POLICY: Blood-borne Viruses: Screening, Reporting and Monitoring of Physicians/Medical Students

   
NOTICE: While this policy is now technically in force, the College is still in the process of transitioning to the new processes set out in the policy, including monitoring by the Physician Health Program.  The College will advise when this transition has been completed and the new policy will be enforced.

 
1. Preamble

When a physician/medical student is infected with a blood-borne virus and performs exposure-prone procedures, additional measures need to be taken to assess the risk of transmission in the tasks performed and method of practice.  The appropriate measures can then be put in place to limit any added risk of transmitting viruses posed by the physician/medical student.

This policy outlines a number of strategies and expectations to protect the public while allowing the infected physicians/medical students to continue with their clinical work.   Principles have been adapted from the Public Health Agency of Canada (PHAC) Guideline on the Prevention of Transmission of Bloodborne Viruses from Infected Healthcare Workers in Healthcare Settings, 2019[1], as well as guidelines from the Society for Healthcare Epidemiology of America (SHEA)[2]  and the UK Advisory Panel (UKAP) guidance BBVs in healthcare workers: health clearance and management.[3]

 

2. Definitions

For the purposes of this policy, the following definitions apply:

Blood-borne virus (BBV) -- viruses including but not limited to hepatitis B virus (HBV), hepatitis C virus (HCV) and/or human immunodeficiency virus (HIV)

Expert Advisory Committee on Blood Borne Communicable Diseases (EAC) – a CPSS committee tasked with providing advice and recommendations to the Registrar, Registrar’s designate, or the Physician Health Program (PHP) approving and implementing standards and guidelines to be used in addressing concerns about physicians who have a blood-borne virus; and providing advice to the Registrar,  Registrar’s designate, or the PHP as to whether there should be conditions or restrictions imposed on physicians who have a blood-borne virus and wish to perform exposure prone procedures.  The EAC is to include members with appropriate expertise and interest in treating patients with blood-borne viruses.

Exposure-prone procedures (EPPs) are interventions where there is a risk that injury to the physician may result in the exposure of the patient’s open tissues to the physician’s blood or body fluid.  EPPs with a documented risk of transmission include:

  1. digital palpation of a needle tip in a body cavity (a hollow space within the body or one of its organs) or the simultaneous presence of the healthcare worker (HCW)’s fingers and a needle or other sharp instrument or object (such as bone splinters, sternal wires etc.) in a blind or highly confined anatomic site, e.g.,  as may occur during major abdominal, cardiothoracic, vaginal, pelvic and/or orthopedic operations;
  2. repair of major traumatic injuries; or
  3. manipulation, cutting or removal of any oral or perioral tissue, including tooth structures, during which the patient’s open tissues may be exposed to the blood of an injured infected HCW.

Medical students or students are undergraduate students who are registered on the CPSS educational register. 

Physician(s) means any individual with a medical degree licensed by the CPSS, including residents and post-graduate trainees who are registered on the CPSS educational register. 

Routine practices – A series of recommendations for the care of all patients incorporating the precautions necessary to prevent the transmission of microorganisms, including blood-borne pathogens, between patients and health care workers.  Formerly, the term “Universal Precautions” was used.  Routine practices include:

  • point of care risk assessment,
  • hand hygiene,
  • use of barriers (e.g., gloves, mask, eye protection, face shield and/or gowns) as per the risk assessment,
  • safe handling of sharps, and
  • cleaning and disinfection of equipment and environmental surfaces between uses for each patient.
Treating physician refers to the physician who is managing the care of the seropositive physician/medical student with respect to their infection with a blood-borne virus.


3. Guiding Principles

While the College is bound to protect the public from the risk of transmission of BBVs by a physician/medical student, it must balance that requirement with the interest of protecting the interests of physicians/medical students in practising their profession and maintaining the confidentiality of their personal health information.  In order for this policy to provide the maximum protection to the public, the Council has adopted the following guiding principles:

3.1   From a personal and public health standpoint, the College encourages all physicians/medical students to know their serological status for blood-borne viruses.

3.2   All physicians and medical students performing or assisting in performing EPPs must know their serological status for blood-borne viruses prior to performing or assisting in performing EPPs.

3.3   The College recommends that all physicians/medical students should be immunized for HBV (unless contraindicated or there is evidence of prior immunity) before possible occupational exposure and should have their antibody status assessed and documented after immunization.

3.4   All physicians/medical students must only perform or assist in performing EPPs when their health and viral loads make it safe to do so. 
          

4.  The College's expectations of physicians/medical students who perform or assist in performing EPPs

4.1  All physicians/medical students who wish to perform or assist in performing exposure-prone procedures in Saskatchewan, as well as those who have a potential to perform or assist in performing EPPs in the course of providing day-to-day care (such as emergency physicians), have a professional and ethical obligation to know their serological status with respect to BBVs prior to performing or assisting in performing EPPs in Saskatchewan. This includes physicians/medical students who perform or assist in performing procedures that may become exposure-prone (for example, a laparoscopic procedure that may convert to an open procedure).

4.2  As all medical students will likely be involved in EPPs, they are required to know their serological status and to comply with the terms of this policy. All residents and post-graduates who will likely be involved in performing or assisting in performing EPPs are required to know their serological status and to comply with the terms of this policy.

4.3  All physicians/medical students who perform or assist in performing EPPs must be tested for HCV and HIV every three years, or earlier if required pursuant to a blood or body fluid exposure protocol, referenced in 4.6 below.

4.4  All physicians/medical students who perform or assist in performing EPPs must be tested annually for HBV unless they have been confirmed immune to HBV or unless required to be done earlier pursuant to a blood or body fluid exposure protocol, referenced in 4.6 below.

4.5  All physicians/medical students who perform or assist in performing EPPs are expected to comply with routine practices to minimize the risk of transmission of blood-borne viruses in healthcare settings, such as those adopted by the Saskatchewan Health Authority[4] and the Government of Canada.[5]

4.6  All physicians/medical students must report blood or other body fluid exposures as per the appropriate protocols (such as the Saskatchewan Ministry of Health Guidelines for the Management of Exposure to Blood and Body Fluids Prophylaxis, the College of Medicine Undergraduate Medical Education Program Blood or Body Fluid Exposure Procedure, the Department of Postgraduate Medical Education Blood Borne Pathogens Policy, or the Saskatchewan Health Authority Control Plan for Bloodborne Pathogens), so that appropriate procedures can be followed.[6]
 

5.  The College's expectations of physicians/medical students who are seropositive for BBVs and perform or assist in performing EPPs

5. 1  If a physician/medical student’s result is positive for a BBV, they must comply with the terms of this policy prior to performing or assisting to perform EPPs.

5.2  Physicians/medical students who are seropositive for a BBV must have a treating physician.

5.3  
Physicians/medical students who perform or assist in performing EPPs and are seropositive for a BBV must report this finding to the Registrar or Registrar’s designate.  
Reporting must occur on first becoming aware of the finding, and thereafter on annual licence renewal.

5.4  Physicians/medical students who have reported to the Registrar or Registrar’s designate will be referred to the Physician Health Program (“PHP”) of the Saskatchewan Medical Association (“SMA”) for management and monitoring.

5.5  The PHP will apply the guidelines agreed upon by the EAC, or if necessary will consult with the EAC on a non-nominal basis to obtain its recommendations, as described in 5.6 below. The PHP will then convey written instructions to the physician/medical student and/or their treating physician of expectations with respect to the alteration of scope of practice, modification of practice techniques, and/or other precautions that are deemed appropriate to protect the public from risk of harm associated with the continuing clinical practice of the physician/medical student, as well as strategies for effective continuous monitoring of the physician/medical student (the “PHP instructions”).The PHP will obtain written commitment of compliance from the physician/medical student.

5.6  When consulted by the PHP, the EAC will review the practice of the reporting physician/medical student according to the level of risk for BBV transmission, and will issue explicit written recommendations with respect to the alteration of scope of practice, modification of practice techniques, and/or other precautions that are deemed appropriate to protect the public from risk of harm associated with the continuing clinical practice of the physician/medical student.

5.7  Physicians/medical students who have been referred to the PHP will have a reasonable opportunity to participate in this process, on a non-nominal basis, including making submissions in response to the PHP instructions, the right to respond with an expert opinion, and the right to request a review of the PHP instructions by the EAC, on a non-nominal basis.

5.8  On such a review by the EAC, the EAC may make a recommendation that the PHP should reconsider its instructions to the physician/medical student and may make recommendations as to the appropriate PHP instructions (the “EAC recommendation”).

5.9  After proceeding through the EAC review as described in paragraph 5.8, if the physician/medical student believes that the process established in this Policy was not met, or that there was a violation of the principles of natural justice or fairness, the physician/medical student may make an appeal to Council. All such appeals will be presented to Council in written form and will be restricted to issues of process and/or natural justice/fairness.

5.10  Upon receiving an appeal pursuant to paragraph 5.9, Council may make any order as may be appropriate and necessary which, without limiting the generality of the foregoing, may include one or more of the following:

5.11  Council may confirm the PHP instructions or the EAC recommendation;

a)  Council may refer the matter back to the PHP or EAC with a direction as to elements to be reconsidered or process to be followed.

b)  Physicians/medical students are required to follow the PHP instructions under paragraphs 5.5 and 5.13 and Council instructions under paragraph 5.10 with respect to their practice, and the appropriate treatment of their disease as recommended by their treating physician.

5.12  Provided the physician/medical student remains compliant with the treatment protocol directed by their treating physician and the PHP instructions, and their viral loads remain in the safe range as designated by the EAC from time to time, there will be no further College involvement aside from annual reporting at licence renewal.

5.13  If at any time the physician/medical student’s viral loads exceed the designated acceptable threshold, the PHP, in consultation with the EAC if necessary, will convey written instructions to the physician/medical student as to appropriate practice restrictions until such time as the viral loads are again below the acceptable threshold.

5.14  
If at any time the physician/medical student is non-compliant with the treatment recommended by their treating physician and/or the PHP instructions, the PHP will refer the physician/medical student back to the Registrar or Registrar’s designate.

5.15  If the physician/medical student is non-compliant, the College will exercise its statutory authority to ensure compliance or take other measures to protect the public from risk of harm. This may include suspending the physician/medical student’s ability to practice or entering into an undertaking restricting their practice such that they will not perform EPPs until they are compliant and/or their viral load is below the designated threshold.

5.16  If practice restrictions are imposed as referenced in 5.5, 5.10, 5.13 or 5.15, the PHP (or, in the case of 5.15, the College) will report those restrictions (but not the underlying personal health information) to the necessary organizations such as the Saskatchewan Health Authority, specific institutions, and the College of Medicine.
 

6. The duty to report

If a physician/medical student becomes aware that one of their colleagues is practising in contravention of this policy, as a first step that physician/medical student should encourage their seropositive colleague to comply with this policy and Bylaw 24.1 and to self-report if required.

Ultimately, physicians/medical students have an ethical responsibility to report to the Registrar or Registrar’s designate a physician/medical student who is known to be practising in contravention of this policy. 

A treating physician of a physician/medical student with a BBV who is subject to section 5 of this policy has an ethical responsibility to report to the PHP and the Registrar or Registrar’s designate such physician/medical student if they are non-compliant with their recommended treatment or the PHP instructions.
 


7. Confidentiality and privacy

The College respects the confidentiality and privacy of all information it receives or creates in the course of fulfilling its regulatory functions.  This includes information about blood-borne viruses and physician/medical student health.

Information about a physician/medical student’s serological status is not shared beyond the Registrar and/or Registrar’s designate except 1) to the extent necessary to refer the physician/medical student to the PHP, 2) to address non-compliance, or 3) to advise other regulatory authorities of a health issue on a request for a Certificate of Professional Conduct in accordance with College bylaws.[7]  Consultation with the EAC will be on a non-nominal basis.  All those who have access to this information know and understand their obligations regarding confidentiality and privacy.

While practice restrictions may be posted on the College website, underlying personal health information will not be included.

 

Acknowledgements

The College acknowledges that this policy has been adapted, in many parts with no changes, from the respective policies of the College of Physicians and Surgeons of British Columbia, College of Physicians and Surgeons of Ontario, and College of Physicians and Surgeons of Manitoba:

  • CPSBC Practice Standard “Blood-borne Viruses in Registrants”
  • CPSO Policy “Blood borne Viruses”
  • CPSM Standards of Practice of Medicine, Schedule J – Bloodborne Pathogens

The College recognizes, with thanks, the contributions of those organizations to the development of this revised policy.

 

Other Resources

College of Physicians and Surgeons of Saskatchewan – Regulatory Bylaw 3.1, Renewal and Expiration of Licences

College of Physicians and Surgeons of Saskatchewan – Regulatory Bylaw 7.1, The Code of Ethics

College of Physicians and Surgeons of Saskatchewan – Regulatory Bylaw 7.2, Code of Conduct

College of Physicians and Surgeons of Saskatchewan – Regulatory Bylaw 24.1, Reporting of Blood Borne Infections

College of Physicians and Surgeons of Saskatchewan – Regulatory Bylaw 37.1, Disclosure of Information in Certificates of Professional Conduct

College of Physicians and Surgeons of Saskatchewan Guideline – Confidentiality of Patient Information

College of Physicians and Surgeons of Saskatchewan Policy – Physicians at Risk to Patients

College of Physicians and Surgeons of Saskatchewan Guideline – Patients Who Threaten Harm to Themselves or Others

Public Health Agency of Canada.  Guideline on the Prevention of Transmission of Bloodborne Viruses from Infected Healthcare Workers in Healthcare Setting.  2019  

Preventing transmission of bloodborne viruses from infected healthcare workers to patients:  Summary of a new Canadian Guideline”, CCDR: 2019, Vol 45-12, pp. 317-322 

CMPA, Physicians with Blood Borne Viral Infections:  Understanding and Managing the Risks

 

STATUS:

APPROVED

Approved by Council:

April 2006

Amended:

In force:

March 2021

June 2021

To be reviewed:

March 2024

 

 


[1] Saskatoon Health Authority Control Plan for Bloodborne Pathogens, 2019 https://www.saskatoonhealthregion.ca/about/OHSPolicies/60-002-3.pdf

[3] See the Saskatchewan Ministry of Health Guidelines for the Management of Exposure to Blood and Body Fluids Prophylaxis.  https://www.ehealthsask.ca/services/Manuals/Documents/hiv-provider-guidelines.pdf

University of Saskatchewan College of Medicine Undergraduate Medical Education Program Blood or Body Fluid Exposure Procedure https://medicine.usask.ca/documents/policies/ugme/FlowchartBloodBodyFluid.pdf

University of Saskatchewan College of Medicine Department of Postgraduate Medical Education Blood Borne Pathogens policy https://medicine.usask.ca/policies/blood-borne-pathogens.php

and Saskatchewan Health Authority Control Plan for Bloodborne Pathogens, 2019 https://www.saskatoonhealthregion.ca/about/OHSPolicies/60-002-3.pdf

[5] Guideline for Management of Healthcare Workers Who Are Infected with Hepatitis B Virus, Hepatitis C Virus, and/or Human Immunodeficiency Virus, 2011.  https://www.shea-online.org/images/guidelines/BBPathogen_GL.pdf