SOUTH CAROLINA DEPARTMENT OF MENTAL HEALTH
Columbia, South Carolina

OFFICE OF THE DIRECTOR OF MENTAL HEALTH   DIRECTIVE NO. 824-01
     (7-100 

TO:      All Organizational Components

RE:      Bloodborne Pathogens: Prevention, Treatment and Control

I.       PURPOSE

A.  To define the obligations of the Department of Mental Health (DMH) as related to the OSHA Bloodborne Pathogen Standard. These bloodborne pathogens include, but are not limited to, hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV);

B.   To establish guidelines for HIV testing and counseling of high-risk patients;

C.   To establish guidelines and mechanisms for the appropriate care of DMH patients diagnosed with HBV, HCV or HIV;

D.   To establish guidelines for management of DMH employees with HBV, HCV or HIV;

E.    To outline procedures to limit the spread of HBV, HCV, HIV, and other bloodborne pathogens.

II.      POLICY

A.   The Department of Mental Health (DMH) accepts for inpatient treatment mentally ill patients or chemically dependent patients who may also have HBV, HCV or HIV. Upon completion of inpatient treatment of the patient's mental illness or chemical dependency, the patient is discharged and referred to a more appropriate health care provider for continued care of HBV, HCV or HIV and associated medical problems.

B.   The attending physician orders HIV serologic testing as clinically indicated, following informed consent and counseling, on any patient(s) deemed at high risk. Examples: Patient with a history or indications of:

1.   High risk sexual activity (whether heterosexual, bisexual, or homosexual), especially with multiple partners, and especially if a partner is known or suspected of having HIV;

2.   Injectable drug abuse;

3.    Accidental or incidental exposure to blood or other potentially infectious body substances;

4.    Blood transfusion/blood products prior to June 1992.

C.   The DMH provides safe, appropriate, and dignified care with an individualized treatment plan to all patients, including those who also have HBV, HCV or HIV. This care includes the consistent usage of current Standard Precautions and standard infection control processes, which eliminate the need for any unique precautions.

D .  The DMH promptly and effectively assists employees with HBV, HCV or HIV humanely and confidentially, to include continued employment if consistent with the findings of their attending physician. To prevent potential exposure situations which could result in possible infection of patients or staff, health care workers with HBV, HCV or HIV who perform invasive procedures which qualify as "Exposure-Prone Invasive Procedures" are required to receive confidential appropriate Expert Panel review and recommendation as set forth in the Health Care Professionals Compliance Act.

III.     PROCEDURES FOR PATIENTS

A.   Testing for HBV, HCV or HIV

1.   DMH physicians in all Inpatient Facilities are authorized to order appropriate serological testing for HBV, HCV or HIV when the attending physician considers the testing, clinically indicated. Informed consent, preferably written and with the signature of the patient, legal guardian or decision maker is obtained when possible and documented for patients undergoing diagnostic HIV testing. HIV specific counseling, both pre-test and post-test, is given to the patients when feasible. If a patient, once counseled, refuses the test, two physicians determine if the patient is to be tested. If the patient forcefully refuses the test, consultation with the Legal Department is sought.

2.    DMH physicians in all Mental Health Centers are authorized to order appropriate serological testing for HIBV, HCV or HIV when the attending physician considers the testing clinically indicated and informed consent has been obtained. Center clients may also be referred for testing to the local health department.

3.    Patient HBV,.HCV or HIV testing for healthcare worker post-exposure evaluation shall be conducted on source patients in accordance with established medical protocols, Center for Disease Control (CDC) recommendations and state law. State law authorizes HIV testing of a patient without consent when related to a health care worker exposure.

4.     HBV, HCV and HIV baseline testing shall be conducted on both patients in the event of an exposure (i.e., percutaneous, ocular, oral, cutaneous, or sexual intercourse) involving two patients.

5.     HCV and HIV positive results will be confirmed by further testing.

6.     As with all medical information, strict confidentiality shall be maintained for test results.

B.      Patient Exposures

1.    In the event of a patient exposure to blood or other potentially infectious body substances the patient shall receive immediate medical evaluation.

2.    HBV, HCV and HIV baseline testing shall be conducted if status unknown or previously negative.

3.    HIV testing is available through the SCDMH laboratory.

4.    If a patient exposes another patient to HIV, the exposed patient shall be informed of an exposure to the HIV but the source patient's identity shall not be disclosed.

5.    If the exposed patient's HIV baseline is seronegative and the source patient is positive for HIV antibody or has HIV risk factors, the exposed patient shall be retested at six (6) weeks, three (3) months, six (6) months and twelve (12) months.

6.    In the event of a patient exposure (i.e., percutaneous, ocular, oral or cutaneous) involving an HIV positive patient, HIV preventive treatment shall be offered and administered, if indicated, according to CDC recommendations.

7.     If HIV preventive treatment is indicated, medical evaluation and treatment shall be obtained promptly. Preventive HIV treatment is most effective if administered within two (2) hours of the exposure incident.

8.     If a patient exposes another patient to HBV, the patient shall receive immediate medical evaluation and preventive treatment is offered.

9.     If a patient exposes another patient to HCV, the exposed patient shall be retested at six (6) months and twelve (12) months.

10.    If an exposed patient is discharged, discharge planning efforts will include referral to an appropriate community health care provider for follow-up care.

C.    Treatment for HBV, HCV or HIV

1.   The Facility and Center directors are responsible for the provision of safe, appropriate, and dignified treatment to patients with HBV, HCV or HIV, with emphasis on the' individualized treatment needs and rights of the patient, as well as ensuring adequate procedural and enviromnental control to protect staff and other patients from possib ' le exposure in accordance with appropriate infection control procedures, including Standard Precautions.

2.   An integral part of the treatment is continued counseling of the patients regarding the nature of their disease, with emphasis on the prevention of transmission of HBV, HCV or HIV to others.

IV.     PROCEDURES FOR EMPLOYEES

A.   Exposure Control Plan

DMH facilities and mental health centers shall maintain an Exposure Control Plan that is reviewed and updated at least annually and whenever necessary that reflects changes in technology that eliminate or reduce exposure to bloodborne pathogens.

B.    Employee Responsibility

The employee is responsible for complying With Bloodborne Pathogen training and policies to prevent the exposure of themselves and others to HBV, HCV or HIV.

C.    Standard Precautions

Since the medical history and examination cannot reliably identify all patients infected with HBV, HCV or HIV, or other bloodborne pathogens, all patients are considered potentially infectious, and Standard Precautions shall be applied consistently in the care of all patients.

D.    Safer Medical Devices

DMH facilities and mental health centers shall provide a process to consider, evaluate, approve, train and implement safer medical devices as they become commercially available, with direct care givers participation.

E.    Occupational Exposure Categories

An exposure category is determined for each employe6:

Category 1: Your job routinely involves potential exposure to blood, body fluids, or tissues.

Category 11: Your job may expose you occasionally or in emergency situations to blood, body fluids, or tissue.

Category III: Your job does not involve exposure to blood, body fluids, or tissue. You do not perform or help in emergency medical care or first aid as part of your job.

F.    Training

DMH facilities and mental health centers shall provide a bloodborne pathogen training program to employees in Categories I and II. This training is provided prior to initial assignment and at least annually thereafter. The content of the training shall include at least the minimum elements listed in the OSHA Bloodborne Pathogen regulations.

G.    Pre-Exposure Protection

1.    Hepatitis B vaccination shall be made available after the employee has received training on bloodborne pathogens and within ten (10) working days of initial job assignment.

2.    Employees who provide direct patient care or who have potential for exposure to blood and other potentially infectious materials, (Categories I and 11 above) are strongly encouraged to receive the Hepatitis B vaccine.

3.    For employees with potential for occupational exposure, who elect to have the protection of Hepatitis B vaccine, the vaccine shall be available through the Employee Health Program.

a. Hepatitis B vaccine, a three step vaccination series, and any associated testing performed shall be provided at no cost to the employee.

b. Participation in a pre-screening program is not mandatory for receiving hepatitis B vaccination nor is it routinely recommended. However, when pre-vaccination lab work is indicated, testing shall be provided by the SCDMH laboratory for facilities located in the Columbia area. Blood samples will be obtained at the employee's home facility and forwarded to the laboratory during normal working hours. Blood sample requisitions will be labeled "pre-vaccine".

c. Post-vaccination testing shall be performed from 30 to 60 days after completion of the vaccine series for employees with potential for occupational exposure. Blood sample requisitions will be labeled "post-vaccine". Re-vaccination with the three dose series will be offered for employees who do not respond to the initial vaccine' series.

4.    Employees with potential for occupational exposure who decline to accept Hepatitis B vaccination shall be required to read and sign'the mandatory Hepatitis Vaccine Declination Statement as required by OSHA.

5.    Employees with potential for occupational exposure who initially decline the hepatitis B vaccination, but at a later date decide to accept, may request and receive HBV vaccination at any time at no cost.

H.   Post Exposure

Accidental percutaneous (needle stick, laceration, or bite), ocular, oral, or cutaneous (chapped, abraded or otherwise non-intact skin) exposure to blood or other potentially infectious materials shall be handled as follows:

1.    The exposed employee immediately thoroughly washes or flushes the exposure site as appropriate.

2.    The exposed employee promptly reports to their supervisor.

3.    The supervisor initiates a P-16 "Report of Injury" form describing the injury and prompt refers the exposed employee to their affiliated health care services for examination, treatment and follow-up. Prompt treatment is essential since preventive treatment is time limited (i.e., HIV preventive treatment is most effective if administered within two (2) hours of the exposure incident).

a.    DMH Facilities and Mental Health Centers

Employees are promptly provided transportation if needed to the designated health care services as indicated by their facility/center policy.

b.    Agency Personnel

Agency personnel who receive injuries that may expose them to blood or other potentially infectious materials are required to report the injury promptly to their agency since they are covered under the agencies' Workers' Compensation Program.

4.    The post-exposure evaluation, treatment, and follow-up are provided at no cost to the employee. All bills incurred are forwarded to the Worker's Compensation Coordinator in the Benefits Office of DMH Human Resource Services.

5.    If the employee terminates employment prior to completion of the Hepatitis B vaccine series, HCV testing series or HIV testing series after a job-related exposure, the employee may make arrangements through their previous facility or mental health center to complete the series.

I.   Record Keeping

A.    DMH facilities and centers shall establish and maintain a medical record for all employees with potential for occupational exposure. Employee Health records of training, vaccinations, immunizations, etc. shall be maintained for the duration of employment, plus thirty (30) years. Employee Health records shall be kept confidential and will not be disclosed or reported without the employees expressed written consent to any person within or outside the facility/center except as required by OSHA Standard or other federal, state or local regulations.

B.    DMH facilities and mental health centers shall establish and maintain a sharps injury log for the recording of percutaneous injuries from contaminated sharps. The information in the sharps injury log is recorded and maintained in such a manner as to protect the confidentiality of the injured employee. The sharps injury log contains at a minimum the type and brand of device involved in the incident, the department or work area where the exposure incident occurred and an explanation of how the incident occurred. If medical treatment beyond minor first aid is rendered, the occupational exposure is recorded on the OSHA log and summary of occupational injuries and illnesses and on the Adverse Incident Report form #C-174.

J.    HBV, HCV or HIV Positive Employees

1.    Only those health care workers who perform invasive procedures which qualify as "Exposure-Prone Invasive Procedures" (EPIPs) are required in accordance with the Health Care Professionals Compliance Act (HCPCA) to determine their HBV, HCV or HIV serostatus. Employees with HBV, HCV and/or HIV comply with current CDC recommendations and the HCPCA. Those who perform EPIPs must seek Expert Panel review and recommendations. If those specific recommendations include notification of a supervisor or employer, this must be complied with or grounds for dismissal exist.

2.    For any other employee it is requested, but not required, that the employee report their HIV positive status to the Employee Health Nurse to allow for accurate interpretation of the annual PPD and to assist in determining need for further evaluation.

3.    If the HBV, HCV or HIV positive employee does not comply with measures recommended to prevent transmission or there is evidence that the employee may be transmitting infection, the need for removal from direct patient care shall be assessed by the Facility Director or designee to assure staff and patient safety.

V.    CONFIDENTIALITY

The fact that a patient or employee is seropositive for HBV, HCV or HIV is confidential medical information.

VI.  RESCISSION

This directive rescinds and supercedes Directive No. 774-93 September 30, 1993 and entitled "Bloodborne Pathogens: Prevention, Treatment and Control."

July 13, 2001