Canadian ICPs urge worker protection

Do walk-through inspections of work areas

Public health officials in Canada are drafting novel occupational health guidelines for health care workers that emphasize risk assessments and the application of an industrial hygiene model to medical settings. The draft document — currently under review and revision by the Centre for Infectious Disease Prevention and Control in Ottawa, Ontario — also places a renewed emphasis on needle safety devices and the growing threat of hepatitis C virus.

The guidelines underscore the importance of protecting health care workers, an issue that has not received enough emphasis in the country, says Sharon Onno, MSc, COHN-C, nurse epidemiologist in the centre’s division of nosocomial and occupational infection. "The emphasis has been on patient care and patient safety," she tells Hospital Infection Control. "The health care worker has not been given enough attention. We have tried to provide the occupational health nurse something they can actually take to their manager and say, I need the resources to be able to carry this out.’"

Indeed, even in a system of nationalized health care, the guidelines are written with the knowledge that occupational health, infection control, and other clinical departments still have to fight for their individual budgets. "The Canadian system has suffered over the last five years because the federal government cut back on transfer payments to the provinces," Onno says. "So [money] is tight."

ICPs in the United States may want to consider some of the approaches in the Canadian guidelines, which, like recommendations by the Centers for Disease Control and Prevention, are voluntary.

"I think the major difference between this and the infection control guidelines by CDC — and the ones that we have done previously — is simply that we took the industrial hygiene method and applied it," Onno says. "It was not without some difficulty, but we wanted to ensure that occupational health nurses throughout Canada were using the same principles and methods that are used in other industries. Health care is an industry, and there seems to be some feeling that health and safety is not as good as it could be in the hospital. This is a method of promoting risk assessments and control measures."

Risk assessments require clinical knowledge

The guidelines call for a program that focuses on prevention, health promotion, and the recognition and reduction of health hazards in medical settings. In order to accomplish that, regular risk assessments should include the potential consequence of the hazard, the likelihood of exposure to the hazard, and the number of persons regularly exposed. Infectious disease risk assessments require adequate knowledge of:

• clinical manifestations and significance of the infectious agent;

• epidemiology, including characteristics, reservoir, mode of transmission, incubation period, and period of communicability;

• transmission factors, including type of exposure, size of innoculum, infectivity of the organism, susceptibility, and control methods.

The guidelines call for surveillance data to be systematically collected and analyzed as part of the effort, which also should include "walk-through" inspections of work sites. Walk-through visits should include an assessment of working conditions, supplies, equipment, standards of practice, and evidence of training. "The high-risk areas should be visited on a more regular basis," Onno says. "Basically, occupational health nurses need to get out of their offices and into the work area more, just as they would in industry."

Preplacement evaluations

The occupational health service also should perform a "preplacement" risk assessment of newly hired health care workers. Information about conditions that may affect skin integrity, latex allergy, and past immunizations is important to placement. "In Canada, you are not allowed to do a medical exam before you hire somebody," she says. "They are hired first, and then there is a placement exam done to determine a suitable place where they should be working. So if somebody has had a back injury, you are not going to put them on an orthopedic ward."

The draft also includes an appendix on blood exposures and needle safety devices to highlight the importance of preventing transmission of bloodborne pathogens to workers. Though current surveillance data are limited, three health care workers in Canada may have acquired HIV on the job. Surveillance has been passive, but a fledgling network of 13 Canadian hospitals is forming to improve reporting of exposures and seroconversions, Onno says. "They are reporting all needlestick injuries, and we will see if anyone converts to HIV or hepatitis B and C," she says.

HCV is a growing concern in Canada, where about 240,000 people (.8% of the population) may be infected. "In Vancouver, for example, there is a very high population of injection drug users," Onno says. "It is a serious concern, and we are hoping to highlight it in this document because we know they seroconvert very easily. Sometimes, I understand, they can seroconvert within a week of injecting drug use. It’s scary."

[Editor’s note: Canadian public health officials are planning to post the draft document — "Infection Control Guidelines for Occupational Health in Health Care"— on the Web sometime in October (after a French translation is completed) at www.hc-sc.gc.ca/hpb/lcdc/dpg_e.html#infection.]