GUEST COLUMN

Conjunctivitis policies may need a second look

Is lost work time really necessary?

By Sharon A. Watts, ND, RNC, FNP
Employee Health Nurse Practitioner
Carol C. Grove, MSN, RNC, PNP
Employee Health Nurse Manager
Employee Health Service
University Hospitals Health System
Cleveland

The policy on conjunctivitis in the employee population is an infection control issue for which the employee health service is responsible.

At University Hospitals Health System in Cleveland, employees with conjunctivitis symptoms traditionally have reported to the EHS, where they are evaluated and treated, and then they are furloughed from work for 72 hours or more, interfering with staffing in the institution. Recently, it was decided to revisit the EHS/infection control policy on conjunctivitis to investigate the necessity for this lost employee work time.

Current recommendations from the American Academy of Pediatrics do not advocate isolating children with conjunctivitis from school activities unless sharing eye materials is unavoidable. While employee health and patient care issues are not specifically addressed, general recommendations for proper hand washing and assessment of potential patient risk are given for contagious diseases such as upper respiratory tract infections.1

Asked about the necessity for employees with conjunctivitis to be off from work for at least three days, infectious disease physicians at the hospital responded that conjunctivitis is not a significant illness. Employees rarely take time off for colds, and conjunctivitis is most often a viral infection, although it also can be an allergic, bacterial, or chemical response.

An expert from the U.S. Centers for Disease Control and Prevention confirmed that no plausible reason exists to furlough employees with treated conjunctivitis. The one exception is for employees who share a microscope with others as part of their job description. If those employees have eye irritation or drainage, they are not to use the equipment until their condition clears.2

Conjunctivitis, commonly known as "pink eye," is a clinical syndrome beginning with lacrimation, irritation, and hyperemia of the conjunctivae of one or both eyes. Mild photophobia and mucopurulent discharge follow. Conjunctivitis may have many causes, including bacteria, virus, allergens, foreign bodies, acute glaucoma, and iritis. Practitioners need to determine an infectious etiology from a potentially severe eye condition prior to treatment. Most cases of infectious conjunctivitis are caused either by a virus (usually with respiratory symptoms) or bacterial agent. The mode of transmission is contact with discharges from the conjunctivae or upper respiratory tracts of infected people, contaminated fingers, clothing, and other articles such as shared eye makeup, eye medications, or eye instruments. The incubation period is usually 24 to 72 hours, and communicability is during the course of active infection.3

Bacterial vs. viral conjunctivitis

A thorough history and physical exam are imperative to rule out more serious eye disorders. Generally, unilateral presentation of eyelashes matted shut in the morning with mucopurulent discharge, no (or minimal) photophobia, and minimal pain with no vision change indicate a bacterial conjunctivitis. A systemic infection, tender preauricular nodes, and thin mucoid discharge with no pain, photophobia, or vision change may accompany viral conjunctivitis.4

Checking for pupillary response to light is helpful to rule out an acute iritis or glaucoma, which will show a poor response to light. Additionally, a foreign body may need to be ruled out by fluorescein staining, or allergic conjunctivitis by a history of symptoms.5

Numerous products available for treating bacterial conjunctivitis include sulfacetamide sodium ophthalmic 10% solution in generic form (if employees are not allergic to sulfa agents), which is probably the least expensive at about $9 a bottle. Two drops are applied to the lower conjunctival sac of the affected eye four times a day for seven days with a warning that it may produce some stinging. An ointment that may be more tolerable is polymyxin B-bacitracin, which can be used at a comparable cost. Tobramycin is a favored drug; however, it can cost up to $20 per prescription. All of the drugs mentioned can be used with penicillin allergy. Use of topical steroids is contraindicated due to the potential of a missed herpes simplex infection that can be exacerbated by steroids, possibly leading to blindness.6

Employee education on proper hand washing and avoiding hand-eye contact is critical in stopping the spread of conjunctivitis. Instruction on cleaning contact lenses, disposing of contaminated eye makeup, and avoiding shared towels at home is encouraged.

There never seemed to be a correlation between an employee’s conjunctivitis and a patient’s diagnosis. More often, it was the employees’ children who transmitted the infection to them, and they stayed home at least three days, as permitted by the policy. No complaints or documented cases of employee-to-patient transmission existed.

University Hospitals Health System decided to change its policy to more realistically reflect the infectious disease thought process. Officials chose to re-evaluate and align the conjunctivitis policy and procedure with sound infection control knowledge.

Changing policy after so long would require a lot of education and explanation. Follow-up would be needed to make sure employees were provided consistent, appropriate care, while at the same time keeping patients safe.

The new policy/procedure passed the infection control committee, and the EHS medical director and infection control medical director signed off on it. (See policy/procedure, p. 10.) It then was introduced to the adult physician group in the emergency department, who would be seeing those employees when the EHS was closed. Surprisingly, the group disagreed with the policy, saying that due to the condition’s contagiousness, the employee should be furloughed for three to seven days with medication. An education session was planned for this group with the infection control medical director/epidemiologist.

Interestingly, however, the pediatric emergency department physician group agreed with the policy, stating that most conjunctivitis is viral and does not require treatment.

The next group to educate was the directors/ managers/supervisors, especially in patient care areas. Some found the new policy a positive change for staffing reasons; others thought patients might worry about receiving care from a worker with "pink eye." However, they all agreed to monitor their areas and share any concerns, trends, or problems with the EHS or infection control.

Implementation of the change required education at all levels of hospital staffing. To date, the new policy/procedure has not been detrimental to employees or patients in the institution. The impact of this policy change is currently being monitored at patient, employee, and administrative levels.

References

1. American Academy of Pediatrics. 1997 Red Book: Report of the Committee on Infectious Diseases. 24th ed. Elk Grove Village, IL: AAP; 1997.

2. Personal communication. Linda Han, MD, epidemiologist, Division of Viral and Rickettsial Diseases, Respiratory and Enteric Branch, Centers for Disease Control and Prevention, Atlanta, September 1997.

3. Benenson AS, ed. Control of Communicable Diseases in Man. 15th ed. Washington, DC: American Public Health Association; 1990.

4. Uphold CR, Graham MV. Clinical Guidelines in Family Practice. 2nd ed. Gainesville, FL: Barmarrae Books; 1994.

5. Hoole AJ, Pickard CG, Ouimette RM, et al. Patient Care Guidelines for Nurse Practitioners. 4th ed. Philadelphia: J.B. Lippincott; 1995.

6. Wray SH, Slamovits TL, Burde RM. Disturbances of vision and ocular movements. In: Wilson JD, ed. Principles of Internal Medicine. 12th ed. New York: McGraw Hill; 1991.