OSHA's final rule for Occupational Exposure to Bloodborne Pathogens [29 CFR 1910.1030(f)] requires the dental employer to make immediately available confidential medical evaluation and follow-up to an employee reporting an exposure incident. An exposure incident is any eye, mouth, mucous membrane, non-intact skin, or other parenteral contact with blood or other potentially infectious material (OPIM). (For example, a puncture from a contaminated sharp such as an injection needle or a cut from a scalpel blade or suture needle.) Saliva in dental procedures is treated as OPIM.
The dental employer must refer the exposed employee to a licensed health care professional. This means a person who is licensed under the laws of the state where he/she practices to independently provide the post-exposure evaluation and follow-up services required by the standard. The health care professional will counsel the individual about what happened and how to prevent further spread of any potential infection. He or she will prescribe appropriate follow-up in accordance with current U.S. Public Health Service recommendations. The licensed health care professional also will evaluate any reported illness to determine if the symptoms may be related to Human Immunodeficiency Virus (HIV) or Hepatitis B Virus (HBV) infection.
Note: The standard is designed to prevent occupational exposure to blood or OPIM. If the required controls are in place and the standard is correctly implemented, then exposure incidents will be relatively uncommon events.
Step-by-Step Guide to Compliance
This section is designed to supplement the flow chart outlining the standard's requirements following an exposure incident.
Flow Chart
A flow chart providing visual step-by-step guidance to the standard's requirements for post-exposure evaluation and follow-up.
Questions and Answers for Dental Employers
Sample "questions and answers" addressing potential dental employer concerns.
Reference List
A Reference List, including OSHA publications, as well as relevant CDC guidelines and recommendations.
Additional Links
Internet resources containing information for health care professionals on infection control and occupational safety.
A Step-by-Step Guide to Compliance
Note: This section is designed to supplement the flow chart outlining the standard's requirements following an exposure incident.
Reporting Incident — Employees should immediately report exposure incidents to the employer to permit timely medical follow-up. According to the U.S. Public Health Service, if HIV postexposure prophylaxis is medically indicated it should be initiated promptly, preferably within 1-2 hours after the exposure incident. Immediate reporting also enables the dental employer to evaluate the circumstances surrounding the exposure incident to try to find ways to prevent such a situation from occurring again.
Referral to a Health Care Professional (HCP) — Following a report of an exposure incident, the dental employer shall make immediately available to the exposed employee a confidential medical evaluation and follow-up at no cost to the employee. The dental employer is responsible for providing follow-up, but is not required to perform the follow-up. The employer must refer the exposed employee to a licensed health care professional who will perform all medical evaluations and procedures in accordance with the most current recommendations of the U.S. Public Health Service.
Note: The bloodborne pathogens standard is a performance oriented standard. As such, it requires that medical evaluation and follow-up be provided in accordance with the U.S. Public Health Service recommendations, but does not cite specific recommendations. OSHA intentionally drafted the standard in this fashion to ensure that the most current recommendations would be followed.
Documentation — The dental employer must prepare a report of the exposure incident, including the route(s) of exposure, the circumstances under which the exposure incident occurred, and the identity of the source patient — if known, and if permitted by law (see Identification and Testing of Source Patient's Blood). This report must be placed in the employee's confidential medical record. A copy also must be provided to the evaluating health care professional.
Note: In the past, larger dental practices (those with 11 or more employees) have been required by a separate OSHA record keeping rule (29 CFR 1904) to record occupational illnesses or injuries and prepare an annual log of injuries and illnesses.
Now, all dental practices—regardless of size—are exempt from the record keeping requirements of 29 CFR 1904. The new exemption applies in federal OSHA states to dental offices or clinics, medical offices or clinics and dental and medical laboratories, as well as other workplaces the agency has determined to be low hazard.*
There is one, rare exception to this exemption. OSHA or the Bureau of Labor Statistics may require individual offices to maintain injury and illness records and logs for a year as part of their efforts to gather national injury and illness data. These offices would also have to report their data to the requesting agency. (OSHA Form 300 can be downloaded at http://www.osha.gov/recordkeeping/RKforms.html.)
*Some states operate their own OSHA programs under the authority of a State Plan approved by OSHA. States operating under OSHA-approved plans must have record keeping rules that are substantially identical to the federal requirements. However, they may adopt more stringent requirements. This might include eliminating the exemption for dental offices and other low risk workplaces. Dentists who practice in State Plan states should contact their constituent societies or their state OSHAs for more information about the record keeping requirements in their states.
Information Provided to the HCP — The dental employer must provide the licensed health care professional with a copy of the bloodborne pathogens standard; a description of the employee's job duties as they relate to the incident; a report of the specific exposure incident, including routes of exposure and the circumstances under which exposure occurred; the results of the source patient's blood testing, if available; and relevant employee medical records, including vaccination status, which are the employer's responsibility to maintain. Multiple copies of the standard need not be given to the same health care professional (e.g., if a copy was provided to the health care professional in connection with an earlier exposure incident).
Identification — The employer must identify and document in writing the source patient in an exposure incident, unless this is not feasible or is prohibited by state or local law. The dental employer must contact the source patient, if known, and ask his or her consent to be tested for HBV and HIV infectivity and to disclose the test results to the exposed employee. If consent is not obtained, and is required by local law, the dental employer must document that fact in writing as part of the report of the exposure incident. If consent is obtained, or if it is not legally required and the source patient's blood is available, the source patient's blood must be tested as soon as feasible. The results of the testing must be made available to the exposed employee and he or she must be informed of applicable laws and regulations concerning further disclosure of the identity and infectious status of the source patient.
Note: For those jurisdictions that do not require consent of the patient, the source patient's blood, if available, must be tested. The term "if available" applies to blood samples that have already been drawn from the source patient. OSHA does not require redrawing of blood for HBV and HIV testing without consent of the source patient.
Collection and Testing of Employee's Blood — This section and the following three sections on Counseling, Post-Exposure Prophylaxis, and Evaluation of Reported Illnesses deal with the medical services that must be provided free of charge to an employee who has an exposure incident. The dental employer is required to arrange with a licensed health care professional to provide these services. If the employee consents, the health care professional will, as soon as feasible, collect the exposed employee's blood and conduct baseline testing to establish the employee's HBV and HIV serological status. Baseline testing allows the health care professional to determine whether any subsequently diagnosed disease was acquired as a result of the exposure incident. The employee has the right to decline testing or to delay testing of the collected blood for up to 90 days. If the employee consents to baseline blood collection, but does not give consent for HIV testing at that time, the sample must be preserved for at least 90 days. If, within 90 days of the exposure incident, the employee elects to have the baseline sample tested, such testing shall be done by the health care professional as soon as feasible. The health care professional will notify the employee of all test results. All laboratory tests must be performed by an accredited laboratory at no cost to the employee.
Counseling — Counseling is a vital component of the required post-exposure follow-up procedures. The health care professional will counsel the employee concerning his or her infectious status, including results of and interpretation of all tests, will discuss with the employee the potential risk of infection, and the need for postexposure prophylaxis and the protection of personal contacts.
Post-Exposure Prophylaxis — The licensed health care professional shall prescribe appropriate prophylactic measures, when medically indicated, as recommended by the U.S. Public Health Service. Note: Since post-exposure testing and prophylaxis is a rapidly changing and developing field, it must be provided according to the recommendations of the U.S. Public Health Service current at the time post-exposure testing and prophylaxis take place. The follow-up process may involve multiple visits to the HCP for serial blood tests, monitoring of medications (if prescribed) etc. For example, for employees who have not received the HBV vaccine series, the HBV vaccine (and in some circumstances hepatitis B immune globulin) is to be offered as soon as possible after the exposure incident, but no more than seven days after the incident.
In addition, for HIV, the 1996 CDC guidelines state that "chemoprophylaxis should be recommended to exposed workers after occupational exposures associated with the highest risk of HIV transmission. For exposures with a lower, but non-negligible risk, postexposure prophylaxis should be offered, balancing the lower risk against the use of drugs having uncertain efficacy and toxicity. For exposures with negligible risk, postexposure prophylaxis is not justified."
E valuation of Reported Illnesses — The health care professional shall also evaluate any reported illnesses of the exposed employee to determine if the symptoms may be related to HBV or HIV infection. This provision ensures that exposed employees will have the benefit of early medical evaluation and recommended treatment and prophylaxis in a timely manner.
Note: This requirement should not be construed to mean that the dental employer is responsible for the cost of treatment of disease, which is beyond the scope of the standard's follow-up requirements.
HCP's Written Opinion — After the health care professional completes the evaluation, he or she is required to send the dental employer a written opinion. The standard requires that the health care professional's written opinion contain only: documentation that the exposed employee was informed of the test results of the evaluation; and the need for further follow-up. If HBV vaccination is provided as part of the post-exposure prophylaxis, the opinion should also state whether HBV vaccine was indicated for the employee and if the employee was vaccinated. All other findings or diagnoses must remain confidential and shall not be included in the written report.
The dental employer must provide a copy of the evaluating health care professional's written opinion to the exposed employee within 15 days of the completion of the evaluation. The original document should be placed in the employee's confidential medical record.
Medical Recordkeeping — The dental employer must establish and maintain medical records in a confidential manner. The standard does not require the employer to maintain possession of the records. If the medical records are left in the possession of the HCP who provides the follow-up protocol, it is the employer's responsibility to arrange with the HCP to maintain and keep the records confidential in accordance with the standard.
Records must be maintained for the duration of employment plus 30 years in accordance with OSHA's standard on Access to Employee Exposure and Medical Records, 29 CFR 1910.20.
Under the standard, dental employers may have to rely on the health care professional to carry out certain OSHA obligations, such as maintaining employee medical records in a confidential manner, retaining the records for the duration of employment plus 30 years and providing appropriate post-exposure evaluation and follow-up services. The dental employer has an obligation to ensure compliance with the standard. However, he or she will not generally be held liable for violations resulting from the health care professional's actions if the dental employer has acted in good faith to contract with a responsible entity and has no reason to foresee that the contractor will not fulfill its obligations.
Prepared by the American Dental Association in cooperation with the Occupational Safety and Health Administration (December 1997). This document is not considered a substitute for any provisions of the Occupational Safety and Health Act of 1970 or for any standards issued by OSHA.