Hazards for Health Care Workers

University of Maryland - School of Medicine
Baltimore, Maryland

Instructor(s): Keogh, James P.; Gordon, Janie
Subject area: Health / Medicine
Department: Occupational and Environmental Medicine
Level: Undergraduate
Duration of exercise: 4 hours
Learning objective: Develop Group Skills, Develop Individual Skills, Provide Information, Provide Real-World Experience
Teaching style: Active Learning, Group Activity, In-class Activity

Please note that the copyright for this course project is retained by the instructor.



This is an Instructor's guide for an exercise with undergraduate medical students at the University of Maryland Medical School. Using resource specialists and a series of case studies, students will learn to:
- identify occupational hazards faced by health care workers
- identify hierarchy of control methods to eliminate adverse exposures
- apply hierarchy of control to addressing specific hazards.

Day 1: 8:00 - 9:50 AM

Part 1: 8:00 - 8:30

Please introduce yourself to the students and tell the students briefly about your job. We will have a handout for you to distribute which will contain vignettes and study questions for 5 patient cases. Spend about 15 - 20 minutes briefly introducing the cases to the students. Then divide the students into 5 teams and assign each team a patient case for which they will have primary responsibility to learn more about the case and answer the study questions. You can use the attached Case Assignment Chart to jot down the names of the students assigned to each case. (If you will not be here for the next day's session please give me the Case Assignment Chart before you leave.) We won't be giving you "mug shots" of the students in your group as we've found the students do not always go to their assigned groups. However, tell the students to be sure to come to the same group the next morning so that they can report back about their case.

Pass out Handout 1 which we'll give you when you check-in. This will be the guide (case vignettes and study questions ) the students will use to investigate their cases. Please note that there is a map (Handout 2) identifying the resource people available for each case and their location in Lab Rooms 229 & 245. You will also have one last handout (Handout 3) which contains websites on each patient case topic. Encourage the students to use their laptops during this session, after they go to the exhibits, to explore these sites for additional information.

Remind the students that after they have looked at the posters and exhibits for their assigned case they MUST also visit the other exhibits. We have brought some great people in to share their expertise with the students so they should enjoy it. Also remind the students that each team will be reporting back to the group the next morning and will be asked to provide thoughtful responses to the questions for their patient case.

8:30 - 9:50 AM.

We hope that you will be able to stay for the Poster/Exhibit session as you can guide the students through their learning process and learn more about some of the topics which may be of special interest to you.


Day 2: 8:00 - 9:50 AM

For those of you who are working with us for the first time your role this morning is to facilitate rather than direct the discussion. Yesterday's exercise and the material should help engage the students in discussion. Use your sheets from yesterday with the names of the students on each team and ask them to talk about what they learned and how they answered each of the study questions. (If you were not here yesterday we will give you the Case Assignment Chart when you check in.) Try to get other students to comment on the issues raised by asking a student what she thinks about a comment that was just made or ask someone if there is another way to look at the question. If unanswered questions come up encourage the students to do some further research using yesterday's website list as a guide.

This discussion should take until about 9:50 AM. If you finish a bit earlier that's fine. Please be sure to let the students go by 9:50 as they have a lecture at 10 sharp in another building.

Thanks for your help!!!! We hope to work with you again next year!!!

Case Assignment Chart

Case #1 Students:
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Case #2 Students:
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Case # 3 Students:
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Case #4 Students:
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Case #5 Students:
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Handout 1: Case Scenarios & Study Questions

Occupational health close to home: Safety at work for the health care worker:

Case # 1: Blood borne pathogens
Jeanette Nazarian, M.D., Pulmonary, University of Maryland School of Medicine
Representatives from Becton Dickinson Safe Medical Device Display

A 31 year old construction worker is brought into the emergency room with multiple injuries incurred when the bobcat he was using on a demolition site broke through a weakened area of decking and fell three stories, tossing him into a dumpster of construction debris including concrete, steel, and glass.

After he is stabilized and sent up to the OR, two co-workers seek your care in the ER walk-in area. The first is a 23 year old nursing assistant who tells you she is 12 weeks pregnant. She reports that in helping to lift the patient onto a gurney her left third and fourth fingertips were cut by a shard of glass that was imbedded in the patients' skin. She noticed this a few minutes later when she saw blood in her glove and discovered the cuts.

You are also asked to talk to a 24 year old EMT who first encountered the patient at the scene. Cleaning up after the run he noticed he had been sprayed with blood, and thinks some might have gotten into his eye.

1. Could these health care workers contract an illness from this type of exposure to blood?
2. What are the most common diseases transmitted by exposure to human blood?
3. How much risk is associated with other body fluids?
4. What are the routes of entry of greatest concern? Can you estimate the risk of illness from a single exposure?
5. What protocol will you follow to assess and minimize a patient's risk after exposure by skin penetration? By splash?
6. Using the usual occupational health hierarchy of controls ( see attached table) discuss how a health care facility can reduce the risks of exposures to blood borne pathogens. What regulations apply to preventing bloodborne pathogen exposure?

Case # 2: The Risk of Tuberculosis
Mary-Claire Roghman, M.D., M.S., VA/Medicine, University of Maryland School of Medicine

During your first week as a junior medical student, your resident tells you to start "working up" a new admission to your medical team. The patient is a 37 year old man with fever and cough who presented to the ER last night. The intern is just leaving the patient's room when you arrive, and tells you to "go ahead and take a history and do the physical and then we can talk about her and go over the orders." The patient is coughing non productively throughout the interview, but you are able to get a reasonable history of a two week history of cough and fever with some chills. She says she has had HIV for three years and is usually followed in the Evelyn Jordan Center. She had been on Bactrim and three anti retroviral drugs she can't remember the name of. She lost her meds when she had to move out of her apartment two weeks ago because of a fire and hasn't had a chance to get new prescriptions. Just as you start to do a physical, a nurse enters the room and asks "Isn't this patient on AFB isolation? Where's your PAPR?" You excuse yourself to the patient and as you leave the room to seek out the intern you notice the nurse is moving the patient to another room.

1. What criteria are used to decide if isolation for possible tuberculosis is necessary?
2. What are the purposes of AFB/airborne isolation, respiratory isolation, contact isolation (Multiple Antibiotic Resistant Organisms isolation) and pediatric respiratory viral isolation?
3. Are health care workers at greater or lesser risk of contracting TB than other people?
4. What steps can be taken to minimize this risk of TB? Think about the hierarchy of controls in deciding the full range of options. (see attached table) What regulations apply to this situation?
5. What does a positive PPD mean? What factors should you consider in deciding on the appropriate response to a positive PPD in a health care worker?
6. What other respiratory pathogens are of particular concern to health care workers, to patients in a hospital or other health care facility? What preventive measures are available to reduce the risk for these agents?

Case # 3: Respiratory hazards to health care workers: Other building associated illnesses.
David Blythe, M.D., Maryland Department of Health and Mental Hygiene
Kathleen McPhaul, RN, MPH, Occupational Health Project (General Internal Medicine), University of Maryland School of Medicine

On your ambulatory care rotation you are working in the family health center which provides employee health services. Your attending physician asks you to see a walk-in patient. He is a 22 year old working during the Christmas holidays in the information services department. While he does some customer response calls to various parts of the health center, he has spent most of the month in a two office basement suite with four other staff members who are working on the LAN. He complains of sneezing and itchy eyes and a sensation that his forehead is burning. He never sees anything abnormal on his skin, but his eyes are sometimes bloodshot. He reports that his symptoms often can be improved by taking a walk at lunchtime, and rarely bother him elsewhere on campus. He has never had symptoms like these before and never gets them on days away from work. He says that one other coworker has similar symptoms, with a similar work related pattern. He says that sometimes he can smell popcorn from the break room used by lab personnel on the second floor and he wonders "if this could be germs from the lab coming in by the air ducts?" He is thinking of quitting, but his boss tells him he really needs him to finish his part of the project before he goes back to school.

1. What respiratory pathogens have caused documented building associated epidemics?
2. Besides infectious agents, what other biological and chemical hazards may be present in indoor air?
3. Are some complaints about indoor air more urgent than others? Which of the hazards you have thought about can lead to fatal illnesses?
4. What factors have been associated with outbreaks of nonspecific building associated illness so called "sick building syndrome"?
5. Why have indoor air quality complaints become more common in recent years?
6. What is a practical method to investigate the cause of building associated illnesses? Who can you enlist to help you in such an investigation?

Case # 4: Back pain in health care workers
Marc Oliver, RN, MPH, Occupational Health Project (General Internal Medicine), University of Maryland School of Medicine

A forty seven year old nurse presents to the urgent care center with complaints of low back pain of 24 hours duration. She reports that the pain began yesterday evening while she was at work, and got progressively worse until she had trouble getting up the steps into her apartment when she got home. She felt a bit better this morning after using naproxen, but after driving in to work was beginning to have worse pain. She asks if she "could get a shot of Toradol (ketorolac) so I can finish my shift. We're short handed and if I can just get through today, I can get someone in to cover for me over the weekend." She denies radiation of pain into her legs. She has had two prior episodes in the last three years, one lasting three days and one lasting two weeks.

1. Is this a work related injury? How can one decide if an episode of back pain was caused by specific work activity?
2. Are back problems more common in health care workers? What does the epidemiology of this problem tell us about its etiology?
3. Why does back pain cause such an economic burden for health care workers and employers ?
4. What methods are useful in the prevention of back injury?
5. How can a health care facility use hierarchy of controls (see attached table) to reduce this problem?

Case # 5: Latex Allergy
Marybeth Bollinger, D.O.
Kim Mudd, RN, Pediatrics, University of Maryland School of Medicine

During your dermatology rotation you see a 26 year old nursing student who presents with complaints of a rash on her hands. The attending asks you to start taking the history while he talks in his office to the family of an older patient from whom you have just helped him remove a suspicious mole. The new patient is shown into the exam room as soon as it is tidied up, but as you take her past medical history, she is increasingly troubled by sneezing and coughing.

1. What proportion of the general population has antibodies to latex? What proportion of health care workers?
2. What populations are at greatest risk?
3. What are the common manifestations of allergy to latex proteins? How can these be managed?
5. Why is latex allergy so much more of a problem now than it was ten years ago?
6. What preventive strategies can be used to reduce problems in the health care setting?

Preventing Occupational Illness and Injury

Hierarchy of control methods

Substitution to eliminate hazard

Change of process to eliminate hazard

Education and Training

Isolation of hazardUse of engineering controls to reduce exposure Administrative ControlsPersonal protective equipment
Medical surveillance to monitor effectiveness of controls


Handout 2: Map for Poster/Exhibit Session

Case # 1: Blood borne pathogens
Lab 229 A Jeanette Nazarian, M.D.
Lab 229 B Representatives from Becton Dickinson Safer Medical Devices

Case # 2: The Risk of Tuberculosis
Lab 229 C Mary Claire Roghman, M.D., University of Maryland School of Medicine

Case # 3: Respiratory hazards to health care workers:
Other building associated illnesses
Lab 229 D Kate McPhaul, RN, MPH, Occupational Health Project, University of Maryland School of Medicine; David Blythe, M.D., Division of Outbreak Investigation
Maryland Department of Health & Mental Hygiene

Case # 4: Back pain in health care workers
Lab 245 A Marc Oliver, RN, MPH, Occupational Health Project, University of Maryland School of Medicine

Case # 5: Latex Allergy
Lab 245 B Mary Beth Bollinger, D.O.; Kim Mudd, RN, University of Maryland School of Medicine


Handout 3: Website List

Case # 1: Blood borne pathogens
OSHA Blood borne pathogen standard:
www.osha-slc.gov:80/OshStd_data/1910_1030.html
www.osha-slc.gov/SLTC/needlestick/index.html

Case # 2: The Risk of Tuberculosis
www.osha-slc.gov/SLTC/tuberculosis/index.html

Case # 3: Respiratory hazards to health care workers: Other building associated illnesses
www.epa.gov/iaq
www.cdc.gov/ncidod/diseases/hip/pneumonia/1_legion.htm#top

Case # 4: Back pain in health care workers
OSHA draft standard on ergonomics
www.osha-slc.gov/SLTC/ergonomics/ergoreg.html
stats.bls.gov/news.release/osh2.t06.htm
stats.bls.gov/news.release/osh2.t09.htm
ftp://146.142.4.23/pub/news.release/osh2.txt

OSHA draft standard on ergonomics
www.osha-slc.gov/SLTC/ergonomics/ergoreg.html

Case # 5: Latex Allergy
pweb.netcom.com/~nam1/latex_allergy.html

NIOSH alert:
www.cdc.gov/niosh/98-113.html

OSHA technical information bulletin:
members.tripod.com/latexallergylinks/LA-TIB.html





This document was last modified on 06/14/2000 03:08:02 PM



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