As we are entering a unique flu season this year, with concerns about both seasonal flu and H1N1 flu, this update is provided to managers as an overview of the employment related issues you may need to address on behalf of your employees. For a general overview of influenza and influenza-like illness (ILI), please refer to the document, “Workplace Exposure to Influenza-Like Illness.”
GENERAL PRECAUTIONS
What precautions should our department be taking to prevent the spread of influenza?
a. Hygiene Measures – Reinforce hand hygiene and cough etiquette guidelines, our most important defenses against the spread of infection.
b. Proper use of PPE when indicated – Know when to use standard, droplet & aerosol precautions(www.dmc.org/flu). Employees must use droplet precautions whenever caring for a patient with ILI. Face masks and hand hygiene are generally adequate; N95 respirators are to be used by employees in certain situations (www.dmc.org/flu). N95 respirators are not intended to be used by patients.
c. Keep ill employees off work
d. Be prepared with adequate staff qualified to wear an N95 respirator (trained, fit tested & certified)
ILL EMPLOYEES
What if an employee has signs of influenza-like illness or is diagnosed with either H1N1 or seasonal influenza?
a. What are the symptoms of influenza? Be attentive to the following symptoms: Recent onset of fever, cough, runny or stuffy nose, body aches and/or sore throat. If you identify an employee at work with fever (100 degree F or greater) AND one of the other symptoms, have them don a facemask (surgical or isolation mask) and send them home.
b. When do I refer the employee to OHS, and when do I send them home? All employees with symptoms of influenza-like illness should stay home from work to avoid exposing patients and coworkers to the illness. If the employee is currently on the job and develops symptoms of flu-like illness, you may send them directly home. A visit to OHS is only necessary if you are unsure about whether or not the employee should go home from work. OHS does not treat personal health conditions. However, if the employee has had a documented exposure on the job and then develops the illness, he or she should be referred to OHS for treatment under worker’s compensation, and an incident report and an SRM report should be completed. OHS will work with disability management on cases that would be covered by Workers Compensation.
c. Shouldn’t OHS see the employee so that they can be treated with medication right away? Most cases of influenza (seasonal or H1N1) do not require medical treatment. Individuals at high risk of complications or with more severe cases of disease may require medical treatment (generally provided by their personal physician).
d. How to address attendance policy issues Employees must follow their departmental call-in procedures and abide by the terms of DMC Attendance Policy 1 HR 503 (posted on DMC intraweb). According to this policy, employees with a communicable disease (including influenza) are classified as having an “excused unscheduled absence.”
CALL INS
What if an employee calls in from home reporting that they are ill with influenza like illness? Ask the employee to stay home until ready to return to work (see above). There is no need to refer the employee to OHS unless you have reason to question whether or not they have ILI. However, the employee should be told to obtain an evaluation from his/her personal physician to confirm that s/he, in fact, has ILI, in order for the illness to be excused under the attendance policy.
RETURN TO WORK FOLLOWING ILI
If an employee has had influenza, when can they return to work and how do I, a manager, determine that? The employee with ILI may return to work 24 hours after last fever (as long as fever is not masked by medications such as Tylenol or Advil). If the HCW is working with severely immunocompromised patients (e.g. bone marrow transplant or solid organ transplant), or if the HCW is still quite symptomatic, please check with DMC Occupational Health Services (OHS) prior to considering returning the employee to work.
INDIVIDUALS AT HIGHER RISK
Are some individuals at higher risk than others? The CDC has defined the following individuals as being at high risk for complications of influenza:
a. Adults 65 years of age and older;
b. Persons with the following conditions: Chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolic disorders (including diabetes mellitus); immunosuppression, including that caused by medications or by HIV;
c. Pregnant women;
d. Persons younger than 19 years of age who are receiving long-term aspirin therapy;
Such individuals are advised not to enter isolation rooms containing patients with ILI, or be present during procedures which may generate aerosols (see above). Such individuals should discuss options for avoiding patients with ILI during this flu season with their supervisor. If the individual chooses to continue caring for patients with ILI (but not around aerosolizing procedures), a fit-tested N95 mask should be worn. Health concerns should be discussed with DMC OHS and the individual’s personal physician.
ENVIRONMENTS & PROCEDURES WITH GREATER EXPOSURE RISK
What Environments and Procedures may pose a higher risk for exposure?
Environments with a higher risk for exposure include patient care areas where it is expected that there may be a high volume of influenza patients (e.g. the Emergency Department or Urgent Care Clinic). “High risk procedures” include:
a. Endotracheal intubation
b. Diagnostic sputum induction
c. Bronchoscopy
d. Airway suctioning
e. Positive pressure ventilation via face mask (e.g., BiPAP and CPAP)
f. High-frequency oscillatory ventilation h. Nasopharyngeal swab sample collection
g. Nasopharyngeal swab sample collection - individuals performing the above procedures should be protected with an N95 respirator and follow any other infection control precautions indicated for the procedure.
EMPLOYEE EXPOSURE
What if an employee has an exposure to a patient with ILI?
a. When to refer to OHS: Individuals who meet BOTH criteria for Exposure and HCW Circumstances should be referred to OHS for counseling and/or treatment:
i. Exposure - either one of the following conditions:
- Unprotected droplet exposure (e.g. patient sprayed HCW with droplets while coughing or sneezing in close proximity), or
- Unprotected aerosol exposure (e.g. HCW not wearing N95 mask around aerosol generating procedures)
AND
ii. HCW circumstances - any one of the following 3 circumstances:
- HCW is at high risk for complications of influenza because of pregnancy or an underlying chronic health condition (as noted above) and is concerned about an exposure, or
- HCW is anxious about their exposure to patients with influenza, or
- HCW develops symptoms of ILI (an incident report must be completed)
If proper precautions are followed, it is believed that HCWs should not be at significantly greater risk at work than in the community. Thus, few individuals are expected to require referral to OHS for an exposure. Your site epidemiology manager will help you identify exposures and will provide you with a form for identifying and referring individuals to OHS.
b. All individuals with documented droplet or aerosol exposure to a patient with Flu should:
- Monitor themselves for symptoms (especially fever and acute upper respiratory symptoms). Most healthy individuals who are not pregnant will not require antiviral medication or prophylaxis.
- All pregnant women and others at high risk of complications of influenza who have documented exposure should report to OHS ASAP (or the emergency department after hours) for evaluation.
- If exposed at work and symptoms develop: Inform supervisor Remain off work Report to OHS during OHS business hours If pregnant or otherwise at higher risk for complications of influenza, report to OHS ASAP (or the emergency department after hours).
EMPLOYEE EXPOSURE AT HOME
What if an employee lives with someone who is diagnosed with H1N1 or another form of influenza?
a. Can the employee work? YES
b. Does the employee need to be evaluated by OHS? NO
c. Is there anything the employee needs to do? The employee should self-monitor for symptoms and should use appropriate precautions at home to minimize exposure risk.
DEPARTMENTS OF GREATER CONCERN
What departments should be especially concerned about influenza?
a. Departments taking care of patients at high risk of complications of either seasonal or H1N1 influenza should be especially concerned.
i. Transplant, oncology, HIV, etc.
ii. ICUs, NICUs
iii. OB, L&D (H1N1)
iv. Emergency Departments
v. Pediatric units
b. Departments most likely to care for patients with influenza
i. Primary care
ii. Emergency Departments including ARCs
c. What should I do differently compared with other departments?
i. Infection Control & Vaccination. All of the same guidelines for infection control apply in any patient care setting at the DMC. It is important that all employees follow these procedures and are vaccinated against both seasonal and H1N1 influenza. However, it is even more vital that employees working in these departments are meticulous about compliance and vaccination.
ii. N95 Fit Testing Further, the manager should carefully assess the need for employees to be N95 fit tested, and consider a plan for increasing the number of N95 fit tested individuals if the need arises. DMC employees and staff are prohibited from caring for patients with TB, entering TB isolation rooms, or entering environments during influenza aerosol generating procedures without an N95 mask. In order to assure adequate staffing, all managers must anticipate needs and ensure that there are enough individuals with up-to date N95 certification to perform the required duties of their departments. Planning must consider preparation for disease outbreaks and pandemics. For future planning, some individuals with beards, but who currently do not need to wear an N95, and their departments, may need to anticipate “just-in-time” shaving and fit testing in the event the need arises.
iii. Staffing - Consider a contingency plan for staffing in the event of excess employee absence.
SEASONAL INFLUENZA VACCINATION
Which employees and staff should receive the seasonal influenza vaccine?
a. For the protection of our patients, all DMC employees and staff should receive the seasonal influenza vaccine as soon as possible unless there is a medical contraindication (the flu vaccinators will screen for such contraindications). Please do your part to actively promote employee vaccination on behalf of our patients.
b. Vaccination availability Seasonal influenza vaccination was initially rolled out to employees through a mass immunization exercise which had the additional benefit of testing our pandemic planning capabilities at each of our hospitals. This has proven to be successful both in distributing vaccine and improving our mass dispensing efficiencies. Currently, seasonal influenza vaccine is available on a “walk-in” basis at each of the three DMC Occupational Health Services locations (Detroit Receiving, Sinai Grace and Huron Valley), and at the DMC Surgery Hospital Emergency Department during the following hours.
• DMC OHS, Detroit Receiving Hospital, UHC 4KM-F, 7 AM – 4 PM
• DMC OHS, Sinai Grace Hospital (next to ExpressCare)M-F, 6:30 AM – 4 PM “Main Street” M-W-F, 7:30 AM – 11:30 AM
• DMC OHS, Huron Valley-Sinai HospitalM-F, 6:30 AM – 4 PM
• DMC Surgery Hospital, Emergency Department24/7
In addition, there are a number of unit-based vaccinators throughout the DMC that serve their local areas.
H1N1 VACCINATION
Which employees and staff should receive the H1N1 influenza vaccine?
a. For the protection of our patients, all DMC employees and staff should also receive the H1N1 influenza vaccine as soon as it is available unless there is a medical contraindication (the flu vaccinators will screen for such contraindications).
b. Vaccine availability H1N1 vaccine, when available (currently we are anticipating receiving vaccine supply in mid to late October), will be distributed in a similar manner as seasonal flu vaccine. That is, starting with a mass immunization exercise, followed by distribution through DMC OHS clinics and unit-based vaccinators.