Sample guidelines for asking Source Patient to consent to blood testing and or answering the risk factor questions

This tool should be used as a guideline only. It should be referenced by the supervisor or designate responsible for phoning or speaking directly to the source patient. Source patient is the patient whose blood or significant fluid type the worker came accidentally in contact with.

Occupational Blood /Body Source Risk Assessment Form – Place source information on top right hand corner.

Introduce yourself. The reason I am calling is:

  1. A Health Care Worker was accidentally exposed to your blood or body fluids.

Should the individual be concerned or have further questions about what “exposed” means, the following information can be provided:

A Health Care Worker accidentally was poked or punctured with equipment that was used on you following the treatment and or the care that was provided to you. This equipment likely contained blood or a body fluid that may have contained blood.

OR

A WRHA Health Care Provider, while providing care to you was accidentally splashed with your blood, or body fluids that may have contained your blood or is considered a high-risk fluid.

  1. It is our role to ensure that we take care of the employee that had this accidental contact. In order to provide the appropriate follow-up and or treatment for this employee, the WRHA Guidelines recommend that we test your blood for HIV, Hepatitis B and Hepatitis C.
  2. This is a routine follow-up procedure for any individual that might accidentally be exposed to another individual’s blood or body fluids.
  3. All testing is voluntary. In order to do the blood work testing we ask that you give us permission either through signed or verbal consent.
  4. All records and results are confidential. The HIV test will not contain your name on the blood requisition form. A special code is used in place of your name. This code is maintained by your health care provider and IV Team.
  5. I will also need to ask you some questions. The answers to these questions will be shared with the Emergency Doctor that is going to be treating the person who was accidentally in contact with your blood or body fluids. These answers will not identify your name and are used to help the Doctor to determine what type of treatment the worker might need.
  6. If you consent to this, I will arrange to have a Home Care IV Nurse come and get your blood samples. Please feel free to ask the IV Team Member any further questions you may have.
  7. The results of your testing will be sent to HSC Department of Occupational and Environmental Medicine. The Occupational Health Nurse and or Physician will be reviewing your results and will contact you or your family physician onlyshould there be any concerns with your blood tests.

October 2004