BLOOD AND BODY FLUID EXPOSURE INCIDENT: CHECKLIST

The following materials are to be completed and/or reviewed with the effected employee according to policy for Exposure Incidents and Post-Exposure follow-up:

Review Exposure Protocol1. Complete Incident Report 2. Review Important Health Information with exposed employee and source

individual3. Obtain consent for HIV testing for exposed employee 4. Obtain consent from source individual for blood testing5. If employee is female and is going to take HIV prophylaxis medication, assess

possibility of pregnancy and/or do pregnancy test6. Complete Quest requisition form for appropriate blood tests after consent

obtained.

Source Individual:Test NameHep B Surface AG w/reflex ConfirmHep C Virus ABHIV SCR w/reflex WB ConfirmHIV Viral Load ( Order if Source is HIV +)

Exposed Worker:Test NameHep B Surface Antibody (Quantitative)Hep C Virus ABHIV SCR w/reflex WB ConfirmIf receiving HIV prophylaxis also order: CBC Comprehensive metabolic panel Urine pregnancy test

7. Indicate “Employee exposure - Bill PCHS” on Quest requisition form. 8. Have employee blood and source individual’s blood drawn. 9. Results to Medical Director, or to provider that assessed/counseled employee.10.After review of results, employee is contacted by Medical Director/provider for

discussion of results and further care/treatment.11. Information from exposure, including Incident Report, laboratory test results, and

care/treatment is forwarded to the Clinical Services Director for retention as required by employment law and OSHA.

12.Supervisor notified

Infection Control Nurse Signature/Date ______________________/___________

Employee Signature/Date ____________________________/___________________

BLOOD AND BODY FLUID EXPOSURE INCIDENT: REPORT OF BLOODBORNE PATHOGEN EXPOSURE

Route of exposure: _____________________________________________________

Source individual information: Identification known? Yes NoIf ID known, was consent obtained for HBV, HIV, HCV testing? Yes No

If no, why? Unwilling Known to be infected with HBV, HCV, or HIV Other

If yes, results: _________________________________________________________

Exposed employee blood drawn for HIV, HBV, HCV status? Yes No

Last Tetanus __________________ Hepatitis B Vaccine _____________________

Pregnancy evaluation done if prophylaxis is indicated? Yes No NA

Recommendations for avoiding repetition: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Supervisor notified: Yes No

Infection Control Nurse Signature ______________________ Date: __________

Employee Signature _____________________________________ Date: __________

BLOOD AND BODY FLUID EXPOSURE INCIDENT:

CONSENT FORM FOR COLLECTION OF BLOOD FROM SOURCE INDIVIDUAL

A member of our facility staff was accidentally exposed to your blood or body fluid. In order to comply with the recommendations of the Centers for Disease Control and our Exposure Protocol, we are requesting your consent to test your blood for the antibody to the human immunodeficiency virus (HIV), Hepatitis B virus (HBV) and the Hepatitis C virus (HCV).

Your consent will enable our facility to provide the necessary care and assist in the proper medical management of the exposed employee. It is important that you understand the following:1. We cannot test for HIV without your consent.2. You will not be charged for this test.3. This signed consent form and test results will be kept confidential, and will be made available only to the person who is exposed. This person has been informed of applicable laws and regulations concerning disclosure of your identity and infectious status.

CONSENT / DECLINATION

I have been informed about the implications and limitations of the antibody to HIV, HBV, and HCV. I have been able to ask questions about these tests. Those questions were answered to my satisfaction. I understand the benefits and risks of the tests.

_____ I hereby consent to have my blood tested for HIV, HBV, and HCV antibody.

_____ I hereby decline to have my blood tested for the HIV, HBV, and HCV antibody.

________________________________ __________________Printed Name Date

________________________________ __________________Signature Date of Birth

If source individual is unable to sign, signature of authorized individual.

________________________________ __________________Signature Date

________________________________ __________________Witness Date

BLOOD AND BODY FLUID EXPOSURE INCIDENT:

HEALTH CARE PROFESSIONAL OPINION

Health care providers: Please complete and return one copy of this written report to the Clinical Services Director within 15 days after evaluation.

If bloodborne pathogen exposure incident occurred, please complete the following:

Hepatitis B vaccination is _____ is not_____ indicated for the following reason:________________________________________________________________________________________________________________________________________

HBV vaccination was administered (date) _________________________________

Findings and recommended follow-up:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_____ Yes _____ No Employee was informed of diagnoses and recommended treatment.

_______________________________ ____________________Provider Signature Date

_______________________________ ____________________Infection Control Nurse Signature Date

cc: Employee

Emergency Medical Problems Protocol

OUR CLINIC PROVIDES EMERGENCY TRIAGE AND BLS EMERGENCY CARE; ACLS CARE AND I.V. ACCESS ARE PROVIDED BY PARAMEDICS VIA 911

IDENTIFY THE EMERGENCY

Chest pain is an emergency. If a person states that they are having chest pain now, consider it an emergency. Follow BLS guidelines Notify the patient’s provider, if in clinic, or else the nearest available provider in clinic at

the time. The supervising lead provider will direct the other health care team members. Notify clinic RN Recruit other MA and clinical staff as available If the pain is new or if it is accompanied by clutching of the chest, call 911

immediately If the patient’s pain has been present for more than 24 hours and is not accompanied by

clutching of the chest or shortness of breath, ask the Provider/RN to evaluate before calling 911

Shortness of breath is an emergency. If a person is gasping for breath or unable to talk because of shortness of breath:Follow BLS guidelines Notify the patient’s provider, if in clinic, or else the nearest available provider in clinic at

the time. The supervising lead provider will direct the other health care team members. Notify clinic RN Recruit other MA and clinical staff as available Bring portable oxygen tank with oxygen tubing and mask to the patient’s location Obtain a pulse oximeter reading Obtain a stat glucose test Obtain a stat hemoglobin test Follow further direction from supervising lead provider

Seizures are an emergency. If a person is having a seizure:Follow BLS guidelines Notify the patient’s provider, if in clinic, or else the nearest available provider in clinic at

the time. The supervising lead provider will direct the other health care team members. Notify clinic RN Recruit other MA and clinical staff as available Bring portable oxygen tank with oxygen tubing and mask to the patient’s location Obtain a pulse oximeter reading Obtain a stat glucose test Follow further direction from supervising lead provider

No pulse is an emergency. If the patient has no pulse:Follow BLS guidelines Call 911Use the automatic defibrillator with the aid of a provider/RN. Notify the patient’s provider, if in clinic, or else the nearest available provider in clinic at

the time. The supervising lead provider will direct the other health care team members. Notify clinic RN Recruit other MA and clinical staff as available Bring portable oxygen tank with oxygen tubing and mask to the patient’s location Obtain a pulse oximeter reading Obtain a stat glucose test Follow further direction from supervising lead provider

If a patient appears to be in severe distress, but you are unsure whether this is an emergency:Follow BLS guidelines Notify the patient’s provider, if in clinic, or else the nearest available provider in clinic at

the time. The supervising lead provider will direct the other health care team members. Notify clinic RN Recruit other MA and clinical staff as available Bring portable oxygen tank with oxygen tubing and mask to the patient’s location Obtain a pulse oximeter reading Obtain a stat glucose test Follow further direction from supervising lead provider

If a patient faints or appears to have altered level of consciousness or is unresponsive, but you are unsure whether this is an emergency:Follow BLS guidelines Notify the patient’s provider, if in clinic, or else the nearest available provider in clinic at

the time. The supervising lead provider will direct the other health care team members. Notify clinic RN Recruit other MA and clinical staff as available Bring portable oxygen tank with oxygen tubing and mask to the patient’s location Obtain a pulse oximeter reading Obtain a stat glucose test Follow further direction from supervising lead provider

Hypoglycemia (low blood sugar)Follow BLS guidelines Notify the patient’s provider, if in clinic, or else the nearest available provider in clinic at

the time. The supervising lead provider will direct the other health care team members. Notify clinic RN Obtain a stat glucose test Follow further direction from supervising lead provider

If a patient complains of extreme pain:

Follow BLS guidelines Notify the patient’s provider, if in clinic, or else the nearest available provider in clinic at

the time. The supervising lead provider will direct the other health care team members. Notify clinic RN Recruit other MA and clinical staff as available Follow further direction from supervising lead provider

If a patient is visibly bleeding or looks excessively pale: Follow BLS guidelines Notify the patient’s provider, if in clinic, or else the nearest available provider in clinic at

the time. The supervising lead provider will direct the other health care team members. Notify clinic RN Recruit other MA and clinical staff as available Bring portable oxygen tank with oxygen tubing and mask to the patient’s location Obtain a pulse oximeter reading Obtain a stat glucose test Obtain a stat hemoglobin test Follow further direction from supervising lead provider

BLS and emergency care: Required Competencies of all nursing and provider staff

1. Recognition of acute medical crisis2. Proper use/application of medical equipment3. Equipment:

a. Oxygen tankb. EKG machinec. Ambu bag and mask ventilationd. Emergency medication boxe. Automatic Electronic Defibrillating (AED) Device

4. Adherence to policy/procedure regarding management of acute medical emergencies, notification and documentation (see Emergency Management Plan)

5. Proper CPR with AED procedures.6. Current BLS certification up to date

a. Clinic will offer and support BLS training every 2 years, to help maintain BLS certification of the clinic staff

Protocol for Treatment of AnaphylaxisCall 911

Place patient in recumbent position and elevate lower extremities.

Monitor vital signs every two to five minutes and stay with the patient.

Administer epinephrine 1:1,000 (weight-based) (adults: 0.5 mL; children: 0.01 mL per kg, up to a maximum dose of 0.2 to 0.5 mL) by IM route and, if necessary, repeat every 10 -15 minutes, up to two doses.

Administer oxygen, 8 to 10 L per minute.

Maintain airway with an oropharyngeal airway device if indicated.

Administer diphenhydramine (Benadryl), adults: 25 to 50 mg; children: 1 to 2 mg per kg), IM

Treat bronchospasm with a beta II agonist given intermittently or continuously.

Transfer to hospital emergency department in an ambulance.

OTHER KEY PRINCIPLES IN EVALUATION AND MANAGEMENT OF PATIENT EMERGENCY SITUATIONS IN THE CLINIC:

1. The patient has the right to refuse to go in the ambulance, but health center staff should not transport emergency patients in their private vehicles.

2. Always use “universal precautions” when managing an emergency.a. One-way masks are available in the laboratory area, RN area and other

areas as identified in the clinicb. An emergency kit is available in a central location in the clinic

3. If a patient calls asking to be seen immediately because “it’s an emergency,” identify the emergency. If possible, ask the RN to assist with this call.a. Ask for the patient’s name, write down the address of the emergency, and

phone number at that location.b. Ask if they need help calling 911 or if they wish to do it themselves.

i. The patient can refuse to call. ii. The patient can refuse to let you call in their behalf.

c. Details of the telephone interaction should be recorded immediately in the EMR by triage or telephone RN.

d. Patient’s PCP provider, or appropriate substitute provider, should be notified directly and immediately by the nurse taking the information, in addition to entry in the patient’s medical record.

e. A patient with an emergency should not be scheduled to come to our clinic. If in doubt, ask the appropriate provider for guidance.

________________________________ _____________________Date

Medical Director

MEDICAL EMERGENCY MANAGEMENT EVALUATION TOOL

FACILITY: ___________________________________ Date: _________________________

TYPE OF DRILL/EMERGENCY (Describe):

COMMUNICATIONS Circle One1. Was the appropriate CODE reported through the intercom system? Y N N/A2. Did all the appropriate staff and individuals hear the CODE/Alarm? Y N N/A3. How quickly did the staff respond? _______________

ORDERS4. Did all staff respond appropriately to the DRILL/EMERGENCY? Y N N/A5. Did the staff call 911 in a timely manner Y N N/A

Y N N/A

PATIENT, PERSONNEL & VISITOR SAFETY6. Did the staff remove unneeded staff, patients and visitors from the area? Y N N/A7. Were all patients & visitors escorted to a safe area and calmed? Y N N/A8. Did all staff respond correctly and avoid injury? Y N N/A9. Did staff maintain the patient’s privacy whenever possible? Y N N/A

EQUIPMENT AND SAFETY FEATURES10. Did the staff know where the emergency equipment/supplies located:

ER Medication box Y N N/A Oxygen Y N N/A EKG machine Y N N/A Ambu Bags (peds adult) Y N N/A

COMMENTS:

Description of the Event

Please describe the circumstances of Medical Emergency below. Touch on all the actions performed throughout the Medical Emergency.

DESCRIPTION:

STAFF PARTICIPATING IN DRILL/EMERGENCY

Staff Completing Evaluation: ________________________________ Date: ______________

Medical Emergency Documentation NoteDate of Event: _________________________________Patient Name: _______________________________MRN:_________ DOB:_________

Criteria Time initiated

Comments Date & Initials

Patient arrivedPatient to room

Assignment of an event keeperVital signs (Use Summary of Events

to record additional VS)B/P P R

Initiation of CPR as indicatedO2 applied

ambu bag initiatedEmergency equipment and supplies

EKG completedTime Ambulance called

Comment if ambulance called by 911Time ambulance arrived

Paperwork sent with ambulanceContent of Emergency Kit reviewed

and supplies ordered

List all employees present during Emergency Event: _______________________________________________________________________________________________________________________________________________________________________________________________

Summary of Events;_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Record of all medications given; include name of medication, dose and amount, route given, time given, and record patient’s response to medication:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Report of family/significant other notification per patient’s consent:___________________________________________________________________________________________________________________________________________________________________________________

Signature and title of employee filling out report: _________________________________

Signature of Provider:_______________________________________

EMERGENCY MEDICINE BOX INVENTORY

1. Maintain inventory listed below.2. on the first Monday of each month by a designated clinical staff member who will check contents and initial column.3. Verify lock number they are removing and enter new one.4. Check expiration dates and replaces outdated items as required.

sign: sign: sign: sign:date: date: date: date:

OLD lock #: lock #: lock #: lock #:

Inventory: Inventory checkDocument exp date

Inventory check Inventory check Inventory check

Albuterol inhalation soln 0.083% (5)EpiPen (2)EpiPen Jr. (2)Nitro Tabs (1 bottle)Aspirin (1 bottle)Glucagon Emergency PrefilledSyringe 1 ml (1)Glucotase 15ml (2)Triple antibiotics individualpackets (6)Benadryl 50mg vial (2)Glucose Tablets (6)Cotton balls (QS)Alcohol pads (QS)Band-Aids (QS)Tape 1inch (2)TB syringes (6)Needles 18g, 20g (3 each)3 cc syringes (3)Penlight (1)CPR Micro shield (2)

NEW LOCK # REASON FOR OPENING

OXYGEN TANK INVENTORY LOG

Year: Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov DecInitialsDate:# tanks on handConc. of Open tank

SUBJECT: CODE STRONG

PURPOSE: Code Strong is designed to assist all clinical areas of the clinic when

immediate staff presence is required to subdue a patient. Code Strong policy will provide

guidance to all staff when immediate staff intervention is required.

POLICY: A Code Strong is called in a situation in which an individual becomes out of control, endangers him/her or others in the area, or destroys property. If this person will not respond to a request to cease his/her actions by the person in charge of the area or the behavior exhibited provokes fear in the staff dealing with the situation, a Code Strong may be called to obtain assistance. (Announced over loud speaker)

It is important in dealing with persons who are "out of control," whether psychotic or angry, to know that physical forms of restraint are used as a last resort. The manner in which persons deal with potentially dangerous individuals or situations will often prevent an incident. The person who intervenes should display a calm, firm, clearly "in control" attitude. A person whose behavior is inappropriate should be dealt with as soon as possible. A staff member who does not feel comfortable in a given situation should notify his/her supervisor immediately for assistance.

Often the "show of force" of calling a Code Strong will solve the situation (i.e., the individual will see the number of persons and calm down). Any member of the Code Strong team can call the police if necessary. More importantly, any member of the staff should not hesitate to call 911 if in his/her judgment a situation warrants assistance from the police or an ambulance is needed. The police should be immediately called by anyone who is able to do so in the event a gun or weapon of any kind is noticed.

PROCEDURE:

A. When an emergency situation occurs, any employee may page "Code Strong" from any phone in the Clinic on the loudspeaker page system. The caller must designate the area - Front Desk, Room Number, etc., where assistance is needed.

When paging, state: "Code Strong (and the area in which persons are needed)," 3 times.

B. All exam rooms are paged by room number. Individual offices will be paged by the person's name, i.e., "Code Strong, Mary Jones' office."

C. Management and clinical staff will comprise the Code Strong team. The first manager on the scene should assess the situation to determine how many persons need to stay, if the police need to be notified, and to assume responsibility for dealing with the patient.

Code Strong Team Evening Clinic (8:30 a.m.-5:00 p.m.)

Clinical Director Medical assistants and lab staff

Medical Director Behavioral health staffDirector Behavioral Health All ProvidersNursing personnel available Any management staff availableTriage Physician/AdultM.S.W./LiCSW CounselorExecutive Director

If police assistance is needed, the individual calling the police should go to the Front Entrance and escort the police to the area needed or designate someone to do so. Peoples Community Health Clinic has no authority over the actions of the police officers responding.

Approval ______________________________Medical Director

Date ___________________________