Approved by Council: November 1998
Reviewed and Updated: September 2005, May 2012, December 2015
Companion Resource: Advice to the Profession
- Classification of BBP Exposure Risk for Otolaryngology–Head and Neck Surgery
- Results from the most recent consultation
Policies of the College of Physicians and Surgeons of Ontario (the “College”) set out expectations for the professional conduct of physicians practising in Ontario. Together with the Practice Guide and relevant legislation and case law, they will be used by the College and its Committees when considering physician practice or conduct.
Within policies, the terms ‘must’ and ‘advised’ are used to articulate the College’s expectations. When ‘advised’ is used, it indicates that physicians can use reasonable discretion when applying this expectation to practice.
Blood Borne Viruses: Blood borne viruses (BBVs) refer to hepatitis B virus (HBV), hepatitis C virus (HCV), and/or human immunodeficiency virus (HIV).
Exposure Prone Procedures: The Centers for Disease Control and Prevention (CDC) defines an exposure prone procedure as one which involves one or more of the following:
- digital palpation of a needle tip in a body cavity (a hollow space within the body or one of its organs) or the simultaneous presence of the health-care worker’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, pelvic, vaginal and/or orthopaedic operations); or
- repair of major traumatic injuries; or
- manipulation, cutting or removal of any oral or perioral tissue, including tooth structures during which blood from a health-care worker has the potential to expose the patient’s open tissue to a blood borne pathogen.1
The College has adapted the list of procedures that have been identified in the SHEA Guideline for Management of Healthcare Workers Who Are Infected with Hepatitis B Virus, Hepatitis C Virus, and/or Human Immunodeficiency Virus as those for which there is a definite risk of blood borne virus transmission (Category III Procedures).
Examples of procedures that are classified as ‘exposure-prone’ are set out in Appendix A.
Routine Practices: Routine Practices refers to a set of practices designed to protect health-care workers and patients from infection caused by a broad range of pathogens including blood borne viruses. These practices must be followed when caring for all patients at all times regardless of the patient’s diagnosis. Key elements of Routine Practices include: point of care risk assessment; hand hygiene; use of barriers (e.g., personal protective equipment, such as gloves, mask, eye protection, face shield and/or gowns) as per the risk assessment; safe handling of sharps; and cleaning and disinfection of equipment and environmental surfaces between uses for each patient.
Routine practices are set out in Appendix B.
Treating Physician: For the purposes of this policy, treating physician refers to the physician who is managing the care of the seropositive physician with respect to their infection with a blood borne virus.
- Physicians must take steps to safeguard their own health and that of their patients, and report their own seropositive status to the College in accordance with the requirements of this policy.
- Physicians must comply with the expectations set out in this section, as well as other precautionary measures, as required and as recommended by their treating physician and relevant public health authorities.2
- Physicians must adhere to Routine Practices in accordance with Appendix B. This expectation applies equally to physicians who are seropositive for blood borne viruses, and physicians who are seronegative.
- Physicians who are not currently and have not previously been infected with HBV are strongly advised to be immunized for HBV and tested to confirm the presence of an effective antibody response03, unless a contraindication exists, or there is evidence of prior immunity.
- Physicians who do not respond to the vaccine (do not seroconvert as evidence of immunity) are advised to seek expert advice on alternative vaccination protocols in order to confirm the presence of an effective antibody response.
Testing for BBVs
Beginning Exposure Prone Procedures in Ontario
- Physicians4 who want to perform or assist in performing exposure prone procedures in Ontario5 must be tested for HCV, HIV and HBV, if they have not been confirmed immune to HBV, before they commence performing or assisting in performing exposure prone procedures in Ontario.
- Physicians who perform or assist in performing exposure prone procedures must be tested for HCV and HIV every three years.
- Physicians who perform or assist in performing exposure prone procedures must be tested annually for HBV unless the physician has been confirmed immune to HBV.
- Physicians who have been exposed to bodily fluids of unknown status through a specific incident, such as a needle prick, or splash onto a mucous membrane or non-intact skin must seek expert advice regarding the frequency of testing that is required to determine if they have been infected with one or more blood borne viruses and whether any post-exposure prophylaxis is necessary.
- Physicians are advised to consult the Blood Borne Diseases Surveillance Protocol for Ontario Hospitals6 and their own hospital’s protocols and/or policies for detailed information about post-exposure protocols, including post-exposure prophylaxis.
Reporting Serological Status
- Physicians who perform or assist in performing exposure prone procedures must report if they are seropositive with respect to HBV, HCV (including either HCV antibody or HCV RNA), and/or HIV through the completion of the Annual Renewal Survey.
- When physicians learn they are seropositive for HBV, HCV (including either HCV antibody or HCV RNA) and/or HIV they must report, outside the context of the Annual Renewal Survey. Physicians must make a report to the College as soon as is reasonably practical after learning of their status and not wait to report their status on the next Annual Renewal Survey.7
- Physicians8 who have tested positive for HBV, HCV (including either HCV antibody or HCV RNA), and/or HIV and who wish to begin performing or assisting in performing exposure prone procedures in Ontario or to continue performing or assisting in performing exposure prone procedures must be under the care of a treating physician who has expertise in the management of their infection (e.g., infectious diseases expert, hepatologist).
- Physicians who have tested positive for HBV, HCV (including either HCV antibody or HCV RNA), and/or HIV must undergo such regular testing as is recommended by their treating physician, and approved by the College for the purposes of monitoring their health, including their viral loads.
SHEA Guideline for Management of Healthcare Workers who are Infected with Hepatitis B Virus, Hepatitis C Virus, and/or Human Immunodeficiency Virus
Examples of Procedures Classified as Exposure Prone
The College has adapted the list of procedures that have been identified in the SHEA Guideline as those for which there is a definite risk of blood borne virus transmission (Category III Procedures). The list that follows sets out examples of procedures that are classified as ‘exposure prone’ for the purposes of the Annual Renewal Survey, and the Blood Borne Viruses policy:
- general surgery, including nephrectomy, small bowel resection, cholecystectomy, subtotal thyroidectomy, other elective open abdominal surgery;
- general oral surgery, including surgical extractions, hard and soft tissue biopsy (if more extensive and/or having difficult access for suturing), apicoectomy, root amputation, gingivectomy, periodontal curettage, mucogingival and osseous surgery, alveoplasty or alveoectomy, and endosseous implant surgery;
- cardiothoracic surgery, including valve replacement, coronary artery bypass grafting, other bypass surgery, heart transplantation, repair of congenital heart defects, thymectomy, and open-lung biopsy;
- open extensive head and neck surgery involving bones, including oncological procedures;
- neurosurgery, including craniotomy, other intracranial procedures, and open-spine surgery;
- nonelective procedures performed in the emergency department, including open resuscitation efforts, deep suturing to arrest hemorrhage, and internal cardiac massage;
- obstetrical/gynecological surgery, including cesarean delivery, hysterectomy, forceps delivery, episiotomy, cone biopsy, and ovarian cyst removal, and other transvaginal obstetrical and gynecological procedures involving hand-guided sharps;
- orthopedic procedures, including total knee arthroplasty, total hip arthroplasty, major joint replacement surgery, open spine surgery, and open pelvic surgery;
- extensive plastic surgery, including extensive cosmetic procedures (e.g., abdominoplasty and thoracoplasty);
- transplantation surgery (except skin and corneal transplantation);
- trauma surgery, including open head injuries, facial and jaw fracture reductions, extensive soft-tissue trauma, and ophthalmic trauma; and
- any open surgical procedure with a duration of more than three hours, probably necessitating glove change.
The information set out in this appendix consists of information found in Public Health Ontario’s documents set out in the references below.
The term “Routine Practices” (RP) refers to a set of practices designed to protect health-care workers (HCW) and patients from infection caused by a broad range of pathogens including blood borne viruses. These practices must be followed when caring for all patients at all times regardless of the patient’s diagnosis. Although RP are targeted to prevent transmission of microbes from patient to patient and HCW to HCW as well as between HCW and patient, the focus of this discussion is the transmission of microbes from HCW to patient and/or patient to HCW, in particular as related to the blood borne viruses hepatitis B (HBV), hepatitis C (HCV) and human immunodeficiency virus (HIV).
RP begin with a point of care risk assessment to consider the potential for microbial transmission during the upcoming process of care. This risk assessment is routinely followed by hand hygiene and donning of the appropriate barrier equipment (Personal Protective Equipment) prior to examining the patient. RP also include care in the use and disposal of needles and other sharp instruments, documented immunity/immunization against HBV as appropriate, and proper reprocessing of medical equipment. HCWs performing exposure prone procedures* are at an increased risk of infection with blood borne pathogens and must be knowledgeable about and diligently adhere to RP. The key elements of RP are discussed briefly below, and a glossary of terms appropriate to this document follows. For more information please check the appropriate reference(s).
Point of Care Risk Assessment
- The risk of exposure to blood, body fluids* and non-intact skin* must be considered by assessing the nature of the upcoming process of care, the patient, the HCW and the health-care environment.
- Strategies (e.g., choice of barrier precautions) must be identified and implemented to decrease exposure risk and prevent the transmission of microorganisms.
- Hand hygiene is the single most important measure to prevent the spread of infection.
- Hand hygiene refers to both washing with soap and water or the use of alcohol-based hand rubs (ABHR).
- Use of ABHR (70-90% alcohol) is the preferred method of cleaning hands when hands are not visibly soiled. Hand washing with soap and water must be performed when hands are visibly soiled.
- Hand hygiene must be performed:
- before initial patient/patient environment contact,
- before performing an aseptic procedure,
- after body fluid exposure risk and after gloves have been removed, and
- after patient/patient environment contact.
To prevent cross-contamination of different body sites, it may be necessary to perform hand hygiene between procedures on the same person.
- Medical grade gloves (clean, non-sterile gloves are adequate for routine care) must be worn when contact with blood/body fluids, secretions, excretions, mucous membranes*, non-intact skin and/or potentially contaminated items is anticipated.
- Gloves must be changed or removed after touching a patient’s contaminated body site and prior to touching the patient’s clean body site or the environment.
- Gloves must be removed promptly after use, followed by immediate hand hygiene.
Personal Protective Equipment: Mask, Eye Protection, Face Shield and Gowns
- Masks, eye protection (safety glasses, goggles or face shield) and/or gowns as appropriate to the type of contact anticipated must be worn in order to protect mucous membranes and/or clothing during clinical procedures, care activities or handling used medical equipment if splashes or sprays of blood, body fluids, secretions, or excretions might be generated.
- Sharps must be handled as minimally as possible.
- Needles must not be re-capped.
- Used needles and other sharps must be discarded in a specially designed sharps container.
- For specific requirements under Ontario’s needle safety legislation see the Occupational Health and Safety Act, O. Regulation 474/07, Needle Safety, available at: http://www.e-laws.gov.on.ca/html/regs/english/elaws_regs_070474_e.htm.
Cleaning and Disinfection of Equipment and Environmental Surfaces
- All used medical equipment must be cleaned and then disinfected or sterilized as appropriate prior to use on another patient.
- Equipment that enters sterile tissues, including the vascular system is referred to as a critical device and must be sterilized after cleaning.
- Equipment that comes in contact with non-intact skin or mucous membranes but does not penetrate them is referred to as a semi-critical device and requires high level disinfection after cleaning.
- Equipment that touches only intact skin and not mucous membranes, or does not directly touch the patient is referred to as a non-critical device and requires low level disinfection after cleaning.
- Single-use items must be discarded after use and never be reprocessed.
*Body fluids: blood, vomit, stool, semen, vaginal fluid, urine, CSF, peritoneal fluids, pleural fluids, droplets from coughing or sneezing, except sweat, regardless of whether or not they contain visible blood.
*Mucous membranes: lining of the eyes, nose and mouth.
*Non-intact skin: open lesions, and dermatitis.
Public Health Ontario. Ministry of Health and Long-Term Care of Ontario. Routine practices and additional precautions in all health care settings. November 2012
Public Health Ontario. Ministry of Health and Long-Term Care of Ontario. Best practices for hand hygiene in all health care settings. April 2014
Public Health Ontario. Ministry of Health and Long-Term Care of Ontario. Best practices for cleaning, disinfection and sterilization of medical equipment/devices. May 2013.
4. This includes physicians who perform or assist in performing procedures that may become exposure-prone (for example, a laparoscopic procedure that may convert to an open procedure) and also includes physicians who have the potential to perform or assist in performing exposure prone procedures in the course of providing day-to-day care (e.g., emergency medicine physicians) even though they may not be currently performing them.
5. This applies to new registrants (including physicians who perform or assist in performing exposure prone procedures in other jurisdictions), physicians who will begin performing or assisting in performing exposure prone procedures as part of their educational training, and physicians who are changing their scope of practice or re-entering practice. Physicians may wish to consult the Ensuring Competence: Changing Scope of Practice and/or Re-entering Practice policy for more general guidance on these topics.
6. This document is available at: https://www.oha.com/Documents/Blood%20Borne%20Diseases%20Protocol%20(November%202018).pdf
8. This includes physicians who wish to perform or assist in performing procedures that may become exposure-prone (for example, a laparoscopic procedure that may convert to an open procedure) and also includes physicians who will have the potential to perform or assist in performing exposure prone procedures in the course of providing day-to-day care even though they may not be currently performing them.