Office of Environmental Health & SafetyPolicy# : OS-6
Policy: Exposure Control Plan for Bloodborne Pathogens
Date: 6/99 Revision# 4 Pages:8
Purpose:
To establish safe operating procedures that eliminate or control employee exposure to human body fluids that may be contaminated with bloodborne pathogens.
Scope: This policy will apply to all employees that eliminate contact, or may contact, possibly infectious human body fluids (refer to Section 1- Exposure Catagories for a list of job classifications with potential exposure).
Responsibilities:
A. All personnel must be responsible for their own and the safety of employees working with around them. To assist in defining this safety responsibility, each employee working in a category 1 or 2 job class will receive a copy of the Federal Bloodborne Pathogens Standard, the Exposure Control Plan, Training, and the necessary personal protective equipment, as well as training in safe operational procedures.
B. It is the responsibility of the University at Albany to provide an exposure control plan for bloodborne pathogens, training, post exposure follow up, as required by the standard, Hepatitis B vaccinations, personal protective equipment necessary to avoid exposure, and a copy of the standard to affected employees. This shall be done in accordance with OSHA's Bloodborne Pathogen Standard.
Section 1 - Exposure Categories
All jobs at this institution have been assessed as to the occupational exposure to human blood, tissue and body fluids. The possibility and probability determines the exposure category listed below. A list of jobs, identified as having actual or probable exposures, is included with this policy. This list will be reviewed on a regular basis and is subject to change as job demands change.
It is the responsibility of all individuals and their immediate supervisors to identify any changes in job function that would alter the exposure category of a job to a category 1 or 2. Should this occur, the Environmental Health and Safety Office should be notified as soon as possible.
Category 1
Tasks that involve exposure to the blood, body fluids, or tissues.
Procedures and job related tasks that involve an inherent potential for mucous membrane or skin contact with blood, bloody fluids or tissues, or potential for spills or splashes.
Category 2
Tasks that involve NO Exposure to blood, body fluids, or tissues, but employment may require performing unplanned Category 1 tasks.
The normal work routine involves no exposure to blood, body fluids or tissues, but exposure, (or potential exposure) may be required as a condition of employment.
Category 3
Tasks that involve No Exposure to blood, body fluids or tissues and Category 1 tasks are not a condition of employment.
The normal work routine involves no exposure to blood, body fluids or tissues. Jobs in this category will not be called on to perform or assist in an emergency medical care, as a condition of employment, or be potentially exposed in some other way.
Category 1 and 2 Job Titles
Nurse : Category - 1 : Exposure- Patient care, Phlebotomy, First aid, assisting with medical procedure
Doctor : Category - 1 : Exposure- Patient care Surgical procedures and Emergency care
Athletic Coaches,Lifeguards and Trainers: Category -2 : Exposure- Provide first aid
Public Safety Officers : Category - 2 : Exposure- First response
Security Guards :Category - 2 : Exposure- First response
Graduate Clinical Psychology Students : Category - 2 : Exposure- Client contact,during human sexuality research
Biological Research : Category- 2 : Exposure- Processing human/primate specimens blood or body tissue
Custodial Services : Category - 2 : Exposure- clean up of human body fluids and exposure to improperly discarded hypodermic needles
Grounds Workers : Category - 2 : Exposure- Clean up human body fluids and exposure to improperly discarded hypodermic needles
The remainder of University job titles: Catagory - 3: Exposure- None expected on the job.
Section 2 - Methods of Control
A. Engineering Controls- Where feasible, engineering controls will be implemented in the work place to isolate, control or eliminate all bloodborne pathogen exposures that could result in employee illness. The controls include, but are not limited to:
1. Puncture resistant disposable containers for used sharps, syringes, and needles.
2. All syringes uses at the University Health Center should be of the self capping variety, or require no capping after use. When this is not feasible, then one handed capping method shall be used.
3. Resuscitation bags or masks shall be used when administering CPR.
4. Disinfectant to clean work surfaces or contaminated equipment.
5. Hand wash stations, complete with antibacterial soap and single use towels, where feasible. Single use, moist towelettes will be provided where handwash stations are not feasible.
6. Leak proof bags and containers will be provided for laundry and personal clothes soaked with blood (body fluids). These bags will be sealed and marked with the Biohazard symbol. Correct disposal of the bags is the responsibility of the University.
7. All bandage, gauze and disposable dressings will be placed into a plastic Biohazard bag. (Refer to Table 2/ Section 2)
8. Mechanical means will be used to pick up contaminated broken glassware, such as tongs, dust pan, broom, forceps, or tweezers.
9. Equipment which has become contaminated with blood or other potentaially infectious materials shall be decontaminated as soon as possible following the contamination. Contaminated equipment that can naot be cleaned immediately shall be isolated by enclosing the equipment in a leak proof bag, and labeled with a Warning /Bio-Hazard Contamination label. Any equipment removed from its use area will also have a label denoting the type and specific site of contamination. All contaminated equipment shall be cleaned with a disinectant and the appropriate PPe shall be worn.
B. Personal Protective Equipment - will be provided to all health care employees, first responders and lab personal in category 1 and 2 jobs. This equipment shall include, but is not limited to:
1. One time use, disposable gloves. The location of the gloves will be made known to each employee, as it pertains to their job. The gloves shall be used whenever the first aid or patient care is given, or when the human/ primate blood/body fluids/tissue are being handled in the lab.
2. Eye protection shall be worn by all health care and first responders when dealing with human body fluids that could potentially spurt or splash in the eyes.
3. Protective outerwear shall be worn by all health care providers and laboratory personnel when they are in contact with patients or lab samples and the possibility of contact with contaminated fluids exist. In the event the outerwear (ie. labcoat) becomes contaminated, the employee shall remove that article of clothing and place it in a red bag, marked Bio-Hazard. A decision will be made, by the supervisor, as to whether the contaminated article should be discarded, washed commercially or in-house. Any article washed in-house will be done so as to avoid further employee exposure and with a disinfectant*.
4. All lab personnel are to wash their hands before leaving the lab area.
* (Refer to In-House Laundering Procedures, contained within this policy).
C. STANDARD OPERATING PROCEDURES FOR THE CLEAN-UP OF BLOOD OR BODY FLUIDS
1. Wear disposable latex gloves when the area to be cleaned is obviously or possibly contaminated with blood or body fluid. Gloves are to be worn during the entire cleaning. Should gloves become ripped or punctured, then remove, wash hands and replace with a new pair, before continuing the cleaning process.
2. Safety glasses, goggles, or a face mask should be worn prior to any situation where splashes of blood/ body fluids may occur. An example would be a puddle or pool of blood.
3. Clean and disinfect all soiled, washable surfaces (i.e., tables, chairs, floors) immediately, removing soil before applying a disinfectant:
a. use paper towels or tissues to wipe up small soiled areas. After the spill is removed, use clean paper towels, soap and water to clean the area.
b. Apply a sanitary absorbent agent for larger soiled areas. After the spill is absorbed, discard material in a sealable plastic bag.
c. Disinfect the area with an approved disinfectant.
4. Clean and disinfect all soiled rugs, carpets, and upholstered furniture, immediately:
a. Apply a sanitary absorbent agent, let dry, and vacuum.
b. Apply a sanitary shampoo with a brush or an extractor, the revacuum. Discard material in a sealable plastic bag.
c. Spray with an approved disinfectant, according to the manufacturer's instructions
5. Clean and dispose of all disposable materials:
a. Soiled tissue and flushable waste can be flushed in the toilet. Discard paper towels and vacuum bag or sweep into a plastic bag , seal and dispose of according to procedure.
b. Rinse broom and dustpan in disinfectant solution after removing debris.
c. Soak mop in disinfectant solution for a minimum of 20 minutes and rinse thoroughly.
d. Used disinfectant solution should be poured down the drain.
6. Remove disposable gloves and dispose. Avoid touching the gloves to exposed skin.
7. Wash hands thoroughly with soap and water, using handwashing procedures.
8. Plastic bags containing contaminated waste should be sealed and disposed of daily, according to procedure.
D. LABELING of all containers used for the transport of blood, body fluids, or tissues shall conform to the requirements of the standard. Containers for waste shall also adhere to these requirements.
TABLE 2-- LABELING REQUIREMENTS
Item Bio Hazard Label Red Container
1.) Regulated waste container (e.g. used sharps containers) YES YES 2.) Reusable, contaminated sharps or instruments. (e.g.scalpels,sissors) YES YES
3.) Refrigerator/freezer used to store blood or other potentially infectious material. YES NO 4.) Containers used for the transport or shipping of blood. YES YES 5.) Blood or blood products for clinical use. No Labels Required NO 6.) Individual specimen containers of blood or other potentially infectious materials. YES YES 7.) Contaminated equipment needing service. YES( plus a label specifying where the contamination exists) NO 8.) Specimens & regulated waste shipped from the primary facility to another for disposal or service. YES YES 9.) Contaminated Laundry YES YES E. Preventing Needle Sticks & Punctures From Sharps - Take care to prevent injuries when using needles, scalpels and other sharp instruments or devices, such as after a procedure, when cleaning instruments of disposing needles.
1. Do NOT bend, recap, shear or break contaminated needles or other sharps.
2. Recap or remove contaminated needles from disposable syringes Only when medically necessary. To recap needles, use a mechanical device or a one handed technique.
3. Place contaminated sharps in an appropriate container, (one that is leakproof, puncture resistant, red in color, and marked Bio-Hazard) immediately after use.
4. Report any sharp containers that are not easily accessible to full to your supervisor. Do not use the container until the hazard has been eliminated.
Section 3-- Training
All employees that may be exposed to human blood, tissue or body fluid during their normal course of employment shall receive training on the hazards of Bloodborne Pathogens. The training shall be tailored to the education and the language level of the employee, and offered during the normal work shift. The training will be interactive and cover the following:
1. The Bloodborne Pathogens Standard CFR1910.1030
2. A discussion of the epidemiology and symptoms of bloodborne diseases.
3. An explanation of the models of transportation of bloodborne pathogens.
4. An explanation of the University's at Albany's Bloodborne Pathogen Exposure Control Plan. Each participant will receive a copy of the plan.
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.
7. Information on the types, use, location, removal, handling, decontamination, and disposal of the PPE's.
8. An explanation on the basis of selection of PPE's.
9. Information on the Hepatitis B Vaccination, including the 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, tissue, or body fluids.
11. An explanation of procedures to follow if an exposure incident occurs, including method of medical follow-up and reporting.
12. Information on the evaluation and follow-up required after an employee exposure incident.
13. An explanation of signs, labels, and color coding systems.
Section 4- Post Exposure Evaluation & Follow-Up
All exposure incidents shall be reported, investigated, and documented. When the employee incurs an exposure incident, it shall be reported to their immediate supervisor. An accident report shall be completed and distributed immediately.
1. History and Physical Examination: A physical exam will be performed at the time of exposure to determine if treatment is necessary. This will be at no charge to the employee and by the physician selected by the employee..
2. Counseling: Professional counseling shall be given to the employee regarding the risk of infection, testing, possible treatment and the U.S. Public Health Service recommendations.
3. Serum Collection: The exposed individuals blood shall be collected as soon as feasible, and tested after consent is obtained. If the exposed individual allows for the baseline collection of the blood sample, but does not wish HIV serologic testing to be conducted at that time, the sample shall be preserved for at least 90 days. If, during that 90 day period, the exposed employee elects to have the baseline sample tested, it shall be done as soon as feasible.
4. Documentation: The healthcare professional responsible for the medical evaluation of the exposed employee will receive a copy of 29 CFR 1910.1030, a written description of the accident (detailing the route of exposure), results of the source individuals blood testing (if available), and all medical records relevant to the treatment of the exposed employee (including vaccination status). In addition, the healthcare professional will be provided with a copy of the exposed employee's job description.
5. Employment Information: The employee shall be provided with a copy of the evaluating healthcare professional's written opinion after completion of the evaluation, and within 15 days of the exam. The employee must be told about any medical conditions resulting from the exposure, which may require further evaluation or treatment.
THE EMPLOYEE SHALL BE GUARANTEED CONFIDENTIALITY THROUGHOUT THE POST EXPOSURE PROCESS, AS IT EFFECTS THEIR HIV STATUS, AND IN ACCORDANCE WITH NYS LAW.
University Health Clinic Protocol for the Disposal of Regulated Medical Waste
The Public Health Law and the Environmental Conservation Law, effective 1988, created requirements for the storage, treatment and disposal of infectious waste. In addition to sharp objects, the requirements include: laboratory waste which has come in contact with possible pathogens and contaminated material resulting from the treatment of patients (e.g. dressings, swabs, sponges, and gloves) must be disposed of in a prescribed manner. Therefore, the following procedures will be instituted:
1). All waste generated from laboratory testing procedures will be discarded in covered step-cans, lined with red bags. These step cans shall be wiped down with a disinfectant each time they are emptied.
2). All gloves, dressings, and related materials are to be discarded in covered step-cans, with red bags.
3). Any other potentially infectious waste is to be discarded in these receptacles. (It is not necessary to dispose of paper towels, table paper, dressing wrappers, under the new procedures unless these items are contaminated with human secretions).
4). The red bagged waste will be stored in a secure area by the health care personnel, until it is properly transported and disposed of n accordance with the new regulations.
The University Health Center Policy for the Management of Post-Exposure Control of Needle Sticks &/or Body Fluid Contamination to Employees*
1. The exposed individual should be evaluated at the University Health Center by a Physician or Physician's Assistant.
2. Care provider at UHC reviews individual's tetnus status and administers tetnus toxoid, if necessary.
3. Wound care provided.
4. If an individual has had Hepatitis B vaccine, HBsAb will be drawn. If positive, the individual is immune. If negative, the individual can be given HBIG.
5. If the individual has not had the HBV vaccine, the care provider can order a Hepatitis Panel, and may give HBIG.
6. Care provider counsels the individual about HIV testing.
7. Student Health provider reviews all the results with the individual and counsels further, reminding him/her that this information is cofidential.
8. If appropriate, given the individuals HIV status and the care providers assessment of the risk, HIV testing may be repeated at some , or all, of the following post exposure dates: 6 weeks, 12 weeks, 6 months, 12 months.
*Note: The term employee includes all full time, part time staff, work study students and student
assistants.
*In-house Laundering of Contaminated Clothing
1. Personnel responsible for the laundering of articles clothing contamianted with blood or human body fluid, are to use universal percautions and engineering controls to negate or limit their exposure. These methods will include wearing PPE, labcoat, gloves and eye protection (if necessary) , good hand washing technique and a disinfectant in the wash load.
2. Washing machines shall be emptied of any other material before laundering begins.
3. Each load shall be dedicated to contaminated items only.
4. Do not over load the washer.
5. Detergent and chlorine bleach shall be used, along with a hot water setting.
6. The washed items should the be placed in the dryer and cycled on HOT, until dry.
7. If the article is not clean, then discard or repeat the above steps.
Guidelines for Controlling Your Exposure to Bloodborne Pathogens
1. Treat all human blood, body fluids and tissue as if it is infected with a bloodborne pathogen.
2. Refrain from physically contacting another persons blood, fluid or injured tissue if you have cuts or lesions on your hands. Use gloves!
3. When the potential exists for blood or body fluid to splash into eyes or onto face, don safety glasses and mask.
4. Do not eat, drink, smoke, apply makeup or handle contact lenses in areas where infectious material may be present.
5. Do not store food where infectious materials are stored, such as a refrigerator.
6. If you spill or splatter blood or other potentially infectious material, cleanup the substance immediately.
7. Never pick up broken glass contaminated with potentially infectious material with your bare hands. Don thick leather gloves or use a dust pan and broom.
8. Remember- the most potentially dangerous route for transmission of HIV and HBV infection is by accidental needle sticks, contamination of the mucous membranes, or through broken, abraded, or irritated skin. Use appropriate caution and maximum protection to prevent such contact.
9. Never recap, clip, or bend needles. Dispose of needle/syringe and other sharps immediately after use, in a sharps container.
10. Handle sharp items with safety awareness. Stay focused on the task at hand.
11. All waste contaminated with potentially infectious blood, tissue, and body fluid should be correctly labeled. (refer to section 2, table 2)
12. Wash hands and arms thoroughly with soap and water after contacting human blood or body fluids, when you change gloves, or your gloves are torn. Similarly, wash any other are of body contact.
13. Flush mucous membranes with water, immediately following contact of body areas with possible infectious material.
14. Participate in the HBV immunization program. Participation is not mandatory, but advisable for those employees in jobs classified as Category 1 or 2.
15. Report every incident involving physical contact (such as needle sticks, cuts...) to your supervisor. Arrangements for follow up procedures will be made. The health risk will then be assessed and addressed by a health professional.
16. Personnel responding to an emergency shall not take contaminated clothing home to launder. (refer to Section 2, paragraph A)
