University of South Carolina School of Medicine s1

University of South Carolina School of Medicine

Clinical Department Employee

Health Policies Manual

University of South Carolina School of Medicine Department of Family and Preventive Medicine 3209 Colonial Drive Columbia SC 29203 (803) 434-2479 FAX: (803) 434-8644 Joshua Mann, MD, MPH Medical Director, University of South Carolina School of Medicine Employee Health Services Updated May 19, 2008

1 Table of contents:

I. Identification of Clinical Employees Page 3

II. Requirement for New USCSOM Clinical Employees Page 3

III. Annual Testing, Vaccinations and Training of Employees Page 4

IV. Cost of Services Page 5

V. Workplace Injuries Page 5

VI. Policy Concerning USCSOM Clinical Employees with Contagious Infections Page 5

VII. Policies on HIV Transmission to Patients Page 6

VIII. Policies on Hepatitis B and Hepatitis C Transmission to Patients Page 9

IX. Policies for Employee Exposure to Blood borne Pathogens Page 10

X. Emergency Contact Information Page 12

XI. Policy Regarding Chemical Dependency in Employees Page 13

Emergency Contact Information Page 12

2 I. Identification of Clinical Employees

A. New Employee Health Risk Assessment

At the time any new USCSOM employee is hired, the supervisor must complete a New Employee Health Risk Assessment Form. This form is then forwarded along with the other routine hiring paperwork to the Human Resources office. Employees who are expected to have direct contact with patients or routinely work within 100 feet of a patient care area are considered to be clinical employees and must be evaluated by the Student/Employee Health Office.

B. Identification of Specific Risks

The risk status of clinical employees will be determined by the Student/Employee Health Office, in cooperation with the supervisor. Clinical employees will be classified regarding their risk of exposure to blood-borne pathogens and the likelihood that they will need to utilize respiratory protection in the workplace.

II. Requirements for New USCSOM Clinical Employees

A. Health History:

All new clinical employees will be required to provide information about their medical history, which will be evaluated to verify that they are physically capable (with reasonable accommodations) to perform their job duties, and that they do not have a medical condition that places patients at unacceptable risk of injury or illness.

B. Tuberculin Skin Testing

1. All new clinical employees must receive tuberculin skin testing, unless they have had a positive skin test in the past. For employees who have not had skin testing within the past twelve months, a two-step test is required.

2. Employees who have a history of a positive skin test must provide a copy of the report from their most recent chest x-ray and complete the TB Symptom Survey. Additional work-up may or may not be required.

3. Prior receipt of BCG immunization is not a contraindication to tuberculin skin testing.

4. Those with positive skin tests will be referred to the Richland County Health Department for evaluation.

C. Measles, Mumps, Rubella, and Varicella Immunization

All clinical employees should be immune to measles, mumps, rubella and varicella. Immunity may be proved in one of the following ways:

 Documented immunization

 Serologic proof of immunity

 For varicella only, convincing clinical history of chicken pox (the Student/Employee Health Office will determine whether the history is convincing)

3 Clinical employees without proof of immunity will be tested for serologic evidence of immunity to measles, mumps, rubella, and varicella. Those who are not immune will be offered the appropriate immunizations. Those choosing to decline immunization will be required to complete an informed refusal form.

D. Tetanus/Diphtheria Immunization

All clinical employees who have not received a tetanus/diphtheria booster immunization within the previous 7 years will be offered the tetanus/diphtheria vaccine. For clinical employees who have not had a tetanus/diphtheria immunization, the combined tetanus, diphtheria and pertussis (Tdap) vaccine will be offered.

E. Hepatitis B Immunization

Clinical employees with blood/body fluid exposure will be offered the hepatitis B immunization series. They are strongly encouraged to be immunized. Those who refuse immunization must complete an informed refusal form.

One to two months following the hepatitis B vaccine series, employees will be tested for serologic evidence of immunity to hepatitis B.

Employees who have already been immunized against hepatitis B must submit serologic proof of immunity. Those who have never been tested for seroconversion will be tested, and will be offered the immunization series again if they are not immune.

If an employee fails to respond following two hepatitis B vaccine series, he or she will be considered a non-responder.

F. Respirator Fit Testing

1. Clinical employees expected to use respiratory protection in the workplace must undergo respirator fit testing. This requires that they first be medically cleared to wear the particular respirator.

2. Employees are trained in proper respirator use.

3. The fit testing procedure takes approximately 15 minutes and involves various maneuvers to ensure that the respirator seal is sufficient to protect the employee from respiratory infections.

G. Blood-Borne Pathogen Training

OSHA-mandated training on how to prevent infection with blood-borne pathogens such as HIV, hepatitis B, and hepatitis C, is provided to all new employees who are expected to have workplace exposure to blood or body fluids.

III. Annual Testing, Vaccinations and Training of Employees:

A. All clinical employees must be screened annually for tuberculosis using the PPD skin test unless they have tested positive in the past.

1. If results of TB testing are positive, the employee will be referred to the South Carolina Department of Health and Environmental Control for evaluation and treatment as indicated.

4 2. If the employee has tested positive previously repeat skin testing is not indicated, however a history of BCG alone is not a contraindicate to TB testing. The employee will complete a brief questionnaire dealing with the presence or absence of symptoms of active tuberculosis. The employee must report to the Employee Health Office if any of those symptoms manifest.

B. Employees with exposure to blood or body fluids must undergo annual blood-borne pathogen training as required by OSHA. A number of options for this training are available through the Employee/Student Health Office.

C. Employees who are expected to use respirator protection in the workplace must undergo annual respirator training and fit testing.

D. Influenza immunization is offered to clinical employees annually during influenza season, on a first-come first-served basis. The immunization is offered first to employees with direct patient contact. If supplies last, then the immunization is offered to employees who routinely work within 100 feet of a patient care area but do not have direct patient contact.

IV. Cost of Services:

All appropriate examinations, trainings, tests and vaccinations as described above will be provided by the University of South Carolina School of Medicine to the clinical employee during regular work hours and at no cost to the employee.

V. Workplace Injuries

On the job injuries will be treated under Worker's Compensation coverage. The office should be notified by telephone that an injury has occurred. The telephone number is 803-434-2479. If no one answers, the employee health nurse should be paged at 803-303-0035. If there is still no answer, the medical director may be paged at 803-654-3143. Please do NOT simply leave a voice mail message, as messages may only be checked a few times each day. A completed USCSOM Employee Injury Report form (HR-81B) must be sent with the employee to the USC School of Medicine Employee Health Office, 3209 Colonial Drive. This form is available from the departmental Administrative Directors or the USCSOM Employee Health Office. VI. Policy Concerning USCSM Clinical employees with Contagious Infections and/or Diseases

The University of South Carolina School of Medicine (USCSM) supports fully the spirit and intent of Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1992 and does not discriminate against qualified clinical candidates for with contagious infections and/or diseases who do not constitute a direct threat to the health and safety of patients or other individuals, and who are otherwise able to fulfill the requirements incident to attending medical school.

It is the policy of USCSM to: provide expert and safe patient care; protect the personal rights of clinical employees with contagious infections and/or diseases, including the right to be free from disparate treatment and improper management of confidential information; provide information, education, and support services that promote the professional and personal well-being of clinical employees; provide a safe working environment for all clinical employees; and provide for the implementation of laws and regulations pertaining to public health and welfare.

5 Therefore, pursuant to the above-stated policy, in appropriate cases, after obtaining the advice and consultation of the appropriate supervisor or department Chair, USCSM will monitor and modify the clinical activities of infected clinical employees who pose unwarranted risks to patients. Examples of infections that should be reported to the supervisor or department Chair and the Employee/Student Health Office include (but are not limited to) varicella, measles, mumps, rubella, influenza, conjunctivitis, and scabies. For employees who are involved in procedures that could result in patient exposure to the employee’s blood, notification must also be made of viral hepatitis and/or HIV infection (see policies below). A decision regarding whether clinical activities must be temporarily or permanently modified will be made by the appropriate supervisor or department Chair and the Medical Director of Employee/Student Health. The decision to modify the clinical activities shall be based upon an objective evaluation of the nature of the infection, the individual employee’s experience, technical expertise, functional disabilities, and the extent to which the contagious infection and/or disease can be readily transmitted.

VII. Policies on HIV Transmission to Patients

The objective of these policies is the prevention of transmission of the Human Immunodeficiency Virus (HIV) from clinical employees of the University of South Carolina School of Medicine (USCSM) to other persons encountered in the work environment.

PREAMBLE: Because it is possible for a Health Care Worker (HCW) to be infected with the HIV for a prolonged period of time without knowledge of the infection, it is important for USCSM to establish guidelines for the performance of duties of the HCWs in the professional setting to promote the safety of all persons, especially patients with whom the HCW comes in contact;

Because the only meaningful exposure that the HCW can present to a contact (patient) in the professional setting would be from the exposure of the contact (patient) to blood or other body fluid of the HCW,

A. USCSM affirms the policy that testing for the presence of the HIV among clinical employees not be mandatory on either a routine or periodic basis.

B. USCSM affirms the policy that a clinical employee who is performing exposure prone procedures and has reason to believe he or she is infected with HIV should periodically have his or her HIV status tested and inform USC Student/Employee Health Services of a positive result so that appropriate duty modifications can be arranged (if applicable).

C. USCSM affirms that, apart from necessary practice modifications, clinical employees with HIV infection will not be discriminated against in any way.

D. USCSM affirms that the HIV status of infected clinical employees will be held confidential, with the exception of notifying those medical professionals who must know the employee’s status to arrange for needed practice modifications.

E. HIV-infected clinical employees who have reason to believe a situation has occurred that places a patient at risk of acquiring HIV infection from that student must notify the patient, and the Student/Employee Health Office immediately.

F. USCSM adopts the AMA Guidance for HIV-Infected Physicians and other Health Care Workers (Policy H-20.912), available at: http://www.ama- assn.org/apps/pf_new/pf_online?f_n=resultLink&doc=policyfiles/HnE/H-

6 20.912.HTM&s_t=hiv&catg=AMA/HnE&catg=AMA/BnGnC&catg=AMA/DIR&&nth=1&& st_p=0&nth=13& and given in its entirety below.

H-20.912 Guidance for HIV-Infected Physicians and other Health Care Workers (1) General Considerations a) A health care worker who performs invasive procedures and has reasonable cause to believe he/she is infected with HIV should determine his/her serostatus or act as if that serostatus is positive; and b) As a general rule or until there is scientific information to the contrary, the HIV-infected health care worker should be permitted to provide health care services as long as there is no significant risk of patient infection and no compromise in physical or mental ability of the health care worker to perform the health care procedures.

(2) Patient Care Duties a) A physician or other health care worker who performs exposure-prone procedures and becomes HIV-positive should disclose his/her serostatus to a state public health official or local review committee; b) An HIV-infected physician or other health care worker should refrain from conducting exposure- prone procedures or perform such procedures with permission from the local review committee and the informed consent of the patient; c) When the scientific basis for patient protection policy decisions are unclear, HIV-infected physicians or other health care workers must err on the side of protecting patients.

(3) Local Review Committee a) If an HIV-infected physician or other health care worker performs invasive medical procedures as a part of his/her duties, then the individual should request that an ad hoc committee be constituted to consider which activities can be continued without risk of infection to patients. Membership on the review committee should be flexible to meet various needs. It should include an infectious disease specialist familiar with HIV transmission risks, the pertinent hospital department chair, a hospital administrator, an epidemiologist, the infected health care worker's personal physician, the infected health care worker, and others as appropriate. Committee members should be unbiased and at least some of the members should be familiar with the performance of the infected health care worker. b) This review committee may recommend to the appropriate authority restrictions upon the infected persons’ practice, if it believes there is a significant risk to patients' welfare. A confidential review system should be established by the committee to monitor the health care worker's fitness to engage in invasive health care activities. Any restrictions or modifications to health care activities that may affect patient safety should be determined by the committee based on current medical and scientific information. When determining practice limitations for HIV-positive physicians, the panel might consider: (i) morbidity and mortality experience of the physician in question; (ii) frequency with which the physician performs the following: procedures that have been associated with injuries to physicians in the course of surgery; procedures that are conducted in confined or difficult to visualize anatomical spaces; procedures where a physician's blood is likely to come in to contact with a patient's mucosal surfaces, open surgical wounds, or blood stream; and procedures that have been known to be involved in HBV transmission;

7 c) Where restrictions, limitations, modifications, or a change in health care activities are recommended, the committee should do its utmost to assist the health care worker to obtain financial and social support for these changes. Consideration should be given to adapting programs for impaired health care workers to serve those who are HIV infected; d) The committee should be empowered to monitor the HIV-infected physician or other health care worker for compliance with any practice limitations established by the committee, provide advice on the need to inform patients of the infected worker’s HIV status, monitor the infected person’s compliance with universal precautions, and assess the effects of the disease on clinical competency. Physicians and others who participate in making these decisions must be protected from legal challenges and personal legal responsibility; e) Any HIV-infected health care worker who repeatedly violates local committee-imposed practice limitations and/or universal precautions should be reported to appropriate authorities, such as the state licensure board, for possible discipline; f) If intra-institutional confidentiality cannot be assured, health care facilities should make arrangements with other organizations such as local or state medical societies to perform the functions of the ad hoc committee; and g) HIV-infected health care workers not affiliated with a hospital may also use this procedure to form an ad hoc review committee.

(4) Review Committee Liability a) State medical societies should be encouraged to survey hospitals and review their own coverage to determine whether existing liability insurance for those serving on peer review or Physicians Health Committees provides protection for those serving on review committees for HIV- infected physicians; b) Our AMA should assist in the establishment of review committees by providing model state legislation that would afford committee members protection in state and federal courts and when they operate in good faith. Further, our AMA should prepare a protocol outlining how review committees would operate and further specify the definition of significant risk.

(5) Confidentiality a) Our AMA expresses its commitment to HIV-infected physicians concerning confidentiality of HIV serostatus, protection against discrimination, involvement in legislation affecting HIV-infected physicians, financial support through such means as insurance disability guidelines, and assistance with alternative careers through its Physician Health Program; b) Our AMA believes the confidentiality of the HIV-infected physician should be protected as with any HIV patient; and c) Knowledge of the health care worker's HIV serostatus should be restricted to those few professionals who have a medical need to know. Except for those with a need to know, all information on the serostatus of the health care worker must be held in the strictest confidence.

(6) HIV-Infected Medical Clinical employees and Resident Physicians a) Our AMA strongly supports indemnification of medical clinical employees and resident physicians infected with HIV as a result of contact with assigned patients. Our AMA supports

8 examining possible mechanisms to achieve the intent of this recommendation, realizing that the issues for medical clinical employees and resident physicians differ; b) An equivalent level and manner of health care provided to medical clinical employees, residents, and other employees with other medical conditions should be provided to those with HIV infection.

(7) Liability Coverage for HIV-Infected Physicians Our AMA will continue the dialogue with liability insurance companies to monitor issues surrounding liability coverage for HIV-infected physicians and will establish guidelines for any collection or use of HIV serostatus data by professional liability carriers. Serostatus information should be treated with strict privacy and nondisclosure assurances. Discussions with liability insurance companies should include the position that to date there are no scientific grounds to require testing of physicians for HIV status. (CSA Rep. 4, A-03)

VIII. Standard Precautions

A. USCSM clinical employees must practice "Universal Standard” (Universal Precautions) when dealing with patients. The actions described as "Universal Standard" (Universal Precautions) include, but are not limited to: 1. the use of barrier protection methods at all times. 2. the use of gloves for handling blood and body fluids. 3. the wearing of gloves by clinical employees acting as phlebotomists. 4. the changing of gloves between patients. 5. the use of a facial shield as protection from splashing. 6. the use of gown and apron for protection from splashing. 7. the washing of hands between patients and if contaminated. 8. the washing of hands after removal of gloves. 9. the availability of rigid needle containers. 10. the avoidance of unnecessary handling of needles. 11. the careful processing of “sharps.” 12. the avoidance of direct mouth-to-mouth resuscitation contact. 13. the minimization of spills and splatters. 14. the decontamination of all surfaces and devices after use.

B. All clinical employees must follow all of the rules, regulations, and guidelines of the institution in which they are providing the patient care.

IX. Policies on Hepatitis B and Hepatitis C Transmission to Patients

Both hepatitis B and hepatitis C are chronic viral infections that are transmitted by exposure to blood and body fluids. They are not transmitted by casual contact. It is important for clinical employees at risk of these infections to receive the hepatitis B immunization series and have serologic testing to confirm an immunologic response. Unfortunately there is no vaccine for hepatitis C. Clinical employees who believe they may be at risk of hepatitis C infection are encouraged to periodically have their hepatitis C status tested.

Clinical employees who know they are infected with hepatitis B or hepatitis C should inform the Student/Employee Health Office of their status. In some cases, modifications to clinical practice may be required. This determination will be made by a panel of experts in the field. With the exception of necessary consultation with experts about the necessity of practice modifications, the

9 employee’s infection status will be kept confidential, and apart from necessary modifications, infected clinical employees will not be discriminated against.

HBV or HCV-infected clinical employees who have reason to believe a situation has occurred that places a patient at risk of acquiring infection must notify the patient, the attending physician, and the Student/Employee Health Office immediately.

X. Policies for USCSOM Employee exposure to bloodborne pathogens:

A. INTRODUCTION

Employees caring for patients in the University of South Carolina School of Medicine (USCSOM) affiliated teaching hospitals and clinics experience risk of exposure to several infectious diseases, including syphilis, hepatitis B (HepB), hepatitis C (HepC), and human immunodeficieney virus (HIV). Consequently, these policies state the required actions expected of all USCSOM employees involved in patient care to prevent transmission of such infections to themselves and to prevent or minimize clinical disease in the event they undergo significant exposure.

In addition to the "Standard (Universal) Precautions" previously mentioned, the following actions are required practice to minimize risk of transmission of infection:

1. Gloves will be worn for all parts of the physical examination in which contact might be expected with the oral, genital, or rectal mucosa of a patient. Gloves are also necessary while examining any skin rash that might be infectious (e.g., syphilis, herpes simplex, etc.)

2. Gloves will be worn in all procedures that involve risk of exposure to blood or body fluids, including venipuncture, arterial puncture, and lumbar puncture. Gloves will also be worn during any laboratory test on blood, serum, other blood product or body fluids.

3. Prior to performing a venipuncture, obtain a needle (and syringe) disposal box and place it adjacent to the venipuncture site. After venipuncture, insert the needle (and syringe) immediately in the disposal box. DO NOT recap or remove needles by hand. Care must be taken to avoid bringing the needle near the body of other persons in the examining room while transferring it to the container.

B. Procedures to be followed in the event of exposure to blood or body fluids:

All exposure incidents shall be reported, investigated, and documented. When the employee incurs an exposure incident, it shall be reported to the USCSOM Employee Health Service and the Departmental Administrative Manager.

Exposure to bloodborne pathogens may occur through direct contact with a patient's blood or body fluid via needle or through contact with non-intact skin or the mucous membranes. If an exposure is suspected the following must be done immediately:

1. The site of the contamination should be thoroughly irrigated or washed with soap and water for five (5) minutes.

10 2. Notify the Student/Employee Health Office and the source patient’s attending physician. This should be done immediately after (or during) the irrigation described above. Be sure to provide the name and medical record number to the Student/Employee Health Office so that source patient labs can be drawn.

3. If the exposure occurs in the outpatient setting, be sure the patient stays until blood can be drawn to test his or her infection status.

HIV test results are normally available within one to two hours. The exposed employee will be informed as soon as these results are available. Hepatitis B and C testing results are normally available on the day following exposure. The employee will also be notified once these results are available. If source patient testing is positive, the employee should present immediately to the Student/Employee Health Office for treatment. The office address is: Richland Family Medicine Center 3209 Colonial Drive Columbia, SC 29203 803-434-2479 Pager 1: 803-303-0035 Pager 2: 803-654-3143 If an exposure occurs after 3 pm, the exposed employee will be provided with contact information for the Palmetto Richland Hospital Administrator On Duty (AOD), to whom results will be made available after hours. The employee is encouraged to check with the AOD at least once every 2 hours when HIV results are pending.

For all work-related injuries that occur after normal working hours (after 4:30 p.m., or on weekends or holidays), or for whom source patient HIV testing results come back positive after hours should report immediately to the Emergency Department at the Palmetto Health Richland Hospital. Subsequent follow-up will be with the PR Family Medicine Center on the next available working day. It is necessary to inform the ER staff that the exposure is a workplace injury for USC, and to follow-up with USCSM Employee/Student Health the next day in order to avoid having the employee billed for the ER services.

The exposed employee will immediately receive a confidential medical evaluation and follow-up, including at least the following elements:

a.) Documentation of the route of exposure, and the circumstances under incident occurred;

b.) Identification and documentation of the source individual.

c.) The source individual’s blood shall be tested as soon as feasible in order to determine HCV, HBV and HIV infectivity.

d.) When the source individual is already known to be infected with HCV, HBV, or HIV the source individuals blood does not need to be retested.

e.) Results of the source individual’s testing shall be made available to the exposed employee and the employee shall be informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual. The employee may have their blood collected for testing of HCV/HBV/HIV serological status depending on results of source blood testing.

11 All employees who incur an exposure incident will be offered post-exposure evaluation and follow-up in accordance with the OSHA standard. All post exposure follow-ups will be performed by the USCSOM Employee Health Service.

C. USCSOM Employee Health EMERGENCY contact numbers: Employee Health Nurse: 803-434-2479; pager 303-0035 Joshua R. Mann, MD, MPH: 803-434-4575; pager 654-3143 Office (PR Family Practice Center): 803-434-6116

Always immediately identify yourself as an employee with a bloodbome pathogens exposure. The staff and faculty are aware of the treatment policy and the need for a rapid evaluation and treatment. For follow-up please use the office number above and identify yourself as a USCSOM employee requiring a follow-up appointment.

Information provided to the Healthcare Professional

The USCSOM Employee Health Service shall ensure that the healthcare professional responsible for the employee’s Hepatitis B vaccination is provided with the following:

a.) A copy of 29 CFR 1910.1030;

b.) A written description of the exposed employee’s duties as they relate to the exposure incident,

c.) Written documentation of the route of exposure and circumstances under which exposure occurred; d.) Results of the source individual blood testing, if available: and

e.) All medical records relevant to the appropriate treatment of the employee including vaccination status

Healthcare Professionals Written Opinion

The USCSOM Employee Health Service shall obtain and provide the employee with a copy of the evaluating healthcare professionals written opinion within 15 days of the completion of the evaluation.

The healthcare professional's written opinion for HBV vaccination shall be limited to whether HBV vaccination is indicated for an employee, and if the employee has received such vaccination. The healthcare professionals written opinion for post exposure follow-up shall be limited to the following information:

a.) A statement that the employee has been informed of the results of the evaluation

b.) A statement that the employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials which require further evaluation or treatment

Note: All other findings or diagnosis shall remain confidential and shall not be included in the written report.

12 X. Policy Regarding Chemical Dependency in Employees

The USC School of Medicine follows the Drug-Free Workplace Policy and Alcohol and Other Drug Information. Refer to University of South Carolina Policy HR1.01.