Skip to main content

Exposure determination and reporting guideline

Purpose of Guideline 

  1. Define significant body substance exposure to potentially infectious materials.
  2. Define the responsibility of faculty members to students with regard to validation of information regarding Universal Precautions.
  3. Describe the procedure for follow-up investigation, management, and prophylaxis of persons with body substance exposures who are enrolled in or employed by the College of Nursing (CON).
  4. Describe the responsibilities of the individual to report incidents and to act as instructed if an exposure occurs.

A. Exposure Potential

Individuals, within the CON, who have the likelihood of being exposed to blood or other potentially infectious materials, are nursing faculty, nursing students, graduate students and lab personnel.

B. Control Methods

All faculty and students are educated on Standard Precautions. Standard Precautions combine the major features of Universal Precautions (UP) and Body Substance Isolation (BSI) and are based on the principle that all blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents. Standard Precautions include a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered. These include: hand hygiene; use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure; and safe injection practices. Also, equipment or items in the patient environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents (e.g., wear gloves for direct contact, contain heavily soiled equipment, properly clean and disinfect or sterilize reusable equipment before use on another patient). See full Standard Precautions details.

All persons within the CON will adhere to Standard Precautions and Universal Precautions, including the appropriate use of hand washing, personal protective equipment and care in use and disposal of needles and other sharp instruments. Individuals who have exudative lesions or weeping dermatitis should refrain from all direct patient care and from handling patient-care equipment and devices used in performing invasive procedures until the condition resolves per agency guidelines.

Students will demonstrate knowledge of standard precautions on an annual basis prior to clinical experiences. Information used to validate knowledge should meet the clinical agency expectations and therefore, the faculty member and the Semester Coordinator should consult with the clinical agency infection control department to obtain validation materials related to standard precautions.

C. Occupational exposure

Occupational exposure is defined as contact with blood, visibly bloody fluids, and other body fluids (i.e., semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, and amniotic fluid, tissues, and laboratory specimens that contain concentrated virus) to which Standard Precautions apply and during the performance of … [student or faculty’s] duties. Modes of exposure include percutaneous injuries, mucous membrane exposures, non-intact skin exposures, and bites. Exposures to body fluids (e.g., feces, nasal secretions, saliva, sputum, sweat, tears, urine and vomitus), do not carry a risk of blood borne pathogen transmission unless these are visibly contaminated with blood. (The National Healthcare Safety Network (NHSN) Manual Healthcare Personnel Safety Component Protocol (updated August 8, 2012). See full manual housed at the CDC training website.

D. Exposure Determination

Individuals will report all needle sticks or suspected body fluid exposures by reporting such incidents immediately to their clinical/lab instructor or supervisor and to the proper authorities within the clinical agency, which will initiate an exposure investigation per the given facility’s policy. Students enrolled in Nurs 495 or any practicum setting will notify their preceptor and the nursing supervisor immediately, if exposure occurs in the clinical setting. The preceptor and/or nursing supervisor will initiate an exposure investigation as listed above. The individual will notify their clinical faculty or supervisor as soon as possible and no later than 24 hours after the exposure.

  1. Clean Needle Stick (No Exposure): If an individual suffers a clean needle stick in the clinical setting or laboratory, the individual and the supervisor will complete the Exposure to Clean Needle Stick in Clinical or Lab Report. Individual will receive a copy of the Instructions for Observation for Infection and Treatment written information sheet. The individual also signs the form agreeing to report to SDSMT Student Health Care Services or healthcare provider if any signs of infection are noted. Student & Faculty complete Report of Accident, Incident, or Unsafe Condition (Non-State Automobile) form within 24 hours. 
  2. Exposure Incident: An exposure incident includes any of the following: a percutaneous injury with contaminated sharp/instrument, or exposures to eye, mouth, other mucous membrane, or non-intact skin with blood, bloody fluid, or tissue, semen, vaginal secretions, cerebrospinal, synovial, pleural, peritoneal, pericardial, or amniotic fluid; respiratory resuscitation with a resuscitation device, bites resulting in blood exposure to either person involved. If an exposure occurs, follow the steps listed in the Exposure Procedure.

E. Reporting Exposure

Depending on the clinical location, the faculty member, Occupational Health Nurse (OHN), Infection Control Nurse, clinical agency Health Care Provider (HCP), or a HCP from Student Health Service will initiate and investigate the possibility of blood-borne disease exposure, recommended diagnostic testing, counseling and education, and recommendation for prophylaxis according to the CDC guidelines. During off-hours, individuals should be referred to the nearest emergency room. The individual should bring a copy of their lab work, if blood is drawn elsewhere. The individual is responsible for paying to have their blood tested and if needed, any further testing procedures or medications.

F. Notification of CON Management

Within 24 hours of the exposure, the faculty or Semester Coordinator will complete a Report of Accident, Incident, or Unsafe Condition (Non-State Automobile) form and report the exposure incident to the designated Assistant Dean, Undergraduate Department. This completed report is taken or faxed to the Dean’s Administrative Assistant, who will send copies to University Police Department (UPD) and Risk Management in Purchasing.

G. Follow-up

The Assistant Dean will coordinate follow-up care, depending on the level of exposure. The current Recommended Guidelines for Blood/Body Fluid Post-Exposure Testing as set forth by the Center for Disease Control Administration of prophylaxis are followed. Individuals may be referred for campus counseling services post-exposure. Initial follow-up is done at the clinical agency where the exposure occurred and by the appropriate health service as designated in the Exposure Procedure; however, the individual can also choose to see their private health care provider. Regardless, the individual is responsible to pay for all procedures, follow-up treatments and medications ordered for prophylaxis. If the individual chooses a private health care provider, the health care provider will need to provide the necessary documentation to the CON.

H. Confidentiality of Records

The designated Assistant Dean will maintain a copy of the Exposure Determination Report and inform the Semester Coordinator or others as needed. The designated health care provider will complete the Exposure to Body Fluids Report and fax a copy to the designated Assistant Dean. The medical staff will retain a copy and mail a hard photocopy once all of the follow-up has been completed. When individuals are found to be positive for infectious disease the Assistant Dean should refer to the Communicable Disease guideline.

Student’s medical records are confidential and no information may be disclosed or reported without the student’s expressed written consent within or outside the University. Records will be maintained for at least the duration of the schooling plus 30 years by the respective healthcare agency.

If the individual consents to baseline blood collection but does not give consent at that time for HIV serologic testing, the sample of blood will be preserved for at least 90 days. If within 90 days of the exposure incident, the individual elects to have the baseline sample tested, such testing will be done as soon as feasible. The individual is responsible for paying to have their blood sample tested and for all subsequent procedures, treatments and/or medications.

Formerly Policy # C1431
Reviewed by the Bylaws and Handbook Committee 4/2019
University links updated 4/23/2019  lp
References updated 4/23/2019 lp