Set policies to balance patient, employee safety

MRSA outbreaks raise level of concern

A staph infection develops among several patients in a unit, and the investigation begins. Lab tests show the cases are linked. Could an employee be the carrier?

When that question arises, be ready to change from your usual employee-oriented perspective to focus on the potential risk to patients. Outbreaks involving methicillin-resistant Staphylococcus aureus (MRSA) have heightened the concern about employees who may potentially spread illness to patients.

The balancing of employee health and infection control presents a challenge as employees may need testing, counseling, treatment, or even a furlough, depending on the organism involved.

"There are certain circumstances where you have a silent infection, but for patients, it isn't silent at all; it's deadly," says William G. Buchta, MD, MPH, medical director of the employee occupational health service at the Mayo Clinic in Rochester, MN.

At the same time, employee health needs to safeguard the employees' privacy and respect their rights. "While patient protection is paramount, there must be at least reasonable suspicion that an employee is a real or potential vector," he says.

While the Centers for Disease Control and Prevention provides some disease-specific guidance in its Guideline for Infection Control Personnel in Health Care Facilities, it is up to hospitals to develop policies on furlough, work restrictions, and employee screening, the guidelines state.

"We try to give hospitals as much leeway as we can," says Elizabeth Bolyard, RN, MPH, technical information specialist at the CDC. Yet hospitals also may be governed by state laws that require health care workers to receive certain immunizations or face restrictions when an outbreak occurs, she notes.

While outbreaks may trigger action, hospitals also must rely on employees to report draining wounds, rash, a prolonged and persistent cough, or other symptoms that could indicate an infection control risk. Whether they report that may depend in part on your hospital's policies.

"We encourage hospitals not to make it punitive for people who have to be furloughed," says Bolyard. "Don't make them use sick time. Pay them for their time off because they're protecting their patients."

Often, the hospital policy differs depending on the source of the infection. At Scripps Memorial Hospital in La Jolla, CA, a couple of employees being treated in the emergency department for a nonwork-related wound have tested positive for MRSA. The information was relayed to employee health, which implemented a furlough. Because the injury was not work-related, the employees used their sick time.

"We've handled it on a case-by-case basis, but required that the wound be completely healed before they come back to work," says Linda Good, RN, MN, COHN-S, employee occupational health coordinator.

New employees are told at their orientation that they must have vaccinations or immunity to certain diseases and must report certain infectious diseases as a condition of their employment, Good says. "Because of the nature of the business we're in, we have to have those standards," she says.

The Mayo Clinic is developing a policy to address work restrictions or furlough. The supervisor must be involved in the decision, as well as employee health and infection control, says Buchta. "There's got to be some latitude for the individual, but there can be some general guidelines," he says.

There are other sticky issues. Who pays for treatment if an exposed employee has no symptoms but needs prophylaxis in order to work? The policy should cover that as well, says Buchta. "There's a gray zone between workers' compensation and personal health insurance," he says. "A lot of times we pick up the cost."

Clear protocols also can prevent unnecessary treatment following an exposure and inflated recordable injuries, notes Denise Knoblauch, RN, BSN, COHN-S/CM, clinical case manager for the OSF SFMC Center for Occupational Health at Saint Francis Medical Center in East Peoria, IL. For example, when a patient has a suspected case of meningitis and employees are concerned about exposure, an attending physician or medical resident may simply write prescriptions for prophylaxis without contacting employee health, she says.

"In that circumstance, we don't have a confirmed culture," she notes. "We'd prefer it be the occupational health physician who writes the script."

It helps to make reporting and tracking as simple as possible. When the mumps outbreak occurred in the Midwest, employee health put forms on the Intranet for managers to report an exposure.

Collaboration between infection control and employee health is commonplace, but not always assured. Knoblauch says she is working to improve that relationship in her hospital. "You need to have communication and share the responsibilities for educating staff as well as patients," she says.

At Scripps, Good attends all infection control meetings and has a regular spot on the agenda. She writes quarterly reports about employee health-related infection control issues and she has input into the employee health-related policies in the infection control manual.

"I have good visibility so they automatically think of me when they have a question about employee health," she says.

(Editor's note: Further information about CDC recommendations on furlough of employees exposed to infectious diseases is available at www.cdc.gov/ncidod/dhqp/pdf/guidelines/InfectControl98.pdf.)