Dear Director: I don’t understand why I can’t have food and drink at my workstation during my shift. I never get a chance to take a break, and I really need my coffee. What does the Joint Commission have against us?
I like (and rely) on my coffee as much as anyone in the ED I know. And there’s certainly shifts that end with me wondering how I managed to not even get a sip of water for nine hours and how that can’t be good for me. Back in the day, I clearly remember a chief resident who would carry his cup of coffee into the room for every trauma and critical care patient that he supervised. He never spilled his coffee on the patient, ruined a computer, or got sick from drinking something bad. Everyone sees the signs that go up and the emails that go out reminding people of the “no food and drink rule in the clinical areas” when Joint Commission is at your hospital. So the question is, how did we get to such a place, who made the rule, and is there a way where we can eat and drink while we take care of patients?
History Lesson
Hospitals are considered one of the most hazardous workplaces in the U.S. The Occupational Health and Safety Administration (OSHA) is charged with protecting the safety of workers. Hospital workers are twice as likely to get hurt on the job as people in private industry [1]. The Joint Commission is charged to “continuously improve the safety and quality of care provided to the public through the provision of health care accreditation,” and are typically the group who inspects hospitals and enforces existing rules and/or interprets and enforces rules of other agencies such as OSHA. Although your hospital should have a consistent enforcement policy of all Joint Commission standards, most of us realize that each hospital approaches the food and drink in the workstation rule to varying degrees, therefore, reminders to avoid food and drink at the workstations pop up on our computer screens when JC (or other official inspectors like CMS) are in the building. Yet, this ban on food at the workstations has nothing to do with patient safety or spilling and ruining a computer, but comes from the organization charged with protecting employee’s health and safety while at work. OSHA wants to protect us from all the hazardous and toxic agents that sit at our workstations that could end up on our food/drink and ingested by us.
This standard has been around for so long, and is so entrenched in history, that there’s a letter OSHA has online from 1992 addressed to Senator Tom Daschle explaining why one of his constituents can’t have food at the nursing station [2]. In their response, OSHA states that, “The prohibition against eating and drinking in such a work area is consistent with other OSHA standards and is good industrial hygiene practice.” Twenty five years ago, OSHA felt that “employers have a particular responsibility to ensure that workers do not come into direct contact with blood or other potentially infectious materials while performing their job,” because of the risk of transmission of HIV and hepatitis B. More recently, May 2006, and available on the OSHA website, they state, “OSHA does not have a general prohibition against the consumption of beverages at hospital nursing stations. However, OSHA’s bloodborne pathogens standard prohibits the consumption of food and drink in areas in which work involving exposure or potential exposure to blood or other potentially infectious material takes place, or where the potential for contamination of work surfaces exists [29 CFR 1910.1030(d)(2)(ix)] [3].” For the same reasons, your hospital may have similar rules for applying cosmetics or handling contact lenses, and they may also prohibit food and drink in areas (refrigerators, cabinets, etc..) where potentially infectious materials are kept.
So What Does That Mean? Hydration Stations and Break Areas
I never considered my computer workstation area clean, nor do I consider it all that dirty given the pressure we’re under to gel in and gel out of rooms. However, I also see a huge percentage of our staff wipe down their workstation at the start of the shift, hoping to kill all the random bugs that were contaminating it. So, clearly, many are worried about the bacteria and viruses at the workstations. While I’m no germophobe, one of my biggest fears is becoming immunocompromised and then getting an infection with all the crazy superbugs I’ve been exposed to over my career. It doesn’t mean I don’t want my coffee while I type but at least I understand the theoretical background to the rule and that perhaps it’s in my interest to follow it.
Of course, I find it a little bewildering that patients can eat in their rooms. I presume it’s because they’re exposed to their own germs and that the room was spotless and germ free before that patient got there. I also understand why many people’s heads throb when they consider they can’t drink coffee at their workstation after leaving a patient’s room but can stroll into the doctor’s lounge on the other side of the hospital in their white coat and it’s assumed they’re now germ free. It would be easier to digest all of this if there were some data that would support the number of infections that would be caused if we were all routinely eating and drinking at the nursing station. In my brief search of the literature and in talking to an ID colleague, I didn’t find any data showing that staff who eat at workstations may be sick more often than those who don’t eat at workstations. Of course, playing devils advocate, it does seem that about 30% of my docs had a GI illness over the winter and had to call out of at least one shift, and I’m sure they all picked it up from a patient they took care of. In my mind, we do definitely pick up some germs from patients no matter how much we gel and wash our hands.
Since it seems unlikely OSHA will change there stance on this, we need to find a way to eat and drink. I’ve never been a big snacker at work, so I’m not the kind of person that likes to keep food at my workstation throughout the shift (even if I was allowed). But I know there are many of you out there, and I definitely like sipping my coffee throughout the first couple hours of a shift. Since we work in a fishbowl, where patients and their families typically watch us, even if we were allowed to have food at our workstations, I’m not sure I would encourage people to do that since it doesn’t appear professional.
OSHA has thrown us a bone and perhaps a bit of a loophole. Basically, OSHA states that the employer is responsible evaluating the workplace and for determining where food and drink can be safely consumed versus areas that are at risk for occupational exposure. “An employer may determine that a particular nurse’s station or other location is separated from work areas subject to contamination and therefore is so situated that it is not reasonable under the circumstances to anticipate that occupational exposure through the contamination of food and beverages or their containers is likely,” and then the employees would be allowed to eat and drink there [3]. “OSHA standards set minimum safety and health requirements and does not prohibit employers from adopting more stringent requirements [3].” But, in my mind, this means we have some wiggle room to create a place to keep food and drinks, though getting your infection control people on board may be challenging.
There are many EDs that have created “safe zones” where people can leave their drinks throughout the shift, stopping by for a sip. They’re safe because they’re outside the patient care areas, unlikely to be contaminated, and deemed “safe” by the employer. These are the true non-clinical areas and are typically our break rooms and the area surrounding the fridge where we keep those delicious turkey sandwiches and the apple juice for patients. This is the area I’ll scarf down some graham crackers or eat my protein bar on those long evening and night shifts when the cafeteria is closed. But standing up having a snack is not really ideal either. I’m sure there are docs who work in a room far removed from the clinical area, and there may also be parts of the nursing station that would be considered low risk because they are so far removed from the patient care area and not used in the routine work flow of going in and out of patient’s rooms.
Maybe we should take these obstacles and turn them to our advantage. About 13 years ago, I realized the ED wouldn’t fall apart if I left the clinical area for 10 (and sometimes 15 if I have to run upstairs to get food) minutes to eat. While this isn’t ideal for hydration, it is a nice excuse to sit down and eat for a few minutes in a “safe” place. Timing an escape from the ED can be a challenge. I won’t usually leave until there is a natural break in patient flow. My calls to docs need to be completed and the “waiting to be seen rack” needs to be in a decent place (my definition is my colleagues can handle it, short wait, no critical patients) but I think the mental break of sitting and eating like a human is really helpful, and it’s probably healthier for us as well. I recognize that this isn’t always possible, particularly if you’re in a single coverage situation. But if you have a couple docs working, communicate and take turns. This might be a chance to refuel and also provide a little mental health break.
Going Forward
I don’t think we’re going to win a battle against OSHA. However, starting a discussion with your safety/quality team about how contaminated work areas are defined seems like a good starting point. Is the workstation contaminated because specimens are there or only because we were in rooms with patients and then came and sat down? Perhaps it’s related to the keyboard we’re using after we’re in the patient’s room, but I don’t understand the difference between coming out of a patient room and going to my workstation versus coming out of a room and going to the break room to eat. I either gelled by hands or not and my white coat is still on. I would encourage everyone to try to get a few minutes to sit down and eat away from his or her workstation. Clearing your head and talking to staff about “life” outside of the ED does wonders for making it easy to go back and pick up the pace.
REFERENCES
- https://www.osha.gov/dsg/hospitals/
- https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=20828
- https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=25506)
6 Comments
Actually, I reversed the rule in my department. I simply have notified admin that pathogens shall not be in my food area, which is my desk.
OSHA’s laws or so inconsistent that they lack all validity. As you noted, how can it be OK for a patient to eat or drink in a room that has been continually occupied with sick (and some injured) people, but not at the nurses’/doctors’ stations, where the workers are, presumably, relatively healthy? Also, how do all of the germs magically jump of my medical uniform if I get a chance to walk 20 feet back to the break room, then magically jump right back on as soon as I return to my work station? Besides, the real transmissible dangers to healthcare workers in the ED are being bled on, coughed on, and vomited on by the patients, and respiratory pathogens are much more of a hazard in the ED, while food borne pathogens are usually due to fecal/oral transmission (I agree that we should wash our hands before we eat) or to undercooked food or food that has been left sitting out. Just one more reason that, while I think that a single payer system would be the most simple and fair, I can’t really get behind it because the only rational provider of such a plan is the government, and they have repeatedly demonstrated that they have no understanding of what goes on in healthcare. We’ve all seen altered mental status patients due to hypoglycemia, yet it’s somehow good for me to work 12-13 hours without a bite of food while making life and death decisions?
Agree absolutely. And a single handed ED physician practices more safely when he/she leaves the clinical area empty and walks to a staff room some 25 yards away in order to eat a sandwich, which he could just as easily and safely eat sitting by his workstation?
Give us a break, nanny!
Something’s got to give.
Either provide a doctor with the ability to snack and drink or provide them with the opportunity to leave the Dept to do so.
This essay speaks vaguely of employer defined options and it speaks optimistically about leaving the Dept to refuel. We often have a stressful job, made even more difficult by occassionally going 9-12 hours without proper food. Let’s do our best to keep the work load reasonable and make the work environment better.
Amen to Dr. Kochert! I’m retired from emergency medicine for 11 years and so old I remember the days of ED’s being staffed by doctors who had office practices down the street and worked in ED for a few extra bucks. I remember one doc in Jacksonville, NC, who’d lost his legs below the knees in a WWII bomber and worked out of a wheelchair, smoking a cigar. He’d park his cigar on the edge of a sink while he sutured. (I recall one lady complaining about the cigar smell and he opened his hands and said “I ain’t got no cigar!” It was across the room on the sink!) Those were the days. Now we can’t carry coffee OR smoke cigars in the ED!
I think the best solution is for physician’s to have a proper break during the shift. I think that a few minutes to eat at an almost leisurely pace, after properly washing my hands, and without the several interruptions I face each minute in the clinical arena, allows me to return to patient care feeling somewhat refreshed. On the other hand when my stomach is growling, and my head is spinning a bit from hypoglycemia, it is challenging to focus on patient care when I have to interrupt my patient’s and their family members who are picnicking in the emergency department.