Convenient hours facilitate TB screening compliance
January 1, 1998 7 minutes read
Convenient hours facilitate TB screening compliance
By Cherie Rickert, RN
Nancy James, RN
Eva Brehm, RN
Associate Health Nurses
Associate Health Department
Centegra Health System
McHenry, IL
Creating and delivering a tuberculosis program for the 2,000 employees of this health system has been an ongoing challenge. Limited employee health office hours in past years has left employee health nurses, employees, and management biting their nails each year to ensure the staff are appropriately screened for tuberculosis as recommended by the Centers for Disease Control and Prevention, and mandated by the Occupational Safety and Health Administration.
Comments such as "You’re never there when I come up," or "I didn’t know I had to do it," or "I forgot" are just some of the roadblocks to creating a warm and fuzzy program. With the unending mandates that health care workers are required to fulfill, nothing brings out the groans like having to come back for their TB test on top of all the other return trips during non-working hours. Our previous program clearly lacked accessibility, flexibility, accountability, and convenience.
Centegra Health System has developed and painlessly delivered a TB skin-testing program that has overcome these obstacles for the last three years. The first step was soliciting buy-in from management. Their understanding of the principle behind the program was key to gaining that support.
To meet the needs of the staff who deliver patient care around the clock and who often have large gaps of time between shifts, the program has to offer accessibility. For Employee Health to be available at all times, office hours have to mirror the staffing schedule of the employees, and in a 24-hour-per-day operation that just wasn’t possible.
The first step toward solving that problem was pulling the in-house nursing supervisors into partnership with employee health. They are on duty 24 hours per day, and have the clinical expertise to assist in the program. Fortunately for our hospital, this group of 15 or so nursing leaders opened their professional hearts and agreed to help.
A review of administration guidelines was offered, and supervisors were directed to refer all suspected positive results to employee health the very next day. The goal was to offer TB testing over a long enough period of time so that we could ensure that all staff would have an opportunity to receive testing regardless of vacations or gaps in schedules. (The irregularity of our on-call staff was a big concern.)
The first year we announced that the TB program would take place over a period of six weeks. This year we reduced it to four weeks as a result of better compliance and familiarity with the program.
Testing was made available 24 hours a day, seven days a week, with a midnight deadline six weeks later. A goldenrod-colored memo went out to staff with distribution of paychecks the pay period before the start date. Weeks before, we had enlisted the help of our volunteer staff to label a memo with the name of each employee. The letter contained:
• a list of designated testers, including nursing supervisors, emergency room charge nurse, or employee health nurses at all main campuses;
• the guidelines for the PPD converters;
• those employees who were hired within the last 90 days who were exempt from retesting.
Testing could be administered by one person and read by another as long as the employee had their form in hand.
Employee keeps record of compliance
The nurse reads the test, completes the form (see copy of form on p. 9), and hands it back to the employee to submit to employee health. The two-part form itself is carbonless, and one form is for the employee’s records. The employee turns in the original to the health office. This eliminated problems caused when the original is lost and the staff member is believed to be noncompliant. The carbonless form provides proof of their compliance.
At mid-month, a list is sent to each department leader identifying employees who still have not completed the testing. Departments are notified that staff not yet in compliance at the end are to be deleted from their department schedule until testing is done.
Employee health ensures convenience of testing services by strategically placing TB kits in the medication refrigerators throughout the clinical areas. Our commitment to recycling is demonstrated by using discarded medication trays from our inpatient pharmacy and dressing trays from the operating room to hold the supplies.
The kits contain forms, alcohol wipes, TB syringes, and a vial of PPD. As the nursing supervisors make their rounds, an employee can request testing, and the materials needed are close at hand.
Each week employee health replenishes the supplies. We also take our program "on the road," visiting various departments with our equipment on a cart. We test at off-site facilities as well. The staff appreciate curbside service because clinical demands often prevent them from leaving their units.
This also provides visibility and insight into other health concerns throughout the hospital. Department leaders have invited us to staff meetings and inservice training events for mass testing, and take pride in completing their department requirements early in the month of screening.
As we receive the completed test forms, the data are entered into the computer system, giving us the ability to create reports and enhance quality improvement. We can identify staff whose tests are outstanding, the number of known positive converters, and any conversions from last year’s testing. This information is an important tool for our TB risk assessment. This year we also took advantage of our whole-house screening to perform a quality check pertaining to chickenpox immunity.
When TB testing is completed, we can all sit back and breath a sigh of relief. Clearly, the success of our TB program is a direct result of the partnerships developed among management, supervisors, volunteers, employees, and employee health. No longer is TB testing the mandate of a stand-alone department, but a team effort with a common goal; to provide our patients and staff with a healthy, safe environment.
LaMontagne AD, Kelsey KT. Evaluating OSHA’s ethylene oxide standard: Employer exposure-monitoring activities in Massachusetts hospitals from 1985 through 1993. Am J Public Health 1997; 87:1119-1125.
An in-depth study was conducted in 1993 to characterize the implementation of the U.S. Occupational Safety and Health Administra tion’s 1984 ethylene oxide (EtO) standard in all Massachusetts hospitals. Health care workers are the largest occupational group potentially exposed to EtO, which is used in hospitals to sterilize heat- and moisture-sensitive medical supplies. EtO is a potent neurotoxin, a known human carcinogen, a potential reproductive hazard, and an allergic sensitizer.
The EtO standard requires initial exposure monitoring consisting of worker breathing-zone air samples that represent the eight-hour time-weighted average for permissible exposure limit and action level, and 15-minute short-term exposures of each employee for excursion limit. When exposures exceed the action level or excursion limit, employers must repeat monitoring at least every three months. They also must develop written plans for emergency EtO situations.
The Massachusetts study takes an evaluation or intervention research perspective, focusing on hospitals’ activities and findings in response to OSHA’s mandated EtO exposure monitoring. In addition to providing worker exposure information, the study was designed to examine organizational behavior and the dynamics of implementing OSHA requirements among a population of workplaces.
A mail, telephone, and on-site survey of EtO health and safety was conducted among all 159 Massachusetts hospitals. Respondents were managers of EtO sterilization operations. The survey covered the period from 1985, when the exposure-monitoring sections of the OSHA standard became effective, through 1993. At least 96% of EtO-using hospitals were recruited into the study.
A detailed EtO exposure history addressing both personal and area monitoring activities was determined for each hospital. In addition, respondents were asked if they had "an alarm which will sound when EtO is accidentally released." OSHA inspection data were obtained under the Freedom of Information Act.
Results showed that most hospitals performed eight-hour personal monitoring one or more times during the study period. However, the initial implementation of eight-hour or action-level monitoring typically occurred after 1985. By the end of 1985, only 43% of hospitals had performed action-level monitoring. More hospitals had never monitored for the excursion limit compared with the action level as of 1993. Initial monitoring occurred closer to the required date for excursion-limit monitoring in 1988 than for initial action-level monitoring. Nevertheless, only 48% of the 89 hospitals responding to the question on initial excursion-limit monitoring had performed that monitoring by the end of 1988.
Many hospitals responded to OSHA’s emergency alert requirement by installing EtO alarms. However, by the end of 1985, when the alert requirement became effective, only five hospitals reported having an alarm.
About one-third of the hospitals that performed action-level monitoring or excursion-limit monitoring exceeded those levels one or more times during the study period. From 1990 through 1992, roughly one-fourth of hospitals that monitored found levels above the action level or excursion limit.
Either the action level or excursion limit was exceeded at 27 hospitals from 1990 through 1992. Among those 27, only seven hospitals exceeded both, indicating some distinction between the two overexposure events.
More than half of all hospitals in the study reported one or more accidental EtO releases since 1985, with almost all such accidents resulting in worker exposures or likely worker exposures. Importantly, accidental overexposures were not captured by personal-monitoring activities. During the study period, about two-thirds of responding hospitals reported evacuations of the sterilization department or area due to a real or suspected EtO leak or an EtO alarm. In contrast, only about one-third of hospitals carried out EtO emergency drills in which workers actually evacuated the department.
Study results indicate that while most hospitals implemented OSHA’s EtO personal-monitoring requirements, a substantial number had not fulfilled all requirements as of 1993. Hospitals that did perform monitoring greatly exceeded minimal requirements, the authors note.
In post-survey EtO health and safety reviews provided to each hospital in the study, the researchers observed a widespread lack of understanding of the alert requirement. Among hospitals that installed EtO alarms, there was much confusion and controversy over the EtO concentration at which an alarm should sound.
The researchers also point out that anticipated mechanisms for documenting employee exposures for follow-up, compensation claims, and epidemiologic study are not recording important EtO overexposure events. From this and other findings of the study, they find an urgent need for improved excursion-limit and alarm-monitoring practices, as well as strategies to prevent accidental EtO releases.
They also conclude that the study shows widespread but incomplete implementation of monitoring requirements. More OSHA enforcement activity and educational outreach might improve exposure-monitoring practices and reduce exposures, they suggest.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content