How Can OSHA Assure the Safety and Health of Both Practitioners and Patients?
Joan M. Davis, RDH, PhD; Charles John Palenik, MS, MBA, PhD; and Eve Cuny, MS
Joan M. Davis, RDH, PhD: Historically, the Occupational Safety and Health Admin-istration's (OSHA) 1991 Bloodborne Pathogen Standard motivated dentists to write compliance manuals, provide employee training, and purchase personal protective equipment (PPE)—no one wanted OSHA showing up at their office door. Remember back to the days of hot, full-coverage over-gowns, annoying side shields, and required bloodborne pathogens training for employees at the time of hire and annually? Oh, and there was that required post-exposure follow-up in the event of a needlestick injury. Dentists made sure they had a standing agreement with a post-exposure medical facility, just in case. And all practices kept employees' hepatitis B virus immunization and booster records separate from the main employee records and are, even today, maintaining those records for 30 years after the period of employment. And then there was that recommendation from the National Institute for Occupational Safety and Health (NIOSH) to periodically test nitrous oxide levels with a dosimeter and report the results to any affected employees. Beyond employee safety, the US Centers for Disease Control and Prevention's (CDC) infection control guidelines encouraged dentists to test and treat dental waterlines, biologically monitor every sterilizer on a weekly basis, and finally get rid of that “cold sterilizing” container, using single-use items only once and heat-sterilizing everything else that goes in the mouth.
But OSHA rarely, if ever, showed up at dental practitioners' doors, and after the 1990s, the perceived “heat” was off. In 2017, the state of compliance in dentistry would lead one to believe that the decision to adhere to standards is really up to the practitioner and his or her motivation to do the right thing. What will motivate dentists to keep up with and apply the laws and recommendations to keep themselves, their staff, and their patients safe? Short of conducting an actual inspection, OSHA is not really in a position to “assure” the health and safety of patients or practitioners. However, both OSHA (eg, https://www.osha.gov/SLTC/dentistry/) and the CDC (eg, https://www.cdc.gov/oralhealth/infectioncontrol/guidelines/) have some excellent resources that can help practitioners stay abreast of and apply current laws and recommendations. Dentists need to step up, take the high road, and reemphasize the laws and recommendations that protect the heath and safety of practitioners and their patients.
Charles John Palenik, MS, MBA, PhD: The burden and cost of inadequate patient safety, a leading cause of death in the United States, has been well-documented and is now a major focus for most healthcare institutions. Less well-known is the elevated incidence of work-related injury and illness among healthcare workers and the impact that this has on workers, their families, the local community, and ultimately patients. Therefore, it is not surprising that patient and worker safety and health often are seen as interrelated.
Although the main emphasis of OSHA standards is the protection of workers, they can also have protective benefits for others. There are many examples of how OSHA compliance can serve as a force multiplier.
OSHA requires employers to provide hepatitis B vaccination for at-risk employees at no cost. Immunizing employees protects them, but also decreases the chances of viral transmission to unprotected patients and family members. Prior to the vaccine's release in 1981, there were reports of outbreaks among patients of infected dentists. Approximately, 5% of otherwise healthy individuals who are infected as adults will develop chronic infection, and 20% to 30% of adults who are chronically infected will develop cirrhosis and/or liver cancer. Technically, this makes the hepatitis B vaccine the first anti-cancer vaccine.
The use of PPE (eg, face shields and gloves) protects both patients and practitioners from potential infectious agents. In the pre-glove era, there was occupational acquisition of herpes simplex infections (ie, herpetic whitlow) with the potential for transmission from infected practitioner fingers to other patients.
In addition, OSHA requires dental offices to properly contain (ie, collect, isolate, store, neutralize, and dispose of) all forms of regulated waste, such as contaminated sharps. Proper waste management protects patients, practitioners, cleaning staff, and the local community.
Workplace hazards may result in injury or illness not only to workers, but also to patients. Because both are tied to many of the same underlying cultural and systemic issues, a safer environment for workers would also be a safer environment for patients.
Eve Cuny, MS: OSHA was created by an act of Congress in 1970 to, “assure safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education, and assistance.”
Although the OSHA standards that apply to dental offices and clinics, such as the Hazard Communication Standard, The Bloodborne Pathogens Standard, and the agency's general duty clause, are intended to protect workers, by their very nature they also serve to protect patients. Many of the hazards addressed by OSHA affect anyone who is present in the setting, not just the employees. The labeling of hazardous materials protects everyone in the office or clinic, whether they are patients, visitors, or personnel, from accidental contact with or ingestion of these chemicals. The use of PPE, including gloves, during patient treatment protects practitioners from inadvertent contact with patients' body fluids, but also protects the patient from diseases that can be carried by the practitioner, especially on his or her hands. Vaccination against the hepatitis B virus helps prevent healthcare workers from contracting the disease from exposure to patients and in turn, protects patients from contracting it from a caregiver who has developed hepatitis B due to workplace exposure. OSHA's Bloodborne Pathogens Standard mandates annual training for all healthcare providers. This training helps ensure that practitioners understand the mode of transmission of bloodborne diseases and how to prevent their transmission in the dental setting.
Where the OSHA standards fall short of protecting patients, CDC's guidelines and recommendations can help practitioners understand what additional steps should be taken to ensure that patients are fully protected. CDC has setting-specific infection control guidelines for dentistry as well as guidelines for specific topics, such as sterilization and disinfection, hand hygiene, and immunizations, that apply to all healthcare settings.
Joan M. Davis, RDH, PhD,
is the director of research and special projects at the Missouri School of Dentistry & Oral Health at A.T. Still University, St. Louis, Missouri.
Charles John Palenik, MS, MBA, PhD,
recently retired after 30 years at Indiana University School of Dentistry, Indianapolis, Indiana, where he held a number of academic and administrative positions.
Eve Cuny, MS,
is associate professor of diagnostic sciences and assistant dean of global relations at the Arthur A. Dugoni School of Dentistry, University of the Pacific, San Francisco, California.