Download Blood/Body Fluid Exposure Protocol

NEW ENGLAND BAPTIST HOSPITAL
EMPLOYEE HEALTH
INFECTION CONTROL POLICY GUIDELINES
Section VI-O #2
Page 1 of 22
_________________________________________________________________________________________________
BLOOD/BODY FLUID EXPOSURE PROTOCOL
_______________________________________________________________________________
Subject:
Effective Date: March, 2006
Supersedes: 3/04
Approved By: Infection Control Committee, 3/15/06
Author: Jeanine Shaughnessy, RN, CS, MSN, COHN-S
Eileen O’Donnell, RN, BSN
__________________________________________________________________________________________________
PURPOSE
To provide specific guidelines and procedures for the Employee Health, and Ambulatory Services
personnel for implementation of the Hospital policy on Blood/Body Exposure Control Plan. For the
purpose of this protocol, the Employee Health Clinician may be interchangeable with the clinicians in other
designated areas (specifically, Ambulatory Services and Occupational Medicine Clinic).
I.
PERSONNEL ISSUES
A.
Employee Exposure
1.
2.
Report to:
Employee Health
Monday – Friday (7:30am – 3:30pm)
Ambulatory Services
Monday- Friday (3:30 pm – 10:00 pm)
Weekends/Holidays (7:00 am – 10:00 pm)
Night Nursing Coordinator
Monday- Friday (10:00 pm – 7:30 am)
Weekends/Holidays (10:00 pm – 7:00 am)
Completion of Incident Report Form
The designated Employee Health Department clinician responsible for the New England
Baptist Hospital (NEBH) employees shall ensure that the Incident Report Form has been
completed including the name and medical record number of the source patient (if
known), and the “Employee” box has been checked off on the form.
3.
Treatment of an Exposure Site
Wounds and skin sites that have been in contact with blood or body fluids should be
washed with soap and water; mucous membranes should be flushed with water. No
evidence exists that using antiseptics for wound care or expressing fluid by squeezing the
wound further reduces the risk of bloodborne pathogen transmission; however, the use of
antiseptics is not contraindicated. The application of caustic agents (e.g., bleach) or the
injection of antiseptics or disinfectants into the wound is not recommended.
4.
Registration/Baseline Serology
The designated Employee Health Department clinician responsible for the New England
Baptist Hospital (NEBH) employees shall create a separate, confidential exposure file.
Send the employee to the lab with the appropriate lab requisitions for the following
serology’s: HBsAG, HBsAB, Anti-HCV, ALT, and Anti-HIV (only if consent signed).
Any testing or treatment for a work-related injury or illness will be provided free of
charge to the employee. The visit will be documented on the Blood/Body Fluid Exposure
Record form (Appendix A). Should an employee be seen in Ambulatory Services this
information will be forwarded to the designated Employee Health Clinician for NEBH
employees. A unique exposure incident number will be used for all lab work for privacy
reasons. Access to assigned numbers are restricted and unidentical.
Employee Health-Blood/Body Fluid Exposure Protocol
Section VI-O #2
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5.
6.
Identification/Assessment of Source Patient
A.
If source patient is known, Employee Health Clinician shall:
1)
Review patient’s medical record for evidence of known viral
Hepatitis/HIV, request HBsAG, Anti-HCV, ALT, and HIV testing of
the patient, and provide appropriate prophylaxis to the employee
(Appendix B, L & M).
2) Document patient’s medical record number and Hepatitis/HIV status on the
Blood/Body Fluid Exposure record form (Appendix A).
3) If source patient has known Hepatitis B, provide appropriate prophpylaxis
to the NEBH employee (Appendix B)
B.
If source patient is unknown, the designated Employee Health Department
clinician responsible for NEBH employees shall:
1. provide baseline testing for HBsAg, HBsAB, Anti-HCV, ALT, HIV
antibody (need informed written consent):
2. provide followup testing for HBsAg, Anti-HCV and HIV antibodies in 3
months, 6 months and 12 months after exposure.
3. provide appropriate post-exposure prophylaxis for exposure to hepatitis B
virus (Appendix B) and HIV post exposure prophylaxis for percutaneous
injuries (Appendix M) or for mucous membrane and contact skin (Appendix
N)
HIV Status of Source Patient
A.
If HIV status of source patient is unknown, the designated Employee Health
clinician responsible for the NEBH employees shall:
1.
Place the red informational letter to the attending physician (Appendix C)
regarding the Occupational Blood/Body Fluid Exposure, the Source Patient
Consent for HIV Antibody Testing form (Appendix D), completed lab slip and
completed doctors order sheet in the source patient’s medical record in the
Physician’s Order Section.
2.
Contact the patient’s attending physician, advise the physician of the exposure
incident involving his/her patient, request that the physician obtain source
patient’s informed consent for HIV testing, and request physician to notify the
designated Employee Health Department clinician, responsible for the NEBH
employees, of the patient’s decision regarding HIV testing. If attending
physician not readily available, request permission to have designee (eg, Fellow,
Resident, Hospitalist) sign consent with source patient.
> If source patient consents to HIV testing, charges for testing will be free of
charge as coded by the letter “R” on top right hand corner of lab slip and results
of testing will be forwarded to Employee Health. The nurse assigned to the
source patient is responsible for notifying the laboratory and providing patient’s
name and room number, and request that the blood be drawn. Phlebotomist will
pick up lab slip and yellow copy of HIV Consent form prior to drawing of blood
to ensure source patient signed consent form. These results will be forwarded to
the designated Employee Health clinician, responsible for the NEBH employees.
> If source patient declines HIV testing, the signed declination form will be
obtained by the attending physician and forwarded to Employee Health
Department. The signed declination will be placed in the employees’
confidential record.
7.
Follow-Up
Employee Health-Blood/Body Fluid Exposure Protocol
Section VI-O #2
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A.
If source patient is HIV seronegative
If source patient has no clinical evidence or risk factors for HIV infection,
baseline serologic testing will be provided. Follow-up HIV testing will be
provided in 6 months for employee (Serologic testing for HIV at baseline and 6
months shall be strongly recommended to satisfy the minimum eligibility
requirements for the Employee HIV Benefit Plan.) A unique exposure incident
number will be assigned to the employee for HIV testing to ensure
confidentiality.
B.
If source patient is HIV seropositive, high risk or is unknown source:
1)
As soon as possible after the exposure, eg, hours rather than days, the
employee shall be counseled regarding the risk of infection (Appendix
M & N). Baseline serologic testing of the exposed employee for HIV
shall be performed after consent for testing (Appendix E) has been
obtained. A unique exposure incident number will be assigned to the
employee for HIV testing. This number will be used on the laboratory
slip in place of the employee’s name and/or medical record number for
privacy purposes. Access to assigned numbers are restricted and
confidential. The employee HIV consent resides in the Employee
Health Department in a locked file.
2)
The designated Employee Health Clinician and/or Infection Control
Physician for NEBH, shall be requested to provide counseling
regarding Post Exposure Prophylaxis (PEP). The National Prophylaxis
hotline is available as a resource, 24-hours a day, 7 days a week for
consultation at 1-888-448-4911. See Appendix O for additional
occupational exposure management resources.
3)
The employee shall be:
a)
Advised to report and seek medical evaluation for any acute
febrile illness that occurs within 12 weeks following the
exposure.
b)
Offered follow-up visits and serologic testing for HIV at
baseline and intervals of six weeks, and three (3), six (6) and
twelve (12) months post-exposure to determine if HIV
seroconversion has occurred.
NOTE: HIV Seroconversion usually takes place within one month.
c)
Encouraged to follow U.S. Public Health Service
recommendations for preventing transmission of HIV during
the initial follow-up period, especially during the first 12
weeks (contained in Appendix I).
d) Counseled by the designated Employee Health Clinician and/or
Infection Control Physician on call regarding PEP therapy.
Employee Health-Blood/Body Fluid Exposure Protocol
Section VI-O #2
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4)
5)
If employee agrees to PEP prophylaxis, the designated Employee
Health Clinician and/or Employee Health Physician responsible for
NEBH employees shall:
a)
Ensure that the employee is given the medication information
sheet and has signed the Informed Consent for Antiviral
Prophylaxis Following an Occupational Exposure to Blood
and/or Body Fluids (Appendix F).
b)
Order baseline lab studies: CBC with diff & platelets, U/A
with microscopic exam (only if protease inhibitor prescribed),
ALT, AST, Alk. Phos., Total Bilirubin, BUN, Creatinine, lipid
panel and CPK. Adjustments in baseline lab studies can be
made if source HIV testing will be available within 24 hours.
c)
Order a Stat HCG (pregnancy test) if the employee is a woman
of child bearing age. If the employee is pregnant, contact her
obstetrician immediately prior to dispensing antiviral
prophylaxis.
d)
Provide the “starter” doses which can be obtained from
Ambulatory Services pyxis system if post exposure
prophylaxis will be initiated (Appendix G). Post-exposure
prophylaxis should be initiated as soon as possible after
exposure (hours rather than days).
If the employee chooses to take antiviral therapy, the following protocol
shall be followed:
a)
The exposed employee shall follow up with the designated
Employee Health Clinician and/or Infection Control Physician
within 7 days.
b)
CBC with diff & platelets, U/A with microscopic exam (only if
protease inhibitor provided), ALT, AST, Alk. Phos., Total
Bilirubin, BUN, Creatinine and CPK shall be checked every
two weeks while taking antiviral therapy through the
Employee Health Department.
c)
Abnormal lab results shall be reviewed by the Employee
Health Clinician in collaboration with the Infection Control
Physician.
d)
When administering PEP an important goal is the completion
of a 4-week regimen. However, if the employee develops
complications or experiences side effects from the therapy, the
designated Employee Health Clinician in collaboration with
the Infection Control Physician responsible for NEBH
employees will meet with the employee and a decision will be
made whether or not to continue the therapy.
NOTE: If, after counseling, the employee declines follow up at NEBH, she/he
shall be advised to contact the Massachusetts Department of Health for further
information regarding available resources.
Employee Health-Blood/Body Fluid Exposure Protocol
Section VI-O #2
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C.
If source patient declines testing:
The designated Employee Health Clinician responsible for NEBH employees
shall use the available clinical information on the source patient to advise the
employee on the risk of infection. Guided by this information, the employee will
be permitted to proceed either as if the source patient was seropositive.
D.
If source is unknown and employee chooses antiviral therapy:
The designated Employee Health Clinician responsible for NEBH employees
and the employee will discuss the circumstances of the exposure and may
collaborate with the Infection Control Physician in deciding whether to pursue
serial HIV testing of the employee.
NOTE: In accordance with OSHA guidelines, an employee undergoing postexposure evaluation is entitled to have a baseline specimen frozen and stored for
up to 365 days, however the Infection Control Committee has decided to
increase this to one year for possible later HIV screening.
B.
E.
If source patient is HBsAg negative, provide baseline testing for HBsAg and no
further testing is required.
F.
If source patient has known Hepatitis B, provide appropriate prophylaxis to
NEBH employee (Appendix B)
G.
If source patient is Anti-HCV negative, provide baseline testing for Anti-HCV
and ALT and follow up testing in 6 months.
H.
If source patient is Anti-HCV positive, provide baseline testing for Anti-HCV
and ALT. At 1 month, 3 months, 6 months and 12 months and obtain Hepatitis C
viral, RNA by quantitative by PCR, anti-HCV and ALT. If employee becomes
Anti-HCV positive and/or ALT is significantly abnormal, the following blood
tests may be obtained: ALT, total bilirubin, direct bilirubin, AST, ALK Phos,
gamma glutamyl transpeptidase, total protein, and albumin. Additional follow up
with hepatologist and/or infection disease physician may be indicated.
Student/Contractor/Vendor/Visitor/Out-of-State Student/Non-Baptist Employed
Practitioner/Physician/Resident Exposure
The results of source patient testing will be provided to the exposed individual and/or
his/her designated health care provider according to the current protocols and
recommendations of the CDC. Initial exposure steps are the same as for employee.
Follow-up is different in that person will follow-up with their own provider or own
Employee Health Department.
C.
Employee Counseling
The designated Employee Health Clinician responsible for NEBH employees shall:
1.
Provide and review the following information with the employee:
a.
b.
c.
Post-Exposure Results Form (Appendix H)
Important Points For You to Know Following an Occupational
Blood/Body Fluid Exposure (Appendix I).
Universal/Standard Precautions Sheet (if appropriate) (Appendix J).
Employee Health-Blood/Body Fluid Exposure Protocol
Section VI-O #2
Page 6 of 24
2.
Make a follow-up appointment within two weeks with the employee for the
purpose of:
a.
b.
c.
Providing additional prophylaxis treatment/counseling.
Reviewing laboratory testing results and providing written opinion and
laboratory results by the designated Employee Health Clinician
responsible for NEBH employees (Appendix H).
Initiating post Exposure Follow-Up protocol form (Appendix K) and
making an appointment for the employee to have next scheduled
laboratory screening tests.
3.
Follow-up notice sent prior to follow-up date to home address. If employee is a
no show, a second and final notice will be sent.
4.
Complete and send copy of the Employee Incident Report form to the
employer’s manager for completion and safety precautions follow up.
REFERENCES:
CDC, Updated US Public Health Service Guidelines for the Management of Occupational Exposures to HIV and
Recommendations for Post Exposure Prophylaxis. MMWR 2005; 55 (No.RR-9); 1-17.
CDC, Updated US Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV
and HIV and Recommendations for Post Exposure Prophylaxis. MMWR 2001; 50 (No.RR-11); 1-42.
CDC, Public Health Service Guidelines for the Management of Health-Care Worker Exposures to HIV and
Recommendations for Postexposure Prophylaxis. MMWR (supplement) May 15, 1998:47(No.RR-7)
CDC. Public Health Service statement on management of occupational exposure to human immunodeficiency virus,
including considerations regarding zidovudine postexposure use. MMWR 1990;39(no. RR-1).
CDC. Case-control study of HIV seroconversion in health-care workers after percutaneous exposure to HIVinfected blood-France, United Kingdom, and United States, January 1988-August 1994. MMWR 1995;44:929-33.
Federal Register, Vol. 56, No. 235, 29 CFR Part 1910. 1030, Occupational Exposure to Bloodborne Pathogens,
Final Rule, pp. 64175-82, December, 1991.
Gerberding JL. Management of occupational exposures to blood-borne viruses. N. Engl J Med 1995;332:444-51.
Horan, C. CDC convenes experts to discuss HIV post exposure management. Assoc. of Occ Health Professionals;
1996, May/June;6-8.
Kinloch-de loes S, Hirschel BJ, Hoen B, et al. A controlled trial of zidovudine in primary human immunodeficiency
virus infection. N Engl J Med 1995;333:408-13.
Tokars JI, Marcus R, Culver DH, et al. Surveillance of HIV infection and zidovudine use among health care workers
after occupational exposure to HIV-infected blood. ANN Intern Med 1993;118;913-9.
Update: Provisional Public Health Service Recommendations for Chemoprophylaxis after Occupational Exposure to
HIV. MMWR 1996;45(no.22).468-472.
BBFEmp2MAR06
REVISED:
DISTRIBUTION:
12/20/2000, 3/01, 03/04 3/06
Employee Health, Infection Control and Ambulatory Services
Employee Health-Blood/Body Fluid Exposure Protocol
Section VI-O #2
Page 7 of 24
APPENDIX A
NEW ENGLAND BAPTIST HOSPITAL / EMPLOYEE HEALTH
BLOOD BODY FLUID EXPOSURE RECORD
Name_________________________________________
Staff code_____________________________________
Date of Incident_________________________
Immunization History:________________________
Name_____________________________________
MR # _____________________
Unknown_________
HBV Immunization:
Date Dose #1__________
Standing Orders to patient chart
Attending notified (Date/Time)___________________
________________
Physician letter to patient chart __________________
#2__________
Testing After Exposure
#3__________
Date
Results
HBsAg
_______
_______
Anti-HCV
_______
_______
ALT
_______
_______
HIV Consent _______
Yes
No
if no, documented in MR
Antibody Status
and Date Tested____________________________
Tetanus Booster Date___________
Testing After Exposure
HBsAg
Anti-HBs
Anti-HCV
Date
_______
_______
_______
Results
_______
_______
_______
ALT
_______
_______
HIV Consent
_______
Blood saved for ONE year
Anti-HIV
#1(exp.)______
#2(6wk)______
#3(3mo)______
#4(6mo)______
Anti-HIV
Transfusion
IV Drug Use
History of Hepatitis
History of Hemophilia
Abnormal Liver
Function Test
Pertinent Sexual
Activity
Consent for Release
of Testing Results
Treatment
Tetanus Booster
HBV Booster
HBIG - Dose
#1
#2
Antiviral(s) Started
Stopped
______
Risk Factors
Yes No
Yes No
______
______
______
______
Date
______
______
______
______
______
______
_______
N/A
______
______
______
______
______
______
Yes
____
____
____
____
No
____
____
____
____
Unknown
_____
_____
_____
_____
____
____
_____
____
____
_____
____
____
_____
Route of Exposure:

Percutaneous-punctured or broke the skin
 Mucous membrane-contact with mouth, eyes or other mucous membranes

Skin-was skin intact
 Bite-bite where the skin was broken

Blood visible on device before exposure
__Yes
__No
__Yes
__No
Exposed to (identify type of fluid)_________________________________________________________________________
Body Part __________________
Describe the depth of the injury:
 Superficial-injuries such as a scratch
 Moderate-those injuries that are more serious than scratch, but not so serious that they would be considered to be deep
(eg, superficial laceration or tissue avulsion)
 Deep-injuries that touched bone or muscle contracted.
Device/item involved in incident________________
Was device/item a safety device __Yes
Was device/item part of prepacked kit?
__Yes
__No
__No
Who was holding device when incident occurred?__________________
Equipment Manufacturer and Brand Name of device__________________________________________________________
Circumstances under which exposure occurred:
1.
Type of Work______________________________________________________________________________________
2.
What was cause of incident? (accident, equipment failure, etc.) _______________________________________________
List Personal Protective Equipment worn:
Gloves: Single__ Double__ Eye Protection __ Face Shield__ Mask__ Gown__
Signature:_________________________________________
Other:____________________________
Rev 3/06
Employee Health-Blood/Body Fluid Exposure Protocol
Section VI-O #2
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APPENDIX A (Continued)
What suggestion does the employee have for preventing similar injuries in the future:
Signature of Employee______________________________________________ Date________
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Section VI-O #2
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Appendix B
Recommended Postexposure Prophylaxis for Exposure to Hepatitis B Virus
Vaccination and antibody
response status of exposed
workers*
Source
HBsAg¹ positive
Treatment
Source
HBsAg¹ negative
Source
unknown or not
available for testing
Unvaccinated
HBIG² x 1 and initiate HB
vaccine series§
Initiate HB vaccine series
Initiate HB vaccine series
Previously vaccinated
Known responder**
No treatment
No treatment
No treatment
Known nonresponder"
HBIG x 1 and initiate
revaccination or HBIG x 2^
No treatment
If known high risk source, treat
as if source were HBsAg
positive
Antibody response
unknown
Test exposed person for antiHBs#
No treatment
Test exposed person for antiHBs
1. If adequate# no treatment is
necessary
2. If inadequate# administer
vaccine booster and recheck
titer in 1-2 months
1. If adequate,** no treatment is
necessary
2. If inadequate”, administer
HBIG x 1 and vaccine booster
*Persons who have previously been infected with HBV are immune to reinfection and do notrequire postexposure prophylaxis.
¹ Hepatitis B surface antigen.
² Hepatitis 8 immune globulin; dose is 0.06 mL/kg intramuscularly.
§ Hepatitis B vaccine.
**A responder is a person with adequate levels of serum antibody to HBsAg (i.e., anti-HBs  10 mlU/mL).
" A nonresponder is a person with inadequate response to vaccination (ie., serum anti-HBs < 10 mIU/mL).
^The option of giving one dose of HBIG and reinitiating the vaccine series is preferred for nonresponders who have not completed
a second 3-dose vaccine series. For persons who previously completed a second vaccine series but failed to respond, two doses of
HBIG are preferred.
#
Antibody to HBsAg.
Source: CDC, Updated US Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV and
HIV and Recommendations for Post Exposure Prophylaxis. MMWR 2001; 50 (No.RR-11); 1-42.
Employee Health-Blood/Body Fluid Exposure Protocol
Section VI-O #2
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APPENDIX C
NEW ENGLAND BAPTIST HOSPITAL
EMPLOYEE HEALTH/ EMPLOYEE HEALTH
INFECTION CONTROL
OCCUPATIONAL EXPOSURE PHYSICIAN LETTER
Employee Health
New England Baptist Hospital
125 Parker Hill Avenue
Boston, MA 02120
(617) 754-5804
Date:____________________________
Dear Dr._________________________________________.
Our employee from New England Baptist Hospital sustained an Occupational Blood/Body Fluid Exposure on
____________________________from your patient _________________________________________________
whose medical record number is ______________________. In order to test your patient for HIV status we need
their consent. We ask the attending physician to obtain this consent from their patient in the event the patient has any
questions regarding the HIV antibody test. You will find an enclosed HIV consent form. Once you have obtained
the consent from your patient, blood will be drawn free of charge by New England Baptist Hospital. These results
will be shared with the employee and the Employee Health Clinician. If you have any questions please do not
hesitate to contact me. Thank you for your cooperation in this matter.
Sincerely,
Employee Health Clinician
Reviewed by Med. Rec. Committee 12/96,10/03
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APPENDIX D
NEW ENGLAND BAPTIST HOSPITAL
EMLOYEE HEALTH/INFECTION CONTROL
PATIENT CONSENT FOR HIV ANTIBODY TESTING
(Human Immunodeficiency Virus Antibody)
I UNDERSTAND THAT MY BLOOD WILL BE TESTED FOR THE PRESENCE OF
ANTIBODY TO THE HIV VIRUS WHICH IS THE VIRUS IMPLICATED IN THE ACQUIRED
IMMUNODEFICIENCY SYNDROME (AIDS). I UNDERSTAND THAT THIS IS NOT A TEST FOR
THE VIRUS ITSELF. I UNDERSTAND THAT CONFIRMATORY TESTS ARE AVAILABLE BUT
THAT NEITHER A POSITIVE NOR A NEGATIVE TEST CAN BE USED ALONE TO DIAGNOSE
AIDS. I UNDERSTAND THAT TEST RESULTS WILL BE ENTERED IN MY MEDICAL RECORD.
I UNDERSTAND THAT MY PHYSICIAN MAY BE REQUIRED TO REPORT POSITIVE RESULTS
TO HEALTH OFFICIALS. I FURTHER UNDERSTAND THAT ADDITIONAL INFORMATION
AND COUNSELING ARE AVAILABLE THROUGH MY PHYSICIAN.
 I elect to have the HIV Antibody Testing. I acknowledge that I have been given all the information I
desire concerning the blood test, its expected benefits and risks and have had all my questions
answered.
 I do not elect to have the HIV Antibody Testing.
__________________________________________________________________________________
(PRINT) LAST NAME
FIRST NAME
_______________________________________
SIGNATURE OF PATIENT
___________________________________________
DATE
_______________________________________
PHYSICIAN’S NAME
___________________________________________
PATIENTS MEDICAL RECORD NUMBER
_______________________________________
SIGNATURE OF WITNESS
___________________________________________
DATE
NOTE: SEND THIS CONSENT FORM TO PATHOLOGY LABORATORY TO BE REVIEWED BY THE PATHOLOGIST AND FORWARDED
TO MEDICAL RECORDS
PATHOLOGY OFFICE USE:_________________________________________________________
occmed/hivsent/12/28/00/IA
WHITE - MEDICAL RECORD
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APPENDIX E
NEW ENGLAND BAPTIST HOSPITAL
EMPLOYEE HEALTH/ INFECTION CONTROL
HIV ANTIBODY TEST CONSENT
for Occupational Exposure
Human immunodeficiency virus (HIV) is the cause of acquired immunodeficiency syndrome
(AIDS). All persons infected with HIV can spread it to others through unprotected sex, needle
sharing, and donating blood or other tissues. Infected mothers can pass HIV to their newborns.
Testing for HIV infection is voluntary.
WHAT THE TEST MEANS
The HIV test tells if HIV antibody is in the blood. Antibody is the body’s reaction to the
virus. A positive test means that a person is infected with HIV and can pass it to others. The test
does not tell how long the infection has been present. By itself a positive test does not mean that
a person has AIDS, which is the most advanced stage of infection.
A negative test means that antibody to HIV cannot be detected. This usually means that
the person has never been infected with HIV and is now not carrying the virus. In some cases,
however, the infection may have happened too recently for the test to turn positive. The blood
test usually turns positive in one month after infection. In rare cases it may take six months or
longer to turn positive. Therefore, if you were infected recently, a negative test could be false.
False negative results (a negative testing in someone who is infected, or a false positive
test in someone who is not infected) are rare. Indeterminate results (when it is unclear whether
the test is positive or negative) also are rare. When a test result is inconsistent with the patient’s
history, a repeat test or special confirmatory test may help to determine whether a person is or is
not infected.
PRIVACY AND CONFIDENTIALITY
HIV test results will be held in the strictest confidence. Your test results will not be
released to any other person, agency, company, or government without your specific written
permission, except as permitted by law. I understand I will receive a copy of my lab results on
my two week follow-up visit. In the event the test results are positive, I will be offered
counseling and referral for further health care.
 I elect to have the HIV Antibody Testing. I acknowledge that I have been given all the
information I desire concerning the blood test, its expected benefits and risks and have had
all my questions answered.
 I do not elect to have the HIV Antibody Testing and understand my blood will be held for
365 days should I decide to have the testing. If I decide to have the testing, it is my
responsibility to notify the Employee Health Clinician within the 365 day period. I
understand that on day 366 my blood will be discarded.
___________________________________________________________________________________________
PRINT (LAST NAME)
(FIRST NAME)
_______________________________________
SIGNATURE OF PATIENT
___________________________________________
DATE
_______________________________________
SIGNATURE OF WITNESS
___________________________________________
DATE
occmed/hivsent12/28/00/ia
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APPENDIX F
NEW ENGLAND BAPTIST HOSPITAL
EMPLOYEE HEALTH/ INFECTION CONTROL
INFORMED CONSENT FOR ANTIVIRAL PROPHYLAXIS FOLLOWING AN OCCUPATIONAL EXPOSURE TO BLOOD
AND/OR BODY FLUIDS
Information Regarding ANTIVIRAL PROPHYLAXIS





As a part of the Post Exposure Follow Up and Treatment Protocol, the New England Baptist Hospital offers and
makes available to employees who are occupationally exposed to material which may contain human
immunodeficiency virus (HIV), the virus which causes AIDS, a course of prophylactic (preventive) treatment with
single or combined antiviral medications.
For exposure for which PEP is considered appropriate, knowledge about the efficacy and toxicity of PEP is
limited. Only zidovudine has been shown to prevent HIV transmission in humans.
Although there is no data to address whether adding other antiretroviral drugs provides any additional benefit for
PEP, experts recommend combination drug regimens because of increased potency and concerns about drugresistant virus.
Studies to date of HCW’s exposed to human blood infected with HIV indicate that the risk of infection is low, but
directly related to the type of exposure as well as the volume, concentration, and viability of the innoculum.
Even a short course of antiviral medications may have important and serious side effects. The most common is
nausea; the most important is anemia. Most short term risks are reversible. There may also be important long term
risks such as an increased risk of cancer. AZT has been found to cause cancer in lab animals. The applicability of
this research to humans is not known. The treatment may involve risks which are currently unforeseeable to the
person receiving antiviral medication or to the embryo or fetus if the person is or may become pregnant.
I have read the above and I have considered the potential risks of treatment and the unproven nature of the
treatment.
 I have decided that I wish to receive the recommended antiviral therapy. I
understand that this course of treatment is made available subject to the
following conditions:




I will receive antiviral therapy under the supervision of a designated Employee Health Clinician from New
England Baptist Hospital who will prescribe the drug(s). As an employee, I will be provided with
review/monitoring of follow up testing for short term adverse reactions. The course of treatment will be provided
to me without cost. It is my responsibility to comply with recommended testing while taking the antiviral
medication(s). As a non-employee I will contact my health care provider of choice for follow up and inform New
England Baptist Hospital who my provider will be.
I understand that it is uncertain whether the medication(s) has any effects on sperm, ova, or embryo. I should
avoid conception, breast feeding, and/or organ donation during this course of treatment.
Information about my treatment and the results of lab tests obtained to monitor the effects of medications will be
kept in my confidential post exposure follow up chart separate from my Employee Health chart and medical
record.
Post exposure counseling has been provided to me.
I have reviewed the above information and any questions I have regarding treatment have been
answered to my satisfaction. I,__________________________________________________request
administration of this unproved and unapproved use of AZT and/or combination of antiviral
medication(s) to me.
 I have decided not to receive the offered/recommended/not recommended
antiviral therapy (circle appropriate therapy).
Exposed Individual:
Witness:
__________________________________________
Date:______________________________________
___________________________________
Date:_______________________________
EH/Forms/Anti Pro/12/00,10/03,4/04
Employee Health-Blood/Body Fluid Exposure Protocol
Section VI-O #2
Page 14 of 24
APPENDIX G
NEW ENGLAND BAPTIST HOSPITAL
EMPLOYEE HEALTH/ INFECTION CONTROL
OCCUPATIONAL EXPOSURE PHARMACY PROTOCOL
Basic and Expanded Post-Exposure Prophylaxis
Employees potentially exposed to Human Immunodeficiency Virus (HIV) contaminated fluids may elect to
receive prophylactic treatment. The employee should begin treatment as soon after exposure as possible
(preferably hours rather than days)
Prophylaxis therapy may consists of:
1.
Basic regimen with Nucleoside analogue
 Zidovudine-600mg/daily in divided doses .
 Lamivudine-300mg/daily in divided doses.
 ***Combivir is the combination of Zidovudine(300mg) and Lamivudine(150mg). It is
given as 1 tab, twice a day.
2. Expanded regimen with HIV Protease inhibitors.
 Kaletra (Lopinavir 133.3 mg, Ritonavir 33.3 mg) 3 caps BID with food
 Or other protease inhibitors
***The drugs are in the Pyxis under brand names.****
Employee Health Department issues a two week supply of medications. Ambulatory Care Unit (ACU) will
issue a 4 day supply medications
The Pharmacy dispensing procedure is as follows:
A written and signed prescription is required before medication is dispensed. The prescription will
not have a patient name, but will be for “Occupational Exposure.”
Employee Health Department (new or continued treatment)
1.
2.
3.
Employee Health clinician will write on a blank prescription pad, Occupational,
Exposure (must be exact) for a 2 week supply of nucleoside analogue and if indicated
HIV protease inhibiter or other drugs as ordered..
A written and signed prescription is brought to the Pharmacy by a member of clinic staff.
In exchange for this signed prescription, a two week supply of medication will be given to
the staff member. The employee being treated for possible exposure will be given their
drug(s) with proper instructions prior to leaving the Employee Health Department.
Ambulatory Care Unit (new prescriptions only)
When the Employee Health Department is closed, the Ambulatory Care Unit treating the
employee may dispense a one to four day supply of medication from the Pyxis system.
Pharmacy
The Pharmacy will bill or charge Workers Compensation for this. All bills will be
forwarded to Employee Health for approval.
* The CDC recommends the use of zidovudine in all exposure prophylaxis treatments. Lamivudine should
usually be added to zidovudine for its synergistic activity. Kaletra (a protease inhibitor) or combination deemed
appropriate by consulting clinician based on source (viral load, potential resistance & current drug) should be added for
exposure with the highest risk for HIV transmission. The decision on which antiretroviral combination will be used
will be made by the employee and advising physician/NP.
Employee Health-Blood/Body Fluid Exposure Protocol
Section VI-O #2
Page 15 of 24
APPENDIX H
NEW ENGLAND BAPTIST HOSPITAL
NEW ENGLAND BAPTIST HOSPITAL
EMPLOYEE HEALTH/ INFECTION CONTROL
OCCUPATIONAL EXPOSURE TEST RESULTS
I understand that I have had a blood or body fluid exposure. The risk of this exposure, the
results from my laboratory tests and the source laboratory tests (if applicable) have been
explained to me.
The results are the following:
EMPLOYEE
LAB TEST
HbsAg
Anti- Hbs
Anti- HCV
ALT
HIV
RESULT
DATE
SOURCE *
LAB TEST
HbsAg
Anti- HCV
ALT
HIV
RESULT
DATE
*You are obliged to keep the source information strictly confidential
I understand that the Hepatitis B Vaccine is
 indicated
 not indicated
I have been informed of the results of the evaluation and of any medical conditions
resulting from the exposure that require further evaluation or treatment..
_______________________________________
Employee Signature
_______________________________________
Health Care Professional Signature
_______________________________________
Date
WHITE COPY- OM
Rev: 12/00,3/01,10/03, 3/06
occmed/forms/results/ia
YELLOW COPY - EMPLOYEE
Employee Health-Blood/Body Fluid Exposure Protocol
Section VI-O #2
Page 16 of 24
APPENDIX I
NEW ENGLAND BAPTIST HOSPITAL
EMPLOYEE HEALTH/INFECTION CONTROL
IMPORTANT POINTS FOR YOU TO KNOW FOLLOWING AN
OCCUPATIONAL EXPOSURE







You shall be counseled regarding the risk of Hepatitis B infection from your exposure. If you have not
had Hepatitis B vaccine, you will be strongly advised to begin the Hepatitis B vaccine series
immediately. You may also be offered Hepatitis B Immune Globulin (HBIG) for added protection as
appropriate.
You shall also be counseled regarding the risk of HIV infection from your exposure. It is important for
you to be tested for HIV antibody to determine your baseline and the appropriate follow-up for your
exposure. If the result is negative, you may be retested at pre-determined intervals to determine if HIV
transmission has occurred. In addition, the source patient will also be requested to submit to HIV
antibody testing. You should know that it is not easy to get HIV even after a known exposure. The
average risk for HIB infection from all types of percutaneous exposures to HIV-infected blood is 3 in
1000 exposed. The risks after mucous membrane and skin exposures to HIV-infected blood are
approximately 1 in 1000 and less than 1 in 1000 respectively.
You will be scheduled for a follow-up appointment with Employee Health Department to receive the
results of your laboratory tests regardless of the outcomes of these tests. The Employee Health
Department utilizes a confidential coded system. No names are used in the ordering of laboratory tests
and the confidentiality of your tests will be strictly respected.
New England Baptist Hospital is committed to providing quality health care to all patients, regardless
of HIV status. Although data from the Centers for Disease Control (CDC) indicate the risk of infection
to health care workers to be very small, we recognize that treatment of patients with this disease
exposes employees to some risk. We are also aware that employees who are not health care workers
may be exposed to HIV in the course of their employment. Therefore, we want to provide support to
those workers who might become infected with HIV.
The New England Baptist Hospital has developed an HIV Benefit Plan. The plan provides financial
assistance and other support services to an employee who becomes HIV positive as a result of a workrelated incident at the institution. The financial assistance provides a lump sum payment of
$200,000.00. This payment is in addition to any amounts that are payable under the institution’s benefit
plan, Workers’ Compensation, and other insurance plans. This program is provided at no cost to
eligible participants. Eligibility requires a baseline HIV test within five(5) days of the exposure incident
and repeat HIV test after 6 months. Please refer to the “Work-Related HIV Benefit Plan” booklet for
further details of the plan.
You shall be counseled during this follow-up period to follow the CDC recommendations for
preventing transmission of HIV, including refraining from blood, semen, or organ donation.
CDC also advises using appropriate protection during sexual intercourse. Use of latex condoms
and water soluble lubricant are recommended. Women are advised to refrain from breast
feeding and planning to get pregnant in the period while undergoing testing to prevent possible
exposure of the infant to HIV infection.
You shall be counseled to report and seek medical evaluation for any acute fever, especially one
associated with a body rash, swollen lymph nodes, muscle achiness, fatigue, or malaise which occurs
during the follow-up period, especially during the first 12 weeks after exposure.
Employee Health-Blood/Body Fluid Exposure Protocol
Section VI-O #2
Page 17 of 24
Important Points for You to Know Following an Occupational Exposure (cont.)





Page 2
If, after investigation, the source patient is found to be HIV positive, you will be offered a baseline
physical examination by a physician designated by Employee Health or by your own PCP.
An Infectious Disease physician or your PCP will discuss antiviral therapy with you. Be advised there
is no PROVEN or APPROVED treatment to prevent HIV infection from occurring. Although AZT
has not been proved to prevent HIV infection, findings of a new research study printed in the 1995
MMWR summarizes the findings of factors associated with risk for and prevention of HIV infection in
Health Care Workers following occupational exposure. The analysis of the study data suggests the use
of AZT post exposure may be protective as the study model indicated the risk for HIV infection was
reduced in Health Care Workers who used AZT.
Studies to date of Health Care Workers exposed to human blood infected with HIV indicate that the
risk of infection is low, but DIRECTLY related to the type of exposure as well as the volume,
concentration, and viability of the innoculum.
Even short courses of antiviral therapy may have important and serious side effects:
*
The most common is nausea. The most important is anemia. Most short term
risks are reversible.
*
There may also be other important risks such as bone marrow depression.
*
The treatment may involve risks which are currently unforseeable to the person
receiving the antiviral prophylaxis or to the embryo or fetus if the person is or
may become pregnant.
This information sheet is designed to assist you during the post-exposure follow-up period and is
intended to anticipate any questions you may have about specific tests, procedures, and prophylaxis. If
you have any additional questions, please ask the Employee Health Clinician or your designated
physician.
Rev: 11/96,12/00,3/01,10/03
Employee Health-Blood/Body Fluid Exposure Protocol
Section VI-O #2
Page 18 of 24
APPENDIX J
NEW ENGLAND BAPTIST HOSPITAL
EMPLOYEE HEALTH/ INFECTION CONTROL
POST-EXPOSURE REVIEW OF UNIVERSAL/STANDARD PRECAUTIONS
Universal/Standard precaution techniques shall be utilized for all New England Baptist Hospital patients
(inpatients and outpatients) regardless of their diagnoses. These techniques shall also apply to the handling
of all medical equipment and materials contaminated by blood or body fluid. Each employee shall utilize
protective barriers when having direct contact or potential exposure to blood or body fluid(s) via mucous
membrane or non-intact skin.
Gloves
Gloves shall be worn whenever hands are likely to be in contact with blood, body fluid, or body secretions.
Hands shall be washed routinely before and after any job-related task that may potentially expose the
employee to blood, body fluid, or body secretion. The following are examples but not necessarily all
inclusive of activities which require wearing of gloves:
o
o
o
o
o
o
o
o
o
o
o
o
Examining patients
Drawing blood
Starting IV’s
Invasive or operative procedures
Endoscopy, colonoscopy, bronchoscopy
Handling lab specimens, soiled waste, or soiled linen
Intubation
Suctioning
Catheter insertion
Cleaning soiled equipment
Administering injections
Handling tubes of blood
Hands shall be washed after removing gloves.
Gowns
Gowns shall be worn if soiling of clothing is likely to occur; for example, when performing the following of
similar activities:
o
o
o
o
Cleaning soiled equipment
Handling grossly contaminated linen
Operative or other procedures which produce extensive
splattering of blood or body fluids
Cleansing the skin of incontinent patients
o
o
o
Endoscopy, colonoscopy, bronchoscopy
Intubation
Insertion of arterial or central lines
Gowns shall be removed if they become grossly contaminated.
Masks and Safety Glasses (Goggles)
Masks and goggles shall be worn whenever it is likely that eyes and/or mucous membrane might be
splashed with blood or body fluids; for example, during the following activities:
o
o
Intubation
Suctioning
o
o
Emptying drainage devices
Insertion of arterial or central lines
o
o
Contact with patient with productive cough
Operative or other invasive procedures which produce
splattering of blood or body fluids
Needles and Sharps
Contaminated needles and sharps, e.g., needles, scalpels, blades, pipettes, glass slides, etc., shall be
handled with extreme caution. Contaminated sharps shall be disposed of in the closest puncture resistant
container immediately after use. Each employee shall observe the following rules:
Do not recap, bend, or break needles under any circumstances;
Remove and replace puncture resistant sharps disposal containers as soon as they are full;
Use needle-safe devices;
Communicate with colleagues of whereabouts of sharps when appropriate;
Be constantly alert to injury potential when handling sharps
Employee Health-Blood/Body Fluid Exposure Protocol
Section VI-O #2
Page 19 of 24
Post-Exposure Review of Universal Precautions Page 2
Infectious Waste
Trash that is heavily contaminated or saturated with blood or body fluids shall be discarded into covered
hazardous waste receptacles. Soiled linen shall be bagged at the point of origin; linen that is heavily soiled
or wet with blood or body fluids, shall be placed in an impervious bag.
Reporting of Puncture Wound or Exposure to Blood or Body Fluid
I understand it is my responsibility to report any puncture wound or other exposure to blood or body fluids
immediately (within the hour of exposure) to Employee Health or other designated areas to ensure
appropriate HIV/HBV follow-up and management.
Rev: 10/03
OccMed/Forms/BBFEduca/11/2000/IA
Employee Health-Blood/Body Fluid Exposure Protocol
Section VI-O #2
Page 20 of 24
APPENDIX K
NEW ENGLAND BAPTIST HOSPITAL
EMPLOYEE HEALTH/ INFECTION CONTROL
POST-EXPOSURE FOLLOW UP FORM
NAME:________________________________
EXPOSURE DATE:______________________
Today’s Date:__________________________
TYPE OF FOLLOW UP
 2 WEEK
 1 MONTH
 3 MONTHS
 6 MONTHS
 12 MONTHS
Since your last visit, have you had or do you have any of the following signs or symptoms? (Please check all that
apply)





fever
chronic lymphadenopathy (swollen glands)
joint/muscle pain
body rash
other (specify)





night sweats
malaise/fatigue
weight loss - unexpected
flu-like symptoms
none of the above
Any concerns or comments:_______________________________________________________
______________________________________________________________________________
----------------------------------------------------------------------------------------------------------------------------------------To be completed by the Employee Health Clinician:
HIV AB drawn
 yes
 no
Comments_____________________________________________________________________
______________________________________________________________________________
_______________________________________
Employee Health Clinician
Rev: 10/03, 3/06
occmed/forms/POSTF-U/12/2000/ia
Date
Employee Health-Blood/Body Fluid Exposure Protocol
Section VI-O #2
Page 21 of 24
APPENDIX L
Recommended HIV Postexposure Prophylaxis for Percutaneous Injuries
Infection Status of Source
Exposure type
HIV-Positive
Class 1 *
HIV-Positive
Class 2*
Source of unknown
HIV status
Unknown Source -
HIV – Negative
Less Severe--
Recommend basic
2-drug PEP
Recommend expanded
3-drug PEP
Generally, no PEP warranted;
however, consider basic 2-drug
PEP for source with HIV risk
factors ++
Generally, no PEP
warranted; however consider
basic 2-drug PEP** in
settings where exposure to
HIV infected persons is
likely
No PEP warranted
More severe **
Recommend expanded
3-drug PEP
Recommend expanded
3-drug PEP
Generally, no PEP warranted;
however, consider basic 2-drug
PEP for source with HIV risk
factors ++
Generally, no PEP
warranted; however consider
basic 2-drug PEP in settings
where exposure to HIVinfected person is likely
No PEP warranted
* HIV-Positive, Class 1 - asymptomatic HIV infection or known low viral load (e.g., <1,500 RNA copies/mL); HIV-Positive, Class 2-symptomatic HIV infection, AIDS, acute
seroconversion, or known high viral load. If drug resistance is a concern, obtain expert consultation. Initiation of postexposure prophylaxis (PEP) should not be delayed pending expert
consultation, and because expert alone cannot substitute for face-to-face counseling, resources should be available to provide immediate evaluation and follow-up care for all exposures.

Source of unknown HIV status (e.g., deceased source person with no samples available for HIV testing)
- Unknown source (e.g, a needle from a sharps disposal container).
-- Less severe (e.g.. solid needle and superficial injury).

The designation "consider PEP" indicates that PEP is optional and should he based on an individualized decision between the exposed person and the treating clinician.
++ If PEP is offered and taken and the source is later determined to be HIV-negative. PEP should be discontinued
** More severe (e.g., large-bore hollow needle, deep puncture, visible blood on device, or needle used in patient’s artery or vein)
Source: CDC, Updated US Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV and HIV and Recommendations for Post Exposure
Prophylaxis. MMWR 2001; 50 (No.RR-11); 1-42.
Employee Health-Blood/Body Fluid Exposure Protocol
Section VI-O #2
Page 22 of 24
APPENDIX M
Recommended HIV Postexposure Prophylaxis for Mucous Membrane Exposures and Nonintact skin
Infection Status of Source
Source of unknown Unknown Source
HIV status
Exposure type
HIV-Positive
Class 1”
HIV -Positive
Class 2”
HIV Negative
Small Volume **
Consider basic
2-drug PEP
Recommend basic 2drug PEP
Generally. no PEP
warranted; however,
consider basic 2-drug
PEP for source with
HIV risk factors
Generally, no PEP warranted;
however consider basic 2drug PEP in settings where
exposure to HIV infected
persons is likely
No PEP warranted
Large Volume
Recommend basic 2drug PEP
Recommend expanded
3-drug PEP
Generally, no PEP
warranted; however,
consider basic 2-drug
PEP for source with
HIV risk factors
Generally, no PEP warranted;
however consider basic 2drug PEP in settings where
exposure to HIV-infected
person is likely
No PEP warranted
* For skin exposures, follow-up is indicated only if there is evidence of compromised skin integrity (e.g., dermatitis, abrasion, or open wound).
” HIV-Positive, Class 1 - asymptomatic HIV infection or known low viral load {e.g., <1,500 RNA copies/mL). HIV-Positive, Class 2-symptomatic HIV infection, AIDS, acute
seroconversion, or known high viral load. If drug resistance is a concern, obtain expert consultation. Initiation of postexposure prophylaxis (PEP) should not be delayed pending expert
consultation, and because expert consultation alone cannot substitute for face-to-face counseling, resources should be available to provide immediate evaluation and fol1ow-up care for
all exposures.

Source of unknown HIV status (e.g. deceased source person with no samples available for HIV testing)

Unknown source (e.g., splash from inappropriately disposed blood).
** Small volume (i.e., a few drops).

The designation, “consider PEP”, indicates that PEP is optional and should be based on an individualized decision between the exposed person and the treating clinician.

If PEP is offered and taken and the source is later determined to be HIV-negative, PEP should be discontinued.

Large volume (i.e., major blood splash).
Source: CDC, Updated US Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV and HIV and Recommendations for Post Exposure
Prophylaxis. MMWR 2001; 50 (No.RR-11); 1-42.
Employee Health-Blood/Body Fluid Exposure Protocol
Section VI-O #2
Page 23 of 24
APPENDIX O
Occupational Exposure Management Resources
National Clinicians' Postexposure Prophylaxis Hotline
{PEPline)
Run by University of California San Francisco/San
Francisco General Hospital staff; supported by the Health
Resources and Services Administration Ryan White CARE
Act HIV/AIDS Bureau AIDS Education and Training
Centers and CDC
Phone: (888) 448-4911
Internet: <http://www.ucsf.edu/hivcntr>
Needlestick!
A website to help clinicians manage and document
occupational blood and body fluid exposures. Developed
and maintained by the University of California, Los
Angeles (UCLA), Emergency Medicine Center, UCLA
School -of Medicine, and funded in party by CDC and the
Agency for Healthcare Research and Quality.
Internet: <http://
www.needlestick.mednet.uc1a.edu>
Hepatitis Hotline
Phone: (888) 443-7232
Internet: <http://www.cdc.gov/hepatitis>
Reporting to CDC: Occupationally acquired HIV
infections and failures of PEP
Phone: (800) 893-0485
HIV Antiretroviral Pregnancy Registry
Phone:(800) 258-4263
Fax: (800) 800-1052
Address:
1410 Commonwealth Drive
Suite 215
Wilmington, NC 28405
Internet:
< http//www.glaxowellcome.corn/ preg_reg/antiretroviral>
Food and Drug Administration
Report unusual or severe toxicity to antiretroviral agents
Phone: (800) 332-1088
Address:
MedWatch
HF-2, FDA
5600 Fishers Lane
Rockville, MD 20857
Internet:
<http://www .fda.gov/medwatch>
HIV / AIDS Treatment Information Service
Internet: <http://www.hivatis.org>
Employee Health-Blood/Body Fluid Exposure Protocol
Section VI-O #2
Page 24 of 24
Appendix P
NEW ENGLAND BAPTIST HOSPITAL
EMPLOYEE HEALTH
617-754-5804
BLOOD/BODY FLUID EXPOSURE FOLLOW-UP
The following dates are when it is strongly recommended you follow up after your blood and body fluid
exposure:
Exposure Date: _____________
2 weeks-for results only
1 Month ___________________
3 Months: _________________
6 Months: _________________
12 Months: _________________
Additional Instructions: __________________________________________________.
One notice will be mailed to you prior to each recommended follow up. You may also contact Employee
Health at any time with questions or concerns.
Please call us if you develop any flu-like symptoms such as rash, fever, unexplained weight loss, fatigue,
swollen glands, muscle/joint pain, or night sweats.
Finally, if you transfer to another department, change your address or change your telephone number,
please let us know as we use the information you supplied to us for communicating with you.
Thank You
__________________________
Employee Health Provider