Although rare in a dental office, an exposure to blood or bloody saliva requires fast action on the part of many people in the practice. This is truly an example of the need for pre-planning and education of all staff at risk.
Before moving on to the process of responding to an exposure, addressing prevention is always important in the over-all review. Prevention must be at the top of your priority list and should include training on the appropriate use of personal protective equipment, use of engineering controls including safety devices, and appropriate surface disinfection. Worker safety should be a part of the culture in every practice and as such may lead to the prevention of an exposure event.
The potential routes of exposure include:
• Stick with a contaminated needle.
• Stick with a contaminated sharp object, for example, scalers, surgical instruments, or scalpel blades.
• Splash to the mucous membranes of the eyes, nose, mouth.
• Splash to non-intact skin.
Once the exposure occurs the clock literally starts ticking. Employees must know the correct measures to take, and how and to whom to report the incident. Your practice should have a health care provider identified in advance who can provide an immediate medical evaluation and counseling of your worker and testing of the source patient.
When establishing the relationship for the healthcare provider consider the following items in your selection process.
• Ease of access for both the worker and the source patient.
• Potential wait times to be seen.
• Ability to obtain the rapid HIV test for the source patient.
• Availability of post exposure medication if indicated for the employee.
First, we will address the care needed for the source patient, then move to the exposed worker. Finally, we will review a scenario with an unknown source exposure.
Source Patient Testing Process
1. Dental practices must have a process identified for source patient testing. After informing the patient of the exposure and obtaining consent, immediate access to care is necessary. If the source patient refuses testing, contact your local health department for assistance.
2. A Rapid HIV test is the standard of care in an exposure situation and should be utilized if available. If rapid HIV is not available, expedite the HIV test. Post exposure prophylaxis (PEP) for the exposed worker, if necessary, should begin within hours for maximum effectiveness, according to the latest CDC guidance.
3. Hepatitis B Surface Antigen (HBsAG).
4. Anti-Hepatitis C virus (Anti-HCV).
5. The results of the source patient tests must be made available to the physician providing treatment to the exposed employee. Additionally, forward the results to any physician as requested by the source patient.
As a reminder, the cost of all source patient testing is the responsibility of the practice.
Care of the Exposed Employee
The employee should immediately wash the affected area with soap and water or flush the mucous membranes with copious amounts of water. As soon as the first step is completed the event should be reported. Follow these steps for the benefit of the exposed employee.
•Complete an incident report identifying the route(s) of exposures and the circumstances under which the exposure incident occurred.
•Make a confidential medical evaluation available immediately and follow-up, post exposure prophylaxis if indicated, and counseling by a qualified healthcare provider. This step is Bloodborne Pathogen standard.
•Obtain employee consent to treatment and any bloodwork which may be completed. If the worker does not choose to move receive testing or treatment, employers must get a signed declination of care to document that care was offered.
When sending the employee for care, bring the following information to the treating provider:
•Medical records relevant to the appropriate treatment of the employee including the information on Hepatitis B vaccinations and titers.
•A description of the employee’s duties as they relate to the exposure incident.
•Documentation of the exposure incident.
•A copy of the OSHA 1910.1030- Bloodborne Pathogen Standard.
Baseline bloodwork may be drawn on the exposed employee if indicated. If the source patient is negative for any disease, testing is not required for the exposed employee. Determination of the need for testing should be based on current CDC Guidelines. Provide the name of the healthcare professional treating the source patient if different than the provider for the exposed worker, to ensure communication occurs between treating providers.
Unknown Source Exposure
The same standards apply to the care provided for the exposed worker as with any other known source exposure. Make a risk evaluation to determine the risk of potential transfer of disease based on patient population and type of exposure to determine if post exposure prophylaxis is indicated.
The following tests should be obtained initially and for up to a six-month period of time:
• HIV Antibody
• Hepatitis B Surface Antigen (HBsAG)
• Anti-Hepatitis C Virus (Anti-HCV)
One of the final steps required by OSHA 1910.1030(f)(5) is a letter sent to the employer of the exposed employee within 15 days of the initial treatment by the treating provider. This letter should only indicate the following:
• that the employee has been informed of the results of the evaluation; and
• that the employee has been told about any medical conditions resulting from exposure to blood or other potentiallyinfectious materials which require further evaluation or treatment.
All other findings or diagnoses are confidential and should not be included in the letter. The exposed employee must be provided a copy of this letter as well.
To save time, prepare packets in advance with documentation and blank report forms for employees to fill out if an exposure occurs. Preparation will make it easier for everyone to provide and receive post exposure care.
Confidentiality is extremely importance in an exposure event. As a general rule, the Safety Officer is the only person who has access to the confidential medical information stored in the employees’ medical file and should facilitate the care received by the exposed employee and source patient.
Hopefully an employee in your practice will never experience an exposure event, but advance planning and training can ensure care is provided to both the source patient and practice employee in timely and efficient manner.
Total Medical Compliance is an endorsed partner of the Georgia Dental Association. To learn more, visit GDAplus.com/tmc
Karen Gregory, RN is the Director of Compliance and Education for Total Medical Compliance. TMC is a private consulting company providing affordable turnkey programs and seminars for health care providers in the Southeast to achieve and maintain compliance with government safety and privacy regulations such as HIPAA, OSHA and Infection Control. A TMC consultant works in partnership with the safety and privacy officers at your location to ensure all aspects of the regulations are addressed. TMC provides on-site employee training, customized compliance manuals, office inspections and ongoing support with newsletters and customer service. Information on seminar schedules and products can be found on the TMC web site TotalMedicalCompliance.com. For additional information call 888-862-6742 or email Karen@totalmedicalcompliance.com.