DIRECTIVE NUMBER: CPL 2-2.53
EFFECTIVE DATE: January 7, 1991
SUBJECT: Guidelines for First Aid Training Programs

U.S. Department of Labor
Assistant Secretary for Occupational Safety and Health
Washington, D.C. 20210

OSHA Instruction CPL 2-2.53

JAN 7, 1991
Directorate of Technical Support

Subject: Guidelines for First Aid Training Programs

A. Purpose. Eight OSHA standards have first aid requirements. These guidelines provide institutions teaching first aid courses, and consumers of these courses, what OSHA considers basic and essential elements of a first aid program. These guidelines can also assist compliance officers evaluating individual plant first aid programs during the inspection process.

B. Scope. This Instruction shall apply OSHA-wide.

C. Action. OSHA National Office Directors, Regional Administrators, and area Directors shall provide these guidelines to individuals inquiring about first aid programs. It must be clear OSHA does not teach or certify first aid training programs, instructors, or trainees.

D. Federal Program Change. This instruction describes a Federal program change which effects State Programs. Each Regional Administrator shall:

1. Ensure that a copy of this change is promptly forwarded to each State designee using a format consistent with the Plan Change Two-way Memorandum in Appendix P, OSHA Instruction STP 2.22A, Ch-2.
    
2. Explain the content of the change to the State designees as requested.
    
3. Advise the State designees that they may participate in the program as indicated in paragraphs A and C of the Instruction, but a plan supplement is not required.
    
4. Ensure that State designees are asked to acknowledge receipt of this Federal program change as soon as the State's intention is known, but no later than 70 calendar days after the date of issuance (10 days for mailing and 60 days for response).

Gerard F. Scannell
Assistant Secretary

Distribution:
National Regional and area offices, all compliance Officers

State Plan Designees 7 (c)(1) Consultation Project Managers

Directives
CPL 2-2.53 - Guidelines for First Aid Programs

DIRECTIVE NUMBER: CPL 2-2.53
EFFECTIVE DATE: January 7, 1991
SUBJECT: Guidelines for First Aid Training Programs

TABLE OF CONTENTS

I. Overview
II. Introduction
III. General Program Elements

A. Teaching Methods
B. Responding to a Health Emergency
C. Surveying the Scene
D. Basic Adult Cardiopulmonary Resuscitation (CPR)
E. Basic First Aid Intervention
F. Universal Precautions
G. First Aid Supplies
H. Trainee Assessments
I.  Program Update

IV. Specific Program Elements

A. Type of Injury Training

1) Shock
2) Bleeding
3) Poisoning
4) Burns
5) Temperature Extremes
6) Musculoskeletal Injuries
7) Bites and Stings
8) Medical Emergencies

a) Heart Attack
b) Stroke
c) Asthma Attack
d) Diabetes
e) Seizures
f) Pregnancy

9) Confined Spaces

B. Site of Injury Training

1) Head and Neck
2) Eye
3) Nose
4) Mouth and Teeth
5) Chest
6) Abdomen
7) Hand, Finger, & Foot

I. OVERVIEW
OSHA does not teach first aid courses, or certify first aid training courses for instructors or trainees. The goals of these guidelines are to provide institutions teaching first aid courses, consumers of these courses, and OSHA personnel who review courses, the essential elements of what OSHA considers a basic first aid program.

II. INTRODUCTION
In the United States, injuries (all types) may represent the single most important public health problem. Moreover, estimates of work related injury fatalities may exceed 10,000 workers per year, while work related disabling injuries number approximately 1.8 million. Approximately 35 million lost work days occur each year due to nonfatal injuries. The direct and indirect costs of occupational injuries is estimated to be 47 billion dollars per year.

The outcome of occupational injuries depends not only on the severity of the injury, but also the rendering of first aid care. Prompt, properly administered first aid care can mean the difference between life and death, rapid vs prolonged recovery, temporary vs permanent disability.

Given the potential positive impact first aid care can provide, several OSHA standards have included first aid provisions (General Industry (CFR 1910.151), Construction (CFR 1926.50), Shipyard (CFR 1915.98), Longshoring (CFR 1918.96), Diving (CFR 1910.410), Hazardous Waste and Emergency Response (CFR 1910.120), Temporary Labor Camps (CFR 1910.142), and First Aid and Lifesaving Facilities (CFR 1917.26). Although these standards require first aid training, they do not specify what constitutes "adequate training."

In the United States first aid training is primarily received through the American Red Cross, the National Safety Council, and private institutions. The American Red Cross offers standard and advanced first aid courses throughout the United States via their local chapters. After completion of the course and successful passing of the written and practical tests, trainees receive two certificates; one in adult cardiopulmonary resuscitation (CPR) and the other in first aid. The National Safety Council provides educational materials to train individuals in basic first aid knowledge and skills. However, they do not conduct training courses or certify trainers or trainees. Private institutions also teach courses in basic first aid, but they do not certify their trainees.

III. GENERAL PROGRAM ELEMENTS

A. Teaching Methods

1. Trainees should develop "hands on" skills through the use of manikins and trainee partners during their training.

2. Trainees should be exposed to acute injury and illness settings as well as the appropriate response to those settings through the use of visual aids, such as video tape and slides.

3. Training should include a course workbook which discusses first aid principles and responses to settings that require interventions.

4. Training duration should allow enough time for particular emphasis on situations likely encountered in particular workplaces.

5. An emphasis on quick response to first aid situations should be incorporated throughout the program.

B. Principles of responding to a health emergency

The training program should include instruction in:

1. Injury and acute illness as a health problem.

2. Interactions with the local emergency medical services system. Trainees have the responsibility for maintaining a current list of emergency telephone numbers (police, fire, ambulance, poison control) easily accessible to all employees.

3. The principles of triage.

4. The legal aspects of providing first aid services.

C. Methods of surveying the scene and the victim(s)

The training program should include instruction in:

1. The assessment of scenes that require first aid services including:

a. general scene safety.
b. likely event sequence.
c. rapid estimate of the number of persons injured.
d. identification of others able to help at the scene.

2. Performing a primary survey of each victim including airway, breathing, and circulation assessments as well as the presence of any bleeding.

3. The techniques and principles of taking a victim's history at the scene of an emergency.

4. Performing a secondary survey of the victim including assessments of vital signs, skin appearance, head and neck, eye, chest, abdomen, back, extremities, and medical alert symbols.

D. Basic Adult Cardiopulmonary Resuscitation (CPR)

1. Basic Adult CPR training should be included in the program. Retesting should occur every year. The training program should include instruction in:

a. establishing and maintaining adult airway patency.
b. performing adult breathing resuscitation.
c. performing adult circulatory resuscitation.
d. performing choking assessments and appropriate first aid interventions.
e. resuscitating the drowning victim.

E. Basic First Aid Intervention

Trainees should receive instruction in the principles and performance of:

1. Bandaging of the head, chest, shoulder, arm, leg, wrist, elbow, foot, ankle, fingers, toes, and knee.

2. Splinting of the arm, elbow, clavicle, fingers hand, forearm, ribs, hip, femur, lower leg, ankle, knee, foot, and toes.

3. Moving and rescuing victims including one and two person lifts, ankle and shoulder pulls, and the blanket pull.

F. Universal Precautions

1. Trainees should be provided with adequate instruction on the need for and use of universal precautions. This should include:

a. the meaning of universal precautions, which body fluids are considered potentially infectious, and which are regarded as hazardous.

b. the value of universal precautions for infectious diseases such as AIDS and hepatitis B.

c. a copy of the OSHA proposed Standard for occupational exposure to blood borne pathogens or information on how to obtain a copy.

d. the necessity for keeping gloves and other protective equipment readily available and the appropriate use of them.

e. the appropriate tagging and disposal of any sharp item or instrument requiring special disposal measures such as blood soaked material.

f. the appropriate management of blood spills.

G. First Aid Supplies

The first aid provider should be responsible for the type, amount, and maintenance of first aid supplies needed for their particular plant. These supplies need to be stored in a convenient area available for emergency access.

H. Trainee Assessments

Assessment of successful completion of the first aid training program should include instructor observation of acquired skills and written performance assessments. First aid skills and knowledge should be reviewed every three years.

I. Program Update

The training program should be periodically reviewed with current first aid techniques and knowledge. Outdated material should be replaced or removed.

IV. SPECIFIC PROGRAM ELEMENTS

A. Type of Injury Training

1. Shock

Instruction in the principles and first aid intervention in:

a. shock due to injury
b. shock due to allergic reactions.
c. the appropriate assessment and first aid treatment of a victim who has fainted.

2. Bleeding

a. the types of bleeding including arterial, venous, capillary, external, and internal.
b. the principles and performance of bleeding control interventions including direct pressure, pressure points, elevation, and pressure bandaging.
c. the assessment and approach to wounds including abrasions, incisions, lacerations, punctures, avulsions, amputations, and crush injuries.
d. the principles of wound care including infection precautions, wounds requiring medical attention, and the need for tetanus prophylaxis.

3. Poisoning

Instruction in the principles and first aid intervention of:

a. alkali, acid and systemic poisons. In addition, all trainees should know how and when to contact the local Poison Control Center.

b. inhaled poisons including carbon monoxide, carbon dioxide, smoke, and chemical fumes, vapors and gases as well as the importance of assessing the toxic potential of the environment to the rescuer and the need for respirators. Trainees should be instructed in the acute effect of chemicals utilized in their plants, the location of chemical inventories, material safety data sheets (MSDS's), chemical emergency information, and antidote supplies.

c. topical poisons including poison ivy, poison sumac, poison oak, and insecticides.

d. drugs of abuse including alcohol, narcotics such as heroin and cocaine, tranquilizers, and amphetamines.

4. Burns

Instruction in the principles and first aid intervention of:

a. assessing the severity of the burn including first degree, second degree, and third degree burns.

b. differentiate between the types of third degree burns (thermal, electrical, and chemical) and their specific interventions. Particular attention should be focused upon chemical burns, and the use of specific chemicals in the workplace which may cause them.

5. Temperature Extremes

Instruction in the principles and first aid intervention of:

a. exposure to cold including frost bite and hypothermia.

b. exposure to heat including heat cramps, heat exhaustion, and heat stroke.

6. Musculoskeletal Injuries

The training program should include instruction in the principles and first aid intervention in:

a. open fractures, closed fractures, and splinting.

b. dislocations, especially the methods of joint dislocations of the upper extremity. The importance of differentiating dislocations from fractures.

c. joint sprains.

d. muscle strains, contusions, and cramps.

e. head, neck, back, and spinal injuries.

7. Bites and Stings

Instruction in the principles and first aid intervention in:

a. human and animal (especially dog and snake) bites.

b. bites and stings from insects (spiders, ticks, scorpions, hornets and wasps) Interventions should include responses to anaphylactic shock; other allergic manifestations; rabies and tetanus prophylaxis.

8. Medical Emergencies

Instruction in the principles and first aid intervention of:

a. heart attacks

b. strokes

c. asthma attacks

d. Diabetic emergencies including diabetic coma, insulin shock, hyperglycemia, and hypoglycemia.

e. Seizures including tonic-clonic and absence seizures. Importance of not putting gags in mouth.

f. Pregnancy including the appropriate care of any abdominal injury or vaginal bleeding.

9. Confined spaces

a. the danger of entering a confined space to administer first aid without having the appropriate respiratory protection. If first aid personnel will be required to assist evacuations from confined spaces additional training will be needed.

B. Site of Injury Training

Instruction in the principles and first aid intervention of injuries to the following sites:

1. Head and Neck

a. including skull fractures, concussions, and mental status assessments with particular attention to temporary loss of consciousness and the need for referral to a physician.

b. including the appropriate approach to the management of the individual who has suffered a potential neck injury or fracture.

2. Eye

a. foreign bodies, corneal abrasions and lacerations.

b. chemical burns and the importance of flushing out the eye.

c. the importance of not applying antibiotics without physician supervision.

3. Nose

a. nose injuries and nose bleeds.

4. Mouth and Teeth

a. oral injuries, lip and tongue injuries, and broken and removed teeth. The importance of preventing inhalation of blood and teeth.

5. Chest

a. rib fractures, flail chest, and penetrating wounds.

6. Abdomen

a. blunt injuries, penetrating injuries, and protruding organs.

7. Hand, Finger, and Foot Injuries

a. finger/toe nail hematoma, lacerations, splinters, finger avulsion, ring removal, and foreign bodies.

b. the importance of identifying amputation care hospitals in the area. When an amputation occurs, appropriate handling of amputated fingers, hands, and feet during the immediate transportation of the victim and body part to the hospital.