Definition/Introduction

The Occupational Safety and Health Administration (OSHA) is a United States Department of Labor branch that oversees overall workplace safety and sets safety standards for specific working conditions. Many of the guidelines OSHA puts in place transcend many fields. However, some are more specific to the healthcare setting, such as working with blood and bloodborne pathogens, laboratory chemicals, infectious disease, and personal protective equipment standards.

One OSHA workplace safety topic that applies to almost all fields is electrical safety, ranging from standard electrical outlets or extension cords to specific workplace hazards like power lines or massive generators in places like factories or dams. Harnessing electricity is one of the most important modern inventions utilized in nearly all aspects of life, but the unique physical properties of electrical energy that allow it to power our world also make it extremely dangerous.

In the workplace, electricity is defined as the flow or propagation of charged particles through a substance, commonly a conductive material that allows these charged particles to move with minimal resistance, including metals like copper. Though electrical energy propagates easily through metals, the human body is another low-resistance vessel that electricity can flow through easily. The nervous system and its role in carrying out bodily functions like movement and secretion show that endogenous electrical energy flows easily through the body via nerves. However, these nerve impulses are tiny compared to exogenous electrical energy like that from an electrical outlet.

The combination of high electrical energy and relatively low resistance poses significant risks for any person who comes in contact with electrical energy. Therefore, electrical safety is given utmost respect because of the catastrophic effects a breach in safety can have on an individual. Regulated under electrical-specific standards 29 CFR 1910.300-399, personal protective equipment standard 29 CFR 1910.137, and special industry-standard 29 CFR 1910.269, electrical safety is monitored and enforced by OSHA to reduce work-related electrical injury and deaths.

Issues of Concern

Despite OSHA training and interventions, workplace hazards are still widespread and result in roughly 5,000 deaths annually in the United States.[1] A large portion of these deaths is attributed to electrical energy, which is the 5th leading cause of work-related death in the United States. Powerlines are especially dangerous because of the very high levels of electrical energy traveling through a live line and contribute to up to 61% of electrical deaths on the job. Analyses of work-related electrical deaths have shown that the five most common scenarios that lead to death include: direct contact with a live powerline, direct contact with live equipment, vehicular contact with a powerline, poorly placed or damaged equipment, and indirect contact with a live powerline via conductive equipment.[2] Further, if the initial shock is not enough to cause sudden death, severe burns to both the skin and internal organs can also lead to death.

Many factors contribute to the total electrical energy encountered by a person, but one of the most important is the amount of current measured in amps (A). At stimulation levels of a single milliamp (mA), there is nearly no perception of the stimulus.[3] However, the effects quickly increase as current at 16 mA is the maximal limit a person can touch an electrical source and remove their hand from it. At 20 mA, there is muscle paralysis, which is of particular concern with respiratory muscle involvement. At 100 mA, death can occur as ventricular fibrillation is induced, and complete cessation of cardiac muscle activity occurs at 2 A. The danger of electricity in the workplace is highlighted here in the fact that the normal fuse breaker will trip at 15 to 20 A, which is about 1,000 times more energy than what is needed to cause respiratory muscle paralysis.[3] Environmental hazards are also relevant for outdoor workers because the current of a lightning strike can be as high as 50,000 A.[4]

Of equal importance to the damage inflicted by electrical energy is resistance, which is measured in ohms (W). Every physical object has a baseline level of resistance. Low resistance materials are considered conductors because they allow electrical energy to flow freely through them; these include metals like copper. High-resistance materials are insulators because they do not allow electrical energy to flow well, including wood and rubber. The skin, which almost always is the first organ to come in contact with an electrical source, has a relatively high level of resistance of around 100,000 W. This level of resistance is protective against smaller levels of electrical energy, which is important considering the resistance of the body below the skin is as low as 300 W. The integrity of the skin is a factor in its level of resistance meaning that breaks in the skin like a wound or cut allow direct access to the low resistance bodily core, and thus tissue damage can occur at much lower levels of electrical energy than normal.[3] 

Based on Ohm’s law, the amount of current and resistance can be multiplied to know the voltage of an electrical impulse, which is measured in volts (V). Because voltage accounts for both the current and resistance of an electrical impulse, electrical injuries and burns are therefore commonly separated by the total voltage encountered with low voltage injuries induced by <1,000 V and high voltage injuries caused by >1,000 V. The extent of injury varies between these two designations with high voltage injuries including the subcutaneous fat, muscle, and potentially bones while low voltage injuries are far less extensive.[5]

Based on the dangers of working with electricity, OSHA has established requirements for hospitals to follow to maximize electrical safety. The specific hazards that can contribute to electrically induced shocks, fires, arc flashes, and explosions laid out by OSHA include:

1. Using equipment with damaged connectors like bent plug prongs.
2. Unsafe practices like pulling equipment by the cord.
3. Using electrical equipment with wet hands.
4. Using faulty equipment such as frayed cords, damaged cords, old cords, damaged receptacles, and any damage resulting in insulation breaks, short-circuits, or exposed wires.

Additional OSHA electrical standards required by both hospitals and as part of the general electrical safety requirements include examining all equipment to ensure they are free of damage or anything that would signify compromised safety of the device like wire bending and disrupted insulation. Any compromised equipment must immediately be removed and cannot be used again until repairs have been made to prevent electrical injury. The equipment must also be assembled properly and have adequate labeling according to the manufacturer’s instructions. The area around the equipment must be safe, including having adequate space to operate the device safely, and devices are not near any water, or if they are properly grounded.

Finally, proper employee practices are crucial to the safety of the worker and those around them; the requirements to ensure this include not working with electrical equipment when wet, using correct safeguards and personal protective equipment, and following standard practices for the safe use of any electrical equipment. Standard safeguards include a ground-fault circuit interrupter, which is a standard electrical outlet circuit breaker so that the circuit breaker can quickly shut off power should there be a ground fault. The integrity of the breaker is compromised when there is damage to electrical equipment, such as exposed wires or insulation breaks, so ensuring the equipment is safe will also maintain the proper functioning of the circuit breaker.

Clinical Significance

The presentation of a patient with an electrical injury can vary greatly depending on the amount of electrical energy encountered. Additionally, the extent of contact is also important because the electrical field strength, which is directly related to voltage and inversely related to the total area of contact, can vary greatly and with small surface areas causing greater transmission of the electrical energy.[6] As such, the extent of injury often cannot be determined by physical exam alone, and an extensive workup is necessary.[6]

In the field, the first step in evaluating a victim of electrical shock is to ensure the area is safe. The presence of a live wire, fire, or if the patient is lying in water may make the scene unsafe. After establishing a safe scene, the patient should quickly be assessed for breathing and circulation. Appropriate life support should be performed as the patient is transported to the hospital. Upon arrival, if the patient is awake and alert, a history of the event should be taken. However, it is possible they will not be conscious. Given the potential for electrical shocks to influence heart conduction, an electrocardiogram should be taken. A complete blood count, complete metabolic panel, urinalysis, arterial blood gas, and serum creatine kinase should be performed for all patients and serum troponin levels if suspicious for cardiac involvement.[7]

Because the injury is likely to affect muscles, patients may experience rhabdomyolysis resulting in greatly elevated creatine kinase and myoglobinuria. Burns to the skin are also likely and should be managed appropriately, focusing on hydration, electrolyte balance, and cleaning the affected area acutely with betadine and chlorohexidine and during healing with silver sulfadiazine.[8] The long-term impact of electrical shocks on survivors includes but is not limited to neurologic injury, behavior changes, memory lapses, depression, cataracts, chronic pain, fatigue, and muscle spasms.[9]

While electrical injuries are very dangerous, electrical energy also plays a key role in modalities across many fields of medicine. An automated external defibrillator is a common example that can provide an electrical impulse to the heart to cease an abnormal rhythm.[10] Electrocautery is commonly used in surgical fields for cutting and coagulation.[11] Radiofrequency ablation can burn nerves at various locations for pain management.[12]

Electrical energy can also be applied directly to nerves to modulate their firing or the propagation of their impulses, called neuromodulation. This can be used to manage chronic pain like dorsal root ganglion stimulation or with deep brain stimulation for Parkinson disease patients.[13][14][15]

Techniques like neuromonitoring are even developed to reduce the potential risks associated with these electrical devices.[16] The widespread use of electrical devices in medicine makes electrical safety a very relevant topic within the hospital.

Nursing, Allied Health, and Interprofessional Team Interventions

While the morbidity and mortality associated with electricity are often related to workplace-related injuries, the healthcare team can play a critical role in reducing the prevalence of electrical shocks in both the healthcare setting and non-workplace settings.

Children are particularly prone to electrical shock, so maintaining a safe environment for pediatric patients and educating parents/guardians on strategies to keep access to electrical sources is an important way to reduce shocks. This would include using and education on covering electrical outlets, close monitoring while using electrically powered devices, and removing connections to power sources, such as extension cords, from areas they may be. Educating adults on electrical safety is also essential as they will be more likely to be working with electricity during tasks like home maintenance and using powered devices. Within the hospital, continued monitoring for any damage to electrical devices or sources should be performed to limit exposures.

Water is also of concern via spills and inpatients after showers, so drying the excess water should be completed as soon as possible to reduce electrical shock risk. Outside of the hospital, small changes like turning off the lights while changing a light bulb, switching the circuit breaker off while working in an area of their home, and not using devices in or around water can limit shocks.[6]

This education should be carried out by any member of the healthcare team during scenarios that may increase the risk of exposure, such as when having a child, moving homes, building or reconstructing a home, beginning a new profession, or working in a high-risk profession. In particular, the medical and nursing teams may do this in the clinic, and the physical therapy, occupational therapy, and social work teams may do this when visiting a patient’s home or assessing home safety and logistics.

Nursing, Allied Health, and Interprofessional Team Monitoring

Electricity is a very common source of energy used to power many of the devices we use every day. However, a significant risk exists, should electricity and electrical devices be mishandled that can lead to significant injury or death. The risk is exceptionally high in the workplace due to the industrial-grade electrical generators that are commonly used for power. Outside of the workplace, risks are still present with everyday electrical sources like power outlets. At just 120 V, a standard power outlet can produce a strong enough current to inflict significant damage and even induce deadly arrhythmias.

The workup of a patient with recent electric exposure will involve extensive teamwork between healthcare professionals for acute stabilization and long-term recovery from the shock. The initial EMS team must stabilize the patient, begin initial life support, and transport them to the hospital. Once at the hospital, the emergency department team of emergency medicine physicians, physician assistants, and nurses must evaluate the patient and begin the workup, including labs and imaging.

The trauma surgery and anesthesia teams should be quickly consulted should surgical intervention be necessary. Given an electrical burn is likely, the burn team should also be consulted. High voltage shocks may involve the bone, so an orthopedic surgery consult may also be necessary. Cardiology should also be consulted for cardiac monitoring. Pharmacy interventions will be necessary and should stabilize the patient and reduce further injury or secondary complications. After the acute stabilization, the rehabilitation team of physiatry, physical therapy, and occupational therapy will all play essential roles in returning the patient to normal functioning or helping them adapt to their new normal. Social work should also be involved to negate the risks that led to this shock.

The dangers of electricity are undeniable as it is clear this is a significant source of mortality worldwide in professional work, the home, and the outside environment. Given the risks associated with electricity, performing trials associated with exposure would be unethical. Nonetheless, evidence shows that electricity is among the most common causes of workplace injury and therefore must be addressed and respected by both employers and employees.[17] [Level V]

Reducing electrical shock risks in the healthcare setting involves carrying out standard safety protocols and ensuring the working environment is free of electrical risks. In procedural rooms, this may include using an electrical parameters monitoring system, formulation of procedures for electrical faults and fires, and standard inspection of devices for both safety and performance.[18] [Level 5]

Practicing safety techniques is a commonly used strategy by industry and the healthcare system to ensure training competency is maintained longitudinally. Specific to electrical safety, simulation of real-life cases proved to be an effective way of developing and strengthening electrical safety competency.[19] [Level 5] Such techniques may be beneficial when utilized by workplaces to maintain the highest level of safety when working with electricity.

Electrical safety is an essential aspect of overall workplace safety that aims to reduce the injuries and deaths associated with electrical shock. Strict adherence to OSHA standards is critical to maintaining the safety of all employees in the workplace.