PURPOSE 1. The purpose of this policy is to minimize or eliminate employee exposure to communicable diseases. 2. To provide a standard for effective personnel protection against communicable diseases while performing EMS related activities. 3. To institute safety procedures to be used when providing care to patients. 4. To provide a standard for the effective cleansing and decontamination of personnel, clothing and equipment when contaminated by any bodily fluid. POLICY STATEMENT The Northern Zone, San Mateo County Fire Agencies (Brisbane, Colma, Daly City, Pacifica, San Bruno) have established a written Infection Control Manual that is available at all fire stations. The North Zone JPA Coordinator is the Infection Control Coordinator for this program. When the North Zone JPA Coordinator is absent the on-duty immediate supervisor of the given agency is responsible for administering the program. The Northern Zone Agencies are committed to full compliance with applicable laws and policies dealing with infection control. The involved departments will develop plans leading to compliance for any deficient areas identified by this program. Each employee of the Northern Zone is responsible for following the policies and procedures outlined in the Infection Control Manual. The Infection Control Manual contains guidelines for the following areas: 1. Precautions and Prevention 2. Personal Protective Equipment 3. Scene Management 4. Cleaning and Disinfecting 5. Infectious Waste Disposal 6. Immunizations 7. Exposure Determination 8. Post-Exposure Evaluation and Follow Up 9. Medical Surveillance 10. Record Keeping 11. Training Requirements DATE 11/1/98 12/1/03 DATE 12/1/2005 PAGE 1 of 20 EMS PO 1-1
The Infection Control Program will be reviewed and updated as necessary to reflect significant changes in tasks or procedures. 1. PRECAUTIONS AND PREVENTION Each Northern Zone Fire Agency requires: A. that employees wash their hands when possible after removal of gloves or other personal protective equipment that have contacted blood or other potentially infectious materials. B. removal of personal protective equipment when possible upon leaving the emergency scene; and placed in an appropriately designated area or container for storage, washing, decontamination or disposal. C. that all providers do procedures involving blood or other body fluids so that they minimize splashing, spraying, or aerosols of these substances. D. that all used needles and other sharp objects are not sheared, bent, broken, recapped, or resheathed. 2. PERSONAL PROTECTIVE EQUIPMENT Each Northern Zone Fire Agency: A. provides and assures that employees use appropriate personal protective equipment where biomedical hazards are possible. B. assures that the appropriate personal protective equipment in the appropriate sizes is readily accessible at the worksite, or individually issued to the employee. 3. SCENE MANAGEMENT Each Northern Zone Fire Agency: A. uses the Incident Command System to manage the emergency scene effectively. B. assures that personnel follow infection control measures at all emergencies. C. assures that personnel consistently and correctly answer infection control questions arising from contact with the public. 4. CLEANING AND DISINFECTION Each Northern Zone Fire Agency: A. provides for the cleaning, laundering or disposal of required personal protective equipment. B. repairs or replaces personal protective equipment as needed to maintain its effectiveness. C. establishes a schedule for the cleaning of medical equipment and method of disinfection, based on the location, type of surface to be cleaned, type of contaminant present, and tasks or procedures done. Medical boxes are to be washed each month or as soon as a Company returns to their station, should the box have become contaminated at an incident. DATE 11/1/98 12/1/03 DATE 12/1/2005 PAGE 2 of 20 EMS PO 1-1
5. INFECTIOUS WASTE DISPOSAL Each Northern Zone Fire Agency: A. assures that personnel place all infectious waste needing disposal in a closable, leak-proof container or bag that is marked, color coded, or labeled, as required by law. B. assures that personnel dispose of infectious waste according to applicable Federal, state, and local regulations. 6. IMMUNIZATIONS Each Northern Zone Fire Agency: A. makes available Hepatitis B vaccination to all employees who have a potential for occupational exposure. B. will provide a booster dose(s) for Hepatitis B at a future date, according to standard recommendations for medical practice. C. recommends that employees obtain other vaccinations recommended for health care workers by the Center for Disease Control (CDC). 7. EXPOSURE DETERMINATION Each Northern Zone Fire Agency: A. establishes a Level III Exposure as one of the following: contaminated needle stick injury blood or body fluid contact with mucous membrane of eyes, nose, or mouth blood or body fluid contact with open skin (non-intact skin) cuts with sharp objects covered with blood or body fluid injury sustained while cleaning contaminated equipment B. provides employees with a method for the reporting of occupational exposures. 8. POST-EXPOSURE Each Northern Zone Fire Agency: A. provides post-exposure and follow up for all employees with an occupational exposure. (See #7-A) B. assures that a licensed physician does, or supervises, all medical evaluations and procedures. C. assures that the employee is informed of the results of the medical evaluation; and that the employee is told about any medical conditions resulting from exposure to blood, or other potentially infectious materials, that require further evaluation or treatment. DATE 11/1/98 12/1/03 DATE 12/1/2005 PAGE 3 of 20 EMS PO 1-1
9. MEDICAL SURVEILLANCE Each Northern Zone Fire Agency: A. provides all evaluations, procedures, vaccinations, and post-exposure management to the employee at a reasonable time and place, and according to standard recommendations for medical practice. 10. RECORD KEEPING Each Northern Zone Fire Agency: A. maintains accurate medical records for each employee for at least the duration of employment plus thirty years. B. keeps all employee medical records confidential, and does not release them to any person within, or outside the workplace, except as required by law. C. maintains all training records for five years in compliance with Section 29, Code of Federal Regulations, 1910.20. D. forward all records to North Zone JPA Coordinator. 11. TRAINING REQUIREMENTS Each Northern Zone Fire Agency: A. assures that all emergency response personnel who are at risk for potential occupational exposure participate in a training program. B. provides training at the time of initial employment, and at least annually after that. C. assures that the training program contains those elements required by law. DATE 11/1/98 12/1/03 DATE 12/1/2005 PAGE 4 of 20 EMS PO 1-1
NORTHERN ZONE, SAN MATEO COUNTY AGENCIES INFECTION CONTROL PROGRAM MANUAL PURPOSE This manual is a teaching tool designed to educate emergency response personnel about infection control. The goal of infection control is to prevent infection from occurring in the patient, emergency response personnel, and their families. The dangers faced by emergency response personnel are not always obvious. The occupational hazards of AIDS, hepatitis, and other communicable diseases are unseen and real. An effective Infection Control Program provides the means to minimize, but not eliminate, health risks. EMPLOYER RESPONSIBILITIES The Northern Zone Fire Agency provides policies that exist to: 1. designate the North Zone JPA Coordinator as the Infection Control Coordinator for the Department. 2. teach all health care workers in its employ about the epidemiology, modes of transmission, and prevention of HIV and other blood-borne infections. 3. emphasize the need for routine use of universal blood and body fluid precautions for all patients. 4. provide equipment and supplies necessary to minimize the risk of infection with HIV and other blood-borne pathogens. 5. monitor employee adherence to recommended protective measures. When monitoring reveals a failure to follow recommended precautions, appropriate counseling, education, or retraining will be provided. If these measures are unsuccessful, appropriate disciplinary action will be considered. EMPLOYEE RESPONSIBILITIES The employee must learn the basics of infection control, including modes of disease transmission, and exposure risks. Each employee is responsible for ensuring compliance with the policies and procedures outlined in the Infection Control Manual. DATE 11/1/98 12/1/03 DATE 12/1/2005 PAGE 5 of 20 EMS PO 1-1
DEFINITION OF TERMS BLOODBORNE PATHOGENS Pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV), hepatitis C and human immunodeficiency virus (HIV). (CAL OSHA) CONTAMINATED The presence or the reasonably anticipated presence of blood or other potentially infectious materials on a surface or in or on an item. (CAL OSHA) EXPOSURE INCIDENT (BLOODBORNE) A specific eye, mouth, other mucous membrane, non-intact skin or parenteral contact with blood or other potentially infectious material that results from the performance of an employee's duties. (CAL OSHA) EXPOSURE INCIDENT (AIRBORNE) Occupational exposure to airborne pathogens may occur when an emergency response employee shares air space with a patient who has an infectious disease caused by an airborne pathogen. (RYAN WHITE) Exposure to airborne pathogens usually occurs after prolonged time with an infectious patient in a small, poorly ventilated space. This exposure depends on a variety of factors including infectiousness of patient, ventilation, area of enclosure, space and time. Generally, transporting patients in a vehicle with flowthrough ventilation will not generate an airborne exposure. (SMCPHD) OCCUPATIONAL EXPOSURE Reasonably anticipated skin, eye, mucous membrane or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee's duties. (CAL OSHA) OCCUPATIONAL RISK Occupational exposure may occur in many ways, including needle sticks, cut injuries, or aerosols of body fluids. Health care workers are at high risk for blood-borne infections due to routinely increased exposure to body fluids from potentially infected patients. Any exposure to a communicable disease carries a certain amount of risk. Emergency response personnel are in an occupation that directly exposes them to body fluids and must be considered at substantial risk of occupational exposures. DATE 11/1/98 12/1/03 DATE 12/1/2005 PAGE 6 of 20 EMS PO 1-1
COMMUNICABLE DISEASE A communicable disease is a disease that can be transmitted from one person to another. It is also known as a contagious disease. BODY SUBSTANCE ISOLATION The Centers for Disease Control (CDC) recommends the use of "Body Substance Isolation" when emergency response personnel work with blood or body fluids from any patient. This precaution says that emergency response personnel must consider all body substances from any patient as potentially infectious. Body Substances Isolation exceeds Universal Precautions, which states that blood, or certain body fluids from any patient may be potentially infectious. MODES OF TRANSMISSION A communicable disease can be spread via direct contact, through the air (droplet and airborne transmission), and by carrier substances (vehicles) in or on which the agent can survive for a time. Bloodborne diseases spread through direct blood-to-blood contact. Blood is the single greatest source of HIV and HBV in the workplace. Airborne diseases spread via large or small droplets or particles expelled into the air by a productive cough or sneeze. LEVELS OF "EXPOSURE" (BLOODBORNE) The following is a quick reference guide concerning the different levels of "exposure" of bloodborne pathogens that personnel may encounter. Note that this system is for clarity of record keeping practices. Only a Level III contact is considered a true exposure, necessitating follow-up action for employee and source individual. Level I Contact limited to merely being No special action in the presence of a person required by response suspected of having a personnel; decontamination communicable disease; affected personal contamination of personal protective equipment protective equipment Level II Exposure to healthy, intact skin Complete COMMUNICABLE from victim s body fluids. DISEASE EXPOSURE FORM. See Airborne policy. Forward all copies of the completed form to the Infection Control Coordinator DATE 11/1/98 12/1/03 DATE 12/1/2005 PAGE 7 of 20 EMS PO 1-1
Level III Whenever there is contact with Special Action Required. infected blood or body fluids Complete COMMUNICABLE through open wounds, mucous DISEASE EXPOSURE FORM. membranes, or parenteral Notify the designated on duty routes. supervisor. Notify the Infection Control Coordinator. Follow Any of the following procedure outline in Level III is a Level III exposure Exposure Protocol. Contaminated needlestick injury. Blood or body fluid contact with rescuer's mucous membrane of eyes, nose or mouth. Blood or body fluid in contact with non-intact skin. Cuts with sharp instruments covered with blood or body fluid. Any injury sustained while cleaning contaminated equipment. MEASURES FOR PREVENTION HEALTHY HISTORY A complete and detailed health history for each employee is a critical preventive measure. An individual's health history helps to identify potential high-risk areas that may require special attention. All emergency response personnel will participate in a pre-employment physical. Emergency response personnel will receive periodic examinations as recommended in post exposure situations. IMMUNIZATIONS/VACCINATIONS Immunizations reduce the risk of contracting a communicable disease. This protects the health of the workers and their families. Due to the nature of emergency services the CDC and the North Zone JPA highly recommends that all personnel maintain immunizations against: Hepatitis B measles, mumps, and rubella (MMR) diphtheria, polio, and tetanus (DPT) influenza (yearly) DATE 11/1/98 12/1/03 DATE 12/1/2005 PAGE 8 of 20 EMS PO 1-1
The employee is responsible for ensuring that all recommended immunizations/vaccinations are up to date. Each Northern Zone Fire Agency complies with the OSHA mandate by providing the Hepatitis-B vaccination free of charge to all emergency response personnel. Although partner agencies cannot require anyone to receive the immunization, it strongly recommends it. Any Fire Department emergency responder who declines the vaccination must notify their department of such declination and may be required to complete and sign a waiver. Such an individual may change their mind at any time and receive the vaccination free of charge. Hepatitis B vaccines are available for all personnel. Contact the Infection Control Coordinator for details about the Hepatitis-B vaccination series, or to obtain a waiver form if the vaccination is declined. Influenza is highly recommended for all health care professionals. The employee will contact their departments Occupational Health Plan or the Infection Control Coordinator for yearly influenza vaccination. PERSONAL PROTECTIVE EQUIPMENT Emergency response personnel often work in unpredictable and uncontrolled situations. To minimize the risk of exposure, safe work practices and appropriate protective equipment must be used. Personal protective equipment includes protective equipment for eyes, face, head, and extremities. Each Northern Zone Fire Agency will provide, and emergency response personnel must use, personal protective clothing to reduce personal exposure to infected blood or body fluids. Personal protective clothing must be maintained in a sanitary and reliable condition. Such clothing must be properly used when necessary because of hazard or environment. Emergency response personnel must ensure that any personal cuts, abrasions, wounds, etc., are always properly dressed for their own protection and the patient's. GLOVES Disposable gloves are a standard component of emergency response equipment. Gloves should be donned by all personnel before initiating any emergency care tasks involving delivery of patient care. Gloves must be of appropriate material, usually intact latex or intact vinyl, of appropriate quality for the procedures done, and of appropriate size for each emergency response personnel. Gloves should be changed after contact with each patient. Employees should replace a torn glove when possible. Apparatus drivers shall change gloves before entering the driver's compartment. This will prevent contamination of the steering wheel, radio, seats, etc. DATE 11/1/98 12/1/03 DATE 12/1/2005 PAGE 9 of 20 EMS PO 1-1
MASKS AND EYE PROTECTION Personnel are required to use masks and protective eyewear, or face shields, when there exists a possibility for exposure to contaminated body fluids from the following: mucosal membranes eyes, mouth, or nose where splashes or aerosols of material are likely to occur Such protective equipment is mandatory when providing emergency care to a patient's airway. Masks may be placed on a patient when the potential for airborne transmission of disease exists. Routine care does not require the use of masks on a patient. HAND WASHING Hand washing is the single most important means of preventing the spread of infection. After removing gloves, hands and other skin surfaces will be washed thoroughly. Personnel should scrub hands briskly for 15 seconds with soap and warm water followed by vigorous drying. Emergency response personnel shall NEVER wash their hands in food preparation areas. When facilities are not available, personnel should use a waterless hand cleaner according to manufacturer's directions. Waterless microbacterial hand cleaner shall be available on all response vehicles. SHARP INSTRUMENTS To prevent needle-stick injuries, contaminated needles will not be: recapped with two hands purposely bent or broken by hand removed from disposable syringes otherwise manipulated with two hands NON-NEEDLE SHARPS If sharps other than needle devices are used, these items shall include engineered sharp injury protection features. Immediately after use, employees shall activate the engineered safety mechanisms and dispose the device directly into the sharps container. Sharps will be handled by: assuring an appropriate sharps container is within arms reach before use shall not be passes to another person for disposal will not accept a sharp that has been passed by such persons the above includes needles, IV catheters, lancets, scalpels, etc. DATE 11/1/98 12/1/03 DATE 12/1/2005 PAGE 10 of 20 EMS PO 1-1
If a needle must be recapped because a container for sharp instruments is not readily accessible, place the cap on a flat surface, or step on it. The needle can then be placed in the cap, and then secured with the other hand. As of January 1999, all personnel will be trained and comply with Needle Safe products when available by manufacture. At no time, the employee will use a non-needle safe product in lieu of a needle safe product. RESUSCITATION EQUIPMENT Mechanical respiratory devices are available to all emergency response personnel that respond, or potentially respond, to medical emergencies or victim rescues. Disposable resuscitation equipment should be the primary means of artificial ventilation. SCENE MANAGEMENT INCIDENT COMMAND Emergency response personnel will use the Incident Command System to manage the emergency scene effectively. This includes the following infection control measures, but is not limited to: proper use of PPE (gloves, masks, eye protection, etc.) for patient care proper packaging and disposal of contaminated equipment The Incident Commander will assure that personnel answer infection control questions arising from contact with the public consistently. Citizen inquiries about the use of PPE will be answered as follows: "Our use of personal protective equipment is as much for the patient's safety as ours. Wearing such equipment assures your safety, and ours, from any contaminants that may be present." CARE AND CLEANING EQUIPMENT CATEGORIES There are three distinct levels of patient care equipment, each of which requires a different level of cleaning/decontamination. NON-CRITICAL EQUIPMENT - such as stethoscopes and blood pressure cuffs. This level of equipment requires cleaning. SEMI-CRITICAL EQUIPMENT - such as backboards, stokes baskets, communication headsets and drug boxes. This level of equipment requires disinfection. DATE 11/1/98 12/1/03 DATE 12/1/2005 PAGE 11 of 20 EMS PO 1-1
CRITICAL EQUIPMENT - such as resuscitation equipment and laryngoscope blades. This level of equipment requires sterilization or high-level disinfection. CLEANING Cleaning is the physical removal of dirt and debris. Personnel should use soap and water, combined with scrubbing action. The scrubbing action is the KEY to rendering all items safe for patient use. Cleaning is generally sufficient for non-critical equipment. However, if non-critical equipment has become grossly contaminated with blood or body fluids, they also must be disinfected. DISINFECTION Disinfection is reducing the number of disease-producing organisms by physical or chemical means. Personnel should clean the item with soap and water, then apply a disinfecting solution. Solutions such as bleach and water at a 1:10 dilution ration are acceptable disinfectants (a 1:10 dilution ratio translates into one cup of bleach for each gallon of water). When disinfecting laryngoscopes, it is acceptable to spray and wipe blades with diluted bleach or soak up to one hour. Do not soak equipment longer than one hour as it will cause damage. A fresh disinfectant solution must be made every day. DO NOT use bleach solution in the cleaning of electronic equipment. Refer to the MSDS for each disinfectant solution to decide what personal protective equipment may be needed. Remember that disinfectants can be toxic or caustic. Disinfection solutions should have an EPA registry number and show that they are effective against mycobacterium tuberculosis. Routine disposal of the germicidal cleaning water in the drainage is acceptable. CLEANING/DISINFECTING AREAS Used equipment from an emergency incident should be bagged and transported to the designated cleaning area. Burn boxes designated for contaminated equipment must have the biohazard symbol. Each station will allocate a specific area for cleaning contaminated equipment. Designated area will be the "Decontamination Area": the area must only be used for cleaning contaminated equipment this area should not be used for the cleaning of SCBA face pieces this area needs to be away from the station living quarters the area must be conspicuously marked with limited access to prevent accidental exposures DATE 11/1/98 12/1/03 DATE 12/1/2005 PAGE 12 of 20 EMS PO 1-1
Medical equipment shall never be cleaned or disinfected in the station's living quarters, especially food preparation or eating areas. MSDS sheets for each disinfectant will be posted at a prominent place in the designated cleaning area. LAUNDRY Employees who wear their uniform between work and home should routinely change into a freshly laundered uniform before leaving the station. This minimizes the risk of carrying unknown germs or disease home on a dirty uniform to their family. Uniforms that are grossly blood soiled should be disposed of as biomedical waste. CARE OF SPECIFIC CONTAMINATED EQUIPMENT CLEANING KEY 1 = Dispose 2 = Cleaning 3 = Disinfection (1:10 bleach/water solution) 4 = High-level disinfectant 5 = Launder ARTICLE CLEANING PROCEDURE Airways (including ET tubes, Oropharyngeal, Nasopharyngeal) 1 B/P Cuffs 2 Backboards 3 Bite Sticks 1 Bulb Syringe 1 Cannulas, Masks 1 Cervical Collars 1 or 2 Dressings and Paper Products 1 Drug Boxes 3 Electronic Equipment 1 Firefighter Protective Equipment 5 Regulators, Tanks 2 KED 3 Penlights 1 or 2 Pocket Masks 1 or 4 Resuscitators 1 or 4 Scissors 3 Splints 2 Stethoscope 2 Stokes 3 DATE 11/1/98 12/1/03 DATE 12/1/2005 PAGE 13 of 20 EMS PO 1-1
Suction Catheters 1 Suction Unit (V-Vac) 1 Uniforms 5 In cases where the level of contamination is low, i.e., blood or vomitus is present on the bag-valve mask resuscitator's exterior, it should be cleansed and disinfected. Personnel should take care to make sure that the device is still materially sound before placing back in service. (The disposable items are more susceptible to wear than non-disposable items.) It is acceptable to dispose of only the contaminated mask while salvaging the resuscitator. BIOHAZARD WASTE BIOHAZARD WASTE CONTAINERS Each Northern Zone Fire Agency supplies biohazard containers that meet, or exceed, OSHA and EPA specifications. When personnel generate biohazard waste at an incident, it is their responsibility to dispose of that material in a properly marked biohazard container. When transporting biohazard waste aboard emergency response vehicles, the workers will place such waste in appropriately marked leak-proof containers. Each emergency response vehicle will have at least one biohazard container available for their use. Each station will have at least one large container with a designated area for the storage of and pick up of biohazard waste. When preparing a biohazard box for disposal personnel will wear both gloves and eye protection. This area must be away from the station living area and clearly marked with the biohazard symbol. CONTAMINATED GLOVES When gloves become contaminated they should be removed when possible, taking care to avoid contact with the exterior of the gloves. Contaminated gloves must be disposed of in an approved biohazard container. Personnel should never leave used gloves on scene. BIOHAZARD BAGS Two sizes of biohazard bags have been provided for each station. Any regulated waste generated by our personnel which cannot be disposed of properly on scene (i.e., in the biohazard container in the ambulance) shall be placed in the smaller biohazard bags and sealed by tying in a knot while still on scene and then transported back to the station. The larger bag shall be kept in the station, near the "Decontamination Area" for use as a storage receptacle for the sealed, smaller bags. As the larger bags get full, they shall be sent to an approved biohazard waste disposal company. Care should be taken to not introduce excessive air into the bags in order to keep the overall volume to a minimum. Below listed is the contracted companys that can dispose of biohazard waste: DATE 11/1/98 12/1/03 DATE 12/1/2005 PAGE 14 of 20 EMS PO 1-1
21 Great Oaks Blvd. San Jose, CA 95119 (408) 363-1660 Fax (408) 363-3587 Attn: Megan Landers Regulated Waste means "liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials." (OSHA 29CFR, part 1910.1030(b)) NOTIFICATION The Ryan White Comprehensive AIDS Resources Emergency Act of 1990 mandates that the receiving hospital's Infection Control Practitioner must notify the Department's Infection Control Coordinator within forty-eight hours of a communicable disease diagnosis in a patient treated by a pre-hospital team member. Upon notification, the Infection Control Coordinator will notify the involved employee(s) and initiate any necessary follow-up. It is the responsibility of the Infection Control Coordinator to document the incident and coordinate any follow-up activities. Hospitals are to have a form for "Exposure to Reportable Communicable Disease." Copies of this form are kept in the emergency room and are available from the "Charge Nurse." This form is referred to as the "Royce Form." It is designed for pre-hospital care personnel and is the quickest way to gather information on a possible communicable disease exposure. The completed form should be handled to the Charge Nurse in the emergency room. This can be accomplished by the firefighter who accompanies the patient. If a firefighter does not accompany the patient, the paramedics could be asked to fill out the form (or add Fire Department personnel names to their own form). This latter method should be followed up by a phone call to the Emergency Room Charge Nurse. Be prepared to give the information as listed on the form EMS-501 (see next page). Employees may want to use the Fire Administration address and phone number for notification when they are off duty. In any event, be sure to identify yourself as "Fire Department" personnel. This is the quickest and best way to receive information about the disease status of the patient. However, this shall not be a substitute for using form "Exposure Report Form, Blood or Body Fluid." This form is intended as permanent documentation of a possible exposure and stays in employee's personal medical file. it also helps with follow-up procedures and used for data tracking to develop and maintain a Occupational Health and Safety Program. DATE 11/1/98 12/1/03 DATE 12/1/2005 PAGE 15 of 20 EMS PO 1-1
Therefore, if an employee suspects an exposure to a communicable disease, the employee should first report it immediately to the Receiving Medical Center using either their "Royce Form" or by phoning the Charge Nurse. Secondly, each Northern Zone Fire Agency should have their employee complete an exposure report form for a permanent record and follow-up. VERIFICATION Verification is the process of deciding if a reported exposure poses a real health risk to the employee. The Infection Control Coordinator will advise the employee of any required follow-up treatment. The Operational Medical Director and/or the Epidemiologist at the receiving hospital will determine the appropriate follow-up treatment. The employee will be verbally notified of any treatment within twentyfour hours, with written documentation to follow within forty-eight hours. TREATMENT Treatment is medical care given to reduce the chance of contracting a communicable disease after exposure. The type and timing of treatment varies with different diseases. Depending on the disease, treatment may be short-term or long-term. Diseases that usually require post-exposure treatment include, but are not limited to: HIV hepatitis B non-a, non-b hepatitis meningitis tuberculosis All post-exposure testing will be obtained at your department s designated medical facility. The exception would be when the exposure is in conjunction with an injury, such as a laceration, that requires prompt emergency care. In such cases the initial testing and treatment should be done simultaneously. Emergency response personnel will be informed of the results of medical evaluation. They must be told about any medical conditions resulting from exposure to blood or other potentially infectious materials that require further evaluation or treatment. Serologic testing is available. This is available to all emergency response personnel with concern about a possible communicable disease exposure, provided that they have documented the potential exposure. DATE 11/1/98 12/1/03 DATE 12/1/2005 PAGE 16 of 20 EMS PO 1-1
LEVEL EXPOSURE PROTOCOL (FOR USE AS A GUIDE/DETERMINED BY MD) I. Injuries involving unused, sterile needles should be reported the same as any other minor injury. Care at the time of injury should consist of: A. Local wound care B. Consideration of need for tetanus-diphtheria toxoid II. III. Level II Occupational Exposures with an UNKNOWN contamination source will be treated as Level III unless directed by the Infection Control Officer. Level III Occupational Exposures with a KNOWN contamination source should be handled as follows: A. The hospital receiving the patient will be contacted and informed that a Level III Occupational Exposure has occurred. B. The Infection Control Coordinator will contact the Infection Control Practitioner at the receiving hospital to find out whether the patient is a carrier for the HIV or Hepatitis B virus. Determination of risk will be based on: 1. Interview of patient 2. Interview of patient s physician 3. Review of patient's chart C. The injured firefighter/provider should be interviewed regarding any history of Hepatitis, risk factors for exposures to Hepatitis C, Hepatitis B, and Hepatitis B antibody status. The following blood tests will be requested: 1. Anti-Hep BsAg (antibody to Hepatitis B surface antigen) 2. HIV antibody 3. Any personnel receiving a Level III exposure from an HIV positive patient should have an additional HIV antibody test done six weeks post exposure. 4. The above tests need to be redone at 3, 6, 12 month intervals. The results of these tests will be provided to the firefighter/provider with counseling from a physician. The results of these tests will remain in strict confidence between the firefighter/provider and the attending physician. The employee will provide their supervisor with information necessary to comply with worker's compensation laws, and other Fire Department policies only. These tests will be done at the expense of the individual departments. DATE 11/1/98 12/1/03 DATE 12/1/2005 PAGE 17 of 20 EMS PO 1-1
CLINICAL ACTION REQUIRED FOR LEVEL III OCCUPATIONAL EXPOSURES For Daly City, Colma, and Pacifica From the hours of 0830 1700 hours, Mon. - Fri. For San Bruno F.D. From the hours of 0730 1630 hours, Mon. Fri. Kaiser Occupational/Hospital After business hours and on weekends, employees will be evaluated at: Kaiser South San Francisco Emergency Department Seton s Emergency Department Peninsula Occupational Health 1720 El Camino #225 Burlingame, Ca 94010 (650) 696-5838 After business hours and on weekends, employees will be evaluated at: Mills/Peninsula Emergency Department. REPORTING REQUIREMENTS Employers have a responsibility under various federal and state laws and regulations to report occupational illnesses and injuries. Existing programs in the National Institute for Occupational Safety and Health (NIOSH), Department of Health and Human Services; the Bureau of Labor Statistics, Department of Labor, and the Occupational Safety and Health Administration receive such information for the purposes of surveillance and other objectives. State Health Departments report cases of infectious disease, including HIV and HBV, to the Centers for Disease Control. CONFIDENTIALITY OF PATIENT INFORMATION DISCLOSURES All patient related information must be considered confidential. Generally, notification laws emphasize patient confidentiality, not full disclosure to the attending emergency response personnel. The social stigma associated with AIDS, or testing positive for the virus that causes AIDS (HIV), is very strong in this country. Anyone can become a victim of this deadly disease, and not always through behavior on their part. No matter the means through which a person gets the disease AIDS, these people suffer humiliation, harassment, neglect, and abandonment by our society. This is just as true for the hemophiliac that gets AIDS from a blood transfusion as it is for the intravenous drug user. DATE 11/1/98 12/1/03 DATE 12/1/2008 PAGE 18 of 20 EMS PO 1-1
EMS personnel learn things about patients through their patient care contact that the patient's most intimate friends or relatives don't know. They obtain this information because the patients trust them. EMS personnel have a tremendous moral responsibility not to betray those confidences, as well as a legal one. Emergency response personnel will use knowledge of a patient's communicable disease status for patient care only, not infection control purposes. The same confidentiality standards apply to information regarding the communicable disease status of workers involved in EMS. This information is between the worker and the attending physician. The sharing of this information through any other means, including the "grapevine," is a violation of confidentiality standards. Appropriate disciplinary action will be taken towards individuals who violate these confidentiality standards. TRAINING The Training Division will assure that all high-risk employees receive education on precautionary measure, epidemiology, modes or transmission and prevention of HIV/HBV. High-risk employees will receive training regarding the location and proper use of personal protective equipment, work practices, and precautions to be used in handling contaminated articles and infectious waste. Training records will show the dates of training sessions, the content of those training sessions, the names of all persons conducting the training, and the names of all whom attended the training. Training records will be maintained for five years. All new hire firefighters will receive this training before any patient care contact. REFERENCES DATE 11/1/98 12/1/03 DATE 12/1/2005 PAGE 19 of 20 EMS PO 1-1
OSHA Instruction CPL 2-2.44B, Enforcement Procedures for Occupational Exposures to Hepatitis B Virus and Human Immunodeficiency Virus, February 27, 1990 20 Code of Federal Regulations 1910-1030, Occupational Exposure to Bloodborne Pathogens National Fire Protection Association 1500, Standard for Fire Department Occupational Safety and Health Programs, 1987 National Fire Protection Association 1581, Standard on Fire Department Infection Control Program, May 1991 Centers for Disease Control, Morbidity and Mortality Weekly Report, Vol. 38, No. S-6, 1989 Guide to Developing and Managing an Emergency Service Infection Control Program, United States Fire Administration, June 1991 DATE 11/1/98 12/1/03 DATE 12/1/2005 PAGE 20 of 20 EMS PO 1-1