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Pathogens

BLOODBORED PATHOGENS EXPOSURE CONTROL PLAN

06/01/2000

I. Policy & Scope
II. References
III. Administration of Program
IV. Exposure Determination
V. Implementation and Methodology

    1. Compliance
    2. Needles
    3. Containers for Sharps
    4. Work Area Restrictions
    5. Specimens
    6. Contaminated Equipment
    7. Laundry Procedures
    8. Personal Protective Equipment
    9. Regulated Waste Disposal

VI. Hepatitis B Vaccination

    1. Post Exposure Follow Up
    2. Interaction With Health Care Professional

VII. Labels & Signs
VIII. Training
IX. Record Keeping

 

I. Policy & Scope

The purpose of the Exposure Control Plan is to eliminate or minimize employee occupational exposure to blood and other potentially infectious materials.

II. References

    1. 29 CFR 1910.1030 Bloodborne Pathogens Standard
    2. Advantage Systems Inc., Bloodborne Pathogens Exposure Control Plan
    3. OSHA's Guide to Compliance With 29 CFR 1910.1030 Bloodborne Pathogens Standard

III. Administration of the Program

    1. The administrator of this program shall be the Director of Safety and Security who has full responsibility for its development and coordination.
    2. Deans, Directors, Department Chairs and Supervisors are responsible for ensuring employee compliance with this program and they should conduct routine monitoring of their subordinates.
    3. Disciplinary action will be administered by supervisory personnel to those employees who fail to comply with the provisions of this policy.
    4. The administrator of this program shall maintain surveillance of college facilities and degree of employee exposure.

IV. Exposure Determination

Occupational Exposure means "reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee's duties."

At Lycoming College, the following job categories are considered to have occupational exposure:

      1. Safety and Security Officers
      2. Health Services
      3. Athletic Trainers (includes student trainers)
      4. Housekeepers and Plumbers

The following job classifications may have unplanned occupational exposure:

      1. Athletic Coaches
      2. On-Call Personnel

V. Implementation Schedule and Methodology

OSHA also requires that this plan also include a schedule and method of implementation for the various requirements of the standard. The following complies with this requirement:

    1. Compliance Methods

                    Universal precautions will be observed at Lycoming College in order to 
                    prevent contact with blood or other potentially infectious materials.  All blood 
                    or other potentially infectious material will be considered infectious regardless 
                    of the perceived status of the source individual

                    Engineering and work practice controls will be utilized to eliminate or minimize 
                    exposure to employees at this facility.  Where occupational exposure remains   
                    after institution of these controls will be utilized:

                               1.)  Sharps Containers             Health Services
                                                                              Athletic Training Room
                               2.)  Shielded Needle Device    Health Services

                     The above controls will be examined and maintained daily.  The supervisor 
                     for each of the respective departments, Health Services and Athletic Training, 
                     are responsible for reviewing the effectiveness of the controls. 

                     Hand washing facilities are also available to the employees who incur 
                     exposure to blood or other potentially infectious materials.  OSHA requires 
                     that these facilities be readily accessible after incurring exposure.  Lycoming 
                     College hand washing facilities are located:
                                             Athletic Training Room
                                             Health Services
                                             Housekeeping Closets
                                             Safety and Security Office
                                             Numerous Other Locations Throughout Campus
                     In the unlikely event hand washing facilities are not readily available at the 
                     area of exposure, antiseptic towelettes can be used.  It should be noted that 
                     this does not replace hand washing with soap and water.  That should be 
                    done as soon as possible

                     After removal of personal protective gloves, employees shall wash hands and 
                     any other potentially contaminated skin area immediately or as soon as 
                     feasible with soap and water.

                     If employees incur exposure to their skin or mucous membranes then those 
                     areas shall be washed as soon as feasible following contact.

             B.    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. At this facility recapping or removal is only permitted for the following procedures

      No procedure exists at this time

      (list the procedures and also list the mechanical device to be used or alternately if a one-handed technique will be used)

  1.  Containers for Reusable Sharps

    Contaminated sharps that are reusable are to be placed immediately, or as soon as possible, after use into appropriate sharps containers. At Lycoming College the sharps containers are puncture resistant, labeled with a biohazard label, and are leak proof. Sharps containers located in Health Services are checked daily by the Director of Health Services.

  2. Work Area Restrictions

      3. 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

      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: (list methods, such as covers on centrifuges, usage of dental dams if appropriate, etc.)

      Health Services

      Centrifuge

  3. Specimens

      4. 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 OSHA standard.
      No specimens will be sent if they can puncture a primary container.

      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.

  4. Contaminated Equipment

      5. Equipment which has become contaminated with blood or other potentially infectious materials shall be examined prior to servicing or shipping and shall decontaminated as necessary unless the decontamination of the equipment is not feasible. (Employers should list here any equipment which it is felt can not be decontaminated prior to servicing or shipping.)

  5. Laundry Procedures

      6. Laundry contaminated with blood or other potentially infectious materials will be handled as little as possible. Such laundry will be placed in appropriately marked bags at the location where it was used. Such laundry will not be sorted or rinsed in the area of use. All employees who handle contaminated laundry will utilize personal protective equipment to prevent contact with blood or other potentially infectious materials.

  6. Personal Protective Equipment

    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.

    Protective clothing will be provided to employees in the following manner:

    Area supervisors are responsible for providing employees under their supervision with all appropriate disposable personal protective equipment.
    All personal protective equipment will be disposed of by the supervisor at no cost to employees.  All repairs and replacements will be made by the supervisor at no cost to employees.
    All garments which are penetrated by blood shall be removed immediately or as soon as feasible.  All personal protective equipment will be removed prior to leaving the work area.  The following protocol has been developed to facilitate leaving the equipment at the work area:

    Dispose of contaminated used gloves in bio-hazard bags in Health Services or Athletic Training Room.  Gloves shall be worn where it is reasonably anticipated that employees will have hand contact with blood, other potentially infectious materials, non-intact skin, and mucous membranes.
    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 are torn, punctured, or when their ability to function as a barrier is comprised.

    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 when their ability to function as a barrier is compromised.

    Masks in combination with eye protection devices, such as goggles or glassed with solid side shield, or chin length face shields, are required to be worn whenever splashes, spray, splatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can reasonably be anticipated.  Situations at this facility which would require such protection are as emergency first aid only.  The OSHA standard also requires appropriate protective clothing to be used, such as lab coats, gowns, aprons, clinic jackets, or similar outer garments.  The only situations requiring such protective clothing be utilized is emergency first aid.

    This facility will be cleaned and decontaminated according to the following schedule:
                      Athletic Department - Daily or after any use
                      Student Health Services - Daily or after use
    Decontamination will be accomplished by utilizing the following materials:
                      1.  Bleach Solution
                      2.  Sani Wipe Pad Cleaning Cloths
                      3.  3M Neutral Cleaning Disinfectant Solution

    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 shall be inspected and decontaminated on a regularly scheduled basis by the supervisor in the area they are located.  
    Any broken glassware which may be contaminated will not be picked up directly with the hands.  Disposable clean-up kits will be used.

  7. Regulated Waste Disposal

    All contaminated sharps shall be discarded as soon as feasible in sharps containers which are located in 
                       Student Health Services
                                Exam Rooms
                       Athletic Training Room
    Regulated waste other than sharps shall be placed in appropriate containers.  Such containers are located in 
                       Student Health Services
                                Exam Rooms
                       Athletic Training Room

 


VI. Hepatitis B Vaccination

 

To protect our employees as much as possible from Hepatitis B infection, Lycoming College offers a vaccination series to all employees who have a potential for occupational exposure, and a post-exposure evaluation and follow-up to all employees who have had an exposure incident. These vaccinations, evaluations, and follow-ups are available at no cost to the employees. Lycoming College shall ensure that all employees with a potential for occupational exposure participate in a training program during working hours at no cost to the employee. Employees who decline the Hepatitis B vaccine will sign a waiver which uses the wording in Appendix A of the OSHA standard.

Employees who initially decline the vaccine but who later wish to have it may then have the vaccine provided at no cost.

Department supervisors as listed in Section III are responsible for assuring that the vaccine is offered. The Director of Student Health Services or their appropriate designee will administer the vaccine.

    1. Post Exposure Evaluation and Follow-Up

When the employee incurs an exposure incident, it should be reported to (list who has responsibility to maintain records of exposure incidents): Their area supervisor as listed in Section III. The supervisor is then responsible for informing the Director of Safety and Security. All employees who incur an exposure incident will be offered post-exposure evaluation and follow-up in accordance with the OSHA standard.

This follow-up will include the following:

      1. Documentation of the route of exposure and the circumstances related to the incident
      2. If possible, the identification of the source individual and, if possible, the status of the source individual. The blood of the source individual will be tested (after consent is obtained) for HIV/HBV infectivity.
      3. Results of testing of the source individual will be made available to the exposed employee with the exposed employee informed about the applicable laws and regulations concerning disclosure of the identity and infectivity of the source individual. (Employers may need to modify this provision in accordance with applicable local laws on this subject.)
      4. The employee will be offered the option of having their blood collected for testing of the employee's HIV/HBV serological status. The blood sample will be preserved for at least 90 days to allow the employee to decide if the blood should be tested for HIV serological status. However, if the employee decides prior to that time that testing will be conducted then the appropriate action can be taken and the blood sample discarded.
      5. The employee will be offered post exposure prophylaxis in accordance with the current recommendations of the U.S. Public Health Service. These recommendations will be explained by Susquehanna Health System.
      6. The employee will be given appropriate counseling concerning precautions to take during the period after the exposure incident. The employee will also be given information on what potential illnesses to be alert for and to report any related experienced to appropriate personnel. The procedures listed above will be available through the work center at the Susquehanna Health System or the emergency room after work center hours.
      7. The following person(s) has been designated to assured that the policy outlined here is effectively carried out as well as to maintain records related to this policy:

Office of Safety and Security

               B.    Interaction with Health Care Professionals

A written opinion shall be obtained from the health care professional who evaluates employees of this facility. Written opinions will be obtained in the following instances:

      1. When the employee is sent to obtain the Hepatitis B vaccine
      2. Whenever the employee is sent to a health care professional following an exposure incident

Health care professionals shall be instructed to limit their opinions to:

      1. Whether the Hepatitis B vaccine is indicated and if the employee has received the vaccine, or for evaluation following an incident
      2. That the employee has been informed of the results of the evaluation, and
      3. That the employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials. (Note that the written opinion to the employer is not reference to any personal medical information.)

VII. Labels and Signs

Biohazard labels shall be affixed to containers used to store, transport, or ship potentially infectious material. 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 OSHA.

VIII. Training

Training for all employees will be conducted prior to initial assignment to tasks where occupational exposure may occur. Training will be conducted in the following manner:

Training for employees will include the following explanation of:

 

    1. The OSHA standard for Bloodborne Pathogens
    2. Epidemology and symptomatology of Bloodborne diseases
    3. Modes of transmission of Bloodborne Pathogens
    4. This Exposure Control Plan, i.e. points of the plan, lines of responsibility, how the plan will be implemented, etc.
    5. Procedures which might cause exposure to blood or other potentially infectious materials at this facility
    6. Control methods which will be used at the facility to control potentially infectious materials
    7. Personal protective equipment available at this facility and who should be contacted concerning post exposure evaluation and follow-up
    8. Signs and labels used at the facility
    9. Hepatitis B vaccine program at the facility

Area supervisors as designated in Section III are responsible for training. Training consists of video tapes, written materials, and testing.

All employees will receive annual refresher training. This training is to be conducted within one year of the employee's previous training. The outline for the training material is located in the department where training takes place.

IX. Record Keeping

All records required by OSHA standard will be maintained by the Personnel Office. The exception to this will be records related to an employee exposure. They will be kept in the Safety and Security Office.


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