Employee health professionals can expect more proactive, informative guidance in the areas of risk assessment and medical evaluations in the upcoming CDC update and revision of its Guideline for Infection Control in Healthcare Personnel.

Originally published in 1998, the guideline must now address not only new infectious threats, but sweeping regulatory changes, says David Kuhar, MD, a medical officer in the division of healthcare quality promotion at the CDC.

“When we started looking at updating the [1998] guideline, one of the things that came up from the user community is that the section that addressed the infrastructure of the occupational health service for providing infection control to healthcare personnel was not the most useful section of the [old] guideline,” he tells Hospital Employee Health. “So we tackled that section, looking at not only what has changed since 1998, but how can we make this more useful for readers. That is how we approached it. We needed more detail to resonate with occupational health providers.”

Among the issues addressed in a draft of the guidelines is the employee health role in the assessment and reduction of infection risks to healthcare workers. A draft version recently discussed at a meeting of the CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC) calls for administrators and leaders of healthcare organizations to regularly review results of risk assessments related to occupational infection prevention, set performance goals, and reduce risks.

Employee health leaders and staff would conduct the risk assessments or collaborate with colleagues to identify and reduce occupational infectious threats to workers. As recommended in the CDC draft, they would also participate in committees and decision-making processes that affect occupational infection prevention efforts. Employee health would advise colleagues and administrators on risk reduction strategies and other occupational infection prevention issues.

A section on conducting medical evaluations of healthcare workers has also been expanded and is more prescriptive in terms of recommendations. For example, the draft guidelines emphasize the importance of “pre-placement” medical evaluations be done after a worker is hired, but before they are assigned to a specific duty or area in the hospital. These exams would include looking for any immunity problems, pregnancy, or other conditions in the worker, as well as the risk of infections associated with their designated duties.

These exams would be followed by periodic and “episodic” medical evaluations, with the latter most likely occurring in the context of an exposure or outbreak. Of course, immunization status for various conditions would be assessed as part of ensuring all recommended vaccinations are given. In addition to serologic testing for evidence of immunity, (e.g. immune response to hepatitis B vaccine) and periodic tuberculosis screening, employee health professionals would provide or refer workers for medical clearance for respirator fit testing. With the first sections of the draft expected to open for review and comment in the coming months, Kuhar spoke to HEH about the ongoing revision process.

HEH: This guideline seems to be advocating a much more proactive role for employee health in terms of risk assessment, communication with leaders, and participation on committees. Is this suggesting a more formalized role than has traditionally been apparent in employee health programs?

Kuhar: Since 1998 quite a lot has changed, and among those changes were a number of new regulations that affected occupational health services to personnel. There were new OSHA standards, like the respiratory protection standard, that require training as well as education for workers who have to use respirators as part of their work duties. The other issue is there are a lot of requirements from accreditation and federal agencies, like CMS [requiring] reporting of healthcare influenza immunization rates [of HCWs]. As occupational health programs are [performing these functions], we wanted to indicate that they provide services that, in a way, are irrevocably tied to these [and other] markers of quality of care.

When we went to update this, we had to consider what are the things that people are expecting occupational health services to do? What is reasonable to ask that all occ health providers across the nation be prepared to at least be involved in? We wanted to put those forward, so we added two new elements, if you will, to an occ health service that we thought were important. One of those is assessment and reduction of risk among populations of healthcare personnel. So for that section, we wanted to put forward that assessing risk in the workplace is something that occupational health providers are often asked to be a part of. Not always to lead, but to be a part of. That’s why we were careful in the way we recommended it — to make sure we were not placing the burden solely upon their shoulders, but we wanted to indicate this is something that occ health providers need to be a part of because they can provide valuable input.

HEH: If I understand you right, you are making this guideline more proactive and detailed for employee health professionals, but you don’t want it to be too onerous for those that don’t have the resources.

Kuhar: You’re basically right. The real challenge in this is the diversity in how occupational health services are provided out there. Larger healthcare organizations might have an onsite group that provides this for the organization, but small freestanding facilities may contract their services from a provider that is not part of their organization. The diversity in these services means that not all occupational health providers have access to the facility and [employee] data. We wanted to be careful to not inappropriately place ownership of, for example, walking through a workplace to assess it for safety, when they may be a contracted offsite health service.

However, they could be asked to do it, so we wanted to be sure that we framed the recommendations in a way that was sensitive to those that might not have the access to provide those services. So we made them generally applicable to raise people’s awareness that these issues are important — to raise their awareness to the things that are being asked for by payers, purchasers, and accreditation agencies. Hopefully [this will] facilitate their ability to provide these services.

HEH: Are you going to get into the ongoing issue reported in some studies about the lack of compliance with respirator guidelines, meaning in some cases they are no more effective against respiratory infections than surgical masks?

Kuhar: I would say that is probably an issue for a different guideline — more related to the effectiveness of infection control measures. What we wanted to do here is highlight the role that occupational health services might play in facilitating readiness to use a respirator. You use your pre-placement medical evaluations to assess a provider’s ability to use a respirator in compliance with OSHA requirements. If your staff needs to use a respirator, then those assessments need to be repeated [annually or periodically]. This guideline is really focused on what items occupational health service providers are going to do [to ensure] personnel are ready to use a respirator. Typically, occupational health services will do the medical clearance for respirator fit testing, and then depending on the structure of the program, some people have separate fit testers and some occ health services might do the fit testing. It depends on how their program is set up.

HEH: Medical evaluations in this draft guideline also seem to have more specificity and detail than the 1998 CDC guidelines. Are there new issues and conditions you now have to think of including in the medical evaluations?

Kuhar: Right, we are proposing a more extensive medical evaluation section. However, I would say that what you might do in a medical evaluation has not changed drastically since 1998. There are more requirements that affect how we do a medical evaluation, and we added more detail on the type of medical evaluations that occupational health service might provide.

We highlighted the importance of the pre-placement evaluation. This is after the person is hired but before they actually start their job duties. They have a medical evaluation to address their risks of acquiring or transmitting infections at work as well as to address their evidence of immunity and possible need for immunizations before they set foot on the wards. We also wanted to highlight the need for periodic evaluations, there might be planned repeated visits to the occupational health clinic, as well as the episodic ones — say, when an exposure has happened. We wanted to offer much more specific guidance as to the types of medical evaluations that occupational health services typically provide.