G. Infection Control

General Patient Care Protocol

General Patient Care Protocol
Subject: III. Clinical – G. Infection Control
Effective Date: July 20, 2021
Reviewed or Revised Date: 08/17/2021, 02/25/2022

UMSOD adheres to OSHA and CDC Guidelines: CDC Guidance for Dental Settings
OSHA Guidance on Preparing Workplaces for COVID-19

Hand Hygiene

Ensure HCP practice strict adherence to CDC Hand Hygiene in Healthcare Settings, including:

• Before and after all patient contact, contact with potentially infectious material, and before putting on and after removing personal protective equipment (PPE), including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process.
• Use Alcohol-Based Hand Sanitizer (ABHS) with 60-95% alcohol or wash hands with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to ABHS.

Facility Considerations

• Take steps to ensure patients and staff adhere to respiratory hygiene and cough etiquette, as well as hand hygiene, and all patients follow triage procedures throughout the duration of the visit.
• Post visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, break rooms) to provide instructions (in appropriate languages) about hand hygiene and respiratory hygiene and cough etiquette. Instructions should include wearing a cloth face covering or facemask for source control, and how and when to perform hand hygiene.
• Provide supplies for respiratory hygiene and cough etiquette, including alcohol-based hand rub (ABHR) with 60– 95% alcohol, tissues, and no-touch receptacles for disposal, at healthcare facility entrances, waiting rooms, and patient check-ins.
• Install physical barriers (e.g., glass or plastic windows) at reception areas to limit close contact between triage personnel and potentially infectious patients.
• Place chairs in the waiting room at least three feet apart.
• Remove toys, magazines, and other frequently touched objects that cannot be regularly cleaned or disinfected from waiting areas.
• Minimize the number of persons waiting in the waiting room.
• Patients may opt to wait in a personal vehicle or outside the dental facility where they can be contacted by mobile phone when it is their turn for dental care.
• Minimize overlapping dental appointments.
• Ideally, dental treatment should be provided in individual patient rooms whenever possible.
• For dental facilities with open floor plans, to prevent the spread of pathogens there should be:
  • At least 3 feet of space between patient chairs.
• Patient volume - Ensure to account for the time required to clean and disinfect operatories between patients when calculating your daily patient volume.

Universal Source Control

As part of source control efforts, Healthcare Providers (HCP) should wear a facemask at all times while they are in the dental setting.

• HCP whose job duties do not require PPE (such as clerical personnel) will wear regular facemasks for source control while in the dental setting.
• Other HCP (such as dentists, dental hygienists, dental assistants) will wear regular facemasks for source control when they are not engaged in direct patient care activities and then switch to UMSOD approved respirator when PPE is required.
• HCP should remove their respirator, perform hand hygiene, and put on their cloth face covering when leaving the facility at the end of their shift.
• HCP should also be instructed that if they must touch or adjust their mask or cloth face covering, they should perform hand hygiene immediately before and after.

Because facemasks and cloth face coverings can become saturated with respiratory secretions, HCP should take steps to prevent self-contamination:

• HCP should change facemasks and coverings if they become soiled, damp, or hard to breathe through.
• Cloth face coverings should be laundered daily and when soiled.
• HCP should perform hand hygiene immediately before and after any contact with the facemask or cloth face covering.

Using Personal Protective Equipment (PPE)

For all dental procedures, HCP should wear:

• Gown
• Head Cover
• N95 Respirator or Equivalent with Surgical Mask Over the Respirator Mask
• Full-Face Shield
• Gloves

Sequence for HCP includes:

Before entering a patient room or care area:

1. Perform hand hygiene.
2. Put on head cover
3. Put on a clean gown or protective clothing that covers personal clothing and skin (e.g., forearms) likely to be soiled with blood, saliva, or other potentially infectious materials.
   • Gowns, protective clothing, and head cover should be changed:
     • If they become soiled
     • Between patients if exposed to aerosol
4. Put on N95 respirator or equivalent.
   • Mask ties should be secured on the crown of the head (top tie) and the base of the neck (bottom tie). If mask has loops, hook them appropriately around your ears.
   • Respirator straps should be placed on the crown of the head (top strap) and the base of the neck (bottom strap). Perform a user seal check each time you put on the respirator.
   • A surgical mask should be worn over the N95 mask
5. Put on eye protection.
   • Personal eyeglasses and contact lenses are NOT considered adequate eye protection. 
   • Put on face shield (full-face shield is also required for all procedures
   • Eye
6. Perform hand hygiene.
7. Put on clean non-sterile gloves.
   • Gloves should be changed if they become torn or heavily contaminated.
8. Enter the patient room. After completion of dental care:

After completion of dental care:

1. Exit the patient room or care area.
2. Remove gloves and discard in medical waste.
3. Remove face shield carefully by grabbing the back and pulling upwards and away from head. Do not touch the front of face shield.
4. Remove gown and discard in a dedicated container for waste or linen.
   • If they become soiled
   • Between patients if exposed to aerosol
5. Perform hand hygiene.
6. Remove eye protection (loupes) carefully by grabbing the back and pulling upwards and away from head. Do not touch the front of any eye protection.
7. Remove respirator.
   • Do not touch the front of the respirator.
   • Surgical mask: Carefully untie the mask (or unhook from the ears) and pull it away from the face without touching the front.
   • Respirator: Remove the bottom strap by touching only the strap and bring it carefully over the head. Grasp the top strap and bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator.
8. Remove head cover and discard in a dedicated container for waste or linen.
   • If they become soiled
   • Between patients if exposed to aerosol
9. Perform hand hygiene.
10. Put on clean non-sterile gloves to disinfect reusable face shield and loupes according to manufacturer’s instructions prior to reuse.
11. Remove gloves and discard in medical waste.
12. Perform hand hygiene.

Pre-Appointment Screening

• Contact all patients prior to dental treatment.
  • Telephone screen all patients for symptoms consistent with COVID-19. If the patient reports symptoms of COVID-19, avoid non-emergent dental care and use the Phone Advice Line Tool for Possible COVID-19 patients. If possible, delay dental care until the patient has recovered.
  • Telephone triage all patients in need of dental care. Assess the patient’s dental condition and determine whether the patient needs to be seen in the dental setting. Use tele dentistry options as alternatives to in-office care when possible.
  • Inform patient of the limit of visitors accompanying the patient to the dental appointment to only those people who are necessary.
  • Advise patients that they, and anyone accompanying them to the appointment, will be requested to wear a cloth face covering or facemask when entering the facility and will undergo screening for fever and symptoms consistent with COVID-19.

Arrival at School

• Patients should not attempt entry into the school until 15 minutes before appointed time
• Entry – first floor entrance; need physical distancing in the line
• Screening at School Entrance - Systematically assess all patients and visitors upon arrival. Step by step procedure, see COVID Screening - Triage Procedure 
  • Ensure that the patient and visitors have donned their own cloth face covering. Provide a facemask if supplies are adequate.
  • Screening questions; temperature taken; mask required; UMSOD will provide mask as needed; hand gel available.
    • Pass – patient permitted to enter school and proceed to proper clinic
    • Fail – patient referred to personal physician for evaluation; medical clearance will be required for future appointments
  • Ask about the presence of fever or other symptoms consistent with COVID-19.
  • Actively take the patient’s temperature.
  • If the patient is afebrile (temperature < 100.4˚F)* and otherwise without symptoms consistent with COVID-19, then dental care may be provided using appropriate engineering and administrative controls, work practices, and infection control considerations (described below).
    • *For the general population, fever is measured as a temperature ≥100.4˚F. Fever may be subjective or confirmed. If the patient has a fever strongly associated with a dental diagnosis (e.g., pulpal and periapical dental pain and intraoral swelling is present), but no other symptoms consistent with COVID-19 are present, care can be provided with appropriate protocols.
  • Escorts – must wear mask
    • One escort is permitted if patient has need
      • Language interpreter
      • Guardian or parent (one parent only)
  • Children are not permitted to accompany patients past the front door entrance; patient will need to re-schedule appointments if they have children.
  • Spouse / partner – may accompany to clinic wait room; may not go into treatment area.

Reception Area

• Rearrange seating to ensure 3-foot social distancing. For seats that cannot be split up, block off neatly ensuring 3-foot social distancing.
• Remove all magazines, books, etc.
• Patients and escorts must wear masks.
• Hand sanitizer is available.
• Arm rests and tables wiped down every morning and periodically during the workday.
• Goal is to be timely with appointments to minimize presence in reception areas.

Patient Check-in at Reception

• Physical distancing in effect – need to mark floor
• Students / residents should be ready to receive patient as soon as they arrive.
• Patients can sit in reception room chairs – avoid chairs that are marked off.
• Restrooms – patient restrooms with physical distancing marked; recommend that patient use facilities if they need as they will not be able to leave treatment area.

Operatory Protocol

• Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly after each patient. Clean and disinfect the room and equipment according to the Guidelines for Infection Control in Dental Health-Care Settings – 2003.
• Limit clinical care to one patient at a time whenever possible.
• Set up operatories so that only the clean or sterile supplies and instruments needed for the dental procedure are readily accessible. All other supplies and instruments should be in covered storage, such as drawers and cabinets, and away from potential contamination. Any supplies and equipment that are exposed but not used during the procedure should be considered contaminated and should be disposed of or reprocessed properly after completion of the procedure.
• Avoid aerosol-generating procedures whenever possible. Avoid the use of dental handpieces and the air/water syringe.
• If aerosol-generating procedures are necessary for dental care, use four-handed dentistry, high evacuation suction and dental dams to minimize droplet spatter and aerosols. The number of Healthcare Providers (HCP) present during the procedure should be limited to only those essential for patient care and procedure support.
• If possible, all aerosolizing procedures should be performed with the Ajax Extraoral Evacuation Device.
• Preprocedural mouth rinses (PPMR) - All patients will rinse with 20 ml of Listerine for 30 seconds prior to every dental appointment.
• Clean and disinfect room surfaces.
  • ALL clinical contact surfaces will be disinfected with EPA approved surface disinfectant.

Treatment Areas

• Patients should continue to wear masks until instructed to remove mask
• Patients may not leave treatment area once procedure begins
• Student or Resident provider should remain in treatment bay until procedure is completed
• Employ runners to bring additional supplies – students not involved in active treatment can perform that function

Additional Precautions or Strategies for Treating Patients with Suspected or Confirmed COVID-19

• If a patient arrives at your facility and is suspected or confirmed to have COVID-19, defer dental treatment and take the following actions:
• If the patient is not already wearing a cloth face covering give the patient a facemask to cover his or her nose and mouth.
• If the patient is not acutely sick, send the patient home, and instruct the patient to call their primary physician.
• Provide patient with handout INFORMATION FOR INDIVIDUALS DENIED ACCESS TO SCHOOL OF DENTISTRY DUE TO COVID SCREENING.
• Patient will have to provide written medical clearance from their physician that their patient is clear of the virus before the patient can be treated in any clinic in the school.
• If the patient is acutely sick (for example, has trouble breathing), refer the patient to a medical facility, or call 911 as needed and inform them that the patient may have COVID-19.

Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel (HCP) with Potential Exposure to COVID-19.

CDC Guidance for Risk Assessment and Work Restrictions for Healthcare Personnel with Potential Exposure to COVID-19.

• “Prolonged” is defined as a time period of 15 or more minutes.
• Any duration of exposure should be considered prolonged if the exposure occurred during performance of an aerosol-generating procedure.
• The time period that should be used for contact tracing after exposure to asymptomatic individuals who test positive for SARS-CoV-2 is 2 days. Recent data suggest that asymptomatic persons may have a lower viral burden at diagnosis than symptomatic persons.
• Work Restrictions
  • Exclude from work for 14 days after last exposure
  • Advise HCP to monitor themselves for fever or symptoms consistent with COVID-19.
  • Any HCP who develop fever or symptoms consistent with COVID-19 should immediately contact their established point of contact (e.g., occupational health program) to arrange for medical evaluation and testing.

Monitor and Manage Health Care Personnel

• As part of routine practice, HCP should be asked to regularly monitor themselves for fever and symptoms consistent with COVID-19.
  • HCP should be reminded to stay home when they are ill.
  • If HCP develop fever (T≥100.0˚F) or symptoms consistent with COVID-19 while at work, they should keep their cloth face covering or facemask on, inform their supervisor, and leave the workplace.
• Screen all HCP at the beginning of their shift for fever and symptoms consistent with COVID-19.
  • Actively measure their temperature and document absence of symptoms consistent with COVID-19.
  • Clinical judgement should be used to guide testing of individuals in such situations.
  • Medical evaluation may be warranted for lower temperatures (<100.0˚F) or other symptoms based on assessment by occupational health personnel. Additional information about clinical presentation of patients with COVID-19 is available.
• If HCP experience a potential work exposure to COVID-19, follow CDC’s Healthcare Personnel with Potential Exposure Guidance.
  • If HCP suspect they have COVID-19:
  • Do not come to work.
  • If HCP are ill at work, have them keep their cloth face covering or facemask on and leave the workplace.
  • Notify their primary healthcare provider to determine whether medical evaluation is necessary.
  • HCP with suspected COVID-19 should be prioritized for diagnostic testing.
  • Information about when HCP with suspected or confirmed COVID-19 may return to work is available in the Interim Guidance on Criteria for Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19.
• For information on work restrictions for health care personnel with underlying health conditions who may care for COVID-19 patients, see CDC's FAQs.

UMSOD Face Mask Policy

Subject: III. Clinical – G. Infection Control

Effective Date: July 12, 2021

Reviewed or Revised: 08/30/2021

Policy or Procedure: UMSOD Face Mask Policy

• Everyone must follow the Aug. 6, UMB Policy Requiring Use of Face Coverings which requires face coverings to be worn indoors at UMB regardless of vaccination status.
• Unvaccinated students/residents/faculty and staff
  •  Unvaccinated individuals must wear an appropriate face-mask the entire time they are in any area of the UMSOD.

• Vaccinated students/residents/faculty and staff
  • All individuals, including fully vaccinated individuals, must wear an appropriate face mask the entire time they are in any of the clinical spaces of the 1st to the 5th floor within the UMSOD.
    • This includes patient waiting rooms, hallways within the clinic, dental labs, clinical and simulation areas.
  • Vaccinated individuals on floors 6 - 9 must wear a face mask in those areas.
  • Vaccinated individuals in the lecture halls must wear a mask in the lecture halls. 
    • Fully vaccinated lecturers have the option to remove their masks while lecturing as long as 6 feet of physical distance is between them and their audience.
• UMSOD COVID-19 NON-COMPLIANCE STATEMENT:
  • Faculty, staff, and students who are non-compliant will receive warnings, reprimands, or other appropriate discipline. Persons who do not comply with this policy may will be asked to leave the School of Dentistry. Faculty, supervisors, and administrators are responsible for monitoring and encouraging compliance with UMSOD-UMB COVID-19 policies and procedures.

UMSOD Policy and Procedure on Infection Control, Exposure Prevention and Management

Subject: III. Clinical – G. Infection Control

Effective Date: July 2016

Reviewed and/or Revised: 10/7/16, 09/01/2017, 01/18/2024

Purpose: The purpose of exposure reporting and management is to ensure a prompt response from SOD nurses trained to act in a supportive manner with both the exposed individual and exposure source individual to facilitate post exposure follow-up; if an exposure to bloodborne pathogens is not reported, it cannot be managed appropriately. Reporting and Managing bloodborne pathogen exposures is necessary to comply with the OSHA Bloodborne Pathogens standard found in Title 29 of the Code of Federal Regulations at 29 CFR 1910.1030.

A secondary purpose of exposure reporting and management is to identify actual problems or potential risks of occupational exposure, and circumstances that must be eliminated or modified to prevent personal injury resulting in an exposure to pathogens from blood or other potentially infectious materials.

Definitions:

• Bloodborne: Carried or transmitted by the blood, as in a bloodborne pathogen (BBP).
• Exposure / Double Exposure / Occupational Exposure / Percutaneous Exposure / Mucocutaneous Exposure: 
  • Exposure: Contact with microorganisms, or pathogens, via blood or other potentially infectious material. 
  • Double Exposure: Occurs when an exposure with a contaminated item occurs to a healthcare worker, and subsequently to the patient as well.
  • Mucocutaneous Exposure: Exposure via a splash to the inside of the eyes, nose or mouth (mucous membranes).
  • Occupational Exposure: Refers to reasonably anticipated contact with blood or other potentially infectious materials by healthcare workers with non-intact skin, especially as a result of a puncture, bite, cut, or abrasion, or a splash into the eyes nose or mouth (mucous membranes), as a result of their job duties.
  • Percutaneous Exposure:  Exposure via a puncture through the skin (also known as parenteral contact or exposure) 
• Pathogen: An agent that causes disease, especially a living microorganism such as a bacteria, virus or fungus.
• Source Individual: means any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to the employee. 

Policy: UMSOD will educate all staff (employees, dean’s faculty, residents and undergraduate students) with occupational exposure to pathogens, via blood or other infectious materials, regarding the importance of the proper management and prompt reporting of any exposure.

Note: This procedure is posted on each SOD nurse’s door, and on each clinical computer desktop under the Clinical Support Documents icon. It was created to be a a quick reference document, for the UMSOD, in the event of exposure. Click the following link to access the Exposure Reporting and Management Procedure, Baltimore Campus (PDF)

Infection Control Compliance

To prevent exposures to Bloodborne Pathogens, it is the responsibility of all faculty, clinical staff and students to be compliant with UMB and UMSOD Infection control standards and to report infractions to a G.P. Manager or Program Director. Dental assistants will report incidents of non-compliance directly to the infection control nurse.

Infection Control, Areas of Non-Compliance 

Attending faculty will notify and counsel the student about the infection control violation. Faculty should enter an "F" grade for professionalism and describe the violation in the dialogue box on the grade card. Alternatively, a counseling report could be sent to the student and the G. P. Director or Program Director by the Infection Control Nurse. Violations will be monitored by G. P. Directors and Program Directors and be reported to a dental school nurse so they may be recorded in the dental school infection control compliance database and receive re-education regarding proper procedure. Individuals with multiple violations will be referred to the Associate Dean of Clinical Affairs for counseling and disciplinary action, as necessary. Please refer to the Flowchart of Infection Control Areas of Non-Compliance PDF.

UMB Policy on Prevention and Management of Student and Employee Infection with Bloodborne Pathogens

Subject: III. Clinical – G. Infection Control

Effective Date: 2008

Reviewed and/or Revised: 10/7/16, 09/01/2017

Policy and/or Procedure:

This Policy sets forth the principles and general practices of UMB with respect to prevention and management of infection with bloodborne pathogens. All related policies, guidelines and practices of UMB's schools and other units are expected to be consistent with this Policy. This Policy shall be communicated to the UMB community and to prospective students and employees. Notice of this Policy and the opportunity to review it upon request shall be afforded to current and potential clients and patients through appropriate means.

As an employer, UMB must comply with the laws and regulations relating to bloodborne pathogens which have been enacted or issued by the United States Government and by the State of Maryland. Other UMB policies specifically address compliance with those regulations. This Policy shall be interpreted to be consistent with State and Federal law and regulations in all respects. This Policy also shall be interpreted and applied consistent with the applicable Maryland and federal laws of professional licensure, informed consent, and confidentiality of student and other personally identifiable records. The President of UMB may waive or modify this Policy as required to attain compliance with such other laws and regulations.

Definitions:

In this Policy, the following terms have the meanings set forth in this paragraph:

1. Bloodborne Pathogens: Hepatitis B virus, human immunodeficiency virus, and hepatitis C virus. In the future, the President of UMB may identify additional pathogens as Bloodborne Pathogens if such pathogens are identified by the Occupational Safety and Health Administration, the Centers for Disease Control, or a relevant State or federal law or regulation as requiring control or prevention measures similar to those required for HIV, HBV or HCV under the OSHA Standard.
2. Confirmed Source Individual: A Source Individual known, as a result of pre-exposure or post-exposure testing, to be infected with a Bloodborne Pathogen.
3. Exposure Incident: A specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of the duties or assignments of any UMB Personnel.
4. HBV: hepatitis B virus.
5. HCV: hepatitis C virus.
6. HIV: human immunodeficiency virus.
7. Occupational Exposure: Reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of UMB Personnel's duties or assignments, including assigned work, volunteer tasks, academic programs, and practicum experiences. Occupational Exposure may occur in many contexts, including but not limited to, patient care, client services, research activities, classroom work, housekeeping, maintenance and security services.
8. OSHA Standard: The Bloodborne Pathogens Standard issued by the Occupational Safety and Health Administration, United States Department of Labor, as amended from time to time and published as 29 CFR 1910.1030.
9. School: Any of the following schools which comprise UMB's educational units: School of Medicine, School of Nursing, School of Social Work, School of Law, Dental School, School of Pharmacy, University of Maryland Graduate School - Baltimore.
10. Source Individual: Any individual, living or dead, whose blood or other potentially infectious materials may be a source of Occupational Exposure to UMB personnel. Examples include, but are not limited to, hospital and clinic patients; clients in institutions for the developmentally disabled; trauma victims; clients of drug and alcohol treatment facilities; residents of hospices and nursing homes; human remains; and individuals who donate or sell blood or blood components.
11. UMB Personnel: (i) all part-time and full-time students of UMB, as well as any special students who are not registered; (ii) all employees of UMB, including full-time, part-time, temporary, contractual, and visiting personnel in any employment category; and (iii) all volunteers participating in UMB activities.
12. Unit: Any administrative, service, or research unit of UMB which does not report, directly of indirectly, to the Dean of a School.
13. Universal Precautions: An approach to infection control according to which all human blood and certain human body fluids are treated as if known to be infectious for Bloodborne Pathogens. More specifically, Universal Precautions means the universal precautions recommended by the Center for Communicable Diseases, U.S. Public Health Service.
14. Any term used in this Policy which is defined in paragraph (b) of the OSHA Standard shall have the meaning set forth in the OSHA Standard unless a different meaning is set forth in this part of this Policy.

Non-Discrimination

All Schools and Units of UMB shall make their facilities and services for health care and client services available to patients and clients without regard to their status as Source Individuals or Confirmed Source Individuals. However, as medically appropriate, some Source Individuals and Confirmed Source Individuals may be referred to treatment in special settings or denied access to some programs in order to safeguard their welfare, the health of other patients or clients, and the safety of UMB Personnel. All UMB Personnel who provide health care, counseling or other client services are required to provide services to all eligible patients and clients.

All program brochures, catalogues, and other materials for clients, patients, students and employees shall provide notice of the policy of non-discrimination and the expectation that UMB Personnel will provide service to all patients and clients.

Universal Precautions

Each School and Unit is responsible to identify its UMB Personnel who have Occupational Exposure and are at risk of an Exposure Incident; to ensure that these UMB Personnel receive training in Universal Precautions; and to require the use of Universal Precautions by these UMB Personnel. Failure to use Universal Precautions as required is grounds for dismissal or discipline.

Education and Communication on Bloodborne Pathogens

Each UMB School and Unit shall communicate with its UMB Personnel concerning known biohazards and shall educate its UMB Personnel on aspects of HIV infection, Acquired Immune Deficiency Syndrome, and HBV and HCV infection appropriate to expected educational and job-related behaviors. The requirements of paragraph (g) of the OSHA Standard shall be followed for employees and, to the fullest extent practical and appropriate, shall be followed for other UMB Personnel.

Admissions and Hiring Practices

Inquiries about infection with HBV, HCV or HIV will not be made of prospective UMB Personnel. Neither admission nor employment will be denied any otherwise qualified individual on the basis of infection with Bloodborne Pathogens. However, limitations on the training and professional activities which may result from infection with Bloodborne Pathogens will be communicated to prospective students and employees. (See next section.)

Advice on Risks and Limitations

Each School and Unit in which UMB Personnel have Occupational Exposure will provide advice to those UMB Personnel having Occupational Exposure concerning risk of infection with Bloodborne Pathogens and, for health care students and employees, possible relationships between infection and career opportunities for health care workers. Such advice will also be provided to applicants for the benefit of applicants who know themselves to be infected with Bloodborne Pathogens. This will include information on possible limitations resulting from infection with Bloodborne Pathogens as a health care worker in the specific profession or pursuit to which the application is being directed.

Advice will include notice that modifications of activities may be necessary for infected individuals engaged in patient care activities at UMB or at affiliated training or employment sites. Although UMB has no policies limiting the health care activities of individuals infected with Bloodborne Pathogens who have no physical or mental impairment as a result of their infection, some affiliated health care sites have imposed restrictions and it is possible that State licensing bodies will limit health care activities of infected individuals

Applicants who are infected with Bloodborne Pathogens are not required to identify themselves to UMB. Advice to applicants will be provided in a general form available to all applicants.

If infection with a specific Bloodborne Pathogen (e.g., HBV) could prevent a person from completing the curriculum or subsequently practicing the intended profession as a result of scientifically established contagion risk, this information will be included in the general information which the School distributes to applicants.

Testing

Testing for infection with Bloodborne Pathogens is not required for employment or admission or as a condition of continued enrollment or employment. Absence of infection with Bloodborne Pathogens is not utilized as a criterion in selecting successful applicants for academic enrollment or employment.

Voluntary testing is strongly encouraged for prospective students or employees who will have Occupational Exposure. These persons are well advised to be aware of their status with respect to Bloodborne Pathogens infection and should be advised that free testing is available through local government health testing facilities. Knowledge of status is valuable baseline information for evaluating outcomes of Exposure Incidents.

UMB Personnel who are or will be engaged in invasive procedures in the course of caring for patients have Occupational Exposure and should be aware of their status with respect to infection with Bloodborne Pathogens. Such personnel are encouraged to maintain awareness through periodic voluntary testing.

Voluntary testing will be available to UMB Personnel on request through Student and Employee Health. Any costs incurred must be covered by health insurance or by the tested individual. Free testing is available through other local health testing facilities.

Student and Employee Health will not inform School or Unit administrators of positive HIV, HBV or HCV tests of UMB Personnel unless the tested individuals provide written consent.

Immunization Against HBV

Students enrolling in academic programs that will involve participating in invasive or exposure-prone procedures must be vaccinated against HBV at their own expense unless an individual School has elected to provide vaccination at no cost to its students. Students may be vaccinated at Student and Employee Health. Those who were immunized prior to enrollment must provide evidence of immunization to the enrolling School. Immunization can be waived only for documented medical contraindications. Each School, in consultation with Student and Employee Health, will establish the schedule for students to obtain vaccination or present evidence of immunization.

As required by the OSHA Standard, UMB shall make available the HBV vaccine and vaccination series to all UMB employees who have Occupational Exposure or have had an Exposure Incident. The vaccination shall be offered at no cost to employees. Employees who decline the vaccination must sign a Hepatitis B Vaccine Declination Statement.

Any UMB Personnel who are neither students nor employees, and who have Occupational Exposure, shall be offered the HBV vaccine and vaccination at their own expense. Alternatively, the School or Unit in which such personnel work may support the cost of vaccination, at the discretion of the responsible administrator.

Voluntary Disclosures; Confidentiality

Persons who are not engaged or to be engaged in invasive patient care activities are not required or encouraged to disclose infection with a Bloodborne Pathogen. Prospective or current students, employees, or other UMB Personnel who are infected with a Bloodborne Pathogen, and whose work or academic program does or will include invasive procedures, are strongly encouraged but not required to disclose infection to the appropriate School- or Unit- specific Bloodborne Pathogens Review Panel described under section 12 below. Any person's disclosure of infection will be maintained in confidence by the individual affiliated with UMB to whom the disclosure was made unless other persons must be informed in order to implement this Policy.

A statement encouraging disclosures by persons who may or will be involved in invasive procedures may be included in School and Unit bulletins that advertise or describe academic programs to prospective and current students. Information regarding Review Panels and disclosures may be provided at enrollment, or soon thereafter, and at employee orientations. By one of these means it is expected that all students, employees, and other UMB Personnel currently or prospectively involved in invasive procedures will be informed by their School or Unit that:

1. Voluntary disclosure is encouraged;
2. The health status of a person who discloses infection will be held in confidence by UMB, and only persons who have a need to know the status in order to implement this Policy will be made aware of the status;
3. Voluntary and timely disclosure permits the School or Unit to assist in developing appropriate accommodations of maximum benefit to the disclosing individual; and
4. Disclosure itself cannot be the basis for academic dismissal or termination of employment, which would only follow careful consideration of a person's situation as discussed in this Policy.

Ombudsman

Each School and Unit will appoint a standing ombudsman or advocate to whom any applicant, student or employee can go in confidence for advice on policies and procedures related to infection with Bloodborne Pathogens and on the implications of testing and disclosure for enrollment or employment status.

Review Panels

UMB Personnel infected with a Bloodborne Pathogen who will be engaged in invasive procedures as a part of employment, educational program, or volunteer activities, are encouraged to disclose their status to their School or Unit Review Panel rather than to an administrative or academic official of the School or Unit. Each School or Unit will have a Bloodborne Pathogen Review Panel whose core membership will be determined under procedures developed by that School or Unit. Core membership should include: an individual knowledgeable about modes and risks of transmission of infection by Bloodborne Pathogens; a person expert in the practice of the professional discipline or work activities of the School or Unit; and a representative of the School's or Unit's infection-control group (where such a group exists). This membership may be drawn from individuals appointed or employed in other Schools or Units as well as from the School or Unit of the infected person.

To facilitate availability of qualified individuals for Review Panels, especially the panels of Schools or Units that may have an insufficient number of persons with the necessary experience or knowledge to serve on Review Panels, each School and Unit will compile a list of qualified individuals in its employ who would be available for service on its own Review Panel and other UMB Review Panels.

For each case pending before a Review Panel, the panel may seek information and recommendations from the infected person's personal physician (if available and authorized by the person to participate); a discipline-specific consultant if the infected individual is engaged in specialized work; and other consultants as needed to provide informed evaluation and recommendations.

The Bloodborne Pathogen Review Panel, after confidential review and deliberation, will recommend one or more of the following:

1. No restriction of activities;
2. Appropriate accommodation through changing the conditions of academic program or employment;
3. Restrictions of permitted activities;
4. Discontinuance of enrollment or employment. Recommendation (d) will be made only if the infected individual is physically or mentally incapable of performing required work related or academic activities or, although capable, poses a medically determined risk of transmission to patients, and there are no reasonable means by which accommodation and changes of activities could be devised which would allow continued employment or enrollment and completion of the academic program or employment responsibilities.

Review Panels will function under the general principle that not all health care workers infected with HIV, HBV or HCV need be prohibited from engaging in all invasive procedures; rather, each case will be individually considered, taking account of the skills and possible impairment of the individual.

For a student, the Review Panel's recommendations will be transmitted confidentially to the Dean of the student's School, who will develop a plan of action in consultation with the Review Panel, UMB legal counsel and the UMB President. The Dean may consult other University administrators, School faculty, licensing bodies, and medical consultants before reaching a decision concerning the Review Panel's recommendations or other actions. With respect to all consultations, the Dean shall preserve the confidentiality of the student. In determining whether to permit a student to continue in an educational program, the Dean will take into account the policies of affiliated teaching sites where the student would be assigned to complete educational requirements. The Dean's decision, i.e., the final plan, will be transmitted confidentially to the student and, with anonymity preserved, to the President and University legal counsel.

For an employee or other member of UMB Personnel, the Review Panel's recommendation will be transmitted to the concerned Dean or Unit head. The Dean or Unit head may consult with intermediate supervisors, University legal counsel, other University administrators, licensing bodies, and medical consultants before reaching a decision concerning the Review Panel's recommendation or other action. With respect to all consultations, the Dean or Unit head shall preserve the confidentiality of the individual under consideration. In determining whether to permit an individual to continue in employment or volunteer activities, the Dean or Unit Head will take into account the policies of affiliated sites where the individual would be assigned. The Dean or Unit head's decision will be transmitted confidentially to the infected individual and, with anonymity preserved, to the President and University legal counsel.

Accommodations

When necessary and reasonable, appropriate accommodations, including modifications of activities, curriculum, and job responsibilities, may be made for infected students or employees who otherwise would be engaged in invasive procedures or exposed to medically unacceptable risks of opportunistic infection. Inquiries with respect to competencies of prior performances by such individuals may be made by a Review Panel, a Dean or a Unit head as an aid to designing appropriate accommodations.
Curriculum modifications will be subject to decisions of each School's advancement or curriculum committee (as determined by the School) and the School's Dean.

Monitoring

If any restriction of activity is imposed as a result of considering recommendations from a Bloodborne Pathogen Review Panel, the Dean or Unit head imposing the restriction will assign (an) individual(s) to monitor compliance with the restrictions. The individual(s) ordinarily will be selected from among those who have significant responsibility for supervision of the person whose activities are restricted. Assignment of monitoring responsibilities will be in accordance with a plan that is to be included in recommendations from the Review Panel.
Non-compliance with any approved restrictions or with a monitoring plan shall be reported to the Dean or Unit head, who, using the Review Panel as an advisory body, will decide whether further restrictions, modifications of activities, or discipline are warranted. The affected individual will be given full information about alleged violations of restrictions and the opportunity to present arguments to the Dean or Unit head before a decision is imposed. Due to confidentiality concerns, violations of monitoring requirements will not be referred for action under regular misconduct or disciplinary policies of the Schools or the UMB campus unless the infected individual requests such action.

Affiliated Institutions

Many UMB Personnel perform health care services in affiliated institutions having their own infection control policies and, in some cases, their own policies concerning the scope of activities allowed for health care workers infected with Bloodborne Pathogens. Most of the affiliated institutions require that UMB Personnel assigned to them be subject to the institutions' infection control and Bloodborne Pathogens policies. UMB Personnel assigned temporarily or permanently to affiliated institutions are expected to know and follow the policies of those institutions concerning disclosure of health care workers' infections to the institution. If an affiliated institution places restrictions on the activities of UMB Personnel infected with a Bloodborne Pathogen, and those restrictions if any, exceed those of UMB, imposed by an individual's Dean or Unit head, the School or Unit will attempt to reassign the individual to a site where he or she can carry out activities permitted by UMB.

Look-Back Studies

The utility of look-back studies after potential exposure of patients to HIV-infected health care workers is not supported by the evidence from previous studies. Therefore, UMB will not conduct such look-back studies except in extraordinary cases as determined by the President of the campus. With respect to other Bloodborne Pathogens, look-back studies may have medical value and will be given consideration.

Notification to Patients and Clients

UMB patients and clients who have been served by an individual among the UMB Personnel who is known, or becomes known, to be infected by a Bloodborne Pathogen, may be informed of the individual's infectious status if there was an Exposure Incident involving the blood or other body fluids of the individual. In such cases, testing and pre-test and post-test counseling will be made available without cost to the patient or client. Under other circumstances, patients ordinarily would not be contacted.

Management of Exposure Incidents

1. Management of Exposure Incidents of UMB Personnel will comply with the OSHA Standard. Exposure Incidents involving students during experiences that are required or are otherwise part of their UMB educational program will be managed under the OSHA Standard notwithstanding that the Standard applies only to employees. Occupational Exposure plans shall be developed by schools and publicized among students. These plans shall provide information about the steps to be followed in the event of an Exposure Incident.
2. Following a suspected or known Exposure Incident, the affected UMB Personnel should report the incident to the appropriate School or Unit authority identified in the Occupational Exposure plan. Testing of UMB Personnel following a reported Exposure Incident will be available through Student and Employee Health. Testing is at the option of the exposed individual, and will be performed only after obtaining written informed consent. It is recommended that a blood sample for testing be drawn immediately after an Exposure Incident, even if a decision to consent to testing of the sample has not been made. Pre-test and post-test counseling will be provided.
3. Costs of testing, counseling and treatment for students, other than AZT prophylaxis or other anti-viral medications, are covered under the Student Health fee. Testing, counseling and treatment, other than AZT prophylaxis or other anti-viral medications, will be provided at no cost to UMB employees. Costs for other UMB Personnel are the responsibility of the individuals being tested unless a School or Unit agrees to assume such costs.
4. Counseling will include a review of the advantages and disadvantages of AZT prophylaxis or administration of other currently appropriate anti-viral preventive medication, which generally can be offered by (but usually is not paid for by) UMB. It will be available at the individual's cost if it is desired. The individual's School or Unit will be responsible for any uninsured cost of AZT or other recommended medication administered to UMB Personnel upon medical recommendation immediately following a massive exposure to blood of a Source Individual or Confirmed Source Individual during a work or education activity.
5. If UMB students choose to be tested and receive care off campus, UMB will not be responsible for costs, even in instances of massive exposure.
6. Exposure Incidents of UMB personnel while at affiliated sites optimally should be handled by an appropriate exposure control plan and procedures in place at that site; however, if appropriate procedures are not available, Student and Employee Health will provide testing, counseling and treatment services as specified above.
7. If an Exposure Incident involves a patient in a Maryland hospital which is an affiliated site, the exposed UMB Personnel can request that the Source Individual be tested (with consent) for Bloodborne Pathogens. In order for the Source Individual to be tested, the exposed UMB Personnel must agree to be tested for Bloodborne Pathogens. If hospital infection control staff do not offer assistance in securing patient testing, the exposed UMB Personnel should notify Student and Employee Health and seek assistance.
8. If an Exposure Incident involves as the Source Individual a patient or client who is not in a Maryland hospital, Student and Employee Health will assist in seeking consent of the Source Individual for testing.
9. To the extent permitted by law, UMB will provide to exposed UMB Personnel, and will ask its affiliates to provide to exposed UMB Personnel, information about the infectious status of Confirmed Source Individuals involved in Exposure Incidents with UMB Personnel.

Respective Roles of Schools and Units and the Office of Environmental Health and Safety (EHS) in UMB Policies for Bloodborne Pathogens

In general, it will be the responsibility of Schools and Units of UMB to implement and monitor compliance with the OSHA Standard, this Policy, and other UMB, School and Unit policies (as applicable in specific cases) related to Bloodborne Pathogens. Each School or Unit required to do so by the nature of its activities will develop an exposure control plan. The plan should be developed in consultation with, and subject to approval by, the UMB Biosafety Committee. A single, campus-wide exposure control plan applicable in its entirety to all Schools and Units is not feasible.

Each School or Unit will be responsible for identifying its personnel having Occupational Exposure (such identification to be made on the basis of job responsibilities, not job title), communicating that determination to EHS for approval, and maintaining a list of such positions.

Each School or Unit should develop for its internal purposes a list of procedures within its educational or patient service purview that it considers to be invasive procedures as discussed above in this Policy.

Schools and Units will arrange with EHS appropriate training programs as required by the OSHA Standards. Such training may be accomplished either by course(s) developed and given by EHS, or by courses developed and given by the School or Unit after review and approval of course content and format by EHS. Development and conduct of training by Schools or Units, rather than by EHS, is preferred.

EHS will keep Schools and Units informed of changes in law and regulations pertinent to infection with or exposure to Bloodborne Pathogens.

Disability Insurance

UMB will review markets and opportunities for disability insurance at reasonable cost that insures UMB Personnel against loss of income due to disability resulting from infection by Bloodborne Pathogens. UMB will request that the State Department of Personnel likewise attempt to secure such coverage to protect UMB Personnel who are State of Maryland employees. However, UMB may not be able to make available policies that provide such coverage. UMB recommends that each student or employee who is not covered by appropriate disability insurance through the State of Maryland or University of Maryland System benefit system, or through an insurance plan through the individual's School or Unit, consider obtaining individual insurance.