In April 1994, one of the most important laws protecting emergency response employees (EREs) who were exposed to communicable diseases went into effect. The Ryan White Comprehensive AIDS Resources Emergency Act, Public Law 101-381, required inclusion of all emergency response employees—firefighters, emergency medical technicians, paramedics, law enforcement officers and volunteers—in the post-exposure medical notification process in the event of an exposure to a bloodborne or airborne transmissible disease. This law was necessary because medical facilities often only focused on their employees' post-exposure and not on emergency response personnel's. After we had this dual standard of care for many years, this law essentially forced medical facilities to have source patients tested if an exposure occurred in the field and enabled EREs to receive source patient test results in a timely fashion.
The Ryan White law was a comprehensive HIV funding bill that required reauthorization every five years. There was no problem until the last reauthorization in late December 2006, when the emergency response provisions were deleted from the law. These provisions have been of great assistance in getting EREs important information when exposures occur and have been a great help when medical facilities were not cooperative in testing or revealing source patient results. We need to get it back, but it will take some time.
Why do we need this law? Because OSHA's bloodborne pathogen regulation does not give us the coverage the Ryan White notification law encompassed. Let's look at what has been lost and why OSHA's regulation does not meet our needs:
- The Ryan White notification law specifically included volunteers. OSHA does not cover volunteers unless a specific state has granted them coverage, which leaves out a large number of persons on a nationwide basis.
- State and municipal employees are not covered by OSHA unless states have their own OSHA plans and inspectors. Without a state plan, there is no coverage for EREs, unless a separate law has been passed providing such coverage.
- The Ryan White law stated that each employer of EREs must have a designated officer to act on their behalf to ensure source patient testing and proper medical follow-up and testing. This helped ensure proper care for exposed employees and in turn lowered liability risks for the employer. OSHA only requires the employer "to ensure proper care and counseling" post-exposure.
- Under the Ryan White law, the designated officer makes the first determination of whether an exposure occurred. Having a designated officer trained to do this saves the ED time and the employer money. Simply sending an ERE to the ED without an initial screening generates two costs: one to sign in and one to be seen by a physician. If there was not an exposure, the department may have generated a cost of $1,000 or more. Check the fees at your medical facilities.
- If an exposure did occur, there is a step-by-step process in the Ryan White law that clearly lists the responsibilities of the employer and the medical facility. The OSHA regulation does not give a step-by-step process, but simply states that compliance is "performance-based." You have to figure out the process and get the medical facilities to cooperate. Even with the law there have been problems across the country. Some facilities say they are not responsible for testing source patients for ERE exposures because they are not their employees.
- The Ryan White law states that medical facilities must get source patient test results back to the designated officer as soon as possible, but no longer than 48 hours. OSHA does not give a timeframe, but refers to the Centers for Disease Control & Prevention (CDC) guidelines. Many facilities are either not familiar with timeframes or just ignore them.
- If a designated officer determines that an exposure occurred and the medical facility disagrees, the Ryan White notification law contains an administrative process to assist the designated officer. The public health officer or someone at the CDC/NIOSH is assigned to intervene. This is not addressed in the OSHA regulation.
- With regard to a patient death and exposure to that patient, the Ryan White notification law states clearly that the person who determines cause of death is responsible for obtaining testing on the source patient. This is not addressed in the OSHA regulation.
- The Ryan White notification law lists coverage for more diseases than OSHA. It covers HIV, HBV, TB, meningitis, hemorrhagic fevers, plague and rabies, but does not list hepatitis C, which is covered under OSHA regulation.
- The Ryan White notification law states that medical facilities have a responsibility to notify the designated officer for the EREs who transported a patient suspected for or diagnosed with an airborne transmissible disease. Again, this must be within the ASAP timeframe and no longer than 48 hours.
The Ryan White notification law was not perfect, but it put the designated officers who work on your behalf in charge of the post-exposure management process. Efforts are underway to bring the law back. This may also pave the way for improving and making it stand-alone law that is not attached to another bill.
|Ryan White Notification Law||OSHA Bloodborne Pathogens & TB|
|Requires a liaison (designated officer) for exposures 24/7||Says a person should be charged with program management|
|Sets up a step-by-step process for hospitals and departments to follow||States compliance is "performance-based"; does not give a set process|
|Gives coverage to volunteers||No clear coverage for volunteers|
|Covers all emergency response employees in all states||Does not give coverage in states that do not have their own state OSHA plans|
|Gives set timeframes for medical facilities to turn around test results||Does not give set timeframes; refers to CDC guidelines|
|Requires medical facilities to notify emergency response employees if they transported a person suspected with or confirmed for TB or meningitis||Not noted by OSHA|
|Gives an administrative process for medical facility non-compliance||No administrative process|
|States medical examiner responsibilities for testing deceased persons if an exposure occurred||Not addressed|
|States designated officer makes the first call on an exposure||Not addressed|
|States medical facilities have responsibility to test the source||Not as clear|
|Requires hospitals to notify the designated infection control officer regarding rare and uncommon diseases; more diseases covered||Only addresses HIV, HBV, HCV, syphilis and tuberculosis|
LIMITED EDITION PRINT AVAILABLE AT EMS EXPO
Self-taught artist Teri Forero didn't begin her career painting firefighter images on canvas. But after a fateful night in April 2004, when firefighter/paramedics rushed to her home when she was having trouble breathing, Teri forged an inspirational relationship with the prehospital industry.
After her release from the hospital she stopped by the fire station to thank her heroes. "You must receive tons of thank you cards," Teri stated. Her heroes replied, "two, and one of them was sent by you." She couldn't believe it and says her paintings are her way of making up for the people who did not take the time to say thank you.
Shortly afterward, she painted her first piece, titled The Final Call. This piece was replicated as an exterior memorial at Firefighters Park in South Florida. It is a free-standing wall, measuring 6' x 4½'.
Teri is now honored to be painting a 20th anniversary commemorative limited edition collectible painting and print for EMS EXPO, being held October 13–17, 2008, at the Las Vegas Convention Center. When approached by EMS EXPO, Teri graciously offered her time and talent.
Best known in the EMS community as paramedic Johnny Gage from the television series Emergency!, Randolph Mantooth will be delivering this year's keynote presentation at EMS EXPO, titled EMS/Fire Service: Then and Now. During initial sketches of the painting, Teri received a call from Randy offering a historical perspective and vision for EMS. Taking this into account, they agreed on the painting's emotion, detailed elements and industry representation in wanting the painting to be about honoring efforts of all emergency response providers.
A limited edition of 551 prints will be available at EMS EXPO 2008 with all proceeds benefiting the County of Los Angeles Fire Museum restoration fund of Engine 51. Attendees of EMS EXPO will have the opportunity to meet Randolph Mantooth in person at the Third Alarm Fire Shop, booth number 2022, when he hosts a fundraising autograph session on behalf of the museum. The artist's story and signature will appear on the back of the print. All prints will be hand numbered and not offered for sale outside of EMS EXPO 2008.
Following EMS EXPO 2008, the painting will be donated to the County of Los Angeles Fire Museum, which is currently in negotiations to build a new Museum/Event Center, showcasing vintage fire and EMS apparatus, equipment, artifacts and photographs. The collection includes nearly 60 vintage vehicles, including Emergency! originals Squad 51 and the Ward LaFrance Engine 51, recently returned to the museum from service in Yosemite.
Teri has developed her art her entire life and made it her full time career after quitting her job with Princess Cruises eight years ago. Her unique style shines through on murals, faux finishes and portraits. Donating her art to charitable causes is important to her and something she truly believes in. She has donated murals to public schools and recently a set of her prints has been donated to the National Fallen Firefighters Foundation, another set is on display in the new administrative offices at FEMA headquarters in Washington, DC, where the United States Fire Administration offices are located.
Teri will also be displaying and selling her artwork and firefighter themed apparel at EMS EXPO in booth number 2147. View Teri's salute to firefighter series paintings and her other art at www.tforero.com. For information on EMS EXPO, visit www.emsexpo2008.com.
CPL 2-2.69: Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens, U.S. Department of Labor, November 27, 2001.
Ryan White CARE Act (Public Law 101–381), U.S. Congress, 1990.
Ryan White CARE Act (Public Law 109-415), U.S. Congress, 2006.
Katherine West, BSN, MSEd, CIC, is an infection control consultant with Infection Control/Emerging Concepts in Manassas, VA, and a member of EMS Magazine's editorial advisory board.