Perspectives of hospital occupational health nurses ...

Perspectives of hospital

occupational health

nurses regarding the

prevention and early

detection of hand

dermatitis

D Linn Holness

Rosemary Ku

Kathryn Nichol

Disclosures

• Centre for Research Expertise in Occupational Disease

funded by Ontario Ministry of Labour

Background

• HCW at risk of HD – prevalence varies but generally 20%-30% of

workers

– SMH operating room staff - 184

• 26% reported current skin problems

• 9% findings of mod-severe HD

• 10% findings of moderate dryness

Holness et al. Contact Dermatitis 1995;32:352-258

Background• ICD

– Wet work

– Cleaning agents

• ACD

– Rubber accelerators, preservatives, excipients in hand

cleansers, antiseptics, dental materials

• Underlying atopic/dyshidrotic dermatitis

• Holness and Mace – HCW with HD

– 61% ICD, 31% ACD, 27% CU, 11% both ACD and CU

Holness and Mace AM J Contact Dermatitis 2001;44:80-84

Background

• Importance of early detection

– Adisesh et al CD 2002 – those that improve average duration

5.3Y, those that didn’t 7.6Y

– Holness Dermatitis 2004 – if had rash <1Y 53% improved, if rash

>1Y 23% improved

– Malkonen et al BJD 201 – duration of HD strongly associated with

improvement

• If early detection improves outcomes, opportunity for screening

Background• Screening studies – SMH work

• Shin and Holness

– Developed tool and tested on 139 HCW in attending occ health

– 31% HD, those exposed to wet work 4.8 times more likely to report HD

• Nichol et al – pilot

– Modified initial tool

– 183 HCW – 72% mild to moderate HD

• Nichol et al feasibility and validity study

– 508 HCW, self screen (283), nurse screen (225)

– 30.5% HD

Shin and Holness. Dermatitis 2014, Nichol et al. Occ Med 2016, Nichol et al. CD 2019

Background• Screening studies – SMH work cont’d

• Mixed methods – survey and interviews

• Survey

– 17/22 Toronto area hospitals

– 77% standard screening protocol – hire or if HCW identifies problem

– If reported screening – 38% mandatory, 31% voluntary and 31%

mandatory at hire but voluntary after

– None tracked prevalence

– Training – usually part of hand hygiene as part of new employee

orientation (59%)

– 77% printed materials, 6% web-based, no workshops

– Compensation claims: 6 no claims, 5 1-2 claims, highest 10/Y Nichol K, Kersey K, Copes R, Kendall A, Eriksson J, Holness DL, Dermatitis screening

practices within Toronto hospitals. OOHNA Journal 2015;Fall-Winter:3-6

Background• Screening studies – SMH work cont’d

• Mixed methods – survey and interviews

• Interviews

– 12 occupational health nurses (OHN)

– Screening only formally done at hire

– HD underreported because HCWs don’t want to be removed from

clinical work

– Lack of collaboration between OHS and infection prevention and control• Infection prevention and control does training, OHS does management but OHNs weren’t

aware whether there was HD prevention training included and problems related to

recommendations for moisturizers

Nichol K, Kersey K, Copes R, Kendall A, Eriksson J, Holness DL, Dermatitis screening

practices within Toronto hospitals. OOHNA Journal 2015;Fall-Winter:3-6.

Ontario Context

• Publically funded health care system including hospitals

• Ongoing funding cuts

• Small number of WSIB claims from HCW for contact dermatitis

Ontario Context: Public Health Ontario

• 2012 PHO conducted an environmental scan to identify key issues

in health care system re OHS and IPC

• > 1000 responses from nursing, OHS, IPC, education, clinical

management and administration

• Represented hospitals, long-term care, emergency services,

community clinics, home health care, correctional and social

services

Ontario Context: Public Health Ontario

• Occupational contact dermatitis a key concern and serious issue

• Highlighted need for education and training on preventive

strategies for OCD for front-line HCW and effective tools to help

manage OCD

– Resources

– Policies

– Management support

Objectives

• Describe how OHNs identify and manage mild hand

dermatitis

• Describe the facilitators and barriers associated with the

identification and management of mild hand dermatitis

Methods

• REB approval

• Qualitative study

– Interviews

– HD related resources were collected

• Purposive sampling to identify OHN from hospitals in GTA

• 26 hospitals contacted, 15 interviewed from 11 hospitals

Methods

• Interview guide formulated on literature

• Interviews were audio recorded and transcribed verbatim

• Directed content analysis

– Becoming familiar with the data by reading and re-reading,

generating codes, counting the codes, categorizing codes into

broad themes

– 3 investigators independently analysed then met and reached

consensus on codes and themes

Results

• Work Practices – identification practices

– Identification of disease at time of hire or when HCW reports to

OH

– mild=redness, dryness, itchiness

– cracked skin often reported as marker for mod-severe disease

– Obtain history – exposures, hand hygiene practices,

aggravating and alleviating factors to identify possible irritants

and/or allergens

Results

• Work Practices – identification practices

– After history, visual hand inspection (extent, severity, impact on

function) and cracking

– Some used a clinical tool, some relied on their clinical

judgement

– Some had a tool available but didn’t use because it was too

long or time consuming other

Results

• Work Practices – management practices

– Many OHN managed the case themselves, others refer to occ

med MD or family physician

– First line treatment, use of moisturizers

– Review proper hand hygiene practices

– Remove from clinical duties if cracked skin

– Many reported HD resources sparse and, if available, hand

hygiene oriented

Results

• Work Practices – management practices

– HCW were instructed to return to OH for FU (2-12 weeks)

– Often HCW did not return, leading OHN to assume that the

HCW was compliant with treatment

Results• Barriers – HCW do not report to OH

– Report seeing 2-20 cases of mild HD/year

– Key barrier was HCWs not reporting to OH

• HCW tries to manage themselves until becomes

unmanageable

• Risk of modified duties

• Lack of time

• Belief that HD was an inherent part of job

• Not knowing if work-related

• Presence of underlying skin condition (e.g. eczema)

Results

• Barriers – modified health review process for new hires

– New hire process has changed

• 5 hospitals no longer see new hires in person, rather new hires

asked to complete health history form and visit a physician to

obtain immunizations

• Information reviewed by OH – only if concerning information

would worker be contacted for further investigation

• Thought to be due to decreased funding, human resources and

time, mgt changes

Results

• Barriers – modified health review process for new hires

– Six unique health review forms collected

• Each gathered information about skin differently

• Most very limited information about skin (allergy to latex)

• Only one hospital reported a formal hand assessment was

completed for new hires

Results

• Barriers – lack of collaboration between OH and IPAC

– Hand hygiene training, product selection primarily done by

IPAC with little involvement from OH

– Concern for hand hygiene impacted OH

– Although OHN recognized importance of hand hygiene, led to

over sanitizing their hands leading to compromised skin

integrity

Results

• Facilitators – education and awareness

– More education for HCW

• Highlight clinical signs and symptoms

• Highlight wet work as a risk factor

• Encourage HCW to utilize OH

– Formats recommended

• Print materials, online or in person training

– Need to educate supervisors so they can instruct and support

HCW

Results

• Facilitators – common assessment tools and resources

– Need for common assessment tools

– Tool should outline best practices across severity categories

and include pictures and flow charts

– Resource for HCW with mild HD would be valuble

Next Steps

• PHO – systematic review and recommendations for hand

dermatitis in health care workers – fall 2019

• Development of tools to support recommendations of

PHO report