Blood and Body Fluid Exposure Protocol

Applies to Surgical Specimens and Autopsies

This webpage is designed to be used ONLY by the Pathology Residents at the UTHSC Memphis campus. All others please visit University Health Service's Injuries and Exposures webpage for procedures.

If you are exposed to Blood or Body fluids, get immediate care and then go to the clinic or ER. Contact the Program Director and Mr. Barry Handy (Pager: 533-5262).

Immediate Care Following Exposure

The procedure is slightly different in an autopsy case compared to a surgical case in the grossing room.

  1. Assess and clean any wound, possibly allowing the wound to bleed a bit. Use lots of soap, water, and an antiseptic. If exposure is to a mucous membrane such as the eyes, immediately wash eyes at an eyewash station followed by 3 to 6 liters of normal saline in the ER or clinic.
  2. Autopsy Procedure: If it is an autopsy case, you or someone else can try to call the hospital lab where the patient was treated and see if they have enough blood that is adequate for testing from the "source patient" to check for HIV, Hepatitis B, and Hepatitis C. If not, try to extract blood from the cadaver. Collect 1-2 red-top tubes (serum separator tubes: 5 -10 ml blood).
  3. Contact the Program Director and Mr. Barry Handy (Pager 533-5262)

Go to Clinic/ER

Report to clinic or ER preferably within hours (ASAP) to see if you meet criteria for significant risk of HIV exposure. You might require Hepatitis B Immunoglobulin. When asked for insurance information, tell the ER or clinic personnel that the cost of the visit is to be covered by the State of Tennessee workman's compensation company, which is currently Sedgewick & James. Request the clinic/ER professionals to start checking the status of the source patient.

Hospital Regular hours Contact address and/or phone no. Contact Info. after regular hours Comments
Regional Medical Center (MED) 7:00 am to 4:30 pm M-F Occupational Health Clinic Ground Floor of Medplex 545-7166 (office) 790-9697 (pager) 790-9697 (pager) Go to MED ER Contact Barry Handy 448-5630 (o) 533-5262 (pager)
VA Medical Center 7:30 am to 4 pm M-F Occupational Health 523-8990 ext. 5538 or 5532 Go to VA ER N/A
Regional Forensic Center 8:00 am to 5 pm M-F Uni. Health Services 910 Madison Ave Suite 922 448-5630 (office) 533-5262 (pager) 533-5262(pager) Go to MED ER N/A
Baptist Hospital East N/A Baptist ER Baptist ER On the paperwork, list Regina Rogers as the "supervisor".
Trumbull Labs 8:00 am to 5:30 pm M-F Concentra Medical Center 3965 South Mendenhall Rd. 365-1800 (other locations available) Baptist ER or Baptist Minor Medical 3295 Poplar Ave. 327-8188 (other locations available) Also need to notify Dale 542-6899 (office) dale.hoskins@ trumbulllabs.com (e-mail)
Methodist Univ. Hospital 7:00 am to 3:30 pm M-F Associate Health 516-7784 Methodist ER N/A
St. Jude 8:00 am to 4:30 pm M-F Occupational Health 495-2531 or 495-3562 Call Pager 626-6006 N/A
Le Bonheur Children's Hospital 7:00 am to 4 pm M-F Employee Health 287-6327 Le Bonheur ER Can call Duty Administrator 418-9095 (pager) N/A
University Health Services 8:00 am to 5 pm M-F 910 Madison Ave. Suite 922 448-5630 (office) 533-5262 (pager) 533-5262 (pager) N/A

Report the incidence to the appropriate authorities

Report to Barry Handy or his assistant on the day of or, if not able to meet with him the day of the incident, then by the next business day. He will be following up lab work on the patient and your lab work. He may possibly follow up on any necessary treatment, which may have been initiated by the respective clinic or ER at the respective institution that you went to initially.

Always contact the Program Director and Mr. Barry Handy (Pager 533-5262)

Required forms

At least three forms will need to be filled out on the day of or by the next business day, if incident occurs on a non-business day. (These forms are kept on record for 30 years.) Print the forms (pdf format) and fill them out.

  1. One or two of the following forms:
  2. Supervisor's Report of Employee Accident icon (one page) and you may have to help fill it out. It also needs to be signed by the supervisor of the rotation, usually the attending.
  3. Accident Report State of Tennessee Division of Claims Administration icon (two pages) To be filled out by you in case the event will need to be covered by workman's compensation. After it is completed by you and the supervisor, make sure to return it to Ms. Karen Weatherly at office phone no. 448-5577 on the same or the next business day. It is mandatory that this form be filled out within 24 hours or by the next business day.

Algorithm

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