Infection Control/OSHA Compliance for Dental Personnel - PowerPoint PPT Presentation

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Infection Control/OSHA Compliance for Dental Personnel. Katherine West,BSN,MSEd,CIC Infection Control Consultant. Objectives. Review laws & regulations pertaining to dental practice Review bloodborne pathogens & TB Define Exposure Describe the process for post exposure medical management

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Infection Control/OSHA Compliance for Dental Personnel

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Infection Control/OSHA Compliance for Dental Personnel

Katherine West,BSN,MSEd,CIC

Infection Control Consultant

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  • Review laws & regulations pertaining to dental practice

  • Review bloodborne pathogens & TB

  • Define Exposure

  • Describe the process for post exposure medical management

  • List infection control practices for daily dental practice

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Laws & Regulations

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Laws - Regulations

  • OSHA Bloodborne Pathogens

  • OSHA – CDC TB Guidelines 2005

  • CDC Guidelines for dental practice - 2003

  • Needlestick Safety & Prevention Act

  • State laws

    • HIV

    • Medical Waste

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OSHA Bloodborne Pathogens



2001 (update)

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Updated Standard

  • Federal Standard

    • 1/18/2001

      • Needle Safe Devices

      • Sharps Injury Log

      • CPL 2-2.69 (Compliance Directive)

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Exposure determination


Hepatitis B Vaccine Program/ TB skin testing

Personal Protective Equipment

Engineering controls

Post-exposure Management

Medical Waste Management

Compliance monitoring


Exposure Control Plan

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HCCDC Definition

  • Health-care personnel - employee, student, contractor, attending clinician, public-safety worker, or volunteer whose activities involve contact with blood/OPIM

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Infection Control Concepts

  • Universal Precautions

  • Body Substance Isolation

  • Standard Precautions**

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Exposure Control Plan

  • Readily accessible at the worksite

  • Copy in 15 days if requested

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Plan -Review Process

  • Annually (at least every 12 months)

  • And, Whenever -

    • new procedures

    • employee positions (at risk)

    • new tasks

    • document consideration/implementation of effective engineering controls

Comp Dir. ,1999, 2001 OSHA

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Training Clarification

  • New hire training

  • Annual update training

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Annual Training

  • Refresher training must cover topics listed in the standard to the extent needed and must emphasize new information or procedures

OSHA, 1910.1030

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“Qualified Instructor”

  • Work experience in subject matter area

  • Degree in subject matter area

  • Certificate of additional specialized training

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CDC Guidelines

  • The law of the land

  • OSHA enforcing many of them

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Work Restriction - Guidelines

  • CDC published 1997

  • Don’t come to work sick

    • Risk to co-workers

    • Risk to patients/clients

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Needlestick Safety and Prevention Act, P.L. 106-430

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Needle Safe - Dental

  • Self-sheathing anesthetic needles

  • Dental units designed to shield burs

  • Blunt suture needles

  • Engineered butterfly needles

CDC. 2003

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  • Deposit into sharps container

  • Container at site of use

  • Full at 3/4 mark

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Exposures – 2008

  • 20 contaminated sharps injuries reported

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Medical Waste Regulations

  • State laws prevail

    • Ohio (OAC) 33745-27 and 3745-37

      • Does not include patient care waste

      • Does include sharps/glass

  • Copy in Exposure Control Plan

    • Include in training

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Post Exposure Management

  • Must be done outside the dental practice

    • confidentiality

CDC, 2003 , OSHA

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Patient Consent to Testing

  • State law controls

    • Informed consent/deemed consent

  • OSHA bloodborne pathogens protocol

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Ohio Testing Law

  • Consent with exception

    • Healthcare worker exposure

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Patient Consent

  • Have consent signed when patient comes in as a new patient

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OSHA – Rapid HIV Testing

  • OSHA states that “an employers failure to use rapid HIV testing when testing is required by paragraph (f)(3)(ii)(A) would usually be considered a violation of that provision”

OSHA Letter, July 21, 2006

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Rapid HIV Tests

Blood - Rapid HIV Test - currently available





CDC January 2007

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Testing Issues - Post Exposure

  • If source patient is negative with rapid testing = no further testing of health-care worker

  • Use of rapid testing will prevent staff from being placed on toxic drugs for even a short period of time

  • CDC, May , 1998, CDC June 29, 2001, September 2005

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Declination Form

  • Decline to follow medical advice for exposure follow up treatment

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OSHA Enforcement

  • CDC post exposure guidelines

  • TB Guidelines

  • Vaccinations/immunizations

  • Work restriction guidelines

  • Hand Hygiene guidelines

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Understanding Risk

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Formula For Infection




Mode of




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IIncubation Period

  • Time following exposure until the onset of signs/symptoms

  • Time one can transmit the disease to others

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Exposure Does NOTMean Infection

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Disease Review

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Hepatitis B - Transmission

  • Blood

  • Sexual Transmission

  • Indirect - contaminated objects

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Hepatitis B

  • Measurable Risk Data –

    • Needlestick injury

      • 6% - 30% in the non-vaccinated healthcare worker who does not report an exposure

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Hepatitis B Infection

  • 50% - 60% of infected persons have no outward signs or symptoms of the disease

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Hepatitis B Long Term Effects

  • Chronic Carriers - 10%

    • Chronic Active Hepatitis - 3% - 5%

    • Cirrhosis

    • Liver Cancer

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Hepatitis B - Prevention

  • Vaccines -

    • Heptavax HB

    • Recombivax HB

    • Engerix - B

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Hepatitis B Vaccines

  • Safe Effective Recombinant - NO human factors

  • Allergy Issues - Yeast & Thimersol

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Hepatitis B Vaccine

  • CDC - 1992

    • Vaccine is safe for women who are pregnant, thinking of becoming pregnant or who are breast feeding

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Hepatitis B Vaccine Series

  • OSHA-

    • To be administered within 10 days of assignment to a risk position

    • Administered after education and training

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Hepatitis B Vaccine

  • Informed Denial

  • Informed Consent

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Titer – Blood test

  • Required- employer pay

  • 1-2 months after completion of vaccine series

  • Once positive titer on file- no need to titer even post exposure

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Hepatitis B Vaccine

  • Offers protection via “immunologic memory”

  • There is NO formal requirement or recommendation for a booster

    • CDC, 1992,1997, 2001, 2006

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Universal Vaccination

  • Healthcare workers- 1982

  • All newborns – 1990

  • All high school/college students – 2000

  • All persons - 2006

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HBV Infection Rate- US

  • 0.4%

CDC, September, 2008

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Hepatitis C Viral Infection

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Hepatitis C - Transmission

  • Blood

    • IV drug use*

    • Mother to infant

    • Intranasal cocaine use

  • Sexual Contact

    • High-risk sexual practices

NIH/CDC, 2008

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CDC- Tattoos & Body Art

  • CDC has published info on website


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Hepatitis C Cases

Incident rate continues to decline

  • Rate in US- 1.3%

  • September, 2008

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Hepatitis C - Occupational Risk

  • Primary risk related to needlestick injury- 1.5%

  • One reported case of transmission via splash into the eye (1997)

  • One transmission via non-intact skin (1999)

    • CDC, July 28,2000, & June 29,2001, March 21, 2008

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Hepatitis C - Testing

  • Antibody testing had a high rate for false-positives

  • Now, other more accurate testing is available

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  • New rapid test for HCV

  • Takes 23 mins.

  • More accurate than other antibody tests

  • Performed on the source !

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Confirmatory Test

  • RIBA - recombinant immunoblot assay

  • required after a positive EIA

CDC, 1999, 2001

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Reminder -

  • If you are exposed to a hepatitis C positive patient, you should have a blood test in 4- 6 weeks

  • HCV-RNA (blood test)

    • $65.00

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Hepatitis C – Early Treatment

  • Studies – Germany & France

    • HCV-RNA positive begin treatment

    • 24 weeks – clear viral load

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Modes of Transmission

  • Primary

    • Sexual

    • Blood

    • Mother to Infant

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Modes of Transmission

  • Secondary

    • Contaminated blood products

    • Occupational exposure

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Infected Healthcare Workers- Occupational Infection-HIV

  • 1978 - December 2006

    • 57* documented cases

      • 0 in dental personnel

      • 49 were sharps related exposures

HIC, Jan., 2007(CDC)

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No new cases since 2000

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HIV Virus- Survival

  • HIV is unable to reproduce itself outside the living host, except under laboratoryconditions ,therefore it does not spread or maintain its infectiousness outside the host

CDC, 1980

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  • Availability of the quick test on the source patient in an exposure may prevent the unnecessary administration of chemoprophylaxis in the health care worker

CDC, May 1998, June 2001, Sept. 2005

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Rapid Testing

  • Sensitivity - 99.9% (false negatives)

  • Specificity - 99.6% (false positives)

  • No false positives

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Sharps injury

Mucous membrane

Non-intact skin



one in prospective studies (1999)

Risk Data - HIV

Sept., 2005

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Viral Load Testing

Key to risk - dose related

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  • HIV positive for 16-20+ years

  • Never ill

  • Immune system intact

  • No virus in blood

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Gene Issues - HIV

  • Mutation of the second receptor CCR5 and are resistant to HIV infection

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New Treatments

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Cocktail Mixture

  • AZT, (ZDV)

  • 3TC and

  • Protease inhibitor

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AIDS Cocktail

  • Combination of 2, 3 or 4 drugs

  • Stops HIV from producing new virus in some patients

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  • Now a chronic disease for many infected persons

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Fla. Dentist Case

  • No testing by genetic sequencing showed support for a link between virus strains

Annals of Internal Medicine, Dec. 1994

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Syphilis Cases

  • Continue to rise in the U.S.

  • Post exposure follow up if source is HIV positive or Hepatitis C positive

  • Low risk

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Highest States for cases - 2007

  • District of Columbia

  • California

  • Maryland

  • Georgia

  • Texas

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CDC - Plan

  • Update plan to eliminate syphilis by 2015

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Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings

December 30, 2005

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Risk Assessment

  • Based on new formula

  • Three listings

    • Low risk

    • Medium risk

    • Potential for on-going transmission

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  • HIPAA permits disclosure of TB information

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Low Risk

On hire

2 step with TST or QFTB-Gold( blood test)

Post exposure testing

Medium Risk

On hire

2 step or QFTB-Gold

Annual Testing

Post exposure testing

Testing Recommendations

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Define Exposure

Bloodborne Pathogens

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Defining Exposure - Bloodborne Pathogens

  • A contaminated Needlestick Injury

  • Blood/OPIM in contact with the surface of the eye, inner surface of the nose or mouth

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Defining Exposure- Bloodborne Pathogens

  • Blood/OPIM in contact with an open area of the skin

  • Cuts with sharp objects covered with blood/OPIM

  • Human bites (bloody)

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Synovial fluid

Pleural fluid

Amniotic fluid

Peritoneal fluid

Any body fluid containing gross visible blood

Define - Other Potentially Infectious Materials -OPIM

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Nasal Secretions


Non -Risk Body Fluids, HIV, HBV,HCV

  • CDC, May 15, 1998, June 29, 2001, Sept. 2005

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Define Exposure - TB

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Tuberculosis - Transmission

  • Inhalation of droplets from an infectious patient

  • Contact time

  • Ventilation present

  • Your health status

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OSHA & TB- Dental

  • dental offices = low risk

    • Do not perform “cough inducing” procedures

OSHA Review October, 2008

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Safe Work Practices/Basic Infection Control

Additional protection

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Routine Immunizations

  • HBV Vaccine

  • MMR

  • Tdap

  • Chickenpox Vaccine

  • Flu Vaccine

CDC, 1997, OSHA,1999,2005

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Tdap -

  • All health care workers

    • 1X dose

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Hands - CDC/OSHA

  • Non intact skin - cover with a dressing

  • If too large to cover, restrict from risk task activities

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Major protective measure

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CDC New Requirements

  • No antibacterials for routine handwashing

  • No artificial nails or extensions

  • Use alcohol based foams or gels

CDC, October 25, 2002

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destroying or hindering the growth of bacteria


preventing or destroying the development of microbes

kills viruses

Definition of Terms

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Cleaning Solutions

  • Check label claims

    • EPA registered

    • Bleach & water

      • 1:100

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Surface Cleaning

  • Tuberculocidal level cleaners are not required for routine surface cleaning

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New Skin Prep Recommendation

  • Chlorohexidine

    “ CHG reduces skin microflora more effectively and better

    residual activity than povidone-iodine after a single application”

APIC 2005

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  • When in contact with:

    • patient mucous membranes

    • contaminated surfaces

    • Patient open wounds

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  • Mask & Eyewear

  • Face shield

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  • If a pullover style is worn -

    • if large amount of contamination, the employee is to be trained how to remove without contact to the face

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  • Remains under employer “control”

  • Washer/dryer in office

    • No special water temp (120-160)

    • No additive needed

  • Contract

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Shoe Safety

  • Not permitted in work areas where there is danger of foot injuries due to falling, rolling, or piercing objects

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  • In closed dispensers

  • Wash before refilling

  • Use only at the end of the workday

CDC, 2003

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Clean/Dirty Areas well defined

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Surface Cleaning

  • Wipe down

  • Cover ?

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MRSA – Dental Operatory Surfaces

  • Study – MRSA transmission via dental surfaces

    • MRSA on air-water syringe

    • MRSA on reclining chair

    • 8 out of pts. Out of 140 infected or colonized

British Dental Journal, 2006

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Remember to Clean Your Workplace

  • Nothing beats plain old cleaning

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No data to support risk

  • No data to support risk to immunocompromised patients

  • Water 500 colony forming units of bacteria per milliliter of water (CDC)

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Biological Indicators

  • Use “at least” weekly

  • Always use a control as test indicator

    • Quarantine until results are know

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Extracted Teeth

  • Can be given to the patient!

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Post Exposure Medical Management

  • Detailed procedures to follow

    • Who to call

    • First Aid

    • Treatment facility

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Post Exposure Treatment

  • The employer must provide post-exposure medical care


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Post Exposure Treatment

  • Must be done outside the practice

    • CDC, 2003

  • Selection of care provider

  • Letters of Agreement

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Post Exposure Care

  • The word “immediate”

    • an exact time is not given because the time limit varies with each disease

    • HIV follow up is now worded “hours but not days”

OSHA 1999

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Exposed Employee

  • Right to refuse care

  • Must sign declination form

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HIPAA & Source Patient Testing

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  • Must have a system for protecting employee identity and test results

  • Exposed employee has become a patient !

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Letter of Written Opinion

  • Issued by the treating within 15 days of the exposure event

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Medical Records

  • Refers to OSHA 1910.1020 -Medical Records Standard

  • Medical Records are to be kept confidential

  • Disclosure is permitted only when required by this standard or other Federal, State or local law

Comp. Dir., pg.64

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Procedure to access their records

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Compliance Monitoring

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Compliance Monitoring

  • OSHA required

  • Who has responsibility

    • employee have a role for their safety

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Disciplinary Action Policy

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Failure to have an Exposure Control Plan

Failure to update Exposure Control Plan annually

Failure to offer new hire training

Failure to use engineering/work practice controls

Failure to offer HBV vaccine within 10 days of hire

Failure to have a sharps injury log

Failure to discard sharps into sharps containers ASAP

Failure to have employee input to selection of needle safe devices

Failure to reflect review of technology in the ECP

Failure to offer annual training

OSHA Most Common BBP Citations-2007

OSHA Jan. 2008

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Most Common OSHA Citations

  • Failure to have an Exposure Control Plan

  • Failure to conduct new hire training

  • Failure to conduct annual training

  • Failure to use needle safe devices

OSHA, 2007

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Questions & Answers

(703) 365 – 8388

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