Strategies to prevent infections in patients have typically focused on preventing the transfer of pathogenic organisms from environmental surfaces, equipment, and the hands of home care and hospice staff. But what about when home care and hospice staff come to work sick with a potentially communicable illness? This topic was recently studied by Szymczak et al. (2015) by asking physicians and advanced practice providers to complete an anonymous survey on whether they have gone to work while "sick" and experiencing symptoms. More than 80% of the respondents had worked with patients while sick and would work with symptoms of a contagious illness, such as fever, diarrhea, and acute respiratory tract symptoms, yet 95.3% of the respondents believed that working while sick put patients at risk. Despite this belief, 83.1% reported working sick at least one time in the past year. The reasons for working while sick included: not wanting to let colleagues or patients down, fear of ostracism by colleagues, staffing concerns, and concern about continuity of care. Other reasons included extreme difficulty in finding coverage, a strong cultural norm to work unless remarkably ill, and not being clear about what constitutes being "too sick to work." These factors created a climate in which the respondents perceived they had no choice but to work while sick, despite recognizing that this choice put patients at risk (Szymczak et al., 2015). Even though this study was conducted at a large children's hospital, the candid responses obtained in this survey may be consistent with healthcare professionals working in other care settings, including home care and hospice.

Going to work while sick with an illness that could be transmitted to others places both the patient and other staff at risk for infection. When staff members are exposed to a communicable illness, their becoming sick would create a cumulative effect of fewer "well" staff being available to make home visits and patient visits being subsequently delayed or even missed. Being exposed to infectious diseases from patients is expected, and staff members mitigate these risks by implementing infection prevention and control strategies, but staff members don't plan for, or expect to be, exposed by peers.

Frequent exposures to potentially communicable diseases are an occupational hazard for home care and hospice staff, and as such, the home care and hospice organization should have nonpunitive, flexible sick leave policies. The policies should:

* Identify when a staff member with a suspected or confirmed communicable illness should not work;

* Identify when a staff member that had a communicable illness may return to work;

* Not require staff to obtain a physician's note to validate their illness or approve their return to work for influenza (Centers for Disease Control and Prevention, 2013) and other communicable illnesses as defined by the organization; and

* Be communicated to all staff, including contracted staff who make home visits.

Infection control strategies should also be developed and implemented to minimize the risk that pathogenic organisms will be transmitted from staff to patients, and between staff. If the staff member is at work and develops symptoms of an infection that can be transmitted to others, he or she should don a face mask if experiencing respiratory symptoms, and promptly contact a supervisor to review the clinical signs and symptoms, and obtain further instructions. If instructed to not work, the staff should be educated to stay at home, except to get medical care, and away from others as much as possible to prevent transmission. Staff with respiratory infections may often have lingering respiratory symptoms, such as a cough, and wearing a mask when in close contact with the patient and others may be an option to consider to maintain productivity and continuity of care while reducing the risk for transmission.

For staff providing care in the home setting, exclude staff from work:

* For a minimum of 48 hours after the resolution of symptoms of acute gastroenteritis (vomiting, watery, nonbloody diarrhea with abdominal cramps, and nausea) (MacCannell, 2011).

* Until at least 24 hours after the staff no longer has a fever (without the use of fever-reducing medicines, such as acetaminophen).

Many staff who do not qualify for health benefits and do not have paid sick time (e.g., staff working on a per visit basis) may work while sick to not lose income. For staff who cannot control their "symptoms," but may feel well enough to work (and do not want to call in sick from work), alternative strategies should be considered to maintain continuity of care and staff work productivity. Examples include (depending on the role of the staff or management): working off-site and logging into an electronic heath record to conduct clinical record audits, case managing and coordinating care and scheduling staff off-site, logging into an e-mail system to communicate with staff, or participating in case conferences or meetings via telephone or videoconference. When the staff members return to work, remind them of the need to:

* Adhere to respiratory hygiene and cough etiquette.

* Perform frequent hand hygiene, especially before and after each patient contact and contact with the nose or respiratory secretions.

A person permitted access to the staff's personal health information should be identified, and if permitted, monitor and track the reasons why an employee called off of work when related to a communicable illness. If three or more staff members report the same symptoms of a communicable illness on the same day, this may indicate an outbreak. Additional actions should be taken, as needed, to limit the exposure of other staff members and patients through infection prevention and control strategies (McGoldrick, 2015).

Home care and hospice employees often work under "less than desirable" situations and overall are a strong, dedicated group of individuals. As such, staff may have a tendency to "buck up" and go to work even when not feeling 100% and have symptoms of a communicable illness for a number of reasons. For the sake of your patients and colleagues, think twice before going to work sick and look into "alternative" ways to continue working without putting others at risk.

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