OK, well, we're going to go ahead and get started. So we're getting the candy situation settled up here. If you've been in a session with Wendy before, you'll know that she likes to hand out chocolate. So we've got some for you today. Well, thank you guys for being here for this 2023 edition of Stump the Chomps, Conundrums and Quandaries in Medical Center Occupational Health. I think this is our fourth or fifth time doing this session, at least. And we really enjoy doing this just because of you guys. You all bring the questions. And it's an opportunity for us to learn from each other. We're sort of the guinea pigs up here who've volunteered to provide our insights and experience. But it really is a collaborative effort, this session. So we look forward to hearing some questions from you. Just a couple of housekeeping items, including introducing this amazing panel. And then we'll get started. So first, I will actually go ahead and introduce everybody. First, we have Melanie Swift right here to my immediate right. She's the Medical Director at the Physician Health Center and an Associate Medical Director of the Occupational Health at Mayo Clinic. Next to her, we have Rachel Liebu, who is the Medical Director of Occupational Medicine Services at the Atlantic Health System in New Jersey. Then we have Amy Behrman, Medical Director of Occupational Medicine here at the University of Pennsylvania. And then we have Wendy Tanasi, Medical Director of Workforce Health and Wellness and Professor of Primary Care and Population Health at Health Science at Stanford Medicine. And Rebecca Guest is the Director of Employee Health and Wellness at Memorial Sloan Kettering Cancer Center. And with us in spirit, although he had unfortunately missed this session because of an unavoidable work conflict, is Mark Roussey, who's the Director of Occupational Health Services at Yale. And I'm Lori Rolando. I'm the Director of Faculty, Staff, Health, and Wellness at Vanderbilt University Medical Center. Remind them it's all Medical Center. Yes. So yeah. Our learning objectives, as you can see here, are to increase our ability to manage challenging clinical and or regulatory situations in medical center occupational health settings, to increase the awareness of resources available to help manage in a medical center setting, and increase understanding of the scope and nuances of medical center occupational health practice. And you'll notice in each of those three learning objectives, medical center occupational health. So that's what we would like to focus on today. We will take any question about any topic relevant to medical center occupational health With the exception, we would please ask that you defer any questions about MRO and drug testing, just because that tends to get really complicated because individual state laws are different. And it's just kind of challenging to apply that with a really broad brush. And Doug Martin and his colleagues do a wonderful session completely on MRO topics each year. So we defer to him with regard to that. But other than that, again, we have an amazing panel. I could go on and on about each of them, but that would probably take the whole hour in and of itself. So just suffice it to say that they are cherished colleagues and each has an engaging and knowledgeable way of presenting information and a breadth of experience in medical center occupational health. And so we look forward to your questions and are happy to get started. So who has a question for us? We know they're out there, so don't be shy. Hi. Yes, sir. I'm sorry. Oh, there we go. So with the new hepatitis B guideline that just came out from the CDC on your needle sticks, are you going to add hepatitis B, C testing on your source? OK, so you're referring to CDC's newly published recommendation for population screening for hepatitis C, no, hepatitis B, core antibody testing when you get a surface antibody test that is negative, correct? Well, they were doing a triple test on everybody. Triple test for everyone. That's true. OK, true. So there's a new CDC recommendation that is not yet a US Preventive Services Task Force recommendation for the general population. This is not specific to health care workers. This is a public health recommendation. Again, not yet a US Preventive Services Task Force and necessarily insurance-covered screening, but a recommendation for a one-time screening for hepatitis B with a hepatitis B surface antibody, core antibody, and I believe surface antigen in everyone one time. So this is similar to the hepatitis C and the HIV recommendations as part of routine, going for pap smears, get your blood pressure checked periodically, and get this one-time screening. And so I think that it's broader than health care. In health care workers, we are first assessing their immunization and need to make sure that they're immunized. But we are starting to see laboratories, including ours at Mayo, reflex automatically to do the rest of the screening if a surface antibody is negative. So I'm interested if anyone else is starting to do that. But I think it's not something that, as the employer in the health care setting, that we need to be doing the screening for infection in all workers. Not the workers. How about the source on a needle stick? Because they did call out health care in the article. They called out health care personnel as a separate entity to be considered. And they did have only hep C positives that they were talking about in the article. It just made it confusing. I can't. Go ahead. No, go ahead. I guess I was going to just say, I'm not sure how to interpret a hep C if the source panel is surface, if the source is surface antigen negative, antibody negative, and core positive. I don't, I would, I think I would question that result. Our institution on the source patient, we just order the surface antigen because that's what we're concerned about in terms of whether or not the individual is infectious. If I could just add two secs to that. I think we're all working out how that new guidance statement will impact us. What we're going to currently do is what Dr. Rolando said for the source patients. We'll target it to the antigen only, since we're really only addressing infectivity, and leave it to the source patient providers to do more if they choose to. We're also, at this time, could change, not going to add the full triple screen to our high volume post-vacc, routine post-vaccine testing. We'll see where we go with that. But we probably will add it for non-responders when we do their second test. Hi. Bill Buck, I'm a recovering medical director of employee occupational health services, Mayo Clinic. Have any of you had to grapple with identifying your personnel in health care as safety sensitive, other than the obvious commercial drivers or your med life pilots who obviously have to have federal certification? Have you identified your subset of your population that are considered safety sensitive? And of course, the definition of safety sensitive is very controversial. And if so, what additional measures have you instituted to protect the public from those people? Which is why we do driver exams and pilot exams. One of the things that we do is for drivers that don't have to have a CDL license, they are given the DOT exam. And to make sure that they meet the requirements, even though technically they don't need it. But they have safety sensitive positions driving patients around. So we have them do that. Yeah, I mean, that's a really good question. And when Bill walked up, we were like, oh, no. It's going to be hard. That's a really hard question. We did discuss this with our HR legal, who consulted with another legal person, honestly. Because this is beyond just occupational health. It's also a legal and HR question. And the decision that we came to was certain groups, which are, like you mentioned, the federal groups, of course. Like the drivers, CDL drivers, of course. Anybody who fits in that. And we also have a large potential for nuclear explosion at Sloan Kettering. So anybody who's sort of working or has access to that facility. And then we also basically individually consider the situation. But we didn't make any job categories other than what I mentioned that are not federally that sort of automatically consider safety sensitive. That being said, LIPs, physicians, nurses, APPs, we tend to generally consider that they're safety sensitive. But we don't have any legal or policies about that. We just use our discretion, knowing that those people, those individuals, if impaired, for example, would have a potentially bad, could have a bad impact. So we, those are basically the groups. Can I ask another one? So on your non-responders for hep B, have you had any luck? So we traditionally give six vaccines and then give up. And then have you had any luck with the trivalent, the heptaslav, or whatever that is? Have you moved to that instead of the second boost series? Is that what you want to do? Yes. And so I'll pass this down because I think we all have an answer for that. But yes, we've gone to doing HEPLISAV for non-pregnant healthcare workers. So just a caveat, HEPLISAV is not recommended for pregnant and pregnant healthcare workers. Or pregnant individuals, yeah. Although I think you can have that risk conversation with their OBGYN. HEPLISAV, the adjuvanted two-dose hepatitis B series, has much better immunogenicity in older adults and adults with diabetes and other chronic conditions. So particularly if they're over 40 and they're diabetic, they're going to respond much better to HEPLISAV than to the traditional recombinant hepatitis B three-dose series. Not to mention the ease of following up and completing the series with vaccine space, just two doses one month apart. It's hard enough. You know, you can never get them back. Six months later and then one to two months after that, come back again for the blood test. You know, it's crazy. So yes, we have definitely gone to HEPLISAV. And we'll pass the mic down. One thing I just want to add is if you have somebody that's been a non-responder to six doses, you could try and give HEPLISAV and they may actually develop an immune response. Actually, I have nothing to add. Actually, I do have one thing to add. We're also using the HEPLISAV as our go-to for the first series as well. I don't know if you all are arguing successfully that the added cost of the vaccine is more than made up for by the saved cost and not tracking people down for six months. And yeah, we do the same thing. We use HEPLISAV now for both the initial series and as a second series for folks who didn't respond to the first. And the other thing I will mention, and I think Amy touched on it earlier when you asked your initial question, but if you do have somebody who has been a non-responder through two series, do make sure that you get a full hepatitis B panel just to make sure that they're not chronically infected and that's why they didn't respond. Yeah, we switched to HEPLISAV too and also brought back a lot of the non-responders and we've had really good luck with them actually showing immunity after HEPLISAV. So we do have questions from the live stream audience as well and we want to include them in the conversation as it were. So William Kan has posted a question. Are you aware of any best practice guidelines to help medical centers implement, wait for it, hazardous drug surveillance as described in USP 800 Medical Surveillance for Hazardous Drugs? Well, we are missing Mark Russi at this moment, aren't we? Because Mark Russi out of Yale gives an absolutely fabulous talk on this and I can't, you know, give exactly the numbers but what is the interpretation of the USP 800 guidelines varies institution to institution. I'm trying to take a hard line on screening as being whatever I want it to be as opposed to testing which is very straightforward. So screening can be surveillance. Screening that we're doing is at the VA where I was also. So hi, Wendy, VA. We would keep up with the environmental controls that were needed for USP 800. We did not do any sort of surveys or surveillance but when there was any sort of exposure, they would come to the clinic and then knowing what the exposure was to, we had a better chance of ordering the right test. So if it was nephrotoxic, if it was some big dose of adriamycin, you could get an adriamycin level. I think in most cases we don't do anything but at least the employee has that connection with the LIP and the comfort and we make sure that it's cleaned and we can follow up with them because a lot of it's emotional fear too, right, when people have exposures. So for this question about screening and surveillance, we don't do any testing and the Mark Roussey study shows very clearly that you can do as much testing as you want and all you're going to get is random tests that are out of range that have nothing to do with the work they're doing or the chemicals they're working with usually. You know, certainly there's an exception if you have somebody who's using one chemical in a situation when the environmental controls are not appropriate but the USPA 800 covers everything. Like it covers Tylenol, right? And so screening, doing random screening tests was taken away by the US Preventive Service Task Force for General Health a decade ago and so to do it now and to think that somehow we could go backwards and link it to something that they may possibly have been exposed to at some point in their job doesn't make any sense. So that's our approach and it's minimal and it saves me a lot of time. So. Thank you. I'm just going to add that I completely agree. This is Rebecca Gast at Sloan Kettering Cancer Center and to just screen 25,000 employees with CBCs and renal function tests, it just, I don't think that we would get value. I think we'd get a lot of noise and that being said, if there's an exposure, if there's a documented incident or an employee with a specific concern about an exposure, we go back to the basics. We look at the environment. We ask our industrial hygienists and we look at our, we work with safety and we, if there are concerns, we go and check if the primary prevention is good before we jump to testing the individual because of their concerns of exposure. If there is, of course, a finding in the environment or there is sort of outside of the normal exposure, you know, a dramatic exposure that's not just sort of a concern but a documented actual exposure, then we do that individual assessment based on what their concern is. And so I can share a little bit about the Mayo experience. I want to give a shout out to Laura Brear who's probably in the audience here somewhere and sorry, Laura, people may corner you afterwards for your paper. So there's been some investigation of this or assessment of this recommendation in a very intentional way at our institution, beginning with a qualitative study of, you know, what institutions around the country are doing and what they think of it, similar to, you know, what we're discussing now. Then a quantitative assessment around the country showing wide variability in implementation. So you ask for is there a best practice? There's no one best practice yet. And then what Laura published in JOEM a few years ago at the request of the editors was an example program that is what we've implemented at Mayo, which is a voluntary program that consists of a questionnaire and every two years and a CBC, which is optional. And the next step, which we're in the midst of right now, is analyzing that data so that, because there's really nothing published of to show NIOSH what the outcomes are in even a very large institution with thousands of individuals, what are we able to actually do with the CBC? And I won't forecast the findings of that right now, but watch for it in a publication coming soon. But the recommendations from USP 800 are based on NIOSH recommendations, which is expert panel recommendations. It's not database. So what we have found, though, in terms of value is one question on that survey. Do you have concerns about the safety in your area? We have a second question. Would you like to speak with an occupational health professional about it? And so that is the most bang for the buck that we have found on the ground so far. But watch for that paper to be coming soon. So Laura, sorry, I probably sicked a bunch of people on you after the talk. I'd like to add to that. Good. Thank you, Dr. Swift. So two things for you. One, the WOMA section, the Western Occupational Med section, just came out with a really nice opinion paper on USP 800 and testing. And I encourage everybody to look that up. And then your power, I don't know where your bias is if you're looking to do more testing or to do less, but your power is in the word use. And when the language says screening, you can interpret it. If the language says testing, you're kind of stuck. But it doesn't say testing. It says screening. People will mix those up all the time. And I see that in TB all the time. They'll use testing for screening. You can interpret screening as a big umbrella. It can be surveys. It can be questionnaires. Or it can just be the environmental services people are taking care of this space. They're screening the space. And we're testing the employees if there's an exposure. So I want to give you that power if you're looking to not test using the guidelines as support. Thanks. Please go ahead. Do you guys have any comments or experience with like competency-based testing for color vision standards, specifically towards like lab workers or kind of the multitude of point of care tests that nurses will sometimes be using, like hemodialysis. In other settings? Oh, yeah. So this is my personal occupational health whack-a-mole. Okay. This comes up over and over again. So what you need to be aware of is that CAP, the organization that accredits your laboratories, has a standard that requires assessment of the ability to detect colorimetric test results. And laboratory workers performing tests. And that your institution and CAP have policies and criteria for the performance of point of care testing, which also requires that you verify the individual can perceive the results of the, perceive and interpret the results of the test. Now what it does not say is that you must perform medical color vision testing, right? So the ADA says you can do functional testing of, you know, competency, but you cannot perform unnecessary medical tests unless they're tied to the job. And so with these, you know, what's happened around the country I think is an extrapolation of, well, it's tied to the job because you have to do a urine dipstick. So we can have everyone go and do an Ishihara test at hire. Okay. Most common color vision deficiency in the country? Red-green color deficiency, right? X-linked, like 8% of males, right? So, oh, it's genetic too. Hi, Gina. What is the spectrum of a urinalysis dipstick? Is it red-green? No. It's blue-yellow. And many of the tests are blue-yellow. And Ishihara is not able, if you're going to do yellow-blue color vision deficiency, you need to be doing a Farnsworth or something else. But we don't have the capacity to do that, right? So around the country, nurses are getting lined up at hire and being subjected to Ishihara testing. Okay. Let's walk this through in an ADA analysis. You fail your Ishihara test. Does that mean that you can't interpret a urinalysis dipstick? No. Because people with color vision deficiency, A, they might still have yellow-blue. They may still be able to do that. B, even if they can't and they're seeing violet and olive, they can still match it to the control result, right? They can match it to the key, and they can still perform it. So what do you do? They fail color vision, you have them do competency tests, to see if they pass. Here's the thing we're not doing as much as we should in the country. They pass the Ishihara. Do you still have them do the competency test? Because you should, right? Because we've just determined they can tell red from green. We haven't determined if they can actually, not only interpret the yellow-blue, but by the way, can they coordinate the timer and, you know, how many seconds have to pass before you look at nitrites versus looking at the pH versus looking at everything else? And it needs to be done in the lighting and the conditions of the laboratory. So I really want to exhort you to talk with your areas that are doing color vision testing, I mean your color metric testing, point of care testing, and look at their competency testing program. Is it systematic? Is it every employee? Do they have a positive and a negative control? And by the way, yellow-blue color vision deficiency is most often acquired due to chronic diseases like diabetic retinopathy. So if I test you at higher when you're 28 years old and you're working for me for 30 years, yeah, I feel real good about your test when you were 28, right? So the annual competency testing is the key to making sure people can accurately interpret those tests and perform them, not a medical test administered at higher. That was going to be my follow on is what interval. So I think an annual interval is really good. It's easy to kind of operationalize. With a lot of chronic disease, the progression is such that you're going to very readily catch that before the disease progresses very significantly. So like prediabetic diabetes is like a decade. So I think that's a great approach. Have you guys had any pushback from departments or have you had problems operationalizing at competency-based testing? It seems like people like want to really just do, oh, just do Ishihara plates on everyone. And it's like, that doesn't make sense. Yeah, I think laboratory directors will often really push for it for their laboratory staff. And you can broker a compromise. Let's do both. You know, let's do both. But make sure you've got that competency testing in there. And make sure that your HR and your legal folks are involved in that decision. That's a pretty comprehensive. Would you guys mind commenting about cognitive testing in the aging staff position? They all should be actually a year older than me, but after that. I was going to say, I don't, I mean, we personally, we're not doing routine cognitive testing on individuals at any given age. I think you would probably get in, I mean, I'm not a lawyer. But I think that just sort of blanket saying at this age we're going to start doing testing might get you into trouble. But it's a case-based situation. If there are observable concerns, observable behaviors that are causing question regarding safety and ability to practice, then those, we have a formal process at our institution for getting those individuals evaluated and doing a full evaluation, including cognitive testing if that's warranted. So it's an individualized situation. So, and there is a national movement toward doing, credentialing for older physicians based upon an age cutoff. And this is, you know, extremely dicey ADA territory. I can tell you that at a very prominent institution, EEOC is looking into this right now. And in point of fact, it's another sort of simplistic answer to a problem that may be real but is quite complex. Any physician that can't pass a mini mental status examination has been flagged by their peers long, long ago, right? There's no screening cognitive test of adequate subtlety and sensitivity to detect the kinds of complex cognitive tasks, impairment in those tasks that for a physician. And yet, there are definitely hospitals that send us people. And we have a physician health center at Mayo. They send us folks saying, I need a letter saying that I'm cognitively fit to practice. So I do think there's real cause for concern if you're the employer doing that. And I think the other thing that's overlooked if you're really interested in making sure people are able to practice safely is to consider offering them the chance to be screened for their vision to get their loops prescription updated and to have a hearing test. Those are far more common actually than cognitive impairment that goes undiagnosed or unaddressed in the workplace. So I think it's very dicey, Dr. Sammo. I'm not sure this adds a ton, but I'll just say I'm uneasy. I'm comfortable with the fact that we also do essentially for cause neuropsych testing under the aegis of our practice on a targeted basis as Dr. Rolando described. It's pretty straightforward, relatively rare, usually productive. The institution does run surveillance testing, cognitive testing on older licensed providers in a frankly very secretive way that is not under our aegis and that it has a very dampening effect as I kind of think it's intended to on people's decisions to remain in practice. That's a totally editorial comment on my part. But, yeah, should I go? Yeah, I have a question. My name is Melissa Fresh. I'm the medical director at University of Maryland Medical Center. And my question is aside from the OSHA respirator screening questionnaire, on hire are you folks asking medical questions to help you determine whether someone's cleared or not, as well as are you checking blood pressure? Currently we are doing those, but I'm feeling like we're going to shift away from that. And I think the question is always in what circumstance do we need to get a doctor's note from a treating provider? So I'd be curious to hear how you folks are handling that. And I'm going to add an online comment which I think dovetails with that, do all institutions represented perform pre-placement physicals for all hospital workers regardless of type? So we could bundle those two questions together. We do not do uniform pre-placement exams on every employee. We do them in a targeted manner for those groups that have specific job-related requirements to meet commercial drivers, our lifelight air ambulance crew, child care workers, things like that, that have either a federal or a state regulation or some accreditation requirement to meet certain physical requirements. And then we have those individuals that we do pre-placement and ongoing surveillance exams. So there's sort of the regulatory fitness for duty. You have to meet these requirements in order to be able to perform the job versus the surveillance. We want to get your information at baseline and then monitor you to see if you're having any ill effects as a result of the work that you do. So we do those, but we don't do regular exams. Now blood pressures, we offer sort of what we call know your numbers, our biometric screening as part of our wellness program on a voluntary basis to individuals on hire if they want to get their baseline numbers. And we use that as one of our pieces of our overall comprehensive wellness health promotion incentive program, but that's totally voluntary as well. Okay. Yeah. So the same, and we'll just go down, I think, same. And remember the ADA AAA prohibits a medical examination unless it is directly related to the job duties. Yeah. So, and that's certainly pre-hire, post-hire, you have a little more latitude, but still, if you ask a lot of questions, you're now in possession as the employer of medical information you have solicited. If you don't need that information, but you've got it, and then down the road there's an adverse employment action that has to be taken to that employee, then I think you do open yourself up to the claim that, well, I was really terminated because they knew I had cancer. I was really terminated because they knew I was going to cost a lot to the medical plan. So I think you have to be super careful about that, but we take a very similar approach as Lori described at Vanderbilt. I would say that I just want to present an alternative. First, I think it's important to look at what your state regulations are for healthcare workers because in New York State, there's a regulation that you have to do a pre-placement, not pre-employment, but a pre-placement evaluation of healthcare workers, inclusive of a physical exam in history and medical history. And so, and I'm hearing on my left, New Jersey as well. So I think you need to check with the state that you're practicing. Because of that regulation, we do take a history and do a physical. We leave out the GINA. We don't ask about genetics or family history, but we do do that on all of our healthcare workers. I'm in New Jersey, and it is required. So what we do is a pre-placement assessment, including a targeted exam, except like the other people that we're speaking, we do it for people that need a CDL exam or people that need surveillance exams. We'll get baseline testing. And also for our clinical staff, who we often sign their credentialing papers, we'll do a history and physical on them because that is required for credentialing. And one other thing, I think it's important to ask oncoming team members if they feel they're able to meet the essential functions of their job. Right. That's the alternative, which is probably more defendable, actually. Right. So, okay. And I have a question related to your question for us. Yeah. So how do you identify if people need some sort of accommodation, or does the post-off or pre-hire identify that themselves? So that's what our nursing team seems to do. They identify that someone needs an accommodation, and they contact HR or other sources. Yeah. I mean, I think if we have a finding during the history, the targeted history and physical that suggests that the person might need an accommodation, then we suggest that to the employee. Right. Again, this is post-offer. Right. So I can't think of ever a history or physical precluding a person from doing their job. Yeah. I mean, I think. But it is an opportunity to identify potential disability. But if you don't do the, if you don't do it, like Lori and Melanie, if you don't do the PP, what do you do in accommodations? Yeah. We let folks know that if they feel that they need an accommodation for some reason, then they go through the, we have a standard accommodations process at our institution, so they can reach out to, you know, it's a branch of HR employee relations that will move them through, you know, guide them through the process to get the position attestation of need, et cetera, et cetera. And then they work with the individual and the department to determine whether an accommodation is feasible. Yeah. Similar. So I think it's based on the answer to that question. Yeah. Can you, you know, do you need an accommodation? You know, and at different institutions, that's placed in different areas, right? So some places it's the hiring recruiter who's asking that question, and for us it's the occupational health nurse is asking that question, and, you know, so that's just an interactive discussion with the individual. Yeah. Okay. Great. Thanks so much. I think we had a question online that you wanted to get to. Yeah. So there's a question online from Ediberto Garcia. Any special labs or panels for those starting to work in dialysis units? So I'll start and see what the rest of the panel says, but as far as the workers go, no, just the routine baseline, you know, we want to make sure that they're vaccinated for an immune to hepatitis B, but we don't require any ongoing testing for the workers. Now, there is some guidance out that suggests that patients who are on dialysis may need, I think it's regular or boosters for hepatitis B vaccine, whereas the general public does not typically require a booster, sort of the once immune, always immune, but for dialysis patients that may not necessarily always be the case, but as far as the workers themselves, we don't require anything additional. I have it in my hand, so I'll just say we do the same. So I have a question. This one will be for, I think, Dr. Tenassi. This is a question that came up at our institution. Okay. New hire getting their new hire TB testing. Okay. This is a new healthcare worker, U.S. born, no previous exposure, never tested positive for TB before. We do quantifer on gold at our institution, and the results come back, so you know how quantifiers are done. There's a negative control and a positive control, and then there's two TB antigen tubes, and it comes back as a quantitative result from zero to ten. By the way, it can't report over ten, so sometimes that if you're ever wondering. So the results come back positive, and we, in low-risk people, we always repeat this. So here's the results we got back on the positive. Negative control, .05. Positive control, zero. TB tube one, six and a half. TB two, zero. So the nurses following protocol repeated it the very next day. Negative control, 0.05. Positive control, eight. TB tube one, zero. TB tube two, zero. Doctor, I'm going to throw this one to Dr. Tenassi. Hi, everybody. So that was just perfect. So you know the four tubes, right? The mitogen tube is the positive control. So Melanie or Dr. Swift are saying that your patient had a zero on the first one, and then a positive on the second one. And then a positive on the third one, but a six on the TB antigen, and was reported out positive, which is what the laboratory and the company should do. That's in the algorithm. So even if the test is essentially an invalid test because there was no mitogen result, the lab should report out, and it should be reported as a positive if there's a reaction in the TB antigen one or two tube. Because a positive control is looking for the patient's immune system. So if the patient is severely immune, immune deficit, so they can't mount a response in the positive control tube, but they test positive to TB one, they got a lot of TB. They were able to mount a response to the TB. You still want to report that out to the doctor. Your case sounds right away like it's a mistake, right? Essentially zero, nil, a zero on the mitogen, a six on TB one, which is a huge TB response, and then a zero on TB two. So right away it looks like a lab error, which is part of why we need to retest the positives when you don't expect. When your pretest probability is low, you can look at this. You can nuance it, and you can say, in my expert MD job security role, I understand that this is likely to be a false positive, or you can just knee jerk it to another test, which you did, and then it sounds like it came out negative. And I know that what is discussed in these kind of situations is when you have that setting, labels can be switched. So if the mitogen was supposed to be the six, and the TB one was supposed to be the zero, that's that sort of next level thinking that could possibly be what happened. So when do you get a bad mitogen result? When the tube gets too hot, when the label gets switched. That's definitely possible. Yeah, and so that's the main thing. So I would just retest it, make sure that's on your algorithm, to retest anyone with a low pretest probability, and then yourself, you can have fun with it and look at the numbers and see what happened. You can call your laboratory and ask them after the first round, hey, by the way, I think there was a mistake. Maybe there's some training opportunity here, and then if it were to have repeated to that crazy result, that would, well, it really can't. It would have been read out as positive, and you'd have to send that person to ID. Poor Dr. Bukta's been standing there in the bright light. Does that help? Is that good? Look at the values. That's why we look at the values on the tubes. They're so important. They can give you so much of a story. Thank you. I think the lab thinks that the labels got switched, actually. And it was really a lesson for us about more education for our nursing team, who are following the interpretation, but need a little more. We don't always go into the deep dive of how the test is done and how to interpret the test with every nurse who might be looking at a result. And so it causes us to sort of flush out our nursing protocols a little more nuanced, with a little more deep thinking for them to be able to do. Dr. Bukta's ankles are swelling. I'm exceeding my restriction. Sorry. I'm back. Rebecca, this won't be terribly difficult. I'm just wondering. 10 or 15 years ago, and this segues on the safety sense of the question, there was a somewhat rabid faction of anesthesiologists who were advocating that if one of their colleagues was identified as having a substance use disorder, that there was a one-strike rule. They were immediately removed from the service and told to go work somewhere else. Have you run into that? Has that come to reality? Is that old news, dead news? Yeah, I mean, I think that there are always going to be people that have that approach and attitude. But I don't agree with it. And I would fight back against that. But obviously, that's your personal opinion. And as a medical director, I think that's our role to present an alternative point of view. I think when we have a provider with reasonable suspicion of impairment, or any employee with reasonable suspicion of impairment, we follow a very fair process for evaluation. And I think that when there is an opportunity for the person to get treated, I always fight for that. I always will go down. I mean, I always fight for that. I think that one of the reassuring aspects, one of the things that tends to reassure people who are against treatment and return to work is my reassurance to them that any impaired provider that does return will be monitored long term. And I take on that responsibility as the medical director, saying that when a person, you know, an anesthesiologist or a person like that, does go through treatment and returns to work, we take on the responsibility of monitoring them. And we actually have a pretty, we've enhanced the rigor of monitoring, to be quite honest, and the duration. Because it's been shown that physicians are much less likely to relapse when they're monitored. And physicians do very well with rehabilitation, because of the importance of their job. So that being said, HR, you know, we have a drug free workplace policy. And HR ultimately has the decision making authority to terminate an employee. That being said, I think it's ethical, and I think it works to let people have a second chance, knowing that it's going to be a lot of work for you to monitor that person. And a lot of responsibility, but I think it's worth it. So my question is in a different domain, or exposure, if you will. And I'm curious if in your respective medical centers you have any pre-developed medical surveillance protocols on exposure to formaldehyde. And this is the scenario. You know, industrial hygienist, safety and health, calls you and says, we have a tech in the surgical pathology unit who, quote unquote, feels that he has aggravated ear, nose, throat irritation because of the work with formaldehyde. And they bring up the OSHA standard that says employers should have medical surveillance. Question is, what do you do for that particular employee? Do you, as occupational health, do you see them to make the diagnosis? Do you send them to the specialist? Do you address removal from the workplace? Do you address PPE? What should be our next step in this quagmire? Yeah, I think potentially yes to any and all of the questions that you asked. We have a formaldehyde surveillance program for our folks at our institution. And we work very closely with our, it's now called the Office of Clinical and Research Safety. It's essentially our environmental health and safety colleagues, as well as the individual, whether it's a clinical lab or the autopsy lab in the medical school, all of our residents who rotate through their autopsy rotations and such. And so we look at what the exposure levels are to determine who needs to be enrolled in the medical surveillance, including and who needs to be enrolled in respirator PPE. So we clear them medically for respirators. And we also do a questionnaire and a targeted physical examination, as well as PFTs, essentially, on an annual basis. And we also do evaluations for anyone who has a concern of a potential exposure. And we will see them. And we'll get the history. We'll go through the process of figuring out what their exposure was. Was their exposure likely? Are their symptoms likely related to their exposure? If we have questions, concerns, we will get additional testing as the situation warrants and referral to a specialist if the situation warrants. So at that point, it becomes an individualized process. But in general, yes, we do have a surveillance program set up for those individuals. We do periodic monitoring to determine if the medical surveillance program is needed. But yeah. Quick follow up. So if you determine that it is a sensitization to formaldehyde, would you advise as a policy that this should be filed at the workers' comp? I think if the individual believes it is work-related, then yes, they can file a workers' comp. Thank you. And by doing that, you get them into the accommodations or transitional work programs where the employer won't dismiss them from that job, but will be obligated to find them another position, or at least offer them another position. That's a great protection. I just had that with an oxicide allergy. I don't know if any of you have had that. I had an employee who had two full-on anaphylaxis events requiring multiple epi's in the ER from oxicide, which has parasitic acid in it. And it was a debacle, I must say. Don't tell my employer. Because the employee ended up quitting the hospital center because she hadn't been given opportunities to transition to different work. And it created this big cluster. And what should have happened, even though the workers' comp case was open, is it should have been made a permanent and stationary. And then we should have accommodated her in another position, or at least offered it. And so we're still mopping that up. But this certainly happens. And Wendy, I was just going to say, you kind of asked. You don't know if anybody else has had that happen. But we've noticed a significant number of individuals, or an increased number of individuals, who have had respiratory complaints as a result of working in the office as well. They're doing a study on that, if you want to catch them here. Yeah, they're looking for institutions to go study for parasitic acid, oxicide, respiratory problems. Hi, Wendy. This is one of the things we ask about before we do a TV screening to a Q of T is immunocompromising drugs, steroids, that type of thing. There are so many immunocompromising products out there, biologics, and levels of steroid use. What's your recommendation regarding the one-off Meddrel dose pack versus the person on chronic, low-level steroids, 5, 10 milligrams a day, and also the other commonly used biologics? Do you delay the quantiferon for four weeks, or six weeks, or just moved right to chest X-ray? How do you navigate that? So that's a really interesting question. The reason that we do testing on people who are going on to biologics is not because the test will be compromised by the fact that they're on those medicines. The test should be just as good. But it's a fact that if they get tuberculosis on these immunocompromising medications, that tuberculosis will progress. So this is a really common issue. People who are immune-compromised are not more likely to get TB in our first-world setting. But if they're immune-compromised and already have latent TB, then they'll progress at two to three times the rate to active TB than other people will. So diabetes, steroids, other biologics won't affect the test, won't make it false positive or false negative. So you can count on that being negative in the beginning if it's truly negative. But if they're already positive when you see them, and they have diabetes, or they're on immunocompromising medications, or have kidney disease, those are the people who need treatment. They need their treatment right away because they are the ones who are the most likely in the entire population to progress, about equal to the brand new exposures. Does that help? So are you suggesting we remove that question, not remove it, leave it on there perhaps, don't delay the test, or don't substitute the test with a chest X-ray, go ahead, get the result, and if positive, push that forward for treatment, but not worry about a false negative or a false positive? That's exactly right. And I just had to redo our paperwork at Stanford because it's so commonly misunderstood, the difference between the risk of getting infection versus the risk of progressing. And they're different pots, and they're different people. So I don't like to collect the extra medical information early, so we eliminated those questions early. Once they're positive, and then confirmed positive, as Dr. Swift said, once you've got the test and then you've retested them in a low-risk population, you know they're confirmed positive, now there's an action to take. And so the same question, different scenario, live virus vaccines, again, the recommendation to delay, no need to delay. Yeah, that was garbage. It was so garbage. Some of this is from that QFT FAQ from the Quantify Your Own TB-Pooled product. That was super unbelievable garbage. Sorry. All my CDC colleagues, right? Amy goes, what do you really think? OK, so live vaccines in the 1970s with some studies with the skin test. What is the relationship with where we are now? The mRNA vaccine wasn't even a live vaccine. Most people aren't even doing skin tests anymore. So the whole thing was like theoretical six steps removed, created all this chaos for AHRQ health docs to wait four weeks from this or 17 days from that. It was such nonsense that they finally rescinded it. So August 12, 2022, a little star on my calendar, they finally went back in there. Oh, yeah, yeah, never mind. So it's not related. It should never have been there. I'm sure it was well-intentioned. I love the colleagues. But it was too many steps away. And not enough science. Right, and that extrapolation began not with adults, with children. So the concern, false negative skin test in children following live vaccine. Live measles in 1974. Yeah, extrapolated to maybe all live vaccines and extrapolated to maybe all adults and extrapolated to maybe quantiferon 2. Yeah, not live vaccine, mRNA. Well, then with COVID, extrapolated to COVID. So that was remarkable. And that's the job security, too. It's hard to push back against those. But definitely not only use your knowledge, but reach out to the rest of us, all of the colleagues you've met here, when something doesn't seem right or is really getting in your way. And get the support of colleagues. I do that all the time. We had one question online that I think we'd like to get to. And then we'll get to your question. And if folks don't mind, I know we're just about at time. But the respirator. OK, so here's the question. Margaret Hasek from Loyola posts, does your organization explicitly specify which job roles are covered in your respiratory protection program? So trying to avoid having to annually fit test people who really don't need it. And so she's trying to determine in a tertiary or advanced academic medical center, trying to get a best practice. How do you identify who you enroll in your respiratory protection program? Well, do you want to start? All I was going to say is it's a good question with a very difficult to address. I think our institution has, if we have erred, have erred on the side of casting an extremely wide net, which you could argue does no harm, except that it's a significant burden on our own staff for onboarding and for the safety staff for testing. And during the time of COVID, it was a significant issue in terms of wastage, frankly, of the N95 respirators. We have been approaching this using job classes in our human resource information system. And it leads to probably testing way too many people. I wish I had a better answer than that. We do something similar. We categorize folks by job. Often, it's a combination of department and job that they're in. So it's not necessarily just the job title. Now, physicians, advanced practice providers, yes, they get included because they are in the hospitals. Potentially seeing people who need airborne precautions. But then beyond that, it is looking at not just this person is a nurse, but this person is a nurse in this department where they're potentially seeing inpatient airborne precautions folks as opposed to maybe an outpatient specialty cardiology clinic where that likelihood is much lower. So we wouldn't necessarily cast that net so broadly. We do something similar. But what we do at the time of hire is we fit test everyone so that we have a baseline fit test. And then if they're doing annual testing, they just would have to sign an attestation that nothing has changed in their history. And that saves a lot of time for our department. My question was, what medical record do you all use for employee health? And is that the same medical record that you use for occupational medicine? We're out of time, unfortunately. I figured that was the answer. We use OHS Pure Safety for our employee records for occupational medicine. And for all non-work related visits that are not occupational medicine, the institution uses Epic. Yeah. At Stanford, they use Epic for patient care. And for workers comp and employee health side, we use Agility, which is not really slick looking, but it's a pretty good program, very modifiable. I think that if we were using it better, it would be better. And so we have another facility out in Tri-Valley, Stanford Tri-Valley, and they use it beautifully. And they have all these wizards set up. And everything builds a node. And they transmit directly to the TPA. And so Agility. And we've had good results also with the support services for that. At the VA, your tax dollars, that would be paper. Toner cartridges, printers, staples, boxes, lots of boxes. And then we mail them to the Midwest, where we put them in caves. And I'm not clever enough to make that up. You can look it up. The thing is that as of December 22, the caves are full. We moved from Nebraska to Kansas caves while I was in employment. Filled those caves, and now the caves are full. And the boxes are stacking up. And there's some impetus to go to an electronic health record. Sure, I'll top that. I can't top that. The short of it is we're using QWERTY. I would recommend that. There was a whole talk about electronic medical records and occupational health and employee health given on Sunday by Marcia Issacari. And I think that her slides are on, are available to us. So if you missed that, I would take a look at that. Because she did a nice survey asking employee health and medical center occupational health centers just that question, and asked us to rate what we liked about it, what we didn't like about it, et cetera. And she presented the results of that survey. And we use, for our clinical patient care, we use eSTAR for the actual exams, the employment-related exams. We use eSTAR, but there's a separate what's called sort of a sequestered database, or a sensitive database, that's blocked from anybody else, any other providers other than us, seeing that information. Because we're the provider, but as part of Vanderbilt, we're also the employer, as are other providers within Vanderbilt. So there's that barrier, so nobody else can see that. And then we have our own sort of homegrown database that we use to capture and track all of the services we provide, workers' comp, return to work, immunizations, things of that nature. And our database actually can communicate with the medical records. So if we give a vaccine, it will automatically go to the medical record. If we order a lab for compliance purposes that's run in the lab, that will import into our database. So we have all of our tracking so that we can report compliance and that sort of thing, and get any reports on any of the data we need from our database. That's really good to hear. Because on the be careful what you wish for train, when I went to Stanford, they are going electronically to Epic now. And the battle, because they've never had an occupational health, zero, kind of including me since I'm grandfathered in from emergency medicine, zero people trained in occupational health for the whole institution. They're just like blend in Epic and employee health and workers' comp, and I'm trying to put the brakes on and trying to use Marcia. But it's a very difficult question. And I'd love to work more with Lori to figure out how you, I'm not even keen on doing any transferring, but I understand that people want to transfer the immunizations over. I get it. And then we also have to feed out into the California CDPH system and the CDC system. So a lot of people are going to Epic. Epic has a steering committee. They're building modules. But I think that's a real slippery slope between the two, isn't it? So I'm a little anxious. All right. All right. I think we're, yes, we're out of time. But I think we'll be here if anybody has any other questions. Thank you so much. Please drink and be merry. Thank you all so much. If you asked a question and want chocolate, or even if you didn't ask a question and want chocolate, we have chocolate.

medical center occupational health

panel discussion

medical directors

experts

formaldehyde

medical surveillance

tuberculosis test results

substance use disorder

respiratory protection programs

individualized assessment