OSHA 2000: A Review of Compliance Issues

Eve Cuny, RDA, BA

Ms. Cuny and William M. Carpenter, DDS, will present "OSHA 2000" at CDA’s Fall Scientific Session in San Francisco. The presentation will be from 10 a.m. to 12:30 p.m. and continues from 2:30 to 5 p.m. on Friday, Sept. 15, in Room 135 of the Moscone Convention Center.

Copyright 2000 Journal of the California Dental Association.

The California Occupational Safety and Health Administration is responsible for enforcing worker safety regulations in the state of California. The infection control regulation, while the best known to dentists, is only one of many that affect every dental practice. The past two years have brought significant changes to Cal/OSHA rules. This paper reviews some of the current regulations that apply to dental offices.

The California Occupational Safety and Health Administration is responsible for enforcing worker safety regulations in the state of California. Often, dentists and other health care employers misinterpret the scope of Cal/OSHA’s authority. Infection control, while the best known of these regulations to dentists, is only one of many that affect every dental practice. Cal/OSHA regulates chemical exposures, general safety, fire and emergency, employee exposure to medical waste, ergonomics, exits, fire extinguishers, pressure vessels (compressors), and numerous other areas of potential workplace hazard.

Cal/OSHA has authority for only those hazards that affect workers and is not charged with authority for patient safety. Other regulatory agencies -- such as the Dental Board of California, the California Department of Health Services, and local regulatory agencies -- have authority over the practice of infection control in dentistry as it may affect patients and the public.

As a whole, dentistry is not a high priority for Cal/OSHA since employees of dental practices rarely become injured, become ill, or die from workplace exposures. From June 1998 through May 1999, Cal/OSHA inspected 56 dental offices in California (Table 1). Nearly all of those inspections were based on an employee complaint. The number of OSHA inspections in California for all industries during the same period was 11,458.

The past two years have brought the most significant changes to the Cal/OSHA regulations since the introduction of the bloodborne pathogens rule in 1992.¹ The bloodborne pathogens rule received major revisions in 1999, affecting virtually all dental offices. The controversial Ergonomics Standard also completed a lengthy series of court challenges with a final ruling handed down in March 2000.

Ergonomics

The California Occupational Safety and Health Standards Board added Title 8, Section 5110, to the California Code of Regulations in July of 1997. The new requirement that addresses repetitive motion injuries was almost immediately met with challenges to the exemption provided for employers with nine or fewer employees. In March 2000, after several judgments and reversals, the Superior Court issued instruction to the Standards Board to revise the regulation and remove any small-employer exemption. The final judgment requires all California employers -- regardless of business size -- to comply with the ergonomics rule.

The ergonomics rule requires employers to implement its provisions if more than one employee suffers a repetitive motion injury under the following circumstances:

* The repetitive motion injuries were predominantly (50 percent or more) caused by a repetitive job, process, or operation.

* The employees incurring the repetitive motion injuries were performing a job process or operation of identical work activity. Identical work activity means that the employees were performing the same repetitive motion task such as, but not limited to, word processing, assembly, or loading.

* The repetitive motion injuries were musculoskeletal injuries that a licensed physician objectively identified and diagnosed.

* The repetitive motion injuries were reported by the employees to the employer in the past 12 months but not before July 3, 1997.

If these four circumstances occur in the dental practice, then the employer is required to implement an ergonomics program. The program must include worksite evaluations of the job type associated with the injuries, control of further exposure, and training. The elements of the training program must include an explanation of the employer’s program, exposures associated with repetitive motion injuries, symptoms and consequences of such injuries, reporting of symptoms and injuries to the employer, and methods used to minimize such injuries.

The regulation does not require a written program if the two repetitive motion injuries are not reported in the one-year period. However, it would appear prudent for a dentist/employer to include a copy of the one-page ergonomics rule² in his or her safety manual with a policy statement indicating that the employer’s intent is to be aware of the regulation and address ergonomic concerns as they become apparent.

It will be important for employers to follow the development of the ergonomics standard currently under review by federal OSHA. This proposed regulation is broader in scope and would require additional action by employers. Federal OSHA has ultimate jurisdiction over the states. Although 23 states operate their own plans, including California, federal OSHA must approve and monitor the state-run programs. The state programs must have regulations that are at least as strict as federal rules.

Bloodborne Pathogens Rule

Major revisions to the Cal/OSHA bloodborne pathogens rule became effective on July 1, 1999. These revisions were a result of legislation intended to reduce the risk of exposure to blood and other body fluids that may result in the transmission of infectious diseases from patients to health care workers. A number of new requirements went into effect, including development of a sharps injury log, use of engineered safety devices, and employee participation in the annual review of the written exposure control plan.

Sharps Injury Log

A sharps injury log is required to record each exposure incident involving sharp instruments or devices. This is in addition to existing paperwork requirements such as the OSHA 200 log. The information must be recorded within 14 working days of the incident being reported to the employer. The bloodborne pathogens rule specifies the information that must be included on the log. A sample injury log containing the required fields for information is provided as Figure 1.

Use of Engineered Safety Devices

According to Cal/OSHA, engineered sharps injury protection means either:

"A physical attribute built into a needle device used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids, which effectively reduces the risk of an exposure incident by a mechanism such as a barrier creation, blunting, encapsulating, withdrawal, or other effective means; or a physical attribute built into any other type of needle device, or into a non-needle sharp, which effectively reduces the risk of an exposure incident."

Therefore, needles, scalpels, and other sharp instruments that are available with built-in protection must be provided by the employer. Devices do not have to be provided under specific circumstances that are contained in the revised regulation.³ Exceptions include circumstances in which there is no device available, the available device will jeopardize patient safety or the success of the procedure, the engineering control is not more effective than the alternative in use, and reasonably specific and reliable information is not available on safety performance of the device. If devices are available but employers choose not to use them, they must demonstrate that they have made the determination only after evaluation of the devices. It is important for dentists to remain informed of developments in sharps protection devices and carefully determine whether the devices are appropriate for use in their practices.

Postexposure Management

An exposure incident is defined by Cal/OSHA as "a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee’s duties."¹ Previously, the employer was required to provide confidential postexposure evaluation and follow-up by a licensed health care provider.⁴ The employer was also required to request that the patient submit to testing for human immunodeficiency virus and hepatitis B virus. Included in the regulation was a statement that, "additional collection and testing shall be made available as recommended by the U.S. Public Health Service."¹

Since the date of original promulgation of the bloodborne pathogens rule, a test for hepatitis C virus has become available. In the revised regulation, it is stated that the employer must also provide follow-up for HCV. This would include testing of both the health care worker and the patient, if consent were obtained. It is important to remember that the employer must make a good-faith effort to identify the source patient and request that the patient submit to testing for HIV, HBV, and HCV. Only if the patient declines to be tested is the employer released from this responsibility.

Review of the Exposure Control Plan

Every dental office is required to have a written exposure control plan that is accessible to employees in the workplace. The exposure control plan must be reviewed and updated at least annually. Modifications should reflect new or modified tasks and procedures that affect occupational exposure, reflect progress in implementing the use of needleless systems and sharps with engineered injury protection, acknowledge new or revised employee positions, evaluate exposure incidents, and respond to any deficiencies in the exposure control plan.

It is expected that employees with occupational exposure will be involved in the review and update and provided the opportunity to contribute to the content of the written plan. An individual office may develop its own program or may use a "fill in the blanks" type of program, as long as the specific requirements for the exposure control plan are included.

Prospective Changes to the Cal/OSHA Regulations

A number of potential changes in OSHA regulations that may affect dentistry loom on the horizon and should be followed by practitioners. Additional changes to the bloodborne pathogens rule and ergonomics rule and the addition of a tuberculosis standard all have a potential to affect California dentists.

Federal OSHA is considering an ergonomics standard that, if implemented, may necessitate the revision of the California rule. A bill is under consideration in the federal legislature requiring sharps injury protection (similar to existing California law) that would also require the state to modify its rule if the federal requirements are more strict than existing California regulations.

In 1997, federal OSHA proposed standards for protection of workers against occupational exposure to tuberculosis.⁵ This regulations remains under consideration; and there is no existing requirement in California, in spite of several companies advertising "OSHA-required TB Exposure Control Plans." If the proposed rule is adopted as currently written, most dental offices would be unaffected by the regulation. Only those practices in high-risk facilities such as correctional facilities, long-term care facilities, homeless shelters, and hospital areas treating active TB patients would be included.

Infection control and other regulatory requirements are likely to continue to change as new pathogens and hazards emerge and new control measures are developed or identified. Dentists should stay involved in professional associations, continuously review the literature, and seek out sources of reliable information to ensure all available protections for personnel are in place and that the office is protected from charges of regulatory violation.

Author

Eve Cuny, RDA, BA, is the director of environmental health and safety at the University of Pacific School of Dentistry.

1. Bloodborne Pathogens. CCR, T8Sec 5193.

2. Repetitive Motion Injuries. CCR, T8 Sec. 5110 [Online} Available: http://www.dir.ca.gov/title8/5110.html [June 2, 2000].

3. Cuny EJ, Fredekind RF, Budenz AW, Safety needles: New requirements of the OSHA Bloodborne Pathogens rule. J Cal Dent Assoc 27(7):525-30, 1999.

4. Cuny EJ, Carpenter WM, Occupational exposure to blood and body fluids: New postexposure prophylaxis recommendations. J Cal Dent Assoc 26(4):261-71, 1998.

5. Department of Labor, Occupational exposure to tuberculosis. Proposed Rule Federal Register 62:54159-309, Oct 17, 1997.

To request a printed copy of this article, please contact/Eve Cuny, RDA, BA, UOP School of Dentistry, 2155 Webster St., San Francisco, CA 94115 or at ecuny@uop.edu.

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