(Client Address)
(Applies to all Company locations) / Provided by
Risk Department
TITLE
BLOODBORNE PATHOGENS
EXPOSURE CONTROL
BLOOD BORNE PATHOGENS EXPOSURE CONTROL
TABLE OF CONTENTS
1.PURPOSE
2.REFERENCES
3.ENCLOSURES
4.RESPONSIBILITIES
5.DEFINITIONS
6.PROCEDURES
7.RECORDS
Hepatitis B Vaccine Declination
Potential Exposure Incident Report
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BLOOD BORNE PATHOGENS EXPOSURE CONTROL
1.PURPOSE
1.1.The purpose of the exposure control plan for (Client Company) is to implement the requirements of state and federal regulations, thereby reducing the risk of employee infection with bloodborne pathogens including, but not limited to, Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV) which results in the disease commonly known as AIDS, through occupational exposure to blood and other body fluids.
2.REFERENCES
2.1.OSHA Standard 29 CFR 1910.1030 (Bloodborne Pathogens)
2.2.United States Department of Health and Environment
3.ENCLOSURES
3.1.Hepatitis B Vaccine Declination
3.2.Exposure to Bodily Fluids Form
4.RESPONSIBILITIES
4.1.The Safety Coordinator shall assure the policy outlined here is effectively carried out and ensure that all records are maintained in accordance with state and federal regulations. The Safety Coordinator will be responsible for identifying which employees, by job position, may incur occupational exposure to blood or other potentially infectious materials. The Safety Coordinator will be responsible for the training and records required for the effective maintenance of this program and maintaining all records of exposure incidents in accordance with state and federal laws
4.2.Employees will be held responsible to ensure the appropriate personal protective equipment (PPE) is worn in accordance with the guidelines established in this procedure. Employees will also be responsible for notifying the Safety Coordinator immediately of any exposure or possible exposure to bloodborne pathogens.
5.DEFINITIONS
5.1.Biohazardous – Capable of transmitting infectious disease.
5.2.Bloodborne Pathogen – Pathogenic organisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B (HBV) and human immunodeficiency virus (HIV).
5.3.Contaminated – The presence of or reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.
5.4.Contaminated Laundry – Laundry, which has been soiled with blood or other potentially infectious materials or may contain sharps.
5.5.Contaminated Sharps – Any contaminated object that can penetrate the skin, including but not limited to needles, scalpels, broken glass, broken capillary tubes and exposed ends of dental wires.
5.6.Decontamination – The use of physical or chemical means to remove, inactivate or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface of the item is rendered safe for handling, use or disposal.
5.7.Exposure Control Plan – A documented plan or procedure that contains the following elements: exposure determination, methods of compliance, engineering and work practice controls, housekeeping, HIV and HBV Research Laboratories and Production Facilities, hepatitis B vaccination and post-exposure evaluation and follow up, health care professional’s written opinion, communication of hazards, the keeping medical records, training records, and declination statements, and other requirements as imposed by Title 29 CFR 1910.1030: Occupational Exposure to Bloodborne Pathogens.
5.8.Exposure Incident – A specific eye, mouth or other mucous membrane, non-intact skin or contact with parenteral blood or other potentially infectious materials that result from the performance of an employee’s duties.
5.9.Occupational Exposure – Reasonably anticipated skin, eye, mucous membrane or contact with parenteral blood or other potentially infectious materials that may result from the performance of an employee’s duties.
5.10.Parenteral – Piercing mucous membranes of the skin barrier through such events as needle sticks, human bites, cuts and abrasions.
5.11.Personal Protective Equipment – Appropriate means of protection which does not permit blood or other potentially infectious materials to pass through to or reach the employee’s work clothes, street clothes, undergarments, 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.
5.12.Regulated Waste – Liquid or semi-liquid blood or other potentially infectious material; contaminated items that could release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; pathological and microbiological wastes containing blood or other potentially harmful materials.
5.13.Source Individual – Any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to the employee. Examples include but are not limited to: hospital and clinic patients; clients in institutions for the developmentally disabled; trauma victims; clients of drug and alcohol treatment facilities; residents of hospices and nursing homes; human remains; and individuals who donate or sell blood or blood components.
5.14.Universal Precautions – An approach to infection control. According to the concept of universal precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV and other bloodborne pathogens. Under circumstances where differentiation between body fluid types is difficult or impossible, all body fluids shall be considered potentially infectious materials. HIV has been isolated from blood, semen, vaginal secretions, saliva, tears, breast milk, cerebrospinal fluid, amniotic fluid and urine, and is likely to be isolated from other body fluids, secretions and excretions. However, epidemiological evidence has implicated only blood, semen, vaginal secretions and possibly breast milk in transmission.
5.15.Work Place Controls – Controls that reduce the likelihood of exposure by altering the manner in which a task is performed (eg – prohibiting recapping of needles by a two hand technique). For further definitions of other terms used in this exposure control procedure.
5.16.Other potentially infectious materials include:
5.16.1.Semen
5.16.2.Vaginal secretions
5.16.3.Cerebrospinal fluid
5.16.4.Peritoneal fluid
5.16.5.Amniotic fluid
5.16.6.Saliva in dental procedures
5.16.7.Any fluid that is visibly contaminated with blood
5.16.8.All body fluids where it is difficult or impossible to differentiate between fluids
5.16.9.Any unfixed tissue or organ (other than intact skin) from a human (living or dead)
6.PROCEDURES
6.1.Exposure Determination
6.1.1.The Safety Coordinator will perform an exposure determination concerning which employees may incur exposure to blood or other potentially infectious materials. The exposure determination is made without regard to the use of personal protective equipment (ie – employees are considered to be exposed even if they wear personal protective equipment). This exposure determination is required to list all job classifications in which all employees may be expected to incur such occupational exposure, regardless of frequency.
6.2.Compliance Methods
6.2.1.Universal precautions will be observed at (Client Company) in order to prevent contact with blood or other potentially infectious materials. All blood or other potentially infectious materials will be considered infectious regardless of the perceived status of the source individual.
6.2.2.Hand washing facilities are available to the employees who incur exposure to blood or other potentially infectious materials. Hand washing facilities are located in lavatories.
6.2.3.After removal of personal protective gloves, employees shall wash hands and any other potentially contaminated skin area immediately or as soon as feasible following contact.
6.3.Work Practices
6.3.1.All procedures shall be conducted in a manner that will minimize splashing, spraying, splattering and generation of droplets of blood or other potentially infectious materials.
6.4.Personal Protective Equipment
6.4.1.All personal protective equipment (PPE) used by employees will be provided at no cost to personnel administering first aid. PPE will be chosen based on the anticipated exposure to blood or other potentially infectious materials.
6.4.2.Protective clothing is provided to employees at each first aid station. Management will ensure appropriate PPE is located at all first aid stations.
6.4.3.When there is potential for occupational exposure, employees shall use appropriate personal protective equipment such as:
6.4.3.1.Gloves
6.4.3.2.Face Protection
6.4.3.3.Eye Protection
6.4.4.The appropriate PPE will be discussed with each individual and shall be required based upon the tasks involved and the hazards associated with the job tasks.
6.4.5.Gloves shall be worn when it can reasonably be anticipated that the hands will come in contact with blood, other potentially infectious materials, mucous membranes, non-intact skin and when touching or handling contaminated items or surfaces.
6.4.5.1.Disposable (single use) gloves, such as surgical or examination gloves, shall be replaced as soon as possible when contaminated, torn, punctured or when their ability to function as a barrier is compromised. Disposable gloves shall not be washed or disinfected for re-use.
6.4.6.CPR breathing masks, eye protection or chin length face shields shall be worn whenever splashes, spray, spatter, droplets or aerosols of blood or other potentially infectious materials may be generated and eye, nose or mouth contamination can be reasonably anticipated.
6.4.7.All garments that are penetrated in blood shall be removed immediately or as soon as feasible. All personal protective equipment will be removed prior to leaving the work area and placed in a sealed plastic bag. The sealed bag will be placed into the appropriate containers designated for waste. All waste disposal equipment shall be provided at or near all first aid stations. Disposable gloves used at this facility are not to be washed or decontaminated for re-use. They are to be replaced as soon as practical when they become contaminated or if they are torn, punctured or when their ability to function as a barrier is compromised.
6.5.Housekeeping
6.5.1.Decontamination of areas that have been contaminated with blood or other potentially infectious materials will be accomplished by utilizing clean bleach of at least a 10% solution with water and general cleaning utensils. All contaminated work surfaces will be decontaminated as soon as feasible.
6.5.2.Waste containers will be placed next to each First Aid station.
6.5.3.Regulated waste will be placed in containers that are closable, constructed to contain all contents and prevent leakage of fluids during handling, storage, transport or shipping. Container shall be labeled in accordance with this program
6.5.4.If outside contamination of the regulated waste container should occur, it shall be placed in a second container meeting the same requirements as stated above.
6.5.5.Warning labels shall be affixed to containers of regulated waste. Labels shall be fluorescent orange or orange red with lettering or symbols in a contrasting color.
6.5.6.Labels shall be affixed as close as possible to the container by string, wire, adhesive or other method to prevent their loss or unintentional removal.
6.5.7.Red bags or red containers may be substituted for labels, provided they will be solely utilized for potentially BBP contaminated waste only.
6.5.8.Labels required for contaminated equipment shall state which portion of the equipment is contaminated. Regulated waste that has been decontaminated need not be labeled or color coded.
6.5.9.Regulated waste shall be disposed of in accordance with Federal and State regulations. The Safety Coordinator will contact the appropriate agencies for removal.
6.6.Hepatitis B Vaccine
6.6.1.All employees who have been identified as having exposure to blood or other potentially infectious materials as defined in Section 6.1.1 will be offered the Hepatitis B Vaccine, at no cost to the employee.
6.6.2.The vaccine will be offered to employees as soon as possible, but in no event later than 24 hours, to all unvaccinated first aid responders who have rendered assistance in a first aid incident involving the presence of blood or other potentially infectious materials regardless of whether the employee has actually incurred an exposure incident as defined by the standard. All incidents of first aid will be reported by the end of the work shift to the Safety Coordinator in order to ensure that proper precautions concerning the incident are followed and that the vaccine is offered to unvaccinated employees within hours. Employees who decline the Hepatitis B Vaccine will sign a waiver. (See enclosure 3.1)
6.6.3.Employees who initially decline the vaccine but who later wish to have it may then have the vaccine provided at no cost. The Safety Coordinator will ensure the vaccination will be offered and ensure the appropriate appointments are made with the occupational physician who will administer the vaccine. The employee will at that time be responsible for attending the scheduled appointment.
6.7.Evaluation of Circumstance Surrounding Exposure Incidents
6.7.1.When the employee incurs an exposure incident, it shall be reported to their Supervisor and to the Safety Coordinator. The Safety Coordinator will ensure the records of exposure incident are maintained.
6.7.2.All employees who incur an exposure incident will be offered post-exposure evaluation and follow up in accordance with the OSHA Standard.
6.7.3.This follow up will include:
6.7.3.1.Documentation of Exposure to Bodily Fluids form (Enclosure 3.2) of the route of exposure and the circumstances related to the incident.
6.7.3.2.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 and results given to the exposed employee.
6.7.3.3.Results of testing of the source individual will be made available to the exposed employee after he has been informed about the applicable laws and regulations concerning disclosure of the identity and infectivity of the source individual.
6.7.3.4.The employee will be offered the option of having their blood collected for testing of the employees HIV/HBV Serological status. The blood sample will be preserved for at least 60 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.
6.7.3.5.The employee will be offered post exposure prophylaxis in accordance with the current recommendations of the US Public Health Service.
6.7.3.6.The employee will be given appropriate counseling concerning precautions to take during the period after the exposure incident through a local agency. The employee will also be given information on what potential illnesses to be alert for and to report any related experience to appropriate personnel.
6.8.Training
6.8.1.All (Client Company) employees identified as having potential occupational exposure will participate in training conducted by appropriate (Client Company) personnel or an outside vendor certified to conduct such training.
6.8.2.Employees will be trained at the time of initial assignment to tasks where occupational exposure may occur and annually thereafter.
6.8.3.Additional training may occur when changes such as modifications of tasks or procedures or when new tasks or procedures may affect employees occupational exposure.
6.8.4.At a minimum, the training of employees with potential occupational exposure will include:
6.8.4.1.A copy of OSHA’s Bloodborne Pathogens standard 1910.1030 and an explanation of its contents.
6.8.4.2.A general explanation of the epidemiology and symptoms of bloodborne disease.
6.8.4.3.An explanation of the modes of transmission.
6.8.4.4.An explanation of this exposure control procedure and the location where an easily accessible copy will be kept.
6.8.4.5.An explanation of methods employees may use to recognize tasks that may involve occupational exposure.
6.8.4.6.Information on the selection, limitations, location, decontamination and proper disposal of personal protective equipment.
6.8.4.7.Information on Hepatitis B Vaccine, including information on its effectiveness, safety, method of administration, benefits of vaccination and that vaccine will be administered without cost to the employee.
6.8.4.8.Information on appropriate action and the person(s) to contact in the event of an emergency involving blood or other potentially infectious materials.
6.8.4.9.An explanation of proper procedures to follow if an exposure incident occurs, including reporting procedures and the medical follow-up that will be made available.
6.8.4.10.Information on post-exposure follow-up that the employer will provide.
6.8.4.11.An explanation of the labels/color coding system at the facility.
6.8.4.12.An opportunity for the employer to ask follow-up questions and obtain answers during the training.
6.8.5.A record of the training required by this procedure will be kept by (Client Company).
7.RECORDS
7.1.Completed Training Documents, Exposure Incident reports and Waivers shall be maintained as a record in accordance with (Client Company) policy.
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BLOOD BORNE PATHOGENS EXPOSURE CONTROL
ENCLOSURE 3.1
Hepatitis B Vaccine Declination
Employee Name: ______Job Title: ______
I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be a t risk of acquiring Hepatitis B (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B Vaccine, at no charge to myself. However, I decline the Hepatitis B Vaccine at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and if I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me.
Signed: ______Date: ______
Printed Name: ______
Witness: ______Date: ______
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BLOOD BORNE PATHOGENS EXPOSURE CONTROL
ENCLOSURE 3.2
Potential Exposure Incident Report
DATE: TIME: ______
FIRST AID PROVIDER:
SOURCE PERSONNEL:
DESCRIPTION OF INJURY:
TYPE OF EXPOSURE:(BLOOD, SALIVA, etc.)
ROUTE OF EXPOSURE:(EYES, MOUTH, CUT, etc.)
DESCRIPTION OF INCIDENT:(INCLUDE PPE WORN, TREATMENT GIVEN, TYPE AND DURATION OF EXPOSURE, PRECAUTIONS TAKEN BEFORE AND AFTER EXPOSURE, WITNESSES TO THE INCIDENT.)
FIRST AID PROVIDER: DATE: ______
SOURCE INDIVIDUAL: DATE: ______
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