Bloodborne Pathogens Policy

In 1992, the Executive Faculty of the School of Medicine formally adopted a Medical Campus policy on human immunodeficiency virus (HIV) and hepatitis B virus (HBV) infections. This policy was updated in 2001 to include hepatitis C virus (HCV) infections. The purpose of the policy is to provide guidelines to prevent or reduce the transmission of these infectious agents between patients and health care workers. It is an ethical and moral obligation for students/employees to report bloodborne pathogen infections.

The policy deals with the following: (1) the university's responsibilities to infected patients, including obligation to treat, confidentiality, and appropriate serologic testing; (2) appropriate health and safety precautions and procedures for faculty, students and staff, including compliance with Centers for Disease Control and Prevention guidelines, blood and body fluid precautions, and handling of needles or sharp instruments; and (3) the university's responsibilities to faculty, staff or students who are infected with HIV, HBV or HCV, including admission to medical school, participation in clinical rotations, serologic testing confidentiality, and medical treatment.

The policy makes a distinction between Category I activities (those involving no risk of transmission from infected health care workers to patients, such as routine history/physical examinations, minor surface suturing, and elective phlebotomy), Category II activities (those for which bloodborne virus transmission is theoretically possible but unlikely, such as minor local procedures, central venous lines, and other specialty procedures), and Category III activities (those for which there is a definite risk of bloodborne virus transmission, such as general surgery, cardiothoracic surgery, neurosurgery, and other surgeries as well as nonelective procedures performed in the emergency department).

In 2012, a committee was formed that included representation from Administration, Legal – Risk Management, Infectious Disease, Occupational Health, and Student Health Services. The Student Health Services director meets with infected students and discusses the need for restricted activities and proper follow-up.

Needle Stick/Human Blood and Body Fluid Exposure Policy

All exposures to human blood and body fluids must be reported immediately to the Health Service, which maintains a 24-hour reporting system. During working hours (8 a.m.-4 p.m.), the office can be reached at 314-362-3523 or 314-362-3528. After hours, the Health Service can be contacted through a digital beeper at 314-871-2966.

Needle Stick Procedure

Cleanse the wound immediately with soap and water. If a mucous membrane has been exposed, rinse with copious amounts of water.

  1. Identify the source of exposure.
  2. Call the Health Service for further instructions. The source patient will be evaluated for HIV, HBV and HCV. The physician in charge of the case is responsible for acquiring patient consent for testing. The employee will notify the physician. All source patient charges will be the responsibility of the Health Service.
  3. Complete the Injury/Exposure Report form.
  4. Employees and students will report to the Health Service for follow-up. Individuals will be evaluated for the following:
    1. HIV or serum sample save
    2. HBV vaccination
    3. Hepatitis B surface antibody testing (a positive test in the past eliminates the need for further testing)
    4. HCV vaccination
    5. Tetanus and diphtheria vaccination
    6. Post-exposure prophylaxis

Human Blood and Body Fluid Exposures Procedure

  1. Clean the area with soap and water.
  2. Call Employee Health (314-362-3528) or Student Health (314-362-3523). After hours, call the digital beeper (314-871-2966).
  3. Keep the source or patient available for HIV, HBV and HCV testing.
  4. Follow the instructions given by the Health Service. Complete an incident report.

Always wear Personal Protective Equipment!