Post Blood & Body Fluid Exposure Checklist

Transcription

1 Post Blood & Body Fluid Exposure Checklist Employee Name: : First Aid completed (If exposure was to eye, irrigate for 20 minutes at the nearest eye wash station. If exposure was to skin, wash affected area with soap and water). Supervisor or PCC notified of exposure/assisting with paperwork found on KWeb (within the HURT Form) OR in red exposure packet. HURT form filled out on KWeb OR call made to HURT line (ext 4878) RN/PCC notify Source of occurrence and give written education regarding HIV test (counseling). Written consent obtained from Source. RN/PCC initiates Source lab testing. Employee notified of source HIV status within one hour. Employee consent completed. To complete lab testing employee must register with Patient Access before presenting to the lab window. If after hours, register with operator. Employee Exposure Risk Assessment completed and returned to Kadlec Employee Health Clinic (KEHC). Supervisor s Incident Report form completed and returned to KEHC. Upon receipt of lab results (3-4 days), employee will be notified by KEHC to make an appointment with the Occupational Healthcare Provider for follow-up. This appointment will go over additional forms (provided at appointment): This checklist Alternate Form for Employee Exposure Health Care Professional s Written Opinion OSHA Facts Sheet Follow-up exams/labs will be done at 3/6/12 months from date of exposure. KEHC will contact Employee when it is time for the follow-up labs. Signature of Exposed Employee Signature of PCC or Supervisor FOR OCCUPATIONAL HEALTHCARE PROVIDER USE ONLY: Labs for employee & source have been received Green Alternate Form for Employee Exposure completed Employee Exposure Risk Assessment completed Health Care Professional s Written Opinion completed & copy provided to employee. Forms sent to HR Generalists at Kadlec

2 Consent Form HIV Consent: To be used in the management of Blood Borne Pathogen exposures for KRMC. AKNOWLEDGEMENT AND CONSENT FOR HIV ANTIBODY BLOOD TEST I acknowledge that I have been informed by a PCC, Nurse Manager, or HCP that my blood will be tested in order to detect whether or not I have antibodies to the human immunodeficiency virus (HIV) which is the causative agent of acquired immune deficiency syndrome (AIDS). I understand that the test is voluntary and that it is performed by withdrawing blood and testing it for the presence of antibodies to the HIV virus. I understand that I have the right to consent or refuse testing. I acknowledge that I have been informed that the test involves a two step process and that two separate tests may be used to determine the presence of HIV antibodies in my blood. I understand that there is a possibility of false positive, false negative, or inconclusive test results and that more testing at a future date may be needed to rule out HIV infection. I acknowledge that I have been informed that any questions I have regarding the nature of the blood test, its expected benefits, its risks, or alternative tests may be asked before I consent to the blood test. I have had the opportunity to ask questions regarding this procedure and my questions have been fully answered. I understand that the results of this blood test will only be released to the persons directly involved in my care and treatment, and to other persons only as required by law. I further understand that no additional release of the results will be made without my express written authorization. Employees: I understand that I am not permitted to release the results of testing done on a patient as part of follow-up for an exposure. By my signature below, I acknowledge that I have been given all of the information I desire concerning the blood test and release of the results. I hereby give my consent to the performance of a blood test to detect antibodies to HIV. : Time: Signature of Employee Print Name Witness (PCC/Nurse Manager/HCP): : Time: Signature SEND TO EMPLOYEE HEALTH

3 Patient Label Here 888 Swift Boulevard Richland, WA (509) Please take this form to the hospital lab. KRMC/KMA/KC/KNC/OTHER: EXPOSURE LAB ORDER SLIP KADLEC REGIONAL MEDICAL CENTER Client: OCCUPATIONAL HEALTH EXPOSURE LAB REQUEST X Initial KRMC KMA KC/KNC Other NAME: BIRTHDATE: BILL TO: SPECIAL CONTRACT-KRMC OCC HEALTH DATE OF INJURY/EXPOSURE: Name of Source: Please complete the following tests: EXPOSURE PANEL 12HIVR HBSAB HBSAG HBCAB HEPC ALT/AST Employee Occupational Health Clinic ext.4179, Fax:

4 SUPERVISOR'S INCIDENT REPORT Department Name: PART I -- TO BE COMPLETED BY SUPERVISOR OR PCC Supervisor's Name: NAME OF EMPLOYEE: OCCUPATION: Employee ID# DATE OF INJURY: TIME OF INJURY: AM/PM LOCATION: DATE REPORTED: TIME REPORTED: AM/PM REPORTED TO WHOM: HOME MAILING ADDRESS: HOME OR CELL PHONE: [ ] MALE [ ] FEMALE DATE OF HIRE: TIME EMPLOYEE BEGAN WORK DATE OF BIRTH: AM/PM SUPERVISOR/PCC - DESCRIBE IN DETAIL WHAT EMPLOYEE WAS DOING JUST BEFORE THE INCIDENT OCCURRED. DESCRIBE THE ACTIVITY, AS WELL AS THE TOOL, EQUIPMENT, OR MATERIAL THE EMPLOYEE WAS USING (add add'l pages as needed). Supervisor/PCC- How did the injury occur? [ ] Defective Material [ ] Warning signs Disregarded [ ] Sickness [ ] Weather Conditions [ ] Protective Equipment Not Available [ ] Fatigue [ ] Unsafe Storage [ ] Protective Equipment Not Used [ ] Toxic/Hazardous Substance [ ] Lack of Policy/Procedure [ ] Horseplay [ ] Illumination [ ] Other-Explain [ ] Patient SUPERVISOR - IF PATIENT LIFTING INJURY: What day of the w eek did the injury occur?: Was lifting equipment used? [ ] Yes [ ] No If no, w hy not?: Was the lift facilitator called? [ ] Yes [ ] No If no, w hy not?: SUPERVISOR/PCC - WHAT ACTION HAS OR WILL BE TAKEN TO PREVENT REOCCURRENCE? [ ] Developed Safety Procedure [ ] Employee Counseled [ ] Personal Protective Equipment Ordered [ ] Requested Assistance in Resolving Unsafe Situation [ ] Safety Training Scheduled [ ] Equipment Placed Out of Service for Repair or Replacement [ ] Warning Signs Ordered [ ] Other (Explain) SUPERVISOR/PCC - DID THE EMPLOYEE PHONE THE HURT-LINE? [ ] Yes [ ] No INDICATE WHY EMPLOYEE DID NOT PHONE THE HURT-LINE: PART OF BODY (CIRCLE SIDE IF APPLICABLE) [ ] Head [ ] Hand (L or R) [ ] Knee (L or R) [ ] Eyes (L or R) [ ] Finger [ ] Abdomen [ ] Nose [ ] Leg (L or R) [ ] Entire [ ] Mouth [ ] Foot (L or R) [ ] Glasses [ ] Ear [ ] Toes [ ] Teeth [ ] Shoulder (L or R) [ ] Internal [ ] Groin [ ] Back [ ] Multiple [ ] Neck [ ] Chest [ ] Ankle (L or R) [ ] Elbow (L or R) [ ] Arm (L or R) [ ] Wrist (L or R) [ ] Rib [ ] Hip [ ] Face MARK INJURED AREAS ABOVE Supervisor/PCC: : PART II -- TO BE COMPLETED BY EMPLOYEE Employee statement of how incident occurred, including w itnesses and how it could have been avoided (add add'l pages as needed): What w ere you doing just before the incident occurred? MEDICAL RELEASE AUTHORIZATION: I hereby authorize my physician, clinic, hospital, agency, HMO netw ork, or therapy provider to release my employer's representative any medical records regarding current or previous treatment(s) that has been furnished to me. Employee's Signature: :

5 EMPLOYEE INFORMATION: Name of employee Occupational/department Address of Birth Phone number Employee Exposure Risk Assessment Today s : of exposure Time of exposure (circle one) am pm SOURCE PATIENT INFORMATION (person whose blood the employee was exposed to) (Place Sticker Here) CHARACTERISTICS OF SOURCE MATERIAL (Check one): Infectious Non-infectious (without visible blood)* Blood or serum *(If exposure to material in this column, Other infectious material post-exposure prophylaxis for HIV is not Fluid or tissue with visible blood recommended unless there is visible blood.) Amniotic fluid Saliva Cerebrospinal fluid Sputum Pericardial fluid Stool Peritoneal fluid Sweat Pleural fluid Urine Semen Vomitus Synovial fluid Vaginal secretions CHARACTERISTICS OF SOURCE PATIENT (Check one Category) (Category 1) HIV Positive asymptomatic or known low viral titer (Category 2) HIV Positive symptomatic with acute retro viral syndrome (infected within past few weeks and mononucleosis like illness) (Category 3) HIV Positive preterminal, CD4 <100 or viral titer >50,000 (Category 4) HIV Serostatus unknown Review chart to determine if patient has any of the following risk factors [circle all that apply]: male homosexuality, injecting drug use, prostitution, sex with known HIV positive person, sex with injecting drug user, blood component transfusion between (Category 5) HIV Negative* (Category 6) Patient unknown (anonymous needle)* *Note: If category (5) or (6) post-exposure prophylaxis for HIV is not recommended. CHARACTERISTICS OF EXPOSURE (Check one Type) Percutaneous injuries: (Type A) Visibly bloody device or device used in source patient s Type of Sharp artery or vein Safety device used (Type B) Deep intramuscular injury No safety available (Type C) Superficial injury Mucosal contacts: (Type D) Large volume (>1cc) or prolonged contact (>5 minutes) PPE used (Type E) Small volume (<1cc) and brief contact (<5 minutes) Skin contacts: (Type F) Skin integrity obviously compromised or large volume (>1cc) or prolonged contact (>5 minutes) or extensive area of contact (Type G) Intact skin, small volume (<1cc) and brief contact (<5 minutes) *Brief description of incident: - BRING TO OCCUPATIONAL HEALTHCARE PROVIDER EXAM