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Engage surgeons to protect selves, patients
[Editor's note: This is the second part of a two-part series on a new guideline from the Society for Healthcare Epidemiology of America (SHEA) regarding the management of providers who are infected with hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV). In last month's issue, we gave you an overview of the guideline, which procedures are at greatest risk of transmission, and the recommendations for infected staff. In this issue, we further explain the new guidelines and discuss how to decide which workers to test.]
The new Society for Healthcare Epidemiology of America guideline is embedded in a long, detailed, and heavily referenced document, says Janine Jagger, PhD, MPH, director of the International Health Care Worker Safety Center at the University of Virginia in Charlottesville.
"Without going into excruciating detail, the main difference between the previous guideline and this one is that the number of cases in which patients have been infected by providers has grown," Jagger says.
There is one paragraph embedded in the 29-page document that sums up the philosophy neatly, Jagger says: "The accumulated experience and data provide reassuring evidence that the magnitude of risk for provider-to-patient transmission of HIV, HCV and HBV, although not zero, is exceedingly small. At the same time, the burdens of certain restrictions that have been placed on healthcare providers out of concern for patient safety have been disproportionately high. ... These burdens, associated with highly personal and stigmatizing diagnoses, seem unjustified in the face of an extremely low risk . . ."
She says, "In other words it is better to sacrifice the patient's health possibly life in order to protect health care providers from discriminatory restrictions than to protect the patient's health at the expense of the health care worker's right to practice his or her profession."
The guideline are on the side of the health care worker, Jagger says. "Although the philosophy underpinning the new guideline remains unchanged, we are in a very different situation today than when the guidelines were first introduced almost 20 years ago," she says. "We have an effective vaccine for hepatitis B, effective treatments for hepatitis C, and effective treatments and post-exposure prophylaxis for HIV."
Health care provider-to-patient transmission of bloodborne pathogens is limited to a narrow scope of health care, Jagger says. "This is an issue affecting surgeons, and only those performing procedures that involve hands in a body cavity in proximity to sharp objects," she says. "We do not need a scattershot policy encompassing all health care workers. This issue needs to be worked out with surgeons."
It is in surgeons' best interest to know their bloodborne pathogen status, "although some may still need to be convinced of that," Jagger says.
Scientific and medical advances have not yet been fully incorporated into policies, she says. "We have the knowledge and resources to create new policies that are not based on a choice of whom to sacrifice, whom to protect," Jagger says. "There is no time like the present for surgeons to engage in this discussion and put forward some enlightened policy proposals that protect their patients as well as their own interests. I believe they are up to the challenge, and the goal is within reach."
Facilities must decide which workers to test
At the Infected Health Care Worker Program in the Minnesota Department of Health, nurse specialist Stephen Moore, RN, MPH, has a case load of 150 health care workers who have HIV, hepatitis B, or hepatitis C. Some are administrators not involved in patient care. Only about 20 are nurses, doctors, or dentists who perform invasive procedures that are considered exposure-prone, according to a 1991 guideline from the Centers for Disease Control and Prevention.
The new guideline of the Society for Healthcare Epidemiology of America (SHEA) provides some updated approaches to monitoring but also presents challenges, says Moore. Since the guideline was released in March, health care managers have been determining how or whether they will adapt their policies. Many states have laws relating to health care workers infected with HIV or HBV, and facilities must adapt any changes to those statutes.
"For the 15% of the licensed health care workers I deal with who have some chance of transmitting [a bloodborne pathogen], it probably has some benefits to raise awareness and send a message to the public that we do look out for this," Moore says. "We work hard with health care workers in modifying their practices to make sure people don't lose their careers. When we work with people, we treat them as if they have honor and ethics and they're good at what they do they just happen to have this disease."
Bi-annual testing of viral load would add a new wrinkle to the monitoring. It also will raise the question of cost: Who pays for the testing? Physicians and even some surgical techs might be independent contractors and might perform procedures at more than one facility. Moore plans to meet with infection diseases experts and the state attorney general to consider policy changes. "I plan to seek input on the SHEA guidelines from infection preventionists, governing boards, and other state agencies," he says.
The Joint Commission expects health care facilities to consider national guidelines related to health care workers infected with a bloodborne pathogen. But they don't necessarily have to adopt the monitoring protocol recommended by SHEA, says Robert Wise, MD, vice president of The Joint Commission's Division of Standards. "We would expect the organization to have thought through how to handle a situation," he says. "We don't demand that they use the SHEA guideline, but we would expect some sort of pronational guideline be used to direct their policy."
A recent review of state laws and guidelines found that only one addressed hepatitis C, and 15 required notification of patients before an invasive, exposure-prone procedure if the worker was infected with a bloodborne pathogen. None of them addressed the issue of viral burden, said Sarah Turkel, MPH, an investigator with the National Institutes of Health Clinical Center in Bethesda, MD, who presented the findings this year at the Fifth Decennial International Conference on Healthcare-Associated Infections. In 19 states, the issues of possible practice restrictions are handled at the hospital level, her review found.
How often should you test HCWs?
A recent HBV transmission from an HBV-positive orthopedic surgeon to patients forced the University of Virginia (UVA) Health System in Charlottesville to reconsider issues of testing and restrictions. The surgeon had been a nonresponder to HBV vaccination. He discovered that he had hepatitis B infection with a viral load of 17 million international units per ml of blood in baseline testing after a reported sharps injury.
The health system then tested patients in 237 procedures and discovered two HBV-positive cases that were linked to the surgeon and four that were likely cases of transmission, says Kyle Enfield, MD, MS, assistant hospital epidemiologist, who presented the findings at the Fifth Decennial International Conference. After treatment, the surgeon was allowed to resume performing procedures, with restrictions, says Enfield. He must double-glove and must report any potential exposures. He must have a non-HBV-infected surgeon with him in the operating room. He is also restricted from performing the most exposure-prone procedures, such as total hip or total knee replacement. The health system does not require him to reveal his HBV status to patients prior to surgery.
"The risk of transmission with a low viral load is infinitesimally small," says Enfield. UVA now conducts further testing of nonresponders to the HBV vaccine to determine if they are HBV-infected, says Enfield. The health system does not require routine testing of surgeons who perform invasive, exposure-prone procedures.
That is in keeping with the new SHEA guideline, which calls for "voluntary confidential testing" but not mandatory testing of providers.
Facilities will need to make a determination about testing of providers, says Neil Fishman, MD, director of health care epidemiology, infection prevention, and control at the University of Pennsylvania Health System in Philadelphia, an author of the guideline and president of SHEA. "At the least, every institution should offer confidential and readily available testing to providers," he says. "Then it's up to each institution to decide whether that should be mandatory if someone is going to perform these exposure-prone procedures." At the University of Pennsylvania, for example, Fishman says, "we make testing readily available and strongly recommended. We're considering whether to make it mandatory."
For physicians, testing could take place when their credentials are periodically renewed, he says.