Occupational Exposure Checklist

(Optimal Outcome is Time-Dependent)

triage Rn to complete this section

1. Triage occupationally exposed worker and bring to ED, then

- Notify Senior Resident or Attending of Occupational Exposure and need for immediate evaluation.

- Notify microbiology lab of potential SUDS testing at Ext. _____________________.

- If any possibility for pregnancy exists, send blood for HCG.

2. Give PINK information sheet to patient to review while waiting.

MD TO COMPLETE THIS SECTION

3. HISTORY of EXPOSURE (critical elements to be charted by MD)

- Date of exposure

- Time of exposure

- How exposure occurred

- Details of exposure:

• Type and amount of fluid

• Severity of exposure (e.g., depth of injury, whether fluid is injected)

- If available, obtain details of exposure source (whether source material contained HIV, bloodborne pathogens, known high-risk behaviors)

- If a source is a known HIV+ patient, if available, obtain

• Stage of disease

• History of anti-retroviral therapy

• Viral load

4. MD to determine exposure code (EC), see Step One of BLUE sheet

(If no source is available, go to #6)

primary rn to complete this section

5. If "SUDS" and/or Hep C are ordered:

- Label blood with source’s name (with enclosed label), complete miscellaneous slip by filling in source’s name, fill in MD name on red flag, attach red flag to blood, and send to microbiology.

- CONSENT FORM for HIV must accompany specimen to lab.

• If consent is unavailable, Hep C should still be sent (correct misc slip).

• If MD is to obtain consent from source, they can reference the back of the consent form (enclosed in packet) for HIV testing counseling guidelines.

- Primary nurse to notify charge nurse that SUDS test is sent, and recheck time is ________ (45 min)

MD TO COMPLETE THIS SECTION

6. MD makes decision on Postexposure Prophylaxis (PEP), step 2 and 3 on BLUE sheet:

(Circle one) NO PEP PEP-basic PEP-expanded

if ordered, pep packets are available in pyxis

7. MD counsels exposed patient and obtains consent for PEP:

(PEP consent form in packet)

- Medication Education

- Serial Testing

- Methods to Prevent Secondary Transmission

- Pregnancy Prevention

- Refrain from Donating Blood, Plasma, Tissue, or Semen

- Follow-Up Care

8. If PEP is started, order baseline labs of CBC, AST, ALT.

9. Notify Infection Control at _________/ beeper _________ of results and follow-up instructions.

Called @ ________________ Returned call @ ________________

PRIMARY RN TO COMPLETE THIS SECTION

10. If ordered, dispense PEP from Pyxis, give medication sheets to patient. (GREEN sheets included in packet)

11. Give discharge instructions from Logicare (or YELLOW sheet in packet), listed under "Occupational Exposure to Infectious Diseases."

12. Fax this completed occupational exposure checklist to ____________________________

13. Place this occupational exposure checklist in manager’s box when completed. (DO NOT PLACE IN CHART.)

COMPLETED BY: ______________________________ MD

For more information about the occupational exposure packet, contact:

J. Celeste Kallenborn, RN, BSN, Department of Emergency Medicine, University of Louisville, Louisville, KY 40292. Telephone: (502) 852-7917. Fax: (502) 852-0066. E-mail: celeste@ louisville.edu.

Anna Smith, RN, MSN, University of Louisville Hospital, Emergency Services, 545 S. Jackson St., Louisville, KY 40202. Telephone: (502) 562-3970. Fax: (502) 562-3444. E-mail: annasm@ ulh.org.