With the wide variation and limited effectiveness of healthcare policies to prevent presenteeism in sick healthcare workers, has the situation devolved to unspoken policies of “don’t mask, don’t tell?”

Michael A. Gelman, MD, PhD, turned the phrase recently in San Francisco at the IDWeek 2018 meeting after a presentation on the complex and continuing problem of presenteeism.

“It really speaks to the difficulty of getting hard data in a situation where you’re looking at a behavior that is fundamentally a secret,” said Gelman, medical director of infection control at the James J. Peters Veterans Affairs Medical Center in Bronx, NY. “It’s ‘don’t mask, don’t tell.’ We need to have a mechanism for collecting data in a standardized way. We need to work with our colleagues in occupational health with support from our C-suites.”

Gelman commented during the question-and-answer session after an IDWeek presentation on the issue by Hilary Babcock, MD, medical director of occupational health at Barnes-Jewish and St. Louis Children’s Hospital.

Babcock concurred with the assessment, saying “I think the lack of data is one of the barriers to moving this forward, and it is very difficult to track. There are a lot of competing demands that I think create challenges in that area.”

Babcock described numerous barriers to healthcare workers staying home when sick with the flu or influenza-like illness (ILI). The various loopholes and disincentives described made it clear that many healthcare workers are reporting for duty instead of sick bay, putting patients and co-workers at risk.

“Frankly, this is affecting patients and patient care in ways that we don’t even fully understand,” Gelman said.

Policies on Paper Only

The CDC recommends that healthcare workers with ILI not work until afebrile for 24 hours, Babcock noted. “But we know that in practice, this doesn’t always happen.”

She assessed hospital policies and practices on presenteeism in a national survey, netting 232 responses.

“Most institutions have work restriction policies regarding ill healthcare workers, but there is a lot of variability in terms of policy communication, adherence, monitoring, and enforcement,” she said.

There was significant variability in the availability of flu testing, treatment, and antiviral prophylaxis, she added.

“Tracking of healthcare worker illness, presenteeism, and sick time taken is not standardized and really presents significant challenges,” Babcock said. “It makes it more difficult to track adherence to existing policies and [assess the] potential impact of policy changes on presenteeism of healthcare workers.”

Overall, 89% of respondents reported an existing work restrictions policy for flu or ILI.

“Only about 63% reported that this policy was communicated to staff on a regular basis, at least annually,” Babcock said. “About half reported that adherence to the policy was not monitored.”

Relaying a comment that summed up the sentiment of many, survey respondents said essentially, “We have a policy but it is mostly ignored. Healthcare personnel work with ILI all the time,” she said.

Return-to-work policies were sporadically enforced at many hospitals. “The lack of enforcement varied by job title so that the ‘not-enforced’ category was highest for attending physicians,” she said.

Overall, 79 of 169 respondents who answered this question listed fever as exclusion criteria, with most requiring the afebrile period of 24 hours. However, 12 of 169 respondents specified a set number of days excluded from work — usually five to seven days. In addition, 7% required occupational health clearance to return to work. Additional criteria at a few hospitals included wearing a mask, particularly around high-risk patients.

Overall, 44% of respondents reported they had a single pool of paid days off that they used for both vacation and illness.

“Multiple comments suggested that this model of a shared pool of days off really decreases compliance with work restriction policies,” Babcock said. “People taking a sick day have actually deprived themselves of a vacation day later in the year.”

These types of arrangements as well as paid sick days and other factors varied by department, union status, and groups of workers.

“Policies in general were less likely to apply to physicians, residents, and students,” she said. “It was noted that many private practitioners and attending physicians really don’t have any sort of coverage scheme or [sick leave] arrangement, especially with busy clinics and surgical schedules. No one wants to cancel patients.”

Essential Presenteeism?

One of the most telling findings of the survey was that many respondents said their healthcare facility needed sick workers on the job to keep the system running.

“People noted that without presenteeism, there would be a critical shortage of providers,” she said. “They said, ‘The system is not set up to actually have these people off when they are sick. We don’t have enough providers to cover for that.’”

In addition, counterproductive policies like tying year-end bonuses to attendance certainly discouraged people from calling in sick.

“There are ongoing barriers to ill healthcare workers staying home, including financial impact, loss of vacation days, and the sense of responsibility to patients and colleagues,” she said. “Some people feel irreplaceable.”

About half of those surveyed said their facility offered influenza testing and treatment for any employee. Another 20% offered testing only after occupational exposures. About one-third offered treatment after an occupational exposure.

“After an occupational exposure, the majority of places offered antiviral prophylaxis, but about one-third based it on work location or complication risks,” Babcock said.

However, many work places did not provide antiviral prophylaxis to workers who were non-occupationally exposed, including those, for example, who had a family member sick with flu.

“Commenters noted that occupational health was not really resourced to serve as urgent care during influenza season, and that led to a lot of practice variation,” she said.

The facilities’ workers’ compensation policies may affect occupational health’s willingness to provide care vs. refer out for treatment, she said.

“Policies for prophylaxis might be informed by the vaccine efficacy for that year,” Babcock said. “So if there is lower vaccine efficacy, they may be more liberal with PEP [post-exposure prophylaxis], and in years with good efficacy they might limit that a little bit more.”