1. The Role of Infection Prevention in Healthcare Occupational Health Richard A. Van Enk, Ph.D., CIC Director, Infection Prevention and Epidemiology, Bronson Methodist Hospital vanenkr@bronsonhg.org

2. Objectives You will be able to: Identify the activities of healthcare personnel that place them at risk of infection and relate the organization’s infection prevention to the occupational health program Implement programs to reduce the risk of infection for healthcare personnel Respond appropriately when healthcare personnel are exposed to infection 2

3. Introduction For the infection preventionist, preventing infections in healthcare personnel is just as important as preventing infections in patients Although programs to protect staff from harm are usually multi-departmental, the infection preventionist is the lead person managing the processes related to infection and is the one responsible for the program, according to the Joint Commission There are many factors contributing to employee safety, so the infection preventionist must collaborate with many departments, usually in a multidisciplinary committee 3

4. Who is a healthcare worker? “All paid and unpaid persons working in healthcare settings who have the potential for exposure to infectious materials” Everyone with a hospital name badge Does not require traditional employment; includes physicians, volunteers, contractors, emergency medical service, researchers, product representatives, official visitors (like Joint Commission), local pastors Almost everyone on our property except patients and their visitors We need to protect them all 4

5. Infection-related objectives of a healthcare occupational health program 1.Educate personnel about their risk of infection and how to reduce those risks 2.Collaborate with the infection prevention department to investigate exposures and outbreaks 3.Provide care to personnel with exposures or work-related illnesses 4.Identify work-related risks of infection 5.Minimize risks of infection to reduce costs due to absenteeism and disability 5

6. Examples of multidisciplinary nature of employee safety Goal Safe products Staff training Tracking exposures Reducing exposures Tracking exposure costs Engineering controls Managing exposures Administrative support Department Purchasing Education Employee Health Environmental Safety Human Resources Facilities Emergency Department Executives 6

7. The Infection Prevention/Employee Health relationship These two departments work very closely together Putting them near each other physically and in the organizational structure is a good idea; that ensures they are in alignment EH should sit on the infection prevention committee and IP should sit on the employee health committee They both should work together on many programs and projects 7

8. Role of the infection preventionist Things infection preventionists add to the team: – Identifying the risks of infection to personnel working in the healthcare setting – Assessing the risks – Designing and implementing systems to minimize the risks – Analyzing data – Evaluating the effectiveness of the systems in reducing the risks 8

9. Elements of a healthcare employee health program related to infection Surveillance of infections in personnel, with investigation of exposures and outbreaks Pre-employment medical evaluation with occupational health history to identify risks Pre-employment and ongoing staff education, for example OSHA bloodborne pathogens and tuberculosis Determination of infection risks for each job category (bloodborne or tuberculosis) TB screening program 9

10. Elements of a healthcare employee health program related to infection Immunization programs; new hire and recurring Management of job-related illnesses and exposures Management of work restrictions for staff with contagious conditions Management of occupational exposures Management of the respiratory protection program (respirator fit testing or PAPR) Maintenance of occupational medical records Annual OSHA 100 and 200 reporting 10

11. The pre-employment medical evaluation Starts your responsibility for the new employee – Done after an offer of position – Documents only information that affects the employee’s performance and safety on the job – Housed in the employee health department, separate from their patient medical record, and not accessible to administration – A true medical record; requires a release of information – Some employees also require a periodic evaluation if they work with certain chemicals – Case study: what do you do if the employee changes jobs? 11

12. Surveillance of infections in personnel Staff should report all potentially work-related infections to employee health, but assessing whether they are work-related and doing an outbreak investigation is the IP’s job Case study: your annual tuberculosis screening program finds three new positive skin test converters among your employees. What should you do? Case study; a nurse caring for a patient with MRSA develops an MRSA infection. What should you do? 12

13. Pre-employment medical evaluation It is your job to assess and manage the risk of new-hires with significant health conditions related to their risk of infection Case study: a new-hire employee in a patient care position reports that they are HIV positive. What should you do? Case study: a prospective job applicant says that they have rheumatoid arthritis so they cannot receive any vaccines. What do you do? 13

14. Staff education We are legally required to ascertain the risk category (yes or no) of every job class for bloodborne pathogens and airborne infections (among other things) and provide pre- employment and annual education for all employees in those job classes. Case study: your hospital wants to shorten the orientation time for new employees so they propose to skip the respiratory and bloodborne pathogen education at hire. What should you do? 14

15. Determination of infection risks There are two OSHA-mandated infections risks for health care workers; bloodborne pathogens and tuberculosis – Each risk drives the pre-employment and annual minimum work requirements – Direct patient care (or specimen) staff have both – Everyone that works in a patient care building has the tuberculosis requirement (share an air source) Case study: what risks does someone who works in an off-site finance building have? 15

16. TB screening program All hospitals are required to do a tuberculosis risk assessment annually and implement their TB control program and respiratory protection programs based on these annual assessments – The infection preventionist does this assessment – Includes information from the county and state – Found in the 2005 MMWR RR-17 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm Case study: your hospital provided care for four patients with active tuberculosis in 2012. What does that mean for your TB Control Program? 16

17. Management of job-related illnesses and exposures The hospital is responsible for assessing and follow-up of all documented exposures of employees to infectious diseases. The most common cases we deal with are meningococcal meningitis, bloodborne pathogens and tuberculosis – The incident should be reported immediately after it occurs, then it becomes your job to make sure the follow-up is done correctly; you work closely with the EH department – In some cases antibiotic prophylaxis is needed, and you should make sure the right people are prophylaxed 17

18. Management of job-related illnesses and exposures Case study: a patient is admitted through the Emergency Department for an unknown respiratory condition. On the second day of admission, the physician orders sputum cultures for AFB, and the first one is positive. What do you do? 18

19. Management of job-related illnesses and exposures Case study: a patient is admitted for altered mental status, a lumbar puncture is performed, and the Gram stain of CSF shows Gram negative intracellular diplococci, many WBCs, high protein and low glucose. What do you do? 19

20. Management of job-related illnesses and exposures A surgery resident doing a procedure is poked by something sharp in the incision. The resident is bleeding and patient’s blood is on the punctured glove. The HIV status of the patient is unknown. What should you do? 20

21. Work restrictions for staff with contagious conditions There are about 20 infectious diseases that require some sort of work restriction – Table in the APIC manual page 26-4, individually listed in Red Book Some restrict the employee from the care of patients, some exclude from all duty The duration criteria differ for each, you need to look each one up – Some are a specific time, some are clinical; require a follow-up medical evaluation to clear the employee to work, can get complicated 21

22. Examples of work restrictions; what would you do? Disease Diarrhea Hepatitis B HIV Pertussis Staphylococcus aureus infection Strep throat Shingles Restriction 22

23. Examples of work restrictions; what would you do? Disease Diarrhea Hepatitis B Pertussis Staphylococcus aureus infection Strep throat Shingles Restriction Restrict from patient care until symptoms resolve None, unless employee performs procedures Exclude from duty until 5 days of treatment Restrict from patient contact Restrict from patient care until 24 hours of treatment Cover lesions 23

24. Preventing bloodborne pathogen exposures Each hospital is required to have a Safer Sharps committee that reduces the risk of percutaneous injuries through product selection The infection preventionist is a lead person on this committee 24

25. Management of the respiratory protection program The infection preventionist is involved in the airborne (usually tuberculosis) program, usually not the chemical program There are two types of respiratory protection – Particulate respirator – Powered Air Purifying Respirator (PAPR) Both require training 25

26. Management of the respiratory protection program Respirators – Cheap ($1.25) and disposable, one-time use – Require annual fit-testing using the respirator the person will use – A significant expense PAPRs – Expensive but reusable, more comfortable, fits everyone, stored in equipment management department – Requires one training on the PAPR the person will use – Perhaps more cost-effective 26

27. Resources: Association of Occupational Health Professionals in Healthcare A professional association just for healthcare – Membership, training, certification, journal, research – Some infection preventionists become dual certified by both APIC and AOHP – http://www.aohp.org/i ndex.html http://www.aohp.org/i ndex.html 27

28. References, Text Kuhar, D. C, et al. 2013. Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis. Infection Control and Hospital Epidemiology, Vol. 34, No. 9 (September 2013), pp. 875-892. Sebazco, S. 2009. Occupational health, pp. 26-1 to 26-16. In: APIC Text of Infection Control and Epidemiology, 3rd edition. Association of Professionals in Infection Control and Epidemiology, Washington, DC. 28

29. References, text Mayhall, C. G., editor. 2012. Epidemiology and prevention of healthcare-associated infections in healthcare workers, pp. 1076-1179. In: Hospital Epidemiology and Infection Control, fourth edition. Lippincott Williams & Wilkins, Philadelphia, PA. Falk, P. S. 2012. Infection control and the employee health service, pp. 1393-1400. In: Hospital Epidemiology and Infection Control, fourth edition. Lippincott Williams & Wilkins, Philadelphia, PA. 29

30. References, links http://www.shea- online.org/View/ArticleId/46/Guideline-for- Management-of-Healthcare-Workers-Who-Are- Infected-with-Hepatitis-B-Virus-Hepatitis-C-V.aspx http://www.shea- online.org/View/ArticleId/46/Guideline-for- Management-of-Healthcare-Workers-Who-Are- Infected-with-Hepatitis-B-Virus-Hepatitis-C-V.aspx http://www.acoem.org/uploadedFiles/About_ACOEM/ Components_And_Sections/Section_Home_Pages/MC OH%20Guidance.pdf http://www.acoem.org/uploadedFiles/About_ACOEM/ Components_And_Sections/Section_Home_Pages/MC OH%20Guidance.pdf http://www.cdc.gov/HAI/prevent/ppe.html http://www.cdc.gov/sharpssafety/ http://www.cdc.gov/niosh/topics/healthcare/ http://www.cdc.gov/mmwr/preview/mmwrhtml/rr541 7a1.htm http://www.cdc.gov/mmwr/preview/mmwrhtml/rr541 7a1.htm 30