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Screening Consent for Blood-borne Viral Diseases
Information contained within this document is governed by the Data Protection Act 1998. Disclosure of information is only with your informed written consent. Recommendations to your employer will be directed to essential information regarding your health and the hazards and risks of your employment and with due reference to other relevant statutory requirements and professional practice.
Hepatitis B, hepatitis C and the human immunodeficiency virus (HIV) are viruses that can be transmitted to patients from an infected health care worker during surgery or other procedures where there is opportunity for the worker’s blood to get into the patient e.g. after an accidental injury from a needle or surgical instrument. To minimise risk to patients the Department of Health require that all healthcare workers be offered testing for evidence of infection with hepatitis B, hepatitis C and the human immunodeficiency virus (HIV).
If you are found to be infected with hepatitis B, hepatitis C or HIV you will be offered counselling about the test result by the Occupational Health Service (OHS) and referred to your general practitioner for follow-up and specialist referral. You will be allowed to continue working but would not be allowed to assist with or undertake surgery or other ‘exposure-prone’ procedures on patients unless the infection can be eradicated or (in the case of hepatitis B) satisfactorily suppressed. Infection will not prevent you from qualifying or practicing as a doctor, except for the restriction on exposure- prone procedures.
Undergoing testing for bloodborne diseases is additional to standard assessment for healthcare workers. It is not compulsory and your consent is required before you can be tested. If you do not agree, however, you will not be allowed to participate in or undertake Exposure Prone Procedures (EPPs). For those healthcare workers who do not wish to participate in EPPs it is still a Department of Health requirement that new health care workers (including medical students) be offered testing for bloodborne viruses. As well, the General Medical Council expects healthcare professionals who could have been exposed to bloodborne virus risk to seek advice and be tested. Further information about this testing is included in the fact sheet in Appendix 1. For a definition of EPPs see Appendix 2. You should read both these documents, decide whether you agree to have a test, and then tick the relevant boxes.
APPENDIX 1 (Information Sheet)
Information sheet: this aims to provide you with the information needed to decide whether to give informed consent to being tested for bloodborne viruses and to provide answers to the questions you may have about screening.
WHY AM I BEING OFFERED ADDITIONAL HEALTH SCREENING?
The Department of Health has recently introduced requirements stating that all new health care workers, including medical students, who participate in exposure prone procedures (EPP), must undergo testing for hepatitis B, hepatitis C and HIV. This testing is being offered by your agency so that healthcare workers can be compliant with these guidelines.
Hepatitis B and C can cause a chronic infection of the liver, which over time can lead to cirrhosis and death from liver failure or cancer. A person may be a carrier of hepatitis B (have antigen) even though they appear to have a satisfactory antibody level. For this reason, hepatitis B antibody and antigen are tested. Hepatitis B and C can sometimes be eradicated with medication. Human immunodeficiency virus infection is a chronic condition which over a period of years progressively damages a person’s immune system, eventually causing AIDS. There is no cure for HIV at present, but treatment with anti-viral drugs can suppress viral replication enough to prevent or slow down the damage to the immune system.
A bloodborne virus carrier may be unaware that he or she is infected with a bloodborne virus. If a healthcare worker who is infected with any of the viruses injured themselves during exposure prone procedures this could allow the virus to be transmitted to the patient. As new healthcare workers, under Department of Health requirements, medical locums/temporary staff who wish to participate in EPP must first be tested under identity validated conditions for hepatitis B, C and
If found to be a carrier of a bloodborne virus you must receive OHS advice. As part of this, you will not be allowed to assist with, or undertake, surgical procedures unless cleared of the infection. This restriction will be formalised by the Occupational Health Department.
The Department of Health recommends that all new healthcare workers, whether undertaking EPPs or not, should be offered the opportunity of having tests for hepatitis B, hepatitis C and HIV carrier status.
WILL I REQUIRE RESCREENING?
Routine re-screening in the UK will not normally be required. However, Healthcare Workers will still be bound by their professional obligations to inform Occupational Health if, after original screening, they may have been exposed to risk of contracting a BBV. Based on an individual risk assessment further testing could be required. Detectable antibodies to bloodborne viruses may not develop until some weeks after infection, so a test carried out in the first 3 months after an exposure may not be reliable. A test carried out after this time will be accurate.
Examples (non-exhaustive) of risk factors for bloodborne viral disease and carrier status include:
- You have ever injected drugs using equipment shared with someone else
- You have been accidentally exposed to blood of a person infected with hepatitis B, hepatitis C or HIV (e.g. a needlestick injury)
- Blood transfusions where blood is not effectively screened for bloodborne viruses
- You have had unprotected penetrative sex (i.e. without using a condom)
- You have had a tattoo or body piercing in places with poor procedures for sterilising equipment or materials.
- Medical or dental treatment in countries where hepatitis B, C or HIV is common and where equipment may not be sterilised properly.
WHAT ARE THE ADVANTAGES OF BEING TESTED FOR BLOODBORNE VIRUSES?
You will be complying with your professional duty to get tested if you have been at risk. If you have been worrying about possibly being infected, a test can give you certainty. If negative, it can provide you with peace of mind. If positive, you can start to take control of your problem. If you turn out to be infected, you can take steps to limit the risk of transmission to others, including sexual partners.
WHAT ARE THE DISADVANTAGES OF BEING TESTED?
Discovering that you are infected with bloodborne viruses can be stressful. If you are infected you may have difficulty obtaining life insurance. NB Insurance companies do not impose higher premiums simply because a person has had a test for HIV or hepatitis. Some countries will not grant visas to foreign nationals infected with HIV. You may encounter prejudicial behaviour from others if they discovered you were HIV or hepatitis C positive.
If you have had unsafe sex in the past, a negative test may give a false sense of security and tempt you to continue this risky behaviour.
If you have been at risk of exposure in the past 12 weeks, a test now may be falsely negative. You should defer testing until 12 weeks after your last risk.
Tests can yield false positive results. However, this risk is very small.
WHAT WILL HAPPEN IF I DO NOT AGREE TO BE TESTED?
Testing is voluntary. If you do not agree to be tested, the Occupational Health Nurse will inform your agency that you are not cleared for participation in exposure prone procedures.
WHAT WILL HAPPEN IF I AM NOT CLEARED FOR PARTICIPATION IN EXPOSURE PRONE PROCEDURES?
Your agency is required to have robust procedures in place for ensuring that locum workers who have not received health clearance do not participate in exposure prone procedures. As well, a responsibility lies with the healthcare worker to ensure that they and their patients are not put at risk.
If you have not been cleared, whether through declining testing or because of a positive result, your agency will be advised to arrange for you to be counselled about the limitations that you should place on your practice. This restriction will be normalised by Occupational Health and you will be required to agree to conformity with the list of restrictions.
WHAT PRE-TEST COUNSELLING WILL BE OFFERED?
The principal method of pre-test counselling will be the provision of the written information contained in this fact sheet. This is consistent with current BBV screening practices in other sectors of the health service, such as antenatal care. However, as already stated, if you first require more information or have any queries you can discuss matters, in confidence by asking your agency to arrange an appointment with Occupational Health.
WHAT POST-TEST COUNSELLING WILL BE OFFERED?
Individuals whose tests are negative will be informed in writing. No further counselling will be offered but is available upon request. A copy of the laboratory report will be provided in addition to a complete set of immunisation/blood test details since the commencement of your registration. You will receive the results of the blood tests as soon as Occupational Health are able to collate them, although due to the time it takes for the laboratory to process the samples this may take up to two weeks. Healthcare workers who test positive for a BBV will be offered the guidance of an Occupational Health Physician who will facilitate referral to an appropriate specialist, in full consultation with your General Practitioner.
WHAT SHOULD I DO IF I AM CONCERNED THAT I MAY HAVE RISK FACTORS PLACING ME AT HIGHER RISK OF A POSITIVE TEST?
If you believe that you are at higher risk of having a bloodborne virus infection, you may undertake screening as planned. However, you may wish to seek advice and personal counselling from Occupational Health, and/or from another health professional, prior to testing. If you have had exposure to risk within the preceding twelve weeks, you should contact your agency and ask for an appointment with Occupational Health.
APPENDIX 2 Definition of Exposure-prone procedures (EPPs)
Exposure prone procedures are those invasive procedures where there is a risk that injury to the worker may result in the exposure of the patient’s open tissues to the blood of the worker. These include procedures where the worker’s gloved hands may be in contact with sharp instruments, needle tips or sharp tissues (e. g. spicules of bone or teeth) inside a patient’s open body cavity, wound or confined anatomical space where the hands or fingertips may not be completely visible at all times. However, other situations, such as pre- hospital trauma care and care of patients where the risk of biting is regular and predictable, should be avoided by health care workers restricted from performing exposure prone procedures.
When there is any doubt about whether a procedure is exposure prone or not, expert advice should be sought in the first instance from a consultant occupational health physician who may in turn wish to consult the UK Advisory Panel for Health Care Workers Infected with Bloodborne Viruses (UKAP). Some examples of advice given by UKAP about exposure prone procedures are provided in Guidance on the management of HIV/ AIDS infected health care workers and patient notification (issued under cover of Health Service Circular 1998/ 226) * . These may serve as a guide, but cannot be seen as necessarily generally applicable, as the working practices of individual health care workers vary.
Procedures where the hands and fingertips of the worker are visible and outside the patient’s body at all times, and internal examinations or procedures that do not involve possible injury to the worker’s gloved hands from sharp instruments and/ or tissues, are considered not to be exposure prone, provided routine infection control procedures are adhered to at all times.
Examples of procedures that are not exposure prone include: taking blood (venepuncture); setting up and maintaining IV lines or central lines (provided any skin tunnelling procedure used for the latter is performed in a non-exposure prone manner i.e. without the operator’s fingers being at any time concealed in the patient’s tissues in the presence of a sharp instrument); minor surface suturing; the incision of external abscesses; routine vaginal or rectal examinations; simple endoscopic procedures.
The decision whether an HIV, hepatitis B or hepatitis C infected worker should continue to perform a procedure, which itself is not exposure prone, should take into account the risk of complications arising which necessitate the performance of an exposure prone procedure; only reasonably predictable complications need to be considered in this context.
Notes to the above:
Revised guidance to replace the above has recently been out for consultation. A final version of the revised guidance will be issued in Spring 2003. See http://www.doh.gov.uk/aids.htm Exert from: HIV Infected Health Care Workers – A Consultation Paper on Management and Patient Notification: Annex A – Examples of UKAP advice on Exposure Prone Procedures:
The following advice has been given by UKAP in relation to specialities and procedures:
- Accident and Emergency: A+ E staff who are restricted from performing EPPs should not provide prehospital trauma care (see Paramedics).
- These staff should not physically examine or otherwise handle acute trauma patients with open tissues because of the unpredictable risk of injury from sharp tissues such as fractured bones. Cover from colleagues who are allowed to perform exposure prone procedures would be needed at all times to avoid this eventuality.
- Other exposure prone procedures which may arise in an A+ E setting would include rectal examination in presence of pelvic fracture, deep suturing to arrest haemorrhage and internal cardiac massage. In addition, situations where risk of biting of health care workers’ fingers is considered significant (such as a violent patient or during an epileptic fit) should be avoided where possible unless the EPP restricted worker is the only person available to provide an immediate life-saving intervention. Mouth to mouth resuscitation should not be withheld if the EPP restricted worker is the only immediately available person competent to provide this, but ideally should be delegated to a colleague not restricted from performing EPPs. (see Resuscitation).
Anaesthetics: Procedures performed purely percutaneously are not exposure prone, nor have endotracheal intubation nor the use of a laryngeal mask been considered so. Arterial cutdown involving tissue dissection has been considered exposure prone. Skin tunnelling (used in some pain control procedures) may or may not be exposure prone depending on whether the operator’s fingers are at any time concealed in the patient’s tissues in the presence of a sharp instrument. It is considered possible to perform a skin tunnelling procedure in a non- exposure prone manner.
Bone Marrow transplants. Not exposure prone.
Cardiology Percutaneous procedures including angiography / cardiac catheterisation are not exposure prone, provided cutdown is not performed to obtain vascular access. Arterial cutdown involving tissue dissection is considered exposure prone. Implantation of permanent pacemakers (for which a skin tunnelling technique is used to site the pacemaker device subcutaneously) may or may not be exposure prone. This will depend on whether the operator’s fingers are or are not concealed from view in the patient’s tissues in the presence of sharp instruments during the procedure.
Chiropodists – see Podiatrists
Dentistry (including hygienists) – The majority of procedures in dentistry are exposure prone, with the exception of examination using a mouth mirror only.
Ear, Nose and Throat Surgery (Otolaryngology) ENT surgical procedures generally should be regarded as exposure prone with the exception of simple ear or nasal procedures, and procedures performed using endoscopes (flexible and rigid) provided fingertips are always visible. Non- exposure prone ear procedures include stapedectomy/ stapedotomy, insertion of ventilation tubes and insertion of a titanium screw for a bone anchored hearing aid.
Endoscopy – Simple endoscopic procedures (e.g. gastroscopy, bronchoscopy) have not been considered exposure prone but should be avoided by EPP restricted health care workers if a significant risk of biting of the worker’s fingers is deemed to be present such as in a violent or fitting patient.
In general there is a risk that surgical endoscopic procedures (e. g. cystoscopy, laparoscopy – see below) may escalate due to complications which may not have been foreseen and may necessitate an open exposure prone procedure. The need for cover from a colleague who is allowed to perform exposure prone procedures should be considered as a contingency.
General Practice – Exposure prone procedures are rare in General Practice. Possible areas where they may be encountered are minor surgery, obstetrics and trauma situations. See relevant sections for procedures.
Gynaecology (see also Laparoscopy) – Open surgical procedures are exposure prone. Many minor gynaecological procedures are not considered exposure prone, examples include dilatation & curettage (D& C), suction termination of pregnancy, colposcopy, surgical insertion of depot contraceptive implants/ devices, fitting intrauterine contraceptive devices (coils), and vaginal egg collection provided fingers remain visible at all times when sharp instruments are in use.
Performing cone biopsies with a scalpel (and with the necessary suturing of the cervix) would be exposure prone. Cone biopsies performed with a loop or laser would not in themselves be classified as exposure prone, but if local anaesthetic was administered to the cervix other than under direct vision i.e. with fingers concealed in the vagina, then the latter would be an exposure prone procedure.
Haemodialysis / Hemofiltration – See Renal Medicine.
Laparoscopy – Mostly non- exposure prone because fingers are never concealed in the patient’s tissues. Exceptions are, exposure prone if main trocar inserted using an open procedure, as for example in a patient who has had previous abdominal surgery. Also exposure prone if rectus sheath closed at port sites using J- needle, and fingers rather than needle holders and forceps are used.
In general there is a risk that a therapeutic, rather than a diagnostic, laparoscopy may escalate due to complications which may not have been foreseen necessitating an open exposure prone procedure. The need for cover from a colleague who is allowed to perform EPPs should be considered as a contingency.
Midwifery – Simple vaginal delivery and the use of scissors to make an episiotomy cut are not exposure prone. Infiltration of local anaesthetic prior to episiotomy, suturing of an episiotomy and attaching sharp scalp electrodes to baby’s head are considered exposure prone.
Minor Surgery – In the context of GP minor surgery and elsewhere: excision of lipomata and sebaceous cysts should not be performed by an EPP restricted HCW. Any more complex procedures which are occasionally performed in GPs’ surgeries by doctors with appropriate experience, such as herniorrhaphy, are exposure prone also.
Needlestick/ Occupational Exposure to HIV – Health care workers need not refrain from performing exposure prone procedures pending follow up of occupational exposure to an HIV infected source. The combined risks of contracting HIV infection from the source patient, and then transmitting this to another patient during an exposure prone procedure is so low as to be considered negligible. However in the event of the worker being diagnosed HIV positive, such procedures must cease in accordance with this guidance.
Nursing – General nursing procedures do not include exposure prone procedures. The duties of operating theatre Medical Locums should be considered individually. See also sections on Accident and Emergency, Resuscitation and Renal Medicine/ Nursing.
Obstetrics/ Midwifery – See midwifery. Obstetricians may also perform other surgical procedures, many of which will be obviously exposure prone according to the criteria.
Operating Department Assistant / Technician – General duties do not normally include exposure prone procedures. Ophthalmology – With the exception of orbital surgery which is usually performed by maxillo- facial surgeons (who perform many other EPPs), routine ophthalmological surgical procedures are not exposure prone as the operator’s fingers are not concealed in the patient’s tissues. Exceptions may occur in some acute trauma cases, which should be avoided by EPP restricted surgeons.
Orthodontics – Because of the presence of sharp wires on fixed orthodontic appliances which may cause injury to the orthodontist’s fingers inside the mouth, and the need for oral examination which may involve the use of sharp instruments, it would be difficult for a worker unfit for EPPs to pursue a career in orthodontics. See also Dentistry as some orthodontists perform general dental procedures, the majority of which are exposure prone.
Paediatrics – Neither general nor neonatal/ special care paediatrics has been considered likely to involve any exposure prone procedures, with the exception of cutdown to obtain vascular access (involving tissue dissection). Paediatric surgeons do perform EPPs.
Paramedics – In contrast to other emergency workers, a paramedic’s primary function is to provide care to patients. Direct patient care including intravenous cannulation is not a risk to patients as it is not exposure prone; however, paramedics who are EPP restricted should not perform duties at emergency sites because of risk of injury due to the unpredictability of the situation.
Pathology – In the event of injury to an EPP restricted pathologist performing a post mortem examination, the risk to other workers handling the same body subsequently is so remote that no restriction is recommended.
Podiatrists – For podiatrists who are not trained in and do not perform surgical techniques, routine procedures are not exposure prone. EPP restricted podiatrists should not train in surgical techniques, nor should an EPP restricted surgical podiatrist continue to perform surgery. Prior to formalising criteria for exposure prone procedures, the UKAP agreed with a representative from the podiatry profession that there was risk that injury to a podiatrist could result in contamination of a patient’s open tissues with the podiatrist’s blood.
Radiology – Arterial cutdown involving tissue dissection should not be performed by EPP restricted workers. All percutaneous procedures, including imaging of the vascular tree, biliary system and renal system, drainage procedures and biopsies as appropriate, are not exposure prone procedures.
Renal Medicine – Obtaining vascular access at the femoral site in a distressed patient may constitute an exposure prone procedure as the risk of injury to the HCW may be significant. This is more likely to be a problem for haemofiltration (often performed in an emergency) than for haemodialysis (more likely to be instigated electively and patients less likely to be distressed than those who need haemofiltration). The working practices of those staff who supervise haemofiltration and haemodialysis circuits do not include exposure prone procedures.
Resuscitation – Unless an equally competent colleague who is allowed to perform exposure prone procedures is present, EPP restricted HCWs should provide immediate life saving mouth to mouth resuscitation if they are competent so to do; potential benefit to the patient greatly outweighs the small risk of BBV transmission in these circumstances. Surgery (see also Laparoscopy, Minor Surgery) – Open surgical procedures are exposure prone. This applies equally to major organ retrieval because of the risk of contamination of the organ during the procedure and the potential risk to the recipient.