Physiotherapy Alberta’s primary role is to ensure the public is protected when receiving physiotherapy services. The Standards of Practice direct physiotherapists to practice in a manner that provides safe and effective care with the focus on the patient and what they can expect when receiving physiotherapy services. However, two of the Standards, the Safety Standard and the Infection Control Standard not only require physiotherapists to protect their patients when providing care, but to also protect themselves from potential harm or illness while caring for the public. These Standards require members to practice in a safe environment, to adhere to applicable legislation, and to use best practices to limit or prevent the spread of infections.2
This is important both for the individual clinician’s safety, but also from a public health perspective to ensure neither clinicians nor patients put others at risk if they have an infectious disease. Following best practice infection, prevention and control guidelines ensure everyone can provide and receive services in a safe environment.
Health-care practitioners, including physiotherapists working in both hospital and community settings, may be at risk of blood and body fluid exposures (BBFE). Exposures to blood-borne pathogens such as HIV, Hepatitis B and Hepatitis C can occur in many health-care occupations and work environments1 and have the potential to result in a blood-borne illness.
In 2017, Physiotherapy Alberta and 11 other health profession regulators partnered to create resources to educate clinicians about BBFEs. The intent of this project was to develop educational resources for use by all regulated health professionals. The project’s goals were to promote the prevention of BBFEs and ensure that follow-up of occupational exposure to blood-borne pathogens was consistent and in accordance with current best practices and provincial legislation.
What is a BBFE?
A BBFE occurs when blood or body fluids from one individual come into contact with the skin, mucous membranes, or subcutaneous tissue of another individual.1
Many of us may think that a BBFE is not something physiotherapists need to be concerned about. We would be misinformed. Physiotherapists can be exposed in many situations. Handling wound care instruments, using or handling needles in practice, having blood, sputum or other bodily fluids splashed on you, or simply coming in contact with a contaminated surface in the hospital or clinic are a few examples of situations that can put a physiotherapist at risk. The Potential Biological Hazards and Controls resource will provide you with more detailed information related to potential means of transmission of blood borne pathogens in physiotherapy practice.
Avoiding a BBFE
The primary goal of any health-care facility, physiotherapy clinic or individual health-care practitioner must be to prevent a BBFE before it happens. The responsibility to protect workers is clearly defined by the Occupational Health and Safety Act (OHS Act)3 and is shared by employers and workers. The Act outlines both employer and worker responsibilities for maintaining safe work environments. Under the OHS Act and the Occupational Health and Safety Regulation, employers are required to ensure the health and safety of workers.3,4 Workers are required to take reasonable care to protect the health and safety of themselves and other workers.3,4
Employers are required to perform an assessment to identify any and all potential hazards including those that may expose workers to contact with blood or body fluids.3,4 Once these hazards have been identified, the employer must implement controls that prevent or limit the risks of harm.3,4 Controls are actions taken to eliminate or lower risk at work.
Methods of hazard control include:5
Engineering controls: The most effective controls are engineering controls that reduce or prevent the potential for exposure at the source.6 In the case of a BBFE, these controls may include limiting the use of sharps, the use of safety engineered sharps, the use of single use items in the place of multi-use equipment which requires disinfection or sterilization, and having sharps containers at the point-of-care (eliminating the need to transport sharps). Vaccination programs are also considered engineered controls.7
Administrative controls: Administrative controls are controls designed to alter the way work is done.6 These controls may include an organization’s Occupational Health and Safety policies, worker education programs, required safe work practices, immunization programs, and routine practices including hand hygiene.7 Safe disposal of waste materials and good housekeeping procedures are also considered administrative controls.7
Personal Protective Equipment (PPE): This control includes the provision of any protective equipment to be used by workers to reduce the exposure to or contact with a biohazard.6 Examples include the use of gloves when using needles in practice or using masks and face shields when suctioning.
Physiotherapists also have responsibilities identified under the OH&S Act.3 First and foremost, all workers/contractors or service providers must “take reasonable care to protect the health and safety of the worker and of other persons at or in the vicinity of the work site while the worker is working.”3 Physiotherapists must be knowledgeable about the hazards present at their work site or inherent in their practice. They must use any safety equipment available (including PPEs), ensure equipment used is safe and appropriate for the intervention, and follow the organization’s safe-work practices and policies. For more information, have a look at the interactive online module Protecting yourself and preparing your workplace.
Let’s expand on what is meant by routine practices. Routine practices are actions that are employed to help prevent the spread of infections. Routine practices are used with every patient, every time. All patients are presumed to be infectious.8 Examples of routine practices include:
Performing a Point of Care Risk Assessment (PCRA). Prior to providing care to any patient, the risk of exposure to an infection is assessed by the care provider. This may include taking a patient history and noting any potential contact you may have with blood or body fluids or other infectious agents.8
Performing effective Hand Hygiene. This is the single most important step to prevent contracting or spreading infections.8 For more information about Hand Hygiene click here.
Using PPEs. Examples of PPEs include gloves, masks, face and eye shields and gowns.7 As already stated, employers are required to provide PPEs appropriate for the risks encountered at work. Workers are required to use the PPEs as indicated. For more information about when and how to use PPEs click here.
Identification of risk factors does not mean you can decline to treat a patient. The Code of Ethical Conduct indicates that physiotherapists have an ethical responsibility to not “refuse care or treatment to any client on the prohibited grounds of discrimination as specified in the Canadian Human Rights Act as well as on the grounds of social or health status.” If you have identified a risk of exposure to an infection during your PCRA, following routine practices will minimize the risk of spreading any infections between individuals.
What should I do if I think I have been exposed?
It is important for physiotherapist to understand when they may have experienced a BBFE and what to do next. Knowing what to do before you are exposed can decrease the worry you may feel if you experience a BBFE. The Post-Exposure Pathway interactive online module and the Post-BBFE algorithm outline steps that should be taken anytime a suspected BBFE has occurred.
Steps to be taken include:
Reporting any suspected BBFE to your immediate supervisor or employer.3 This report should include a clear description of what you were doing, what you were exposed to (i.e., blood, sputum, saliva) and where the exposure occurred.1
Providing first aid immediately. This includes:9
Cleansing body sites exposed to potentially infectious blood/body fluids immediately with soap and water.
Avoiding the use of alcohol, hydrogen peroxide, bleach or other chemical cleansers/antiseptics/disinfectants.
Not “milking” the wound, as squeezing may promote hyperemia and inflammation at the wound site, potentially increasing exposure if HIV is present.
Allowing the injury/wound to bleed freely, then covering lightly.
Flushing exposed mucous membranes (including eyes) with water or normal saline.
Seeking a medical assessment as soon as possible! You should contact a health professional with expertise in BBFEs as soon as possible.9 The sooner you seek medical attention the better (preferably within 1-2 hours) as it increases the likelihood of receiving timely and effective treatment if post exposure prophylaxis is needed.9 Treatment may not be available if it cannot be started within 72 hours.9 Don’t wait until end of your shift or the next day to seek medical attention! If a health professional with expertise in this area (e.g., an infectious disease specialist) is not available at your workplace, go to your local emergency department.
The doctor said my exposure is not significant. It sure feels significant to me
You may see the words significant or non-significant exposure in the literature or on your medical report following a BBFE. If you are the one who has experienced a BBFE, the event is sure to feel like a significant one from your perspective; however, in this case the term relates to the likelihood of transmission of a blood borne illness from the exposure.
The assessment completed by the infectious disease specialist or other health-care professional knowledgeable in this area will include a review of the circumstances of the exposure and determine the risk of contracting a blood-borne illness. This assessment considers the substance you were exposed to, the means of transmission (IV, deep or superficial transcutaneous, intact or compromised skin, etc.), and the quantity of the fluid involved.9 The assessor will also need to consider the source of the blood or body fluid and will determine if further testing of the source individual is required.9
Only a knowledgeable and trained health-care professional can make this determination. Although the risk of contracting a blood-borne disease in physiotherapy practice is generally considered low, you should still seek assessment as soon as possible. For more information about the risk of contracting a blood-borne illness see the AHS resource Know the Facts if you may have been exposed to HIV, Hepatitis B or Hepatitis C.
It is important to remember that, per OH&S legislation, the employer is responsible for the costs of first aid and any follow-up medical treatment required.3,4 You should never be asked to pay for any post-exposure medical treatment yourself.
What not to do
If you suspect you have experienced a BBFE, your first instinct may be to approach the source individual to ask them to be tested for a blood borne illness. Don’t! As the person exposed, this is not your role.
The source individual should be informed of the event and asked for permission to test for blood borne diseases. However, this request should be made by an appropriately trained health professional, such as a Medical Officer of Health or an Infectious Disease Specialist.9 It is very important that the source patient provide voluntary consent to testing and that there is no potential for the individual to feel pressured or coerced. If you are requesting the testing when you are feeling a little panicked or anxious immediately after the exposure, this may put unintended pressure on the source patient to consent.
Resources available to employers, workers or self-employed physiotherapists
Online learning modules, posters that can be posted at your worksite, the Post BBFE Process Algorithm and links to many other useful resources specific to BBFEs are available at http://bbfeab.ca/index.html.
It is everyone’s responsibility to be knowledgeable about the risks of BBFEs, how to avoid being exposed and what to do if you have been exposed.
As my mother always said, an ounce of prevention is worth a pound of cure! Be aware, be prepared and be safe.
Workers’ Compensation Board – Alberta. Worker Fact Sheet: Contact with blood and other bodily fluids. Available at https://www.wcb.ab.ca/assets/pdfs/workers/WFS_Contact_with_blood_and_other_bodily_fluids.pdf Accessed Feb 4, 2020.
Physiotherapy Alberta (2017). Standards of Practice. Available at https://www.physiotherapyalberta.ca/files/standards_of_practice.pdf Accessed Feb 4, 2020.
Government of Alberta (2018) Occupational Health and Safety Act. Available at http://www.qp.alberta.ca/1266.cfm?page=O02P1.cfm&leg_type=Acts&isbncln=9780779800865&display=html Accessed Feb 4, 2020.
Government of Alberta (2018) Occupational Health and Safety Code. Available at http://www.qp.alberta.ca/ohscode.cfm Accessed Feb 4, 2020.
Government of Alberta (2015), Hazard Assessment and Control: a handbook for Alberta employers and workers. Available https://open.alberta.ca/publications/9781460121535 Accessed Feb 4, 2020.
Government of Canada. Canadian Centre for Occupational Health and Safety: OHS Answers Fact Sheets: Hazard Control. Available at https://www.ccohs.ca/oshanswers/hsprograms/hazard_control.html Accessed Feb 4, 2020.
Blood and Body Fluid Exposure (BBFE) Resource for Health Care Professionals. Potential Biological Hazards and Controls. Available at http://bbfeab.ca/links.html Accessed Feb 4, 2020.
Alberta Health Services.(2018) Infection Prevention & Control: Routine Practices. Available at https://www.albertahealthservices.ca/ipc/hi-ipc-routine-practices-info.pdf Accessed Feb 4, 2020.
Blood and Body Fluid Exposure (BBFE) Resource for Health Care Professionals: Post-BBFE process. Available at http://www.bbfeab.ca/algorithm2016.pdf Accessed Feb 4, 2020.
Patient Safety. Every Person. Every Time.
Regulating Alberta's physiotherapy profession and acting as an association by providing member services.