Exposure Prone Procedure (EPP) Risks in Healthcare

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Published: 03 May 2021

Healthcare workers are responsible for protecting their patients’ health and safety. This includes preventing the transmission of bloodborne viruses, particularly when performing exposure prone procedures (EPPs).

All registered health practitioners who perform exposure-prone procedures now have to declare that they comply with the Communicable Diseases Network Australia’s Australian National Guidelines for the Management of Healthcare Workers Living with Blood Borne Viruses and Healthcare Workers Who Perform Exposure Prone Procedures at Risk of Exposure to Blood Borne Viruses, including any testing requirements (Medical Board of Australia & APHRA 2020, 2021).

This commitment must be made upon initial registration, and then at each renewal, the practitioner must state that they did comply with the CDNA guidelines in the previous registration period and will commit to complying again in the next registration period (Medical Board of Australia & APHRA 2020).

What are Exposure Prone Procedures?

Exposure prone procedures (EPPs) are medical processes where there is potential for the healthcare worker to become injured and bleed into a patient’s open tissues (NSW Health 2018).

EPPs involve the HCW’s hands (gloved or ungloved) making contact with sharp instruments, needle tips or sharp tissues such as teeth inside a patient’s open body cavity, wound or confined anatomical space where the HCW’s hands or fingertips are not completely visible throughout the entirety of the procedure (CDNA 2017).

EPPs include certain types of:

  • Cardiothoracic surgery
  • Dentistry
  • Gynaecological surgery
  • Neurosurgery
  • Obstetric/midwifery procedures
  • Open surgical procedures
  • Orthopaedic procedures
  • Otolaryngology, head and neck surgery
  • Cosmetic surgery
  • Trauma.

(CDNA 2019)

A more extensive list of examples can be found in Guidance on Classification of Exposure Prone and Non-exposure Prone Procedures in Australia 2017.

exposure prone procedures healthcare worker injury
Exposure prone procedures (EPPs) are medical processes where there is potential for the healthcare worker to bleed into a patient’s open tissues.

Procedures that are not considered EPPs are those where:

  • The HCW’s hands are visible and outside of the patient’s body at all times, or
  • There is no potential for the HCW’s hands to be injured by sharp instrumentals or tissue.

(CDNA 2017)

Note that some non-EPP procedures may escalate and will require a professional who is appropriately qualified to perform EPPs (CDNA 2017).

The major risk associated with EPPs is that HCWs may transmit certain bloodborne viruses to their patients (or vice versa) if the HCW’s blood comes into contact with the patient’s open tissues (NSW Health 2018).

These viruses include:

  • Human immunodeficiency virus (HIV)
  • Hepatitis B virus (HBV)
  • Hepatitis C virus (HCV).

(NSW Health 2018)

While the risk of transmission is considered very low, it is still a significant cause for concern and caution (NSW Health 2018).

What is the Likelihood of Bloodborne Disease Transmission During an Exposure Prone Procedure?

Mode of transmission Risk of infected HCW to patient transmission Risk of infected patient to HCW transmission
Hepatitis B virus
  • Percutaneous skin
  • Mucosal skin
  • Non-intact skin (e.g. psoriasis, eczema, burns, wounds)
  • Infected blood or body fluid
0.2% - 13.19% 1% - 62%
(depending on the patient’s hepatitis B e-antigen status)
Hepatitis C virus
  • Blood
  • Body fluid contaminated with blood
0.04% - 4.35% 0% - 7%
Human immunodeficiency virus (HIV) 0.0000024% - 0.000024% 0.3%

(Adapted from CDNA 2019)

There have only been four cases worldwide of HIV transmission to patients during EPPs. In all of these cases, the HCW was not taking antiretroviral therapy (CDNA 2017).

Recommendations for Healthcare Workers

In general, all HCWs should be aware of their BBV status and take reasonable precautions to avoid transmission. Those who are at risk of contracting a BBV outside of work should seek regular testing (CDNA 2017).

Furthermore, all HCWs (including students) are expected to be vaccinated against Hepatitis B before commencing their employment (CDNA 2017).

Read: Workforce Immunisation for Healthcare Staff

Those who perform EPPs should be tested for bloodborne viruses at least once every three years and should seek follow-up care and testing in a timely manner if they have potentially been exposed to a BBV occupationally or outside of work (CDNA 2018).

BBVs may be asymptomatic or mild, meaning that a HCW who has not been tested may not be aware that they have contracted a BBV (CDNA 2018).

Risk Factors for Blood or Body Fluid Exposure

  • Being injected with over 1mL of blood or body fluid
  • Parenteral exposure to laboratory specimens containing a high concentration of a BBV
  • Suffering a skin penetrating injury, including:
    • An injury from a needle that is contaminated with blood or body fluid
    • An injury that results in bleeding and is caused by an instrument that is visibly contaminated with blood or body fluid
    • An injury that causes the mucous membrane or conjunctival contact to come into contact with blood
  • A wound or skin lesion (not fresh) being contaminated with blood or body fluid
  • Direct vaccination with HIV tissue or material, or material likely to contain HIV, HBV or HCV (in laboratory settings).

(Queensland Health 2017)

What to do if you are Exposed to Blood or Body Fluid

exposure prone procedures washing hands
Thoroughly wash any areas of skin that have come into contact with blood or body fluid (even if there are no cuts or abrasions).

If you are exposed to blood or body fluid, immediate steps should be taken:

Note: Always adhere to your organisation’s policies and procedures.

  • Using soap and water, wash any wounds and skin sites that have come into contact with blood or body fluid
    • Put a sterile dressing on the affected areas. Apply pressure to the dressing if the site is bleeding
    • Avoid squeezing or rubbing the affected area
  • Using soap and water, thoroughly wash any areas of skin that have come into contact with blood or body fluid (even if there are no cuts or abrasions)
  • If the eyes have been splashed, flood them while open for at least 30 seconds using water or normal saline (remove contact lenses first). This should be done gently but thoroughly
  • If blood or bodily fluids have entered the mouth, spit them out and rinse the mouth out with water multiple times, spitting the water out each time
  • Remove any contaminated clothing and shower if required.

(Queensland Health 2017; SA Health 2020)

Documentation is crucial after an incident of exposure has occurred. It should include:

  • Information about the exposure
    • Date and time of the exposure
    • Type of exposure including blood or body fluid involved
  • Information about the source person
    • BBV status of the source individual
    • Demographic factors (gender, country of origin etc.)
  • Information about the exposed person
    • Status of the exposed person with respect to BBVs, including vaccination
    • Pregnancy risk and lactation
    • Medical history.

(Queensland Health 2017)

What Happens if a Healthcare Worker Tests Positive for a Bloodborne Virus?

A HCW who tests positive for a BBV must stop performing EPPs immediately (CDNA 2017).

They will be allowed to resume performing EPPs if they:

  • Seek ongoing and appropriate medical care for the BBV
  • Undergo testing for viral load levels
  • Maintain viral load levels that comply with the criteria stated in CDNA Guidelines
  • Undergo any required treatment as stated in the CDNA Guidelines, and
  • Comply with other relevant criteria as stated in the CDNA Guidelines.

(CDNA 2017)

The pathway for resuming EPPs after a BBV diagnosis is as follows:

Note: Always adhere to your organisation’s policies and procedures.

exposure prone procedures testing requirements
(Adapted from CDNA 2019)

Note: False positives for BBV are possible but very rare, as screening involves a two-step testing process (CDNA 2017).

What to do if a Patient is Exposed to the Blood or Body Fluid From a Healthcare Worker With a Bloodborne Virus

Note: Always adhere to your organisation’s policies and procedures.

If this occurs, a comprehensive risk assessment should be performed in consultation with the HCW’s treating practitioner. This risk assessment should comprise:

  • The significance of the exposure
  • The exposed patient’s status
  • The HCW’s BBV status, including:
    • Current viral load
    • BBV history
    • Adherence to treatment
    • Frequency and severity of fluctuations in viral load
    • Any factors that might increase viral load.

(CDNA 2019)

If there is any concern that the HCW’s viral load is above the allowed level, the HCW should be tested immediately. Post-exposure prophylaxis and any other follow-up should be offered to the patient based on local policies (CDNA 2019).

Additional Resources


References

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