Infection Prevention Manual

EXPOSURE CONTROL PLAN that HIV testing of the source patient is medically necessary to determine the course of treatment. C. Follow-up procedures after possible exposure to HIV/HBV : If a health care worker has a percutaneous (needlestick or cut) or mucous membrane (splash to eye, nasal mucosa, or mouth) exposure to body fluids or has a cutaneous exposure to blood when the worker's skin is chapped, abraded, or otherwise non-intact, consent is attained and the source patient shall be informed of the incident and tested for HIV and HBV infections. The health care worker shall be evaluated clinically. HIV antibody testing will be done as soon as possible and the health care worker will be advised to report and seek medical evaluation of any acute febrile illness that occurs within 12 weeks after exposure. HIV seronegative workers shall be retested 6 weeks post-exposure and on a periodic basis thereafter (12 weeks and 6 months after exposure). The type of procedures followed for health care workers exposed or potentially exposed, depend on the immunization status of the worker (i.e., whether HBV vaccination has been received and antibody response is adequate) and the HBV serologic status of the source patient. No adverse action by the employer can be taken if a health care worker refuses to submit to the procedures in (A) or (B) above. The procedures are designed for the benefit of the exposed health care worker. The health care worker's signature for consent/refusal shall be obtained per Agency policy. IX. Medical Record Keeping : An accurate medical record for each health care worker with occupational exposure shall be established and maintained for the duration of employment plus thirty (30) years. This record shall include : T The name and social security number of the employee T A copy of the employee's Hepatitis B vaccination status including the dates of all Hepatitis B vaccinations and any medical records relative to the employee's ability to receive vaccination. T A copy of all results of examinations, medical testing and follow-up procedures. T The Agency's copy of the health care professional's written opinion. T A copy of the information provided to the health care professional. Confidentiality - The Agency shall ensure that the employee's medical records are kept confidential. Not disclosed or reported without the employee's express written consent to any person within or outside the workplace except as required by law. X. Quality Monitoring : The agency shall assess the health care worker's compliance with Universal Precautions and personal protective practices at least ANNUALLY . XI. Sharps injury log . The agency maintains a sharps injury log for the recording of percutaneous injuries from contaminated sharps. The information in the sharps injury log shall be recorded and maintained in such manner as to protect the confidentiality of the injured employee. The sharps injury log shall contain, at a minimum: T The type and brand of device involved in the incident, T The department or work area where the exposure incident occurred, and T An explanation of how the incident occurred. This log is reviewed as part of the annual program evaluation and maintained for at least five years following the end of the calendar year covered. If a copy is requested by anyone, it must have any personal identifiers removed from the report.