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Thomas Davis, CRNA Chief CRNA The Johns Hopkins Hospital.

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Presentation on theme: "Thomas Davis, CRNA Chief CRNA The Johns Hopkins Hospital."— Presentation transcript:

1 Thomas Davis, CRNA Chief CRNA The Johns Hopkins Hospital

2 Protecting the Pregnant Worker Compliance with State/Federal Law Getting the job done

3 Beth is a CRNA who has worked on your staff for 8 years. She went into premature labor at 33 weeks with her last pregnancy and blames work related stress and fatigue. She is requesting shorter work days and limited lifting.

4 Amy is a CA3 Resident who believes that Universal Precautions are not truly effective in the chaos of the Operating Room and requests NOT to be assigned to any patients who have known communicable diseases.

5 Juanita is a new graduate in her first year of practice and newly pregnant. She says that the first trimester is critical for development and refuses to work in any cases involving radiology.

6 Heather was a pediatric ICU nurse prior to becoming an anesthetist. She has requested NOT to be assigned to do inhalation inductions while pregnant.

7 What are the concerns of the pregnant OR worker? What Laws protect the pregnant worker? What can we do to provide reasonable accommodation?

8 Pregnancy Discrimination Act of 1978 PDA, 42 U.S.C 2000e(K) Family and Medical Leave Act (FMLA)

9 Employer may not discriminate on the basis of sex to include pregnancy Childbirth must be treated as any other medical condition Employer sick leave applies to childbirth Employer health care plan must cover childbirth as any other health condition.

10 Employer may not discharge you for taking time off for childbirth You must be reinstated in the same manner as other employees with temporary disability Employer can not require you to take maternity leave For male employees, wife must receive the same health care benefits as female employees.

11 Title VII of the Civil Rights act of 1964 Male employees who go on paternity leave must be treated in the same manner as a female who takes leave for child-care purposes.

12  Applies to any employer with 50 or more employees  Entitles person to up to 12 weeks of unpaid leave ◦ Based on a 12 month rolling calendar  State laws may also apply.

13  Employee MUST have worked 12 months and at least 1,250 hours to qualify.  Time off authorized for: ◦ Care of newborn ◦ Care of new adopted child ◦ Care of seriously ill family member ◦ Care for yourself after serious illness or injury

14 Employee must be reinstated unless: They are physically or mentally unable to do the job They are considered a “key” employee and the company could suffer substantial eccnomic injury

15 Must provide 30 days written notice unless it is an immediate emergency Provide medical proof Clarify use of sick time versus unpaid leave Respond to employer’s request to update/verify status

16 Inhalation Agents Radiation Exposure to infectious disease Stress/fatigue

17  Prospective studies are not available  National Institute for Occupational Safety and Health (NIOSH) ◦ Clinical research ◦ Animal studies ◦ Epidemiologic studies

18  Anesthetic Gases: Guidelines for Workplace Exposure, OSHA Directorate of Technical Support and Emergency Management [formerly Directorate of Technical Support] July 20, 1999 Revised May 18, 2000  Waste Anesthetic Gases, Information for Management in Anesthetizing Areas and the Postanesthesia Care Unit (PACU), ASA Task Force on Trace Anesthetic Gases of the ASA Committee on Occupational Health of Operating Room Personnel

19 Human epidemiologic studies Animal studies Nitrous Oxide interacts with Vit B12 Inhibits Methionine synthase Inhibits thymidine synthesis and effects DNA Women who work with Nitrous Oxide in the absence of adequate scavenging have increased risk of spontaneous abortion. Rowland et al, Am J Epidemol 1995;141(6), 531-8

20 Halothane & Isoflurane Early studies (1980’s) Increased spontaneous abortions Increased premature deliveries Later studies No increased risk for anesthesia providers in the OR Female Veterinarians (2009) Increased spontaneous abortion and premature delivery when working in unscavenged areas.

21  Desflurane & Sevoflurane ◦ Little evidence of risk with newer agents ◦ OSHA recommends max exposure of 2ppm  Based on time weighted averages. ◦ Spontaneous abortion slightly higher in pediatric anesthesiologists doing inhalation inductions.

22 Poor ventilation / scavenging Tank valves High/low pressure machine connections Breathing circuit connections Defective hoses, reservoir bags, ventilator bellows

23 Leaving vaporizer on Spillage of liquid agent Poor face mask fit LMA or ET cuff under inflation

24  “There is no association between occupational exposure to trace levels of anesthetic gases in properly scavenged operating rooms and adverse health effects in pregnant women”

25 Effective Scavenging systems Dilution ventilation Anesthesia technique Gas off when circuit not connected Proper cuff inflation Proper mask fit Proper equipment maintenance Environmental monitoring Air quality checks Individual detection badges available

26  Methyl methacralate (Bone Cement) ◦ No known harmful effect to pregnant worker or fetus.  Homlar K, et al Journal of Arthroplasty 2013;28(3) 406-9  Organic Solvents ◦ Have not been studied in the operating room ◦ In industry associated with spontaneous abortion, premature delivery, impaired neurocognition and language.  Laslo-Baker Arch pediatr adolesc med 2004 158(10);956-61

27 I can’t do that case… I’m pregnant!

28 Utilize your internal resources Radiology safety officer Protocol for pregnant radiology technicians HR Department Occupational Health Review established guidelines American college of Radiology CDC Radiation and pregnancy fact sheet

29  First 2 weeks after conception are the greatest risk for fetal loss (all or none effect)  3-4 weeks is most lethal for fetus  4-8 weeks; malformation/growth restriction  8-15 weeks; growth restriction/cognitive impairment  15 weeks-term; growth restriction/imtellect impairment. ◦ Brent, RI Am J Obstet Gynecol 2009;200(1):4-24

30  No documented genetic risks for exposure prior to conception  No risk until levels exceed 150mGy ◦ Radiologic study approx <20mGy ◦ CT scan 10-35 mGy

31 “In summary, there is no need for medical intervention for the parturient or the fetus when undergoing routine diagnostic tests. Even when increased radiation doses are used for pregnant patients to enhance image quality, the additional dose is often absorbed by the additional adipose tissue “ Rev McCollough. Radiation Exposure and Pregnancy: When Should We Be Concerned? Radiographics 2007, Jul- Aug;27(4)909-17

32 Limit time near radiation source Increase distance from source (6 ft.) Shielding Wrap around apron Thyroid shield Eye protection Exposure monitoring Double badge when pregnant.

33 I can’t do that case! The patient is on isolation and I am pregnant.

34 Strict adherence to Universal precautions Effective handwashing Vaccination (Centers for Disease Control and Prevention [CDC], 1998).

35 DiseaseCategory of IsolationReassignment Necessary? Comments YesNo AIDS/HIVUniversal/ Standard Precautions x HUMAN PARVOVIRUS B19 (Fifth Disease) (Erythema Infectiosum) Universal/ Standard Precautions Respiratory Precautions x It is highly advised that pregnant personnel not care for patients admitted with aplastic crisis only CYTOMEGALOVIRUS (CMV) Universal/ Standard Precautions x Studies of HCW have not shown transmission of CMV from patient to personnel, but should observe universal/standard precautions at all times HEPATITIS AUniversal/ Standard Precautions Contact Precautions x HEPATITIS BUniversal/ Standard Precautions x Immunization against hepatitis B encouraged HEPATITIS CUniversal/ Standard Precautions x HERPES SIMPLEX (Types I and II) Universal/ Standard Precautions x Avoid direct contact with lesions HERPES ZOSTER (Shingles) VARICELLA (Chickenpox)** Universal/ Standard Precautions Contact Precautions Airborne Precautions xThe non-immune HCW, pregnant or not, should not have contact with Varicella or zoster (shingles) patients who have vesicular or open draining lesions. The immune HCW, pregnant or not, can safely care for a patient with shingles or Varicella RSVUniversal/ Standard Precautions Contact Precautions x RSV being treated with Ribavirin Universal/ Standard Precautions Contact Precautions x It is highly advised that a pregnant employee not provide direct care to the patient during the administration of Ribavirin and clean-up thereafter RUBELLA**Universal/ Standard Precautions and Respiratory Precautions for postnatal rubella Universal/Standard precautions and contact precautions for congenital rubella x The non-immune HCW, pregnant or not, should not have contact with patients with rubella RUBEOLA (Measles)**Universal/ Standard Precautions Airborne Precautions x The non-immune HCW, pregnant or not, should not have contact with patients with rubeola TOXOPLASMOSISUniversal/ Standard Precautions x TUBERCULOSISUniversal/ Standard Precautions Airborne Precautions x Annual PPDs should be administered Note. Adapted from AAOHN Journal (AAOHN J), p331, by J. Hood, 2008

36 AIDS/HIVUniversal/ Standard Precautions X HUMAN PARVOVIRUS B19 (Fifth Disease) (Erythema Infectiosum) Universal/ Standard Precautions Respiratory Precautions X It is highly advised that pregnant personnel not care for patients admitted with aplastic crisis only CYTOMEGALOVI RUS (CMV) Universal/ Standard Precautions X Studies of HCW have not shown transmission of CMV from patient to personnel, but should observe universal/standard precautions at all times Note. Adapted from AAOHN Journal (AAOHN J), p331, by J. Hood, 2008

37 HEPATITIS AUniversal/ Standard Precautions Contact Precautions X HEPATITIS BUniversal/ Standard Precautions X Immunization against hepatitis B encouraged HEPATITIS CUniversal/ Standard Precautions X HERPES SIMPLEX (Types I and II) Universal/ Standard Precautions X Avoid direct contact with lesions HERPES ZOSTER (Shingles) VARICELLA (Chickenpox)** Universal/ Standard Precautions Contact Precautions Airborne Precautions XThe non-immune HCW, pregnant or not, should not have contact with Varicella or zoster (shingles) patients who have vesicular or open draining lesions. The immune HCW, pregnant or not, can safely care for a patient with shingles or Varicella Note. Adapted from AAOHN Journal (AAOHN J), p331, by J. Hood, 2008

38 RSVUniversal/ Standard Precautions Contact Precautions X RSV being treated with Ribavirin Universal/ Standard Precautions Contact Precautions X It is highly advised that a pregnant employee not provide direct care to the patient during the administration of Ribavirin and clean-up thereafter RUBELLA**Universal/ Standard Precautions and Respiratory Precautions for postnatal rubella Universal/Standar d precautions and contact precautions for congenital rubella X The non-immune HCW, pregnant or not, should not have contact with patients with rubella Note. Adapted from AAOHN Journal (AAOHN J), p331, by J. Hood, 2008

39 RUBEOLA (Measles)** Universal/ Standard Precautions Airborne Precautions X The non-immune HCW, pregnant or not, should not have contact with patients with rubeola TOXOPLASMOS IS Universal/ Standard Precautions X TUBERCULOSISUniversal/ Standard Precautions Airborne Precautions X Annual PPDs should be administered Note. Adapted from AAOHN Journal (AAOHN J), p331, by J. Hood, 2008

40 Most common intrauterine infection in U.S. Frequent contact with children is greatest risk 400 infant deaths/3,400 cases of infant injury per year Causes placental inflammation and reduces oxygenation Birth injuries related to CMV Growth retardation, hydrocephalus, microcephaly, hearing loss, hepatomegaly

41 Transmitted via respiratory secretions Exposure to children is the greatest risk Inhibits the production of red blood cells Effects on Fetus Miscarriage, stillbirth, fetal anemia, inflammation of the fetal heart. Most adults have immunity Less than 1% fetal problems when mother gets the disease.

42 Greatest Risk to fetus in first trimester Deafness Eye abnormalities Congenital heart disease Other problems Spleen, liver, bone marrow problems Low birth weight Hepatomegaly Developmental delay

43 Vaccination Immunity testing where appropriate Universal Precautions Consider reassigning if: Fifth disease RSV treated with Ribavirin Rubella Rubeola (measles) if non-immune

44 Many references on the web HHS CDC March of Dimes State health web sites

45 Risks of stress Spontaneous abortion Premature labor Heart defects in the baby Increased risk for stillbirth Infertility

46  Break time for nursing mothers is protected ◦ US Dept of HHS ◦ US Dept of Labor ◦ CDC ◦ US Breastfeeding Committee ◦ Affordable care act ◦ FLSA (Fair Labor Standards Act, sect 7) ◦ State Labor laws

47 State law prevails if it provides greater protection for the mother Applies to companies with 50 or more employees Applies only to non-exempt employees

48 An Employer shall provide: Reasonable time to express breast milk for up to 1 year after the birth of the child A place, other than a bathroom, that is shielded from view and free from intrusion from coworkers and the public.

49 Thomas Davis, CRNA Chief CRNA The Johns Hopkins Hospital


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