key: cord-0965260-nn1blfv9
authors: nan
title: How Did Occupational and Employee Health Services Innovate to Maintain Core Business While Meeting the Increased Work Demands of the COVID-19 Pandemic?
date: 2020-11-10
journal: J Occup Environ Med
DOI: 10.1097/jom.0000000000002081
sha: 166eb9a447f7548640931959f58a8ce0491f9b54
doc_id: 965260
cord_uid: nn1blfv9

nan

T he Coronavirus-19 (COVID-19) pandemic, unprecedented in the number of individuals affected, and in the financial and social impact, can only be compared with the 1918 H1N1 virus influenza pandemic. Presenting unique challenges to health systems in general and to Occupational and Employee Health (OE&H) Services in particular, a key challenge was maintaining OE&H health care service delivery. One of the six building blocks of the World Health Organization (WHO) Framework 1 for strengthening Health Systems to Improve Health Outcomes, previously described by Omeogu and McKenzie, 2 was how to maintain usual occupational health service delivery, in the midst of increasing demands to address the new employee health challenges presented by COVID-19.

Initial efforts to ''work as usual,'' while trying to accommodate the demands of the increased workload due to new tasks were made. These new tasks revolved around managing the exposure assessment and return to work of the increasing numbers of health care personnel (HCP) exposed to or acquiring COVID-19 illness.

The ability to test employees timely and efficiently had to be instituted and scaled, as was the provision of exposure management for those infected, potentially infected, or with significant exposures. In addition, processes to allow for safe return to work of HCPs after COVID-19 illness or significant exposure; to enhance collaborations towards efficient and effective contact tracing; and to inform and maintain employee health databases had to be rapidly stood up.

Despite efforts to maintain prior work tasks and build capacity for new ones, it soon became clear that usual tasks would need to be modified in order to meet the increased demands allowing more time for pandemic related occupational safety and health activities. Once space was made to meet these demands, new tasks filled the space. To this end, some surveillance evaluations and posthire/pre-placement physical examinations deemed non-essential, were deferred. This calmed anxieties of both the health care providers and applicants, as each group feared potential COVID-19 infection from the other, given the face-to-face interaction that would have been traditionally employed. Post-hire/pre-placement physical examinations considered essential were modified to become more focused, sometimes reducing a 45-minute process to 10 minutes where only the most important information was gleaned. Only those annual surveillance examinations deemed essential, such as the Law Enforcement Officer (LEO) surveillance evaluation, were prioritized and completed as O&EH staff continued to ensure that officers were fit to safely perform their job duties, such as those related to emergencies.

Other work modifications specific to O&EH mission were the assessment for latent tuberculosis (LTB) where laboratory tests to evaluate for LTB, such as the Quantiferon Gold test and the T-spot, were substituted for the intradermal purified protein derivative (PPD) test given. Given that the former two could be completed in one visit while the latter would need two visits, the potential exposure for both the HCPs and the employee were reduced. Efficiencies could be further increased as well as exposure further reduced as the Quantiferon Gold or the T-spot could be ordered with other commonly ordered post-hire serologies such as the antibody titers for measles, mumps, rubella, varicella, and hepatitis B and C, as indicated. Spirometry, a bulwark of O&EH, was another function placed on hold. The reasons were twofold. First, ill advisement to conduct the test without adequate engineering controls given the risk of potential aerosolization of the virus during the procedure, [3] [4] [5] and the lack of PPE, such as the N95 respirator. The latter was especially acute during the early days of the pandemic.

Telehealth soon became the mainstay, for routine injury and illness care, especially during times when the number of COVID-19 positive cases was at their peak. Many specialty referral visits were postponed, during the early days of the pandemic once again to reduce exposure to both the HCP and to the employee. Physical therapy in-person visits were also postponed. Telehealth made a foothold and even when practices once again increased in-person visits, telehealth visits have continued, with projections that it will be a permanent part of the landscape of medicine. The U.S. Department of Health and Human Services (HHS) sweepingly approved the use of telehealth services as part of the Coronavirus Preparedness and Response Supplemental Appropriations Act. 6 Given that the core business and traditional charge of O&EH is to keep employees safe and healthy, this specialty was called upon to move swiftly and innovatively, in collaboration with stakeholders to meet the novel challenges presented by the COVID-19 pandemic. The relationships formed over the years with key stakeholders such as Infection Control (IC) Specialists, Hospital

Epidemiologists, Industrial Hygienists, Safety Experts, Human Resources Professionals, Workers' Compensation & Pension Officers, Facilities, and Health System Leadership was beneficial as the collaboration already in place allowed for a more facile coordinated response to COVID-19, to successfully meet the new demands. New tasks for which O&EH took a leadership role, in collaboration with stakeholders, included the screening of both employees and patients prior to their entering the physical space of the health system. Thermometer scanning was also placed at entrances of facilities to monitor temperatures in patients and employees as they entered and some as they exited facilities daily. Some facilities did manual temperature checks. Screening questions for both staff and patients were composed and administered to all entrants. The questions went through an iterative process based on the latest Center for Disease Control (CDC) guidelines and entity Infection Control/Disease guidance to increase sensitivity and specificity. This changed as more was learned about this novel virus. Employees with a positive screen may then be referred to O&EH services for further evaluation regarding COVID-19 illness risk, their symptoms, and disposition. Questionnaires ranged from oral and written responses, and later moved to scanning a QR code, using a smartphone app, or downloading the questionnaire from a website. The employee would provide evidence to the screeners that they were to be cleared for entry. Again, O&EH may be called for evaluation and disposition for employees who screened positive. Visitors may be referred to their primary care provider.

Another source of increased workflow demand for O&EH was the task to monitor quarantine for employees exposed to a COVID-19 positive patients or fellow employees, or to a person under investigation (PUI) for COVID-19. There was concern not only for the employees with workrelated COVID-19 infection but also for household members with whom they lived, that they may in turn infect. The possibility of carrying the virus home and infecting vulnerable family members heightened the enormity of the situation. A large section of the workforce was assigned to work from home, 7 and plans had to also be made to monitor and treat these employees in the event of COVID-19 exposure or illness. The parameters for quarantine, time for testing, and other relevant parameters were determined by and with Infection Control for the entity based on Centers for Disease (CDC) and/or local Health Department guidelines. OE&H services closely watched CDC guidelines in this regard and helped create institution guidance. CDC guidelines regarding the length of quarantine and whether to return HCP who developed COVID-19 illness based on time since symptoms onset, or based on negative test results, also evolved as knowledge of the virus increased. As knowledge of the virus grew-official, and in turn institution guidance changed including modifying the length of quarantine in order to mitigate against staff shortages, based on CDC guidance, which had added flexibility for surge capacity. 8 For example, modifications to guidance included asking exposed but asymptomatic employees to continue to work while consistently wearing PPE such as a mask or N95 respirator as appropriate, as well as eye protection. With the assigned risk levels based on CDC guidance, those deemed low risk may be allowed to continue working. O&EH worked closely with Infection Control to sure up this undertaking.

O&EH was also engaged in the guidance regarding the use of respirators and masks at work. Given the initial shortage of both surgical masks and N95 respirators, 9 as the PPE limitation was relieved, and knowledge of the virus increased, the policies regarding masks also evolved. In some institutions, earlier on in the pandemic, exposed employees, PUIs, and travel returnees were strongly encouraged to wear masks at work, resulting in some stigmatization by colleagues due to fear of contagion. Based on CDC guidelines and rapid acquisition of knowledge of how the virus was transmitted as well as its infectivity, a universal masking policy for all staff and patients quickly ensued. O&EH collaborated with Infection Control and HR to help increase employee understanding of the guidance as well as help assure its implementation.

Testing of employees was another task in which OE&H was very engaged. Initially, only symptomatic employees were being tested. As testing became more available with opportunities for testing both internally within healthcare institutions and externally, many testing policies practices evolved. Testing capacity was increased, so that employees could be tested at work in many institutions, irrespective of where the virus may have been acquired. 10 Those employees working in direct patient care and who had been exposed were prioritized initially until testing was more widely available, and employers were able to provide COVID-19 testing to asymptomatic employees. In time, the CDC issued guidelines for routine periodic testing of employees and residents of extended care facilities. 11 Much testing was conducted outdoors given the superior ventilation to indoors. In order to expedite care for employees and avoid unnecessary work absences, communicating COVID-19 test results was a priority. Electronic health record (EHR) systems were modified to include new COVID-19 tests for different testing scenarios.

Contact Tracing, which also involved OE&H services, was shared with or carried out by Infection Control/Infectious Disease. In order to effectively conduct contact tracing, the supervisor may need to be involved and informed of staff test results while ensuring strict confidentiality. O&EH staff supported employees primary care providers and worked collaboratively to ensure safe return to work of HCPs. Innovative Contact tracing tools and Smartphone Apps were introduced and are still in evolution, to identify staff that may have been in close contact with a COVID-19 patient.

In summary, OE&H was integral to the COVID-19 response by strengthening health systems from the start. The population management and epidemiology skillset inherent to this specialty could be harnessed. The man hours needed to cover O&EH work increased dramatically-from managing and monitoring and managing the database of sick, exposed and quarantined employees, to contributing to committees pertaining to operations, PPE, mask decontamination, and advising leadership, among other areas of need. Given the increased workload more OE&H staff were needed. Facility health systems responded by moving HCPs from other areas, deploying them to O&EH, where they were quickly trained to provide various services. Technology was employed to increase efficiencies. As the economy reopens and as hospitals start doing more elective procedures and seeing more patients in-person, one can only imagine that the needs of the health system will continue to evolve, as more is learned about the capricious SARS-CoV-2 virus. Health systems need to remain vigilant, agile, and forward thinking in order to be able to meet the rapidly evolving needs, presented by both known and anticipated unknown foes. Versatility is essential.

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How did occupational and employee health services strengthen their health system to meet the challenge presented by the COVID-19 pandemic?

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