Thanks, Paul Ogden from Colorado, I have two very different questions. So the first question is for hepatitis B immune globulin for the unknown needle stick. And I don't know if any of you have called the PEP line recently, I've talked to them a couple of times trying to sort out protocols for our group. Do we really need to give HBIG? We went through quite a time where we were given a lot of HBIG and now based on the recommendations from the PEP line, we've sort of backed off on it, but I'm really confused. Should we give it to everybody? Should we only give it if it's a super high risk exposure? Should I worry about it on the unknown exposures at all? I would give it, hepatitis B is very contagious. So if you have any doubt, it doesn't harm to give, it's not a harm to give somebody HBIG to prevent them from getting hepatitis B potentially. That's my personal opinion. Can I take a stab at this one too? So in this is one of these, there's a little chapter that I wrote for some book somewhere. And it's got a table that's an adaption of the Shilley table. So those latest CDC guidelines for hepatitis B have a table and that's where it says treat them all with HBIG. I had to put a caveat because I think you've got to use judgment. If you've got a 30 year old healthcare worker who's fully vaccinated, never got an antibody test, they're not a titer unless you want to give a seizure to your laboratorian, but they've never had a test and they're negative. And the patient to which they're exposed could not be tested, but they're also a 30 year old and you've got a record of three doses of vaccine on the source patient, neither of these people are infected. They're both immune. Do not waste HBIG on that person. I think, but we have to put our thinking caps on for these. And so there's a few in one of these, blood borne pathogen exposure, quick reference, I think it's called 131, we'll have the table with some footnotes at the bottom for exactly that situation. Yeah. Thank you. And you've got some time. Yeah. Yes. Up to a week. So the decision doesn't need to be made within an hour. I mean, you've got, you've got a window there where, where probably you have reasonable effect up to 72 hours of administering the HBIG. So that may be enough time, whether it's, it's getting more information on the source patient, potentially testing the healthcare worker again with a head B surface antibody. There's a little bit of a window. My second question, causality for influenza acquired at work and causality for COVID acquired at work early on in the pandemic. And then more recently with a ubiquitous nature of COVID I can speak to COVID at least in our institution. I mean, early on, and I think this was the case in most places, I mean, I could be wrong, but I think at least, you know, where we were practicing it early on, it was a very low threshold to accept a case. Again to your point, it's become so ubiquitous now that I think the causation determination is being more, we're discerning more in terms of whether there was a known exposure, whether they, you know, there was a circumstance where there was a possibility. What did the individual say? Because when we do our contact tracing, for example, we ask the individual, you know, how do you think you got it? And there are certain, you know, was it a home exposure? Was it a social exposure? You know, do you even know, or do you think it was a workplace exposure? And so that kind of narrows things down. If they can themselves say, you know, my spouse is positive or, you know, I went out to dinner with some friends and that's where, you know, somebody else was positive. So as it's gone along and we've gotten a little better at kind of discerning that, things have gotten a little more specific. It's a painful issue because OSHA has rules around reporting for safety purposes that differ dramatically from reporting and causation rules for compensation purposes. And in fact, section 4B4 of the OSHA Act says nothing in this act shall influence workers' compensation and cost issues. So OSHA's position has always been when in doubt report, there's no harm in reporting. We don't punish people for elevated rates of this, that, and the other. So early on, there was a lot of attention to that. These days, OSHA says the only thing that OSHA is still enforcing from the emergency temporary standard is the record keeping part, which is you must report hospitalizations and disease, deaths and hospitalizations within a period of time. So if you do a reasonable assessment and you think it's not work related, my impression is you don't actually have to put that on the log. That question has come up several times and I've suggested somebody send in a formal request for a letter of interpretation. But my assumption is that enforcement programs will say, if you say it's not related and you have good evidence to think that, that's your position. I'm from Philadelphia. I'm Ken Lank and I'm at Thomas Jefferson University and University Hospitals. And being from Philadelphia, I just actually have a very unacademic but very practical question to pose to the group. And that has to do with pre-employment testing, screening, understanding that we are the guardians of our workforce collectively. We want people to be safe and healthy. And we want to stay on the right side of the law, given our esteemed colleague here, especially we want to make sure that we're following the rules. But in earnest, we all understand, for example, you need to have a driver's license, even if you're only going to drive for one day. So I just wanted to ask the question, is there any tiered type of screening programs that you have, given that these days, particularly at academic centers, many of our people who cycle in, A, they're not actual, they're contractors, or B, they're not with us for very long. Do we give them the same criteria that we would for our own employees, who are permanent employees? And on one hand, you ask the question, well, someone who walks in your door, so what are we talking about? Do they need to be screened for TB, for example? Do they need a drug test for somebody who's an international scholar coming in from Switzerland or Taiwan, and they're going to observe a special surgery, and they're going to be with you for two days? Do they need the complete battery of things, A, could just be a regulation, you want to be fair to everybody, or is there a tiered approach, and do you take this individually to say, hey, what is the yield of me drug testing a professor of epidemiology from Denmark? Thank you. Sorry for the long winded, but I think you get it. I'll take a first pass from Philadelphia, if you like. This might be the simplest part of the answer. For contagious illnesses, we do actually require the same screening and standard, but we absolutely accept documentation from the home institution, and we have a standardized form that we send to people ahead of time so that they can get it certified at their own institution, and that has, I think, not been terribly onerous for people. I know that's, again, probably the simplest part of the question, tuberculosis and vaccine preventable diseases, but that's what I got. I don't believe we do any drug testing. Usually seen one VA, you've seen one VA, so all the rules are often different. We did the same thing, though, so we have the status of contractors, it's actually written into the contract, so infection prevention and occupational health work with the contracting team once every couple years, usually, depending how it's going, and say these are the things that are required, and then when a contract is given, even to our construction workers, it says that to be in fulfillment of the contract, they have to have met these criteria, and we don't check it. For all of you in occupational health, that is not our job to deal with the contractors. If you put it right in the contract up front, that should cover it. Same thing covers the university students, the visiting students, the education office has those requirements in it. As Dr. Berman said, why is Philadelphians, as Amy said, the education office sends it out to the educational institution, says yes, they can come in and do this rotation if they meet these criterion. We accept their medical clearance for respiratory fit. We do re-respiratory fit them on our masks. We don't do a new medical clearance, but they often aren't using the same mask we're using, so that's a huge pain all the time, but we have to redo that, and since we keep running out of masks and using different ones, you know, as the inventory changes, that's a lot of work. And then, yeah, for anybody incoming, the vaccine-preventable diseases, so tuberculosis, influenza, and COVID, if we were to tier it, those are the top ones, and those are the ones that we wouldn't bring them on campus until we had evidence of that clearance, otherwise MMR, VCV, those, you know, can be drawn and then kind of figure it out later. Sound the same as most people? Yeah, so the question is often put to you, could you exempt this person from this requirement? They're coming in for Japan. They're only going to be here one day. It is not within my purview to say that this person is exempt from the state laws and regulations. That's a question for the institution's attorneys as to whether they're willing to accept the risk of noncompliance. That's not your decision, and occupational health, we don't have the power to exempt people from law, and many of these are state regulations that have the weight of law. And just for the record, we can clear people or non-clear people. We aren't police. We can't keep them on campus. We can just either say they're medically cleared or they're not. And the police functions in health care, OSHA and the Joint Commission both view temporary workers as having to underlie the same rules. So the logic around TB requires that somebody have looked, even if they don't have time to reactivate, but OSHA looks at temporary workers, you know, nurses who were there for two weeks. People get cited when they're not cleared for respirators and the like. Al Thurman, Richmond, Virginia. I have two questions. One's for Dr. Behrman and anyone else who wants to chime in. Do you have any data on the efficacy of the fourth COVID vaccine? I don't know that you're going to be satisfied with this answer. The only data that I'm aware of that seems really robust was from Israel where there was a, you know, a very imperfect study comparing two different populations, but showing significant added protection in terms of serious disease and a strong implication that there was actually a temporary decrease in acquisition and transmissibility. And I don't think that I – yes, 60 and older, I think. If you listen in on the meetings, they toss it around like hot baseball. They're like, well, should we do 80? No, 65 is Medicare. Well, maybe 50. Literally, legit. So it's a little haphazard. I would say on the Israel data too, the definition of serious disease in Israel is O2 sat under 94, which is like our baseline obesity, you know, or at altitude oxygen saturation here. So it's interesting that their definition of serious disease is quite lower than ours. Moderna's request was for age 18 and up pending, you know, it hasn't been all reviewed yet, but what they were submitting was requesting a second booster for ages 18 and up, and Pfizer was requesting for 60 or 65 and up. And so behind the closed doors, the negotiation was let's recommend it at 50. Lovely. There's nothing better than medical decision making made by politicians or by people trying to placate everyone. No one's going to be happy. The next question is for Dr. Rolanda, and that is, are you familiar with transcranial magnetic stimulation, TMS therapy, and what its relationship to MRI, because it uses magnets. I would presume it's stronger magnets only because, you know, they're either localizing, but because they're expecting it to actually change brain chemistry, supposedly indicated for depression, stuff like that. So while we've all been told, oh, MRIs are safe, they don't affect your body, you know, you're pregnant, you can be there, it's no problem. And now they're telling us it affects brain chemistry. So it's got to be more, you know, stronger magnets. It's got to be. Yeah. I will be honest. I'm not, I'm not well versed in that at all. I don't know if anybody else on the panel is. Our hospital doesn't do it, but I've had the TMS therapists come and, you know, basically like drug reps, try to convince us to send patients there, and it's like, okay, how does that work? I really, I truly don't understand it. Magnets. Hey, Ross Mullinax, Yokosuka, Japan. I had a question regarding Hep B vaccination. So I was involved in a pretty robust discussion recently amongst health providers regarding the part, and I believe it's the CDC guidance that says that, you know, the titer is only reliable if you've had all three doses. And so the recommendation is, unless you don't have documentation of all three doses, that you get all three doses. And so then that was, there was a very wide range of opinion on what to do with that all the way from, hey, if they think they got all three, their titer's good, then I'm good. With somebody else saying, unless I have crystal clear documentation, I'm making them go back and get all three vaccines before I do any titer at all. And I don't know. It's curious from the panel of experts to see what you think about that question. But I understand what you're saying. But one important point to make about hepatitis B vaccine, if you're using the three dose series, that third dose. We only use the three dose, I think, in the Navy. So that's what we're referring to. The third dose is the dose that confers long-term immunity. So if you check a titer for somebody after they've only had two doses, it's probably going to be positive. But you have to give them that third dose anyway to confer the long-term immunity. In terms of whether to accept the person's word for it or not, ideally, you would like to see their vaccine documentation. And they should make every effort to try and get that documentation for you. We do accept their titers as proof of vaccination or possibly infection. But if they have a bloodborne pathogen exposure, we're going to check them again to make sure that they still have antibodies. So if they are hired in 2000, and then they have a bloodborne pathogen exposure in 2003, for example, if they're negative in 2003, and they said they had three doses, I don't know what we would do with that, unless we know that they were positive. It would only really make a difference if that positive titer were done recently, after they had a recent, you know, scan. Right. Because the immunity can wear off. Right. Right. If they still got titers for 20 years, then that is long-term immunity. Right. Right. So absent... Go ahead, Laurie. You take it. Oh, well, I mean, I don't know if you were going to piggyback off of that point. But you're right. And I think, as Rachel mentioned, I think the concern is that in the absence of having the full documentation of a full series, whether, you know, now, whether it's the two-dose series or, you know, the three-dose series, is it possible that someone was in the middle of a series when they got their titer drawn? And it may be, or... And this is just kind of how I interpret that statement, is that when they did the studies, the only people they were looking at were people who had a full series and then a titer. So they are the... That is the only group that they can confidently comment on. So it's a little bit of a, you know, we've really got to be, you know, err on the side of caution kind of a thing. So in our institution, what we are doing is for the purposes of compliance, if they have an antibody, positive antibody, we will accept it, even if they don't have the documentation of the vaccines for compliance purposes. But we will tell them at the time, we will talk with them about what the CDC's recommendation is, and we will offer them the vaccine series again, since there's really no harm in getting it, and it's at no cost to them. If they say no, we'll have them sign a declination, and then if they have an exposure where there's a potential concern for an unknown source or a positive source, we'll check a titer again at that time. And then if it's negative and we can't confirm it, we would probably err on the side of caution and treat them with HBIG. I'm just being honest. It's about... Yeah, and I would just emphasize that it's not that two doses have been shown to confer only temporary immunity. It's that there aren't adequate data on two doses. And a three-doser with a positive surface antibody in 2003, despite the fact that they'll probably be negative now, should be regarded as protected lifelong. Absent stem cell transplant? Or hemodialysis? Right. Exactly. So, but to the earlier points made, if all you have is the lab test and you never got confirmation of their vaccination, then that's the situation where you've got to question if they truly have long-term immunity. And if they did have serial antibodies 20 years ago, positive now, they probably had their third dose, right? Thank you. I think that's a very reasonable approach. A follow-on question is, please correct me if I'm wrong. To my knowledge, there's no case report of anyone who had a positive titer that still got infected anyway. Right. Post three doses. That's right. Nor post two doses in a titer. I mean, that's theoretical, but it's not actually happened, right? Thank you. Not that I'm aware of. Okay. Thank you. Tom McClure from Montana. I have a couple of questions unrelated to topics that were covered today, but actually one just came up. What about naturally acquired hepatitis B surface antibody? Is that not acceptable? I think I would if you've got a panel that shows that they have their core antibody positive and their surface antibody positive, then they're immune by natural infections. Okay. Good. If you're in drug screening for marijuana... I'll answer. I'll answer. Stop doing it. Stop doing it. Stop doing it. Okay. Well, that's simple. Good. I like that. I respectfully disagree. It depends on your institution. It's against federal law. So we do, and it's an exclusion for hire, and it's a source of being sent to EAP if you're a current... So what? It's against federal law to test for? No. So for federal service, if you're selected as a random candidate for... Which is why I didn't get the hemp salad the other day. If you're selected for a random drug testing and all patient care related positions that are required to do drug testing on hire, even though they don't know it because they live in the state of California where California is legal, federal it's not legal and they will not be hired. And there will not... There's a second chance maybe six months later if they redo the whole application. So I'd say the answer to urine drug testing depends on your facility and your facility's tolerance and its location. So in our state, our lawyers recommended that we remove THC from the post-offer testing sometime after it became legal for medical marijuana in the state of Pennsylvania. So we did that. And we included, of course, in for-cause drug testing for healthcare personnel or anybody actually. And in the 16 months that this has been in place, the number of people with impairment who have had THC in their screens is zero. I don't know the denominator offhand, but it's zero out of whatever the denominator is. And folks on medical marijuana, we also advise them at their post-offer evaluation, if they are on that, they need to be aware that in the event they are subject to for-cause testing because they appear impaired at work, and that marijuana, despite it being legally acquired, is found, then their evidence of impairment at work will be attributed to that. It will be a positive drug screen under MRO review. Of course, that's, you don't downgrade medical marijuana to a negative screen. So they need to know that they're taking their medical marijuana at work. If they end up in a for-cause situation, it's going to result in the same adverse consequences as if they didn't have that medical marijuana certificate. And there was an abstract from one of the MROs talking about the results of post, for-cause post-incident testing, and over 60% of his samples were THC positive in comparison to what a reputable academic institution has as its staff. One thing I just wanted to add is that whenever we have a new hire that has a positive drug screen for marijuana, we meet with them individually and let them know what our substance abuse policy is, that nobody can report to work impaired or should work while impaired, and ask them what measures are they going to take to make sure that they're not reporting to work in an impaired state. And then we have a conversation about inhalation versus ingestion and unpredictability of absorption through the GI route, and how they, and then we give them a time frame where they should refrain from using marijuana prior to work. And then also, if they do accidentally, oh, they forgot, and then they have this shift like in six hours, they shouldn't report to work for that shift because they may be impaired, because we all know marijuana can impair your judgment longer than you even realize that you're impaired. But they can be hired with a positive THC? Yes, but they have to be cleared through our department. All right, second question I think is simpler, resumption of spirometry post-COVID. So you might be in a clinical setting of your occupational medicine practice, and are you resuming spirometry in your spirometry labs for your clinical practice? This is, yeah, this would be just in the occupational medicine clinic. The pulmonary function lab has been operating all through the COVID pandemic, I think. Yeah, yeah, so I think it might be a little bit outside the purview of medical center occupational health for healthcare workers per se, because very few of our healthcare workers would ever need to get spirometry. And I think the American Society of Chest Physicians is putting together a white paper on sort of how we did this. At least we had a reach out from Cleveland Clinic and Mayo, who kept their spirometry going throughout the entire COVID pandemic successfully without any evidence of transmission. So there should be a paper coming out in chest, I believe, pretty soon, but I don't know the nitty-gritty of it. So I mean, it's really, it's a question I think we all think about, especially if we have clinics that see both healthcare personnel, who they themselves very rarely need, I wouldn't say never, but rarely needs spirometry versus other populations. Indeed, as I think several people said, we have been depending on our extremely well-resourced, well-ventilated, and I think safe pulmonary function lab, rather than doing our own. And I think in terms of just protecting our own healthcare personnel, I think that was the right decision. Thank you. I had two questions. One, I did run into the issue of latent TB several times now. The thing that, the argument against a person with latent TB acquiring treatment is that they came from a region where endemically, there was very high rates of drug-resistant TB. So if I give them the regimen, they didn't want to take it because they don't, didn't think it would matter anyways. Yeah, that's great. And it touches on a very sophisticated question, which is, I remember when being in hospitals in France, they have a lot of West African nurses there, and they weren't treating their latent TB because they were going back to their West African areas. Your situation is different. If you have people with latent tuberculosis coming into your healthcare system, that's a separate and distinct issue from a multi-drug-resistant active tuberculosis disease. So I don't see any reason one wouldn't treat that latent tuberculosis infection. In fact, there's much more of these countries that are going to treating the LTBI early. Even, you know, some of the most highly endemic countries that are treating their LTBI early because it's not really good evidence of when is one reinfected and how are they reinfected. And again, we're trying to chip, make that iceberg smaller and smaller. So where's your location? This was, this location was specifically in Wyoming. Wyoming, yeah. So it's interesting, I get a lot of calls from Wyoming. I think they have so, it's true, I think they have so few TB that it's the LTBI, the latent tuberculosis seems to worry them a lot. And I think there's still confusion about that difference between a non-infectious, non-activated, latent disease and the activated one. So this latent sitting there disease is not infectious to anyone else, it's not resistant to anything. So go ahead and treat it as latent tuberculosis so that one can prevent it from activating. And don't be afraid of infection. So that's a very sophisticated question. Dr. Hodgson asks, would you do a blood test, an IGRA afterwards? I would, and there's, you're going to see all sorts of different literature on that, but that's, it's, what we don't know is if somebody has one of these blood tests that are positive, the IGRA that's positive, and then you treat them. The early literature showed about 42 percent of them were reverting to negative. I don't think they were really reverting to negative. I think they were probably not positive in the beginning, because that's awfully close to that 50, 55 percent that test negative the second time anyway. They were probably the low positives early on. They were treated and they were negative anyway. But what we're getting at is we don't really know. So I do tell people to go ahead and get another IGRA some months later after that latent treatment, because if they are negative, you have a new baseline. And that helps you if you think they're going to go back to their native country, stay in their village for a prolonged period of time, and potentially get re-exposed. But I think all of those ifs aren't enough to justify not treating somebody who's sitting right in front of you who has a disease that could reactivate and infect people around them. Yeah, and I would just add that there are things we still don't know about this. William Stead, who was one of the grandfathers of TB research, wrote a very nice review which was published either in the archives or the Annals of Internal Medicine in the mid-90s. And he cataloged a number of tuberculosis outbreaks, and he looked at individuals who had been exposed in those outbreak settings who were PPD negative prior and who were PPD positive already prior. And guess what he found? All of the transmissions of disease in the outbreaks occurred with individuals who were prior PPD negative. And that the rate of active tuberculosis in those who had been PPD positive prior to their outbreak exposure was no greater than would be expected by the ongoing conversion of latent to active disease. So this has been this question, hey, I'm going to go spend six months in South Africa every year for the next 20 years, should I really treat my latent TB? And that's been the basis of the argument, well, maybe you shouldn't. The thing that I think we still don't understand adequately, and Wendy, correct me if I'm wrong, is when you treat latent TB, do you necessarily do away with whatever protection that individual may have had based on the fact that they harbored latent TB? And it seems that in at least some individuals, you don't. But I think we don't actually know the answer to the question. It's a sticky wicket. I want to know if you're now thoroughly confused. No, the issue is I was actually, it was a nurse from the Philippines, had a known history of family drug-resistant TB, and goes back home. But the argument from the employee health nurse was that they did not want this nurse to undergo treatment because of the risk of side effects from treatment for latent TB. And I was arguing against that, and I was arguing for it. I'm like, I understand she's going back, however her family has been treated. Her family had been treated. My understanding, that doesn't mean that it was successful. It doesn't mean they weren't latent TB carriers. But at the same time, I still had recommended treatment. Absolutely. Multi-drug resistant TB is a horrendous activation. The treatment for it is horrible. It can go on 18 months. Many people die of multi-drug resistant TB. So if you have an employee in front of you who can be treated with 12 days of antibiotics and get rid of their latent TB so that they don't reactivate, you've got to grab a hold of that. Or send them to ID, and they'll take care of it. I didn't. So in Wyoming, we don't have a lot, there's not a lot of ID docs, so I'll give you that. Give us a call. But so, but yeah, we would, we can do telemed, but so it was just one of those situations where there was a little bit of an argument on it. It's confusing. Yeah. Can I ask another question? But you don't necessarily get a second cookie. What if I have two little girls? You get three cookies. So my, if I don't have one for each, it gets to be a fight. So my other question is, considering what had happened with the pandemic and where we are now and where we were before, what does an appropriately staffed health center, employee health and safety department look like? What does that staffing model look like? Because the end of the day is that the finances for employee health and safety are going to wane. Eventually it's going to go back to, I want to cut dollars, I want to cut cents, and employee health and safety is going to be one of the first places in the budget that gets cut. And maybe I'm wrong. I pray to God that I'm wrong. However, I don't expect to be wrong with that because that's what I've seen even in my short tenure as an attending physician. So, you know, I want to push for long-term financial support for employee health and safety programs and healthcare. What does that look like so that we aren't caught with our pants down next time? Thank you. So under the Department of Veterans Affairs, after Michael left, his protege spent a long time trying to do a staffing model for us at the VA. You know, we're big and complex. We have multiple hospitals and clinics. The answer is it's absolutely impossible to do because every occupational health does different things. Some of them have workers comps, some don't. At Stanford, occupational health didn't run their COVID. They had a whole COVID team that did it separately. So it's an impossible thing to answer. I'd suggest if you're the chief or the leader of the department, write down what your specific duties are, assign your baseline duties, and then if you're allowed to have some slush, like for COVID, add a couple of people, but know what your baseline is absent a pandemic, and then try to have a, what I have in my facility is I have a whole cohort, five or six people who are on my, what's my called my fee basis, like my hourly list, and I use them like two or three times a week because no one checks our budget because it's your tax dollars. So anyway, so you, so have, but then, you know, that's also the model of emergency medicine is you have a full-time staff and then you have a lot of moonlighters. So I would create your model, like you do respiratory fit testing, you do influenza, you do pre-employment, whatever you do, staff it the way you need to staff it for your baseline and create a cadre of temporaries, overtimes, you know, whatever you call your part-timers to fill in, your hospital will have to be responsive to the next pandemic. I would build in COVID as a relatively permanent situation at this point. We know there's probably going to be more boosters. It's probably going to be an annual vaccine. So build COVID in like another line of influenza, at least, be my recommendation. Sound good? Totally. I'll pay for it. One of the things that we've been doing is we had a whole exposure team for COVID and it was up to 18 people at one point. We were a department of maybe 18 people and then at the peak of the pandemic, we were up to 50 because we got a lot of redeploys and we got a lot of extra help. But now that things started to wind down, although they're starting to tick up again, we repurposed the COVID exposure team and added other exposures to it so that we have expanded our coverage for exposures, including influenza, you know, any kind of bloodborne pathogen exposures, any kind of an exposure and or a work injury. We have that exposure team on that immediately and getting back to the team member to make sure that they're okay and find out what they need and they're triaged and given an appointment if they need it. So we're repurposing them and in the event that there's another surge or when there's another surge, they can transition back to that and other people can pick up the things that they were doing. Yeah, like they can pick up TB Tuesdays. Don't forget to ball that in. The critical thing is to define the functional needs in your institution across the various things that get covered in occupational health. So those include environmental stuff, pollution discharges, traditional safety, industrial safety, and parapets and guardrails. Those include infection control and thinking about the staffing and infection control and where your hospital does what element of infection control and quality management, who manages the annual review of sharp safety and device replacement, who does actually the workers' compensation, initial injury follow-up and case management, who actually sees patients, the physician or advanced practitioners, and so thinking through carefully what all the functions are at a routine level and what your reserve needs may be, making sure that's in writing and that your hospital leadership knows what the range of things are and that if there's a surge, if you don't get such and such, you can't do this and that and making sure that in writing has gone up the line because any time in an institution you're doing work, you want to know whether you can accept responsibility along with authority or if people want to give you responsibility but don't give you the needed resources, you can show you have tried to get those and then there's no harm in saying I can't do that. I asked for this. You don't give me resources. I can't do that work. Or explain, just select which of these programs you want us to cut if you're cutting our resource. Do you want us to no longer evaluate needle sticks? Do you want us to no longer evaluate work injuries? Do you want us to no longer have the state-mandated TB program? Tell me what to cut. Hi, Rachel Thies from Sanford Health in Sioux Falls, South Dakota. I just wanted to briefly ask for any of those, any of you who do diaphysicals for hyperbaric chambers at your facilities, if you could just briefly comment on what the diaphysical entails and the frequency at which you perform those physicals. It's a questionnaire for the staff. So for the staff, if you don't have a hyperbaric chamber, you're talking about for the staff who have to enter the chamber and stay with the patient throughout the course of their treatment. So it's a questionnaire. We don't require physical exam unless something on the questionnaire triggers the need for that. They're extensively educated, you know, Eustachian tube, equilibrium, et cetera, because they're the ones educating the patients. So we do it at higher, and you know, I think we just, it's an annual, has anything changed rather than repeating the whole thing? We do it annually. It's probably over. Do you do anything differently than a questionnaire? Yeah, actually we put our hands on them. Okay. Again, I'm not sure I can justify that with evidence that we've prevented anything, but we do. No, just for you speaking. I'm sorry. Yes, we see them manually and do a physical exam. Okay, great. Melanie, did you want to do these questions? But we'll do them as a rapid fire, so because everybody's glucose is like 40. All right, yes. Okay, Dr. Rooste, source patient's HIV negative, but is high risk at time of needle stick. Do you continue testing the employee? Is there a window of infectivity without detection? The window's smaller and smaller. That might be a case where I would PCR test the source patient, and if the PCR and the source patient were negative, then I would not follow follow-up tests the exposed health care worker. All right, excellent. Dr. Berman, tighter negative, but twice immunized for varicella or measles, is not vaccinated at higher. What do you do if that person is exposed? I consider that person to assuming that person has documentation of their two vaccines at an appropriate interval, and assuming they are immune competent. I tell them I believe them to be immune. They meet CDC criteria for immunity. I am not going to furlough that person after exposure. I would hope that, like everyone else, they will be self-monitoring for fever, rash, or constitutional symptoms, and will isolate and contact me if that happens. And that 2011 document from ACIP that's in your syllabus is a great source for that stuff. Dr. Tanasi, any restrictions on an employee who's undergoing TB prevention, TB, LTBI treatment? So, for the latent TB infection, remember the more latent stage. We now know this to be a continuum. It's not really latent and active like a binary. You can think of something like climbing up the iceberg. There is a continuum in there, but for this 12-day treatment or this one-month treatment, these ones for the latent stage of tuberculosis, there's no limitation on their work because that's not an infectious state. Um, do you give TD or Tdap after a needle stick if it's been more than five years? Dr. Swift. Yeah. Yeah. But Tdap. So, as Dr. Berman said earlier, anytime you're going to give a Tdap, I think the question is, which would you give? Okay, Tdap. Yeah. If you have the opportunity and they need a tetanus booster, go ahead and give them a pertussis booster because by the time their tetanus is worn off, their pertussis is worn off three times. And you may not be changing the hospital safety, but you're protecting at least... Or is it, do you do either one or none at all? Yeah. Do you do either one or none? Yeah. So, yeah. So, the needle stick is, it's recommended to sort of make sure that's an opportunity to make sure they're up to date on their tetanus, but they're extremely low risk. There's essentially no risk. It's a capture point rather than really a treatment for thinking that that needle carried tetanus. It's just a touch point with the employee. Yep. Bingo. What software is your hospital using to track COVID among employees? Wow. So, you're going to get one, two, three, four, five, six, seven, eight different answers to that question. So, join us for drinks. I don't think we can go into that. Excel. It's true. Yeah. Anyone else? We use RedCap because it's HIPAA compliant. It's a great survey tool. So, we use that. We use our own occupational health tracking system that got customized with quiz bangs for COVID. We have a, actually, let's be honest. We have two different custom built systems that overlap, but are not exactly the same. We're using Salesforce and we're using QWERTY to be fair. So, that's been challenging integrating them, everything, but. Anyway, Dr. Tanasi, did you go? Oh, I did Excel. Microsoft Office Suite. We color it in and everything. Dr. Rusi? Custom. All right. I mean, occupational health tracking software and systems, honestly, around the country, you can lift the hood of any occupational health program in the country. The engine is going to be completely different. They may look the same on the outside. They may run great. But inside, some of these are Porsches. Some of them are a Volkswagen with a little gerbil on a wheel. Some of them are tinker toys and duct tape. We call that an opportunity for improvement. Bingo. And with that concludes the Medical Center Occupational Health Basics course. Thank you all so much. Thank you so much, you guys. You were very patient.

occupational health experts

hepatitis B

COVID-19

drug testing

spirometry

latent tuberculosis infection

staffing

hyperbaric chamber diaphysicals