The CDC is updating its Guideline for Infection Control in Healthcare Personnel, which was originally published in 1998 before a series of emerging pathogens posed occupational threats via SARS, H1N1 pandemic flu, MERS, Ebola, and Zika.
While such emerging infectious diseases underscore the ever-changing threat to healthcare workers, the new employee health guidelines continue to focus more on the longstanding day-to-day threats and broaden the umbrella of protection beyond hospitals, explains David Kuhar, MD, a medical officer in the division of healthcare quality promotion at the CDC.
“Emerging pathogens provide more unique challenges,” he says. “Ebola, for example, provided a lot of challenges for healthcare workers. They were using equipment that isn’t typically used in hospitals [that] required specialized training and post-exposure management that is different from anything occupational healthcare services are used to providing. These emerging pathogens require unique considerations for healthcare worker safety and that’s why when they emerge, there are specific guidelines developed for, say, PPE for healthcare workers with Ebola or a separate infection control guideline for MERS-CoV.”
Of course some pathogens emerge and do not fade away, with HIV perhaps the most notorious example in the modern era.
“Some emerging pathogens are a temporary issue and some could become a permanent one, so depending on what happens over time if one becomes more common it tends to become part of routine guidance,” he says. “Until that happens, CDC tends to address them with uniquely developed guidelines.”
Though they will continue to be addressed in separate guidelines, the recurrence of new infectious threats stresses the importance of flexibility in employee health programs.
“The employee health function has to be agile enough that there is an ability to respond to whatever comes up,” says Ruth Carrico, PhD, RN, FSHEA, CIC, assistant professor of health promotion and behavioral sciences at the University of Louisville (KY). “We can’t just say, ‘This is our list of problems from an organism or a situation perspective.’ You’ve got to have a program that can recognize and respond to issues and can train and provide the care and follow-up that is necessary. I think this is an opportunity to really look at our programs and say what are doing well, what we are not doing well, and how do we need to change.”
As outlined at a March 31, 2016, meeting of the CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC), the new guidelines will include overall program elements and protect workers from a broad range of infectious agents. (See related story in this issue.)
The guidelines will address employee health challenges beyond the hospital, including outpatient settings, clinics, ambulatory surgery centers, home healthcare, non-acute care inpatient facilities, and long-term care. The plan is to address both on- and off-site occupational health services, including contracted services.
“The locations where care is delivered are changing rapidly,” says Carrico, a former HICPAC member who is serving as an advisor on the guidelines. “It’s very hard to say, ‘Here is an occupational health program that can be implemented any place.’ I think we need to take a step back and say what is the framework that will address the need in any setting where care is delivered? We are trying to make sure wherever care is delivered that we are recognizing the risks to healthcare workers and figuring out a process to minimize those risks.”
Ebola was a game-changer
The recommendations will be aimed at healthcare administrators who oversee occupational health services as well as the leaders and staff of the programs.
“I think a lot of it is refreshing the information that was in there previously, but also just as we have information about what constitutes an infection prevention and control program, there will be an effort to do something very similar with the employee health and occupational health program,” Carrico says. “This really is a program that is important if we are looking at protecting the healthcare workforce. Watching what happened with Ebola really brought that forward. We need to develop a greater and more organized appreciation for the occupational health function [in healthcare].”
Of course, employee health professionals deal with non-infectious challenges like back injuries and ergonomic issues, but the infection control aspect of the job has taken on a greater urgency in the aftermath of Ebola.
“There is a very strong infectious diseases component,” Carrico says. “We need to make sure that is very clear and that there is a methodology for investigating, monitoring, and follow-up of these kind of issues. In a patient care setting, the healthcare workers themselves can be involved in transmission. So it becomes a unique situation to try to look at transmission in both directions: to the healthcare worker and to the patient.”
In recent years, the patient safety movement has evolved to recognize healthcare workers as a critical part of an overall culture of safety, but employee health professionals are still stretched thin in terms of resources, says Amber Mitchell, DrPh, MPH, CPH, president and executive director of the International Safety Center (aka EPINet).
“Our healthcare workers and healthcare systems are asked to take on more with less,” she says. “More patients, less time. More public health and community outreach, less funds. More emerging infection risks, less ready access to proper protection. If we don’t collectively begin putting our healthcare workers [first] and making their environments safer, we won’t have workers well and prepared enough to care for us as patients.”
In that regard, the CDC should ensure the guidelines include a recommendation for full support and adequate resources for employee health services, Mitchell says.
“Adequate funding, resources, and staffing for employee health departments allows healthcare facilities to operate more safely and efficiently,” she says. “Perhaps CDC should consider an idea to summarize or reference facilities that have had great successes doing that. OSHA has some good case studies on high-performing hospitals in their guidance where focus on worker safety means a parallel increase in patient safety.”
Asked about the CDC guidelines recommending resources for employee health programs, Kuhar says, “Our intent is not to do so in great detail, but rather at a very high level. I think it’s pretty clear that without resources and staffing provided, you can’t provide the appropriate services. It’s obviously relevant, but we won’t address it in great detail [like], for example, you need this number of occupational health providers for this number of personnel.”
A ‘living document’
In addition to specific pathogens, many of which will be updated from the 1998 version, the new CDC guidelines will be a “living document” that will be updated electronically. In that regard, the plan is to post the sections of the new guidelines sequentially as they are completed and approved by HICPAC.
The first section will outline the baseline infrastructure and routine practices of occupational health service. The proposal is to include descriptive text plus hyperlinks to supplementary materials that can be updated over time (e.g., immunizations on hire for HCWs). The second section will focus on epidemiology and prevention of selected infections as well as protection of special healthcare worker populations (e.g., pregnant, immune compromised, and those temporarily working outside the U.S.).
“We are updating a small section at a time so that parts of it will come out in sequence,” Kuhar says. “So the first section, which I presented a HICPAC, we are planning to have the committee review some drafts in July. I think the changes that are required will really determine the timeline of when it gets posted online. Each time we finish a section we will take up another one and post them sequentially.”
Asked about the perception by Mitchell and others that protecting healthcare workers has become a more complicated enterprise, Kuhar reminds that many more worker protections are now in place than there were in 1998.
“There have been a lot of new regulations and guidelines put in place to protect healthcare workers as time has gone on and as we have begun to better recognize the threat that certain pathogens pose in healthcare,” he says. “One example is the [OSHA] bloodborne pathogen standard, which has been updated since 1998 with the Needlestick Prevention Act. There have been more requirements for employers to ensure protection.”
Speaking of OSHA, the agency has been mulling issuing an infectious disease standard for several years. Given the increasing collaboration between federal agencies in recent years on infectious diseases, any OSHA proposed rule would no doubt incorporate key aspects of the CDC occupational health guidelines currently being drafted.