New SHEA guidelines relax restrictions on tasks performed by infected workers
Occupational health practitioners assigned major role
Health care workers infected with hepatitis C virus (HCV) or human immunodeficiency virus (HIV) should be allowed to perform any patient care activities, including invasive procedures, without informing patients of their infections unless they have been incriminated in an infection transmission incident, according to a new position paper issued by the Society for Healthcare Epidemiology of America (SHEA).1
Updating its 1990 guidelines,2 SHEA also recommends that hepatitis B virus (HBV) e-antigen-positive HCWs routinely double-glove and avoid patient care activities that have been epidemiologically identified as associated with a risk for provider-to-patient HBV transmission despite the use of appropriate infection control procedures, such as cardiac and major pelvic surgery.
SHEA also recommends against:
• routine mandatory testing for providers;
• competence-monitoring procedures directed at infected workers;
• pathogen-specific educational requirements for infected providers.
Instead, the recommendations call for giving all providers and trainees comprehensive education concerning bloodborne pathogens, and for managing infected providers in the context of a comprehensive approach to the management of all impaired providers. (See specific recommendations, p. 88.)
In emphasizing the importance of worker privacy and medical confidentiality, SHEA calls on hospital occupational health departments to segregate infected workers’ medical records from routine hospital medical records, to exclude information about the HCWs’ condition from the institutional computer system, and to generally lead the way in placing "the highest premium" on maintaining HCW privacy throughout the institution.
In addition, occupational health departments are assigned a central role in managing infected workers. "Healthcare institutions should develop comprehensive occupational health programs to manage impaired HCWs, including evaluation of workers’ fitness for duty, based on competence, ability to perform routine duties, and compliance with established guidelines and procedures," the recommendations state. Employee health programs are advised to establish a liaison with an infected HCW’s private physician to stay informed about the worker’s condition.
More resources for employee health
"Any worker who is ill or has any kind of handicapping condition needs to have some practitioner, usually a physician, looking after his or her health, and in the ideal world the occupational health service of the institution would form a liaison with the practitioner caring for a worker to be able to share information about the worker’s status," says Michael L. Tapper, MD, chairman of SHEA’s AIDS/TB Committee, which developed the guidelines. "If appropriate modifications of work are necessary temporarily or permanently, that information can be shared in a confidential fashion."
The importance of a health care institution’s occupational health service in managing infected workers cannot be overemphasized, Tapper says. Instead of downsizing or downplaying a department’s significance, hospitals should be infusing employee health services with more resources, he tells Hospital Employee Health.
"Particularly nowadays, it’s essential to put resources into occupational health services, both in staffing and dollars, to bring them up to speed in terms of support, computer services, and access to the most recent information to do the things they’re being charged to do," says Tapper, who also is hospital epidemiologist and chief of infectious diseases at Lenox Hill Hospital in New York City. "We’re asking people in occupational health services to make very complicated decisions about some very difficult issues on the limits of knowledge and science with respect not only to HIV- or hepatitis B-infected workers, but also in respect to post-exposure prophylaxis and evaluation of source patients. We need to put the resources at their disposal to enable them to do the job we’re asking them to do."
Kathleen VanDoren, RN, BSN, COHN-S, executive president of the Reston, VA-based Association of Occupational Health Professionals in Healthcare, is pleased that the SHEA position paper recognizes the importance of hospital occupational health programs.
"I was glad to see the recommendations emphasize the need for a central area that is monitoring the whole infected health care worker management program, and that the central area is the occupational health department," she says. "Occupational health overlaps every hospital department, whether it comes to practice or surveillance. We have a huge responsibility."
When one person the occupational health manager is primarily responsible for maintaining worker confidentiality, breaches are unlikely to occur, VanDoren states. She suggests filing records according to a private coding system and not directly identifying a worker’s infection when charting in the confidential medical record.
"The more fingers in the pie, the more chance of breaking confidentiality," she notes.
New information prompted update
Tapper says SHEA decided to update its 1990 recommendations based on seven years of additional experience and information about the risks of provider-to-patient transmission of HIV and other bloodborne pathogens. Reports in the literature have shown very low risk of HCW-to-patient HIV transmission, with only two documented cases, one involving a Florida dentist and another a French orthopedist.3-5 A major change in the updated guidelines relates to the earlier version’s proscription against HIV-infected workers performing certain procedures identified as exposure-prone for hepatitis B transmission.
"At the time, the only model we had for risk of transmission was hepatitis B, so in making recommendations we depended very heavily on a small group of procedures identified as a risk for hepatitis B transmission, and we thought HIV-infected workers should on a voluntary basis refrain from doing those procedures," he explains. "The major change here is that we removed that caveat and basically said there should be no a priori restrictions whatsoever on any procedure by an HIV-infected health care worker who understands basic infection control and has no evidence of cognitive impairment."
On the other hand, there has been more evidence on the risk of hepatitis B transmission by e-antigen-positive HCWs, he adds, citing several clusters of provider-to-patent HBV transmission in the past several years in the United States and elsewhere.6
Workers who are HBV e-antigen-positive, even those who take appropriate infection control precautions, still can transmit infection under certain circumstances, Tapper says, so the position paper is more restrictive toward those workers. Only two cases of HCW-to-patient HCV transmission have been documented,7,8 and SHEA estimates the hospital-associated transmission risk as "intermediate between the HIV and HBV risk."
In recommending that HIV-infected workers be permitted to perform even so-called exposure-prone procedures without restriction, the SHEA guidelines break with the federal Centers for Disease Control and Prevention’s current recommendations for preventing HIV and HBV transmission, which were issued in 1991.9 CDC guidelines call for invasivists (i.e., surgeons) who are infected with HIV or HBV e antigen to go before expert review panels and to inform prospective patients.
The SHEA paper identifies several "problematic" aspects of the CDC guidelines:
• the difficulty of defining or classifying exposure-prone procedures;
• the requirement that infected practitioners notify prospective patients of their status;
• the legal and administrative implementation strategies concerning expert review panels.
"Current CDC guidelines were issued in incomplete form based on these so-called exposure-prone procedures," Tapper says. "That group of procedures has never been defined because surgical specialty societies and other groups were not able to agree on what constituted an exposure-prone procedure."
But one of the biggest "sticking points" has been the CDC’s recommendation that patients of infected providers be notified prior to exposure-prone procedures, which SHEA has never supported, he adds. Transmission risk is so small and "the jeopardy to an infected HCW’s career is so overwhelming that routine disclosure does not appear justified," the SHEA recommendations say.
CDC considering revisions
The CDC’s position has spawned legal problems for hospitals and providers, Tapper notes, with actions filed against infected HCWs, not for infecting patients but for causing mental anguish, "pain and suffering," or failure to comply with the "duty to warn" the patient of risk. Even if those lawsuits are unsuccessful, some HCWs have lost their privileges to perform certain procedures because their infection status became known and hospitals feared liability.
Those issues prompted SHEA to update its recommendations, and might also spur the CDC to do the same.
"In any area of controversy, such as the HIV-infected worker, there’s always a tendency to let sleeping dogs lie, and since there has not been a lot of concern and hullabaloo in the press recently, then there’s always a certain sentiment and I think the CDC reflects this not to get into some of these sticky wickets over and over again," Tapper says.
But in fact the CDC has begun reviewing its 1991 guidelines, although officials have not decided whether revisions are warranted, says Denise Cardo, MD, acting chief of the HIV infections branch of the hospital infections program at the CDC.
"The guidelines are being reviewed, but we don’t know exactly what’s going to happen yet," she says. "We started the process of reviewing the whole thing because of new available data regarding HIV and hepatitis B and also because in the 1991 guidelines we didn’t say anything about HCV. Everyone [at CDC] is aware of all the new information and some of the limitations of the guidelines, but the outcome has not been decided yet."
Cardo expects that any new guidelines resulting from the review process would be released around the end of the year. Also later this year, the CDC’s Hospital Infection Control Practices Advisory Committee plans to issue a preliminary version of its updated Guidelines for Infection Control in Health Care Personnel, which could incorporate any revisions to the agency’s bloodborne pathogens guidelines.
References
1. AIDS/TB Committee of the Society for Healthcare Epidemiology of America. Management of healthcare workers infected with hepatitis B virus, hepatitis C virus, human immunodeficiency virus, or other bloodborne pathogens. Infect Control Hosp Epidemiol 1997; 18:349-363.
2. Rhame FS, Pitt H, Tapper ML, et al. Position paper: The HIV-infected health care worker. Infect Control Hosp Epidemiol 1990; 11:647-656.
3. Centers for Disease Control. Possible transmission of human immunodeficiency virus to a patient during an invasive dental procedure. MMWR 1990; 39:489-493.
4. Centers for Disease Control. Update: Transmission of HIV infection during an invasive dental procedure Florida. MMWR 1991; 40:21-33.
5. National Public Health Network of France (Reseau National de Sante Publique). HIV transmission from an orthopedic surgeon to a patient. 1997; press release.
6. Bell D, Shapiro CN, Chamberland ME, et al. Preventing bloodborne pathogen transmission from healthcare workers to patients: The CDC perspective. Surg Clin North Am 1995; 75:1189-1203.
7. Esteban JI, Gomez J, Martell M, et al. Transmission of hepatitis C virus by a cardiac surgeon. N Engl J Med 1996; 334:555-560.
8. Public Health Laboratory Service. Hepatitis C transmission from health care worker to patient. PHLS Communicable Disease Report 1995; 5:121.
9. Centers for Disease Control. Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures. MMWR 1991; 40(RR-8):1-9.
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