This document discusses an ethical scenario involving an operating room nurse in a small Texas hospital who is HIV positive. It provides background on HIV/AIDS in the American workplace, how HIV can be transmitted in healthcare settings, standard precautions to prevent transmission, and ethical and legal considerations regarding HIV-infected healthcare workers. The recommendations are to determine if the nurse's duties involve exposure-prone invasive procedures, ensure patient consent if so, respect the nurse's confidentiality, and provide training on relevant laws and guidelines.

1. Employee Privacy vs.
Patient Safety
Consulting Firm #8
Teresa Long
Francisco Lopez
Fall 2012

2. AIDS in the American Workplace
 AIDS has profoundly impacted the American workplace
 One in six U.S. worksites with greater than 50 employees
and one in 15 U.S. worksites with less than 50
employees have or have had an employee or employees
with HIV infection or AIDS (ACOEM 2008)
 The AIDS epidemic brought a wide range of sensitive
medical, social, and political issues with it
 Confidentiality
 Discrimination
 Safety
 As treatment has improved, more HIV positive and AIDS
infected workers have become integrated into the
workforce
 Social stigmas still exist
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3. The Scenario
 The administrator of a small hospital in Texas
becomes aware that one of the operating room
nurses is HIV positive, and is concerned about the risk
this employee poses to patients in the operating
room
 Hospital employees are spreading confidential
information about the nurse that should remain
private
 Several doctors and nurses have expressed that they
do not wish the allegedly infected nurse to continue
assisting with surgical procedures
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4. The Facts

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Human immunodeficiency virus(HIV)
causes AIDS
HIV attacks the immune system,
rendering the body susceptible to
infections caused by viruses, bacteria,
and yeasts
HIV is transmitted via blood, semen,
saliva and other bodily fluids. Three
conditions are necessary for HIV to be
transmitted:
 An HIV source
 A sufficient dose of virus(viral
load)
 Access to the bloodstream of
another person
HIV is not transmitted by casual contact
Laws guarantee patients certain rights
and require certain duties of health care
providers
Currently, there is no cure for AIDS
Source: CDC
4

5. How may HIV be Transmitted in a
Healthcare Setting?
 Transmission from patients to healthcare workers
occurs via:
 Percutaneous or mucosal exposure of workers to blood or
other bodily fluids of infected patients
 Direct inoculation of virus into cutaneous scratches, skin
lesions, abrasions, and burns
 Inoculation of virus onto mucosal surfaces of the
eyes, nose, or mouth through splashes
 Does not spontaneously penetrate intact skin
 Airborne transmission does not occur
 CDC retrospective case-control study determined
average risk for HIV transmission
 ≈0.3% following percutaneous exposure
 ≈0.09% following mucous membrane exposure
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6. Mechanisms of Transmission
 In the United States
 No confirmed cases of transmission from patients to
healthcare workers since 1999
 Only one instance of patients becoming infected by a
health care worker
 Involved HIV transmission from one infected dentist
to six patients
 Investigations of more than 22,000 patients of 63
HIV-infected physicians, surgeons, and dentists have
identified no other cases
 Worldwide
 French orthopedic surgeon—transmission to one patient
during a prolonged surgical procedure
 Spanish gynecologist—transmission to one patient during
a Caesarean delivery
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7. Preventing Exposures
 Transmission can be minimized via:
 Practicing standard infection control precautions
 Written protocols for
reporting, evaluation, counseling, treatment, and
follow-up of all occupational exposures
7

8. Standard Precautions
 Applies to:
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
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Blood
All body fluids, secretions, and excretions (except sweat)
Non-intact skin
Mucous membranes
 Core elements:
 Hand washing after patient contact or contact with blood
or body fluids
 Using barrier precautions (e.g., gloves, gowns, and facial
protection) to prevent mucocutaneous contact
 Minimal manual manipulation of sharp instruments and
devices
 Disposal of these items in puncture-resistant
containers
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9. Needlestick Injuries
 95% of HIV occupational
seroconversions are
caused by needlestick
injuries (WHO)
 One in five healthcare
workers receive a
needlestick injury
every year
 Preventable with
practical, low-cost
measures
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10. Preventing Needlestick Injuries
Double gloving when
performing exposure prone
invasive procedures
Use of safety devices
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11. The Risk
 When standard infection control precautions are
strictly adhered to, the majority of health care
procedures pose no risk of HIV transmission from an
infected health care worker to a patient
 Healthcare procedures identified as exposure-prone
invasive procedures pose a small risk of HIV
transmission from an infected health care worker to a
patient
 There is a greater risk of a patient transmitting HIV to
a health care worker
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12. Post-exposure Prophylaxis
 Most medical procedures are safe if standard
infection control procedures are followed
 HIV has a short lifespan outside the human body
 Promptly wash areas where splashing may have
occurred
 If fluids get into eyes or cuts in the skin, flush
thoroughly with clean water
 If exposure is suspected due to accidental needle
sticks, etc.
 Post-exposure chemoprophylaxis can reduce the risk
of transmission
12

13. Ethical Considerations
 Health Care Workers who know they are HIV positive
and perform exposure prone invasive procedures
have an ethical obligation to self-report to the
profession's regulatory body and must take all
necessary steps to avoid transmission to patients
13

14. American Medical Association H-20.912
Guidance for HIV-Infected Physicians
and other Health Care Workers
 General Considerations
 A health care worker who performs invasive
procedures and has reasonable cause to believe
he/she is infected with HIV should determine his/her
serostatus or act as if that serostatus is positive
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15. American Medical Association H-20.912
Guidance for HIV-Infected Physicians and
other Health Care Workers
 Patient Care Duties
 An HIV- infected health care worker should be
permitted to provide health care services as long as
there is no significant risk of patient infection
 A physician or other health care worker who performs
exposure-prone procedures and becomes HIV-positive
should disclose his/her serostatus to a state public
health official or local review committee
 Should refrain from conducting exposure-prone
procedures or perform such procedures with
permission from the local review committee and the
informed consent of the patient
 Must err on the side of protecting patients
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16. American Medical Association H-20.912
Guidance for HIV-Infected Physicians
and other Health Care Workers
 Local Review Committee
 If an HIV-infected physician or other health care
worker performs invasive medical procedures as a part
of his/her duties, then the individual should request
that an ad hoc committee be constituted to consider
which activities can be continued without risk of
infection to patients
 Consideration should be given to adapting programs
for impaired health care workers to serve those who
are HIV infected
 Any HIV- infected health care worker who repeatedly
violates local committee-imposed practice limitations
and/or universal precautions should be reported to
appropriate authorities, such as the state licensure
board, for possible discipline
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17. American Medical Association H-20.912
Guidance for HIV-Infected Physicians
and other Health Care Workers
 Confidentiality
 AMA believes the confidentiality of the HIV- infected
health care worker should be protected as with any
HIV patient
 Knowledge of the health care worker's HIV serostatus
should be restricted to those few professionals who
have a medical need to know
 Except for those with a need to know, all information
on the serostatus of the health care worker must be
held in the strictest confidence
17

18. HIPPA Laws
 Balanced rule which provides federal protections for
personal health information held by covered entities
 Establishes patient rights
 Permits disclosure of personal health information
necessary for patient care
 Pertains to all entities that transmit healthcare
information electronically
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19. OSHA’s Bloodborne Pathogen Standard
1910.1030
 Requires the development of written exposure
control plans, the use of engineering and work
practice controls to reduce exposures, and annual
Health Care Worker training
 Promulgated widespread adoption of standard
precautions in U.S. hospitals
 Skin and mucous membrane contacts frequently can
be prevented with the use of barrier precautions, such
as gloves, masks, gowns, and goggles
 Percutaneous injuries require changes in technique
and/or use of safety devices
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20. Health Care Workers
and the Americans with Disabilities Act
 Federal law prohibiting discrimination against individuals with
disabilities
 Applies to employees and applicants, but not independent
contractors
 Includes rules stating when employers may seek medical
information from job applicants or employees
 An employer may make disability-related inquiries or require a
medical examination if there is reasonable cause for believing
that the employee may pose a direct threat due to a medical
condition
 An employer may exclude an applicant or employee with a
disability from a position if that person poses a direct threat to
health or safety
 A qualified individual with a disability is entitled to reasonable
accommodation to perform a job or to enjoy the benefits and
privileges of employment unless it imposes an undue hardship
on the employer
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21. Source: The Center for HIV Law & Policy
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22. HIV Infected Health Care Workers:
Management and Patient Notification
 HIV infected health care workers have ethical and
legal obligations to protect the health and safety of
their patients
 Informed patient consent required in Texas
 HIV infected health care workers who do not perform
exposure prone procedures but continue to provide
clinical care to patients should remain under regular
medical and occupational health supervision
 HIV infected health care workers have a right to
expect that their confidentiality will be respected and
protected
 When an employer or staff member is aware of the
health status of an infected health care worker, there is
a duty to keep such information confidential
 HIV infected health care workers are entitled to the
same rights of confidentiality as any patient seeking or
receiving medical care
 Employers must ensure that new and existing staff are
aware of ethical and legal responsibilities
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23. The Recommendations
 Define exposure prone invasive procedures used in
the Weimer, TX facility with the help of a review
committee
 Determine if infected worker is involved in exposure
prone invasive procedures
 HIV positive health care workers may be assigned to
assist in performing exposure prone invasive
procedures on HIV positive patients
 HIV positive health care workers may be reassigned
to a position that doesn’t pose a risk to patients
 Texas law requires informed written consent of
patients before any exposure prone invasive
procedure is performed
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24. The Recommendations
 Ensuring the privacy of HIV infected health care
workers
 All health care workers and patients have the right to
expect that their confidentiality will be respected and
protected
 Confidential healthcare information should be
restricted to those with a need to know
 Disciplinary action up to and including termination for
staff members that violated the HIV positive health
care worker’s right to privacy
 Ensure all workers receive initial and annual refresher
training regarding confidentiality and privacy laws
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25. Works Cited
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"Recommendations and Reports." Centers for Disease Control and Prevention. Morbidity & Mortality Weekly Report, 02
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<http://www.eeoc.gov/facts/health_care_workers.html>.
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