OSHA Chemical Hazards And Communication

Issues of Concern

There are roughly 5,000 work-related deaths in the United States each year and millions of injuries, which is significantly reduced relative to OSHA intervention but still a significant cause of concern that OSHA attempts to negate.[2] Chemicals are used daily in both low-risk and high-risk industries, whether that be cleaning products, ingredients to create new products, or combining chemicals to formulate or activate a different chemical, to name a few. Thousands of chemicals may be used in workplaces across the country. Still, the exposure-related hazards have been narrowed down to 16 different physical hazards, 10 health hazards, and 1 environmental hazard, all of which are included in the GHS.

The physical hazards include oxidizing solids, liquids, and gases; flammable solids, liquids, gases, and aerosols; explosives; gases under pressure; self-reactive substances; self-heating substances; pyrophoric solids and liquids; substances that emit a flammable gas when in contact with water; organic peroxides; and corrosive to metals. The health hazard warnings include acute toxicity; single and repeated exposure target organ toxicity; skin corrosion or irritation; eye damage or irritation; respiratory and skin sensitization; aspiration hazard germ cell mutagenicity; reproductive toxicology; and carcinogenicity. Finally, the single environmental hazard is if the chemical is hazardous to the environment acutely or chronically. Each chemical should be stored in a labeled container with a designated symbol that signifies the specific physical and health hazards associated with exposure.

Additionally, OSHA requires a detailed safety data sheet also be provided with specifics on the chemical that include identification; hazard identification; composition, first-aid, firefighting, and accidental release measures; handling and storage; physical and chemical properties; stability and reactivity; ingredient information; exposure controls/personal protection; disposal considerations; and information on toxicology, ecology, transport, and regulations.[3]

The OSHA HCS was developed to inform employees about the chemicals they are handling. OSHA requires employers to adhere to HCS by implementing the following standards:

1. Inform the employees of the specific hazardous chemicals they can expect to be exposed to in the workplace. Importantly, this includes any possible exposures, whether as part of the normal role or by accident. The health and physical hazards associated with the chemical should also be shared.
2. In addition to informing employees, employers must also provide appropriate training for employees handling hazardous chemicals. This must occur when the employee begins a new position or a new hazardous chemicals are used as part of their role.
3. Employees must be trained on specific protective measures determined by the employer to minimize exposures.
4. Develop and maintain a written plan for communicating chemical hazards.
5. Maintain safety data sheets for each hazardous chemical.
6. Maintain an inventory of chemicals on-site and ensure a warning label is written in English and included in the container where the chemical is stored. The required contents of the hazard label are described next.

The OSHA HCS has recently changed from the performance-based standards set in the 1990s to a more structured labeling system designed to provide brief visual warnings for the user. Hence, they quickly know the hazards of the chemical. Requirements for the label include:

1. The name, address, and phone number of the chemical’s manufacturer.
2. The identifying name, code, or batch number of the chemical.
3. Signal words indicate the severity of the hazard.
   1. “Danger” is used when the severity of the hazard is high.
   2. “Warning” is used when the severity of the hazard is low.
4. Hazard statements regarding the nature of the hazard, including the type of contact necessary to inflict the hazardous reaction and the physical, health, and environmental hazards of the chemical.
5. Precautionary statements describe specific steps to minimize exposures and hazardous effects, steps to take depending on the nature and bodily location of the exposure, how to store the chemical, signs, and symptoms that indicate the need to seek medical attention, and how to dispose of the chemical.
6. Pictograms include a red diamond-shaped frame with an image specific to the chemical hazard within the frame. These pictograms are meant to notify the user of the most pertinent hazards quickly. These pictograms are displayed as:
   1. Health hazards include carcinogenic, mutagenic, respiratory sensitizers or induce reproductive, organ, or aspiration toxicity.
   2. Flame warns of flammable chemicals, pyrophoric, self-heating, emitters of flammable gas, self-reactive, or organic peroxides.
   3. Exclamation mark warns of chemicals being skin, eye, or respiratory tract irritants, skin sensitizers, inducers of nonfatal acute toxicity, narcotic-like, or a non-mandatory label of a hazard to the ozone layer.
   4. A gas cylinder indicates that the gas is under pressure.
   5. Corrosion warns that the chemical can cause skin corrosion or burns, eye tissue damage, or metal corrosion.
   6. Exploding bomb, which warns that the chemical is explosive, self-reactive, or an organic peroxide.
   7. Flame over a circle, which indicates the chemical is an oxidizer.
   8. Skull and crossbones indicate the chemical can induce acute toxicity that can be fatal.
   9. Environment, which indicates the chemical causes aquatic toxicity. This pictogram is required by the GHS but by OSHA.

A concern that has arisen in recent years is the misclassification of chemicals and misinterpretation of chemical hazard communication signage. Improvements could be made to harmonize the classification system internationally and the criteria for selecting an expert who determines the classification of a chemical.[4] Further standardization of the classification process is likely warranted. Interpretation of the chemical hazard information associated with a specific chemical label is also of concern, as prior reports have shown that the level of education, prior training, and the inclusion of the GHS pictogram associated with a chemical hazard are factors influencing the interpretation of a chemical hazard.[5] Based on these results, additional steps to provide improved initial and longitudinal training for employees on the hazards of certain chemicals and the label warnings associated with them may be beneficial for identifying hazards. Specific to the healthcare field, the clinical pathology laboratory is the area of the hospital that works most intimately with hazardous chemicals.[6] While these chemicals are necessary for clinical tests, sample analyses, and tissue handling, chemicals such as formaldehyde, xylene, ethylene oxide, glutaraldehyde, and many other carcinogens, neuro- and nephrotoxins, irritants, corrosives, and sensitizers exist in the laboratory setting.[7] Proper labeling, handling, and personal protective equipment for the risks associated with the chemicals being used should be considered a top priority for the short- and long-term health and safety of all clinical laboratory staff members.[8]

Clinical Significance

Because of the wide array of chemicals that workers may be exposed to on the job, it may be difficult to determine the offending chemical and subsequent treatment strategies. A recent analysis of 12 professions highlighted this by reporting that as many as 685 different disinfectants are not made for human use, with 152 active ingredients and 763 insecticides with 97 active ingredients used in the industry currently.[9] Two other analyses showed that chemical exposures had been reported with 200 to 308 different chemicals across multiple professions.[10][11] Such a wide variety of chemicals used in the workplace can make workups difficult, so obtaining a quick but thorough history from either the patient or a witness is critical to narrow in on a specific chemical exposure and subsequent treatment strategy.

Past analyses have shown that the most common chemical exposures, most of which were in the workplace, were corrosive liquids and flammable gases.[10] The most common chemicals causing the hazardous insult were propane-butane, hydrochloric acid, sulfuric acid, methane, hydroxides, ammonia, and butyric acid. While this is not an exhaustive list of the potential chemical exposures that may present from outside the hospital, they are the most common. Therefore, they should be higher on the differential diagnosis when dealing with unknown chemical exposure. The chemical agents commonly associated with chemical exposures within the hospital include cleaning chemicals like sterilizing agents, disinfectants, detergents, solvents, heavy metals, medical treatments like antineoplastic or antibiotic drugs, and anesthetic gases and laboratory chemicals like formaldehyde and xylene.  Certain hospital personnel are more likely to work with these chemicals than others, so exposure to chemicals commonly used within their job description should be higher on the differential diagnosis. Additionally, just as employees working with radiation sources like fluoroscopy must monitor their exposure, steps should be taken to monitor both individual exposure and ambient levels to chemicals of interest to reduce overall chemical exposure.[12]

Secondary exposure is a topic of concern when treating patients with chemical exposures. A recent analysis of over 120,000 chemical incidents showed that only 9 secondary exposure cases were experienced by hospital personnel when treating a patient with chemical exposure. The most common mechanism of secondary exposure was inhalation. They concluded that standard personal protective equipment, including gloves and a gown, is sufficient to protect hospital personnel when treating these patients. Further equipment is only necessary when treating highly toxic like sarin.[13]

One of the most underrepresented problems associated with hazardous chemical exposure is the long-term sequelae. People exposed to hazardous chemicals may not present with acute health problems and may not be further concerned. However, the pathogenesis of disease states like cancer may take many years to develop after the exposure, depending on the nature and duration of the exposure. For people who have acute exposure to a hazardous chemical like an accidental spill or inhalation, long-term monitoring should be performed to identify any signs of disease.[14] Additionally, steps should be taken to reduce further exposure, likely worsening and speeding up any pathologic states.

Nursing, Allied Health, and Interprofessional Team Interventions

As with many other safety standards, education, and training are some of the most important factors that can be addressed to reduce chemical exposures. While this is a requirement set by OSHA, a specific emphasis should be placed on longitudinal training to revisit topics that may not be part of daily practice and, therefore, forgotten. A recent survey of over 12,000 hospital employees showed that chemical-specific training for handling high-risk chemicals like antineoplastic or aerosolized medications, strong disinfectants and sterilants, and surgical smoke was as low as 52% and 57% for aerosolized antibiotics and surgical smoke, respectively.[15]

Further, the survey also showed that responders only reported having employer procedures to reduce the risk of exposure to surgical smoke or anesthetic gases 32% and 56% of the time, respectively.[16] Informing workers of chemical hazards and the HCS signage associated with each 1 is an excellent way to reinforce the steps necessary to handle hazardous chemicals properly.[17] Just as this improves safety for hospital employees, this process may also involve the hospital outreach team collaborating with local businesses carrying out high-risk work to educate on the acute and long-term implications of chemical exposures. Awareness campaigns may be an actionable step taken by the healthcare team to promote chemical handling safety and proper identification of hazardous chemicals.[18]

When patients present with chemical exposures, the interprofessional team must act quickly to determine the chemical causing the insult. In some scenarios, the patient may not communicate this, so the EMS and emergency department teams must gather as much history as possible from witnesses or coworkers to determine the chemical. Appropriate treatment can better be determined with this crucial piece of history. At the hospital, specific antidotes should be determined by the pharmacy team and administered by the emergency department medical and nursing teams. Depending on the nature of the exposure and symptoms, the specialist team associated with the organ system(s) involved should be consulted. After stabilization, the extent of injury should be determined, and an appropriate follow-up should be scheduled. If the exposure was debilitating, the physical therapy and occupational therapy teams should be involved to rehabilitate the patient. Finally, the social work team should work with the patient and employer to further exposure to the patient or other employees.

Nursing, Allied Health, and Interprofessional Team Monitoring

The hospital and healthcare team should be involved in the active promotion of chemical safety and education on the risks associated with exposures. Additionally, proper signage, warning labels on containers holding dangerous chemicals, and the use of appropriate personal protective equipment can help maintain hospital employee safety and save lives.[8] Strategies during the education process should include pictograms and labels associated with the specific hazards of a chemical so hospital employees can better understand the risks and implications of chemical exposure. The inclusion of these clear visual depictions of the chemical hazard has proven very effective. It is estimated to have contributed to a reduction of between 107,000 and 459,000 acute chemical injuries as well as significant decreases in carcinogen exposures since their widespread use began.[19][20] Chemical hazards pose a significant threat to employees' health when handling them. Still, proper education, precautions, and labeling have significantly reduced the incidence of acute exposure and long-term complications.