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 of Applicability

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
    1. If the Source Patient has already left, Exposed Person, Supervisor, or appropriate person must first contact the Source Patient and request that they return.
    2. If returning is not an option for the Source Patient, the Director of Clinical Compliance will identify UNC Hospital affiliate locations that the Source Patient can visit. Director of Clinical Compliance will coordinate with UEOHC on securing appropriate Lab Order Forms for locations.
    3. If none of the locations above are feasible, and the Source Patient lives further than an hour from the list of affiliated locations, a blood draw may be completed at the Source Patient’s primary care physician’s office.
  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.
    1. If the Source Patient has already left, Exposed Person, Supervisor, or appropriate person must first contact the Source Patient and request that they return.
    2. If returning is not an option for the Source Patient, the Director of Clinical Compliance will identify UNC Hospital affiliate locations that the Source Patient can visit. Director of Clinical Compliance will coordinate with UEOHC on securing appropriate Lab Order Forms for locations.
    3. If none of the locations above are feasible, and the Source Patient lives further than an hour from the list of affiliated locations, a blood draw may be completed at the Source Patient’s primary care physician’s office.
  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

  1. 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.
  2. Supervisor or appropriate person will complete an EHS Supervisor Accident Report Form and NCIC Form 19 within 30 days of accident.
    1. If the incident involves serious bodily injury or death, EHS is to be contacted immediately by calling (919) 962-5507.
  3. Supervisor Forms can be located through the EHS Forms Site  and uploaded through the Online Incident Documentation Upload.
    1. If the incident involves serious bodily injury or death, EHS is to be contacted immediately by calling (919) 962-5507.
    2. Supervisor is to upload all documentation, both supervisor and employee documents, in one submission. Failure to do so may result in an automated message warning that document submission was not accepted.
    3. Uploading of documentation is automatically encrypted, logged, and forwarded to the appropriate individuals.
    4. Confirmation response of upload will be provided with an Upload ID Number for record keeping purposes
  4. Exposed Person will complete an EHS Employee Accident Report Form and Form 18 within 30 days of accident or as soon as realistically possible, within a maximum of up to 2 years after the incident.
    1. Forms can be located through the EHS Forms Site
    2. Exposed Person will need to provide this paperwork to their supervisor or appropriate person within the above time limit, so that all information can be uploaded at once.
  5. Corrections to an Incident Report Form can be completed by a supervisor through the Incident Correction Form

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.
    1. Provide the Source Patient’s name, date of birth, Medical Record Number (MRN), and any HIV risk factors.
    2. 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. If returning is not an option for the Source Patient, the Director of Clinical Compliance will identify UNC Hospital affiliate locations that the Source Patient can visit.
    4. If none of the locations above are feasible, and the Source Patient lives further than an hour from the list of affiliated locations, a blood draw may be completed at the Source Patient’s primary care physician’s office.
  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

  1. 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.
  2. Instructor or appointed person can upload any supplemental information through the Online Incident Documentation Upload.
    1. Uploading of documentation is automatically encrypted, logged, and forwarded to the appropriate individuals.
    2. Confirmation response of upload will provide with an Upload ID Number, for record keeping purposes
  3. Corrections to an Incident Report Form can be completed by a supervisor through the Incident Correction Form.

Points of Contact

Who do I contact if a needle stick / sharps / or instrument puncture occurs at the pre-doctoral student clinics?

If a needle stick or instrument puncture incident occurs on the clinic floor you need to notify the Dental Assistant Supervisor or Lead Instructor. If the Dental Assistant Supervisor is not available, contact any available staff Dental Assistant. If no Dental Assistants are available, contact the Director of Clinical Compliance.

If a needle stick or instrument puncture incident occurs in the Central Sterilization Unit, notify the Supervisor or Shift Supervisor.

Who are the points of contact for each Department / Division Area?

Each point of contact is automatically alerted to an incident. However, should the point of contact need to be contacted, see the list below for each area point of contact

Points of Contact
Department Area Name Email
Admissions / Urgent Care "Jenn" Shull jennifer_shull@unc.edu
Craniofacial Center "Jessi" Hill jessi_hill@unc.edu
Central Sterilization Unit Lisa Torkewitz
Win Naing
Lisa_Torkewitz@unc.edu
Win_Naing@unc.edu
Dental Faculty Practice Wendy Chambers wendy_chambers@unc.edu
Endodontics Haley Encarnacion haley@unc.edu
Geriatrics / Special Needs "Jessi" Hill jessi_hill@unc.edu
Go Health Wendy Lamm wendy_lamm@unc.edu
Grad Operative Callie Howlett chowlett@email.unc.edu
Oral Surgery Jeneen Williamson
Tasha Curtis
Darla
Shay
jeneen_williamson@unc.edu
tasha_curtis@unc.edu
darla@email.unc.edu
shayb4@email.unc.edu
Orofacial Pain Tia Moore tiam@email.unc.edu
Orthodontics Courtney Fearrington
JC Underwood
courtrh@email.unc.edu
jcunderw@ad.unc.edu
Pediatrics “Azi” Rohanian-Perry
Terry Hurdle
Lisa Mauldin
Azadeh_RohanianPerry@unc.edu
Terry_Hurdle@unc.edu
lisa_mauldin@unc.edu
Periodontics Avie Smith
Callie Howlett
thompsaj@live.unc.edu
chowlett@email.unc.edu
Prosthodontics Callie Howlett
Danielle Eshleman
chowlett@email.unc.edu
danielle_eshleman@unc.edu
PRU (Dental Hygiene) "Jenn" Shull
Mary Mackenzie
jennifer_shull@unc.edu
mary_mackenzie@unc.edu
Radiology Amber Dodson Amber_Dodson@unc.edu
Student Clinic - 3rd Floor "Jenn" Shull jennifer_shull@unc.edu
Student Clinic - 4th Floor "Jenn" Shull jennifer_shull@unc.edu

Related Requirements

External Regulations and Consequences

  1. Campus Health Services: BBP Exposure for Health Science Students
  2. 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
  3. OSHA Bloodborne Pathogens Standard 1910.1030
  4. 10A NCAC 41A .0201: Control Measures - General
  5. 10A NCAC 41A .0202: Control Measures - HIV
  6. 10A NCAC 41A .0203: Control Measures - Hepatitis B
  7. 10A NCAC 41A .0206: Infection Prevention - Health Care Settings
  8. 10A NCAC 41A .0207: HIV and Hepatitis B Infected Health Care Workers
  9. UNC Health Care Exposure Control Plan (including Campus Health and Dental School)
  10. UNC-CH EHS - Bloodborne Pathogens
  11. UNC-Chapel Hill Environment, Health and Safety Manual - Chapter 03.03: Injury, Illness, and Near Miss - Incident Investigation of Injuries, Illnesses, and Near Misses
  12. 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.)
  13. 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

  1. Adams School of Dentistry: Infection Control Manual
  2. Documentation Upload Site
  3. Incident Correction Site

Details

Article ID: 131302
Created
Thu 4/8/21 9:05 PM
Modified
Wed 1/4/23 2:29 PM
Effective Date
If the date on which this document became/becomes enforceable differs from the Origination or Last Revision, this attribute reflects the date on which it is/was enforcable.
03/08/2021 12:00 AM
Issuing Officer
Name of the document Issuing Officer. This is the individual whose organizational authority covers the policy scope and who is primarily responsible for the policy.
Issuing Officer Title
Title of the person who is primarily responsible for issuing this policy.
Director of Clinical Compliance
Last Review
Date on which the most recent document review was completed.
03/08/2021 12:00 AM
Last Revised
Date on which the most recent changes to this document were approved.
06/04/2021 12:03 PM
Next Review
Date on which the next document review is due.
07/01/2022 12:00 AM
Origination
Date on which the original version of this document was first made official.
10/14/2019 12:08 PM
Responsible Unit
School, Department, or other organizational unit issuing this document.
Clinical Compliance

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