Ensuring Occupational Health: A Shared Partnership

By Kelly M. Pyrek

Occupational health in the healthcare environment sounds simple -- find ways to reduce the transmission of infections from patients to healthcare personnel and from personnel to patients, according to a document from the CDC's HICPAC in 1998. But more than a decade later, the job has become increasingly complex, as the hazards that healthcare workers face have escalated. Sharps injuries, bloodborne pathogen exposure, latex allergies, respiratory exposure -- these are just a few of the numerous hazards healthcare workers face daily.

These issues are reflected in a survey of Association of Occupational Health Professionals in Healthcare (AOHP) members conducted in August 2010 to identify healthcare workers top issues and concerns. AOHP released its 2011-2013 Public Policy Statement based on the survey results.

"AOHP conducts formal member surveys every five years and topic-specific surveys periodically," explains Sandra Domeracki, RN, FNP, COHN-S, executive president of the AOHP and regional manager of employee health services for Sutter Health West Bay Region-California Pacific Medical Center in San Francisco. "Practice standards and clinical guidelines have been the leading practice issues in the surveys. Public policy concerns have been bloodborne pathogens, safe patient handling, respirator use in healthcare and the healthcare work environment. These issues are inherent in occupational health in healthcare settings and will be ongoing issues as new treatments, techniques and even new organisms emerge."

In its 2011-2013 Public Policy Statement, AOHP advocates for a policy that supports a safer environment for employees via the use of safer technology, education, training and prevention regarding sharps injuries. AOHP is concerned about the underreporting of sharps injuries and it continues to work on these issues in conjunction with key partners such as the Occupational Safety and Health Administration (OSHA), the National Institute for Occupational Safety and Health (NIOSH) and the Centers for Disease Control and Prevention (CDC).

The AOHP also supports efforts to ensure a safer workplace for employees by utilizing systems and processes that are evidence-based and supported through research. The association advocates for increased research, training and education related to respiratory protection from tuberculosis (TB) and other airborne respiratory transmissible diseases. With AOHP and NIOSHs Memorandum of Understanding, a collaborative relationship has been developed with the National Personal Protective Technology Laboratory (NPPTL) in Pittsburgh, Pa., where groundbreaking healthcare-related research is being conducted to determine the scientific need for annual fit testing, general respirator use, respirator use in pandemics, and other areas related to respirator use in healthcare.

Occupational health is a shared partnership between a healthcare institution and its employees. "OSHA mandates that employers provide a safe working environment," says MaryAnn Gruden, MSN, CRNP, NP-C, COHN-S/CM, community liaison for the AOHP and manager of employee health services at Allegheny General and The Western Pennsylvania Hospitals, West Penn Allegheny Health System in Pittsburgh, Pa. "Both occupational health and infection prevention help to drive the effort to reduce occupational exposures for healthcare workers related to infectious diseases. In addition, there are a number of other hazards in the healthcare environment that must also be addressed. The Joint Commission and state departments of health drive the safety efforts for healthcare facilities and often these requirements are primarily related to patient safety. Time constraints and the focus on patient safety are the leading barriers to reducing occupational exposures. Although the OSHA standard holds the employer responsible for employee safety, it is also the employees responsibility to work in a safe manner and follow proper procedures and use personal protective equipment as indicated."

Occupational health is becoming an important part of many infection preventionists' job responsibilities, underscoring the connection that healthcare worker safety and health has with the prevention and control of infections caused by occupational exposures. Infection preventionists at acute-care hospitals are increasingly responsible for wearing the occupational-health hat, and Domericki addresses what they can do to better tend to the health and safety needs of healthcare workers.

"In the last two AOHP surveys, the respondents indicated that their primary role as organizational leaders was in employee/occupational health," she says. "Other leadership roles within the organization were in medical surveillance and workers compensation. Occupational health professionals collaborate on a daily basis with infection prevention colleagues and appreciate their great knowledge and expertise in this specialty. It is a challenge anytime one has to broaden his/her area of expertise and function in a dual role. There are a number of resources that are available through professional organizations such as Getting Started: Occupational Health in the Healthcare Setting published by AOHP. This document is also presented as a one-day workshop for the novice in occupational health in healthcare. It is a great resource as an overview of the scope of practice for the occupational health professional in healthcare."

Domericki adds, "Regardless of the professional who carries out the above roles, the primary focus for all healthcare providers, whether providing direct or indirect patient care, is for the patient to receive the highest quality and safest care for the best possible outcome."

Bolyard, et al. (1998) offer advice that never goes out of date: "The infection control objectives of the personnel health service should be an integral part of a healthcare organizations general program for infection control." These imperatives include:

- Educating personnel about the principles of infection control and stressing individual responsibility for infection control

- Collaborating with the infection control department in monitoring and investigating potentially harmful infectious exposures and outbreaks among personnel

- Providing care to personnel for work-related illnesses or exposures

- Identifying work-related infection risks and instituting appropriate preventive measures

- Containing costs by preventing infectious diseases that result in absenteeism and disability.

The CDC (1998) emphasizes, "These objectives cannot be met without the support of the healthcare organizations administration, medical staff, and other healthcare personnel."

One of the key ways healthcare workers can stay health for themselves and for their patients is to receive the proper vaccinations. Healthcare personnel vaccination recommendations include:

- Hepatitis B

- Influenza

- Varicella

- Measles, Mumps, and Rubella

- Tetanus, diphtheria, pertussis

- Meningococcal disease

- Tuberculin skin test

The Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC) organize recommendations for administration of vaccines and other immunobiologic agents to healthcare workers in three broad disease categories:

- Those for which active immunization is strongly recommended because of special risks for healthcare workers (i.e., hepatitis B, influenza, measles, mumps, rubella, and varicella)

- Those for which active and/or passive immunization of healthcare workers may be indicated in certain circumstances (i.e., tuberculosis, hepatitis A, meningococcal disease, typhoid fever, and vaccinia) or in the future (i.e., pertussis)

- Those for which immunization of all adults is recommended (i.e., tetanus, diphtheria, and pneumococcal disease)

Specifically for influenza vaccination of healthcare workers, Pearson, et al. (2006) make the following recommendations:

- Educate HCP regarding the benefits of influenza vaccination and the potential health consequences of influenza illness for themselves and their patients, the epidemiology and modes of transmission, diagnosis, treatment, and non-vaccine infection control strategies, in accordance with their level of responsibility in preventing healthcare-associated influenza.

- Offer influenza vaccine annually to all eligible HCP to protect staff, patients, and family members and to decrease HCP absenteeism. Use of either available vaccine (inactivated and live, attenuated influenza vaccine [LAIV]) is recommended for eligible persons. During periods when inactivated vaccine is in short supply, use of LAIV is especially encouraged when feasible for eligible HCP.

- Provide influenza vaccination to HCP at the work site and at no cost as one component of employee health programs. Use strategies that have been demonstrated to increase influenza vaccine acceptance, including vaccination clinics, mobile carts, vaccination access during all work shifts, and modeling and support by institutional leaders.

- Obtain a signed declination from HCP who decline influenza vaccination for reasons other than medical contraindications.

- Monitor HCP influenza vaccination coverage and declination at regular intervals during influenza season and provide feedback of ward-, unit-, and specialty-specific rates to staff and administration.

- Use the level of HCP influenza vaccination coverage as one measure of a patient safety quality program.

In light of recent outbreaks, in February 2011, members of the CDC's Advisory Committee on Immunization Practices (ACIP) voted to bring guidance for healthcare personnel in line with pertussis recommendations the ACIP issued for the general population in 2010. Healthcare workers who have not previously received the Tdap vaccine are advised to receive a single dose as soon as possible regardless of the interval since their last dose of tetanus and diphtheria toxoids (Td) vaccine.

References:

Bolyard EA, et al. Guideline for infection control in healthcare personnel, 1998. AJIC. Vol. 26, No. 3.

Immunization of Health-Care Workers: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR. December 26, 1997 / 46(RR-18);1-42.

Pearson ML, Bridges CB and Harper SA. Influenza Vaccination of Health-Care Personnel: Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP). MMWR. Feb. 24, 2006. 55(RR02);1-16.