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UWHC,UWMF,

Policies,Clinical,UW Health Clinical,Infection Control

Management of Exposure to Blood or Body Fluid (4.1.17)

Management of Exposure to Blood or Body Fluid (4.1.17) - Policies, Clinical, UW Health Clinical, Infection Control

4.1.17


UW HEALTH CLINICAL POLICY 1
Policy Title: Management of Exposure to Blood or Body Fluid
Policy Number: 4.1.17
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: August 28, 2017

I. PURPOSE

To provide guidelines for the management of employees, contracted non-employees, volunteers, students,
and patients potentially exposed to bloodborne infections through blood or body fluid exposures.

II. DEFINITIONS
A. An exposure to blood or body fluids may include:
i. A puncture or laceration caused by a needle or sharp item contaminated with blood or other body
fluid.
ii. Blood or body fluids which contaminate the eyes, nose, mouth, or non-intact skin.
iii. Human bite.
B. For the purpose of this policy, “employee” also refers to contracted non-employees, volunteers, and
students.
III. POLICY ELEMENTS

Employee Health Services (EHS) is responsible for the appropriate assessment, treatment, and follow up of
employees and contracted non-employees potentially exposed to bloodborne infections. Employees must
contact EHS as soon as possible after an exposure has occurred. If it is after-hours (after 4:00 pm on
weekdays or all day Saturday and Sunday), the employee should also follow their location’s after-hours
process (see document, After-Hours Process by Location).

IV. PROCEDURE
A. The Employee's Role
i. Prevention of exposures to blood and body fluid must always be the first goal and can be achieved
through the following measures:
a. Organization provided sharps safety devices must be properly and consistently used.
b. Do not recap used needles or sharps.
1. If you must recap, use a one-hand technique.
c. Dispose of sharps or needles immediately after use in impervious sharps containers. DO
NOT leave on tables, trays, or in bed linens. NEVER put sharps or needles in the trash.
d. The healthcare worker who generates the used sharp is responsible for its prompt and
proper disposal into an appropriate sharps container.
e. Use gloves, gowns, masks, and goggles or face shields as appropriate when anticipating
contact with blood or body fluids (see UW Health Clinical Policy 4.1.8 Standard
Precautions and Isolation).
f. Routinely report exposures to blood and body fluids as outlined below.
ii. If exposure to blood or body fluid occurs, risk can be reduced by immediate first aid and
appropriate follow up:
a. Treatment immediately following the injury includes:
1. If a needle puncture, laceration (scratch), or other broken skin:
A. Cleanse the wound thoroughly with soap and water. The wound may be
further cleansed with an antimicrobial agent.
2. If a mucous membrane or conjunctival exposure occurs:
A. Irrigate the affected area immediately with copious amounts of water or
normal saline for at least 3 minutes.
b. After administration of first aid, notify EHS by phone at (608) 263-7535 immediately. If
EHS is closed, follow your site’s after-hours procedure for reporting exposures to blood or
body fluids. See the document, After-Hours Process by Location (in the related tab of this
policy on U-Connect).
c. It is also recommended to report the incident by completing a PSN.



UW HEALTH CLINICAL POLICY 2
Policy Title: Management of Exposure to Blood or Body Fluid
Policy Number: 4.1.17

iii. If after-hours procedures are utilized, EHS should always be contacted the next business day by
the employee for review of the injury and completion of treatment, if required.
iv. All exposures to blood or body fluid should be reported by completing the Worker’s Compensation
report appropriate for their employer. Completing the online or paper accident report does not
constitute notification of EHS.
B. The Role of EHS
i. EHS has the responsibility for the assessment of occupational risk, coordination of post-exposure
prophylaxis and follow up of the employee with an exposure to blood or body fluids.
ii. EHS will follow the most current post-exposure protocols promulgated by the CDC for providing
post-exposure prophylaxis and monitoring.
iii. Divergence from current recommendations will be coordinated through the Infection Control
Committee.
C. Patients exposed to employee's blood
i. In the event that a patient is exposed to the blood of a health care worker, the incident should be
promptly reported to EHS.
ii. In such circumstances, the same rigorous evaluation of the source blood, in this instance the
employee, will be undertaken when permitted by law and, where appropriate, baseline serologic
testing of the exposed patient will be performed when permitted by law (see UWHC policy #4.30,
Consent for HIV Testing & Release of Protected Health Information). The specific screening and
testing that will be done in each exposure will be determined on a case by case basis under the
direction of the EHS, Infection Control and the patient's treating provider.
V. FORMS

Diagnostic HIV Test Form


VI. COORDINATION

Author: Manager, Employee Health Services
Senior Management Sponsor: VP, HR Operations
Reviewers: Manager, Employee Health Services, Infection Control Department, Director of Recruitment,
Employee Health Services, and Wellness
Approval committees: Infection Control Committee, UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: July 17, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VII. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J.Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VIII. REFERENCES

UWHC policy #4.30, Consent for HIV Testing and Release of Protected Health Information
UW Health administrative policy #9.17, Workers Compensation
UW Health clinical policy #4.1.9, Healthcare Worker with Bloodborne Pathogen Infection
UW Health clinical policy #4.1.13, Hand Hygiene
UW Health clinical policy #4.1.8, Standard Precautions and Isolation
UW Health Bloodborne Pathogens Exposure Control Plan



UW HEALTH CLINICAL POLICY 3
Policy Title: Management of Exposure to Blood or Body Fluid
Policy Number: 4.1.17

After-Hours Process by Location (in the related tab of this policy on U-Connect)

Centers for Disease Control and Prevention. CDC Guidance for Evaluating Health-Care Personnel for
Hepatitis B Protection and for Administering Postexposure Management. December 20, 2013/62 RR-10.

Centers for Disease Control and Prevention. Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to HIV and Recommendations for Post exposure Prophylaxis.
September 30, 2005. 54/ No.RR-09.

Centers for Disease Control and Prevention. Updated U.S. Public Health Service Guidelines for the
Management of Occupational Exposures to HBV, HCV and HIV and Recommendations for Post Exposure
Prophylaxis. June 29, 2001/Vol. 50/No. RR-11.
Wisconsin Act 209: HIV Testing
Department of Labor. 29 CFR part 1910.1030. Occupational exposure to bloodborne pathogens: Final Rule.
Federal Register, 2001.

Wisconsin Statutes and Administrative Code pertaining to Acquired Immunodeficiency Syndrome (AIDS)
and Human Immunodeficiency Virus (HIV) infection. Wisconsin Department of Health and Family Service.
December, 2002.

Centers for Disease Control and Prevention. Immunization of Health-Care Workers: Recommendations of
the Advisory Committee on Immunization Practices ACIP) and the Hospital Infection Control Practices
Advisory Committee (HICPAC). December 26, 1997. 46 / No.RR-18.

Centers for Disease Control and Prevention. Recommendations for Prevention and Control of Hepatitis C
Virus (HCV) Infection and HCV-Related Chronic Disease. October 16, 1998. 47 / No. RR-19.

IX. REVIEW DETAILS
Version: Revision
Last Full Review: August 28, 2017
Next Revision Due: August 2020
Formerly Known as: UWHC policy #9.28, Management of Biohazardous Injuries