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Ask the Expert
| Author: Dr. Sheila Dunn |
| Article Date: 11/1/2007 |
Flu Shots for Staff
Q. I'm having a problem getting some of our employees to take the flu vaccine. WhatÕs the percent of healthcare workers nationwide that get vaccinated?
A. Last year, only 42% took the vaccine, presumably due to lack of awareness by healthcare workers that they are among the groups needing to be vaccinated; lack of access to vaccine; cost; and the misperception that influenza is not a serious disease.
Make the vaccine free and offer it at a convenient time. If workers balk, remind them that while the flu may be an inconvenience for them, it can be life-threatening to elderly and very young patients, so for that reason alone, they should be vaccinated. Annually, flu causes 200,000 hospitalizations and 36,000 deaths.
Also, visit 'www.cdc.gov/flu/professionals/flugallery' for a full array of educational materials, including a free poster directed at nurses called, 'They count on you to get an influenza vaccine every year.'
Test for Pink Eye
Q. I'm interested in a test kit called Adeno DetectorŹfor conjunctivitis. Is it CLIA-waived? What is the CPT code and Medicare fee cap?
A. Similar to a strep or pregnancy test, this test for adenovirus test is CLIA-waived and provides a definitive result within 10 minutes. By differentiating bacterial from viral conjunctivitis, physicians can help reduce ocular antibiotic resistance and limit the spread of contagious viral conjunctivitis. A new CPT code (effective 1/2008) is 87809 with a Medicare fee limit of $16.76.
Tracking Down HBV Records
Q: One of our employees was previously vaccinated for HBV but doesn't have any documentation. What do I do now?
A: Track down the employee's actual record by contacting their previous employer where the vaccination was administered. Since it's a requirement for employers to maintain hepatitis B vaccination records for the duration of employment plus 30 years, a previous employer who administered the vaccine should have copies of those records. If the records are truly impossible to locate (e.g., the person was employed by a facility that is no longer in business or is overseas), offer the employee the hepatitis B vaccine again, then perform a titer after the series. Alternatively, the employee could sign the hepatitis B vaccine declination form.
CLIA Waived Chemistry Tests
Q. I'm interested in doing chemistry panels in our office, but want to remain CLIA waived. What instruments might work?
A. First, determine exactly what tests you need. For instance, if you want to screen for and monitor those with heart disease, you will need both lipid and liver panels, so instruments such as the Cholestech LDX or the Abaxis Piccolo may fit the bill.
If you want a general chemistry panel, including from 6-13 tests, then either the Abbott I-STAT or the Abaxis Piccolo would be ideal, although the I-STAT is positioned more toward the acute care setting. (See Table Below)
Also, there are other CLIA-waived tests considered 'chemistry' tests, such as A1c and BNP that are only available on individual CLIA-waived instruments, such as the Seimens DCA2000 and the BioSite Triage. So, to select the best analyzer(s) for your needs, first determine which diseases you want to detect or monitor and work backward from there. Another idea is to look at the tests you routinely send out, and try and match that up with the CLIA-waived tests cartridges offered by the companies below.
CLIA Waived Chemistry Panels
Disinfectant Contact Times
Q. One of the physician offices in our building had an OSHA inspection and was cited because of the 'contact time' for the disinfectant they used for their countertops. Can you explain please, how they violated OSHA regs?
A. What I suspect happened is that the OSHA inspector asked a worker what the contact time was for the disinfectant she was using, and she didnÕt know. The contact time is the length of time the disinfectant must remain wet on the surface to kill pathogens, such as HIV or TB. Contact times range up to 30 minutes and are clearly stated on the label. The shorter the contact time, the more attractive the disinfectant, because theyÕre generally used in exam rooms between patients, and you wouldn't want to keep an exam room empty for 30 minutes between patients, right? Just be sure that you know what the contact time is for the disinfectant you use, because if you donÕt abide by it, OSHA'll fine you big time.
Lab Reagents
Q. We just had our CLIA inspection and were told that we had to validate each control before using it. This is our third CLIA inspection, but itÕs the first time IÕve ever heard of this requirement. This has me stumped. We use assayed controls Š whatÕs there to validate? If this is really a new CLIA requirement, how do we go about complying?
A. It's true that CLIA inspectors now require labs to validate new lot number of controls, not every vial of control thatÕs opened. Because of this, it makes sense to change to new lot numbers of controls as infrequently as possible, so work with your distributor to sequester lot numbers of controls for you.
To validate a new lot number of control material, just open it before the old lot number expires, and run it up to 20 times to be sure that it meets the manufacturer's specifications before beginning to use it for patient testing. Both assayed and unassayed controls fall under this requirement.
This issue has recently emerged because CLIA inspectors are finally issuing citations for violations of the 'final, final' CLIA regulation, which went into effect in 2004. They let labs slide for two inspection cycles, issuing only educational suggestions, but now they're playing hardball. I personally think this is a silly requirement for assayed controls, and it hangs with me like a bad burrito, but if you can stock up on controls to the extent that you only change lot numbers every couple of years, it wonÕt be so bad!
Superbugs Coming to a Doctor's Office Near You
Q. Do you have any nationwide guidelines on exactly what an outpatient facility should be doing to stop the spread of MRSA? ItÕs been all over the headlines lately and I'm wondering if we need to begin doing anything differently to protect patients and employees in an outpatient setting.
A. Methicillin resistant staph aureus, or MRSA, has made headlines recently for two main reasons. First, four student died: a preschooler in Salisbury, N.H.; an 11-year-old in Vancleave, Miss.; a 12-year-old in Brooklyn, N.Y.; and a 17-year-old in Bedford, Va. Second, the superbug made headlines again when Medicare declared that beginning in 2008, payments wouldn't be made for hospital patients' complications from MRSA, because they didnÕt come into the hospital with the infection! Hospitals are going nuts looking for ways to screen patients before admission to prove that an MRSA infection wasnÕt acquired in the hospital, to ensure Medicare payments for any MRSA complications that arise.
CA-MRSA, or 'community associated' MRSA, often presents in the doctor's office as a bump on a patient's extremity resembling a spider bite, and the infection is transmitted from these uncovered skin infections. MRSA is difficult to eradicate because it requires vigilant hand hygiene and high-touch surface disinfection. Our company, Quality America offers a free white paper on our Website that you can print off that answers everything physician offices need to know about the MRSA menace: What exactly is it? How is it transmitted? What types of patients have MRSA and how should they be treated? What can healthcare workers do to protect themselves? And what should practices do when healthcare workers do become infected with MRSA?
Patient Blood Specimen Radioactive?
Q. WeÕve been told that when a patient has a bone scan injection (radioactive) it is not safe to draw the patientÕs blood or handle their urine. What is the time that should elapse before drawing or handling a specimen? We've questioned the nuclear medicine department and they donÕt see a problem with immediate exposure, but when we questioned another nuclear med tech she was sure immediate exposure was not safe (especially for lab techs of child bearing age). What are your thoughts on this?
A. Most nuclear medicine studies are done with Technetium 99m, and in the unlikely event that a patient is injected for a bone scan and blood is immediately drawn, a phlebotomist holding a 10 cc tube continuously until it decayed away would receive a hand dose that would be less than 1% of the annual dose limit. So, we agree with your nuclear medicine department.
Q. I'm having a problem getting some of our employees to take the flu vaccine. WhatÕs the percent of healthcare workers nationwide that get vaccinated?
A. Last year, only 42% took the vaccine, presumably due to lack of awareness by healthcare workers that they are among the groups needing to be vaccinated; lack of access to vaccine; cost; and the misperception that influenza is not a serious disease.
Make the vaccine free and offer it at a convenient time. If workers balk, remind them that while the flu may be an inconvenience for them, it can be life-threatening to elderly and very young patients, so for that reason alone, they should be vaccinated. Annually, flu causes 200,000 hospitalizations and 36,000 deaths.
Also, visit 'www.cdc.gov/flu/professionals/flugallery' for a full array of educational materials, including a free poster directed at nurses called, 'They count on you to get an influenza vaccine every year.'
Test for Pink Eye
Q. I'm interested in a test kit called Adeno DetectorŹfor conjunctivitis. Is it CLIA-waived? What is the CPT code and Medicare fee cap?
A. Similar to a strep or pregnancy test, this test for adenovirus test is CLIA-waived and provides a definitive result within 10 minutes. By differentiating bacterial from viral conjunctivitis, physicians can help reduce ocular antibiotic resistance and limit the spread of contagious viral conjunctivitis. A new CPT code (effective 1/2008) is 87809 with a Medicare fee limit of $16.76.
Tracking Down HBV Records
Q: One of our employees was previously vaccinated for HBV but doesn't have any documentation. What do I do now?
A: Track down the employee's actual record by contacting their previous employer where the vaccination was administered. Since it's a requirement for employers to maintain hepatitis B vaccination records for the duration of employment plus 30 years, a previous employer who administered the vaccine should have copies of those records. If the records are truly impossible to locate (e.g., the person was employed by a facility that is no longer in business or is overseas), offer the employee the hepatitis B vaccine again, then perform a titer after the series. Alternatively, the employee could sign the hepatitis B vaccine declination form.
CLIA Waived Chemistry Tests
Q. I'm interested in doing chemistry panels in our office, but want to remain CLIA waived. What instruments might work?
A. First, determine exactly what tests you need. For instance, if you want to screen for and monitor those with heart disease, you will need both lipid and liver panels, so instruments such as the Cholestech LDX or the Abaxis Piccolo may fit the bill.
If you want a general chemistry panel, including from 6-13 tests, then either the Abbott I-STAT or the Abaxis Piccolo would be ideal, although the I-STAT is positioned more toward the acute care setting. (See Table Below)
Also, there are other CLIA-waived tests considered 'chemistry' tests, such as A1c and BNP that are only available on individual CLIA-waived instruments, such as the Seimens DCA2000 and the BioSite Triage. So, to select the best analyzer(s) for your needs, first determine which diseases you want to detect or monitor and work backward from there. Another idea is to look at the tests you routinely send out, and try and match that up with the CLIA-waived tests cartridges offered by the companies below.
CLIA Waived Chemistry Panels
Disinfectant Contact Times
Q. One of the physician offices in our building had an OSHA inspection and was cited because of the 'contact time' for the disinfectant they used for their countertops. Can you explain please, how they violated OSHA regs?
A. What I suspect happened is that the OSHA inspector asked a worker what the contact time was for the disinfectant she was using, and she didnÕt know. The contact time is the length of time the disinfectant must remain wet on the surface to kill pathogens, such as HIV or TB. Contact times range up to 30 minutes and are clearly stated on the label. The shorter the contact time, the more attractive the disinfectant, because theyÕre generally used in exam rooms between patients, and you wouldn't want to keep an exam room empty for 30 minutes between patients, right? Just be sure that you know what the contact time is for the disinfectant you use, because if you donÕt abide by it, OSHA'll fine you big time.
Lab Reagents
Q. We just had our CLIA inspection and were told that we had to validate each control before using it. This is our third CLIA inspection, but itÕs the first time IÕve ever heard of this requirement. This has me stumped. We use assayed controls Š whatÕs there to validate? If this is really a new CLIA requirement, how do we go about complying?
A. It's true that CLIA inspectors now require labs to validate new lot number of controls, not every vial of control thatÕs opened. Because of this, it makes sense to change to new lot numbers of controls as infrequently as possible, so work with your distributor to sequester lot numbers of controls for you.
To validate a new lot number of control material, just open it before the old lot number expires, and run it up to 20 times to be sure that it meets the manufacturer's specifications before beginning to use it for patient testing. Both assayed and unassayed controls fall under this requirement.
This issue has recently emerged because CLIA inspectors are finally issuing citations for violations of the 'final, final' CLIA regulation, which went into effect in 2004. They let labs slide for two inspection cycles, issuing only educational suggestions, but now they're playing hardball. I personally think this is a silly requirement for assayed controls, and it hangs with me like a bad burrito, but if you can stock up on controls to the extent that you only change lot numbers every couple of years, it wonÕt be so bad!
Superbugs Coming to a Doctor's Office Near You
Q. Do you have any nationwide guidelines on exactly what an outpatient facility should be doing to stop the spread of MRSA? ItÕs been all over the headlines lately and I'm wondering if we need to begin doing anything differently to protect patients and employees in an outpatient setting.
A. Methicillin resistant staph aureus, or MRSA, has made headlines recently for two main reasons. First, four student died: a preschooler in Salisbury, N.H.; an 11-year-old in Vancleave, Miss.; a 12-year-old in Brooklyn, N.Y.; and a 17-year-old in Bedford, Va. Second, the superbug made headlines again when Medicare declared that beginning in 2008, payments wouldn't be made for hospital patients' complications from MRSA, because they didnÕt come into the hospital with the infection! Hospitals are going nuts looking for ways to screen patients before admission to prove that an MRSA infection wasnÕt acquired in the hospital, to ensure Medicare payments for any MRSA complications that arise.
CA-MRSA, or 'community associated' MRSA, often presents in the doctor's office as a bump on a patient's extremity resembling a spider bite, and the infection is transmitted from these uncovered skin infections. MRSA is difficult to eradicate because it requires vigilant hand hygiene and high-touch surface disinfection. Our company, Quality America offers a free white paper on our Website that you can print off that answers everything physician offices need to know about the MRSA menace: What exactly is it? How is it transmitted? What types of patients have MRSA and how should they be treated? What can healthcare workers do to protect themselves? And what should practices do when healthcare workers do become infected with MRSA?
Patient Blood Specimen Radioactive?
Q. WeÕve been told that when a patient has a bone scan injection (radioactive) it is not safe to draw the patientÕs blood or handle their urine. What is the time that should elapse before drawing or handling a specimen? We've questioned the nuclear medicine department and they donÕt see a problem with immediate exposure, but when we questioned another nuclear med tech she was sure immediate exposure was not safe (especially for lab techs of child bearing age). What are your thoughts on this?
A. Most nuclear medicine studies are done with Technetium 99m, and in the unlikely event that a patient is injected for a bone scan and blood is immediately drawn, a phlebotomist holding a 10 cc tube continuously until it decayed away would receive a hand dose that would be less than 1% of the annual dose limit. So, we agree with your nuclear medicine department.