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SHANAHAN
NORRIS
Q: Can physicians use your service?
SHANAHAN: Yes, in several ways. Most often we see doctors for their annual tuberculosis surveillance and to report work-related injuries such as exposure to a patient's body fluid. Doctors may also receive annual influenza and hepatitis B vaccines from us if they choose. JCAHO and Title 22 mandate that we do annual TB surveillances on everyone, physician and nonphysician, who sees patients. We send them reminder notices every three months. Current TB surveillance is part of the recredentialing process which occurs every two years for active staff members.
NORRIS: Physicians don't have to remember to come in. They get notices from Employee Health to do it.
SHANAHAN: We're here to do TB surveillance for them. But, if they do this somewhere else, they need to provide documentation that the test was done.
NORRIS: We will also give flu vaccines to doctors, as well as to employees. By the way, we're hoping we'll have an adequate supply of a viable vaccine this year even though manufacturers this year have had a difficult time fine-tuning the appropriate strains and initially had trouble getting supplies out.
SHANAHAN: We should be fine. We ordered and received 3,000 doses this year.
Q: What is your role as medical director of Employee Health?
NORRIS: To provide medical support for Ruth or one of the other practitioners. I'm their supervising physician. The nurse practitioners handle more than 99 percent of all cases on their own - and they do it very well. In reality, what happens is that Ruth or one of the other nurses calls to bounce situations off me. I may have an answer, or I may direct them to people with specialized expertise.
Q: How is it that the emergency services chief is also the Employee Health medical directorÉ
NORRIS: . . . is there logic to that? Well, I inherited that role from my predecessor, [former chief of emergency services] Paul Auerbach, but it makes sense. Our work areas are located in close proximity for one thing. The nursing staff can always run a question by the Emergency Department attending physician or send the patient over to the Emergency Department if necessary. Also, in emergency medicine we see a lot of work-related injuries on a daily basis.
Q: Several years ago a physician was available on site to see Employee Health patients. As the medical director are you comfortable having nurse practitioners see patients in most cases without direct physician involvement?
NORRIS: Yes, definitely. The nurse practitioners in this department are highly trained and experienced in the area of employee health. I'm very confident in their abilities and I'm also confident that if they get outside their comfort zone, they will ask for help. I've never lost any sleep over that one. SHANAHAN: If Bob is not available we can always go to the emergency department attending physician right next door.
Q: When would you typically refer cases to a physician?
SHANAHAN: Infectious disease situations are the most common. These situations are often complicated, and it is important to understand them thoroughly because if an employee may be infectious, he or she can't work in the hospital. For example, an employee had a possible exposure to Valley fever, and we needed to understand whether a positive test 23 years ago would remain positive over a lifetime. The answer is yes.
NORRIS: We thought so, but we conferred with the ID [infectious disease] folks.
SHANAHAN: Sometimes when a patient tests positive for TB, but because of allergy or other medical reasons can't take the usual antitubercular drugs, we'll refer them to an ID fellow for follow-up treatment.
Q: How often do you, Bob, as medical director, have to become directly involved with a specific Employee Health case?
NORRIS: Once or twice a month, maybe, while Employee Health is open. I'm more frequently involved during nights and weekends.
SHANAHAN: Our employees are mainly healthy people, so we don't have a lot of emergent issues arise. We typically have situations such as "this employee is allergic to this drug on our protocol, and we need to prescribe a drug that isn't on our protocol. What do you suggest and would you sign the prescription?" A patient may have an allergic reaction to an anti-inflammatory, such as Motrin, and we may consult with Dr. Norris about whether we can use a new agent not on our protocol, such as Vioxx, for example.
NORRIS: The nurse practitioners write prescriptions from the protocol list that have been approved by me.
Q: What are some special conditions that make Employee Health different in a hospital, as opposed to, say, a corporate setting?
SHANAHAN: Our employees come in contact with many immunocompromised patients. A common cold can be life-threatening to patients, so we must take extra precautions. You wouldn't want an employee working in the bone marrow transplant unit with a contagious new cold, even if the employee felt ok.
NORRIS: At a non-health care company they're worried mostly about the impact of an illness on the individual employee, whereas here we have to worry not only about the individual employee but also about all the patients he or she might come in contact with.
Q: What are some key issues Employee Health is dealing with?
NORRIS: One of Employee Health's most important functions is to respond to needle sticks - blood and body fluid exposure cases. That's a role we take very seriously. It is also an area that is changing constantly in terms of drug development. Right now we're part of a task force evaluating our whole BBF protocol, including consideration of new rapid HIV tests, which are rather controversial in terms of their sensitivity and specificity.
Q: How often do you have blood and body fluid exposure situations?
SHANAHAN: Usually we see four or five exposures per week, but it's very rare that the exposure is to active HIV infection.
Q: What is the protocol for a needle stick or blood or fluid exposure?
SHANAHAN: If we're open, which is between 7 a.m and 4 p.m., Monday through Friday, staff or physicians should come to us. When we're not open, they should go to the Emergency Department.
NORRIS: If the patient comes to the ED directly, he or she is generally evaluated by the nursing supervisor or the Life Flight nurse, whoever is available promptly. All the Life Flight nurses and the supervisors have been trained on how to run the BBFP [blood and body fluid protocol]. We recognize that BBFP patients have their own triage needs. We have a pathway that we follow to account for variables. We ask: Does the employee know the source of the body fluid? Or were they stuck with a needle from a trash can? What kind of fluid was it? Was the fluid blood tinged? Was the needle stick percutaneous? Was it a mucous membrane exposure? What's the immunization status of the employee? Once we work through the protocol, and based on the literature, we develop recommendations as to whether or not prophylaxis should be recommended for hepatitis or HIV exposure. It's important to point out that the tests run on the employee are kept confidential.
Q: What's a worst-case scenario?
SHANAHAN: A surgeon operating on a patient with active AIDS, a high viral load, cuts him or herself and gets a large amount of the patient's blood in the cut.
Q: What would you do in a case where urgent prophylaxis appears warranted?
SHANAHAN: After providing careful wound care, we assess the risk and can prescribe the "triple therapy" recommended by the CDC consisting of 150 mg of zidovidine (AZT), 300 mg of lamivudine and 800 mg of indinavir daily for 28 days. It's important to note that the three drugs have significant side effects. That's why we don't automatically start drug therapy. We are involved in follow-up and would see the person at least twice during the first month following exposure. We would do some baseline lab tests, including checking for other bloodborne viruses besides AIDS. We would also follow the patient with serial titers - at six weeks, three months and six months.
Q: Are these drugs really effective?
SHANAHAN: The CDC believes these are effective if prescribed within the first couple of hours after exposure.
NORRIS: That's why there really is a sense of urgency.
Q: Do you need to ask permission from patients to test for HIV if their status isn't known?
SHANAHAN: We always seek permission to test the patient.
Q: What happens if a patient refuses?
SHANAHAN: That's extremely rare, but we have a state-mandated protocol. First, we inform the attending physician that his or her patient is the source of exposure and has refused HIV testing. We have to wait five days for the patient to decide whether to agree to be tested. Meanwhile, we must test the employee to ensure that he or she is negative and, if conditions warrant, we will start prophylactic drug treatment. After five days, if the patient doesn't sign a permission slip, we can run a blood test on the source patient from a sample we have already obtained for other purposes. We tell the patient's physician the result of the blood test, and it's up to the physician to decide how to use this information. But we have the right to give the employee who was exposed the results. In those rare cases when a blood sample hasn't been taken, it would be considered assault to take blood from a patient who refuses permission. Blood samples, by the way, are routinely kept in the lab seven days.
Q: You have to wait five days while the patient decides whether to give permission for test? That's way beyond the several hour window you talked about earlier?
SHANAHAN: Yes, but we could start medication for the exposed employee while we were waiting for the decision and the results.
NORRIS: Again, we evaluate the potential variables to decide whether to start prophylaxis.
SHANAHAN: Source patients who refuse to be tested are extremely rare.
Q: What advice can you give physicians to avoid needlesticks?
NORRIS: Understand safety devices. For a lot of physicians, including myself, safety sharps and related devices were initially a little foreign and a little more difficult to use. We must get beyond the inconvenience factor, because these are definitely safer devices, and we need to learn how to use them. The reality is that if you're unfamiliar and use the new devices incorrectly, you are more likely to get injured than with the older devices. Safer sharps are indeed safer but require some basic understanding. I almost stuck myself the first time I used one. There is some technique required. You want to get that experience before the heat of the moment. By the way, a big issue, particularly one that we see in the Emergency Department, is just carelessness as to where needles are left -on trays, in suture sets, etc. So whoever comes to clean the tray off is put at risk. Awareness and using extra caution is the key.
SHANAHAN: There is an extra sheath on safety sharps, so loading and disposing is different, but the technique of using the needle is the same. If physicians need some practice, the easiest thing for them to do is to ask a nurse on a unit where they practice for a demonstration.
Q: What other issues in employee health and safety are you concerned with?
NORRIS: A latex-safe environment is another important, new issue for employees as well as patients.
SHANAHAN: We've become aware of latex sensitivities because since we started universal precautions - wearing gloves whenever we do patient care - many people have become sensitive to latex. The least serious reaction is a rash on the hands. The most serious reaction can be respiratory arrest, anaphylaxis.
Q: Why is latex allergy becoming a major issue now?
NORRIS: HIV has been a major force in requiring protection. The government has been far more aggressive about instituting regulations. Since July 1999 we've had a lot of regulations mandating safety devices, including gloves.
Q: Has the transition to latex-safe gloves been smooth?
NORRIS: In the operating room, there has been a learning curve as surgeons and others become familiar with latex-free gloves. This is largely a patient safety issue, and it's vital. We don't want to wait for a patient to be anesthesized before finding out they are allergic to latex. But this will be a very difficult transition until somebody comes up with a nonlatex alternative that really looks and feels like latex. After all, dexterity is vital for a surgeon.
SHANAHAN: Right now latex gloves are still available in the OR. There is an OR committee looking at the issue. I would strongly encourage surgeons to try out different latex-free gloves. Maybe take a pair or two home and play with them.
Q: What common injuries in the hospital setting come to mind?
SHANAHAN: Well they really run the gamut of a small city. Slips and falls in the parking lot happen more often than they probably should. One of the more bizarre common injuries is slipping and falling on jello or lettuce in the cafeteria. We've also had an employee struck by a falling dead tree in the parking lot. Several employees were bitten by squirrels who lived in the tree before it fell. People slip on waxed floors with some frequency. It's kind of a dilemma, since you need to wax the floors to keep them clean.
Q: Do you offer ongoing medical treatment for employees?
SHANAHAN: Our assigned duty is to determine if an employee is fit for duty. If they have a migraine headache or other common health issues, we might be able to offer an analgesic, but our goal is to refer them to their primary care physician. If a patient has a headache and asks for an aspirin, we prescribe the aspirin. We also tell them that if their headache isn't relieved, they should see their physician. We don't have the resources to take extensive histories or observe vital signs.
Q: If a physician sees an employee, for example, a nurse colleague, coughing on a unit, what should he or she do?
SHANAHAN: Ask the employee to come see us so we can ascertain if the employee is safe to be around patients. If we feel they aren't, we send a note with them to their supervisor advising that they are going home and will consult their physician. Ill employees need to stay home until their symptoms subside. Anytime a physician sees someone he or she doesn't think is fit for duty, mentally, physically, or because of potential substance abuse, they should refer the person to Employee Health. If the person doesn't want to go, the doctor should talk with the employee's supervisor.
Q: Do supervisors have any say about whether an on-duty employee can be placed on a work restriction?
SHANAHAN: No, but the supervisor has the right to say the employee can or cannot remain in the department and work with restrictions. For instance, if one of the nurses in the ED sprained an ankle, more than likely he or she won't be able to return to work for four or five days because the work requires standing and walking. Sometimes special projects are available where he or she could sit.
Q: Has the nature of problems you deal with changed over the years?
SHANAHAN: With the advent of the computer, repetitive motion problems, such as carpal tunnel syndrome, have become a major issue in hospitals and most other industries.
Q: What practical advice can you give to people - including physicians who have joined the computer revolution?
SHANAHAN: If they are not aware of what "ergonomically correct" means, they should check the literature on how work stations should be set up. Or they can even check with us here at Employee Health for a brochure NORRIS: The University and Hospital both have experts who will come to your office and analyze your work station to see if it is ergonomically healthy (University 725-3209, or Hospital 723-8143). You'll be surprised at what they come up with.
SHANAHAN: Yes, surprisingly good, practical fixes can often make a world of difference. That's true in the area of workstation ergonomics, but it also applies in a broader context. Common sense, intelligently applied, can often achieve outstanding results.
