (1996). Latex allergy: Protect yourself, protect your patients. Workplace Information Series. Washington, DC: American Nurses Association.

Association of Operating Room Nurses. (1998). Standards, recommended practices and guidelines. Denver, CO: Association of Operating Room Nurses

Culver, B.I. (1995). Latex sensitivity in healthcare workers: Reality, risk and remedy. Journal of the Association of Occupational Health Professionals in Healthcare, 9 (3), 2-11.

Culver, J. (1995). Latex sensitivity in healthcare workers. Journal of the Association of Occupational Health Professionals in Healthcare, 9 (3), 2-11.

Gliniecki, C. (1998). Management of latex reactions in the occupational setting. Journal of the American Association of Occupational Health Nurses, 46 (2), 82-92.

Health Care Without Harm, The Campaign for Environmentally Responsible Health Care. (1998). Healing the harin, a handbook. Washington, DC: Health Care Without Harm, The Campaign for Environmentally Responsible Health Care.

Jackson, D. (1995). Latex allergy and anaphylaxis - What to do? Journal of Intravenous Nursing, .1 (18), 33-50.

McRae, G., Shaner, H., & Bisson, C.L. (1993). An ounce of prevention: Waste reduction strategies for health care facilities. Chicago, EL: American Society for Healthcare Environmental Services of the American Hospital Association.

Rogers, B., & Travers, P. (1991). Occupational hazards of critical care nursing: Overview of work related hazards in nursing-health and safety issues. Heart and Lung, 20, 486499.

Shaner, H. (1997). Environmentally responsible clinical practice: Clinician's role in waste management. Washington, DC: Health Care Without Harm, The Campaign for Environmentally Responsible Health Care.

Smith, S., Tyndall, J., & Young, A. (1993). Do you have a latex allergy protocol? Canadian Operating Room Nursing Journal, 11 (3), 26-28.

Sussman, G., & Beezhold, D. (1995). Allergy to natural rubber latex. Unpublished manuscript. Rochester, MN.

Barbara Sattler, DrPH, RN, is Director of the Environmental Health Education Center in the School of Medicine at the University of Maryland Dr Sattler acknowledges the assistance of Becky Hess, BSN, RN, in preparing this chapter

Updated Selected References: 1999 through June 2001

Note: These references are not part of the independent study module, but are provided to you as suggestions for additional reading.

Aufseeser_Weiss, M.R., Ondeck, D.A. (June 2001). Medication use risk management: hospital meets home care. Journal of Nursing Care Quality, 15 (2), 50-7.

Fragala, G. (November 2000). A guide to developing an ergonomics program. Hospital Employee Health.19 (11), 127-129, 132.

Hood, J. (June 2000). Is "latex safe" possible? Using a systematic approach in occupational health. AAOHN Journal 48 (6), 291-296.

Karvonen, C.A. (November 1999). Latex allergy in health care workers: what are the risks? AAOHN Journal 47 (11), 519-525.

Kohn, P. (January 1999). Legally speaking. The legal implication of latex allergy. RN, 62 (1), 63-5.

Miller, K.K. (June 2000). Research based prevention strategies: management of latex allergy in the workplace. AAOHN Journal, 48 6, 278-90.

Strinko, J.M., Howard, C.A., Schaeffer, S.L., Laughlin, J.A., Berry, M.A. Turner, S.N. (June 2000). Reducing risk with telephone followup of patients who leave against medical advice or fail to complete and ED visit. Journal of Emergency Nursing, 26 (3), 223-32, 282-288.