The Ryan White Bill

[Chief1C]

Full Bill text on link (PDF)

http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:s1793enr.txt.pdf

The Ryan White HIV/AIDS Treatment and Extension Act of 2009 passed the House yesterday by a vote of 408 to 9. The Senate passed the bill earlier this week so the bill now goes to President Obama for his signature into law. There are several new additions to the Ryan White Act which affect emergency care – and specifically emergency responders.

It is important to note that the ‘list’ established under Sec. 2695 is very powerful – it essentially determines what infectious diseases should be considered ‘potentially life-threatening’. The list is also used to determine whether or not emergency responders must be notified of an exposure.

The entire bill can be found at this link http://bit.ly/2YZs1o

Here are the sections affecting emergency care and emergency responders:

The bill adds a new section to Ryan White – “Part G Notification of Possible Exposure to Infectious Diseases”

Within 180 days after enactment, Section 2695 Requires the Secretary of HHS to complete the development of:

* a list of potentially life-threatening infectious diseases, including emerging infectious diseases, to which emergency response employees may be exposed in responding to emergencies (The list developed shall also include a specification of those infectious diseases on the list that are routinely transmitted through airborne or aerosolized means.)

* guidelines describing the circumstances in which such employees may be exposed to such diseases, taking into account the conditions under which emergency response is provided;

* guidelines describing the manner in which medical facilities should make determinations when an emergency responder is requesting a determination as to whether or not a patient he/she transported had an infectious disease

* This list will then be distributed to the public and the states

* NOTE: This list is very important because it is relied heavily upon in determining whether or not a responder has been exposed to an infectious disease.

The bill also reestablishes some of the notification provisions that were struck during the last Ryan White authorization. This is good news for emergency responders. Specifically, the bill requires Prompt notification – not later than 48 hours after determination is made – to emergency responders when:

* A patient is transported and it is determined that the patient has an airborne infectious disease AND WHEN

* A patient that is transported by emergency responders dies at or before reaching the medical facility, the medical facility ascertaining the cause of death shall notify the designated officer of the emergency response employees who transported the victim to the initial medical facility of any determination by the medical facility that the victim had an airborne infectious disease.

The bill also contains a provision for emergency responders to request a determination as to whether or not a patient had an infectious disease. Basically the provision states that:

* The employee must first make a request

* The request is then examined, facts are collected by a designated officer

* The designated officer then makes a determination – if the designated officer feels that an exposure may have occurred then he/she submits a request to the medical facility

* Once the medical facility receives the request, it has 48 hours to respond

* The medical facility will make a determination, based on the information possessed by the facility, regarding whether or not the emergency responder was exposed to an infectious disease that appears on the list (created above).

* The medical facility can make 3 determinations, Notification of Exposure, Finding of No Exposure, Insufficient information

* If a finding of insufficient information is made, the public health officer for the community in which the medical facility is located can also evaluate the request if the designated officer submits the request to him/her.

[spenac]

Thanks for the info.

[VentMedic]

Let's clarify a few things about what the Ryan White Act actually does. For the large part, the IAFF should have spent their money lobbying at the state level for improved state regulations about testing and seeing their own departments had effective DICOs. In 1990, largely at the insistence of the IAFF, this section was added. Its purpose was to get money to set up some education for employees and a Designated Infection Control Officer in EMS/FDs. Since this was not the primary purpose of the Act, EMS/FDs did establish a DICO but it was usually just a title and not necessarily a working job description. Policies should have been written but often they relied on those from a hospital for exposure on a case by case basis. However, Public Health laws are enforced and if the DICO of any agency taps into them with their policies, the blood and airborne pathogens that are worrisome are covered. In the states that have OSHA, they can also be used for policy making guidelines. Hospital infection control officers will also contact an agency but they can not force the DICO of EMS/FD to do whatever. Public Health notification for certain diseases are there to also assist and enforce certain regulations for that state.

The other thing the Ryan White Act does not do is mandate testing without consent for an exposure to a blood borne pathogen. If the state does not allow it, then you again have to rely on your department's policy for prophylactic treatment or to obtain a court order if the exposure is serious enough. OSHA does spell this out and in the states that don't have OSHA, they either a specific state statute or a section in their Public Health laws that addresses this. The DICO should be familiar with his/her policy to get the employee whatever care is necessary. The employee should also make sure they understand their policies. If neither the DICO or the employee take some responsibility, it doesn't matter how many people notify them.

Since the Ryan White Act is almost a $3 Billion/year expenditure for People With AIDS/HIV over the next four years and it has been each year for 20 years, EMS/FDs departments would be foolish to rely on those few paragraphs buried inside this Bill. The intent of this Bill was to provide health care and housing to people living with HIV/AIDS. It is a good piece of legislation that is needed and actually $3 Billion in not nearly enough. But, any health care reform could again repeal this Act. It is also sad when most in EMS/FDs only know a couple paragraphs of this Act and believe the Ryan White Act is solely about them. Few even know who Ryan White is.

If EMS/FDs fail to establish an effective DICO and have the necessary policies in place to protect their employees there is no assurance that anything from the Ryan White Act will even be followed by that department regardless of the hospitals' part per the Public Health regulations. Most of these regulations are stricter and can be enforced more easily. However, there is no guarantee that the hospitals will test for some diseases if it does not pertain to the immediate illness/injury. Even TB has gone undetected for several ED visits because the symptoms were not all present. So, if you are waiting for an engraved letter from the hospital, you may be waiting a long time if there is no reason to notify you because testing was not done. That doesn't mean you do nothing for a needle stick or when you feel you may have been exposed to something. Again, that is what your DICO is for. He/she should have a relationship with the various hospitals and a policy to see you are covered quickly for whatever exposure. There is also nothing more frustrating than when the ED doctor already knows what he/she is going to diagnose a patient with and asks the EMT(P)s who their DICO is so they can be contacted and prophylactic treatment can be given but all the doctor gets is a blank stare. Sometimes that blank stare is even from the EMS supervisor when approached about a situation.

Side note, Florida does have a section in its statutes for testing without consent. California leaves it to the discretion of a doctor and the written informed consent is no longer required. I believe NY still requires consent before blood can be tested for HIV. The same for the Veteran's Administration system which is Federal.

The hesitation of some states to have testing without consent is for the protection of the employee and everyone else who enters the health care system. Many states do mandate that if you have HIV or Hep C and are working in health care that you disclose this. However, mandatory testing for health care employees has not yet been legislated and enforced.

Edited October 23, 2009 by VentMedic

[CBEMT]

It's also pretty frustrating when you hand the state EMS exposure form to the charge nurse, as directed, and get a blank stare. Or when the ER doesn't even have any forms.

[VentMedic]

It's also pretty frustrating when you hand the state EMS exposure form to the charge nurse, as directed, and get a blank stare. Or when the ER doesn't even have any forms.

The forms generally come from the EMS agency and you or your supervisor should have easy access to them which contain all the information and authorization for treatment and follow up. Hospital EDs see many different providers and it is difficult to keep track of every form and every company contact person. Each company may also have its own policy and will vary from others. However, it is your right to know what that policy is and it should be clearly stated in your employee manual.

If the hospital later determines the patient is positive for something like TB or meningitis, they have their own Public Health forms for followup with your EMS agency and hopefully that information is correct. This is why there should be a Designated Infection Control Officer for each agency.

Edited November 28, 2009 by VentMedic

[CBEMT]

That's right, I forgot. What happens in the hospital is sacrosanct and perfect. It's EMS that are always the screwups. Right?

One form for the whole state. It doesn't even happen that often. Not hard to keep track of. And part of the charge nurse's job. Yet some of them have utterly no idea what we're talking about.