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CM-8 Policy on AIDS (HIV) and Hepatitis Virus (HBV)

POLICY ON AIDS (HIV) AND HEPATITIS (HBV)

PREAMBLE

Faculty, staff, and students who are HIV/HBV infected, and who perform exposure prone procedures are encouraged to self-identify to the Chancellor (or designee) of LSU Health Sciences Center, to their immediate supervisor, who would then report to the Chancellor (or designee) of LSU Health Sciences Center, or directly to the Expert Review Panel (ERP). In reporting their status to the Health Sciences Center, HIV/HBV infected individuals are assured that every effort will be made by the LSUHSC Administration to maintain confidentiality, as determined by the Expert Review Panel (ERP), and that a mechanism is in place, through the HIV/HBV Policy/Procedure and Expert Review Panel (ERP), to maintain balance between the individual's job-related responsibilities and the institution's responsibilities to faculty, staff, students, patients and the community. There is a need to protect the HIV/HBV infected individuals, faculty, staff, and patients. The Expert Review Panel (ERP) designated in the HIV/HBV policy and Procedure in conjunction with the Administration is working to assure a system is in place to fulfill this need.

I. HIV/HBV RISK EVENT

Employees of LSUHSC-S:

When an employee has an accident which is considered an "at risk" incident (i.e., needle stick, puncture or cut from a potentially contaminated source), the employee must immediately report the incident to his/her immediate supervisor.

The supervisor is responsible for reporting the incident and following procedures to insure proper testing and medical treatment are provided. The employee is entitled to seek his/her medical care of choice under Worker's Compensation. Medical care will be made available, if requested by the employee, at the LSUHSC-Shreveport Employee Health Clinic or the Worker's Compensation Physician under contract.

The LSUHSC-Shreveport Employee Health Clinic or the Worker's Compensation Clinic must be notified that the employee has had an "at risk " incident for HIV/HBV and that proper testing must be performed. Based on the initial testing, additional testing or treatment may be warranted and must be recommended by the examining physician at the time of treatment in order to be considered for eligibility under Worker's Compensation.

The First Report of Injury Form must be promptly completed and forwarded to the Office of Human Resource Management within 30 days. The Supervisor's Accident Investigation Report must also be completed. The itemized billing from the health care provider must be submitted to the Office of Human Resource Management within 90 days after services were rendered for eligibility under Worker's Compensation.

The Environmental Health and Safety Office will forward the Supervisor's Accident Investigation Report Form to the supervisor when the First Report of Injury Form has been received and logged by Human Resource Management. Supervisors are required to investigate each accident and to implement corrective action to prevent recurrence.

Counseling for LSUHSC-Shreveport employees is available through the Employee Assistance Program at no cost for initial counseling. Contact the Office of Human Resource Management for more information. The Employee Assistance Program can also provide access to the Expert Review Panel (ERP) on behalf of LSUHSC-S employees.

Summary of steps to be taken when an "at risk" incident occurs:

Students:

When a student has accident which is considered an “at risk” incident (i.e., needle stick puncture or cut from a potentially contaminated source) the student must immediately report the incident to his/her immediate supervisor as determined by each school/department.

The supervisor is responsible for reporting the incident and following procedures to ensure proper testing and medical care are provided. The Louisiana Office of Risk Management has instructed LSUHSC-Shreveport to file the incident as if it were eligible for Worker's Compensation and submit the appropriate forms for coverage. The CDC and OSHA guidelines for risk exposure will be followed and appropriate reporting provided.

The student is entitled to seek his/her medical care of choice. Medical care will be made available if requested by the student at either the LSUHSC-Shreveport Student Health Clinic, or if contracted to another facility or location, from that satellite location following their policy for "at risk" incidents. Injured students may also seek treatment from their personal physician. If possible, contact the Human Resource Management Office before going, to assure eligibility under Worker's Compensation. In all cases, the First Report of Injury and Supervisor's Accident Investigation Report must be filed with the Louisiana Office of Risk Management for eligibility under Worker's Compensation.

The physician and/or clinic treating the student must be notified that the student has had an "at risk" incident for HIV/HBV and that proper testing must be performed. Based on the initial testing, additional testing or treatment may be warranted and must be recommended by the examining physician at time of treatment in order to be considered for eligibility under Worker's Compensation.

A form entitled First Report of Injury must be promptly completed and forwarded to the Office of Human Resource Management within 30 days. The Supervisor's Accident Investigation Report must also be completed. Supervisors are required to investigate each accident and to implement corrective action to prevent recurrence. The Environmental Health and Safety Office will forward the Supervisor's Accident Investigation Form to the supervisor when the First Report of Injury Form has been received and logged by Human Resource Management. The itemized bill from the health care provider must be submitted to the Office of Human Resource Management within 90 days after services were rendered, for eligibility under Worker's Compensation.

Counseling for LSUHSC-Shreveport students is available through the LSUHSC-Shreveport Student Affairs Office.

Summary of steps to be taken when and "at risk" incident occurs:

II. HIV/HBV INFECTED INDIVIDUALS

Standing HIV/HBV Policy and Procedure Committee

The Chancellor or designee will designate the Standing HIV/HBV Policy and Procedure Committee at LSUHSC- Shreveport. This committee, with representatives from each school, will review and update the LSUHSC-Shreveport policy and procedures at least annually. The members are charged with the duty of reviewing new and current information and revising the existing policy and procedure to reflect such changes. The members shall determine the qualifications necessity of additional training and by whom provided in the specific area of HIV/HBV for counselors, supervisors, instructors, physicians, and laboratory personnel providing treatment or testing on behalf of LSUHSC-Shreveport.

Standing Expert Review Panel (ERP)

The Chancellor or designee is authorized to convene the ERP at any time that he/she feels input from the panel is necessity. The Chancellor or designee will convene the Expert Review Panel (ERP) when requested by students, residents, faculty, employees or counselors, as necessary, to deal with individual cases involving LSUHSC-Shreveport personnel. Requests to convene the Expert Review Panel (ERP) shall be addressed directly to the Chancellor or designee in order to retain the individual's confidentiality within the school or department.

Expert Review Panel Membership

Three members will be appointed to the Expert Review Panel (ERP) as follows:

The Chairmanship will rotate among these three members.

Ad hoc committee members - to be appointed by the three appointed panel members:

Ex Officio panel members - these persons will be selected at the individual's discretion (i.e., they are not required):

When a request is received, the chairman of the panel will meet with the individual and the ex officio panel members chosen by the individual. At this meeting, the Chairman will explain the purposes of the panel and how the deliberations will take place. Additionally, the individual may wish to meet with other members of the panel prior to the full panel meeting.

Expert Review Panel

The purpose of the Expert Review Panel (ERP),will be to:

Documentation of the Expert Review Panel's Action

The panel Chairman will prepare a report of the recommendations of the panel. This will be reviewed by the individual involved and signed in the presence of witnesses, by both the individual and the chairman of the panel. This report will be kept in the locked confidential file of the ERP.

The panel should take into consideration that, as of June 10, 1992 the Centers for Disease Control (CDC) still maintains that notification of patients treated by an infected healthcare worker (HCW) and follow-up studies should be considered on a case-by-case basis, taking into consideration an assessment of specific risks, confidentiality issues and available resources.

III. ADDITIONAL REQUIREMENTS AND PROCEDURES

EXPOSURE DETERMINATION

Each school/department shall perform an exposure risk determination analysis to identify all students, faculty and employees who are directly exposed or have a likelihood of exposure to blood or other potentially infectious materials without regard to the use of personal protective equipment.

EDUCATION AND UNIVERSAL PRECAUTIONS

All students and employees who, in the course of their responsibilities, come in contact with blood and/or body fluids of patients/clients should each receive a current copy of CDC Universal Precautions. Each School/Department is responsible for developing and conducting early, comprehensive education regarding CDC "Universal Precautions" and work practice procedures for those personnel and students who potentially may come in contact with blood or body fluids of patients/clients. Students and employees are responsible for familiarizing themselves with the elements of "Universal Precautions" and work practice procedures and for adhering to these procedures whenever they are involved in patient/client care.

Faculty will facilitate and monitor student compliance with these procedures.

Protective equipment (gloves, masks) should be provided at the work site. Each individual should provide protective eyewear for personal use.

Wherever possible, engineering controls should be instituted to eliminate or minimize exposure. Examples of such controls include sharp containers, mechanical pipetting, and splash guards.

All personnel having experience in another agency, must be familiar with and adhere to the infection control policies of that agency.

Individuals admitted to or employed by LSUHSC will receive the CDC's recommendation of preventing transmission of HIV and HBV to patients during exposure prone procedure (MWR40). They will also receive information during orientation, about management of personnel with blood-borne diseases. Their supervisor or instructor will be responsible for making this information available.

MEDICAL/INFECTIOUS WASTE DISPOSAL

Medical /infectious waste will be labeled and disposed of according to the most recent guidance policy.

HOUSEKEEPING AND LAUNDRY PRACTICES

Each school/department providing housekeeping and/or laundry services should prepare a procedure to be followed which includes proper handling of potentially infectious materials, laundry and equipment. The procedure should include protective equipment to be utilized, frequency of disinfection and type or concentration of disinfectant utilized.

RECORD KEEPING

All records relating to a reported at risk@ incident will be kept by the Office of Human Resource Management.

PREVENTION

Information regarding risks and benefits of prophylactic treatment will be made available to persons involved in a HIV/HBV risk events, as described. Access to HIV/HBV testing, gamma globulin, AZT and other medications will be made available to individuals within 24 hours of the reported incident. If such access is not available at the institution of event, individuals may seek these services through Student Health, Comprehensive Health, or the Employee Assistance Program, as described in this policy.

The HBV vaccination will be made available to all employees whose exposure determination identifies a risk of directly contacting blood or other potentially infectious materials.

COUNSELING AND RELATED SERVICE

Employees: The LSUHSC-Shreveport Employee Assistance Program (EAP) provides the following services for LSUHSC employees, faculty, staff and residents:

On behalf of LSUHSC, the Employee Assistance Program (EAP) will also provide the following services, if needed for persons with HIV/HBV:

DISCLOSURE OF INFORMATION

Information concerning LSUHSC-Shreveport employees or students who have tested positive or are receiving treatment for HIV/HBV is confidential.

Inquiries from external sources regarding such information shall be referred to the LSUHSC-Shreveport Director of Informational Services.




Signed: John C. McDonald, M.D. Chancellor
June 1, 2001



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