Introduction
Purpose
This procedure establishes the required response following an occupational or clinical exposure to blood or other potentially infectious material. Requirements support immediate first aid, timely medical evaluation, source patient testing, incident reporting, documentation, and follow up.
Scope
This procedure applies to ASOD faculty, staff, residents, work study students, learners, and other authorized personnel involved in patient care or ASOD operations. Requirements also apply to source patients whose blood or other potentially infectious material is involved in an exposure.
Definitions
| Exposed Person |
Individual whose eyes, mouth, mucous membranes, non-intact skin, or bloodstream may have been exposed to blood or other potentially infectious material. |
| Source Patient |
Individual whose blood or other potentially infectious material was involved in an exposure. |
| Unknown Source |
Exposure for which the source cannot be identified, located, tested, or confirmed. Campus Health or UEOHC determines the appropriate follow up pathway. |
| Double Exposure |
Exposure involving two individuals who may each require evaluation or testing because blood or other potentially infectious material was exchanged in both directions. |
| Medical Record Number (MRN) |
UNC Health identifier required for applicable hospital registration, testing, and treatment. |
| Campus Health |
University health service responsible for evaluating and directing follow up for applicable learners. |
| University Employee Occupational Health Clinic (UEOHC) |
University occupational health service responsible for evaluating and directing follow up for applicable employees. |
| Environment, Health and Safety (EHS) |
University office responsible for applicable occupational safety and workers’ compensation processes. |
Immediate Response
An exposed person must safely stop treatment or other activity, remove gloves, and wash the affected area with soap and water. Exposure sites must not be squeezed. Clean paper towels should be used to dry the area before applying an appropriate covering. Eye, mouth, or other mucous membrane exposures require immediate flushing with water. Emergency assistance must be activated when the exposed person experiences a serious injury, significant bleeding, loss of consciousness, respiratory distress, or another condition requiring immediate intervention.
Notification must be provided promptly to the supervising faculty member, instructor, supervisor, or other responsible person. Information should include what occurred, who was involved, the exposure site, and actions already completed. Information should include what occurred, who was involved, the exposure site, and actions already completed. Immediate care and medical evaluation must not be delayed to complete administrative documentation.
Incident Reporting
Incident reports must be submitted through the ASOD Incident Reporting App: https://go.unc.edu/asod-incident-report. Reports must be submitted once immediate safety and care needs permit, and no later than 24 hours after the incident. Submission should be completed by the exposed person, supervising faculty member, instructor, supervisor, or another authorized individual with sufficient knowledge of the event. Assignment of reporting duties does not transfer responsibility for immediate care, health service notification, patient management, or required clinical documentation.
Incident Reporting App provides role-, time-, and exposure-specific guidance. Current lab forms, maps, contact information, and follow-up resources may be provided through the app, confirmation screen, or related email. Full requirements for corrections, supplemental uploads, reviewer assignment, access, and incident closure are governed by the ASOD Incident Report, Documentation, & Corrections Policy.
Source-Patient Management
Source patients should remain on site until the applicable health service provides direction and required testing has been arranged. A provider or designated individual must contact a source patient who has already left and request a prompt return when testing is recommended. Source-patient consent, testing, and disclosure must follow applicable law, University requirements, and health service instructions. ASOD personnel must not independently order testing, disclose results, or access source-patient results unless authorized to do so as part of the patient’s care.
A source patient must have an MRN before applicable UNC Health testing. An exposed person, supervisor, instructor, or designated individual may call (984) 974-8150 when assistance obtaining an MRN is required. Campus Health or UEOHC determines whether an exposure should be managed as an unknown source exposure. Lack of source-patient cooperation does not delay evaluation of the exposed person.
Employee Exposure Pathway
Employee procedures apply to faculty, staff, residents, and other individuals directed to UEOHC for occupational health follow up.
During UEOHC regular hours, Monday through Friday from 7:30 a.m. through 5:30 p.m., excluding University holidays or other periods of closure, the exposed person must immediately call UEOHC at (919) 966-9119 and follow all instructions. Available information should include the exposure route, injury type, timing, source-patient identity, known risk factors, and source-patient availability. UEOHC determines required evaluation, testing, treatment, counseling, vaccination review, medication, and follow up.
Outside UEOHC regular hours, the exposed person must call HealthLink at (984) 974-6303 and follow the instructions provided. UEOHC must be contacted or notified as directed for continued occupational health follow up.
A provider or designated appointee must escort the source patient to the testing location identified through the ASOD Incident Reporting App. Required lab forms and available MRN information must accompany the patient. Receiving staff must be advised that testing concerns an employee bloodborne pathogens exposure, and applicable specimen routing instructions must be followed. An ASOD representative must remain with the source patient until testing is completed or responsibility is accepted by the receiving health care team.
Applicable employees must also complete workers’ compensation, occupational exposure, or other documentation required by UNC Environment, Health and Safety. Current forms must be obtained from approved University resources and submitted according to the instructions provided. Incident reporting does not replace employee health, workers’ compensation, or EHS documentation requirements.
Employees must not access source-patient results through the patient record for personal exposure follow up as this is considered a HIPAA violation.
Learner Exposure Pathway
Learner procedures apply to DDS, DH, and ASPID learners and other individuals directed to Campus Health for follow up. Program specific instructions may apply to residents, work-study students, affiliates, or other roles.
During Campus Health regular hours, Monday through Friday from 8:30 a.m. through 4:30 p.m., excluding University holidays or other periods of closure, the exposed learner must immediately call Campus Health at (919) 966-6573 and follow all instructions. Available information should include the source patient’s name, date of birth, MRN, exposure details, known risk factors, and source-patient availability when appropriate and permitted. Campus Health determines required evaluation, testing, treatment, counseling, medication, vaccination review, and follow up.
Outside Campus Health regular hours, the exposed learner must follow guidance provided by Campus Health, HealthLink, the ASOD Incident Reporting App, or the receiving health care service. Emergency department evaluation may be required when immediate assessment or post-exposure treatment cannot be delayed. Campus Health must be contacted or notified as directed for continued follow up.
A provider or designated appointee must escort the source patient to the testing location identified through the Incident Reporting App. Required learner lab forms and available MRN information must accompany the patient. Receiving staff must be advised that testing concerns a learner bloodborne pathogens exposure, and applicable specimen routing instructions must be followed. An ASOD representative must remain with the source patient until testing is completed or responsibility is accepted by the receiving health care team.
Learners must not access source-patient results through the patient record for personal exposure follow up as this is considered a HIPAA violation.
Exceptions and Health Service Follow-Up
Campus Health or UEOHC determines the appropriate evaluation, testing, treatment, counseling, vaccination review, medication, and follow up for each exposed person. Exposed individuals must follow all instructions and remain available for communication.
A double exposure may require separate evaluation, testing, and documentation for each affected person. Supervising personnel must ensure that each individual contacts the health service appropriate to their role. Source-patient and exposed-person designations may differ for each individual, and separate lab forms may be required. ASOD Incident Reporting App must identify the event as a double exposure so the appropriate instructions, forms, and notifications can be generated.
An exposed person must contact Campus Health or UEOHC immediately when the source is unknown, unavailable, or unwilling to participate. Evaluation and treatment must not be delayed while personnel attempt to identify or locate the source. Supervising personnel must document the known circumstances without speculating about the source or level of risk.
Source-patient test results may affect the follow up plan, but Campus Health or UEOHC makes the final determination. Positive, indeterminate, delayed, or unavailable results may require immediate or continued follow up. ASOD personnel must not interpret source-patient laboratory results for the exposed person unless authorized to do so. Learners must not access source-patient results through the patient record for personal exposure follow up.
Documentation
Incident Report
Incident reports must contain an objective summary of the exposure, including:
- Date, time, and location;
- Individuals involved;
- Type and route of exposure;
- Device, instrument, or material involved;
- Immediate first aid;
- Notifications completed;
- Availability of the source patient;
- Health-service instructions known at submission;
- Testing or referral arrangements; and
- Supporting documentation available at that time.
Supporting records must be uploaded through the ASOD Incident Reporting App when available. Materials may include lab order forms, occupational forms, health service instructions, or supplemental information requested during review. Sensitive information must be limited to content necessary for care, reporting, and authorized review.
Patient Health Record
Source patient’s provider must document clinically relevant information in the patient’s health record. Documentation may include the event, discussion with the patient, consent or refusal, testing arrangements, and follow up instructions. Using the ASOD Incident Reporting App does not replace patient record documentation.
Supplemental Information
Responsible individuals must add significant follow-up information to the incident report when it becomes available. Supplemental information may include completed testing, source-patient refusal, health service disposition, required forms, or corrective actions. Employee health information, learner health information, and confidential laboratory results must remain within the systems authorized to maintain those records.
Source-Patient Refusal
A source patient may refuse testing when permitted by applicable requirements. The provider must explain the purpose of testing, the potential implications of refusal, and available alternatives without coercion. Refusal must be documented in the patient’s health record and reported to Campus Health or UEOHC. Applicable informed refusal documentation must be completed and uploaded to the incident report when required. Campus Health or UEOHC determines the exposed person’s follow up pathway after a source-patient refusal.
Prevention and Post-Incident Review
Supervising faculty, clinical leadership, and responsible units must review exposure circumstances and identify reasonable measures to prevent recurrence. Review may address work practices, sharps handling, instrument transfer, disposal methods, personal protective equipment, supervision, equipment, environmental conditions, or training. Identified hazards or recurring patterns must be referred to the appropriate department, safety committee, Infection Control, EHS, or ASOD Clinical Compliance. Corrective review does not replace individual health-service follow-up or required exposure-control processes.
System Unavailability
Immediate care and required health-service contact must continue when the ASOD Incident Reporting App is unavailable. Reporters must contact ASOD Clinical Compliance when system access, submission, forms, or uploads are unavailable. ASOD Clinical Compliance may facilitate an alternate submission or create the administrative record after receiving sufficient information. Current forms and maps should be obtained through the Incident Reporting App documentation area whenever available.
Related Requirements
External Regulations
Unit Policies, Standards, and Procedures
Contact Information
| Topic |
Title |
Contact |
| General Questions |
Director of Clinical Compliance |
ASOD_ClinicalCompliance@unc.edu |
| Employee / Resident Exposure |
UEOHC |
(919) 966-9119 |
| After Hours - Employee / Resident Exposure |
HealthLink |
(984) 974-6303 |
| DDS / DH / ASPID Exposure |
Campus Health |
(919) 966-6573 |
| Incident Submission |
ASOD Incident Reporting App |
https://go.unc.edu/asod-incident-report |