Seguridad y Medio Ambiente FUNDACIÓN MAPFRE

Year 29 Nº 115 third quarter 2009

Occupational risks in health centre SAFETY

This article describes the methodology for evaluating occupational risks and planning preventive activity (MERCAPP from Spanish initials) and also for drawing up a prevention handbook and creating a training unit to serve as a common tool for all risk-prevention officers working in health centres. The research was carried out in the 18 primary healthcare centres making up sector Zaragoza II of the Aragón Health Service

By ANA CRISTINA FONTANA JUSTES. Industrial Technical Engineer. Higher Occupational Risks Prevention Officer. Prevention of Occupational Risks. Hospital Universitario Miguel Servet. Agragón Healthcare Services.

Occupational-risk-prevention legislation, standards and criteria have been set up to help us reduce accident rates and occupational illnesses. When the working centres involved have similar characteristics in terms of buildings, work stations and the tasks carried out, it is essential for occupational risk officers to be armed with tools that enable them to establish common procedures for risk evaluation and planning and training the workers and informing them about the risks involved. Only then can they be sure of complying properly with said legislation. This article presents and describes such a tool developed in sector Zaragoza II of the Aragón Health Service (Servicio Aragonés de Salud):

  1. Methodology for Evaluating Risks in Primary Healthcare and Planning Centres (MERCAPP from Spanish initials).
  2. Handbook for the Prevention of Occupational Risks in Health Centres.
  3. Training unit for professionals of the primary healthcare centre.

Health Centres

Health centres are independent multi-storey buildings made up by:

1. The foundations, structure, weight-bearing walls, partition walls, floors, ceilings, roofs, etc. which are generally laid out as the following areas: consulting rooms for the family doctor and nurse; paediatric doctor and nurse; midwife; social worker; oral healthcare; physiotherapy, and emergencies, plus other sundry spaces such as physiotherapy gym; meeting room or classroom; lounge; dressing rooms; toilets; blood samples; injections; healthcare supplies store; waste store; cleaning room and admin-filing area.

These spaces are interlinked for access purposes by means of stairways or ramps, corridors and waiting rooms.

2. The service and utility fixtures such as water, electricity, gas, heating, cooling, telephones, antennae, lifts, etc.

Spaces in the health centre are set aside for the fixtures. These might be sited in the basement, on the ground floor or, in a multi-storey health centre, on the roofs. These fixtures or facilities are the following:

  • Electricity and lighting. Transformation centres, switchboards, general lighting, plugs, switches, generators, lightning conductors, etc.
  • HVAC. This system may be of the following types:
    • Gas boiler - coolers, air conditioner, fancoil.
    • Fuel oil tank, fuel oil boiler, air conditioner.
    • Air pumps, air conditioner.
    • Air conditioner.
  • Water Supply.
    • Electric water heater, water tank, pressure generator.
    • Gas boiler, water tank, pressure generator.
  • Lifts.. With engine room.
  • Fire Protection.. The fire protection system might consist of a water storage tank, portable fire extinguishers, fixed extinguishment systems, fire doors and emergency exits.
  • Emergency lighting.. Safety and standby lighting.
  • Telephones.

3. Sundries: such as garages, gardens, fences and enclosures, auxiliary rooms and in general everything that might be conducive to the centre’s solidity, comfort and hygiene.

The garages might be indoor or outdoor, on the ground floor or in the basement.

A knowledge of the fixtures and facilities involved tells us which industrial legislation applies to each one and the risks involved.

Fixtures, indoor equipment and tasks carried out by healthcare professionals were some of the variables analysed in the health centres studied

A description of the workplace helps us to establish the risks that might crop up and how to control them.

Table 1. Indoor equipment of a family doctor’s consulting room
General furniture Bookcase with lower doors, fixed chair, swivel chair with wheels and arms. Consulting room desk with wing and drawer. Auxiliary table with wheel and stands. Shelves. Plastic litter bin. Wall mounted clothes pegs. Individual metal clothes locker.
Clinical furniture Two- or three-section screen with wheels. Examination couch. Examination-couch mounting-step. Swivel stool with wheel. Large litter bin with lid and pedal.
Healthcare instruments and devices Two-section x-ray viewing screen. Scales with height meter for adults. Standing lamp/magnifying glass. Wall light /wall-mounted polyscope. Blood pressure meter with normal sleeve. Blood pressure meter with sleeve for obese patients. Spirometer /peak flow meter. Brush/water reflex hammer. Optotype. Tuning fork. Scales with height meter. Measuring tape. Tuning fork. Mercury sphygmomanometer with sleeves of different sizes (children, adults and obese adults). Head mirror with built-in direct light or simple. Larynx mirrors of various sizes. Stethoscope for adults and children. Lamp. Reflex hammer. Wall-mounted ophthalmoscope and otoscope. Optotypes. Reflectometer for capillary glycaemia (glucose meter) + blood-letting lancet. Thermometer. Others: podoscope.
Expendables Safety container for biological waste. Tongue depressors. Hypoallergic plasters 2.5 and 5 centimetres wide. Adhesive tapes for taping. Disposable otoscope specula (children and adults). Sterile gauze and dressings. Disposable gloves. Sterile gloves. Lancets for removing foreign bodies from the eye (hemostats). Urological lubricant and vaseline. Reactive strips for capillary glycaemia and urine analysis. Plasters. Cotton swabs.
Sundries Computer. Printer. Trays. Soap dispenser. Paper towel dispenser.
Doctor’s emergency visiting bag Medicaments Cardiovasculares: Nitroglicerina aerosol, Adrenalina, Captopril, etc. Cardiovascular: Nitro-glycerin aerosol spray, Adrenaline, Captopril, etc. Respiratory: Salbutamol aerosol, methylprednisolone ampoules, etc. Digestive: Metoclopropamide ampoules, etc. Analgesics and NSAIDs: Diclofenac ampoules, etc. Central nervous system: Lorazepam, clonazepam ampoules, haloperidol ampoules, etc. Antihistamines: Dexchlorphenidramine ampoules, etc. Antiseptics: Povidone iodine, etc. Eye drops: anaesthetising eye drop, etc. Antibiotics: Amoxicillin, etc. Others: Rapid insulin, etc.
Healthcare Devices/InstrumentsRubber tourniquet. Sphygmomanometer with aneroid manometer Stethoscope. Glucose meter with needles and reactive strips. Lamp with batteries. Reflex hammer. Thermometer. Scissors (for cutting clothes).
Expendables Abocaths, Abbocaths, blood collection wingset and injection stoppers. Hypodermic needles of various sizes. Tongue depressors. Hypoallergic plasters. Sterile gauze. Gloves. Scalpel blades. Syringes. Bandages.

To describe the indoor equipment we will take a typical health centre as our example, with the obvious caveat that the actual rooms of any particular health centre will depend on available space and the services it provides. In such a typical health centre there will generally be common rooms; each room can in turn be broken down into general furnishings, clinical furnishings, healthcare devices/instruments, expendables and sundries. Indoor equipment is also considered to include the contents of the doctor’s visiting bag. Table 1 shows the typical indoor equipment of a family doctor’s consulting room.

Awareness of the indoor equipment present in each one of the rooms making up a health centre allows us to establish needs in terms of workstation design. Knowledge of the equipment, instruments and devices handled therein helps us to establish the security measures that should be adopted.

Primary healthcare centres of each basic health area are the physical structures where professionals carry out primary healthcare activities. They represent the public healthcare services closest to the public at large, usually serving as their first port of call.

One single primary healthcare centre may house more than one basic health zone in the same building.

We thus find that the Zaragoza II sector of Aragón has 18 health centres or primary healthcare centres, comprising 21 health zones (Table 2).

Table 2. The approximate staff of each health centre is the following:

Table 2. The approximate staff of each health centre is the following:

Primary healthcare is the basic and initial attention level, guaranteeing lifelong and blanket coverage for each patient, acting as manager and coordinator of cases and flow regulator.

The healthcare professionals’ tasks take in activities of health promotion, healthcare education, disease prevention, healthcare assistance, health recovery and maintenance and physical rehabilitation and social work.

All these activities, targeted at individuals, families and the community at large, under a biopsychological approach, will be carried out by interdisciplinary teams, guaranteeing quality and accessibility and also continuity between the various healthcare services and coordination and liaison between all the sectors involved.

The services portfolio is a catalogue of the services related to the activities of promotion, prevention, treatment and monitoring of certain health problems in the population, based on the programmes or protocols set up in the primary healthcare sectors.

Awareness of the workplace and its indoor equipment helps us to pinpoint the risks and needs of health centres

Even so, there are some jobs and activities not included in the services portfolio, such as nursing auxiliary, porter, administrative auxiliary, etc., and these should not be overlooked.

Another factor that has to be taken into consideration is where the activities were carried out, at the consulting room, on home visits, etc, since the same task might have different risks in different places. Furthermore, the very fact of travelling outside the health centre might lead to unforeseen accidents (falls, blows, road accidents, etc).

The different jobs and the description and painstaking observation of the tasks carried out in each one will help to pinpoint the specific risks that might occur, the working habits and the necessary personal protection equipment.

Accident Rate

Work-related accidents (with or without time off) obviously have to be studied first and foremost to find out their causes and take the future corrective action to suit. But they also give us valuable insights into the predominant risk factors and how they manifest themselves: the form or type of accidents they cause, material agent, nature of resulting injuries and the part of the body injured in each job. This will help in arranging the preventive actions for eliminating, reducing or controlling these risk factors.

A study has been carried out of the accidents occurring in the health centres of sector II of Zaragoza in 2007 and 2008, furnishing the following information (graphs 1 and 2):

Graph 1.

Graph 1.

Graph 2.

Graph 2.

Accidents involve falls to the same level (1 in 2007 and 2 in 2008), falls to a different level (1 in 2007), impacts (3 in 2008), cuts (2 in 2007 and 1 in 2008), trapped limbs and fingers (2 in 2008), exposure to biological risks (28 in 2007 and 24 in 2008) and strains (1 in 2007 and 3 in 2008).

Broken down by jobs, the professions that suffered most accidents in the period under study were nurses (26 in 2007 and 26 in 2008), doctors (5 in 2007 and 7 in 2008), administrative auxiliaries (1 in 2007 and 6 in 2008), midwives (1 in 2008) and oral hygienists (1 in 2007).

Accidents of a biological origin are therefore the most numerous. We therefore looked into how they occur and what material agents are involved. The findings are shown in graphs 3, 4, 5 and 6:

Graph 3.

Graph 3.

Graph 4.

Graph 4.

Graph 5.

Graph 5.

Graph 6.

Graph 6.

A breakdown by site of the biological accident shows that these accidents occur in the blood extraction rooms (14 in 2007 and 9 in 2008), in consulting rooms (12 in 2007 and 4 in 2008), in patients’ homes (2 in 2007 and 11 in 2008) and in treatment rooms (1 in 2008).

The material agent that causes most of these biological accidents are needles (19 in 2007 and 19 in 2008) and lancets (6 in 2007 and 5 in 2008).

The accident rate is the most trustworthy indicator for evaluating the risk and deciding on preventive actions. Particular heed should be paid to those tasks, pieces of equipment and places where most accidents occur.

Methodology

Development of the Methodology for Evaluating Risks in Primary Healthcare and Planning Centres (MERCAPP). This is defined by the following characteristics:

1st Characteristic: General Methodology

The fact that the study deals with several health centres with similar risks and the same jobs makes it necessary to ensure that the structure of the evaluation and planning is suited to all of them. This will give us comparative figures that shed overall light on the state of occupational risk prevention and allow us to take preventive action in a joint and ordered way.

It is for this very reason that MERCAPP does not claim to be a closed document. Rather is it a document in permanent evolution to keep track of the changing objectives and theoretical progress in the science of occupational risk prevention.

The MERCAPP is structured as follows:

  1. General Figures
    Address of the centre, coordinators, staff, characteristics, service and protection facilities, electromedicine equipment and contracts.
  2. Accident Rate/Occupational Disease
    Historical comparison of the number of accidents and occupational diseases broken down by health centre and job over the last two years.
  3. Workplaces
    • General safety conditions:
      Structural safety; work spaces and hazardous zones; floors, openings, changes of level and handrails; partition walls, windows and spans; pathways; doors and gates; ramps, stairways and service stairs; fixed ladders; step ladders; evacuation pathways and exits; fire protection conditions; electricity system and wiring; disabled people.
    • Cleanliness, tidiness and maintenance:
      Cleanliness, tidiness, maintenance.
    • Service and protection fixtures:
      Specific regulations, stores, waste.
    • Environmental conditions:
      Operating temperature, relative humidity, air currents and draughts, air turnover.
    • Lighting:
      Natural lighting, minimum lighting levels, lighting characteristics.
    • Hygiene and rest areas:
      Dressing rooms, showers, washrooms and toilets; rest areas.
  4. Jobs and workstations
    • General conditions vis-à-vis: Biological risks.
    • Specific conditions of each job or workstation:
      • Family and paediatric doctor: equipment risks, biological risks, postural load during work, load handling risks, computer screen risks and risks arising from travel outside the health centre.
      • Family and paediatric nurse: equipment risks, biological risks, chemical risks, lighting, postural load during work, load handling risks, computer screen risks and risks arising from travel outside the health centre.
      • Nursing auxiliary: equipment risks, biological risks, chemical risks, load handling risks, computer screen risks.
      • Administrative auxiliary: postural load during work, computer screen risks.
      • Porter: load handling risks.
      • Midwife: biological risks, chemical risks, lighting, postural load during work, computer screen risks.
      • Physiotherapist: equipment risks, exposure to ultrasound radiation, microwave radiation, non-ionising optical radiation, postural load during work, computer screen risks.
      • Social worker: computer screen risks and risks arising from travel outside the health centre.
      • Dentist: equipment risks, biological risks, chemical risks, ionising radiation, non-ionising radiation, postural load during work, computer screen risks.
      • Oral hygienist: equipment risks, biological risks, chemical risks, ionising radiation, non-ionising radiation, postural load during work.
  5. Planning
    Planning will be established to suit priorities. These priorities will work at block level and no lower (for example, within the biological risk there will not be preventive actions of priority 1 to 4; all of them will have exactly the same priority).
  6. Training and Information
  7. Coordination of Business Activities
    Data collection file.
  8. Surveys
  9. Data Processing
Table 3. Workplaces
Risks produced by Priority
General safety conditions 2
Cleanliness, tidiness and maintenance 3
Service and protection fixtures 1
Environmental conditions – Thermal comfort 3
Lighting 4
Hygiene and rest areas 4
Table 4. Jobs
Risks produced by Priority
Equipment 2
Travel outside the centre 2
Biological agents 1
Chemical agents 2
Ionising radiation 1
Physical agents 3
Manual load handling 2
Postural load 2
Computer screens 2

MERCAPP does not claim to be a closed document; it has to evolve in line with changing objectives and theoretical progress in the field of occupational risk prevention

2ndCharacteristic: Precise

MERCAPP is based on a series of checklists with questions expressed in an exact and thoroughgoing way, calling forth three possible replies: YES, NO and Observations. Since the question enquires about whether or not a preventive action has been taken, the observations section serves to make one of the following points;

  • That the preventive action is question is not applicable.
  • To quantify the affirmative or negative answers in percentage terms.
  • To add characteristics that clarify the preventive action. (Table 5)
Table 5. Postural load in patient exploration
Code Question YES NO Observations
MFPCP-1 Are the examination couches in consulting rooms fixed, hydraulic or electric? Indicate percentages. % fixed:
% hydraulic:
% electric:

At the end of the methodology the different risks are ordered by priority, but with due weight given to degree of compliance, establishing how many questions are affirmative and how many negative, and indicating percentage compliance (Table 6)

Table 6. General Biological Risk Conditions
Subject No. of yeses/ total questions No. of noes / total questions % compliance
Fixtures
Air precaution
Precaution against drips
Precaution against contact

3rd Characteristic: Thoroughgoing

MERCAPP is not based on general risk assessment methods but rather on compliance with specific standards for each point being valued. (Table 7)

Table 7. Workplaces
General Safety Conditions
ROYAL DECREE 486/1997 of 14 April laying down minimum workplace health and safety conditions.
INSHT TECHNICAL GUIDE for evaluation and prevention of workplace risks.
Cleanliness, Tidiness and Maintenance
ROYAL DECREE 486/1997 of 14 April laying down minimum workplace health and safety conditions.
INSHT TECHNICAL GUIDE, for evaluation and prevention of workplace risks.
Service and Protection Fixtures
ROYAL DECREE 486/1997 of 14 April laying down minimum workplace health and safety conditions.
INSHT TECHNICAL GUIDE, for evaluation and prevention of workplace risks.
ROYAL DECREE 1027/2007 of 20 July, Regulation on Thermal Fixtures in Buildings.
ROYAL DECREE 3275/1982 of 12 November on Technical Conditions and Guarantees in Electrical Power Plants and Transformation Centres
ROYAL DECREE 842/2002 of 12 November on Technical Conditions and Guarantees in Electrical Power Plants and Transformation Centres
ROYAL DECREE 1427/1997 of 15 September approving the complementary technical instruction MI-IP03 «Oil facilities for own use».
ROYAL DECREE 1244/1979 of 4 April approving the Pressure Vessels Regulation.
ROYAL DECREE 2291/1985 of 2 August approving the Low Voltage Electrotechnical Regulation.
ROYAL DECREE 614/2001 of 8 June on minimum provisions for safeguarding workers from electrical risk.
INSHT TECHNICAL GUIDE for the evaluation and prevention of electrical risk.
ROYAL DECREE 865/2003 of 8 February laying down the sanitary-hygiene criteria for prevention and control of legionellosis.
DECREE 136/2005 of 20 July laying down special measures for the prevention and control of legionella.
ROYAL DECREE 1942/1993 of 5 November approving the Fire Prevention System Regulation.
ACT 10/1998 of 21 April on Waste.
ROYAL DECREE 952/1997 of 20 June, Hazardous Waste Regulation.
DECREE 29/1995 of 21 February of the Provincial Council of Aragón on the management of healthcare waste in the Region of Aragon.
Environmental Conditions
ROYAL DECREE 486/1997 of 14 April laying down minimum workplace health and safety conditions.
INSHT TECHNICAL GUIDE, for evaluation and prevention of workplace risks.
UNE-EN ISO 7730:96, Moderate thermal environments. Determination of the PMV and PPD indices and specification of the conditions for thermal comfort.
Lighting
ROYAL DECREE 486/1997 of 14 April laying down minimum workplace health and safety conditions.
INSHT TECHNICAL GUIDE, for evaluation and prevention of workplace risks.
IDAE TECHNICAL GUIDE on energy efficiency in lighting: hospitals and primary healthcare centres.
Hygiene and rest areas
ROYAL DECREE 486/1997 of 14 April laying down minimum workplace health and safety conditions.
INSHT TECHNICAL GUIDE for evaluation and prevention of workplace risks.

MERCAPP Annexes

On occasion the methodology is based on top-up questions related to the subjects dealt with in its annexes, such as:

  • Design of consulting rooms of doctor, nurse and midwife, design of admission desk and dressing rooms.
  • Gloves to be used in healthcare centres.
  • Methotrexate administration procedure
  • Mercury spillage collection procedure.
  • Load handling evaluation procedure (NIOSH).
  • Postural load evaluation procedure (REBA).

The design of a consulting room is shown below by way of example (Figure 1).

Figure 1.

Figure 1.

This design is based on the following standards:

Design Criteria:

  • Decree 19/1999 of 9 February of the Government of Aragón, on the promotion of accessibility and removal of architectural barriers and other barriers in urban furniture, transport and communications.
  • ROYAL DECREE 486/1997 of 14 April laying down minimum workplace health and safety conditions. «Human Dimension and Interior Space», by Julius Panero and Martín Zelnik.
  • Healthcare areas.
  • UNE EN ISO 14738 anthropometric requirements for the design of workstations at machinery.

Training Handbook and Training Unit

Both documents are divided into the following sections:

A short introduction to occupational, biological, chemical and physical risks and risks bound up with safety, facilities, postural load, load handling, computer screens, environmental comfort, road safety and emergencies.

The handbook’s chapter on biological risks is shown below (Figure 2).

Figure 2. Figure 2. Figure 2.

Figure 2.

The study has analysed the accidents in health centres of the Zaragoza II system in 2007 and 2008, serving as the basis for conclusions drawn about the working environment and the specific tasks of safety officers

A slide of the training unit is enclosed by way of example, with an explanation of its structure (Figure 3).

Figure 3.

Figure 3.

Conclusions

The starting point for this research work was the culling of data on health centres, in terms of a description of the building, the indoor equipment and the tasks involved in each job. It was crucial for this information to be neither too vague nor too specific. Numerous visits were therefore made to health centres and many hours were spent observing the various tasks. We consider the result to be sufficiently representative to stand for all health centres, however variable they may be as a set.

The greatest problem posed by drawing up the risk assessment method was to pare down the gist of technical criteria and standards to simple questions on the building characteristics, the tasks carried out, the accidents of recent years, as the basis for deciding on specific action in light of the percentage compliance and planning this action in terms of priorities established by type of risk. A worker survey has also been phased into this section for them to express their perception of occupational risk prevention in the health centre where they work. This methodology does not claim to be static or closed; it has to be dynamic and open to new updates and revisions. Our single objective has been, and still is, to establish a tool for occupational risk assessment and planning of preventive action that is conducive to common and joint preventive action in all health centres. The proof of the pudding will be in the eating, when implementation begins.

As for the prevention handbook, the most complicated aspect was to write it in a clear and succinct form, keeping it brief and well illustrated, so that it serves as a consulting room handbook of written procedures to follow whenever doubts crop up.

The study aims to establish a tool for occupational risk assessment and planning of preventive action that is conducive to common and joint preventive action in all health centres

The aim of the training unit is to establish common training courses for all workers, which they can follow either in person or through the sector intranet.

The aim is for both the manual and the training unit also to reach all health centre stand-in personnel covering those on leave or off sick.


ACKNOWLEDGEMENTS

To Ana Sesé Chaverri, manager, and to Jesús Goicoechea Iribarren, coordinator of occupational risk prevention of the Zaragoza II sector of the Aragón Healthcare Service, for the facilities made available, and to the rest of the sector personnel for their patience and friendliness. This research work has been carried out on a 2007 research grant from FUNDACIÓN MAPFRE.

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