Health Clearance for Tuberculosis, Hepatitis B, Hepatitis C and HIV for New Healthcare Workers with Direct Clinical Contact with Patient

ANNEX B

EXPOSURE-PRONE PROCEDURES ( EPPS)

1. Exposure-prone procedures ( EPPs) are those invasive procedures where there is a risk that injury to the worker may result in the exposure of the patient's open tissues to the blood of the worker. These include procedures where the worker's gloved hands may be in contact with sharp instruments, needle tips or sharp tissues (e.g. spicules of bone or teeth) inside a patient's open body cavity, wound or confined anatomical space where the hands or fingertips may not be completely visible at all times. However, other situations, such as pre-hospital trauma care should be avoided by healthcare workers restricted from performing EPPs.

2. When there is any doubt about whether a procedure is exposure-prone or not, expert advice should be sought in the first instance from a consultant occupational health physician who may in turn wish to consult the UK Advisory Panel for Healthcare Workers Infected with Blood-borne Viruses ( UKAP). Some examples of advice given by UKAP below may serve as a guide, but cannot be seen as necessarily generally applicable, as the working practices of individual healthcare workers vary.

3. Procedures where the hands and fingertips of the worker are visible and outside the patient's body at all times, and internal examinations or procedures that do not involve possible injury to the worker's gloved hands from sharp instruments and/or tissues, are considered not to be exposure-prone, provided routine infection control procedures are adhered to at all times.

4. Examples of procedures that are not exposure-prone include:

• taking blood (venepuncture);
• setting up and maintaining IV lines or central lines (provided any skin tunnelling procedure used for the latter is performed in a non-exposure-prone manner, i.e. without the operator's fingers being at any time concealed in the patient's tissues in the presence of a sharp instrument);
• minor surface suturing;
• the incision of external abscesses;
• routine vaginal or rectal examinations;
• simple endoscopic procedures.

5. The decision whether an HIV, hepatitis B or hepatitis C-infected worker should continue to perform a procedure, which itself is not exposure-prone, should take into account the risk of complications arising which necessitate the performance of an EPP; only reasonably predictable complications need to be considered in this context.

Examples of UKAP advice on EPPs

6. UKAP has been making recommendations about the working practices of healthcare workers infected with HIV since the end of 1991, and healthcare workers who are infected with other blood-borne viruses ( BBVs) since September 1993. Advice for occupational physicians arises from individual queries, cases or general issues which have been referred to the UKAP since its inception.

7. Judgements are made by occupational physicians, or in conjunction with UKAP where doubt or difficulty exists, about whether any procedure is or is not exposure-prone against the following criteria:

Exposure-prone procedures ( EPPs) are those where there is a risk that injury to the worker may result in exposure of the patient's open tissues to the blood of the worker. These procedures include those where the worker's gloved hands may be in contact with sharp instruments, needle tips or sharp tissues (spicules of bone or teeth) inside a patient's open body cavity, wound or confined anatomical space where the hands or fingertips may not be completely visible at all times.

8. Occupational physicians and others who need to make decisions about the working practices of infected healthcare workers may find the advice helpful. In some cases this advice may help clarify matters, and in others may direct the reader to seek further specific advice about the individual case under consideration.

Cautionary note

9. In the past, UKAP has not favoured issuing guidance about what areas or particular procedures of medical, nursing or midwifery practice involve EPPs. This is because individual working practices may vary between hospitals and between healthcare workers. Advice for one healthcare worker may not always be applicable to another. Therefore, this list must be interpreted with caution, as it provides examples only and is not exhaustive. It should also be noted that UKAP keeps its advice under ongoing review.

UKAP's advice

10. The following advice has been given by UKAP in relation to specialities and procedures. Please note that these are only examples and do not obviate the need for a full risk assessment at local level, including the procedures likely to be undertaken by a healthcare worker whose practice is restricted in a particular post; the way in which they would be performed by that individual and the context in which they would operate (e.g. colleagues available to take over if an open procedure becomes necessary).

10.1 Accident and Emergency A+E staff who are restricted from performing EPPs should not provide pre-hospital trauma care.

These members of staff should not physically examine or otherwise handle acute trauma patients with open tissues because of the unpredictable risk of injury from sharp tissues such as fractured bones. Cover from colleagues who are allowed to perform EPPs would be needed at all times to avoid this eventuality.

Other EPPs which may arise in an A+E setting would include:

• rectal examination in presence of suspected pelvic fracture;
• deep suturing to arrest haemorrhage;
• internal cardiac massage.

(See also Anaesthetics, Biting, Paramedics and Resuscitation.)

10.2 Anaesthetics Procedures performed purely percutaneously are not exposure-prone, nor have endotracheal intubation nor the use of a laryngeal mask been considered so.

The only procedures currently preformed by anaesthetists which would constitute EPPs are:

• the placement of portacaths (very rarely done), which involves excavating a small pouch under the skin and may sometimes require manoeuvres which are not under direct vision;
• the insertion of chest drains in A&E trauma cases such as patients with multiple rib fractures.

The insertion of a chest drain may or may not be considered to be exposure-prone depending on how it is performed. Procedures where, following a small initial incision, the chest drain with its internal trochar is passed directly through the chest wall (as may happen, e.g. with a pneumothorax or pleural effusion) and where the lung is well clear of the chest wall, would not be considered to be exposure-prone. However, where a larger incision is made, and a finger is inserted into the chest cavity, as may be necessary, e.g. with a flail chest, and where the healthcare worker could be injured by the broken ribs, the procedure should be considered exposure-prone.

Modern techniques for skin tunnelling involve wire guided techniques and putting steel or plastic trochars from the entry site to the exit site where they are retrieved in full vision. Therefore skin tunnelling is no longer considered to be exposure-prone. (See also Arterial cutdown.)

10.3 Arterial Cutdown Although the use of more percutaneous techniques has made arterial or venous cutdown to obtain access to blood vessels an unusual procedure, it may still be used in rare cases. However, as the operator's hands are always visible, it should no longer be considered exposure-prone.

10.4 Biting Staff working in areas posing a significant risk of biting should not be treated as performing EPPs. In October 2003, UKAP considered a review of the available literature on the risk of onward transmission from healthcare workers infected with BBVs to patients. The review showed that the published literature on this subject is very scarce. In follow-up studies of incidents involving infected healthcare workers working with patients known to be 'regular and predictable' biters, there were no documented cases of transmission from the healthcare worker to the biter. However, where biters were infected, there were documented cases of seroconversion in their victims, and the risk of infection was increased in the presence of:

• blood in the oral cavity; risk proportionate to the volume of blood;
• broken skin due to the bite;
• a bite associated with previous injury, i.e. non-intact skin.

The risk of infection also increased where the biter was deficient in anti- HIV salivary elements (IgA deficient)

Based on the available information, it can only be tentatively concluded that even though there is a theoretical risk of BBV transmission from an infected healthcare worker to a biting patient, the risk remains negligible. The lack of information may suggest that this has not been perceived to be a problem to date, rather than that there is an absence of risk.

UKAP has advised that, despite the theoretical risk, since there is no documented case of transmission from an infected healthcare worker to a biting patient, individuals infected with BBVs should not be prevented from working in or training for specialties where there is a risk of being bitten.

The evidence is dynamic and the area will be kept under review and updated in the light of any new evidence that subsequently emerges suggesting there is a risk. However, it is important for biting incidents to be reported and risk assessments conducted in accordance with NHS procedures. Biting poses a much greater risk to healthcare workers than to patients. Therefore, employers should take measures to prevent injury to staff, and health care workers bitten by patients should seek advice and treatment, in the same way as after a needlestick injury.

10.5 Bone Marrow transplants Not exposure-prone.

10.6 Cardiology Percutaneous procedures including angiography/cardiac catheterisation are not exposure-prone. Implantation of permanent pacemakers (for which a skin tunnelling technique is used to site the pacemaker device subcutaneously) may or may not be exposure-prone. This will depend on whether the operator's fingers are or are not concealed from view in the patient's tissues in the presence of sharp instruments during the procedure.(See also Arterial cutdown.)

10.7 Chiropodists - see Podiatrists

10.8 Dentistry (including work of dental therapists and hygienists) The majority of procedures in dentistry are exposure-prone, with the exception of:

• examination using a mouth mirror only;
• taking extra-oral radiographs;
• visual and digital examination of the head and neck;
• visual and digital examination of the edentulous mouth;
• taking impressions of edentulous patients;
• the construction and fitting of full dentures.

However, taking impressions from dentate or partially dentate patients would be considered exposure-prone, as would the fitting of partial dentures and fixed or removable orthodontic appliances, where clasps and other pieces of metal could result in injury to the dentist.

10.9 Ear, Nose and Throat ( ENT) Surgery (otolaryngology)ENT surgical procedures generally should be regarded as exposure-prone, with the exception of simple ear or nasal procedures, and procedures performed using endoscopes (flexible and rigid) provided that fingertips are always visible. Non-exposure-prone ear procedures include stapedectomy/stapedotomy, insertion of ventilation tubes and insertion of a titanium screw for a bone-anchored hearing aid.

10.10 Endoscopy Simple endoscopic procedures (e.g. gastroscopy, bronchoscopy) have not been considered exposure-prone. In general there is a risk that surgical endoscopic procedures (e.g. cystoscopy, laparoscopy) may escalate due to complications which may not have been foreseen and may necessitate an open EPP. The need for cover from a colleague who is allowed to perform EPPs should be considered as a contingency. (See also Biting, Laparoscopy.)

10.11 General Practice See Accident and Emergency, Biting, Minor Surgery, Midwifery/Obstetrics, Resuscitation.

10.12 Gynaecology Open surgical procedures are exposure-prone. Many minor gynaecological procedures are not considered exposure-prone, examples of which include dilatation and curettage, suction termination of pregnancy, colposcopy, surgical insertion of depot contraceptive implants/devices, fitting intrauterine contraceptive devices (coils), and vaginal egg collection provided fingers remain visible at all times when sharp instruments are in use.

Performing cone biopsies with a scalpel (and with the necessary suturing of the cervix) would be exposure-prone. Cone biopsies performed with a loop or laser would not in themselves be classified as exposure-prone, but if local anaesthetic was administered to the cervix other than under direct vision (i.e. with fingers concealed in the vagina), then the latter would be an EPP. (See also Laparoscopy.)

10.13 Haemodialysis/Haemofiltration See Renal Medicine.

10.14 Intensive Care Intensive care does not generally involve EPPs on the part of medical or nursing staff.

10.15 Laparoscopy Laparoscopy is mostly non-exposure-prone because fingers are never concealed in the patient's tissues. There are some exceptions: laparoscopy is exposure-prone if a main trochar is inserted using an open procedure, as for example in a patient who has had previous abdominal surgery. It is also exposure-prone if the rectus sheath is closed at port sites using a J-needle, and if fingers rather than needle holders and forceps are used.

In general there is a risk that a therapeutic, rather than a diagnostic, laparoscopy may escalate due to complications which may not have been foreseen necessitating an open EPP. Cover from colleagues who are allowed to perform EPPs would be needed at all times to avoid this eventuality.

10.16 Midwifery/Obstetrics Simple vaginal delivery, amniotomy using a plastic device, attachment of fetal scalp electrodes, infiltration of local anaesthetic prior to an episiotomy and the use of scissors to make an episiotomy cut are not exposure-prone.

The only EPPs routinely undertaken by midwives are repairs following episiotomies and perineal tears. Repairs of more serious tears are normally undertaken by medical staff who may include general practitioners who assist at births in a community setting.

10.17 Minor Surgery In the context of general practice, minor surgical procedures such as excision of sebaceous cysts, skin lesions, cauterisation of skin warts, aspiration of bursae, cortisone injections into joints and vasectomies do not usually constitute EPPs.

10.18 Needlestick/occupational exposure to HIV Healthcare workers need not refrain from performing EPPs pending follow up of occupational exposure to an HIV-infected source. The combined risks of contracting HIV infection from the source patient, and then transmitting this to another patient during an exposure-prone procedure is so low as to be considered negligible. However, in the event of the worker being diagnosed HIV positive, such procedures must cease in accordance with this guidance.

10.19 Nursing General nursing procedures do not include EPPs. The duties of operating theatre nurses should be considered individually. Theatre scrub nurses do not generally undertake EPPs. However, it is possible that nurses acting as first assistant may perform EPPs.(See also Accident and Emergency, Renal Medicine, and Resuscitation.)

10.20 Obstetrics/Midwifery See Midwifery/Obstetrics. Obstetricians perform surgical procedures, many of which will be exposure-prone according to the criteria.

10.21 Operating Department Assistant/Technician General duties do not normally include EPPs.

10.22 Ophthalmology With the exception of orbital surgery which is usually performed by maxillo-facial surgeons (who perform many other EPPs), routine ophthalmological surgical procedures are not exposure-prone as the operator's fingers are not concealed in the patient's tissues. Exceptions may occur in some acute trauma cases, which should be avoided by EPP-restricted surgeons.

10.23 Optometry The training and practice of optometry does not require the performance of EPPs.

10.24 Orthodontics See Dentistry and Orthodontics (including hygienists)

10.25 OrthopaedicsEPPs include:

• open surgical procedures;
• procedures involving the cutting or fixation of bones, including the use of K-wire fixation and osteotomies;
• procedures involving the distant transfer of tissues from a second site (such as in a thumb reconstruction);
• acute hand trauma;
• nail avulsion of the toes for in-growing toenails and Zadek's procedure (this advice may not apply to other situations such as when nail avulsions are performed by podiatrists).

Non- EPPs include:

• manipulation of joints with the skin intact;
• arthroscopy, provided that if there is any possibility that an open procedure might become necessary, the procedure is undertaken by a colleague able to perform the appropriate open surgical procedure;
• superficial surgery involving the soft tissues of the hand;
• work on tendons using purely instrumental tunnelling techniques that do not involve fingers and sharp instruments together in the tunnel;
• procedures for secondary reconstruction of the hand, provided that the operator's fingers are in full view;
• carpal tunnel decompression, provided that fingers and sharp instruments are not together in the wound;
• closed reductions of fractures and other percutaneous procedures.

10.26 Paediatrics Neither general nor neonatal/special care paediatrics has been considered likely to involve any EPPs. Paediatric surgeons do perform EPPs.(See also Arterial cutdown.)

10.27 Paramedics In contrast to other emergency workers, a paramedic's primary function is to provide care to patients. Paramedics do not normally perform EPPs. However, paramedics who would be restricted from performing EPPs should not provide pre-hospital trauma care. This advice is subject to review as the work undertaken by paramedics continues to develop.(See also Accident & Emergency, Biting, Resuscitation.)

10.28 Pathology In the event of injury to an EPP-restricted pathologist who is performing a post-mortem examination, the risk to other workers who are handling the same body subsequently is so remote that no restriction is recommended.

10.29 Podiatrists Routine procedures undertaken by podiatrists who are not trained in and do not perform surgical techniques are not exposure-prone. Procedures undertaken by podiatric surgeons include surgery on nails, bones and soft tissue of the foot and lower leg, and joint replacements. In a proportion of these procedures, part of the operator's fingers will be inside the wound and out of view, making them exposure-prone procedures.

(See also Orthopaedics.)

10.30 Radiology All percutaneous procedures, including imaging of the vascular tree, biliary system and renal system, drainage procedures and biopsies as appropriate, are not EPPs.(See also Arterial cutdown.)

10.31 Renal Medicine The 2002 guidance stated: "Obtaining vascular access at the femoral site in a distressed patient may constitute an exposure-prone procedure as the risk of injury to the HCW may be significant". There have since been technological advances in the way venous access is obtained, including in renal units. In procedures performed now, the operator's fingers remain visible all the time during the procedure. Therefore these procedures are not exposure-prone and neither haemofiltration nor haemodialysis constitute EPPs.

The working practices of those staff who supervise haemofiltration and haemodialysis circuits do not include EPPs. Different guidance applies for hepatitis B-infected healthcare workers ⁹.

10.32 Resuscitation Resuscitation performed wearing appropriate protective equipment does not constitute an EPP. The Resuscitation Council ( UK) recommends the use of a pocket mask when delivering cardio-pulmonary resuscitation. Pocket masks incorporate a filter and are single-use.

10.33 Surgery Open surgical procedures are exposure-prone. This applies equally to major organ retrieval because there is a very small, though remote, risk that major organs retrieved for transplant could be contaminated by a healthcare worker's blood during what are long retrieval operations while the patient's circulation remains intact. It is possible for some contaminated blood cells to remain following pre-transplantation preparatory procedures and for any virus to remain intact since organs are chilled to only 10ûC.(See also Laparoscopy, Minor Surgery.)

10.34 Volunteer healthcare workers (including first aid) The important issue is whether or not an infected healthcare worker undertakes EPPs. If this is the case, this guidance should be applied, whether or not the healthcare worker is paid for their work.