Policy Text
University of California, San Francisco
Police Department General Orders
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4.4 Bloodborne Pathogen Rule/Exposure Control Plan
4.4.6 Hepatitis B Vaccine, Post -exposure Evaluation and Follow -up (Revised: 2/1/09)
Even with sound adherence to the specified exposure prevention practices, exposure incidents
can occur. As a result, the Police Department provides for hepatitis B vaccinations and sets up
procedures for post -exposure evaluation and follow -up should exposure to bloodborne pathogens
occur.
A. Vaccinations
See General Order 3.9.1, “Physical Examinatio ns for Sworn Personnel” about hepatitis B
vaccinations.
B. Post-exposure Evaluation and Follow -up
1. If it is suspected that an employee has had an exposure risk to bloodborne
pathogens, the employee shall inform his/her supervisor, and call the Needle
Stick/Exposure Hotline at the pager number 415 -719-3898. Enter your callback
phone number and press the # key after the beep. Hotline staff will provide
expedited access to post -exposure treatment, follow -up and counseling. Calling
may be time -critical; antiviral medications begin to lose effectiveness two hours
post-exposure.
2. If an employee is involved i n an incident where exposure to bloodborne
pathogens may have occurred, his/her supervisor will immediately:
a. Investigate the circumstances surrounding the exposure incident and
b. Ensure the employee receives medical consultation and treatment (if
requi red), as expeditiously as possible.
3. It is essential for a medical evaluation and subsequent treatment to be initiated in
a timely manner after some types of exposures. The highest risk category is a
blood -to-blood exposure with a known infected source. However, as a general
guideline, if the exposure is from a needle stick, splash into or onto mucous
membrane(s) or onto an open area including scrapes, scratches and abrasions, the
employee should seek medical evaluation within two hours of the exposure.
Exposures with less risk of infection should be evaluated by medical personnel
within 24 hours.
4. Depending on the type and severity of the exposure and the medical condition of
the source, the physician may offer, recommend or strongly suggest medical
treatment as a preventive measure. The decision to accept the medical treatment
lies with the employee.
5. The responsible sergeant/supervisor will investigate every exposure incident
occurrence in Department operations and document the information on the UCSF
Supervisor Incident Report form. These investi gations will be initiated upon
notification of an exposure and will contain, at a minimum, the following
information:
University of California, San Francisco
Police Department General Orders
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a. The date and time the incident occurred
b. Where the incident occurred
c. What potentially infectious material(s) (blood, etc.) were involved in the
incident
d. Source of the material
e. Under what circumstances (type of work being performed) the incident
occurred
f. How the incident wa s caused
g. Personal protective equipment being used at the time of the incident
h. Actions taken as a result of the incident, including:
(1) Employee decontamination
(2) Clean up
(3) Notifications.
6. The completed documents will be routed through the chain of command to the
Risk Manager within 24 hours of the exposure (excluding weekends).
7. To ensure employees receive the best and most timely treatment if an exposure to
bloodborne pathogens should occur, the post -exposure evaluation and follow -up
process will be adhered to. An employee’s supervisor is responsible to use the
“checklist” to ensure all the steps in the process have been taken correctly.
8. The information involved in this process must remain confidential. Sergeants and
supervisory person nel will do everything possible to protect the privacy of the
employees involved in an exposure incident. As the first step in this process, the
following confidential information will be provided to the exposed employee:
a. Documentation regarding the rou tes of exposure and circumstances under
which the exposure incident occurred
b. Identification of the source individual (unless infeasible or prohibited by
law).
C. Information Provided to the Health Care Professional
To assist health care professionals, documentation of the exposure incident will be
provided by the Risk Manager within 24 hours or by the on -duty Sergeant/Watch
Commander if the exposure is believed to be high -risk and a medical evaluation is
indicated wi thin two hours of the exposure and the Risk Manager is off -duty.
The following documentation will be provided:
1. A copy of the Bloodborne Pathogens Standard
2. A description of the exposure incident and what the employee was doing at the
time of the inc ident
3. The exposed employee’s relevant medical records
4. Other pertinent information.
University of California, San Francisco
Police Department General Orders
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D. Healthcare Professional’s Written Opinion
After the consultation, the health care professional will provide the Police Department
with a written opinion evaluating the exposed employee’s situation. The Risk Manager
will, in turn, furnish a copy of this opinion to the exposed employee within 15 days of
receipt of the physician’s evaluation. In keeping with this process emphasis on
confidentiality, the writt en opinion will contain only the following information:
1. Whether, after exposure, medical treatment is offered, recommended or strongly
encouraged for the employee
2. Whether hepatitis B vaccination is indicated for the employee
3. Whether the employee has received the hepatitis B vaccination
4. Confirmation that the employee has been informed of