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TCHCC EXPOSURE PROTOCOL
Significant exposure means the employee has sustained a contact which carries a potential for
transmission of HIV or other blood borne disease by one or more of the following:
 Transmission of blood, semen or other body fluid (to which standard precautions apply) into a body
orifice.
 Exchange of blood during the accidental or intentional infliction of a penetrating wound, including a
needle puncture.
 Blood, tissue or other body fluid (to which standard precautions apply) into an eye, an open wound, an
oozing lesion, where significant breakdown in the epidermal barrier has occurred, or exposure is
prolonged or involves an extensive area.
 Exposure from a human bite during which skin is broken.
 The provision of CPR with inadequate or absent barrier protection.
Standard Precautions apply to the following types of body fluid:
 Blood
 Semen
 Vaginal secretions
 Cerebrospinal fluid
 Synovial fluid
 Pleural fluid
 Peritoneal fluid
 Amniotic fluid
 Lab specimens contaminated with HIV
 Any other body fluid containing visible blood
Standard Precautions apply to the following but the risk of transmission of HIV or HBV is extremely low, unless
the material contains visible blood:
 Urine
 Feces
 Sweat
 Vomitus
 Tears
 Saliva
 Sputum
 Nasal secretions
 Breast milk (implicated in perinatal transmission of HIV)
Trempealeau County Health Care Center requires that employees with occupational exposure to blood be
evaluated to determine the potential for exposure to blood borne diseases.
 Employees must report in person promptly to their charge nurse.

Nurse assesses injury and provides immediate first aid as needed.

Employee must complete an Incident Report giving full details of the incident.

Employee or Nurse sends Incident/Accident Report to Human Resources.

Nurse assists employee in completing an Exposure Report.

Employees are to present themselves to a local medical clinic within 24 hours, and are to give the
Exposure Report to the medical provider. The medical provider will evaluate if the exposure has the
potential for transmission of blood borne infection and order appropriate interventions and treatment.
Infection Control/Procedures/Inf Control – Exposure Protocal
Updated 11/2014
The source individual’s HIV and HBV status, if known, will be sent with the employees along with the
employee’s Hepatitis B vaccine status.

The employee is expected to complete testing as ordered by the medical provider, which may include
HIV, Hepatitis B, Hepatitis C, and ALT. In the case of a human bite wound, a tetanus vaccine may also
be recommended. (Tri-County Memorial Hospital has, on file, the standard orders for testing of TCHCC
employees following an Exposure Incident. These orders are signed by Dr. J.S. Persing, TCHCC
Medical Director.)

The Trempealeau County Health Care Center will provide necessary information to the medical
provider concerning the source person and will follow-up with directives concerning testing the source
person.
Quantification of Exposure – If, the incident is significant a determination will be made to describe the
exposure as massive, definite, possible, or doubtful, based on the criteria below.
o
Massive:
 Large volume of patient blood is injected (> 1ml) into the employee.
 Parenteral exposure to lab material containing high titer of HIV virus.
o
Definitive:
 Intramuscular or deep injury with patient blood or body fluid.
 Injection of blood or body fluid.
 Laceration or similar type wound produced by an instrument that is visibly contaminated with
blood or body fluid and wound causes the employees bleed.
 The employee has a laceration or similar fresh wound that is inoculated by patient blood or body
fluid.
o
Possible:
 Subcutaneous injury to the employee with a needle that is contaminated with patient blood or
 Body fluid.
 Wound that is produced by an instrument that is contaminated with the patient blood or body
 fluid and the wound does not cause visible bleeding.
 The employee has an old wound or skin lesion that becomes contaminated with patient blood or
 Body fluid.
 The employee is inoculated on mucous membranes with patient blood or body fluid.
o
Doubtful:
 Subcutaneous or superficial injury with a needle or instrument that is contaminated with non –
Infectious and non- bloody patient fluids.
 A wound is produced by a needle or instrument that is contaminate with a non- infectious patient
body fluid.
 The employee has and old wound or skin lesion that becomes contaminated with non-infectious
patient body fluid.
 The employee’s mucous membranes are inoculated with a non-infectious patient body fluid.
 Intact skin becomes visibly contaminated with patient blood or body fluid.
Infection Control/Procedures/Inf Control – Exposure Protocal
Updated 11/2014
INFORMED REFUSAL OF POST EXPOSURE MEDICAL EVALUATION
I, _______________________________, an employee of the Trempealeau County Health Care
Center. My employer has provided me with the training regarding infection control and the risk of
exposure to blood borne pathogens. I have read and understand the information provided to me. I
understand the risk of exposure.
On _____________________, 20___, I was involved in an exposure incident when I (describe incident
below):
My employer has offered to provide a follow-up medical evaluation for me in order to assure that I have
full knowledge of whether I have been exposed to or contracted an infectious disease from this
incident.
However, I, of my own free will and volition, and despite my employer’s advice, have elected not to
have this medical evaluation.
______________________________
Staff Signature
____________________________
Witness Signature
_____________________________ _
Printed Name of Staff
_____________________________
Printed Name of Witness
______________________ ________
Date
_____________________________
Date
______________________ ______ _
Staff Address
_________________________
City
State
___
Zip
NOTE: Maintain this record for duration of employment plus 30 years.
Infection Control/Procedures/Inf Control – Exposure Protocal
Updated 11/2014