Continuing education

Heat Stress Management Program Improving

Worker Health and Operational Effectiveness
A Case Study
by Rosalyn G. Huss, RN, COHN-S, Scott B. Skelton, MS, CIH, Kimberly L. Alvis, RN, COHN, and
Leigh A. Shane, RN, BSN, CHC

ABSTRACT
Heat stress monitoring is a vital component of an effective health and safety program when employees work in excep-
tionally warm environments. Workers at hazardous waste sites often wear personal protective equipment (PPE), which
increases the body heat stress load. No specific Occupational Safety and Health Administration (OSHA) regulations
address heat stress; however, OSHA does provide several guidance documents to assist employers in addressing this
serious workplace health hazard. This article describes a heat stress and surveillance plan implemented at a hazard-
ous waste site as part of the overall health and safety program. The PPE requirement for work at this site, coupled with
extreme environmental temperatures, made heat stress a significant concern. Occupational health nurses and industrial
hygienists developed a monitoring program for heat stress designed to prevent the occurrence of significant heat-related
illness in site workers. The program included worker education on the signs of heat-related illness and continuous physi-
ologic monitoring to detect early signs of heat-related health problems. Biological monitoring data were collected before
workers entered the exclusion zone and on exiting the zone following decontamination. Sixty-six site workers were moni-
tored throughout site remediation. More than 1,700 biological monitoring data points were recorded. Outcomes included
improved worker health and safety, and increased operational effectiveness.

T
he Occupational Safety and Health Administration
(OSHA) does not have specific regulations regard-
ing heat stress hazards but cites the General Duty
ABOUT THE AUTHORS
Ms. Huss is Senior Medical Specialist, Mr. Skelton is Director of Toxicol-
ogy Emergency Response Program, and Ms. Alvis is Project Medical Spe-
cialist, Center for Toxicology and Environmental Health, LLC, North Little
Rock, AR. Ms. Shane is Occupational Health Nurse, J. P. Morgan Chase
& Co., Dallas, TX.
The authors disclose that they have no significant financial interests in any
product or class of products discussed directly or indirectly in this activity,
including research support.
Address correspondence to Rosalyn G. Huss, RN, COHN-S, Senior Medi-
cal Specialist, Center for Toxicology and Environmental Health, LLC, 5120
North Shore Drive, North Little Rock, AR 72118. E-mail: ghuss@cteh.com.
Received: May 30, 2012; Accepted: January 31, 2013; Posted: February
25, 2013.
Clause to hold an employer responsible to “furnish to
each of his employees employment and a place of em-
ployment which are free from recognized hazards that
are causing or likely to cause death or serious physi-
cal harm” (Henshaw, 2001, p. 1). OSHA, the Ameri-
can Conference of Governmental Industrial Hygienists
(ACGIH), and other agencies and organizations pro-
vide various guidance documents to assist employers in
developing methods to reduce occupational heat stress
hazards. OSHA recommends (1) permitting workers to
drink water liberally; (2) establishing provisions for a
work/rest regimen to decrease exposure time to extreme
temperatures and work rate; and (3) developing a heat
stress program that incorporates training, screening of
health conditions aggravated by heat, an acclimatization

128 Copyright © American Association of Occupational Health Nurses, Inc.

program for return to work or absence of more than 3
days, procedures for heat-related emergencies, and im-
mediate first aid provisions for workers with symptoms
of heat-related illness (Henshaw, 2001).
In this article, the heat stress monitoring program
developed and provided by occupational health nurses,
in collaboration with industrial hygienists and safety per-
sonnel, for workers remediating a hazardous waste site
following a warehouse fire in a facility housing bulk pool
chemicals is described.
Heat stress is defined as the net heat load, includ-
ing metabolic heat; environmental factors such as tem-
perature, humidity, air currents/movement, and radiant
heat; and the clothing or personal protective equipment
(PPE) required for specific hazards to which workers may
be exposed. Heat strain refers to the body’s physiologic
response to the heat stress load (ACGIH, 2012). Heat
stress is dependent on the ambient temperature, humidity,
type of PPE or ensemble, exertion required to perform
assigned tasks, and individuals’ physical conditioning,
level of acclimation, existing health problems, and age.
Because ambient temperatures during the initial remedia-
tion activities were expected to be in excess of 90°F, heat-
related illness was a significant concern. Although it was
not possible to control all factors that contribute to heat
stress, several actions reduced the effects of heat stress on
site personnel.
Heat Rash
Heat rash, also called prickly heat, is caused by con-
tinuous exposure to heat and/or humidity. Profuse sweat-
ing while wearing impermeable clothing causes moisture
to remain on the skin, leading to plugged sweat pores,
retained sweat, and thus inflammation. Signs and symp-
toms of heat rash include multiple tiny, raised, red blis-
ters on affected areas with pricking sensations during heat
exposure. Heat rash is usually mild and transitory. The
condition can be prevented by resting in a cool area dur-
ing break times to allow skin to dry. Frequent showers can
provide relief.
Heat Cramps
Heat cramps are caused by depletion of body electro-
lytes when sweating. If lost fluid is replaced with water
only, body electrolyte levels are diluted. This loss of elec-
trolytes results in painful cramping of the large muscle
groups such as the arms, legs, and abdomen, during or
after work hours.
Cramps may be relieved or prevented by replacing
lost fluids with fortified drinks such as Gatorade and eat-
ing a well-balanced diet with foods containing sodium
and potassium. The use of cooling devices reduces sweat-
ing and the need for fluid and electrolyte replacement.
Heat Exhaustion
Heat exhaustion, or heat fatigue, occurs with sus-
tained work in hot environments when workers have not
acclimated to the warm environment and do not replace
lost fluids. Dehydration and pooling of blood in the pe-
riphery causes decreased circulating blood volume to
WORKPLACE HEALTH & SAFETY • Vol. 61, No. 3, 2013
vital organs, particularly the brain and heart. Core body
temperature rises and workers experience fatigue, head-
ache, nausea, clammy skin, rapid heart rate, slightly
elevated body temperature, and fainting. Although the
condition need not be life-threatening, if workers faint
while engaged in hazardous work, injury could be seri-
ous. Heat exhaustion should be treated immediately to
prevent progression and the occurrence of heat stroke.
Workers should be moved to a cooler area, excess cloth-
ing or PPE removed, and frequent sips of cool water
given.
Heat Stroke
Heat stroke is a life-threatening heat stress disorder
resulting from the body’s inability to regulate core body
temperature. Heat stroke occurs with sustained exertion
in hot environments, usually coupled with other predis-
posing factors. Workers experiencing heat stroke stop
sweating and exhibit hot, dry skin that may be reddish,
mottled, or bluish. Workers will also have elevated body
temperature (in excess of 104°F), mental confusion, loss
of consciousness, seizures, and coma. Heat stroke should
be treated as an emergency with transport to an emer-
gency department. Heat stroke can be fatal if not treated
promptly.
Rapid cooling is essential while awaiting transport.
Workers should be moved to a cool, shaded area, im-
mersed in cool water using a tub, hose, or wetted material
such as towels, and vigorously fanned to promote cool-
ing. Prompt first aid can prevent permanent injury to the
brain and other vital organs.
Prevention of heat stress
Hydration refers to providing water to the body cells.
Drinking water must always be available to workers, and
they must drink water frequently. It is possible to lose
1 liter of fluid each hour by sweating (Lugo-Amador,
Rothenhaus, & Moyer, 2004). Because the body’s total
fluid volume is only about 40 liters, it is apparent why
fluid must be replaced (Sherwood, 2007). Because the
feeling of thirst is not an adequate guide for water re-
placement, employees working in warm environments
should be encouraged to drink water every 15 to 20 min-
utes (Spear, 2009). Sports drinks should not be used as
a substitute for water but rather used as a supplement to
maintain proper electrolyte balance (OSHA, 2011).
Acclimatization refers to gradual human adaptation
to tolerate heat stress (ACGIH, 2012). Acclimatization
to hot conditions has been found to be effective in pre-
venting heat-related illnesses. The process takes 5 to 7
days, during which work hours in the hot environment
are gradually increased. During 7 days of acclimatization,
heart rate and body temperature become lower while per-
forming the same work.
METHODS
Prior to the arrival of site remediation workers, air
monitoring was completed and chemical and environ-
mental hazards were identified. Airborne chlorinated
compounds were identified as potential respiratory and
129
 Table 1
Estimating Energy Cost
Body Position and Type of Work: Light
Movement: Standing Work With Both Arms
(kcal/min) (kcal/min)
0.6 3.5
Note. aReference value.
dermal hazards for site workers. Based on the hazards
identified, it was determined that all personnel enter-
ing the exclusion zone and decontamination personnel
would require Level C PPE, which included a full face
negative pressure air purifying respirator, a chemical-re-
sistant one-piece hooded suit, inner and outer chemical-
resistant gloves, chemical-resistant safety boots, a hard
hat, and two-way radio communication. Site workers in
the support zone wore Level D protection, consisting of
normal work clothing, steel-toed boots or shoes, safety
glasses, and a hard hat.
In addition to the chemical hazards identified, heat
stress was determined to be a significant potential hazard
for all site workers, especially those wearing chemical
protective clothing (CPC). During the initial response
and subsequent remediation of the site, the ambient
temperatures in the area averaged 100°F, with humidity
ranging from 30% to 60%. A heat stress exposure as-
sessment was conducted to account for the contribution
of PPE to workers’ heat stress. Many of the site laborers
were from Florida with prior experience working in hot
and humid conditions wearing PPE. Therefore, for the
purposes of this heat exposure program, workers per-
forming job tasks in CPC were considered acclimatized
based on accounts of their recent outdoor work activity
under similar environmental conditions.
The heat stress exposure assessment was performed
using the Criteria for a Recommended Standard: Oc-
cupational Exposure to Hot Environments (Revised Cri-
teria 1986) (National Institute for Occupational Safety
and Health [NIOSH], 1986). Three types of data were
used to measure heat stress: (1) estimated energy cost
of work by task, (2) basal metabolism, and (3) ambient
conditions measured by a wet bulb globe thermometer
(WBGT). Energy cost was estimated using body posi-
tion and movement, type of work, and basal metabolism
data. Energy cost data are represented in kilocalorie/
minute, or 1,000 calories burned each minute. The basal
metabolism listed in Table 1 is based on the reference
weight of 70 kilograms. Workers evaluated during this
work activity were estimated to weigh an average of
200 pounds, or 90.7 kilograms. A body weight correc-
tion factor was derived using the ratio of actual worker
weight to reference worker weight, resulting in a cor-
rection factor of 1.3 for metabolic heat. Once applied,
the total energy cost per worker was 6.63 kcal/min for
workers performing tasks in chemical protective equip-
ment.
130 Copyright © American Association of Occupational Health Nurses, Inc.
Basal Metabolism Total Energy Cost
(kcal/min) (kcal/min)
1.0a 5.1
The WBGT was used to calculate cumulative heat
stress based on readings collected using the natural wet
bulb thermometer (humidity), globe thermometer (radi-
ant heat load), and dry bulb thermometer (ambient tem-
perature). The WBGT was placed in a location similar to
the conditions experienced by workers performing tasks
wearing CPC. On August 27, 2011, the WBGT was set to
data log for 1 hour, resulting in a 1-hour time-weighted
average value of 38.6°C.
“Thermal balance is achieved when heat gained from
work demands and the environment is balanced by heat
losses to the environment from sweat evaporation and
dry heat exchange (convection and radiation)” (Bernard
& Dukes-Dubos, 2003, p. 479). Convective heat is the
heat exchanged from moving air. Radiant heat is the loss
or gain of heat between the body and the environment.
CPC reduces the body’s ability to reach homeostasis be-
cause of the inhibition of evaporative heat loss and the
contribution of convective heat. Ambient temperatures
exceeding 100°F require a higher evaporative cooling
rate if the body is to maintain homeostasis. For the pur-
pose of applying the total metabolic heat value to the
NIOSH occupational exposure to hot environments rec-
ommended alert level (RAL) (NIOSH, 1986), a clothing
factor of 11°C was added to the WBGT value of 38.6°C,
resulting in a total metabolic heat value of 49.6°C. It was
determined that the total metabolic heat value for these
conditions, including the heat contribution of the CPC,
exceeded the RAL ceiling limits.
Based on the evaluation of metabolic heat, heat con-
tribution by CPC, and WBGT data collected, it was de-
termined that the heat stress likely to be encountered by
workers exceeded the NIOSH RAL guidance values. As
recommended by NIOSH, surveillance was then initiated
for all workers performing similar job tasks while wear-
ing CPC.
As noted above, PPE materials, although designed
to shield workers from chemical hazards, also limit the
evaporation of body heat and moisture, creating a po-
tentially hazardous condition. Heat stress was identified
as a primary hazard for workers performing tasks while
clothed in chemical protective suits and wearing respi-
ratory protection. With increased exertion levels, longer
rest periods were necessary and work duties were also
adjusted by rotating personnel to limit heat stress.
Physiologic heat stress monitoring was provided on-
site by experienced occupational health nurses working
rotating shifts. In addition to the physiologic monitoring,
 Table 2
Site Personnel
Job Position at Site
Contractors responsible for site remediation oversight, including site safety
Laborers, decontamination team, dust suppression, site housekeeping, site control
Rapid Intervention Team, emergency medical technicians
Insurance investigators, fire investigators, engineers
Contaminated water removal
Site environmental monitoring–—environmental scientists, industrial hygienists,
chemists, occupational health nurses
Total site personnel
the occupational health nurses provided education about
the signs of heat stress, importance of early evaluation
for symptomatic individuals, methods of prevention, and
general treatment to site supervisors and workers during
safety briefings. Physiologic monitoring included com-
paring vital signs to baseline data for evidence of heat
stress, as described below.
The frequency of monitoring depended on environ-
mental conditions and work activities. At a minimum,
workers who were performing general site work such as
cleaning, dust suppression, and air monitoring were evalu-
ated at least twice during the shift. Workers who entered
the exclusion or hot zone were monitored pre- and post-
entry. Monitoring was also required immediately for any
individuals who became symptomatic or exhibited signs
of significant heat stress. More frequent monitoring was
employed when indicated by workers’ general physical
condition, age, or history of previous heat-related illness.
Vital signs (i.e., blood pressure, temperature, pulse, oxy-
gen saturation) were monitored by on-site occupational
health nurses and recorded in logbooks. Nurses were also
available to evaluate any workers who were symptomatic.
Nurses were equipped with first aid supplies, an automated
external defibrillator, and instruments for minor first aid
evaluation and treatment.
If signs of severe heat stress or early heat stroke be-
came evident, workers were referred immediately to the
local hospital emergency department for additional evalu-
ation and treatment.
A cooling station, equipped with several misting
fans, bottled water iced down in coolers, cooled fresh
fruits (e.g., bananas, oranges, peaches, and plums), cold
gel neck scarves (purchased at a local discount store),
and electrolyte replacement drinks, was created at the
site for workers during breaks and rest periods. Physi-
ologic monitoring was conducted in the cooling station
by occupational health nurses who encouraged workers
to maintain hydration and provided education and sup-
port. Daily safety briefings reinforced the importance of
adequate hydration at the work site and protective mea-
sures to employ both on and off the job (e.g., avoiding
caffeinated and alcoholic beverages).
WORKPLACE HEALTH & SAFETY • Vol. 61, No. 3, 2013
Number of Employees
12
20
11
3
4
16
66
General work/rest schedules have been developed
by various organizations to address potential heat
stress risks. Site workers were offered breaks in the
cooling station at least every hour. Workers were ad-
vised to notify their supervisor immediately if they felt
symptomatic or needed an earlier break. Rather than
a mandatory work/rest schedule, physiologic and en-
vironmental monitoring were used to adjust work/rest
schedules as needed. Vital sign monitoring was used as
a valuable indicator of the heat stress prevention pro-
gram’s effectiveness and provided additional flexibility
for addressing workers’ individual tolerances for heat
stress.
Physiologic monitoring included body temperature,
blood pressure, and pulse rate, as described below. The
frequency of physiologic monitoring was dependent on
air temperature and humidity, or heat index, and was de-
termined by assigned health care personnel. The proto-
col that was developed and implemented for physiologic
monitoring of site workers was as follows:
1. Workers will not be allowed to re-enter the exclu-
sion zone in impermeable PPE when oral body tempera-
ture exceeds 100.6°F.
2. If oral body temperature exceeds 99.6°F, the next
work period will be shortened by one third for the em-
ployee.
3. If the worker’s heart rate exceeds 110 beats per
minute at the beginning of the rest period, the following
work period will be shortened by one third but the rest
period will remain the same.
4. Workers may re-enter the exclusion zone once
vital signs normalize.
5. If a worker appears to be disoriented or confused
or suffers irritability, malaise, or chills, the worker should
be moved for rest in a cool location with rapidly circulat-
ing air and kept under skilled observation. If any work-
ers display any of the described symptoms while on duty,
they shall be relieved of their duties and given appropriate
treatment. In the case of heat cramps, if the employees are
able to return to work, they shall be assigned less stren-
uous duties for the remainder of their shifts to prevent
more severe heat stress injuries.
131

Table 3
Physiologic Monitoring
Number
of
Workers
Pre-work period 871
Post-work period 854
Random screening 31
Other 5 peratures were taken. However, during the post-work
Total 1,761
With increased exertion, longer rest periods were
implemented and supervisors adjusted work duties by
rotating personnel to different job activities as a method
to limit heat stress. Work/rest schedules were flexible
based on the type of work to be performed, level of PPE
required, and individuals’ general fitness, acclimatiza-
tion, and vital signs. With sustained ambient tempera-
tures over 100°F for several days, the work schedule
was altered to allow exclusion zone entries only at night,
generally after 9:00 p.m. when environmental tempera-
tures were somewhat cooler and no radiant heat was de-
rived from the sun.
In addition to the presence of occupational health
nurses at the site, a Rapid Intervention Team was es-
tablished to respond if site workers became ill or inca-
pacitated while working in the exclusion zone. Para-
graph 1910.120(q)(3)(vi) of the HAZWOPER Standard
(OSHA, n.d.) states that “back up personnel shall stand
by with equipment ready to provide assistance or res-
cue.” This part of the HAZWOPER Standard means that,
as a minimum, the buddy system must be used within
the hazardous area (entry by at least two persons) and
at least two additional personnel shall stand by outside
the hazardous area. At this site, staff opted for a Rapid
Intervention Team whenever workers entered the exclu-
sion zone. The site plan required that, for each worker
entering the exclusion zone, a Rapid Intervention Team
member would be available to respond if an entrant
needed assistance. As each worker entered the exclusion
area, Rapid Intervention Team members donned proper
PPE and self-contained breathing apparatus, stood at the
edge of the exclusion zone, and monitored work activi-
ties and worker behaviors. All Rapid Intervention Team
members were trained emergency responders as well as
emergency medical technicians.
RESULTS
A total of 66 workers were involved in site opera-
tions at any one time. All site workers, regardless of job
classification, were included in the heat stress monitor-
ing program. Site workers included laborers, machine
operators, environmental scientists, site control person-
nel, site health and safety personnel, the Rapid Interven-
tion Team, chemists, industrial hygienists, engineers,
132 Copyright © American Association of Occupational Health Nurses, Inc.
project directors, and managers (Table 2). On arrival at
the site, all workers participated in safety briefings that
included educational information on heat stress signs
and symptoms provided by occupational health nurses
and safety personnel. In addition, safety briefings were
provided daily at the beginning of the shift and before
all entries into the exclusion zone.
Physiologic monitoring of site workers began on
August 2, 2011, and continued for 54 days until Level C
PPE was no longer required and weather conditions had
significantly improved in the area. Initially, oral tem-
testing it was noted that most workers had consumed
cold water immediately on entering the rest area; thus,
an accurate oral temperature was not available. Subse-
quent temperatures were then taken using an ear ther-
mometer. A total of 1,761 physiologic readings were
taken during the heat stress monitoring program at the
site (Table 3); 126 (7%) of the total worker biological
readings revealed some initial signs of potential heat
stress and these workers were monitored in the cooling
station until their vital signs normalized. One worker re-
quired removal by the Rapid Intervention Team and as-
sessment, application of cooling measures, and rehydra-
tion by the occupational health nurse. This worker, who
was approximately 50 years old, exhibited more severe
signs of heat stress during a night exclusion zone entry.
Although his vital signs normalized within 15 minutes,
this worker was precluded from re-entry into the exclu-
sion zone for the remainder of the site work and was
given other, less strenuous duties.
Most site personnel were from Florida and were
previously acclimatized to work in warm environments.
Further, most were young and physically fit and did not
show significant signs of heat-related stress during re-
mediation activities. Older and less physically fit work-
ers occasionally showed evidence of minor change in
biological monitoring points but recovered quickly.
DISCUSSION
The close collaboration of site health and safety
personnel, appropriate environmental assessments, de-
tailed planning, ongoing worker education and training,
and physiologic monitoring resulted in no significant
heat-related illnesses in a work situation with significant
risk for heat stress and stroke. The workers who showed
evidence of some initial signs or symptoms of potential
heat stress were identified early and mitigation measures
were promptly initiated, with resolution of symptoms
and return to baseline in a reasonable time frame. Site
management officials were cooperative and supportive of
all health and safety efforts, including instituting flexible
work/rest schedules and restricting exclusion zone entries
until evening hours. The flexibility in staffing and hours
of operation protected workers and still allowed timely
project completion.
SUMMARY
OSHA does not have a regulation covering heat
stress hazards but does hold employers responsible for
heat-related illnesses under the General Duty Clause. Oc-
cupational health nurses, in collaboration with industrial IN SUMMARY
hygienists and safety professionals, can take a proactive
role in establishing work site-specific heat stress moni-
toring plans to prevent or reduce the risk of heat-related Heat Stress Management
illnesses in exposed workers, which will lead to improved Program Improving Worker
worker health and safety and increased operational effec-
tiveness. Health and Operational
Effectiveness
REFERENCES
American Conference of Governmental Industrial Hygienists. (2012). A Case Study
ACGIH documentation of the TLVs and BEIs with other world- Huss, R. G., Skelton, S. B., Alvis, K. L., &
wide occupational exposure values [CD-ROM]. Cincinnati, OH:
Author. Shane, L. A.
Bernard, T. E., & Dukes-Dubos, F. N. (2003). Managing heat stress.
In D. H. Anna (Ed.), Chemical protective clothing (2nd ed., pp.
Workplace Health & Safety 2013; 61(3), 128-133.
475-491). Fairfax, VA: American Industrial Hygiene Associa-
tion.
Henshaw, J. L. (2001). OSHA interpretation letter to Chip Terhorst: Ac-
ceptable methods to reduce heat stress hazards in the workplace
1 The Occupational Safety and Health Adminis-
tration does not have a specific regulation to
address heat stress but does hold employers
[OSHAct 5(a)(1)]. Cincinnati, OH: Occupational Safety and Health
Administration. responsible to provide a safe working environ-
Lugo-Amador, N. M., Rothenhaus, T., & Moyer, P. (2004). Heat-related ment under the General Duty Clause.
illness. Emergency Medical Clinics of North America, 22(2), 315-
327.
National Institute for Occupational Safety and Health. (1986). Criteria
for a recommended standard: Occupational exposure to hot envi-
ronments (revised criteria 1986) [DHHS (NIOSH) Publication no.
2 Heat stress monitoring is vital to an effective
health and safety program when employees
work in hot environments.
86-113]. Cincinnati, OH: Author.
Occupational Safety and Health Administration. (2011). Protecting
workers from the effects of heat. Retrieved from www.osha.gov/
OshDoc/data_Hurricane_Facts/heat_stress.pdf
Occupational Safety and Health Administration. (n.d.). Hazardous waste
3 Hazardous waste sites in hot environmental
conditions can pose additional heat stress risk
for workers depending on the amount and type
operations and emergency response. 29CFR 1910.120. Retrieved from of personal protective equipment required for
www.osha.gov/pls/oshaweb/owadisp.show_document?p_table= conditions. Establishing a flexible and site-specif-
standards&p_id=9765
Sherwood, L. (2007). Human physiology: From cells to systems (6th ic heat stress monitoring program is paramount
ed.). Belmont, CA: Thomson Brooks/Cole. to ensuring worker safety.
Spear, J. E. (2009). Heat stress management: Assessment and control

4
strategies. Retrieved from www.jespear.com/articles/heatstress09. Operational effectiveness can be maintained
pdf
with close collaboration of site management and
occupational health and safety professionals to
establish site-specific heat stress monitoring.

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