1. Leadership and Management

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

Background

Abbreviations
  • CMS = Centers for Medicare & Medicaid Services
  • CoP = Conditions of Participation
  • HCO = Healthcare Organization
  • HCP = Healthcare Personnel
  • IPC = Infection Prevention and Control
  • OHS = Occupational Health Services
  • OSHA = Occupational Safety and Health Administration
  • PPE = Personal Protective Equipment

Leader(s) of OHS oversee the delivery and monitor the quality of occupational IPC services. Planning and decision-making can be shared with other parts of the organization, including human resources, facility IPC services, facilities management, and environmental services. HCO leadership support for OHS leaders is critical for facilitating intra-organizational collaboration and the effective provision of occupational IPC services.

OHS leaders improve the delivery and quality of occupational IPC services by:

  • developing both routine and emergency response policies and procedures for occupational IPC services,
  • providing accountability for occupational IPC service delivery and quality,
  • engaging in continuous quality improvement activities that improve OHS, and
  • fostering collaboration with other departments or programs that address IPC.

Ensuring the provision of high-quality occupational IPC services can have many benefits, including:

  • improvement of HCP health, job satisfaction, and morale,[1]
  • support for a HCO safety culture,
  • prevention of HCP infections and enhancing the health of patients and others (e.g., co-workers, family members) with whom HCP interact, and
  • economic savings for the OHS and HCO.

The leadership and management of OHS vary widely depending on HCO structure, the location of services with respect to HCP served, facility types and sizes, clinical activities, and HCP characteristics. These variations can affect how, and where, services are provided to HCP. Several organizations provide profession-specific certifications in occupational medicine that include occupational IPC services. For instance, the American Board of Preventive Medicine offers Certification in Occupational Medicine, and the American Board for Occupational Health Nurses offers credentialing as a Certified Occupational Health Nurse and as a Certified Occupational Health Nurse-Specialist. Additional training for OHS leaders and staff focusing on occupational IPC can be developed by an individual HCO or OHS to address the specific needs of their work settings.

Compliance with requirements and standards

OHS leaders may be responsible for ensuring alignment with practice standards, such as clinical guidelines, as well as federal, state, and local requirements. Examples of federally mandated services include, but are not limited to, implementing all applicable requirements of the OSHA Bloodborne Pathogens standard, including annual updates of exposure control plans and providing exposure management services to employees, and implementing applicable Personal Protective Equipment standard requirements for PPE, including training and demonstration of competency.[2-4]

In addition, OHS leaders can ensure alignment with HCO goals for accreditation and reimbursement. For example, The Joint Commission requires that facilities set goals for incremental influenza immunization for HCP,[5] and Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoP) include requirements that hospitals identify and track selected communicable diseases among HCP.[6] The Joint Commission also has standards that require HCOs to work to prevent transmission of infectious diseases among patients, licensed independent practitioners, and staff.

Performance measurement and quality improvement

Performance measures are objective metrics of various aspects of a service’s performance, such as service delivery or outcomes. They can be used to inform OHS and HCO leadership when occupational IPC services are not meeting goals, support the identification of areas for improvement, and quantify progress on quality improvement initiatives by examining trends over time. Regulatory and accreditation groups, payers, and purchasers can require performance measurement or quality improvement activities for OHS, such as the CMS requirement to report HCP influenza immunization coverage as a CoP.[7] Box 1. Examples of Performance Measures lists examples of performance measures for occupational IPC services; some can be used as measures for more than one service. Quality improvement (see section 3. Assessment and Reduction of Risks for Infection among Healthcare Personnel Populations) includes the identification and mitigation of barriers to success, such as access to care, quality of services, or other factors, such as staff awareness of when to seek OHS care.

Emergency planning and outbreak response

The transmission of emerging pathogens to HCP has been reported with increased frequency and highlights the importance of OHS participation in HCO planning for such events. Examples include HCP infections with pandemic influenza,[8] Middle East Respiratory Syndrome Coronavirus,[9] and Ebola Virus.[10] Providing care for patients infected with emerging pathogens can necessitate non-routine occupational IPC services, such as training HCP to use new PPE ensembles,[11] clinical and safety monitoring of HCP providing patient care,[12] and offering postexposure care. Similarly, outbreaks that involve HCP can require OHS assistance with contact tracing efforts, disease screening among HCP, and other activities (see section 7. Management of Potentially Infectious Exposures and Illnesses).

Recommendations

See section 2. Communication and Collaboration for additional related recommendations.

For healthcare organization leaders and administrators

Number

Recommendation

Number

1.a.

Recommendation

Invest in an organizational culture that prioritizes safety and occupational infection prevention and control.

Number

1.b.

Recommendation

Regularly review organizational information about occupational infectious risks, exposures, and illnesses with occupational health services.

Number

1.c.

Recommendation

Dedicate one or more persons with appropriate authority and training to lead occupational infection prevention and control services.

Number

1.d.

Recommendation

Provide sufficient resources (e.g., expertise, funding, staff, supplies, information technology) to implement elements of occupational infection prevention and control:

  • Leadership and management,
  • Communication and collaboration,
  • Assessment and reduction of risks for infection among healthcare personnel populations,
  • Medical evaluations,
  • Occupational infection prevention and control education and training,
  • Immunization programs,
  • Management of potentially infectious exposures and illnesses, and
  • Management of healthcare personnel health records.

Number

1.e.

Recommendation

Oversee, and include occupational health services leaders in, performance measurement and continuous quality improvement activities for occupational infection prevention and control services.

For occupational health services leaders and staff

Number

Recommendation

Number

1.f.

Recommendation

Promote an organizational culture with a consistent focus on safety and occupational infection prevention and control.

Number

1.g.

Recommendation

Develop occupational infection prevention and control services that are tailored to the needs of healthcare personnel and the environment in which they work.

Number

1.h.

Recommendation

Develop, review, and update when necessary, written policies and procedures that adhere to federal, state, and local requirements for elements of occupational infection prevention and control services:

  • Leadership and management,
  • Communication and collaboration,
  • Assessment and reduction of risks for infection among healthcare personnel populations,
  • Medical evaluations,
  • Occupational infection prevention and control education and training,
  • Immunization programs,
  • Management of potentially infectious exposures and illnesses, and
  • Management of healthcare personnel health records.

Number

1.i.

Recommendation

Inform all healthcare personnel and relevant healthcare organization departments about occupational infection prevention and control policies and procedures.

Number

1.j.

Recommendation

Collaborate with appropriate healthcare organization departments and individuals to:

Number

1.j.1.

Recommendation

Achieve compliance with regulations related to occupational infection prevention and control.

Number

1.j.2.

Recommendation

Develop infectious disease emergency and outbreak management plans.

Number

1.j.3.

Recommendation

Develop and monitor performance measures for occupational infection prevention and control services that include the proportion of healthcare personnel with documented evidence of immunity and the proportion of healthcare personnel vaccinated, as appropriate, for each vaccine-preventable disease recommended for healthcare personnel by the Advisory Committee on Immunization Practices (ACIP).

Number

1.j.4.

Recommendation

Set and meet quality improvement goals for occupational infection prevention and control services and report performance measures and areas for improvement to management.

Number

1.j.5.

Recommendation

Periodically assess the effectiveness of occupational infection prevention and control services.

References

  1. Hospital eTool: Administrationexternal icon. Occupational Safety and Health Administration. Accessed August 20, 2019.
  2. Standard 1910.1030 – Toxic and Hazardous Substances, Bloodborne Pathogensexternal icon. Occupational Safety and Health Administration. ) Revised April 3, 2012 Accessed August 20, 2019.
  3. Standard 1910.134 – Respiratory Protectionexternal icon. Occupational Safety and Health Administration. Revised June 8, 2011. Accessed August 20, 2019.
  4. Standard 1910.132 – Personal Protective Equipmentexternal icon. Occupational Safety and Health Administration. Revised November 8, 2016 Accessed August 20, 2019.
  5. Standard IC.02.04.01 Influenza Vaccination for Licensed Independent Practitioners and Staff (HAP, CAH, LTC)external icon. The Joint Commission. Published December 2, 2011 Accessed August 20, 2019.
  6. State Operations Manual Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitalspdf icon[PDF – 546 pages]external icon. Centers for Medicare & Medicaid Services, U.S. Dept. of Health and Human Services. Revised October 12, 2018. Accessed August 20, 2019.
  7. National Healthcare Safety Network (NHSN). CMS Requirements. Centers for Disease Control and Prevention. Revised August 9, 2019. Accessed August 20, 2019.
  8. Wise ME, De Perio M, Halpin J, et al. Transmission of pandemic (H1N1) 2009 influenza to healthcare personnel in the United States. Clin Infect Dis. 2011 Jan 1;52 Suppl 1:S198-204.
  9. Hunter JC, Nguyen D, Aden B, et al. Transmission of Middle East Respiratory Syndrome Coronavirus Infections in Healthcare Settings, Abu Dhabi. Emerg Infect Dis. 2016 Apr;22(4): 647-56.
  10. Chevalier MS, Chung W, Smith J, et al. Ebola virus disease cluster in the United States–Dallas County, Texas, 2014[Erratum appears in MMWR Morb Mortal Wkly Rep. 2014 Dec 5;63(48):1139]. MMWR Morb Mortal Wkly Rep. 2014 Nov 21;63(46):1087-8.
  11. Guidance on Personal Protective Equipment (PPE) To Be Used By Healthcare Workers during Management of Patients with Confirmed Ebola or Persons under Investigation (PUIs) for Ebola who are Clinically Unstable or Have Bleeding, Vomiting, or Diarrhea in U.S. Hospitals, Including Procedures for Donning and Doffing PPE. Centers for Disease Control and Prevention. Reviewed August 30, 2018. Accessed August 20, 2019.
  12. Notes on the Interim U.S. Guidance for Monitoring and Movement of Persons with Potential Ebola Virus Exposure. Centers for Disease Control and Prevention. Accessed August 20, 2019.

Box 1. Examples of Performance Measures that Might Be Used to Assess the Effectiveness of Occupational Infection Prevention and Control Services[a, b]

Selected examples of performance measures that might be used to assess the effectiveness of occupational infection prevention services.
Occupational Infection Prevention and Control Services Examples of Performance Measure(s)
Assessment and Reduction of Risks among HCP Populations
  • Number of HCP who sustain potentially infectious exposure events
  • Number of HCP infectious exposure events through specific mechanisms (e.g., bloodborne pathogen exposures from sharps injury and mucosal exposure, or inappropriate, malfunctioning, or non-use of PPE)
  • Number of HCP who develop infections as a result of occupational exposures
Medical Evaluations
  • Proportion of HCP who underwent preplacement evaluations
  • Proportion of HCP who completed screening for latent TB infection, when recommended by CDC
  • Proportion of HCP using N-95 respirators who received annual fit testing
Occupational IPC Education and Training Programs
  • Proportion of HCP who completed initial and annual refresher occupational IPC education and training
Immunization Programs [c]
  • Proportion of HCP with documented evidence of immunity to each vaccine-preventable disease recommended for HCP by ACIP
  • Rates of completed HCP vaccination, when indicated, for each vaccine recommended for HCP by ACIP
Management of Potentially Infectious Exposures and Illnesses
  • Proportion of HCP who sustained infectious exposures and were offered postexposure prophylaxis within recommended timeframes

Footnotes

  1. See section 3. Assessment and Reduction of Risks for Infection among Healthcare Personnel Populations for further information regarding how to approach assessments and interventions to improve performance measures that do not meet goals.
  2. Some examples in this box correspond with activities required by the Occupational Safety and Health Administration (OSHA).
  3. The NHSN Surveillance for Healthcare Personnel Vaccination page provides information on reporting HCP influenza immunization coverage to NHSN.