Occupational Health Departments Hit Hard by Pandemic
‘Everything happened at least once’
In 2020, many individual clinical departments — EDs, ICUs, infection control — were overwhelmed when a series of COVID-19 surges began to inundate hospitals with infected patients. How did occupational health hold up?
“Just as bad, or worse,” says Kathleen McMullen, MPH, CIC, FAPIC, who worked in both occupational health and infection control during the pandemic.
Suddenly, an essential pandemic response was imperiled: healthcare workers. It fell to employee health professionals to work with colleagues and protect the workforce in a situation not seen in a century.
“At the very beginning of the pandemic, there were a lot of times the person who was responsible for telling the employee that they had COVID was the occupational health nurse,” McMullen said. “They had to make that phone call, and there was a lot of counseling to those employees about themselves and their families. Then, we had to talk about who they had been around in the facility, and call those other employees who may have been exposed and talk to them about their risk.”
This contact tracing duty was very labor-intensive. As other work demands mounted, occupational health personnel experienced some of the same stress, burnout, and moral injury reported by many healthcare workers. “They were working incredibly long hours — they could never get everything done — and then they would go home to their families and rush back to work the next day,” she says.
McMullen worked in employee health and infection control for much of the pandemic at Christian Hospital in St. Louis. Currently, she is director of infection prevention at Mercy Quality and Safety Center in Chesterfield, MO.
“With many co-workers affected by the pandemic and many employee health team members also affected by it, the two intersect at the employee health clinic,” says Cory Worden, PhD, MS, CSHM, a veteran safety professional and occupational health expert based in Houston.
Moreover, employee health remains responsible for other hazards and occupational threats, including needlesticks and patient-handling injuries. Even in a COVID-19 downturn, those other duties loomed.
“There have been plenty of challenges and strains on employee health teams,” Worden says. “Employee health carries the emotional and mental strain of being in the midst of all safety and health for the organization along with being involved in the human consequences of the COVID-19 virus.”
Call to Action
Given her background in employee health, McMullen co-authored the chapter1 on occupational health during the pandemic response in a call to action report by the Association for Professionals in Infection Control and Epidemiology (APIC).
“As recommendations and demand for specific types of PPE have evolved, healthcare workers have clearly perceived a need to remain protected from one source of risk — their patients,” McMullen and a colleague wrote. “However, healthcare organizations have struggled to help workers understand that the risk of exposure to SARS-CoV-2 from other people, including co-workers, is just as real as the risk of exposure from patients.”
Indeed, removing masks and dropping social distancing has been commonly reported when healthcare workers took breaks with colleagues. This risk required “consistent feedback,” according to the report.
“They were seeing these people day after day,” McMullen says. “It’s human nature. They’re their friends and colleagues, and it was easy to get a little lax.”
McMullen did not see a lot of problems with presenteeism early in the pandemic, but during the delta and omicron variant surges in late 2021 and early 2022, many vaccinated workers with mild breakthrough infections reported to work.
“I think they just didn’t believe it,” McMullen recalls. “They were healthy and really just thought they had allergies or something minor. [Presenteeism] definitely happened. There were times that we called an employee and said, ‘Your fellow employee just tested positive.’ The exposed person said, ‘Yeah, I have a runny nose today,’ and so we would send them to get tested. A lot of times they weren’t positive, but it happened. Everything happened at least once.”
Presenteeism, which includes both infection risk to others and the diminished productivity of the ill worker, has been a longstanding problem in healthcare.
“While facilities already had policies in place about illness-related work restrictions, awareness of and adherence to those policies have increased during the pandemic,” the report authors wrote. “Because infection prevention and control (IPC) and employee occupational health (EOH) team members conduct contact tracings, potentially exposed employees — including some who are asymptomatic — have been tested and required to remain out of the workplace until cleared for return.”
The employee screening stations that have become ubiquitous in healthcare facilities during the pandemic may have been a deterrent in the sense that people with fever or other symptoms stayed home rather than trying to go through the gatekeepers, says David Kuhar, MD, of the CDC’s Division of Healthcare Quality Promotion. In any case, available evidence in the literature and anecdotally reveals the stations rarely identified sick workers, he notes.2
“The [consensus] was that they just weren’t picking up a lot of cases,” Kuhar notes. “You can question why. Was the presence of the station itself a deterrent? It still comes down to the basics — work culture and investment. It needs to be expected that when people are sick, they are not going to come into work.”
With that engrained in work culture, there should be sufficient investment to build in worker sick days and a deep enough “bench” to cover those out, Kuhar says.
Employees Must Make the ‘Call’
“With the COVID-19 guidance and algorithms for quarantine and isolation — even with the recent changes being less strict — they provided a process that defined when to return to work after exposure or illness,” Worden says.
As isolation and quarantine are phased down if and when COVID-19 becomes endemic, it becomes more the individual employee’s responsibility to stay home if sick and not expose colleagues or patients.
“This requires a certain fortitude on each employee’s part to be willing to ‘call it’ when feeling ill,” Worden says. “It requires a certain normalization on the employer’s part to know the benefits of employees not working while ill, even if it creates staffing challenges.”
While no data specifically measure the pandemic’s effect on occupational health, many employee health departments were so busy they likely were barely above water.
“Testing healthcare workers would typically fall to the occupational health programs, and there were waves where there were so many exposed healthcare personnel,” Kuhar says. “There has also been a lot of attrition across the board in [staff] during the pandemic. I can’t imagine that occupational health departments were spared from that — meaning fewer people to handle a much heftier load.”
Cascade Effect
Staffing shortages in general create a cascade effect that raises the risk for all manner of duties — including, for example, safe patient handling.
“Patient mobility equipment requires placement, training, disinfection, sling changes, battery charging, and other factors for it to be available and safely [used],” Worden explains. “With fewer people doing more work, the risks increase that the equipment might not be [maintained] properly or that someone might not have training on its use. Each of these factors creates a higher risk that the equipment might not be [used at all], which increases the risk that someone might have a strain from manual lifting.”
With fewer workers to perform required tasks, risk increases beyond SARS-CoV-2 exposure to the gamut of strains, slips, trips, and falls. “For many reasons, these variances in the pandemic situation and associated factors have also increased risks of and incidents of workplace violence,” Worden says. (For more information, see the related story in this issue.)
Facilities that emphasized work safety and occupational health before the pandemic may have experienced fewer of these adverse events. “Even if a team is short-staffed, if safety protocols are successfully [baked in] to prevent disease exposures [and physical injuries], those who are working can continue, and the staffing level is less likely to become lower. This also helps with team morale and job satisfaction, which help decrease turnover,” Worden says.
Planning, Resources, and a Better Mask
In the occupational health chapter of the APIC report, McMullen and co-author recommended these steps for policymakers to prepare for the next pandemic:
- Plan for high demand for maximal respiratory protection, in the form of N95 respirators and powered air purifying respirators (PAPRs), during situations when the evidence about transmission may be unclear and evolving. “Anticipate the staffing needed to prepare and train personnel for more-intensive PPE (such as N95s or PAPRs). For example, design ‘train-the-trainer’ programs and establish plans to continually monitor personnel for ongoing compliance,” the authors wrote.
- Provide adequate resources to allow IPC and EOH teams to conduct contact tracing and employee exposure testing within healthcare facilities. “Develop training modules that can be used to rapidly educate students, interns, and other trainee-level team members to assist with future contact tracings,” the authors recommended. “Develop standard workflows, interview templates for team member interviews, and other ways to streamline the exposure testing process in advance.”
- Be aware that even healthcare workers may be vaccine-hesitant, especially during pandemics, and employee health programs will need funding and resources to help address this issue.
- Fund the development of an off-the-shelf, one-size-fits-all respiratory device that can be used in healthcare facilities for infectious disease emergencies without the need for fit testing. “The National Institute of Occupational Safety and Health (NIOSH) should work with other federal agencies and form public-private partnerships with industry and universities on this research,” the authors emphasized.
A mask equivalent to an N95 respirator that does not require fit testing has been the Holy Grail of respiratory protection for more than a decade. As mentioned, part of the problem is the development and approval of such equipment would require the involvement of industry and at least three federal agencies: the CDC, NIOSH, and the Occupational Safety and Health Administration.
Fit-testing of N95s was problematic during the chaotic pandemic surges, as occupational health departments were inundated with demands and other duties.
“This was a challenge — occupational health departments couldn’t match the need for fit testing,” Kuhar says. “There were periods where they could not keep up.”
In most long-term care facilities and other settings beyond the hospital, there likely was no formal program or capacity to fit-test workers. Some facilities hired a contractor to fit-test a given respirator, only to receive a different type when resupplied.
“They were forced to use those [resupplied] respirators anyway because they had nothing else,” Kuhar said. “It was a mess. [Overall], during the pandemic, there just wasn’t the capacity to fit-test the number of people needing it, and to do it frequently enough.”
REFERENCES
- Holdsworth J, McMullen K. Employee and occupational health for healthcare personnel during a pandemic. Between a rock and hard place: Recommendations for balancing patient safety and pandemic response. March 2022.
- Evans G. Screening ineffective for identifying HCWs with respiratory illness. Hospital Employee Health. Dec. 1, 2021.
In 2020, many individual clinical departments were overwhelmed when a series of COVID-19 surges began to inundate hospitals with infected patients. Suddenly, healthcare workers were imperiled. It fell to employee health professionals to work with colleagues and protect the workforce in a situation not seen in a century.
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