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 thiscountry. They work in traditional settings such as hospitals and nursing homes, butfrequently work outside of these areas in places such as homes and clinics. They aredirect caregivers such as doctors, nurses, respiratory therapists and non-direct caregivers like laboratory staff, central supply staff and pharmacists. They can also bestudents, volunteers, researchers and contracted personnel. All of these persons have thepotential 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 exposurerisks for the staff. Infection control policies and practices for persons who work inhealthcare are important to prevent infections and their spread, guide staff in theirbehavior, and ensure a safe environment of care for both the patient and staff. Makingthat happen involves several coordinated efforts between practitioners and management.

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

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

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

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

Immunization programs play an important role in preventing infections from occurring inHCWs. Whether a researcher in the animal lab or a doctor in the emergency room, optimaluse of vaccines can prevent transmission of vaccine-preventable diseases and eliminateunnecessary illness and work disruptions. An immunization program is far more costeffective than case management and outbreak control. More often than not, however, themost effective way to have employees protected is to mandate the vaccines. Nationalguidelines for immunization of and postexposure prophylaxis of healthcare personnel areprovided by the US Public Health Service's Advisory Committee on Immunization Practices.These guidelines also contain valuable information on the epidemiology ofvaccine-preventable diseases, the safety and efficacy of vaccines and immune globulinpreparations and recommendations for immunization of immune-compromised individuals. Theguidelines include risk assessment of exposure, screening to determine susceptibility andrecord-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 inworkers is important so that the facility can take action. Policies need to be designed toencourage personnel to report their illnesses or exposures. This means that managementneeds to support employees and not penalize them with loss of wages, benefits or jobstatus. One action that facilities frequently take when a healthcare worker reports anillness 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 fromactivities outside the facility. Personnel who are excluded from duty should avoid contactwith susceptible persons both in the community and the facility. Exclusion policies shouldinclude a statement of authority defining who may exclude personnel. Workers' compensationlaws 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 arenot able to work. Notification of emergency-response personnel possibly exposed toselected 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 followup and prevent the spread of the disease. There should be clear delineation of who is tobe notified, maintenance of records, data management and confidentiality. The OccupationalSafety and Health Administration (OSHA), in their 1991 OSHA "Occupational Exposure toBloodborne Pathogens; Final Rule" requires employers, including health carefacilities, to establish and maintain an accurate record for each employee withoccupational exposure to bloodborne pathogens. The regulation goes on to require that eachemployer ensure that an employee's medical records are kept confidential, not disclosed orreported without the employee's express written consent to any person within or outsidethe workplace, except as required by law, and maintained by the employer for at least theduration of the worker's employment plus 30 years.

Health counseling along with medical management of the ill worker is another crucialelement for effectively handling infections or exposure to infection. Health counselingprovides individually-targeted information regarding risk factors, how to preventtransmission to others, risk of long term illness or other adverse outcomes, how thedisease/exposure will be medically managed and consequences to others both inside andoutside the facility.

Specific handling of infectious diseases and/or exposure can be found in the AJICspecial article "Guideline for Infection Control in Health Care Personnel,1998." This extensive guideline discusses educational needs, prevention issues andspecial populations of employees such as the pregnant HCW, laboratory workers, emergencyresponse workers, immunocompromised workers, latex sensitive personnel and persons coveredunder the Americans with Disability Act. These guidelines provide an excellent resourcefor assisting in the development of policies and practices for infection control in HCWs (Table3).

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)

Although much is written about preventing and managing infections in HCWs, the successor lack of success of a program usually comes down to the communication betweensupervisors and workers and the relationship among the group. If personnel fear beingpenalized for reporting signs and symptoms of infectious disease or if there is reprisalfor staying away from the job and creating staffing shortages, then employees will behavecounter to the best interest of the employer and themselves. These barriers to infectioncontrol and prevention in the work force can be alleviated by communication andcollaboration on the policies and practices developed by the facility. When departmentsupervisors understand the intent of the policy and the importance of their support inimplementing it, this is more likely to be passed on to the employees as expectedbehavior. One of the most frequently cited reasons for coming to work sick is staffingshortages or disruptions caused by call-ins. To address this for employees andsupervisors, the head of each department should have a staffing plan that includescontingency plans for absenteeism due to illness. Variance data should be kept andreviewed periodically to determine how well the staffing plan is working for thedepartment and changes made as necessary. If this looks a lot like a quality improvementactivity, 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 healthcarefacilities. There are numerous activities that ensure the prevention of transmissiblediseases. There are practices to help control an outbreak of an infectious disease. Thereare guidelines to assist with educational programming and policy development. Combiningthe use of these tools with communication and cooperation between and among healthcareworkers will support the goal of infection control in healthcare--wherever the setting.