Exposure Control Plan for Bloodborned pathogens

OECP - 107.00
MANAGEMENT OF EMPLOYEE EXPOSURE TO BLOOD AND BODY FLUIDS POST-EXPOSURE EVALUATION AND FOLLOW-UP

Employee Responsibilities
The following steps are to be followed by the employee when s/he has experienced an exposure to blood or body fluids via a needlestick, cut or puncture wound, a mucous membrane splash or a cutaneous exposure (as described in OECP-106.00 "HBV and HIV Exposure Information"), especially if the skin is broken.
1. Wash the exposed site immediately.
  1. If needlestick, cut, puncture wound or cutaneous exposure, wash with soap and water.
  2. If mucous membrane (eyes, nose, mouth) splash, flush with water at the nearest faucet for at least 3 minutes.
2. Employees should immediately inform their immediate supervisor who will inform the CEHS.
3. Employees must fill out a "Bloodborne Pathogens ExposureReport" form (Attachment 2, obtained from a supervisor), describing the incident in detail, including route of exposure and a description of the employee's duties as they relate to the exposure incident. Include information about the source patient, if known (name, address, phone number).
4. Employees must also fill out a University Injury Report obtained from Personnel or a supervisor. Describe the incident as an "exposure to blood and body fluids".
5. Employees must take the completed Bloodborne Pathogens Exposure Report and the University Injury Report to the SIU Health Service or other healthcare professional for post-exposure evaluation.
6. Seek medical attention at the Health Service (453-3311) if open. Contact the Dial-A-Nurse (536-5585) at other times. If neither the Health Service nor Dial-A-Nurse is available, seek attention from Memorial Hospital of Carbondale Emergency Room (549-0721) or any other appropriate health-care provider.
Employer (SIUC) Responsibilities
1. The CEHS will determine whether the exposure is of a nature that may transmit HBV or HIV.
2. The CEHS shall contact the source individual and request that s/he have blood drawn at the Health Service for HBV and HIV tests. If blood is already available at the Health Service, no consent is necessary for HBV or HIV tests to be done.
3. Test results will be sent to the Health Service Medical Director. Neither the exposed employee nor the source individual will be charged for testing.
4. The CEHS shall ensure that the following are provided to the Health Service or other healthcare professionals for post-exposure evaluation:
  1. A copy of this OECP and "Occupational Exposure Regulations"(Appendix 2);
  2. A description of the exposed employee's duties as they relate to the exposure incident;
  3. Documentation of the route(s) of exposure and circumstances under which exposure occurred;
  4. The employee's vaccination status, the identity of the source individual, and the results of the source individual's blood tests, if already available.
5. CEHS shall notify Personnel of every exposure/incident using the University Injury Report Form.
6. Counseling regarding possible HBV or HIV exposure and follow-up testing shall be offered to all employees receiving an exposureto blood/body fluid if determined to be of a nature that may transmit HBV or HIV. Counseling will be done by the Health Service. If the employee received care from a healthcare provider other than the Health Service, CEHS will ensure that counseling and follow-uptesting will be provided.
  1. Hepatitis B vaccine shall be offered to any employee who has not been previously vaccinated. Vaccination is strongly urged for employees in occupationally high-risk groups.
  2. HIV counseling and testing are offered as soon as possible after exposure.
7. Results of the source individual's testing shall be made availableto the exposed employee, and the employee shall be informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source patient.
8. The exposed employee's blood shall be collected as soon as feasible and tested for HBV and HIV serological status after consent is obtained (Attachment 3 Employee Consent for HIV Antibody Testing). Counseling shall be provided as outlined in Attachment 4 "CounselingChecklist for Blood and/or Body Fluid Exposure."
  1. If the employee refuses testing, this fact shall be so documented in the record by the CEHS and counter signed by the employee (see Attachment 3).
  2. If the employee consents to baseline blood collection but does not consent at that time for HIV serological testing, the sample shall be preserved for at least 90 days. If, within 90 days of the exposure incident, the employee elects to have the baseline sample tested, such testing shall be done as soon as feasible.
9. If the source individual is known to be seropositive for hepatitis B or HIV, the CEHS shall ensure that the employee obtains immediate and follow-up medical treatment through SIUC or from his/her personal physician. Retesting of the source individual is not required.
10. If the source individual is seropositive for hepatitis B, the employee will also be given a Hepatitis B Exposure Information form (Attachment 5). Retesting of the source individual is not required.
11. The evaluating healthcare professional shall provide his/her opinion in the employee's confidential health record (Attachment7), and a copy will be provided to the employee and to CEHS, all within 15 days after the evaluation. This written opinion shall be limited to the following information:
  1. The healthcare professional's recommendation as to whether hepatitis B vaccination is indicated and whether the employee has received such vaccination.
  2. A statement that the employee has been informed of the results of his/her evaluation and has been told of any medical conditions resulting from exposure to blood or other potentially infectious materials which require further evaluation or treatment.
  3. All other findings and diagnoses shall remain confidential and shall not be included in the written report.
12. On a quarterly basis CEHS will submit a report to the Biohazards Oversight and Advisory Committee on the number and types of exposures, location, number of source individuals tested, and results, prophylaxis provided and number of positive results for HIV and hepatitis B testing.
13. The CEHS will report seropositive results to the State Health Department as required by law.