June 19, 2019

Ms. Angela Bailey, Chief
Office of the Chief Human Capital Officer
U.S. Department of Homeland Security
Washington, DC 20528

Dear Ms. Bailey:

Thank you for your letter to the Occupational Safety and Health Administration’s (OSHA), Directorate of Enforcement Programs regarding the national Stop the Bleed (STB) awareness campaign and its emphasis on rapid bleeding control, as it applies to occupational safety and health readiness. You requested OSHA’s current interpretations regarding: first aid training, certification, and kits; response times required for first aid; and, the role of medical personnel in providing employers with advice on bleeding control kits. In addition, you inquired whether OSHA would consider updating its website and related publications, such as the 2006 Best Practices Guide: Fundamentals of a Workplace First-Aid Program. This letter constitutes OSHA's interpretation only of the requirements discussed and may not be applicable to any questions not delineated within your original correspondence. Your paraphrased questions and our responses are below.

Background

As a preliminary matter, it should be noted that OSHA standards set minimum safety and health requirements; they do not prohibit employers from adopting more stringent requirements. You should also know that many of OSHA’s requirements are performance-based. As you point out in your letter, some OSHA standards that address first aid, such as 29 CFR 1910.151, 1926.50, 1917.26, and 1918.97, have varying requirements. The degree of specificity of the standards’ requirements is dependent upon the anticipated hazards of that particular industry or operation. For example, the first aid standards for marine terminals and longshoring operations require employers to ensure that one or more on-site individuals are trained in first aid. In addition, 29 CFR 1910. 266(i)(7) requires first aid training for all logging employees, and 29 CFR 1910.269(b)(1)(ii) requires first aid training for all employees working at remote substations in the electric power industry. The commercial diving standard, 29 CFR 1910.410(a)(3), requires that all dive team members must be trained in first aid.

OSHA recognizes the recent incidence of workplace homicides and shootings as stated in a report by the Bureau of Labor Statistics, U.S. Department of Labor, The Economics Daily, There were 500 workplace homicides in the United States in 2016 on the Internet, at https://www.bls.gov/opub/ted/2018/there-were-500-workplace-homicides-in-the-united-states-in-2016.htm (visited December 27, 2018). This report also stated, “Shootings accounted for 394 workplace homicides in 2016 (79 percent of the total).”

OSHA also recognizes the seriousness of injuries resulting in uncontrolled bleeding. For example, a 2014 revision of the OSHA reporting regulation, 29 CFR 1904.39(a)(2), requires an employer to report to OSHA any work related amputation or loss of an eye within 24 hours of the injury. In addition, OSHA’s National Emphasis Program for Amputations, CPL 03-00-019, focuses on serious injuries that could result in uncontrolled bleeding.

Question 1: What is OSHA’s current interpretation regarding the minimum first aid training, certification, and kits employers should provide, with particular respect to bleeding control?

Response: In particular regards to first aid certification and training, the general industry first aid standard, 29 CFR 1910.151(b)¹, provides that where first aiders are required they “...shall be adequately trained to render first aid” (emphasis added). OSHA does not certify first aid training programs, instructors, or trainees. As OSHA noted in a previous letter of interpretation to Mr. Larry M. Starr, PHD, January 6, 1995, “We recognize any nationally accepted and medically sound first aid program that covers the fundamentals of first aid as meeting the requirements stated in 29 CFR 1910.151. The specific content of first aid programs must be consistent with the work environment in question, and with the type of work being done.”

However, the American Red Cross is a nationally-recognized first aid organization upon which OSHA has relied for guidance. As stated in a 1978 agreement between OSHA and the Red Cross, CPL 02-00-002, “Persons who have a current training certificate in the American Red Cross Basic, Standard or Advanced First Aid Course shall be considered as adequately trained to render first aid in fulfilling the requirements of the Occupational Safety and Health Standards, Subpart K., Medical and First Aid (29 CFR 1910.151(b)), The American Red Cross Standard Course is the recommended MINIMUM level of first-aid training.” This agreement is still in effect.

In addition, as stated on OSHA’s Medical and First Aid Safety and Health Topics webpage, “First aid training is primarily received through the American Heart Association, American Red Cross, National Safety Council (NSC), and private institutions. The American Heart Association, American Red Cross and NSC offer standard and advanced first aid courses via their local chapter/training centers.... An emphasis on quick response to first aid situations is incorporated throughout the program.”

For some specific industries, OSHA standards provide that the first aid training must be given by the American Red Cross or an equivalent organization. The general construction first aid standard provides that when a first aider is required the person must have “... a valid certificate in first-aid training from the U.S. Bureau of Mines, the American Red Cross, or equivalent training that can be verified by documentary evidence...” 29 CFR 1926.50(c).

The only operative part of this provision is that the person must have an American Red Cross first aid certificate or its equivalent.² Similarly, the shipyard employment first aid standard requires that where workplace first aiders are required they must have “...current first aid and CPR certifications, such as issued by the Red Cross, American Heart Association, or other equivalent organization.” 29 CFR 1915.87(c)(5). The longshoring first aid standard requires that “...a person holding a valid first aid certificate, such as is issued by the Red Cross or other equivalent organization, shall be available to render first aid when work is in progress.” 29 CFR 1918.97(b). The commercial diving standard requires that all dive team members take the American Red Cross standard first aid course or its equivalent. 29 CFR 1910.410(a)(3).

In particular regard to first aid training content, it is the responsibility of the employer in general industry to assess their work area(s) and reasonably anticipate first aid needs for potential injuries and illnesses. Employers in general industry providing first aid training must ensure it adequately covers the types of injuries/illnesses likely to be encountered in their workplaces and is kept up to date with current first aid techniques and knowledge.³,⁴

As far back as 1910 the American Red Cross Abridged Textbook on First Aid, Industrial Edition, (1910 ARC) gave instructions on using compresses for open wound and tourniquets to stop arterial bleeding.⁵ In 1969 and at least in the early 1970s, the American Red Cross instructed its instructors to teach prospective first aiders to control bleeding by applying direct pressure and in severe, life-threatening situations, to use tourniquets.⁶

As you point out in your letter, in 2015 the American Red Cross and the American Heart Association jointly updated their first aid guidelines on the control of bleeding, among other subjects. According to the guidelines, the standard method to control open bleeding is to apply direct pressure to the bleeding site until the bleeding stops. Tourniquets should be used when direct pressure does not control severe external limb bleeding. A tourniquet may be considered for initial care when a first aid provider is unable to apply direct pressure, such as during a mass casualty incident, with a person who has multisystem trauma, in an unsafe environment, or with a wound that cannot be accessed. Hemostatic dressings may be used where direct pressure or tourniquets cannot be used.⁷

Thus, since 29 CFR 1926.50(c) (construction), 29 CFR 1915.87(c)(5) (shipyards), 29 CFR 1918.97(b) (longshoring), and 29 CFR 1910.410(a)(3) (commercial diving) specifically refer to American Red Cross and/or American Heart Association first aid training, employers relying on American Red Cross or American Heart Association training will have a first aider trained in the new bleeding control techniques. These standards also allow equivalent training. Thus, that training must include instructions on the bleeding control methods described in the 2015 AHA/ARC Guidelines as well. In general industry, in light of OSHA’s 1978 directive relying on American Red Cross training and the long history of American Red Cross training on the techniques to control bleeding discussed above, in order for a first aider to be “adequately trained” within the meaning of 29 CFR 1910.151(b) he or she also shall be trained in accordance with the 2015 AHA/ARC Guidelines. This applies to all workplaces covered by the general industry first aid standard.

In particular regards to the contents of first aid kits, OSHA standards have various requirements. The general industry first aid standard at 29 CFR 1910.151(b) provides in pertinent part: “Adequate first aid supplies shall be readily available.” Appendix A to § 1910.151—First Aid Kits (Non-mandatory) states that an example of the minimal contents in a generic first aid kit is described in American National Standard (ANSI)—Z308.1-1998, “Minimum Requirements for Workplace First Aid Kits.” That document lists compresses and bandages to stop bleeding. The updated ANSI Z308.1-2015 provides recommendations for Class A kits, which are minimum kits for workplaces, and Class B kits, which are for workplaces with a high risk for severe injuries. Class A kits have bandages, trauma pads, and sterile pads to stop bleeding. Class B kits have not only the items in Class A kits to stop bleeding, but also tourniquets. As we have stated above, adequate first aid training includes instructions on applying direct pressure, using hemostatic dressings, and using tourniquets in certain situations. However, the 2015 ANSI standard on first aid kits differentiates between industries in terms of the types of kits which employers should have. Considering both the 2015 AHA/ARC Guidelines and the 2015 ANSI standard together, OSHA interprets the provision to have adequate first aid supplies in 29 CFR 1910.151 with respect to bleeding control to mean that general industry workplaces must have the items for bleeding control listed for Class A kits, unless the workplace has a high risk of serious injuries, in which case the items listed for Class B kits, including tourniquets, are required. Thus, based on historical information, OSHA strongly recommends that industries where amputations are likely use Class B kits (such as, but not limited to, those in OSHA’s Amputations NEP).

The shipyard first aid standard at 29 CFR 1915. 87(d) requires that the employer provide and maintain “adequate first aid supplies” and that the supplies be “adequate” in terms of the hazards present at the worksite, among other things. The preamble to the proposed Subpart F of Part 1915 on general working conditions in shipyards states: “Working in shipyards is one of the riskiest occupations in the United States.” It notes dangers arising from steel fabrication, among other activities. 72 FR 72452, 72453 (Dec. 20, 2007). One of the hazards that could be present at shipyards is the hazard of getting cut by sharp metal, which can cause bleeding. Thus, because of the high risk of severe injuries in shipyard employment, Class B kits are strongly recommended.

Construction is a high hazard industry. www.osha.gov (Construction Industry webpage). Employees in the construction industry also suffer many bleeding injuries. The Bureau of Labor Statistics reports that in 2017 construction employees suffered 13,500 open wounds.⁸ The general construction first aid standard at 29 CFR 1926.50(d)(1) provides: “First aid supplies shall be readily accessible when required.” Appendix A to 29 CFR1926.50—First Aid Kits (Non-mandatory) states that the minimal contents of a generic first aid kit is described in ANSI Z308.1-1978—Minimum Requirements for Industrial Unit-type First Aid Kits.⁹ That kit would have gauze, compresses, and tourniquets. The 2015 ANSI standard lists the same, as well as hemostatic dressings, for Class B kits, which are appropriate for industries with a high risk of serious injuries. Because construction is such an industry, Class B kits are strongly recommended for the construction industry.

Question 2: What is OSHA’s current interpretation of the response times for first aid in response to life-threatening bleeding, including active shooter incidents?

Response: OSHA’s current interpretations of the response times for first aid in response to life-threatening bleeding are addressed in letters of interpretation to Mr. Charles F. Brogan, January 16, 2007, and to Mr. Brian Bisland, March 23, 2007. These letters state in part that,

In workplaces where serious accidents such as those involving falls, suffocation, electrocution, or amputation are possible, emergency medical services must be available within 3-4 minutes, if there is no employee on the site who is trained to render first aid...While the standards do not prescribe a number of minutes, OSHA has long interpreted the term “near proximity” to mean that emergency care must be available within no more than 3-4 minutes from the workplace, an interpretation that has been upheld by the Occupational Safety and Health Review Commission and by federal courts...The basic purpose of these [first aid] standards is to assure that adequate first aid is available in the critical minutes between the occurrence of an injury and the availability of physician or hospital care for the injured employee... Medical literature establishes that, for serious injuries such as those involving stopped breathing, cardiac arrest, or uncontrolled bleeding, first aid treatment must be provided within the first few minutes to avoid permanent medical impairment or death...OSHA recognizes that a somewhat longer response time of up to 15 minutes may be reasonable in workplaces, such as offices, where the possibility of such serious work-related injuries is more remote.

These time limits are maximums. OSHA does not prohibit but encourages shorter response times when feasible.

These recommendations are consistent with the National Fire Protection Association’s (NFPA) Standard 1710, Standard for the Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Career Fire Departments. This standard requires that emergency medical services ideally respond within one minute of turnout, that first responders take 4 minutes to get to the scene, and that other units should arrive within 8 minutes.

A response time of less than three minutes would likely require on-site trained first aid employees at every work site. OSHA encourages every work site to have a trained first aid responder on site, as stated in the letter to Mr. Brogan, “OSHA recommends, but does not require, that every workplace include one or more employees who are trained and certified in first aid, including CPR.” In order for OSHA standards to more comprehensively address response times to uncontrolled bleeding, it would entail a notice of proposed rulemaking and comment effort.

In addition, emergency response procedures for active shooter incidents are addressed on OSHA’s Emergency Preparedness Safety and Health Topics webpage. OSHA recommends that preparing for active shooter incidents be part of an employer’s emergency action plan that includes shelter-in-place and evacuation procedures. Please note, that during an active shooter incident and evacuation, if employees voluntarily choose to stay behind to assist the wounded, OSHA considers this a “Good Samaritan” act. We should also clarify that OSHA standards only protect employees and, therefore, OSHA standards do not apply to non-employee “bystanders.”

In some cases active shooter incidents may be acts of workplace violence. While OSHA does not have a standard specifically addressing workplace violence, it has recommended that employers develop workplace violence prevention programs that include providing prompt first aid.¹⁰

Question 3: What is OSHA’s current interpretation of the role of medical personnel in providing employers with “advice and consultation” under the medical and first aid standards?

Response: The general industry standard at 29 CFR 1910.151(a) provides: “The employer shall ensure the ready availability of medical personnel for advice and consultation on matters of plant health.” OSHA’s current interpretation of the role of medical personnel in providing employers with advice and consultation is partially addressed in an existing letter of interpretation to Dr. Barry Pinchefsky, July 2, 1991, which supports the statement in your letter that, “where the employer has determined that uncontrolled bleeding poses a significant risk, medical consultations should inform an employer’s provision of adequate first aid training and supplies.”

Question 4: Will OSHA consider updating its 2006 Best Practices Guide: Fundamentals of a Workplace First-Aid Program (2006 Guide) to address active shooter incidents, bleeding control, or the aforementioned authorities and resources?

Response: Yes. OSHA will consider updating its 2006 Guide to address new “best practices” in first aid, including bleeding control. OSHA’s 2006 Guide recommends that employers evaluate and update their first aid programs and states that the elements of a first aid program include, “Providing for scheduled evaluation and changing of the first-aid program to keep the program current and applicable to emerging risks in the workplace, including regular assessment of the adequacy of the first-aid training course.” The guide also states, “The first-aid training program should be kept up to date with current first-aid techniques and knowledge.”

OSHA will also consider updating its related webpages with the aforementioned updates to the American Red Cross and American Heart Association training and the 2015 ANSI Z308.1 standard on first aid kits.

An additional avenue for promoting such national campaigns is through OSHA’s cooperative programs, such as the Strategic Partnership and Alliance programs. OSHA currently is engaged in a national alliance with the American Red Cross, which is also promoting the national STB campaign. As information about the STB campaign is shared with OSHA, we will, in turn, share it with our cooperative program participants to help promote broad awareness. A copy of the alliance agreement is available on OSHA’s website at, American Red Cross: Alliance Agreement.

Thank you for your interest in occupational safety and health. We hope you find this information helpful. OSHA’s requirements are set by statute, standards, and regulations. Our letters of interpretation do not create new or additional requirements but rather explain these requirements and how they apply to particular circumstances. This letter constitutes OSHA’s interpretation of the requirements discussed. From time to time, letters are affected when the Agency updates a standard, a legal decision impacts a standard, or changes in technology affect the interpretation. To assure that you are using the correct information and guidance, please consult OSHA’s website at http://www.osha.gov. If you have further questions, please feel free to contact the Office of Health Enforcement at (202) 693-2190.

Sincerely,

Patrick J. Kapust, Acting Director
Directorate of Enforcement Programs

¹This standard was adopted by OSHA in 1971 under section 6(a) of the OSH Act, 29 U.S.C. 655(a), because it was a standard issued under the Walsh-Healey Public Contracts Act, 41 U.S.C. 35 et seq. 36 FR 10466, 10601 (May 29, 1971). The Labor Department had adopted the Walsh-Healey standard after notice and comment in 1969. 41 CFR 50-204.6, 34 FR 7946, 7948 (May 20, 1969). The standard requires an adequately trained first aider “...in the absence of an infirmary, clinic, or hospital in near proximity to the workplace which is used for the treatment of all injured employees...”

²The reference to current certificates from the U.S. Bureau of Mines is no longer operative because that agency was abolished in 1996.

³OSHA’s 2006 Best Practices Guide: Fundamentals of a Workplace First-Aid Program

⁴Letter to Larry M. Starr, PHD, July 24, 1995.

⁵1910 ARC, pp. 36, 43

⁶Industrial First Aid and Safety Program (May 2, 1969); Instructors Manual—Advanced First Aid and Emergency Care (1973), pp.3-5 (“Make sure students understand that use of tourniquet is a last resort measure...Risk sacrifice of limb to save life...”).

⁷Singletary EM, Charlton NP, Epstein JL, Ferguson JD, Jensen JL,MacPherson AI, Pellegrino JL, Smith WR, Swain JM, Lojero-Wheatley LF, Zideman DA. Part 15: first aid: 2015 American Heart Association and American Red Cross Guidelines Update for First Aid. Circulation. 2015; 132(suppl 2):S574-S589, pp. S578-S579. (hereinafter 2015 AHA/ARC Guidelines)

⁸Bureau of Labor Statistics, 2018 Survey of Occupational Injuries and Illnesses, Table R49.

⁹The preamble to the 1998 revision of 29 CFR 1926.50, eliminating the requirement for physician approval of first aid kits, states "... first aid kits that are commercially available will meet the needs of most employers....” 63 FR 33450, 33463 (June 18, 1998). Appendix A to § 1926.50—First Aid Kits (Non-mandatory) states that the minimal contents of a generic first aid kit is described in ANSI Z308.1-1978—Minimum Requirements for Industrial Unit -type First Aid Kits.

¹⁰OSHA publication 3153, Recommendations for Workplace Violence Prevention Programs in Late-Night Retail Establishments (2009) and OSHA publication 3184, Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers (2015)