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

3. 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

4. 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.

5. 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

6. 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

7. 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)

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

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

10. 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

11. 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

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

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

14. 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 , EP 4)

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

16. 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)

17. 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

18. 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

19. 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.

20. Tuberculosis (TB) Exposures
Unprotected exposures: initial testing at time of exposure; repeat 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

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

22. 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,

23. 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.

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

25. 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

26. Measles, Mumps, Rubella (MMR)
Adults born after 1957 and HCWs born before 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

27. 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

28. 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.

29. 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

30. 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

31. Hepatitis B Vaccine
Series of three immunizations (two doses four weeks apart; third dose five months after second)
Titers post-completion of series 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.

32. 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

33. 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)

34. 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