Interim Guidance for Protecting Hospital Workers from Exposure to Coronavirus Disease (COVID-19)
May 22, 2020
Cal/OSHA's regulations require protection for workers exposed to airborne infectious diseases such as the 2019 novel coronavirus disease (COVID-19), first identified in December 2019. This interim guidance provides hospital employers and workers information to reduce the risk of transmission of SARS-CoV-2, the virus that causes COVID-19.
Virus Signs, Symptoms and Transmission
Common signs and symptoms of COVID-19 include fever, cough and difficulty breathing. In reported COVID-19 cases, the severity of the illness ranges from mild symptoms to death. The time from exposure to symptom onset ranges from two to 14 days.
The virus is mostly spread from person-to-person, likely through close contact, and small and large respiratory droplets and particles that may strike the mucous membranes of the eyes, nose or mouth, or may be breathed into the nose or mouth.
In hospitals without strong protective measures, workers will be exposed to the virus that causes COVID-19 during routine patient care, during procedures that require workers to be in close contact with patients, and during aerosol-generating procedures.
The Aerosol Transmissible Diseases (ATD) standard (California Code of Regulations, title 8, section 5199), contains requirements for protecting employees from diseases and pathogens transmitted by aerosols. COVID-19 is an airborne infectious disease covered by the ATD standard.
The ATD Standard applies to:
- Hospitals, skilled nursing facilities, clinics, medical offices, outpatient medical facilities, home health care, long-term health care facilities, hospices, medical outreach services, medical transport and emergency medical services.
- Certain laboratories, public health services and police services that are reasonably anticipated to expose employees to an aerosol transmissible disease.
- Correctional facilities, homeless shelters and drug treatment programs.
- Coroner’s offices, mortuaries, funeral homes and other facilities that perform aerosol-generating procedures on cadavers.
- Any other locations when Cal/OSHA informs employers in writing that they must comply with the ATD Standard.
Hospitals must comply with ATD Standard and establish and implement the following:
- Written ATD exposure control plan and procedures
- Engineering controls
- Work practice controls
- Personal protective equipment
- Respiratory protective equipment
- Medical services
Written ATD Exposure Control Plan and Procedures
Hospitals must establish, implement and maintain an effective, written ATD exposure control plan (plan), which is specific to their work place and their work operations.
Key requirements in the written plan for hospitals include, but are not limited to:
- Name or title of the person knowledgeable in infection control measures who is responsible for administering the hospital’s Plan.
- List of job classifications that have occupational exposure to aerosol transmitted diseases and that perform high hazard procedures.
- List of all high hazard procedures and operations performed in the hospital and by hospital employees.
- List of all assignments or tasks requiring personal protective equipment and/or respiratory protection.
- Methods for implementing engineering controls, work practice controls, personal protective equipment controls and respiratory protective equipment controls.
- Description of the source control measures implemented at the hospital, including ensuring patients with suspect or confirmed COVID-19 are masked when possible.
- Procedures to identify, temporarily isolate and move suspected and confirmed COVID-19 patients to airborne infection isolation rooms or areas. These procedures must include methods to limit employee exposure to patients when they are not in an airborne infection isolation room or area.
- Procedures to communicate with employees and other employers regarding the suspected or confirmed infectious disease status of persons to whom employees are exposed to.
- Procedures to investigate and evaluate each exposure incident.
- Methods for providing employee medical services and training.
- Procedures to ensure the hospital has an adequate supply of personal protective equipment and other equipment necessary to minimize employee exposure to aerosol transmitted diseases, in normal operations and in foreseeable emergencies.
- Procedures for handling surge events that include appropriate work practices, decontamination facilities, and personal protective equipment.
Hospitals must provide employees with comprehensive initial and annual training on aerosol transmissible diseases. Employers must also provide a training update to employees regarding COVID-19 and changes to their ATD exposure control plan that apply to COVID-19. This update must specifically address:
- Description of SARS-CoV-2 and COVID-19.
- Signs and symptoms of COVID-19.
- Modes of transmission of COVID-19.
- Source controls to be used with suspect and confirmed COVID-19 patients.
- Tasks and activities that may expose employees to COVID-19.
- Use and limitations of methods to prevent or reduce exposure to COVID-19, including appropriate engineering controls, work practice controls, personal protective equipment controls and respiratory protective equipment controls.
- Information on the types, limitations, proper use, location, removal, handling, cleaning, decontamination and disposal of personal and respiratory protective equipment.
- Any available vaccines.
- The employer's COVID-19 surge plan.
- What to do if an exposure incident occurs.
A more complete discussion of ATD training requirements is available in The California Workplace Guide to Aerosol Transmissible Diseases.
Employers must use engineering controls where feasible to minimize employee exposures to airborne infectious disease as follows:
- Isolate known or suspected COVID-19 cases in airborne infection isolation rooms or areas where feasible, and exclude all non-essential persons from the area.
- Conduct high-hazard procedures in airborne infection isolation rooms or areas, and exclude all non-essential persons from the area.
- Ventilate all vacated rooms or areas before workers enter according to Table 1 in the Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings for a removal efficiency of 99.9%.
- Use airtight barriers such as windows to eliminate worker exposures to airborne infectious diseases Use non-airtight barriers in reception areas, information booths, emergency department intake booths, triage stations and pharmacy drop-off/pick-up windows. Non-airtight barriers may help reduce exposure, but will not eliminate exposures.
- Use local exhaust ventilation, HEPA air filtration and air disinfection in patient areas.
Work Practice Controls
Employers must use work practice controls where feasible to minimize employee exposures to airborne infectious disease as follows:
- Limit the movement of suspected and confirmed COVID-19 cases within a facility.
- Bundle or combine care activities to minimize room entries (e.g. food trays delivered by health care workers performing other care).
- Screen and delay or redirect elective and non-serious visits when possible.
- Use alternative methods for health care worker and patient means of communication such as telephone and video calls when possible and medically appropriate.
- Place multiple patients infected with the same respiratory pathogen together in dedicated areas (cohorting).
- Clean and disinfect work surfaces, tables, tools, instruments and equipment frequently. Use EPA-approved products for use against COVID-19.
- Wash articles and linens after each use.
- Implement frequent hand washing procedures.
- Implement procedures for safe donning and doffing of personal protection equipment and respiratory protection equipment.
Personal Protective Equipment (PPE)
Employers must provide personal protective equipment to employees to minimize employee exposures to aerosol transmitted diseases such as COVID-19. Workers who care for suspect and confirmed COVID-19 patients need the following PPE:
- Gloves. If there is a risk of injuries that break the skin, wear heavy-duty cut and puncture-resistant gloves over the nitrile gloves.
- Gowns or coveralls.
- Eye and face protection.
- Respirators (surgical masks if respirators are not available).
Respiratory Protective Equipment
The minimum level of respiratory protection under the ATD Standard for workers who care for suspect and confirmed COVID-19 patients is a NIOSH-approved respirator that removes at least 95 percent of airborne particles (N95) or more.
If a particulate filtering facepiece respirator or an elastomeric respirator with particulate filters cannot be provided due to an extreme supply shortages, employees otherwise required to wear an N95 respirator must be provided with surgical masks. During extreme supply shortages, respirator supplies must be managed to prioritize protection of employees engaged in high hazard or aerosol generating procedures. Although collection of specimens by nasopharyngeal swab or oropharyngeal swab is not generally classified as an aerosol generating procedure, employers must prioritize these tasks when allocating respirators due to the close-range exposure. For more information on compliance with the ATD Standard during respirator shortages see Cal/OSHA Interim Guidance on COVID-19 for Health Care Facilities: Severe Respirator Supply Shortages.
It is illegal to discipline, discharge or lay off an employee for exercising their health and safety rights. Please see Labor Code sections 1102.5, 6310 and 6311 for information on prohibited discriminatory action against employees.
Hospitals must also implement a respiratory protection program for employees that use respirators to ensure employees are medically evaluated, trained, and fit-tested. Cal/OSHA has instructions on how to set-up a respiratory protection program online.
Hospitals must offer occupationally exposed employees certain medical services. These services must be performed by or under the supervision of a licensed health care practitioner, and include:
- Vaccinations for seasonal flu and those listed in section 5199 Appendix E.
An assessment for latent TB Infection.
This assessment may be delayed until after the COVID-19 crisis has subsided
Procedures to investigate and take preventative measures when an employee exposure incident occurs:
An exposure incident includes instances when employees are not equipped with appropriate respiratory protection and when they:
- Provide routine care to a suspect or confirmed COVID-19 patient.
- Perform high hazard procedures.
- Perform other high-risk procedures such as taking nasopharyngeal swab or oropharyngeal swab.
- Investigate and analyze exposure incidents to determine which employees had significant exposures to COVID-19. Make the exposure analysis available to the local health officer.
Notify employees who had significant exposures of the date, time and nature of the exposure.
A significant exposure is an exposure to an aerosol transmitted pathogen in which the circumstances of the exposure make transmission of a disease sufficiently likely that the employee needs further evaluation by a licensed health care practitioner.
- Have a licensed health care provider provide medical evaluations to employees who had a significant exposure, which includes any appropriate vaccination, prophylaxis, and medical treatment.
Remove employees from their regular assignment when necessary to prevent spread of COVID-19 if recommended by the licensed health care professional or local health officer.
The employer must maintain the employee's earnings, seniority and all other employee rights and benefits, including the employee's right to his or her former job status, as if the employee had not been removed from his or her job or otherwise medically limited.
- Centers for Disease Control and Prevention. Comprehensive Hospital Preparedness Checklist for Coronavirus Disease 2019 (COVID-19)
- Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19): Infection Control
- Centers for Disease Control and Prevention. Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings
- Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19): Using Personal Protective Equipment (PPE)
- California Department of Public Health. All Facilities Letters - 2020
- Cal/OSHA. Interim Guidance on Respirator Shortages
General COVID-19 Information
- Cal/OSHA webpage on Novel Coronavirus 2019
- CDC webpage on 2019 Novel Coronavirus.
- CDPH webpage on Novel Coronavirus 2019.
- Federal OSHA webpage on 2019 Novel Coronavirus.
For more information about the requirements of the Cal/OSHA ATD Standard, see
- The California Workplace Guide to Aerosol Transmissible Diseases
- Aerosol Transmissible Diseases Model Exposure Control Plan
- Aerosol Transmissible Diseases Fact Sheet