Introduction:

In order to minimize and prevent, when possible, the exposure of nursing students, faculty, and clients to Human Immunodeficiency Virus (HIV) and Hepatitis B Virus (HBV), the School of Nursing has adopted the following policy and exposure control plan to provide education, prevent exposure and contamination, and provide appropriate follow-up should exposure occur. This policy and exposure control plan conforms to and is not in conflict with the requirements of local, state and federal laws and the Centers for Disease Control guidelines for prevention and transmission of HIV/HBV, James Madison University and the clinical sites utilized in the nursing program. It is the responsibility of each nursing student and faculty member to be familiar with the provisions of this policy and to operate accordingly.

The OSHA/VOSH 1910.1030 Blood Borne Pathogens Standard was issued to reduce the occupational transmission of infections caused by microorganisms sometimes found in human blood and certain other potentially infectious materials. Although a variety of harmful microorganisms may be transmitted through contact with infected human blood, Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV) have been shown to be responsible for infecting workers who were exposed to human blood and certain other body fluids containing these viruses, through routes like needle-stick injuries and by direct contact of mucous membranes and non-intact skin with contaminated blood/materials, in the course of their work. Occupational transmission of HBV occurs much more often than transmission of HIV. Although HIV is rarely transmitted following occupational exposure incidents, the lethal nature of HIV requires that all possible measures be used to prevent exposure of workers.

Summary of Policies:

1. Mandatory Immunization: Because of the potential risk and in light of the U.S. Public Health recommendation (June 1989) for health care workers, all JMU nursing faculty and students are required to have the Hepatitis B Vaccine. Faculty or students wishing to be exempt from this requirement are asked to sign a statement of declination. Students are required to present documentation of a completed series of HBV immunizations prior to beginning the first nursing course and prior to any contact with clients. Because of the length of the immunization process, the immunization series needs to be started a year prior to the time the student plans to begin nursing courses.
2. Education: All nursing students and faculty are required to participate in educational activities designed to maintain current knowledge and practices regarding universal precautions, transmission modes and prevention techniques relative to HIV and HBV.
3. Standard Precautions: All nursing students and faculty are expected to utilize standard precautions and other prevention techniques in their practice at all times.
4. Reporting and Follow-Up: A student who believes exposure might have occurred is responsible to report this to the faculty immediately so appropriate treatment and follow-up measures can be initiated. All nursing students and faculty are expected to report and follow established university and clinical agency follow-up guidelines should an exposure to blood borne pathogens occur. Students in a clinical agency without an established protocol should return to the university and follow university procedures; this will be at their own expense.
5. Caring for Clients with HIV/AIDS: Nursing students and faculty are ethically obligated to provide nursing care with compassion and respect for human dignity and are expected to understand and follow rules of confidentiality. No nursing student or faculty member may ethically refuse to treat a patient solely because the patient is at risk of contracting or has an infectious disease such as HIV, HBV or AIDS.
6. Non-Discrimination and HIV Status: Inquiry relative to HIV status is not a part of the application process for students or faculty. Qualified individuals are not denied admission to the program or employment as faculty on the basis of their HIV status. Reasonable accommodations are made by the University and School of Nursing to allow nursing HIV positive students or faculty to continue their education or career.
7. Nursing students or faculty who know they are infected are urged to voluntarily inform the academic unit head who will provide information and referral as necessary. When clinical settings pose additional risk to the personal health of HIV positive students and faculty, faculty and students will be assisted, on a case-by-case basis, in assessing the significance of the risk to their own health and the need for modifications in practicum experiences or job functions. Modification will be based on consideration of the nature of the clinical activity, technical expertise of the infected person, risks posed by HIV carriage, functional disabilities, and the transmissibility of simultaneously carried infectious agents.
8. Testing: A nursing faculty member or student who believes him/herself to be at risk for exposure has an ethical responsibility to know his/her HIV status and has an obligation to be tested. While the decision to be tested is voluntary for the individual in most instances, it is strongly encouraged when indicated. Education and confidentiality safeguards are provided by the school to encourage and support testing. Pre and post testing counseling will be made available according to university policy. Written records relative to testing and HIV status are kept separately from academic or employment files and will be accessible only on a need-to-know basis with the individual's written consent.

Exposure Determination:

1. Since nursing faculty may be exposed to blood and other potentially infectious materials through their role of providing clinical supervision for students, all nursing faculty are considered to be at risk for possible exposure as defined by this standard and are covered by this policy.
2. Nursing students are also at risk of exposure to blood borne pathogens in their clinical laboratory experiences. Since they are not employees of the University they do not fall under the OSHA Standard. However, school policies relative to students in regard to blood borne pathogens exist and are included here as part of the School of Nursing's overall exposure control plan.
3. Copies of this plan are found in the School of Nursing Faculty Handbook and a hard copy is available in the school office. The plan will be reviewed with each new nursing faculty member at the time of their orientation to the school. This exposure control plan will be reviewed annually and updated as necessary during the fall nursing faculty retreat.

Methods of Compliance:

1. Standard Precautions: Universal precautions are based on the fact that the existence of pathogens cannot be known in all situations. In some instances, patients harboring blood-borne infections may never be identified as representing a potential infectious risk. In settings such as outpatient clinics, identification of patients who present a potential infectious risk is impractical if not impossible. Because one can never be sure who might be infectious, STANDARD PRECAUTIONS are recommended for all patient contacts. These precautions should minimize the risk of transmission of blood-borne infections. Therefore, all blood or other potentially infectious materials are to be handled as if they are contaminated by a blood-borne pathogen. Under circumstances in which differentiation between body fluid types is difficult or impossible, all body fluids shall be considered potentially infectious materials. Laboratory specimens from all patients must be treated as infectious.
2. Engineering and Work Practice Controls: The use of appropriate practices are outlined and followed as specified in the individual clinical settings utilized to eliminate or minimize exposure. Where occupational exposure remains after institution of these controls, personal protective equipment is also used.
3. Hand-washing and Other General Hygiene Measures: Hand-washing is a primary infection control measure which is protective of both the employee and the patient and must be diligently practiced. Faculty and students shall wash hands thoroughly using soap and water or other approved antibacterial waterless hand sanitizer whenever hands become contaminated and as soon as possible after removing gloves or other personal protective equipment. When other skin areas or mucous membranes come in contact with blood or other potentially infectious materials, the skin shall be washed with soap and water, and the mucous membranes flushed with water, as soon as possible. Appropriate hand-washing facilities are available in clinical facilities and in the nursing skills center. Blood and body fluid spills should be cleaned up promptly. Gloves should be worn and the area decontaminated according to institutional policy. If not specified, a freshly made solution of one part chlorine bleach to 9 parts water can be used.
4. Sharps Management: Injuries from sharps should be avoided. Needles, especially contaminated needles and other contaminated sharps, should not be bent, recapped or removed. Shearing or breaking of contaminated needles is prohibited. Contaminated disposable sharps shall be discarded, as soon as possible after use, in the disposable sharps containers. In clinical settings procedures are followed as outlined for sharps use and disposal. In the campus-based nursing skills center appropriate containers (closable, puncture resistant, labeled or color-coded, and leak-proof on sides and bottom, and maintained upright throughout use) for the disposal of sharps are provided as a protective mechanism even though sharps are used for practice on oranges, manikins, etc. and do not involve use with human subjects. Nearly full containers are to be promptly disposed of (or emptied and decontaminated in the case of reusable sharps) and replaced. In the skills center the disposal of sharps containers is the responsibility of the skills center coordinator.
5. Personal Protective Equipment: Personal protective equipment is available and is to be used according to the specifications of the individual clinical site being utilized. Students and faculty are expected to wear personal protective equipment when doing procedures in which exposure of the skin, eyes, mouth, or other mucous membranes to blood or other body fluids is likely. The articles to be worn will depend on the expected exposure.
   • Protection for Hands: Gloves should be worn when handling body secretions; when contact with blood or other potentially infectious bodily fluids and mucous membranes or non-intact skin is likely; when handling soiled items or surfaces; and when performing venipuncture or giving parental medications. Gloves should be changed after direct contact with each patient. Environmental contamination should be prevented by removing gloves as soon as possible after contamination. Gloves should not be washed and reused. Hands should be washed after gloves are removed. Gloves should be replaced as soon as feasible when contaminated, torn, punctured, or when their ability to function as a barrier is compromised.
   • Protection for Eyes/Nose/Mouth: Masks and protective eyewear are not routinely indicated. In many instances, personal eyeglasses will provide adequate eye protection. Faculty and students shall wear masks in combination with eye protection devices (goggles or glasses with solid side shields) or chin-length face shields whenever splashes, spray, splatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can be reasonably anticipated. When suctioning intubated patients or caring for patients with productive coughs, e.g., during a sputum induction procedure, protection with masks and eyewear shall be used.
   • Protection for the Body: Gowns are not routinely necessary, but a variety of garments including gowns, aprons, lab coats, clinic jackets, etc. are to be worn when soiling of clothes with blood or other body fluids is likely. Surgical caps or hoods and/or shoe covers or boots shall be worn in instances when gross contamination can reasonably be anticipated. If penetrated by blood or other potentially infectious material, the garments should be removed as soon as possible and placed in a designated container for laundering or disposal.
   • Laundry: Linen soiled with blood or other body fluids are to be placed in bags designed and marked for that purpose as specified in the given institution. Contaminated laundry shall be handled as little as possible with a minimum of agitation. Wet contaminated laundry which may soak-through or cause leakage from bag or containers must be placed in bags or containers which prevent soak-through and/or leakage of fluids to the exterior.
6. Regulated Wastes and Communication of Hazards: Disposal of waste materials regulated by this standard is to be handled according to institutional policy. The presence of hazardous materials is to be identified according to accepted procedures of the given institution.

Hepatitis B Vaccination Policy:

All students are required to have the Hepatitis B vaccination. The vaccination is a series of three injections. The second injection is given one month from the initial injection. The final dose is given six months from the initial dose. There must be documentation of one of the following:

• 3 vaccinations
• Positive antibody titer (lab report required)
• Declination waiver

Procedures for Evaluation and Follow-Up of Exposure Incidents:

1. An exposure incident refers to specific contact of eye, mouth, or other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious material. A significant occupational exposure is defined as:
   • A needle stick or cut caused by a needle or other sharp that was actually or potentially contaminated with blood or other body fluid.
   • A mucous membrane (i.e., splash to the eye or mouth) exposure to blood or other body fluid.
   • A cutaneous exposure involving large amounts of blood or prolonged contact with blood, especially when the exposed skin was chapped, abraded, or afflicted with dermatitis.
2. Immediate antiseptic procedures should be followed after possible or accidental exposure and the CDC guidelines for occupational exposure should be followed.
3. A student or faculty member has an ethical duty to report any incident that exposed him/herself or a patient to the risk of transmission of a blood borne disease and is ethically obligated to be tested for HIV when the patient is exposed to a provider's blood.
4. Faculty having an exposure incident are expected to immediately report their exposure to the academic unit head. Incidents of student exposure are to be reported immediately to the faculty member responsible for the specific experience. The faculty member in turn reports the incident to the academic unit head. Documentation of the exposure incident is to be submitted within 24 hours to the academic unit head and should include: route(s) of exposure; circumstances under which the exposure occurred; identification and documentation of the source individual if feasible; and follow up steps taken. When faculty members report an exposure incident they will be offered a confidential medical evaluation, testing, counseling, follow-up and post-exposure prophylaxis according to outlined university procedures.
5. Students having an exposure incident in a clinical agency without an established protocol should return to the university and follow university procedures. Students will be responsible for payment of any necessary medical testing or care.

Prevention Education:

1. As nursing professionals, faculty have the basis for understanding and practicing universal precautions. This is reinforced through the training required by the OSHA Standard. Nursing faculty receive education regarding blood-borne pathogens annually. Updates will be provided whenever there are changes in tasks or procedures which affect their occupational exposure. The academic unit Head is responsible for arranging and/or conducting training.
   • Nursing students receive both printed and oral information and instructions relative to blood borne pathogens, universal precautions for blood and body infections in accordance with applicable CDC guidelines, Hepatitis B Vaccination, specific protection and exposure control procedures, warning labels, personal health habits, HIV prevention and risk behaviors, procedures for incidents of exposure and post-exposure follow-up, prior to having experiences in a clinical setting where they are at risk of exposure to blood borne pathogens.
2. Students are expected to utilize universal precautions in all their clinical experiences. In addition to operating from this overall premise, additional expectations as outlined in individual agencies or institutions are also followed.

Record Keeping Procedures:

University procedures for maintaining both medical and training records are in place and will be followed.