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University of Colorado Denver

University of Colorado Denver School of Medicine

SDM Protocol for Accidental Clinical Exposure to Body Fluids

    Have you just had an exposure to body fluids, a needlestick, or an instrument/bur stick?

    • First things first - Maybe you're not sure it "counts as a needlestick" and that you've really had an exposure???  Then stop treatment RIGHT NOW, call the PEPLine at 1-888-448-4911 and ask them! The PEPLine is at University of California San Francisco and it's answered 24/7.
    • If what you experienced is "an exposure," you MUST stop treatment immediately and follow the protocol.  That's an ACTS rule and it's an absolute one - choosing not to report a needlestick will get you suspended from ACTS.
    • Why?  Because if you've had a workplace exposure to bloodborne pathogens, we want you evaluated right away - not tomorrow, not later today.  We want documentation of any pathogens the patient might harbor while you have ready access to the patient.  We also want documentation of your current (presumably non-infected) status.
    • In the past, this website referred to antiviral treatment after HCV exposure.  That is no longer recommended by the CDC.  Antivirals will not prevent development of HCV infection, but they are extremely effective in treating an infection should it occur.  So you won't receive antiviral medications unless you develop an HCV infection; in that unlikely event, the medications will effectively cure the infection.  To read the CDC's information page on HCV, click here.
    • Before you leave your ACTS clinic, make sure that blood is drawn from the patient.  Verbal consent from the patient is all that's needed for the blood draw: University of Colorado Hospital (UCH) and the State of Colorado do not require written patient consent for this form of testing.
    • If your ACTS clinic has "rapid testing" available, they can test the patient's blood for you.  The university will reimburse the clinic if they choose to bill us.
    • If your ACTS clinic does NOT have rapid testing available, you must take samples of the patient's blood to the UCH Infectious Disease (ID) Clinic for rapid testing.
    • If you take a patient blood sample to the UCH ID Clinic, you'll be taking two "red top tubes" of the patient's blood, labeled with the patient's name, to campus with you.  You're a health care provider and it is legal for you to transport this blood.  But don't set it on the passenger seat and then throw your backpack on top of it!
    • Download, print, and fill out the Dental Medicine's needlestick post exposure management report form. Fax it to Fabian Walker at 303-724-7066. The top part of the form has Dr Gatseos' latest instructions on what to do.
    • You also need to complete a separate form for Risk Management to provide you with Worker Comp insurance coverage on this incident.  Print this form, fill it out and get it to Fabian along with the Dental Medicine needlestick form:

      CU Risk Management's needlestick post-exposure report form (so insurance claim can be filed)

    • Hop in your car and come to campus! Unless your ACTS clinic has done a rapid test of the patient's blood, make sure you've got the two vials of patient's blood with you in the car.  And be careful with them.
    • Where specifically are you going to drive? If you arrive before 4 pm, you'll be seen at the UCH Infectious Disease (ID) Clinic, here on the AMC campus. If you come later than 4 pm, you'll go to the UCH Emergency Department (ED), aka the "emergency room." See below for specific directions.
    • What's the difference? Both places will take care of you, but you'll be seen much more quickly at the ID Clinic than in the ED.


    Here's some more detailed information, with contact numbers and protocols:

    • Exposures at ACTS Clinics ARE covered by the school's Worker Comp insurance. They are NOT billed to the student's health insurance and there is NO out-of-pocket cost to the student.
    • To make sure the cost is charged to Worker Comp insurance, you must download two forms.  There are links to the Dental Medicine needlestick form and the CU Risk Management needlestick form above on this page.  Print both forms, fill them out with a pen, and fac them to Fabialn Walker at 303-724-7066.
    • NOT SURE IF THE EXPOSURE WAS A BIG DEAL OR NOT? You can call the PEPLine (Post Exposure Protocol Hotline) for counseling on your decision. The PEPLine is answered 24/7: 1-888-448-4911
    • What does ACTS require? We require that the student stop work immediately upon experiencing an exposure and immediately seek care at the University of Colorado Hospital Infectious Disease Clinic.
    • For detailed information about UCDenver's policies, go to CU Risk Management's website