- Selection of Health Care Professional
- Employer Obligation Related to CDC Recommendations
- Changes to CDC Recommendations
- Confidentiality
- Source Patient Consents
- Medical Records
- Employer Obligation to Former Workers
- Temporary Workers Provided by an Employment Agency
- Potential Patient Anxiety
- Employer Obligation for Medical Treatment
- Responsibility for Obtaining Written Opinion
Selection of Health Care Professional
May the dental employer select the health care professional?
Yes, it is the dental employer, rather than the employee, who is entitled to select a health care professional to provide the hepatitis B vaccination and post-exposure evaluation and follow-up services required under the standard. Dental employers would be wise to select a health care professional who is familiar with the standard and the recommended post-exposure evaluation and follow-up protocol. The U.S. Public Health Service recommends that when possible, the medical evaluation and follow-up should be implemented in consultation with persons having expertise in antiretroviral therapy and HIV transmission. On this basis, the dental employer should identify, and have on record, a health care professional with appropriate expertise, or a healthcare professional who consults with a person having such expertise.
Employer Obligation Related to CDC Recommendations
Since the standard incorporates by reference the CDC recommendations for post-exposure prophylaxis, what is the dental employer's obligations when the CDC guidelines are not clear or when the health care
professional recommends treatment beyond what is contained in the CDC guidelines?
Under the standard, it is the dental employer's responsibility, following an exposure incident, to make immediately available to the exposed employee post-exposure prophylaxis, when medically indicated. The standard requires that post-exposure prophylaxis be provided in accordance with the recommendations of the U.S. Public Health Service, but it does not cite specific recommendations.
OSHA intentionally drafted the standard in this fashion to ensure that the most current recommendations would be followed. Because post-exposure testing and prophylaxis are rapidly changing and developing fields, it must be provided according to recommendations of the U.S. Public Health Service current at the time post-exposure testing and prophylaxis take place.
Currently, for employees who have not received the HBV vaccine series, HBV vaccine (and in some circumstances hepatitis B immune globulin) is to be offered as soon as possible after the exposure incident, but no more than seven days after the incident.
With regard to HIV disease, CDC guidelines for post-exposure antiretroviral drug therapy are constantly evolving. The HCP providing post-exposure evaluation and follow-up must ensure that current CDC guidelines are followed. In order to assist the evaluating HCP in following CDC guidelines, the dental employer must ensure that the exposed employee receives immediate post-exposure evaluation (according to the CDC, preferably within 1-2 hours, but no longer than 24 hours) after the exposure incident.
Note: The recommendations of the U.S. Public Health Service provides guidelines for post-exposure chemoprophylaxis. However, the use of post-exposure chemoprophylaxis is a clinical decision which should be individualized for each employee incident.
Changes to CDC
Recommendations
How will dentists know of changes in the CDC guidelines that affect their OSHA obligations?
CDC guidelines and recommendations are widely distributed and readily available to health care professionals either directly from the CDC or through professional associations. Direct subscriptions to the Morbidity and Mortality Weekly Report (MMWR) are available. Due to the ever-changing nature of the health care industry, professionals routinely seek to keep themselves abreast of new developments. Therefore, OSHA does not anticipate that either dental employers or evaluating health care professionals will have any difficulty in obtaining any future CDC guidelines or recommendations. (See References.)
Confidentiality
Why is the dental employer denied access to the HBV or HIV test result of the employee and the
source patient? How can the dental employer obey state laws implementing CDC guidelines on the practice of infected health care workers if the dentist is not entitled to know the employee's test results following an exposure incident?
It is very important to maintain confidential medical records to ensure that employees report exposure incidents and participate in post-exposure evaluation and follow-up. The standard requires that medical records be kept confidential and not disclosed without the employee's consent, except as required by the standard or as may be required by law. For example, if a law requires the information to be released to a county or state health department, the standard does not prohibit its release.
In addition, the standard does not prohibit the dental employer from providing routine testing of all of his or her employees to determine HBV and HIV status. Such routine testing would enable dental employers to learn the HBV and HIV status of all their employees, not just those few who suffer an exposure incident. Dental employers should be aware, however, that Federal, state or local laws that prohibit discrimination against the disabled may make it illegal to conduct routine employee testing. No dental employer should implement such a program without first obtaining the advice of his or her own personal attorney.
Source Patient Consent
Could the dental employer's obligation to document the identity of the source patient and to provide the source patient's test results to the exposed employee conflict with state confidentiality laws?
The standard requires testing of the source patient's blood for HIV and HBV, and disclosure of the results to the exposed employee, only where it is permitted and not in conflict with applicable laws or regulations. The standard further requires that the exposed employee be informed of any laws or regulations concerning disclosure of the identity and infection status of the source patient. The standard does not, therefore, require dental employers to violate any applicable privacy laws.
Medical Records
May the dental employer make arrangements for the evaluating health care professional to maintain the required confidential employee medical
records?
Yes. The bloodborne pathogens standard allows for such arrangements. The dental employer may simply contract with the health care professional who performs the HBV vaccination or post-exposure evaluation and follow-up to maintain the records as part of the service he or she is providing, much like the records that dentists maintain for their own patients. While the standard requires that employers establish and maintain for each employee confidential medical records that include the HBV vaccination status and evaluation and follow-up of exposure incidents, the records need not be kept at the place of employment. The records must, however, be maintained in a manner that makes them accessible to OSHA.
Note: In accordance with OSHA's Standard for Access to Employee Exposure and Medical Records, 29 CFR 1910.1020, employee medical records must be accessible to both the employee (or the employee's representative) and OSHA representatives. To fulfill this obligation, the dental employer must assure that the requestor has the opportunity to examine the relevant employee medical records within a reasonable time (i.e., within 15 working days).
Employer Obligation to Former Workers
What obligation does the dental employer have to pay for post-exposure evaluation and follow-up services after the exposed employee leaves the dentist's employment?
The standard requires the dental employer to make immediately available a confidential medical evaluation and follow-up to an employee reporting an exposure incident. Due to the immediate nature of this requirement, it is not likely that the worker will end his or her employment prior to initiation of the post-exposure evaluation and follow-up. Once an employee ends his or her term of employment, however, the dental employer would no longer be obligated to meet the requirements of the standard since the employer-employee relationship no longer exists. However, employers should be aware that state workers' compensation laws may apply even after the employer-employee relationship ceases.
Temporary Workers Provided by an Employment Agency
When temporary workers are provided through an employment agency, what obligation does the dental employer have to provide post-exposure evaluation and follow-up services?
With regard to temporary workers, all requirements of the standard are applicable. In the case of temporary workers provided through a personnel service, the employer who supplies the workers ("supplying employer") and the client facility to which they supply workers ("using employer") have a shared responsibility to ensure that workers are protected from workplace hazards. The supplying employer, who maintains the continuing relationship with the workers, is required to ensure that all workers are provided with the required vaccinations and follow-up evaluations. The using employer will not be held responsible for providing the required vaccinations and follow-up evaluations unless the contract specifies that the using employer will do so.
Potential Patient Anxiety
The standard requires source patient testing, if feasible, following an exposure incident. Couldn't this requirement interfere with the doctor-patient relationship and cause patient anxiety due
to possible misinterpretation of the request (i.e., that the patient rather than the employee has been potentially exposed)?
Testing of the source patient whenever possible is very important to minimize the anxiety employees experience after exposure incidents. Testing for a source patient's infectious status provides exposed employees with information that will assist them in decisions regarding testing of their own blood, complying with other elements of post-exposure management, and using precautions to prevent transmission to personal contacts. In addition, such testing assists the health care professional in deciding on appropriate follow-up.
We recognize that some dentists may have concerns about potential patient fears; however, we note that the standard is designed to prevent occupational exposure to blood or OPIM and, if properly implemented, exposure incidents will be uncommon events. If an exposure incident does occur, much can be done to eliminate or reduce patient anxiety. Medical professionals must often convey sensitive or unpleasant information to patients and have learned to do so without unduly alarming patients.
For example, when a health care professional treats a patient in a dental office or in any other medical setting, he or she typically explains office procedures and policies to the patient prior to providing services. OSHA suggests that as a part of this discussion, it would be appropriate for the dental employer to explain the standard's requirements for source patient testing to determine if the employee has been exposed. Thoroughly discussing this issue prior to, or at the time of, an exposure incident will likely reduce patient anxiety and possible misunderstandings.
Employer Obligation for Medical Treatment
What obligation does the dental employer have to pay for medical treatment of a disease acquired as a result of an exposure incident?
The standard requires the employer to make available testing, post-exposure prophylaxis (when medically indicated), counseling and evaluation of reported illnesses. Treatment of disease is beyond the scope of the standard's follow-up requirements. (Treatment of disease is generally handled under workers' compensation or other disability insurance.)
Responsibility for Obtaining Written Opinion
What happens if the health care professional fails to
provide a written opinion as required by the standard? Might the dental employer be held responsible?
As noted previously, the dental employer may have to rely on the health care professional to carry out certain OSHA obligations, such as providing appropriate post-exposure evaluation and follow-up services, including providing a written opinion to the dental employer. The dental employer is responsible for providing the health care professional with pertinent information (see Information Provided to the HCP and Flow Chart). In particular, the dental employer must ensure that the health care professional understands the requirements of the standard and agrees to comply.
It remains, however, the dental employer's obligation to ensure that he or she obtains and provides the exposed employee with a copy of the health care professional's written opinion. Failure of the dental employer to obtain the written opinion generally constitutes a violation of the standard. However, the dental employer will not generally be held liable for such violations if the dental employer can demonstrate good faith efforts to obtain the written opinion (i.e., by documented phone calls or written communication to the health care professional). In this way, the dental employer shows that he or she clearly tried to comply with the intent of the standard, and a violation may not exist.