DGD12-015
The purpose of this SOP is to describe the processes of:
1.
Notification, assessment and identification of appropriate scope of practice for health care workers (HCWs) infected with a blood-borne virus (BBV) who work in
Health Directorate facilities, and
2.
How public health advice may be sought from the Chief Health Officer (CHO) in order to inform the assessment of the appropriate scope of practice of HCWs infected with a BBV.
HCWs infected with a BBV pose a potential hazard to public health if their clinical practice involves situations in which the virus may be transmitted to patients or co-workers. Often, no risk arises from clinical practice because there is no opportunity for contact with a HCW’s blood or bodily fluids (e.g. in the medical specialty of psychiatry). For HCWs who perform defined exposure-prone procedures (EPPs) there is, however, a risk that patients or coworkers may come into contact with blood or bodily fluids and transmission of a BBV infection could occur.
This risk of transmitting a BBV infection needs to be accurately assessed and managed to protect a HCW’s patients, co-workers and the HCW’s own health and professional interests.
This may, but will not necessarily, involve seeking public health advice from the CHO.
The Health Directorate Management of Human Immunodeficiency Virus, Hepatitis B Virus
and Hepatitis C Virus Infected Health Care Worker policy outlines the responsibilities of
HCWs who are infected with a BBV and provides a broad framework for managing and supporting these HCWs. This SOP should be read in conjunction with the policy.
This SOP:

Applies to all Health Directorate staff involved in managing the public health risk posed by a HCW infected with a BBV,

Outlines the process for notification, assessment and identification of appropriate scope of practice for HCWs with BBVs, and

Describes the mechanism to seek the CHO’s advice about the risks to public health so that the HCW’s scope of clinical practice may be properly assessed and managed.
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Management of the HCW may then require limiting the scope of clinical practice of health professionals (including doctors, nurses, dentists and allied health staff).
This SOP does not deal with:
1.
Potential processes by which a Health Directorate facility may discover whether a
HCW is infected with a BBV.
2.
Potential processes for handling of information about the infected status of a HCW within a Health Directorate facility.
3.
Potential processes for implementing any limitation in the scope of clinical practice of an infected HCW working in a Health Directorate facility.
This SOP does not specify the processes by which a Health Directorate facility will administer the clinical privileges of its staff.
The operational management of an infected HCW potentially involves:
Director-General (DG)
Through administrative arrangements such as clinical training units and scope of clinical practice committees etc., the DG has responsibility for managing the appropriate scope of clinical practice for HCWs in the clinical divisions in Health
Directorate facilities.
The DG may delegate these functions to an appropriate officer e.g. to the Deputy
Director-General (DDG).
Chief Health Officer (CHO)
The CHO has statutory responsibility for public health hazards in the ACT, which includes the potential for transmission of infectious diseases.
Australian Health Practitioner Regulation Agency (AHPRA)
AHPRA has responsibility for allowing practitioners to practice in particular fields and applies restrictions on registration, as appropriate. It regulates, among other professions, the registration of doctors, nurses and midwives and dentists.
Chief Nurse
Is responsible for making a recommendation as to whether there needs to be any amendment to, or the withdrawal of, the scope of clinical practice of nurses, midwives and students nurses/midwives with BBVs.
Allied Health Advisor
Is responsible for making a recommendation whether there needs to be any amendment to, or the withdrawal of, the scope of clinical practice of Allied Health professionals and allied health students with BBVs.
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Although HCWs infected with a BBV could be working in any clinical environment, hospitals have a key role because of their major role in performing EPPs, such as surgery. Managing infected HCWs in the hospital setting is therefore a priority for this SOP.
1.
Initial notification
1.1
The DG must be notified of HCWs infected with BBVs.
1.2
The DG identifies whether the HCW’s clinical practice involves EPPs.
2.
Assessment
2.1
Whether or not the HCW infected with a BBV performs EPPs, the DG initiates an assessment of the risks of transmission through clinical practice by notifying the following, as appropriate:

Director of the Medical and Dental Professional Standards Unit (MDPSU), for medical officers and medical students. The Director of the MDPSU is also the Chair of the Medical and Dental Appointments Advisory Committee (MDAAC) and
Medical Administrator of the Clinical Practice Committee (CPC). As appropriate, this person will convene the CPC to review the scope of clinical practice of the HCW and make a recommendation as to the requirement for any amendments to, or the withdrawal of, the HCW’s scope of clinical practice,

Chief Nurse, for nurses, midwives and students nurses/midwives

Allied Health Advisor, for Allied Health professionals and students.
Note: If, during the investigation of a notification of an infectious disease (this includes through channels like laboratory notifications or via General Practitioners), it becomes known that a HCW has become infected with a BBV, then this information should be made available to the CHO, who will notify this to the relevant persons as specified in Dot
Points 1-3 above.
3.
Identification of scope of practice
3.1
The director of the MDPSU, Chief Nurse and Allied Health Advisor are responsible for making a recommendation whether there needs to be any amendments to, or the withdrawal of, the HCW’s scope of clinical practice and providing this to the DG for endorsement.
The DG will notify AHPRA of changes to scope of practice for the HCW, and the ACT
Health Services Commissioner when required by the Health Practitioner Regulation
National Law Act 2010.
3.2
For medical practitioners - the CPC may provide notice of an amendment to, or withdrawal of, a scope of clinical practice of a HCW infected with a BBV to AHPRA. The
Health Act 1993 (ACT) confers upon the CPC a discretionary power to disclose protected and sensitive information to the Medical Board of Australia and the Dental Board of
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Australia where it is satisfied that the disclosure would be likely to facilitate the improvement of health services in the ACT. If the CPC gives protected and sensitive information to a Board, then the committee must also give that information to the
Health Services Commissioner.
3.3
If an infected HCW performs EPPs, his or her scope of clinical practice may be amended such that he or she ceases performing EPPs. If an infected HCW does not perform EPPs, his or her scope of clinical practice may be amended such that he or she does not commence performing EPPs.
4.
Assessment of the public health risk posed by an infected HCW by the CHO
4.1
When determining how to mitigate the risk to public health, the DG may seek an assessment of the risk to public health by the CHO. The CHO can provide advice to the
DG on the potential risk to public heath posed by a HCW infected with a BBV and potential actions to mitigate this.
4.2
In formulating advice, the CHO may convene a CHO Advisory Panel (CHOAP). The composition and terms of reference of the CHOAP are provided in Attachment 1.
4.3
The CHO may also take action under the Public Health Act 1997 with respect to a HCW’s scope of clinical practice.
5.
Monitoring of status of health care workers infected with a BBV
5.1
The CHOAP may advise the CHO that the infective status of a HCW be monitored. This is to determine whether the HCW may cease to pose a risk to public health and whether they may be able to perform EPPs.
5.2
If the CHOAP does advise that a HCW be monitored, then the CHO may nominate a doctor to perform this monitoring, provided that the HCW agrees to this.
5.3
The monitoring doctor will provide a letter outlining the infectious status of the HCW to the CHO at intervals determined by the CHO.
5.4
The CHO may elect to ask the advice of the CHOAP in interpreting the monitoring information provided by a doctor in relation to an infected HCW.
5.5
The CHO may, upon receipt of monitoring information, issue new advice regarding the public health risk posed by a HCW infected with a BBV to the DG, or to AHPRA.
5.6
A HCW will only be monitored by the CHO as long as the HCW practices in the ACT.
6.
Non-compliance with a limited scope of clinical practice
6.1
If a HCW continues to practise in a manner which poses a risk to public health despite having been instructed not to do so by the CHO, the DG, or AHPRA, then the CHO may take action under the Public Health Act 1997 (ACT) to mitigate the risk to public health.
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6.2
In addition to this, if the infected HCW is an employee of a public health facility in the
ACT and is not compliant with an instruction not to perform EPPs, administrative arrangements will be made, as far as possible, to reduce the risk to public health.
Outcome Measures
 When an infected HCW who is performing EPPs becomes known, his or her scope of clinical practice may be limited, as appropriate, to prevent ongoing risk to public health.
 When an infected HCW who is not performing EPPs becomes known, his or her scope of clinical practice may be limited, as appropriate, to prevent ongoing risk to public health.
Method

The effectiveness of this SOP in achieving its aims will be evaluated by review of the management of referrals received by the DG, or the CHO by the Director of the
Medical and Dental Professional Standards Unit, the Chief Nurse or the Allied Health
Advisor depending on the profession of the HCW.
Legislation
Public Health Act 1997
Health Act 1993
Human Rights Act 2004
Health Practitioner Regulation National Law Act 2010
Policies
Management of Human Immunodeficiency Virus, Hepatitis B Virus and Hepatitis C Virus
Infected Health Care Worker Policy
Exposure-prone procedure (EPP): an EPP is a procedure where there is a risk of injury to the
HCW resulting in exposure of the patient’s open tissues to the blood of the worker. These procedures include those where the HCW’s hands (whether gloved or not) may be in contact with sharp instruments, needle tips or sharp tissues (spicules of bone or teeth) inside a patient’s open body cavity, wound or confined anatomical space where the hands or fingertips may not be completely visible at all times.
Note: For more information on interpreting this definition applicable to this SOP please see
Australian National Guidelines For The Management Of Health Care Workers Known To Be
Infected With Blood-Borne Viruses, Australian Health Protection Committee (AHPC),
Commonwealth Department of Health and Ageing.
Health Care Worker (HCW): Means a worker regulated under the Health Practitioners
National Law ACT 2010. Of particular relevance to performing EPPs, this includes doctors, nurses and dentists.
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Public health facility in the ACT means health facilities operated by ACT Health Directorate and Calvary Public Hospital
1.
Communicable Diseases Network of Australia: Management of Human Immunodeficiency virus, Hepatitis B virus and Hepatitis C virus infected health care worker policy, 1999.
2.
NHMRC: Australian Guidelines for the Prevention and Control of Infection in Healthcare.
Commonwealth of Australia, 2010.
3.
ACT Health: Management of Human Immunodeficiency Virus, Hepatitis B Virus and
Hepatitis C Virus Infected Health Care Worker policy, 1999.
Attachment 1: Terms of reference for the Chief Health Officer Advisory Panel
Disclaimer: This document has been developed by Health Directorate, specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and
Health Directorate assumes no responsibility whatsoever.
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ATTACHMENT 1: Terms of reference for the Chief Health Officer Advisory Panel
CHIEF HEALTH OFFICER ADVISORY PANEL
The Chief Health Officer Advisory Panel (CHOAP) is an expert panel convened by the Chief
Health Officer (CHO) for the purpose of providing public health advice in regard to a health practitioner who undertakes exposure-prone procedures and is / has been infected with a blood borne virus.
The CHOAP is to take a risk assessment and management approach to the provision of advice. The risk assessment and management advice is to consider both individual health practitioner and health system factors. At a minimum, the risk assessment is to consider:

The health practitioner in the context of the blood borne virus infection;
 The health practitioner in the context of the nature of the exposure-prone procedures that they perform;

The health practitioner in the context of their routine clinical practice standards especially in regard to adherence with standard precautions and infection control; and
 The health system in terms of the standard operating procedures in the work environment, including clinical and administrative procedures.
Chief Health Officer Advisory Panel Terms of Reference
The terms of reference of the CHOAP may be determined by the CHO on a case by case basis. Standard terms of reference are provided for routine deliberations.
 Advise an affected health care worker in relation to public health risk and the requirement to protect the public and HCW colleagues.

Advise health organisations (chief executives and credentialing committees) and treating medical practitioners in relation to public health risk and appropriate public health risk management strategies.

Advise health organisations (chief executives and credentialing committees) and treating medical practitioners in regard to public health risk and the requirement for
“lookback” where the public has potentially been placed at risk
 Assess public health risk in accordance with nationally recognised or endorsed professional guidelines such as the Communicable Disease’s Network Australia –
Guidelines for Managing Blood-borne Virus Infection in Health Care Workers.
Chief Health Officer Advisory Panel Membership
The CHOAP is to consist of the following officials as a minimum:
 Chief Health Officer or delegate (Chair).

A health practitioner with clinical expertise in a relevant discipline e.g. an infectious diseases physician or microbiologist.
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 A health practitioner registered in the same health profession as the referred health practitioner. This health practitioner is to have expertise in the standard clinical practices of the profession.

A lawyer with expertise in the area of medico-legal or discrimination as relevant.
Chief Health Officer Advisory Panel Informants
In conducting a risk assessment the CHOAP may consider advice from:

The treating medical practitioner of the health practitioner infected with a blood borne virus. The advice may include specific detail regarding the nature, severity and clinical management of the health practitioner’s condition.
 A health professional from the clinical area in which the health practitioner works.
This is for the purpose of informing the panel with regard to the day to day health system standard operating procedures.

A health professional with knowledge of the day to day clinical practice of the referred health practitioner. This is for the purpose of informing the panel regarding the personal attributes of the health practitioner in discharging their clinical responsibilities e.g. observance of standard precautions, use of audit to ensure standard of professional practice

A health practitioner advocate nominated by the health practitioner under consideration.
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