Hierarchy of Occupational Infection Controls

Controlling exposures to hazards in the workplace is vital to protecting workers. The hierarchy of controls is a way of determining which actions will best control exposures. The hierarchy of controls has five levels of actions to reduce or remove hazards. The preferred order of action based on general effectiveness is:

1. Elimination
2. Substitution
3. Engineering controls
4. Administrative controls
5. Personal protective equipment (PPE)

Using this hierarchy can lower worker exposures and reduce risk of illness or injury.

To be most effective, the Hierarchy of Hazard Controls needs to be adapted to the healthcare setting.  

Elimination

Elimination control physically removes a hazard at its source or designs the hazard out of procedures. While the elimination of patient and healthcare personnel (HCP) exposure to all Infectious hazards may not be possible, elimination of unnecessary exposure is possible. Additional precautions can be appropriate during epidemics

• Promote community-wide vaccination for treatable communicable disease
• Virtual patient screening for infectious disease may include:
  • telephonic evaluation of patient complaint, signs, symptoms, history
  • at-home test screening
  • pre-admission patient instruction regarding Standard precautions and Transmission-based precautions
• Designate facility entrance and triage station for symptomatic patients during elevated community infection rates to minimize unnecessary exposures.
• Designate isolation units and designated personnel as necessary.
• etc.

Substitution

Substitute technologies, equipment or procedures to reduce risk.

Elimination and substitution can have some crossover potential. A good opportunity to use elimination and substitution is when new technology, equipment or procedures are being evaluated.  Prevention through Design is an approach to proactively include prevention when designing work equipment, tools, operations, and spaces.

Engineering Controls

Engineering controls reduce or prevent hazards from coming into contact with workers. Engineering controls can include modifying equipment or the workspace, using protective barriers, ventilation, and more.

Healthcare engineering controls:

• Optimize the use of engineering controls to reduce or eliminate exposures by shielding HCP and patients from infected individuals (e.g., physical barriers at reception / triage locations and dedicated pathways to guide symptomatic patients through waiting rooms and triage areas).
• Take measures to limit crowding in communal spaces, such as scheduling appointments to limit the number of patients in waiting rooms or treatment areas.
• Improve signage to enhance desired behaviors among staff, clients and visitors
• Install ergonomic, low touch, fixtures, entries, exits and hygiene stations.
• Prominent placement and easy access to hand and respiratory hygiene supplies and waste managment.

Engineering controls can cost more upfront than administrative controls or PPE. However, long-term operating costs tend to be lower, especially when protecting multiple workers. In addition, engineering controls can save money in other areas of the work process or facility operation.

Administrative Controls

• Provide resources and oversight for employee health services related to infection prevention, e.g.,
  • ensure recommended testing and treatment following exposure to infectious or hazardous agents,
• ensure planning and supplies for prevention and treatment of annual influenza outbreaks, pandemic influenza, SARS, bioweapons attacks.
• ensure competent and safe staffing levels,
• consider designating a trained "unit based" nurse infection control liason,
• paid stay-at-home leave for infectious personnel.
• Develop and maintain written infection prevention policies and procedures appropriate for the services provided by the facility.
• Educate the staff, patients, and visitors, regarding the individual behaviors necessary for infection control, e.g., vaccination and treatment, proper handwashing, respiratory etiquette, social distancing, gloves, gowns, masks, and other barrier techniques.
• Communicate community infection issues with the public, facility staff, and state and local health departments.
  https://www.cdc.gov/infectioncontrol/guidelines/isolation/prevention.html

PPE

PPE is equipment worn to minimize exposure to hazards. Examples of PPE include gloves, safety glasses, gowns, respirators, etc. When employees use PPE, employers should implement a PPE program. While elements of the PPE program depend on the work process and the identified PPE, the program should address:

• workplace hazards assessment
• PPE selection and use per manufacturers instruction
• inspection and replacement of damaged or worn-out PPE
• employee training
• program monitoring for continued effectiveness

Employers should not rely on PPE alone to control hazards when other effective control options are available. PPE can be effective, but only when workers use it correctly and consistently. PPE might seem to be less expensive than other controls, but can be costly over time. This is especially true when used for multiple workers on a daily basis.

When other control methods are unable to reduce the hazardous exposure to safe levels, employers must provide PPE.  This includes:

• while other controls are under development
• when other controls cannot sufficiently reduce the hazardous exposure
• when PPE is the only control option available

Administrative controls and PPE require significant and ongoing effort by workers and their supervisors. They are useful when employers are in the process of implementing other control methods from the hierarchy. Additionally, administrative controls and PPE are often applied to existing processes where hazards are not well controlled.

Training and evaluation can help ensure selected controls are successful. Employers should correctly train workers and supervisors on how to use controls. Workers and their supervisors should evaluate controls on a regular basis. Regular evaluation can check whether controls are effective in reducing workers’ exposures and identify potential improvements.

Reference

Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Healthcare Quality Promotion (DHQP), Infection Control. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007). Last reviewed July 22, 2019.  Accessed 12/24/22 from https://www.cdc.gov/infectioncontrol/guidelines/isolation/prevention.html

National Institute for Occupational Safety and Health National Institute for Occupational Safety and Health. Workplace Safety & Health Topics (last reviewed 8/11/2022). Accessed on 12/24/2022, from
https://www.cdc.gov/niosh/topics/hierarchy/default.html

Sehgal NJ and Milton DK (2021) Applying the Hierarchy of Controls: What Occupational Safety Can Teach us About Safely Navigating the Next Phase of the Global COVID-19 Pandemic. Front. Public Health 9:747894. doi: 10.3389/fpubh.2021.747894