Latest SDS dilemma: Should surgeons be tested for bloodborne pathogens?

Take steps to decrease risk of transmission to patients

In the past, a don’t ask, don’t tell mentality permeated the issue of surgeons and their possible infection with bloodborne pathogens such as hepatitis B. However, recent research and publicized cases of transmission to patients are heralding a call for change. Proponents say surgeons should self-test to determine whether they are infected with a bloodborne pathogen.

The movement has the support of the Chicago-based American College of Surgeons, according to Donald Fry, MD, chair of the Governor’s Com-mittee on Bloodborne Infections and Environmental Risks at the American College of Surgeons, and chairman of the department of surgery at the University of New Mexico Health Sciences Center in Albuquerque.

The American College of Surgeons has updated its "Statement on the Surgeon and Hepatitis," and at press time, the updated statement was scheduled to be published in late March.

Some outspoken individuals are going further and advocating a controversial step: universal testing of surgeons for bloodborne pathogens. Some supporters want to include scrub nurses as well.

The United Kingdom has had mandatory hepatitis B virus (HBV) testing and vaccination for all students entering medical school since 1993, explains John W. Wickenden, MD, a retired surgeon in Camden, ME, who has been infected with HBV for more than 30 years.

At a presentation at the most recent annual meeting of the Washington, DC-based Associa-tion for Professionals in Infection Control and Epidemiology (APIC), Wickenden said he would like to see the United States follow the practice. And he doesn’t stop his recommendations there.

"Periodic renewal of licensure and hospital privileges will need to be contingent upon mandatory serologic testing and vaccination. Established surgeons who test positive must be required to withdraw from procedural practices." The issue is a patient safety one, he maintained.

"There is a very real potential for transmission of hepatitis B or C, during surgery, from a surgeon who is serum antigen positive for these," said Wickenden. "Of interest, in the context of all of the concern expressed a decade or more ago, there is very little evidence of transmission of HIV, during surgery, from infected surgeons to patients."

Preventing the transmission of bloodborne pathogens requires "a more stringent strategy for vaccination and testing of surgeons and optimization of infectious disease surveillance," say authors who have researched this topic.1  

Specifically, many infection control experts recommend these steps:

Follow universal precautions diligently. "The practice of universal precautions is often somewhere between absent and sloppy," added Wickenden.

Although there has been improvement in adherence to universal precautions due to concerns about HIV transmission, it’s only a relative improvement, he said. "The realities of the surgical environment still cause injuries. There has been, and there still is, frequent exchange of blood between surgeons and patients."

Experts point to orthopedic procedures as one example of surgeries that involve a lot of blood.

Few physicians thoroughly adopt, in their daily practice, demonstrably valuable infection control techniques, Wickenden pointed out. "They far too often behave as though they deemed the risk to be insignificant," he said. "Just close your eyes, and think for a moment how often surgeons and other health care workers don’t even wash their hands."

Encourage self-testing. Because there are significant treatments available or upcoming to treat viral infections, surgeons should self-test, Fry says. "I would consider it appropriate for surgeons to know their status relative to these viruses, just as they should know they’re hypertensive and diabetic. It’s a matter of their own health and, in the case of HBV, it may be a matter of patients’ health."

The Denver-based Association of periOperative Registered Nurses (AORN) supports voluntary testing after informed consent and counseling for patients and all health care workers regardless of the practice setting.2

Many experts shy away from required testing, however. "From my perspective, universal testing is neither warranted from an infection control standpoint, nor advisable, from a civil rights perspective, i.e., the surgeons’ rights," says Jeffrey Driver, JD, MBA, DFASHRM, chief risk officer at Stanford (CA) University Medical Center. Driver recommends an approach that requires surgeons to self-assess based on personal risk, self-test, and disclose to hospital professionals.

However, disclosure raises another significant issue. "Most doctors don’t want to get tested, and I know why: Because it opens a whole bag of worms that no one has a clear answer to," said William P. Fiser Jr., MD, assistant professor of surgery at the University of Arkansas for Medical Sciences in Little Rock.3 Fiser voluntarily left his position as a cardiac surgeon when he tested positive for the hepatitis C virus (HCV) and was diagnosed with advanced liver disease.

Those unanswered questions may include: Should surgeons who test positive continue practicing? What procedures, if any, should they be allowed to perform, and who decides? If they aren’t allowed to perform procedures, how will they make a living? Should their status regarding bloodborne pathogens be disclosed to patients? (Some states require disclosure to patients.)

If the information is disclosed, how should it be handled?

Before his HCV infection, Fiser opposed mandatory testing of physicians for bloodborne pathogens. He now goes one step further and says not only surgeons, but scrub nurses should be tested when they join a facility’s staff.4 After that initial testing, both groups should be tested when there is a percutaneous injury or other significant blood exposure, he said.

Surgeons who test positive for bloodborne pathogens should, at a minimum, modify their practice. Some experts point to a Minnesota law as a good example of how infected surgeons should be handled. Physicians infected with HBV, HCV, or HIV are assigned a monitor by the state health department. They also sign a contract in which they agree to eliminate exposure-prone procedures and make other modifications to their practice that are recommended by the monitor. 

The Centers for Disease Control and Preven-tion (CDC) doesn’t recommend restricting health care workers infected with HCV because of the low risk, according to Miriam Alter, acting associate director for science in the CDC’s division of viral hepatitis.3

Establish a policy on informing patients. The current CDC guidelines on the issue, developed in 1991, recommend that infected providers who perform "exposure-prone procedures" (such as surgeons) and are infected with HIV or HBV antigen are to inform patients of their status if they continue practicing.

However, not all experts agree with that position, and not all states require disclosure.

"The last time I researched the issue from a risk management perspective, I did not draw a conclusion that surgeons owed a duty to inform patients of potential risk because of the extremely remote odds," Driver says. There have been lawsuits in which patients have been exposed and converted, he acknowledges. Also, there are fears in the risk management community of cases in which a patient has a procedure performed by a surgeon who later is determined to have a bloodborne pathogen, he adds.

Use expert review panels. The CDC’s 1991 guidelines concluded that providers who have HIV or HBV e antigen should go before confidential expert review panels to determine whether they should continue practicing and under what conditions. AORN supports this conclusion.2

Why follow this advice? "To minimize the risk that these pathogens will be transmitted to patients — a risk for which there is some evidence even in minimally invasive surgery," said Wickenden. 

The American College of Surgeons supports the involvement of an expert panel when an HBV surgeon tests positive for the e antigen, Fry says.

"In general, we have recommended that the expert panel decide the scope of what should be done, rather than there being some arbitrary list of what are exposure-prone procedures," he says.

Wickenden has expressed strong opinions on what such a panel should decide. "My personal bias is that surgeons who test positive for HBV or HCV should not be given privileges to perform surgery," he added.

The Americans with Disabilities Act protects employees with bloodborne infections and requires that employers provide reasonable accommodations for those individuals competent to perform the job without undue hardship to their employers, AORN points out.2

Wickenden acknowledged that the issues surrounding surgeons and the potential for transmission of bloodborne pathogens are complex. "This is, for good reasons, an emotionally laden problem for everyone concerned," he said.

[Editor’s note: Should surgeons be universally tested for bloodborne pathogens? Or do you have another question or comment on this topic? Post your views on our Same-Day Surgery web site, www.same-daysurgery.com. Click on "forum." Your user name is your subscriber number from your mailing label. Your password is sds (lowercase) plus your subscriber number (no spaces).]

References

1. Spijkerman IJB, van Doorn L, Janssen MHW, et al. Transmission of hepatitis B virus from a surgeon to his patients during high-risk and low-risk surgical procedures during four years. Infect Control Hosp Epidemiol 2002; 23: 306-312.

2. Association of periOperative Registered Nurses. AORN Revised Statement on Patients and Health Care Workers with Bloodborne Diseases. Denver; 2002.

3. Rabin R. Deciding to step away. Newsday, Dec. 27, 2002:A03.

4. Perry J. A hepatitis-infected surgeon speaks out on OR safety. Outpatient Surgery 2003. Web: www.outpatientsurgery.net/2003/os11/safety.php.

Sources and Resource

For more information, contact:

Donald Fry, MD, Chairman, Department of Surgery, University of New Mexico Health Sciences Center, Albuquerque. E-mail: dfry@salud.unm.edu.

John W. Wickenden, MD, P.O. Box F, Camden, ME 04843. E-mail: johnwick@adelphia.net.

To view the Minnesota law on hepatitis and HIV, go to www.revisor.leg.state.mn.us/stats/214/17.html. Click on "Table of Contents for chapter 214." That hyperlink will take you to statute 214.17 to 214.25, which is the "HIV, HBV, and HCV Prevention Program; Purpose and Scope."