Mercy Hospital Medical Staff Credentialing Manual - Mercy Health

CREDENTIALING MANUAL REVISED AND APPROVED BY THE BOARD OF DIRECTORS JANUARY 24, 2008Medical/Allied Health Professional Staff Members (practitioners and specified health personnel)are required to undergo PPD Testing or show evidence of testing as outlined in the surveillanceguidelines. A letter notifying them of the need for health exam and PPD testing will be sent bythe Central Credentialing Office on a yearly basis.The charge for the annual PPD testing will be incurred by Medical Health Partners if MercyEmployee Health is utilized. Further follow-up testing/treatment will be the responsibility of theMedical/Allied Health Professional Staff Member.Follow-up of positive PPD testing will be coordinated through the Medical Director ofEmployee Health Services and the Chief of Staff.TUBERCULOSIS SURVEILLANCE PROGRAM FOR HEALTH CARE WORKERSI. GENERAL GUIDELINESA. BASELINE TESTING1) All Medical Staff/Allied Health Personnel in the Maternity Unit,Cardiac Cath Labs and Radiation Oncology Departments will be skintested annually for TB using the Mantoux Method of intradermalinjection of PPD (purified protein derivative).2) All Medical Staff/Allied Health Personnel who receive BCG vaccinewill be included in the screening process to establish a baseline. Theywill be given the option to receive a PPD skin test or have a chest x-ray.3) A Medical Staff/Allied Health Professional staff Member who presentsas a known positive TB reactor will be exempt from PPD testing. AllMedical Staff/Allied Health members with a history of a Positive PPDreaction will have a chest x-ray as part of the baseline TB SurveillanceProgram and will be assessed for signs and symptoms of active TB. Arepeat chest x-ray will be necessary only if signs and symptoms of TBOccur.4) When a skin test conversion, abnormal chest x-ray or signs/symptomsof TB occur, directions on how to proceed can be found in theemployee health departments.5) Evidence of no active TB will be based on one of the following:a. Negative PPD skin testb. Known positive PPD Skin Test and absence of clinical signs andsymptoms of active TBc. Newly converted positive PPD skin test with radiologist’sverification of normal chest x-ray.B. ANNUAL PPD SKIN TESTINGEvidence of annual PPD skin testing will be required of all practitioners who have privileges inthe maternity units, cardiac cath laboratories and Radiation Oncology Departments. AllPPD skin testing must be administered and read by a Health Care Professional who has been32