Respiratory therapists may assume some of the highest rates of exposure to occupational injury.
Is health care hazardous to your health? The professions dedicated to the care of people suffering from sickness and injury have always assumed a risk, and those risks are often taken for granted. Hospitals are oriented toward treating disease, rather than maintaining health, and are thereby often part of the problem. In spite of diligent efforts to consistently practice infection control and on-the-job safety, respiratory therapists may assume some of the highest rates of exposure to occupational injury.
According to the National Institute for Occupational Safety and Health (NIOSH), Health care workers face a wide range of hazards on the job, including needle stick injuries, back injuries, latex allergy, violence, and stress.1 Respiratory therapists have additional exposures from infectious diseases and toxic chemicals and potential radiation exposure. While acknowledging that it is impossible to eliminate these risks, NIOSH notes that health care workers are experiencing increasing numbers of occupational injuries and illnesses that have continued to rise over the past decade. Meanwhile, two of the most hazardous industriesagriculture and constructionare safer today than they were a decade ago.
Needlesticks may be the first issue to come to mind when considering occupational safety risks to respiratory therapists, as they are the most frequent source of transmission of blood-borne disease in health care workers.2 While airborne pathogens and stress can be just as sinister, exposure to blood-borne pathogens, especially from needlesticks, is unique in that the exact moment and circumstances of exposure are self-evident. The risk of exposure varies according to the type of exposure (needlestick, eye, mouth, or skin contact), the type of pathogen (ie, HIV, hepatitis B or C), the amount of blood, and the amount of the pathogen in the patients blood at the time of exposure.
Fortunately, a fundamental change has taken place in both the tools we use and the way we use them. Cap-less syringes give us better tools. Readily available sharps containers and gloves, improved education of staff, and strict enforcement of infection control policy do not minimize the frequency of exposure to potential incidents, but they dramatically reduce adverse incidents and outcomes.
Even foolproof tools and consistent training can be foiled in a thoughtless moment, however. I recently observed a colleague draw an arterial blood gas, and withdraw the needle from the patient. Feeling a bit awkward holding the syringe in her left (subdominant) hand, she nearly used her forearm as a hard surface to close the protective sheath over the needle! In an instant, she realized the mistake and found an appropriate surface to leverage the cover closed. Respiratory therapists make these split-second decisions thousands of times each day, and the wrong move occasionally results in an unfortunate incident.
There are an average of 1,000 sharps injuries per day.3 These are only the exposures that are reportedsurveys of health care workers suggest that half or more of health care personnel do not report their needlestick injuries. Experience has shown that workers do not effectively change their behavior unless they believe the risk is real.
While some occupational hazards confront most patient care providers, including back strains and latex allergies, others are of special concern for respiratory therapists. Some experts now describe the health care environment as a chemical soupa complex mixture of medicines and sterilization agents that circulate in the air and are recycled through the heating, ventilation, and air-conditioning systems.4
Inhalation of respiratory drugs and infectious diseases poses a variable risk depending on the nature of the pharmaceutical or pathogen involved. Asthma can also result from exposure to common chemicals, including latex proteins and sterilizing and fixative agents such as glutaraldehyde, formaldehyde, and ethylene oxide.4 Some aerosolized medications, including pentamidine, methacholine, and ribavirin, require specialized aerosol generators with one-way valves and filters to prevent environmental contamination and to protect the RT administering the drug.5 RTs who have asthma should not be exposed to drugs used in asthma challenge testing, and therefore may need to be excluded from performing the tests. Due to rigorous FDA testing and regulation, special handling of respiratory drugs is clearly specified, but it is up to the institution and the individual to heed the warnings.
In addition to inhaling potentially harmful drugs, RTs face the constant onslaught of bacterial and viral infections to which our work necessarily exposes us. Sudden acute respiratory syndrome (SARS), cytomegalovirus (CMV), and tuberculosis get the most press, but much more common nosocomial respiratory infections probably present a more real threat to our health, causing untold loss of work days. We can substantially protect ourselves by diligent hand washing and use of protective masks.
Stress may the most ubiquitous, yet ignored risk posed to health care workers. Long hours, interrupted meal breaks, night shifts, overtime, monitor alarms, irritability of overworked coworkers, and the constant stress of dealing with critically ill patients take a toll in both the immediate and long term. When rescuers, including police and firemen, are exposed to massively stressful situations, the potential for post-traumatic stress disorder is recognized, and rescuers may consequently be provided with or even required to receive counseling. But the cumulative effects of day-to-day stress in a modern hospital setting are just beginning to be understood.
The atmosphere in hospitals was at one time serene, and street signs admonished people to be quiet in a so-called hospital zone. Nowadays, the atmosphere outside a hospital may be just as frenzied as it has become insidejackhammers and bulldozers turn the campus into a construction site as harried visitors and employees vie with one another for parking space.
In an essay in The New England Journal of Medicine, Dr Gerald Grumet laments the fundamental change in the hospital as a workplace: That subdued setting has gradually been replaced by one of turbulence and frenzied activity. People now dart about in a race against time; telephones ring loudly, intercom systems blare out abrupt, high-decibel messages that startle the unsuspecting listener. These sounds are superimposed on to a collection of beeps and whines from an assortment of electronic gadgetspocket pagers, call buttons, telemetric monitoring systems, electronic IV machines, ventilator alarms, patient activity monitors, and computer printers. The hospital, designed as a place of healing and tranquility for patients and of scholarly exchanges among physicians, has become a place of beeping, buzzing, banging, clanging, and shouting.6 EPA noise guidelines for hospitals of 45 dB at day and 35 dB at night are routinely exceeded.
All this takes a toll on workers, and administrators trying to understand and address the causes of burnout need only spend a day looking at and listening to the onslaught of stress and fight-or-flight stimuli a staff therapist endures over a 12-hour shift. RTs wade through the previously described chemical soup of recirculated air, bathed in fluorescent light, and often fueled by caffeine or nicotine to keep them going. A cigarette break is often the closest they come to fresh air and sunshine for a period of days. Some RTs have told me that they continue smoking because it guarantees them a break from the chaos of back-to-back emergencies and critical care patient transports.
Administrators of neonatal intensive care units (NICUs) have begun to heed the numerous studies that document the deleterious effects of noise on newborns. Noise levels have conscientiously been lowered, and environmental noise levels can be monitored to document compliance. Their patients have benefited, requiring significantly fewer days of respiratory support on a ventilator and fewer days of oxygen administration.7,8
In April 2004, the Department of Health and Human Services issued the Summary of Recent Findings on Illnesses, Injuries, and Health Behaviors9 that has alarming implications for respiratory therapists. Overtime was associated with poorer perceived general health, increased injury rates, unhealthy eating habits, weight gain, and increased alcohol use. Increased smoking, illnesses, even increased mortality, and poorer neuropsychological test performance were also noted, especially where 12-hour shifts were combined with 40+ hours of work per week. Nurses working nights or extended rotating shifts were at increased risk for alcohol use and smoking. And as health care workers increased their hours, automobile crashes and on-the-job accidents increased.
Numerous studies published in The New England Journal of Medicine10-13 address the issue of fatigue among clinicians, and its impact on patient safety. Interestingly, when we can show that long hours and stress impact patient health and safety, there is a prompt commitment to resolve the problem. But when the impact is on employee health and safety, changes seem to come more slowly. Other industries have not waited for absolute proof of risk due to operator fatigue. In the transportation industry, federal regulations limit work and duty hours.6 A relatively new and welcome movement is mandating limits on the number of hours medical residents can be expected to work. This fundamental change in the culture of health care organizations is overduestaff exhaustion is beginning to be viewed as a problem that needs correcting, rather than as a sign of dedication.
Whether from the relatively obvious risks posed by needlesticks, the invisible risks of inhaled chemicals and infectious diseases, or the persistent strain of long hours and stressful environment, health care professions are potentially harmful to the health of the workers. The good news is that a commitment to worker health and safety has effectively minimized blood-borne and respiratory exposure. Our NICUs are leading the way toward a safer and saner working environment. By understanding and acknowledging the risks, we can take the necessary steps to eliminate or at least manage the potential damage. We need only admit we have a problem, and begin to agree on solutions.
John A. Wolfe is a respiratory therapist in Fort Collins, Colo, and is a member of RT’s editorial advisory board.
1. National Institute for Occupational Safety and Health. NIOSH Safety and Health Topic: Health Care Workers. Available at: www.cdc.gov/niosh/
2. AARC Clinical Practice Guidelines. Sampling for arterial blood gas analysis. Respir Care. 1992;37:913-917.
3. Panlilio AL, Cardo DM, Campbell S, et al, NaSH Surveillance Group and Epinet Data Sharing Network. Estimate of the annual number of percutaneous injuries in US health-care workers. In: Program and abstracts of the 4th Decennial International Conference on Noso-
comial and Healthcare-Associated Infections; March 5-9, 2000; Atlanta:61. Abstract S-T2-01.
4. Wilburn S. Is the air in your hospital making you sick? Am J Nurs. 1999;99(7);71.
5. Hess D. Nebulizers: principles and performance. Respir Care. 2000;45:609.
6. Grumet G. Pandemonium in the modern hospital. N Engl J Med. 1993;328:433-437.
7. Als H, Lawhon G, Brown E. Individualized behavioral and environmental care for the very low birth weight preterm infant at high risk for bronchopulmonary dysplasia: neonatal intensive care unit and developmental outcome. Pediatrics. 1986;78:1123-1132.
8. American Academy of Pediatrics: Committee on Environmental Health. Summary of Recent Findings on Illnesses, Injuries, and Health Behaviors. Noise: a hazard for the fetus and newborn. Pediatrics. 1997;100:724-727.
9. Caruso CC, Hitchcock EM, Dick RB, Russo JM, Schmidt JM. Overtime and Extended Work Shifts: Recent Findings on Illnesses, Injuries, and Health Behaviors. Cincinnati: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health; 2004.
10. Gaba D, Howard S. Fatigue among clinicians and the safety of patients. N Engl J Med. 2002;347:1249-1255.
11. Philibert I, Friedmann P, Williams WT, ACGME Work Group on Resident Duty Hours. Accreditation Council for Graduate Medical Education. New requirements for resident duty hours. JAMA. 2002;288:1112-4.
12. Volpp K, Grande D. Residents suggestions for reducing errors in teaching hospitals. N Engl J Med. 2003;348:851-855.
13. Sandy L. Homeostasis without reservethe risk of system collapse. N Engl J Med. 2002;347:1971-1975.