Download Disclosure and Reporting of Infection with Blood-Borne

Disclosure and Reporting of
Infection with Blood-Borne
Pathogens: Guidelines for
Registered Nurses
December 2006
Approved by the College and Association of Registered Nurses of Alberta (CARNA) in
December 2006.
Permission to reproduce this document is granted; please recognize CARNA.
College and Association of Registered Nurses of Alberta
11620 – 168 Street
Edmonton, AB T5M 4A6
Phone:
Fax:
E-mail:
Website:
(780) 451-0043 or 1-800-252-9392 (Canada-wide)
(780) 452-3276
[email protected]
www.nurses.ab.ca
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 clients1 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
contact with blood/body fluids containing visible blood by a needle stick or
splash onto mucous membranes or non-intact skin
exposureprone
procedures
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,
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The term ‘client’ can refer to patients, residents, families, groups, communities and populations.
1
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.
2.
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.
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.
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
2
Any registered nurse who has reason to believe that they have been
exposed to blood-borne pathogens through either occupational or non-
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 HealthCare 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.
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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).
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