Harbor:Occupational exposure (dot-phrases)
.OccupationalExposureHistory
Nature of occupational exposure: [delete non-applicable sections and instructions in square brackets “[]” when complete; DO NOT send any blood tests on the exposed employee; complete all applicable sections]
Part 1: Type of Exposure
Non-infectious body fluids are saliva, sputum, urine, vomitus, nasal secretions, sweat, tears, and feces. However, if these fluids are contaminated with visible blood, then they are to be considered potentially infectious. Potentially infectious body fluids are blood and CSF.
[Delete non-applicable sections below]
Needlestick: [fill in parts A-H below]
A. Needle type (solid or hollow bore): _
B. Gauge: _
C. Had needle been in contact with patient’s blood or potentially infectious body fluid (yes/no)? _
D. Specify body fluid type: _
E. If not blood, was body fluid bloody (yes/no)? _
F. Was there visible blood on the needle (yes/no)? _
G. Depth of needlestick (no visible penetration, shallow penetration, deep puncture)? _
H. Was the employee wearing gloves (yes/no)? _
Scalpel wound: [fill in part A below]
A. Did the scalpel have the blood or potentially infectious body fluid on it (yes/no)? _
Mucosal exposure/splash in eyes, mouth, nose: [fill in part A below]
A. Was the exposure/splash to blood or potentially infectious body fluid? (yes/no)? _
For all exposures, provide a narrative account of how the exposure occurred and what steps the employee took following the exposure (e.g., soap/water, eyewash): _
Has the employee completed a vaccine series for Hepatitis B (yes/no)? _
Part 2: Details Regarding the Source Patient
Full name of source patient: _
MRN of source patient: _
Diagnosis or reason source patient is under care: _
Results of review of ORCHID for prior HIV tests (no prior tests on source patient, most recent prior test on [date] that was negative, most recent prior test on [date] that was positive): _
Is source patient known to be Hepatitis C Ab positive (yes/no)? _
If yes, is source patient known to be Hepatitis C RNA positive (yes/no)? _
Is source patient known to be Hepatitis B surface AG positive (yes/no)? _
.OccupationalExposureMDM
The patient’s occupational exposure is (pick only one of the following A-G and use the MDM that corresponds to the risk level for the exposure):
A. Near zero risk because it was limited to contact of the source patient’s blood or body fluid on the employee’s intact skin, independent of whether the material was potentially infectious.
B. Near zero risk because it was limited to exposure to a non-infectious body fluid.
C. Near zero risk because it was limited to exposure to a sharp object (e.g., needle or scalpel) that had not been in contact with any potentially infectious body fluid.
D. Near zero risk because sharp object (e.g., needle or scalpel) did not penetrate skin.
[Use this MDM phrase for options A-D above] MDM for a near zero risk exposure: because the exposure is near zero risk there is no indication to determine the HIV status of the source patient or to send a hepatitis C antibody test on the source patient.
E. A clinically meaningful exposure because it involved a penetrating injury with an object that had been in contact with the patient’s blood or potentially-infectious body fluids.
F. A clinically meaningful exposure because it involved a mucosal splash to the eyes, mouth, or nose by the patient’s blood or a potentially infectious body fluid.
G. A clinically meaningful exposure because it involved a splash to non-intact skin (e.g., broken, disrupted, chapped or abraded skin or skin with active dermatitis) with the patient’s blood or a potentially infectious body fluid.
[Use one of these MDM phrases for options E-G above] MDM for a clinically meaningful exposure:
[If the source patient is already known to be HIV positive based on existing laboratory testing] Since the employee suffered a clinically meaningful exposure and the source patient is documented to be HIV positive, we will contact the HIV service (310-501-4260) for guidance regarding post exposure prophylaxis. Unless the source patient is known to be infected with hepatitis C we will obtain a hepatitis C antibody test on the source patient, for use in follow up care of the exposed employee. We will not perform any laboratory testing on the exposed employee in the ED.
[If the source patient’s HIV status is unknown] We will obtain a rapid HIV test from the source patient, after providing them with an opportunity to opt out from testing. If the source patient is unable to participate in an opt-out discussion (sedated, altered, etc.), or if the source patient refuses, according to California law a rapid HIV test can be ordered on an available blood sample, but only in the context of a clinically meaningful exposure. If the source patient is found to be HIV negative, then the employee will be discharged with instructions to follow up in employee health the next business day. If the source patient is found to be HIV positive and the employee suffered a clinically meaningful exposure, we will contact the HIV service (310-501-4260) for guidance regarding post exposure prophylaxis. Unless the source patient is known to be infected with hepatitis C we will obtain a hepatitis C antibody test on the source patient, for use in follow up care of the exposed employee. We will not perform any laboratory testing on the exposed employee in the ED.
Follow up [Select one of A-D and elaborate accordingly]:
A. Harbor-UCLA Medical Center employees: Employee Health next working day
B. UCLA Medical Students: UCLA Student Health
C. Prehospital Care Providers and Law Enforcement: Refer to their contracted occupational health provider
D. Non-employees: Refer to their Primary Care Provider