Blood and Body Fluid Exposure Policy

Date of original approval: November 29, 2002
Date of last revision and approval: January 31, 2025
Date for next review: 2029

Each of the hospital sites and other health care settings fully or partially affiliated with the University of Toronto Temerty Faculty of Medicine have policies and procedures to follow when sustaining a percutaneous or mucous membrane exposure to blood or body fluids. To ensure safety of themselves and their colleagues, Program Directors must:

• ensure that, at the beginning of the rotation/assignment to a new site, learners know the initial contact point for reporting of “sharps” injuries at the site, to access intervention (Post-Exposure Prophylaxis - PEP) if required
• include blood and body fluid exposure management protocol in the program’s academic curriculum sessions

Program Directors must further ensure that learners in training outside of the University of Toronto’s affiliated teaching hospitals and other health care settings (clinics, elective rotations) are provided with blood and body fluid exposure policies and procedures specific to their training site.

The University of Toronto, Postgraduate Medical Education (PGME) office will maintain records of learners’ Hepatitis B Virus (HBV) immunity as part of mandatory immunization record and will share this information with Hospital Occupational Health Service or Delegate as required.

Procedural Guidelines for Occupational Exposure to Blood and/or Body Fluids:

1. Know your immune status to the Hepatitis B Virus (HBV)

   • RESPONSIBILITY: MEDICAL LEARNER

2. Apply first aid: allow the wound to bleed freely. Wash wound and skin sites which have been in contact with blood or body fluids with soap and water; mucous membranes should be flushed with water. A tetanus shot may be required if the injury is deep, and significant time has lapsed since the last tetanus booster.

   • RESPONSIBILITY: MEDICAL LEARNER
3. Note details of occupational exposure, i.e.: type of injury, underlying disease(s) of source, past medical history, risk factors for bloodborne pathogen infection
   • RESPONSIBILITY: MEDICAL LEARNER, HOSPITAL’S OCCUPATIONAL HEALTH SERVICE OR DELEGATE, DEPENDING ON PARTICULAR HOSPITAL’S PROTOCOL.
4. Report immediately to hospital’s Occupational Health Service or delegate, e.g.: the Infectious Disease consultant, Emergency Department, or the appropriate hospital administrator depending on the hospital’s protocol.
   • RESPONSIBILITY: MEDICAL LEARNER
5. History-taking and Assessment of Risk, e.g.:
   1. by characteristics of source: for example: high risk source includes known positive patients with HIV, HBV, HCV, and patients at epidemiologic risk of HIV, HBV, HCV
   2. by nature of exposure: for example, high risk exposure would be deep percutaneous injury with hollow bore needle which had been in blood vessel of source
   3. by susceptibility of learner, for example: not immune to HBV
      
      RESPONSIBILITY (a) and (b): HOSPITAL OCCUPATIONAL HEALTH SERVICE OR DELEGATE
      RESPONSIBILITY (c): MEDICAL LEARNER
6. Management of follow-up including counseling, baseline and follow-up serology and post-exposure prophylaxis as required.
   • RESPONSIBILITY: HOSPITAL OCCUPATIONAL HEALTH SERVICE OR DELEGATE
7. Report incident to:
   1. PGME office
      RESPONSIBILITY: HOSPITAL OCCUPATIONAL HEALTH SERVICE OR DELEGATE
   2. Program Director
      RESPONSIBILITY: MEDICAL LEARNER
8. Report incident to: Ontario’s Workplace Safety and Insurance Board (WSIB) (according to WSIB directives)
   • RESPONSIBILITY: PGME OFFICE OR HOSPITAL OCCUPATIONAL HEALTH SERVICE, DEPENDING ON EMPLOYER OF RECORD