Operations, Patient Care, Training

Learn the Ups & Downs of Occupational Medicine Contracts

Issue 1 and Volume 38.

Many departments across the country have been signing contacts with occupational medicine groups for a variety of services, including annual physicals, hepatitis B vaccine administration, tuberculosis (TB) testing and post-exposure medical follow-up and counseling. The question: Is this all these occupational medicine groups offer in the way of services? Are they actually offering the practice of occupational medicine, or are they functioning more like a “doc in the box?” In other words, is your department getting the full value of what an occupational medicine practice should or can offer?

The definition of the practice of occupational medicine is as follows: “Occupational medicine focuses on the health of workers, including the ability to perform work; the physical, chemical, biological and social environments of the workplace; and the health outcomes of environmental exposures. Practitioners in this field address the promotion of health in the workplace and the prevention and management of occupational and environmental injury, illness, and disability.”1 This definition suggests that occupational medicine services are actually broad.

Post-Exposure Issues
With regard to post-exposure medical treatment and counseling, the training for occupational medicine providers is generally not present. If the occupational medicine group your department is using offers this service, it would be important to interview and document their specific training in this area of care. This is important, because the Occupational Safety and Health Administration (OSHA) holds the employer responsible for the proper administration of post-exposure care and counseling—not the care provider. The occupational medicine practice is only acting as an agent on behalf of the contracting department and would not be cited by OSHA if proper care wasn’t in place. However, your agency or your government authority—would be.

Some occupational medicine groups sub-contract out post-exposure care and counseling to an infectious disease physician, who is best qualified for handling post-exposure events. Infectious disease practices deal with these issues on a day-to-day basis, so there would be quality of care and consistency of care.

This begs the question: Why use the middle man? If this is the case for your department, look at the cost you’re paying on the contract and determine if this is the best routine to follow.

Another factor is availability of the service. When assessing the use of an occupational medicine group for post-exposure issues, asking key questions before selection and signing on the dotted line is very important. Is the occupational medicine practice available for coverage for exposure events 24 hours a day, seven days a week? If constant coverage isn’t available and you’re required to use an emergency department (ED) during “off” hours, then the cost of care for your employees increases, and the proper care and counseling may not be delivered.

Agency Audit
If you’re currently using an occupational medicine practice, then you might consider conducting an audit. This will assist in protection for your department if an OSHA inspection was to occur, and will identify any areas in need of improvement. The goal is to protect care providers and ensure the department is meeting its needs for compliance.

On Nov. 25, 2011, the Centers for Disease Control & Prevention (CDC) published new guidelines for vaccination and immunization of healthcare personnel. In this document, the CDC states that these records are to be secure and computerized for easy access. This is to facilitate prompt/proper post-exposure medical treatment.

In today’s world, old diseases are back and many individuals are in need of re-vaccination or vaccination. For example, if you received measles, mumps, rubella vaccine (MMR) between the years of 1963 and 1967, you need to be re-vaccinated with the live measles vaccine.

Did your occupational medicine group notify you about this? Was your department notified in 2006 that all healthcare workers were to get boosters for protection from pertussis (whooping cough)? These types of alerts should be included in their role and service. All new hire personnel should be asked to bring copies of their vaccine/immunization records as part of the hiring process. This will assist in the identification of personnel who are in need of vaccines because they haven’t had the diseases or are in need of a booster.

In 2006, the CDC published that all healthcare personnel needed a booster for protection from pertussis. This was not well responded to and was published again in 2011. Occupational medicine groups should be tracking this type of information and sharing it with their clients. Previous vaccine/immunization records can be obtained by an individual from their high school, college or past employers. Each individual must request their records, and should be able to obtain them,
because those records legally belong to each individual.

Current members of your department also need to put forth their records for review of their protective status and childhood disease history. This is all part of health maintenance and prevention from exposure to these diseases. Some of these vaccinations don’t work if given post exposure. This would apply to MMR, for example. Obtaining this information is in your best interest for your protection and also works for the department’s benefit because prevention up front is far less costly than exposure follow-up.

Clearly, the need for expanding protection beyond hepatitis B vaccine and TB testing has long passed. Your occupational health practice should be tracking and maintaining records on all administered vaccine and immunizations.

The CDC stated in May 2008 that these records need to be “readily available at the work location.” If they aren’t available to the Designated Infection Control Officer (DICO), then treatment may be delayed or unnecessary treatment ordered. Your designated officer needs to be able to access these records at any time in an exposure situation.

Data Collection
The CDC and OSHA also have requirements for annual data collection as part of annual education and training and exposure control plan updates. Annual reporting of sharps-related injuries, TB risk assessment and airborne/droplet exposures should occur.

There’s also a need to support the TB risk assessment by conducting TB conversion rates. TB conversion rates are new positive TB tests in department personnel since the last testing period.

This information should be provided by the occupational medicine practice, especially if they are administering TB testing. Departments should also be provided with information regarding the percent of personnel that do not return in time to have their TB skin tests read at 72 hours and have to have them repeated.

This adds to department cost and may enter into a decision to switch over to one of the TB blood test that doesn’t require a return visit or a two-step testing process. A department’s need to perform annual TB testing depends on the number of active untreated TB patients that the department transported in the previous 12 months. Many occupational medicine groups aren’t aware of this and are still advising annual skin testing. Is it better to just do annual testing anyway? No. Continuing annual testing when not needed may lead to false positive test results. More is not always better.

The CDC is now asking that compliance rates with annual flu vaccine be reported annually and that this information be incorporated into annual training in an effort to boost participation. This information should also be tracked and provided by the occupational medicine group. Occupational medicine groups should be spearheading the effort to increase participation rates.

Exposure data should be reviewed on an annual basis and determination made regarding the number that may have been preventable, and recommendations for prevention and educational needs be offered. This may assist in the identification of purchasing needs and serves as a form of compliance monitoring. Compliance monitoring is a required component of OSHA’s exposure control plan.

Work Restriction Guidelines
When should you be at work and when should you stay home due to illness? Work restriction guidelines were originally published by the CDC in 1997 and were updated in November 2011, and should be part of each department’s exposure control plan used by the occupational medicine group. The guidelines offer clear information on when staff is fit for duty or when they should be off duty. Working when ill increases your risk because your immune response is lowered and poses a risk for transmission of your illness to co-workers.

Are these guidelines in place in your department? Vaccine declination forms are an OSHA requirement and are also addressed by the CDC and in NFPA 1581. Is your occupational medicine group collecting them? Your department should get a report on the percent of declination forms signed and an evaluation of the reasons for individuals declining.

Ensuring Compliance
The practice of occupational medicine is much more than simply the administration of hepatitis B vaccine, flu vaccine and TB testing. It also involves the collection of data important to maintaining health and safety of personnel in a department. Because the occupational medicine practice works for your department on a contract basis, conducting an audit for OSHA compliance and ensuring the CDC guidelines are being followed is important. OSHA is responsible for enforcing many of the CDC guidelines, and if they’re not followed, a citation is given to the department.

When contracting with an occupational medicine group, your department should present a list of identified needs, and ask if they can be delivered and at what cost. Using a letter of agreement is also a good idea. The letter should state that the practice will adhere to the CDC guidelines. This offers added legal protection for your department because the CDC guidelines are the medical standard of care.

Many departments put these responsibilities and compliance in the hands of the occupational medicine practice with no oversight to ensure compliance and no cost analysis. Is your department being told you need annual TB testing no matter what your risk assessment shows? Similarly, is your department being told that annual hepatitis B titers are needed annually or that hepatitis B titers are to be performed on all new hires?

If the answer to any of these questions is “yes,” then there’s a problem. None of these is recommended by the CDC, and an audit for OSHA and CDC compliance is in order. The department’s DICO officer can play an important role in performing this audit, and a relationship should be established between the DICO and occupational medicine service.

The DICO serves as a liaison between the department and the treating entity for compliance and quality monitoring. The DICO works to benefit department members, but they also work for administration to ensure compliance and quality of care. Remember, the CDC guidelines set the standard of care, and OSHA enforces most of them, but ultimately, the department is held responsible for compliance.

1. Occupational Health & Safety Administration. CPL 02.-02.069: Enforcement procedures for the occupational exposure to bloodborne pathogens, occupational health & safety administration, Nov. 27, 2001. In U.S. Department of Labor. Retrieved Nov. 1 2012, from www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=DIRECTIVES&p_id=2570.
2. Advisory Committee on Immunization Practices: Centers for Disease Control and Prevention (CDC). Immunization of health-care personnel, recommendations of the advisory committee on immunization practices (ACIP).MMWR Recomm Rep.2011;11(60):1–3.
3. Jensen P, Lambert L, Iademarco M, et al. Guidelines for preventing the transmission of mycobacterium tuberculosis in health-care settings. Morb Mortal Wkly Re. 2005;12(54):1–141.
4. Center for Disease Control & Prevention. Evaluation of results from occupational tuberculin skin tests: Mississippi, 2006. Morb Mortal Wkly Re. 2007;56(50):1,316–1,318.