Medical surveillance a must for dialysis unit
Regulatory information guides policies, procedures
By Sharon A. Watts, RN-C, MS, FNP
Nurse Practitioner, Employee Health
University Hospitals of Cleveland
Hospital occupational health practitioners need to be cognizant of the risks inherent in the dialysis unit setting. Employees working in dialysis units are exposed to large amounts of blood and body fluids, as well as formaldehyde used as a cleaning solvent for dialysis machines. Medical surveillance for dialysis unit staff requires knowledge of federal and state regulations governing hepatitis, blood and body fluids, formaldehyde, and respirator fit-testing.
This author encountered difficulty in locating resources to help draft a dialysis unit medical surveillance policy and procedure for our large (6,000-employee) inner-city hospital. To obtain information, we contacted the dialysis and hepatitis branches of the federal Centers for Disease Control and Prevention (CDC). A local freestanding dialysis center provided information on safety measures for protecting staff. Finally, we reviewed U.S. Occupational Safety and Health Administration (OSHA) guidelines for formaldehyde. The following information represents the result of those multiple inquiries, and is provided to help other hospital employee health departments write surveillance procedures.
HBV prevalence a major problem
At the post-offer pre-employment baseline physical exam, all employees assigned to the dialysis unit receive a complete history and physical exam, spirometry readings, liver enzymes (hepatic profile), and hepatitis B surface antibody (HBsAb) and surface antigen (HBsAg) tests. At least two consecutive HBsAb tests are required to demonstrate evidence of immunity. A positive HBsAb titer must be at least 10 sample ratio units by radioimmunoassay or positive by enzyme immunoassay.1
Employees with protective antibodies to hepatitis B, either by vaccination or natural disease process, need no further testing after two consecutive positive surface antibody tests are obtained. Our employees are permitted to bring evidence of one positive HBsAb titer from a previous employer, if available, to count as the initial test of protective evidence against hepatitis B.
Continued surveillance of hepatitis B exposure is of prime importance once staff have been placed on a dialysis unit. Both the prevalence and incidence of this potentially lethal disease have been a major problem for dialysis units. HBV rates have significantly declined with the advent of vaccine;2 however, vaccine nonresponders or those who waive the vaccine need continued surveillance. Employees without protective antibodies need to be monitored for HBsAg and HBsAb every six months.1
At our institution, HBV vaccine is strongly encouraged, with a total of six doses given if necessary to provide sufficient seroconversion. Signed declinations are maintained in the employee health medical records of all staff with potential blood and body fluid contact as defined in their job descriptions.
Employees known to be hepatitis B chronic carriers are referred to a specialist for further evaluation of liver status. The CDC recommends that those employees be tested for HBsAg yearly.1 Determination of infectivity can be assessed by detection of a positive surface e antigen (HBeAg). Employees with a positive hepatitis B surface antigen and positive e antigen are highly infectious. It may be necessary to evaluate an employee’s job description and consider job reassignment when known infectivity is high, to avoid continued spread of the disease.
Respirator needed for formaldehyde exposure
Exposure to formaldehyde cleaning solvents poses another risk to dialysis staff. Respirator fit-testing is required for employees who change formaldehyde solutions in dialysis machines. OSHA advises a baseline history targeting eyes, ears, nose, throat, respiratory system, and skin sensitivity. Physical examination with particular attention to those systems, as well as spirometry, also is required.3
Follow-up for dialysis employees needing a respirator to handle formaldehyde directly consists of an annual history update and physical focusing on the same areas included in the baseline exam. Spirometry readings need to be measured and monitored for change from year to year. Any employee with an exposure to formaldehyde with an eight-hour time-weighted average above 0.5 parts per million or a short-term 15-minute exposure above two parts per million would need immediate clinical evaluation.3
Finally, yearly tuberculin skin-testing or evaluation of signs and symptoms for those with a history of positive tuberculin skin test is required for all employees hospitalwide.4 With so many other health variables to monitor in dialysis staff, it is important to remember that tuberculosis remains a serious but preventable disease for hospital employees.
State regulations vary, but in Ohio all employees who work with end-stage renal disease clients are required to have a yearly medical evaluation to determine their overall level of health functioning. At our facility, we take a brief history to determine any significant health changes and to ensure immunizations are up to date. We also check medical records to ensure adequate antibodies against rubella, rubeola, mumps, hepatitis B, and varicella are documented.
To pull together the many surveillance requirements for dialysis staff, we developed a table to provide a quick reference (see table, above). Most employee health services are busy departments, so cooperation of dialysis unit head nurses is imperative. Routine lab slips can be forwarded to the dialysis departments, and tuberculin skin tests can be administered on the units to expedite compliance.
Medical surveillance of dialysis staff needs to be comprehensive and compliant with regulatory bodies. Continued staff and client safety is important for a well-functioning dialysis unit and hospital.
References
1. Moyer LA, Alter MJ, Favero MS. Hemodialysis-associated hepatitis B: Revised recommendations for serologic screening. Semin Dial 1990; 3:201-204.
2. Alter MJ, Favero MS, Moyer LA, et al. National surveillance of dialysis-associated diseases in the United States, 1988. Trans Am Soc Artif Intern Organs 1990; 36:107-117.
3. U.S. Occupational Safety and Health Administration. Occupational exposure to formaldehyde, final rule. Fed Reg 1992; 57:22,290-22,328.
4. Centers for Disease Control and Prevention. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care facilities 1994. MMWR 1994; 43(RR-13).
[Editor’s note: Sharon A. Watts is earning her doctorate in nursing at Case Western Reserve University in Cleveland, where she also is an instructor in the nurse practitioner master’s program. She has worked in the occupational health field for 10 years. For more information, she may be contacted at (216) 844-1602.]
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