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Your employee's been stuck... now what?
Laney Kay, JD
Okay, here's the perfect end to the perfect day. You're 30 minutes behind, and your assistant grabs a handful of instruments. A scaler slips and falls to the floor, sticking the as_istant's gloved finger in the process. Now what?
Over the past several months, I've talked to many dental employees all over the state who received a "stick" injury and were unsure as to what actions to take afterward. Is testing necessary? Is treatment necessary? What is the sensible approach to take for a "stick" injury?
Chemical prophylaxis therapy is not indicated for the majority of injuries received in the dental office.
First, let's talk facts. As far as AIDS goes, there has still never been a dental health care worker infected with the AIDS virus from a work-related injury. That's good to hear, especially since AIDS has been around since at least the late 1970s and a lot of people in the dental field have been stuck in that period of time. It usually takes a large amount of blood exposure to pass the AIDS virus and there are very few injuries sustained in dentistry that would result in a significant exposure to blood. Even if there were an exposure, the risk would be negligible. If I took a needle and stuck it in the arm of an AIDS patient and then stuck it in my own arm, I would still only have a 1 in 250 chance of getting the disease.
Unfortunately, that is not necessarily the case with Hepatitis Band C. The hepatitis viruses are much hardier than the AIDS virus. They can live in a drop of dried blood for several days and are more easily passed. If I repeated the same action of sticking a Hepatitis B patient then sticking myself, I would have a 1 in 30 chance of getting the disease; for Hepatitis C, the chance would be somewhere between 1 in 50 to 1 in 70.
The good news is that all of these viruses are easy to kill with any of the hospital-approved disinfectants we use. Most are rendered harmless soon after use and are absolutely dead after the recommended 10 minutes of contact. If you take measures to prevent sticks and you disinfect your instruments, surfaces, and equipment properly, the risk of transmission is very low.
What is the employer required to offer the employee in the event of an exposure incident?
Let me give you all the official information first. If an employee receives a "stick" injury, no matter how superficial, CDC and OSHA guidelines require that an employer must make testing available, provide counseling, and provide any necessary post-exposure prophylaxis treatment and follow up evaluations. The employer is also responsible for asking the source patient to undergo testing for AIDS, Hepatitis B, and Hepatitis C. Generally, workers' comp or another disability policy will pay for this testing and prophylactic treatment.
The employer is not responsible for paying for treatment of the disease or for paying for prophylaxis that is not medically indicated. In other words, if the evaluating physician determines that an injury to an employee is negligible and that further testing and treatment is unnecessary, but the employee wants to go through it and take the prophylaxis anyway, the employee will be responsible for paying for it.
Okay, I know what's supposed to happen if an employee gets stuck. But do my employees really need to go through all that testing, counseling, and follow up if it's just a superficial injury?
Realistically, the threat of infection from the type of injury generally received in dentistry is almost nil. In fact, most injuries require little more effort than cleaning the injured area well and covering the area with antibiotic cream and a bandage. Most employees who have undergone the testing/ counseling/ evaluation process report that they were told during post-exposure counseling that their risk was negligible and that further procedures and follow up were unnecessary.
However, in an effort to reduce your own liability, I would let the evaluating physician make that determination instead of you. Let's say that an ex-employee turns up with Hepatitis C 10 years down the road, and you never offered an official evaluation and follow up. You could have some liability, even though the employee could have gotten it somewhere else during that lO-year period.
What if the employee or source patient refuses testing?
As with everything in dentistry, the most important thing is documentation. OSHA requires dentists to keep employee medical records that include information on vaccination status and any exposure incidents and follow up. (Because of privacy issues, keep these medical records separate from the rest of your OSHA materials and in an area accessible only to the doctor.) If an employee refuses to undergo post-exposure evaluation and testing, the employee's refusal should be documented and the employee should sign and date it.
As far as the source patient goes, if you know that person's HIV/Hepatitis B/Hepatitis C status, you don't have to ask the patient for retesting. Georgia law requires patients to be tested. However, if a source patient refuses testing, there's not much you can do about it besides documenting the refusal. Also, make sure to let the evaluating physician know that
the source patient has refused testing and that the patient's serological status is unknown.
When is post-exposure prophylactic drug therapy indicated to prevent AIDS?
Many dental employees have received a minor "stick" or scratch and have gone to a medical doctor who then hysterically informs them that they should undergo chemical antiretroviral therapy so they won't get AIDS. CHEMICAL PROPHYLAXIS THERAPY IS NOT INDICATED FOR THE MAJORITY OF INJURIES RECEIVED IN THE DENTAL OFFICE. Remember, many medical doctors have no idea about dental offices and how they work, so they are unable to make an informed, intelligent determination as to whether postexposure treatment is indicated. The best method of ensuring a rational recommendation is finding a physician beforehand who understands how we work and won't freak out in the event of exposure incident.
According to the CDC, here are several factors associated with an increased risk of contracting the AIDS virus:
- Deep injury to the health care worker
- Visible blood on the device
- A device previously used in the patient's vein or artery
- Source patient who died from AIDS within 60 days after the exposure
- Exposures involving larger amounts of blood and/or higher levels of HIV in the blood.
Most exposures in the dental office involve a dental employee who is pricked through a glove with a scaler or an explorer. Rarely is there visible blood on the device, rarely do we work on end-stage AIDS patients, and rarely are we exposed to larger amounts of potentially infectious blood or to blood with large amounts of virus. Also, studies have shown that as an instrument passes through a glove, much of the material is wiped off. As a result, for injuries such as these, post exposure prophylaxis is not justified.
If any of the above factors are present, however, and a physician who knows what the heck he or she is talking about determines that the risk is not negligible, post-exposure prophylaxis should be offered. If the risk is significant, chemical prophylaxis should be taken, preferably within 1-2 hours of exposure.
What are the recommendations for Hepatitis B post-exposure evaluation and follow up?
If an employee has been recently vaccinated for Hepatitis B, he or she should be tested a month or so after the series is complete to make sure there are adequate levels of antibodies in the blood. If not, the employee should undergo the complete series again until adequate immunity is established.
If an employee received a vaccination years ago, there is no recommendation for regular testing to monitor antibody levels. Studies have shown that even though an individual may not have detectable levels of antibodies, the person is still probably protected in the event of an exposure incident. Instead, testing is only to be done in the event of an exposure incident. At that time, if antibody levels are not adequate, the employee should get one shot and then get retested to make sure the levels have returned to a detectable level. If not, the employee should undergo the series again.
If an employee has not received a vaccination and is then exposed, the vaccination should be administered within seven days of the exposure incident. A physician may also recommend an immune globulin injection as well. The evaluating physician may also recommend additional follow up testing.
Why do we have to do testing and follow up for Hepatitis C since there is no vaccine and no postexposure prophylaxis available?
Hepatitis C is now the most common chronic infection in the United States, and the scariest aspect of the disease is that 40 percent of the people who have it have no idea where they got it. Also, a full 85 percent of people who develop Hepatitis C become carriers and are able to pass it to others.
Even though there is no postexposure prophylactic treatment for Hepatitis C, public health officials feel that post-exposure testing and counseling should still be performed. If the employee tests positive for Hepatitis C it is important for the liver enzymes to be monitored on a regular basis to make sure the person isn't developing chronic liver disease. With early detection, there are treatments available that can slow down the progression of the disease and, hopefully, lessen the damage to the liver. Because the likelihood of becoming a carrier is so great, preventive measures can be taken to ensure the person does not pass the virus to others.
Is every exposure incident a "recordable injuryl' according to OSHA? Do I have to document it on that big, hard-to-read, OSHA log Form 200 and Form 101?
No. Although you have to follow OSHA's guidelines about post-exposure evaluation, counseling, and treatment, and all incidents should be documented in the employee's medical record, every incident is not considered a "recordable injury." In other words, unless it meets specific criteria, you don't have to prepare a Supplemental Record of Occupational Injuries and Illnesses (Form 10 1) or write it on Form 200.
A recordable injury is one that:
- Results in loss of consciousness
- Requires more than ordinary first aid (if a wound needs stitches" follow up treatment, or chemical prophylactic treatment for example)
- Results in seroconversion.
At that point, an injury must be documented on the correct forms and, if you have more than 10 employees, must be posted on the wall during the month of February.
Laney Kay, JD
Laney Kay, JD has taught OSHA-related courses across the Southeast since 1989. Her husband is a general dentist in Marietta, so she has had exposure to regulations' effects on dentistry since the beginning. She has written articles on OSHA-related regulations for a variety of publications.
GDA ACTION NOVEMBER 2000
Please note: there have been some regulatory changes since this article was published. For example, dental offices are now considered to be a “low-risk” environment and, as a result, are exempted from keeping log 200 forms. Also, the Form 101 (Supplemental Record of occupational Injuries and Illnesses) has been replaced with a form 301 (Injury and illness incident Report)
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