Employee Health Service Research Articles

Challenges in Managing a Tuberculosis Exposure in a High Risk Unit

ISSUE: In spite of ongoing heightened awareness, tuberculosis continues to be a challenging infection control problem. This paper summarizes a recent experience on the exposure and control of tuberculosis in a high risk unit. In September 2005, a patient was admitted through the ER to a negative pressure medical ICU. Chest X-ray showed a cavitary lesion and sputum was AFB positive, subsequently confirmed as Mycobacterium tuberculosis. One month earlier, this patient was admitted to a semi-private room on the oncology unit for 10 days due to subclavian thrombosis. During the August admission, a chest X-ray report of a "suspicious cavitary lesion" was not communicated by the referring care center. PROJECT: Patients within the area of the index patient, hospital staff who cared for the index patient during the August admission and everyone in adjacent units during this time period were identified. A total of 133 inpatients and 252 hospital staff were offered tuberculin skin testing (TST) at baseline and 8-14 weeks post exposure, and chest X-ray. Baseline chest X-rays taken during the August admission were compared to follow-up studies. At baseline, employee TST was repeated if last performed more than three months prior to the exposure and at three months post exposure. RESULTS: Two patients were TST screen positive, chest X-ray negative and asymptomatic. These patients were on the cardiology floor below oncology, with shared air circulation and considered to be in a "lower risk" area. Isoniazid was offered to these patients but was declined by their primary care physicians. One hospital staff member converted to positive at TST screen from the last annual test and was placed on Isoniazid. All three TST reactors had risk factors inclusive and exclusive of this exposure. Sixty patients completed screening. However, 73 patients did not complete screening due to death/palliative care (24), declined (31) or were lost to follow-up (18). The Infection Control team and administration met with the admitting physician to discuss further preventive strategies. LESSONS LEARNED: Effective preventive strategies are needed including ongoing education of the hospital staff in high risk areas for admission assessment of possible TB. Ongoing communication in the continuum of care among health care personnel working in high risk areas, primary care physicians, Infection Control and Employee Health Services is critical to preventing accidental exposure to TB.

The MSLT and MWT Should Not Be Used for the Assessment of Workplace Safety

There is good evidence that the Multiple Sleep Latency Test (MSLT) and, to a lesser extent, the Maintenance of Wakefulness Test (MWT) are both reliable and valid measures of changes in sleep tendency in individuals exposed to sleep deprivation. The MSLT has been used extensively in both research and clinical settings for almost 30 years. It is only natural to wish to extend the use of these tests to other environments in which determination of alertness is essential. In research settings, group differences, often based upon large numbers of individuals, are identified at given levels of probability. However, in clinical practice, the focus is on the individual patient, and group information may be limited by individual variability. When one considers public safety, the focus shifts even more to include not only individuals, but also occupational groups, legislative bodies, employers, and unions. Even the most elegant test of alertness will be of no use in the face of work schedules that violate circadian adaptation or require chronic sleep deprivation or exempt themselves as too important or not subject to universal physiologic rules. A safe workplace requires the presence of specific items such as fire extinguishers and the absence of specific items such as fire arms and alcohol. Unfortunately, society has not accepted that sleepiness has no place in a safe workplace. Necessary evidence of such understanding would include consistent application of already published peer-reviewed empirical research to design work schedules and limit errors; provision of approved areas for naps (the fire extinguisher for mild sleep deficits); provision of sleepiness counseling as a part of employee orientation, continuing education, safety, and health services; and design of the workplace to maximize employee alertness. Acceptance of the importance of sleepiness evaluations will require public and professional education similar to that common for the negative impact of alcohol. Education programs stressing poor productivity and increased medical costs associated with sleepiness need to be directed toward government and corporate entities so that they recognize that improving alertness would pay tremendous monetary dividends in addition to improved health and would lessen the need for workplace tests of alertness. Remarkably, and regrettably, many sleep medicine practitioners have not followed their clinical wisdom into their own sleep schedule and the work-sleep schedule of their students and employees and can also benefit from education. Development times for recognition, treatment, and sanctions for alcohol use and smoking have shown that behavior change in society is a slow process that takes many years. Acceptance of sleepiness as an equally important medical and social problem will require the concentrated effort of our entire field for an extended period. Society now accepts the value of tests of breath alcohol in and out of the workplace. Significant education remains until there is a similar acceptance of the negative consequences of sleepiness. Such acceptance presages evaluations of alertness aimed at the patient (employee) rather than the disease (required working conditions). When given the mandate to evaluate alertness, our research must provide a reliable, valid test and appropriate norms for the group to be examined. Acceptance of the MSLT or MWT as a valid measure of alertness in normals and then in patients would be important first steps. Unfortunately, recent work suggests that our understanding of the relationship between sleep and alertness is still at a relatively rudimentary level. Additional empirical work is needed to properly place tests of alertness within sleep disorders medicine. Obviously, even more understanding will be required to extrapolate those links to the workplace.

A norovirus outbreak among healthcare workers

BACKGROUND: Noroviruses have accounted for numerous outbreaks in communities, long-term care facilities, and hospitals. On February 20, 2004, employee health services (EHS) reported 6 cases of gastroenteritis (GE) among hospital staff members. The infection control department initiated an outbreak investigation. METHODS: A case of GE was defined as a person with two or more episodes of diarrhea and/or vomiting in a 24 hour period. Cultures (5 viral, 3 bacterial) were collected and sent to the Maryland Department of Health and Mental Hygiene for testing. Case finding included a questionnaire administered to employees presenting to EHS with GE symptoms and reports from managers of employees reporting GE illness. Visitors with GE symptoms were restricted from the hospital and no children under age 12 were permitted to visit during the outbreak. Staff members with GE were restricted until 72 hours after symptoms had resolved. Hand hygiene was reinforced. Inservices were conducted. Letters and e-mails were sent to all staff notifying them of the outbreak and instructing them what to do if they experienced symptoms. Signs were posted throughout the hospital notifying staff and visitors of an outbreak. One unit was closed for 8 days due to the number of staff affected. RESULTS: Between February 10 and March 24, 2004, 316 staff (8% of hospital staff), including the only EHS employee, met the case definition. No patients qualified as cases. There were 74 (23%) staff members affected on two units. Three of five specimens submitted for viral testing were positive for norovirus. No bacterial cultures were positive. The outbreak was declared over 30 days after control measures were implemented. CONCLUSIONS: A norovirus outbreak occurred between February and March 2004. Norovirus among hospital staff is difficult to prevent and control when control measures are not strictly and consistently enforced. Areas for improvement for preventing and shortening the duration of future outbreaks include: enforcement of the visitor policy; having ill staff sent more quickly to EHS for evaluation; developing a contingency plan for limited staffing in EHS; consistently enforcing staff restriction from work; and consider providing time off for affected staff during an outbreak. As a result of this outbreak, an outbreak policy was developed. This outbreak highlights the importance of consistent communication and enforcement of policies at all levels of the organization.

Tularemia in New York City: When do we need to suspect bioterrorism?

ISSUE: Tularemia (Tu), known as rabbit fever, is a Category A agent of bioterrorism (BT). It was last seen in New York City (NYC) in 1998. This NYC medical center has been preparing for a BT event, and its emergency management preparedness program proved to be successful when a patient was admitted with Tu around the time of the Republican National Convention (RNC) being held in NYC. PROJECT: The medical center has been conducting nuclear, biologic and chemical (NBC) preparedness training since 2002 for all its healthcare workers (HCWs). The hospital emergency incident command system (HEIC) is used in the event of an emergency. NBC training provides education, communication, guidelines, and response plans to ensure safety and cooperation in the event of an attack. Our plan was tested when the diagnosis of Tu was made after the patient was discharged. RESULTS: A 20-year-old woman from Staten Island presented to the emergency department in August 2004 with an enlarged submandibular lymph node, pneumonia, and a pleural effusion. Pleural fluid and blood cultures grew gram-negative bacilli that were difficult to identify. Close cooperation with the NYC Department of Health identified the bacilli as Francisella tularensis . Because the case occurred around the time of the RNC and Tu is rare in NYC, there was concern as to whether this was a BT sentinel event. A thorough investigation revealed that the infection was naturally acquired. The patient's dog had captured a wild rabbit and then licked the woman's face. The woman survived, and no other cases were reported. Laboratory HCWs who handled the culture plates were contacted and evaluated for risk exposure. Antibiotic prophylaxis was deemed not necessary since specimens had not been handled by any HCW for almost 2 weeks. A fever watch was instituted and the laboratory HCWs were followed by employee health services. None developed any symptoms. LESSONS LEARNED: It is imperative to have an emergency plan in place. Our NBC training program allowed us to facilitate identification, apply precautions, alleviate fears, and communicate with all appropriate agencies in a timely and successful manner. NBC training also ensured that the laboratory had an employee roster with names and phone numbers readily available so that lab HCWs could be notified quickly—this was especially important since notification occurred on a Friday night.

Control of a methicillin-resistant Staphylococcus aureus (MRSA) cluster in critical care by reinforcing hand hygiene and standard precautions

ISSUE: The risk of healthcare-associated MRSA colonization and/or infection is considered to be greater for the patient in the critical care environment. Transmission of MRSA in a hospital setting usually occurs by indirect contact via the hands of healthcare workers. To minimize transmission, contact precautions (CP) have been recommended and used by many facilities. Standard precautions (SP) are used for patients with MRSA at this medical center. From April–July 2002, 22 patients in intensive care unit (ICU) and/or coronary care unit (CCU) and cardiovascular intensive care unit (CVICU) became colonized or infected with MRSA. DNA testing revealed that two clones were operational in the cluster. PROJECT: An infection control services (ICS) investigation included observation of patient care practices, interaction with staff to determine factors that might be contributing to MRSA transmission, DNA testing, literature review, audits of waterless alcohol degermer (degermer) use, and consultation with the hospital epidemiologist and the department of health services epidemiologist. No change from established infection control policy was initiated. An interventional partnership program was established between ICS and critical care, respiratory care services, and associated departments. Procedures and practices were observed, analyzed, and reported back to staff along with ICS recommendations to curtail transmission. RESULTS: Staff members (care partners, registered nurses, respiratory therapists, and physicians) were observed for intervals lasting approximately 30 minutes. Lapses in basic infection control practice were observed. The majority of identified problems centered on missed opportunities for the use of the degermer and/or handwashing and breaches in SP. Degermer audits determined that usage was suboptimal. ICS interventions focused on the importance of hand hygiene, emphasizing use of the degermer and reinforcing the principles of SP. Healthcare workers with direct patient contact were discouraged from wearing artificial nails and staff members were reminded to report any skin conditions to employee health services. The cluster terminated with these interventions. LESSONS LEARNED: Adhering to the principles of SP and hand hygiene was sufficient to end a cluster of healthcare-associated MRSA colonization and/or infection. This approach was relatively easy to implement and saved considerable resources by avoiding the institution of: new policies for CP, culturing patients on admission to the unit, culturing of staff, and cohorting of patients or staff.

Improving compliance with influenza vaccination for hospital healthcare workers from high-risk areas: A 6-year analysis

BACKGROUND: Influenza causes significant morbidity and mortality among patients, mostly those with immunosuppression, at extremes of age, and with significant comorbidities. Healthcare workers (HCWs) play a significant role in preventing morbidity and mortality of their hospitalized patients by being properly immunized against infectious diseases. However, compliance with influenza control programs has been limited overall in the United States, with only 36% of the workers with direct patient care annually immunized. New challenges were placed to increase immunization among HCWs in 2004-2005 due to the influenza vaccine shortage. OBJECTIVES: 1) Increase accessibility to influenza vaccination program for HCWs in high-risk areas at an academic hospital through several activities. 2) Demonstrate through results of aggregated data from 6 years that there was a significant improvement in compliance with the influenza vaccination in those high-risk patient areas. PROJECT: In the past 6 years, we increased the access to influenza vaccination throughout the hospital by 1) open visits to employee health service with nursing staff for vaccination throughout the "flu" season, 2) mobile clinics throughout the hospital's high-risk areas at the various working shifts, 3) intensive educational campaigns, and 4) 12-hour blitzes open to HCWs through a prioritized system. Data on influenza vaccine administered to high-risk HCWs was collected and analyzed by chi square comparing 1999-2000 (baseline) to 2003-2004 and 2004-2005 seasons. LESSONS LEARNED: There was a significant overall improvement in compliance with the influenza vaccination program in high-risk areas (p=0.001) in the year 2003-2004, when compared with baseline year (1999-2000). Two out of five identified high-risk areas had no significant improvement over the past 6 years. Compliance with influenza can be improved with a multifaceted approach emphasizing accessibility. Influenza vaccine shortage may have played a significant role in increasing compliance with the "flu" vaccination among high-risk HCWs. High-risk areas with poor response to the vaccination program will require specific training and different strategic planning.

Use Of A Mobile Cart Influenza Program For Vaccination Of Hospital Employees

Rates of annual influenza vaccination of healthcare workers (HCWs) remained low in our university hospital. This study was conducted to evaluate the impact of a mobile cart influenza vaccination program on HCW vaccination. From 2000 to 2002, the employee health service continued its annual influenza vaccination program and the mobile cart program was implemented throughout the institution. This program offered influenza vaccination to all employees directly on the units. Each employee completed a questionnaire. Vaccination rates were analyzed using the Mantel-Haenszel test. The program proposed vaccination to 50% to 56% of the employees. Among the nonvaccinated employees, 52% to 53% agreed to be vaccinated. The compliance with vaccination varied from 61% to 77% among physicians and medical students and from 38% to 55% among nurses and other employees. Vaccination of the chief or associate professor of the unit was associated with a higher vaccination rate of the medical staff (P < .01). Altogether, the vaccination program led to an increase in influenza vaccination among employees from 6% in 1998 and 7% in 1999 before the mobile cart program to 32% in 2000, 35% in 2001, and 32% in 2002 (P < .001). The mobile cart program was associated with a significantly increased vaccination acceptance. Our study was able to identify HCW groups for which the mobile cart was effective and highlight the role of the unit head in its success.

Reducing percutaneous injuries at an academic health center: A 5-year review

Background The University of Connecticut Health Center Employee Health Service collected and used National Surveillance System for Hospital Health Care Workers (NaSH) data to (1) improve surveillance of health care worker blood and body fluid exposures (BBFEs) and (2) target specific interventions for higher-risk groups (nursing staff, medical and dental students, and residents). Methods All 870 BBFE incidents were abstracted from the NaSH database from the 1997 through 2002 academic years. Incidence rates per 100 full-time-equivalent workers were determined for each targeted occupation group with 95% confidence intervals. Results The number of percutaneous injuries declined among medical/dental students and nursing staff, and to a lesser degree for residents. The incidence rates decreased from 7.9% in 2000 to 2001 to 2.6% in 2001 to 2002 for students and from 9.2% in 1997 to 1998 to 2.7% in 2001 to 2002 for nursing staff. Conclusions Data from a surveillance database provided guidance for administrative, educational, and engineering control interventions. Active surveillance and periodic review of interventions are important aspects to reduce BBFEs in targeted high-risk occupational groups, especially when the workforce has a high turnover, as is typical in academic health centers.

Pertussis (Whooping Cough) Exposure in Pediatric Healthcare Workers

ISSUE: Brookdale University Medical Center (BUMC) is a 530-bed teaching facility with a 52-bed pediatric unit and 6-bed ICU. On March 7, 2003, a foreign-born pediatric resident developed a sore throat, fever, and cough while working in one of the hospital's pediatric clinics. She stayed home and took antibiotic therapy for 2 days. After a week, her son was admitted to the pediatric ward for 1 day with excess coughing. Despite taking cough medicine, the child's coughing increased over a 2-week period, and he was readmitted on March 19, 2003, for 4 days with severe cough and vomiting. Diagnosis with viral syndrome was made. On March 21, 2003, the child was tested for Pertussis, started on erythromycin, and discharged. The resident was also tested for Pertussis and started on erythromycin. Her son become cyanotic and was readmitted the next day to the pediatric intensive care unit (PICU). She stayed with her son in PICU for 3 days. Twenty-three days after initial onset of symptoms, the Employee Health Service of BUMC was notified by the New York City Department of Health of a positive Pertussis test result on the pediatric resident. PROJECT: To prevent exposure of Pertussis in healthcare settings. RESULTS: Immunization status of 71 patients in the pediatric clinic exposed to the resident was reviewed. Of the 18 patient cases with less than 2 doses of DPT vaccination, 16 were given prophylactic medicine. Two of five PICU patients required prophylaxis due to age. There were a total of 98 exposed healthcare workers (to both the child and the resident). 90 received prophylactic medication. No additional cases of Pertussis were identified. LESSON LEARNED: Infection control practitioners should be aware of the potential for adult cases of Pertussis, particularly in healthcare workers who have direct care for patients. Early diagnosis and notification of infection control could prevent exposure of susceptible individuals.

On the road to the OSHA voluntary protection program.

In 1998, representatives from the Employee Health Services, Safety and Security, Physical Therapy, Human Resources, and Legal Affairs Departments and the Risk Management Program at Robert Packer Hospital (RPH) in Sayre, PA began a project to create a "culture of safety." The journey would ultimately lead to application to the Occupational Safety and Health Administration Voluntary Protection Program (OSHA VPP). Four years later, because of the dedication and collaboration of many individuals, RPH received notification that its application for OSHA VPP participation was approved by the Assistant Secretary of Labor. This article describes that journey and provides other healthcare organizations with the information needed to begin their own journey to successful project implementation.

MSJAMA: Government share of health care expenditures.

IT IS ONLY PARTIALLY TRUE TO SAY THAT THE UNITED STATES does not currently have a national health care system. The Centers for Medicare & Medicaid Services (CMS) estimated the 1999 government share of total US health spending as 45.2% ($548 billion). This estimate includes funding for Medicare, Medicaid, workers’ compensation, the Department of Veterans Affairs, public hospitals, and government public health activities. Thus, public funds directly pay for the health care of many people in the United States. Beyond these payments made directly to providers or institutions by the government, there are also other public funds spent on health care that are not included in the CMS estimate. These funds include the premiums paid to private insurance companies to cover government employee benefits, as well as government income that is lost to tax subsidies for health insurance premiums. Such subsidies are taxexempt when provided by an employer, but nonexempt if paid for directly by an individual. Furthermore, this tax subsidy is unequally distributed, averaging $2357 for families with annual incomes above $100000 but only $71 for families with annual incomes below $15000. Thus, for example, the CMS classifies benefits for veterans as government health expenditures, since the government directly funds Veterans Affairs hospitals for their services, while health services for government employees paid for by a private insurer (but funded by the government through premiums) are not listed as public expenditures. Sheils and Hogan consider tax-exempt health benefits to be a seriously underreported cost to the government ($111 billion in 1998). Woolhandler and Himmelstein recently recalculated the government share of health expenditure by including these tax subsidies and public employee private health benefits, and concluded that the government-financed share of total health spending in 1999 was 59.8%, equal to $723.8 billion or $2604 per capita. This figure is 25% higher than the CMS estimates for the same year. A 2000 study by Fox and Fronstin also concluded that the government share of expenditures on health care in 1998 was about 60%. These data indicate that, in addition to spending more and more on health care in absolute terms, the US government has also paid for a progressively larger share of national health expenditures during the last 35 years. Between 1965 and 1999, the government share of taxfinanced health expenditures rose more than 5700%, while overall health costs increased 2900%. In 1965, US government tax-financed health expenditures per capita were less than most other industrialized nations. By 1999, the per capita government proportion of health expenditures in the United States exceeded total health spending per capita in every industrialized nation except Switzerland. Additionally, tax subsidies and public employee benefits, which, again, are usually excluded from the calculation of public health care spending, rose as a proportion of overall governmentfinanced health expenditures between 1965 and 1999, even in the face of large increases in direct federal spending on other programs such as Medicare and Medicaid. Overall, then, the US government is paying for the majority of US health expenditures while a large segment of the population remains uninsured or underinsured. Many of these funds go directly to private insurers who cover government employees. Many go to tax breaks that benefit both employers who purchase private insurance and, disproportionately, the wealthiest, best-insured families in the United States. Another significant component of government (and nongovernment) expenditure goes to redundant and often unnecessary overhead costs. In part because many of the government funds spent on health care go through an extensive, multipayer private system (at least 755 insurance plans exist in Seattle alone), bureaucracy and administration now consume 20% to 30% of the total US health care budget. While part of this spending is necessary for medical system management, the wide variety of insurance plans and payer options inflicts huge amounts of extra paperwork and billing burdens on providers and institutions. The average US hospital spends 25% of its budget on billing and administration without evidence that this improves patient care. In fact, there is evidence that health plans with higher administrative costs deliver worse quality care. By contrast, Canada’s single-payer system has 1% administrative overhead costs, and even its Medicare program only consumes 4% of this total budget. Reducing spending on redundant bureaucracy and complicated insurance billing to Canadian levels could save as much as $140 billion annually without reducing the funds spent on care.

A Century of Practice

Occupational health nursing has grown and developed throughout the last century, from the influence of a few nurses in the late 19th century to 1988. Today's occupational health nurses have a significant impact on millions of workers across the United States and worldwide in multinational corporations. Nurses currently enjoy expanded roles, including involvement in the political arena and policy-making decisions, development of health promotion programs, research, and education, as well as providing more traditional but equally important employee health services, counseling, and teaching. The American workforce, as well as management teams, have seen the outcomes of quality occupational health nursing care and contributions throughout the years. The practice of American occupational health nursing which began in very humble surroundings and conditions in the 19th century continues to thrive in the space age of the 1980s and 1990s and to plan for the challenges of the 21st century.

The Physician's Role in On-Duty Injury Claims

Case A father of three and the sole provider for his family, KC is a loading dock maintenance worker at Peterson Memorial Hospital. He presents to the Department of Employee Health Services complaining of severe lower lumbar pain, and tells the Health Services physician that he injured his back while shifting heavy boxes around on the dock. The Health Services physician advises KC to seek treatment with his primary care physician, Dr. Carlson. Dr. Carlson has been KC's physician for many years, and the 2 enjoy a close and trusting patient-physician relationship.

Adherence to Prescription Medications Among Medical Professionals

We evaluated adherence to medication usage by health care professionals to estimate the expected upper limit of adherence among the general population. In a self-administered survey, physicians and nurses were asked about their use of prescribed medications for acute and chronic illnesses. The settings were a teaching hospital, employee health service, medical college, and educational conferences. Among 435 respondents, 301 physicians and nurses had medications prescribed for acute and/or chronic illnesses within 2 years of the survey. Of 610 prescribed medications, > or =80% were taken as prescribed, with a 77% compliance rate for short-term medications and 84% for long-term medications. Older age was associated with better adherence, whereas a greater number of doses per day was associated with poorer adherence. Approximately 80% of respondents reported properly taking prescription medications > or =80% of the time. Given the nature of the study population, it is unlikely that a nonclinical trial population will consistently achieve better adherence without specific interventions.

Standardized management of patients and employees exposed to pertussis.

Waning pertussis immunity and spread of pertussis by asymptomatic adults contributes to increased pertussis exposures of vulnerable children. The Santa Clara Valley Medical Center had 49 pertussis exposures between July 1, 1989, and June 30, 1997, which originated in pediatric units or clinics and had an impact on the Employee Health Service (EHS) and Emergency Department (ED). We have developed a standardized protocol for management of employees and patients exposed to pertussis. The protocol includes a checklist for infection control staff; memoranda to exposed units conveying exposure information, instructions for employees to report to EHS or ED, and disease symptom information; written guidelines for physician management of patient exposures (prophylaxis and isolation) and EHS or ED management of employee exposures; and prophylaxis recommendations. We allow exposed employees to work while wearing a mask (worn until 5 days of prophylaxis are completed or for the entire potential contagious period if prophylaxis was refused). Employees who develop pertussis are restricted from work. Our protocol and standardized forms provide consistent management of pertussis exposures in both patients and employees.

Employee Health Services

Employee Health Services

Tuberculin Skin Test Conversion Rates in New York City Emergency Medical Service Health Care Workers

Objective: To determine annual tuberculin skin test conversion (infection) rates for prehospital health care workers (EMTs and paramedics) in an urban environment with a high prevalence of Mycobacterium tuberculosis Methods: We conducted a prospective study of prehospital health care workers for the New York City EMS, EMS Employee Health Service, and the Fire Department Bureau of Health Service to determine the tuberculin skin test conversion rates. In 1992, all current and new EMS prehospital health care workers without a known history of a positive tuberculin reaction received a baseline tuberculin purified protein derivative (PPD) skin test. Thereafter, (January 1, 1993–December 31, 1996) all EMS health care workers who had negative PPD skin test results received annual tuberculin PPD skin tests. Tuberculin skin test conversion was defined as induration of 10 mm or greater in a worker with a documented prior negative test result. The PPD skin test reaction was measured by trained professional readers. Results: A total of 7,290 PPD test results were read during this study. Compliance with annual testing was 75%. Annual tuberculin skin test conversion rates were 1.3% in 1993, .7% in 1994, .1% in 1995, and .2% in 1996 (average .5%). In a static subgroup with at least 15 years’ seniority, compliance with annual testing was 100% and annual tuberculin skin test conversion rates were .5% in 1993, 0 in 1994, .5% in 1995, and 1.5% in 1996 (average .6%). Conclusion: Despite the high prevalence of M tuberculosis infection in New York City and the potential for difficulty in the use of respiratory precautions during emergency response operations, EMS prehospital health care workers have an annual tuberculin conversion rate that is relatively low compared with hospital-based health care workers. [Prezant DJ, Kelly KJ, Mineo FP, Janus D, Karwa ML, Futterman N, Nolte C: Tuberculin skin test conversion rates in New York City emergency medical service health care workers. Ann Emerg Med August 1998;32:208-213.]

Hepatitis B vaccination program at a New York City hospital: Seroprevalence, seroconversion, and declination

Background: Despite implementation of hepatitis B vaccination programs, 2 problems have prevented full vaccine–induced protection of health care workers (HCWs). About 10% to 12% of vaccinated HCWs do not develop antibody, and many HCWs continue to decline vaccination. To determine the effectiveness of our hepatitis B vaccine program, we studied rates of postvaccination seroconversion and vaccine declination. Methods: Employee health service records were used to determine demographic features, hepatitis B surface antibody serostatus at baseline, serologic response to vaccine, and declination or acceptance of vaccine. Results: About 26% of HCWs were seropositive at baseline, including those vaccinated before employment. Higher seroprevalence rates were seen among those born outside the United States, nurses, and laboratory workers. Seroconversion occurred in only 79% of HCWs who completed a 3-vaccine series. Increasing age was the only significant risk for failure to convert. Declination rates overall were about 45% and were lowest in HCWs who have jobs that included potential exposure to blood. Conclusion: Hepatitis B seroprevalence among HCWs at our hospital is higher than in many other urban hospitals in the United States; our postvaccination seroconversion rate is substantially lower; and our declination rate of 45% resembles other published series. Declination of vaccine and failure to respond to vaccine continue to thwart achievement of full control of this preventable occupational infection. (AJIC Am J Infect Control 1998:26:423-7)

Employee Health Services Integration: Meeting the Challenge

1. The first step of a successful Employee Health Service integration is to have a plan supported by management. The plan must be presented to the employees prior to implementation in a "user friendly" manner. 2. Prior to computerization of employee health records, a record order system must be developed to prevent duplication and to enhance organization. 3. Consistency of services offered must be maintained. Each employee must have the opportunity to receive the same service. Complexity of services will determine the site of delivery. 4. Integration is a new and challenging development for the health care field. Flexibility and brainstorming are necessary in an attempt to meet both employee and employer needs.

Methods of prioritizing and measuring occupational health risks utilizing hospital back injury data. Development of composite comparative statistics.

The employee health service of a Boston hospital wanted a method to prioritize the risk of occupational injury or illness among its employees as the first step in developing a comprehensive ergonomics program. Data from the safety office and workers' compensation third-party administrator (TPA) was combined with hospital payroll data to create rates that compared all work areas based on the common denominator of 100 full-time equivalents (FTE). Rates for four different aspects of injury experience were calculated: incidence of total reported injuries, incidence of serious injuries, level of severity of injuries, and cost. The use of these simple rates alone was inadequate to accurately prioritize risk. Because most work areas ranked differently from one rate scale to the next, it was unclear which, if any, single rate most accurately defined risk. Composite statistics that combined all of the rates were needed. The Composite Risk Indicator (CRI), the Average Relative Risk (ARR), and the Justified Average Relative Risk (JARR) were developed and examined for their utility. The JARR emerged as the best choice in this setting because it captured all available information about injury or illness experience and provided a meaningful single indicator of risk that could be followed over time.