By Gary Evans, Medical Writer

As the Centers for Disease Control and Prevention (CDC) continues to hammer out new guidelines to protect healthcare workers from infections, recent discussions hit a major sticking point: presenteeism.

The issue of healthcare personnel working sick — and the policies that incentivize them to do so — was the subject of much discussion at a recent meeting of the CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC).

The CDC draft guidelines1 that focus on protecting healthcare workers from infectious diseases outline leadership responsibilities, infrastructure, and resource support issues that will raise the profile of employee health programs. A second, as yet unpublished, section of the guidelines will discuss specific pathogens that threaten healthcare workers with occupational infections.

HICPAC is updating CDC guidelines on healthcare workers originally published in 1998.2 The draft addresses the issue of presenteeism, with the version discussed by the committee recommending “sick leave options that encourage reporting of potentially infectious exposures and illnesses and that discourage presenteeism.”

The CDC recommends that workers have ready access to clinicians with expertise in exposure and illness management 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.

“Implement processes and sick leave policies to encourage healthcare personnel to stay home when they develop signs or symptoms of acute infectious illness (e.g., fever, cough, diarrhea, vomiting, or draining skin lesions) to prevent spreading their infections to patients and other healthcare personnel,” the HICPAC draft guidelines state.

The committee also agreed to a revision that includes contract workers as well as regular employees in all sick leave policies. The draft further recommends ensuring there are no communication breaks between occupational health services, healthcare personnel, and others about return to work policies and restrictions.

Punitive Policies

This is no small challenge. Reporting for work ill has been a longstanding culture at many healthcare facilities, as several HICPAC members observed during the CDC discussion.

HICPAC liaison member Marion Kainer, MD, MPH, director of the Healthcare Associated Infections Antimicrobial Resistance Program at the Tennessee Department of Health, cited a recent outbreak in which a patient with hepatitis A transmitted the virus to another patient and six healthcare workers.

“As we investigated, we became aware of an extraordinary punitive policy that required healthcare personnel to take personal leave before sick leave would kick in,” she said. “Which means that every single one of those infected healthcare workers worked while they were symptomatic. I honestly have never been aware of such punitive sick leave policies.”

Asked to comment further on the situation by Hospital Employee Health, Kainer declined due to the ongoing investigation and an ensuing public health publication. “It just really shocked me how much this sick leave policy was encouraging presenteeism,” she said. “It was not in the interest of our workers or of patient safety.”

The new guidelines certainly discourage presenteeism, but HICPAC members were concerned that the matter needs more emphasis, possibly as an appendix or in a separate document.

HICPAC member Hilary Babcock, MD, MPH, medical director of occupational health at Barnes-Jewish and St. Louis (MO) Children’s Hospitals, led the discussion of the draft guidelines.

“We have had a lot of discussions in our [HICPAC work] group about this specific issue,” she said. “People are trying to research this to understand the interaction between sick leave policies, presenteeism, and transmission of disease.”

Babcock has performed some of this research herself, reporting last year at IDWeek in San Francisco that healthcare sick leave policies are often poorly communicated and haphazardly enforced. Overall, 44% of 232 respondents in a national survey reported they had a single pool of paid days off that they used for both vacation and illness, she reported. (For more information, see the December 2018 issue of HEH.)

“We also have that at our place,” Babcock told HICPAC members. “People have a single bank of time off, and both vacation and sick leave comes out of that. So, the same things ends up happening in practice.”

That said, HICPAC does not want to be overly prescriptive of healthcare sick leave policies, preferring to let facilities adopt and enforce their own strategies.

“We are not specifically saying how this should work because this [guideline] applies to a huge range of [facilities],” Babcock said. “I don’t think we could really be very specific, but we tried to push forward these kinds of policies.”

Concurring was HICPAC liaison member Mark Russi, MD, MPH, professor of medicine and epidemiology at Yale University in New Haven, CT.

“I think rather than making arguments to local administration, it is more powerful to say that there is an overarching statement from CDC which says that the policy should discourage presenteeism and be nonpunitive,” he said.

Others noted in the discussion that presenteeism is essentially a human resources issue, saying that HR should be involved rather than putting the onus on occupational health to enforce such policies.

HICPAC liaison member Paul Conway, of the American Association of Kidney Patients in Tampa, said patient advocacy groups could bring the issue of presenteeism to the forefront.

“Patient safety organizations can engage on this as patients,” he said. “It is a public health issue and a workforce issue. Patients are also in the workforce and are concerned about public health. We can say this is the standard the CDC is recommending, and can work with our patients to start asking questions.”

Separate Document, Toolkit Discussed

Even as a separate document, it would be useful to determine what sick leave policies are being used in healthcare settings, said HICPAC liaison member Linda Spaulding, RN, a DNV GL NIAHO/CIP Surveyor in Milford, OH.

“I have been in places where if you call out three times in a year, you get terminated,” she said.

Options discussed included HICPAC partnering with professional organizations on presenteeism, creating a toolkit, and addressing issues of temp workers and physicians who are not necessarily hospital employees.

“I think that would really be invaluable,” Kainer said.

Discussions then veered into healthcare workers providing evidence of immunity for various diseases, but Babock said the CDC already has comprehensive worker vaccination recommendations that the HICPAC guidelines will reference but not repeat whole cloth.

With another outbreak of Ebola in the news, it was inevitable that the widely reported problems with personal protective equipment (PPE) during the 2014 epidemic would have to be addressed in the CDC occupational health guidelines.

Margaret VanAmringe, MHS, a liaison HICPAC member representing The Joint Commission, brought up the issue of competency, saying “We see a huge gap between training and people actually being able to put on PPE [and remove it correctly].”

Babcock said, “In the narrative, we do have some discussion around competencies, but we can certainly look at that to be sure it is clear enough as to what we are expecting.”

HICPAC member Michael Anne Preas, RN, senior director of infection prevention and hospital epidemiology at the University of Maryland Medical Center, emphasized that employee health cannot be expected to shoulder responsibility for all PPE training and competency assessments.

“I get so nervous when I think that could fall exclusively to occupational health,” she said. “It is critical to patient and worker safety. We can’t leave this all to occupational health. I just want to make sure that is clear.”

Babcock said the training and compliance with PPE is viewed as a collaborative and team-based approach. However, she noted that in the comments received on the draft, some advocated for employee health to ensure such provisions as PPE availability in the workplace, access to safety technology, and cleaning, decontamination, disinfection, and sterilization.

“These areas are really not the primary responsibility of an employee health service,” Babcock said. “The person that is actually ensuring that PPE is available at the door of the patients’ room is normally the manager in that work area working with other people in the hospital. An occupational health nurse should not be out on the floor restocking PPE.”

The draft will clarify that such matters are outside the scope of the guideline, which will also be limited to infectious concerns and not healthcare worker injuries from patient handling, slips, and falls that also are a common concern of employee health professionals.

In response to public comments regarding the confusing use of various names and acronyms for sharps devices with safety features, the HICPAC guidelines cited use in other federal documents in settling on the term Sharps With Engineered Sharps Injury Protection (SESIP).

“This term, while not short, is used by OSHA and CDC,” Babcock said. “We have updated the guideline throughout with this terminology.”

REFERENCES

  1. 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.
  2. CDC HICPAC. Guideline for infection control in health care personnel, 1998.