Adams School of Dentistry: Procedure Following Bloodborne Pathogens Exposure

Purpose

The purpose of this Procedure is to provide detailed, step-by-step guidance for UNC Adams School of Dentistry (ASoD) personnel to follow in the event of a potential bloodborne pathogens exposure.  For a visual aid, see the "Procedure Infographic".

Scope

All UNC Adams School of Dentistry ("ASoD") faculty, staff, residents, students, and patients.

Definitions

1. Exposed Person: the individual who is "at risk" due to exposure to a Source Patient's blood or other potentially infectious bodily material (e.g., needlestick injury).
2. Source Patient: the individual whose blood or potentially infectious bodily material has been exposed to another person creating a significant risk of transmission
3. MRN: Medical Record Number
4. UEOHC: University Employee Occupational Health Clinic
5. EHS: Environment, Health, and Safety

Procedure

General: Faculty, Staff, Residents, and Work-Study Students

1. When an exposure incident occurs, the Exposed Person must safely stop treatment, remove gloves, and wash the exposure site with soap and water. DO NOT SQUEEZE THE EXPOSED AREA (CDC MMWR). Pat the area dry with a clean paper towel and bandage the exposure site to avoid both cross-contamination and other contaminates from entering the exposed site.
2. Exposed Person will inform supervisor or appropriate person of the incident and what steps already taken
3. Supervisor or appointed person will complete an online Incident Report, which will provide summary of next steps, paperwork, maps, alert all individuals of the issue, and automatically document preliminary steps.

Regular Hours: Faculty, Staff, Residents, and Work-Study Students

1. Regular hours are considered to be Monday – Friday, from 8:30 AM – 4:30 PM.
2. Source Patient should be kept on-site and Exposed Person will immediately call University Employee Occupational Health Clinic (UEOHC) at (919) 966-9120. Blood draws can only occur at UNC-Chapel Hill Hospital/Phlebotomy Lab with rare exceptions. If the Source Patient has already left, Exposed Person, Supervisor, or appropriate person must first contact the Source Patient and request that they return.
3. Source Patient will need a Medical Record Number (MR#) if they do not already have one. If an MRN is to be acquired, the exposed Person, supervisor, or appropriate person will call (984) 974-8150.
4. Supervisor or appropriate person will complete an “EMPLOYEE Lab Order Form” and provide to Exposed Person
5. Source Patient’s Provider must escort the patient to UNC Hospital Phlebotomy Services for testing, with the completed “EMPLOYEE Lab Order Form.” Map from ASoD to UNC Hospital Phlebotomy will be attached to automated response from Incident Report.
   1. Services and instructions on arrival are automatically sent to the email address entered into the Incident Form.
   2. Phlebotomy Lab Supervisor receives an alert that a Source Patient will be arriving for a lab work, related to a bloodborne pathogens exposure.
   3. Inform lab staff that the lab order is related to an employee blood exposure, with blood draw to be sent to the Micro Lab (Tube Station #82).
6. Exposed Person may be advised by UEOHC on additional tests or necessary steps.
7. Exposed Person is expected to follow all instructions provided from UEOHC.
8. Map to UEOHC and instructions on arrival are automatically sent when Incident Form is completed.
9. UEOHC generally will wait to see the results from the Source Patient’s blood draw (negative/positive results) or will provide guidance for an unknown Source Patient.
   • Negative Results: Exposed Person likely will not require any further treatment. UEOHC may require an updated Tdap but will advise Exposed Person if this is necessary.
   • Positive Results: Exposed Person will be contacted by UEOHC and advised to head to the UEOHC location for counseling and/or treatment.
   • Unknown Source Patient: UEOHC will advise Exposed Person to arrive at UEOHC, or UNC Emergency Department if after regular hours, immediately for testing. Exposed Person will be notified by UEOHC of blood test results and direct the Exposed Person of the next steps.

Outside Regular Hours: Faculty, Staff, Residents, and Work-Study Students

1. Outside regular hours are considered to be before 8:30 am or after 4:30 pm, Monday – Friday, or anytime on Saturday or Sunday.
2. Source Patient should be kept on-site and Exposed Person will immediately call HealthLink at (984) 974-6303, to report the issue. If the Source Patient has already left, Exposed Person, Supervisor, or appropriate person must first contact the Source Patient and request that they return, since a blood test can only be performed at the UNC-Chapel Hill Hospital/Phlebotomy lab.
3. Source Patient’s Provider will escort the patient, with the completed Lab Order Form, to UNC Women and Children’s Hospital registration desk to obtain a MRN. Map to appropriate area is provided automatically once Incident Form has been completed.
4. After MRN has been secured, Source Patient’s Provider will then escort the patient to Pre-Care at UNC Main Hospital and inform the staff that this is related to a bloodborne pathogens exposure. Map to appropriate area is provided automatically once Incident Form has been completed.

Documentation: Faculty, Staff, Residents, and Work-Study Students

When an Incident Form is submitted, automated responses and instructions are provided, which include but are not limited to a summary of the incident, steps to follow, maps, Incident ID Number, and documentation that will need to be uploaded. Additional paperwork is required for UNC, which can be accessed through the EHS Forms, under the "Workers Compensation" drop down menu. Completed forms can be scanned and emailed to ueohc@office.unc.edu.

General: DDS & DH Students

1. When an exposure incident occurs, the Exposed Person must safely stop treatment, remove gloves, and wash the exposure site with soap and water. DO NOT SQUEEZE THE EXPOSED AREA (CDC MMWR). Pat the area dry with a clean paper towel and bandage the exposure site to avoid both cross-contamination and other contaminates from entering the exposed site.
2. Exposed Person will inform instructor or faculty lead the incident and what steps already taken
3. Instructor or appointed person will complete an online Incident Report, which will provide summary of next steps, paperwork, maps, alert all individuals of the issue, and automatically document preliminary steps

Regular Hours: DDS & DH Students

1. Regular hours are considered to be Monday – Friday, from 8:30 AM – 4:30 PM.
2. Source Patient should be kept on-site and Exposed Person will immediately call Campus Health Services at (919) 966-6573. Provide the Source Patient’s name, date of birth, Medical Record Number (MRN), and any HIV risk factors. If the Source Patient has already left, request that they return as blood draws can only occur at the UNC-Chapel Hill Hospital/Phlebotomy Lab.
3. Source Patient will need a Medical Record Number (MR#) if they do not already have one. If an MRN is to be acquired, the exposed Person, instructor, or appointed person will call (984) 974-8150.
4. Instructor or appointed person will complete a “STUDENT Lab Order Form” and provide to Exposed Person
5. Source Patient’s Provider must escort the patient to UNC Hospital Phlebotomy Services for testing, with the completed “STUDENT Lab Order Form.” Map from ASoD to UNC Hospital Phlebotomy is provided through automated Incident Reporting System.
   1. Services and instructions for arrival are automatically sent when Incident Form is completed.
   2. Phlebotomy Lab Supervisor receives an alert that a Source Patient will be arriving for a lab work, related to a bloodborne pathogens exposure.
   3. Inform lab staff that the lab order is related to an employee blood exposure, with blood draw to be sent to the Micro Lab (Tube Station #82).
6. Exposed Person may be advised by Campus Health Services on additional tests or necessary steps.
   1. Exposed Person is expected to follow all instructions provided from Campus Health Services.
   2. Campus Health Services will contact Exposed Person regarding any potential lab follow up’s necessary. Exposed Person will be advised if they are to make an appointment.
   3. If Campus Health Services advises that Exposed Person is to be seen immediately, they are to follow guidance and Instructor or appointed person will escort the Source Patient for a lab draw.

Outside Regular Hours: DDS & DH Students

1. Source Patient’s Provider will escort the patient, with the completed Lab Order Form, to UNC Women and Children’s Hospital registration desk to obtain a MRN. Map to appropriate area is provided automatically once Incident Form has been completed.
2. After MRN has been secured, Source Patient’s Provider will then escort the patient to Pre-Care at UNC Main Hospital and inform the staff that this is related to a bloodborne pathogens exposure. Map to appropriate area is provided automatically once Incident Form has been completed.

Documentation: DDS & DH Students

When an Incident Form is submitted, automated responses and instructions are provided, which include but are not limited to a summary of the incident, steps to follow, maps, Incident ID Number, and documentation that will need to be uploaded.

Related Requirements

External Regulations

• Campus Health Services: BBP Exposure for Health Science Students
• CDC MMWR: Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis
• OSHA Bloodborne Pathogens Standard 1910.1030
• 10A NCAC 41A .0201: Control Measures - General
• 10A NCAC 41A .0202: Control Measures - HIV
• 10A NCAC 41A .0203: Control Measures - Hepatitis B
• 10A NCAC 41A .0206: Infection Prevention - Health Care Settings
• 10A NCAC 41A .0207: HIV and Hepatitis B Infected Health Care Workers
• UNC Health Care Exposure Control Plan (including Campus Health and Dental School)
• UNC-CH EHS - Bloodborne Pathogens
• UNC-Chapel Hill Environment, Health and Safety Manual - Chapter 03.03: Injury, Illness, and Near Miss - Incident Investigation of Injuries, Illnesses, and Near Misses
• North Carolina Industrial Commission’s Form 18. Notice of Accident to Employer and Claim of Employee, Representative, or Dependent for Workers’ Compensation Benefits. (Under the "Worker's Compensation" tab on the EHS "Forms" page.)
• North Carolina Industrial Commission’s Form 19. Employer’s Report of Employee’s Injury or Occupational Disease to the Industrial Commission. (Under the "Worker's Compensation" tab on the EHS "Forms" page.)

Unit Policies, Standards, and Procedures

• Adams School of Dentistry: Infection Control Manual
• Adams School of Dentistry: Incident Report, Documentation & Corrections

Contact Information