Statement of
The American Nurses Association
Before The
Institute of Medicine's
Committee on Regulating Occupational Exposure
To Tuberculosis

Presented by
Karen A. Worthington, Ms, Rn, Cohn-s

August 7, 2000

Good morning. My name is Karen Worthington, Senior Occupational Safety and Health Specialist for the American Nurses Association. On behalf of the 2.6 million registered nurses in this country I am pleased to address some of the questions posed to this committee by our political leaders as they continue to examine the link between workplace TB exposure and TB elimination efforts in this country.

In addition to my current work at ANA, I have 23 years of nursing experience, including acute, long-term and hospital employee health experience. More recently, I've worked as a CDC investigator of workplace injury and disease and as a biological safety specialist at a large academic medical center. Along with my perspective, ANA's comments draw on the health and safety mandates generated by our membership over the years as well as on the experience of several of our members who have managed TB control programs in public and occupational health settings.

As a backdrop to these proceedings, I would like to recognize two important bodies of work recently completed by the Institute of Medicine. The first is the IOM's groundbreaking 1999 report, To Err is Human: Building a Safer Health Care System. TB control and prevention efforts are a perfect example of system-wide programs in health care that demand study, analysis and improvement to better protect patients. The second report, Ending Neglect: The Elimination of Tuberculosis in the United States was published this year. In your report to Congress, we ask that you reiterate the following relationships pointed out in this report: First, the decreased funding of TB elimination programs in the U.S over 2 decades ago and the recent resurgence of TB, which now includes drug-resistant strains; Second, an increasing global burden of TB infection and an increasing proportion of U.S. cases in foreign-born persons and third, the fact that worldwide, TB is still a leading cause of death.

Workplaces may be the first point-of-contact for many new, foreign-born members of our workforce. Integrating TB detection, treatment and prevention responsibilities into private sector health plans as the report suggests will be an necessary national step, given our decimated public health infrastructure. For the health care employees who treat these persons, only strong health and safety standards will compel employers to provide the vigilance necessary to screen for, treat and prevent the spread of TB. Like other unions speaking here today, we advocate for OSHA to broaden the scope of the standard to cover ambulatory clinics where most active TB cases will be seen, mental health facilities and congregate and long-term care facilities that care for patients of all ages, not just the elderly. Nurses also recognize that social service workers are often TB case-finders and deserve OSHA protection.

Today I will address many of the questions posed by the committee although not in the order listed. First and foremost, ANA believes that we need an OSHA TB standard. The CDC Guidelines for Preventing the Transmission of Mycobacterium TB are only that - guidelines and as such are not enforceable. Enforceable standards are needed in order for our members who are Occupational Health Providers, Infection Control Practitioners and Continuing Education Providers to leverage the necessary resources to protect health care workers. These members have told ANA that without an OSHA standard and the threat of inspection, they are unable, in this era of cost containment in the health care industry, to justify adequate staffing to provide the needed training and testing of workers to prevent exposure and analyze trends; let alone to provide adequate engineering controls and personal protective equipment to comply with the CDC guidelines.

For our fronting nurses who are providing direct patient care and are responsible for explaining, implementing and enforcing respiratory isolation practices on their unit, inadequate TB programs can place patients, visitors and staff at risk for TB infection and delay diagnosis and treatment of TB cases, leading to longer hospital stays and increased costs. Unless mandated to be written into relevant patient care, treatment and training policies at individual facilities, CDC guidelines will not help the inexperienced weekend night staff nurse when she is told to admit a R/O TB case to her floor. Without recent training and clear policies, confusion reigns and interferes with the true priorities at hand, calming the patient's and family's fears as well as those of his or her staff and recognizing that getting that first sputum specimen may actually be the most important activity on the nurses' checklist for the night. Right now, without a standard, luck may be all that dictates whether care that is safe for the TB infected patient, the workers and other patients can be provided in this circumstance.

You have asked how our organization would characterize worker risk of occupational exposure today compared to 1993 when the request was first initiated. Today nurse members who in 1993 never thought they'd have to be concerned because they didn't live in New York City or Florida or Texas, the epicenters of the TB resurgence - nurses from quiet rural areas or those who live along the so-called I- 95 TB corridor, are now concerned. They work in areas where manufacturing and construction workforces are suddenly being made up of workers from foreign countries with high rates of TB or they work in tertiary care facilities where patients at high risk for TB come from other areas of the country or the globe for specialty services.

The Fronting Healthcare Worker Conference is taking place just a few blocks away. Three of our nurses with occupationally acquired HIV are in attendance, I am reminded how one of them was infected with HIV through a needlestick injury nearly a decade ago at a hospital in a rural Pennsylvania farming community where no one was expecting to encounter an HIV positive patient. In this era of globalization, ALL healthcare workers are at risk for exposure to an active TB patient.

In my recent work experience, I utilized several sections and appendices of OSHA's Proposed TB Standard in my last job where I had TB control program responsibilities. To help assure that effective engineering controls were in place, Appendix E: Performance Monitoring Procedures for HEAP filters was used to begin a regular filter maintenance program; Appendix G: Smoke Trail Testing Methods for Negative Pressure Isolation Rooms or Areas was used to develop a standardized smoke testing procedure and correct unsafe air flow. Maintenance and engineering personnel understood the importance of these methods because they came from OSHA. These initiatives also led to the systematic tracing and documentation of air flow to and from negative pressure TB isolation rooms. Prior to this, the knowledge was held solely by our 64 year old, soon to retire VAC. mechanic. In the process we discovered that some expensive but unnecessary engineering controls which had been installed by contractors. Our department soon became key participants in facility design, planning and walkthroughs of new construction.

More important than any single area of activity, publication of the Proposed OSHA Standard forced a critical (versus a rubber stamp) assessment of the institution's TB Exposure Control Plan and brought us back to the basics (and what needs to be the focus) of TB control efforts - early identification, isolation and treatment. It soon became evident that our highest risk exposures to health care workers and patients were occurring in the Emergency Department and that we had no assessment or triage questions in place to identify persons with TB. We gathered TB assessment tools from other facilities and began to work on developing a policy, and educating ED workers about signs and symptoms of TB and the importance of early isolation.

The committee has asked if there are additional activities that would help improve procedures to protect workers from exposure to TB. First, OSHA could include more tools and model programs in their final standard, like those developed by the Francis Curry Center in California. Additionally, in performing the kind of assessment described in the CDC guidelines and better targeting resources to high risk exposures, many health care facilities could use some help. Although the CDC is not in the business of marketing software, perhaps they could partner with vendors of existing employee health software to better integrate gold standard variables and write programs which help map exposures and TEST conversions to individual units and employees. Parallel data systems are cumbersome. As the California Department of Public Health Services identified in their study of TB in Healthcare Workers, the lack of computerized methods in employee health for tracking employee compliance with TB skin testing, is a great deterrent to follow-up. An OSHA standard would make it necessary for health care facilities to produce this data and thus invest in upgrading these computer systems.

In closing, ANA would like to be part of a systematic solution for preventing the spread of TB in general and the resulting medical errors that exposures to TB can cause. An OSHA TB standard would better help us to "think globally, and act locally." Thank you for the opportunity to contribute to the important work of the committee.

2000 press releases

Other past press releases: 1999 | 1998 | 1997 | 1996

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