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Policy

Blood Borne Pathogens Policy

Categories: Pathogens blood borne resident safety PGME

Background

Postgraduate medical education trainees (residents) are physicians and their activities are guided by a variety of agencies including, but not limited to, the University of Saskatchewan, the College of Physicians and Surgeons of Saskatchewan (CPSS), the Canadian Medical Association (CMA) and regional health authorities.

Residents hold educational licenses with the CPSS and as such are governed by their policies related to Blood Borne Pathogens.

Scope

All residents enrolled in a residency training program at the University of Saskatchewan.

Definitions – identified below and as in accordance with policies established by the College of Physicians and Surgeons of Saskatchewan

Blood Borne Pathogens: Hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), acquired immune deficiency syndrome (AIDS)

Exposure Prone Procedure (as defined by CPSS): “Exposure prone procedures are those where there is a risk that injury to the physician may result in the exposure of the patient’s open tissues to the blood of the physician (bleedback). These include procedures where the physician’s gloved hand may be in contact with sharp instruments, needle tips or sharp tissues (spicules of bone or teeth) inside a patient’s open body cavity, wound, or confined anatomical space where the hands or fingertips may not be completely visible at all times”

Non-Exposure Prone Procedures (as defined by CPSS): “Procedures where the hands and fingertips of the physician are visible and outside the patient’s body at all times, and internal examinations or procedures that do not involve possible injury to the physician’s gloved hands from sharp instruments and/or tissues, are considered to be non-exposure prone provided routine infection control procedures are adhered to at all times.”  Examples of such procedures include:

  • The drawing of blood
  • Setting up and maintaining intravenous lines or central lines provided that there has been no skin tunneling and the procedure is performed in a non-exposure prone manner
  • Minor surface suturing
  • The incision of external abscesses
  • Routine vaginal or rectal examinations
  • Simple endoscopic procedures

A decision as to whether an affected physician should continue to perform a procedure which in itself is not exposure prone should take into account the risk of complications arising which might necessitate the performance of an exposure prone procedure. Such procedures should be performed in the cooperative patient only. Such procedures in the uncooperative patient are considered to be exposure prone procedures.

Policy

Postgraduate Medical Education, College of Medicine, University of Saskatchewan endorses the CPSS governing process and policies.

All residents have an ethical obligation to know their serological status for BBPs and are advised to undergo repeat testing when circumstances warrant (i.e. engaging in personal at risk behavior or potential exposure to a BBP).

Moonlighting, electives, global health experiences, program transfers, etc. will be guided by this expectation as well.

Process

Residents are required to self-disclose blood borne pathogens or infections directly to the College of Physicians and Surgeons of Saskatchewan at 306-244-7355 in Saskatoon.

Residents self-report to the Medical Director of the Blood Borne Virus Program of the College of Physicians and Surgeons of Saskatchewan. An Expert Advisory Committee reviews the procedures the resident will perform according to the level of risk for blood borne pathogen transmission, and issues recommendations with respect to training modifications required to accommodate the resident in keeping with precautions deemed appropriate to protect the public and patients from risk of harm.

Any necessary restrictions/modifications are identified and communicated to the resident who is required to notify the appropriate College of Medicine authority (i.e. Program Director) who will assist in assessing whether modification of training requirements is necessary in order to comply with the recommendations of the Expert Advisory Committee. Residents are required to notify their respective Program Directors, and will be required to notify their preceptors on a need-to-know basis.

For patient safety and to accommodate learning, the CPSS will assist the resident to disclose positive serology results directly to the Program Director and Associate Dean, Postgraduate Medical Education.

The Medical Director will obtain written commitment of compliance, and will implement strategies for effective continuous monitoring of the resident’s compliance with the recommendations. If the resident is non-compliant with any of the recommendations made by the Expert Advisory Committee, the CPSS will utilize its statutory authority to insure compliance or take other measures which protect the public’s interest.

Should the resident not disclose his/her condition, the Program Director has an ethical responsibility to report the condition to the College of Physicians and Surgeons of Saskatchewan. The Registrar/Associate or Deputy Registrar is also available for consultation and advice on dealing with such situations.

Residents must also refer to the blood borne pathogens occupational exposure management procedures of the host health care institution for medical testing and follow-up processes.

 

CPSS Policy/Guidelines are subject to change in order to align with national standards and policies.- Contact CPSS for most current policies at (306) 244-7355