The CDC’s draft guidelines for protecting healthcare workers from occupational infections “may inadvertently reinforce siloing of safety issues, which is increasingly recognized as contradictory to promoting a safety culture,” The Joint Commission (TJC) warned in comments on the document.

“The document could be strengthened, however, by greater emphasis on collaboration with infection prevention and control (IPC) staff and the interrelationship between worker safety and patient safety,” according to TJC comments. “To strengthen the guideline, CDC might consider adding a new section devoted to the intersection of worker safety and patient safety.”

The section could include infectious diseases and sharps injuries, as well as exposure reporting systems and example tools for communication, risk assessment, and incident analysis, the commission recommended.

While generally praising the effort to update guidelines that are two decades old, public comments on the CDC draft1 range from recommendations for such broad additions to changes in terms and nomenclature. Other sections will be added to the CDC guidelines, including one on specific pathogens that pose occupational threats to workers. That section is expected to be published for comment this year.

The infrastructure draft acknowledges the massive shift in the delivery of care, emphasizing that occupational health must be extended across the continuum. The draft also includes a leadership and management section that emphasizes that employee health programs must receive adequate support and resources. It calls for periodic assessment of infection risks to workers and whether interventions are working.

“[We] suggest that you add a section for frontline staff,” TJC comments stated. “Communication and collaboration with frontline healthcare workers, including medical staff and other licensed independent practitioners, are critical for effective interventions.”

The accreditation group also recommended that consideration be given throughout the guideline to add “assessments of competence” in addition to training and education. “It is well known that training does not always result in proper implementation,” TJC stated.

“Exposures will continue to happen unless expectations related to engineering controls and use of PPE [personal protective equipment] are standardized,” TJC warned. “It is imperative that healthcare workers follow the same practices to prevent exposure as they move through the continuum of care.”

The CDC also should consider including process measures in addition to outcome measures as examples in the document, the commission added.

“Given the known problems with underreporting, it would be worthwhile to include an example measure related to needlestick injuries,” TJC noted. “Organizations should be encouraged to submit standardized data to reporting systems to receive comparative reports and track trends over time.”

There should be an expectation that leaders purchase and stock adequate supplies of PPE, particularly face and eye protection to address a common area of exposure.

“For example, EPINet data on splash exposures indicates that, in 2017, approximately 62% of exposures involved a splash to the eyes, nose, or mouth, but exposed [healthcare personnel] reported wearing face protection during less than 12% of exposures,” TJC commented.

EPINet Comment

Also making that point was a principal involved in the cited exposure data, Amber Hogan Mitchell, DrPH, MPH, CPH, executive director of the International Safety Center for healthcare workers. A former Occupational Safety and Health Administration (OSHA) official, Mitchell oversees the center’s EPINet surveillance, which has been gathering data on potentially infectious exposures to healthcare workers for many years.

“These updates are long overdue, and the care and effort that went into updating the guidance is a notable undertaking,” she said in public comments to the CDC.

Safer healthcare workers have a direct impact on their ability to provide and maintain safer patient care, she noted.

“While the document is quite comprehensive, there are elements that are missing and others that need clarification and additional points of accuracy,” Mitchell stated in the comments.

For clarity, she recommended, the CDC should include the term “‘occupational infection and illness’ where appropriate and as frequently as possible together throughout the entire document.” She added that “‘infection’ is often associated more with healthcare-associated infection, and ‘illness’ is consistent with OSHA terminology.”

Mitchell also suggested that a greater distinction be drawn between occupational duties such as safety and respirator fit testing, compared to employee health functions like post-exposure prophylaxis and vaccinations. The CDC should drop the use of the term “safety-engineered sharps devices” in favor of the more widely used term “sharps with injury protection (SIP),” she advised. Developed by expert stakeholders, SIP “defines devices with integral features to prevent percutaneous injuries that may cause exposure to blood, body fluids, or other potentially infectious materials,” Mitchell commented.

In other comments, the American Public Health Association (APHA) reiterated the point about drawing a more discernible line between occupational health/safety and employee health. The public health group also recommended including a section on environmental controls to prevent occupational infection.

“We recommend that the guidelines include information such as high efficiency particulate air (HEPA) filtration, other ventilation, UV systems, and anterooms,” the APHA commented.

The labor union group AFL-CIO emphasized that the guidelines should protect all healthcare workers, not just those typically involved in clinical care. This includes “workers who clean and maintain facilities, such as cleaners, waste haulers, and other sanitation and maintenance workers. All of these workers and their associated exposures should be included in any exposure control model that aims to reduce occupational infection and illness.”

Another commenter raised the issue that because some physicians are not legally considered hospital employees, there could be confusion about whether they are expected to comply with the recommendations.

“It is important and pertinent to explicitly state that providers and physicians must be involved in all healthcare personnel occupational health and infection prevention activities,” said Julie Babyar, RN, MPH. “Providers and physicians must be required to submit and follow all vaccination, immunization, TB, and exposure documentation,” she said.

In a point relevant to expanding occupational infection prevention beyond hospitals, she said safe injections must be treated like clinical practices. “The practice of providing injections continues to be performed in many sites as part of an office day, often with HCP walk-ins at random, [and without] clinic rooms.”

The comment period on the CDC draft guidelines closed Dec. 14, 2018.

REFERENCE

  1. CDC. Healthcare Infection Control Practices Advisory Committee. Infection Control in Healthcare Personnel: Infrastructure and Routine Practices for Occupational Infection Prevention Services. Oct. 15, 2018. Available at: https://bit.ly/2JsbUPF.