Elephant in the room is patient on the table

'A single injury, a single drop of blood'

Beyond the logistical disincentives, hassles and headaches of reporting to employee health after an injury in the operating room there is the chilling stigma of what the surgeon may find out about herself and possibly be obligated to tell future patients: "I'm HIV-positive."

Indeed, the elephant in the room is the patient on the table, as reporting injuries raises the difficult issues of testing and informing patients.

Still, the prompt reporting of all needlestick injuries is critical to ensuring proper medical prophylaxis, counseling and legal precautions, says Martin A. Makary, MD, MPH, an associate professor of surgery and director of the Johns Hopkins Center for Surgical Outcomes Research.

"There's definitely a large number of silent [HIV, HCV] carriers in the health care profession," he says. "There have been documented cases of surgeon to patient transmission in the operating room because the entire operative area is an at-risk area of vulnerability to even the smallest drop of contaminated blood from the surgeon. A single needlestick injury could contaminate a wound with a single drop of blood, resulting in transmission."

In a case that recalled the national turmoil during the Florida HIV dental outbreak in the early 1990s, the Centers for Disease Control and Prevention reiterated in 2009 that HIV provider-to-patient infections remain exceedingly rare.1 The CDC report suggested that policy revisions should be reconsidered for HIV-infected providers who perform invasive procedures, particularly the issue of informing patients of their infection. Formed in the wake of the Florida HIV case, those policies were written before the current HIV drugs — which can suppress the virus and possibly lower the risk of transmission — were available.

A cardiothoracic surgeon in Israel specializing in open-heart procedures was found to be HIV-positive in January 2007 during evaluation for fever of recent onset. A look-back investigation of patients operated on by the infected surgeon during the preceding 10 years was conducted under the auspices of the Israel Ministry of Health to determine whether any surgeon-to-patient HIV transmission had occurred. Of 1,669 patients identified, 545 (33%) underwent serologic testing for HIV antibody. All results were negative. "The results of this investigation add to previously published data indicating a low risk for provider-to-patient HIV transmission," the CDC reported.

After considering the clinical details of the surgeon's case, the published literature on HIV transmission from infected health care workers to patients, and the findings of this look-back investigation, a review panel recommended allowing the resumption of work, with no restrictions on the types of procedures the surgeon could perform, provided the surgeon met the following conditions:

  • Instruction by infection control personnel at the surgeon's hospital regarding safe practices, including adherence to standard precautions and hand hygiene requirements, double-gloving during all surgery, and immediate reporting of any cuts in gloves or fingersticks, plus agreement by the surgeon to abide by these practices;
  • Routine health care follow-up at three-month intervals, including measurement of CD4 T-cell count and HIV RNA;
  • Adherence to a prescribed antiretroviral regimen, maintenance of good health, and continued CD4 T-cell level >200 cells/µL, with HIV RNA below the threshold of detection.

On the basis of the published literature, the panel did not require notification of prospective patients of the surgeon's HIV status because of the extremely low likelihood of transmission to patients if the conditions for resuming surgery were met, the CDC concluded.

Reference

  1. Centers for Disease Control and Prevention. Investigation of patients treated by an HIV-infected cardiothoracic surgeon — Israel, 2007. MMWR 2009; 57(53):1,413-1,415.