AORN Position Statement on

PREAMBLE
Bloodborne infections, including human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV), pose an occupational risk to perioperative nurses as well as the entire surgical team. Although the exact prevalence of these diseases in the general population is not known, a study done in a general surgical practice found 38% of the surgical cases studied were positive for the bloodborne pathogens HIV (26%), hepatitis B (4%), and hepatitis C (17%).1 The occupational risk of transmission depends on the route of exposure and concentration of the infectious agent.

The majority of occupational transmissions to health care workers have resulted from hollow-bore needle sticks and cuts from contaminated sharp items. After sustaining a needle stick by a needle contaminated with HIV, 0.3% of health care workers contracted the virus. The next highest incidence of transmission to health care workers occurred via mucous membrane splashes. After a mucous membrane splash, less than or equal to 0.1% of persons exposed contracted HIV.2 Hepatitis viruses have a higher concentration in blood. After sustaining a needle stick by a hollow-bore needle used on a
patient with HBV and with no postexposure prophylaxis, 5% to 35% of health care workers who are unprotected by the hepatitis B vaccine series contracted the disease. This is dependent on hepatitis B e antigen (HBeAg) status and viral titer of the source.3 The risk of developing HCV after percutaneous exposure is 1.8%.2 Cuts and needle stick bloodborne exposures occur in 15% of interventions.The patterns of exposure risk for personnel in the operating room include:
• surgeons and first assistants, 59.1%;
• scrub personnel, 19.1%;
• anesthesiologists, 6.2%; and
• circulating nurses, 6.0%.4
Suture needles and scalpel percutaneous injuries (PIs) in the perioperative area include the following:
• Sharp tip suture needle exposures account for approximately 14% of PIs/year 5 of the estimated
384,000 PIs.6
• Scalpel PI incidence by health care worker category were physician attending 9.1%, physician
resident/intern 9.1%, nurse 27.3%, surgery attendant 36.4%, technologist 9.1%, and other 9.2%.7
• Scalpel injuries involved reusable scalpels 68% of the time and disposable scalpels 32% of the time;7
the injuries occurred to the right hand 39% of the time and to the left hand 53% of the time.8

Federal and state regulations have been passed to reduce the risk of occupational and patient exposure to bloodborne pathogens. The Bloodborne Pathogen Standard, published by the Occupational Safety and Health Administration (OSHA) in 1991, requires an exposure control plan, compliance with universal precautions, engineering controls, barrier protection, free HBV vaccinations, training programs, and postexposure evaluation. Changes in work practices, improved safety, and additional regulations have focused on prevention of sharps-related exposures since 1991. Based on the “Needlestick Safety and Prevention Act” passed by Congress in November 2000, OSHA published revised bloodborne pathogens standards in January 2001. These revised standards add new requirements for employers, including additions to the exposure control plan, soliciting employee input, and record keeping.9 The Centers for Disease Control and Prevention (CDC) published guidelines for the management of occupational exposures to HIV, HBV, and HCV. The CDC recommends postexposure prophylaxis with a combination of medications shown to be the most effective.2 Advances also have been made to protect individuals with bloodborne infections and to provide guidance for minimizing the risk of transmission to patients. Despite the use of standard precautions guidelines and the use of protective devices, there remain a considerable number of exposures.10 It is estimated that only 43% of all bloodborne pathogen exposures are reported in the US.5

This AORN revised position statement incorporates federal regulations and standards based on the most current scientific evidence. The AORN Standards, Recommended Practices, and Guidelines provide direction for many clinical issues related to prevention of occupational transmission.

 
POSITION STATEMENT

Testing for Bloodborne Diseases
Following a bloodborne pathogen exposure, AORN supports voluntary testing after informed consent and counseling for patients and all health care workers regardless of the practice setting. In the unlikely event that a patient incurs an accidental exposure to the blood or hazardous body fluid of a health care worker, the patient should be offered voluntary, confidential testing with appropriate counseling and information to understand the implications of exposure and postexposure prophylaxis as indicated. Perioperative nurses should be aware of state laws related to consent for testing and reporting; states may have differing regulations.

Facility Responsibilities
AORN encourages health care facilities to support health care workers who care for patients infected with HIV, HBV, or HCV. Federal and state regulations provide the framework for developing policies, procedures, and education programs that address infection control, safety, and ethical issues related to prevention and transmission of these diseases. AORN believes that employing facilities should
• provide an environment that minimizes the risk of exposure to bloodborne pathogens,
• provide timely postexposure evaluation and prophylaxis when appropriate, and
• support seropositive health care workers’ endeavors to remain employed when their health status
does not impair their performance or pose risks to patients. The Americans with Disabilities Act
protects employees with bloodborne infections and requires that employers provide reasonable
accommodations for those individuals competent to perform the job without undue hardship to
their employers.
AORN encourages facilities to have in place an exposure control plan that addresses
• vaccination of health care workers;
• availability of personal protective equipment and work practice controls;
• evaluation of safety devices with input from employees;
• education about risks and prevention of exposure, including work practice controls and use of
safety devices;
• prompt reporting of exposures;
• timely postexposure follow-up and prophylaxis as appropriate;
• monitoring compliance to safety practices; and
• periodic evaluation of the effectiveness of the exposure control plan.

Health Care Workers’ Responsibilities
AORN recognizes that care of patients with known or unknown bloodborne infections poses an occupational
risk to perioperative nurses and other health care workers. Perioperative nurses and other health care workers should not discriminate against patients or employees with HIV, HBV, HCV, or any other bloodborne infection. Because of the occupational risk for bloodborne disease transmission, the Association believes perioperative nurses and other health care workers should
• educate themselves about the prevalence and risk of transmission of bloodborne diseases;
• use all measures and safety devices supplied and designed to protect themselves and others;
• participate in the evaluation of work practice and engineering controls to include double gloving,
use of neutral zones, and use of blunt needles;4 and
• promptly report any exposures.
In addition, health care workers should voluntarily
• know their HIV, HBV, and HCV statuses;
• if seropositive, seek counsel from a facility-designated panel to review and modify their practices
based on the best available scientific information; and
• report their status through the appropriate facility system.

Standards, Education, and Development
AORN reaffirms an ongoing commitment to provide safe, equitable, competent, confidential, and individualized care to all patients undergoing surgical intervention. As a professional association, AORN promotes implementation of OSHA’s “Occupational exposure to bloodborne pathogens; needlesticks and other sharps injuries; Final rule,”9 and the “Updated US public health service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis.”2 AORN also encourages continued development and implementation of national standards and guidelines governing infection control practices for invasive and exposure-prone procedures in all settings. AORN is committed to partnering with industry and health care professionals to develop improved safety devices and refine work practice controls. AORN believes in ongoing education of the public about the risk of transmission through high-risk behaviors, including unsafe sexual contact and sharing of contaminated needles and syringes. AORN supports expenditures that focus on prevention, research, and care of patients with bloodborne diseases.

References

1. Weiss ES, Makary MA, Wang T. Prevalence of blood-borne pathogens in an urban, university-based general
surgical practice. Ann Surg. 2005;241:803-809.
2. The Centers for Disease Control and Prevention. Updated US public health service guidelines for the management
of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis.
MMWR Recomm Rep. June 29, 2001;50(RR11):3-8.
3. Beltrami EM, Panlilio AL. Occupational exposure. In: Carrico R, ed. APIC Text of Infection Control and
Epidemiology. Washington DC; Association of Professionals in Infection Control and Epidemiology, Inc;
2005:1-10.
4. Berguer R, Heller PJ. Preventing sharps injuries in the operating room. J Am Coll of Surg. 2004;199:462-467.
5. University of Virginia Health System. International Healthcare Worker Safety Center: EPINet: OR
Multihospital Sharps Injury Surveillance Network. Needlestick and Sharp Object Injury Report [1997-2000;
9888 total injuries; 72 hospitals contributing data]. Available at: http://www.healthsystem.virginia.edu/internet
/epinet/epinet4.cfm. Accessed December 1, 2006.
6. Panlilio AL, Orelien JG, Srivastava PU, Jagger J, Cohn RD, Cardo DM. Estimate of the annual number of
percutaneous injuries among hospital-based healthcare workers in the United States 1997-1998. Infect Control
Hosp Epidem. 2004;25:556-562.
7. Perry J, Parker G. Percutaneous injury rates. In: Jagger J, Perry MA, eds. Preventing Occupational
Exposures to Bloodborne Pathogens. Charlottesville, Va: International Healthcare Worker Safety Center;
2004:99-102.
8. Perry J, Balon M. Suture needle and scalpel blade injuries: frequent but underreported. In: Jagger J, Perry MA,
eds. Preventing Occupational Exposures to Bloodborne Pathogens. Charlottesville, Va: International
Healthcare Worker Safety Center; 2004:31-36.
9. Occupational exposure to bloodborne pathogens; needlestick and other sharps injuries; Final rule. 66 Fed
Regist (January 18, 2001) 5318-5325 (codified at: 29 CFR §1910).
10. Beekmann SE, Henderson DK. Protection of healthcare workers from bloodborne pathogens: nosocomial and
hospital related infections. Curr Opin in Infect Dis. 2005:18:331-336.

Resources

Davis MS. Advanced precautions for today’s OR. In: The Operating Room Professional’s Handbook for the
Prevention of Sharps Injuries and Bloodborne Exposures. Atlanta, Ga: Sweinbinder Publications LLC; 2001.

International Sharps Injury Prevention Society. Available at: http://isips.org. Accessed December 1, 2006.

International Healthcare Workers Safety Center. EPINet. Available at: http://www.bd.com/safety/epinet/.
Accessed December 1, 2006.

The Joint Commission for Accreditation of Healthcare Organizations. Preventing needlestick and sharps
injuries. Sentinel Event Alert. September 28, 2001;22. Available at: http://www.jointcommission.org/Sentinel
Events/SentinelEventAlert/sea_22.htm. Accessed December 1, 2006.

Original approved by House of Delegates,March 1988
Revision: approved by the House of Delegates, February 1989
Revision: approved by the House of Delegates, March 1992
Revision: approved by the House of Delegates, April 1997
Revision: approved by the House of Delegates, April  2002
Revision: approved by the House of Delegates, March 2007 
Sunset review: March 2012