By Gary Evans, Medical Writer
In draft guidelines1 expected to be finalized later this year, the CDC will better define and empower occupational health programs in hospitals and outpatient settings for the first time in 20 years.
The new guidelines are focused on protecting healthcare workers from infectious diseases and outline leadership responsibilities and resource-support issues that should raise the profile of employee health programs generally.
“These CDC guidelines recognize the importance of protecting healthcare workers from infectious diseases,” says Linda Good, PhD, RN, manager of occupational health services for Scripps Health in La Jolla, CA. “Occupational health personnel are the ones who provide hands-on care to the caregivers. These updated guidelines highlight the variety of diseases requiring our vigilance.”
As the next step in a long process of reviewing and updating its 1998 guidelines2 on healthcare workers, the CDC recently published a draft on occupational health program infrastructure. The update is being performed in sections, and the comment period on the program infrastructure guidelines was slated to close on Dec. 14, 2018.
“Transmission of diseases between personnel and patients is a two-way road that requires safety measures for both,” says David Kuhar, MD, of the CDC’s Division of Healthcare Quality Promotion. Kuhar has been the CDC point-person on the guidelines, which are under development by the agency’s Healthcare Infection Control Practices Advisory Committee (HICPAC).
The massive shift in the delivery of care over the last two decades requires an emphasis at the outset that employee health programs are critical across the continuum.
In addition, two new elements in the CDC infrastructure guidelines are “leadership and management” and “assessment of reductions of risk for infection” among healthcare workers, he explains.
The 1998 guidelines were aimed primarily at the leadership of occupational health programs, but the new draft also reaches out to hospital administration.
“We have recommendations that are aimed at senior leaders and management that [emphasize] providing administrative support as well as resource allocation,” Kuhar says. “These services can’t be provided unless they are appropriately funded.”
The CDC draft guidelines recommend that healthcare organization leaders:
- invest in a work culture that prioritizes safety and prevention of occupational infections;
- regularly review occupational infectious risks, exposures, and illnesses with occupational health services;
- dedicate one or more staff with appropriate authority and training to lead occupational infection prevention;
- provide sufficient resources, including expertise, funding, staff, supplies, and information technology.
For their part, employee health program leaders should develop both routine and emergency response policies, be accountable for the program, emphasize continuous quality improvement, and seek collaboration with other departments.
The CDC cites many benefits of establishing a high-functioning occupational health service, including cost savings, reduced risk to workers and patients, and less tangible gains like improved morale and work culture. Employee health can use existing regulatory and accreditation requirements to assess risk and serve as performance measures for improving quality. (See related story in this issue.)
“For example, The Joint Commission has requirements to establish annual influenza vaccination programs for HCP [healthcare professionals] and to set goals for improving influenza vaccination rates, and the Centers for Medicare & Medicaid Services [has] requirements that hospitals identify and track selected communicable diseases among HCP,” the CDC guidelines state.
Other examples of performance measures that could be used to assess program effectiveness include the number of healthcare workers who sustain needlesticks or other potentially infectious exposures. A corollary to that measure could be the proportion of these workers appropriately given post-exposure prophylaxis if indicated.
Additional performance measures cited in the CDC guidelines include the proportion of workers who complete serial screening for latent TB, or the percentage of workers using N-95 respirators who were fit-tested.
The use of risk assessments and performance measures is not necessarily new but is emphasized in the guidelines in part to ensure occupational health beyond the hospital, Kuhar says.
“We wanted to call this out for those that are offsite as well,” he says. “They should be involved in workplace safety. Their opinions and perspectives matter.”
The performance measures in the guidelines are cited by way of example; facilities can use the metrics of their choice, he says.
“They are examples only because there is a lot of diversity in how these programs are delivered,” he says. “But these are some tangible ideas of measures they could use to track how well their program is doing.”
One area where performance is lacking across healthcare is “presenteeism.”
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 emphasizes.
The CDC draft calls for sick leave policies that encourage reporting of illness and discourage working while sick. 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 staff 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 at many healthcare facilities, Kuhar says.
“Presenteeism is a problem,” he says. “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 ingrained culture in facilities where healthcare workers often work because, for example, they do not have paid sick leave.
“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 and occupational health personnel 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.”
Policies and Pathogens
One challenge in creating the guidelines has been to address the multiple infectious threats workers face, avoiding overkill without sacrificing the necessary protections for a broad range of pathogens, Kuhar says. There are likely to be continuing points of contention and clarification on achieving this balance.
For example, a comment on the CDC draft guidelines submitted to the docket by Kevin T. Kavanagh, MD, MS, of Health Watch USA, said the document does not sufficiently address the risk of healthcare workers becoming carriers of MRSA and other drug-resistant pathogens.
“Some of the resistant organisms such as MRSA have become endemic, and different methodologies for prevention of spread need to be instituted, such as routine periodic screening for carriers,” Kavanagh noted in the comments.
To clarify, the CDC has not yet published the guideline section on specific pathogens with important implications for occupational health. That portion was expected to follow the recently published infrastructure section, and a draft likely will be issued later this year.
The pathogen section of the update should better speak to MRSA concerns, as HICPAC discussions included colonization and screening issues for healthcare personnel and patients. Other multidrug-resistant bacteria will be addressed in that section, as well as bloodborne pathogens, tuberculosis, and a broad array of respiratory viruses.
In general, the guidelines will be geared toward routine infectious disease threats to workers, not emerging pathogens like Middle East Respiratory Syndrome (MERS) and Ebola, Kuhar explains.
Those outbreak situations are characterized by a lot of unknowns and can raise issues that could put worker and patient safety at apparent odds. This was seen to some extent with the mask-respirator debate during the 2003 SARS outbreak, as well as the many personal protective equipment issues during the 2014 Ebola outbreak. Both outbreaks resulted in infected healthcare workers. These emerging infection situations are an “additional challenge to the relationship” between employee health, infection preventionists, and other clinical colleagues, Kuhar notes.
“Sometimes, modes of transmission aren’t well established for these pathogens of high consequence,” he says.
Thus, a healthcare system might elect to handle exposures differently to facilitate access to occupational health services, he adds.
“Services and procedures different from the norm very well may be needed for those pathogens, so that’s where the boundary is drawn on this document,” Kuhar says.
Noninfectious adverse occupational events also are beyond the scope of the document, with the CDC deferring to the National Institute for Occupational Safety and Health to provide guidance on issues such as workplace violence, patient handling injuries, and slips, trips, and falls, he says.
In a related development, the Association of Occupational Health Professionals in Healthcare (AOHP) recently released a position statement on the critical role their members play. (For more information, visit: www.aohp.org.) According to the AOHP, these duties include:
- evaluating individuals prior to and throughout employment;
- providing vaccinations, fitness for duty evaluations, and injury management and reporting;
- understanding evolving national and state regulatory standards and guidelines;
- overseeing respirator fit-testing, and safe patient handling and workplace violence prevention programs;
- management of bloodborne pathogen and ergonomics practices.
“I know members of AOHP well, and our guidelines should align with them — that is the expectation,” Kuhar says.
- CDC HICPAC. Infection Control in Healthcare Personnel: Infrastructure and Routine Practices for Occupational Infection Prevention Services. Oct. 15, 2018. Available at: https://bit.ly/2JsbUPF.
- CDC HICPAC. Guideline for infection control in health care personnel, 1998.