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UMASS Memorial Medical Center

Policies/Procedu res and/or Guidelines Manual

# 5008     Management of a Healthcare Worker Infected with a Bloodborne Pathogen      

 Effective Date: 1/ 31/2003

I.          PURPOSE

To provide policies and procedures for the management of healthcare workers at the UMass Memorial Medical Center (UMMMC) that are infected with a bloodborne pathogen. These agents include but are not limited to hepatitis B virus (HBV), Hepatitis C (HCV) and Human Immunodeficiency Virus (HIV). Emphasis is placed on practices to eliminate or control patient and co-worker exposure. A standard protocol is followed if an exposure should occur. This policy is complimentary with the Exposure Control Plan (#5006), the Medical Center  prevention of bloodborne pathogen transmission (#  ), and the Employee Health Services Blood Borne Pathogen Exposure of Health Care Workers Policy & Procedure (#  ).

II.        SCOPE:

All individuals providing direct patient care at UMass Memorial Medical Center  such as medical staff, nursing, therapists, and phlebotomists. Students, affiliating faculty and other contracted HCWs are included as well.


A Blood borne pathogen is an agent that is transmitted via the blood and body fluid route. Most often HBV, HCV and HIV are involved but other such pathogens include malaria, leptospirosis, human lymphotrophic viruses I and II and certain viral hemorrhagic fever viruses.

Members of the UMMMC Bloodborne Pathogen Advisory Committee will include but not be limited to, the Director of the Employee Health Service, the Chairperson of the Infection Control Committee, the Chief of the Division of Infectious Diseases or designee, the Vice President of Human Resources or designee, the Director of EEO, a representative from the Treatment Issues Committee, and a representative from the Office of Legal Counsel. 


The policy is reviewed annually by the UMMMC Bloodborne Pathogen Advisory Committee and recommendations for revision are forwarded to the Medical Staff Executive Committee through the office of the Chief Medical Officer for review and approval.   Managers and Supervisors are responsible for staff awareness of the policy and encouraging the reporting of exposures as soon as they occur. Employee Health provides support, counseling and education in a strictly confidential manner. Employees will comply with the policy as directed. Risk management will determine the need to review events through the critical event process as needed.


UMass Memorial supports the recommendations put forth by the Massachusetts Department of Public Health (Recommendations to Prevent the Transmission of HIV in the Delivery of Health Care Services, October 1992), OSHA (Guideline for the Prevention of Transmission of Bloodborne Pathogens, December 1991 and all associated compliance directives) and the CDC (Recommendations for the Evaluation of a Healthcare Worker Infected with a Bloodborne Pathogen, 1993). The institution endeavors to protect both healthcare workers and patients from bloodborne pathogen exposures and to support the rights of those affected.


1. All HCWs are oriented and updated annually on Standard Universal Precautions and the Exposure Control Plan. Employees at risk of exposure are offered hepatitis B vaccine if they have not previously been immunized or are known to be immune to hepatitis B.

2. Routine screening of HCWs for HBV, HCV and HIV is not required. HCWs at risk for infection due to behaviors outside of work are encouraged to seek appropriate testing and counseling through their personal physician. Individuals who test positive are encouraged to seek regular care from an appropriately experienced physician.

3. All reasonable accommodation will be made for any employee who has tested positive for bloodborne pathogen to continue employment. The employee will be counseled by the Employee Health Service regarding appropriate actions and behaviors. The Employee Health Service shall maintain confidentiality regarding the blood borne pathogen status of employees to the extent provided by law. If an employee’s responsibilities could result in exposing others to HIV, hepatitis B, hepatitis C, or another bloodborne pathogen, or compromise the employee’s health status, the employee must notify the Employee Health Service and a determination will be made as to possible job duty restrictions in consultation with the UMMMC Bloodborne Pathogen Advisory Committee. UMMMC will have the right to restrict from the performance of high-risk procedures individuals implicated in transmission of bloodborne pathogens to patients, as well as HBV e antigen positive individuals. In the event that an urgent determination is required, the director of EHS and the chairperson of the UMMMC Bloodborne Pathogen Advisory Committee or their designees will define temporary restrictions.  In the event that the individual is a member of the medical staff, restrictions will be implemented by the Chief Medical Officer or designee, and will be communicated to the individual’s department chairperson.  As necessary a transition plan will be developed in conjunction with Human Resources and communicated to the Employee Health Service.  For other healthcare workers and employees, restrictions will be implemented by the individual’s immediate supervisor. As necessary a transition plan will be developed in conjunction with Human Resources and communicated to Employee Health Services.

4. In the event that there is transmission of a bloodborne pathogen from an infected health care worker involved in performing invasive procedures, the Chief Medical Officer with input from the UMass Memorial Medical Center Bloodborne Pathogen Advisory Committee may initiate a "look back” investigation. Involved patients will be offered testing, counseling, and medical evaluation. Cases are considered on an individual basis.


This policy replaces the University "HIV and HBV Policy” previously located in the Infection Control Manual,  and Memorial Policy #7008. "Healthcare Worker Infected with a Blood Borne Pathogen dated 1.27.98 and becomes effective upon issuance.



Approved By:               Arthur Russo, M.D., CEO