Guidelines for Safety in Community Settings

For promotion of safety while in community-focused nursing practice courses, please follow the guidelines listed below:

1. Community Health Visits:
   • Wear a uniform or designated dress, student I.D., name tag, and minimal jewelry.
   • Carry only a sufficient amount of money for the day's needs. Important papers, etc., should be locked in your trunk before leaving home. Pocket change to make a phone call may be useful.
   • Be in the field only during daylight hours and at those times specifically assigned. Report to the instructor when departing for and returning from your assignment.
   • Visit only those clients at addresses that have been approved by your instructor.
   • Leave with the instructor a list of the families or organization and the sequence in which you will visit prior to your departure. This list includes full name, exact address, apartment number, and phone number. If family has a phone, telephone prior to visit to confirm visit.
   • Phone your instructor for approval prior to any change in sequence or if you find the family is at another address. Under no circumstances, go to any address or apartment which is not on your list without approval from the instructor, at least by telephone.
   • Check with the instructor for the exact location of your destination and review the exact transportation you will use prior to departure.
   • Walk briskly with a sense of purpose. Never loiter. Obtain clear directions prior to departure for the visit. Consult a map, the client, police, or post office department. Know exactly where you are going. After departure, if in doubt, ask a storekeeper, police officer, postman, or any official agency representative.
   • Walk on the curb side of the street, avoid doorways and alleyways.
   • Use streets that are active and busy and contain residences rather than deserted, dimly lit streets with quiet warehouses and bar areas.
   • Speak to storekeepers and those neighborhood people you see each week. Identify yourself and the agency you represent. Familiarize yourself with the geography of the neighborhood and the locations of "safe" places.
   • Notice which shops have phones you could use in an emergency.
   • Under no circumstances, enter any building when observation or intuition tells you something is not right. Proceed to the nearest phone, and call the agency or the instructor or the police - 911 will put you in direct emergency contact with the police in the town or neighborhood in which you find yourself.
   • Should anyone demand your property during a robbery, give it to them and proceed to the most active situation at hand (traffic, neighborhood store, health center, police or fire department. Report all frightening experiences to the police, your instructor, and the College of Nursing at (561) 297-6261.
   • Should you at any time, for any reason, feel unsafe or frightened, call the Police, 911- and request assistance. Also notify your instructor and the College of Nursing at (561) 297-6261.
   • Should anyone confront you or follow you in an unfriendly manner, seek the assistance of the closest individual on foot or in a motor vehicle. This will attract attention to you. Do not, however, enter any vehicle other than a public bus, licensed cab, or police car.
   • In the event any unusual incident occurs, proceed into the most active situation available, the police precinct, fire house, neighborhood store, social service or health agency, school, housing project office, or board a bus.
   • Use a phone in any one of these places to call the agency or, if indicated, 911 the police. Maintain a list of Police Dept. non-emergency numbers or information requests. Identify yourself, the agency you represent, where you are, and the problem.
   • Student is responsible for adhering to all safety guidelines for external assignments.
   • Students should make community visits in pairs if possible.
2. When arriving or leaving the clinical agency (including utilizing the parking lot) you should:
   • Lock all doors when leaving car. You should not remain in a parked car.
   • Know the designated area for parking.
   • Park in well lighted designated areas.
   • Leave the agency with the group or ask for an escort to your car.

REMEMBER

1. You are never alone.
2. We are a phone call away - 911 or university telephone 561-297-6261.
3. A police cruiser can reach you in minutes.
4. Your best protection is to:
   • Know your neighborhood resources
   • Know the neighborhood people.
   • Have the neighborhood know you in your professional role.

Bloodborne Pathogen Exposure

Policy

Advanced practice nursing students are at a rare risk for exposure to the human immunodeficiency virus (HIV) through needles or other sharp instruments contaminated with blood or through splashes of blood onto the mucous membranes of the eye, nose, or mouth or skin. Universal precautions must be utilized in all appropriate clinical situations.

If it cannot be discerned whether the source patient's blood was HIV infected, beginning post-exposure medication is decided on a case-by-case basis. Likelihood of HIV infection in the known or possible patient source is evaluated in addition to the nature of the blood exposure.

Post-exposure prophylaxis (PEP) should begin in 1-2 hours. It may not be effective if started longer than 24-36 hours after exposure.

Procedure

1. All students must have current health insurance and should carry with them the phone number to call to receive emergency services that are reimbursed by their insurance.
2. Post-exposure: immediately wash cuts and needle sticks with soap and water. Flush splashes to the nose, mouth, or skin with water. Irrigate eyes with clean water or saline.
3. Report the exposure immediately to your clinical faculty, Graduate Program Office and to the health care agency supervisor and ask to be referred immediately to the agency person responsible for managing exposures (occupational health nurse, infection control specialist, emergency department supervisor). The faculty will assist the student in getting immediate care through a provider for whom they have insurance. The faculty is responsible for seeing that an incident report using the agency's form is completed.
4. There is no time to lose following exposure. You need to be immediately seen by a health care provider. You must have counsel regarding the risks of your exposure and weigh the risks and benefits of treatment. Balancing risks is challenging. It is recommended that HIV post-exposure treatment begin within 1-2 hours.
5. Within 24 hours, excluding the weekend, please file an incident report with the Assistant Dean's Office, (561) 297-6261.
6. You should be tested for HIV antibody as soon as possible after exposure and then at 6 weeks, 12 weeks, and 6 months. You should be assured that your test results will remain confidential. If the patient source of the blood does not have a previous diagnosis of AIDS or HIV, the patient should be told of the health care worker's exposure and an informed consent obtained for taking an HIV antibody test. They do have the right to refuse.
7. If you are taking PEP, you should have your blood drawn for a CBC and hepatic/renal function at baseline and at 2 weeks.
8. You should report any severe flu-like illness that occurs during the 12 week follow-up period--this is the usual time for HIV infection to develop. Likewise, most infected people will seroconvert by 12 weeks.
9. During the first 12 weeks of exposure until your blood test demonstrates that you remain free of HIV infection, you should refrain from sexual intercourse or inform your partner and practice safe (but not risk free!) sex with a latex condom used consistently. In addition, women should not breast-feed during this time.

References

U.S. Dept. of Health & Human Services. (1997). Information for health-care workers-occupational exposure to HIV (Brochure). Rockville, MD: Author.

American Association of colleges of Nursing. (1997). Policy and guidelines for prevention and management of human immunodeficiency virus and hepatitis B virus infection in the nursing education community. Journal of Professional Nursing 13(5), 325-328.

CDC National AIDS Hotline 1-800-342-2437

Guidelines for Universal Precautions

The concern for occupational exposure to hepatitis B virus (HBV) and human immunodeficiency virus (HIV) among health care workers had led to the development and implementation of "universal precautions" for all hospitalized patients. Universal precautions were designed and recommended by the Centers for Disease Control (CDC) in 1987 and were revised in 1988, based on epidemiologic evidence regarding the transmission of HBV and HIV. Under universal precautions, blood and certain body fluids of all patients are considered potentially infectious for HIV, HBV, and other blood borne pathogens. Physical examinations and a medical history cannot reliably identify all patients infected with HIV or other blood borne pathogens. In the emergency care setting especially, the risk of blood exposure is increased and the infection status of the patient is usually not known. Universal precautions are intended primarily to prevent parenteral, mucous membrane, and non-intact skin exposures of health care workers to blood borne pathogens; therefore, they apply to blood and to other body fluids containing visible blood. Blood is the single most important source of HIV, HBV, and other bloodborne pathogens in the occupational setting. Universal precautions also apply to the following:

• Tissues
• Semen
• Vaginal secretions
• Cerebrospinal fluid
• Pleural fluid
• Synovial fluid
• Pericardial fluid
• Peritoneal fluid
• Amniotic fluid

Universal precautions do not apply to the following list of substances unless they contain visible blood. The risk of transmission of HIV and HBV from these fluids and materials is extremely low or nonexistent:

• Feces
• Nasal secretions
• Sputum
• Sweat
• Tears
• Urine
• Vomit
• Human breast milk
• Saliva

Gloves need not be worn when feeding patients or wiping saliva from skin; although it is recommended that dentists use special precautions since in their profession contamination of saliva with blood is predictable. Health care workers may want to wear gloves if they work in situations in which exposure to breast milk might be frequent.

1. Immediately and thoroughly wash hands and other skin surfaces that are contaminated with flood, body fluids containing blood, or other body fluids to which universal precautions apply. Wash hands immediately after gloves are removed.
2. Use protective barriers to prevent skin and mucous membrane exposure to blood, body fluids containing blood, and other fluids to which universal precautions apply. The type of protective barrier(s) should be appropriate for the procedure being performed and the type of exposure anticipated.
   • Wear gloves when touching blood of body fluids, mucous membranes, or non-intact skin of all patients.
   • Wear gloves when handling items or surfaces soiled with blood or body fluids.
   • Wear gloves when performing venipuncture and other vascular access programs.
   • Wear gloves for performing phlebotomy if cuts, scratches, or other breaks in the skin are present.
   • Wear gloves in situations in which contamination with blood may occur--for example, when performing phlebotomy on an uncooperative patient.
   • Wear gloves for performing finger or heel sticks on infants and children.
   • Change gloves after contact with each patient.
   • Do not wash or decontaminate disposable gloves for reuse.
   • Wear masks and protective eyewear or face shields during procedures that are likely to generate splashing or droplets of blood or other body fluids to prevent exposure of mucous membranes of the mouth, nose, and eyes.
   • Wear gowns or aprons when you anticipate splashing of blood or other body fluids to which universal precautions apply.
3. Take care to prevent injuries when using, handling, or cleaning needles, scalpels, and other sharp instruments or devices.
   • Do not recap used needles by hand.
   • Do not remove used needles from disposable syringes by hand.
   • Do not bend, break, or otherwise manipulate used needles by hand.
4. Place used disposable syringes and needles, scalpel blades, and other sharp items in puncture-resistant, leak-proof, labeled or color-coded containers for disposal. Locate these containers close to the use area and replace routinely.
5. To minimize exposure during emergency mouth-to-mouth resuscitation, ensure that protective mouthpieces or manual resuscitator bags are available for use in areas in which the need for resuscitation is predictable.
6. Refrain from direct patient care or handling of patient-care equipment if one has exudative lesions or weeping dermatitis.
7. For laboratory specimens, consider all blood and other body fluids from all patients to be infective. Put these specimens in a well-constructed container with a secure lid to prevent leakage during transport. Avoid contaminating the outside of the container and place laboratory requisitions outside of container.