Blood Borne Pathogens (Consultation closed)

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    Consultation closed

    Our Process

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    The College’s Blood Borne Pathogens policy is currently being reviewed. This policy sets expectations for physician conduct to safeguard the health of both patients and physicians, and to minimize the risk of exposure to blood borne pathogens through the provision of care.

    View the current policy

    To assist with this review, we are inviting feedback from all stakeholders, including members of the medical profession, the public, health system organizations and other health professionals on the current policy. Comments received during this preliminary consultation will assist the College in updating the policy. When a revised draft is developed, it will be recirculated for further comment before it is finalized by Council.


    We want to hear your thoughts on the current policy…



    The College has had a policy on blood borne pathogens since 1998. The existing policy was last reviewed and updated in 2012 and sets expectations for physicians who perform or assist in performing exposure prone procedures. Key features of the current policy include:

        • Definition of exposure prone procedures, and Routine Practices;
        • Expectations regarding the use of Routine Practices;
        • Requirement for physicians to report seropositive status to the College through the Annual Renewal Form;
        • Requirement for physicians performing or assisting in performing exposure prone procedures to be tested for blood borne pathogens annually;
        • Additional precautions for seropositive physicians who wish to continue performing exposure prone procedures, consistent with the SHEA (Society for Healthcare Epidemiology of America) Guideline;
        • Detail about the Mandatory Blood Testing Act, 2006 to highlight for physicians that they may be able to seek confirmation of a patient’s serological status if they have been exposed to the patient’s bodily fluids when providing care.

    In addition to the core content contained in the current policy, three appendices accompany the policy, and provide important detail on a range of issues:

        • A description of the CPSO’s own practices with respect to confidentiality and the management of seropositive physicians;
        • Examples of exposure prone procedures, adopted from the SHEA Guideline;
        • Detail regarding Routine Practices, consistent with guidance from the Provincial Infectious Diseases Advisory Committee, Ministry of Health and Long-Term Care of Ontario.

    When approving the current policy, Council had considerable discussion and debate on the requirement for routine annual testing of blood borne pathogens. Council considered relevant evidence, literature and the positions of other regulatory bodies in relation to testing for blood borne pathogens. Council also considered the significant negative impact that physician-to-patient transmission would have on individual patients and their families but also on the reputation and public trust in the medical profession in general. Council was guided by the CPSO’s role as a medical regulator, and its duty to protect and serve the public interest. Council decided that although there was a lack of consensus in the existing evidence and literature around what interval of testing is appropriate, and that an evidence-based decision on this issue wasn’t possible at the time, annual testing was an appropriate position from a regulatory perspective. It would additionally enable physicians to have current information about their serological status, and align with existing institutional requirements for annual hepatitis B virus (HBV) testing.

    In light of the debate regarding annual testing, when approving the Blood Borne Pathogens policy, Council directed that the policy be reviewed on an expedited basis, in 2 years’ time, to consider whether any additional evidence regarding the appropriate interval of testing was available which may suggest policy revisions. Accordingly, the annual testing requirement will be a key focus of this current policy review process.

    Have Your Say

    We would like to hear your thoughts on the current policy, along with suggestions you may have for how the policy could be improved.

    In particular, we are interested to know:

        • Are there issues not addressed in the current policy that should be addressed?  If so, what are they?
        • What other issues or information should we bear in mind while undertaking this review?
        • Are there other ways in which the policy should be improved?

    Please provide your feedback by August 5, 2014.

    Next Steps

    The College is committed to ensuring that the Blood Borne Pathogens policy reflects current practice issues, embodies the values and duties of medical professionalism, and is consistent with the College’s mandate to protect the public. The feedback obtained during this consultation will be carefully reviewed and used to evaluate the draft. While it may not be possible to ensure that every comment or suggested edit will be incorporated into the revised policy, all comments will be carefully considered.

    Once a revised draft policy has been developed, stakeholders will be invited to review the revised document and provide further feedback before it is considered for final approval by Council.

    Final decisions regarding policy revisions are made by College Council.

    To ensure transparency, the College will post all consultation feedback in accordance with our posting guidelines.

    We value your feedback and thank you again for participating in our policy review process.


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    View the feedback received to date

    Send us your feedback by mail:

    College of Physicians and Surgeons of Ontario
    80 College Street
    Toronto, Ontario

    Attention: Policy Department