4. Medical Evaluations

Infection Control in Healthcare Personnel: Infrastructure and Routine Practices for Occupational Infection Prevention and Control Services (2019)

Background

Abbreviations
  • ACIP = Advisory Committee on Immunization Practices
  • ADA = Americans with Disabilities Act
  • CDC = Centers for Disease Control and Prevention
  • HCP = Healthcare Personnel
  • HIPAA = Health Insurance Portability and Accountability Act
  • HIV = Human Immunodeficiency Virus
  • OHS = Occupational Health Services
  • OSHA = Occupational Safety and Health Administration
  • PPME = Pre-Placement Medical Evaluation
  • TB = Tuberculosis

OHS provide or refer HCP for pre-placement medical evaluations (PPME) before starting job duties and for periodic and episodic medical evaluations during the course of employment in order to:

  • ensure HCP have recommended evidence of immunity to vaccine-preventable diseases[1,2];
  • assess and manage occupationally- and non-occupationally-acquired conditions and illnesses that affect HCP safety in the workplace;
  • prevent, evaluate, and manage potentially infectious exposures or illnesses acquired or transmitted by HCP in healthcare settings; and
  • provide individualized health counseling.

Health counseling for HCP can include topics such as:

  • the risk for and prevention of occupationally-acquired infections;
  • risk for, and prevention of, transmission of infections to others (e.g., HCP, patients, HCP family members);
  • strategies for the prevention and management of potentially infectious exposures and illnesses, such as the risks and benefits of postexposure prophylaxis and the importance of staying home when ill or potentially contagious to others; and
  • other HCP health concerns that may affect the risk of acquiring or transmission infections, such as pregnancy, HIV infection, or other immunocompromising conditions.

Pre-placement medical evaluations

The objectives of PPME can include:

  • Documenting the baseline health status of HCP.
  • Implementing measures to reduce HCP risk of acquiring or transmitting infections in healthcare settings, such as
    • ensuring HCP have recommended evidence of immunity to vaccine-preventable diseases[1,2];
    • providing or referring for preplacement testing (e.g., tuberculosis (TB) screening), if indicated[3,4]; and
    • providing or referring for medical clearance and respirator fit testing.
  • Assessing job placement and providing “clearance for duty.”
  • Informing HCP about OHS expectations, services provided, and confidentiality of health information.[5]

Periodic medical evaluations

These evaluations occur after job placement and address routine issues, such as follow-up on issues identified during the PPME, routine screening and testing,[1-3] immunization, and other recurrent services.

Episodic medical evaluations

These evaluations are precipitated by, and limited to, an event that warrants evaluation, such as a potentially infectious exposure. They enable OHS to manage HCP exposures or illnesses, including delivery of postexposure care and monitoring.

Delivery and access to medical evaluations

Ideally, OHS offers on-site clinical services, such as point-of-care testing (e.g., HIV testing), postexposure evaluation and follow-up after sharps injuries, and illness evaluations. On-site access to such services can hasten identification and management of potentially contagious illnesses, build HCP trust in OHS staff, and maintain the stability of the HCP workforce.[5] When OHS services are provided off-site, location and hours of availability can create challenges in providing timely service access to address urgent issues, such as postexposure evaluation after bloodborne pathogen exposures and determining the need for postexposure prophylaxis.[6]

Communication and confidentiality of information obtained in medical evaluations

OHS staff routinely need to communicate with other parts of the healthcare facility or system (see section 2. Communication and Collaboration). Electronic HCP records and databases can speed access to information and databases can facilitate functions such as risk assessments and performance measurements; however, appropriate confidentiality safeguards including strict control of access to information are important to ensure HCP data safety. Communication regarding the exchange of identifiable health information may be subject to authorizations (e.g., the Health Insurance Portability and Accountability Act (HIPAA))[8] or government regulations (e.g., OSHA) (see section 8. Management of Healthcare Personnel Health Records).

Selected requirements that affect the provision of medical evaluations

The Americans with Disabilities Act (ADA) prohibits employers from asking job applicants to undergo medical evaluations before making job offers, or from making pre-employment inquiries about disabilities. It also limits if and how employers may ask employees about medical illnesses and potential disabilities, and requires employers to provide “reasonable accommodation” to enable HCP to perform the essential functions of their jobs.[9] Some state and local governments have additional laws and regulations that specify medical or functional requirements for workers in healthcare settings.

The OSHA Bloodborne Pathogens standard requires that employees are offered hepatitis B immunization before starting work, and job-related postexposure evaluation and follow-up should an exposure to a bloodborne pathogen occur.[10] The OSHA Respiratory Protection standard requires initial medical evaluations as part of a respiratory protection program, as well as fit testing, training, and medical re-evaluations, when indicated, as described in the standard.[11]

Recommendations

See section 7. Management of Potentially Infectious Exposures and Illnesses for additional related recommendations.

For healthcare organization leaders and administrators

Number

Recommendation

Number

4.a.

Recommendation

Provide job descriptions with sufficient detail to assess job-related infection risks to occupational health services staff before the pre-placement medical evaluation.

For occupational health services leaders and staff

Number

Recommendation

Number

4.b.

Recommendation

Develop, review, and update when necessary, policies and procedures for providing preplacement, periodic, and episodic medical evaluations that include health assessments, screening and diagnostic testing, immunization services, exposure and illness management, counseling, and reporting of findings of medical evaluations.

Number

4.c.

Recommendation

For preplacement medical evaluations

Number

4.c.1.

Recommendation

Review each employee’s job description for duties that may affect risk of acquiring or transmitting infections in healthcare settings.

Number

4.c.2.

Recommendation

Collect a directed health inventory to assess:

  • history of medical conditions and other factors that may affect the risk of acquiring or transmitting infections in healthcare settings, and
  • evidence of immunity to vaccine-preventable diseases recommended for healthcare personnel by the Advisory Committee on Immunization Practices (ACIP).

Number

4.c.3.

Recommendation

Conduct or refer healthcare personnel for physical examination, as indicated, to assess medical conditions that might affect risk of acquiring or transmitting infections in healthcare settings.

Number

4.c.4.

Recommendation

Conduct or refer healthcare personnel for infectious diseases screening as recommended by CDC.

Number

4.c.5.

Recommendation

Test for evidence of immunity to vaccine-preventable infections as recommended by the Advisory Committee on Immunization Practices (ACIP).

Number

4.c.6.

Recommendation

Provide or refer healthcare personnel for services that reduce risks of infectious disease transmission (e.g., immunizations, medical clearance for respirator fit testing).

Number

4.c.7.

Recommendation

Provide or refer healthcare personnel for information regarding:

  • health conditions that may increase their risk of acquiring or transmitting infections in healthcare settings, and recommended actions to reduce those risks;
  • procedures for preventing and managing workplace exposures and illnesses;
  • work restrictions and sick leave policies; and
  • confidentiality of their health information.

Number

4.d.

Recommendation

For periodic medical evaluations

Number

4.d.1.

Recommendation

Provide additional doses of vaccines recommended for healthcare personnel by the Advisory Committee on Immunization Practices (ACIP).

Number

4.d.2.

Recommendation

Perform or refer healthcare personnel for indicated follow-up testing.

Number

4.d.3.

Recommendation

Conduct periodic screening for tuberculosis, if indicated, as recommended by CDC.

Number

4.d.4.

Recommendation

Provide or refer healthcare personnel for periodic respirator fit testing, if indicated.

Number

4.e.

Recommendation

For episodic medical evaluations, conduct or refer healthcare personnel for medical evaluations on an as-needed basis to:

Number

4.e.1.

Recommendation

evaluate and manage potentially infectious exposures and illnesses;

Number

4.e.2.

Recommendation

evaluate and manage new health conditions (e.g., pregnancy, rashes) that may affect risk of acquiring or transmitting infections or ability to perform job functions;

Number

4.e.3.

Recommendation

provide pre-placement medical evaluations for healthcare personnel who are changing job duties;

Number

4.e.4.

Recommendation

survey healthcare personnel for exposures and/or illness during outbreaks of infectious diseases in healthcare settings, if indicated.

References

  1. Advisory Committee on Immunization Practices; Centers for Disease Control and Prevention. Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2011 Nov 25;60(RR-7):1-45.
  2. Schillie S, Murphy TV, Sawyer M, et al. CDC guidance for evaluating health-care personnel for hepatitis B virus protection and for administering postexposure management. MMWR Recomm Rep 2013 Dec 20;62(RR-10):1-19.
  3. Jensen PA, Lambert LA, Iademarco MF, et al. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep 2005 Dec 30;54(RR-17):1-141.
  4. Mazurek, GH, Jereb J, Vernon A, et al. Updated Guidelines for Using Interferon Gamma Release Assays to Detect Mycobacterium tuberculosis Infection – United States, 2010. MMWR Recomm Rep 2010 Jun 25;59(RR-5):1-25.
  5. Russi M, Buchta WG, Swift M, et al. Guidance for Occupational Health Services in Medical Centers. J Occup Environ Med. 2009 Nov;51(11):1e-18e.
  6. Gershon RR, Qureshi KA, Pogorzelska M, et al. Non-hospital based registered nurses and the risk of bloodborne pathogen exposure. Ind Health. 2007 Oct;45(5):695-704.
  7. Joseph, HA, Shrestha-Kuwahara R, Lowry D, et al. Factors influencing health care workers’ adherence to work site tuberculosis screening and treatment policies. Am J Infect Control. 2004 Dec;32(8):456-61.
  8. Health Insurance Portability and Accountability Act of 1996. Public law 104-191pdf icon[PDF – 169 pages]external icon. 104th Congress. () Published August 21, 1996. Accessed August 20, 2019.
  9. Information and Technical Assistance on the Americans with Disabilities Actexternal icon. U.S. Dept. of Justice, Civil Rights Division. Accessed August 20, 2019.
  10. Standard 1910.1030 – Toxic and Hazardous Substances, Bloodborne Pathogensexternal icon. Occupational Safety and Health Administration. Revised April 3, 2012. Accessed August 20, 2019.
  11. Standard 1910.134 – Respiratory Protectionexternal icon. Occupational Safety and Health Administration. Revised June 8, 2011. Accessed August 20, 2019.