BBP Source Protocol Guide

A source protocol is required when you have an *identifiable source for an employee bloodborne pathogen exposure.

*If you cannot identify the source, the source is deceased, your protocol has masked their identity due to HIPAA regulations, or HIPAA does not allow you to contact the source, then you do not need a protocol.

A source is the person whose blood, body fluid, or tissue is the source of an occupational exposure. The source should be evaluated for HBV, HCV, and HIV infection as soon as possible, by informing the source of the incident and requesting them to be tested for evidence of bloodborne virus infection.

Know where your protocol is, how to access it quickly, and keep it updated. The source is not required to consent to the testing. The goal is to make the process as easy as possible for the source if consent is given.

Your protocol should contain this information (a sample protocol is included in this guide):

1. Who will talk to/contact the source?

  1. This must not be the exposed person.
  2. Examples include: supervisor, lab/clinic manager, physician, principal investigator, chairperson, department administrative staff, graduate student in laboratory, etc.

2. What will the person say to the source?

  1. Let them know that an MSU employee was exposed and how (i.e. working with their sample, needlestick, etc.)
  2. Ask that they consider going to have blood drawn to be tested for HIV, HBV, and HCV.
  3. Let them know that Michigan State University will pay for the testing.
  4. If source is not present, ask for fax# or email to send the lab form. (This can also be sent directly to the lab) If present, give them the “Source Patient Lab Worksheet”
  5. Remember the source does not have to consent to being tested.

3. What paperwork is needed?

  1. A “Source Patient Lab Worksheet” should be given/sent to the source.
  2. Complete the top box with the BBP exposure date, exposed employee’s department, and the exposed employee’s supervisor/PI. This must be done before giving/sending the form to the source.

4. Where can the source go for testing?

  1. They can go to the closest lab (as stated in your source protocol)
  2. They can also go to any Lansing Urgent Care, or any lab that is convenient to the source.

Possible scenario on handling the source after an employee bloodborne pathogens exposure:

Jerry in Dr. Smith’s lab accidently poked himself with a needle. The needle had been used to obtain a blood sample from an identified patient that the lab is allowed to contact. Jerry tells his supervisor, Dr. Smith who retrieves the source protocol and instructs Jerry to wash the area on the skin for 15 minutes, then to fill out an Authorization to Invoice MSU form and take it with him to Lansing Urgent Care (LUC). Dr. Smith contacts the source to ask for consent to have his/her blood tested. Consent is given. Dr. Smith sends the source the “Source Patient Lab Worksheet” with the top box completed with the BBP exposure date, exposed employee’s department, and the exposed employee’s supervisor.

References

Bloodborne Pathogens