This chapter provides information to prepare physician assistant (PA) students for safe clinical experiences. Health professional students are typically required to hone many skills by working and practicing on real patients. Students are sometimes placed in “educational” situations with minimal supervision and asked to perform procedures for which they are not adequately trained. Such circumstances place students at risk for injuries ranging from needlestick to more substantial injuries.
All PA programs require students to provide basic health information when they are admitted. The only confidential student health information that can be disclosed to the program involves immunizations and results of tuberculosis (TB) screening. Programs do not have access to other types of health information on students. Students usually complete a health status form describing any medical concerns or significant items in their medical history. In addition, programs require an immunization record, with special emphasis on the currency of rubeola, rubella, and tetanus booster. Most, if not all, programs require students to obtain the hepatitis B vaccine before enrollment. TB testing is also performed on entry into the program and is repeated annually. The Accreditation Review Commission for the Education Physician Assistant directs these basic requirements as part of the PA program’s accreditation process and by the educational institution with which the program is affiliated.
Before enrollment or at orientation, many programs require students to undergo background checks, drug screening, or both. These procedures help to ensure a safe environment within the educational institution.
Students may receive required information on sexual harassment, bloodborne pathogens, safety, and the Health Insurance Portability and Accountability Act (HIPAA). PA programs cover these topics to ensure a level of student health and safety. The greatest potential for exposure to risk starts when students begin clinical rotations. The exposures may include infectious agents (hepatitis, human immunodeficiency virus [HIV], TB), physical injury (needlestick, laceration, latex allergy, physical attack by a patient), and emotional abuse (verbal abuse, belittlement, sexual harassment). Programs differ in the ways they educate, prevent exposures, and protect students. In the following sections, safety issues important to the clinical portion of a PA training program are explored.
To maintain your safety on clinical rotations, common sense is the rule. Be aware of your surroundings at all times, especially when at a new location. Ask your preceptor to review clerkship safety policies. Ask questions regarding who has access to the clinic space, whether chaperones are required for male and female examinations, what to do in case of an emergency, and what to do if you sustain an injury. Remember to have your needlestick injury protocol available on rotations.
One area often neglected by students is the consistent use of universal precautions. Universal precautions are infection control guidelines designed to protect health care providers from exposure to diseases spread by blood and certain body fluids. Implemented in the 1980s as HIV infection became more prominent, universal precautions eliminated concerns about which patients might require precautions because of infection and which patients were not infected. Simply put, universal precautions require that you assume everyone may be able to transmit hepatitis B, HIV, or other infectious agents, and therefore, the same precautions are used for all patients. The types of exposures for which universal precautions should be used and for which they are not necessary can be found in Table 5.1 .
|Universal Precautions Required||Universal Precautions Do Not Apply|
|Vaginal secretions||Nasal secretions|
|Pericardial fluid |
|Vomitus unless contaminated with blood Saliva unless contaminated with blood|
Universal precautions involve the use of personal protective equipment such as gloves, gowns, masks, and protective eyewear, which can reduce the risk of bloodborne pathogen exposure to the health care student’s skin or mucous membranes. As a student and future professional, it is incumbent on you to use universal precautions whenever appropriate. If you are performing phlebotomy, suturing a laceration, or performing a punch biopsy, these precautions are in place to protect you from exposure to infectious agents, but they are effective only if you use them consistently.
Increasing numbers of health care students travel outside the United States as part of their clinical experience. International rotations are frequently seen as exciting and exotic adventures. These types of experiences provide students with a unique appreciation of diverse cultures, intensive language development, and opportunities to observe uncommon diseases. Most traveling students have a wonderful experience, bringing back lifetime memories and a desire to return to these areas in the future. However, to enjoy this type of clinical experience, you must consider your safety a priority and devote a portion of your preparation time to this goal.
Many international clinical destinations are in developing countries that may pose safety concerns. Before you leave the United States, participate fully in the planning of your trip. Check with your medical insurance company to determine if you are covered for emergency care while abroad. Evacuation back to the United States can easily cost $10,000 or more, depending on your location and medical condition. If you are not already covered by such insurance, purchase a policy that provides medical coverage and evacuation if necessary. The U.S. Department of State ( www.state.gov/travel ) is an excellent resource for information on traveling to foreign countries, including facts on medical emergencies and evacuation.
Needlestick and Sharps Injuries
Needlestick and sharps injuries are the most common method of transmitting bloodborne pathogens between patients and health care providers; therefore, they pose a significant risk to health care workers and students. According to the Centers for Disease Control and Prevention (CDC), approximately 385,000 needlestick and other sharps-related injuries occur each year in hospital-based situations. Needlestick and sharps injuries are primarily associated with transmission of hepatitis B, hepatitis C, and HIV, but other types of infections can also result. Health care students are at especially high risk for needlestick injuries because of their relative inexperience; exposure rates have been reported as between 11% and 50% of students. One PA program found that 22% of its students had some type of exposure, 60% of which were percutaneous injuries.
The most important points of this discussion of student safety are prevention of needlestick injuries and reporting of an injury if one occurs. Prevention of needlestick and sharps injuries has improved significantly through the adoption of safer needles, protocols on handling sharps, and improved provider education on safety techniques. It is incumbent on PA educational programs to train their students in safe procedures and to establish a comprehensive response process for handling expected injuries.
Physician assistant students must take advantage of their programs’ training opportunities in areas of phlebotomy, initiation of intravenous lines, suturing, and other procedures that involve needles and sharps. Usually, training in these techniques takes place far in advance of actual clinical experience. Students should be closely supervised to ensure that they are performing appropriate procedures for which they have been trained and that they are doing so correctly. It is natural to want to impress the supervisor or preceptor, which can lead students to perform procedures for which they are not yet qualified. To remain safe, students must be aware of these behaviors and understand their roles in caring for patients.
Physician assistant programs are required to provide students with a process for reporting and seeking medical care in the unfortunate event of a needlestick injury. Current recommendations call for the student to be evaluated and given appropriate postexposure prophylaxis within hours after an exposure. PA programs provide this information; however, it is imperative that you keep it readily available so that you can make appropriate contacts when the need arises. Exposures that occur in a training hospital are usually handled quickly, but injuries in a rural site without access to appropriate prophylactic medications can be a challenge. Any student who will be in a rural clinical location needs to be familiar with the program’s needlestick reporting process.
A troubling concern identified in the medical literature is the failure of health care workers and students to report needlestick and sharps injuries. Reasons for not reporting include fear of losing insurance or employment, concerns about effectiveness of postexposure prophylaxis, and a tendency to deny personal risk. Failure to report even what is considered an inconsequential exposure can have a significant impact on future ability to practice. Although it may seem inconvenient, reporting provides several benefits to both the student and the health care entity. Reporting an incident may be useful for future insurance and disability claims. It typically results in the student being evaluated medically and helps the institution assess internal systems that may prevent similar exposures for other health care workers.
During a busy Saturday morning in the emergency department (ED) of a rural community hospital, a senior PA student was busy suturing a laceration on the scalp of a male patient. The patient was being held by local law enforcement for drug dealing. He had been in a fight at the jail, resulting in his laceration. The patient was somewhat uncooperative, and while the PA student was placing a suture, the patient moved suddenly, causing the bloody needle to deeply puncture the student’s gloved right middle finger. The student called for a nurse to assist him and to monitor the patient while he spoke with the family physician covering the ED. He asked the physician what he should do and was told to thoroughly clean the puncture site and then contact his program for advice. The student remembered he had been given a needlestick emergency contact card with a toll-free telephone number to call in case of an injury. After cleaning the site, he called the appropriate number and was given information about testing, follow-up, and postexposure prophylaxis, as well as points to discuss with the patient about having his blood tested for infectious diseases. The patient refused to consent to testing for HIV and hepatitis B and C. The student underwent baseline testing and decided to begin HIV prophylaxis medication. He was counseled on the risk for developing HIV, the need for safe sexual practices, and length of time for follow-up. He completed the postexposure prophylaxis without incident, and his HIV test result remained negative 1 year later.
As part of any type of formal health care training, students are required to be screened for TB annually. For PA students, this is required as part of a PA program’s accreditation. TB is still a significant disease process for which health care workers are at increased risk. According to the CDC, in 2014, health care workers accounted for 3.7% of reported TB cases nationwide. The rate of health care student conversion while in training is unknown, but because of increased risk for exposure, all health care workers and students are screened annually.
The CDC recommends that groups considered to be at high risk undergo targeted tuberculin testing using the purified protein derivative (PPD) tuberculin skin test for latent TB infection. Three cut points have been recommended for defining a positive tuberculin reaction: induration of 5 mm or more, 10 mm or more, or 15 mm or more. For individuals at the highest risk for developing active TB, 5 mm or more of induration is considered a positive result. For groups with the lowest risk for contracting TB, a skin reaction is considered positive if it is 15 mm or more of induration ( Table 5.2 ). You will undoubtedly learn more about TB during your training; however, it is important to have an understanding of the rationale for your annual tuberculin skin testing.
|Positive IGRA Result or TST Reaction ≥5 mm of Induration||Positive IGRA Result or TST Reaction ≥10 mm of Induration||Reaction ≥15 mm of Induration|
|HIV-infected persons||Recent immigrants (<5 yr) from high-prevalence countries||Persons with no risk factors for tuberculosis ∗|
|Recent contacts of a TB case||Injection drug users|
|Persons with fibrotic changes on chest radiograph consistent with old TB||Residents and employees of high-risk congregate settings (e.g., correctional facilities, nursing homes, homeless shelters, hospitals, and other health care facilities)|
|Organ transplant recipients||Mycobacteriology laboratory personnel|
|Persons who are immunosuppressed for other reasons (e.g., taking the equivalent of >15 mg/day of prednisone for 1 month or longer, taking TNF-α antagonists)||Children younger than 4 years of age or children and adolescents exposed to adults in high-risk categories|