By Gary Evans, Medical Writer
Over the years, employee health professionals have occasionally found themselves at odds with their colleagues in infection prevention on issues like mandated flu shots or the level of respiratory protection needed to protect a worker from an emerging infection. The different paradigms for occupational health and infection control were brought to the fore during the Ebola outbreak, but were probably most acutely contrasted during the controversy over infection control measures, or the lack thereof, used to protect healthcare workers during the SARS outbreak in Toronto in 2003.1
Generally speaking, the disciplines have different, though certainly not mutually exclusive, prime directives. One is bound to the protection of the healthcare worker; the other committed to the safety of the patient. With the next emerging infection threatening to bring both fields to another crisis point, it makes sense that establishing a routine day-to-day rapport and collaboration could better protect both workers and patients in an emergency.
In that regard, an upcoming CDC guideline will emphasize the importance of collaboration between the two departments. The first section of the draft “Infection Prevention in Healthcare Personnel” is expected to be released for review in the next few months. (For more information, see related story in this issue.)
“In some centers, they are paired where infection prevention and occupational health are managed by the same people,” says David Kuhar, MD, medical officer in the CDC’s Division of Healthcare Quality Promotion, who is spearheading the development of the guidelines. “When there are outbreaks, for example, that could involve a healthcare provider. Communication between infection preventionists, who may be involved in detecting it and managing it, with the occupational health providers who are going to do the personnel management portion [is important]. So, yes, we absolutely talk about it in the guideline.”
By way of a real-world example, meet two colleagues who work out of the same office, one with the welcoming Zen vibe of a Himalayan salt lamp, plants, and an aromatic oil diffuser.
“We try to make sure that the office is a welcoming space for our staff,” said Theresa Schrantz, LPN, CIC, employee health coordinator at Brooks Memorial Hospital in Dunkirk, NY. “Sometimes they come in and they just want to talk, take a breather or a mental health break. We are in the same room and we work as a team. It shows the staff that we are trying to always look out for them and to send them home safe to their families as well. How do we do that? Well, caring and sharing.”
Schrantz and colleague Lisa Maslak, BSN, RN, CIC, director of infection control at the hospital, profiled their collaborative program recently in Portland at the annual meeting of the Association for Professionals in Infection Control and Epidemiology (APIC).
“Great teamwork comes from equality and mutual respect, not sameness,” Maslak said.
With a shared office space, there is some inevitable cross-coverage. “I will tell you when she is not in there, everybody comes in for their PPD,” Maslak joked.
Schrantz countered that the last time her colleague took a vacation, The Joint Commission showed up.
Like many professionals in both fields, Maslak once held both jobs and the two proverbial hats that go with them. For those in that situation, she recommends knowing “what absolutely has to be done” on a given day.
“You need to organize and prioritize,” she said. “That’s the main thing. Have a routine. Make files, spreadsheets, let the calendar be your friend. Keep track of what your due dates are. On a daily basis, what has to be done for the patients and the staff to be safe? Because obviously, that’s your No. 1 priority. Everything else can wait.”
An opportunity arose with the merger with another facility, and Maslak decided, “I’m either going to jump off a cliff or I’m going to change what I’m doing.” Her request to focus exclusively on infection control and hire someone to lead employee health was granted.
“Fortunately, I had worked with Theresa at an ophthalmology office and I knew her work ethic,” she says. “I was able to recruit her to do employee health at my main facility and we figured out how we were going to go from there to make the whole department work together.”
Schrantz was given some leeway to define her new job as a complement to Maslak’s infection control efforts.
“Because this was basically a new position, I was able to work toward making it my own,” Schrantz said. “I had to do a lot of research to figure out what really needed to be done. I reviewed our state rules for employee health and best practices.”
In addition to compliance with state regulations, she reviewed the OSHA requirements and the expectations of accrediting agencies.
“Look at what you are doing, what should you be doing, and who are the people who you can go to for help with that,” Schrantz says. “Our peers have a wealth of knowledge. Look for those people that can help, and don’t be afraid to reach out.”
In terms of daily duties, Schrantz said she routinely checks with nursing stations and other staff reporting sources to find out who has called in sick. The follow-up on these reports sometimes blurs the line between personal health issues and injuries and illness related to the job, she says.
“When we have a call-in, I ask, ‘What are the signs and symptoms?’” Schrantz says. “Sometimes our staff doesn’t seem to think that they need to tell us what is wrong. OK, that’s fair, but if you have something contagious, we need to know. I don’t care — well, I do care — but it’s not necessary for me to know if you need a mental health day. What I need to know is if what you have could be something that is [related to] other staff members or our patients. That’s what I need to know, and if Lisa finds something on the patient end of things that could be affecting our employees, she will let me know.”
The two colleagues also must enforce a New York state law that healthcare workers declining flu vaccination must wear masks for patient care.
“I not only have to keep track of that for recording purposes, but also to stop people in the hall and say, ‘Where is your mask?’” Schrantz says. “I hunt people down — track them for their annual health assessments, their PPDs, their exposure follow-ups, follow-up hep B doses, fit testing, safe patient handling, in-services. That takes quite a bit of time on my part.”
Of course, staff education is necessary on the various employee health and infection control issues, including the correct use of personal protective equipment for isolation precautions.
“I am observing staff not using appropriate PPE — that’s frustrating,” Schrantz says. “We talk to the staff in a hospitalwide orientation about PPE. If [a patient] has scabies, everybody is putting on things from top to bottom. They don’t care about MRSA or VRE, so we ask them, ‘What are you taking home to your family?’ You have to hit them where it hurts — that is something you learn after doing this a few years.”
By the same token, healthcare workers are told to remind families and visitors about the importance of wearing PPE when in the room of an infectious patient.
“We talk to the new nurses in orientation about how to talk to the patients and their families about wearing PPE. We tell them why it is important to wear the PPE,” she says. “The [family] may say, ‘I live with this person at home. I am already exposed,’ but we say while you are here in the hospital there are a lot of other sick people who are here. There are people taking care of other sick people. Every day is an education process.”
Schrantz compiles health records of new employees, something Maslak may turn to as a resource if the situation warrants.
“When patients come down with things that could be related to employees, I need to know what employees were vaccinated — especially in an exposure situation,” Maslak says. “It is important that I work with her to find out what employees are immune to what we are looking at. There are policies that affect both patients and staff. If infection control writes a policy that involves employees, employee health should know about that. And vice versa — if employee health has any [new policy] that has to do with patients, then we need to know that as well.”
There have been several incidents where cooperation and teamwork became paramount, including the time a patient not in isolation was later determined to have TB.
“You can imagine we have an influx of calls and people coming to our office that needed to have further testing,” Maslak said. “Eighty-one staff members — which, for us, is a lot — had to follow up with PPDs and we had to get them retested again at 12 weeks. People get pretty frantic when they think they’re exposed to something like that.”
Schrantz adds, “It was a process, but we worked together. We were able to go through records together to figure out who we needed to find. That was a large project for us.”
Another exposure incident that tasked the team involved pertussis, as an undiagnosed case exposed healthcare workers and revealed a larger problem of a lack of Tdap immunization in staff.
“In our area we have a large Amish population, and most of them are not vaccinated,” Maslak said. “When they come into our ED and there is a pertussis exposure, the staff all want prophylaxis, and we were trying to determine what was your exposure and do you really need prophylaxis? We found with this particular pertussis exposure that not only was our patient not vaccinated, but most of our staff wasn’t — so Theresa got right on that.”
Indeed, uptake of Tdap vaccine is poor at many facilities, with a recent CDC report estimating only about a 42% immunization rate in healthcare workers. (For more information, see related story in this issue.)
“I went to the powers that be and said, ‘We really need to do something about getting our staff vaccinated with Tdap,’” Schrantz said. “Now, we are able to vaccinate with Tdap free of charge to our staff. Even though they all may or may not have needed to receive prophylaxis, they did think, ‘Maybe I ought to get that Tdap vaccination.’ That ‘free’ word is good, too. Unfortunately, we had an exposure, and that’s not a good thing. But the good thing that came out it was that everybody got vaccinated.”
Connect With Colleagues
For those in facilities that have separate and largely autonomous employee health and infection control departments, Maslak emphasized having a clear process for delineating the various job and tasks and striving for optimal communication.
“Infection control and employee health are puzzle pieces that fit together,” she said. “It may take time to find those pieces, so keep working at it. Communication is key. Listening and respecting each other’s roles are imperative to a successful relationship.”
Joining the discussion, a member of the APIC audience said it is critical to at least determine a worker exposure reporting policy if you are in a facility where employee health and infection control operate separately.
“I’m in a facility where infection prevention is not in the same department — it is not even located close to employee health,” said Tiffany Horsley, BSN, RN, CIC, an infection preventionist at the University of Kansas Hospital in Lenexa. “Because of my experience with employee heath, I’m now the liaison. One of the things that we have worked on is a process for who gets notified when an employee has an exposure. Sometimes it’s them, sometimes it’s us, and sometimes it goes into an incident reporting system. It’s important to keep communications open. It’s more challenging. It’s so important — no matter what the situation is — the way we communicate with each other.”
Indeed, it is not a given that such partnerships or collaborations are the norm.
“If you are an IP, do you even know who your employee health nurse is?” Maslak asked the APIC audience. If not, you may soon realize that you have a blind spot in your program planning, she emphasized.
“What is your infection control plan for the year and does it involve employee health and the staff?” she said. “If I want to have higher flu vaccination rates, then employee health needs to know that. If there is an exposure to shingles, do I know who has been vaccinated for chickenpox? Theresa is a great resource because she knows how to get that information quickly.”
- Silversides, A. Post-SARS: More protection needed for health care workers. CMAJ 2007;176;4:434-435.