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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?

    • Maybe you are not sure it "counts as a bloodborne pathogen exposure." You may call the PEPLine (Post Exposure Protocol Hotline) at 1-888-448-4911 for counseling on your decision. The PEPLine is at University of California San Francisco and it is answered 24 hours a day, 7 days a week.
    • If you experienced an exposure, you must stop the treatment immediately, notify your preceptor and follow this protocol. You must report all bloodborne pathogen exposures. 
    • If you have experienced a bloodborne pathogen exposure, we want you to be tested right away. It is best to have your blood drawn for post-exposure within two hours. 
    • Your ACTS clinic will draw the source patient's blood and they will send it to their medical laboratory for testing.  The university will reimburse the clinic if they choose to bill us.
    • If the ACTS site is more than a 60-minute drive from campus, you must seek treatment through your ACTS clinic. Each ACTS clinic has a protocol that their staff members are required to follow in the event of a bloodborne pathogen exposure. Follow the same protocol that your preceptor would follow if she/he had a bloodborne pathogen exposure. 
    • If you are less than 60 minutes from the Anschutz Medical Campus, go to the University Hospital Infectious Disease clinic. The clinic is located in the outpatient pavilion on the 7th floor. The address is below. The ID clinic is open from 8 a.m.- 4 p.m. Monday through Friday. 
    • If you are less than 60 minutes from the Anschutz Medical Campus, but you will arrive after 4 p.m., go to the University of Colorado Hospital Emergency Department (UCH ED). The address is below. 
    • If you are working at Children's Hospital dental clinic, follow their protocol for bloodborne pathogen exposure. 
    • Before you leave your ACTS clinic, write down the name and phone number of the person who can provide the source patient's test results to your provider at UCH.
    • Once your blood is collected, complete BOTH of the following forms: ​the University of Colorado Needlestick or Body Fluid Exposure report; an occurrence report. Your coordinator can help you complete these forms. 
    • Exposures at the ACTS clinics are covered by the school's Worker Compensation insurance. They are not billed to the student's health insurance and there is no out-of-pocket cost to the student UNLESS the student fails to complete BOTH forms. 
    • If the source patient is infected with HIV, there are antiviral medications that can be used to reduce the very unlikely chance of transmission to an even lower risk. These medications will be made available to you if they are appropriate, but there are side effects to these medications. Your Infectious Disease provider will discuss the risks and benefits with you. 
    • Antivirals will not prevent the development of HCV infection, but they are extremely effective in treating an infection should it occur. You will not receive HCV antiviral medications unless you develop an HCV infection; in that unlikely event, the medications will effectively cure the infection. For more information, go to the Hepatitis C Questions and Answers for the Public

Infectious Disease Clinic
University of Colorado Hospital 
Anschutz Outpatient Pavilion, 7th floor
Anschutz Medical Campus
1635 Aurora Court
Aurora, Colorado 80045
Phone 720-848-0191

University of Colorado Hospital Emergency Department
Anschutz Inpatient Pavilion 2, 1st floor
Anschutz Medical Campus
12505 E. 16th Avenue
Aurora, Colorado 80045
Phone 720-848-9111

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