Disclosure and Reporting of Infection with Blood-Borne Pathogens: Guidelines for Registered Nurses

Transcription

1 Disclosure and Reporting of Infection with Blood-Borne Pathogens: Guidelines for Registered Nurses December 2006

2 Approved by the College and Association of Registered Nurses of Alberta (CARNA) in December Permission to reproduce this document is granted; please recognize CARNA. College and Association of Registered Nurses of Alberta Street Edmonton, AB T5M 4A6 Phone: (780) or (Canada-wide) Fax: (780) Website:

3 DISCLOSURE AND REPORTING OF INFECTION WITH BLOOD-BORNE PATHOGENS: GUIDELINES FOR REGISTERED NURSES INTRODUCTION Registered nurses and other health-care workers who are infected with blood-borne pathogens are concerned with the provision of safe care to the clients 1 they serve. The purpose of this document is to provide guidance on the disclosure and reporting of an infection for those registered nurses who have been infected with blood-borne pathogens such as hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV). Disease transmission from health-care workers during exposure-prone invasive procedures has been documented but it is very rare (Moloughney, 2001). While the performance of exposure-prone invasive procedures by health-care workers places clients at greater risk for acquiring blood-borne infections, it is recognized that most registered nurses are not involved in exposure-prone procedures. The literature has identified only one case in which a nurse has transmitted such an infection to a client. This occurred in France and was reported in the year 2000 (Alberta Expert Panel for Health Care Workers with Blood-borne Infections, 2006). Guidelines for the prevention of transmission of infection from the client to a nurse is also included as this has become an area of concern to registered nurses in the provision of care. Familiarity with the following definitions is essential to the understanding and correct interpretation of this document: blood/body fluid exposure exposureprone procedures contact with blood/body fluids containing visible blood by a needle stick or splash onto mucous membranes or non-intact skin Exposure-prone procedures are procedures during which transmission of HBV (hepatitis B virus), HCV (hepatitis C virus) or HIV (human immunodeficiency virus) from a HCW (health-care worker) to patients is most likely to occur and includes the following: a) digital palpation of a needle tip in a body cavity or the simultaneous presence of the HCW s fingers and a needle or other sharp instrument or object in a blind or highly confined anatomic site, e.g., during major abdominal, cardiothoracic, vaginal and/or orthopedic operations, or b) repair of major traumatic injuries, or c) major cutting or removal of any oral or perioral tissue, including tooth structures, during which there is a potential for the patient s open tissues to be exposed to the blood of an injured HCW. (Health Canada, 1 The term client can refer to patients, residents, families, groups, communities and populations. 1

4 Laboratory Centre for Disease Control, 1998, p. 5) Examples of exposure-prone procedures performed by registered nurses are assisting with some surgical procedures such as sponging, placing and holding retractors, suturing and wound debridement. GUIDELINES FOR THE DISCLOSURE & REPORTING OF INFECTION 1. Confidentiality The registered nurse is entitled to the right to privacy and confidentiality of their personal health information. Registered nurses are not required to disclose their infection with a blood-borne pathogen to the employer or colleagues. 1.1 If, during the provision of care, the client is exposed to the blood/body fluids of a registered nurse infected with blood-borne pathogen(s), the client must be informed. 1.2 Whenever possible, a third party (e.g., client s personal physician, supervisor in the workplace, etc.) should inform the client of the exposure, including post-exposure follow-up and counselling, without revealing the identity of the registered nurse. 2. Serological Testing Mandatory testing of registered nurses for blood-borne pathogens upon hire or at regular intervals throughout employment is not recommended because it does not contribute to the provision of safe nursing care. Current assessment of the risk of transmission from an infected registered nurse while providing care does not support the diversion of resources required to support such a program. 2 Recommending mandatory testing for registered nurses may have a harmful effect on the provision of safe care by increasing a false sense of security produced by a negative result that would be valid for only a short period of time (Alberta Human Resources and Employment, 2004). An individual may actually be infected with HIV, and transmit this infection to another person before a blood test indicates a positive result. 3. Responsibilities of Registered Nurses Infected with Blood-Borne Pathogens The infected registered nurse has the right to be treated as any other health-care worker who has a condition that could affect their nursing practice. The College and Association of Registered Nurses of Alberta (CARNA) Nursing Practice Standards (2003), the Canadian Nurses Association Code of Ethics for Registered Nurses (2002), and the Registered Nurses Profession Regulation under the Health Professions Act (HPA) obligate all registered nurses to maintain fitness to practise and not place clients at risk. 3.1 Any registered nurse who has reason to believe that they have been exposed to blood-borne pathogens through either occupational or non-

5 occupational risks have a professional and ethical duty to learn their serological status for HIV, HBV, and HCV. 3.2 All persons, including registered nurses, who have potentially been placed at risk for the acquisition of HIV, HBV and HCV should be appropriately counseled prior to voluntary testing. In Alberta, all notifiable diseases are nominally reportable to the public health authority in accordance with the provisions of the Public Health Act (2000) and the Communicable Diseases Regulation (2001). All Albertans who test positive for infection with a blood-borne pathogen will be contacted for public health follow-up. 3.3 Reporting to CARNA is not necessary in all cases of an infection with a blood-borne pathogen. CARNA provides support and information for the registered nurse who may have questions related to their practice. Any registered nurse infected with a blood-borne pathogen who has questions about whether they are involved in an exposure-prone activity must contact the registrar for clarification and information. All consultations with the registrar are confidential. If a registered nurse is engaged in exposure-prone activities and is infected with a blood-borne pathogen, then they have a responsibility to consult with the Alberta Expert Review Panel for Blood-Borne Infection in Health-Care Workers. This is facilitated by contacting the registrar of CARNA. CARNA will provide support, information and reimbursement of expenses to consult with the Alberta Expert Review Panel. In order to maintain anonymity, the infected registered nurse may elect representation by a third party. The Alberta Expert Review Panel for Blood-Borne Infections in Health- Care Workers was established to review the circumstances of health care workers and make recommendations concerning continued or modified professional practice. The Alberta Expert Review Panel members are selected for their expertise and represent their designated disciplines. Members include: an infectious disease specialist a medical officer of health an infection control officer a public health nurse an occupational health nurse a public representative 3.4 The infected registered nurse has an obligation to complete an ongoing self-evaluation of competence and risk of disease transmission. 3.5 Infection with a blood-borne pathogen alone does not constitute sufficient grounds for dismissal or reassignment of duties unless the risk assessment indicates otherwise. 3

6 3.6 To ensure objective and fair treatment, policies that address registered nurses infected with blood-borne pathogens should be developed by agencies/institutions employing registered nurses prior to being faced with the situation. PREVENTION OF TRANSMISSION OF INFECTION FROM THE CLIENT TO A REGISTERED NURSE Registered nurses are at risk of exposure to blood/body fluids that may be infected with blood-borne pathogens. Routine practices of infection control and protection are essential if registered nurses and other health-care providers are to prevent the transmission of a blood-borne pathogen from a client to a health-care worker (Diaz-Mitoma, Paton, & Giulivi, 2001). In Canada, the term routine practices is used rather than universal precautions or standard precautions. Health Canada (1999) infection control guidelines address: hand washing/ hand antiseptic the use of gloves masks, eye protection, face shields gowns accommodation patient care equipment and environmental control in acute care, long-term care, ambulatory and home care practice settings. Recent research indicates that health care workers do not always implement routine practices, relying instead on their own subjective assessment of patients blood-borne viral status (Cutter & Jordan, 2004; Gammon & Gould, 2005; Lymer, Richt & Isaksson, 2003; Osbourne, 2003). Prevention of transmission of blood-borne pathogens from an infected client to a registered nurse includes the following measures: consistent use of routine practices appropriate handling of sharps such as needles, scalpel blades and other sharp instruments or devices (Alberta Human Resources and Employment, 2004) immunization with hepatitis B vaccine (Department of Health & Human Service Centers for Disease Control and Prevention, 2003). education with respect to infection control and occupational risk of blood-borne pathogen transmission (Society for Healthcare Epidemiology of America, 1997). an institutional climate of safe practice with support from management and key clinical leaders (McKoy, Beekmann, Ferguson, Vaughn, Torner, Woolson, & Doebbeling, 2001) If a nurse is exposed to a blood-borne pathogen they should have access to a comprehensive post-exposure program to ensure they receive accurate information, guidance and support (American Nurses Association, 1991). 4

7 REFERENCES Alberta Department of Health and Wellness. Ministerial Order 23/99. (1999, July). Alberta Expert Review Panel for Health Care Workers with Blood-Borne Infections (HBV, HCV, HIV). (2006). Blood-borne infections in health care workers. Edmonton: Author. Alberta Human Resources and Employment. (2004). Precautions for workers exposed to HIV. Workplace Health and Safety Bulletin, March, American Nurses Association. (1991). Position statement: Post-exposure programs in the even of occupational exposure to HIV/HBV. Retrieved June 1, 2006, from Beck, D. M. (1992). Mandatory HIV testing for healthcare workers: Is it ethical? Nursing Forum, 27(4), Canadian Nurses Association. (2002). Code of ethics for registered nurses. Ottawa, ON: Author. College and Association of Registered Nurses of Alberta. (2003). Nursing practice standards. Edmonton, AB: Author. Communicable Diseases Regulation, 206/2001, Alta. Reg. Cutter, J. & Jordan, S. (2004). Uptake of guidelines to avoid and report exposure to blood and body fluids. Journal of Advanced Nursing, 46(4), Department of Health & Human Services Centers for Disease Control and Prevention. (2003). Exposure to blood: What health-care personnel need to know. Atlanta, GA: Author. Diaz-Mitoma, F., Paton, S. & Giulivi, A. (2001). Hospital infection control and bloodborne infective agents. Canada Communicable Disease Report, 27(S3). Gammon, J. & Gould, D. (2005). Universal precautions: A review of knowledge, compliance and strategies to improve practice. Journal of Research in Nursing, 10(5), Government of Alberta. (1995). The transmission of HIV and other blood-borne infectious diseases in health care settings: Summary report and recommendations of the Review Committee. Edmonton, AB: Author. Health Canada Laboratory Centre for Disease Control. (1997). Preventing the transmission of blood-borne pathogens in health care and public service settings. Canada Communicable Disease Report, 23 (S3). 5

8 Health Canada Laboratory Centre for Disease Control. (1998). Proceedings of the consensus conference on infected health care workers: Risk for transmission of bloodborne pathogens. Canada Communicable Disease Report, 24 (S4). Health Canada Laboratory Centre for Disease Control. (1999). National surveillance of occupational exposure to the human immunodeficiency virus (HIV). Ottawa, ON: Author. Health Canada Laboratory Centre for Disease Control. (1999). Routine practices and additional precautions for preventing the transmission of infection in health care. Canada Communicable Disease Report, 25 (S4). Lymer, U., Richt, B., & Isaksoon, B. (2003). Health care workers action strategies in situations that involve a risk of blood exposure. Journal of Clinical Nursing, 12, McCoy, K. D., Beekmann, S. E., Ferguson, K. J., Vaughn, T. E., Torner, J. C., Woolson, R. F., & Doebbeling, B. N. (2001). Monitoring adherence to standard precautions. American Journal of Infection Control, 29(1), Moloughney, B. W. (2001). Transmission and post-exposure management of blood-borne virus infections in the health care setting: Where are we now? Canadian Medical Association Journal, 165(4), Osborne, S. (2003). Influences on compliance with standard precautions among operating room nurses. American Journal of Infection Control, 31(7), Public Health Act, R.S.A. 2000, c. P-37. Registered Nurses Profession Regulation, Alta. Reg. 232/2005. Society for Healthcare Epidemiology of America. (1997.) Management of healthcare workers infected with Hepatitis B Virus, Hepatitis C Virus, Human Immunodeficiency Virus, or other blood-borne pathogens. Infection Control and Hospital Epidemiology, 18(5), Tinmouth, A. (1993). The HIV-positive health care worker and testing for HIV. Canadian Medical Association Journal, 148(2),