Okay, thank you, everybody, for coming to the 2024 iteration of Stump the Chumps, our Medical Center Occupational Health Session. We should have a sign that says Chumps. Yeah. Yes, we are the Chumps, by the way. Chumps. Chumps. So, just a couple of housekeeping announcements that AOHC would like us to mention. Please silence your cell phones and other electronic devices. You can evaluate and claim credit for the session in the app. Go for the neon green links toward the bottom at the end of the session to make sure you do an evaluation of us, and that way you can get your CME credit. If you haven't already, download the event app, SWAT card, it'll tell you everything you need to know about the conference. And if you need assistance, the registration desk or the AECOM membership booth across from the exhibit hall will be your best resources. Or just look for anybody wearing red lanyards that says Team AECOM, and they'll be able to help you. They've been wonderful. I've already availed myself of their expertise today. So, with no further ado, we've got our wonderful team here, and I will just go through and introduce everyone briefly. Starting here on your left at the end of the table, we have Dr. Melanie Swift, who's Vice Chair of the Division of Public Health and Infectious Diseases and Occupational Medicine, and the Medical Director of the Physician Health Center, and the Associate Medical Director of Occupational Health at Mayo Clinic, and she's also an Associate Professor of Medicine at Mayo. Next to her, we have Dr. Mark Roussey, who is Emeritus Professor of Medicine in the Occupational and Environmental Medicine Program at Yale. We have Dr. Wendy Tenassi, here next to me, who is a Physician with the Occupational Health Services at the VA Palo Alto Healthcare System, and Senior Medical Director for TB and Infectious Diseases at QIAGEN Corporation. I am Lori Orlando. I'm the Executive Director of Faculty, Staff, Health, and Wellness at Vanderbilt. Next to me here is Rachel Liebu, who is the Medical Director of Occupational Medicine Services for Atlantic Health System, and a Clinical Assistant Professor at Thomas Jefferson University. Next, we have Rebecca Guest, who is a Senior Medical Director for Occupational Health Services at Montefiore Medical Center, and Associate Attending at Albert Einstein College of Medicine. Your swap card app might say Memorial Sloan-Kettering, but she has newly moved into her new role at Montefiore and Einstein. And then last, but certainly not least, is Dr. Amy Behrman, who is Division Chief of Occupational Medicine, and a Professor at the Perlman School of Medicine at the University of Pennsylvania. And we are absolutely delighted to be here with you again for this iteration. For those of you who have been to this session before, it is your opportunity to just ask us any question that you might have that pertains to medical center occupational health. The one caveat that we ask is to, if you have medical review officer questions, there was just a session on medical review officer questions, and if we start going down that road, it tends to become a medical review officer session, and we would like to avail ourselves of the opportunity to ask other questions pertaining to medical center occ health. So anything else is fair game, and we will answer to the best of our abilities. So we encourage you, if you think you have a question, others likely do as well, so please do not be shy, and we look forward to those questions. The only disclosure we have is that Dr. Tenassi, as I mentioned, does have an employment relation with QIAGEN Life Sciences, which is the Quanafuran gold testing company. And these are just our objectives. We want you to be able to walk away being able to manage challenging clinical and regulatory situations in a medical center setting, identify resources available to help manage medical center occupational health questions, which includes all of us and all of you out there as colleagues. We want to be a resource for each other. This is an opportunity to plug our medical health, medical center occupational health section for the college. We have a great group of folks who want to be a resource for each other, and better define and integrate the nuances of medical center occ health. So with all of that said, we will, does anyone have- I think Wendy's looking for a microphone for the audience. Yeah, we were going to have someone potentially roam. He is over there. Patrick is a very- Patrick, would you like to be our, we have a first year medical- So Patrick McGinnis is a first year medical student at the University of Maryland. He had no idea he was going to be introduced to this august body today, so thank you, Patrick. But a first year medical student interested in occupational medicine. And this is, Patrick is doing rotation in an elective in his first year of medical school with Mary Ann Cloran at University of Maryland, learning about our specialty. And I think what he's learned about occupational medicine is if you show up, you get voluntold. And on this side of the room, we present Christina Manette, who will carry around the microphone for you guys over here. Wonderful, thank you. Thank you both. So who would like to be first? All right, wonderful. Good afternoon, David Cochran, Dartmouth-Hitchcock. So I want to start with color vision testing. It's all our favorite topic. I am well aware that it has almost no value. The challenge I have is we have joint commission coming sometime between now and August. And all of our internal pre-inspectors are hammering us on how are you going to test everybody for color vision. So it's not, I know what the right answer is, but I don't know how to answer this false regulatory demand. And I was wondering if you'll have any experience with that. So the long game is one thing. The short game is another. And so in a nutshell, there is a need to demonstrate if you're doing color metric testing in a laboratory that you're able to read that test correctly. So the easy answer is let occupational health do some Ishihara plates. They pass that, they're good. Ishihara plates test red-green. A lot of the color metric testing is blue-yellow. A lot of color vision deficiency is acquired over time. You're going to test them every year and see if their glaucoma is changing then. Lighting conditions are wrong. Job task is wrong. You guys know this stuff. You're occupational doctors, right? So yes, proving that they can do the test correctly is required. And that can be done through a proficiency test if it's done well. But the easier thing is say let's make it a medical test and let's have occupational health do it. So the long game is to have a good, long, heart-to-heart with your employment attorney in your institution. Explain to them what color vision deficiency is. It's not that you see black and white. It's not that you're suddenly on Turner Classic movies when you look around. Use one of those visioning things where you can go online. You can see this is what it looks like if you have deuteranopia. This is what it looks like if you have tritanopia. Let them understand the issues about genetic color vision deficiency. Eight percent of males have red-green color vision deficiency. Hello, Gina. We're going to do a genetic test now. The others that are yellow-blue are often due to diabetes, diabetic retinopathy, glaucoma. Oh, hi. We're going to find out some medical information about you that has nothing to do with your job. But if you fail this, we're going to send you to your unit, and you're going to have to prove through a good proficiency test that you do this test correctly. Not just that you can see the colors but that your hand doesn't shake, you get the drop in the right place, and you can time that thing because it's ten seconds. Oh, I have trouble doing them. I just can't switch assets. Anyway, if you fail the color vision test, you do that. If you pass the color vision test, you still need to go do that, right? So you're putting in a medical test that does not change what you do, okay? So that's the discussion that you need to have with the attorney, and then your attorney is the one that shows up when joint commission is there. And if your attorney has your back and they talk about we have this, there's nothing in joint commission that requires a medical test, and joint commission explicitly states we do not require a medical color vision test. Okay, hello. Hi, thanks, everybody. Follow-up vision question. We recently had a spat of quality issues in central sterile supply with little specks of foreign bodies on surgical trays. The CNO of the hospital asked me if we should do vision testing for all the folks who process the trays, and many of them are over the age of 50. So the follow-up question was for all of our maturing clinical folks who have to read small print and such, is there merit to consider near vision testing for our folks on an annual basis? Arguably we could probably plug it into our fit testing, so get a twofer out of the deal. So logistically there's a place to do it, but I was wondering if that's something that you've considered with your institutions. Thank you. Can I ask for a clarification? Was the suggestion to test only those over the age of 50 for fine print or everyone, just more broadly? Okay. I was going to say that could potentially, I mean, I don't know what others think, but I think that could get a little dicey if you put an age limit on whom you're going to test because the fine print could be an issue for anybody. But we don't do that, but I don't know. I am well over 50, and I have trouble with small font, and as an IME physician I see many reports that even a magnifying glass to tenfold is hard to read, and they get blurry. I think that maybe there should be a standardization of a size of font that doesn't go below a certain point, and to make miniaturized records makes them totally illegible. It makes it hard for anyone to read. I think we should be standardized. You're talking about universal design. Yeah, let's not make small font. Let's burn more paper. Exactly. So I think you've made two excellent, really important points here. One is that in order to do any kind of clearance for duty, you need to know what the standard is. So you need to know what is the requirement. It's not required that you be 20, 20, just like DOT, just define what the requirement is, and then it could be evaluated that way. And the other thing that you said, Ed, was annually. So many people who do visual acuity testing, they just do it at hire. But there are a lot of other considerations to think about because of lighting conditions, et cetera. I see really well in looking at the Snellen chart in a well-lit doctor's office, but if you're drawing up medication in an ICU where the room lights are out for the patient's ability to sleep, your vision is going to be different. So lots of factors. There's another way to go about this, which is an annual question. Are you having any difficulty with your vision? Did you know we have a vision plan? Did you know that Occ Health will screen you if you think you want that? So it doesn't necessarily have to go to a mandated every year test. There's some other ways because people usually do know if they're having some difficulty, if they're squinting, and if they can't see without their readers on. So there's different ways to go about it. So this is a question, I think, for Dr. Rusci, and it's a WHO versus CDC question, and prevention of transmission of respiratory diseases in the health care setting, how we will do that, and are we going to pay attention to the WHO or the CDC? I thought this might come up. Can we take the center mic on this? No, no, no, this is good. So for years there has existed a paradigm that divided transmission via air into droplet transmission, which was regarded as essentially a three- to six-foot range, and the particles are arcing their way toward the ground, and if you get in that particle's way with a surgical mask, you can prevent the transmission, and airborne transmission where there's, of course, longer range potential, and nature is very, very good at defying any effort of human beings to categorize in that way, and essentially all it was was sort of an explanation for the epidemiological observation that diseases transmit better up close than they do far away. We all know that. You could eliminate droplets entirely from nature, and you would probably still see the same phenomenon because you'd have a higher concentration, very small aerosol particles up close, and less concentration far away. So in 2007, the isolation guidance from CDC essentially utilized that droplet airborne paradigm, and CDC asked HICPAC, and HICPAC asked a work group to draft new guidance around isolation precautions a couple of years ago, and I'm on that work group and, of course, represent the college on HICPAC, and we drafted recommendations, and we eliminated the category of droplet transmission, and we essentially characterized transmission as occurring through the air into three grossly described categories, and that was routine air, special air, and extended air, and routine air calls for the use of surgical masks, does not require eye protection, and does not require negative pressure isolation, and routine air is meant to apply to relatively common viral respiratory illnesses to which the population generally has pretty good immunity where there is perhaps a vaccine and where the consequences of infection are not high. The next category is special air. It actually does require a fit-tested N95 respirator. It does require eye protection, and while there's a recommendation for single room and adequate airflow, it does not require negative pressure isolation, and that category is meant to apply to anything that we have not adequately characterized. At the time that novel H1N1 came out, that would have been the category that applied to that, and certainly that would be the category that would apply to COVID-19. This, of course, is something that has not existed before. This is more protective than what was in place before, and as everyone knows, there was contingency guidance for many months that allowed for the use of surgical masks with COVID-19. This would be a change that would actually not allow that sort of thing to happen with any new or emerging pathogen. The third category is extended air precautions, and that is basically the old airborne transmission, so that calls for a fit-tested N95 respirator. It does require negative pressure isolation and does not automatically require eye protection and TB varicella measles. So that draft was presented many months ago to HCPAC. It was unanimously passed by HCPAC. There has been, as many of you know, a concern on the part of certain unions and industrial hygiene groups, and CDC made the decision to establish four additional questions that were to come back to HCPAC and the work group, the first of which, which is the one we are still working on, is should there be a category at all that calls for surgical masks? And the work group, there have been some additions to the work group, industrial hygiene, aerosol science, some additional input on the work group, and we are making our way through those key questions at this point. The other sort of principal area was around source control, and there is language in the draft guidance around source control. Essentially, when there is heightened community transmission, that medical centers may make the choice to apply one of two categories of source control. The first would be that health care workers wear source control whenever they're encountering a patient, and the slightly more involved would be that anyone who walks into a medical center is wearing a mask at all times. So that's where we stand right now. There are people who think that the only thing that should be worn at all in a medical center is an N95 respirator, and there are folks who think that they should be worn at all times. So there's also a whole world of unintended consequences. It's very interesting when you look at this literature. I mean, we screened 7,000 papers and eventually whittled it down to a smaller number of papers that comprised about 18,000 individuals. And when you look at transmission of viral respiratory disease, you actually do not see in the meta-analysis a difference between surgical masks and N95 respirators. I mean, there are a couple of studies that have shown it. Raina McIntyre years ago in China did a study where she was able to show a difference between N95 respirators that were not fit-tested and surgical masks, but there was no difference between fit-tested respirators and surgical masks. So go figure. But we also broke it out looking at seasonal respiratory disease, where there was clearly no difference between the two, and then we looked at sort of novel respiratory agents. And the studies were so heterogeneous that they really couldn't be meta-analyzed, but there was not anything that was statistically significant. And when I said unintended consequences, it may well be that one of the reasons that our instrument is too blunt to perceive a difference between an N95 and a surgical mask in an epidemiological study is that it's hard to wear an N95 respirator all day long. I see you even took yours off, Bob. We'll call him out. And so there are a number of things that actually, you know, those practical matters of reality that make it a little bit more difficult, too. And all of this exists in the context in this country of the requirement for annual fit testing of an N95, and that has, I think the effect of that has been essentially to raise the threshold in the United States of America for using an N95 respirator, and we can talk about that some other time, but, you know, I'm sure the opinions vary in the room around the necessity for annual N95 fit testing, but it is what we have to live with here. I will say one other thing, and that is that we also made clear in the draft guidance that in the routine air group that healthcare workers, as per OSHA, could choose to use an N95 under voluntary use. Which means not fit tested. Which means not fit tested. I just want a quick follow on to ask you, Dr. Roosie, what I'm hearing is that everybody in this room is going to be in a lot of meetings with infection control when this comes out, because there's going to be confusion and major changes in the way the nursing services, in particular room patients, label rooms, and the way healthcare workers approach a room with the protective gear that they're wearing. So for everybody to understand, like, the reason Dr. Roosie could explain that so much is that you're ahead of the curve now in knowing that this is coming down the pike. What I want to ask Dr. Roosie is, when is it coming? Dr. David Roosie does not know the answer to that question. Ballpark, Dr. Roosie, ballpark me. Six or eight months, maybe. I don't know. Okay. So six months-ish away. Probably. Okay. I don't know, but. I heard it here first. I had two unrelated specific questions. So one is monocular vision in a health worker working in a safety-sensitive position that develops during the course of employment. The other one is, do the regulations of ADA kick in at a post-offer physical or the first day of employment? Because there might be separation by days, et cetera, during the two. So that's more of a, like, attorney question, and there are logistics involved, but the devil is in the details, and I was wondering if anyone has an opinion on it. I call the vision question. I call not it on the ADA question, that side of the table, plan your answer. So monocular vision for a safety-sensitive job really depends upon the job. As many of you, I'm sure, are aware, the Department of Transportation, FMCSA, has changed on that, and monocular vision, there's an exception now, a pathway for that. And largely, that's about depth perception and field of vision, right? So I think that that would be a very individualized assessment as far as, you know, the depth of vision, depth perception needed for that particular task, right? So in a surgeon who's, you know, needing to, you know, judge their depth very carefully, then you might need a special evaluation for that. In a healthcare worker in a psychiatric facility, Dr. Berman will probably have a story that she might be able to illustrate with this, and imagine you're in a psychiatric facility and you're wearing a PAPR, and so you have some limited field of vision because of the hood you're wearing, but you also are at risk and need to be aware of your environment around you due to potential violence threats, and you need to see what's coming, right? So I think it's very, very job-specific, and this is where we have job security. Can I just add a kind of philosophical comment? You can all disagree with me freely, but it seems to me that the questions that we've addressed so far having to do with, I mean, touching on respirator fit testing annually, touching on color vision specifically, the monocular vision, fitness for duty, these are kind of data-free zones to me. I'm not aware of any evidence basis for a specific level of acuity or a specific level even of color vision or a specific level of fit testing success that actually correlates with an outcome, and I think that that is just another way of less eloquently stating what Melanie just said, that we really need to look at people individually and whether they can actually perform or be protected, depending on what you're talking about, until and unless we have the data to drive those decisions. Just to piggyback off of that a little bit with regard to your second question, and I would love to hear what other folks up here have to say as well, and I will preface this by saying I am in no way, shape, or form an attorney, so that's a good question for your legal team, but I think to the point that I think was being alluded to too, it's can they do the job with or without an accommodation? When you're asking that question and you're doing the exam, it's can you do this job, and that's part of the evaluation is, if an accommodation is needed, what would that be, and is that something that can be worked into the job? You want to make sure you're asking that question. Again, I would reiterate to definitely check with your attorney on your other question, but generally the ADA applies as the person is applying to the job. Yes, it's not sequential. It kicks in as soon as the person applies for the job, so you have to make an accommodation for the applicant with a disability or a potential disability to apply for the job. I was just seeking validation on that because that's what I think is right. Yes, I think that's correct, but then to get into nuances and everything, I would check with your attorney. Yes, I mean, I think the ADA applies across the spectrum, the ADA applies to a lot of different things. It's just what does it say about that stage, so pre-employment, the ADA prohibits you from conducting or requiring any medical test, and they explicitly say a pre-employment drug screen is not a medical test under the ADA, so you can do that, but before you've made any offer of the job, you can't make health inquiries or do any medical tests. Once there's a provisional offer of work, then you can conduct a medical inquiry or exam that's pertinent to the job that's done for every person that's going into that job. The ADA says different things at different stages of the process, but it's always with this. I mean, it's there when you go to the movie theater. There's more to the ADA than just employment, right? It's all about access and making our world accessible as well, so it's a big, big act, but I think I know what you're talking about, yeah. Yeah. Like I said, I was seeking validation about that, because sometimes you don't need that all on the same page. I wanted to solicit your reaction and recommended occupational health and or HR policies to address the following scenario. We have a medical center employee who is found to be impaired at work with a prescribed opioid. They are deemed not fit for duty and should be sent home, and they decline alternative transportation and insist on driving themselves home. When they eventually return to work, because their substance test was only positive for a prescribed medication, the MRO declared them MRO negative, and they returned to work with full compensation for the hours that they missed. How would you go about trying to remedy the conditions that would have allowed that scenario to come to pass? I would say that even though the medication was prescribed, what I do when I'm talking to people that have a positive marijuana drug screen, because marijuana is legal in our state now, we can't say you can't have the job because your marijuana drug screen was positive, but what I do is I tell them that our policy is that no one should report to work impaired or work while impaired, and then I ask them, what measures are you going to take to ensure that you don't report to work in an impaired state, knowing that you have a safety-sensitive position? In the case of marijuana, also knowing that marijuana can impair your judgment for longer than you may realize you're impaired, you need to make sure that you are not taking the drug within a certain period of time before you start work. If you have taken the drug, and for some reason they call you into work because somebody called out sick, do not report to work if you've taken the drug within that prescribed period of time. I think you have to look at what your HR policy says about working impaired, and that's where, if that's not in your policy, then the HR needs to look at that again. I think what I'm hearing also is a little bit of a question of process, or a gap in the process potentially, so I'm not sure if I understood, but the MRO said you're good to go, it was negative, but I would say that the loop should be closed when there's a referral to you to evaluate a person for reasonable suspicion of impairment, that you should be the person or the department, meaning occupational health, not the MRO, the clinician, should be the department that determines whether the person is safe to return to work. So there was a gap in the process because an MRO who made the right decision in terms of it was a prescribed substance didn't consider the entire scenario, which is was the person impaired. So if it had gone back to you, then you would have said, okay, I understand that the screen is negative because it's prescribed, however, again, getting back to what Rachel said, what measures are you going to take, and I would push it a little further, I'm a little more heavy handed, especially if it's a licensed independent practitioner, that you are not working while impaired with that opioid, and that might be changing the dosing schedule, for example, so that it's, you know, the half-life is considered, et cetera. So I think that's the gap, is that the clearance process shouldn't have gone through the MRO. It should have gone through the occupational medicine doctor, in my opinion. And if I may, and you may know this, I would add to that that there are safety-sensitive physicians, and so that MRO or the physician in occupational health has the opportunity to say there's a safety-sensitive concern here. This person is a police officer carrying a gun on federal property. I had this happen twice, actually, three times, actually, where the prescription medication was incongruent with the safety of the facility and the management of our particularly sensitive patients. Secondly, if they're sent to you because there's a performance problem, that performance pathway is still open to you. So whether or not the medication is prescribed and being used appropriately, if they're being reported because their performance is inadequate and there's concern about their performance, you can still go down the employee relations performance pathway, irrespective of the medications, because they're not doing their job up to the standard that's required by the service. You may have known that, but for others who are newer. Thank you. Yeah. One quick question. Is your MRO internal, or is it occupational health? You doing the MRO? It's external. The other thing to consider is having a conversation with your MRO. Say, we want to know, negative with a safety concern, anytime someone is, it's a reasonable suspicion test and there is something potentially impairing that they have a prescription for. And then that allows you to then evaluate, is this a safety sensitive position? And that gives you more information. And now, if the MRO reports negative with a safety concern, that gives you the red flag that, okay, it's probably a prescription medication here that we can evaluate and have the conversations as Wendy and Rebecca said. I'll, Dr. Behrman has a comment as well, but I'll, Drs. Tenassi and Swift kind of reiterated what I was going to say about the idea of the safety concern and, you know, you still have the ability to go down that path. But I want to touch on one other thing briefly when you commented about the person sort of denying another ride home. And I think, and if I'm not mistaken, I think in our policy for when someone, when there's a reasonable suspicion screen, it's actually in the policy that the person will get an alternate way home. So you can always, if that's the case and you have that as part of your policy, because the idea, I mean, you don't want to let somebody who you've just done a drug screen because you think they're impaired, let them get behind the wheel and go home. You can always, if you have that, you can always fall back on policy and say, look, I understand, but this is policy, it's for your safety, it's for our safety, it's for everyone's safety. We need to call you an Uber, we need to call a family member, we need to have someone else take you home. So that, if that's not in your policy, you can think about that. There can, in fact, be an institutional Uber contract in the policy. I mean, I'm not joking, actually, I think it's very important. I just wanted to say, in addition to everything you've been discussing, maybe this is obvious, but impairment, intoxication, illicit drug use are all really quite different things. And I would say that half of the people, roughly speaking, that I've evaluated for impairment over the years have been impaired, but they have not, it was not related to any medication, or at least definitely not to, for instance, an opioid or another pain medication. So it really isn't, those fitness for duty impairment evaluations are really an opportunity for us to use our judgment and look very broadly for things that a new neurologic condition, a new psychiatric condition, a new orthopedic condition that are, in fact, impairing, do need to be addressed, possibly accommodated, likely treated, but are actually separate from whatever the MRI was going to find. I think that's a really important point, because, as I think was alluded to before, it's about the behavior. And so, as a physician, you know, I mean, people can come in, or the manager may come in, I think they're intoxicated, I think they're under the influence of something. But for us, there needs to be a differential diagnosis, and that is part of it, and the drug screen is a piece of the evaluation. And two things can also be true, right? I mean, somebody can have a medication on board, or a substance on board, but there could also be something else going on as well. So we just always want to think about what is the behavior, and what's the potential differential for what could be causing that behavior, and address accordingly. And this is why we limit MRO questions. This is what happens. We could talk all day on this stuff. Hi, my name is Inas, and I have a question about hearing conservation. Our clinic handles the medical surveillance piece, the hearing conservation program is under our EH&S department, but the question is addressing causation of hearing loss for those who are enrolled in the hearing conservation program. And the reason being, we had a case where a gentleman filed a workers' comp claim for hearing loss. And he indeed had hearing loss. However, looking at his records, he had hearing loss upon hire, but it obviously progressed over the years, because he had almost a 20-plus year career at this medical center. The audiologist report said, yes, there is a threshold shift, but if you correct for age, there's no true shift. And if you practice in a state like California, where you only need 1% to support causation, it was very hard to challenge that, okay, did the 25 years of working with the machines and in a stream room all the time not contribute even 1% to that person's hearing loss? So I guess the main question is, is anybody who's enrolled in a hearing conservation program, if they do show evidence of declining hearing loss, would that be viewed as compensable or not? And if not, what would be the explanation? I'll take a stab. Okay, so we tend to focus mostly, as the medical supervisor of the hearing conservation program, on whether it's OSHA recordable. So there's three things there, right? Is your hearing abnormal? Is the shift 10 or more, which can be age-corrected? And thirdly, is it work-related? Now that is not workers' comp compensability statement, is it work-related? This is that, as the medical supervisor of the hearing conservation program, and if Raul's in here, he can correct me, anyone else can correct me on this, that is what gets it recorded on your OSHA log. And so for that, you make this, you make the individual decision looking at things like, what's the pattern? Well, this is low-frequency hearing loss, that doesn't look noise-related, right? Or this person just had a head injury and had ear surgery as a relationship, that's not work-related, et cetera. So you make that judgment, but as far as a compensability claim, I think that's a very specific state-by-state. I do not do workers' comp causation, and I don't know that anyone here does workers' comp causation. Yep. Sorry, our workers' comp folks have asked us specifically not to comment on whether or not it's, well, yeah, there's some reasons for that, but. Yeah, so we just tell the person, your hearing has changed, would you like us to refer you to audiology, would you like to get hearing aids, you know, and we do all the stuff. When we notify safety, if there's a shift, all the stuff happens, really for us, if there's a shift, whether we think it's work-related or not, we still do all the stuff, make sure they're protected and make sure their hearing protectors are working and all of that, and then we decide if it goes on the OSHA log. It's up to them if they want to file a workers' comp claim, I never know if they actually do. That's up to them. Yeah. So in this case, he actually did file a claim, that's why it's the same, because we see them in the same clinic as well. So you have to do causation assessments, yeah, I can't answer that for the state of California. I don't know. You're just going to own that one? Yeah, I mean. Straight up. It's all right, I mean, it's all right, they, you know, I always tell the patients they have, they're very lucky, they have two different insurance policies. You know, luckiest people in the country, they've got a private insurance and they've got a work-related insurance, and it's just a matter of deciding which insurance company is going to pay for it. And if they were our loyal worker for 20, 25 years around machinery, I mean, I can give them 1 percent and let the insurance companies work on it. I kind of try to keep it simple, K-I-S-S. Thank you. I'm self-insured. So are we. So. Yeah. Hi. Good afternoon. My question has to do with biologic exposure, infectious disease exposure in healthcare workers and application of some risk assessment. Usually you find these with the CDC. They may be good, they may be bad, but they give you something to go on, right? We kind of all remember COVID when the CDC finally came up with the six feet, 15 minutes. It wasn't good, but it gave you something to go on. You know, you may have brucellosis in a laboratorium. There's a risk assessment and you take some action based on your risk assessment, right? Whether it's quarantine or maybe post-exposure prophylaxis. TB is one of our greatest, you know, most frequent common exposures in healthcare. They can be very challenging. Sometimes it's, if you were to include every employee, it could be in the, literally in the hundreds, right? They show up in the ED. It's not recognized as TB. They end up on the floor, they go to the ICU, they go to the OR. So what do you folks do? And I guess this is a question for everybody. What do you folks do with your risk assessment and how do you get your TB exposures down to a manageable number? Nobody's happy with what you do, right? Your city DOH doesn't ever like what you do. Your state DOH doesn't like what you do. CDC doesn't really offer a lot of help. So I'm just curious in your experience, how do you folks approach TB and come up with a risk assessment that would satisfy, you know, everybody out there? Terrific. Hi, I'm Wendy. I'm only going to stand because you're on the other side of the podium. So otherwise I wouldn't. Look, I think all of you have dealt with this and we want to deal with tuberculosis exposures less and less and less often. And it was a pleasure to meet you recently. You know, there's the infection control, what do you call it, standard of sort of concentric circles. So what I always work on is the concentric circle. And unfortunately, every state and every locality, as you mentioned, has a different definition of what an exposure is. So in California, it's eight hours of continuous exposure over a 24-hour period. They're trying to say in California that you live in a congregate setting, which they are defining as sharing housing. There will be other places where it's within six feet for 15 minutes where neither person is masked. What you bring up is how important it is to have a definition of exposure. As the occupational health chief, I just advocate that you use your concentric circle and define that however you want. It's a very effective process. So your concentric circle is who were the people who had the most contact for the longest time. And if you define that as being within six feet for 15 minutes where neither person was masked, you can ask your infection control team to look through the record and see who was in the room, who documented and charted. Was it the chaplain? Was it social work? Was it occupational therapy? Was it housekeeping? Make sure that you can get through the record who was in that closest concentric circle. Test them, ideally with a test that's rapid, an interferon gamma release assay. You get the answer back in 48 hours usually. And if you find even one conversion in that concentric circle, you broaden the circle. And that's the standard for infection control exposures. We do have in the JOEM paper that we all wrote together, a table that we spent quite some time on trying to define what is an exposure. It's probably one of the most important things you can do. I see Dr. Chang is here, a new chief. For you who are new chiefs, do sort out through a couple of pathogens how you want to define exposure. How you want to define policy, so you can fall back on it. You can't really be wrong. The only way I think you can be wrong is if your circle is too big. And you're now testing 400 people, 500 people, I call them drive-bys. You know, people who drop off a meal, a tray in a room, they walk past the open door, they sit in the ante room charting, those are drive-bys. I like Dr. Chang, Sally Foster Chang is agreeing, we've done a bunch of TB exposures together. Be careful of the drive-bys. They will get panicked. Be very reassuring of your staff. We're here to keep you safe. This is how we're going to approach it. Nothing is going to change in tuberculosis between this week and next week. We're not going to miss you. It's a slow-growing bacteria. And we will find it if it happened to you. The other thing is if you really have panic and you need to test some people on the side, they say, oh, you know, granny's at home with stage four lymphoma. My wife is pregnant. I'm pregnant. You can modify your circle, but be careful about the trickle-down to everybody else in the department. So you can also say, I'm going to use my concentric circle and on an individual basis. And that individual basis can include the severely immune-compromised or others. Best if you've defined that in a few paragraphs in your policy. Dr. Berman, anything? So Dr. Berman has actually treated. So the other way you prevent it is what Dr. Berman has done. She's my hero in preventing tuberculosis. She has prevented active tuberculosis in her facility by treating latent tuberculosis for over 20 years. And she's a real model for how we prevent active TB in our facilities. That's a kind word, and I am an apostle for treating latent TB in the workplace, regardless of what the ideology of that latent TB is. And I think it's one of those situations, like running a good immunization program, where you're benefiting people in a way that you may never see in the workplace, but you are benefiting them and their community and possibly your workplace. That said, we are not, in fact, doing an incredible job as a country. Can you all hear me? Not so well. Great. I can't tell this. Hold it closer. Sorry. Is that better? So this is the most important thing I'm going to say, though. It's the part of the equation that you started with. There are people reactivating with TB. Regrettably, the numbers probably are rising. It certainly seems that way to me. And with almost no exceptions, these are people who are known to have latent TB infection that was not treated. These were all preventable, not necessarily by us. But if you can play an enlightened role on your infection control committee, and, well, that's probably the main one, so that there's education and outreach to the primary care providers, and not just the primary care providers, to really tackle this before anybody is exposed, we will all benefit. I was just going to add, just in terms of educating others in the hospital environment, it was pretty clear in those dark years in the mid-1990s when there was a TB resurgence that what was most effective in hospitals at reducing PPD conversions among healthcare workers was actually employing a low threshold for isolating patients that might have TB. We should probably be putting 20 to 40 patients in negative pressure for everyone who turns out to have TB. And having attended in medicine for 30 years, and, you know, it's like, you know, the 81-year-old Estonian immigrant with a 30-pound weight loss, coughing up blood, who's been sitting in a room with another individual for five days, being treated, you know, with Levaquin for community-acquired pneumonia. So I think efforts to make sure the emergency department staff and others who were sort of on that front line are employing an extremely low threshold for putting people into negative pressure isolation whenever there's a suspicion of TB would be time well-used. And I'm not disagreeing, but I want to reiterate with what Dr. Berman said, which is that please look at preventing active TB in your facility by treating latent TB. You can't use the word treatment in occupational health a lot, but we are allowed to prevent, right? We can give flu vaccines. We can give COVID vaccines. We can give everything else, every other vaccine, because we are allowed to prevent active disease. We're not necessarily even treating latent TB, because there's nothing to treat. They're not sick. They're not infectious. So start using the language of, I want to prevent active TB, and I want you to support me in this facility with offering latent tuberculosis treatment to the onboarding employees who are latent TB positive. It's so important. It's so easy. Ask Dr. Berman how to do it. She has done it as a healthcare provider for her pre-employees for over 20 years. There's the short course treatment that's only 12 days of antibiotics. It's not video DOT. We called it TB Tuesdays when I set it up at a couple institutions. And so I just remind them, you know, hey, here's a text message. Remember to take your medicine. It's TB Tuesday. Super easy. 12 weeks, once a week of medication. But that's how you prevent the healthcare worker. Our MD Anderson person came to me. You know, they had a healthcare worker, I had a healthcare worker who we high-fived for like six years in a row that they were positive, and we never prevented her from getting active TB until the first person who she infected was a heart transplant. That groan is the same thing that kept me up night after night after night. It makes you sick to the pit of your stomach to have known that your employee, you knew they were positive and didn't help prevent that active TB. Six years, Filipina nurse, mid-50s, you know, treated twice for a URI in the fall. You know, cough, fever, cough, fever, treated twice by her private, kind of malaise, kind of fatigue, oh, menopause, no, active tuberculosis. That was on my birthday. So it's really, but it's that important. The one I heard from MD Anderson is three months of coughing and fatigue in an ICU nurse. Mine was a post-operative care nurse. And so she had taken care of this post-transplant patient who was there for myocardial biopsy, and he left with a door prize of active tuberculosis. The other person was a colleague of hers, 24 years old, who got active tuberculosis, had started Embrel one year before. We knew it was negative, right, because we had that negative test, and got active TB at 24 years old from a colleague. So we really can make a really big difference. There's not a lot of stuff, like this vision, what are you going to do? There's not a lot we can do really well. We could do TB really, really well. So there's my push. I see I stood up for that. I wanted to get that, yes. And before we leave this particular question, though, you brought up something else, and I just wanted to share what we're trying at Mayo right now. It was this, you know, oh, we had someone who coughed for six months and went everywhere, and so we're going to test 500 people, right? And so we embarked on a project with our infection prevention colleagues, our state public health departments in two states, and then four states, to get to an agreement of let's do some risk assessment. And you do have to kind of make this up and get consensus. What we landed on was an initial assessment by IPAC, which is based on the patient, to put them into a kind of category. So clearly, you know, laryngeal TBs appear, you know, aerosol-generating procedures appear, no threshold of time for those people. And then there's people that don't have cavitary disease, but they're smear-positive, and that's a longer amount of time. And then we still test smear negatives, even. They turn out to later, you know, they culture positive, and so we still test our smear negatives. We found out our health department does not care if we test smear-negative contacts, contacts of smear-negative source patients, but we do. And so we put a number of hours of exposure on that. And we'll follow that, because we look back at our data over 10 years of testing everybody, and we found three post-exposure conversions, and they all would have fallen in that no time limit category, right? Cavitary disease, I intubated somebody, they turned out to have laryngeal TB. They were high-risk, and that's who converts, right? So if you have the data, and you can track it, and you can work collaboratively with IPAC, and you get buy-in from your public health, that's when you can go and have the conversation with your impacted workers in the biggest hitting areas, right? The people in pulmonary CRIT, the people that are in the ED, who that's who's going to be afraid if you say, yeah, you weren't that exposed, we're not going to test you, right? So you need to really have the evidence behind you, have the numbers behind you, have stakeholders working with you, and then you can put forth kind of what you're talking about, a more of a risk assessment framework for limiting unnecessary testing, and essentially formalizing the concentric circles that Wendy was talking about. Who do you define who's in that first circle? Yeah. Hi. I have a question related to the police officers and the sleep apnea. So sleep apnea, police officer has been there in our department for a long time, revealed the history of sleep apnea, never being on a CPAP, started on the CPAP, but not using, uses more than four hours, is just around 46%. How you will take, like, proceeding further, because this is well-established, and the comment I got, oh, you know, we have all the police officers, they have the sleep apnea. And my second question is, EMS worker with the visual equity for many years, so one eye is 20 by 200, the other one is 20-40, the job requirement for them is 20-20 in one and 20-40 in the other. How will you address as a part of pre-employment clearance for these folks? Maybe you want police and sleep apnea. I had a lawsuit related to that. So police and sleep apnea, really difficult. I spent a ridiculous amount of time reading about this through the VA, so I only know from the federal point of view, it's very difficult. You can go to DOT and SAMHSA, the Department of Transportation, and look at, because police officers drive, and look at sleep apnea, every policy is going to be different. But I came to the conclusion that there was no good evidence to support sleep apnea as a restriction for police officers, unless it was moderate or high. And a lot of them were mild. So you need to get the sleep report on their sleep apnea, and mild made up a lot of them. And mild did not show impairment related to automobile accidents and outcomes, but moderate sleep apnea and severe sleep apnea did, in which case we then at the VA required their sleep, their reports, every year. And we required the CMS standard, the Medicaid standard, which is 70% compliance, four hours or more per day, right. And we would require that it was turned in, and we would actually put them on desk duty. They were not cleared if they didn't meet those standards. Our lives were made a lot better, a lot easier when we eliminated the mild category, because it was so many. And I see some nods of people who had similar experiences. There's a standard, it's either in the SAMHSA standard, I don't remember if it was in Cal Ops. But there is a police standard that gives you the walkthrough of how to walk them over time. You know, the first time that you see them that they're noncompliant, they have one month. It's that next time they have three months, the next time they have six months. So if they refuse to comply in the first year, there's this stepwise one-year process of bringing them back into compliance that entails them being off of active duty or not driving a car for the first month. I'm not saying it's what you should do, but at least gives you a standard in this world lacking standards to fall back on and say, we are going to follow the Department of Transportation standard for sleep apnea and driving. If anybody else in the audience, by the way, we're just the chumps. You all are also the experts. If there's a police or sleep apnea expert out here, or somebody who wants to reply to that question, please just raise your hand and we'll get you a mic. And you had a second question. We might be out of time. Did we need to give one last question? Yeah. Could you just follow up a little bit on the latent TB, Dr. Berman? I love your success. Is it policy? Are you requiring it on those pre-employments? Do you give them candy? What do you do? Okay. Happy to answer that, although they may not be the answers you want to hear. I got the funding for this program to treat all the new hires because 25 years ago in my naivete was just about, a little bit longer ago than that, when the first, the 95 TB standard had just come out, and it talked about latent TB. This is not new in 2019. And in my naivete, I thought, what difference does it make if the person converted in our emergency department or converted in their prior job or their childhood? What difference does it make? If they have latent TB, they should be treated. And so I brought that back when my job offer was made, and I said, well, we need to be able to treat everybody. And they said, no, only work-related. And I said, well, I just can't take the job. And I went home for a month, and then they called me and said, we crunched the numbers. We can do this. You can treat anybody you want. So we treat them with no, we don't bill. There's no barriers. If you want to be treated, we will treat you. We will not be out of pocket for a penny. We'll make it as convenient as we can. And that's worked beautifully. However, the acceptance rate, which I think is kind of buried in your second question there, is not awesome. It's about 50%, roughly. We do not have a policy that requires people to be treated, although, of course, we follow our own policy and the current CDC guidance that persons with, health care personnel with untreated latent TB must be assessed at least annually in terms of symptoms, absolutely, which is also your opportunity to push them to be treated. But it hasn't broken the bank. And we continue to do it. It rolls right into our workflows. And the real cost of this is quite low. The drugs are not that expensive. All right. I wonder if he has any ideas for us. If there are any, we'll be up here hanging around if anybody has any residual questions. But thank you all so much for coming. We really appreciate it. And hopefully, this has been beneficial for you.

housekeeping announcements

AOHC

silencing devices

session evaluation

team members

medical review officer

occupational health management

color vision testing

respiratory diseases transmission

tuberculosis exposure risk assessment