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Bloodborne Viruses Procedure

Approval Date: 2021-12-16

Effective Date: 2021-12-16

Responsible Unit: Office of the Dean of Medicine

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Definitions

Bloodborne Viruses (BBV) — As per the CPSNL Standard of Practice: Bloodborne Viruses, includes, but is not limited to, hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV).

Confidentiality — In the context of this policy, confidentiality refers to the manner in which information regarding serology status is treated, whether that information is provided with an expectation of privacy or not. Access to confidential records will be limited to persons authorized to access the information contained therein, except as required by law or where health, safety, or security of a person or persons is a concern.

Exposure Prone Procedures — As per the CPSNL Standard of Practice: Bloodborne Viruses, invasive procedures where there is a higher than average risk that injury to the physician may result from the exposure of the patient’s open tissues to the blood or body fluid of the physician. A further description of what procedures may be considered exposure-prone can be found in the Public Health Agency of Canada’s Guideline on the Prevention and Transmission of Bloodborne Viruses from Infected Healthcare Workers in Healthcare Settings (as amended)An exposure prone procedure includes but is not limited to the following:

  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 health-care worker’s fingers and a needle or other sharp instrument or object in a blind or highly confined anatomic site (e.g., during major abdominal, cardiothoracic, vaginal and/or orthopaedic operations); or 
  2. repair of major traumatic injuries; or 
  3. manipulation, cutting, or removal of any oral or perioral tissue, including tooth structures during which blood from a health-care worker has the potential to expose the patient’s open tissue to a bloodborne virus.

Learners (UGME/PGME) — Individual currently enrolled within the undergraduate or post graduate medical education program at Memorial University (Memorial) Faculty of Medicine (FoM). This also includes individuals who are accepted into a program with plans to enroll and all visiting learner(s) from another medical school.

Procedure

A.0 Learners

A.1 Has serology testing completed as per CPSNL guideline recommendation

A.2 Learners sign a Declaration: Blood Borne Pathogens Serology Expectations form. 

A.3 When performing or assisting in the performance of Exposure Prone Procedures, notifies the CPSNL of serologically positive results. 

A.3.1 For patient safety and to accommodate learning, the CPSNL may disclose confidentially positive serology results of medical learners to the UGME Office and of postgraduate learners to the PGME Office. 

A.4 Adheres to any accommodation implemented by the FoM or CPSNL. 

B.0 Faculty of Medicine 

B.1 Coordinates BBV serology testing for Learners through the Learner Health Service of Memorial as appropriate. 

B.2 Implements appropriate counselling, accommodation, notification (e.g. notifying a Regional Health Authority), etc. as per CSPNL recommendations for Learners who require same. The FoM will make accommodations, where possible, to allow the learner to continue their medical education, as per the Procedure for Arranging Learner Accommodations.

B.3. The FoM will address any concerns expediently, and should be able to respond within 7-10 days (expected timelines).

Policies using this procedure: