MENDOCINO COAST DISTRICT HOSPITAL
INFECTION CONTROL POLICY AND PROCEDURE STATEMENT
NUMBER: 170.1011
PAGE: 4 OF 5
TITLE: FACILITY REPORTING OBLIGATIONS REGARDING EXPOSURE OF EMERGENCY RESPONSE EMPLOYEES TO INFECTIOUS DISEASE DURING TRANSPORT OF PATIENTS TO HOSPITAL
PURPOSE:
In accordance with the federal Ryan White Comprehensive AIDS Resources
Emergency Care Act (the "Act"), medical facilities are to notify the "designated
Officer" (DO) when emergency response employees ("EREs") are exposed to
specified infectious diseases during the transport of a patient to the hospital.
POLICY:
If a patient is determined to have an infectious disease, the Infection Control Coordinator will report this to the DO of the EREs who transported the patient to Mendocino Coast District Hospital.
The infectious diseases currently covered are:
A. Airborne Diseases
Infectious pulmonary tuberculosis
B. Other Infectious Diseases
Hepatitis B
HIV infection (including AIDS)
Diphtheria (Corynebacterium diphtheria)
Meningococcal disease (Neisseria meningitides)
Plague (Yersinia pestis)
Hemorrhagic fevers (Lassa, Marburg, Ebola, Crimean-Congo, and other
viruses yet to be identified)
Rabies
PROCEDURE:
1. The Mendocino Coast District Hospital will notify only the DO and EREs who transported the victim, not those who may have also treated the victim prior to transport. Notification will be the responsibility of the Infection Control Coordinator or designee.
a. This notification must be made as soon as is practicable, but not later than 48 hours after the determination is made.
b. Mendocino Coast District Hospital must inform the DO of the name of the infectious disease involved and the date on which the patient was transported by EREs to the facility. No other information, including the name of the patient, should be released.
c. If the required notification to the DO is made by mail, Mendocino Coast District Hospital must inform the DO (by telephone or in person) that the notification has been sent; the DO must, within 10 days inform Mendocino Coast District Hospital whether the notification was received.
d. The DO for MCDH is the Employee Health Coordinator.
2. Any ERE who attended, treated, assisted or transported a patient may request a determination whether there was an exposure to an infectious disease from his or her DO.
a. If the DO determines that the ERE may have been exposed to one or more of these infectious diseases, the DO must submit a request for response to Mendocino Coast District Hospital, to which the patient was transported. This request must be in writing, contain a statement of the facts surrounding the circumstances of the potential exposure, and be signed by the DO.
b. Mendocino Coast District Hospital must evaluate the facts submitted by the DO and determine whether, on the basis of the medical information possessed by the facility regarding the patient, the ERE was exposed to an infectious disease listed above.
c. If the Infection Control Coordinator or designee determine that an ERE was exposed to an infectious disease listed above, he/she must so notify the DO in writing as soon as is practicable, but not later than 48 hours .after receiving the request.
i. The Infection Control Coordinator or designee must inform the DO of the name of the infectious disease involved and the date on which the patient" was transported by EREs to Mendocino Coast District Hospital. No other information, including the name of .the patient, should be released.
ii. If the required notification to the DO is made by mail, Mendocino Coast District Hospital must inform the DO (by telephone or in person) that the notification has been sent; the DO must, within 10 days, inform MCDH whether the notification was received.
d. If the Infection Control Coordinator or designee determines that an ERE was not exposed to a listed infectious disease, the facility must so notify the DO in writing as soon as practicable, but not later than 48 hours after receiving the request.
e. If the facts are insufficient to determine whether the ERE was exposed to a listed infectious disease, the Infection Control/Employee Health Coordinator must notify the DO in writing of the insufficiency of the facts as soon as is practicable, but not later than 48 hours after receiving the request.
i. If the DO so requests, the local public health officer in Mendocino County may evaluate the request and the response, and make an independent determination and response to the DO.
ii. If the public health officer believes the facts provided to MCDH were sufficient or the public health officer obtains additional and sufficient facts, the public health officer will resubmit the request to MCDH. Mendocino Coast District Hospital must then provide the DO the appropriate response.
f. If Mendocino Coast District Hospital determines that it possesses no information on whether the patient had an infectious disease listed above, MCDH must notify the DO in writing of the insufficiency of the medical information as soon as is practicable, but not later than 48 hours after receiving the request. However, if MCDH later determines that the patient had a listed infectious disease, the facility must notify the DO (see Section C below for the time limit in this requirement).
g. If a patient dies at or before reaching Mendocino Coast District Hospital, and MCDH receives for request for response under Act, MCDH must provide a copy of the request to the facility that is ascertaining the cause of death, if there is a different facility involved. That medical facility then has the responsibility of making the required determination and appropriate response.
3. Limitations on Mendocino Coast District Hospital Duties: The Act specifically limits MCDH's responsibilities as follows:
a. The duties of Mendocino Coast District Hospital under the Act terminate at the end of the period during which MCDH provided medical care to the victim for conditions arising from the emergency, or at the end of the 60 day period beginning on the date on which the victim is transported by EREs to MCDH, whichever period is shorter — except that MCDH's duties will continue if a request is received within 30 days of the date of the applicable period.
Examples: Example 1: If a victim is transported to a medical facility and released after two days, the facility must respond to request if it is received within 30 days of the date the victim was discharged from the facility.
Example 2: If the victim remains in the facility for more than 60 days, the facility must respond to a request if it is received within 30 days of the expiration of the 60 day period (this turns out to be 90 days from the date of the alleged exposure, which would be the maximum period of time that the facility would have notification obligations for that exposure).
4. The Act does not authorize or require Mendocino Coast. District Hospital to test any patient for any infectious disease. As a result, MCDH and physicians must follow existing consent requirements, including the requirements for informed and written consent for HIV tests. In this regard, testing may fall under the federal and state regulations requiring employers to test a source individual's blood for HIV and hepatitis following an occupational exposure"-1- but only after consent is obtained from the source individual. If the source individual does not consent, MCDH may not perform the test unless conditions are in accordance with SB 1239.
5. The Act also does not authorize or require any facility, DO, or ERE to disclose identifying information with respect to a patient or an ERE.
6. The Act does not authorize any ERE to fail to respond to, or deny services to, any victim of an emergency.
References:
Ryan White Comprehensive AIDS Resources Care Act
New: 07/1997 Revised: 10/2008
Approval Signatures:
______
Infection Control Coordinator Date
______
Chairperson, Infection Control Advisory Committee Date
______
Chairperson, Integrated Quality Management Committee Date
______
Medical Chief of Staff Date
______
Chief Executive Officer Date
______
President, Board of Directors Date
170.1011 Reporting Exposure of Emergency Response Personnel.doc