The University of the South

BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN


In accordance with the OSHA Bloodborne Pathogens Standard, 29 CFR 1910.1030, the following exposure control plan has been developed:

A. Purpose

The purpose of this exposure control plan is to:
  1. Eliminate or minimize employee occupational exposure to blood or certain other body fluids;
  2. Comply with the OSHA Bloodborne Pathogens Standard, 29 CFR 191O. 1030.

B. Exposure Determination

OSHA requires employers to perform an exposure determination concerning which employees may incur occupational exposure to blood or other potentially infectious materials. At this facility the following job classifications are those in which all employees may be expected to incur exposure:

University Health Service Staff

Volunteer Firefighters and Emergency Medical Service Staff

The following job classifications and associated tasks are those in which some employees may have occupational exposure.

Job Classification Task/Procedure
athletic staff potential contact in treating sports injuries
police officers potential contact in emergencies
science lab technicians/faculty potential contact with a lab injury or incident
custodians potential contact in cleaning
plumbers potential contact in plumbing repairs
other Physical Plant workers potential contact in maintenance



C. Compliance Methods

Universal precautions, work practice controls, and engineering controls will be used at the University in order to prevent contact with blood or other potentially infectious materials. All blood or other potentially infectious material will be considered infectious (contaminated) regardless of the perceived status of the source individual. Where occupational exposure remains after institution of these controls, personal protective equipment shall also be utilized. Controls will be examined on a regular basis.

The following is a description of the work practice and engineering controls.
  1. Needles

    Contaminated needles and other contaminated sharps will not be bent, recapped, removed, sheared or purposely broken. OSHA allows an exception to this if the procedure would require that the contaminated needle be recapped or removed and no alternative is feasible and the action is required by the medical procedure. If such action is required then the recapping or removal of the needle must be done by the use of a mechanical device or a one-handed technique.

  2. Containers for Contaminated Sharps

    Contaminated sharps are to be placed immediately, or as soon as possible, after use into appropriate sharps containers. At this facility the sharps containers are puncture resistant, labeled with a biohazard label and are leak proof. University Health Services-all patient rooms contain sharps containers as well as lab area. Containers are checked on a daily basis for fullness. If full, containers are removed from area by RN or FNP and will be sealed. The sealed containers are removed by environmental services and disposed of properly.

  3. Work Area Restrictions

    In work areas where there is a reasonable likelihood of exposure to blood or other potentially infectious materials, employees are not to eat, drink, apply cosmetics or lip balm, smoke, or handle contact lenses. Food and beverages are not to be kept in refrigerators, freezers, shelves, cabinets, or on counter tops or bench tops where blood or other potentially infectious materials are present. Mouth pipetting/suctioning of blood or other potentially infectious materials is prohibited. All procedures will be conducted in a manner which will minimize splashing, spraying, splattering, and generation of droplets of blood or other potentially infectious materials. Methods which will be employed at this facility to accomplish this goal are: Covers on centrifuges; mouth pipetting is prohibited. Face shields, masks and goggles are available if needed.

  4. Specimens

    Specimens of blood or other potentially infectious materials will be placed in a container which prevents leakage during the collection, handling, processing, storage, and transport of the specimens. The container used for this purpose will be labeled or color coded in accordance with the requirements of the OSHA standard. Universal precautions must be used in the handling of all specimens. Any specimens which could puncture a primary container will be placed within a secondary container which is puncture resistant. If outside contamination of the primary container occurs, the primary container shall be placed within a secondary container which prevents leakage during the handling, processing, storage, transport, or shipping of the specimen.

  5. Contaminated Equipment

    The Director of University Health Services and Nurse Practitioner, the Director of Physical Plant Services, Athletic Trainer, Chief of Police, Biology Department Safety Officer, and the Director of Emergency Medical Services are responsible for equipment which has become contaminated with blood or other potentially infectious materials and it shall be examined prior to servicing or shipping and shall be decontaminated as necessary unless the decontamination of the equipment is not feasible.

  6. Personal Protective Equipment

    The Director of University Health Services and Nurse Practitioner, the Director of Physical Plant Services, Athletic Trainer, Chief of Police, Biology Department Safety Officer, and the Director of Emergency Medical Services are responsible for implementing the following provisions in their respective areas.

    All personal protective equipment used at this facility will be provided without cost to employees. Personal protective equipment will be chosen based on the anticipated exposure to blood or other potentially infectious materials. The protective equipment will be considered appropriate only if it does not permit blood or other potentially infectious materials to pass through or reach the employees' clothing, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used.

    Gloves, goggles, face shields, masks, and other appropriate equipment will be provided to University employees.

    PPE Use

    The Director of University Health Services and Nurse Practitioner, the Director of Physical Plant Services, Athletic Trainer, Chief of Police, Biology Department Safety Officer, and the Director of Emergency Medical Services shall implement appropriate PPE in the appropriate sizes at the work site or is issued without cost to employees. Hypoallergenic gloves, glove liners, powderless gloves, or other similar alternatives shall be readily accessible to those employees who are allergic to the gloves normally provided.

    PPE Cleaning, Laundering and Disposal

    All personal protective equipment will be cleaned, laundered, and disposed of by the employer at no cost to the employees. All repairs and replacements will be made by the employer at no cost to employees.

    All garments which are penetrated by blood shall be removed immediately or as soon as feasible. All PPE will be removed prior to leaving the work area.

    When PPE is removed, it shall be placed in an appropriately designated area or container for storage, washing, decontamination or disposal.

    Gloves

    Gloves shall be worn where it is reasonably anticipated that employees will have hand contact with blood, other potentially infectious materials, nonintact skin, and mucous membranes; when performing vascular access procedures and when handling or touching contaminated items or surfaces.

    Disposable gloves used at this facility are not to be washed or decontaminated for re-use and are to be replaced as soon as practical when they become contaminated or as soon as feasible when they are torn, punctured, or when their ability to function as a barrier is compromised. Utility gloves may be decontaminated for re-use provided that the integrity of the glove is not compromised. Utility gloves will be discarded if they are cracked, peeling, torn, punctured, or exhibit other signs of deterioration or when their ability to function as a barrier is compromised.

    Eye and Face Protection

    Masks in combination with eye protection devices, such as goggles or glasses with solid side shield, or chin length face shields, are required to be worn whenever splashes, spray platter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can reasonably be anticipated.

    Additional Protection

    Additional protective clothing (such as lab coats, gowns, aprons, clinic jackets, or similar outer garments) shall be worn in instances when gross contamination can reasonably be anticipated.

  7. Housekeeping

    All work areas in this facility which are routinely contaminated will be cleaned and decontaminated according to the following schedule:

    AREA SCHEDULE CLEANER
    Health Services kept at University Health Services appropriate cleaners will be used
    Emergency Medical Services Ambulance whenever needed appropriate cleaners will be used
    Athletic Training Room whenever needed appropriate cleaners will be used
    Biology Labs whenever needed appropriate cleaners will be used

    Decontamination will be accomplished by utilizing the following materials including bleach solutions or EPA registered germicides.

    All contaminated work surfaces will be decontaminated after completion of procedures and immediately or as soon as feasible after any spill of blood or other potentially infectious materials, as well as the end of the work shift if the surface may have become contaminated since the last cleaning.

    All bins, pails, cans, and similar receptacles at this facility shall be inspected and decontaminated on a regularly scheduled basis.

    Any broken glassware which may be contaminated will not be picked up directly with the hands.

  8. Regulated Waste Disposal

    Disposable Sharps

    Contaminated sharps shall be discarded immediately or as soon as feasible in containers that are closable, puncture resistant, leak proof on sides and bottom and labeled or color coded.

    During use, containers for contaminated sharps shall be easily accessible to personnel and located as close as is feasible to the immediate area where sharps are used or can be reasonably anticipated to be found (e.g., laundries).

    The containers shall be maintained upright throughout use and replaced routinely and not be allowed to overfill.

    When moving containers of contaminated sharps from the area of use, the containers shall be closed immediately prior to removal or replacement to prevent spillage or protrusion of contents during handling, storage, transport, or shipping.

    The container shall be placed in a secondary container if leakage of the primary container is possible. The second container shall be closable, constructed to contain all contents and prevent leakage during handling, storage and transport, or shipping. The second container shall be labeled or color coded to identify its contents.

    Reusable containers shall not be opened, emptied, or cleaned manually or in any other manner which would expose employees to the risk of percutaneous injury.

    Other Regulated Waste

    Other regulated waste shall be placed in containers which are closable, constructed to contain all contents and prevent leakage of fluids during handling, storage, transportation or shipping.

    The waste must be labeled or color coded and closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping.

    NOTE: Disposal of all regulated waste shall be in accordance with applicable United States, state and local regulations.

  9. Laundry Procedures

    Laundry contaminated with blood or other potentially infectious materials will be handled as little as possible. Such laundry will be placed in appropriately marked (biohazard labeled, or color coded red bag) bags at the location where it was used. Such laundry will not be sorted or rinsed in the area of use.

  10. Labels and Signs

    Biohazard labels shall be affixed to containers of regulated waste, refrigerators and freezers containing blood or other potentially infectious materials, and other containers used to store, transport or ship blood or other potentially infectious materials.

    The universal biohazard symbol shall be used. The label shall be fluorescent orange or orange-red.

    Red bags or containers may be substituted for labels. However, regulated wastes must be handled in accordance with the rules and regulations of the organization having jurisdiction.

    Blood products that have been released for transfusion or other clinical use are exempted from these labeling requirements.

D. Hepatitis B Vaccine and Post-Exposure Evaluation and Follow-Up

General

The University shall make available the Hepatitis B vaccine and vaccination series to all employees who have occupational exposure, and post exposure follow-up to employees who have had an exposure incident.

The Director of Health Services and Nurse Practitioner shall ensure that all medical evaluations and procedures including the Hepatitis B vaccine and vaccination series and post exposure follow-up, including prophylaxis are:

  1. Made available at no cost to the employee;

  2. Made available to the employee at a reasonable time and place;

  3. Performed by or under the supervision of a licensed physician or by or under the supervision of another licensed healthcare professional; and

  4. Provided according to the recommendations of the U.S. Public Health Service.

All laboratory tests shall be conducted by an accredited laboratory at no cost to the employee.

Hepatitis B Vaccination

The Director of Health Services and Nurse Practitioner is in charge of the Hepatitis B vaccination program.

Hepatitis B vaccination shall be made available after the employee has received the training in occupational exposure and within 10 working days of initial assignment to all employees who have occupational exposure unless the employee has previously received the complete Hepatitis B vaccination series, antibody testing has revealed that the employee is immune, or the vaccine is contraindicated for medical reasons.

Participation in a pre-screening program shall not be a prerequisite for receiving Hepatitis B vaccination.

If the employee initially declines Hepatitis B vaccination but at a later date while still covered under the standard decides to accept the vaccination, the vaccination shall then be made available.

All employees who decline the Hepatitis B vaccination offered shall sign the OSHA required waiver indicating their refusal.

If a routine booster dose of Hepatitis B vaccine is recommended by the U.S. Public Health Service at a future date, such booster doses shall be made available.

Post Exposure Evaluation and Follow-up

All exposure incidents shall be reported, investigated, and documented. When the employee incurs an exposure incident, it shall be reported to the Director of Health Services and Nurse Practitioner.

Following a report of an exposure incident, the exposed employee shall immediately receive a confidential medical evaluation and follow-up, including at least the following elements:

  1. Documentation of the route of exposure, and the circumstances under which the exposure incident occurred;

  2. Identification and documentation of the source individual, unless it can be established that identification is unfeasible or prohibited by state or local law.

  3. The source individual's blood shall be tested as soon as feasible and after consent is obtained in order to determine HBV and HIV infectivity. If consent is not obtained, the University Legal Counsel shall establish that legally required consent cannot be obtained. When the source individual's consent is not required by law, the source individual's blood, if available, shall be tested and the results documented.

  4. When the source individual is already known to be infected with HBV or HIV, testing for the source individual's known HBV or HIV status need not be repeated.

  5. Results of the source individual's testing shall be made available to the exposed employee, and the employee shall be informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual.

Collection and testing of blood for HBV and HIV serological status will comply with the following:

  1. The exposed employee's blood shall be collected as soon as feasible and tested after consent is obtained;

  2. The employee will be offered the option of having his or her blood collected for testing of the employees HIV/HBV serological status.

    The blood sample will be preserved for up to 90 days to allow the employee to decide if the blood should be tested for HIV serological status.
All employees who incur an exposure incident will be offered post-exposure evaluation and follow-up in accordance with the OSHA standard. All post exposure follow-up will be performed by the Director of Health Services and Nurse Practitioner.

Information Provided to the Healthcare Professional

The Director of Health Services and Nurse Practitioner shall ensure that the healthcare professional responsible for the employee's Hepatitis B vaccination is provided with the following:

  1. A copy of 29 CFR 1910.1030;

  2. A written description of the exposed employee's duties as they relate to the exposure incident;

  3. Written documentation of the route of exposure and circumstances under which exposure occurred;

  4. Results of the source individual's blood testing, if available; and

  5. All medical records relevant to the appropriate treatment of the employee including vaccination status.

Healthcare Professional's Written Opinion

The Director of Health Services and Nurse Practitioner shall obtain and provide the employee with a copy of the evaluating healthcare professional's written opinion within 15 days of the completion of the evaluation.

The healthcare professional's written opinion for HBV vaccination shall be limited to whether HBV vaccination is indicated for an employee, and if the employee has received such vaccination.

The healthcare professional's written opinion for post exposure follow-up shall be limited to the following information:

  1. A statement that the employee has been informed of the results of the evaluation; and

  2. A statement that the employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials which require further evaluation or treatment.

  3. Note: All other findings or diagnosis shall remain confidential and shall not be included in the written report.

E. Information and Training

The Director of University Health Services and Nurse Practitioner, the Director of Physical Plant Services, Athletic Trainer, Chief of Police, Biology Department Safety Officer, and the Director of Emergency Medical Services shall provide training at the time of initial assignment to tasks where occupational exposure may occur, and that it shall be repeated within twelve months of the previous training. Training shall be tailored to the education and language level of the employee, and offered during the normal work shift. The training will be interactive and cover the following:

  1. A copy of the standard and an explanation of its contents;

  2. A discussion of the epidemiology and symptoms of bloodborne diseases;

  3. An explanation of the modes of transmission of bloodborne pathogens;

  4. An explanation of the University's Bloodborne Pathogen Exposure Control Plan (this program), and a method for obtaining a copy.

  5. The recognition of tasks that may involve exposure.

  6. An explanation of the use and limitations of methods to reduce exposure, for example engineering controls, work practices and personal protective equipment (PPE).

  7. Information on the types, use, location, removal, handling, decontamination, and disposal of PPEs.

  8. An explanation of the basis of selection of PPEs.

  9. Information on the Hepatitis B vaccination, including efficacy, safety, method of administration, benefits, and that it will be offered free of charge.

  10. Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials.

  11. An explanation of the procedures to follow if an exposure incident occurs, including the method of reporting and medical follow-up.

  12. Information on the evaluation and follow-up required after an employee exposure incident.

  13. An explanation of the signs, labels, and color coding systems.

    The person conducting the training shall be knowledgeable in the subject matter.

    Employees who have received training on bloodborne pathogens in the twelve months preceding the effective date of this policy shall only receive training in provisions of the policy that were not covered.

    Additional training shall be provided to employees when there are any changes of tasks or procedures affecting the employee's occupational exposure.

F. Record keeping

Medical Records

The Director of Personnel and University Services is responsible for maintaining medical records as indicated below. These records will be kept in the Personnel Office.

Medical records shall be maintained in accordance with OSHA Standard 29 CFR 1910.20. These records shall be kept confidential, and must be maintained for at least the duration of employment plus 30 years. The records shall include the following:

  1. The name and social security number of the employee.

  2. A copy of the employee's HBV vaccination status, including the dates of vaccination.

  3. A copy of all results of examinations, medical testing, and follow-up procedures.

  4. A copy of the information provided to the healthcare professional, including a description of the employee's duties as they relate to the exposure incident, and documentation of the routes of exposure and circumstances of the exposure.

Training Records

The Director of Personnel and University Services is responsible for maintaining the following training records. These records will be kept in the Personnel Office.

Training records shall be maintained for three years from the date of training. The following information shall be documented:

  1. The dates of the training sessions;

  2. An outline describing the material presented;

  3. The names and qualifications of persons conducting the training;

  4. The names and job titles of all persons attending the training sessions.

Availability

All employee records shall be made available to the employee in accordance with 29 CFR 1910.20.

All employee records shall be made available to the Assistant Secretary of Labor for the Occupational Safety and Health Administration and the Director of the National Institute for Occupational Safety and Health upon request.

Transfer of Records

If this facility is closed or there is no successor employer to receive and retain the records for the prescribed period, the Director of the NIOSH shall be contacted for final disposition.

G. Evaluation and Review

The Provost or his designee is responsible for annually reviewing this program, and its effectiveness, and for updating this program as needed.