A Study of Occupational Health and Safety Measures in theCentral Sterilization and Supply Department of a PrivateTertiary Care Teaching Hospital, Bengaluru

Introduction

Occupational Health and Safety is defined as “conditions and factors that affect, or could affect, the health and safety of employees, temporary workers, contractor personnel, visitors or any other persons in the workplace”.¹ Any occupation, regardless the nature of work, is associated with occupational hazards. Occupational settings may vary from large manufacturing, automobile, agricultural settings to as small as household involving a house wife.² Health care settings are facilities providing/receiving health services. Health Care Workers (HCWs) are at risk from exposure to hazardous biological, chemical, and physical agents and repetitive strains, violence/ fatigue-many of these maybe life-threatening in nature. Exposure to hazardous agents depends upon the job category and the work environment of the HCW.³

According to World Health Organization (WHO) estimates there are 59.8million HCWs worldwide. About two-thirds of them (39.5million) provide health services; the other one-third (19.8 million) are management and support workers which includes those working in ancillary departments like Laundry, Dietary, Central Sterilisation and Supply Department (CSSD), Laboratory, Mortuary, Ambulance Services and Administrative Departments.^3-7

HCWs need protection from these workplace hazards just like workers in any other occupational settings. Numerous studies have documented hazards among HCWs in clinical settings and there are very few studies on Ancillary departments.^6-12 In this study the researcher is aiming at studying the hazards in CSSD as a preliminary step before assessing the Health risk assessment and the hazard risk assessment.

Materials and methods

Study design: A cross-sectional study done at a private tertiary care teaching hospital located in Bengaluru City with bed strength of 1200 beds and bed occupancy of 85%. The Hospital provides super-speciality, sub-speciality services at outpatient, inpatient departments and at outreach areas. CSSD is integral part of hospital for the optimum functioning of these clinical services.

Selection of the study population:

Currently working individuals at the time of study who consented were included and who could not be met at workplace even after three attempts were excluded.

Study period: The survey was undertaken between September 2009 and August 2010.

Instruments used for the study

An observation checklist was developed by the investigator-partly based on the Occupational Hazard Checklist by the "OSHA"13 "AND" partly altered based on interactions and/observation of activities at the department.

Validation of the Observation Checklist: The checklists were face validated by three experts in the field of Occupational Health working in large tertiary care hospitals in Bengaluru City and their comments and suggestions were incorporated. This was field tested and validated for applicability for this study. Institutional Ethical Committee had approved the study.

Method of data collection

Non-participatory Observation: Multiple visits (eight) were made and the activities were observed in order to document the work processes and occupational safety measures in place therein. Unannounced visits were also made to observe the practice of use of PPE.

Interviews with workers: Informed consent was obtained from the workers before the factors determining the appropriate use of PPEs were identified by administering a pre-tested schedule to them.

Qualitative Data

The qualitative data was documented by on site interaction with the workers during the visits to determine the reasons for not utilising the PPEs and also by key informant interviews conducted to in-charge of the department, activity supervisor, selected workers in the department using a semistructured questionnaire form.

Analysis of data

The data collected was entered into Excel spreadsheets and analysed using Microsoft Excel. Frequency tables were used to describe the distribution of study variables in the population.

Results and discussion:

The CSSD has been divided into various sections based on the activities that happen in that specific area. The broad categorisation of areas includes unsterile and sterile zones (Figure 1).

Unsterile Zone: This is a zone where all instruments and other items present are unsterile. This zone comprises of the following areas:

Receiving Counter: An area where infected materials from various departments are received (both outpatient and inpatient departments).

Changing Area: Area where visitors and employees change their clothes.

Washing Area: Infected materials collected are washed manually and mechanically using a scrubber and a UV washer. Infected gloves are screened, and the damaged and discoloured gloves are separated while rest of them are washed using a washing machine.

Packing Area: The washed materials are separated wiped, dried and packed into different sets. The gauze pieces and cotton pads (dressing sets) are prepared. Cotton rolls are also rolled and cut into desired sizes using a cutting machine.

Ethylene oxide (ETO) steriliser machine: Area where the ethylene oxide sterilisation of the unsterile items is done. ETO gas Diffusion Area: This is a designated closed space where sterile equipments that are unloaded from the ETO Steriliser are placed for diffusion of ETO gas.

Steam Sterilisation Area: This room consists of five steam sterilisers which are manually controlled and used for sterilisation of the instruments.

Boiler Room: This is the room where the steam is generated using a diesel boiler. The steam that is generated is used for sterilisation.

Sterile Zone

Sterile Equipment’s Storage Area: All instruments which are sterilised are arranged based on the requirements by different departments.

Sterile Equipment’s Issuing Area: This is the area concerned with issuing sterile equipment to the different departments.

Characteristics of the CSSD

Of the 29 workers studied in the CSSD, 86% were males and 14% were females. Most (around 35%) of the workers were in the age of 26-35 years (Table 1 and Table 2). 76% of the workers were permanent and among them 86% were males. Among all the workers 19 (65.5%) had work experience of more than 15 years of which 18 (94.7%) were permanent employees. Of the 4 females working in the CSSD, 3 were nurses while one female was in charge of housekeeping within the CSSD (Table 3).

Hazards observed at the CSSD –

Biological hazards at the CSSD: It was observed that some of the unsterile equipment’s received at the receiving Area were not pre-treated with 1% hypochlorite solution at the wards. It was observed that some had blood stains, betadine stains and fluid remnants in/on them. Occasionally pre-treatment of these items was found to be ineffective (dipping them in plain water or in hypochlorite solution for few seconds thus not allowing for adequate contact time). This practice was seen especially in the morning hours due to the increased workload. The nurses and nursing aides at the wards when enquired reported that due to paucity of time, they only dipped the dressing tray and lid in plain water for cleaning. This was because time was prioritised for other activities such as bed making, cleaning the tubs and bathing of the patients. These materials were not fully dried. This existing practice poses the threat of spilling the rinsed remnants of water on clothing of the nursing aides, onto the floor of the ward area and also in the path traversed to reach the CSSD collection point, thus having the potential to spread infections. To minimize this exposure the hospital has policies in place like pre-treatment of these items at the point of generation (e.g. wards); training of the workers and providing barriers (PPEs) to prevent exposure and protecting the workers through immunization against some infections like Hepatitis B and others. Most of the CSSD workers have received complete immunization against Hepatitis B.

The workers were found wearing traditional holy threads/bands and wrist watches with metal and leather straps during work. It was observed that the water (splashing) gets collected underneath these accessories and increases the contact time of the pathogen to the bare skin area. During the process of segregation/transferring of the items at the Receiving Area there is generation of aerosols that can be inhaled/exposed to conjunctiva of the workers.

On some occasions, sharps are reported to be found in the linen and/or in the dressing sets and has injured the workers. The sharps found are usually injection needles, scalpel/ surgical blades/glass pieces. The practice of documentation of injuries was lacking in CSSD. Studies conducted byMalakM et al¹⁴ (2001-05) at a teaching hospital in Saudi Arabia and by KhuriBulos et al¹³ in Jordan reported a low occurrence of needle stick injuries at CSSD in comparison to other departments. It is important to ensure that adequate precautions are taken at this level.It was reported and also noticed by the investigator that at the CSSD, these waste sharps are contained in the waste container meant for general waste, which is a potential hazard for needle stick injury and infection to the workers handling the waste.

In the washing Area, the activity generates aerosols, spillages and splashes and exposes the workers to the hazard of infections. The workers in the Packing Area are exposed to pathogens while wiping and arranging the equipment’s into different sets.

The workers in the Steam Sterilisation Area are exposed to heat and humidity and are at risk of fungal infection (Tinea cruris).

The workers involved in receiving of the unsterile plastic items at the receiving Area for Ethylene Tri Oxide (ETO) sterilisation are also exposed to the spills of the fluids in the equipment’s. It was noted that the workers do not use gloves consistently in this area.

Physical and environmental hazard at the CSSD

At the receiving area and at the Drying and Packing area, the workers were exposed to noise especially while segregating and arranging metallic dressing sets – may expose the workers to the hazard of OIHL.

The workers are at risk of incised injuries owing to sharp edges of the metallic dressing trays during the activity of receiving and segregation in the receiving area and while preparing a dressing set in the Drying and Packing Area.

Some of the glass items like tubes of inter-costal drainage apparatus are wrapped in the cloth. It was reported that on rare occasions the glass tube in the cloth is broken and this can cause cut injuries to the workers handling these items. The workers reported that the inter-costal drainage tubes sent for sterilisation were to be inserted into the rubber stopper manually. This activity required the worker to forcefully insert the tube into the hole of the rubber stopper. It was reported that, during this process the glass tube had broken many a time and had caused puncture or cut injuries to the worker handling it.

At the Steam Sterilisation Area the workers were exposed to the burns and scalds due to due to contact of their hands and forearm to the hot surfaces of the steam steriliser while unloading the items after a cycle of sterilisation. These hazards documented here were also mentioned in the OSHA module⁹ for exposure to burns or cuts by the United States Department of Labor which states that the burns can occur from handling or sorting hot sterilized items or sharp instruments when removing them from autoclaves/sterilizers.

Chemical hazards at the CSSD

The workers are exposed to various chemical agents including hypochlorite solution, enzyme used in the Washing Area to digests and disintegrates the organic matter (blood stains and tissue matter) is reported to be hazardous. It is corrosive to the skin and can cause contact dermatitis. The aerosols and the vapours of the chemical are hazardous to the respiratory tract. They are stated to be irritants and can cause exacerbation of bronchial asthma. It was observed during the visits that a few workers suffered from dermatitis more than usual as the ultrasonic machine used for rinsing and cleaning the items was under repair and the workers were manually handling the items. According to the policy of the institution the workers are provided gloves and masks to prevent these hazards. However, the masks provided were inappropriate and also the use of PPEs was inconsistent among the workers.

Workers are exposed to the cotton dust during activities like wrapping cloth, preparing gauze pieces/cotton pads. They complained of repeated attacks of Allergic rhinitis, sneezing and upper respiratory tract infections.

Exposure to ETO gas: All the Unsterile items at Receiving Area are packed in the separate plastic covers for sterilisation by ETO gas. As the ETO steriliser in CSSD is automated with inbuilt safety mechanisms that prevent the opening of the door prior to completion of the sterilisation cycle the workers are not exposed to the gas during the cycle. Moreover the gas is purged through a separate vent into the external atmosphere at the end of the cycle. The ETO machines at the CSSD comply with the safety standards set by OSHA. However, when the Standard Operating Procedures (SOPs) for the process are not observed the workers could be exposed to the ETO gas. Errors can occur during this process when the workers “forget” to load the entire batch for sterilisation and therefore need stop the sterilisation cycle to open the steriliser.The equipment’s are laid out in the open for the dilution and diffusion of the gas after the sterilization cycle. The area designated for this process is ill ventilated and could therefore be potentially hazardous to the workers in the area.

Ergonomic hazards at the CSSD

The worker involved in the segregation of items at the Receiving Area, packing area, sterilisation area and issuing area was frequently rotating his trunk sideways for placing the segregated items or when loading/transferring items from one area to another. This repetitive movement makes the worker prone for Musculo Skeletal Disorders (MSD) and Repetitive Stress Injury (RSI).

The Wash Area is moist most of the time and this may lead to growth of fungus, bacteria, and algae. This organic material makes the floor slippery. There is a risk of accidental falls which can cause injuries.

The steel items like cups, artery/mosquito forceps, scissors, blunt forceps, toothed forceps, needle holder, sponge holder etc, are segregated in dedicated receptacles and transported to the washing area using a trolley. However, when there is a shortage of time the worker either drags the plastic bucket or lifts the tub and physically transports them to Washing Area. On an average the weight of the bucket and tub with instruments is 20-22 kilograms. Bending and dragging a bucketful of steel instruments can cause loin pain, back pain and shoulder pain. Lifting of tub full of instruments can cause hernia due to increased intra-abdominal pressure.

On many occasions the workers followed improper ergonomic practices while lifting heavy containers, pushing over-loaded trolleys, and also maintained abnormal sitting postures while involving in the activities. The poor condition of the wheels of some trolleys demanded extra efforts from the workers to push them around. The workers involved in these activities complained of musculoskeletal pains and joint pains. Of all the MSDs, low backache was most common. The joints involved were knee, shoulder, wrist, and elbow. The chairs in this department were not ergonomically designed. Many workers sat on a stool which did not have a back rest.

The chairs available for all the workers were not ergonomically designed. Many were sitting on a stool which did not have any back support.

As soon as the machine is opened the workers load the plastic covers on a trolley and transport them to the open space at the rear end of the department, where the materials from the ETO steriliser is laid in the open space to dilute the gas by diffusion. The workers are at risk of exposure to the ETO gas since this area did not have good ventilation.

Repetitive movements: The workers involved in washing, segregating, loading, unloading, and packing items suffer repetitive stress injuries. A survey done in Australia by the Heads of Workplace Safety Authorities (HWSA) reported that in the CSSD areas, 27% OHS managers and 26% workers agreed that heavy lifting/heavy loads was the topmost hazardous task. 15% of workers stated pushing/pulling trolleys were next most hazardous.

At the CSSD most of the workers were males (Table 1). This can be explained by the fact that the job responsibility involves energy intensive physical activity like pushing trolleys, lifting heavy weights, loading, and unloading the items into and out of the sterilizers and so on. The females were nurses who because of their knowledge of hospital requirements were incharge the supply of sterile items to various departments and managing the personnel.

Personal Protective Equipment’s

Table 4 and Table 5 depict the compliance of PPEs among workers with respect to designation and years of experience respectively. The nursing aides were not using appropriate PPEs during washing. Most of them used ill-fitting gloves (incorrect size). It was reported that the seepage of water causes discomfort to the worker by making the gloves slip off. This may also cause skin infection by the virtue of prolonged exposure to moisture. This is what is described as “washer man’s hand”.

The workers were not consistent in use PPEs. The reasons were that masks are uncomfortable to wear. Goggles were not used because they were not aware about use of these during the activity and were not available. None of the aides wore shoes to protect them from spills. They were wearing sandals and rubber slippers that did not cover their feet. During the transportation, they did not wear gloves and boots. The reasons were that during transportation they are not exposed to any risk of infection as they carry it on a trolley and that the items had been rinsed at the point of generation. No apron was used even though it was available in the department since the workers were not comfortable using it. They reported that it restricts their movements and delays the process.

Inconsistent use of appropriate PPEs among the workers in CSSD. The reasons were:

Difficulty in breathing, communication with others, discomfort due to irritation and increased sweating, medical reasons such as latex allergy, limited awareness of hazards due to the activities (NIHL), inadequate awareness regarding the use of few PPEs, ill-fitting PPEs causing discomfort, injuries and infections and non-availability of appropriate PPEs.

CONCLUSIONS

This study was done in 2009-10 documented the conditions then at the CSSD. Even though there now the CSSD has been transformed into a modern facility, At the point of study the CSSD had Occupational Health and Safety Hazards.

HCWs were exposed to the physical, chemical, biological, and ergonomic hazards. The same hazards are prevalent in the CSSD as well. Here too the exposure to biological hazards varied depending upon the type of activity. This being the case the consistent use of PPEs following a change in behaviour and attitude of the workers is to be expected. Regular education sessions, motivation and monitoring will help improve compliant use of PPEs.