Penn State Emergency Medical Services

Penn State EMS Standard Operating Procedures and Constitution

University Ambulance Service
Centre County Company 20
Procedures Manual

 ADMINISTRATIVE PROCEDURES

TABLE OF CONTENTS


Bloodborne Pathogen Exposure Response 

 Blood Spills - Reporting and Clean-up

Employee On The Job Injury Reporting

Employee Tuberculosis Screening

Fire Alarm Response

Medical Emergency Response 


BLOODBORNE PATHOGEN EXPOSURE RESPONSE

Purpose:

To outline the procedure to be followed when an employee is contaminated by
blood, bodY fluids or sustains a dirty needlestick.

Procedure

1. Immediately wash the site with Betadine scrub solution and running water. If the
exposure is in the eyes, irrigate with a minimum of 500 cc. sterile normal saline to
each eye. If exposure is to skin, flush with large amounts of water.

2. Employee reports incident to supervisor who will notify the infection control
nurse or the UCC physician after hours.

3. Complete UHS Incident Report and CRIQS form and forward to Risk
Management Coordinator.

4. Physician will evaluate and treat injury. At this time the physician will certify that
a significant exposure has occurred. Documentation of exposure and treatment
recommendations will be done on treatment record by physician. Infection Control
Nurse will complete (code) lab slips and superbill.

5. If known, source patient should be contacted by Infection Control Nurse or Nurse
Manager and consent obtained for Hbsag and RPR and HIV testing.

6. Exposed individual will be tested for RPR and HBV with HIV infectivity.

7. Follow-up will be initiated, including HBIG and/or HBV vaccine.

8. Lab tests will be ordered by predetermined code number to ensure confidentiality.

9. If the source patient is seropositive for RPR, HBV and/or HIV or the source is
unknown the exposed employee should be retested according to the Follow-up
(F/U) visit schedule:

	a) F/U visit #1 (at 6 weeks post exposure): HIV b) F/U visit #2 (at 12 	weeks
post exposure): HIV/RPR c) F/U visit #3 (at 6 months post 	exposure):  HIV d)
Appropriate HBV screening should be done according 	to attached  guidelines.

10. An "Employer' s Report of Occupational Injury or Disease" report form should
be obtained from the Risk Management Coordinator, completed and returned.

11. Superbill for charges incurred is submitted to checkout clerk. Charges include
laboratory charges and fees for health education counseling.

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BLOOD SPILLS - REPORTING AND CLEAN UP

Purpose:

To outline the procedure to be used to report significant blood spills occurring
within UHS.

Procedure:

1. If a significant blood spill occurs in a non-clinical area a UHS employee should
notify his/her supervisor and UHS housekeeping. The employee is not to attempt
to clean up the spill. Housekeeping staff will clean and decontaminate the spill area.

2. If a blood spill occurs in a clinical area a clinical staff member may clean the spill
utilizing the "Blood Spill - Cleaning and Decontamination" procedure (see Infection
Control Addendum of the various clinical departments' procedure manuals).

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EMPLOYEE ON THE JOB INJURY REPORTING

Purpose:

To outline the procedure to be used by UHS employees who sustain an occupational
injury.

Procedure:

1. Report the injury to his/her supervisor.

2. Report to the Occupational Health Department for assessment and treatment.

3. Complete a UHS ''Confidential Report to Improve Quality of Services (CRIQS)"
form (see Administrative Forms Usage Guide) and send the form to the UHS Risk
Management Coordinator.

4. Complete a PSU "Employee' s Report of Occupational Injury or Disease" form (see
Administrative Forms Usage Guide) and send to the UHS Risk Management
Coordinator who will send the form to the employee' s supervisor for review and
signature. This form will be sent to the PSU Office of Risk Management.

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EMPLOYEE TUBERCULOSIS SCREENING

Purpose:

To outline the TB screening procedures for UHS employees.

Procedure

I. TB Screening of New Employees

		A. New employees at UHS will have TB screening within 30 days of
employment. Skin testing will be done according to the UHS "Tuberculin Skin Test"
procedure (see Clinical Services Procedure Manual).

		B. New employees who have a history of TB or a positive PPD or other
reason that TB skin testing should be omitted will be required to complete a UHS TB
Screening Questionnaire (see Forms Usage Guide).

		C. New employees who exhibit a significant reaction (according to UHS
"Tuberculin Skin Test" procedure) at the time of testing will be referred to their
private physician or the Pennsylvania State Health Department for follow-up .

II. Annual TB Screening of Employees

		A. All employees with a previous negative PPD will be required to
have an annual PPD.

		B. The PPD must be read within 48-72 hours by an RN or clinician
other than oneself.

		C. Those persons who convert from negative to positive will be treated
as converters according to section III below.

		D. All employees who have previous positive PPD skin tests, a history
of TB or any medical condition which would prevent skin testing will be required to
complete a TB Screening Questionnaire form.

III. Employees with New Positive PPD Skin Tests

	A. Employees who convert from negative to positive PPD at time of
		annual screening will:

	1. Have a chest x-ray
		2. Be referred to the Chair of Infection Control Committee for
evaluation and possible treatment.
		3. Complete a "Confidential Report to Improve Quality of Services"
(CRIQS) form and an "Employers' Report of Occupational Injury or Disease" form
(see Administrative Forms Usage Guide) to report this exposure as an on the job
injury. These completed forms are sent to the UHS Risk Management Coordinator,
Room 208.

IV. Unprotected Exposure to TB

	A. All employees with unprotected exposure to active TB during
		employment will be treated as follows:

		1. If an employee has had a negative PPD skin test in the past he/she
will be retested at 10 weeks post exposure.
		2. If an employee has a history of TB or Positive PPD he/she will be
screened annually according to Section II.D.
		3. If an exposed employee converts from negative to positive PPD,
he/she will be treated as a converter according to Section IIIA. of this procedure.

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FIRE ALARM RESPONSE

Purpose:

To describe staff actions when a fire is detected or an alarm sounds in Ritenour
Building. This procedure is intended to apply to other circumstances requiring
similar action (e.g., toxic fumes, bomb threats or other need to evacuate the
building).

Procedure

Discovery of Fire or Smoke 

1. Any staff member or occupant of Ritenour Building who senses smoke or other
signs of fire should exit the building by the nearest exit.

2. Anyone recognizing a fire should activate the nearest pull station, causing the fire
alarm to sound and call 9-1-1 to report the fire to the Centre County emergency
dispatcher.

3. A call should be placed immediately to PSU Police Services (3-1111) by the person
assigned to answer the UHS phone number 865-6556, to advise that an alarm is
sounding, requesting that an officer respond to assist in the investigation of the
possible source of the fire or smoke.


Building Evacuation - Staff and Ambulatory Occupants

l. When a fire alarm sounds, all personnel not committed to the evacuation of
others should leave the building by the nearest available exit and report to the patio
in front of the Robeson Cultural Center.

2. Once on the patio, staff shall congregate by work group, thus facilitating an
accounting of departmental personnel. In the event of inclement weather, those
requiring shelter may move into Robeson or, in the event Robeson is locked, move
into the ambulance garage. Supervisor staff members may ask Police Services to
unlock Robeson if necessary.

3. Clinical personnel must assure the safe evacuation of the patients for whom they
are responsible.

4. If time permits, staff should close the windows in the immediate area and close all
room doors and exit doors upon departure. Staff and others shall not use elevators
when leaving the building. Allow no action taken during departure to delay
evacuation of the build for more than 15 to 30 seconds.

5. Assigned staff will monitor exit doors to keep patients and others from entering
the building.

6. Prior to leaving the building each supervisor shall check his/her area for
complete evacuation of staff, patients and others.

7. Staff shall not re-enter the building unless instructed to do so by authorized public
safety personnel (police, fire or EMS personnel).


Building Evacuation - Ill Patients and Non-Ambulatory Individuals

Upon the initial sounding of the alarm, the supervisors in clinical areas shall assure
that the following tasks are performed:

1. Patients should be evacuated from the building by the nearest exit. Non-
ambulatory (wheelchair) patients on the first floor will evacuate the building using
the ramp at the first floor staging area in the northwest corner of the building.

2. In the event the patient has a condition which could be worsened by immediate
evacuation and if no actual fire has been detected, the staff responsible for the
evacuation of that patient must determine if the patient should be taken to the
staging area on each floor.

3. Only those patients whose condition might be adversely affected by building
evacuation should be moved to the staging area located at the northwest corner of
the building on the basement, first floor and second floor levels. Patients of this type
should be prepared for evacuation from the staging areas if necessary. A UHS staff
member will stay with these individuals. If fire or signs of fire are detected en-route
to the staging area, remove these patients through an alternate exit without delay.

4. Non-ambulatory (wheelchair) patients on the basement and third floors will
remain at the staging area stairwells. A UHS staff member will stay with these
individuals.

5. If no fire is detected, non-ambulatory patients on the basement and third floors
and those described in section 4 above may be held in the staging areas. If a sign of
fire is detected or reported by anyone, the clinical staff member responsible for the
welfare of these patients will evacuate or supervise their evacuation.

6. Once out of the building, the clinical staff member shall assist their patients to the
Robeson patio or ambulance garage where they will remain with their patients until
instructed to return to the Ritenour Building. Staff shall not re-enter the building
with their patients unless instructed to do so by authorized safety personnel (police,
fire or EMS personnel).

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MEDICAL EMERGENCY RESPONSE

Purpose:

To outline the procedure used by a UHS staff member to activate the Medical
Emergency Response when she/he witnesses a medical emergency within the
Ritenour Building.

Procedure:

1. To activate the Medical Emergency Response Team dial 3-9611 and when operator
answers say, "STAT Team to Room _" or exact location.

2. If phone is not nearby, call loudly for assistance and request responder to activate
the Medical Emergency Response Team.

3. Do not leave patient unless you cannot be heard.

4. Assess the victim for breathing, chocking, pulse, etc.

5. If you are trained, start CPR if indicated.

6. The assigned Urgent Care physician and nurse supervisor (STAT Team members)
will go to the emergency location.

8. When the STAT Team arrives at the location the physician will be in charge and
will direct the care and treatment of the patient.