Infection Control Protocols

Needle Sticks and Other Blood/Body Fluid Exposures

1. Learn and always observe Standard Precautions (Universal Precautions).
2. If you have an exposure to blood or other body fluids (e.g., needle stick, cut), immediately clean the wound with soap and water.
3. Exposed oral and nasal mucosa should be decontaminated by vigorously flushing with water. Exposed eyes should be irrigated with clean water or sterile saline. Eyewash facilities can be accessed quickly in the emergency department for each hospital.
4. Follow the protocol of the hospital in which the incident occurred to the fullest including all follow-up (through the hospital's Employee Health Service). It is especially important that you report your exposure to the hospital's Employee Health Service as soon as possible so that a timely evaluation can be performed. Additionally, your exposure may guide future preventive efforts (e.g., education, training, selection of devices). If prophylactic medications are indicated, it is recommended they be initiated as soon as possible after the exposure, ideally within two hours.
5. If you are uncertain of the procedures for reporting and obtaining care at the facility where your exposure occurred, call the Woodruff Health Sciences Center (WHSC) Needle stick Hotline for assistance at 404-727-4736.
6. Acute serology should be drawn to establish one's baseline antibody titers to hepatitis B virus (if you have not previously been determined to be HBsAb positive [immune to Hepatitis B]) and, if indicated, to HIV and/or Hepatitis C Virus [HCV] (if the source patient is HIV-positive or HCV-positive).
7. Depending on the results of one's serology and the baseline serology of the patient (from which the incident occurred), you may need follow-up serologies as per the hospital protocol where the injury occurred.
8. If the source patient is HIV-infected, the administration of post-exposure prophylaxis (PEP or "prophylactic" antiretroviral medications) to decrease the risk of patient-to-healthcare worker transmission should be strongly considered. Medications may be initiated pending results of HIV serology on the source patient. If used, these medications should be taken as soon as possible after the needle stick injury. Each hospital has a protocol and will counsel you and give advice as needed. PEP regimens are complicated; therefore, be sure that the individual who manages your exposure consults with the Hospital Epidemiologist (see list below).
9. Again, call the WHSC Needle Stick Hotline 404-727-4736 if you have any questions about management of the needle stick or other occupational exposure.
10. If you are exposed to blood or other body fluids at another facility follow their guidelines and follow-up instructions. If you are unsure of the reporting procedures or have difficulty obtaining immediate care, call the WHSC Needle Stick Hotline for assistance at 404-727-4736.

The following list of specific areas and/or individuals should be contacted at the facility in which the exposure occurs:

Contacts for Infection Control Protocol

Grady Memorial Hospital and Affiliated Sites

• Healthcare worker goes directly to the Employee Health and Wellness (EHW) Center (now located on the ground floor). An EHW nurse will facilitate post-exposure care in collaboration with an EHW doctor. EHW staff will arrange for source patient testing
• EHW staff may call the ID attending on call for needle sticks/other body fluid exposures for consultation as needed.

After hours and on weekends:

Healthcare worker should NOT go to the emergency room unless they need an emergency eye wash. Healthcare worker calls STIX Hotline (404-616-STIX) and follow directions:

• Press 4: to be connected directly to the cell phone of the Health System Administrator HSA (who is physically present in the hospital). This cell number is: 404-319-7367
• Press 5: to leave a voicemail message for the Health System Administrator. This message will be delivered immediately to their cell phone, and they will return the call promptly.

HCW may also call the WHSC Needle Stick Hotline and the Grady ID attending on-call for blood and/or body fluids (BBF) exposures will be paged. The attending will inform the HCW of reporting procedures and assist them. HSA will personally arrange for source patient testing. Rapid HIV test results should be back within the 4 -hour time frame for starting ART PEP.

If source patient is known to be HIV positive or the rapid test returns positive, the HSA will escort the HCW to the Emergency Department where they will receive care from an ED attending with consultation from the ID attending on call for BBF exposures. The HSA will contact the ID attending on call for BBF exposures. The ID attending will discuss the exposure with the ED attending (and the HCW) and make recommendations for ART PEP. The first dose of PEP will be given in the ED. Additional doses needed to last until the next business day will also be provided directly to the HCW.

If the source patient tests HIV negative, the HCW will be instructed to report to EHS on the next business day to get final lab results on the source patient (hep C, hep B sAg) and determine if additional follow-up is needed.

Other contacts at Grady:

• Employee Health Nurse on call (from home): 404-809-7470
• Susan Ray, MD cell: 404-536-8233 or PIC 17255

VA Medical Center

• Report incident directly to VA Occupational Health Injury Management
• Location: 1B 170
• Email: VHAATGOccupationalHealth1@va.gov
• Phone number: extensions: 20-5400 (x5400) and 20-1521 (x1521) (main number is 404-321-6111)

After hours and on weekends:

• Contact the nurse supervisor on call (physically present in the hospital): Call hospital operator and ask for the "AOD" on call.
• The HCW is seen in Emergency Room for Treatment with follow-up in VA Occupational Health the next business day. This is important for OH to forward BBPE information to Emory for further follow-up

Other contacts at VAMC:

• Lauren Epstein, MD, Hospital Epidemiologist – cell: 202-255-3672
• Alton Greene, MD, VA Occupational Health Director – x5400
• If you are unable to reach any of the above individuals, call the WHSC Needle Stick Hotline 404-727- 4736.

Emory University Hospital - Midtown

• Daytime hours, Monday thru Friday (7 am to 4 pm)
• Occupation Injury Management (OIM) 404-686-2352

After hours, and on weekends:

• Healthcare worker calls Occupation Injury Management (PIC 50464) or calls the WHSC Needle Stick Hotline (404- 727-4PEM).
• If WHSC Needle Stick Hotline called, the on-call OIM nurse practitioner will be paged (PIC 50464). The Occupational Injury Management (OIM) nurse practitioner will facilitate immediate post- exposure care. Healthcare worker should go to OIM during the next business day to have baseline labs drawn.

Other contacts at Midtown:

• Hospital epidemiology pager: 51427

If you are unable to reach any of the above individuals, call the WHSC Needle Stick Hotline 404-727-4736.

Emory University Hospital

• Daytime hours, Monday thru Friday (7 am to 4 pm) Employee Health/Occupational Injury Management Office 1364 Clifton Road, Room D219
• Occupational Injury Management (Worker's Compensation) 404-686-8587
• Employee Health Services 404-686-8589

After hours and on weekends:

• Healthcare worker calls Occupational Injury Management (OIM) (PIC 50464) or calls the WHSC Needle Stick Hotline (404- 727-4PEM)
• If WHSC Needle Stick Hotline called, the on-call OIM nurse practitioner will be paged (PIC 50464). The OIM nurse practitioner will facilitate immediate post-exposure care.
• Healthcare workers should go to OIM during the next business day to have baseline labs drawn.

Other contacts at EUH:

• Hospital epidemiology pager: 51090

If you are unable to reach any of the above individuals, call the WHSC Needle Stick Hotline 404-727- 4736.

Children's Healthcare of Atlanta (CHOA) (Egleston, Scottish Rite, or Hughes Spalding)

• Any needle sticks or blood borne pathogen exposure is referred to the 24/7 hotline 404-785-7777. This is staffed by an employee health nurse who will provide guidance to students.
• Employee Health Digital Pager 1-800-682-4549 or Needle Stick Hotline (ext. 4444 at Egleston and ext. 824444 at Scottish Rite)

Other contacts at CHOA (if students cannot reach employee health nurse via hotline or pager)

• Andi Shane, MD – cell: 404-354-7692 or office 404-727-9880
• Infectious Disease Service Team on Call – pager: 404-785-7778 and ask for the ID Service Team on Call

If you are unable to reach any of the above individuals, call the WHSC Needle Stick Hotline 404-727- 4736.

Financial considerations of accidental needle sticks

The cost of the follow-up and necessary medications may be borne by Emory University Affiliated Hospitals or may need to be submitted through the student's health insurance. Any uncovered costs will be covered through the Office of Medical Education & Student Affairs if the procedures outlined above are followed.

For medical students and students in the health professions, initial evaluation of the exposure should be as explained above. Following this initial evaluation, all incidents and follow-up for exposures occurring at a hospital should be reported by the student within 4 days to the Registrar, Ms. Mary Kaye Garcia 404-712-9921.

Conversions

PPD tuberculin skin tests will be performed every year (at a minimum) or at the time of exposure for medical students. Those with PPD conversions will be referred to an appropriate physician in the University Health Services for follow-up. Expense of drugs, x-rays, and laboratory testing will be covered as long as protocol is followed.

Students Infected with HIV, Hepatitis B, Hepatitis C

Emory University School of Medicine requires any student who is infected with Human Immune Deficiency Virus (HIV), Hepatitis B virus "e" antigen positive, or Hepatitis C virus to notify the Executive Associate Dean for Medical Education and Student Affairs of their positive status so that the school may help to define any limitations necessary on clinical rotations and make such accommodations as may be reasonable to permit the student's continued matriculation.

The Executive Associate Dean for Medical Education and Student Affairs, or their designee, will make recommendations for students continued education on a case-by-case basis, utilizing the best currently available scientific knowledge and any established recommendations from the U.S. Centers for Disease Control and Prevention and other applicable governmental guidelines regarding what, if any, limitations need to be applied to clinical activity for persons with the given condition. In conducting this evaluation and making such recommendations, the Executive Associate Dean will consult with the student, the student's personal physician, student affairs deans and others, including faculty of the School of Medicine, as determined appropriate to assist in this individualized judgment. Within the parameters of existing law, the student's confidentiality will be maintained during this process.

Reasonable efforts to assist the student in completing the requirements for an MD degree will be made by the School of Medicine. In addition, the student will be offered counseling concerning the options for the future selection of a career pathway in the profession of medicine.

More Specific Guidelines on Students Infected with Blood-Borne Pathogens

Students should be allowed to complete the MD degree, if at all possible, with an effort by all to maintain confidentiality to the degree that it is possible.

In such instances, the clinical department chairs need not be notified of the name of an individual student involved or the type of blood-borne pathogen involved. However, the Clerkship Director for the Departments of Surgery, Obstetrics/Gynecology, Emergency Medicine and any other Clerkship Directors (if indicated) will be informed of the name of the individual student so that any special assignments can be made if indicated.

Students will be carefully counseled concerning their potential risk to patients and their risk to themselves. They will be instructed to be punctilious in the use of universal precautions and up-to-date hospital infection control techniques. They will be referred to appropriate physician caregivers for optimal follow-up and therapy.

Students with blood-borne pathogen infections (HIV, Hepatitis B, Hepatitis C) will be advised on a case-by-case basis. There are now therapies for HIV, Hepatitis B and Hepatitis C which are able to effectively suppress viral loads (HIV and Hep B) and even eradicate infection (Hepatitis C). Students who are on antiviral therapy and achieve effective suppression of HIV and/or Hepatitis B (HIV undetectable, HBV load <= 1000 IU) and undetectable Hepatitis C (sustained viral response (SVR)) should not have any restrictions on their patient care activities.

For students who do not have effective treatment (viral tests above the thresholds detailed above), there should be a careful review by an oversight panel (chosen by the Deans) to determine whether/which "exposure prone" procedures the student may assist with or participate in during their training. "The oversight panel should determine the precise procedures for which permission is sought, the historical risks for HCP-to-patient bloodborne pathogen transmission associated with these procedures in the literature and as reported in their facility, the HCP's experience with such procedures, and the likelihood of patient exposure to HCP blood during these procedures. Thus, the list of exposure-prone procedures may be best determined for each practitioner in conjunction with the oversight panel. The panel should also gather evidence regarding the HCP's skills, practices, and adherence to infection prevention procedures (particularly with respect to standard precautions) while making every effort to assure privacy and confidentiality. Also, with the HCP, the panel should investigate and discuss the availability of safer devices that may mitigate the risk for patient exposures." (source: SHEA White Paper - Management of healthcare personnel living with hepatitis B, hepatitis C, or human immunodeficiency virus in US healthcare institutions; ICHE 2020 doi:10.1017/ice.2020.458) The student will be allowed to withdraw without penalty from any clinical setting that the student feels might present a risk for infectivity.

The student's condition will be re-evaluated at least annually by the Executive Associate Dean for Medical Education and Student Affairs to determine if any additional limitations are indicated. The student's clinical status as well as the regimen of anti-retroviral therapy that is being employed can be useful in assisting in any decision making by the medical school if the student will allow the Executive Associate Dean to discuss the results with their healthcare provider.

Students who fail to show a response to Hepatitis B vaccination by serologic means will be counseled to see a physician to determine their Hepatitis B viral load. They will be encouraged to report this finding to the Office of the Executive Associate Dean, Medical Education & Student Affairs and then to be followed as per protocol.