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Peggy Swerhun: Thank you, Christine.

Good afternoon. My name is Peggy Swerhun. I'm the consultant with the Health Care Health and Safety Association and represent the central and northeast region. On behalf of the Ontario Safety Association for Community and Healthcare, we would like to welcome all participants joining us.

Today we are going to present blood-borne pathogens, and following the presentation we invite you to stay on line for a question-and-answer period.

Before introducing our speaker, I have a few reminders for the audience. Please make sure that there is no background noise or discussion during your call, as this will affect the audio quality. Make sure you come to the microphone if you are conferencing in a large room. Make sure all pagers and cell phones have been turned off. And, finally, if your building has a PA system, you may want to ask them to turn it down or off if possible.

It's time to get started, so let's proceed. Our speaker today is Nora Boyd. Nora is the past president of the Community and Hospital Infectious Control Association for Canada. Nora is a registered nurse and obtained her diploma in nursing from Kingston General Hospital. She received her Bachelor of Nursing from McGill University and Master of Education from Queen's University.

Nora is currently the infection control officer for the Lambton Hospitals Group where she has developed an infection control program for a 160-bed acute-care hospital and a 100-bed complex continuing care facility. She has also developed education videos and self-learning packages on MRSA and BRE for the community.

Nora is a member of the Ministry of Health Committee on Infection Prevention and Control for Antibiotic-Resistant Organisms. Nora's facility recently revised their needle-stick follow-up protocol and works with the public health to ensure consistent follow-up for health-care providers in the community.

Nora is an excellent speaker and an expert in infection control. We are very pleased that she can be with us today. Welcome, Nora.

Nora Boyd: Thank you, Peggy. I always wish that my mother could be online when I get an introduction like that—I think for most of us.

I wanted to just take a little bit of a segue, because those of you who know me, I do this all the time. And for my Community and Hospital Infection Control Association, just to remind you about infection control week coming up October 21st to the 25th. And our theme this year I think is something near and dear to everybody's heart: stop the hesitation, get the vaccination—all about flu shots. So there will be posters and all kinds of information out about that.

I'm here representing my facility, Lambton Hospitals Group, but I want you to know that the people who've done all the work, it's not just me by myself. I have some very special thanks to give to my occupation health nurses, Jane Younger, Karen Sheridan and Charlene McWaters; to our Lambton Health Unit public health nurse Christie Clarke; and to our Sexual Assault Treatment Centre leaders Monica Voteur and Georgie Houston (sp). They've all worked as a team in terms of updating our blood-borne pathogen procedure, which is what I'm sharing with you today, so that that's certainly very important.

The music as we came on was very unusual for sort of a health-care facility on a Tuesday afternoon, and it sort of reminded me of what research has shown about people listening to speakers. Apparently one-third of them will be listening about a past-positive sexual experience, one-third will be anticipating a future-positive sexual experience, and one-third will actually be paying attention to the speaker. So for those of you who are paying attention, thanks for joining us.

The executive summary on this talk is—what I will talk about is—I want to talk about the risk of blood-borne pathogens, their diseases after sharps injuries. I want to talk about Canadian data on needle sticks and the Canadian Communicable Diseases Report from December 15th, 2001, has some excellent data, and I will update what you have in your handout because the stuff I did from the handout was from their previous report. I want to talk about risk reduction strategies, and then I want to talk about blood exposure follow-up.

So to start off with blood-borne diseases, I know when I did my occupational health and safety training, they talked about 25 different blood-borne diseases and things that you can contact through blood exposure. For the talk today, we're really going to talk about the main risks, which are hepatitis B at a three- to 30-per-cent risk, hepatitis C at a three- to ten-per-cent risk, and HIV/AIDS at a 0.3 per cent. Now, 0.3 per cent is three in a thousand, and I think a lot of people don't quite understand that.

The statistics are probably less compelling amongst a population that still buys lottery tickets and for those one-in-7-million chances, you do think you're going to win. So these kinds of statistics really don't sell that well to staff when you're trying to tell them that their risk is low.

The things that have changed in the last sort of three or four years is that the follow-up for blood-borne diseases is required to be in one to 24 hours for HIV and four to seven days for hepatitis B. In fact, 48 hours is even better for hepatitis B, so there's more pressure on the time issue for this. So for Canadian data, I wanted to look at—again, this is from the report from the Canadian Communicable Diseases Weekly, December 15th, 2001. And if you go on the Health Canada web site under publications, you'll be able to pull it up. And it has a surveillance of health-care workers exposed to blood-borne pathogens from April 1st, 2000, to March 31st, 2001. And I will be updating the rates of exposure and the stats that are in the handout I gave you. This just came out in December, so it has a full year of information, whereas the previous information I gave you was just based on six months. So some if it has changed.

The first thing that's interesting—and again, I work in a world where indicator data and being able to benchmark your indicators to someone else's is very important, so I'm really excited about this information. In terms of exposure rate, the new rates are 4.24 per hundred FTEs in a hospital, or 16.13 per hundred beds. And again, it all depends on—you can choose how you want to report your needle-stick data.

The other comparison would be 0.06 per hundred patient days, or 0.54 per hundred patient admissions. Again, these rates give you comparative data that you can then look at how you're doing versus the Communicable Disease weekly report. Their data is based on 12 hospitals, and if you download the document you'll see where they were. They range in size—most are teaching facilities, so that if you're a small community hospital such as mine, you would expect that we would come in under what you would see in a larger teaching hospital, but it does give you some benchmark data.

The other ones that are in there (and I've given some of it in RNs and community RNs, the 4.88 per hundred FTEs), again as a comparator to what you're doing in your community, for phlebotomists it's 42.78 per hundred FTEs, for medical residents it's 20.97, for sterilization attendants it's 12.14 per hundred FTEs, and for medical specialists, 10.06 per hundred FTEs. I know in our facility we don't break it down as finely as that, but it does highlight to you the importance of safety procedures for your phlebotomists and your sterilization attendants. They have much higher risk than in fact your RNs, although I think in the data you'll find that most of the people who actually get the exposures are your registered nurse staff.

So of your reported exposures, you're going to find that 85 per cent were percutaneous and 15 per cent mucocutaneous. Needle sticks accounted for 66 per cent of all percutaneous injuries, and splash exposures accounted for 46 per cent of all—13 per cent of all injuries. Forty-six per cent were splash to the eye, and I guess that becomes important when you go back through their data and you find out that 65 per cent of health-care workers were not wearing protective eye wear or face shields. And if you're looking for risk-reduction strategies, that definitely points you in that direction, doesn't it?

Four or five injuries involved blood, and 50 per cent of the injuries occurred between 9:00 and 3:00 o'clock in the afternoon. So it isn't just something that happens after hours.

I think the locations of exposures aren't particularly surprising. The operating room was the most common location of an exposure; the medical ward, 15 per cent; the surgical ward, 9 per cent; emergency room, 8.4; and intensive care, 7.2. Those are actually quite low when you think about what kind of a risk they would have working in those areas where things tend to happen sort of quickly. And the dialysis unit, obviously you've got nurses working in dialysis units that are careful because there is a lot more risk of exposure to lines and to significant blood in the dialysis unit if it's not cleaned up or through the percutaneous accessing of dialysis patients.

The types of devices that caused the injuries: needles with syringes were 23 per cent (and again, that's an update for the whole year's data); suture needles were 11 per cent; winged IV needles at 8 per cent; blood collection needles were actually 14 per cent; and scalpel blades were 7 per cent. And this is based on a whole year's data. That's why it's different from what's in your handout.

Forty-three per cent of the percutaneous injuries occurred during use of the items; 33 per cent occurred after use; and only 12 per cent were related to incomplete disposal.

Of those percutaneous injuries, 23 per cent were injections, 14 per cent were drawing venous blood; 11 per cent were suturing; 7 per cent, starting an IV line; 9.7 per cent, recapping a needle; and 12 per cent, disposal injuries. Some of those have changed based on the updating of that full-year data.

Mucocutaneous injuries: 71 per cent were on mucous membranes; 62 per cent were splash to the eye; and 10 per cent, splash to the mouth (you can just see where the reductions can happen if people are wearing eye protection); and only 21 per cent was on non-intact skin.

So in terms of the follow-up in this study, when they looked at actually what the risks were for people with exposure and the source patients were tested and source patients were identified in 84 per cent of the 1,436 cases, only ten per cent were not screened. So that's a pretty good indicator, a pretty good feedback on that.

What's interesting about this, too, is that we're seeing—in the House of Parliament in Ottawa, they're looking to introduce a bill where patients would be required, it would be mandatory for them to allow themselves to be tested. My sense is that, for the most part, we're actually getting patients to volunteer to be tested, and I'm not sure that that's such a huge concern. All of the issues around informed consent and everything else I think still has to be taken into account when dealing with patients.

So for our patients who were positive, the updated results for the whole years again: the hepatitis B, in a year there were 15 positives; hepatitis C, there were 77 positives; HIV, there were 24 positives; and 116 positive results on a 104 patients. In fact, you had seven patients that were both hepatitis C positive and HIV positive, one patient who was hepatitis B positive hepatitis C positive, and two patients who had all three: hepatitis B, hepatitis C, and HIV. So you get kind of a bit of a different view.

The prevalence of blood-borne pathogens was 1 per cent for hepatitis B, 7 per cent of hepatitis C, and 2 per cent for HIV. So the greatest risk to our health-care providers right now for needle-stick injuries percutaneous is hepatitis C. That's the highest incidence, and I think when we go back to look at what the greatest risk of transmission was, hepatitis B was the greatest risk of transmission, hepatitis C was second, and HIV. So in this one, when you're looking at what the prevalence is out there in Canada, 7 per cent for hepatitis C.

Now, this said, each of you should be in contact with your health units in terms of understanding what are the issues in your own community for prevalence of these hepatitis B, hepatitis C and HIV. And your health unit can give you much better data in terms of what's happening. This is all based on aggregate data, but it does sort of identify—most of us worry most about hepatitis B, but in fact the follow-up for hepatitis C will be very important as well. And the HIV, it's there, but it's not as great a risk as we thought. I think our universal vaccination programs for hepatitis B have been very useful in terms of reducing the risk, and I would suggest that probably in another 10 or 15 years, as those kids grow up who've all been vaccinated, that hepatitis B won't be nearly the concern that it was.

So once we know what's out there and what the risk is, I think for most of us the concern we want to do is look at risk-reduction strategies. And of course this goes back very much to the occupational health and safety sort of view of things. You always want to work on risk reduction or prevention first before you go into how you're going to treat it afterwards.

In the Health Canada report, it was suggested that 45 per cent of the percutaneous injuries could have been prevented by proper handling and disposal of used needles. And I have to tell you that in my facility, we have made a real effort to increase the number of sharps containers everywhere. If I really had my druthers, we'd have one hung around every health-care provider's neck, because they're never exactly where you want them to be. But in most of our patient-care units in our rooms, we have two to three sharps containers to try to make them so they're accessible to people and you're not having to walk with an unshielded needle.

The other kinds of things that of course you're looking at are your hepatitis B vaccination rates, and I think most places, our youth, virtually everybody under 25 is now vaccinated for hepatitis B with the universal vaccination programs in the schools. That's made a big difference. It tends to be more of the older people around who are not vaccinated, your older health-care providers who may not have seen the risk or were concerned about the original hepatitis B vaccination with blood products, which no longer is the case. I know again at our facility, virtually annually we do a big campaign on hepatitis B vaccinations, and I have to say it's really rewarding to learn that in your operating rooms you have a 93-per-cent vaccination rate. I think that's the kind of numbers that everyone's looking for, so that you do it by department and you target each one to help promote hepatitis B vaccinations.

And then, of course, engineering safer workplaces. You need to know where the risk is, and that's what the Canadian Diseases Weekly article does identify fairly clearly for these other hospitals. You need to know what your risks are in your hospitals, and so tracking your needle-stick injuries—we do it on a quarterly basis. I mean, we review them every month, but quarterly we look at whether they're handling, disposal, what kind of injuries they are, and basically look at what we can do then to deal with that. We have a standing item on our occupational health and safety committee of looking at sharps injuries and what's happening in terms of what initiatives our facility is taking.

So we've tried to look at where the injuries are and where we're going to have an impact and identify where the risk is and what we can do to reduce that risk. We've introduced needleless products. That's been very successful. We've brought in safety syringes in a high-risk area such as psychiatry, and we're looking at introducing—we're on our second trial for safety IV catheter for that, so that all of those are methods that are very simple to do. There are safety syringes out there. My big concern from my facility is the cost, and I hope that when we have some dialogue with questions, that people can maybe share with me successes that they've had with various things that they've brought in.

The other thing we look at is protective practice, and again this involves the use of gloves. We know that if somebody has gloves on and they get a needle stick, they've reduced their risk by 50 per cent, because there's 50 per cent less blood that gets through those gloves. I talked previously about the number of mucocutaneous exposures to the eye. We've done a big job on bringing in eye protection, and our old, unattractive eye protection has been replaced by something that's very lights, fits over glasses, and is disposable, and the cost of it is pretty minimal.

And I have to say I took a page from "ER": I looked at what they were wearing there and decided that if they were movie stars and they would wear this stuff, maybe my staff would, too, and it really was effective. So eye protection. And again, the whole thing with eye protection is so many times you can't actually anticipate a splash. I think probably the only body fluid you can really anticipate a splash with, other than in the operating room (it's pretty much a guarantee), would be when you're doing endotracheal suctioning on someone. You can pretty much guarantee you're going to get some splash, but of course we've reduced most of that with in-line catheters.

But eye protection is something that if you're working in an area where the stuff happens, you really generally don't have time to stop and put it on, so that wearing it in places like emergency, in your ICUs, encouraging people to wear eye protection and setting a standard so that it's acceptable I think is very important.

It was suggested that two-thirds of mucocutaneous injuries could be prevented by eye protection, and again, you're much better to engineer those controls in and encourage staff to participate in that.

I've put into the handout a risk-hazard analysis, and again, each needle stick you might want to go back in or even have each department go through and identify some risks and where they are, and have staff maybe discuss at your staff meetings where things possibly can happen, where they go wrong, what happens. I was trying to correlate our needle sticks with some sort of graph for workload measurement, and I wasn't terribly successful in our place, but I think again you almost think—I know at your place we have a bed alert when we run out of beds, but you almost want to have a safety alert that, when you're getting to a point where your acuity and your workload is getting so high, that's when people are more at risk. And so any of the things we can do to engineer controls to reduce that risk, to alert people to slow down if they feel that they're being over-rushed, that they need to take the time.

And just as your first aid course tells you, the first thing to do is always make sure that you have protected yourself. In the old days, when someone was falling, we would leap and try to cushion their fall and hold onto them. I think most of us know now, with the incidents of back injuries and with care, that we're always trying to assist patients, but we do have to protect ourselves first for all of this. I know in my community we have a pool program as part of our facility, and we don't ever do mouth-to-mouth CPR. We always use a mask, and that's a requirement—again, part of the thing of protecting yourself first.

So I've just added in that risk-hazard analysis, and I would certainly recommend that you use it if you're having problems in different departments.

What we did in our facility, we identified a gap in post-exposure follow-up. When we got together with the health unit, and also just internally, we found that the follow-up post-exposure was really not as well done as we'd like. People often waited in the emergency department, because if yours is like ours, you know that you have to go with the acuity, and whatever's coming through the door, if it's a level four, it takes precedent over anything. So our staff were in fact left sitting on the side and not getting as quick a response as we would like.

So we looked at it and we collaborated with the health unit because we found that they weren't in fact tracking the needle sticks, and if you work in health care, you always hear out in the community about things in follow-up and things that aren't done. So we collaborated with them. The hospital would provide the 24-hour, seven-day-a-week coverage, an we went internally into our hospital to look at how we could do that and provide specific coverage just for staff who had a needle stick. So it was a dedicated response. And we collaborated with the health unit in terms of them using our common forum for follow-up so that no matter where the person came from (if they were a health-care provider in our facility, if they were a health-care provider in the community, or if they were somebody who got stuck with a needle in a park or in a hotel room), they would all get similar follow-up.

Our follow-up is based on the Ontario Hospital Association, Ministry of Health and Ontario Medical Association follow-up guidelines that were revised in the year 2000. Who we used for our particular follow-up is our sexual-assault treatment centre people. They have a team of nurses who are available 24 hours a day, seven days a week on an on-call basis, and within 40 minutes they can be in the hospital to provide follow-up care. We felt this was a nice marriage because they had a lot of experience in a lot of the pre-HIV testing counselling, and they certainly had experience with people who'd been traumatized and were very good at dealing with people one on one.

We wanted to get our needle-stick victims out of the emergency setting because that is a pretty wild place often, and provide them with confidentiality and make sure that they had appropriate pre-HIV testing counselling. I think anybody who's ever had a needle stick, you know that your world kind of stops and everything slows down, and things that you never thought about or never worried about all of a sudden are coming rushing at you and all kinds of information, and you do need to have someone to sort of take you through that process. And if you're a community person and not aware of any of the concerns, then it is much better done in a quiet setting with proper counselling.

So what we've done is we use our sexual-assault treatment people. They will be called in to deal with this, and they've had special training to allow them to do the appropriate follow-up. And what it means is that no matter where you get your needle stick, whether it's in a long-term care facility, in a hospital or in the community, your follow-up will be done in a very consistent and timely fashion. Again, I mentioned back in the beginning, with the HIV prophylaxis, your timing for follow-up is one to 24 hours, so that's made a big difference.

And we use common forums and we have common follow-up policies. The benefits of our partnership have been with plain language expertise of the health unit. They've actually put together a whole bunch of information sheets. We had sheets before, but I have to tell you, I kind of like theirs better. They're much better at doing this kind of thing than we are. We use the counselling expertise of the health unit for HIV testing. They did a special package on HIV counselling for people who've had needle sticks. It has much less emphasis on the sexual transmission. It certainly covers that, but it's much more geared to somebody who's had a needle stick, and I think, for our health-care providers, the regular counselling that is out in brochures and things really just doesn't cut it for them. They need something that's just a little bit more focused, so our health unit put together a package and actually did the education for our staff.

We have the 24-hour, seven-day-a-week coverage. People come in through the emergency department and the system is accessed where the sexual-assault treatment workers will come in on call and do the follow-up for our patients or for the clients.

So we have these standardized follow-ups, and I think that's been very positive. We're also in the process of a joint education for community and hospital. We've done an internal one for our hospital people, and now at every opportunity we've done it for our long-term care facilities. We're also identifying the need to do it for our dentists out in the community and for our physicians as well.

We do get calls asking for pieces of information about follow-up on needle sticks, and I always recommend that they just come to the emergency department. It is such a complex procedure to do this appropriate follow-up that I think it's definitely worthwhile to try to encourage people to use your facilities.

The outstanding issues—and I don't want anybody to think that I had all the answers, that's for sure—but payment for HIV prophylaxis outside the hospital. We do have a system where when people are recommended or given prophylaxis, that we give only a three-day packet of the prophylaxis, and then we have them follow it up by their own family physician if they prefer. Or in our community, lack of family physicians is pretty common, so we have a follow-up process where they'll be followed up by the health unit or by an internal medicine specialist because the drugs for the HIV prophylaxis aren't something that everybody uses. And typically we follow up with that with a weekly packet, and again, with more follow-up, so that they're not taking the whole $1,500 worth of drugs out all at once. But payment for HIV prophylaxis outside the hospital, again, that's something in our health-care system we tend to just hand all this stuff out, and that would be an issue for some people.

The other issue that we had was in terms of giving H-BIG. We give it because it's a physician order, and we give it fundamentally like a drug, but there were some questions about whether people should have to consent about it, being a blood product. So that was an area, and I certainly would be interested in listening and hearing if you have other things.

One of the things that we do do is we pay our physicians in emergency for the follow-up for our staff. They consider that to be extra, in addition to their regular emergency, because they're in a sense acting as an occupational health physician. So typically that would only happen after hours or if the occupational health physician isn't available.

And for community people, people off the street or who have had needle sticks in the park or blood exposures there, obviously the emergency physician, that's part of his responsibility to provide care to the community. So there's no need to pay them in that case.

One of the other issues I guess that's come up is WSIB, do we have to report every needle stick? And from our end, I think we're looking at, if we have a written protocol (which of course we do), then the only things we have to report are if they need treatment. And that treatment would include if they required a tetanus shot or if they required H-BIG. And there are forms on the WSIB web site that you can download that speak to that issue.

I did want to talk a little bit about our algorithms (and I'm not sure all of you received them) in terms of post-exposure follow-up. We found the process to be really quite complicated, so we made up some algorithms and we started out by who does what, who's on first, who's on third in terms of a needle stick, and what the responsibility of the individual is, what the responsibility of the manager or delegate, and what the emergency or occupational health nurse does, and then what the physician does. And we have been using these and finding that it really does make things a lot clearer. The first aid is identified, what you do right on the site, and then how do we do follow-up afterwards?

So we do have a lovely algorithm that's exposure to blood and body fluids. I'm not sure if all of you have that. We've given you a checklist for sharps injuries, and there is extra pieces in the package that I think you can access through Susan Griffith at the Ontario Safety Association for Community and Healthcare. But we found when we did an algorithm and you actually put out who does what, it made it a lot simpler for everybody to follow. And of course when you've got a team of people doing it, then you have to be sure that everybody is following the same algorithm, the same follow-up procedures.

I'm looking at the time. I still have some time, but I think we may have a number of questions, and I'd be interested in knowing sort of where the issues are for the people in the audience.

I think at this point I'll open it up to questions.

Operator: Thank you, Ms. Swerhun. Thank you, Ms. Boyd.

We will poll for questions today using our quick-queue polling feature. If you have a question, please press 1 on your touch-tone telephone. If you are using a speaker phone, please lift the handset and then press 1. And should you wish to your question, please press the number sign. Please press 1 at this time if you do have a question.

Our first question will come from Joanne Lianza (sp) from Rouge Valley Health. Please go ahead.

Heather Halkany (sp): Hi. This actually is from Heather Halkany, the occupational health nurse at this site. My question about using a sexual-assault team (which I think is a wonderful idea): Do you think that you would have less reported injuries if people knew that they had to go through a longer process than coming through the occupation and health nurse?

Nora Boyd: Oh, I don't think there's any question, and I want to clarify. During regular office hours, our occupational health nurses do all the follow-up. It's only for the after hours. It's only sort of after they leave at 4:30 and before they come in at 8:30 that we use the sexual-assault treatment people. We don't actually advertise that. We just say you, "Go to emergency and someone will be coming in to deal with just you." And I know for our nurses, the time is really important to know that there's going to be someone there quickly.

Heather Halkany: So you would negotiate that, then, through occupational health and the emergency department?

Nora Boyd: Yes. That's how we did it.

Heather Halkany: Oh. Okay. Thank you.

Nora Boyd: We're basically looking for a solution, how you get quick response, and you can't judge what's going to happen in your emergency department. I mean, that's a given. Plus training all of your emergency nurses, again, it gets to be a bit too much. We haven't found that it's terribly costly to do it this way.

Heather Halkany: I think it's a great idea. Thank you.

Operator: Thank you, ma'am. Once again, if you do have a question, please press 1 at this time. Our next question will come from Sally Lloyd from Lakeridge House. Please go ahead.

Sally Lloyd: I was wondering, when the employees go to the emergency department, then, do they actually get registered for an emerg visit, or do the doctors, like you indicated, bill separately to the occupational health program?

Nora Boyd: They are actually registered for an emerg visit because we need to be able to have the physician as part of that. So they are registered, and then it goes through a slightly different process than going through a regular triage.

Sally Lloyd: Okay. Thank you.

Operator: Thank you, Ms. Boyd. Once again, if you do have a question, please press 1 at this time. Our next question will come from Bella Redwood of Halton Health Care. Please go ahead.

Shirley Lancette (sp): This is Shirley Lancette, the infection control clinician at Halton Health Care. My question, Nora, relates to your specific incidents data that you would collect in-house and how you would use this to target your high-risk areas for various reduction strategies. Have you been able to use that incidents data in certain areas to initiate quality improvement changes?

Nora Boyd: Yes, we have. What we found over the last year is that our highest incidents of sharps injuries was in the operating room. Surprise. So then we had to identify where those were, and of course it was a whole bunch of different things. It wasn't just scalpels, it wasn't just—it was a whole bunch of different things. So we basically did a big campaign in terms of awareness to the staff and we talked to them a number of times. We also did a big awareness for surgeons and the people working in the operating room. We put up a lot of posters and some signage, and sometimes awareness makes a big difference, because our numbers are dropping. We have actually an appointment to go and see the operating room committee to discuss further what other things we can do in terms of things like no-touch passing and that kind of thing. But we've seen our numbers plummet in terms of sharps injuries. So I think an awareness and sort of a safety eye to be out there, and for people to realize that it's unusual to have such a big group—our OR was head and shoulders above any other department for sharps injuries, and so they've taken some responsibility for that. And we've looked at sort of all of the engineering things that we can do to try to reduce those.

Shirley Lancette: Thank you.

Operator: Thank you, ma'am. Once again, if you do have a question, please press 1 at this time. Our next question will come from Linda Prevost from St. Francis Memorial.

Linda Prevost (sp): With regards to the earlier question about registering the ER visits, would this not then automatically be a WSIB claim?

Nora Boyd: I might refer to my colleague in Sarnia, Jane. Is Jane there? She can't get on the line? Okay. She can't get on the line.

Operator: Jane, if you are on line, if you just press 1.

Nora Boyd: I was going to refer to my colleague in occupational health who could be more specific on that. I'm not sure actually, then, if they do register, but I know that we do have follow-up and forms that are filled in for them, so if you think that that actually triggers the treatment part, then maybe they aren't registered.

Operator: Ma'am, do you have a further question? Ms. Prevost, do you have a further question?

Linda Prevost: Sorry. Thanks.

Operator: Our next question is a follow-up question from Bella Redwood from Halton Health Care. Please go ahead.

Shirley Lancette: The other question I had for you, Nora, related to the infected health-care worker. And do you have any protocol to deal with the actual infected health-care worker?

Nora Boyd: I think we all know that Health Canada has put out some guidelines recommending that anybody who is positive for either hepatitis B, hepatitis C, or HIV should know their status, and that's an expectation. And I know in Ontario, the recommendation is that you refer it to your college for an expert panel to assess whether you are at risk of transmitting in terms of what you do. I think for most people, you're looking at surgeons or physicians who would be more at risk of transmitting any of those things, but there is a recommendation that you do that, and that's part of the guidelines, then, from the Ministry of Health, the OHA and the Ontario Medical Association. So we certainly speak to our staff about that, and there is a responsibility for them to identify themselves. Does that answer your question?

Shirley Lancette: Yes, it does. I just wondered if you had—right now, it's a recommendation?

Nora Boyd: M'hm.

Shirley Lancette: It's not a —

Nora Boyd: It's not mandatory.

Shirley Lancette: It's not mandatory.

Nora Boyd: Yeah.

Shirley Lancette: Other than obviously oc. health, there's a certain amount of counselling that would go on at the oc. health level.

Nora Boyd: Yes.

Shirley Lancette: But in terms of exposure-prone procedures, say that were a person involved in exposure-prone procedures, if there was any kind of internal strategies that you have developed or adopted based on the recommendations?

Nora Boyd: Really it hasn't come up as an issue for us, but I know the Ontario Medical Association has some policy statements on that and you may want to refer to them.

Shirley Lancette: Thank you.

Operator: Thank you, ma'am. Once again, if you do have a question, please press 1 at this time. Our next question comes from Anne Birchbaum from the Credit Valley Hospital. Please go ahead.

Debbie Lauzon: Actually, this is Debbie Lauzon, risk management at Credit Valley. I just wondered what your issues were related to the consent for the H-BIG.

Nora Boyd: I think the issue was that it's a blood product, and so our people actually consenting to having a blood product. Do they understand that it is a blood product? And typically, when a physician orders a drug, which H-BIG is a drug, we don't question the order or we don't get consent around it. We haven't in the past with H-BIG, but it was something that came up.

Debbie Lauzon: Does your hospital have a policy that requires consent prior to administration of blood products?

Nora Boyd: No.

Debbie Lauzon: Because if you have a specific—my background is in transfusion medicine actually, —

Nora Boyd: Right.

Debbie Lauzon: — so the requirement from the Creaver recommendations, there were two things: one, that you notify the person that they are receiving a blood product; and the other recommendation was that there is a separate consent form. With most of our intramuscular injections for rig and varicella, we actually have said that a verbal consent is okay.

Nora Boyd: Okay.

Debbie Lauzon: But the person should be informed that it is a blood product, and then, if you have some data around the risk of infection—which is very low with all of the fractionation products that are prepared in the way that H-BIG and some of the other products are prepared, excluding Factor 8, which was a high before it was monoclonal.

Nora Boyd: Thank you, Debbie. That's very helpful in terms of understanding that. I think a verbal consent, that would be good to include that in our follow up. I appreciate your input on that.

Debbie Lauzon: Okay.

Nora Boyd: It's something we tossed around and we weren't quite comfortable, and yet you don't want to scare people, but yet you want to certainly fulfil that people have a right to know.

Debbie Lauzon: Well, and they really should know.

Nora Boyd: Yeah.

Debbie Lauzon: I think that's the key. It's the same with our H-immune globulin. A lot of people don't realize that it is a blood product.

Nora Boyd: Right. So that would be fairly simple to do. Thank you for that.

Operator: Thank you, ma'am. Our next question is a follow-up question from the Halton Health Care. Please go ahead.

Shirley Lancette: I was wondering if you could tell me if you do your testing for your needle-stick victims in-house, and if so, what your turn-around time is.

Nora Boyd: Our testing—this is sort of in process right now. I was actually talking to my lab people yesterday, and they've just been told that their hepatitis B rapid tests are not meeting standards and they're out looking for a new one. So we do send stuff out. The HIV test we send out, and the hepatitis B and hepatitis C we will also be sending out, which puts us in a bit of a crunch in terms of following up and getting those results back. The HIV tests coming back, we're generally looking at at least 48 hours for those results, and sometimes up to seven days, depending on whether it's on a weekend or where that turnaround is. So some of the follow up is actually done without full knowledge.

And I guess one of the things that hasn't been brought up here is the whole thing of hepatitis B and following up for people who've been vaccinated and have been shown as positive, to have a positive titre. And I know people keep asking me, "Do you need to get a booster if you've had your hepatitis B vaccination and you've shown that you've been a positive—you've had a positive titre post-vaccination series?" The NASTI (sp) guidelines don't recommend any follow-up boosters for people, but it is important that you know what your status is and that you did have a positive titre post-vaccination. It does make a difference in terms of the OHA Ministry of Health guideline follow-up. If you have had a positive titre post-vaccination, even though we do your titre now and it's less than ten, they're saying that your body has a memory and you don't require any follow-up. You'll just be followed and counselled about watching for signs and symptoms of hepatitis. So that's kind of a big change that's come out of those new guidelines for follow-up.

Now, in the Health Canada guideline for follow-up, one of the things that they identified is that health-care providers don't always know their hepatitis B status. I know I was vaccinated for hepatitis B 20 years ago, and I had follow-up titre done. I couldn't tell you what the titre was, but I didn't have to have further vaccinations, so my assumption is that I'm then protected and I would be one of those people that is well protected for hepatitis B.

Is anybody else having an issue with this in your facility? Is anybody there?

Shirley Lancette: We send our testing for hepatitis out to a reference lab and the turn-around time is an issue.

Nora Boyd: It's not really quick enough, is it?

Shirley Lancette: No, it's not.

Nora Boyd: Yeah. I understand that they're looking to get some newer tests on the market, but the ones that we had been using I gather had not met the latest round of standard setting, so that we're going to be in the same boat that you are in terms of getting those results.

The most important thing, I think, is going to be knowing if your health-care worker has been vaccinated and if they've had a positive titre. And then, after that, I have to tell you I think we're going to treat most things—most patients as a positive source. In the guidelines, they are quite low response on unknown sources, but because the risk of hepatitis B is significant, we're treating most unknown sources as a positive to do appropriate follow-up. My sense is you only have one chance to do this, and you need to be pretty aggressive. I guess I see it as a propensity for action: because our staff are not always vaccinated, that we have an opportunity to prevent disease, and we need to take that.

Any comments on that?

Shirley Lancette: Does that not mean, then, Nora, you're giving out H-BIG—you're giving out a fair bit of H-BIG?

Nora Boyd: Yes, we would be giving more H-BIG than if we took an unknown source of being somebody who was stabbed from a needle in a sharps container and you didn't know—it was an aggregate kind of thing, we would definitely want to follow them up. If they'd had no vaccine, we'd follow them up with H-BIG and a vaccine, and if they'd received two or more doses and we didn't have their antibody status, we would test them and we'd give them vaccine.

Shirley Lancette: Are there any efforts made at your facility for those health-care employees who've been there for a fair length of time (I'm not talking about new hired, but employees who've been there a significant amount of time) where the antibody titre is not evident or not recorded, and the health-care provider doesn't know? Is there any initiative to go back and do antibody screening on these individuals to establish that, or —

Nora Boyd: I think that wouldn't be probably appropriate use of resources, because my understanding is that even though your titre could be under ten, if you initially did respond, —

Shirley Lancette: M'hm.

Nora Boyd: — then your body has a memory and you will mount a response. So that for anybody who's had the three doses... I guess the other group will be this whole group of school kids that come through that have all been vaccinated, but they've not ever had any post-titre done. But again, for most of us, even handing out the H-BIG and doing that, you're still talking about a relatively small group of people that you're dealing with versus your whole facility. The average age of nurses out there is, what, about 48, so you've got a whole bunch of people that have been vaccinated some time ago. My sense is that to go back and do titres now at the cost of the titres and in terms of what kind of outcomes you're going to get, you're not going to make a difference.

If you had concerns that they didn't know about whether they were vaccinated or not, if they couldn't remember, again, you might want to do some education with your health-care providers around the importance of hepatitis B vaccination, around how do they know if they're vaccinated or not. And I know in our facility we have done where we've actually identified people who are vaccinated so that they know that they're on the list, so to speak, to remind them. So they should know what their status is.

So we have done that amount, but we haven't done follow-up titres for old people. The new people getting vaccinated all get follow-up titres.

Shirley Lancette: Right. Exactly.

Nora Boyd: That's not a nice way to put it, is it, the old people? Some of the new people are old. Any other questions?

Operator: Thank you. And our next question will come from Vladi Stouffer (sp) from Beamington District Memorial Hospital. Please go ahead.

Vladi Stouffer: Hello. Do you have a benchmark, Nora, for hepatitis B vaccination in health-care workers that you use to compare your health-care workers to?

Nora Boyd: In terms of what we would consider appropriate?

Vladi Stouffer: M'hm. I mean, you're going for 100 per cent, obviously, but —

Nora Boyd: That's right. You're going for 100 per cent, but you're always going to have people who have various reasons not to or whatever, and I would just say that you're continually trying to drive that up. I know for the flu vaccination, last year they identified they wanted 70 per cent of health-care providers vaccinated. We all sort of gasped and struggled, and I think most of us got up to about 60, 65 per cent, and I see this year they're setting the benchmark at 90 per cent. So I think you look at where people work and what the risk is and where the incidents of hepatitis exposures are happening, —

Vladi Stouffer: Okay.

Nora Boyd: — and I think you just work with that. Again, you're always aiming for 100 per cent, —

Vladi Stouffer: Right.

Nora Boyd: — but for me, I think if you're looking at the various departments and where they work, I would look, from Health Canada, where the injuries were occurring.

Vladi Stouffer: M'hm.

Nora Boyd: And obviously the operating room is your highest risk, and I would think the medical unit was a high risk, your ICUs would be considered a high risk.

Vladi Stouffer: M'hm.

Nora Boyd: I think any of those, if you can get them up to 70, 80 per cent, then congratulations.

Vladi Stouffer: Okay. Thank you.

Operator: Thank you, ma'am. And our next question will come from Joanne Lianza from Rouge Valley Health. Go ahead.

Joanne Lianza: Hi there. Now, I'm getting a little confused here. If I have people that are coming into my facility who are older employers, more mature employees, who have been working at different facilities and have had their hepatitis B titres test done, they've had their vaccinations, now usually when I get new employees, if I don't know what their titres are, I do their titres at that time. Now, if they were below ten, are you saying that you wouldn't repeat—give them a booster? Because if that's the case, then why do anti-HBS on them to not do follow-ups?

Nora Boyd: Why are you doing a titre when it's been a long time? Can they tell you that they've been vaccinated and they've had follow-up titres done?

Joanne Lianza: They're unsure, they don't have records.

Nora Boyd: Yeah.

Joanne Lianza: And I want to know if they're protected.

Nora Boyd: That's right.

Joanne Lianza: So what would you do if it was below ten and they're working in an emergency department?

Nora Boyd: Again, I'm not an expert on—I'm not an occupational health physician sort of on this, so I feel like I'm a little bit out of my scope. (technical difficulty) ...you're asked that, so that you would then have a record of what they had. I think that would be more useful, but again, I would consult an occupational health physician for something like that.

Joanne Lianza: Okay. Thank you.

Operator: Thank you, ma'am. And our next question is a follow-up question from Halton Health Care. Please go ahead.

Lynne Athlin (sp): Hi. This is Lynne Athlin, manager in obstetrics, in the labour and delivery area. I was just wondering if your facility had low numbers of exposures in that area or if there was a reason why you left that area out? We also have our OR within our labour and delivery, and I was wondering if you had incorporated the OR into your statistics from maybe the operating room/labour and delivery at your facility.

Nora Boyd: Lynne, I have to tell you that our labour and delivery area had very low rates of needle sticks, so they've never sort of come up on the radar as somebody [sic] that we do follow-up or we've done a big push. We certainly do a big push for hepatitis B vaccinations and they are certainly up to date in terms of the exposure and follow-up that needs to be done, but we're not seeing in my facility a lot of needle sticks or exposures there. Do you think I'm missing something?

Lynne Athlin: No. I'm saying good for you.

Nora Boyd: It is an area where there can be a lot of dangerous fluids and things happening relatively quickly. If you read the literature in the Canadian Medical Association Journal about transmissions and post-exposure—this is August 21st, 2001, the Canadian Medical Association Journal—it has an interesting article and it talks a lot about physician exposure and follow-up, and they do certainly mention labour and delivery in there in terms of physician exposure.

Lynne Athlin: Thank you.

Peggy Swerhun: We have time for just one more question.

Operator: Sure. Absolutely. Our final question will come from Anne Birchbaum from the Credit Valley Hospital. Please go ahead.

Anne Birchbaum: Hello. I have a question and also a comment. My first question is, in relation to the percentages of exposures, do you have any new information about conversion rates for employees where the patient source was positive for one of the diseases?

Nora Boyd: For the stuff from Health Canada, which is based on 1,436 exposures in that April 1st to March 31st for 2001, in those ones there were no serial conversions.

Anne Birchbaum: That's encouraging.

Nora Boyd: It is very encouraging.

Anne Birchbaum: Yeah.

Nora Boyd: And in Canada, I think we have very low rates of conversion. I have read literature —

Anne Birchbaum: So I understand, yeah.

Nora Boyd: — that talks about two nurses in 1998 who serial converted for HCV.

Anne Birchbaum: Okay. That doesn't surprise me.

Nora Boyd: But I think we do have very low rates of serial conversion here in Canada. I have to tip my hat to Health Canada to be doing this needle-stick follow-up, and I will put in a plug for Shirley Paton and her group up at Health Canada. They are looking for more facilities to sign on to be part of their needle-stick follow-up, and this is really good data for all of us out here to know sort of some Canadian data and to know what the real risk is for our people who get needle sticks. So if anybody's interested in following up on that, I would direct you to the Health Canada web site and Shirley Paton and her needle-stick follow-up group.

Anne Birchbaum: Is that Shirley Paton, P-A-T-T-O-N?

Nora Boyd: P-A-T-O-N.

Anne Birchbaum: P-A-T-O-N. Okay. My comment was that I'm an occupational health nurse here at Credit Valley Hospital, and we're seeing some service workers (and that includes the whole housekeeping group and some of the kitchen staff), and they're often the recipients of an injury from an unknown source, whether they come upon a sharp in the bed linen or on a food tray. And we're making a concerted effort to make sure that they get educated and immunized against hep B, because that's a group that doesn't really have the greatest knowledge base perhaps in terms of medical information and they are at risk, and they make up a large percentage of our hospital population. So I just wonder if anybody else is.

Nora Boyd: I think it's really important to target those groups for hepatitis B vaccination. I think the sterilization staff, the housekeeping and the kitchen staff, those are downstream injuries, and I know that whenever those happen in our facility, we do a lot of discussion about where the source was and what's been happening that that would have occurred, because those are very scary kinds of injuries.

Another group in our place that we've identified is the maintenance department. When they take apart drains, apparently they often find needles in them.

Anne Birchbaum: Oh, yes.

Nora Boyd: And I did one of those famous discussions about HIV with them, walking in and handing them all out condoms, and unfortunately found out that virtually all of them were men in stable, monogamous relationships for a long period of time. So I set them up for some interesting questions with their spouse at home when they walked home with these condoms in their pockets.

Anne Birchbaum: Yes.

Nora Boyd: But they didn't forget what my message was, which was about protecting themselves and their wives in terms of hepatitis B vaccination.

Anne Birchbaum: Right. Thank you.

Nora Boyd: You do what you can, —

Anne Birchbaum: Yeah, that's right.

Nora Boyd: — but make the message stay alive.

Anne Birchbaum: Thank you.

Operator: Thank you, ma'am. And at this time there are no further questions registered. I would now like to turn the meeting back over to you, Ms. Swerhun.

Peggy Swerhun: Thank you very much, Christine.

I would like to thank Nora for taking time out from her busy schedule to speak to us today. I'm sure we all agree how informative it was. Thank you once again, Nora.

And finally, before we end, I would like to remind you about our next teleconference to take place on June the 2nd at 1:30. We will be presenting indoor air quality. Please check the May newsletter for details or contact Susan Griffith at 416-250-7444.

Thank you very much. This concludes our presentation for today.