Recent study makes the assertion that illness transmission by healthcare employees represents a grave public health hazard.
By John Palmer
It’s no secret that that healthcare can be a dirty profession. So why is it that despite the warnings about the dangers of not wearing appropriate protection around hazardous drugs and infectious diseases, workers still choose to put themselves in danger?
It’s an interesting conundrum, and wearing the proper Personal Protective Equipment (PPE) is just as much for the protection of the patient as it is for the worker. In fact, a report published in the November 2017 issue of the American Journal of Infection Control found that as many as 4 out of 10 healthcare professionals show up at work even when they are sick with flu-like illnesses.
The study makes the assertion that illness transmission by healthcare employees represents a grave public health hazard.
Lead researcher Dr. Sophia Chiu called the findings “alarming” and cited an earlier study that showed patients exposed to a medical worker who is sick are five times more likely to get a healthcare-associated infection. “We recommend all healthcare facilities take steps to support and encourage their staff to not work while they are sick,” she added.
The survey of nearly 2,000 health workers during the 2014-2015 flu season interviewed doctors, nurses, nurse practitioners, physician assistants, aides, and others who self-reported flu-like symptoms at work such as fever and cough or sore throat.
“Healthcare personnel (HCP) working while experiencing influenza-like illness (ILI) contribute to influenza transmission in healthcare settings,” the report’s authors wrote. “Influenza infections are associated with thousands of deaths in the United States each year. Transmission in healthcare settings, where there is a higher concentration of elderly persons and individuals with immunosuppression or severe chronic disease, is a major concern.”
According to the report’s findings, of the people surveyed 414 (21.6%) of the workers reported flu-like symptoms, and 183 (41.4%) reported working with the symptoms for at least three days at a time. Pharmacists (67.2%) and physicians (63.2%) had the highest frequency of working with symptoms suspected to be the flu.
By work setting, hospital-based workers had the highest frequency of working with flu symptoms—more than 49%. The most common reasons given for working while sick included still being able to perform job duties and not feeling bad enough to miss work. Among workers at long-term care facilities, the most common reason was inability to afford lost pay.
So, what does this mean? Well, perhaps most revealing about the study is the prevalence of healthcare workers who think it’s acceptable to show up for work when they aren’t feeling well.
“Training to change social and cultural norms of HCP, such as the expectation to work unless experiencing severe symptoms among clinicians, might address these misconceptions,” the authors wrote. “Different strategies for modifying norms might be needed for different healthcare occupations. For example, physicians develop their sense of professional identity and adopt professional norms and values over a long period of training, which may differ from the experience of nonclinical HCP.”
In addition, the authors of the study came up with several suggestions that healthcare facilities can use to try to fight the problem of workers coming to work sick.
Make workplace policies clear. After listening to the reasons workers gave about why they came to work sick, including the ubiquitous “I could still perform my job duties,” and “I wasn’t feeling bad enough to miss work,” it became clear that individuals may not be the best ones to make the decision about whether they should work. For that reason, the authors stressed that there should be a clear policy and culture that stresses the importance of infection control in the healthcare workplace.
“Employers can convey that the perspective of infection control at the institutional level is important for HCP to consider when deciding whether to work during (an illness),” according to the report. “For example, one academic medical center instituted a triage system requiring HCP with fever or upper respiratory symptoms to undergo evaluation and viral testing. This system provided symptomatic HCP with more information regarding their risk to others. This institution also instituted mandatory absence from work for at least 7 days if testing was positive for influenza.”
Make it easier to take sick time. Many healthcare workers interviewed in the survey said did not take time off from work when they were sick because they were could not afford to lose pay for time off. This may mean that you need to consider a change in policy for sick time. The reports authors suggested institution-level resources to accommodate sick leave, including a “jeopardy system” in which some workers are held in reserve to back up sick colleagues.
This “may help reduce common perceived barriers to taking sick leave when the risk of transmission to others is taken into account,” the report said. “Such barriers include difficulty in finding coverage and desire to not burden colleagues.”
Make the flu shot mandatory, but remember that it isn’t a guarantee. Many facilities encourage their workers to get the flu shot every year, and in fact some make it mandatory. The report’s authors claimed that the fact that a worker received the flu vaccination at any time during the 2014-2015 influenza season may have contributed to the decision to come to work, even with symptoms. In other words, their perception is that there is no way they could have the flu if they’ve gotten the shot, which of course is not the case. Workers should be educated about the flu vaccine, and again, should be encouraged not to come to work if they feel sick.
In many places, it’s still not legal to require flu shots for employees, and if unions get involved it’s a much more complicated issue. Many people still have religious requirements, or moral protests against required flu shots. But the truth is that the flu shot has been proven to be safe and extremely effective.
Therefore, employees who work with patients should be encouraged to get a flu shot each year. In most cases, the flu vaccinations are free, and they really will make things healthier in your facility. Statistics show that those who get the shot stay healthier with very little risk of side effects. That translates to healthier workers who can come to work and not get patients sick. At the very least, there must be a very strict policy in place preventing patient contact when workers are sick, and in all cases, they must wear face masks when working anywhere around patients with compromised immune systems.
During the winter months, you should encourage workers to stay healthy. Your staff cannot help patients when they are not well, so encourage them to keep healthy by living a healthy lifestyle. They should be washing their hands regularly, eating well, and getting plenty of sleep—and staying home when they are sick. They should be getting plenty of exercise, downtime, and time to spend with their families and pursuing hobbies.
Make PPE mandatory, and train more. It should be common sense, and common practice, for anyone who works in healthcare that PPE is part of the job. Yet for some reason, workers still come up with every excuse not to use it.
Over the years, PPE—and standards from OSHA and other regulators—have been developed to help reduce and prevent workers from getting hurt or sick on the job. Yet, every year, we hear more about how healthcare workers have some of the highest workplace injury rates in any industry in the United States. To make things worse, every so often an illness rarely, if ever, seen in the U.S. makes its way into the country’s healthcare facilities (think MERS in 2012 or Ebola in 2014) and changes the way the healthcare community looks at PPE. In addition, training often takes a back seat because of shrinking budgets and lack of time.
“PPE does not remove the hazards; it protects the individual,” says Marjorie Quint-Bouzid, MPA, RN, NEA-BC, who currently serves as vice president of nursing at Parkland Hospital and Health System in Dallas. “Healthcare organizations must continue to attempt to mitigate potential hazardous situations or practices as the first line of defense.”
The trouble doesn’t stop with infection control. Pharmacists who handle hazardous drugs, and the nurses who then administer them, are at high risk of occupational exposure. These exposures can cause acute health effects, from sore throats to hair loss; allergic reactions; cancer; and reproductive toxicity—including an increased risk of miscarriage.
A 2011 National Institute for Occupational Safety and Health (NIOSH) survey reported that the most common reason given for failing to wear gloves was that “skin exposure was minimal”—an opinion at odds with various biological measures of worker exposures.
In 2011, NIOSH surveyed 2,069 healthcare workers—most of them nurses—who had administered one of more than 90 specific antineoplastic drugs in the previous week about their adherence to safe work practices. According to the survey, which was published in the Journal of Occupational and Environmental Hygiene in 2014, workers reported that they had engaged in risky activities or been exposed to hazardous drugs by incidents that included:
- Failing to wear a nonabsorbent gown with closed front and tight cuffs (42%);
- Priming intravenous (IV) tubing with the antineoplastic drug (6% had done this themselves; another 12% reported that this was done by the pharmacy);
- Taking potentially contaminated clothing home (12%);
- Spills or leaks of antineoplastic drugs during administration (12%);
- Failing to wear chemotherapy gloves (12%); and
- Lack of hazard awareness training (4%).
When NIOSH asked healthcare workers why they did not wear their personal protective equipment (PPE), including double gloves and gowns, while compounding or administering hazardous drugs, it found that workers were essentially shrugging off the risk. “Skin exposure is minimal” was the most common answer to the question, followed by “not part of our protocol” and “not provided by employer.” The researchers concluded that “there is a perception among respondents that chemotherapy drugs pose a minimal exposure risk.” In addition, workers reported that employers failed to implement safe work practices and provide PPE in many cases.
John Palmer is a contributing writer to PSQH.