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Home My WebLink About106.005 - EMS-15, Communicable Disease Exposure ReportEffective Date: June 2008 Kevin Reynolds, Captain Current Revision Date: 07/13/2022 Section 106.005 Next Revision (2) Date: 07/13/2024 Page 1 of 6 100 Administrative Manual SECTION 106.005 Communicable Disease Exposure Report (EMS-15) PURPOSE The EMS-15 form is used for communicable disease exposure reporting for members seeking immediate medical treatment following an exposure incident. This policy includes testing and treatment plans for the physician’s reference. APPLICATION The following form is to be completed any time a member is exposed or suspects he/she has been exposed to another person’s blood and/or body fluids or has been stuck by an exposed needle. OPERATIONAL POLICY This policy will be placed on all Department apparatus to instruct members on required procedures to follow on a communicable disease exposure. The first two pages have basic instructions and checklists to guide the member through the reporting process. The EMS-15 form will be completed with the exposed member’s information. Once completed, the form will be given to the treating physician upon arrival at the treating facility. OPERATIONAL GUIDELINE This section intentionally left blank. PROCESS Following an exposure or suspected exposure: 1. Report the exposure or suspected exposure incident to supervisor. Document how the exposure occurred, the routes of exposure, the source individual and/or source material, and the situation surrounding the exposure. Fresno City Fire Department Effective Date: June 2008 Kevin Reynolds, Captain Current Revision Date: 07/13/2022 Section 106.005 Next Revision (2) Date: 07/13/2024 Page 2 of 6 2. Immediately report the exposure to the Designated Infectious Control Officer (DICO). a. Phone Number (559) 621-4155 3. Complete Form EMS-15, Communicable Disease Exposure Report a. Section I: To be completed by the employee. b. Section II: To be completed by the treating physician (if medical attention is sought). c. Bottom Section (Exposure Response): To be completed by the DICO. 4. Determine if the exposed member requires medical attention. If so, medical care should be sought immediately. a. Medical treatment may be obtained at one of the approved medical clinics or the hospital emergency room (when appropriate) and is provided through the City Worker’s Compensation Program. b. Treating physician completes Section II of Form EMS- 15, Communicable Disease Exposure Report. c. Exposed member may decline medical attention; however, the appropriate exposure incident report must be completed with a notation the member declined medical treatment. 5. Obtain consent and make arrangements to have the source individual tested to determine infectivity. a. If the source individual is already known to be infected, new testing may not be needed. b. Exposed member should be provided with source individual’s test results. Effective Date: June 2008 Kevin Reynolds, Captain Current Revision Date: 07/13/2022 Section 106.005 Next Revision (2) Date: 07/13/2024 Page 3 of 6 c. If source individual refuses consent, the exposed member may be able to obtain consent through a court order. 6. Email the completed Form EMS-15, Communicable Disease Exposure Report within 24 hours to the DICO at firedico@fresno.gov or fax it to the DICO at (559) 457-1198 or (559) 457 1262. 7. If medical attention is received, report the exposure as a work-related illness within 24 hours using the City Worker’s Compensation forms and guidelines. Please include the completed Form EMS-15, Communicable Disease Exposure Report, with the completed Worker’s Compensation forms when routing to the DICO. 8. When this form is returned to the DICO, it will be reviewed, and a hard copy will be kept in a locked file cabinet, as well as electronically filed in a secured “DICO Only” folder on the Training Unit T drive. INFORMATION The Form EMS-15, Communicable Disease Exposure Report, includes instructions on needed testing and an area for the physician to document treatment, follow-up plan, and instructions to return processed form to the DICO for follow-up. This policy follows all guidelines set from Cal OSHA Title 8. DEFINITIONS Exposure Incident: specific eye, mouth, mucous membrane, non-intact skin, or parenteral contact with blood, bodily fluids, or other potentially infectious materials, which results from the performance of a member’s duties. Parenteral: piercing mucous membranes or the skin barrier through such events as needle sticks, human bites, cuts, and abrasions CROSS-REFERENCES Administrative Manual Section 203.10, Infection Control Effective Date: June 2008 Kevin Reynolds, Captain Current Revision Date: 07/13/2022 Section 106.005 Next Revision (2) Date: 07/13/2023 Page 4 of 6 COMMUNICABLE DISEASE EXPOSURE REPORTING PROCEDURE If during the course of performing one’s duties, a member is exposed or suspects he/she has been exposed to another person’s blood and/or body fluids or has been stuck by an exposed needle, the exposure incident(s) shall be reported to the following: • Appropriate supervisor • Physician or medical care provider (if medical attention is required) • DICO An exposure incident is defined as specific eye, mouth, mucous membrane, non- intact skin, or parenteral contact with blood, bodily fluids, or other potentially infectious materials, which results from the performance of a member’s duties. Parenteral means piercing mucous membranes or the skin barrier through such events as needle sticks, human bites, cuts, and abrasions. Checklist Members shall use the following guide during an exposure or suspected exposure: Report the exposure or suspected exposure incident to supervisor. Document how the exposure occurred, the routes of exposure, the source individual and/or source material, and the situation surrounding the exposure. Immediately report the exposure to the DICO. • Phone Number (559) 621-4155 Complete Form EMS-15, Communicable Disease Exposure Report. • Section I: To be completed by the employee. • Section II: To be completed by the treating physician (if medical attention is sought). • Bottom Section (Exposure Response): To be completed by the DICO. Effective Date: June 2008 Kevin Reynolds, Captain Current Revision Date: 07/13/2022 Section 106.005 Next Revision (2) Date: 07/13/2023 Page 5 of 6 Determine if the exposed member requires medical attention. If so, medical care should be sought immediately. • Medical treatment may be obtained at one of the approved medical clinics or the hospital emergency room (when appropriate) and is provided through the City Worker’s Compensation Program. • Treating physician completes Section II of Form EMS-15, Communicable Disease Exposure Report. • Exposed member may decline medical attention; however, the appropriate exposure incident report must be completed with a notation the member declined medical treatment. Obtain consent and make arrangements to have the source individual tested to determine infectivity. • If the source individual is already known to be infected, new testing may not be needed. • Exposed member should be provided with source individual’s test results. • If source individual refuses consent, the exposed member may be able to obtain consent through a court order. Fax the completed Form EMS-15, Communicable Disease Exposure Report within 24 hours to the DICO at (559) 457-1198 or (559) 457-1262. If medical attention is received, report the exposure as a work-related illness within 24 hours using the City Worker’s Compensation forms and guidelines. Please include the completed Form EMS-15, Communicable Disease Exposure Report, with the completed Worker’s Compensation forms when routing to the DICO. Section 106.005 Page 6 of 6 EMS-15 CONFIDENTIAL Communicable Disease Exposure Report Reporting Procedure Any member who believes he/she has been exposed to blood, body fluids, or a disease shall: 1. Report the exposure to his/her immediate supervisor 2. Follow the Department reporting procedures, 3. Complete Section I (All that apply to exposed member), 4. IMMEDIATELY report exposure to the DICO at (559) 621-4155 5. If exposed member requires medical attention, treating physician completes Section II 6. Fax report to (559) 457-1198 or (559) 457-1262. SECTION I (Complete all in SECTION I that applies to exposed member) Person Exposed: Name: Date of exposure: Time of exposure: Work Phone: Cell Phone: Home Phone: Employer: Dispatch: PCR #: Address/Location of exposure: Other agencies present: Patient/Suspect Information: Name: Male Female Age: Date of birth: Address: Apt #: City: State: Phone: Patient destination: Type of Exposure: Blood Body Fluid Respiratory Illness Other Briefly Describe Incident: Signature of Designated Officer / Designee: SECTION II Treatment & Testing Guidelines (This section completed by treating physician) 1. Rapid HIV and HCV (within 2 Hours) 2. Syphilis 3. Hepatitis B (HBIG) if no prior infection or vaccine 4. Baseline Hepatitis C 5. Tetanus, if last shot was more than ten (10) years ago 6. Testing for HIV – If no HIV testing available at your facility, you can refer the patient to Firm Associates to begin the testing process IMMEDIATELY report exposure to the DICO at (559) 621-4155; Fax (559) 457-1198 or (559) 457-1262 Services Rendered by Treating Physician: Follow Up Plan: Treating Physician’s Signature: Exposure Response from DICO: No Exposure/No Follow Up Unable to contact exposed to verify if exposure occurred True Exposure – Follow up to be done at: Recommendations: DICO Signature: