Procedures for Reporting and Managing Exposure Incident

In the event of any applicable exposure to blood or other potentially infectious materials, staff will follow the procedures outlined in this manual.

1. The employee or her/his supervisor will notify the Employee Health Nurse immediately. 

2. The supervisor or her/his designee will work with the site manager to enter the incident on the appropriate recordkeeping forms. 

3. The supervisor or her/his designee will notify the head of Human Resources and the Division Director. 

4. The Division Director will notify the NKY Health Director of Health.

The Employee Health Nurse will:

• File and retain the reports in the appropriate file.

• Provide the following information to the evaluating physician:

• A copy of this regulation.

• A description of the employee’s duties as they relate to the employee’s occupational exposure.

Immediately upon learning of an incident, the supervisor or her/his designee will follow these steps:

1. Determine whether a true exposure has occurred. NKY Health’s current guidelines for exposure are in Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, HIV, and Recommendations for Postexposure Prophylaxis,” MMWR,Vol. 50,No. RR-11, dated June 29, 2001.

2. Report ASAP to immediate supervisor/coordinator/manager and Employee Health Nurse.

3. Follow the Supervisor's Procedures for Reporting Incident in the "Incident Management" section of this manual.  (Be sure to follow the Instructions for Completing Form IA-1 and work with the site manager to record the incident as a privacy concern case on the OSHA 300/300A forms.)

4. Initiate NKY Health's Post-Exposure Post-Exposure Incident Consent - Exposed Employee form.

5. Initiate NKY Health's Post-Exposure Incident Consent - Source Individual form.

6. Follow guidelines for HIV, HBV and HCV testing as outlined in this Plan.

7. Initiate a Physician Treatment form. This is to be completed by the designated treating physician.

8. Adhere to the follow-up treatment regimen and/or testing as prescribed by the physician.

9. Notify the employee's Division Director, the head of Human Resources and the Employee Health Nurse.

For each evaluation under this section, the NKY Health shall obtain and provide the employee with a copy of the evaluating physician’s written opinion within 15 working days of the completion of the evaluation. The written opinion will be limited to the following information:

• The physician’s recommended treatment and limitations based upon the employee’s ability to receive Hepatitis B vaccination.

• A statement that the employee has been informed of the results of the medical evaluation and that the employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials which require further evaluation or treatment.

• Specific findings or diagnoses which are related to the employee’s ability to receive Hepatitis B vaccination. Any other findings and diagnoses shall remain confidential.

In the event the employee refuses to be treated according to the guidelines for treatment of an exposure Incident, the Employee Health Nurse will:

1. Ensure the employee completes and signs an NKY Health Incident/Complaint Report form and sends it to her.

2. Have the employee indicate on the NKY Health Incident/Complaint Report his/her refusal for care.

3. Report the incident and refusal of the employee to the appropriate personnel at NKY Health.

4. Report the incident to the Kentucky Department for Public Health’s Division of Epidemiology if a reportable condition is involved.

5. File and retain the reports in the incident file.

All work-related needlestick injuries and cuts from sharp objects that are contaminated with another person’s blood or other potentially infectious material (human bodily fluids, tissues, and organs; or other materials infected with HIV, HBV or HCV such as laboratory cultures or tissues) must be recorded on the OSHA 300 (Log of Work-Related Injuries and Illnesses) and the OSHA 301 (Injury and Illness Incident Report) forms as an injury. 

When an employee is splashed or exposed to blood or other potentially infectious materials without being cut or scratched, the incident is recorded on the OSHA 300 form as an illness if it results in the diagnosis of a bloodborne illness (HIV, HBV, HCV) or it meets one or more of the criteria listed in the Guidelines for OHSA 300 Form Recordable Cases. 

To protect the employee’s privacy, enter the information as a "privacy concern case."

See the "Retention and Updating" subsection of Instructions for Completing OSHA 300/300A Forms in the "Incident Management" section of this manual.