Greater Dayton Hospital Association and Greater Miami Valley EMS Council Infectious Disease Exposure Reporting Policy Template

A. PURPOSE

This document provides public safety personnel (including fire, EMS, and law enforcement) and hospitals with a set of standard guidelines and expectations for defining, responding to, and following up on an infection control exposure incident involving an emergency response provider.

B. BLOODBORNE EXPOSURE

  1. DEFINITION OF A BLOODBORNE EXPOSURE

    An EXPOSURE incident that may place a public safety worker at risk for Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), or Human Immunodeficiency Virus (HIV) infections or other blood borne pathogens that includes:

    What is NOT an exposure?

    1. A percutaneous injury (e.g., a needle stick or cut), or

    2. Contact of mucous membrane or non-intact skin (e.g., exposed skin that is chapped, abraded,

      or afflicted with dermatitis) with blood, tissue, or other body fluids that are potentially infectious.

    3. A percutaneous injury with a clean or sterile needle or instrument.

    4. Intact skin splashed with potentially infectious blood, body fluid, or tissue.

  2. POST EXPOSURE PROCEDURE

    1. An exposed public safety worker should take the following immediate “first aid” action steps:

      •  Immediately irrigate the involved area.

      •  Flush eyes with copious amounts of IV fluids, if indicated.

      •  Wash skin vigorously with soap and water. If soap and water is not available, rinse area

        with another available solution such as IV fluids or a water-based liquid. Waterless hand cleaners are not recommended for post-exposure gross decontamination, but can be used when other options are not available.

    2. Employee shall report the exposure incident to the receiving hospital and to their immediate supervisor.

    3. Exposed employees are REQUIRED to register as a patient at the receiving hospital (same receiving hospital as the source).

    4. Once at the receiving hospital, the exposed employee should locate and complete the “Request for Information by Emergency Care Workers (RIECW)” form (see Appendix A). When completed, the form should be submitted to the nurse handling the exposed employee’s care in the Emergency Department (ED).

    5. The EMS Coordinator for the receiving hospital can serve as a liaison between the organization and the hospital. The department’s infection control officer (ICO) or designated supervisor 1should, upon receiving notification that there has been an exposure incident, notify the receiving hospital’s EMS Coordinator.

    6. Follow-up care/exam(s) will be provided to each employee involved when indicated. All follow-up care/exam(s) will be coordinated through your employer.

  3. TESTING THE SOURCE PATIENT

    1. A blood sample is required to determine whether a patient has HIV, HBV or HCV. Blood/Body Fluid (B/BF) testing of a source patient includes the following (MMWR, June 29, 2001):
      * HIV antibody
      * HBV surface antigen (HBsAg)
      * HCV antibody

    2. If the source patient is TRANSPORTED to a hospital:

      1. 1)  The ED obtains patient consent and the blood specimen for testing.

      2. 2)  In the event that the patient refuses to or cannot give consent (e.g., due to an altered level of conscious) a hospital’s “infection control committee... or other body of a health care facility performing a similar function” has the authority to obtain the HIV screening

        when there has been a significant exposure (Ohio Revised Code §3701.242).

    3. If the source patient REFUSES TRANSPORT to a hospital:

      1. 1)  If the patient refuses to give consent for blood sampling and refuses transport, the public safety worker must follow up with their ICO or designee. At this point it is a legal matter to obtain the source patient’s blood for testing (Ohio Revised Code §3701.247). Following a significant exposure in which the source patient refuses to provide a blood sample and refuses transport, the employee should seek immediate medical evaluation and counseling for themselves (MMWR, Sept. 30, 2013).

      2. 2)  In cases where the patient refuses transport, or in exposure incidents where the source patient is unknown, an exposed employee should follow the steps outlined in Section 5- Patients Not Transported to a Hospital.

      3. 3)  EDs or hospitals will not run source patient blood samples if the source patient is not a patient at their hospital.

  4. SOURCE PATIENT (TRANSPORTED TO HOSPITAL) RESULTS

    1. Hospital-run HIV test results should be available within an hour (may be longer for “stand alone” or smaller EDs); HBV and HCV results may not be available for several days.

    2. The exposed employee is expected to remain a patient in the ED until they have received the results of the rapid HIV test and any additional counseling from the attending physician.

    3. The employee is expected to communicate his/her follow-up needs to your department’s ICO or designated supervisor.

    4. Written notification of positive test results shall be provided directly to the affected employee by the hospitals designated infection control point of contact within three (3) days after oral notification (Ohio Revised Code §3701.248).

    5. Confidentiality of the source patient and public safety worker information shall be maintained at all times. Only information pertaining to source patient results will be released to the organization’s ICO or designee and/or an employee who is still present in the ED as described above. The department ICO or designee and the public safety worker shall not disclose any medical information publicly about the source patient.

  5. PATIENTS NOT TRANSPORTED TO A HOSPITAL BY EMS

    1. Employees should notify their immediate supervisor, and their immediate supervisor should notify the organization’s ICO or designee. Federal regulations dictate that, “following report of an exposure, the employer shall make immediately available to the exposed employee a confidential medical evaluation and follow-up” (OSHA 29 CFR, 1910.1030(f) (3)).

    2. Exposed employee should be directed to any ED for treatment.

    3. Employee shall locate, complete, and sign the Request for Information by Emergency Care Workers (RIECW) Form (Appendix A), which should be available, completed, and submitted to the nurse handling care in the ED.

    4. If the public safety worker is aware that the patient went to an ED by other means, the employee’s supervisor may call the ED charge nurse of the patient’s destination and notify them of the exposure, with a request to obtain baseline testing of the source patient. The written Request for Notification of Test Results shall be faxed to the ED charge nurse as soon as possible by the employee or the department’s ICO.

  6. PROPHYLAXIS FOR BLOOD/BODY FLUID EXPOSED PUBLIC SAFETY WORKER

    1. Post-exposure prophylaxis (PEP) treatment may be offered to the public safety worker by the ED or workplace health provider in accordance with current clinical guidelines and local PEP protocols. Additionally, the employee may wish to consult their personal physician.

      1. 1)  The decision to take PEP includes a risk-based assessment based on known or unknown source patient and type of exposure.

      2. 2)  Employees receiving PEP treatment should be followed up within 72 hours of starting treatment.

      3. 3)  The PEP treatment decision should consider laboratory results when available.

    2. HIV prophylaxis:

      1. 1)  Decisions about chemoprophylaxis can be modified if additional information becomes available.

      2. 2)  Public safety workers must register as ED patients to receive HIV prophylaxis from the hospital.

      3. 3)  HIV PEP should be started as soon as possible.

      4. 4)  Consideration should be given by the ED for expert consultation and guidance on HIV

        PEP (e.g., infectious disease physician, MMWR, 2011) or the National Clinicians’ Post

        Exposure Prophylaxis Hotline @ #888-448-4911).

      5. 5)  Counseling should be made available through the agency's employee assistance program

        (EAP) or by contractual agreements. Hepatitis Prophylaxis:

    3. Hepatitis Prophylaxis

      1. 1)  Hepatitis Prophylaxis is dependent on the public safety worker’s vaccine status. A small percentage of immunized individual’s protection from the vaccine declines over time, which may require Hepatitis B Immunoglobulin (HBIG) and additional doses of the Hepatitis B vaccine to protect against both the current exposure and future exposures. The results of the HBV Surface Antibody test will demonstrate the employee’s immunity to HBV, but are not typically given in the ED as the results of the HBV Surface Antibody test are usually not available immediately. Employees must follow up with his/her organization’s workplace health provider for related prophylaxis as soon as possible.

      2. 2)  There is no prophylaxis for HCV at this time. In cases of positive source HCV results, the employee should follow up with his or her workplace health provider for medical evaluation and care.

  7. PUBLIC SAFETY WORKER BASELINE TESTING

    1. Baseline testing of the exposed public safety worker is the employee’s choice. Agencies should maintain signed statements of employees who decline baseline testing/evaluation at the time of an exposure.

    2. Baseline testing is the term given to the set of initial laboratory tests that should be drawn on an exposed employee. This data may be used to compare future assessments in determining if an infectious disease was contracted. Baseline testing is not emergent; however, evaluation for PEP as discussed above should be considered urgent and care sought immediately.

    3. In cases where PEP was determined not an appropriate emergency treatment, the public safety worker should seek follow up care as instructed. This follow up should be by the organization’s workplace health provider. This follow up should optimally occur the next day and no later than seven days post exposure (MMWR, 2001).

    4. In cases where the source patient testing is negative but the public safety worker still wants further testing, the employee is encouraged to follow up with their private physician or your department’s workplace health provider.

    5. Public safety worker baseline testing includes at minimum:

      1. 1)  HIV antibody

      2. 2)  Hepatitis B surface antibody

      3. 3)  Hepatitis B surface antigen

      4. 4)  Hepatitis C virus antibody

C. RESPIRATORY EXPOSURE

  1. Respiratory exposure is defined as contamination with an infectious agent through the respiratory tract. This occurs via one of two routes (CDC, Rationale for Isolation Precautions in Hospitals, 1996):

    1. Via airborne infectious agents with small-particle residue [5 μm or smaller] of evaporated droplets containing microorganisms that remain suspended in the air for long periods of time (example is tuberculosis, rubella, and varicella virus).

    2. Via droplet infectious agents which are propelled a short distance (less than three feet) through the air by coughing or sneezing: these droplets are acted upon rapidly by gravity (examples are meningitis, pertussis and influenza).

  2. Respiratory exposures may not be immediately known by the public safety worker, especially if the patient is not overtly symptomatic.

  3. IMMEDIATE ACTIONS OF THE AIRBORNE-EXPOSED PUBLIC SAFETY WORKER

    1. Don PPE as soon as possible at the scene or during transport if the patient is known to have a respiratory infection or is coughing or spraying secretions.

    2. If secretions are splashed or coughed into the eyes or other mucous membranes, flush with copious amounts of IV fluids as soon as possible.

    3. The public safety worker who suspects a respiratory exposure or is notified of such an exposure should:

      •  Notify the department ICO that an exposure occurred

      •  Notify the ED charge nurse of the exposure upon delivery of the patient

      •  Complete the Request for Notification of Test. In these cases being checked in as an ED patient may or may not be necessary.

        Upon receipt of the source patient’s diagnosis, follow-up care and prophylaxis may be necessary for those exposed. At this point exposed employees may have to return to the receiving hospital and be checked in as a patient to receive care. In other situations follow-up care and prophylaxis may come from your department’s workplace health provider.

  4. PROPHYLAXIS FOR THE AIRBORNE-EXPOSED PUBLIC SAFETY WORKER

    1. If an exposed employee needs prophylaxis, prophylaxis should be coordinated thru the receiving (or notifying) hospital or when immediately available at the department’s workplace health provider’s clinic.

  5. TESTING THE SOURCE PATIENT

    1. Source testing for respiratory exposures is done by the hospital based on patient symptoms.

  6. SOURCE PATIENT RESULTS

    1. The hospital ICO or designee will notify the department ICO or designee of the infectious agent as soon as possible after symptoms of clinical presentation, or within 48 hours of a positive infectious agent determination.

    2. Your organization’s ICO, possibly after consulting with your department physician, will assess the potential exposure of the employee based on the interaction history with the source patient and the agent involved.

    3. Confidentiality of source patient and the employee’s information shall be maintained at all times. Only information pertaining to source patient results will be released to the department’s ICO.

D. BLOOD or BODY FLUID & AIRBORNE EXPOSURES BY CORONER’S CASES

  1. In cases where there is a public safety worker exposure during resuscitation efforts, it is recommended that crews transport the patient to the hospital where source testing can be performed, rather than follow field termination procedures. However, in some incidents, exposure of a public safety worker may occur from a deceased victim who must remain at a scene for a period of time pending a coroner’s investigation.

  2. Immediate actions of the exposed provider:

    1. Decontaminate self as described in previous sections.

    2. Notify the department ICO or designee that the exposure occurred.

    3. At the direction of the department ICO or designee, seek treatment at an ED or at your

      organization’s workplace health provider.

    4. Consider prophylaxis based on the index of suspicion.

  3. Actions of the ICO or designee:

    1. The Coroner or Coroner’s Investigator shall be notified as soon as possible by the department’s ICO or designee that an exposure has occurred.

    2. A Request for Information by Emergency Care Workers form (Appendix A) shall be forward to the Coroner’s Office as soon as possible after notification.

  4. Testing the source patient:

    1. The Coroner shall make every effort to test a source patient by the next business day of being notified of the exposure. In some cases, the Coroner may elect to send a specimen to an outside lab for testing. The public safety worker shall not wait for testing results from the Coroner to seek medical evaluation.

  5. Source patients test results:

    1. The Coroner or Deputy Coroner shall notify the department ICO or designee of source patient test results as soon as possible. Oral notification of source HIV status (positive or negative) shall be provided to the department ICO or designee within two days of test results, and written notification of positive test results shall be provided within three days after oral notification (ORC §3701.248).

 

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