Two-step testing for employees not voluntary
Follow OSHA’s new standard, or risk citation
As recent sampling of an Internet discussion among health care workers indicates confusion reigns over whether health care facilities are required to give two-step PPD skin testing to employees. According to officials at the U.S. Occupational Safety and Health Administration (OSHA) in Washington, DC, however, the matter is straightforward do it or risk citation.
"A two-step baseline shall be used for new employees who have an initially negative PPD test result and who have not had a documented negative skin test result during the preceding 12 months," according to OSHA’s enforcement procedures and scheduling for occupational exposure to tuberculosis. The regulation is part of an OSHA program change following new recommendations for TB control and prevention published by the Centers for Disease Control and Prevention in 1994.1
Health care facilities in states under OSHA plans are required to comply with two-step testing requirements recommended by the CDC and adopted by an OSHA program change two years ago, says Ruth McCully, director of OSHA’s Office of Health Compliance Assistance. The regulation is expected to be unchanged in the proposed OSHA TB standard, which is now under review by the federal Office of Management and Budget in Washington, DC.
Were employees infected while on the job?
Also referred to as a "boosted" Mantoux test, two-step testing allows health facilities to accurately assess whether employees have been occupationally exposed to TB. The first test boosts the immune system and allows for a more accurate reading during the second test, taken between one and three weeks later. Without the second baseline test, an employee who tests positive may be considered newly infected when actually he or she was exposed prior to being hired.
"It is to their advantage to do their two-step. If someone down the road has a conversion, then you know it is a real conversion rather than one carried over from a previous infection," McCully says, adding it is required only for the baseline test.
States must adopt the OSHA program change or opt to develop an alternative, which is deemed as effective, she says. Some states that don’t fall under federal OSHA, such as Washington, require two step testing only for new employees over age 35. Other states make two-step testing dependent on local prevalence rates.
Although the OSHA program change incorporates the CDC’s revised TB guidelines, many health care workers are not aware of the new employee skin testing requirement, which covers not only hospitals but nursing homes, correctional facilities, hospices, and homeless shelters. TB programs that don’t implement TB abatement methods, including two-step testing, can be cited under Section 5(a)(1) of the OSHA Act. Each employee not tested can count as a single citation.
Two-step testing is inexpensive and is, literally, a one-shot deal, and yet health care facilities have been slow to comply. Health officials in Georgia have been pushing two-step testing for several years now, but they estimate that 15% to 20% are still not performing two-step testing.
"They have held off for as long as they could because they think it’s a lot of extra work," says Eydie Davis, RN, CS, the state’s public health nursing consultant for TB. "A lot of the employees resist it because they say they have had BCG."
Health care workers discussing employee testing on the Internet argued that the tests were just another administrative hoop to jump through and constitute a barrier to potential employees.
Other workers defended employee testing as imperative to monitoring TB outbreaks.
"In three years, we have had at least 15 offices exposed to TB, and one of those was from an employee," wrote one nurse. "Two step and annual TB testing is a small price to pay. OSHA is very helpful in assisting managers and owners to comply with the regulations. They are not out to get you unless you are lining your pockets at the expense of employee health and safety."
Less clear is whether TB screening is required for new volunteers. Many hospitals require new volunteers to have a two-step TB screening and offer hepatitis B vaccine for those at risk. And while most health care administrators recommend treating volunteers the same as employees, the only mention of volunteers is found in the CDC’s guidelines for preventing TB transmission in health care facilities.1
CDC epidemiologist Elizabeth Bolyard, RN, MPH, CIC, says the agency recommends that hospital volunteers be included in the TB screening program as much as employees, with the frequency of such screening based upon the hospital’s TB risk assessment as specified in the guidelines. Two-step testing should be performed for new volunteers.
Presently, the CDC does not have any other recommendations for volunteer screenings or immunizations. New CDC guidelines for infection control in hospital personnel are due out in the spring; that document might contain some recommendations for volunteers, Bolyard says.
"Many hospitals have their own standards and recommendations," she adds. "Some [hospitals] screen volunteers the same as they do employees, and others don’t screen because they don’t allow volunteers to have patient contact."
The American Hospital Association (AHA) in Chicago has no recommendations, either.
"Most hospitals do TB testing but not much beyond that," says AHA spokeswoman Carol Schadelbauer. "They might do hepatitis B [screening and vaccination], but it depends where the volunteer is working. It’s up to the hospitals what they do."
Davis and other TB experts agree that volunteers should be offered the same tests as employees.
"If they volunteer on a regular basis and have contact with patients, then I think they should be tested," she says.
"Whatever programs you provide to your health care workers should be extended to your volunteers," says Gina Pugliese, RN, MS, former director of infection control for the AHA and now a vice president with Chicago-based Sullivan Kelly, consultants to health care facilities in the areas of infection control and risk management.
Pugliese advises basing employee and volunteer health services on factors such as a hospital’s patient population, the kinds of diseases for which employees are at risk, the volunteer’s age, the hospital’s services, and the nature of the volunteer’s job.
While it is not necessary to restrict what volunteers do, "you would tend not to put them in high-risk activities," she adds, "but it’s really hard to define what is high risk."
Jeanne Culver, RN, COHN, director of employee health services at Emory University Hospital in Atlanta, says the lack of government mandates (except for TB screening) means individual hospitals must set their own standards.
"It depends upon how you define the job duties of a volunteer whether they come into direct contact with patients, serve the public, work in offices, or are out on units. I can’t imagine volunteers being put in a place where they would be exposed to blood," Culver says. "That would be an inappropriate use of a volunteer."
Reference
1. Centers for Disease Control and Prevention. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health care facilities, 1994. MMWR 1994; 43(No. RR-13):1-112.
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