3.2 - Exposure Control Plan Procedures

Faculty, supervising provider, clinic director, or Director of Compliance will decide if the incident is, in fact, an exposure before initiating the post-exposure procedures. Determination will be made by using the BBP Exposure Management and Treatment flowchart.

If a WM sustains an exposure incident, (such as a stick with a contaminated needle, a cut by a scalpel or dental wire, or a splash of potentially infectious material in the eye, mouth, mucous membrane, or non-intact skin), the exposed person should immediately proceed with BBP exposure treatment depending on if the source is known or unknown. 

1. Treat the exposure site.
   1. Without squeezing to cause blood flow, use soap and water to wash areas of potentially infectious fluids as soon as possible after exposure.
   2. Flush exposed mucous membranes with water for 15 minutes.
   3. Flush exposed eyes at an eyewash station with water or saline solution for 15 minutes.
2. Immediately report exposure to faculty, clinic manager, and then to the COD Office of Compliance.
   1. Contact the Director of Compliance (DOC) at 405-271-3083 or
   2. Contact Compliance Coordinator at 405-271-7744 ext. 46876.
3. If the source patient is known:
   • Do not let them leave the clinic. The COD Office of Compliance will speak with the patient to obtain consent for infectious disease testing.
   • If the patient has already left the clinic, contact them to inquire if they will return for infectious disease testing.
   1. Documentation will be provided to source patients who consent to have labs drawn. Source patients should be escorted to the lab for testing.
   2. Source patient’s labs must be drawn within 1 – 2 hours of exposure for best results and treatment but no more than 24 hours after exposure.
4. WM and the Office of Compliance will document exposure on the required forms.

Employees:

1. OUHSC:
   Follow up with OU Health Employee Health the next business day. No Appointment is necessary.
   711 Stanton L. Young Blvd., Suite 400
   Oklahoma City, OK 73104
   405-271-3959
2. OU Tulsa:
   Visit Access Medical for Bloodborne Pathogen Exposure from a known source.
3. Externship or After-hours: If unable to report to a designated site listed above, visit the nearest hospital emergency room for Bloodborne Pathogen Exposure from a known source.

Students:

1. OUHSC:
   OUHSC Student Health Clinic
   900 NE 10^th Street
   Oklahoma City, OK 73104
   405-271-9675
2. OU Tulsa:
   OU Tulsa Student Health Clinic
   4502 E. 41^st Street, Suite 1C76
   Tulsa, OK 74135
   918-660-3102
3. Externship or After-hours: If unable to report to a designated site listed above, visit the nearest hospital emergency room for Bloodborne Pathogen Exposure from a known source.

Remote sites (Ardmore, Bartlesville, or Weatherford): Refer to the site-specific Exposure Control Plan.

The COD Office of Compliance will provide more instructions on how to continue with testing and medical care. Required source patient labs, for the determination of infectious disease status, will be provided at no cost to the source patient or WM.

Tests performed on source patients are:

• 30–40-minute rapid HIV 
• Hepatitis B Surface Antigen with Reflex Confirmation
• Hepatitis C Antibody with Reflex to Quantitative
• HIV 1/2 Antigen/Antibody, 4^th Generation with Reflex

Results of the source patient’s testing shall be made available to the exposed WM and the proper OU Health Employee Health Clinic or OUHSC/OU Tulsa Student Health Clinic. WM shall be informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source patient.

• Redaction of source patient’s PHI is preferred before disclosure of results.

Source patient’s labs will be drawn at:

1. 1. OUHSC:
      OU Health Physicians Lab
      825 NE 10^th Street, 1^st Floor
      Oklahoma City, OK 73104
      405.271.6161
      Hours: 7:30 am – 5:00 pm, Monday – Friday

1. 2. OU Tulsa Students:
      OU Health – Schusterman
      4444 E. 41st St.
      Tulsa, OK 74135

1. Treat the exposure site.
   1. Without squeezing to cause blood flow, use soap and water to wash areas of potentially infectious fluids as soon as possible after exposure.
   2. Flush exposed mucous membranes with water for 15 minutes.
   3. Flush exposed eyes at an eyewash station with water or saline solution for 15 minutes.

2. Immediately report exposure to faculty, clinic manager, and then to the COD Office of Compliance.
   1. Contact the Director of Compliance (DOC) at 405-271-3083 or
   2. Contact Compliance Coordinator at 405-271-7744 ext. 46876.

3. If the source patient is unknown, WM and the Office of Compliance will document exposure on the required forms. 

Employees:

1. 1. 1. OUHSC:
         OU Health Emergency Room for a Bloodborne Pathogen Exposure from an unknown source.
      2. OU Tulsa:
         Access Medical for a Bloodborne Pathogen Exposure from an unknown source.
      3. Externship or After-hours: If unable to report to a designated site listed above, visit the nearest hospital emergency room for Bloodborne Pathogen Exposure from an unknown source.

Students:

1. 1. 1. OUHSC:
         OUHSC Student Health
         900 NE 10^th Street
         Oklahoma City, OK 73104
         405-271-9675
      2. OU Tulsa:
         OU Tulsa Student Health
         4502 E. 41^st Street, Suite 1C76
         Tulsa, OK 74135
         918-660-3102
      3. Externship or After-hours: If unable to report to a designated site listed above, visit the nearest hospital emergency room for Bloodborne Pathogen Exposure from an unknown source.

1. Remote sites (Ardmore, Bartlesville, or Weatherford): Refer to the site-specific Exposure Control Plan.

1. Following an exposure incident, a confidential examination and follow-up shall be made available to the WM to address such infectious diseases as HBV, HCV, and HIV. This shall include confidential post-exposure prophylaxis and counseling following the current CDC protocol.
2. The healthcare professional providing treatment must forward a written opinion (as outlined in the OSHA regulation) to the WM and the appropriate OU Health Employee Health clinic, OUHSC/OU Tulsa Student Health clinic, or for satellite locations, the COD Director of Compliance, and maintain a copy on file.
3. Additional information regarding the OUHSC/OU-Tulsa policies and procedures for Hepatitis B vaccination and post-exposure follow-up may be found in the OUHSC/OU-Tulsa Infectious Diseases Policy.
4. If the source patient’s HIV test is positive, prophylactic medications are available in the inpatient pharmacy.
5. If the source patient's results are positive or if the source patient is unknown, the WM should undergo periodic laboratory testing.
   1. Initial baseline test
   2. Six weeks
   3. Three months
   4. Six months

• OU Health Employee Health or OUHSC/OU Tulsa Student Health will manage the post-exposure evaluation and ensure the WM receives necessary care throughout the process.

6. If the source patient’s HIV test is negative, there is no further testing or follow-up needed.

Procedures for evaluating circumstances surrounding exposure incidents:

1. Once the incident report is received by the COD Office of Compliance, a review of the circumstances of all exposure incidents will be completed to determine the following:
   1. Engineering controls were in use at the time.
   2. A description of the device being used (including type and brand).
   3. PPE or clothing that was used at the time of the exposure incident (e.g., gloves, face shields, safety glasses, etc.).
   4. Location of the incident.
   5. The procedure being performed when the incident occurred.
   6. WM’s training.
2. The COD Office of Compliance will record the percutaneous injuries from contaminated sharps in the sharps injury log.
3. If revisions to the ECP are necessary, the Director of Compliance will ensure proper changes are made such as safer devices, adding job functions to the exposure determination section, procedural changes, etc.

To ensure that workforce member's concerns regarding needle sticks and other sharp injuries are addressed; the EHSO asks that they complete a Safer Needle Device Questionnaire annually.