wsh healthcare guidelines

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Workplace Safety andHealth GuidelinesHealthcare


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1 Introduction

2 Commitment fromTop Management

3 Managing WorkplaceSafety and Health

in Healthcare Workplace Safety and

Health Policy

Planning

Implementationand Operation

Checking andCorrective Actions

Management Review

4 Incident Reportingand Investigation

5 Risk Management

Preparation

Risk Assessment

Hazard Identication

Risk Evaluation

Risk Control

Implementation and Review

Record-keeping

Contents

6 Hazards inHealthcareEnvironment

Chemical Hazards

Management of Hazardous

Chemicals Programme Anaesthetic Waste Gases

and Vapours

Sterilising andDisinfecting Agents

Solvents

Mercury

Natural Rubber Latex

Biological andInfectious Hazards

Infectious DiseasesManagement Programme

Bloodborne Pathogens

Infectious Agents

other than Bloodborne Pathogens

Airborne Infections

Infections Transmitted by Direct Contact

Biological Matter

Physical Hazards

Falls from Heights

Slips, Trips and FallsYear of issue: 2008First revision: 2015

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workplace safety and health guidelines 3

Ergonomics

Noise

Vibration

Ionising Radiation

Non-ionising Radiation

Sharps

Psychosocial Hazards

Shift Work, Overtime, Stressand Burnout

Workplace Harassmentand Violence

7 HazardousDrug Handling

8 HazardousWaste Management

9 EmergencyPreparednessand Response

Emergency Response Plan

Fire Chemical Spill or Leak

Pandemic Flu, SARSand EmergingInfectious Diseases

First Aid

10 FacilitiesManagement

Safety in Constructionand Renovation

Indoor Air Qualityand Ventilation

Safe Means of Accessand Egress

Maintenance of Facilities

Lighting

Signs, Colour Coding

and Marking

11 Personal ProtectiveEquipment

Personal ProtectiveEquipment Programme

RespiratoryProtection Programme

12 Appendices

Appendix A – List of NotiableOccupational Diseases inSingapore under the WorkplaceSafety and Health Act

Appendix B – Examples ofInfections and Routesof Transmission

Appendix C – Summary of Hazardsin Healthcare by Location

Appendix D – Useful Links

13 Acknowledgements

14 Amendments

1 Introduction

1The healthcare clusters – Alexandra Health Pte Ltd, Eastern Health Alliance, National Healthcare Group,National University Health System, Jurong Health Services and Singapore Health Services.Source: Singapore Economic Development Board.

The healthcare industry in Singapore is growing and adapting to new challenges inorder to meet the growing healthcare demand. Due to heightened awareness of q ualityhealthcare services, a rapidly greying population, longer life expectancy and greatereconomic growth, the healthcare industry will need to review its work processes andensure that the lives of their e mployees and patients are safe and healthy.

Healthcare employees are as vulnerable to workplace safety and health (WSH) hazardsas any other employee. A safe and healthy work environment can boost the wellbeing,morale and productivity of these employees. Poor WSH practices can contribute toillness, absenteeism, productivity loss, disability and even death. The WSH Act coversall workplaces including healthcare facilities, and all stakeholders must take reasonablypracticable measures to ensure the safety, health and wellbeing of every individual.

Recognising that healthcare employees are exposed to a wide array of work-related safetyand health risks, this set of guidelines was developed in 2008 and subsequently revisedin July 2015 to provide useful guidance on the proper management of WSH risks inhealthcare facilities. This second issue of the guidelines highlight information on potentialcommon hazards faced by healthcare employees as well as good industry WSH practicesto prevent and control these hazards. The guidelines i s applicable to various publichealthcare clusters, private hospitals, community hospitals, private general practitioner(GP) clinics, nursing homes, Tradition Chinese Medicine ( TCM) clinics and veterinary clinics.

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workplace safety and health guidelines 54 healthcare

The leadership and commitment from management is essential in establishing a safe andhealthy workplace. Active involvement from leaders is critical to the success of workplacesafety and health (WSH) management initiatives. A clear WSH policy endorsed by topmanagement would be a good start to demonstrate the organisation’s commitment toemployees’ safety, health and wellbeing.

Management can appoint champions at various organisational levels to promoteawareness and build capabilities in WSH. A member of senior management could also beidentied to ensure that all workplace issues are looked at from all perspectives includingWSH and the impact of work on health and vice-versa is considered.

2 Commitment from Top Management

Managing Workplace

Safety and Healthin Healthcare

Figure 1: Sample WSH policy.

(Name of Organisation)Workplace Safety and Health Policy

All Management and Employees pledge to• Comply with relevant Workplace Safety and Health (WSH) regulatory and

other relevant requirements;

• Create a safe and healthy workplace for all employees, customers andmembers of the public;

• Improve and sustain WSH performance; and

• Develop a positive WSH culture within the organisation.


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• Communicated effectively to allemployees to ensure that they areaware of their individualWSH obligations;

• Made available to interested parties;• Reviewed periodically to ensure it is

relevant to the facility; and

• Committed to the protection of thesafety and health of all members ofthe facility by preventing work-relatedaccidents, ill-health and incidents;continual improvement and compliancewith current applicable legislation (e.g.WSH Act, Biological Agents and ToxinsAct, etc.) and other requirements towhich the facility subscribes to.

A systematic approach where themanagement of WSH goals is integratedwith the organisation’s managementobjectives is essential to manage risksand prevent accidents and ill-health ina healthcare facility. Each facility shouldhave some form of safety and health

management system in place thatcovers safety, health and wellbeing of allemployees in the workplace.

Regardless of the size of the facility, aneffective WSH management systemshould include ve key elements(see Figure 2).

3.1 Workplace Safetyand Health Policy The leadership and commitment frommanagement is critical for an effectiveWSH management system. Themanagement should develop a clearWSH policy that communicates thehealthcare facility’s overall safety andhealth objectives and how it aims toachieve its commitment. The policy should be:

• Endorsed by the facility’stop management;

• Suitable to the nature and scaleof the facility‘s WSH risks;

• Understood by all employees;

2Source: SS506 – Part 1: Specications

3 Managing Workplace Safety andHealth in Healthcare A plan with clear objectives and standards

is essential to maintaining a consistentapproach in the implementation of aWSH management system. Adequateand appropriate planning based on initialreview, subsequent reviews and otherrelevant data should include:

• WSH objectives to protect the safetyand health of employees;

• Responsibilities and performancecriteria indicating what is to be done bywhom and when;

• Selection of measurement criteria toconrm the objectives are met; and

• Allocation and provision of adequateresources such as time, money,manpower etc.

Together with the plan, all employeesmust be aware and understand allsignicant WSH hazards within theorganisation. The risks posed by thesehazards must be reduced through theimplementation of control measures. Thiswill form the foundation of an effectiveWSH management system.

Procedures should be established inthe WSH management system for theidentication of hazards, assessment ofrisks, and implementation of necessarycontrol measures.

The procedures to conduct riskassessment (RA) are explained inChapter 5.2.

Figure 2: Key elements of a WSHmanagement system 2.

3.2 Planning

Management

review

Continual Improvement

OH & S policy

Planning

Implementationand operation

Checking andcorrective action


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All facilities, regardless of size, shouldimplement relevant proceduresto address:

• Recordkeeping and notications(includes incidents, accidents anddangerous occurrences, ill nesses, riskassessments (RA) and training records);

• Emergency response plans (includesres, chemical spills, airborne releaseof hazardous substances and naturaldisaster emergencies, etc.);

• Regular review of WSH programme(s);

• Management of change (modicationor introduction of new work methods,materials, processes or machinery);

• Exposure monitoring (includesmonitoring of workplace levels ofchemical, noise hazards and/or medicalsurveillance and action plans);

• Preventive maintenance programme(includes critical equipment andsystems); and

• WSH training for employees (includesinduction and periodic training andassessment for competency).

The following may be included in theWSH management system, dependingon the size of the facility and needs ofthe organisation.

• A WSH committee (members shouldcome from different functions andlevels such as management, operations,clinical professionals, human resource,and safety and health);

All facilities should establish proceduresto monitor and measure WSHperformance on a regular basis forcontinual improvement. Checks on theWSH management system should bedone periodically by the facility and byconducting regular audits of the system.

WSH personnel should look out forunsafe acts and conditions above andbeyond those notiable to the Ministryof Manpower (MOM). Corrective and/or preventive actions should be takento eliminate the causes of actual andpotential accidents or incidents ofill-health.

A review of an existing WSHmanagement system should assess theperformance against key indicatorssuch as:

• Compliance to relevant legislation;

• Number of WSHprogrammes implemented;

• Number of workplace accidents,incidents and ill-health recorded; and

• Percentage of controlmeasures implemented.

Following the WSH performanceassessment, proposed improvementsto the system and its connectingprocesses should be reviewed throughRA process prior to implementation.

3.3 Implementationand Operation

3.4 Checking andCorrective Actions

• Regular WSH Inspections or workplacevisits; and

• Management of contractual,outsourced and insourced work,medical students, temporary staff andvolunteer work.

Access to specialised advice such asoccupational hygiene, occupationalmedicine, etc can be made available on aneed-to basis. The roles and responsibilities

of personnel who manage the WSHmanagement system or are involved inany of its sub-elements should be clearlydened, documented and communicatedto ensure an effective implementation.All personnel should also be trainedcompetently to perform their roleseffectively. Training procedures should alsotake into account the responsibilities andabilities of these personnel.

All facilities should also have proceduresto make sure that important WSHinformation is communicated betweenemployees and other interested parties.Examples of these communications (butare not limited to) include:

• Review of WSH policies, RA and

risk control measures andsupporting programmes;

• Safe work procedures (SWPs);

• Selection, use and maintenance ofpersonal protective equipment (PPE); and

• Emergency procedures for thehealthcare facility.

Any changes in the documentedprocedures resulting from correctiveand preventive actions should bedocumented and communicated toaffected employees to ensure continuity.Evaluation of the residual risk shouldbe performed to ensure that the riskwas reduced.

Procedures should be established forperiodic audits of the WSH managementsystem. This is necessary to determine if the system:

• Conforms to what was specied inthe procedures and documents;

• Implemented and maintainedproperly; and

• Meet the facility’s policy and objectives.

Wherever possible, audits shouldbe conducted by personnel who areindependent of the processes oractivities that are being examined(e.g. internal auditors from anotherDepartment). The audit results shouldthen be documented and communicatedto the management and personnelresponsible for follow up actions.


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The facility’s top management shouldreview the WSH management systemto ensure its suitability, adequacyand effectiveness. Reviews shouldbe conducted at intervals set by themanagement and of duration suitable forthe type of facility. The results of periodic

audits will help the management tofocus on areas of concern duringsuch reviews.

Taking into consideration the auditresults, changing circumstances andneed for continual improvement, thereview should address potentialchanges to:

• WSH policies;

• Objectives and targets;

• Elements of the WSH managementsystem; and

• WSH programmes.

The WSH (Incident ReportingRegulations requires employers to reportaccidents, dangerous occurrences and allwork-related traffic accidents involvingtheir employees. Employers and doctorsmust also report occupational diseasesat workplaces.

Employers are advised to submit the

report within 10 days of the incident toMOM through the electronic reportingsystem, iReport (http://www.mom.gov.sgiReport).

3.5 ManagementReview

Further information can beobtained from:

• Singapore Standard SS506:Occupational safety and health (OSH)management systemPart 1: 2009 RequirementsPart 2: 2009 Guidelines for theimplementation of SS506: Part 1Part 3: 2013 Requirements for thechemical industry

• British Standard (BS) OHSAS 18001Occupational Health andSafety Management

• International Labour Organisation (ILO)Guidelines on Occupational Safety andHealth Management Systems

4 Incident Reporting and Investigation

Figure 3: Reportable incidents, accidents andoccupational diseases.

Employers must submit noticationsof occupational diseases within 10days of receipt of a written diagnosis.Reports or notications made under theRegulations must be kept for at leastthree years from the time of reporting.

Employee injuries and illnesses whichare not reportable to MOM could be

recorded and kept by the facility formonitoring purposes. These recordscan provide insight into the WSHperformance of the facility as well as theeffectiveness of its WSH programme(s).

Other useful information that could becaptured in such a monitoring logcan include:

• Severity of the injury or illness;

• Date and time of the occurrence;

• Brief description of the occurrence;

• Particulars of the employee(s)involved; and

• Lost time associated with the injuryor illness.

Reportable Incidents, Accidents andOccupational Diseases

(1) An accident in the course of work thatresults in:

• Fatality; and • Hospitalisation for at least 24 hours; or • the injured is given more than three days

of medical leave (cumulative)

(2)Work-related traffic accidentsinvolving employees

(3) A dangerous occurrence such as:• Explosion or re;• Collapse of structure or equipment; and • Machinery damage

(4) An occupational disease (regardless ofwhether any medical leave was given).Refer to Appendix A for the list of notiableoccupational diseases


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5.1 Preparation

Figure 5: Three steps to assess workplace risks.

1. Hazard Identications 2. Risk Evaluation 3. Risk Control

• Identify hazards.• Identify potential

accidents or incidents.

• Estimate the risk levelsof the workplacehazards identied.

• Prioritise the hazardsto be controlled.

• Formulate the controlmeasures accordingto the Hierarchy ofControls (see Figure 4)

• Analyze and evaluateresidual risks.

A multi-disciplinary RA team should beformed, consisting of personnel whohave different job responsibilities forthe work operations, personnel whoare familiar with the potential hazardsand risks of the work activities such asWSH officers, healthcare professionalsand human resource representatives.

Individual Health Factors• Older employees,employees with pre-

existing health conditions,obese employees etc.

Work Organisation• Work overload, prolonged

working hours, poorcommunication betweensuperviors and staff etc.

Physical WorkEnvironment & Processes

• Exposure to airbornepathogens, infectious

diseases, forceful exertionsduring manual handling

of patients etc.

Figure 6: Three aspects of hazard identication.

5.2.2 Risk Evaluation

For each hazard identied, estimate therisk levels of the hazards and determinetheir acceptability. The outcome of a riskevaluation will help in prioritising actions

to control the hazards and minimisesafety and health risks to theaffected employees.

When estimating the risk level associatedwith each hazard, predict the severity ofthe hazard and estimate the likelihoodof the accident or ill health by takinginto consideration existing risk controls.Once the severity and likelihood havebeen established, the risk level can beobtained by using a risk matrix.

5.2 Risk AssessmentRelevant information pertaining tothe work and operations such as alist of work activities should also becollated beforehand to facilitate betterunderstanding by the team.

After completing the preparatory work,the workplace risks are then assessed inthree simple steps: hazard identication,risk evaluation and risk control.

All activities within the facility should beassessed and the information should bekept up-to-date. The activitiesshould include:

• Routine activities (e.g. disposal ofbiohazardous waste);

• Non-routine activities(e.g. testing of backup generator,

equipment maintenance);• Emergency conditions

(e.g. spillage of chemotherapeuticdrugs during transport);

• Activities of all personnel having accessto the facility including volunteers,medical students, subcontractors andvisitors; and

• Facilities at the workplace, whetherprovided by the facility or others.

5.2.1 Hazard Identification

When identifying hazards, three aspectsshould be considered and evaluated sideby side. These aspects are the physicalwork environment and processes, work

organisation and individual healthfactors. The possibility of exposure tohazards from other work processes inthe facility and the behaviour or workpractices of employees at work shouldalso be considered. Figure 6 illustratesthe three aspects with some possibleexamples or areas to consider.

Types of hazards that could be facedby healthcare employees in the courseof their work are further described inChapter 6.


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Figure 7: Risk evaluation using a 5x5 matrix with corresponding risk prioritisation numbers (RPNs).

Figure 7 gives an example of how severity and likelihood help to determine the risklevel via a 5x5 risk matrix with risk prioritisation numbers (RPNs).

LikelihoodSeverity

Rare(1)

Remote(2)

Occasional(3)

Frequent(4)

Almost Certain(5)

Catastrophic (5) 5 10 15 20 25

Major (4) 4 8 12 16 20

Moderate (3) 3 6 9 12 15

Minor (2) 2 4 6 8 10

Negligible (1) 1 2 3 4 5

Level Severity Description

5 Catastrophic Fatality, fatal diseases or multiple major injuries.

4 Major Serious injuries or life-threatening occupational diseases(includes amputaions, major fractures, multiple injuries,occupational cancer, acute poisoning).

3 Moderate Injury requiring medical treatment or ill health leadingto disability (includes lacerations, burns, sprains, minorfractures, dermatitis, deafness, work-related upperlimb disorders).

2 Minor Injury or il l health requiring rst-aid only (includes minorcuts and bruises, irritation, ill health with temporarydiscomfort).

1 Negligible Not likely to cause injury or ill health.

Level Likelihood Description

1 Rare Not expected to occur but still possible.

2 Remote Not l ikely to occur under normal circumstances.

3 Occas ional Poss ible o r known to occur.

4 Frequent Common ocurrence.

5 Almost Certain Continual or repeating experience.

Risk Prioritisation Number (Severity x Likelihood Risk Level

1 - 3 Low Risk

4 - 12 Medium Risk

13 - 25 High Risk

5.2.3 Risk Control

Based on the risk level or RPNdetermined, risk controls shouldbe selected to reduce the risk to anacceptable level. Figure 8 suggests theacceptability of risk for the different risk

levels and the recommended actions. The most effective way to reduce riskis to tackle the risk at the source. Thiscan be achieved through upstream

risk controls starting by eliminatingthe risk, followed by substitution, andimplementation of engineering controls,according to the Hierarchy of Controls(see Figure 9). Engineering controls are

physical means to reduce exposure tothe hazards such as mechanical guardsor local exhaust ventilation, etc.


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5.3 Implementationand Review The risk control measures onceapproved by the management shouldbe implemented immediately. For riskmanagement (RM) to be effective, thehazards and their control measures must

be communicated to the employeesperforming the work. The managerwho oversees the work area, functionor activity where the risks exist shouldensure that all persons who will beexposed are informed about the risksand the associated mitigating measures.

Regular inspections or audits can becarried out to verify the effectiveness ofthe control measures put in place.

ELIMINATION

SUBSTITUTION

ENGINEERINGCONTROLS

ADMINISTRATIVE

CONTROLS

PERSONALPROTECTIVE EQUIPMENT

MostEffective

LeastEffective

Figure 9: Hierarchy of Controls.

Figure 8: Recommended actions for risk levels.

RiskLevel

RiskAcceptability Recommended Action

Low Acceptable • No additional risk control measures may be needed.

• Frequent review and monitoring of hazards are requiredto ensure that the risk level a ssigned is accurate anddoes not increase over time.

Medium Tolerable • A careful evaluation of the hazards should be carriedout to ensure that the risk level is reduced to as low asreasonable practicable within a dened time period.

• Interim risk control measures such as administrativecontrols or personal protective equipment (PPE) may beimplemented while longer term measures arebeing established.

• Management attention is required.

High Not acceptable • High risk must be reduced to at least medium riskbefore work commences.

• There should not be any interim risk control measures.Risk control measures should not be overly dependenton PPE.

• If practicable, the hazard should be eliminated beforework commences.

• Management review is required before workcommencement.

This will ensure that the measures arecurrent and working to manage the risksat the workplace.

RA must be reviewed or revised at leastonce every three years. It must also bereviewed after an accident, incident oroccurrence of an occupational diseaseas a result of exposure to a hazard, asignicant change in the work processesthat could affect the safety and health ofemployees e.g. introduction of a newclinical procedure.

5.4 Record-keeping

All WSH RAs and related documentsshould be kept for at least three yearsand must be made available uponrequest by the Commissioner for WSH.

For more information on RM, refer to theWSH Council’s Code of Practice on WSHRisk Management at www.wshc.sg.


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Hazards in

the HealthcareEnvironment

6.1.1 Management ofHazardous ChemicalProgramme

Where hazardous chemicals are used,handled or produced, a managementprogramme should be established andimplemented to safeguard the safetyand health of persons who are liableto be exposed to these chemicals. TheManagement of Hazardous ChemicalsProgramme (MHCP) should form part ofthe overall WSH management systemof the facility. The MHCP must cover thesafety and health aspects throughout thelife cycle of the hazardous chemicals thatare used or produced, transportation,storage, handling, usage and disposal ofthe chemicals. The programme shouldinclude the objectives, targets, record-keeping process and written SWPs. The facility which uses or handles anyhazardous chemical may choose toimplement the relevant elements orcomponents of the MHCP dependingon the nature of its work, operation orprocess carried out, and the hazardouschemical(s) used or handled. As aminimum, the programme should coverRA and hazardous communicationthrough safety data sheets (SDS) andlabelling as these are essential forchemical safety management. Facilitiesare encouraged to adopt the GloballyHarmonised System of Classication andLabelling of Chemicals (GHS) for GHSSDS and product labels for the chemicalsthat they are using.

The range of workplace hazardsthat exist in healthcare facilities candiffer from other types of healthcareestablishments and is dependent onthe size and range of medical servicesprovided. This chapter focuses onboth common healthcare hazards (e.g.ergonomic risk factors, slips, trips andfalls, and sharps) and hazards that are

specic to certain medical services (e.g.mercury waste from amalgam removal,exposure to anaesthetic gases andchemotherapeutic agents).

The following sections describe thedifferent types of hazards in detail.

6.1 Chemical HazardsChemicals exist in different forms andthey can elicit varying toxic responses onthe human body from mild irritations topotentially serious or even fatal damageto body tissues and organs. Many factorscan inuence the risk of human exposureto chemicals used in healthcare facilitiesand these include:

• Toxicity and physical properties ofsubstances used;

• Nature and duration of exposure;

• Routes of entry into the human body;

• Aggregated effects ofcombined exposures;

• Work practices; and

• Susceptibility of the individual.

6 Hazards in the Healthcare Environment


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To understand more about theestablishment and implementation ofthe MHCP, refer to the WSH Guidelineson the Management of HazardousChemicals Programme.

6.1.2 Anaesthetic WasteGases and Vapours

Uses

Anaesthetic gases are used to provideinhalation anaesthesia in adults andchildren undergoing surgery, dentaland obstetric procedures. The commonagents used are nitrous oxide andhalogenated agents such as isourane,desurane, sevourane, enurane andhalothane. Healthcare workers can beexposed to waste anaesthetic gases(WAGs) when they leak out from varioussections of the anaesthetic circuits orwhen patients in the recovery roomexhale the gases into the air.

Effects of Exposure

Exposure to high levels of WAGs mayoccur with the use of unscavenged

systems and/or poor general ventilation.Common symptoms of exposure includeeffects on the central nervous systemsuch as mood disorders, headaches,fatigue and impaired neuropsychologicalperformance. Though rare, occupationaldiseases such as hepatitis due tohalothane, bronchial asthma due toenurane and allergic contact eczemadue to halothane or isourane can occur.

Locations where Used/Found

Healthcare workers can be exposed toWAGs and vapours in:

• Operating rooms;

• Recovery rooms (post anaesthesiacare units);

• Intensive care units;

• Obstetric delivery rooms; and

• Dental facilities.

Exposures can be higher in paediatricsurgery, otorhinolaryngologic (ENT)surgery and dental surgery. In ENT anddental surgery, the close proximity of the surgeon and attendant staff to thepatient’s mouth results in increasedexposure to the exhaled anaestheticvapours. Levels of WAGs are higher whenmask anaesthesia is used and the mask does not t the patient properly.

Workers at Risk

• Anaesthetists;

• Anaesthetic nurses and assistants;

• Post anaesthesia care nurses and staff;

• Surgeons and surgical staff;

• Dentists;

• Dental nurses, assistants andattendant staff;

• Recovery room nurses and other staff;

• Delivery room staff such asobstetric nurses;

• Medical technicians;

• Operating room personnel;

• Emergency room staff; and

• Radiology department personnel.

Routes of Exposure and Sourcesof Leaks

The main route of exposure is throughinhalation. In operating theatres, themain sources of leaks include:

• Tank valves;• High and low-pressure

machine connections;

• Connections in the breathing circuit;

• Defects in rubber and plastic tubing;

• Hoses;

• Reservoir bags;

• Ventilator bellows; and

• Y-connectors.

In addition, selected anaesthesiatechniques and improper practices canalso contribute to the escape of WAGsinto the atmosphere of the operatingroom such as:

• Leaving gas ow control valves open;• Leaving vaporisers on after use;

• Spillage of liquid inhaled anaesthetics;

• Poorly tted patient face masks; and

• Improperly inated tracheal tube andlaryngeal mask airway cuffs.

In recovery rooms, obstetric and dentalfacilities, the main source of WAGs isfrom the vapours contained in the airthat patients exhale.

Management of WasteAnaesthetic Gases

Anaesthetic gases are widely used inhealthcare facilities such as obstetricsdepartments, operating theatres anddental facilities. As there is a potentialfor side effects on the neurological andreproductive systems with excessiveexposure, a management system shouldbe in place to ensure that employeesare protected.

Management Policy

A policy stating the responsibility andcommitment of management inprotecting employees from exposure toWAGs must be written and implemented. This policy should be communicatedto all employees. Specic policies onthe exposure to pregnant and lactatingemployees should also be included.

Risk Assessment

Areas where anaesthetic gases areused or could be present should beidentied and documented. Employeesat increased risk for exposure to WAGsshould be identied.

Exposure to WAGs can be quantied byvarious means including:

• Measuring airborne concentrationsof WAGs;

• Identifying sources of leaking or wasteanaesthetic gases; and

• Personal sampling measurements ofexposed staff.


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Control Measures

The control of exposure to wasteanaesthetic gases should followthe hierarchy of controls. The use ofengineering controls is preferred,followed by safe work practices as thereduction of the hazard at source isgenerally the most effective.

Engineering Control Measures

Scavenging systemAn effective system to collect anddispose of anaesthetic gases in bothoperating and non-operating theatresettings must be put in place. WAGsshould be exhausted to the outsideatmosphere. In the operating theatre,an active scavenging system attachedto the site of overow in the breathingcircuit with a minimum ow rate of 40 l/min is an effective method of reducingexposure to WAGs. The presence of avolumetric buffer regulation systemis preferred.

All gases in the anaesthetic systemshould be channelled to the exhaust andthen to the scavenging system.

Reduction of leakages The amount of leakage in anaestheticmachines should be reduced to as lowas practically possible. Where possible,an automatic leakage detector shouldbe installed; otherwise, regular testsfor leaks should be performed and theresults documented and necessaryactions are being taken.

General ventilation There should be adequate ventilation inthe operating theatres or other roomswhere anaesthetic gases are used toensure there is additional dilutionventilation of the WAGs. The rate ofair change should be more than 15 airchanges per hour or as stipulated bynational regulations.

Safe Work Practices

Anaesthetic practicesExposure to high levels of anaestheticgases can occur during the inductionand emergent phases of anaesthesia.

Preparation of anaesthesia• An anaesthesia system should be

chosen to minimise leakage and allowactive scavenging of WAGs.

• Use of a low ow or minimum owsystem for fresh gas is preferred.

• Before anaesthesia is administered, acomplete inspection of the anaesthesiaapparatus should be done daily beforethe commencement of the rst caseand an abbreviated check before

every case.• Face masks should be properly tted

and sealed to minimise leakage.

• Face masks should only be used iflaryngeal or tracheal tubes cannotbe used.

• If tracheal tubes, laryngeal masks andother airway devices are used, theyshould be positioned properly with thecuffs inated adequately.

• For intubation without a cuff,choose a tube size that inducesminimum leakage.

Induction of anaesthesia

• Exposure to WAGs can be reduced byusing either intravenous induction or adouble mask system.

• Check that the scavenging deviceis correctly connected before eachpatient is anaesthetised or wheneverthe apparatus is moved.

• Start using the scavenging systemduring the induction phase ofthe anaesthesia.

• Turn on the supply of the anaestheticgases after the face mask is placedproperly or after the tube is connectedto the patient system.

Maintenance of anaesthesia

• In mask anaesthesia, the effectivenessof the seal of the mask should bechecked constantly.

• When patient is disconnected from thebreathing system, the exhaust valveshould be opened while the open end

should be closed. Alternatively, the gassupply should be cut off briey and theanaesthetic gases in the buffer balloonis emptied via the scavenging system.

Emergence from anaesthesia

• Before removal of the mask or tube,oxygen should be administered at theend of the anaesthesia at a high owrate to ush any anaesthetics out ofthe anaesthesia system and thepatient’s lungs.

• The washed out anaesthetic gasesshould be removed by thescavenging system.

• The supply of anaesthetic gasesshould be turned off at the end ofthe anaesthesia.

Filling of vaporisers

• Handling of anaesthetics such as llingof vaporisers should not be done in therecovery room.

• Use safety devices when llingvaporisers to minimise the opportunityfor spills of volatile anaesthetic agents.

• Vaporisers should be lled in a wellventilated area. Use of a closed systemfor lling of vaporisers is preferred.

• Routine procedures for detection ofleaks should be present.

Maintenance Programme

There should be a regular preventivemaintenance programme for thefollowing equipment carried out bytrained individuals.

• Anaesthetic apparatus, hoses,

connections, reservoir bags, etc.;• Wall plugs;

• Anaesthetic gas piping;

• Anaesthetic gas scavengingsystems; and

• Ventilation systems.

During maintenance, points to note are:

• Care should be taken to assemble theequipment properly;


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• Connectors should be close-tting,gas-specic and appropriate to thespecic anaesthetic equipment;

• Parts that are damaged or of inferiordesign should be replaced;

• Regular checks for the properfunctioning of the scavenging systemshould be in place; and

• Records of maintenance shouldbe kept.

In addition, there should be anestablished, written maintenance planand scheduling of maintenance forthe various components of theair-conditioning and exhausting systems.

Administrative Measures

Record keeping

The following records should beadequately kept:

• Types of anaesthesia apparatus andvolatile agents in use;

• Daily inspections of apparatus andscavenging systems in use;

• Written work instructions for proper

use of anaesthetic apparatus,scavenging systems, proceduresfor lling of vaporisers, spill or leakmanagement, safe work practices andmaintenance of apparatus;

• Records of preventive maintenanceand checks;

• Incident investigation reports;

• Action plans, if any;

• Monitoring records of WAGs, ifavailable; and

• Medical surveillance results, if any.

Training and education

All staff handling or using volatileanaesthetic agents should be regularlytrained in the following aspects:

• Health effects of exposure tothese agents;

• Rationale of engineeringcontrol measures;

• Proper use of anaesthetic equipment;

• Safe work practices;

• Use of appropriate PPE; and

• Management of spills or leaks. The training should be updatedwhenever there is a change inequipment, processes or anincident occurs.

Personal Protective Equipment

Personal protective equipment (PPE)should not be used as a substitute forengineering control measures, safe work

practices or administrative controls inprotecting employees from exposure toWAGs. In the event of a spill, PPE shouldbe used in conjunction with engineeringmeasures, safe work practices andadministrative controls to contain andclean up the spill. Choice of appropriatePPE such as chemical resistant gowns,gloves, goggles and respirators dependson the type of agents used. Informationin the SDS should be consulted.

Management of Spills and Disposalof Liquid Anaesthetic Agents

Spills of small amounts of liquidanaesthetic agents would probably haveevaporated at room temperature beforea cleanup can be initiated. There shouldbe a written procedure for thecontainment, clean up and disposal of large spills. Only adequately trainedand equipped staff should be allowedto respond to such spills. If you areunsure of the specic procedures andappropriate PPE, consult the SDS orthe manufacturer.

General guidelines to help minimiseexposure of employees to waste liquidanaesthetic agents are:

• Wear appropriate PPE – chemicalprotective gowns, gloves, respiratorand goggles;

• Ventilate the area where possible;

• Persons without PPE should not bepresent until the area is deemed safe bytrained personnel;

• Collect spilt liquid and absorbentmaterials used and put in a tightly

capped glass or plastic container. Sealand label the container; and

• Container should be handed over tothe proper waste disposal contractorsand should be disposed of according tonational or international regulations.

Monitoring

Monitoring exposure at the workplace

Measuring the airborne levels of anaesthetic gases at the workplaceis a method of evaluating workplaceexposures. Different methods and typesof measurements can be used. Choiceof method and sampling strategywould depend on the objective of thesampling and staff are advised to consult

technical experts and manuals for theappropriate method. Data obtained fromthe monitoring can be used to assesseffectiveness of control measures so asto ensure the lowest levels of WAGs.

Reporting and record keeping

There should be a reporting system inplace so that staff exposed to WAGs canreport incidents. Exposure records andbiological tests of exposed staff shouldbe properly kept and maintained.As WAGs may have effects on thereproductive system, the organisationshould develop a policy regardingexposure of all staff particularlyvulnerable workers such as thosepregnant, lactating and planning for

a pregnancy.

Medical surveillance

The organisation may want to put inplace a surveillance system for earlydetection of health effects fromexposure to WAGs.


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Recommended elements to be includedin the programme are:

• Baseline or pre-placement medicalquestionnaire including:

- A detailed occupational history;

- Past exposure to WAGs;

- Past medical history with emphasison hepatic (liver), renal (k idney),neurological (nervous system),cardiovascular (heart and

circulation) andreproductive functions;

- Medical evaluation includinghistory and physicalexamination; and

- Suitable laboratory tests where applicable;

• Annual questionnaire emphasising theabove systems;

• Appropriate laboratory/biological testsif necessary;

• Case nding to allow for reporting ofhealth effects by employees;

• Incident reporting in the event there isexposure to high levels of anaestheticagents such as spills or leaks, etc.;

• Reproductive hazards policy to addressworker exposure and reproductiveeffects in both male andfemale employees;

• Final review if a worker requests for a job transfer or leaves the job;

• Maintenance of SDS for all anaestheticagents in use;

• Exposure and medical records ofemployees who may be exposed toanaesthetic agents should be properlykept and maintained; and

• Information in the surveillance systemshould be used to review workingconditions and control measures.


• US Occupational Safety and

Health Administration (OSHA):Anesthetic Gases: Guidelines forWorkplace Exposures

• Centers for Disease Control andPrevention, National Institute forOccupational Safety and Health(CDC, NIOSH): Waste Anesthetic GasesOccupational Hazards in Hospitals

• CDC, NIOSH: Control of Nitrous Oxide inDental Operatories

• WSH Guidelines on the Management ofHazardous Chemicals Programme

• WSH (General Provisions) Regulations

6.1.3 Sterilising andDisinfecting Agents

Healthcare facilities use a variety of sterilising solutions to sterilise/disinfecta variety of heat-sensitive instruments,such as endoscopes, bronchoscopes,and dialysis equipment. These solutionsmay also be used as biological tissuexative and as a component in X-raylm developers.

Common sterilising agents includeglutaraldehyde, ortho-phthalaldehyde(OPA) and ethylene oxide.

Glutaraldehyde

Trade names of glutaraldehyde-basedproducts include but not limited to,Cidex®, Sonacide®, Sporicidin®, Hospex®,and Omnicide®. Inhalation of vapoursand aerosols can cause nose, throat andlung irritation. Respiratory sensitisationcan cause allergic rhinitis and asthma-like reactions. In addition to causingrespiratory effects, glutaraldehydeacts as a contact allergen, giving riseto contact dermatitis, usually on the

hands but occasionally on the face.Individuals who become sensitisedto glutaraldehyde can developdermatitis after coming into contactwith solutions containing as little as0.1% glutaraldehyde. The permissibleexposure limit for glutaraldehyde is0.2 ppm 3 (short term).

3Parts per million

Ortho-Phthalaldehyde (OPA)

OPA (Trade name Cidex® OPA) is aclear blue solution with little odour.It is a potential irritant that can causestinging, excessive tearing, coughingand sneezing to the eyes, skin, nose andother tissues. It is a potential skin andrespiratory sensitiser that may causedermatitis. Staff who have prolongedor repeated contact may developoccupational asthma or pre-existingbronchitis or asthma may be aggravated.In addition, the product stains proteinson surfaces to grey/black.

Exposure to such sterilising solutions canoccur during the following activities:

• Activating and pouring sterilisingsolution into or out of a cleaningcontainer system (e.g. soaking basinin manual disinfecting operations andreservoir in automated processors);

• Opening the cleaning container systemto immerse instruments tobe disinfected;

• Agitating the sterilising solution;

• Handling of soaked instruments;

• Removing instruments from thecontainer system;

• Rinsing the channels of instrumentscontaining residual sterilising solution;

• Flushing out instrument parts witha syringe;

• Drying instrument interiors withcompressed air;


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Control Measures

• Performing maintenance proceduressuch as lter or hose changes onautomated processors that have notbeen pre-rinsed with water;

• Cleaning up sterilising solutionspills; and

• Aerosolisation of solution (e.g. withspray bottles to spray-wipe surfaces).

• Substitute with a less hazardous chemical.

• Store soaking basins and processing units in

enclosed areas.• Provide local exhaust ventilation (e.g. laboratory hoods)

for open soaking.

• Automate the transfer of sterilising solution from drumsinto process containers using pumps and closedtransfer lines.

• Provide general dilution ventilation (10 air changes perhour, ANSI/AMMI 1996) for rooms where disinfection orsterilisation are carried out.

• Ensure that all containers containing sterilising solutionare covered at all times with tight-tting lids.

• Provide eyewash stations in all areas where sterilisingsolutions are handled.

• Use of PPE to prevent skin contact such as gloves (nitrilerubber gloves, butyl rubber gloves, and 100% copolymergloves may be used), sleeve protectors, safety eyewearand uid-resistant gowns or aprons.

Hierarchical approach Examples of control measures to reduce exposure

Elimination/Substitution

Engineering Controls

Safe Work Practices

Administrative Controls

Personal ProtectiveEquipment

Healthcare personnel who will comeinto contact with these agents includethose who work with cold sterilisationequipment (e.g. within endoscopydepartment and operating theatres,theatre sterile supply units (TSSU),central sterile supplies units (CSSU) anddental clinics).

For other approved neutralising agent,refer to the manufacturer’s instructionson neutralisation time. Discardneutralised solution into drain. Flushdrain thoroughly with water.


• US OSHA: Best Practices for the SafeUse of Glutaraldehyde in Health Care

• Society of Gastroenterology Nursesand Associates, Inc. (SGNA): Guidelinefor Use of High Level Disinfectants &Sterilants for Reprocessing FlexibleGastrointestinal Endoscopes

• CDC, NIOSH: Glutaraldehyde –Occupational Hazards in Hospitals

• Occupational Safety and Health Service,Department of Labour, New Zealand:Guidelines for the Provision of Facilitiesand General Safety and Health in theHealthcare Industry

• SA Health: Guideline for the Safe Use ofOrtho-phthalaldehyde (OPA)



Disposal of CIDEX OPA: CIDEX OPAshould be neutralised prior to disposal.Either glycine (free base), at theminimum rate of 33 g per 5 L ofCidex® OPA solution, or an approvedneutralising agent may be used asa neutraliser prior to disposal. Theminimum recommended neutralisationtime for glycine is one hour.


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Routes of exposure to ethyleneoxide include:

• Inhalation of ethylene oxide gas in air;

• Skin, eye or mucous membrane contactwith the liquid or with ethylene oxideabsorbed in solid materials;

• Oral – residual ethylene oxide iningested material; and

• Intravenous leaching of ethylene oxidefrom inadequately aerated medicaldevices inserted intravenously.

Control Measures

• Store supply cylinders in a ventilated enclosure (either aventilated cabinet or a hood that covers the point wherethe cylinder is connected to the steri liser supply line).

• Keep the steriliser enclosed either in a mechanicalaccess room or a cabinet, and the enclosure should beexhausted to a dedicated ventilation system.

• Cover oor drains with an anti-siphon air gap. The air gap,at the junction of the vacuum pump discharge line with

the oor drain should be enclosed. Dedicated exhaustventilation should be provided for the enclosures.

• Local exhaust ventilation sufficient to effectively removeethylene oxide should be as close as possible to the topof the steriliser door.

• Provide appropriate local exhaust ventilation (e.g.laboratory hoods) for sterilisers using cartridges orglass ampoules.

• Provide general dilution ventilation for rooms wheresterilisation is carried out.

• Provide real-time monitoring devices with audio andvisual alarm for ethylene oxide sterilising facilities.

• Centralise sterilising operations and access to steriliserrooms should be restricted.

• Develop a maintenance plan which includes regularchecks of door gaskets, valves, tubing, and pipingconnections for all steriliser units.

• Provide proper PPE to prevent skin orinhalation exposures.





Ethylene Oxide

Ethylene oxide (EtO) is commonlyused as a sterilising agent for medicaldevices and equipment that are heatand moisture-sensitive and thus cannotbe sterilised by steam. High vapourconcentrations of ethylene oxide (inthe order of 1000 ppm) can causeirritation and damage to the eyes andupper respiratory system, hoarseness,cough, headache, nausea and recurrentvomiting, fatigue and pulmonaryoedema. Less frequently reportedeffects include muscular weakness,abdominal discomfort and diarrhoea,and nervous system disorders. Ethyleneoxide liquid has the capacity to causeburns, blisters and dermatitis when itcomes into contact with skin. Ethyleneoxide is toxic in various body systems. Itis also a mutagen, an established animalcarcinogen and a human carcinogen(International Agency for Research onCancer (IARC), 2007) that may haveadverse reproductive effects on humans. The permissible exposure limit forethylene oxide is 1 ppm (long term).

Healthcare personnel who work inoperating rooms, central supply, renaldialysis units, respiratory therapydepartments and areas where ethyleneoxide is used such as autoclaves will beprone to these hazards. The odour of EtOcannot be detected below approximately700 ppm, therefore workers who areexposed to high concentration of thiscompound may not be aware.


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• CDC, NIOSH: Current IntelligenceBulletin 52: Ethylene Oxide Sterilizersin Health Care Facilities - EngineeringControls and Work Practices



Formaldehyde

Formaldehyde is a tissue sterilising agentand preservative often used in dialysisunits, histopathology laboratories andoperating theatres. Formaldehyde isoften combined with methanol andwater to make formalin. Formaldehydevapour can cause irritation to the eyesand the respiratory tract. In liquid orsolution form, it can cause both primaryirritation and sensitisation dermatitis andrarely, occupational asthma.

Control Measures

• Provide local exhaust ventilation over work stations usingformalin or specimens preserved in formalin.

• Provide eyewash station in all areas where formalinis handled.

• Provide traps in oor drains.

• Provide spill-absorbent bags for emergencies.

• Ensure that all containers containing formalin are coveredat all times with tight-tting lids.

• Purchase small quantities of formaldehyde in plasticcontainers for ease of handling and safety.

• Use of PPE to prevent skin contact such as respirators,gloves (nitrile rubber gloves, butyl rubber gloves, and100% copolymer gloves may be used), face shields, uid-resistant aprons and boots.



Safe Work Practices



Formaldehyde is recommended tobe handled as a known carcinogen(International Agency for Research onCancer (IARC), 2006) in the workplace. The short term permissible exposurelimit of formaldehyde is 0.3 ppm (shortterm). There is no long-term safeexposure level.

Healthcare personnel who are at riskinclude laboratory technicians, nurses,surgeons/dentists and pathologistsetc., where formaldehyde is used,e.g. operating theatres, pathologylaboratories or dialysis centres.


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6.1.4 Solvents

There are a wide range of solvents usedin healthcare facilities and they arereagents used in medical laboratories,cleaning agents and paints used inequipment maintenance workshops,cleaning agents used in housekeepingand renovation works (e.g. xylene,toluene and alcohols). Most solventscan be absorbed through the skin orby inhalation and ingestion. Manysolvents act as central nervous systemdepressants, causing headaches,dizziness, weakness, nausea, and othersymptoms. Solvents may also irritateeyes, skin and the upper respiratorytract. Prolonged contact may result indefatting and dehydration of the skin.

Long-term exposure to some solventshas been associated with cancer, adversereproductive effects, cardiovascularproblems, and damage to the liver,kidneys, central nervous system andhematopoietic system.

Healthcare personnel at risk includelaboratory technicians, workshoptechnicians, contractors andhousekeeping staff. Dentists, surgeonsand their assistants can also be exposedto volatile organic compounds andsolvents such as methacrylateand chloroform.

Control Measures

• Substitute hazardous solvents with lesshazardous alternatives.

• Provide local exhaust ventilation and enclosure of solventvapour sources for controlling exposures to solventsin laboratories.

• Provide warning signs and labelling of solvent containerswith information on the hazards of exposure to solventsand the precautions to take.

• Use protective equipment to prevent skin contact andinhalation such as gloves, respirator (for organic vapours)rubber aprons, goggles, and boots.






6.1.5 Mercury

Mercury can be found in equipmentsuch as thermometers, blood pressureapparatus and sphygmomanometers.Mercury is also used in dental amalgams.Exposure to mercury in the hospitalis usually the result of an accidentalspill arising from breakage of mercury-containing equipment and apparatus.Although inhalation is the major route of entry for mercury, the element can alsobe absorbed through the skin.

Exposure to short-term high levels ofmercury can produce severe respiratoryirritation, digestive disturbances andmarked renal damage. Long-termexposure to low levels of mercury resultsin the classic mad hatter syndrome,named for the makers of felt hats whoused mercury in processing.

This syndrome is characterised byemotional instability and irritability,tremors, inammation of the gums,gingivitis, excessive salivation, anorexia,and weight loss. Mercury has also beenreported as a cause of sensitisationdermatitis. The permissible exposurelimit for mercury vapour is 0.025 mg/m 3

(long term). Employees who areexposed to or are handling mercury orits compounds are required to undergomedical examinations. The test requiredis urine mercury and this must beconducted by a Designated WorkplaceDoctor and the results submitted tothe MOM.

• Provide exhaust systems to prevent the accumulationor recirculation of mercury vapours in equipmentmaintenance rooms/biomedical workshops.

• Provide mercury spill clean-up kits and training foremergency response staff.

• Establish emergency procedures for handling mercurycontamination including procedures for cleanup and forrespirator selection.




Control Measures


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6.1.6 Natural Rubber Latex

A number of proteins that make upnatural rubber latex (NRL) can cause thedevelopment of occupational asthmaand dermatitis in people exposedto them. In powdered NRL gloves,the proteins are easily carried on thecornstarch powder can become airborneand inhaled. Chemicals, also knownas accelerators, are added to latexin the processing phase. Chemicalsmost likely to cause reactions arethiurams, dithiocarbamates andmercaptobenzothiazoles (MBT).Healthcare workers are also exposed bydirect contact to NRL or chemicals inrubbers and plastics.

Exposure Situations/Procedures

• Healthcare workers in direct patientcare where the use of gloves is requiredand NRL gloves are used – clinics,operating theatres, clinical andresearch laboratories, wards, ICUs andautopsy rooms.

• Use of rubber containing equipmentsuch as IV bungs, catheters,

sphygmomanometers, drains,dental dams, anaesthesia masks,stethoscopes etc.

• Rubber containing consumer productse.g. rubber bands, washing up andother utility gloves, stress balls, erasersetc. kitchens, toilets and other generalfacilities, clinical areas, offices.

• Stretchy rubber products pose a higherrisk than dry rubber products.

Workers at Risk

• Healthcare workers using NRL gloves

particularly the powdered type–doctors, dentists, nurses andrelated staff, laboratory staff,research staff and pathologists.

• Kitchen staff, waste disposal staff,security staff.

• Workers with past history of multiplesurgical procedures.

• Workers with history of certain foodallergies such as banana, avocado, kiwiand chestnut.

• Workers with atopic allergic diseases.

• Substitute natural rubber latex gloves with alternativessuch as vinyl or other non-latex gloves.

• Use low protein, powder free gloves.

• Provide appropriate non-latex gloves innon-clinical tasks.

• Educate and raise awareness.

• Provide appropriate latex-free PPE.





Control Measures


• Health and Safety Executive (HSE), UK:Latex allergy – Occupational aspects ofmanagement – A national guideline

• CDC, NIOSH: NIOSH Alert: PreventingAllergic Reactions to Natural RubberLatex in the Workplace


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6.2 Biological andInfectious HazardsIn treating and caring for patients,healthcare workers and supportingstaff are exposed to various infectionssuch as Hepatitis B, Hepatitis C, HIV,Mycobacterium tuberculosis, varicellazoster (VZV), measles, mumps, rubella,gastrointestinal infections and scabies.In addition, exposure to animals andvegetable matter can cause allergies,dermatitis and asthma.

Infectious Diseases

Healthcare workers are exposedto infectious agents by inhalation,injection, ingestion or dermal contact.As infectious agents have the potentialto multiply, breaking the chain of transmission is important in the controlof infection.

Factors to determine if the healthcareworker has been infected are:

• How the infection is spread;

• Dose of the organisms;

• Duration of exposure;

• Virulence of the infectious organisms;

• Availability of vaccines;

• Immune status of healthcare worker;

• Availability of post-exposureprophylaxis where applicable; and

• How well the organism survives inthe environment.

6.2.1 Infectious DiseaseManagement Programme Facilities should implement a healthand safety management programmefor infectious diseases to protect thehealth of the workers. This meanstaking an active role in carrying out risk assessments, setting health and safetystandards and developing policies,together with monitoring of standards

and enforcement of compliance. Specicfunctions such as carrying out risk assessments may be assigned tothe management line.

Management Policyand Strategy

The policy is a written statement of afacility’s intent to provide a safe andhealthy environment and should enlistthe support of employees in achievingits aims. The policy should detail thehealth and safety responsibilities withinthe facility. There should be systemsand procedures in place for ensuringhealth and safety of its employees. Allareas where there is potential exposure

to biological hazards such as wards,clinics, operating theatres, sterilisingdepartments, cleaning, housekeeping,laundry and portering and so on shouldbe included.

Register of Work Activities

A register of all processes related toinfection control should be documentedincluding routine, non-routinework, disposal of infectious matter,

housekeeping, laundry and maintenanceof contaminated equipment. Thisregister should also include informationon the staff who may be exposed andthe areas in which they work.

Risk Assessment and Risk Control

Management should ensure that suitableand sufficient RA are made for allactivities where there is handling orexposure to infectious agents. RA is ameans of determining the risk associatedwith exposure to a particular hazardor work.

The steps in doing RA include:

• Hazard identication;

• Determine workers who are at risk andhow harm could arise;

• Likelihood of harm arising, assessmentof adequacy of existing precautions;

• Document ndings and controlmeasures selected as well as any othersteps necessary to reduce exposureto risk; and

• Review the RA if there is a change inthe nature of work or process.

The coverage of the risk assessmentsshould include:

• Routine work;

• Non-routine work;

• Emergency situations;

• Activities of personnel with access tothe facility such as visitors,volunteers,subcontractors and workers;

• Vulnerable persons such as expectantmothers and those with impairedimmune systems; and

• All facilities at your workplace.

Risks should be controlled at sourceand control measures should followthe hierarchy of controls viz eliminationor substitution, engineering controlmeasures, administrative measuresand PPE.

Documentation of RA and controlsshould be kept up-to-date. These shouldbe reviewed periodically or wheneverthere is a change in the nature of theprocess, substances or equipment usedor on the occurrence of an incident or anoccupational disease.

Safe Work Procedures

There should be written procedures onany work where there is exposure toinfectious matter and should includeemergency areas, patient care areas,operating theatres, laboratories,housekeeping and laundry, mortuary wastedisposal and biomedical maintenance.

The SWPs should include the correct useof appropriate PPE and the safetyand health precautions to be taken inthe course of work. Existing programmessuch as infection control programme,tuberculosis (TB) infection control,standard precautions for preventionof bloodborne infections, contact,airborne and droplet precautions can beincorporated into the infectious diseasemanagement programme.


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The use of standard precautions appliesto all patients in any health care facilities.It is based on the premise that blood,body uids, secretions, excretions exceptsweat, non-intact skin and mucousmembranes may contain transmissibleinfectious agents. The components arehand hygiene, use of PPE such as gloves,uid resistant gowns, mask, eye or faceshield and proper handling of potentiallycontaminated equipment. The extentof PPE used depends on the risk of healthcare workers – patient interaction.Healthcare workers should ensure thatPPE’s are not brought out of clinical orlaboratory areas.

Environmental Infection Control

Certain infections can be transferredby direct contact with contaminatedsurfaces. There should be a programmefor cleaning and decontaminatingclinical contact areas in order to reducetransfer of infections to healthcareworkers and other patients. Maintaininga clean environment by goodhousekeeping would also reducedisease transmission.

Disposal

Operations where biological/infectiouswastes are generated should begoverned by a waste managementsystem that include proper labellingaccording to national or internationalcodes, proper storage, treatment,transport and disposal of such wastes.

Personal Protective Equipment

Personal protective equipment (PPE)includes respirators, safety glasses, faceshields, overalls, aprons, gloves andboots. Selection of PPE should be basedon transmission routes of infection,risk group of the organisms, otherconcomitant hazards and the natureof work. To ensure that employeesare effectively protected, PPE shouldbe properly selected, correctly used,comfortably tted and regularlymaintained. A suitable PPE programmeshould be implemented taking intoaccount the above elements.

Emergency Planning

Emergency planning is required forincidents, accidents or emergenciesthat might occur such as sharps injuries,aerosolisation of highly infectiousorganisms, spills of organisms outsideof biological safety cabinets. The planshould describe what needs to be done.

For example, emergency procedures, rstaid procedures, use of safety equipmentand appropriate PPE, decontaminationand cleaning, and proper waste disposal.Emerging infectious diseases is anotherarea that should be catered for.

Post-Exposure Programme

A post-exposure programme should beimplemented to cope with employeeswho are infected with or occupationallyexposed to infectious diseases. Treatment given would depend on thenature and type of infection the worker

has been exposed to. The programmeshould also address if a healthcareworker should be restricted from workand determine when he/she would be tto return to work.

Health Surveillance

Surveillance is dened as an ongoing,systematic collection, analysis,interpretation, and dissemination ofdata regarding a health-related eventfor use in public health action to reducemorbidity and mortality, and toimprove health.

A system should be put in place todetect early signs of work-related illhealth in employees exposed to certainhealth risks and to act on the results.

Vaccinations (Immunoprophylaxis)

Employees at increased risk of exposureto vaccine-preventable infectionssuch as Hepatitis B, inuenza, varicellazoster and rubella might benet fromthe implementation of a vaccinationprogramme. The programme shouldincorporate information on theepidemiology of such infections andinclude inputs from an infectiousdisease consultant in accordance tothe institution’s policy or any otherregulatory guidelines.

Case Finding

A facility should have a system for activecase nding of healthcare workerswith clusters of fever symptoms,gastrointestinal or other symptoms,

or single cases of sharps injuries,occupational asthma, dermatitisand other occupational diseases. Asystematic epidemiologic investigationshould be done to determinecommonalities in persons, place, andtime; and guide implementation of interventions and evaluation of theeffectiveness of those interventions.

Records

A facility should keep exposure recordsof its employees who work with morehazardous organisms in the laboratoriesor in clinical areas. Information in therecords should include type of work,location of work done and specicincidents or exposures that occurred.Where required by current legislation,occupational diseases should bereported to MOM. All records should beproperly kept and maintained for at leastve years.

Monitoring and Review

Information on occurrence of infectiousdiseases should be monitored andanalysed with regard to frequency,health effects, absenteeism andperformance of the safety andhealth management system. The safetyand health management team shouldreview the overall policy, planning andimplementation of the infectious diseasemanagement programme regularly toensure it effectiveness and relevance.


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Education and Training

All employees should be given suitableand sufficient information about thebiological agents they could be exposedto and the risks due to the exposure. They should also be informed of theresults of the RA, the measures totake, usage of PPE, emergency andrst aid procedures, infection controlpolicies, vaccinations, post-exposureprophylaxis and reporting proceduresfor occupational accidents and diseases.A health and safety training programmeshould be implemented to ensure thatSWPs are known and understood byall staff.

6.2.2 BloodbornePathogens

Healthcare workers are potentiallyexposed to bloodborne pathogenssuch as Hepatitis B, Hepatitis C and HIV. They are at risk to these diseasesfrom getting infected by needlestickinjures or cuts from other sharp objectscontaminated with an infected patient’sblood or through contact of the eyes,

nose, mouth or non-intact skin with aninfected patient’s blood or bodily uids.Hepatitis B, Hepatitis C and HIV/AIDS arethe most common infections that can betransmitted to healthcare workersby blood and bodily uids. The mainroutes of exposure are by percutaneousinoculation or permucosal means i.e.contact of an open wound, non-intactskin or mucous membranes (due to spillsand splashes).


• Procedures resulting in a percutaneousinjury or contact of mucosal membraneor non-intact skin with infectedblood, tissues or bodily uids such asneedlestick or sharps injuries, spills orsplashes and human bites;

• Venepuncture e.g. in wards, clinics andoperating theatres;

• Laboratory work e.g. in clinicallaboratories, research laboratories,animal facilities;

• Surgery e.g. in operating theatres;

• Resuscitation e.g. in emergencydepartments, wards,operating theatres;

• Transport of injured patients who haveopen bleeding wounds;

• Post-mortem procedures –autopsy rooms;

• Disposal of biohazardous wastee.g. in wards, clinics, operatingtheatres, laboratories, waste holdingand treatment areas; and

• Repair of medical anddental equipment.

Workers at Risk

• Doctors;

• Nurses;

• Phlebotomists;

• Laboratory workers;

• Emergency room staff;

• Waste handling and disposal workers;

• Ambulance and related staff;

• Biomedical technicians andengineers; and

• Mortuary staff.

• Eliminate use of needles or sharps for IV drug delivery.

• Consider use of alternative IV delivery systems.

• Consider substitution of non-needle systems for certaintypes of blood prick tests.

• Explore other routes of medication delivery e.g. oral.

• Review specimen collection procedures.

• Engineer sharps or needles with built-in sharps injuryprevention features.

• Adopt a needleless intravenous (IV) delivery systems.

• Use blunt tipped suture needles where appropriate.

• Use blunt-ended scissors.

• Place proper sharps disposal containers inconvenient locations.

• General safe work practices:

- Prohibit eating, drinking, smoking and theapplication of cosmetics in areas where there is arisk of contamination;

- Prevent puncture wounds, cuts and abrasions,especially in the presence of blood andbody uids;

- Cover all breaks in exposed skin by usingwaterproof dressings and suitable gloves; and

- Procedures for administration of medications toconfused or combative patients.

• Use standard precautions:

- Hand hygiene before and after procedures; and

- Safe handling of needles and sharps - no recapping,bending, breaking needles.




Safe Work Practices

Control Measures


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• Safe injection practices:

- Practise basic principles of aseptic technique for thepreparation and administration ofparenteral medications;

- Use sterile, single-use, disposable needle andsyringe for each injection given;

- Prevent contamination of injection equipmentand medication;

- Use single-dose vials (preferred over multiple-dose vials);

- Dispose glass ampoules properly as soon aswithdrawal of contents is completed; and

- Proper patient handling techniques for phlebotomyon uncooperative patients.

• Control contamination of surfaces:

- Contain the infectious agents;

- Use appropriate decontamination procedures byheat or chemical means; and

- Proper management of spills and other formsof contamination.

• Safe handling and disposal of waste:

- Use appropriate sharps containers i.e. puncture-resistant plastic containers.

• Work in operating theatres:

- Use instruments, rather than ngers, to graspneedles, retract tissue, and load/unload needlesand scalpels;

- Give verbal announcements when passing sharps;- Avoid hand-to-hand transfer of sharps; use a basin

where appropriate;

- Use alternative cutting methods such as bluntelectrocautery and laser devices when appropriate;

- Substitute endoscopic surgery for open surgerywhere possible; and

- Use round-tipped scalpel blades instead of sharptipped blades.


• Maintain and ensure proper cleaning anddecontamination of equipment.

• Adopt infection control practices for speciallumbar procedures.

• Develop a management policy on healthcare workersinfections for HBV, HCV and HIV and exposureprone procedures.

• Screen HBV, HCV and HIV for healthcare workers especiallythose who perform exposure prone procedures:

- Provide counselling for above workers.

• Education and awareness:

- Staff should be aware of the hazards of bloodborneinfections and trained in safe work practices.

• Use appropriate PPE such as:

- Impervious gowns;

- Gloves;

- Eye protection such as face shields/goggles/safetyspectacles/visors where splashes are possible; and

• Rubber boots or plastic overshoes where the ooring/ground is likely to be contaminated.




Further information can be obtained from:

• Ministry of Health (MOH) Singapore: Guidelines for Preventing Transmission ofBloodborne Infections in a Healthcare Setting


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6.2.3 Infectious Agents otherthan Bloodborne Pathogens

Pathogens of various classes suchas bacteria, viruses, fungi, parasites,prions can cause infections. The routesof infection vary with the organismand type of infection. Some organismscan also be transmitted by multipleroutes and not all organisms aretransmissible from person to person.

Droplet Infections

Respiratory droplets (usually more than5µm in diameter) carrying infectiouspathogens transmit infections whenthey travel directly from the respiratorytract of the infectious individual to themucosal surfaces of the susceptiblerecipient, usually over short distances. This usually happens when infectedpatients cough, sneeze or talk andhealthcare workers inhale the particles.Examples of infections spread in thisway are SARS-CoV, Mycobacteriumtuberculosis (TB), inuenza, adenovirus,rhinovirus, Group A Streptococcus,Mycoplasma pneumoniae, Bordetellapertussis and Neisseria meningitidis.


• High risk situations where there isaerosolisation of patient’s respiratorysecretions such as endotrachealintubation, bronchoscopy, sputuminduction, performance of laryngealswabs, cough induction by chestphysiotherapy, cardiopulmonaryresuscitation, surgical procedures,autopsy etc.

• Caring for infective patients i.e.individuals with infections such asSARS, TB, inuenza etc.

• Generation of aerosols of infectedlaboratory samples.

• Dental procedures.

Workers at Risk

• Healthcare workers in direct patientcare particularly departments ofrespiratory medicine, infectiousdiseases, emergency care, andareas involving care ofimmunocompromised patients.

• Clinical and researchlaboratory workers.

• Mortuary workers and autopsyroom staff.

• Dental healthcare workers includingdentists, assistants and technicians.

• Negative pressure rooms are desirable.

• Consider use of microbiological safety cabinets forlaboratory work such as immunomagnetic separation andinnoculation of biochemical test kits that maygenerate aerosols.

• Droplet precautions:

- Provide single occupancy room for patient is preferred;

- Cohorting of patients if single room is unavailable –to discuss with infectious disease consultant;

- Spatial separation of more than one metre betweenbeds in multi-bed wards;

- Keep curtain drawn between beds in multi-bed wards;

- Use of uid resistant mask for close contact withinfectious patient;

- Wear a mask before entering a room;

- Change protective attire and per form hand hygienebetween contact with patients in the same room; and

- Adhere to the proper sequence of removing PPE.

• Patients to wear a uid resistant mask (if tolerated)when being transported outside the room and to followrespiratory hygiene/cough etiquette.

• A respiratory hygiene/cough etiquette programmeshould be:

- Used with any patients and accompanying persons

with undiagnosed transmissible respiratoryinfections; and

- Applied to those with cough, congestion,rhinorrhea, or increased production of respiratorysecretions when entering a healthcare facility.

• Elements of a respiratory hygiene/cough etiquetteprogramme are:

- Educate healthcare facility staff, patients and visitors;

- Source control measures such as covering themouth/nose with a tissue when coughing andprompt disposal of used tissues;



Safe Work Practices

Control Measures


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- Use surgical masks on the coughing personwhen tolerated;

- Ensure hand hygiene after contact with respiratorysecretions; and

- Spatial separation, ideally more than one metre, ofpersons with respiratory infections in commonwaiting areas when possible.

• Education and training on hazards and effects as well assafe work practices.

• Use surgical masks (uid resistant).• Use impervious gowns.

• Use gloves.

• Ensure eye protection such as face shields/goggles/safetyspectacles/visors where splashes are possible.

• Wear rubber boots or plastic overshoes where theooring/ground is likely to be contaminated.




6.2.4 Airborne Infections

Airborne infections are transmittedwhen the infectious aerosols (such asairborne droplet nuclei or small particles)are small enough to remain airbornefor a longer time and distance. Micro-organisms can be carried by air currentsand be dispersed over longer distancesand infect individuals who are not inthe vicinity of infected individuals.Such infections include Mycobacteriumtuberculosis (TB), rubeola virus (measles)and varicella zoster (chickenpox). Variola(smallpox) can also be transmitted bythis route under certain conditions.

Limited airborne transmission of SARS-CoV, inuenza, rhinovirus, norovirus androtavirus has also been demonstrated.

Healthcare workers can become infectedwhen they inhale the infectious particles.


• High risk situations where there isaerosolisation of patient’s respiratorysecretions such as endotrachealintubation, bronchoscopy, sputuminduction, performance of laryngealswabs, cough induction by chestphysiotherapy, cardiopulmonaryresuscitation, surgical procedures andautopsy etc.

• Caring for infective patients such asindividuals with infections such asSARS, TB, inuenza.

• Outpatient clinics, physicians’ offices.

• Emergency departments.

• Respiratory and infectiousdisease departments.

• Aerosolisation of infectedlaboratory samples.

• Performing post mortems ofinfected patients.

• Dental procedures.

Workers at Risk

• Healthcare workers in direct patientcare particularly departments ofrespiratory medicine, infectiousdiseases and emergency care, andareas involving care ofimmunocompromised patients.

• Emergency room staff.

• Surgical staff.

• Clinical and researchlaboratory workers.

• Biological waste handlersincluding cleaners.

• Housekeeping staff.

• Mortuary workers and autopsy roomstaff, particularly if using anoscillating saw.

• Dental healthcare workers includingdentists, assistants and technicians.

• Ambulance crew.


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Control Measures

• Ventilation design.

• Laminar ow.

• Use high efficiency particulate air (HEPA) lters.

• Use biological safety cabinets in the laboratory whenperforming aerosol generating tests.

• Use airborne infection i solation rooms (AIIR) (negativepressure to the atmosphere); a single roomis preferable.

• In airborne infection isolation rooms (AIIR):

- Ensure that t he air pressure is checked visually dailywith the use of smoke tubes or utter strips; and

- At least 12 air changes per hour (new facility) or 6 airchanges per hour (old/existing facilities).

• During resuscitation, use of mouthpieces, pocketresuscitation masks with one way valves, and otherventilation devices.

• Maintain proper hand hygiene between contactwith patients.

• Adhere to the proper sequence of PPE removal.

• Use standard precautions:

- In waiting rooms, separate infectious patients suchas those with cough or sneezing in a separateenclosed room away from others; and

- Maintain a distance of at least one metre betweensymptomatic and non-symptomatic patients in thewaiting room.

• Implement a respiratory hygiene/coughetiquette programme which should be:

- Used with any patients and accompanying personswith undiagnosed transmissible respiratoryinfections; and

- Applied to those with cough, congestion,rhinorrhea, or increased production of respiratorysecretions when entering a healthcare facility.



Safe Work Practices


• Elements of a respiratory hygiene/cough etiquetteprogramme are:

- Educate healthcare facility staff, patients and visitors;

- Source control measures such as covering the mouthnose with a tissue when coughing and prompt disposalof used tissues;

- Use surgical masks on the coughing personwhen tolerated;

- Ensure hand hygiene after contact with respiratorysecretions; and

- Spatial separation, ideally more than one metre, ofpersons with respiratory infections in common waitingareas when possible.

• Safety equipment:

- Biological safety cabinets should be used for laboratorywork where necessary; and

- Type and specications of such cabinets woulddepend on the risk level of the microbiological agentsand procedure being performed.

• Educate and train staff on hazards and effects as well assafe work practices.

• Fit-tested particulate respirator N95 or higher;

• Appropriate eye protection such as safety goggles or faceshields depending on the risk.

• Use impervious aprons.

• Use appropriate gloves.• Wear rubber boots or plastic overshoes where the

ooring/ground is likely to be contaminated.




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6.2.5 Infections Transmittedby Direct Contact

Healthcare workers can become infectedwhen they

wsh healthcare guidelines

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