AORN Position Statements

AORN Revised Statement on Patients and Health Care Workers with Bloodborne Diseases

Editor's note: At press time, this position statement was under revision. The revised position statement will be presented to the House of Delegates at the next annual Congress. If ratified, it will be reprinted in the AORN Journal and the 2008 edition of Standards, Recommended Practices, and Guidelines.

PREAMBLE
Bloodborne infections, including human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV), pose an occupational risk to perioperative nurses. Although the precise prevalence of these diseases in the general population is not known, researchers have found that among patients seeking treatment in an emergency room, 6% were seropositive for HIV, 5% were seropositive for HBV, and 18% were seropositive for HCV.¹ The occupational risk of transmission depends on the route of exposure and concentration of infectious agent. The majority of occupational transmissions to health care workers have resulted from needle sticks and cuts with 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% contracted HIV. Hepatitis viruses have a higher concentration in blood; therefore, after sustaining a needle stick by a hollow-bore needle used on a patient with HBV and with no postexposure prophylaxis, 6% to 30% of health care workers contracted the disease. The risk of developing HCV after percutaneous exposure ranges from 0% to 7%, with the average being 1.8%.²

Federal and state regulations have been passed to reduce the risk of occupational and patient exposure to bloodborne pathogens. The Bloodborne Pathogen Standard, first 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. Since that time, changes in work practices, improved safety, and additional regulations have focused on prevention of sharps-related exposures. 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.³ In June 2001, 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.4 Advances also have been made to protect individuals with bloodborne infections and to provide guidance for minimizing the risk of transmission to patients. During the past two decades, much of the fear of occupational acquisition of bloodborne infections has been dispelled through education and efforts to improve the safety of workplaces.

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.

TESTING FOR BLOODBORNE DISEASES
The Association 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.

FACILITY RESPONSIBILITIES
The Association 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.

The Association 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
The Association 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 that perioperative nurses and other health care workers should

educate themselves about the prevalence and risk of transmission of bloodborne diseases,
utilize measures to protect themselves and others,
participate in the evaluation of work practice and engineering controls, and
promptly report any exposures.

In addition, health care workers should voluntarily

know their HIV, HBV, or HCV statuses;
if seropositive, seek counsel from an expert 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
The Association reaffirms the ongoing commitment of its members to provide safe, equitable, competent, confidential, individualized care to all patients undergoing perioperative intervention. As a professional association, AORN promotes implementation of OSHA's "Occupational exposure to bloodborne pathogens; needlesticks and other sharps injuries; Final rule," and the "Updated US public health service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis."^4,5 Further, AORN 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 between 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 through sharing of contaminated needles and syringes. The Association supports expenditures that focus on prevention, research, and care of patients with bloodborne diseases.

References
1. G D Kelen et al, "Hepatitis B and hepatitis C in emergency department patients," The New England Journal of Medicine 21 (May 21, 1992) 1399.
2. 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," Morbidity and Mortality Weekly Report 50 (RR-11) (June 29, 2001) 3-8.
3. "29 CFR Part 1910: Occupational exposure to bloodborne pathogens; needlestick and other sharps injuries; Final rule," Federal Register 66 (Jan 18, 2001) 5318-5325.
4. "Updated US public health service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis," 4-8.
5. "29 CFR Part 1910: Occupational exposure to bloodborne pathogens; needlestick and other sharps injuries; Final rule," 5318-5325.

Original statement adopted by the Board of Directors July 10, 1987; ratified by the House of Delegates March 10, 1988.
Revised; ratified by the House of Delegates February 23, 1989.
Revised; approved by the Board of Directors September 29, 1991. Ratified by the House of Delegates March 19, 1992.
Revised January 1997 by Anne Uruburu, RN, MBA, CNOR, task force chair; Nancy Bjerke, RN; Cecil A. King, RN, BSN, CNOR; Jane E. Kuhn, RN, MSN, CNOR, task force members; Eileen Ullmann, RN, MHS, CNOR, staff consultant.

Approved by the Board of Directors March 1997; ratified by the House of Delegates April 10, 1997.
Revised; approved by the House of Delegates April 25, 2002.
Sunset review: March 2007