Healthcare workers’ Safety and Health Forum

Healthcare workers’ Safety and Health Forum

I.Organizer: Taiwan Public Health Association
Executive organizer: Center of Medical Employee Safety & Health

II.Time: 14:00 ~ 16:00, 25th September (Friday) 2009

III.Venue: Lecture hall 205, NTUH International Conference Center (Room 205, 2F, No. 2-2 Xuzhou Rd., Zhongzheng District, Taipei City, 10055)

IV.Agenda:

Date Time Topic
25th September (Friday) 14:00

14:10-14:10 Opening remark by Chairman Wei-Chien Chen (陳為堅); Taiwan Public Health Association

14:10-15:00 Needle-stick Issue
(1) Background report (Professor Judith Shu-Chu Hsiao (蕭淑銖) 10 minutes)
(2) Topic 1: How to implement thorough promotion of compulsory report of needle-stick injury?
(3) Topic 2: How to prevent victims of needle-stick injury from being blamed by medical institutes and implement reasonable process after needle-stick injury under “consideration of none-negligence”?
(4) Topic 3: Popularity of safety needle devices for highly contagious medical work and consideration of NHI reimbursement

15:00-15:40 Consideration of respiratory infection from work
(1) Background report (Professor Yu-Liang Kuo, 5 minutes)
(2) Topic 1: Respiratory protection for healthcare workers.
(3) Topic 2: Additional work and stress related to respiratory infection.
(4) Topic 3: Consideration of holidays for ill healthcare workers.

15:40-15:50 How to promote effective pre-employment and continuous education for healthcare workers to prevent contagious occupational accidents
(1) Educational content that shall be covered
(2) Target of education and direction of promotion

15:50-16:00 Closing remark

V. Minutes:
1. Opening
Wei-Chien Chen (陳為堅) – Chairman of Taiwan Public Health Association
Today, both Professor Yu-Liang Kuo (郭育良), the Standing Director of Taiwan Public Health Association and his wife, Professor Judith Shu-Chu Hsiao will carry out topics related to safety and health for healthcare workers, which are also quite important from the aspect of public health. I recall my role of intern doctor during academic years, where needle-stick injury occurred to a student of another school. The injury caused fulminate hepatitis and the student passed away. Since healthcare workers stand at the front line of highly hazardous environment and contribute efforts for the public health every day, the effect cannot be achieved thoroughly if certain measures are not met, which may even spread out the source of virus. Among the medical works, needle-stick occurs quite often but they are easily neglected. Moreover, the attack from H1N1 is quite powerful this year; so let’s use the time this afternoon to discuss these issues to well extent. Firstly, I would like to invite each participant to give a short self-introduction.

Chiong-Chao Hong Lin (洪林瓊照) – Secretary-General of Taiwan AIDS Foundation:

I was the first civil servant that dealt with HIV test and promotion of epidemic prevention. Recalling the days of epidemic prevention more than 20 years ago, I also confronted resistances and rejections from many co-workers. Therefore, I think this meeting is very important and meaningful.

Huan-Jan Fu (傅還然) – Director General of Department of Labor Safety and Health, CLA: I mainly deal with setting the system of medical safety and health regulations and I have one good news to share with you all. Regarding the prevention of biological and hazardous needle-stick, the committee of CLA just passed an additional regulation yesterday, that in concern of excessive repulsion from administrators of medical institutes if the compulsory report of needle-stick injury is to be implemented thorough and immediately, only “Specific medical institute” has to report at present and size of such institute can vary. In the next step, the Department will discuss on how to commence with the specific medical institute. In the past, biological infection was not governed properly under medical health regulations. We have added the prevention against infection in the facility regulations this time. Furthermore, we will also set certain regulations for the employers, which mainly serve to protect the cleaning workers. The protection kit of labors must all comply with the national standards.

Kun-Yu Chao (趙坤郁) – Deputy Minister of Bureau of Health Promotion: The infection in medical institutes is surely administered by the Center for Disease Control; the Bureau of Health Promotion deals with construction of occupational health. Therefore, we work together with the CLA to monitor the safety of healthcare workers in the working environment.

Ching-Hui Hsu (徐儆暉) – Chief of Occupational Medicine Division, Institute of Occupational Safety and Health: The needle-stick to be discussed today has always been one of our major focuses, yet there are still spaces for improvement and breakthrough. I am here today to learn from everyone and I hope to obtain some new inspiration on where to improve and which direction to go in the future.

Shao-Hsing Liu (劉紹興) – Director of Division of Environmental Health and Occupational Medicine (DEHOM), National Health Research Institute: I am an Occupational Medicine Physician myself and surely happy to attend such meeting for discussion on occupational health and safety for healthcare workers.

Miao-Ching Chen (陳妙青) – Chief of Nursing Section 3, Bureau of Nursing and Health Services Development, Department of Health (DOH), Executive Yuan: Nursing personnel occupy 60% of all healthcare workers and they stand at the frontline of patient care. Over recent years, the DOH has been actively promoting positive occupational environment and notification of occupational injury for the nursing personnel. I hope to gain and also contribute in the meeting today.

Kuang-Wan Ho (賀光卍) – Representative of Taiwan Association for Victims of Occupational Injuries (TAVOI): I am a victim of occupational injury myself and our Association mainly focuses on rights, compensation and rebuilding future for labors after the occupational accident. The topics of seminar today are highlighted on personnel working in medical institutes, so I am honored to discuss and learn with every one here.

Assistant Professor Chih-Tai Fang (方啟泰) – Executive Secretary of Institute of Infectious Disease, NTU: I am also the Attending Physician of Infectious Diseases Division, Department of Internal Medicine, NTUH and I have experienced quite a few needle-stick incidences personally. Since I am often exposed in premises with highly infectious risks, I don’t think it is as hard as we think to improve the occupational safety. One deep impression I had when studying medicine some 20 years ago was that fulminate hepatitis became the major cause of death among medical students. In average, one student would die from it per year (e.g. TMU this year, NYMUSM the next year and NTUCM the year after…). The strategy NTUCM adopted at then was to carry out hepatitis B antibody test for every medical student of intern doctor-to-be. The student without antibody would be allocated under highly hazardous group of fulminate hepatitis and such student would receive the vaccine against hepatitis B. After implementation of the strategy, the rate of fulminate hepatitis to medical students reduced dramatically. However, the challenge nowadays is more complicated. Hepatitis B was the greatest threat in the past, yet there are more viruses now, such as hepatitis C, HIV…etc. Therefore, the measures of prevention shall be improved further.

Wen-Chuan Tsai (蔡文全) – Section Chief of Special Medicine & Equipment Section, NHI: In spite of government employee’s insurance and labor insurance in the past to era of health care nowadays, the needle-stick issue has always been focused very much. Since 1998, the NHI has imported certain amount of safety needle devices. I personally think that health insurance should fall under category of subsequent supplement; fundamentally, the education of healthcare workers’ safety must still be enhanced. Recently, the development of safety syringe with needle has boosted extensively. Although such needles are excellent medical equipments, the expense should not be relied on NHI totally since we also face certain financial stress. It is impossible to pay everything from the health insurance. Having said that, I am still very glad to attend today and listen to the discussion on safety protection.

Tsung-Neng Wu (吳聰能) – Vice Chancellor of College of Chinese Medicine: We are all partners in the study field of occupational safety. Detailed discussion will be carried out later.

Wen-Yi Shih (施文儀) – Deputy Director-General of Center for Disease Control, Department of Health (CDCDH), Executive Yuan:

I am honored to attend the seminar related to needle-stick and infection control in hospitals today and the CDC surely shall contribute also. As for the future collocation, I worry the distribution of responsibility the most. The matter of control involves with various aspects such as infection, nosocomial infection, occupation health…etc. Since there are different separations, responsibilities and authorities, I felt rather uneasy to hear words of “…infection in medical institutes is surely administered by the Center for Disease Control…” It is correct that the Center shall bear certain responsibilities, but sometimes the law does not allow us enough power to bear them. This relates to more parties with arbitrary ideas or involvement, which is also my reason to participate the discussion today. If we can all open our minds and strive together for the practical risks on medical personnel and eliminate the subjective mindset, as well as brain-storming together, maybe we can create new opportunities.

Chung-Ching Shih (施鐘卿) – Case Manager-HIV, NTUH: I am a Case Manager of HIV with years of practical experiences. Safety is the priority of our job and I hope to provide some sparkle for the discussion today.

I-Ling Su (蘇逸玲) – Nursing Supervisor of Taipei Veterans General Hospital: I am glad to have the opportunity today because we witness many needle-stick injuries in clinical cases and medical personnel are always the first ones to be affected. Moreover, cleaning personnel are often neglected, yet they also need protection since they are staff as well.

San-Chia Lin (林三加) – Attorney of Legal Aid Foundation: I attend this meeting on behalf of our Secretary-General Chih-Jen Kuo (郭吉仁). Since I have less experience in occupational safety and accident for healthcare workers, I will observe the discussion today. If there is future need of the Legal Aid Foundation, please feel free to propose for joint consultation.

2. Needle-stick Issue
Background report by Professor Hsiao: Needle-stick is the most common occupational injury to healthcare workers. Over the past few years, I was commissioned by the Institute of Occupational Safety and Health (IOSH) to implement some needle-stick investigation. Now I would like to make a simple report. The needle-stick may seem small, but various consequences of different degree are generated according to source of infection to the patients. According to verification from literatures, the chance of healthcare workers’ infection from needle-stick injury is 25-30% from Hepatitis B carrier, 4-10% from Hepatitis C carrier and 0.1-0.3% from AIDS carrier. The Government has started to focus on this issue since 2000 and the needle-stick investigation consigned by IOSH was accepted in 2003. We applied the EPINet notification system created by Professor Jagger from Virginia University in USA. The system has been translated into more than 10 languages and used by more than 40 countries at present. After approval from Professor Jagger, we translated the system into Chinese and developed it as an online notification system, which could download reports entered by medical institutes and execute some simple statistics at the same time. We found from the statistics that all different parametric such as days of hospitalization, number of patients in hospitalization produced the same results: Whether there were more healthcare workers, days of hospitalization or number of patients in hospitalization, the number of needle-sticks increased relatively, which indicates that occupational injury such as needle-stick is inevitable. In addition, we also derived approximately 8000 needle sticks per year in Taiwan; in other words, 4.5 needle sticks accidents would occur from per 100 full-time healthcare workers per year. If analyzing from types of needles, we derived 6000 injuries from hollow-bore needles (4000 needle-sticks from general hollow-bore needle and more than 400 needle-sticks from IC needle) in Taiwan per year. Without major change of work environment, re-cap needle accounted 16.5% of major cause for needle-stick injury, which induced no extensive change from the 18% compiled from retrospective investigation in the past. Looking from the present data analysis, the number of needle stick injuries per year in Taiwan caused by sharp objects used was 1168 by Hepatitis B carriers, 1200 by Hepatitis C carriers, 200 by syphilis patients and 59 by AIDS patients. Although the medical works appeared to be full of hazards, only 20% of reporting rate among all healthcare workers was estimated, which did not increase extensively from the 18% of reporting rate estimated from retrospective investigation implemented more than a decade ago. At present, a total of 36 needle-stick injuries per 1000 medical workers have been reported and only 1 medical worker per 5 needle-stick injury makes notification. This is very low comparing to certain advanced countries, such as 60-70% in USA and 50-60% in Italy. Although few doctors here also feel threatened by needle-stick injury under the medical environment during work, it was found from investigation that doctors are least willing to report the needle-stick injury. The nursing personnel still reflect greater cooperation in notification at approximately 30% of reporting rate, which is followed by approximately 27% for medical technologists and 13.6% for support personnel; however, these results are still not good enough. The reasons of not reporting could be the requirement for supervisor’s approval, time consuming, self-recognition of low infection chance or possession of antibody. By estimating with 100% of reporting rate, the number of needle-stick injuries per year over Taiwan should be 30,000, which means an average of 4 needle-stick injuries per hour. Regarding investigation of safety needle devices, if the popularity of safety needle increase 1% according to estimation from current data, the number of needle-stick injuries per year can reduce by 0.2 times. Although the NHI has provided numerous items of allowances and extended the scope of using safety needle devices, only 38 out of the 80 medical institutes under EPINet uses safety equipments. Looking from the categories, 31 out of the 80 medical institutes use vacutainer with safety needle/ lancets, 39 institutes use safety IC needles and only 1 institute uses safety syringe with needle. Since additional investigation on condition of working environment for nursing personnel under district hospitals is under implementation at present, few supervisors of the nursing personnel were approached and they expressed their greatest concern: Many HIV patients are aware of their own HIV status but not willing to receive confirmation and attend clinical consultation at one hospital regularly. Instead, such patients switch between different hospitals and in many cases, the HIV disease was only found after treatment of emergency or operation. This evidently points out that healthcare workers working in small hospitals may face much greater threats of potential infection comparing to large hospitals. The work of medical care is not as health and safe as perceived by general public, nor can the expert of medical care eliminate risk of disease fully. Therefore, we shall prevent the infectious diseases and properly address its possibility of developing into occupational disease by setting thorough measures of response.

Chairman Chen: Thanks for Professor Hsiao’s briefing and I would like to ask every one for effective use of time on discussing the topics today.

Deputy Director-General Shih of CDCDH: From the perspective of disease control, our statistical number will increase if the needle-stick incidence develops into a notifiable infectious disease. Frankly, that’s not what we want. Any excellent professional injured is a great loss to the country. If the injury develops into disability or death, the loss is even greater. With these vivid numbers, however, healthcare workers are not particularly alert or nervous; I am not sure if they feel fully confident or something else. So how do we administer the whole thing?! From the aspect of Contagious Disease Act, the Center strives to facilitate closer notification – although not enforcing. The agenda is printed with words of “thorough promotion” and I am not sure of how different are these words from “enforced promotion”. In fact, the Center for Disease Control has already promoted the concept of “thorough” progressively: We have provided a checklist under the infection control measures set according to Article 32-2 of Communicable Disease Control Act. The checklist divides needle-stick into 2 levels. Compliance with the very fundamental items will affect the future hospital assessment upon audit of infection control. The score will be higher if the performance is better, hence it is a system of precise award and punishment. The hospital has free choice on level of performance and this will surely cause use of items with higher score as supplement to items with lower score. If not for the SARS or H1N1 infection, people are quietly likely to neglect the infection control since this is a postponed process in terms of hospital operation. The same needle-stick issue is always left till the last stage to deal with, if the hospital is to implement with cost. Anyway, our effort is limited to help the medical workers. Although there is a system for promotion, the true incentive of execution does not seem enough. In that case, shouldn’t we set a law? But which aspect shall we use to set the legal regulations? Shall it be the Communicable Disease Control Act, or the occupational protection? All these are yet to be confirmed. Furthermore, some infectious diseases can be prevented with vaccine and in that regard, we regulate the hospitals to remind, persuade and protect the staff, where the person in charge of supervision surely needs to have sufficient knowledge in epidemic prevention. This involves with unequal knowledge of medical personnel, which shall be improved from medical education till pre-employment and regular occupational training, as well as health examination. In this regard, some items do require legal enforcement to regulate. Moreover, the special behavior of hospitalization from certain AIDS patients mentioned by Professor Hsiao just now did cause problems to the healthcare workers. However, people working in medical institutes must have correct mindset basically and never take chances. I think this is important.

Chairman Chen: Deputy Director-General Shih is proposing to discuss from 2 aspects, namely the enforced request for notification and methods of promoting occupational health.

Deputy Minister Chao of Bureau of Health Promotion: From the perspective of health instruction, I think each hospital has established the rule of staff pre-employment health examination, which compiles health condition of the employee before he/she enters the unit to work. As for notification procedures after the needle stick accident, many hospitals actually have such system already. Although we cannot deny that the status of execution varies from hospital to hospital, it is rather better to facilitate the existing systems into the same standard comparing to propose for legislation of enforced promotion now. This is far more helpful in practice for workers in hospitals comparing to enhance notification independently. Regarding the question from Deputy Director-General Shih on whether to commence from the infectious disease or labor safety, the needle-stick is surely an injury, but not yet a disease. Under notification for labor safety according to current law, such injury only needs to be reported when the incidence turns into major occupational accident of more than 3 people or one of the victims dies. If 2 personnel had scratch injury from falling down in the factory but put on medicine immediately, no external notification is required according to law. If independent legislation on needle-stick injury from the aspect of labor safety, the example of whether to notify the occupational accident occurred to 2 personnel in the factory shall be considered. On overall aspect of the system, common infection in hospitals has been included in the Disease Summary during recent revision. Surely, the needle-stick can also be included if it can be verified as an infectious disease. At present, the expense of needle-stick test is mostly covered by the hospital and some tests can be paid by the health insurance. If legislation will take place in future, the above mentioned shall be included to the stipulation. The enforced notification mentioned just now shall emphasize on whether the entire notification system in hospital is thorough or not, which could be far more important than whether the hospital notifies or not. If the system in hospital is thorough, adequate process can be followed. If the individual case of needle-stick is to be reported to the Government administration, the doctors from Section of Infectious Disease in hospital might feel overwhelmed or doubt the Government’s expertise. They would consider procedures of handling needle-stick incidence in hospital as unnecessary to acquire assistance from a clerk or another staff without clinical experience. There might be no problem for development in academic unit and once the procedure will become a standardized process; such system must be persuasive to each tier of personnel. As for doctors from Section of Infectious Disease or Internal Medicine in hospitals, we still need to trust them on consequent process of needle-stick incidence.

Representative Ho of TAVOI: Regarding current revision of Occupational Accident Labor Protection Law, we are trying to promote thorough notification of occupational accident. The needle-stick incidence surely needs to be notified since it is also an occupational accident. Deputy Minister Chao mentioned that needle-stick is an injury and can possibly cause disease, yet he did not agree with notifying such injury to the supervising agency. If we don’t record the cause, how can we prove the future result? If the needle-stick causes disease in future, will the absence of notification not jeopardize the right to claim against occupational accident? I think the notification is important and surely, the quantified statistics are also important; so the supervising agency can understand the importance and severeness for further improvement. Regarding charging of responsibility on needle-stick incidence, it is still necessary to compile factors over the entire structure, such as consideration of excessive work load, insufficient manpower, over-stretched working hours, different culture in each hospital, hierarchical (occupation-orientated) treatment, educational difference, performance and commercialization to healthcare workers. Since more than 40 years till now, the employers always blame the employees. Yet if we observe further into layers of structural problems, we have to doubt whether the labors are always to be blamed as stated by the employers? In fact, my main purpose today is to solve the structural problem. Although the topic is about needle-stick, this tiny problem leads us to see the structural problem, i.e. the employer wants to save cost. However, if the situation of insufficient manpower and bad equipments continue to exist, how can the efficiency be improved, so as the achievement of zero needle-stick and negligence? The false accusation and blame on victims can only be eliminated when these problems are rectified. If sick leave is required for disease generated from needle-stick, our opinion is that sick leave for occupational injury shall be granted with salary. Lastly, the work safety kit for needle-stick prevention shall be covered by the employer. If a hospital is to be established for operation, there must clear allocation in the financial distribution for budget of labor’s occupational safety rather than paying out from the health insurance. I personally think the later is very unreasonable.

Director Fu of Department of Labor Safety and Health, CLA: I think Mr. Ho just pointed out key point of the issue that mainly replies on whether the employer is willing to protect the labors or not. Although some big hospitals put most of the strengths on major items in hospital assessment and uses the scores obtained to balance out non-major items deemed by the employers. I hold different view from the DOH and I think both internal and external notification must be done. When the needle-stick incidence occurs, there must be a specific unit in hospital to accept the notification. After reception, such unit must investigate the location and hazardous degree of the infectious source. If there is hazard of infectious disease after investigation, the labor in question must receive health examination on specific items and the employer must cover and examination expense. Blood test must be adopted according to doctor’s advice together with prompt provision of preventive medication and measures, as well as record-keeping. For the external part, I've learnt a lot from studies made by Chief Hsu and Professor Hsiao of IOSH over the past few years. At present, they have established a EPINet notification system translated from overseas and a total of 80 medical institutes volunteered to join. The more data of notification, the more information we can use and this is very important for developing direction of overall policy for the nation in future. The EPINet is easy to operate and shall not cause too much burden to hospitals. Based on requirement on policy aspect, we are thinking of randomly appoint few hospitals to execute the notification and only the hospitals appointed are obliged to notify. No penalty for the first time, but the second time. The severe injury or death under Article 28 of Labor Safety Act is for checking the labor safety and not applicable for our measures. Our measure is a prevention based on Article 5, for helps us to decide our policy but not is a labor safety check.

Chairman Chen: Judging from current status of discussion, the appeal to notification does imply prevention and elimination.

Professor Judith Shu-Chu Hsiao (蕭淑銖) of NTU: One important consideration I need to remind for external notification is that after the needle-stick incidence really generates infection to healthcare workers, many hospitals would repress it and lead the healthcare workers to failure of claiming thorough rights.

Deputy Director-General Shih of CDCDH: Since there is no negligence on needle-stick, mistake only occurs when no notification is made. However, “no notification” means “no payment”. I personally think it’s more correct with payment by health insurance; because the employer will try to cover up and not notify due to no payment granted from health insurance and greater damage will occur to labors' right. Therefore, it's important to establish a positive mechanism; so personnel of proper action do not bear negligence and liability for any excuse. Person who does not notify will have to bear the consequence, which is followed by no payment, no compensation and no indemnification. The compensation for occupational accident is based on the internal notification. If this is done properly, the CDCDH will be notified if infection really happens. The national mechanism does exist and it’s only a matter of how to connect the mechanisms up.

Representative Ho of TAVOI: Obviously, the mechanism hasn’t really covered the labors’ condition. The labors would always want to maintain their working rights. When the needle-stick incidence occurs, they would wonder if the employer will apply many managing tactics against their notification. In this regard, many labors will let the small injuries be. Without the government’s support, it’s very difficult for labor to fight against the employer. I think it’s necessary to consider the issue of dominate and subordinate relationships.

Chief Chen of Bureau of Nursing and Health Services Development, DOH: Doctors are not labors and therefore not listed under labor insurance. In addition, some public servants working in public hospitals are not covered by labor insurance either and it will also be a problem in notification. If thorough promotion is to be commenced, there are still some constraints at present.

Chief Tsai of NHI: At first I would like to explain the process deciding a medical equipment should be in the health insurance or not. We have a team of experts in special materials for acknowledgement. The members include representatives from medical associations and nursing personnel, as well as experts in medical economy and medical engineering. Any revision, inclusion or elimination of payment with health insurance will be acknowledged by this team. Since 1998, the payment standard for some safety needle devices and imported items used in hospital has been loosened progressively. If the manufacturers of safety needle devices are willing to reduce the price, NHI is also willing to progressively expand the scope of using safety needle devices in hospitals. Mr. Ho mentioned about having NHI to pay for these safety needle devices and I would like to ask you all for further thoughts. Some country like Thailand with large AIDS population has used safety needle devices throughout the country. In Taiwan, the use of safety needle devices in emergency room falls within out scope of coverage. Just now, I also saw a number that verified one doubt in my mind: The NHI has introduced 30 brands of safety syringe with needle in total since 2002, but the rate of use is very low. The question now is that since the health insurance already covers this item, why are the hospitals not using it? Are there additional concerns, because the safety needle devices are 2-3 times more expensive than general syringe with needles? The use of safety IC needles shows a progressive increase every year but in very small amplitude; and the amount of other few categories is really little. We think the payment for these categories are sufficient and the problem at present seems to be hospitals’ willingness to use. Of course, the NHI will review the payment regulations again, provided the entire expense can be covered. We also hope that the manufacturers can reduce the price progressively and we will also include the items into payment progressively. We expect to achieve the best distribution.

Director Liu of National Health Research Institute: Occupational diseases involve with common law and statue law. The greatest reason of not classifying infectious disease as occupational disease was that CLA already set regulations about it. However, the Communicable Disease Control Act was better than the common law, so the occupational disease was only included via Vice-Chancellor Wu’s continuous effort at then. The same problem goes to notification now; if the standard of safety facility for biohazard already requests for notification but no provision is set in the Communicable Disease Control Act, notification will not occur in the future for sure. Yet the acknowledgement of occupational disease specifies that compensation and indemnification are only allowed if such disease is notified. I think the health administration must think of a solution for this problem.

Secretary-General Hong of Taiwan AIDS Foundation: A safe working environment is very important to healthcare workers. Although there is no negligence for needle-stick and no payment is granted for failure to notify, there are still many problems that lead nursing personnel to the decision of not to notify; because certain side effects will take place for preventive medication and it may affect the performance rating in future. One needle-stick may cause known or unknown infection of hepatitis B, hepatitis C, HIV, syphilis and the risk of infection will drive excellent personnel away or to the other occupational fields. The CLA’s biohazard measures were already approved and the NHI also said that safety needle devices with high risk of infection was already included under scope of payment, so why not apply thorough use of safety needle devices from the system? Of course, there might be elimination effect on quality and efficiency, so shouldn’t we establish a special budget other than the NHI reimbursement, which thoroughly promotes the use of safety needle devices?

Nursing Supervisor Su of Taipei Veterans General Hospital: There is danger everywhere when working in medical unit and we know all patients’ blood is infectious. The hazard of infection is not limited to conditions paid by health insurance. In this case, we hope that the medical industries can reduce the selling price and the NHI to put more thoughts on feasibility of thoroughly promoting the use of safety needle devices. Regarding notifications, the Taipei Veterans General Hospital is willing to share some experiences: All new personnel must receive the training that includes needle-stick prevention and procedures of compulsory report of needle-stick injury. Our exclusive needle-stick unit receives notifications in the labor safety room at beginning and the Infection Control deals with the test follow-up of individual cases. I personally think that on-job and pre-employment training as well as providing safety facilities to healthcare workers are the most important processes to apply. In addition, many healthcare workers might not know the rights and welfares regarding occupational accidents if no powerful promotion is implemented. In view of this, there shall be no incidence of zero notification from medical health care workers if the notification measures are thorough and complete.

Deputy Director-General Shih of CDCDH: I respond to words from Director Liu. Since the prior action against infectious disease is prevention and followed by control, more notification will be good if it can achieve prevention. The problem is that thorough notification cannot prevent needle-stick and even if yes, it only achieves indirect effect instead of direct effect. Therefore, infection cannot be prevented with notification. Regarding the control, there will be no ending if needle-stick is notified and controlled as infectious disease. We won’t have time to deal with H1N1 and this is also why needle-stick isn’t infectious disease. If prevention against infectious disease is really needed, the CDCDH is surely duty-bound. Yet there must be a mechanism for “thorough notification”, so the situation of not knowing, not wanting, not willing or afraid to notify can be eliminated first; and this can't be solved smoothly with the Communicable Disease Control Act. If the topic of discussion today clearly lies on how to thoroughly promote compulsory report of needle-stick injury, where the term “thorough” is not strictly regulated by law, what can be done? The victim of needle-stick shall feel relieved to notify without obstruction, negligence and the employer’s consent; On the other hand, the employer also need to have a channel to be educated about the employee’s work injury. Shall such mechanism be specified under certain Act or clearly stipulated for “needle-stick without negligence”, so all hospital managements understand that needle-stick is an incidence without negligence.

Vice Chancellor Wu of College of Chinese Medicine: Everyone here thinks needle-stick is very important, but does it need to be notified or not? I feel rather strange about Deputy Director-General Shih’s words just now. I think it’s fine for not implementing from Communicable Disease Control Act, because disease might not occur from needle-stick and therefore cannot be regulated under the Act. But if the implementation is made by individual, I as the victim will surely seek assistance from several attorneys and sue the hospital to bankruptcy since there is clear stipulation of “no negligence”. The so-called “needle-stick without negligence” is a theory of innocent labors and the employer has to be responsible under such situation since the labor’s injury is caused by no provision of safe working environment. As stated by Chief Tsai, more than 30 brands of safety needle devices have been provided but not used or demanded. Since the employer needs cost saving in every way under the bad economy nowadays, it’s not possible for the employer to purchase safety needle devices for employees. Under such situation, the government should request the employer certain degree of request. I personally think the request must come from the CLA since the needle-stick might not transform into infectious disease. Each governmental department has its own duties and there is overlap of adaptation between the laws. Since we have these safety equipments already, the employers shall be requested to certain degree. Of course, it’s not adequate to apply penalty at present. Instead, reward shall be offered and the government can do so by finding the key point. Regarding execution of compulsory report of needle-stick injury since 1996 but with little and slow increase in quantity, I think the 80 hospitals joined notification cooperation shall be announced, so the general public knows that healthcare workers in these hospitals are the safest. Furthermore, addition of the hospital assessment shall be considered. In the aspect of payment by health insurance, we can also consider to grant 90% for hospitals not joining the notification and 110% for the ones with duly notification.

Professor Yu-Liang Kuo (郭育良) of NTU : I think the opinion of structure from Mr. Ho just now was very correct. I attended a meeting of a big medical center and the Labor Safety Office expressed that the performance bonus for division/section with more needle-stick incidence will be reduced. I commented on the scene that such administration would cover up the truth instead of reducing the needle-stick incidence. For Topic 2, therefore, the statement should be “any needle-stick incidence shall be notified properly, but the employer may not discriminate or blame the personnel suffer from needle-stick.” We must let the employer knows about such incidence instead of blaming. However, further study is required on where to write the notification. Regarding Topic 3, I propose to include following words under the Act or Direction: “Relevant safety needle devices complied with payment rules of special material under health insurance shall be further promoted for use in different tiers of hospitals. Should infectious needle-stick occur due to absence of reasonable protection, the employer must be liable consequently.” Moreover, I would like to thank Director Fu. Although more than 100 Articles turned to 9 Articles at the end, they are still very helpful for protection of healthcare workers’ safety.

3. Consideration of respiratory infection from work

Background report by Professor Kuo: In 29 countries over the world, a total of 8422 people were infected by SARS and 21% of them were healthcare workers. In Taiwan, about 1/3 of SARS infected are healthcare workers, which accounted 1/150 of population in Taiwan; so it was derived that healthcare workers faced about 50 times of hazards greater than common public. This was the status for SARS and we don’t know about H1N1 yet, which might not seem so different with overseas, but could vary. The impact then related to infectious occupational disease. Originally, notifiable infectious disease was listed as non-occupational disease but many disputes arise after SARS, so such disease could be considered as occupational disease and it was an important milestone. However, no consequent follow-up was made because there weren’t that many infectious diseases at later stage. With the H1N1 now, BMJ wrote “Healthcare workers should get top priority for vaccination” and WHO agrees with this concept. Although many WHO policies are continuously revised along with the disease evolution, H1N1 appears to be more contagious than seasonal influenza, and frontline healthcare workers are at high risk of exposure during infectious disease outbreaks. Regarding the personal protection, the Institute of Medicine (IOM) in USA accepted consignment from CDC recently to perform a study and suggested that “healthcare workers in frequent exposure to H1N1 and similar influenza shall use qualified N95 mask or more effective protection kit verified by the government”. It was not certain to be a national policy yet, because more words were provided in the study: “One need to comprehend that there is still dispute in clinical guidance since many factors affect the setting for personal protection equipment in addition to consideration on effect of protection. The factors include economy, supply of protection equipment, availability of vaccines, status of immunity, acceptance of healthcare workers and consideration on backups”. The communicable disease network in Australia suggests that since healthcare workers differ from general public and the hazard varies, group of greater risk requires more attention. Redeployment by means of transfer may keep the healthcare workers away from highly hazardous group, but the adjustment in work has to be considered. If it’s not possible to transfer, such workers must be at least 1 m away from the contagious patient. Moreover, procedures with great hazard cannot be executed, e.g. tube passing, respiratory treatment, mucus suction, inspection on mucus and fluid samples during SARS. In addition, our policy seems not clearly define which group of healthcare workers requires special protections, where WHO has pointed out pregnant women or people with chronic diseases in respiratory passage, heart and metabolism or diabetics, overweight, unhealthy liver, kidneys, blood, nerves, neural muscle and worse immunity. We shall think of method to set adequate policy. The stress issue was mentioned just now and it was the study presented by Professor Hsiao on Nursing Ethics. During SARS period, 7.6% of nursing personnel were found of considering resignation for three major reasons: 1) The great hazard of death from SARS; 2) Many additional work procedures increase for SARS with consequent increase of work loads and stress; 3) Social factors of rejecting by friends in fear of being infected. Therefore, the entire body, mind of medical care worker and the society had to be considered instead of only considering the infection. Such consideration does not only protect the healthcare workers, but also break the infectious chain. During SARS in Hong Kong, 10 people were infected by the first patient. Among them, patient A, H, J later infected the healthcare workers in hospital and the epidemic crisis worsen extensively (Patient J alone infected 99 healthcare workers), which was a lesson we shall remember. I repeated Professor Hsiao’s words that we must face the situation where infectious disease has become occupational disease to healthcare workers. By setting the preventive measures, we can protect all authorities in safety and health, as well as keeping healthcare workers away from becoming part of the infectious chain.

Chairman Chen: Let’s discuss according to the agenda now. I would like to invite Ms. Chung-Ching Shih (施鐘卿), the Case Manager of NTUH who is closely related to the issue to address your opinion.

Chung-Ching Shih (施鐘卿), the Case Manager/HIV of NTUH: Regarding the needle-stick incident discussed just now, needleless connectors were used when I worked in the AIDS ward in past and no needle-stick happened in 10 years. Because of the price or the manufacturer was unable to supply, few needle-sticks occurred once the needleless connector were not used. Therefore, I regard this as a very typical process. In other words, if the user does not know his/her right in safety, he/she cannot ask the employer or via any channel for sufficient supply of such equipment. This actually responds to respiratory infection since it induces more severe infection, unlike the needle-stick incident; so the respiratory protection is very crucial in our works. Let me share one case happened during SARS: our first healthcare workers got infected by SARS due to patient caring at close distance. As long as the quality of protection kit is inferior or slight negligence occurs, the chance of getting SARS increases continuously. In addition, insufficient knowledge to cause of disease does create great risk. Furthermore, the issue of salary provision after 14 days of quarantine and type of leaves used during SARS to my opinion, are also the topic of right that will cause great disputes.

Chairman Chen: Regarding the leaves, since we have legal expert here, I would like to invite Mr. Lin from Legal Aid Foundation to address your opinion.

ttorney Lin from Legal Aid Foundation: According to what I heard, that doctors are not applicable to the Labor Standards Law, neither are the lawyers. As far as I understand, the CLA is reviewing on the consideration of including lawyers into the Labor Standards Law. In other words, the employees are meant to be protected by the Law and for the doctors comparatively, I would say doctors shall also be included under the protection of Labor Standards Law. This part may involve with discussion that needs participation of representatives from industrial unions for joint contribution. Another part is related to the insurance. The premise of medical work causes occupational accident or disease such as needle-stick or infection to the healthcare workers might not be covered by health insurance fully, or not only covered by labor insurance. In addition to establishment of notification system, there might still be a mechanism of enforced insurance. If there is precise proportion on needle-stick, then the insurance policy shall be able to calculate. If each medical institute needs to notify and accept enforced insurance, some portions could be reflected. In other words, certain amount from the insurance is used to buy the safety equipment and reduces the proportion of needle-stick. Regarding the notification system, if there is no clearer law, would there be different result between large hospital and small clinics? In other words, would the notification mechanism for small clinics cause many un-notified cases? With the above statement, I am all ears to your comment.

Chairman Chen: Mr. Lin mentioned about insurance and it was less considered by everyone. In fact, insurance does relate to the medical negligence. In Taiwan, the medical disputes always turn vigorous because there is no such insurance, so the doctor has to face the problem personally. There is slight problem about the concept of “without negligence” because it actually refers to consequence in spite of negligence. Since the disease or other incident gets very complicated, there is no way to judge the relevance, but the result has already occurs. In this regard, the risk shall be share by everyone via insurance to reduce the impact and the NHI shall not be requested directly for payment since the incident is an accident. In fact, lots of thoughts are involved on this matter. The healthcare workers have to pay premium first when entering the workplace, so as the employer. Once the medical dispute occurs, such insurance will pay off and no worry is needed in this way. For example, when the doctor already contributes utmost effort in certain medical dispute but the result is still not as expected, and the family member will fight for the money, which creates a very special relationship between doctors and patients in Taiwan. The insurance mentioned by Mr. Lin is based on such concept, but only bigger.

Doctor Fang as Executive Secretary of Institute of Infectious Disease, NTU: I think there is mutual understanding on providing medical personnel with adequate protection equipment in the aspect of respiratory infection. Of course, there won’t be incidence of not allowed to use the equipment with knowingly TB or influenza. The bigger question is the consideration on leaves for infected healthcare workers with symptoms, which mainly relies on the mindset of hospital management. Most of these managers did not major in infectious disease and therefore can’t assess the status. If the medical care worker with symptoms needs day-offs for rest, the first thing comes to the manager’s mind is insufficient manpower. When we held internal meeting of infection control, one of the Directors addressed that “I have only 2 resident doctors of 2nd year on shifts. If one of them has fever, my manpower will be insufficient and unable to satisfy the social needs; what can I do?” Therefore, there is naturally a strong thought of keep working as long as the doctor still has strength. In fact, this will cause tremendous hazard to medical personnel and lost of control towards nosocomial infection. From perspective and acknowledgement, a general education is needed. All personnel throughout the tier under Superintendent to each unit must understand that subordinate on fever have to be quarantined immediately and treated with medication that is best to be given within few hours of the symptom, no matter if it is TB, SARS or influenza. This is very helpful for reducing consequent problems and the conceptual correction is even more important.

Chief Hsu of IOSH: I’d like to return to the needle-stick issue since it’s relevant with the Institute. After summing up opinions of all participants here, I will discuss with Professor Hsiao later on how to offer consequent rewards to hospitals participated the system and propaganda of “without negligence”. Actually, we have invited Professor Hsiao to start with some teaching material this year for nursing students in school. As for whether to apply internal or external notification, the main idea is to ensure consequent process for healthcare workers who got needle-stick, which is expected to prevent needle-stick incidence in future. Regarding records in writing, if we can achieve internal notification, it’s not a point to make internal or external notification. However, one advantage for external notification is that the statistics of needle-stick rate can be used to compare with other hospitals to improve precaution on prevention and performance management. Furthermore, if all hospitals execute the notifications, the hospitals with higher rate of notification can learn from the one with lower rate, which is encouraged. Actually, the external notification offers an opportunity for everyone to learn. Back to the respiratory infection, every one must wear protection kit in hospital, but correct methods of wearing it and coherence are very important. From SARS, the general public and personnel have learnt the lesson; now people know that mask must be worn if having flu. With this popularity of correct concept, the hygienic habit shall be put into practice as well; for example, how often must the doctor’s work uniforms be washed? Where should the doctor wear or not wear work uniforms?

Chairman Chen: When I go to the basement of NTUH for meal, I see doctors in their white robe or uniform directly from operation room. I recall my visit to Tokyo University last year, where they have a restaurant in the hospital. I saw no one in doctor’s uniform, because there was a room provided next to the restaurant for storing the doctor’s uniform. In other words, the doctors always took off the work uniform and stored them in that room before entering the restaurant. Such a simple measure really removed people’s worry about hygiene. Taiwan shall re-emphasize this since it’s a very important measure for safety. With a food court established in basement and you enter the premise in doctor’s uniform, people would wonder whether you are clean or not! A study in UK pointed out that ties are really not helpful to doctor’s work. Although the hospital requests doctors to wear ties for professional image, ties are actually quite dirty.

Nursing Supervisor-Mrs. Su of Taipei Veterans General Hospital: In our hospital, the unit with highest rate of compulsory report of needle-stick injury is rewarded and the Nursing Department always wins this reward. During the performance assessment, it’s always emphasized not to degrade personnel with official leave, funeral leave or any other leave of irreversible nature. In other words, if certain staff always shows great performance, he/she will not be degraded for having the mentioned leaves.

Deputy Director-General Shih of CDCDH: Since words from Professor Kuo still related a lot to the CDCDH, I respond briefly. Firstly, H1N1 is not SARS but pandemic. In other words, every occupation is under great risk and there is no evidence to show greater risk on doctors yet. Judging from 292 patients confirmed with severe illness, there seem to be no theoretical number of 2 patients from healthcare workers as 1/150 of population. Does that mean doctors are stronger, infected with mild symptoms, or difficult to be infected because of the elder age? Anyway, the current evidence doesn't show that H1N1 is more severe to doctors and there might be third wave of future pandemic in fall, winter this year or next year; we’ll just have to wait and see and maybe collect some data for analysis. However, we can be certain that H1N1 is definitely not SARS. For preventive measures against respiratory infection in hospitals secondly, we have set relevant standards for needle-stick during SARS period and there were lots of questions, including the food court at basement mentioned just now. If I remember correctly, the regulations now forbid patients’ presence in such premise wearing patient clothes, but I’m not sure if doctor's uniform is also restricted. Thanks for Professor Chen’s opinion and I will check again. Both doctor and nurse’s uniforms are not allowed in food court. But nurses have to change clothes, right? But it’s troublesome to do so if the work is busy. Even if this is for the sake of infection control, everyone would want to save the trouble and therefore created many blind spots. I don’t think we need to execute penalty on this and some propaganda for restricting doctor and nurse’s uniforms, as well as patient clothes will be sufficient. In our roles, we should question that and when the public stop dinning at food court for hygiene concern, there will be improvement naturally. I agree with Vice Chancellor Wu for encourage or set adequate mechanism to adapt the situation. In addition, if the insurance gets listed as Class I notifiable infectious disease where injury, death, severe disableness, disableness and severe condition to medical workers caused by infection, I think the relevant compensation for death is NT$ 10 millions and set after SARS. H1N1 was allocated under Class I at the beginning and now re-allocated to Class IV. It might be allocated to other Class depending on the disease. If the virus become more severe and the death rate is estimated at 0.1 to 0.04, such disease might not be allocated to Class I since the death rate is even lower than the seasonal flu. If there is mutation after the winter and the death rate become higher than normal season, e.g. higher than 2% in Mexico at beginning of its epidemic situation, then the matter has to be re-considered urgently. If medical personnel do face greater risks than the general public, there will be some mechanism and executed immediately. The medical personnel do not need to worry too much about this, but that doesn’t guarantee for risk-free environment absolutely. As Chief Hsu said just now, the protection equipments must be used properly, so safety can be ensured. After SARS, we regulated that each hospital must maintain sufficient inventory or penalty will be executed.

Director Fu of Department of Labor Safety and Health, CLA: Regarding safety equipments, we have not set specific article. We have need for environmental protection but there seems to be great dispute related to cost. My concern divides into two directions: Firstly, the mechanical equipment internationally includes C MARK from Europe with design concept of zero injury to the dumbest worker. In the past, we applied the concept of “zero-accident” from Japan and covered 60-70% of risks. The remaining 30-4% of risks were borne by the site workers; but these workers would receive many training and apply each step properly, hence the rate of accident was very low but that was then. The workers nowadays do not follow the rules and they are less skilled, so the rate of mechanical damage increases rapidly. At the end, the plan of zero accident became a failure. Nowadays, the concept of zero hazard from Europe is more popular; so certain ISO, safety designs and technology from EU have been transferred to Taiwan. Recent discussion from international health and safety trend pointed out that equipment capable of production with zero hazard shall be applied as much as possible. Let’s see if the NHI can apply this concept also! If this is still not possible due to limited finance or resources, we can share the risk and start from more hazardous area – although this is not correct enough. In view of this, we need data to evaluate the risk and determine the priority. Apparently, there is no such data in Taiwan at present. Shouldn’t we establish a database and notification mechanism, so the system can be commenced. Otherwise, the whole thing will stay unclear and no action can be done without notification and judgement.

Deputy Minister Chao of Bureau of Health Promotion: In Labor Insurance, the notifiable infectious disease is not listed as occupational disease; meaning that if a labor in factory or service industry gets infected by TB colleague, such disease cannot be listed as his/her occupational disease. Nowadays, the Bureau of Labor Insurance has listed most of the notifiable infectious diseases as occupational diseases applicable to healthcare workers and environmental personnel dealing with medical waste. For other factories and the service industry, there is another mechanism to deal with notifiable infectious disease infected between colleagues. If healthcare workers and environmental personnel dealing with medical waste get infectious disease not listed or not notifiable according to the category of occupational disease, there is still another in-depth assessment can be executed. Furthermore, rewards shall be considered from the aspect of mechanism together. Whether in the Taipei Veterans General Hospital, Mackay Memorial Hospital or Changhua Christian Hospital, thorough mechanism of notification procedure and consequent process have been established since more than 10 years ago for internal notification of needle-stick incidence and even the pre-employment health examination mentioned earlier. I believe that they even have the internal statistics. So rewards to these hospitals can be considered and thorough mechanisms shall be considered first.

Representative Ho of TAVOI: In consideration of infectious occupational disease firstly, labors shall be allowed to participate in decision of establishing safety facilities in workplace, so they know what they will use. According to our experience, the employers often purchase cheaper equipments for the employees and disregard the ones with better quality. There seems to be no supervising organization on equipments in medical institutes at present and this sets the greatest concern. Secondly, the cases of respiratory infection at work increase and generate much mental stress to the worker, which may even lead to melancholia on occupational disease. We suggest that mental health shall be included under the consideration for health and safety, so these workers can be guided and relieved. Thirdly, there should be no problem on leaves for workers with symptoms as occupational accident; but such worker will face another problem before taking the leave, i.e. is this an occupational accident or not? If the worker gets H1N1, how do we determine whether the infection occurs at work or during shopping? Legally speaking, the Occupational Accident Labor Protection Act specifies that the employer must still offer sick leave during the period in dispute till issuance of doctor’s assessment on occupational disease. If the infection occurs at work, the leave is converted into occupational sickness leave.

Vice Chancellor Wu of College of Chinese Medicine: I am reminded about the special meeting with the Ministry of Education few days ago on changing the order of vaccination. During discussion, the schools nurses were proposed to receive vaccine at first order since they need to take care of the students. What about the factory nurses, since they also look after health of personnel over the entire factory? Therefore, I propose to include the factory nurses into consideration.

Chairman Chen: Although many opinions have not been expressed today, we need to dismiss the meeting due to time constraint. Should you wish to express more, please do so in our consequent written draft, thank you all.

Center of Medical Employee Safety and Health
Address: Room 307, No. 2-1, Xuzhou Rd., Zhongzheng District, Taipei City 10055
http://www.cmesh.org.tw/
Email: cmesh@cmesh.org.tw
Tel.: (02) 2394-7740
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