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Bloodborne Pathogen Exposure Protocol

The following could result in bloodborne pathogen exposure: needle stick, cut, splash, abrasion or exposure to blood, tissue, or bodily fluids. (Read the complete UK HealthCare transmissible agent policy on Occupational Exposure to Bloodborne Pathogens.)

Proper treatment and recording of any potentially infectious exposure should begin as soon as possible:

  • Perform basic first aid.
    • Clean the wound, skin or mucous membrane immediately with soap and running water. Allow blood to flow freely from the wound. Do not attempt to squeeze or “milk” blood from the wound.
    • If exposure is to the eyes, flush eyes with water or normal saline solution for several minutes, or use an eye wash station.
  • Notify your supervisor immediately. If you are at UK Good Samaritan, page the nursing House Supervisor.
  • If you are at UK Chandler Hospital, locate a red exposure packet in your patient care area. This contains the Reportable Occurrence form and the Occupational Exposure form.
  • If you are located in UK Good Samaritan, the nursing House Supervisor will have a red exposure packet containing the Reportable Occurrence form and the Occupational Exposure form.

You and your supervisor will need to:

  • How to Report Exposure & Schedule an Appointment

    When speaking with Workers’ Care or the appointment line (instructions below), inform them immediately if it is a high-risk exposure (i.e. the source patient is HIV+, Hepatitis B+ or Hepatitis C+).

    Do not try to have your own blood drawn. Your blood tests will be ordered by Employee Health personnel.

    If exposure happens between 8 a.m. and 4:30 p.m. Monday - Friday:

    • For employees: Call Workers' Care at 1-800-440-6285. Workers' Care will schedule an appointment at Employee Health located in the University Health Service building.
    • For students: Call 323-APPT (2778) to schedule an appointment at Employee Health located in the University Health Service building.
    • Bring the completed red exposure packet to your appointment.

    If exposure happens between 4:30 p.m. and 8 a.m. or on a weekend or holiday:

    • For employees: call Workers' Care at 1-800-440-6285. Workers' Care will report the incident and will connect you with the UHS physician on-call who will provide a consultation and determine the risk of exposure.
    • For students: Page the UHS physician on call at 323-5321. The UHS on-call physician will provide a consultation and determine the risk of exposure.
    • Bring the completed red exposure packet to your appointment.
  • How to Complete the Red Exposure Packet

    Get a "red exposure packet" at any of these five locations, or email Leslie Ehrmantraut.

    • The information desk on the first floor of the Kentucky Clinic across from the pharmacy
    • IPAC
    • Capacity Command/Central Staffing Office in Chandler Medical Center
    • Pavilion A Emergency Department
    • Good Samaritan Laboratory

    Steps for completing the packet:

    1. Fill out the "Physician Order Form and Miscellaneous Lab" slip.

    • Enter the source patient's name, DOB, Date/Time collected and collector's name
    • Enter the source patient's name and DOB on the tube stickers provided and label each tube(the lab will not accept the blood if the tubes are not properly labeled). The white copy is to go to the lab and the yellow copy to Infection Prevention and Control.

    2. Have the source patient's blood drawn and document it.

    • If the source patient is a Hospital Patient, the RN or Phlebotomist is responsible for the patient will draw the blood: (1) Purple Top and (2) Gold Tops, place blood tubes in a bag and send blood and lab request to lab central receiving.
    • If the source patient is a Kentucky Clinic Patient, the source patient may be escorted to the Kentucky Clinic lab along with the patient request.
    • If you have questions about the blood, call the lab at 323-5432 or if using the tube system, tube to station #161.

    3. Fill out the "Source Patient Occupational Exposure Form" and place patient stickers on both copies.

    • If the source patient is not known, write "unknown" at the name.
    • Enter the dates, source patient's Attending MD, and select the type of exposure.

    4. The white copy (or electronic copy) will go to Medical Records and discarded upon the source patient's discharge, the white copy will go to Infection Prevention & Control, and the yellow copy goes back into the red envelope for you to take to your Employee Health visit.

    5. Take the red envelope with the pink and yellow copies to your appointment at UHS.