The Employee Health Service and Infection

Control in US Hospitals, 1976-1977

I. Screening Procedures
Robert W. Haley, MD, T. Grace Emori, RN, MS

\s=b\To assess the extent to which US hospitals have established employee the completion of this survey, addi¬
health services with infection control functions, we analyzed information tional, more detailed guidelines for
obtained in the SENIC Project (Study on the Efficacy of Nosocomial Infection implementing an employee health
Control) from interviews with hospital officials and staff nurses in a service have been published.3 In this
5

representative sample of 433 hospitals. Sixty-eight percent of hospitals had article we describe the frequency and
a formal employee health service. The percentage routinely screening distribution of formal employee
employees varied widely from the more common tests, such as the yearly health services in US hospitals and
chest roentgenogram (89%) and skin test (83%), to less common tests, the procedures used to screen employ¬
including stool cultures (43%) and blood testing for hepatitis B (41%) and ees for potentially contagious infec¬
rubella (33%); 40% routinely obtained cultures of personnel. Although most tions. In a future article we will
hospitals appear to screen adequately, a sizeable minority either fail to describe the methods used to manage
employ recommended screening tests or continue unnecessary, expensive employees who have such infections.
ones.
MATERIALS AND METHODS
(JAMA 1981;246:844-847)
The information presented in this arti¬
cle was collected in phase II of the SENIC
Project, the Hospital Interview Survey.
AN IMPORTANT responsibility of a employee health service, either de¬ The details of the study design have been
hospital's infection surveillance and voted mainly to the control of conta¬ described elsewhere67 and will only be
control program is the monitoring gious illnesses or as part of a more summarized here. The Hospital Interview
and prevention of infection trans¬ comprehensive program of employee Survey consisted of interviews with
mitted to and from its personnel.1 health care. The employee health ser¬ selected hospital personnel involved in
Since its first edition in 1968, the vice may consist of only a part-time various aspects of infection surveillance
American Hospital Association's2 physician or may be a formal clinic or and control in a sample of 433 hospitals
(AHA) Infection Control in the Hospi¬ department, depending on the size of representing the SENIC target population:
tal has provided guidelines for an the hospital and the number of full- all general medical and surgical hospitals
time employees. that are short term, not federally or state
As part of the SENIC Project owned, have at least 50 beds, and are
From the Hospital Infections Branch, Bacterial located in the contiguous 48 United
Diseases Division, Center for Infectious Diseases, (Study on the Efficacy of Nosocomial States.' The interviews were conducted at
Centers for Disease Control, Atlanta. Infection Control), we evaluated the the hospitals by Centers for Disease Con¬
Reprint requests to Attn: SENIC Project, Hospi- extent to which US hospitals have trol (CDC) staff members from October
tal Infections Branch, Bacterial Diseases Division,
Center for Infectious Diseases, Centers for Dis- implemented programs to control 1976 to July 1977. The information pre¬
ease Control, Atlanta, GA 30333 (Dr Haley). infection through such services. Since sented in this article was obtained from

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personal interviews with the infection con¬
trol nurse (or most nearly equivalent
respondent in each hospital) and the direc¬
tor of the microbiology laboratory. To
provide estimates of the employee health
service characteristics in the SENIC tar¬
get population of US hospitals, the
responses were weighted approximately by
the reciprocal of the hospital's probability
of having been selected by the stratified
random sampling process.'
To examine whether the hospital setting
influenced the implementation of the
employee health service, the information
from the interviews was analyzed by the
following major characteristics of hospi¬
tals: hospital size (seven categories based
on the number of beds),6 size of the
hospital staff (deciles of the number of
full-time employees), affiliation with a
medical school, geographic region (north¬
east, north central, south, west), urban-
rural location (size of the standard metro¬
politan statistical area [SMSA]),8 and type
of ownership or control of the hospital
(proprietary, nonprofit, or owned by local
government). In addition, the following
hospital characteristics were used in
selected analyses: presence of obstetric
services (no births vs any births), size of
the obstetric service (fertiles of number
of births), and presence of facilities and
services for inpatient hemodialysis, a neo¬
natal intensive care unit, and an inpatient
tuberculosis or respiratory care unit.
These data were obtained from AHA's
1976 Annual Survey of Hospitals.*
The regions were defined by the follow¬
ing combinations of census divisions:
northeast (divisions 1 and 2), north central
(4 and 6), south (3, 5, and 7), and west (8
and 9).1 For analyses of staff size, the
hospitals were divided into ten equal
groups on the basis of the number of
full-time staff members. For the analysis
comparing staff size with presence of an
employee health service, adjacent decile
categories with similar percentages were
grouped to form four categories of staff
size as follows: small (deciles 1 and 2: 35 to
160 full-time employees); medium-small
(deciles 3 to 6: 161 to 474); medium-large
(deciles 7 to 9: 475 to 1,449); and large
(decile 10: 1,450 or more).
To study the distribution of employee
health service characteristics among the
different types and locations of hospitals,
we first examined the association of each
of the employee health service characteris¬
tics with all of the hospital characteristics
by means of the appropriate cross-tabular
or correlational techniques. We then per¬
formed a series of multivariate analyses to
determine the relative strengths of the
associations between hospital characteris¬
tics and the employee health service char¬
acteristics. Since the employee health
service characteristics are virtually all
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bivariate random variables, we used a
multiple discriminant analysis procedure
for these analyses; interactive effects were
studied further through cross-tabular
techniques.
RESULTS
Extent of Programs
According to the infection control
nurse or equivalent respondent in
each hospital, at the time of the
interviews 68% of US hospitals in the
SENIC target population had an
employee health service, defined as "a
health facility, clinic, department,
etc, that is capable of detecting and
treating infections among employ¬
ees." Although the likelihood of hav¬
ing an employee health service varied
significantly by hospital size, number
of full-time employees, medical school
affiliation, community population
size, and region of the country, a
multivariate discriminant analysis
showed the variation to be related
primarily to the number of full-time
employees and secondarily to region.
Specifically, hospitals with a larger
staff were more likely to have an
employee health service in each
region (pooled x2=38.3, df=l2,
P<.0001), while the relationship with
region was significant only for the
groups of hospitals with medium-
small and medium-large staffs
(x2=10, df=3, P=.02 for each of the
two groups) (Fig 1).
To estimate the extent of services
offered, we asked the infection con¬
trol nurses about five screening pro¬
cedures that might be provided by an
employee health service. Among hos¬
pitals with an employee health ser¬
vice, the most frequently offered
procedures were a yearly chest roent¬
genogram (89%) and skin test (PPD
or tine test) for tuberculosis (83%),
while "stool culturing of new employ¬
ees for evidence of Salmonella" (43% ),
testing for hepatitis B antigen-anti¬
body (41%), and testing for rubella
antibody (33%) were offered less
widely.
Among hospitals with an employee
health service, skin testing for tuber¬
culosis was offered somewhat more
often in larger hospitals (P=.005) and
was available in each of the 5% of
hospitals that had special tuberculo¬
sis or respiratory care units. The
annual chest roentgenogram was of¬
fered about equally in all types of
hospitals. Routine stool culturing of
new employees was significantly re¬
lated only to the hospital's regional
and urban-rural location (P<.0001):
In the western states it was per¬
formed by about 65% of the hospitals
regardless of the size of the communi¬
ty; however, it was performed more
often in hospitals in the largest cities
(population, 2.5 million or more) than
in those in smaller cities or rural
areas in the north central region
(50% vs 36%, respectively, P=.14),
the northeast (88% vs 47%, P=.0003),
and the south (90% vs 23%, P=.05).
Screening for hepatitis B was
offered somewhat more often in larg¬
er hospitals, but this difference was
almost entirely accounted for by the
stronger association with the pres¬
ence of renal dialysis facilities, with
hepatitis B screening being offered in
63% of hospitals with inpatient dialy¬
sis but in only 34% of those without
(P-C0001). Likewise, screening for
rubella immunity was offered more
often in larger northeastern hospi¬
tals, but this difference was explained
by the stronger association with the
presence of larger, more specialized
obstetric services, although it was not
associated with a hospital's merely
having an obstetric service. Screening
for rubella immunity was offered in
59% of hospitals with large obstetric
services (more than 875 births per
year) but in only 22% of hospitals
with smaller (or no) obstetric services
(P<.0001) and in 56% of hospitals
with a neonatal intensive care unit
but in only 30% of those without one
(P<.0001). Moreover, among hospitals
without a neonatal intensive care
unit, rubella screening was more like¬
ly to be offered in northeastern hospi¬
tals (55%) than in those of other
regions (27%, P<.0001), regardless of
the number of births.
Another indicator of employee
health service activity is the practice
of routinely obtaining cultures from
personnel for signs of asymptomatic
carriage of various pathogenic organ¬
isms. According to the heads of the
microbiology laboratories in the sam¬
ple hospitals, 40% of hospitals ob¬
tained routine personnel cultures,
such as cultures of the nose, throat,
or stool, to monitor employees
who work in certain high-risk
areas such as the nursery or the
operating rooms. Routine cultures

Percentage of US hospitals with an employee health service, by number of staff (full-time
employees) and region, 1976-1977.
were more often performed in hospi¬
tals not affiliated with medical
schools (P=.0003) and in those with
smaller numbers of full-time employ¬
ees (P=.006). Among those hospitals
that performed such routine cultures,
the number performed each year
ranged from one to 3,600, averaged
179 (±11[SEM]), and was not signifi¬
cantly related to the hospital charac¬
teristics studied; instead, hospitals
that generally performed larger num¬
bers of environmental cultures tended
to collect more routine personnel cul¬
tures (P=.005).
COMMENT
In this survey of the "mainstream"
of US hospitals, we find that the
majority of hospitals have a formal
employee health service and, as rec¬
ommended both by the AHA and the
CDC, larger hospitals and those with
more employees are more likely to
have one.2'3 Although published guide¬
lines recommend that the five screen¬
ing procedures studied in the survey
be provided by all hospitals under
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carefully specified conditions, the
percentage of hospitals doing so
varies widely. Current recommenda¬
tions suggest that all new employees
be skin tested for tuberculosis before
they begin work to determine wheth¬
er infection has occurred at some
time in the past and that nonreactive
employees be skin tested again at an
interval appropriate to their risk of
infection.910 All personnel found to be
tuberculin positive should have an
initial chest roentgenogram to deter¬
mine the presence, extent, and activi¬
ty of pulmonary tuberculosis and
should be followed up with repeated
roentgenograms every six to 12
months unless they are completing a
course of chemoprophylaxis with iso-
niazid or another appropriate chemo-
therapeutic agent. Skin testing and
chest roentgenograms are provided in
almost all hospitals; however, their
excessive use (eg, repeated skin test¬
ing in tuberculin-positive persons and
routine, periodic chest roentgeno¬
grams in tuberculin-negative per¬
sons), not studied in this survey, is
probably a more widespread problem
that, if curtailed, might reduce em¬
ployee screening expenditures sub¬
stantially.
Routine screening of new employ¬
ees (or periodic screening of regular
employees) for asymptomatic car¬
riage of Salmonella has not generally
been recommended, since it is an
expensive and inefficient means of
preventing nosocomial enteric infec¬
tion.23 The comparatively large per¬
centage of hospitals offering this
screening procedure in the largest
metropolitan areas may, however,
suggest that hospitals are primarily
acting to comply with local health
regulations that require screening for
carriage of S typhi or other enteric
pathogens.
Blood testing for hepatitis B and
for rubella, though recommended for
certain groups of employees, is the
least likely of the five screening pro¬
cedures to be provided. Although pub¬
lished recommendations discourage
the routine application of these proce¬
dures for all hospital employees, the
recommendations suggest that all
female hospital employees of child-
bearing age undergo serological
screening for rubella (and that all
who are susceptible but not pregnant
be vaccinated)25" and that all person¬
nel working in areas with high risk of
infection with hepatitis B be screened
for hepatitis B antigen and antibody
before employment and regularly
thereafter on a schedule dictated by
the results of the tests and the degree
of risk involved.12 Our finding that
rubella screening is offered more fre¬
quently in hospitals with more active
obstetric and neonatal services sug¬
gests that the broad guideline for
rubella screening in all hospitals is
not followed; rather, such screening is
largely confined to hospitals where
employees are likely to be exposed to
cases of congenital rubella. The fact
that hepatitis B screening is offered
largely in hospitals with hemodialysis
programs is compatible with the rec¬
ommendation, although more than
one third of hospitals with dialysis
programs do not yet offer such
screening. In general, screening pro¬
cedures such as the five studied
should be performed in conjunction
with a system of surveillance for
identifying and dealing with overt
cases of contagious disease in patients
and employees.
Routine culture testing of person¬
nel for asymptomatic carriage of
pathogenic organisms such as staphy-
lococci or salmonellae, though not
recommended, is practiced commonly.
In contrast to the usually positive
association of infection surveillance
and control activities with size of
hospital, such culturing is more likely
to be practiced in smaller hospitals
and in those not affiliated with a
medical school, and its extent seems
to be related more to a general com¬
mitment to environmental monitor¬
ing than to other specific indications
or hospital characteristics. Hospitals
might save considerable resources by
discontinuing routine culture testing
1. Accreditation Manual for Hospitals. Chica-
go, Joint Commission on Accreditation of Hospi-
tals, 1976, pp 49-56.
2. Infection Control in the Hospital, ed 3.
Chicago, American Hospital Association, 1974,
pp 30-36.
3. Kaslow RA, Garner JS: Hospital personnel,
in Bennett JV, Brachman PS (eds): Hospital
Infections. Boston, Little Brown & Co, 1979, pp
27-52.
4. Werdegar D: Guidelines for infection con-
trol aspects of employee health. J Assoc Pract
Infect Cont 1977;5(September):17-22.
JAMA
75 YEARS AGO
Au g 25, 1906
The Fetich of Disinfection
[Original Article, pp 574-580]
Futility of Disinfection
If then, as all evidence tends to show,
contagious diseases usually extend by
means of pretty direct contact between the
infected and non-infected, and transmis¬
sion by fomites has little influence on such
extension, it follows that even the most
thorough disinfection will have little
checking these diseases. There is
effect in
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of personnel and reserving this type
of screening for outbreaks of actual
infection, where a prompt search for
carriers guided by a specific epidemi-
ologic investigation might provide
useful results. Of course, state or local
regulations requiring such screening
must also be observed.
Thus, it appears that the majority
of US hospitals are routinely per¬
forming the recommended tests to
detect potentially contagious infec¬
tions among their employees, and
hospitals with employees at presum¬
ably higher risk of acquiring such
infections (eg, those with hemodialy-
sis units) are more likely to be per¬
forming the appropriate screening
tests. There appears to be, however, a
References
5. Werdegar D: Guidelines for infection con-
trol aspects of employee health. J Assoc Pract
Infect Cont 1977;5(December):15-22.
6. Haley RW, Quade D, Freeman HE, et al:
Study on the Efficacy of Nosocomial Infection
Control (SENIC Project): Summary of study
design. Am J Epidemiol 1980;111:472-485.
7. Quade D, Culver DH, Haley RW, et al: The
SENIC sampling process: Design for choosing
hospitals and patients and results of sample
selection. Am J Epidemiol 1980;111:486-502.
8. Guide to the Health Care Field. Chicago,
American Hospital Association, 1977, pp 10-13.
certainly no rational basis for making it
such an important feature in public health
work, and holding it of equal value with
isolation.
Another thing to be borne in mind in
connection with this subject is that a good
deal of disinfection does not disinfect.
Until eight or nine years ago sulphurous
anhydrid was the chief disinfectant, and
this is now considered to be entirely
unreliable. Then formaldehyd came into
use and at first most of the disinfection
with it did not accomplish more than the
sulphur. Even now a great deal of formal¬
dehyd disinfection is inefficient, and at the
best only exposed surfaces can be disin¬
fected. As the larger part of the clinical
evidence of the value of disinfection dates
from a time when the process was very
imperfect, the value of that evidence is
much impaired.
In Providence we have been making a
practical test of the value of disinfection
by omitting it entirely in some cases. It
sizable minority of hospitals in
which the appropriate screening tests
are not being offered and many in
which unnecessary but expensive
screening procedures (for example,
routine culturing of employees) are
continuing despite recommendations
to the contrary.2"6 It is likely that
rechanneling those misdirected re¬
sources toward the recommended
practices would improve the health of
employees while reducing the total
expenditures of the employee health
service.
The Hospital Interview Survey was supported
in partby 1% evaluation funds through the
Office of
Program Planning and Evaluation.
9. Preventive therapy of tuberculous infec-
tion, American Thoracic Society. Am Rev Respir
Dis 1974;110:371.
10. Guidelines for Prevention of TB Trans-
mission in Hospitals. Atlanta, Centers for Dis-
ease Control, 1975.
11. Rubella virus vaccine, Public Health Ser-
vice Advisory Committee on Immunization Prac-
tices. Morbidity Mortality Weekly Rep 1971;
20:304.
12. Perspectives on the control of viral hepati-
tis, type B. Morbidity Mortality Weekly Rep
1976;25(suppl):1.
seems useless to disinfect an apartment
unless we can be fairly sure that its
occupants are not propagating the germs
of disease. In diphtheria we can have no
reasonable assurance of this without get¬
ting at least two negative cultures from
the nose and throat of every member of
the family. To require such cultures is
impracticable. Disinfection, however, is
refused after diphtheria, unless the above-
named reasonable conditions are met,
which very rarely happens, or unless it is
especially requested after a death. During
the last year the warning card has been
removed 258 times without disinfection,
and there has been a recurrence in the
family within two months in four cases, or
1.55 per cent. In 87 instances in which
disinfection was practiced during that
period or a few months preceding it, there
was a recurrence in 2.3 per cent, of the
cases. The total number of cases of diph¬
theria fell, however, from 780 in 1904 to
562 in 1905.