Case Management/Outbreak Control

Keeping Employees Healthy
Education and Communication can Prevent Infectious Outbreaks

By Pat Tydell, RN, MSN, MPH

It is estimated that over eight million people are healthcare workers (HCWs) in this country. They work in traditional settings such as hospitals and nursing homes, but frequently work outside of these areas in places such as homes and clinics. They are direct caregivers such as doctors, nurses, respiratory therapists and non-direct care givers like laboratory staff, central supply staff and pharmacists. They can also be students, volunteers, researchers and contracted personnel. All of these persons have the potential to be exposed to infectious materials and to expose patients and others as well. Materials such as body substances, contaminated medical supplies and equipment, contaminated environmental surfaces, or contaminated air are all examples of exposure risks for the staff. Infection control policies and practices for persons who work in healthcare are important to prevent infections and their spread, guide staff in their behavior, and ensure a safe environment of care for both the patient and staff. Making that happen involves several coordinated efforts between practitioners and management.

Prevention of infection has always been the goal of infection control. A comprehensive program of prevention of infection for HCWs includes education, appropriate immunization program, isolation precautions to prevent exposures, and good personal hygiene practices.

HCWs are more compliant with an infection control program if they understand its rationale. Therefore, personnel education is key for an effective infection control program. Policies should be written clearly and coordinated between departments. Content for the educational sessions needs to focus on areas of infection risks, principles of infection control, procedures for caring for exposed persons, monitoring activities performed, outbreak control and personal responsibility and accountability for the prevention of infection in the workplace. Additionally, discussing the cost of illnesses related to workplace infections in terms of time, money, absenteeism and disability helps.

Many educational programs for professional healthcare workers do not include basic information on wellness or self-care. Teaching workers the body's signals of infectious disease and actions to take when they occur can go a long way in counterbalancing many healthcare workers' habit of stoically enduring illness. Supporting good wellness behaviors designed to protect the worker from becoming seriously ill and others from being exposed is an area that tends to be forgotten in programs (Table 1).

Table 1: Common Symptoms
Associated with Infectious Diseases
  1. Nausea
  2. Vomiting
  3. Diarrhea
  4. Fever
  5. Sore throat
  6. Headache
  7. Cough
  8. Nasal congestion
  9. Pink eye
  10. Body aches
  11. Swollen glands
  12. Rashes
  13. Open sores and skin infections
  14. Other symptoms believed to be significant

One of the most important behaviors of self care that cannot be stressed enough is that of handwashing. Whether direct care givers or non-direct, all educational programs should include this most basic and effective method of infection prevention (Table 2). Other basic behaviorial information that needs to be reinforced in educational sessions include covering the mouth and nose when sneezing or coughing, hand care to counteract the effects of the chemicals used to cleanse the hands, safe places to eat/smoke, keeping the work environment clean, sources of infection in the workplace, and stress management.

Table 2: Wash Your Hands...
  1. After using the bathroom, changing a diaper or undressing.
  2. Before and after eating, drinking, chewing tobacco or gum, or smoking.
  3. After touching contaminated items or taking out the garbage.
  4. After sneezing, coughing or blowing your nose.
  5. After touching your hair, nose, eyes or mouth.
  6. After removing gloves.
  7. After touching uncooked food.
  8. After touching animals or their cages.
  9. After cleaning.

Immunization programs play an important role in preventing infections from occurring in HCWs. Whether a researcher in the animal lab or a doctor in the emergency room, optimal use of vaccines can prevent transmission of vaccine-preventable diseases and eliminate unnecessary illness and work disruptions. An immunization program is far more cost effective than case management and outbreak control. More often than not, however, the most effective way to have employees protected is to mandate the vaccines. National guidelines for immunization of and postexposure prophylaxis of healthcare personnel are provided by the US Public Health Service's Advisory Committee on Immunization Practices. These guidelines also contain valuable information on the epidemiology of vaccine-preventable diseases, the safety and efficacy of vaccines and immune globulin preparations and recommendations for immunization of immune-compromised individuals. The guidelines include risk assessment of exposure, screening to determine susceptibility and record-keeping requirements.

Isolating patients with infectious diseases is relatively simple and straightforward. The patient's symptoms are recorded and reported, the pathogen is isolated and identified, and practices to protect others from the pathogen and get the patient well are initiated.

For HCWs, this process does not always work well. Prompt diagnosis of infection in workers is important so that the facility can take action. Policies need to be designed to encourage personnel to report their illnesses or exposures. This means that management needs to support employees and not penalize them with loss of wages, benefits or job status. One action that facilities frequently take when a healthcare worker reports an illness from or exposure to an infectious disease is to exclude that person from duty. This exclusion should be interpreted as exclusion from the healthcare facility and from activities outside the facility. Personnel who are excluded from duty should avoid contact with susceptible persons both in the community and the facility. Exclusion policies should include a statement of authority defining who may exclude personnel. Workers' compensation laws do not cover exclusion from duty for exposure to infectious diseases; therefore, policies need to include a method for providing wages during the period that personnel are not able to work. Notification of emergency-response personnel possibly exposed to selected infectious disease is mandated by the 1990 Ryan White Act.

Case Management/Outbreak Control

When a HCW does develop an infectious disease, the facility needs procedures to follow up and prevent the spread of the disease. There should be clear delineation of who is to be notified, maintenance of records, data management and confidentiality. The Occupational Safety and Health Administration (OSHA), in their 1991 OSHA "Occupational Exposure to Bloodborne Pathogens; Final Rule" requires employers, including health care facilities, to establish and maintain an accurate record for each employee with occupational exposure to bloodborne pathogens. The regulation goes on to require that each employer ensure that an employee's medical records are kept confidential, not disclosed or reported without the employee's express written consent to any person within or outside the workplace, except as required by law, and maintained by the employer for at least the duration of the worker's employment plus 30 years.

Health counseling along with medical management of the ill worker is another crucial element for effectively handling infections or exposure to infection. Health counseling provides individually-targeted information regarding risk factors, how to prevent transmission to others, risk of long term illness or other adverse outcomes, how the disease/exposure will be medically managed and consequences to others both inside and outside the facility.

Specific handling of infectious diseases and/or exposure can be found in the AJIC special article "Guideline for Infection Control in Health Care Personnel, 1998." This extensive guideline discusses educational needs, prevention issues and special populations of employees such as the pregnant HCW, laboratory workers, emergency response workers, immunocompromised workers, latex sensitive personnel and persons covered under the Americans with Disability Act. These guidelines provide an excellent resource for assisting in the development of policies and practices for infection control in HCWs (Table 3).

Table 3: Immunobiologics and schedules for healthcare personnel (modified from ACIP recommendations): Immunizing agents strongly recommended for healthcare personnel

Generic name

Hepatitis B recombinant vaccine
Influenza vaccine (inactivated whole or split virus)
Measles live-virus vaccine
Mumps live-virus vaccine
Rubella live-virus vaccine
Varicella-zoster live-virus vaccine

Primary booster dose schedule

Two doses IM in the deltoid muscle 4 weeks apart; third dose 5 months after second; booster doses not necessary.
Annual single-dose vaccination IM with current (either whole- or
split-virus vaccine)
One dose SC; second dose at least one month later
One dose SC; no booster
One dose SC; no booster
Two 0.5 ml doses SC, 4-8 weeks apart if 13 years of age or older.

Indications

Healthcare personnel at risk of exposure to blood and body fluids
Healthcare personnel with contact with high-risk patients or working in
chronic care facilities; personnel with high-risk medical conditions and/or are 65 years or over.
Healthcare personnel born in or after 1957 without documentation of (a) receipt of two doses of live vaccine on or after their first birthday, (b)
physician-diagnosed measles, or (c) laboratory evidence of immunity;
vaccine should be considered for all personnel, including those born
before 1957 who have no proof of immunity.
Healthcare personnel believed to be susceptible can be vaccinated; adults born before 1957 can be considered immune.
Healthcare personnel, both male and female, who lack documentation of receipt of live vaccine on after their first birthday, or of laboratory evidence of immunity; adults born before 1957 can be considered immune, except women of childbearing age.
Healthcare personnel without reliable history or varicella or laboratory
evidence of varicella immunity.

Major precautions and contraindications

Women pregnant when vaccinated or who become pregnant within three months of vaccination should be counseled on the theoretic risks to the fetus, the risk of rubella vaccine-associated malformations in these women is negligible. MMR is the vaccine of choice if recipients are also likely to be susceptible to measles or mumps.
Because 71-93% of persons without a history of varicella are immune,
serologic testing before vaccination may be cost-effective.
IM (Intramuscularly); SC (subcutaneously)

  • Persons immunocompromised because of immune deficiencies, HIV infection, leukemia, lymphoma, generalized malignancy, or immunosuppressive therapy with corticosteroids, alkylating drugs, antimetabolites or radiation.

Although much is written about preventing and managing infections in HCWs, the success or lack of success of a program usually comes down to the communication between supervisors and workers and the relationship among the group. If personnel fear being penalized for reporting signs and symptoms of infectious disease or if there is reprisal for staying away from the job and creating staffing shortages, then employees will behave counter to the best interest of the employer and themselves. These barriers to infection control and prevention in the work force can be alleviated by communication and collaboration on the policies and practices developed by the facility. When department supervisors understand the intent of the policy and the importance of their support in implementing it, this is more likely to be passed on to the employees as expected behavior. One of the most frequently cited reasons for coming to work sick is staffing shortages or disruptions caused by call-ins. To address this for employees and supervisors, the head of each department should have a staffing plan that includes contingency plans for absenteeism due to illness. Variance data should be kept and reviewed periodically to determine how well the staffing plan is working for the department and changes made as necessary. If this looks a lot like a quality improvement activity, it is. JCAHO even has a standard on staffing plans and variance reporting (CAMH, Human Resource Standards).

Keeping the HCW healthy is as important as caring for the patients in healthcare facilities. There are numerous activities that ensure the prevention of transmissible diseases. There are practices to help control an outbreak of an infectious disease. There are guidelines to assist with educational programming and policy development. Combining the use of these tools with communication and cooperation between and among healthcare workers will support the goal of infection control in healthcare--wherever the setting.

Hide comments

Comments

  • Allowed HTML tags: <em> <strong> <blockquote> <br> <p>

Plain text

  • No HTML tags allowed.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
Publish