Title: COMMUNICABLE DISEASE EXPOSURE REPORT
Total Page：16
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ADMINISTRATIVE MANUAL
FORMS
106.5 COMMUNICABLE DISEASE EXPOSURE REPORT
EFFECTIVE: JUNE 2008
INFORMATION SHEET
Form Number: EMS-15
Title: COMMUNICABLE DISEASE EXPOSURE REPORT
Contents: Communicable disease exposure reporting procedure for members seeking immediate medical treatment following exposure. This policy includes testing and treatment plans for the physician’s reference.
Frequency: All communicable disease exposures.
Responsibility: Exposed members, supervisors, or the Designated Infectious Control Officer (DICO)
Channels Through: DICO
Remarks: This form will be given to the treating physician and faxed or given directly to the DICO for follow up on an exposure case.
Cross References: This policy follows all guidelines set from Cal OSHA Title 8.
Administrative Manual Section 203.10, Infection Control
Revised 6/17/13 Section 106.5 Page 1 of 5 INSTRUCTION SHEET
This policy shall be placed on all Department apparatus to instruct members on required procedures to follow on a communicable disease exposure. The first two pages have basic instructions and checklists to guide the member through the reporting process.
The form on page 5 shall be completed with the exposed member’s information.
Once completed, the form shall be given to the treating physician upon arrival at the treating facility.
This form includes instructions on needed testing and an area for the physician to document treatment, follow-up plan, and instructions to return processed form to the DICO for follow-up.
When this form is returned to the DICO, it will be reviewed, and a hard copy will be kept in a locked file cabinet, as well as electronically filed in a secured “DICO Only” folder on the Training Unit T drive.
Revised 6/17/13 Section 106.5 Page 2 of 5 COMMUNICABLE DISEASE EXPOSURE REPORTING PROCEDURE
If during the course of performing one’s duties, a member is exposed or suspects he/she has been exposed to another person’s blood and/or body fluids or has been stuck by an exposed needle, the exposure incident(s) shall be reported to the following:
appropriate supervisor, physician or medical care provider (if medical attention is required), and DICO
An exposure incident is defined as specific eye, mouth, mucous membrane, non- intact skin, or parenteral contact with blood, bodily fluids, or other potentially infectious materials, which results from the performance of a member’s duties. Parenteral means piercing mucous membranes or the skin barrier through such events as needle sticks, human bites, cuts, and abrasions.
Checklist: Members shall use the following guide during an exposure or suspected exposure.
Report the exposure or suspected exposure incident to supervisor. Docu- ment how the exposure occurred, the routes of exposure, the source individual and/or source material, and the situation surrounding the exposure.
Immediately report the exposure to the DICO. Phone Number (559) 621-4155
Complete Form EMS-15, Communicable Disease Exposure Report Section I: To be completed by the employee. Section II: To be completed by the treating physician (if medical at- tention is sought). Bottom Section (Exposure Response): To be completed by the DICO.
Determine if the exposed member requires medical attention. If so, medical care should be sought immediately. Medical treatment may be obtained at one of the approved medical clinics or the hospital emergency room (when appropriate) and is pro- vided through the City Worker’s Compensation Program. Treating physician completes Section II of Form EMS-15, Communi- cable Disease Exposure Report
Revised 6/17/13 Section 106.5 Page 3 of 5 Exposed member may decline medical attention; however, the appro- priate exposure incident report must be completed with a notation the member declined medical treatment.
Obtain consent and make arrangements to have the source individual test- ed to determine infectivity. If the source individual is already known to be infected, new testing may not be needed. Exposed member should be provided with source individual’s test re- sults. If source individual refuses consent, the exposed member may be able to obtain consent through a court order.
Fax the completed Form EMS-15, Communicable Disease Exposure Report within 24 hours to the DICO at (559) 457-1198 or (559) 457-1262.
If medical attention is received, report the exposure as a work-related ill- ness within 24 hours using the City Worker’s Compensation forms and guidelines. Please include the completed Form EMS-15, Communicable Dis- ease Exposure Report, with the completed Worker’s Compensation forms when routing to the DICO.
Revised 6/17/13 Section 106.5 Page 4 of 5 EMS-15 CONFIDENTIAL
Communicable Disease Exposure Report
Reporting Procedure
Any member who believes he/she has been exposed to blood, body fluids, or a disease shall: 1. Report the exposure to his/her immediate supervisor 2. Follow the Department reporting procedures, 3. Complete Section I (All that apply to exposed member), 4. IMMEDIATELY report exposure to the DICO at (559) 621-4155 5. If exposed member requires medical attention, treating physician completes Section II 6. Fax report to (559) 457-1198 or (559) 457-1262.
SECTION I (Complete all in SECTION I that applies to exposed member) Person Exposed Date of Time of Name exposure exposure Work Phone Cell Phone Home Phone Employer Dispatch PCR # Address/Location of exposure Other agencies present: Patient/Suspect Information Name Male Female Age Date of birth Stat Phon Address Apt # City e e Patient destination: Type of Exposure Blood Body Fluid Respiratory Illness Other Briefly Describe Incident Signature of Designated Officer / Designee:
SECTION II Treatment & Testing Guidelines (This section completed by treating physician) 1. Rapid HIV and HCV (within 2 Hours) 2. Syphilis 3. Hepatitis B (HBIG) if no prior infection or vaccine 4. Baseline Hepatitis C 5. Tetanus, if last shot was more than ten (10) years ago 6. Testing for HIV – If no HIV testing available at your facility, you can refer the patient to Firm Associates to begin the testing process IMMEDIATELY report exposure to the DICO at (559) 621-4155; Fax (559) 457-1198 or (559) 457-1262 Services Rendered by Treating Physician:
Follow Up Plan: Treating Physician’s Signature
No Exposure/No Follow Unable to contact exposed to verify if exposure Exposure Response from DICO: Up occurred True Exposure – Follow up to be done at: Recommendations DICO Signature
Revised 6/17/13 Section 106.5 Page 5 of 5