University of Kentucky Hospital, Chandler Medical Center
Policy Number: HP03-01
FIRST ISSUED: 2/84; CURRENT AS OF: 12/06
SUBJECT: Hospital Employee Health Program
SEE ALSO: Hospital policies HP03-03, Hepatitis B Immunization; HP03-07, Control of Varicella; HP03-17; Monitoring Exposure to Transmissible Agents; HP03-19, Management of Employees with Communicable Diseases; HP10-33, Reportable Occurrences;
HP09-25, UK Worker's Care
Information and instructions
The University of Kentucky Hospital Employee Health Program is designed to provide a means of protection for patients and employees against Hospital acquired and/or work-related infections or injuries. This protection is to be accomplished by initial and periodic screening of employees, taking into consideration the degree of exposure to certain conditions and to specific hazards related to their job. This screening is not intended to be a substitute for services provided by the employee's private physician. The Employee Health Program is to serve as a focal point for the collection of information and disposition of employee job-related health problems.
The objective of the program is to protect both patients and employees from illnesses that could be transmitted while on the job. Consequently, all individuals who are employed by or volunteer in the Hospital are required to participate in the Employee Health Program. The Employee Health Program is also established to meet the requirements of the Kentucky Cabinet for Human Resources regarding tuberculosis screening for all Hospital employees and the requirements of the OSHA Bloodborne Pathogens regulations as well as other state and national recommendations for the protection of health care workers.
Note: Any non-Hospital employee or person who provides patient care-related services must also meet these Employee Health requirements. It is the responsibility of the non-Hospital employee's employer or agency to ensure that requirements are met.
The extent of participation for individuals or groups will be defined by Employee Health in consultation with Hospital Administration. The following individuals will be covered under the program:
- All Hospital employees
- House staff
- Contract staff
- Other employees, including autopsy room staff and employees with joint appointments
- Employee Health screening on initial appointment and periodic re-screening will be the responsibility of the Employee Health Program.
- Except under special circumstances, which must be cleared by the medical or nursing director for Employee Health, employees must be screened within the first week of employment.
- Responsibility for ensuring that all employees are seen in Employee Health on a timely basis lies with the service director.
1. Health questionnaire
Each new employee will complete a health questionnaire to assist Employee Health personnel in providing appropriate care.
2. Mantoux Tuberculin Skin test
As a condition of employment, each new employee will be given a two-step Mantoux tuberculin skin test in the manner recommended by the Centers for Disease Control. In some circumstances, the new employee may be required to participate in other health screening (e.g., chest x-ray for skin test-positive new employees who have not had a recent chest x-ray). The employee must return to Employee Health to have the skin test read.
3. Measles, Mumps, and Rubella (MMR) status
As a condition of employment, new Hospital employees born in or after 1957, who are scheduled to have patient contact, upon employment, must provide evidence of two MMRs, or documentation of physician-diagnosed measles, mumps, and rubella, or laboratory evidence of measles, mumps, or rubella immunity. If the employee cannot provide this evidence, they will receive one MMR at the time of employment and will be re-vaccinated at no less than one month later. Employees who have documentation of one MMR who were born in or after 1957 will receive one dose of MMR upon employment. Employees born before 1957 do not need to show immunity to measles, mumps, or rubella.
The MMR is not to be given to pregnant women or to women who are planning to be pregnant within one month. It is not to be given to persons who have had an anaphylactic reaction to eggs. It should not be given for three months after immune globulin has been administered. Routine titers are not performed.
Currently employed patient-contact personnel born in or after 1957 will receive an MMR or will provide proof of immunity at their next annual employee health screening following institution of this policy. Currently employed persons who have proof of one MMR will receive one dose of MMR at their next annual employee health screening. Currently employed persons who have no proof of vaccine or proof of immunity will receive one dose of vaccine at screening plus one dose one month later. No titers will be drawn. The MMR vaccine is a one time requirement for all employees born during/after 1957. Currently employed personnel born before 1957 do not need to show immunity to measles, mumps, or rubella.
For those women of child bearing age who are uncertain of their immunity to rubella or rubeola and wish to receive the vaccine, but do not have patient contact, the vaccine will be given at their request as an employee benefit. The proof of immunity to rubella and rubeola or MMR vaccination is a requirement for patient contact personnel only. Each employee receiving the MMR will sign an informed consent which becomes a part of the permanent record.
4. Hepatitis B (HBV) vaccine
Within 10 days of employment, all employees identified as having potential for occupational exposure will be offered the HBV vaccine; the vaccine is offered at no cost to all Hospital employees. All employees must sign a declination form, which will be provided and kept by the employee's supervisor, if they choose not to receive the HBV.
All employees completing the hepatitis B vaccination series will be required to have a titer drawn within two months after the last injection is received. Employees with positive titers are considered to be protected from hepatitis B. Employees with negative titers will repeat the vaccination series. Another titer will be performed within two months after the second vaccination series to determine if the employee is protected from hepatitis B. Failure to demonstrate a positive titer at this point will result in a medical consultation with the medical director of Employee Health.
5. Varicella (see Hospital policy HP03-07, Control of Varicella)
The Hospital requires that all health care workers who have 30 consecutive minutes or more per month of direct patient care contact to demonstrate immunity to varicella either by history of the disease, demonstrated antibody titer, or varicella vaccine (completed series of two injections, one month apart).
Employee Health will determine and record the employee's history of immunity to varicella-zoster virus at the initial employee health screening, and provide that information to the service director.
The service director will make any necessary decisions about job reassignments necessary due to lack of varicella immunity for all Hospital employees and volunteers, residents, physicians, and faculty.
Routine HIV testing is not offered by Employee Health to employees. Testing is performed as a result of occupational blood-borne pathogen exposure, which is a worker's compensation injury.
7. Post-occupational exposure prophylaxis for HIV and Hepatitis B
These will be provided under the supervision of the medical director for Employee Health through UK Worker's Care.
8. Quadrivalent Meningococcal vaccine
All microbiology lab staff will be offered the quadrivalent meningococcal vaccine.
After these initial screenings, the supervisor will provide a letter of need to the employee, which the employee will submit to Employee Health at the time of vaccination. There are no current recommendations for revaccination.
Annual screening and follow-up
As required by 902 KAR 20:016, all Hospital employees must have a tuberculin skin test at least annually on or before the anniversary date of the last skin test. This is a condition of employment. Tests will be administered and read by Employee Health personnel only. Employees who are designated as high-risk for tuberculosis exposure may be required to have skin testing on a more frequent basis.
An employee who is found to be a new tuberculin skin test reactor will be referred to the medical director of Employee Health and will have a chest x-ray ordered at the time of skin test reaction. If there is no clinical evidence of disease and the x-ray is negative, the employee will be offered Isoniazid (INH), unless contraindicated. If the employee elects to take INH, they will be monitored monthly by Employee Health. A symptoms list will be provided to each reactor. The employee will complete a symptoms questionnaire on an annual basis on or before the due date (or more often in some designated high-risk areas) and will be urged to report any of these symptoms to Employee Health at the time of occurrence.
Employees who have had prior BCG vaccination will be skin-tested using the Mantoux method unless a recent significant reaction can be documented. The result of the skin test in persons who have had previous BCG vaccination will be interpreted and acted upon in the same manner as those in personnel who have not been vaccinated.
Exposure to a patient with known tuberculosis for whom precautions were not used constitutes a workers' compensation injury. The employee and/or supervisor must contact UK Workers' Care to report the exposure. Personnel will then be screened by Employee Health at the time of exposure and at 12 weeks post-exposure. Skin test conversion related to exposure will be handled in the same manner as other tuberculin skin test conversions and constitutes a worker's compensation injury. Chest x-rays may be ordered on skin test positive employees after exposure at the direction of the medical director of Employee Health.
Responsibility for fulfilling employee health requirements
It is the responsibility of each department to notify employees of the due date for annual employee screening. A list of all employees with their due dates for Employee Health examination will be provided to the service director monthly.
Employees overdue for testing will be suspended from work without pay until the employee has completed the TB skin test or other Employee Health requirements; if the employee fails to have the TB skin test or other required tests completed within ten days after suspension the employee will be terminated. The tuberculin skin test is not considered complete until it has been read by Employee Health personnel.
All employees will be given a verification slip by Employee Health stating that the required activity has been completed. The employee will give this verification slip to their supervisor, to be filed in the employee's personnel file. The supervisor should maintain copies of the last three years of the verification slips in the employee's file.
Medical support of Employee Health will be provided by University Health Services.
Injuries sustained while on the job will be treated as any UK Worker's Care injury. Care will be covered by UK Worker's Care or by the employee as deemed appropriate. Care for UK Worker's Care injuries is not to be the responsibility of Employee Health (see Hospital policy HP09-25, Worker's Care).
Employees who have patient care responsibilities and have signs or symptoms of a transmissible disease must report to their supervisor. Employees may be reassigned, restricted, or excluded from work. The department representative may consult with Employee Health for a final determination regarding work restrictions.
An employee who has health considerations (i.e., pregnancy, immune deficiency) that may result in increased vulnerability to infection should notify their supervisor who may consult with Employee Health. The employee will be counseled regarding work-related risks and may have work restricted or assignment changed as deemed necessary.
The director of University Health Service, in conjunction with all Hospital service area directors, is responsible for administration of the provisions of this policy. The Employee Health Advisory Committee has oversight responsibility for the Employee Health Program.
- Approved by Karen Stefaniak, Chief Nursing Officer
- Approved by Richard Lofgren, M.D., Chief Medical Officer
- Authorized by Murray B. Clark, Jr., Associate VP for MC Operations