Healthcare facilities should have specific criteria clarifying when infected healthcare workers should stay home, as gray areas and disincentives currently result in exposures to patients and colleagues, the CDC reports.
CDC draft guidelines1 for healthcare worker infection prevention call for sick leave policies that encourage reporting of illness and discourage presenteeism. To do this, the CDC recommends that workers have access to clinicians with expertise in exposure and illness management 24/7 to ensure prompt testing and treatment.
Policies for exposed or ill healthcare workers should specify both how work restrictions are imposed and under what conditions personnel can return to duty.
“Specify methods of communication between occupational health services, healthcare personnel, and others (e.g., human resources, managers) about work restrictions,” the CDC guidelines recommend.
Reporting for work ill has been a “longstanding culture” for many healthcare facilities, says David Kuhar, MD, of the CDC’s Division of Healthcare Quality Promotion.
“Presenteeism is a problem. Coming to work ill risks transmitting an infection to not only patients, but co-workers. Then, they can also transmit it to their patients and others that they interact with.”
However, CDC recommendations can only go so far to change an engrained culture in facilities where healthcare workers often work because, for example, they do not have paid sick leave, he says.
“That can actually encourage people to come to work when ill,” Kuhar says. “There are many things that discourage people from staying home that go far beyond the scope that can be addressed in this guideline.”
The CDC hopes to get a message through to healthcare leaders, occupational health personnel, and infection preventionists that specific policies are needed to reduce presenteeism.
“It is really helpful for every healthcare provider to know, for example, if they have a temperature above a certain threshold or a fever, they shouldn’t be showing up at work,” he says. “Preferably, they would have paid sick leave so they can stay at home and not bring in a potential infectious disease.”
The CDC concedes that developing policies that discourage presenteeism can be challenging, as different categories of workers may have different criteria for missing work.
“Clearly defining the criteria for work restrictions is a key piece for people understanding when they can and when they shouldn’t be coming to work,” Kuhar says. “The point is if an infection is suspected, you want to make sure that people are not bringing it into a healthcare facility.”
The Rest of the Iceberg
How chronic is this problem? A recent study presented at IDWeek 2018 in San Francisco described a level of presenteeism that is likely underappreciated and occurring nationally. The disturbing details were provided by Hilary Babcock, MD, an epidemiologist and medical director of occupational health at Barnes-Jewish and St. Louis Children’s Hospital.
For example, the CDC recommends that healthcare workers with influenza-like illness (ILI) stay home until afebrile for 24 hours, Babcock noted. “But we know that in practice, this doesn’t always happen,” she stated.
Babcock 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 they had 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, 7% of 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 type of arrangements as well as paid sick days and other factors varied by department, union status, and by 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.”
A Broken System?
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 can discourage 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 a third based it on work location or complication risks,” Babcock said.
However, many work places did not provide antiviral prophylaxis to workers who were nonoccupationally 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’ comp 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, and in years with good efficacy, they might limit that a little bit more.”
With the wide variation and limited effectiveness of healthcare policies to prevent presenteeism in sick healthcare workers, an IDWeek audience member questioned whether working sick has become the “secret” new normal.
“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 Michael A. Gelman, MD, PhD, medical director of infection control at the James J. Peters VA 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.”
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.”
Indeed, the various loopholes and disincentives described by Babcock made it clear that sick healthcare workers are routinely reporting for duty.
“Frankly, this is affecting patients and patient care in ways that we don’t even fully understand,” Gelman said.
- CDC. HICPAC: Infection Control in Healthcare Personnel: Infrastructure and Routine Practices for Occupational Infection Prevention and Control Services (Draft Guideline). Oct. 15, 2018. Available at: https://bit.ly/2JsbUPF.