COLLEGE POLICIES AND PROCEDURES
MEMORANDUM NO. 308

INFECTIOUS AGENT AND
BLOODBORNE PATHOGEN EXPOSURE POLICY

Revised: November 17, 2008

Purpose and Definition
The purpose of this policy is to describe the management of incidents of exposure to bloodborne pathogens that involve Community College of Philadelphia faculty and staff, during the time when they are performing their work activities and for students when they are participating in College activities related to their educational coursework.

Bloodborne pathogens are microorganisms that are present in human blood or other potentially infectious material and can cause diseases in humans (e.g., Hepatitis B, Hepatitis C, and HIV).
 
An “exposure” that may place an individual at risk to bloodborne pathogens is defined as a percutaneous injury (e.g., a needle stick or cut with a sharp object), contact with airborne droplets (e.g., tuberculosis), direct contact or prolonged contact with mucous membranes or contact with skin (especially when the exposed skin is chapped, abraded, or afflicted with dermatitis, or the contact is prolonged or involving an extensive area) with blood, tissues, or Other Potentially Infectious Materials (OPIM) that may result from faculty, staff, and students performing their duties.

Other Potentially Infectious Materials (OPIM) refers to the following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids; any unfixed tissue or organ (other than intact skin) from a human; HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions.  Non-intact skin includes skin with dermatitis, hangnails, cuts, abrasions, chafing, acne, etc.

Policy Statement

In accordance with the Federal Occupational Safety and Health Administration (OSHA) and Centers for Disease Control (CDC), the following describes the Community College of Philadelphia’s policy developed to manage, record, document, and suppress exposures.

PROTOCOLS FOR STUDENT AND EMPLOYEE INJURY AND EXPOSURE


Faculty, staff or students exposed to an infectious agent or bloodborne pathogen must comply with this Infectious Agent and Bloodborne Pathogen Exposure Policy.   In this Policy, any person (e.g., employee, student, attending clinician, contract worker, security guard, housekeeping personnel) whose activities place them in contact with an individual’s blood [e.g., human immunodeficiency virus (HIV)], airborne pathogens (e.g., mycobacterium tuberculosis) or other body fluids either on campus or at an approved clinical or laboratory setting off campus must abide by this policy.  This policy also includes contact as a representative of the College to clients on campus requiring first aid.

An exposure to an infectious agent will be managed according to the following procedures:

 

ON-CAMPUS AND OFF-CAMPUS INCIDENTS AT APPROVED CLINICAL SITES

  1. An injured or exposed student, faculty member or staff member must report the incident immediately to his/her supervisor.  Students must also report the incident to their Faculty Instructor.
  2. Immediate first aid should be administered as follows:

Needle stick injury or cut with contaminated object - Wash the affected area immediately with disinfectant soap and water, followed with treatment as wound indicates.

Splashes to Skin, Nose, Mucous Membranes or Mouth - Flush with copious amounts of water for at least 3 minutes.

Splashes to the Eyes - Irrigate with copious amounts of clean water, saline, or sterile irrigants for at least 3 minutes.

STUDENT AND EMPLOYEE PROTOCOL FOR BLOODBORNE PATHOGEN INCIDENTS

Any student or employee who has a potential bloodborne pathogen injury must seek treatment within two hours of exposure.  The following highlights the procedures for students and employees to follow for any suspected or actual bloodborne pathogen injury.

The College uses the services of Worknet Occupational Medicine Facility to treat students and employees who have a suspected or actual bloodborne pathogen injury.  They are located on the ground floor of Hahnemann Hospital, Broad & Vine Streets, Philadelphia, PA.  Their operating hours are from 7:30 a.m. to 5:00 p.m., Monday thru Friday.  They provide a free van shuttle service during the hours listed above. 


STUDENT PROTOCOL:
FACULTY/STAFF PROTOCOL:
WorkNet will provide appropriate medical care at the first visit and for one follow-up visit. Blood tests will be performed at the first visit to screen for appropriate bloodborne illnesses. WorkNet will also contact the source patient for necessary testing. The cost of the first visit, one follow-up visit and blood tests will be paid by the College. If medication is recommended by the attending physician, the cost of this medication is to be paid by the individual. WorkNet will provide appropriate medical care that will be covered under the College’s Workers’ Compensation Program.  Blood tests will be performed at the first visit to screen for appropriate bloodborne illnesses.  WorkNet will also contact the source patient for necessary testing.  The cost for all visits, blood tests and medication will be paid through the College’s Workers’ Compensation Program.
On-Campus Incidents
On-Campus Incidents
The Faculty Instructor will immediately notify Security at extension 8111 of the incident.  Security will fill out the Bloodborne Pathogen Exposure Incident Report and copies of the Bloodborne Pathogen Exposure Incident Report must be retained by Security, sent to the Human Resources Department, the Vice President for Student Affairs and the appropriate Deans.  Security will then inform the injured or exposed individual of the need to go to WorkNet, the College’s Workplace Incident/Injury Medical Facility, within one or two hours of the incident.  WorkNet has a complementary van service for transportation from the Main Campus which can be called by Security if necessary.  WorkNet Occupational Medicine is located on the first floor of Hahnemann Hospital at Broad and Vine Streets. The Immediate Supervisor will notify Security at extension 8111 of the incident.  Security will fill out the Bloodborne Pathogen Exposure Incident Report and Report and copies of the Bloodborne Pathogen Exposure Incident Report must be retained by Security and a copy sent to the Human Resources Department. A copy of the report will also be given to the injured or exposed individual who will be informed to go to WorkNet, the College's Workplace Incident/Injury Medical Facility, within one or two hours of the incident. WorkNet has a complementary van service for transportation from the Main Campus which can be called by Security if necessary.  WorkNet Occupational Medicine is located on the first floor of Hahnemann Hospital at Broad and Vine Streets.
Off-Campus Incidents
Off-Campus Incidents
The on-site Supervisor or Faculty Instructor will fill out the Bloodborne Pathogen Exposure Incident Report and notify the Program’s Clinical Site Supervisor who in turn will notify the appropriate Program Director (Allied Health) or the Department Head (Nursing) of the incident.  Copies of the Bloodborne Pathogen Exposure Incident Report should be sent to the Human Resources Department, the Program Director/Department Head, the appropriate Dean, and the injured or exposed individual.  The Faculty Instructor should contact WorkNet, the College’s Workplace Incident/Injury Medical Facility at 215-762-8525 to arrange for the injured or exposed individual to be treated as soon as possible. The injured or exposed individual will be responsible for presenting a copy of the Bloodborne Pathogen Exposure Incident Report to WorkNet.  WorkNet Occupational Medicine is located on the first floor of Hahnemann Hospital at Broad and Vine Streets.  WorkNet is open Monday through Friday from 7:30 AM to 5:00 PM. The on-site Supervisor will fill out the Bloodborne Pathogen Exposure Incident Report and notify the Program’s Clinical Site Supervisor who in turn will notify the appropriate Program Director (Allied Health) or the Department Head (Nursing) of the incident.  Copies of the Bloodborne Pathogen Exposure Incident Report should be retained by the Human Resources Department, the on-site Clinical Supervisor, the Program’s Clinical Site Supervisor, the Program Director/Department Head and the injured or exposed individual.  The on-site Supervisor should contact WorkNet, the College’s Workplace Incident/Injury Medical Facility 215-762-8525 to arrange for the injured or exposed individual to be treated as soon as possible. The injured or exposed individual will be responsible for presenting a copy of the Bloodborne Pathogen Exposure Incident Report to WorkNet.   WorkNet Occupational Medicine is located on the first floor of Hahnemann Hospital at Broad and Vine Streets.  WorkNet is open Monday through Friday from 7:30 AM to 5:00 PM.
Emergency Room
Emergency Room
An injured or exposed student has the right to elect to report directly to an emergency room of his/her choosing or to his/her primary care physician.  Hahnemann Hospital has an agreement with Community College of Philadelphia to treat any student at the Emergency Room with or without medical insurance. An injured or exposed faculty/staff member should report to WorkNet during working hours (7:30 AM – 5:00 PM).  If the incident occurs after working hours or if the injured or exposed faculty/staff member is not in a location convenient to WorkNet, the faculty/staff member should report to the nearest emergency room.  The cost will be covered by the College’s Workers’ Compensation Program.
Refusal of Treatment
Refusal of Treatment
An injured or exposed individual has the right to refuse treatment. If an individual refuses care, he/she must sign a refusal waiver form located on the back of the College's Bloodborne Pathogen Exposure Incident Report. The form must be signed by the individual immediately following the injury or exposure.  Copies of the waiver form for a student must be retained by the on-site Clinical Supervisor, the Program’s Clinical Site Supervisor, the Program Director/ Department Head and the injured or exposed student.  If treatment is refused, a clinical site may refuse to permit the student to continue to report to the clinical site and this could result in dismissal from the program for the exposed student.An injured or exposed individual has the right to refuse treatment. If an individual refuses care, he/she must sign a refusal waiver form located on the back of College's Bloodborne Pathogen Exposure Incident Report. The form must be signed by the individual immediately following the injury or exposure. Copies of the waiver form for a faculty/staff member must be sent to the Benefits Office in the Human Resources Department. If treatment is refused, a clinical site may refuse to permit the faculty member to continue to report to the clinical site.

INJURY PROTOCOL

  1. Protocol for injury is usually:
    1. Identification and documentation of the source individual. Documentation should include: route of exposure, circumstances under which exposure occurred, PPE in use, work practices, location of incident and procedure being performed.
    2. Testing the source individual’s blood as soon as feasible to determine Hepatitis B, Hepatitis C, and HIV infectivity.
    3. Written consent to test for HIV should be obtained from the source patient, by the Clinical Site Supervisor, Dean of Students or Program Director (Allied Health or Department Head Nursing).
    4. Counseling should be provided to the injured party to discuss recommendations for treatment, follow-up care and testing and the EAP can be utilized for employees.
    5. HIV prophylaxis treatment should be initiated within two hours of exposure.

 

  1. Certain clinical sites may have established policies for treatment of injuries or an exposure to pathogens.  Injured or exposed individuals may elect to follow such policies, but the Bloodborne Pathogen Exposure Incident Report must still be completed and sent to the appropriate individuals as stated above.

  1. An injured or exposed individual has the right to refuse treatment.  If an individual refused care, he/she must sign a refusal waiver form on the back of the College’s Bloodborne Pathogen Exposure Incident Report. The form must be signed by the individual immediately following the injury or exposure. Copies of the waiver form should be retained by Security and Human Resources.  If treatment is refused the College may refuse to permit the individual to return to campus and/or the clinical site for a stipulated period of time based upon an assessment of the threat of harm to the individual or others.
CASES OF SELF-REPORTED OR SUSPECTED INFECTIONS

An individual who suspects they have contracted an infectious illness (e.g., MRSA, TB) or who suspects they could be in direct contact with someone who has an infectious illness should follow the guidelines as stated below.

  1. Students, who are self-reporting, reporting the suspected illness of another individual or employees who suspect a student is infected, should state their concerns to the Dean of Students.  The Dean of Students will take the appropriate steps to determine the accuracy of the information.  If an incident of infectious illness is confirmed, the infected individual will be asked by the Dean of Students to seek medical attention from his/her own physician. In PA, the state does not require individual incidents of MRSA to be reported to the Health Department. Also, students are not restricted from attending school as long as the wound is covered and the student is receiving treatment.

 

  1. Employees who are self-reporting or reporting the suspected illness of another individual should state their concerns to their immediate supervisor.  If an incident of infectious illness is confirmed, the immediate supervisor will contact Human Resources.  Human Resources will contact the infected individual and ask that he/she seek medical attention from his/her own physician.

 

CLEARANCE

Any individual who has been exposed to an infectious or bloodborne pathogen must present evidence of his/her ability to return to work, to school, and to any clinical site according to the following protocol:

  1. Students in Nursing and Allied Health Programs should present the information to the Department Head (Nursing) or Program Director (Allied Health). The Department Head or Program Director will be responsible for informing the clinical site that the student has been cleared and may return to the clinical site.  Students who fail to provide such clearance may be administratively withdrawn from a program if they are unable to return to class and/or complete their clinical assignment.
  1. Students not enrolled in Nursing and Allied Health Programs should present the information to the Dean of Students.   
  1. Faculty and staff must present information to the Human Resources Department.  A statement from the attending physician which clears the employee to return to work is required or the employee will not be permitted to return to work without a clearance notification from the attending physician. 

 

 
RECORD KEEPING

The Bloodborne Pathogen Exposure Incident Report and all pertinent records will be considered confidential and they will be kept for 30 years in accordance with OSHA guidelines.  Records for employees and students will be kept in the Human Resources Department.