Needlestick or Bloodborne Pathogen Exposure Protocol

Follow the steps listed below if a student, staff or faculty member has a:

  • percutaneous injury (needlestick or cut) from a contaminated instrument.
  • mucous membrane (splash to eye, nasal mucosa or mouth) exposure to body fluids

Protocol

  1. Immediately wash the exposed area with soap and water. Mucous membranes should be flushed with water or sterile saline for 10 minutes.
  2. Inform the source patient of the incident without revealing the identity of the exposed individual. Keep the source patient in the clinic until they have been asked to consent for a blood draw at NUNM. (The lab has a standing order for post-exposure testing AT NO COST to the source patient.)
  3. Immediately report the exposure to the supervising faculty member or employee’s supervisor.
  4. The supervisor must fill out an online Incident Report. Choose Bloodborne Exposure Report under Reporter Type. Include the route of exposure and the source individual, if known.
  5. The supervisor must also immediately call the Exposure Control Officer (Chief Medical Officer) with the exposed student/staff/source individual’s names and phone numbers. Please use the following information to contact our Exposure Control Officer:
    • Name: Dr. Regina Dehen
    • Office: 503-552-1966
    • Cell: 503-380-7694
    • Email: rdehen@nunm.edu
  6. If the exposure occurs during NUNM Health Centers business hours, send the student/staff and source individual to the NUNM Lab to have their blood drawn immediately or as soon as possible.
    1. Download, print and provide the source patient with Form B and the exposed patient with Form C (Consent for Laboratory Testing). If the source patient or exposed individual refuses to consent to having their blood tested, document any contact/conversation and include it in the incident report.
    2. The HIV test is done in house and the results are back within 30 minutes.
    3. The hepatitis panel will be sent out and results are back within 2-4 days.
  7. If the exposure occurs when the NUNM Lab is closed, or at an off-site facility and the patient is unable to get to the NUNM Lab, give the student/staff and source individual the Off-Site Testing Form (D) instruction sheet. Ask the student/staff/source individual to present the form to the front office personnel at an urgent care center or emergency department for a blood draw at no cost to themselves as soon as possible.
  8. The student, staff or faculty member is requested to return to the lab at 2 weeks, 6 weeks, 3 months, 6 months and 1 year following the incident for follow-up free HIV and Hepatitis panel testing (OSHA panel follow-up).
  9. Lab results are sent to the Exposure Control Officer and kept on file.
  10. All HIPAA and, in the case of student exposure, FERPA rules regarding confidentiality of the source patient’s and NUNM student, staff or faculty member’s protected health information will be followed.
  11. The Exposure Control Officer will confirm that the Human Resources Director records the incident in the “Log of Work-Related Injuries and Illnesses” in the NUNM OSHA manual.
  12. The Exposure Control Officer will conduct follow-up procedures and review the test results with the exposed student/staff/source individual. The student/staff/source individual may begin post-exposure prophylactic treatment with the provider of their choice. The Exposure Control Officer will explain all options to the exposed student/staff/source individual.

Refusal of Medical Evaluation, Exposure Testing and Post-Exposure Prophylaxis

If the student, staff or faculty member refuses to be tested, he/she must download and fill out the Medical Evaluation Refusal Form (E) and make 2 copies. They should keep the original and give one copy to the Exposure Control Officer (Dr. Regina Dehen). Students should give the second copy to the Dean of Students. Employees should give the second copy to the Director of Human Resources.

Updated 2016-Sept-28
Adopted from the US Dept of Labor OSHA