Policy on Blood and Body Fluid Exposure (Needle stick)

I. PURPOSE

It is the purpose of this policy to define the procedures for blood and body fluid exposures for New York Medical College (“NYMC” or the “College”) students.

II. POLICY

It is the policy of NYMC to have standardized procedures for handling blood and body fluid exposures which includes needlestick injuries.

III. SCOPE

This policy applies to all NYMC students in the School of Medicine, the Graduate School of Basic Medical Sciences and all physical therapy and speech and language pathology students in the School of Health Sciences and Practice.

III. DEFINITIONS:

Blood and body fluid exposure (“BBFE”): an exposure of human blood or a body fluid/tissue that meets non-intact skin or mucous membranes. Such exposures pose a potential risk of transmission of blood borne pathogens. Needle stick injuries are included in the term blood and body fluid exposure.

Blood borne pathogens: These primarily are human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV). Depending upon the clinical situation, blood borne pathogens may not be limited to these infectious agents.

Risk of transmission: The likelihood of acquiring an infection. For blood borne pathogens, the risk of transmission depends upon the nature of the exposure, the infectiousness of the source, and in the case of HBV, the immune status of the exposed individual.

NYMC Health Service: Health services for all of NYMC and performs the follow-up for student blood and body fluid exposures.

NYMC School of Medicine directors:

Site Director: Faculty at each clinical site responsible for the clinical training in a given discipline.

Phase 2 clerkship directors: Directors for core clerkships within a discipline across all clinical sites.

Phase 3 sub-internship director: Director who oversees advanced clerkships within a discipline at a site. 

V. RELATED POLICIES:   

Policy on Students Infected with Blood Borne Pathogens.

VI. PROCEDURES

A. Student Responsibilities - Initial Procedures when blood or body fluid exposure occurs:

1. Care of the Wound or Mucous Membrane: Immediately wash the exposed area thoroughly with soap and water; a germicidal soap may be used. For mucous membrane exposures, irrigate with copious amounts of water and flush thoroughly. Five minutes of irrigation is a suggested time period.

2. Notify your Supervisor: The exposed person will need to leave their current duties and report immediately to the Employee Health Service or Emergency Room for treatment. Post-exposure prophylaxis for HIV is to be started within 2 hours of the injury, thus one should not delay in the procedures below. 

3. Report to Employee Health Service or Emergency Room:

a. In hospitals, or outpatient sites within a hospital complex:

i. Blood and body fluid exposures that occur off-hours (nights/weekends) are handled in the Emergency Room.

ii. During regular working hours blood and body fluid exposures may be handled by the Employee Health Service or by the Emergency Room.

iii. Check with your supervisor or clerkship director for the appropriate site.

b. During student outpatient rotations geographically separate from a hospital:

i. As blood tests and a medical evaluation will be required, the exposed person is to go to the closest site that can perform the necessary blood tests for both the exposed student and the source patient.

ii. The clinical supervisor is to advise the student on where to go.

4. For SOM students:

a. Directors at a clinical site will ensure that source patient testing is completed and directors are involved in the administrative reporting of blood and body fluid exposures.

b. Exposed students are to notify the director at the clinical site as listed below.

c. Please inform the director of the exposure and the source patient’s name, medical record number and date of birth. 

d. Notification is as follows:

i. Notify your site director when in a core clerkship.

ii. Notify your sub-internship director when you are in an advanced clerkship.

iii. Notify your elective director when you are doing an elective.

5. Billing:

a. Students are to present health insurance information for billing purposes at the time of medical evaluation.

b. Students cannot be considered as Workers’ Compensation as they are not employees.

6. After the initial medical evaluation, notify NYMC Health Services:

a. It is essential that the exposed student report the injury to NYMC Health Services; if the injury occurred after hours, this can be reported on the next working day.

b. This is required to provide needed follow-up for blood tests, answer questions, seek consultation if needed, and in the case of HIV prophylaxis, to prescribe the medications needed to complete the course of treatment.

7. Obtain a copy of your off-campus medical evaluation and any tests performed to bring to NYMC Health Services and find out who will be responsible for communicating the source patient lab result to NYMC Health Services. Source patient results are sent to Health Services in a de-identified manner. See below.

B. Student medical evaluation of the student at the time of exposure-What to Expect: 

1. Blood and body fluid exposures require a medical evaluation. Expect the following: 

a. You will be asked to recall the specific events of the injury and to provide a clear description of how the exposure occurred, what type of needle or device was involved, the body fluids involved, and whether or not the injury involved visible blood from the source patient or the exposed person. For needle sticks, please note, if the needle was a hollow bore needle and if the needle was directly placed in a vein or artery.

b. Completion of an incident report: Students may be asked to complete an incident report for the hospital / clinical site in accordance with procedures for that site.

c. Information regarding the source patient: You will need to provide the person evaluating you with the source patient’s name, medical record number and date of birth.

d. Exposed student - Baseline blood tests:

i. Tests for HIV antibody, HCV antibody are required.

ii. A HBV surface antibody and HBV surface antigen is performed only if the exposed student does not know his/her Hepatitis B surface Ab status.

iii. If the student knows they are immune to HBV, repeat testing is unnecessary and should not be done.

iv. A complete blood count and differential, complete metabolic profile, and a pregnancy test are obtained if HIV post-exposure prophylaxis is to be started.

e. Tetanus booster: If the exposed person has not received a tetanus booster within the past 10 years, a booster may be administered at the time of evaluation.

f. Evaluation of source patient: 

i. The clinician responsible for the source patient is to assist with determining the source patient status for HIV, HBV and HCV. 

ii. Clinical site directors may be needed to assist with ensuring the information is available to the clinician evaluating the student and to ensure the information will be communicated to Health Services.

iii. Below are procedures depending upon the status of the source patient:

• HIV status Unknown or Negative: An HIV test of the source patient is to be performed in accordance with Department of Health procedures for informing the patient of the need for the test/ consent. A rapid HIV test for the source patient is preferred to allow this information to be available to assist with the decision of post-exposure prophylaxis.

• HIV Positive Source: Information regarding the potential infectivity of the source patient, including CD4 cell count, viral load and current antiretroviral medications is to be provided if possible. 

• HBV status and HCV status of source: are determined through the tests, HBV core antibody, HBV surface antibody and HBV surface antigen and HCV antibody obtained for the source patient.

• Other transmissible agents: The primary care provider for the source patient may indicate that the source patient was infected with another agent that is potentially transmissible by blood or body fluid exposure. This information is communicated to the clinician evaluating the exposed person.

g. Medical Determination of need for post-exposure prophylaxis

i. Based upon the information known regarding the source patient, the clinician evaluating the student will discuss the risks of exposure and make a recommendation for post-exposure prophylaxis. 

ii. Infectious Diseases telephone consultation is advised in the case of a blood or body fluid exposure involving an HIV infected patient.

iii. Procedures for Infectious Diseases consultation are followed as per the procedures at the clinical site in which the exposure occurred.

iv. Procedures for HIV Post-exposure prophylaxis: If HIV post-exposure prophylaxis is advised, a 48-72 hour supply of medications is provided through the Emergency Room or Employee Health Service evaluating the individual. Students sustaining blood or body fluid exposure at a private office must bring a prescription to a local pharmacy.

• Post-exposure prophylaxis should not be interrupted. All doses are to be taken until further assessment. The follow-up assessment may change the duration of prophylaxis depending on further information regarding the source patient or tolerability of prophylaxis.

• The possible side effects of medications and the need for birth control during chemoprophylaxis are discussed with the exposed person.

• In the event HIV post-exposure prophylaxis is recommended and the exposed person declines post-exposure prophylaxis, the exposed person is to sign a declination of treatment

v. Exposures involving a source patient that is infectious for HBV: The need for prophylaxis depends upon the immune status of the exposed person. Exposed persons who are seronegative for HBV or who have declined HBV vaccination may require receipt of HBV immune globulin in the case of a high risk injury.

vi. Exposures involving a source patient that is infectious for HCV: The exposed person will require periodic blood tests to assess transmission. No post exposure treatment currently recommended. 

VII. Affiliated Hospital/Clinical Site/NYMC Faculty Responsibilities

A. Responsibilities of the Faculty Site Director, Sub-internship Director, Elective Director

1. At orientation, students at a clinical site are to be informed of where to go to in the event of a blood or body fluid exposure. The medical evaluation above indicates that HIV post exposure prophylaxis is to be started within 2 hours of the injury.

2. Assist with testing and communication of source patient status if needed: The clinician evaluating the student will need source patient’s blood test results to assure appropriate follow-up and medical management of the student.

3. Paperwork for the student:

a. The exposed student will need copies of medical evaluation plus copies of any tests performed on student, and recommendations for prophylaxis and the de-identified results of the source patient testing.

b. Source patient testing is de-identified by removing (blackout) the name, date of birth and medical record number of the patient.

c. Write on the laboratory sheet: Source patient to exposure for “student name and date of exposure"

4. For School of Medicine: Administrative reporting of BBFE: 

b. The site director, sub-internship director, or elective director informs the appropriate NYMC clinical director of the BBFE with name of the student, the date and time of exposure, and the status of source patient testing.

c. The NYMC clinical director then informs NYMC Health Services of the blood and body fluid exposure and the status of source patient testing. This is done by calling Health Services at 914-594-4234 during working hours or sending a secure email to Health_Services@nymc.edu; 

SOM rotation	Student informs	Site, sub-intern, elective  director informs	NYMC Health Services  informed by:
Phase 2 core clerkship	Site director	Clerkship director	Clerkship director
Phase 3 sub-internship	Sub-internship  director	Not applicable	Sub-internship director
Elective: Phase 2 or Phase 3	Elective director	Phase 2 or Phase 3 director	Phase 2 or Phase 3 director

In the event the student has not yet contacted Health Services, Health Services will reach out to the student to begin the follow up procedures listed below.

B. Procedures by Health Services:

1. Health Services meets with the exposed person by telephone or in-person (depending upon the nature of the injury) and reviews the data from the medical evaluation performed at the site of the exposure. This occurs on the day of the exposure of the next working day depending upon the time of the exposure. 

2. NYMC Health Services Blood and Body Fluid Exposure Form is completed by the student (see fillable form on the website).

3. Follow-up testing for any blood-borne pathogen may be required. NYMC Health Services sends the student an Exposure Lab Follow-up Form after the source patients labs are received. This form is sent even when no further follow up is needed to confirm closure of the case.

4. Co-pays for medical evaluation or post-exposure prophylaxis medications are reimbursed through NYMC Health Services for NYMC School of Medicine, Doctor of Physical Therapy and Speech and Language Pathology students. Students must present an appropriate explanation of benefits information to Health Services for reimbursement.

VIII. REFERENCES

Updated US public health service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis, May 23, 2018 update, downloaded on June 20, 2023.

Centers for Disease Control and Prevention. Testing and clinical management of health care personnel potentially exposed to hepatitis C virus. – CDC guidance, United States 2020.

IX. EFFECTIVE DATE

This policy is effective immediately.

X. POLICY MANAGEMENT

Executive Stakeholder: Director, Health Services 
Oversight Office: NYMC Health Services