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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.
    • If your 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 provider at the Infectious Disease clinic (or at the ED) will discuss the risks and benefits with you.
    • Antivirals will not prevent development of HCV infection, but they are extremely effective in treating an infection should it occur.  You won't receive HCV 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 source-patient by your ACTS clinic's medical staff.  Verbal consent from the source-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.
    • Your ACTS clinic will draw the source-patient's blood for you and they will send it to their medical laboratory for testing.  The university will reimburse the clinic if they choose to bill us.
    • 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.



    • Hop in your car and come to campus!
    • 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.
    • 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. It's on the 7th floor of the Anschutz Outpatient Pavilion (AOP).
    • If you come later than 4 pm (when the ID clinic closes), you'll go to the UCH Emergency Department (ED), also known as the "ER."
    • 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 do both reports, the SDM report and the CU online report.
    • 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.