By Kelly M. Pyrek
Late last year, the Centers for Disease Control and Prevention (CDC) sought feedback from the healthcare community on a draft guideline, Infection Control in Healthcare Personnel: Infrastructure and Routine Practices for Occupational Infection Prevention and Control Services. Specifically, the CDC is looking to "facilitate the provision of occupational infection prevention and control services to healthcare personnel and to prevent transmission of infections between healthcare personnel and others." The CDC is updating two sections addressing protocol for infrastructure and routine practices, which initially were published in 1998. Since 2015, the Healthcare Infection Control Practices Advisory Committee (HICPAC) has collaborated with academics, health professionals, healthcare providers and other partners to update the guidance.
"This guidance is not only a crucial tool to improving worker health and safety in healthcare, but a testament to CDC’s ongoing focus on this issue," confirm Amber Hogan Mitchell, DrPH, MPH, CPH, president and executive director of the International Safety Center (ISC), and Elise M. Handelman, BSN, MEd, RN (ret), a board member of the ISC, in comments provided to the CDC. "Often patient safety far overshadows worker safety in healthcare settings and frankly, without healthcare personnel, there is no healthcare. In fact, safer healthcare workers have a direct impact on their ability to provide and maintain safer patient care."
Mitchell emphasizes that it is critical for guidance related to occupational health in healthcare reflect requirements and messaging from both OSHA and NIOSH. "CDC has historically drafted guidance with little input from either organization," she says. "Guidance must include careful attention to assessing risks and implementing preventive strategies that are established in the hierarchy of controls. Providing examples of how that can be carried out by healthcare facilities would be incredibly beneficial."
For example, Mitchell points out:
• Elimination: Remove sharp sutures for skin closure where appropriate and replace with zipper technologies, adhesives, strips, or other non-sharps;
• Substitution: Replace sharp sutures with blunt-tip sutures for internal fascia closures; replace needles for intravenous connections with needleless connectors.
• Engineering controls: Use sharps with injury protections (SIPs), needleless IV systems; use of robotic equipment to reduce risk during invasive procedures when appropriate;
• Administrative and work practice controls: activate a safety feature after use on a SIP device immediately after use, immediately dispose of sharps after use, use “neutral zone” for passing sharps among surgical personnel; ensure that employees receive training on new devices and procedures;
• PPE: Use eye protection, face shields, gloves, gowns, etc. to prevent exposures.
A number of areas pertaining to occupational health in healthcare need to be bolstered in this guideline, according to the individuals and organizations submitting public comments and feedback to the CDC. Relating to sharps safety and blood and body fluid exposures, Mitchell recommends the following issues be addressed in the updated proposed guideline:
-- Post-exposure prophylaxis, vaccination/immunization, and employee health records need to be addressed fully. Since HIPAA explicitly excludes employee/employment records; suggest additional research by authors on exclusions in employment relationships, including more careful attention to the requirements set for in OSHA’s Access to Employee Exposure and Medical Records and Recordkeeping Standards.
-- Build out post-exposure follow-up and treatment for pathogen exposures, including sharps injuries and mucocutaneous exposure incidents and guidance for “after hours” exposures including accessing local emergency department for HIV, HCV source and employee testing.
-- Given extraordinarily high co-infection among patient populations of HIV and HCV or HBV, recommend spending more time on needlesticks, sharps injuries, and mucocutaneous exposures especially since exposure incidents have been rising year over year since 2013. Additionally, more focus on eye protection since nearly 50 percent of all reported mucocutaneous exposures occur to the eye with only 3 percent of employees indicating they are wearing eye protection at the time of the incident. https://internationalsafetycenter.org/wp-content/uploads/2018/10/Officia...
-- Also bolster the importance of not just using engineering controls (devices with sharps injury prevention features), but the criticality of frontline employee feedback on identification, evaluation, selection of devices to improve safety feature activation and safe disposal to prevent not only injuries to users, but those downstream (EVS, laundry).
-- Given so many recently published studies on self-contamination upon PPE doffing -- hand hygiene recommendations must be built out to include, including appropriate glove donning and doffing procedures and timing.
-- Consider adding more information about the increased prevalence of co-infection in patient populations, resulting in potential occupational exposure to not just BBP, but several including MDROs (especially in body fluid in eye exposures). Potential references include: https://www.cdc.gov/hepatitis/hiv-hepatitis-coinfection.htm and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4484961/ and https://www.cdc.gov/mmwr/volumes/67/wr/mm6722a2.htm
-- Consider adding more information about whistleblower and employee rights statements.
"Additional review from the OSHA Directorate of Enforcement Programs will make this document more accurate and ultimately more protective for healthcare personnel and the patients and communities they care for, as well as review by an industrial hygienist and/or safety engineer at the NIOSH National Personal Protective Technology Laboratory (NPPTL) and a review by the NIOSH Office of the Director prior to publication," Mitchell adds.
Several organizations have provided commentary on the proposed updated guideline; let's examine the specifics from the key agencies.
In public comments, signed by Mary Miller, MN, RN, and Celeste Monforton, DrPH, MPH, co-chairs of the Policy Committee of the Occupational Health and Safety Section of the American Public Health Association (APHA), emphasized that "Protecting healthcare workers from occupational injuries and illnesses is critically important to a sustainable and effective healthcare system." The organization recommended that the draft guidance document be reviewed by the National Institute for Occupational Safety and Health (NIOSH) and the Occupational Health and Safety Administration (OSHA) to ensure that the terminology used is consistent with OSHA’s Bloodborne Pathogens Standard (29 CFR 1910.1030), Access to Medical Records (29 CFR 1910.1020) and other OSHA standards, as well as terminology used by occupational health and safety professionals.
APHA also recommended the term “infection” be replaced as much as possible with the phrase “occupational infection and illness.” As Mitchell advises the CDC, "Include 'occupational Infection and Illness' where appropriate and as frequently as possible together throughout the entire document. Infection is often associated with more of a healthcare associated infection (HAI), and illness is consistent with OSHA terminology. It makes the document stronger and more consistent with OHS IPC professionals. Either could occur – occupational MRSA, occupational flu, occupational HIV, etc."
In addition, APHA also recommended that a clear distinction be made between a facility’s occupational health and safety (OHS) program and its employee health (EH) program. As the group explained in its public comments, "Typically, an OHS program is managed by industrial hygienists, safety professionals, EH&S staff who are responsible for tasks such as hazard evaluations, respirator fit testing, and ergonomic assessments. In contrast, occupational health nurses and physicians are typically responsible for a facility’s EH programs and handle tasks such as vaccinations and post-exposure prophylaxis."
APHA adds that emphasis should be placed on employee involvement, as OSHA’s Safety and Health Program Guidelines include “worker involvement” as an essential element of an effective OHS program. The group advises, "We recommend that the guidelines integrate best-practice guidelines to involve staff and their union representative in the design and implementation of an occupational infection and illness control plan."
The organization identified a lack of information on the role of environmental controls as a critical means to prevent occupational infection and illness and note, "We recommend that the guidelines include information, such as high efficiency particulate air (HEPA) filtration, other ventilation, UV systems, and ante rooms." It also recommends that the guidelines include information on safe and effective cleaning, decontamination, disinfection and sterilization. These are essential components of an effective occupational infection and illness control plan.
The American Nurses Association (ANA), through its public comments signed by Debbie Dawson Hatmaker, PhD, RN, FAAN, the ANA's chief nursing officer/executive vice president, addressed greater protection of healthcare workers from sharps injuries. As it noted, "Current terminology used throughout the industry, scientific community, government regulatory agencies as well as accreditation bodies to refer to safety engineered sharps devices are varied and confusing. That includes the SESIPs acronym utilized by OSHA, NIOSH and CDC which remains unclear in its meaning for many who utilize sharps. The ANA Sharps Injury Prevention Stakeholder Group, composed of sharps safety experts across the country, has been engaged in efforts for more than a year to simplify safety device terminology and proposes Sharps with Injury Protection (SIP) for universal use throughout this updated guideline." (Parenthetically, the APHA says it concurs that the term "SIP" should replace the various terms used in the document, such as safer devices and safety-engineered devices.)
The ANA asked for the CDC to consider bolstering language in the document related to the reporting and surveillance of occupational exposure incidents; and providing access to appropriate safety technology and PPE. As the group explained, "EPINet and Massachusetts data indicate that continued use of non-safety devices where SESIPs or SIPs are available and appropriate remains widespread despite since NSPA enactment in 2001. It falls to leadership and management to ensure compliance with current requirements re: use of SIPs wherever appropriate within clinical settings."
The ANA also suggested that "specific mention of annual updates of Exposure Control Plans as integral to OHS leaders’ responsibility for promoting reduction in sharps injuries," and requested language providing for “...the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard requirements for provision of exposure management services to employees, annual updates of Exposure Control Plans, and the Personal Protective Equipment (PPE) Standard requirements for PPE training."
The group advocated inserting language to “…identification and mitigation of barriers to success, such as access to care, access to appropriate safety technology and PPE, quality of services, or other factors, such as staff awareness of when to seek OHS care."
Of special note to infection preventionists, in its public comments signed by Margaret VanAmringe, MHS, executive vice president for public policy and government relations, the Joint Commission said the document "could be strengthened by greater emphasis on collaboration with infection prevention and control (IPC) staff and the interrelationship between worker safety and patient safety."
As the Joint Commission explained, "The current version may inadvertently reinforce siloing of safety issues, which is increasingly recognized as contradictory to promoting a safety culture. To strengthen the guideline, CDC might consider adding a new section devoted to the intersection of worker safety and patient safety. Many national groups are now promoting this integration including the Institute for Healthcare Improvement, the National Patient Safety Foundation, and the National Academies of Sciences, Engineering, and Medicine. Relevant topics for this section could include infectious diseases, needlestick injuries, injury and exposure reporting system, tools to enhance communication such as daily huddles, and tools for risk assessment and incident analysis."
Additionally, the Joint Commission emphasized the importance of the assessment of competence in addition to training and education: "It is well known that training does not always result in proper implementation. For example, Examples of Performance Measures that Might Be Used to Assess the Effectiveness of Occupational Infection Prevention and Control Services includes a measure around the completion of initial and annual occupational IPC education and training as well as several measures to track HCP exposure events but does not include any measures around competency or use of personal protective equipment (PPE). The Joint Commission also asserts that exposures will continue to happen unless expectations related to engineering controls and use of PPE are standardized. It is imperative that healthcare personnel follow the same practices to prevent exposure as they move through the continuum of care."
The Joint Commission adds that it understands that the CDC does not seek to be too prescriptive in listing performance measures that might be used to assess the effectiveness of infection prevention and control services, but it recommends that the agency consider including process measures in addition to outcome measures as examples, particularly as it relates to the risk assessment process: "Given the known problems with under-reporting, it would be worthwhile to include an example measure related to needlestick injuries. Additionally, The Joint Commission recommends that the importance of examining trends over time be added to the discussion on performance measurement and quality improvement. Organizations should be encouraged to submit standardized data to reporting systems to receive comparative reports and track trends over time."
The guideline currently says to "Inform all healthcare personnel and relevant healthcare organization departments about occupational infection prevention and control policies and procedures." The Joint Commission asserts that in this context, "use of the word 'informing' in this requirement implies that no action is required by healthcare personnel in an element that is crucial to effective implementation of safe occupational health practices. The Joint Commission proposes that this sentence be revised to “ensure all healthcare personnel and relevant healthcare organization departments understand their role in implementing occupational infection prevention and control policies and procedures.”
The Joint Commission also recommends that the CDC add language to the guideline that would require drills based on institutions' infectious disease emergency and outbreak management plans, and observes, "IPC-related emergencies are more likely to happen than many other emergencies that organizations are required to drill. In guidance for surveyors, providers and suppliers for natural disaster preparedness, CMS notes that 'in keeping with the all-hazards methodology, infectious diseases pose a threat to the community, healthcare workers as well as national response and recovery efforts.' When this type of emergency occurs, the results can negatively impact the availability of healthcare personnel and creates potential for exposures in the community. Encouraging organizations to drill response to IPC-related emergencies ensures readiness and could dramatically decrease exposures and illness."
Finally, the Joint Commission calls for the CDC to consider adding a requirement to ensure the availability and use of task-specific engineering control and PPE for high-risk situations based on HCO experience: "Since exposures of healthcare personnel happen every day in healthcare, leaders need to set clear expectations of where PPE should be stocked and when PPE must be worn. It has been shown that healthcare personnel wear gloves but often do not wear other essential PPE. For example, EPINet data on splash exposures indicates that, in 2017, approximately 62 percent of exposures involved a splash to the eyes, nose or mouth, but exposed healthcare personnel reported wearing face protection during less than 12 percent of exposures.
In public comments from the American Federation of Labor and Congress of Industrial Organizations (AFL-CIO), Rebecca L. Reindel, MS, MPH, senior safety and health specialist, referenced the long-established industrial hygiene practice called hierarchy of controls: "It is widely instituted and recognized because it is the most effective method of controlling hazardous exposures, including biological exposures, and recognizes the environment of the worker, rather than only the worker and the worker’s task, in the exposure control model. According to the hierarchy, the most effective method for controlling workplace hazards begins with substitution with a safer product or process; followed by engineering controls such as isolation or installation of safety engineered Sharps devices; administrative and work practice controls; and only as the final line of defense, personal protective equipment (PPE), including respiratory protection, gloves and protective clothing. It is fully recognized, and often in healthcare, that PPE can be used in combination with other control measures but should not be the primary reliance of protection to protect workers and bystanders, such as other workers and the public at-large."
The AFL-CIO explains that the hierarchy of controls has been adopted by industrial hygiene professionals, health and safety professionals, public health organizations, businesses and regulatory agencies throughout the U.S. and the world. Most notably, OSHA has incorporated the hierarchy of controls into every health standard it has issued, requiring that engineering and administrative controls be implemented first and fully to reduce exposures.
The AFL-CIO clarifies that the hierarchy of controls does not prohibit all respirator use: "OSHA’s Respiratory Protection Standard, 29 CFR 1910.34 states: 'Respiratory protection is a backup method which is used to protect employees from toxic materials in the workplace in those situations where feasible engineering controls and work practices are not available, have not yet been implemented, are not in themselves sufficient to protect employee health, or in emergencies.' However, respirators have significant limitations and deficiencies, and are less effective than engineering and work practice controls. In addition to exposing coworkers and others nearby to an infectious agent while wearing a respirator, it is difficult for workers to breathe, especially when performing heavy physical labor; respirators are uncomfortable to wear, especially in hot environments; and it is difficult for workers to communicate with each other, which compromises safety. Using respirators are difficult to implement -- they are required for every person, and the process for selecting, supplying and maintaining their effectiveness if done properly can be resource intensive. People do not always wear them correctly, sometimes do not have them available and respirators alone are not sufficiently protective for certain tasks."
The AFL-CIO asked the CDC to more strongly emphasize the hierarchy of controls in the proposed updated guideline and noted, "By updating and improving these guidelines, CDC has a significant opportunity to address the incidence and spread of occupational illness … we urge CDC to revise its guidelines to reflect current standards and practice to eliminate or reduce worker risks to biological exposures."
The IP's Role
The International Safety Center's Amber Hogan Mitchell suggests that infection preventionists have a role to play. "Infection prevention starts first with clinician self-care," Mitchell says. "The best way to protect patients from healthcare associated infections, is to first start with personal (clinician) infection prevention meaning careful attention to adherence to the hierarchy of controls, including the use of engineering controls, safe work practices, and better compliance with PPE use. If clinician infection prevention is in place and solid, it provides the foundation for a facility’s capability to best protect its patients from harm."