Mycobacterium abscessus Cluster in Cardiac Surgery Patients Potentially Attributable to a Commercial Water Purification System.

BACKGROUND: Nontuberculous mycobacteria are water-avid pathogens that are associated with nosocomial infections. OBJECTIVE: To describe the analysis and mitigation of a cluster of Mycobacterium abscessus infections in cardiac surgery patients. DESIGN: Descriptive study. SETTING: Brigham and Women's Hospital, Boston, Massachusetts. PARTICIPANTS: Four cardiac surgery patients. INTERVENTION: Commonalities among cases were sought, potential sources were cultured, patient and environmental specimens were sequenced, and possible sources were abated. MEASUREMENTS: Description of the cluster, investigation, and mitigation. RESULTS: Whole-genome sequencing confirmed homology among clinical isolates. Patients were admitted during different periods to different rooms but on the same floor. There were no common operating rooms, ventilators, heater-cooler devices, or dialysis machines. Environmental cultures were notable for heavy mycobacterial growth in ice and water machines on the cluster unit but little or no growth in ice and water machines in the hospital's other 2 inpatient towers or in shower and sink faucet water in any of the hospital's 3 inpatient towers. Whole-genome sequencing confirmed the presence of a genetically identical element in ice and water machine and patient specimens. Investigation of the plumbing system revealed a commercial water purifier with charcoal filters and an ultraviolet irradiation unit leading to the ice and water machines in the cluster tower but not the hospital's other inpatient towers. Chlorine was present at normal levels in municipal source water but was undetectable downstream from the purification unit. There were no further cases after high-risk patients were switched to sterile and distilled water, ice and water machine maintenance was intensified, and the commercial purification system was decommissioned. LIMITATION: Transmission pathways were not clearly characterized. CONCLUSION: Well-intentioned efforts to modify water management systems may inadvertently increase infection risk for vulnerable patients. PRIMARY FUNDING SOURCE: National Institutes of Health.

Cluster of Burkholderia cepacia Complex Infections Associated With Extracorporeal Membrane Oxygenation Water Heater Devices.

BACKGROUND: Burkholderia cepacia complex is a group of potential nosocomial pathogens often linked to contaminated water. We report on a cluster of 8 B. cepacia complex infections in cardiothoracic intensive care unit patients, which were attributed to contaminated extracorporeal membrane oxygenation (ECMO) water heaters. METHODS: In December 2020, we identified an increase in B. cepacia complex infections in the cardiothoracic intensive care unit at Brigham and Women's Hospital. We sought commonalities, sequenced isolates, obtained environmental specimens, and enacted mitigation measures. RESULTS: Whole-genome sequencing of 13 B. cepacia complex clinical specimens between November 2020 and February 2021 identified 6 clonally related isolates, speciated as Burkholderia contaminans. All 6 occurred in patients on ECMO. Microbiology review identified 2 additional B. contaminans cases from June 2020 that may have also been cluster related, including 1 in a patient receiving ECMO. All 8 definite or probable cluster cases required treatment; 3 patients died, and 3 experienced recurrent infections. After ECMO was identified as the major commonality, all 9 of the hospital's ECMO water heaters were cultured, and B. contaminans grew in all cultures. Cultures from air sampled adjacent to the water heaters were negative. Water heater touch screens were culture positive for B. contaminans, and the sink drain in the ECMO heater reprocessing room also grew clonal B. contaminans. Observations of reprocessing revealed opportunities for cross-contamination between devices through splashing from the contaminated sink. The cluster was aborted by removing all water heaters from clinical service. CONCLUSIONS: We identified a cluster of 8 B. cepacia complex infections associated with contaminated ECMO water heaters. This cluster underscores the potential risks associated with water-based ECMO heaters and, more broadly, water-based care for vulnerable patients.

Assessing the filtration efficiency and regulatory status of N95s and nontraditional filtering face-piece respirators available during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has severely disrupted supply chains for many types of Personal Protective Equipment (PPE), particularly surgical N95 filtering facepiece respirators (FFRs; "masks"). As a consequence, an Emergency Use Authorization (EUA) from the FDA has allowed use of industrial N95 respirators and importation of N95-type masks manufactured to international standards; these include KN95 masks from China and FFP2 masks from the European Union. METHODS: We conducted a survey of masks in the inventory of major academic medical centers in Boston, MA to determine provenance and manufacturer or supplier. We then assembled a testing apparatus at a university laboratory and performed a modified test of filtration performance using KCl and ambient particulate matter on masks from hospital inventories; an accompanying website shows how to build and use the testing apparatus. RESULTS: Over 100 different makes and models of traditional and nontraditional filtering facepiece respirators (N95-type masks) were in the inventory of surveyed U.S. teaching hospitals as opposed to 2-5 models under normal circumstances. A substantial number of unfamiliar masks are from unknown manufacturers. Many are not correctly labelled and do not perform to accepted standards and a subset are obviously dangerous; many of these masks are likely to be counterfeit. Due to the absence of publicly available information on mask suppliers and inconsistent labeling of KN95 masks, it is difficult to distinguish between legitimate and counterfeit products. CONCLUSIONS: Many FFRs available for procurement during the COVID-19 pandemic do not provide levels of fit and filtration similar to those of N95 masks and are not acceptable for use in healthcare settings. Based on these results, and in consultation with occupational health officers, we make six recommendations to assist end users in acquiring legitimate products. Institutions should always assess masks from non-traditional supply chains by checking their markings and manufacturer information against data provided by NIOSH and the latest FDA EUA Appendix A. In the absence of verifiable information on the legitimacy of mask source, institutions should consider measuring mask fit and filtration directly. We also make suggestions for regulatory agencies regarding labeling and public disclosure aimed at increasing pandemic resilience.

Health Behaviors and Overweight in Nursing Home Employees: Contribution of Workplace Stressors and Implications for Worksite Health Promotion.

BACKGROUND: Many worksite health promotion programs ignore the potential influence of working conditions on unhealthy behaviors. METHODS: A study of nursing home employees (56% nursing aides) utilized a standardized questionnaire. We analyzed the cross-sectional associations between workplace stressors and obesity, cigarette smoking, and physical inactivity. RESULTS: Of 1506 respondents, 20% reported exposure to three or more workplace stressors (physical or organizational), such as lifting heavy loads, low decision latitude, low coworker support, regular night work, and physical assault. For each outcome, the prevalence ratio was between 1.5 and 2 for respondents with four or five job stressors. Individuals under age 40 had stronger associations between workplace stressors and smoking and obesity. CONCLUSIONS: Workplace stressors were strongly associated with smoking, obesity, and physical inactivity, even among the lowest-status workers. Current working conditions affected younger workers more than older workers. Although this study is cross-sectional, it has other strengths, including the broad range of work stressors studied. Strenuous physical work and psychosocial strain are common among low-wage workers such as nursing home aides. Workplace health promotion programs may be more effective if they include measures to reduce stressful work environment features, so that working conditions support rather than interfere with employee health.

Shoulder joint loading and posture during medicine cart pushing task.

Excessive physical loads and awkward shoulder postures during pushing and pulling are risk factors for shoulder pain. Pushing a medicine cart is a major component of a work shift for nurses and medical assistants in hospitals and other health care facilities. A laboratory experiment was conducted to examine the effects of common factors (e.g., lane congestion, cart load stability, floor surface friction) on shoulder joint moment and shoulder elevation angle of participants during cart pushing. Participants pushed a medicine cart on straight tracks and turning around right-angle corners. Peak shoulder joint moments reached 25.1 Nm, 20.3 Nm, and 26.8 Nm for initial, transition, and turning phases of the pushing tasks, indicating that shoulder joint loading while pushing a medical cart is comparable to levels previously reported from heavy manual activities encountered in industry (e.g., garbage collection). Also, except for user experience, all other main study factors, including congestion level, cart load stability, location of transition strip, shoulder tendency, surface friction, and handedness, significantly influenced shoulder joint moment and shoulder elevation angle. The findings provide a better understanding of shoulder exposures associated with medicine cart operations and may be helpful in designing and optimizing the physical environment where medicine carts are used.

Changes in ergonomic exposures of nursing assistants after the introduction of a safe resident handling program in nursing homes.

We evaluated the effect of a nursing home safe resident handling intervention on the ergonomic exposures of nursing assistants. The healthcare version of the Postures, Activities, Tools and Handling (PATH) method was used by 12 observers to examine postures, manual handling, and resident handling pre-intervention and at three months, 12 months, 24 months, and 36 months post-intervention. There were marked downward trends in proportion of work time spent repositioning and transferring residents, and an increased use of handling equipment in transferring (Cochran-Armitage tests: all p-values <0.001). While resident handling, nursing assistants were also more likely post-intervention to be in neutral trunk postures, walking rather than standing still, working with both arms below 60°, and less likely to lift loads greater than 22.7 kg. Lateral transfer devices were infrequently observed in use for repositioning; additional training on the use of this equipment is recommended to increase the benefits from the intervention program. RELEVANCE TO INDUSTRY: The study describes reductions in postural and manual handling loads of nursing assistants in nursing homes resulting from increased use of resident handling equipment following equipment installation with training and administrative support.

Biomechanical Exposure to Upper Extremity Musculoskeletal Disorder Risk Factors in Hospital Laboratories.

Exposure to ergonomic risk factors has been reported for laboratory workers over decades. However, these exposures are not well characterized with respect to the type of laboratory or work organization. This study compared biomechanical exposure to upper extremity (UE) postures and hand activity levels (HALs) in general hospital laboratories by job, work, and laboratory type. The study used observational data gathered using a revised version of the Posture, Activity, Tools, and Handling (PATH) method, generating frequencies of categorized exposures. Eighteen workers were observed in 11 job titles (seven laboratories) in a single hospital by two investigators over a 7 month period. A taxonomy was constructed to categorize the extent to which the laboratory operations were automated. Overall, there were markedly high exposures to postural strain for the distal UE, especially wrist/forearm deviation (73% of observations), gross grasp (71%), and pinch grip (49%). For the HAL categories, 61% of the observations were in the moderate range (3.3-<6.7). Shoulders and elbows tended to remain in the neutral postural range. Posture frequencies were similar among the job categories studied and laboratory types. HAL was higher when the hand was in a pinch grip. Manual operations represented a higher proportion of work time than semi-automated or automated operations. Biomechanical exposure can be documented more extensively and diversely when using the revised PATH approach along with the taxonomy, with respect to exposure variables, such as the type of job, work, or organization in the industry including the hospital laboratories.

Violence at the workplace increases the risk of musculoskeletal pain among nursing home workers.

BACKGROUND: Despite the high prevalences of workplace physical violence and musculoskeletal symptoms among health care workers, very few studies have examined the relationship between these two phenomena. METHODS: We surveyed 920 clinical nursing home workers by questionnaire regarding musculoskeletal pain in the low back, shoulders, wrists or hands, and knees. Information was also collected on exposure to physical assaults at work during the preceding 3 months, other workplace safety features, physical workload and psychosocial work environment. Log-binomial regression was used to estimate the prevalence ratios (PR) with 95% CIs. RESULTS: Almost one-half of respondents reported being assaulted at least once during the preceding 3 months by a resident or resident's visitor. The prevalence of low back pain increased from 40% among non-assaulted workers to 70% among those assaulted three or more times. The highest risk was found for widespread pain (three or more areas), with an adjusted PR of 2.7 (95% CI 1.8 to 3.9) for workers assaulted three or more times. Good workplace safety buffered the effects, so that violence increased the risk of most pains considerably less in a work environment perceived to be safe. CONCLUSIONS: To our knowledge, this is the first study to show a dose-response association between physical assaults and musculoskeletal pain in a health care setting where violence is a frequent occurrence. This emphasises the need to address violence as a workplace hazard through practical measures for prevention as well as in future aetiological research on musculoskeletal disorders.

Use of O*NET as a job exposure matrix: A literature review.

BACKGROUND: O*NET is a publicly available online database that describes occupational features across US job titles and that has been used to estimate workplace physical and psychosocial exposures and organizational characteristics. The aim of this review is to describe and evaluate the use of O*NET as a job exposure matrix. METHODS: A review of the peer-reviewed published and gray literature was conducted. Twenty-eight studies were found that used O*NET to estimate work exposures related to health or safety outcomes. Each was systematically evaluated across eight main features. RESULTS: Many health outcomes have been studied with O*NET estimates of job exposures. Some studies did not use conceptual definitions of exposure; few studies estimated convergent validity, most used predictive validity. Multilevel analysis was underutilized. CONCLUSION: O*NET is worthy of exploration by the occupational health community, although its scientific value is still undetermined. More studies could eventually provide evidence of convergent validity. O*NET has the potential to allow examination of occupational risks that might have otherwise been ignored due to missing data or resource constraints on field data collection of job exposure information.

Assessing the quality of nontraditional N95 filtering face-piece respirators available during the COVID-19 pandemic.

BACKGROUND: During the current COVID-19 pandemic, supply chains for Personal Protective Equipment (PPE) have been severely disrupted and many products, particularly surgical N95 filtering facepiece respirators (FFRs; "masks") are in short supply. As a consequence, an Emergency Use Authorization (EUA) from the FDA has allowed importation of N95-type masks manufactured to international standards; these include KN95 masks from China and FFP2 masks from the European Union. METHODS: We conducted a survey of mask in the inventory of major academic medical centers in Boston, MA to determine provenance and manufacturer. We then assembled a simple apparatus for performing a necessary (but not sufficient) test of filtration performance and tested masks from the inventory; an accompanying website shows how to build and use the testing apparatus. RESULTS: Our survey showed that, seven months after the start of the COVID-19 pandemic, over 100 different makes and models of N95-type masks are in the inventory of local hospitals as opposed to 2-5 models under normal circumstances. A substantial number of unfamiliar masks are from unknown manufacturers. Many did not perform to accepted standards and are likely to be counterfeit. Due to the absence of publicly available information on mask suppliers in the FDA EUA and confusing or inconsistent labeling of KN95 masks, it is difficult to distinguish legitimate and counterfeit products. CONCLUSIONS: Many of the FFR masks available for procurement during the COVID-19 pandemic do not provide levels of fit and filtration similar to those of N95 masks and are not acceptable for use in healthcare settings. Based on these results, and in consultation with occupational health officers, we make six recommendations for end users to assist in acquiring legitimate products. In particular, institutions should always assess masks from non-traditional supply chains by checking their markings and manufacturer information against data provided by NIOSH and the latest FDA EUA Appendix A. In the absence of verifiable information on the legitimacy of mask source, institutions should consider measuring mask fit and filtration directly. We also make suggestions for U.S and Chinese regulatory agencies with regard to labeling and public disclosure aimed at increase pandemic resilience.

Ergonomic and socioeconomic risk factors for hospital workers' compensation injury claims.

BACKGROUND: Hospital workers are a diverse population with high rates of musculoskeletal disorders (MSDs). The risk of MSD leading to workers' compensation (WC) claims is likely to show a gradient by socioeconomic status (SES) that may be partly explained by working conditions. METHODS: A single community hospital provided workforce demographics and WC claim records for 2003-2005. An ergonomic job exposure matrix (JEM) was developed for these healthcare jobs from direct observation of physical workload and extraction of physical and psychosocial job requirements from the O*NET online database. Occupational exposures and SES categories were assigned to workers through their O*NET job titles. Univariate and multivariate Poisson regression analyses were performed to estimate the propensity to file an injury claim in relation to individual factors, occupational exposures, and SES. RESULTS: The jobs with the highest injury rates were nurses, semi-professionals, and semi-skilled. Increased physical work and psychological demands along with low job tenure were associated with an increase in risk, while risk decreased with psychosocial rewards and supervisor support. Both occupational and individual factors mediated the relationship between SES and rate of injury claims. CONCLUSIONS: Physical and organizational features of these hospital jobs along with low job tenure predicted WC injury claim risk and explained a substantial proportion of the effects of SES. Further studies that include lifestyle risk factors and control for prior injuries and co-morbidities are warranted to strengthen the current study findings.

Description and analysis of hand forces in medicine cart pushing tasks.

The primary objectives of this study were to describe and analyze the hand force exertion patterns of experienced nursing home nurses and nursing students during dynamic medicine cart pushing tasks in Initial, Sustained, Turning, and Stopping motion phases. A 2 × 2 × 2 factorial experiment was conducted with 22 participants to estimate the effects of lane congestion, precision cart control, and floor surface on horizontal hand forces. Root mean squared (RMS) lane deviation patterns were also described to provide an indicator of cart handling difficulty across the different study conditions. Descriptive statistics revealed that nurses exerted greater mean hand force (10%) and made more (12%) lane deviation than students and that the highest two-hand forces of 147N were measured in the Turning phase on carpet. Strong correlations between work experience group, body mass, and BMI required that force data for nurses and students be collapsed in analytical models where no group differences existed. Predicted pushing forces on carpeted floor surface were significantly greater than on tile in Initial (14N), Sustained (14N) and Turning (18N), except in stopping where pulling forces were 37N lower. High lane congestion predicted significant peak force increases of 4N and 7N in Sustained and Turning, respectively, but decreased by 20N in Initial. High precision control led to significant decreases in two-hand forces that ranged from 4 to 20N across motion phases. Complex interactions among the experimental factors suggest that work environment (lane congestion and floor surface) and work demands (precision control) should be included in the evaluation of pushing tasks and considered prior to making renovations to nursing home environments.

Inter-rater reliability of PATH observations for assessment of ergonomic risk factors in hospital work.

This study examined the inter-rater reliability of expert observations of ergonomic risk factors by four analysts. Ten jobs were observed at a hospital using a newly expanded version of the PATH method (Buchholz et al. 1996), to which selected upper extremity exposures had been added. Two of the four raters simultaneously observed each worker onsite for a total of 443 observation pairs containing 18 categorical exposure items each. For most exposure items, kappa coefficients were 0.4 or higher. For some items, agreement was higher both for the jobs with less rapid hand activity and for the analysts with a higher level of ergonomic job analysis experience. These upper extremity exposures could be characterised reliably with real-time observation, given adequate experience and training of the observers. The revised version of PATH is applicable to the analysis of jobs where upper extremity musculoskeletal strain is of concern.

Job strain predicts survey response in healthcare industry workers.

OBJECTIVES: To examine the effect of job strain on survey response. METHODS: 1,613 health care workers received a self-administered questionnaire. Thirty percent of them completed the survey on personal time without any personal monetary compensation. Working conditions were extracted by job title from the national database O*NET 6.0. Job strain was defined as the ratio of job demands to job control. Two complementary models (multi-level logistic and binomial pseudo Poisson regressions) were used to model individual survey response as a function of individual level demographic variables (age and gender), job-level socioeconomic status (SES) and job strain, and facility type (third level). RESULTS: Survey response was associated with higher SES and with less job strain. The association of SES and survey response was mediated by job strain. CONCLUSION: Employees' exposure to job strain may be an important influence on survey response, at least for workers who are not compensated for their time in completing a survey.

Inter-method agreement between O*NET and survey measures of psychosocial exposure among healthcare industry employees.

BACKGROUND: Imputed job characteristics had been used as proxy of exposure to working conditions. O*NET database provides job information that could be useful to evaluate psychosocial working conditions. METHODS: Consistency and total agreement between O*NET and self-reported psychosocial exposure (demand/control (DC), effort/reward (ER) proxy models, and emotional labor scale) were compared between healthcare specific (12 occupations, 215 workers) and other jobs (12 occupations, 146 workers). RESULTS: For dimensions of the DC and ER models, Spearman correlation and ICC coefficients were, in general, consistently high (ICC = 0.61 for decision latitude, 0.41 for rewards, 0.53 for ER ratio, and lower for others), particularly in the healthcare specific jobs. CONCLUSION: O*NET and questionnaire based psychosocial indicators showed a good job level agreement particularly on healthcare specific jobs. O*NET may be a useful source of job level psychosocial exposure, especially for the DC and ER models, for healthcare occupations within these types of facilities.