Unfortunately, “working while sick” has historically been an all-too-common practice in healthcare, endangering patients and other healthcare staff. The fact that this trend continues unabated recently led to a call for action on presenteeism by infection control advisors to the Centers for Disease Control and Prevention (CDC).
Marion Kainer, MD, MPH, a liaison member of the CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC), 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 at the HICPAC meeting, held May 16-17 at the CDC in Atlanta.
“[That] 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,” Kainer said.
HICPAC is updating CDC infection control guidelines1 for healthcare workers originally published in 1998.2 In doing so, 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.
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.
“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 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.
Discouraging presenteeism certainly has been emphasized by HICPAC member Hilary Babcock, MD, MPH, medical director of occupational health at Barnes-Jewish and St. Louis (MO) Hospitals.
For example, she explained last year at IDWeek in San Francisco that healthcare sick leave policies often are poorly communicated and haphazardly enforced. She pointed out that 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. (See Hospital Infection Control & Prevention, December 2018.)
“We also have that at our place,” Babcock told HICPAC members at their recent meeting.
“People have a single bank of time off, and both vacation and sick leave come out of that. So, the same things end up happening in practice.”
That said, HICPAC does not want to be overly prescriptive with healthcare sick leave policies, preferring to let various types of 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 (HR) 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, FL, 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.”
Even if done 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, DNV GL NAIHO/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.
- 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.