/policies/,/policies/clinical/,/policies/clinical/uw-health-clinical/,/policies/clinical/uw-health-clinical/infection-control/,

/policies/clinical/uw-health-clinical/infection-control/419.policy

201607204

page

100

UWHC,UWMF,

Policies,Clinical,UW Health Clinical,Infection Control

Healthcare Worker with Bloodborne Pathogen Infection (4.1.9)

Healthcare Worker with Bloodborne Pathogen Infection (4.1.9) - Policies, Clinical, UW Health Clinical, Infection Control

4.1.9


UW HEALTH CLINICAL POLICY 1
Policy Title: Healthcare Worker with Bloodborne Pathogen Infection
Policy Number: 4.1.9
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: July 21, 2016

I. PURPOSE

To provide guidance for assessing and minimizing the risk of occupational transmission of bloodborne
pathogens from an infected healthcare w orker to patients.

II. DEFINITIONS

Bloodborne Pathogen (BBP): For the purposes of this policy, the term bloodborne pathogens w ill refer
specif ically to HIV (human immunodeficiency virus), HBV (hepatitis B virus) , and HCV (hepatitis C virus).

Healthcare w orker (HCW): All paid or unpaid persons w orking in a healthcare setting w ho have direct
contact w ith patients, or the potential for exposure to infectious patient materials including blood, body f luids,
tissues, or items soiled w ith these patient materials.

Exposure-prone invasive procedure: Any procedure in w hich there is simultaneous presence of the HCW's
digits and a needle or other sharp instrument or object in a poorly visualized or highly confined anatomic
site. Exposure-prone invasive procedures include, but are not limited to: intra-abdominal and colorectal
surgery, intra-thoracic surgery, including cardiac surgery, major orthopedic surgery, major gynecological
surgery, caesarean and vaginal deliveries requiring suturing, surgery in the oral cavity, and digital palpation
of a needle tip in a body cavity.

III. POLICY ELEMENTS

A. HCWs infected w ith BBPs are ethically responsible and strongly encouraged to provide this medical
information to Employee Health Services (EHS) so that risk reduction strategies, counseling, and support
may be offered.
B. HCWs w ho perform exposure-prone invasive procedures, as defined in section II of this policy, w ho are
infected w ith a BBP infection are required to obtain testing to determine the viral load of the infection. An
expert review panel w ill be convened to assess risks and recommend risk reduction strategies .
C. All protected medical information, including BBP test results from HCWs, w ill be kept in strict confidence.
D. The HCW w ith BBP infection, as w ith any other potentially transmissible illness, w ill be managed under the
provisions of UWHC Administrative policy #9.22 Fitness for Duty - Health Service Clearance to Return to
Work/Continue Work.
E. HCWs w ho do not perform exposure-prone invasive procedures, as defined in section II of this policy, are
unlikely to present a BBP infectious risk to patients under normal conditions provided that they routinely
follow Standard Precautions. No specif ic restrictions or testing requirements are w arranted for these HCWs
regardless of BBP infection status.
F. Immediate intervention w ill be taken by EHS in order to provide medical follow -up in the event of know n BBP
exposure events (percutaneous injuries and mucocutaneous exposures to blood or other body f luids) , and
by Infection Control should epidemiologic evidence suggest that BBP infection in a patient, or cluster of
patients, has an iatrogenic source.

IV. PROCEDURE

A. All bloodborne pathogen exposure events (percutaneous injuries and mucocutaneous exposures to blood or
other body f luids) involving exposure of a HCW or a patient must be immediately reported so that
appropriate follow -up can be provided, as detailed in UWHC Administrative policy #9.28, Management of
Biohazardous Injuries.
i. The follow ing must occur to ensure completeness of follow -up if a patient suffers signif icant
exposure to body f luids of a HCW:
a. The same rigorous evaluation of the source blood, in this instance the blood of the
employee, w ill be undertaken w hen permitted by law and, w here appropriate, baseline
serologic testing of the exposed patient w ill be performed w hen permitted by law (see
Hospital Administrative policy #4.30 Consent for HIV Testing & Release of Protected



UW HEALTH CLINICAL POLICY 2
Policy Title: Healthcare Worker w ith Bloodborne Pathogen Infection
Policy Number: 4.1.9

Health Information). The specif ic screening and testing that w ill be done in each exposure
w ill be determined on a case by case basis under the direction of the Employee Health
Service, Infection Control and the patient’s treating physician. The basic eva luation w ill be
very similar to that undertaken for employees exposed to patients’ blood or body f luids in
biohazardous injuries. In addition, the employee should complete an Accident Report and
an Occurrence Screen/Patient Safety Net (PSN) documenting the patient’s exposure.
b. Baseline testing of the exposed patient and the source HCW w ill be coordinated through
EHS, or the Emergency Department if EHS is closed.
c. Follow -up testing of the exposed patient w ill be coordinated through EHS in conjunction
w ith the patient's attending physician if an inpatient or primary care provider if the patient
has been discharged at the time that follow -up testing is needed.
d. If necessary, provision of appropriate prophylaxis to the exposed patient w ill be
coordinated through their attending physician if an inpatient or primary care provider if not
an inpatient.
e. The patient’s attending physician (or primary care provider if not an inpatient), Risk
Management and Patient Relations w ill be notif ied if the source HCW is know n to carry a
blood-borne pathogen (see definition of BBP above) or is found to test positive for a BBP
in the course of the exposure evaluation.
f. The Infectious Disease Service w ill be consulted if questions as to appropriate prophylaxis
regimens or medical follow -up arise.
B. Healthcare w orkers are ethically responsible and strongly encouraged to receive BBP testing if they have
risk factors for such infection.
i. HCWs w ho perform exposure-prone invasive procedures may obtain confidential BBP testing
through EHS at no cost.
ii. HCWs w ho do not perform exposure-prone invasive procedures are encouraged to seek
confidential BBP testing through their personal healthcare provider.
iii. Employee Health Services w ill provide appropriate baseline and follow -up testing at no cost to any
employee in the event of occupational exposure, as described in section IV.A.
C. Healthcare w orkers w ho are aw are that they are infected w ith a BBP, follow ing testing performed outside of
EHS, are ethically responsible and strongly encouraged to report their infection status to EHS so that
counseling and support can be made available to them.
i. Healthcare w orkers infected w ith a BBP w ho perform exposure-prone invasive procedures are
ethically responsible and strongly encouraged to report this to EHS so that, in addition to
counseling and support, risk reduction strategies appropriate to the exposure-prone procedures in
w hich they participate may be discussed and implemented.
D. Healthcare w orkers w ho perform exposure-prone invasive procedures and w ho are infected w ith a BBP are
required to obtain testing to determine the viral load of the infection.
i. Timeline for viral load testing of the BBP infection for HCWs w ho perform exposure-prone invasive
procedures w ill be as follow s:
a. As soon as feasible, but not to exceed 7 days after the receipt of test results, or
information divulged by the individual, indicating that a HCW currently employed by
UWHC or UWMF is BBP positive.
ii. Confidential viral load testing of the BBP for this employee population may be obtained through
EHS at no cost.
iii. Positive BBP test results obtained by a provider other than EHS must be reported to EHS as soon
as feasible.
iv. Healthcare w orkers w ho perform exposure-prone invasive procedures and w ho are infected w ith a
BBP infection w ill be restricted from performing exposure-prone invasive procedures until
completion of review by an expert review panel as described in section IV.E.
E. When indicated, an expert review panel w ill be convened in order to rev iew the duties and w ork practices of
the affected HCW and to consider potential interventions to reduce patient risk.
i. Reasons for convening an expert review panel may include, but are not limited to:
a. Assess risk and recommend risk reduction strategies for an individual HCW w ho performs
exposure-prone invasive procedures and is infected w ith a BBP infection.
b. Assess risk and recommend risk reduction strategies if a HCW is implicated as the
confirmed source of BBP infection of a patient after an exposure event.
c. Assess risk and recommend confirmatory testing of any HCW epidemiologically implicated
as the likely source of iatrogenic BBP infection in a patient or cluster of patients.



UW HEALTH CLINICAL POLICY 3
Policy Title: Healthcare Worker w ith Bloodborne Pathogen Infection
Policy Number: 4.1.9

d. Reassess risk in the event that the HCW is implicated as the source of BBP infection
subsequent to implementation of risk reduction strategies, or if it becomes evident that the
HCW is noncompliant in adhering to these strategies.
ii. The expert review panel w ill consist of the follow ing:
a. The affected HCW's personal physician(s).
b. The Hospital Epidemiologist or an infectious disease physician w ith expertise in the
epidemiology of bloodborne pathogen transmission.
c. A health professional(s) w ith a similar level of expertise in the procedures performed by
the affected HCW.
d. Individuals from other disciplines w hen their representation is deemed necessary by the
Hospital Epidemiologist. These may include, but are not limited to:
1. Risk Management
2. Legal Affairs
3. Individuals familiar w ith current technologies to reduce risks of percutaneous
injuries
iii. The expert review panel w ill consider in detail the exposure-prone invasive procedures in w hich the
HCW participates and w ill have broad authority to mandate precautions to mitigate the risk of BBP
transmission to patients. These risk reduction strategies may include:
a. Specif ic precautions to be used during performance of invasive procedures (e.g., double
gloving, use of reinforced gloves).
b. Use of medical devices w hich may mitigate injury risk (e.g., blunt suture needles).
c. Periodic review of compliance w ith precautionary measures promulgated by the panel.
iv. The affected HCW w ill be notif ied w hen the expert review panel w ill meet and w ill have the
opportunity to be present at initial phases as w ell as an opportunity to appeal any restrictions to the
Medical Board.
v. Evidence of non-compliance w ith the risk reduction strategies implemented by the expert review
panel, or of subsequent BBP transmission to a patient(s) after risk reduction strategies have been
implemented w ill prompt reconvening of the expert review panel and in the case of non-
compliance, possible disciplinary action.

V. COORDINATION

Author: Employee Health Services Manager
Senior Management Sponsor: SVP, Human Resources
Review ers: Employee Health Services Medical Director, Director of Risk Management, Infection Control
Committee, HR Compliance Counsel
Approval committees: Infection Control Committee; UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: June 20, 2016

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospital and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VI. APPROVAL

Peter New comer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VII. REFERENCES

1. Centers for Disease Control and Prevention. Updated CDC Recommendations for the Management of
Hepatitis B Virus-Infected Health-Care Providers and Students. MMWR 2012;61(No. RR-3):1-12.




UW HEALTH CLINICAL POLICY 4
Policy Title: Healthcare Worker w ith Bloodborne Pathogen Infection
Policy Number: 4.1.9

2. Henderson DK, Dembry L, Fishman NO, et al. SHEA guideline for management of healthcare w orkers
w ho are infected w ith hepatitis B virus, hepatitis C virus and/or human immunodeficiency virus. Infect
Control Hosp Epidemiol 2010;31:203–32.

3. Centers for Disease Control and Prevention. Recommendations for Preventing Transmission of Human
Immunodeficiency Virus and Hepatitis B Virus to Patients During Exposure-Prone Invasive Procedures.
MMWR 1991;40(No. RR-8):1-9.

VIII. REVIEW DETAILS
Version: Revision
Next Revision Due: July 2019
Formerly Know n as: Hospital Administrative policy 9.25