SAN MATEO COUNTY HEALTH SERVICES AGENCYDEPARTMENT OF HOSPITALS AND CLINICS

BIOHAZARDOUS WASTE:DEFINITION AND GUIDELINES FOR MANAGEMENT OF

SHARPS CONTAINERSBIOHAZARDOUS/

REGULATED WASTE(red bag)

- Needle/syringe units, needles,butterfly needles, suture needles

- Blood, blood elements, vials ofblood, specimens for microbiologicculture, used culture plates andtubes- Scalpel blades, disposable

razors

- Guidewires- Containers of CSF, synovial,pleural, peritoneal, pericardialand amniotic fluid

- Glass slides, covers, pipettes

- Disposable sharp instruments- Any dressings, peripads, orcontainers that would releaseblood or other potentiallyinfectious materials (OPUvJ)in aliquid or semi-liquid state ifcompressed; items that are cakedwith dried blood or GPIM and arecapable of releasing thesematerials during routinehandling

- Dental wires

- Surgical specimens

OTHER:

REGULAR TRASH

- Empty urine or stool cups andother empty specimen containers,empty urinary drainage bags orbedpans

- Non-bloody dressings,bandages, cotton balls orswabs, Chux*, diapers,peripads where fluid iscontained, etc.

- Used personal protectiveequipment, including those fromisolation rooms

- Paper towels fromhandwashing

- Materials used to clean upspills (unless bloody)

- Food waste (ex: soda cans,paper cups, plastic cutlery ... )

1. Sputum. emesis. urine and stool are not required to be handled as regulated waste unless visibly contaminated\\;with blood. Ifunclear as to the origin or the body fluid/substance. handle as biohazardous/regulated. A brownbag may be used to bag dressings prior to disposal.

2. Containers \\with liquid blood or other body fluids should be emptied prior to disposal if possible. The liquidmay be chemically treated w/lsolyzer to render it a solid ifthe container cannot be emptied.

3. Containers \\with sharp edges may be double-bagged or padded to keep the original bag intact.4. Housekeeping is responsible for emptying or replacing sharps containers, and for the disposal of regulated

trash.5. Sharps containers are to be routinely checked and changed when> 3/4 filled. The container is to be closed

and maintained in an upright I position. The container is NOT to be left unattended on the floor. ContactHousekeeping to remove the filled container.

Revised 6/96

EMPLOYEE BLOOD BORNE PATHOGEN EXPOSURE / SHARP INJURY PACKET

If you have been exposed to blood or other person's body secretions or experienced a sharp injury you will need to usethe contents of this packet for reporting it, treatment and follow-up. Notify your immediate supervisor or nursingsupervisor immediately for assistance with this procedure.

EMPLOYEE INSTRUCTIONS:1. Notify your immediate supervisor or the nursing supervisor immediately for assistance with this procedure.

2. In this orange packet, remove the biohazard lab guard plastic specimen bag with 1 red top tube with mise lab slip forHIV and one yellow top tube with serology lab slip for Hep B antigen & Hip C. Use these to draw the patient /source blood. This is not for your blood testing.

3. Inform the patient / source of your exposure. You no longer need a consent for HIV. You will test the sourcefor Hepatitis B antigen, Hepatitis C, and HIV. You may draw blood and test for hepatitis without the source'spermission. After drawing source blood, see that the requisitions are filled out with name of source, medical recordnumber, name of the test and have BBFE on the slip.

4. Put the requisitions and two tubes back into biohazard lab guard plastic bag with the lab slips and see that bloodcomes to hospital laboratory immediately .. Do not enter in the computer. Use these slips and label tubes.

5. Also in this envelope is the exposure to blood/OPIMworksheetform report form. This is two-sided yellow paper.ALL areas on this form are to be filled out. Put the filled out paper back into this orange envelope and send to MaryWebb, Infection Control, in the Administration Building 54, 3rd floor, room A 16 or place in the pony mail. PONYis HOS 316 IC, so it can be refilled. Please leave a telephone message at extension 3409 (650-573-3409) with yourname, phone number, describe incident. Include date and time of exposure.

6. The directions/map to US HealthWorks Medical Group, formerly known as Work Force, the treating facility isprinted on green paper for you. Currently it may be US HealthWorks Medical Group or Sequoia Hospital ER forevaluation and treatment. The green sheet is to locate US HealthWorks Medical Group. Discuss with yourimmediate supervisor or nursing supervisor your departure, time and site for evaluation of your exposure. If youdecline to go for evaluation, you & the supervisor sign the declination form. Keep one copy for yourself. Onecopy goes back into orange envelope & goes to Mary Webb at HOS 316 IC.

7. You will also need to complete the papers inside a white workers comp envelope according to the directions printedon the outside of the envelope. Your immediate supervisor will select papers that you will need to take with you tothe treating facility.

SUPERVISOR INSTRUCTIONS:1. If employee declines follow-up evaluation & treatment, sign the declination statement & forward to Mary Webb at

Pony HOS 316 IC. Give employee a signed copy.

2. If source is known, assure that the source's blood was drawn and sent to the SMMC hospital laboratoryimmediately. Notify the source case's physician.

3. Review the patient / source's medical record for past test results. If there are previous lab tests, send a copy ofsource's previous Hepatitis and HIV results with injured employee going to the treating facility. If there is areasonable possibility that the source case is or may be HIV +, the employee should go immediately for evaluation& treatment. Prophylaxis should be initiated promptly after exposure to maximize potential benefit of theprophylaxis.

11.3 orange envelope front 11 24 08

San Mateo County Health Services Agency Division of Hospitals and Clinics

Exposure to BLOOD / OPIM Worksheet Report Form

CIRCLE NUMBERS DESCRIBING INCIDENT: this information willassist in the evaluation of occupational exposures. If the incidentoccurred while subduing a person, only applicable sections should befilled out, with the bulk ofthe explanation in the narrative.)

BODY FLUID INVOLVED IN NEEDLE STICK EXPOSURE1. Large quantity of blood: _2. Visibly Bloody Fluid (specify): _3. Other Body Fluid (specify): _

Job Classification: please circle oneRN Housekeeper / LaundryLVN Phlebotomist / Lab TechAIDE StudentMD DDS PODATRIST./.Other

NEEDLE STICK EXPOSUREList Make and Model # ----------------I. Injection Needle2. Vacutainer Needle3. Butterfly Needle4. IV Catheter

5. LPNeedle6. Stylet7. Suture Needle8. Other (specify): _

AT TIME OF EXPOSURE, THE NEEDLE WAS BEING USED FOR:1. IMlSQ Injection 8. IV Line Placement (central, peripheral, or2. Heparin Lock Manipulation other indwelling Line. _3. Skin Test (PPD, etc.) 9. Arterial Line Placement or Arterial Stick4. Manipulating Piggyback / Secondary Line 10. Drawing Blood Cultures via venipuncture5. Phlebotomy (venipuncture only) 11. Aspirating Fluid Site6. Withdrawing Blood From a Central Line or 12. Suturing7. Local Anesthesia Infiltration 13. Other (specify) _

MECHANISM OF ACCIDENT1. Recappinglresheathing2. Filling Blood Tubes/Culture Bottle3. Handling Needle Prior to Disposal4. Disposing Needle in Sharps Container

5. Passing Instruments6. Needle Left in Unusual Location7. Other (specify): _

OTHERPERCUTANEOUSEXPOSUREORSHARPList Make and Model # -------------1. Lancet, Scalpel 4. Instrument (specify): _2. Glass 5. Weapon: _3. Bone 6. Other (specify): _

MUCOUS MEMBRANE EXPOSURE1. Mouth 2. Eyes 3. Nose 4. Other: _

CONTAMINATION OF NON-INTACT SKIN1. Chapped (reddened and dry)2. Inflamed (reddened and warm)3. Ulcerated (open area)4. Cracked/Weeping5. Open Hangnails (open skin around nails)

6. Open Pustule or Papules (e.g. acne)7. Lacerated (describe): _8. Abraded (describe): _9. Other (describe): _

TETANUS IMMUNIZATION - What year did you have your last Tetanus booster? _

OTHER COMMENTS: _

Send this completed form to Mary Webb, RN, CIC, ext 3409. Pony HOS 316 ICBBFE/exposure worksheet second page 12 17 08

County of San Mateo Risk Management EH I San Mateo Medical CenterEXPOSURE TO BLOOD/OPIM WORKSHEET REPORT FORM

INJURED EMPLOYEE'S NAME _Side 1 of 2 sidesSEX: male female Birth date: What department do you work in?

Shift you work: days evenings nights Where is this department located?

Name of your Supervisor & phone? What is the phone number of this area?

GENERAL EXPOSURE INFORMATIONDate & Time of Exposure: I Body Part Injured: Left or Right

Location / Department / Room of Accident:

What happened? What chain of events lead up to this incident?

TREATMENTTreatment Required: First Aid Only: YES NO

What did you do? Washed, rinsed, or flushed? Other? Did you go to Sequoia Hosp ER? YES NO

Did you go to US Healthworks Med Groupformerly Workforce Medical Center? YES NO

PPE CAUSE---

What Personal Protective Equipment were you using: Basic Cause of Exposure / Incident

Gloves Mask Eye Protection Gown/Apron Personal Error Equipment Failure Unsafe ConditionInadequate Procedure / Precaution

Other (Specify): Other (Specify):

DEVICE INFORMATIONIf sharp had no engineered sharps injury protection, do you Do you have an opinion that any other engineering, administrativehave an opinion that such a mechanism could have prevented or work practice control could have prevented the injury?the injury? NO YES N/A NO YES

Did the device being used have engineered sharps injury protection? NO YES Don't know N/A

Was the mechanism fully activated? Did the exposure incident occur:YES Partially NO N/A Before During After activation N/A

EMPLOYMENT/EXPERIENCESafety Information:Is there Lost Time? NO YESAre there Modified Days? NO YES

Amount of Experience Employee possesses for the job or activity-not the amount of time at this facility or in this positionYears Months Days

HEPATITIS INFORMATION-------- -- -- - ------- --

EMPLOYEE: Have you, the injured employee received the Do you know if you have immunity? YES NOHepatitis B Vaccinations? YES NO Positive Negative UnknownIf yes, how many shots have you had?SOURCE !PATIENT Name: MedRec#:Has patient been diagnosed with Hepatitis or HIV? NO YES Don't know Draw blood now for Hep B antigen, Hep C, HIVDraw one red top tube and one yellow top tube. HIV consent no longer required. Send to hospital lab. Mark BBFE.Call Mary Webb at 650-573-3409 & let her know what happened and that blood has been drawn. Thank you.

BBFE/exposure worksheet front page 12 17 08

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COUNTY OF SAN MATEOBLOODBORNE PATHOGENS STANDARD

EXPOSURE CONTROL PLAN SHARPS SAFETY POLICY

DECLINATION OF MEDICAL SERVICESFOR OCCUPATIONAL EXPOSURE TO BLOOD/OPIM

Instructions: Please initial all boxes as they apply to you, and sign in the presence of a supervisor.

I refuse testing or treatment for Hepatitis B exposure and/or immunization protection forHepatitis B as covered in the protocol included in the County of San Mateo blood bornepathogens standard exposure control plan sharps safety policy.

I refuse testing for Hepatitis C exposure as covered in the protocol included in the County ofSan Mateo blood borne pathogens standard exposure control plan sharps safety policy.

I refuse testing for and/or treatment for HIV exposure as covered in the protocol included in theCounty of San Mateo bloodborne pathogens standard exposure control plan sharps safetypolicy.

I refuse testing for HIV exposure at this time. However, I request that blood be drawn and heldfor 90 days in the event that I desire HIV testing within that time.

I offer my signature below declaring:

1. It has discussed, in my presence, all relevant points in the Exposure Control Plan concerning myoptions for free medical attention and treatment for occupational exposure to Hepatitis B, Hepatitis Cand HIV, including counseling services.

2. I have been informed about all benefits and risks associated, including serious disease, disability ordeath, and have been given the opportunity to ask questions which have been answered to mysatisfaction.

3. I decline all free medical testing and treatment for my occupational exposure to blood or otherpotentially infectious materials. I do not hold the hospital or the county responsible should I contracthepatitis B or C, or HIV disease.

4. I understand that I may rescind this refusal at any time by written notification to US HealthWorksMedical Group, County Risk Management / EH or the Infection Control Practitioner, or the EmployeeHealth Nurse. Appropriate testing and treatment protocol will then be implemented.

PRINT EMPLOYEE'SNAME EMPLOYEE'SSIGNATURE/DATE

PRINT SUPERVISOR'SNAME SUPERVISOR'SSIGNATURE/DATE

PLEASE PROVIDE COPY TO EMPLOYEE

h/pol/section 3/ Declination of medical tx 12 23 08