Management of Blood and Body Fluid
Exposure Procedure
1. Purpose
This Procedure outlines the process for the management of blood or body fluids exposure by
West Coast District Health Board (WCDHB) staff members.
2. Application
This Procedure is to be followed by al clinical staff throughout the WCDHB.
3. Definitions
For the purposes of this Procedure:
Blood and Body Fluid Exposure is taken to mean a puncture that penetrates the skin from a
device that has had contact with blood or body fluids, including a bite or scratch that breaks the
skin, a splash to the eyes, mouth, ears or broken skin.
Source is taken to mean the origin of the exposure
Recipient is taken to mean the individual exposed.
4. Responsibilities
For the purposes of this Procedure:
Clinical Nurse Specialist Infection Control is required to:
- oversee all aspects of this Procedure
- monitor the performance of WCDHB staff members in relation to this Procedure;
Staff Members are required to:
- ensure they abide by the requirements of this Procedure;
- abide by al WCDHB Infection Control Policy and Procedures;
- abide by all WCDHB Health and Safety Policy and Procedure.
5. Resources Required
This Procedure requires:
i) Soap and Water
iv) Antiseptic Eye Ointment
ii) Antiseptic
v) Blood and Body Fluid Exposure Kit
iii) Waterproof Dressing
6. Process
1.00 Bleed area immediately if possible – by squeezing or milking the puncture site.
1.01 Wash thoroughly with soap and water, avoiding vigorous scrubbing.
1.02 Apply an antiseptic to area (Betadine, Chlorhexadine in Alcohol).
Management of Blood and Body Fluid Exposure Procedure
Page 1 of 4
Document Owner: Infection Control Committee
WCDHB—IC 0023, version 6, reviewed March 2012, issued Dec 2012
Master Copy is Electronic
1.03 If exposure involves a deep penetrating injury that has had contact with a vein or artery,
and involves a device with obvious sign of blood on it, or the source is known to have an
infective status, then Zidovudine therapy should be offered in consultation with the on-
call Physician within 2 hours, regardless of the infection status of the source.
1.04 For eye splashes, rinse under running water for five minutes. An antiseptic eye ointment
may need to be applied. For eye injuries, medical treatment in outpatients must be
sought.
1.05 i) Emergency stock 24 hrs supply. Zidovudine 100mg (@ 3 capsules BD = 6 capsules)
Wil be held on Foote Ward, Buller Hospital, at Whataroa Clinic and in the
Emergency Cupboard at Greymouth Hospital.
ii) Held within the Greymouth Hospital Pharmacy Held wil be 3 days combination
antiretroviral therapy Lamivudine (3TC) 150mg bd and Efavirenz (Stocrin) 600mg
nocte (as 3 x 200mg) for recipients who receive a definite parenteral exposure
iii) Pharmacy “On Call” staff need to be notified so that they are able to arrange further
supply to complete the 28 day treatment course. Pharmacy need to be able to check
that the staff member has been given adequate counseling re side effects, and has
given informed consent to treatment.
1.06 Apply waterproof dressing for 24 hours until the site has healed.
1.07 A blood sample must be sent to the Grey Hospital Laboratory within 24 hours of the
Incident to establish the source HIV, Hepatitis B (HBV), and Hepatitis C (HCV) status.
1.08 Consent must be obtained before a blood sample is taken. Consent must be obtained
prior to any blood being taken for testing. Written consent is obtained on the WCDHB
Blood Test Consent Form.
1.09 A WCDHB Accident/Incident Form (including Blood and Body Fluid Exposure Form)
must Be completed as soon as practicable after the incident and forwarded to the relevant
staff members. The incident is also to be documented in the patient’s clinical record.
1.10 The Clinical Nurse Specialist Infection Control or the Occupational Health Nurse are to
ensure the Laboratory is informed of the timeframes for testing and arrange follow-up
and medical intervention as necessary and as required
1.11 Counseling is to be offered to the affected staff member and is to be organised by their
Manager in conjunction with the OSH Advisor.
1.12 Where the blood test results for HBV are:
i) Negative - no further action is required
ii) Positive – immunity of recipient is to be checked:
- where no immunity is demonstrated, immunoglobulin is suggested
- where immunity is demonstrated, no further action is required
1.13 Where the blood test results for HCV are:
i) Negative - no further action is required
Management of Blood and Body Fluid Exposure Procedure
Page 2 of 4
Document Owner: Infection Control Committee
WCDHB—IC 0023, version 6, reviewed March 2012, issued Dec 2012
Master Copy is Electronic
ii) Positive – the on-cal Physician is to be notified.
1.14 Where the blood test results for HIV are:
i) Negative – no further action is required
ii) Positive – the on-cal Physician is to be notified, combination therapy with
Zidovudine, Lamivudine and Efavirenz offered and instigated if consent obtained.
Pre-therapy blood screen is to be performed (liver function tests including amylase and
bilirubin, full blood count including differential, and lipids).
1.15 Within one week of the incident the CNS Infection Control is to investigate the incident
and make any recommendations regarding corrective actions to reduce the potential of a
repetition of the incident. Investigation and recommendations are to be included in the
CNS Infection Control’s monthly report to the WCDHB Infection Control Committee.
1.16 Six months after the incident the CNS Infection Control is to arrange for the recipient to
be tested again (as per Sections 1.07 and 1.08). If the results are:
i) Negative – no further action is required;
ii) Positive – a referral to the on-cal Physician and OSH Advisor is made by the CNS
Infection Control.
1.17 Twelve months after the incident the CNS Infection Control is to arrange for the recipient
to be tested again (as per Sections 1.07 and 1.08). If the results are:
i) Negative – no further action is required;
ii) Positive – a referral to the on-call Physician and OSH Advisor is made by the CNS
Infection Control.
1.18 If a staff member chooses not to accept Zidovudine and/or combination antiretroviral
therapy, a declaration is completed outlining the following:
• What the incident relates to.
• That the person had been offered treatment and the impact of non- treatment had been
discussed.
• Advice is given regarding the strict adherence to Standard precautions for both Patient
and Staff safety.
• Declaration is signed by the recipient of the injury and the counseling party as the
witness. Date and time are also documented. This declaration is then forwarded to the
CNS Infection Control for inclusion in the incident file.
7. Precautions and Considerations
Treatment must be obtained as soon as is practicable after exposure
Blood must be sent to the Grey Hospital Laboratory within 24 hours of the incident
WCDHB Accident/Incident Form (including Blood and Body Fluid Exposure Form) must be
completed in as soon as practicable after the incident
Management of Blood and Body Fluid Exposure Procedure
Page 3 of 4
Document Owner: Infection Control Committee
WCDHB—IC 0023, version 6, reviewed March 2012, issued Dec 2012
Master Copy is Electronic
8. References
New Zealand Standard – Infection Control (NZS 8142:2008)
Australian Guideline for the Prevention and Control of Infection in Healthcare. Australian
Government (2010)
9. Related Documents
Nelson Marlborough DHB Management of Blood & Body Fluid Exposure Procedure
WCDHB Infection Control Procedure Manual
WCDHB Health and Safety Policy and Procedure Manual
WCDHB Informed Consent Procedure & Consent forms
WCDHB Accident/Incident Form
Management of Blood and Body Fluid Exposure Procedure
Page 4 of 4
Document Owner: Infection Control Committee
WCDHB—IC 0023, version 6, reviewed March 2012, issued Dec 2012
Master Copy is Electronic
Document Outline
