Blood and body fluid exposures

1. Blood and body fluid exposures Source patient testing in WizOrder and exposure reporting Vanderbilt Occupational Health Clinic 2004

2. When a healthcare worker is exposed to a patient’s blood or infectious body fluids, the stakes are high. Vanderbilt Occupational Health Clinic 2004

3. What is the chance that an exposure will cause disease? Vanderbilt Occupational Health Clinic 2004

4. Risk of infection after a needlestick from an infected patient • Hepatitis B - 30% or 1 in 3 needlesticks • Hepatitis C – 1 to 10% (best estimate 1.8%) or 1 in 100 needlesticks • HIV - 0.3% (0.09% for splashes) or 1 in 333 needlesticks (1 in 1000 splashes) CDC - MMWR 1998 Vanderbilt Occupational Health Clinic 2004

5. The risk is higher if • the wound is deep, • the needle was hollow-bore, or • the patient has a high viral load. Vanderbilt Occupational Health Clinic 2004

6. Time is of the essence Antiviral therapy given within the first 2 hours reduces the risk by 80%. Vanderbilt Occupational Health Clinic 2004

7. You can help • If your patient is the source of a needlestick or splash, you may be asked to order source patient testing • Source testing now includes a rapid HIV test • Results are available within an hour.* • *If ordered 11pm – 7am Sat. or Sun. it will be run at 7am the next morning Vanderbilt Occupational Health Clinic 2004

8. WizOrder instructions In Wiz, type keyword "exposure" or "source" or "needlestick" • Select “Evaluate source patient whose blood/body fluids caused exposure."  • Accept all tests in the order set: • Rapid HIV antibody • Hepatitis C antibody • Hepatitis B profile  • When this order set is used, the patient will not be billed Vanderbilt Occupational Health Clinic 2004

9. Insert screenshot of Wiz Step 2: Select “evaluate source patient” Step 1: Type “source” (or “needlestick” or “exposure”) Vanderbilt Occupational Health Clinic 2004

10. The necessary lab tests are bundled together Vanderbilt Occupational Health Clinic 2004

11. Accept all orders in the set. The patient will not be billed. Vanderbilt Occupational Health Clinic 2004

12. ****Important**** Make sure the exposed employee goes to Occupational Health or the ED, regardless of the HIV results. Vanderbilt Occupational Health Clinic 2004

13. What does the employee need? • baseline labs (NOT the same tests as the source patient) • counseling about risk • possibly prophylactic medication • a follow-up plan • documentation of the exposure DO NOT order labs or prescribe medication for exposed employees! Vanderbilt Occupational Health Clinic 2004

14. Who can order lab tests on the exposed worker? • Only Occupational Health and the ED! • Confidentiality: • These lab results are stored in a separate database, not visible in StarPanel except to Occupational Health. • Billing: • Employee labs are billed differently, not the same account as the source patient Vanderbilt Occupational Health Clinic 2004

15. Why should the worker seek care if the patient is HIV negative? • Counseling: • Not all patients with HIV have antibodies yet – counseling is still needed to make an informed decision. • Hepatitis C found in 2% of source patients • Documentation: • The exposure must be documented and baseline labs drawn to qualify for Worker’s Compensation which would pay for any care that the worker may need. Vanderbilt Occupational Health Clinic 2004

16. When should I go to the ED instead of OHC? • Go to Occupational Health during office hours • 7:30am – 5:30pm, Monday – Friday • When Occupational Health is closed, go to the Emergency Department and identify yourself as an employee who has had an exposure Vanderbilt Occupational Health Clinic 2004

17. The ED drew my blood - why follow up with Occupational Health? • The initial evaluation establishes if you had disease BEFORE the exposure • OHC does follow-up testing to see if you develop disease AS A RESULT OF the exposure • Occupational Health will track down source patients if further testing is needed • When ordered correctly, only Occupational Health can obtain your results Vanderbilt Occupational Health Clinic 2004

18. In addition…. • Occupational Health • tracks how all exposures occur at Vanderbilt, • identifies unsafe products and practices • identifies high risk jobs and departments who need additional training • works with Infection Control and the Value Analysis Committee to implement safety improvements Vanderbilt Occupational Health Clinic 2004

19. Report every exposure Vanderbilt Occupational Health Clinic 2004

20. Report your injury • Reporting gives us the information we need to prevent future injuries • Even if your source was low risk, the next exposed worker might not be so lucky • Reporting is our tool to identify dangerous products and practices, so we can act to make Vanderbilt a safer place to work Vanderbilt Occupational Health Clinic 2004

21. Interventions A safer disposal system: • Needlesticks were happening while disposing of needles, • Sharps boxes had unsafe design • A hospital-wide change of sharps boxes reduced the injury rate. Vanderbilt Occupational Health Clinic 2004

22. Safer devices: • Butterfly needles were most frequent injury type • Purchase of new, safer butterfly needles, reduced the injury rate further Vanderbilt Occupational Health Clinic 2004

23. Results: This program reduces needlestick injuries Vanderbilt Occupational Health Clinic 2004

24. Take home points • Order source patient labs in WizOrder through the appropriate order set • A rapid HIV test will be done on source patients • Send exposed employees to Occupational Health, or to the ED after hours, for evaluation. DO NOT TREAT EXPOSED EMPLOYEES YOURSELF!! • Report ALL exposures, even if the source is HIV negative so we can keep lowering the risk at Vanderbilt Vanderbilt Occupational Health Clinic 2004