Clusters could signal an outbreak  

The first sign of an outbreak in your hospital may come from your employees. A cluster of sick workers in one unit raises an alarm. Is this just a seasonal spike in illnesses — or is a disease being spread within your hospital?

During the SARS scare, health care worker symptoms were closely monitored as a kind of “sentinel” for emergence of the disease. Now, pandemic influenza planners are asking hospitals to develop a method for detecting signs and symptoms of influenza among their staff.

Here are some examples of “sickline” surveillance systems hospitals have adopted to pick up on patterns in employee illness.  

Leaving a sickline message

The sickline at Regions Hospital in St. Paul, MN, began after a gastrointestinal outbreak. A nurse manager noticed that a couple of her patients had diarrhea — and a few of her employees were out sick with similar symptoms. An investigation revealed that they were all afflicted with a highly contagious norovirus.

After the hospital got the outbreak under control, employee health and infection control professionals began talking about how such outbreaks could be detected more quickly. “We decided we really didn’t have a good way to track sick calls because they go to [different] people,” says Mary Brodehl, RN, nurse manager of employee health services.

The sick call line, a dedicated voice mail in the employee health office, began in late 2004. The hospital focused the program on nursing and dietary workers — employees who have close patient contact and have exposure throughout the hospital. When those workers call in sick, they are transferred to the voicemail and prompted to leave their name, phone number, unit, job description, and symptoms.

Every morning, someone in employee health listens to the messages and logs them on a spreadsheet. Employee health categorizes the illnesses as respiratory, gastrointestinal, musculoskeletal, or other. It takes about 20 minutes to half an hour to log the calls, Brodehl says. While it varies with the season, the call line averages 20 calls a day.

The sick call line is confidential, notes Brodehl. Employees are encouraged to simply say “mental health day” if they are taking a day off but aren’t really sick, she says.

Employees are comfortable with the system and have been cooperative. “It’s part of the culture now,” she says.  

‘If you have a sore throat, press 1’

If three nurses in the same unit have similar symptoms for three days, infection control steps into action at Maine Medical Center in Portland. The cause may be an illness circulating in the community, but it still points out a need for greater vigilance, says Maggie Kelley, MSN, NP, COHN-S, director, employee health services.

For example, the hospital recently saw a rise in gastrointestinal symptoms, and Kelley sent out a notice urging staff to use “exemplary” hand hygiene. Fortunately, the trend abated.

Nursing staff members call an 800 number to report unscheduled absences. Using a touch-tone phone, they press “1” if experiencing an illness or “2” if they are calling for another reason. After pressing “1,” the caller is prompted to respond by pressing “1” for yes and “2” for no for the following symptoms: fever, nausea/vomiting/diarrhea, stiff neck with headache, rash, cough, sore throat, nasal congestion or sneezing, or conjunctivitis. A nurse manually records the responses onto a confidential tracking tool. So far, two spikes have been detected involving nausea/vomiting/diarrhea.

The program doesn’t incorporate the hospital’s entire staff of about 5,400, though that is the goal if a fully automated data collection system becomes available, Kelley reports. “In the interim, nursing representation across the ‘house’ gives us an overall impression of staff illness trends,” she says.

“We’re trying to establish our baseline so we can compare year to year,” says Kelley. “Our infectious disease specialists are comparing the trends to see if the employee trend is the same as [in] the community. If we see something off track, it prompts us to evaluate further.”

If hospitals across the country collected surveillance data on employees, that could provide an early alert system to minimize disease spread, says Kelley. “It could also be a useful tool for early identification of potential novel viruses,” she adds.

Baystate Health System in Springfield, MA, wants to know if employees have the flu. This limited sickline ramps up each year with the start of the flu season, usually in December or January. It stops when the cases drop to a trickle, usually by March, reports James Garb, MD, director of occupational health and safety. It encompasses the health system’s 9,400 employees at three hospitals.  

Baystate System sniffs out the flu  

The Baystate’s sickline began about two years ago when the influenza vaccine was in short supply. The health system had purchased a supply of amantadine. “We wanted to know when we should consider prophylaxis [rather than just] treatment,” says Garb. “If we saw several nurses with influenza-like symptoms, we might offer prophylaxis to the rest of the staff on the unit.

“We’ve had enough vaccine and we do not have a stockpile of amantadine at this point,” he says. “But with all the talk about pandemic influenza, we thought we’d continue what we have in place.”

Employees either can fill out a survey on the health system’s intranet or can call the nurse line. Those nurses have been trained to collect information on influenza symptoms among employees. They ask about fever higher than 101° F, headache, muscle aches or pains, sore throat, and cough. Employees identify their unit but do not need to give their name.

“We’re very focused,” says Garb. “We don’t ask them to report any other types of symptoms. We’re just looking for influenza symptoms.

“We ask if they had the flu vaccine, and if they did, how far before the onset of their symptoms,” he says. “I try to categorize the symptoms into two different groups. If someone just had a sore throat and no fever or myalgia, then that’s not influenza.”

If they have influenza symptoms despite having the vaccine, Garb records that as a vaccine failure. He acknowledges that the method is crude; some employees may have an influenza-like illness that is not actually influenza. But it gives a picture of possible influenza activity.

At the peak of the flu season, the surveillance picks up about 40 cases per week. So far, it hasn’t identified any clusters in a particular department, says Garb. But with the concern about avian influenza, Baystate plans to continue the system.

“It’s a tool that would probably be moderately sensitive in picking up something if it were out there,” he says.