Download BBF PROTOCOL NEBH

PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
NEW ENGLAND BAPTIST HOSPITAL
OCCUPATIONAL MEDICINE/ EMPLOYEE HEALTH
INFECTION CONTROL POLICY GUIDELINES
Section VI-O #2
Page 1 of 22
_________________________________________________________________________________________________
BLOOD/BODY FLUID EXPOSURE PROTOCOL – NEBH EMPLOYEES ONLY
_______________________________________________________________________________
Subject:
Effective Date: March, 2001
Supersedes: 3/99
Approved By: Infection Control Committee
Author: Irene M.E. Anderson, M.S.A., R.N., COHN-S/CM
__________________________________________________________________________________________________
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 Occupational Medicine Clinician may be interchangeable with the
clinicians in other designated areas.
I.
PERSONNEL ISSUES
A.
Employee Exposure
1.
2.
Report to:
Occupational Medicine-Employee Health
Monday - Friday (8AM4PM)
Ambulatory Services
Monday- Friday after 4 P.M.
Weekends/Holidays
Completion of Incident Report Form
The designated Occupational Medicine Center 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.
Registration/Baseline Serology
The designated Occupational Medicine Center 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, Anti-HBS, Anti-HBc,
Anti-HCV, SGPT (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) page 7. Should an employee be seen in Ambulatory
Services this information will be forwarded to the designated Occupational
Medicine Clinician for NEBH employees.
4.
Identification/Assessment of Source Patient
a.
If source patient is known, Occupational
Medicine Clinician shall:
1
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
Section VI-O # 2
Page 2 of
22
NEW ENGLAND BAPTIST HOSPITAL
OCCUPATIONAL MEDICINE/ EMPLOYEE HEALTH
INFECTION CONTROL POLICY GUIDELINES
b.
5.
1)
Review patient’s medical record for evidence of known viral
Hepatitis/HIV, request HBsAG, Anti-HBc, Anti-HCV, and
HIV testing of the patient, and provide appropriate prophylaxis
to the employee (Appendix B & M) page 8 &21 .
NOTE:
At this time their is insufficient data to warrant
routine testing of source patients for Hepatitis C
antibody and the Centers for Disease Control are not
requesting such testing but the Infection Control
Committee strongly recommends these tests to
protect NEBH employees.
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 A, B, C, provide
appropriate prophylaxis to the NEBH employee (Appendix
B).
If source patient is unknown, the designated Occupational Medicine
Center clinician responsible for the New England Baptist Hospital
(NEBH) employees shall follow the Hepatitis B algorithm (Appendix
B) and Post Exposure Prophylaxis algorithm ( Appendix M) for the
appropriate prophylaxis.
HIV Status of Source Patient
If HIV status of source patient is unknown, the designated Occupational
Medicine Center clinician responsible for the New England Baptist Hospital
(NEBH) employees shall:
a.
Place the informational letter to the attending physician (see Appendix
C) page 9 regarding the Occupational Blood/Body Fluid Exposure and
the Source Patient Consent for HIV Antibody Testing form (see
Appendix D) page 10 in the source patient’s medical record in the left
front plastic pocket of the record binder.
b.
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 Occupational Medicine Center
clinician, responsible for the New England Baptist Hospital (NEBH)
employees, of the patient’s decision regarding HIV testing.
>If source patient consents to HIV testing, charges for testing
will be free of charge and forwarded to Occupational
Medicine, notify laboratory, provide patient’s name and room
number, and request that blood be drawn . Phlebotomist will
pick up 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 Occupational
2
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
Section VI-O # 2
Page 3 of 22
NEW ENGLAND BAPTIST HOSPITAL
OCCUPATIONAL MEDICINE/ EMPLOYEE HEALTH
INFECTION CONTROL POLICY GUIDELINES
Medicine Center clinician, responsible for the New England
Baptist Hospital (NEBH) employees.
>
6.
If source patient declines HIV testing, obtain the signed
declination form and place in the employees’ confidential
record.
Follow-Up
a.
If source patient is seronegative
If source patient has no clinical evidence or risk factors for HIV
infection, no follow-up of exposed employee shall be required
following the initial visit. However, routine serologic testing for HIV
at baseline, 6 weeks, and three months shall be strongly recommended
to satisfy the minimum eligibility requirements for the Employee HIV
Benefit Plan.
b.
If source patient is seropositive, high risk or is unknown source:
1)
As soon as possible after the exposure, preferably within two
hours, the employee shall be counseled regarding the risk of
infection.(Appendix M page 21) Baseline serologic testing of
the exposed employee for HIV shall be performed after
consent for testing (Appendix E) page 11 has been obtained.
2)
The designated
Occupational Medicine Clinician or Infection Control
Physician for NEBH ,shall be requested to provide counseling
regarding post exposure prophylaxis (PEP)
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, six, and 12 months post-exposure to determine
if seroconversion has occurred.
NOTE: 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).
3
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
4
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
Section VI-O # 2
Page 4 of 22
NEW ENGLAND BAPTIST HOSPITAL
OCCUPATIONAL MEDICINE/ EMPLOYEE HEALTH
INFECTION CONTROL POLICY GUIDELINES
d) Counseled by the designated Infection Control Physician
on call regarding PEP therapy.
4)
5)
If employee agrees to PEP, the designated Occupational
Medicine Clinician or Infection Control 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) page 12.
b)
Order CBC,diff, & platelets; U/A with microscopic
exam; SGPT, Alk. Phos., Total Bilirubin,
Creatinine.
c)
If the employee is a woman of child bearing age,
order a stat HCG (pregnancy test). If the employee
is pregnant, contact her obstetrician immediately
prior to dispensing antiviral prophylaxis.
d)
If antiviral prophylaxis will be initiated, provide the
“starter” doses, which can be obtained from the
pharmacy (Appendix G) page 13.
If the employee chooses to take antiviral therapy, the
following protocol shall be followed:
a)
The exposed employee shall follow up with the
designated Infection Control Physician within 5
days.
b)
CBC,diff, & platelets; U/A with microscopic exam;
SGOT, Alk. Phos., Total Bilirubin, Creatinine shall
be checked every two weeks while taking antiviral
therapy through the Occupational Medicine Center.
c)
Abnormal lab results shall be reviewed by the
Occupational Medicine Clinician in collaboration
with the Infection Control Physician who prescribed
the AZT therapy.
d)
If the employee develops complications or
experiences side effects from the therapy, the
designated Occupational Medicine 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.
5
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
Section VI –O #2
Page 5 of 22
NEW ENGLAND BAPTIST HOSPITAL
OCCUPATIONAL MEDICINE/ EMPLOYEE HEALTH
INFECTION CONTROL POLICY GUIDELINES
NOTE: If, after counseling, the employee declines follow-up
at NEBH, s/he shall be advised to contact the
Massachusetts Department of Health for further
information regarding available resources.
c.
If source patient declines testing:
The designated Occupational Medicine 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, or as if the source patient were
seronegative.
d.
If source is unknown and employee chooses antiviral therapy:
The designated Occupational Medicine 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 post-exposure evaluation is entitled to
have a baseline specimen frozen and stored for up to
90 days, however the Infection Control Committee
has decided to increase this to one year for possible
later HIV screening.
B.
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.
C.
Employee Counseling
The designated Occupational Medicine 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) page 14
Important Points For You to Know Following an
Occupational Blood/Body Fluid Exposure (Appendix I) page
15.
Universal/Standard Precautions Sheet (if appropriate)
(Appendix J) page 16.
6
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
Section VI-O #2
Page 6 of
22
NEW ENGLAND BAPTIST HOSPITAL
OCCUPATIONAL MEDICINE/ EMPLOYEE HEALTH
INFECTION CONTROL POLICY GUIDELINES
2.
Complete the Blood/Body Fluid Exposure Required Information
Checklist (Appendix K) page 17.
3.
Make a two week follow-up appointment with the employee for the
purpose of:
a.
b.
providing additional prophylaxis treatment/counseling.
Reviewing laboratory testing results and providing written
opinion and laboratory results by the designated Occupational
Medicine Clinician,responsible for NEBH employees
(Appendix H).
c.
Initiating post Exposure Follow-Up protocol form (Appendix
L) page 18 and make an appointment for the employee to
have next scheduled laboratory screening tests.
4.
Complete and send copy of the employee Incident Report form to the
employer’s manager for completion and follow -up by the manager.
REFERENCES:
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
HIV-infected 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.
REVISED:
12/20/2000
7
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
DISTRIBUTION:
Occupational Medicine-Employee Health, and Ambulatory Services
8
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
Section VI-O #2
Page 7 of 22
APPENDIX A
NEW ENGLAND BAPTIST HOSPITAL
OCCUPATIONAL MEDICINE/ EMPLOYEE HEALTH
BLOOD BODY FLUID EXPOSURE RECORD
Employee
Source
Name____________________________________
Staff code_________________________________
Immunization History:______________________
Name_____________________________________
MR # _____________________
Unknown_________
HBV Immunization:
Date Dose #1__________
Standing Orders to patient chart
#2__________
____________
Physician letter to patient chart _______________
#3__________
Antibody Status
and Date Tested____________________________
Tetanus Booster Date___________
Testing After Exposure
Testing After Exposure
HBsAg
Anti-HBs
Anti-HBc
Anti-HCV
Date
_______
_______
_______
_______
SGPT
_______
HIV Consent
_______
Blood saved for ONE year
Anti-HIV
#1(exp.)______
#2(6wk)______
#3(3mo)______
#4(6mo)______
#5(1yr) ______
Results
_______
_______
_______
_______
_______
Yes No
Yes No
______
______
______
______
______
Treatment
Tetanus Booster
HBV Booster
HBIG - Dose
#1
#2
Antiviral(s) Started
Stopped
Date
______
______
______
______
______
______
N/A
______
______
______
______
______
______
HBsAg
Anti-HBc
Anti-HCV
SGPT
Date
_______
_______
_______
_______
Results
_______
_______
_______
_______
HIV Consent _______
Yes
No
if no, documented in MR
Anti-HIV
_______
______
Risk Factors
Transfusion
IV Drug Use
History of Hepatitis
History of Hemophilia
Abnormal Liver
Function Test
Pertinent Sexual
Activity
Consent for Release
of Testing Results
Yes
____
____
____
____
No
____
____
____
____
Unknown
_____
_____
_____
_____
____
____
_____
____
____
_____
____
____
_____
Informed of Source results____________________
Date of Incident____________
Time of Incident_______________ Route of Exposure______________________
Exposed to_____________________________________________________________________________________
Equipment Manufacturer and Brand Name ___________________________________________________________
List Personal Protective Equipment worn __________________________________________________________
Circumstances under which exposure occurred:
1. Type of Work____________________________________________________________________
__________________________________________________________________________________
2. What was cause of incident? (accident, equipment failure, etc.)
__________________________________________________________________________________
3. Other Comments_________________________________________________________________
Signature:_________________________________________
occmed/bbf-up/11/2000/ia
9
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL copy.08/12/17, 1:07 PM
Section VI-O #2
Page 9 of 22
APPENDIX B
NEW ENGLAND BAPTIST HOSPITAL
OCCUPATIONAL MEDICINE/ EMPLOYEE HEALTH
INFECTION CONTROL
HEPATITIS STATUS AND HIV EXPOSURE ALGORITHM
EXPOSURE EVENT
SOURCE KNOWN
Known Hepatitis B
(+HBsAG)
Known Hepatitis A
Known Hepatitis C
 Draw HAV
 Give ISG
 Offer Hep A & B Vaccine
 Follow algorithm for Hepatitis B
 Repeat Anti-HCV in 6 mos.
Employee Immune (Hx Disease/Vaccine)
 Draw Anti-HBs, HBsAG, Anti-HBc, Anti-HCV,
SGPT, Anti-HIV (Results in 24 hours).
+Anti-HBs
 No further treatment
SOURCE UNKNOWN
Discuss with designated Occupational
Medicine Clinician.
 Draw Anti-HBs, HBsAG, AntiHBc, Anti-HCV, SGPT, Anti-HIV
(Results in 24 hours).
 Offer ISG
Employee Non-Immune
 Draw Anti-HBs, HBsAG, Anti-HBc, Anti-HCV,
SGPT, Anti-HIV (Results in 24 hours).
 Offer #1 Hep B vaccine/schedule #2 in one month
 Give HBIG
-Anti-HBs
 #4 Hepatitis B Booster
 Schedule #5 in one month
 Give HBIG
occmed/hep/hiv/exposure/12/98/ia
10
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL copy.08/12/17, 1:07
PM
Section VI-O #2
Page 9 of
22
APPENDIX C
NEW ENGLAND BAPTIST HOSPITAL
OCCUPATIONAL MEDICINE/ EMPLOYEE HEALTH
INFECTION CONTROL
OCCUPATIONAL EXPOSURE PHYSICIAN LETTER
Occupational Medicine-Employee Health
Converse 5
125 Parker Hill Avenue
Boston, MA 02120
(617) 754-5804, 754-5631
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 Occupational Medicine Clinician. If you have any questions please do not
hesitate to contact me. Thank you for your cooperation in this matter.
Sincerely,
Occupational Medicine Clinician
Reviewed by Med. Rec. Committee 12/96,
11
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL copy.08/12/17, 1:07
PM
Section VI-O #2
Page 10 of 22
APPENDIX D
NEW ENGLAND BAPTIST HOSPITAL
OCCUPATIONAL MEDICINE/ 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
YELLOW- LAB
12
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
Section VI-O #2
Page 11 of
22
APPENDIX E
NEW ENGLAND BAPTIST HOSPITAL
OCCUPATIONAL MEDICINE/ 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 Occupational Medicine 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
13
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
_______________________________________
SIGNATURE OF WITNESS
occmed/hivsent12/28/00/ia
WHITE- OCCMED
___________________________________________
DATE
YELLOW-LAB
Section VI-O
#2
Page 12 of 22
APPENDIX F
NEW ENGLAND BAPTIST HOSPITAL
OCCUPATIONAL MEDICINE/ 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.
There is no proven or approved treatment to prevent HIV infection from occurring. Antiviral medication has not
been proved to prevent HIV infection following exposure to blood/body fluids. In addition, the use of antivirals in
this situation has not been approved by the United States Food and Drug Administration.
Although AZT has not been proved to prevent HIV infection, there is interest in it as a possible preventive
measure because of animal studies in which early administration of AZT prevents or attenuates infection by
viruses similar to HIV. The MMWR, December 1995, summarizes the findings of a new study of factors
associated with risk for and prevention of HIV infection in health care workers (HCW’s) 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 HCW’s who used AZT.
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 Occupational Medicine Physician 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.
14
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
 I have decided not to receive the recommended antiviral therapy.
Exposed Individual:
Witness:
__________________________________________
___________________________________
Date:______________________________________
Date:_______________________________
Occ. Med./Forms/Anti Pro/12/00
15
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
Section VI-O #2
Page 13 of 22
APPENDIX G
NEW ENGLAND BAPTIST HOSPITAL
OCCUPATIONAL MEDICINE/ EMPLOYEE HEALTH
INFECTION CONTROL
OCCUPATIONAL EXPOSURE PHARMACY PROTOCOL
Zidovudine(ZDV), Lamivudine(3TC) and Indinavir
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 within 1-2 hours)
Prophylaxis therapy may consists of:
 zidovudine 200mg three times daily.
 lamivudine 150mg two times daily.
 indinavir 800mg every 8 hours(on an empty stomach).
 or other protease inhibitors.
Occupational Medicine Center (Employee Health) issues a two week supply medications (84 capsules of
zidovudine, 28 tablets of lamivudine and 84 capsules of indinavir).
Ambulatory Services Unit (ASU) will issue a 4 day supply medications (24 capsules of zidovudine, 8
tablets of lamivudine and 24 capsules of indinavir) when the Employee Health is closed.
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.”
Occupational Medicine Center (OMC)(new or continued treatment)
1.
Occupational Medicine will write on a blank prescription pad, Occupational, Exposure
(must be exact) for a 2 week supply of zidovudine, lamivudine and indinavir.
2.
A written and signed prescription is brought to the Pharmacy by a member of OMC staff.
3.
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 Occupational Medicine Center.
Ambulatory Services (new prescriptions only)
1
2.
3.
When OMC is closed, the unit treating the employee (Ambulatory Services) may dispense
a four day supply of zidovudine, lamivudine and indinavir from the Pharmacy.
A written and signed prescription with Occupational, Exposure (must be exact) is
brought to the Pharmacy by a member of the Ambulatory Services staff.
In exchange for this signed prescription, a four day supply of medication is given to the
staff member. The employee being treated for possible exposure will be given their
drug(s) with proper instructions prior to leaving these areas.
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. Indinavir (a protease inhibitor) or Nelfinavir 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.
16
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
17
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
Section VI-O #2
Page 14 of 22
APPENDIX H
NEW ENGLAND BAPTIST HOSPITAL
NEW ENGLAND BAPTIST HOSPITAL
OCCUPATIONAL MEDICINE/ 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- Hbc
Anti- HCV
SGPT
HIV
RESULT
DATE
SOURCE
LAB TEST
HbsAg
Anti- Hbc
Anti- HCV
SGPT
HIV
RESULT
DATE
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.
_______________________________________
Employee Signature
_______________________________________
Health Care Professional Signature
_______________________________________
Date
WHITE COPY- OM
YELLOW COPY - EMPLOYEE
occmed/forms/results/12/00/ia
18
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
Section VI-O #2
Page 15 of 22
APPENDIX I
NEW ENGLAND BAPTIST HOSPITAL
OCCUPATIONAL MEDICINE/ 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 may be offered Serum Immune Globulin(SIG) and/or Hepatitis B Immune
Globulin (HBIG) within 24 to 48 hours of the exposure. You will also be strongly advised to begin the
Hepatitis B vaccine series immediately if you have not received it.
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 will need to 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 will be scheduled for a follow-up appointment with Employee Health 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.
Work-Related HIV Benefit Plan for New England Baptist Hospital employees.





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
$100,000.00. 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 12 weeks. 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 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.
If, after investigation, the source patient is found to be HIV+, you will be offered a baseline physical
examination by a physician designated by Employee Health or by your own PCP.
19
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
 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
20
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
Section VI
Page 16 of
22
Important Points for You to Know Following an Occupational Exposure (cont.)




Page 2
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 long term important risks such as an increased risk of cancer.
*
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.
Adapted from Deaconess Hospital/Karen Bithell, R.N.
11\2000\ia
21
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
Section VI-O #2
Page 17 of 22
APPENDIX J
NEW ENGLAND BAPTIST HOSPITAL
OCCUPATIONAL MEDICINE/ EMPOYEE 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:
of similar activities:
for example, when performing the following
o
Cleaning soiled equipment
o
o
o
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.
22
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
Section VI-O #2
Page 18 of 22
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.
I have read and understand the post-exposure review of universal/standard precautions. All
my questions have been answered.
Date:_________________________
Signature:____________________________
OccMed/Forms/BBFEduca/11/2000/IA
23
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
Section VI-O #2
Page 19 of 22
APPENDIX K
NEW ENGLAND BAPTIST HOSPITAL
OCCUPATIONAL MEDICINE/ EMPLOYEE HEALTH
INFECTION CONTROL
BLOOD BODY FLUID EXPOSURE CHECKLIST FOR OCCUPATIONAL HEALTH CLINICIAN
EMPLOYEE NAME:________________________________ EXPOSURE DATE:___________________
EMPLOYEE CODE:________________ SOURCE PT NAME:_________________________________
SOURCE PT
 Source pt HIV consent form given to Nursing Coordinator or Primary Nurse to give to PCP
 Source pt Physician order sheet given to Nursing Coordinator or Primary Nurse to obtain lab work
 Received hard copy of results on Source pt
 HBsAG
 Anti-HCV
 Anti-HIV
 SGPT
EMPLOYEE
 Employee pre-test counseling completed and educational material received and signed
 Employee signed HIV consent form
 Employee blood obtained and coded
 Received hard copy of results on Employee
 HBsAG
 OSHA recordable:
 Anti-HBs
 Anti-HCV
 SGPT
 Anti-HIV
Hep B vaccine administered
Other:____________________________________________________________________
 Completed Post Blood Exposure Evaluation Form signed off by employee
 Gave copy of Post Blood Exposure Evaluation form to employee
 Scheduled follow-up appointment on employee Date:_______________
Time:____________
Signature of Occupational Health Clinician________________________________________________
occmed/form/bbf list/ia/12/2000
24
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
Section VI-O #2
Page 20 of 22
APPENDIX L
NEW ENGLAND BAPTIST HOSPITAL
OCCUPATIONAL MEDICINE/ EMPLOYEE HEALTH
INFECTION CONTROL
POST-EXPOSURE FOLLOW UP FORM
6 WEEKS, 3 MONTHS, 6 MONTHS, 1 YEAR
NAME:________________________________ EXPOSURE DATE:___________________
Todays date:__________________________
TYPE OF FOLLOW UP
 6 WEEK
 3 MONTHS
 6 MONTHS
 1 YEAR
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
other (specify)




night sweats
malaise/fatigue
weight loss - unexpected
none of the above
Any concerns or comments:_______________________________________________________
______________________________________________________________________________
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------To be completed by the Occupational Medicine Clinician:
Weight____________________
HIV AB drawn
 yes
BP_________________________
 no
Comments_____________________________________________________________________
______________________________________________________________________________
_______________________________________
Occupational Medicine Clinician
Date
25
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
occmed/forms/POSTF-U/12/2000/ia
26
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
Section VI-O#2
Page 21 of
22
APPENDIX M
NEW ENGLAND BAPTIST HOSPITAL
OCCUPATIONAL MEDICINE/ EMPLOYEE HEALTH
POSTEXPOSURE PROPHYLAXIS TREATMENT ADVICE
27
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
Section VI
-O # 2
Page 22 of 22
APPENDIX M
NEW ENGLAND BAPTIST HOSPITAL
OCCUPATIONAL MEDICINE/EMPLOYEE HEALTH
POSTEXPOSURE PROPHYLAXIS TREATMENT ADVICE
28
PLEASE NOTE: This on-line, read-only version of the Policy and Procedure is the OFFICIAL
copy.08/12/17, 1:07 PM
29