Employee Health Program Requirements for ASCs Mary T. Post, RN, MS, CNS, CIC Infection Prevention Specialist Oregon Patient Safety Commission

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Objectives List three elements of an employee health (EH) program that should be included in your Infection Prevention Program (IPP) Plan Describe two recently published guideline changes for immunization and screening of healthcare workers Identify three post-exposure interventions to follow after an occupational exposure to potential bloodborne pathogen viruses and TB

CMS Requirement: ASC Identifies Risks for Acquiring & Transmitting Infections Include employee related data in your analysis: Percentage of individuals compliant with TB screening policy If applicable, number of TB employee conversions Number of unprotected communicable disease exposures Blood and body fluid exposure/sharps injury rates Employee compliance rates with immunizations and screenings Essential to think out of the box- beyond immunizations/screenings. How Employee Health Programs can partner with ICP’s to promote communication, education, data for successful organizations.

Set Goals Based on Identified Risks Limit unprotected exposure to pathogens (PPE, hand hygiene) Limit the transmission of infections associated with the use of medical equipment, devices (sharp safety), and supplies

CMS Requirement: ASC Has an Infection Prevention Plan Include employee infection prevention data and goals Include employee exposures/potential source for possible disease outbreaks Occupational health programs may assist with communication of responsibilities to licensed independent practitioners (LIPs) and staff; if service is contracted, be certain contractor’s role is well defined

Role of employee health programs in pandemics: CMS Requirement: ASC Prepares to Respond to Influx of Potentially Infectious Patients Emergency Management Role of employee health programs in pandemics: Exposure management Employee illness tracking/evaluations Vaccinations Respiratory protection (N95 masks)

Implementing IPP Plan Communicate responsibilities to LIPs and staff; include hand and respiratory hygiene Report, share employee infection prevention data with LIPs and staff

ASC Infection Prevention Policies The ASC has policies and procedures to prevent the transmission of infectious disease among patients, licensed independent practitioners, and staff.

Immunizations and Screening Screening for exposure and/or immunity to infectious diseases should be available to LIPs and staff Tuberculosis screening Screening for vaccine preventable diseases

Ill Provider Policies If suspected of having an infectious disease that places others at risk, must have a system to provide or refer LIPs/staff for assessment, potential testing, prophylaxis/treatment, or counseling

Exposure Follow-up and Treatment Refer or provide assessment and potential testing, prophylaxis/treatment, or counseling to staff or LIPs with occupational exposures

Influenza Vaccination The ASC offers vaccination against influenza to licensed independent practitioners and staff

Influenza Vaccination Program Educates LIPs and staff Influenza vaccine Non-vaccine control and prevention measures Diagnosis, transmission, impact Accessible sites Evaluates rates and reports to state Declination reasons Improves vaccination rates licensed independent practitioners and staff about, at a minimum, the influenza vaccine; non-vaccine control and prevention measures; and the diagnosis, transmission, and impact of influenza. (See also HR.01.04.01, EP 4)

Interventions for select communicable diseases Post-occupational Exposure Interventions for select communicable diseases

Exposure Determination Verify the diagnosis and patient infectivity Determine if PPE worn by healthcare workers (HCWs) Identify the exposed HCWs Determine if the individual is susceptible Determine appropriate disease specific post-exposure follow-up Always use as a “teachable moment” Promote your program and resource needs Go to the source to determine diagnosis- confirm lab. Work with IC team to determine if patient was actually infectious (Varicella may be crusted, TB treated with no AFB’s on smear, may have another type of meningitits).Disease specific follow up may be (i.e., monitor clinical symptoms, work restrictions, prophylaxis)

What to do if You Have a Blood or Body Fluid Exposure 1. Wash the area well with soap and water 2. Flush eyes well with water if splashed Immediately report accident according to your facility’s policy Encourage employee to bring patient name, medical record number, and any known HIV risk factors for post-exposure prophylaxis (PEP) consideration Employers are required to provide confidential and free baseline and follow up lab testing and counseling

Blood & Body Fluid Exposures Lab Work Exposed employee Hepatitis B surface antibody HIV Elisa/EIA Hepatitis C antibody Repeat at 6 and 12 weeks and 6 months based on source patient lab results Source patient Hepatitis B surface antigen HIV ELISA/EIA standard Rapid HIV (consider) * HBSab if none on file. Extend HIV testing to 12 months if employee becomes HCV positive post-exposure

HIV Post-exposure Prophylaxis If indicated, start PEP (drugs) as soon as possible Reevaluate 72 hours after exposure Be familiar with agents, their side effects, contraindications, and the management of toxicity Anticipate toxicity labs for renal/hepatic failure, complete blood count Counsel employee on risks and symptoms of bloodborne pathogens OHSU uses Kaletra (two 200/50 mg tablets twice a day) and /truvada (300 mg. q day) – reevaluate-(labs back, more information about exposure)Drugs often cause diarrhea, nausea, vomiting. Truvada may cause serious liver and kideny problems, rash, Interacts with many antiviral agents. Kaletra may cause increase in cholesterol/triglycerides. Drug interactions- viagra, antihistamines, sedatives, anti-cholesterol and anti-fungal drugs, St. Johns Wort. Pregnant or breast feeding, malignancy, ill health, Be prepared to presribed antiemetic and antimobility agents. Men or women should practice safe sex, don’t donate blood, semen or tissue until f/u is negative, avoid substance abuse, should complete their drug regimen.

Tuberculosis (TB) Exposures Unprotected exposures: initial testing at time of exposure; repeat 10-12 weeks post-exposure Employees should monitor for symptom onset Usually have “teachable moments” with possible TB exposures Two-step testing for baseline on employment has shed light on conversions Manage convertors to r/o active TB, place on INH

Immunizations for Healthcare Workers MMWR January 14, 2011 Recommended Adult Immunization Schedule, United States Immunizations for Healthcare Workers

Contraindications As always, check the vaccinations for age exclusions, allergy exclusions, underlying medical condition exclusions, and other possible vaccination contraindications Tdap, Live Influenza vaccine have age exclusions,

Tetanus, Diptheria, and Acellular Pertussis (Td/Tdap) Tdap should replace a single dose of Td for adults who have not received Tdap (can now be given if > 64) Tdap for unvaccinated pregnant women (preferably during the third or late second trimester), close contacts of infants aged < 12 months, HCWs Direct patient care HCWs: interval = 2 years since Td suggested, but can be shorter Focus for HCW’s has moved away from risk groups- now recommended for all.

Varicella Vaccination Adults without immunity should have 2 doses total HCWs have contact with persons at high risk of disease and should be immune

Varicella Documentation of Immunity (HCWs) Documentation of two doses of varicella at least four weeks apart Laboratory evidence of immunity or confirmation of disease History of varicella or zoster based on diagnosis or verification of varicella by a healthcare provider Atypical or mild case of varicella, seek epidemiologic link

Measles, Mumps, Rubella (MMR) Adults born after 1957 and HCWs born before 1957 without immunity: Should consider vaccinating personnel with 2 doses of MMR at the appropriate interval (Measles, Mumps) and 1 dose Rubella During outbreaks, healthcare facilities should recommend workers receive 2 doses of MMR (Measles, Mumps) and 1 dose Rubella Measles Mumps Rubella

MMR Documentation Second dose of MMR recommended for HCWs Documentation of vaccination(2 dose mumps and measles, 1 dose rubella) Laboratory evidence of immunity Documentation of physician-diagnosed measles or mumps

Seasonal Influenza Vaccination Occupational: all healthcare personnel (including those employed by long term care and assisted living facilities) and caregivers of children aged < 5 years should receive annual influenza vaccinations New high-dose vaccine approved for > 65 years Name of the new Influenza vaccine.

Influenza Vaccine HCWs may receive either inactivated influenza vaccine (IIV) or live attenuated influenza vaccine (LAIV) Restrict HCWs from care of patients in protective environments for 7 days post-LAIV

Hepatitis B Vaccination HCWs who are exposed to blood or other potentially infectious body fluids per OSHA Recommended for all adults in many ambulatory practice areas Safe vaccine No booster doses are currently recommended Should be offered- or have them sign declination form or waiver. Ambulatory practice areas-(i.e., STD treatment facilities, HIV testing and treatment facilities, drug-abuse treatment and prevention services, correctional facilities, etc.)V

Hepatitis B Vaccine Series of three immunizations (two doses four weeks apart; third dose five months after second) Titers post-completion of series 1-2 months later Non-responders repeat 3rd dose 4-6 months after the second dose. Accelerated dose-8 weeks minimum between 2nd and 3rd dose. Non-responders convert 15-25% after 4th dose, 30-50% after three additional doses. Fewer than 5% of persons receiving 6 doses of Hep B vaccine administered appropriately, fail to develop detectable anti-HBs antibody.

Oregon ASC Employee Health Program Findings Evidence in personnel records of new employee TB screening and Hepatitis B immunization within 30 days of employment was not present

Toolkit Contents Screening and Immunizations for Vaccine-preventable Diseases and Tuberculosis Policy (6.01) Declination of Influenza and Hepatitis B Forms (6.02a-b) Tuberculosis Screening Documentation Form (6.03) HCW Communicable Disease Illness Policy (6.04) Occupational Exposure to Communicable Diseases Policy and Procedure (6.05) Blood & Body Fluid Exposure Policy (6.06) Blood & Body Fluid Exposure Documentation Form (6.07)

Conclusion The ASC’s employee health program: Plays an important role in assuring patient safety and a safe work environment Is an essential component of the Infection Prevention Program (IPP) and should be reflected in the organization’s IPP Plan