Download Blood and Body Fluid Exposure Policy

Policy and Procedure Manual
SECTION:
TITLE:
POLICY#
PAGE:
EFFECTIVE DATE:
REVISION DATE:
Surveillance, Prevention and Control of Infection
Blood and Body Fluid Exposure Policy
IC.9.20
1 of 4
06/1992
03/16/2004. 5/22/2007, 12/12/08
OBJECTIVE:
To minimize the transmission of blood and body fluid infections.
Health care workers are at risk for transmitting infection to patients and/or acquiring infections from patients.
One of the most common methods for infection transmission is through blood or body fluid exposure. This
procedure will apply to all tissue and body fluids determined by the Centers for Disease Control (CDC) to be
infectious for HIV, HBV, HCV and other bloodborne pathogens. These fluids include blood, saliva, semen,
vaginal secretions, tissues, cerebrospinal fluid (CSF), synovial fluid, pleural fluid, pericardial fluid, and amniotic
fluid. Other body fluids are included if they contain visible blood.
PROCEDURE (S):
1) Provide immediate care to the exposure site.
 Wash wounds and skin with soap and water.
 Flush mucous membranes with water.
2) Evaluate the exposed employee/person.
Exposures occurring Monday – Friday 8:00 am – 5:00 pm:
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
The affected employee must immediately notify his/her Clinic Director or On-Site Manager/Provider
of the exposure. The Clinic Director/On-Site Manager/Provider refers the employee to Primary Health
Care Inc’ s occupational health services provider (Des Moines University, 3200 Grand Avenue, Des
Moines, Ia 50312). Our goal is to have our employee evaluated within 4-hours of the exposure.
Our occupational health services provider will initiate and provide follow-up treatment according to
the indicated exposure management protocol. The employee will be counseled about BloodBorne
Pathogen exposure management, the potential for transmission of HIV/HBV/HCV infection and the
precautions to consider until determination can be made that no infection transmission has occurred.
Exposures occurring outside of the normal business hours as listed above:

APPROVAL:
The affected employee must immediately notify his/her Clinic Director or On-Site Manager/Provider
of the exposure. The Clinic Director/On-Site Manager/Provider refers employee to Mercy Medical
Center Emergency Department for evaluation and treatment: 1111 6th Avenue, Des Moines, Phone: 515247-3211 / Fax: 515-643-8712. Transport (according to Policy IC 9.15) the source patient’s specimen(s)
OPERATIONS TEAM
BOARD OF DIRCTORS
DATE
DATE
02/06/2004; 04/02/2004
02/18/2004; 04/21/2004
S:\Administrative Policies & Procedures
Policy and Procedure Manual
SECTION:
TITLE:
POLICY#
PAGE:
EFFECTIVE DATE:
REVISION DATE:
Surveillance, Prevention and Control of Infection
Blood and Body Fluid Exposure Policy
IC.9.20
2 of 4
06/1992
03/16/2004. 5/22/2007, 12/12/08
and a completed “Blood and Body Fluid Exposure – Source Specimen Form” with you for the Mercy
Medical Center Clinical Lab.

Mercy Medical Center Emergency Department will initiate the indicated exposure management protocol.
Our occupational health services provider will provide any follow-up evaluation and treatment. The
employee will be counseled about BloodBorne Pathogen exposure management, the potential for
transmission of HIV/HBV/HCV infection and the precautions to consider until determination can be made
that no infection transmission has occurred.
3) Evaluate exposure source.
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Obtain specimen and test known source(s) as soon as possible for Hepatitis B Surface Antigen (HbsAg),
Hepatitis C Virus (HCV) antibody, and Human Immunodeficiency Virus (HIV) antibody - using rapid
HIV testing as available and within 4 hours of exposure.
Appropriate clinical procedures should be followed including informing the source patient about the
incident, our Blood and Body Fluid Exposure Policy, as well as counseling source patient on source
specimen testing and results.
Appropriate clinical procedures should be followed for testing source persons. Persons determined to be
infected with HBV, HCV, or HIV will be referred for appropriate counseling, evaluation and treatment.
The source patient’s specimen will be drawn, by Primary Health Care, Inc staff, and transported
(according to Policy IC 9.15) to Mercy Medical Center Clinical Laboratory within 4-hours of exposure.
Refer to Blood and Body Fluid Exposure: Form #1, “Source Specimen Form” on page ___ of this policy.
This form must accompany the specimen to Mercy Medical Center Clinical Laboratory. Please keep a
copy of the form for employee’s occupational health file.
4) This exposure protocol will be followed at no expense to either the patient or the PHC employee.
5) A separate occupational health record will be maintained for the employee and will contain information
related to management of the exposure. This record is separate from the employee’s personnel record.
6) Information regarding the source patient will be maintained in their medical record.
7) Documentation within 24-hours of exposure incident: Exposed employee will complete 1) “Report of
Exposure to Infectious Disease” which is in the “BBP Folder” in each clinic, and 2) an “Adverse Event
Report” which is available in electronic format on the Primary Health Care, Inc Intranet.
APPROVAL:
OPERATIONS TEAM
BOARD OF DIRCTORS
DATE
DATE
02/06/2004; 04/02/2004
02/18/2004; 04/21/2004
S:\Administrative Policies & Procedures
Policy and Procedure Manual
SECTION:
TITLE:
POLICY#
PAGE:
EFFECTIVE DATE:
REVISION DATE:
APPROVAL:
Surveillance, Prevention and Control of Infection
Blood and Body Fluid Exposure Policy
IC.9.20
3 of 4
06/1992
03/16/2004. 5/22/2007, 12/12/08
OPERATIONS TEAM
BOARD OF DIRCTORS
DATE
DATE
02/06/2004; 04/02/2004
02/18/2004; 04/21/2004
S:\Administrative Policies & Procedures
BLOOD AND BODY FLUID EXPOSURE: Form #1
*SOURCE SPECIMEN FORM*
____________________________________________________
(Patient Name)
___________________________
(PHC Medical Record #)
Instructions to Employee/Manager:
Specimen Collection and Delivery Instructions:
 Obtain one lavender-top tube and one red-top tube from the source patient.
 Deliver to Mercy Medical Center Clinical Laboratory with this form ASAP.
o Mercy Medical Center Clinical Laboratory: (ph) 515- 247-4439.
o Location: Mercy Medical Center: 1111 6th Avenue, Des Moines. Enter through main entrance, on University
Avenue, walk past the gift shop and information desk, there is a sign directing you to the Laboratory.
o If Larry/PHC Transport is not available, another staff should assume transport responsibility.
 If there are any questions, please contact Mercy Medical Center Clinical Laboratory (515-247-4439) or contact
Laboratory Supervisor; Kim Kirkpatrick (515-643-2251).
** In event of “after hours” exposure** Instructions for Mercy Medical Center Emergency Department Staff:

This employee is being referred by Primary Health Care, Inc. for initial management of a blood or body fluid
exposure. The source specimen accompanies this form and will be taken to the Mercy Medical Center Clinical
Laboratory for testing. Mercy Medical Center’s exposure policy should be followed. If you have any questions
regarding management of this individual, please contact Pamela Arnold Powers, RN, ND, Infection Control Coordinator
for Primary Health Care, Inc. (515-248-1464).
Instructions to Mercy Medical Center Clinical Laboratory Staff:
Tests to be Performed: Laboratory Tests to be performed on source patient (please circle appropriate HIV test):
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
Hepatitis B Surface Antigen
Hepatitis C Antibody
HIV Antibody Test or HIV Antibody Rapid Test (Rapid test is indicated if source is tested within 4 hours of
exposure)
Ordering Physician: ____________________________________________________________
Reporting Results:
 Please call results to Pamela Arnold Powers, RN, ND, Infection Control Coordinator as soon as they are available
(515-248-1464).
Instructions for Billing of Services: Send billing invoice and hard copy of lab results as soon as possible to:
Primary Health Care, Inc.
Attention: Erin Baldwin, Operations Director
9943 Hickman Road, Suite 105
Urbandale, Iowa 50322
If our employee is evaluated in the Mercy Medical Center Emergency Department, Primary Health Care, Inc. will be considered
the guarantor. Billing information as above.