Emergency Medical Services Personnel Exposure Law

(Emergency Medical Services Agency Version)

On April 18, 2000, legislation was signed into law (MN Statutes 144.7401-144.7415) that requires every Minnesota hospital to establish a specific protocol for the evaluation and management of Emergency Medical Services (EMS) personnel who have had a significant exposure to the blood or potentially infectious body fluids of a source individual while on duty.¹ Any hospital violating this law will be guilty of a misdemeanor.

Potentially infectious body fluids and significant exposures are defined as per the most recent guidelines of the United States Public Health Service (PHS).² Source individuals are defined as those persons whose blood or body fluids have been the source of a significant exposure to EMS personnel. EMS personnel are those persons who provide out of hospital emergency medical services such as firefighters, licensed peace officers, paramedics, EMS technicians, licensed nurses, crime laboratory workers, rescue squad personnel and those who serve as employees or volunteers of ambulance services or first responder squads. Persons acting as Good Samaritans rendering emergency assistance, persons executing citizen's arrests and crime victims are also included.

Because blood or body fluid (BBF) exposures to EMS personnel typically occur outside of the hospital setting, it has sometimes been difficult for these persons to receive the same type of post-exposure evaluation that hospital employees receive. In particular, it has been difficult to have source individuals tested for bloodborne pathogens. This law does not grant additional rights to EMS personnel, but rather attempts to offer these persons the same type of exposure evaluation that hospital employees receive. Although rarely, if ever, invoked, hospitals have always had the right to petition the court to order non-consenting source individuals to submit to bloodborne pathogen testing.

Since 1996, when the PHS issued provisional recommendations regarding the use of antiviral post-exposure prophylaxis (PEP) for HIV exposure, the importance of prompt evaluation of such exposures has been stressed.³ To best evaluate these exposures, it is extremely helpful to have information about the source individual, if the identity of that individual is known. Information as to whether or not the source individual is infected with a bloodborne pathogen is very important in determining whether or not PEP will be offered. The most recent PHS guidelines (published in 1998) emphasize that "occupational exposures should be considered urgent medical concerns to ensure timely administration of PEP."²

In addition to covering EMS personnel and crime victims through a Department of Health statute, separate laws were passed which cover correctional facility personnel through a Department of Corrections statute and secure treatment facility personnel through a Department of Human Services statute. All three statutes establish specific protocols for the management of BBF exposures. This summary pertains only to the Department of Health statute that covers EMS personnel and crime victims, although the protocols for correctional facility employees and secured treatment facility employees are similar.

Protocol
EMS Agency Responsibilities

• EMS agencies will have procedures for EMS personnel to notify a hospital that they may have experienced a significant BBF exposure.
• EMS agencies will have a protocol to locate the source individual if the source individual is not at the hospital that is evaluating the exposed EMS person. In such circumstances, EMS agencies will notify the evaluating hospital of the source individual's location if that individual is located. It is the responsibility of th hospital to attempt to contact the source individual once their location is known.
• EMS agencies must pay or arrange payment for the costs of counseling, testing and treatment of the exposed EMS person and the costs associated with testing the source individual.
• EMS agencies must petition the court to obtain an order for testing a source individual if there is no blood available from the source individual and the source individual refuses to have blood drawn/tested. Such petitions submitted by EMS agencies must contain affidavits documenting that:
  • the hospital followed the protocol (below) and attempted to obtain bloodborne pathogen test results;
  • a significant exposure occurred; and
  • a physician with specialty training in infectious diseases, including HIV, has documented that the exposed person has provided a blood sample and consented to testing for bloodborne pathogens and that bloodborne pathogen test results on th source individual are needed to determine medical treatment for the exposed person

Hospital Responsibilities

• Hospitals must use the following protocol when EMS personnel request evaluation of a BBF exposure. This protocol will be used if EMS personnel have an exposure to a source individual's blood or potentially infectious body fluids and the following conditions are met:
  1. The hospital determines that a significant exposure has occurred;
  2. A licensed physician participating in the evaluation requires the source individual's test results to determine appropriate treatment of the exposed person; and
  3. The exposed person consents to provide a blood sample for bloodborne pathogen testing. If the exposed person does not want their blood tested initially the hospital must hold the sample for at least 90 days.
• The evaluating hospital will adopt and follow a post-exposure protocol for EMS personnel who have experienced a significant exposure. The protocol must adhere to the most recent recommendations of the PHS² and include, at a minimum, the following:
  1. A process for an infectious disease specialist or licensed physician to:
     a. determine whether a significant exposure occurred; and
     b. provide recommendations for appropriate treatment and follow-up;
  2. A process to determine if the source individual is infected with a bloodborne pathogen;
  3. A process for providing EMS personnel appropriate counseling regarding the likelihood of bloodborne pathogen transmission, recommendations for testing, treatment and follow-up according to the most recent recommendations of the PHS, and any other counseling as needed;
  4. A process for providing appropriate counseling to the source individual; and
  5. Compliance with applicable state laws relating to data practices, confidentiality, informed consent and the patient bill of rights.
• Because it is important to determine if the source individual is infected with a bloodborne pathogen, EMS agencies will have a protocol to locate source individuals who are not patients at the evaluating hospital. The EMS agency will make reasonable efforts to locate the source individual and inform the evaluating hospital of the source individual's location. If the source individual is not in a hospital, it is the responsibility of the evaluating hospital to make reasonable efforts to contact the source individual. If the source individual is at another hospital, that hospital will be responsible for contacting the source individual.
• The evaluating hospital must ask exposed EMS personnel and the source individual (if at that hospital) if they have ever had any positive tests for bloodborne pathogens. If the source individual is at another hospital, that hospital is responsible for contacting the source individual to obtain this information.
• If there have been prior positive tests, the hospital must attempt to obtain these test results before taking steps to obtain a blood sample or testing blood for bloodborne pathogens.
• The evaluating hospital will disclose the source individual's test results to the exposed person without the name of the source individual or other identifying information. The exposed person must be informed about confidentiality requirements and penalties for release of information before this disclosure is made.
• If a prior blood sample is available from the source individual, it may be tested with the consent of the source individual or their representative.
• When the hospital is required to seek consent under this law, the hospital will follow its usual procedure for obtaining consent from an individual or their representative.
• A hospital may not base decisions about admission or the provision of care or treatment on any requirement that the source individual consent to bloodborne pathogen testing.
• Before consent is obtained the source individual will be informed that:
  1. Their test results will be reported to the exposed person (without name or other identifying information) if the results are requested by the exposed person;
  2. Their test results cannot be used in criminal or civil proceedings;
  3. Their test results cannot be used by insurers to take an action with respect to coverage;
  4. They may refuse to provide a blood sample, but such refusal may result in court action to require them to provide a sample; and
  5. The hospital will inform the exposed person of the confidentiality requirements and penalties for release of information.
• If a blood is available, testing can be performed without consent if the exposed person or their agency requests the testing and the following criteria are met:
  1. A documented exposure has occurred;
  2. The evaluating hospital has determined that the exposure was significant and the results are needed to determine appropriate treatment of the exposed person;
  3. The exposed person provides a blood sample for testing for bloodborne pathogens;
  4. The hospital asks the source individual to consent to a test for bloodborne pathogens and the source individual does not consent;
  5. The hospital has provided the source individual with all of the information required prior to testing; and
  6. The evaluating hospital has informed the exposed person of the confidentiality requirements and penalties for release of information.
• Consent from a source individual or their representative for bloodborne pathogen testing of an existing blood sample obtained from the source individual is not required if the hospital has made reasonable attempts to obtain consent and consent cannot be obtained within 24 hours of the exposure.
• If the source individual dies before an opportunity to consent to blood collection or testing occurs, the hospital does not need the consent of the deceased person's representative for the purposes of this law.
• If there is no prior blood sample available, the hospital contacting the source individual will obtain consent from the source individual before collecting a blood sample for bloodborne pathogen testing.
• If the source individual (or their representative) consents to providing a blood sample, the hospital will collect the blood sample and test the blood sample for bloodborne pathogens.
• If there is no blood available and the source individual refuses to have blood drawn:
  1. The evaluating hospital will inform the exposed person about the source individual's refusal;
  2. The EMS agency or, if there is no agency, the exposed person may bring a petition for a court order to require the source individual to provide a blood sample for bloodborne pathogen testing. The petition will be filed in the district court in the county where the source individual is hospitalized or resides;
  3. The hospital will cooperate with the petitioner in providing any necessary affidavits for the petition to the extent that the hospital staff can attest under oath to the facts in the affidavit; and
  4. If a petition is filed, the source individual has the right to legal counsel.
• The court may order a source individual to provide a blood sample if:
  1. There is probable cause to believe the exposed person has experienced a significant exposure from the source individual;
  2. The court imposes appropriate safeguards against unauthorized disclosure and specifies the persons who will have access to the test results and the purposes for which the test results may be used;
  3. A licensed physician participating in the evaluation of the exposed person needs the test results to determine appropriate medical treatment for the exposed person; and
  4. The court finds a compelling need for the test results.
• The evaluating hospital will inform the exposed person of their own test results and the insurance protections.
• The hospital that contacted the source individual will inform the source individual of their test results. If testing of the source individual's blood is done without consent because the source individual has left the hospital and they or their representative cannot be located, the hospital will provide test result information to the source individual or their representative when it is possible to do so.
• EMS agencies will pay for, or arrange payment for, the testing, counseling and treatment of exposed EMS personnel and also for costs associated with testing the source individual.
• The evaluating hospital will have a protocol that states whether the hospital will pay for the cost of the counseling, testing and treatment of a person exposed while executing a citizen's arrest or acting as a Good Samaritan.

The "Emergency Medical Services (EMS) Personnel Communicable Disease Exposure Report Form" developed by MDH in 1990 is no longer available. This form was intended to be a template for such forms and was never required by MDH. Agencies and hospitals may develop their own forms for this purpose. Such forms should include information about testing for hepatitis C, in addition to HIV and hepatitis B.

Agencies must also establish internal procedures to document the route of exposure and the circumstances under which exposure incidents occur per MN Statute 182.6555 which was signed into law on April 10, 2000 (Reducing Occupational Exposures to Bloodborne Pathogens through Sharps Injuries)⁴. This documentation must include:

1. Environmental controls in use at the time of the incident
2. Work practices followed
3. A description and brand name of the device in use
4. Personal protective equipment or clothing that was used at the time of the incident
5. Location
6. Procedure being performed when the incident occurred
7. The employee's training
8. The injured employee's opinion about whether any other engineering, administrative, or work practice control could have prevented the injury and the basis for that opinion

Other Provisions of the EMS Law

EMS Personnel Exposure to Tuberculosis

The law requires hospitals to establish a protocol for notifying EMS personnel about exposures to tuberculosis (TB) as well as providing information about such exposures and any necessary follow-up.

• If EMS personnel are exposed to person with TB while on duty, the Infection Control Practitioner (ICP) at the hospital treating the person with TB shall notify the EMS agency's exposure control officer by phone and by written correspondence. The hospital's ICP will provide exposed EMS personnel with information about screening and, if indicated, follow-up.

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References

1. Minnesota Statutes 144.7401-144.7415.
2. CDC. Guidelines for the Management of Occupational Exposures to Hepatitis B, Hepatitis C, and HIV and Recommendations for Postexposure Prophylaxis
3. CDC. Update: provisional Public Health Service recommendations for chemoprophylaxis after occupational exposure to HIV. MMWR 1996;45:468-472.
4. Minnesota Statute 182.6555. Reducing Occupational Exposures to Bloodborne Pathogens through Sharps Injuries.