CONTINUING CARE ADMINISTRATIVE MANUAL POLICY

Transcription

1 CONTINUING CARE ADMINISTRATIVE MANUAL POLICY NUMBER III-10 DATE Draft June 8, 2010 PAGE 1 OF 3 APPROVED BY: SITE: CATEGORY TITLE: Vice President & Senior Operating Officer, Rehab & Continuing Care Edmonton General, Youville Home, St. Joseph s, Lethbridge Health, Wellness and Safety Health Care Workers Exposed to Blood/Body Fluids All Covenant Health staff who sustain any blood or body fluid exposure will immediately notify the Occupational Health and Safety (OH&S) Office as outlined below: 1. During office hours, Monday through Friday, report immediately to your site Occupational Health and Safety Office with a completed Employee Incident/Injury Reporting and Investigation Form (#CH-0102). 2. At other times, complete the Employee Incident/Injury Reporting and Investigation Form, phone your site Occupational Health and Safety Office and record your name, department, source name, source date of birth, hospital number and PHN number. Then immediately proceed to an Emergency Department for follow-up.

2 COVENANT HEALTH BLOOD AND BODY FLUID EXPOSURE PROTOCOL BLOOD AND BODY FLUID EXPOSURE PROTOCOL INVOLVING CARITAS STAFF Table of Contents A. INTRODUCTION B. DEFINITIONS C. PROCEDURES 1.0 Functional Responsibilities: 1.1 Employee 1.2 Manager/Person in Charge/Resident Care Manager 1.3 Occupational Health and Safety 1.4 Emergency 1.5 Laboratory 1.6 Infectious Disease Physician 1.7 Pharmacy D. PRE-TEST CONSENT FOR BLOOD/BODY FLUID EXPOSURE (BBFE) SOURCE PATIENT E. BLOOD AND BODY FLUID EXPOSURE PROCEDURE AT THE EDMONTON GENERAL May 2005

3 A. INTRODUCTION: The Covenant Health Blood and Body Fluid Exposure (BBFE) Protocol involving Covenant Health staff has been developed to protect the health and safety of employees by: Providing an established assessment, treatment and follow up for such exposures. Defining the specific responsibilities of individuals/departments involved. A coordinated cooperative approach between these groups is essential. Establishing Occupational Health and Safety (OH&S) as a centralized location for statistical data collection regarding Blood and Body Fluid Exposures. B. DEFINITIONS: 1.0 SIGNIFICANT EXPOSURE: An exposure to blood or body fluid is significant if: The needle or sharp was contaminated with blood or body fluid and it punctured the skin of the exposed person. The blood or body fluid contacted a mucosal surface (eye, lips, mucosa of the mouth, nose, or genital area). The blood or body fluid from the source of exposure contacts open skin (cut, abrased, chapped) of the exposed person. 2.0 BLOOD OR BODY FLUIDS: This term refers to fluids which could potentially transmit Hepatitis B, Hepatitis C or HIV to the exposed person. Includes: Blood, semen, vaginal secretions, body tissue, cerebrospinal fluid, synovial, pleural, pericardial, peritoneal, and amniotic fluids. Does not include: Nasal secretions, sputum, saliva, urine, sweat, tears or vomitus, unless they contain visible blood. 3.0 SOURCE OF EXPOSURE: The individual whose blood or body fluids were involved in the exposure of the recipient. 4.0 EXPOSED PERSON / RECIPIENT: The individual receiving significant exposure to blood or body fluids from the source of exposure. 5.0 HBsAg: Hepatitis B surface antigen.

4 6.0 ANTI HBs/HBsAb: Antibody to Hepatitis B surface antigen. 7.0 HBIG: Hepatitis B Immune Globulin - a form of gamma globulin containing high titre antibodies to Hepatitis B. It is only available through the Red Cross in limited supply. 8.0 ANTI HCV/HCAb: Antibody to Hepatitis C. 9.0 Anti HIV/HIV Ab: Human Immunodeficiency Virus Antibody. C. PROCEDURES: 1.0 FUNCTIONAL RESPONSIBILITIES: 1.1 Employee: Immediately report any blood or body fluid exposure by: Reporting blood/body fluid exposure to person in charge. Completing an Incident/Injury Form Contacting OH&S at the site where the exposure occurred. During OH&S Office Hours: Report to OH&S immediately in person with the completed Incident/Injury Form. During Off Hours (Shift/Weekends/Holidays): Leave a message on the OH&S voic including your name, home phone number and the area where you work. For Edmonton General: - Contact Resident Care Manager/ARCM on duty - The Resident Care Manager/ARCM will follow the OH&S guidelines, Blood and Body Fluid Exposure Procedure at the Edmonton General Section E of this document. - Forward the Incident/Injury Form to OH&S

5 1.2 Manager/Person in Charge/Resident Care Manager (RCM): Ensure the employee is referred to OH&S or Emergency (when OH&S is closed) immediately for follow-up. Obtain informed consent for bloodwork on source of blood/body fluid exposure for Hepatitis B, Hepatitis C, and HIV. Document if consent obtained (or refused) in patient chart/health record. Notify OH&S if consent refused (See Section D The manager is to complete the investigation section of the Incident/Injury Form 1.3 Occupational Health and Safety: Maintains employee confidentiality regarding the exposure. Provides treatment, counselling and follow-up. 1.4 Emergency Department: Provides treatment. Initiates testing by completing pre-labelled requisitions for both the source of exposure and the exposed person. During off-hours the employee is seen in Emergency where a physician will order the medication. The appropriate prelabelled medication with teaching sheets will be retrieved from the Pharmacy Night Cupboard and/or Pyxis. Notifies the Infectious Disease Physician on call for Caritas if source of exposure is HIV positive or has an AIDS - related condition. A completed Blood Transfusion Service Regional Requisition is required by the OH&S nurse or Emergency Department staff to obtain HBIG from the site blood bank. Refers exposed person to OH&S for follow-up. Note: If post exposure prophylaxis medication is initiated, the exposed person is to have a CBC, AST, ALT, bilirubin (total) urinanalysis, amylase, BUN and creatinine completed. 1.5 Laboratory: Is responsible for collecting, analysing and reporting blood results as per their protocol. 1.6 Infectious Disease Physician / Occupational Health Physician: Is consulted for additional counselling and post exposure prophylaxis. 1.7 Pharmacy: Provides post exposure prophylaxis medication as per Standing Order and information sheets regarding medications. They will ensure the Pharmacy Night Cupboard and/or Pyxis is appropriately stocked.

6 D. PRE-TEST CONSENT FOR BLOOD/BODY FLUID EXPOSURE (BBFE) SOURCE PATIENT When an incident occurs a verbal informed consent from the source for testing shall be requested by, the charge nurse, or a designate. Contact OH&S if consent for testing is refused so that appropriate follow-up and referral is completed. Document request for consent and response on patient chart prior to drawing blood. Prior to drawing blood, Lab will confirm with nurse in charge if consent from patient (source) was received. Attending physician is to be informed patient is being tested. Below is suggested wording for obtaining consent for source testing. Suggested wording An incident has occurred where one of our employee s was exposed to your blood through: blood splash a needlestick other (describe incident) It is the Hospital s policy to consider ALL blood as potentially infectious and to request the permission of all patients involved in such incidents to be tested. The reason for this testing is that we need to know whether you are infectious or not, in order to provide the employee with the treatment and/or reassurance. We would like your permission to test you for Hepatitis B, Hepatitis C and HIV (the virus which causes AIDS). Results will be sent to your attending physician, the Occupational Health and Safety Office and Infection Control.

7 E. BLOOD & BODY FLUID EXPOSURE PROCEDURE AT THE EDMONTON GENERAL ν Draw 1 GOLD (SST) tube (tubes on 9Y) of blood from resident (SOURCE) test for: HBsAg HCV HIV Label tube with resident s name and SOURCE in brackets. ν Place in plastic bag with requisition stamped with Resident s name. ν For staff member (RECIPIENT) draw 1 GOLD (SST) tube of blood test for: HBsAB HCV HIV Label tube with staff member s name and RECIPIENT in brackets. If employee (RECIPIENT) is to have blood drawn at lab they can go AFTER their shift is completed and will need requisition. ν Place blood in plastic bag with requisition stamped with Employee s name. ν Place both plastic bags in lab containers at reception. ν Blood to go to Provincial Laboratory. ν Call Checker Cab or Barrel Cab Information Desk). Φ STAT pick up to go to Specimen Receiving Microbiology & Public Health Laboratory Walter MacKenzie Health Sciences Center Street, Edmonton (BILL to Account # DKML) ν If unable to collect the EMPLOYEE S blood direct the employee (with requisition), AFTER completion of shift, to Laboratory at either the GREY NUNS or MISERICORDIA. *** IF EMPLOYEE EXPOSED TO HIV POSITIVE BLOOD - Send to GREY NUNS or MISERICORDIA EMERGENCY DEPARTMENT STAT for FOLLOW-UP *** ν If the exposure occurs during the night shift the blood may be drawn from the SOURCE and verbal consent from the guardian obtained the next morning if resident lacks capacity. May 2005