Policy 4215 – Exposure Control Plan for Bloodborne Pathogens (ECP)
Revision Date: 11/1/2011
Responsible Office: Environmental Health And Safety
NOTE: THE ECP IS PART OF THE SAFETY PLAN
“HARD COPIES ARE ABVAILABLE FROM THE OFFICE OF ENVIRONMENTAL HEALTH AND SAFETY
LOUISIANA TECH UNIVERSITY
EXPOSURE CONTROL PLAN FOR
( 2011 Update)
The Louisiana Tech University Exposure Control Plan for Bloodborne Pathogens (ECP) is part of the Louisiana Tech University Safety Plan. General safety rules and policies which apply to task involving the potential exposure to bloodborne pathogens are set forth in the Safety Plan and the “Biosafety” section of the Laboratory Safety Manual supplement to the Safety Plan. This Bloodborne Pathogen supplement addresses those measure employees and their supervisors must take to minimize occupational exposures to these infectious agent and those actions which must be taken, should an employee be exposed to these agents.
On December 6, 1991, the Occupational Safety and Health Administration (OSHA) promulgated the final rule (29 CFR 1910.1030) for occupational exposure to bloodborne pathogens. The rule, commonly referred to as the bloodborne pathogen standard, was promulgated under the authority of the Occupational Safety and Health Act of 1970 and was designed to eliminate or minimize occupational exposure to Hepatitis B virus (HBV), Human Immunodeficiency Virus (HIV), and other bloodborne pathogens.
The rule making effort was based on an OSHA determination that employees face a significant health risk from occupational exposure to blood and other potentially infectious materials considering that these materials may contain bloodborne pathogens, including Hepatitis B virus which causes Hepatitis B, a serious liver disease, and Human Immunodeficiency Virus, which causes Acquired Immunodeficiency Syndrome (AIDS). In an effort to eliminate or minimize exposure to bloodborne pathogens, the standard requires employers to institute a program of engineering and work practice controls, personal protective clothing and equipment, informational training, Hepatitis B vaccination, post exposure evaluation and follow-up, sign and label programs, and other provisions for employees who may be reasonably anticipated to come into contact with blood or other potentially infectious materials during the performance of their duties.
The preamble to the final rule for occupational exposure to bloodborne pathogens, published in the Federal Register on December 6, 1991 (56 FR 64004), describes the rationale behind the standard and discusses provisions of the standard. The text to the final rule is presented with these key elements:
- Scope and application of the rule
- Exposure control
- Methods of compliance
- Hepatitis B vaccination and post exposure evaluation and follow-up
- Communication of hazards to employees
- medical and training records
- Compliance dates
The complete regulatory text of the OSHA Bloodborne Pathogen Standard is contained in Appendix 1. Agencies of the State of Louisiana are required by the Louisiana State Office of Risk Management (ORM) to comply with these regulations.
OSHA and ORM have provided the following definitions to assist Budget Unit Heads and their employees in determining the exposure risk:
Bloodborne Pathogens means pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV) and human immunodeficiency virus (HIV).
Contaminated means the presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.
HBV means hepatitis B virus.
HIV means human immunodeficiency virus.
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.
Other Potentially Infectious Materials means (1) The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids; (2) Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and (3) HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.
“Good Samaritan” acts, such as assisting a co-worker with a nosebleed, would not be considered occupational exposure.
Employees shall be classified as “high risk” or “low risk” by the agency “High-risk” positions shall be identified by the agency and listed in the plan. Some examples of “high-risk” occupations include: healthcare workers, lab technicians, police officers, first responders, firefighters, custodial staff (that handle contaminated linen), kitchen staff (that may handle sharp equipment), public safety workers, plumbers, etc.
The training schedule for both “low risk” and “high risk” employees shall be contingent upon the level of exposure to BBP. All employees shall receive training within three (3) months of hire and at least once every 5 years thereafter. “High risk” employees must have refresher training EACH YEAR. All training shall be given during working hours and at no cost to the employee and training records shall be maintained for five years
The University is required to comply with the requirements established in these standards,considering the scope of applicability of the standard and the fact that Louisiana Tech University conducts activities utilizing or involving blood and other potentially infectious materials and employs individuals identified as employees who may be reasonably anticipated to come into contact with blood or other potentially infectious materials during the performance of their duties.
The Office of Environmental Health and Safety (EHS) and the Louisiana Tech University Biosafety and Radionuclide Institutional Review Committee (BRIRC) are charged with the overall responsibility of developing and monitoring of the university bloodborne pathogen compliance policies. Compliance with these policies are the responsibility of Deans, Directors, Department Head and their respective employees.
The policies are designed to provide and achieve regulatory compliance and, most importantly, will provide a means in which university employees will be better informed and protected from exposures to blood and other potentially infectious materials during the performance of their duties. The Office of Environmental Health and Safety will provide technical assistance to individual university departments in their effort to address the mandates established in the standard.
Budget Unit Heads
Specific responsibilities of Budget Unit Heads who assign new or existing employees to task where there is the possibility of routine exposure to human blood or other potentially infectious material are:
- Assure that these activities/tasks have been approved by the BRIRC prior to assigning the employee(s) to them;
- Submit the name(s) of these employee(s) to the EHS who will then provide the prescribed basic and advanced bloodborne pathogen training employee prior to assigning the employee(s) to them;
- Obtain verification that the employee(s) have received the Hepatitis B vaccination series and notify EHS of this or schedule these vaccinations through EHS. Documentation of these vaccinations must be kept in the Budget Unit, in perpetuum.
- Review the ECP, the portions of the Safety Plan and Laboratory Safety Manual and all Budget Unit-specific policies and procedures which are associated with working with agents, equipment, or individuals that may be contaminated with bloodborne pathogens. This review must be documented and kept on file in the Budget Unit, in perpetuum.
- Monitor all “high-risk” activities to verify that all appropriate rules are being followed.
- Report any incident that results in an employee’s possible exposure to bloodborne pathogens using a DA 2000when an employee AND immediately diret the employee to the Student Health Service for appropriate medical evaluation and follow-ups. EHS is also to be notified.
- Conduct the appropriate post-exposure evaluation and followup, as detailed in the ECP.
- “Low risk” employees are to attend the ORM Basic Bloodborne Pathogen Training program during their probationary period and again at least every 5 years
- “High risk” employees must also attend the EHS Advanced BBP training
- each year. DO NOT ATTEMPT ANY “HIGH RISK” TASKS UNTIL THIS AND ALL
- BUDGET UNIT-SPECIFIC TRAINING HAS BEEN COMPLETED;
- “High risk” employees must supply their Budget Unit Head with documentation of having received the Hepatitis B vaccination series or submit a signed, “Hepatitis B Vaccination Declination” to Human Resources with copies to your Budget Unit and EHS.
- Report any exposure incident to your Budget Unit, immediately.
- Follow all appropriate safety rules/policies.
Student Health Services
- Administer Hepatitis B vaccinations to high-risk employees when appropriate.
- Conduct or coordinate all medical evaluations related to an exposure incident ( see matrix) .
Employees incur risk each time they are exposed to blood or other potentially infectious materials. Any exposure incident may result in infection and subsequent illness. Considering the possibility of becoming infected from a single exposure incident, exposure incidents must be prevented whenever possible. The goal of the bloodborne pathogen standard is to reduce the significant risk of infection by:
- eliminating or minimizing occupational exposure to blood and other potentially infectious materials
- providing the Hepatitis B vaccine
- providing post exposure medical evaluation and follow-up
Identifying the tasks and procedures where occupational exposure may occur and the positions whose duties include those tasks and procedures is a critical element of exposure control. By identifying those job classifications with occupational exposure, those employees who are entitled to the provisions of the standard can be identified. All personnel who hold positions determined to have occupational exposure are entitled to the protection afforded by the standard.
Exposure Control Plan
The key provision of the bloodborne pathogen standard is the written Exposure Control Plan. The Exposure Control Plan identifies individuals who will receive training, protective equipment, vaccinations, and other provisions of the standard. The written Exposure Control Plan is designed to eliminate or minimize employee exposure and:
- provide a means in which employees are able to find out what provisions are in place in his or her work place
- provide a document for regulatory officials to evaluate the university’s compliance status
- can be used for the employee training effort
Based on the requirements established by the standard, the Louisiana Tech University Exposure Control Plan for Bloodborne Pathogens has been developed and designed to eliminate or minimize university employee occupational exposure to bloodborne pathogens during the performance of their duties and to achieve regulatory compliance with the OSHA Bloodborne Pathogen Standard.
The university’s plan contains the following elements:
- exposure determination
- schedule and methods for implementation of:
- universal precautions, engineering and work practice controls, personal protective equipment, and housekeeping
- Hepatitis B vaccination and post-exposure evaluation and follow-up
- communication of hazards to employees
- procedure for the evaluation of circumstances surrounding exposure
The plan will be reviewed annually and updated whenever necessary to reflect new or modified tasks and procedures which affect occupational exposure and to reflect new or revised employee positions with occupational exposure.The plan will be provided upon request for examination and copying to all university employees, employee representatives, and regulatory authorities. The Office of Environmental Health and Safety is the university custodian of the document. Arrangements to examine or copy the document can be made by contacting the Office of Environmental Health and Safety at 257-2120 or by mail:
Office of Environmental Health and Safety
Louisiana Tech University
PO Box 3187 TS
Ruston, LA 71272
Budget Unit Heads ( Deans, Directors, Department Heads, Supervisors) are solely responsible for reviewing all employee positions in their area(s) of responsibility to determine which employees have occupational exposure to blood or other potentially infectious materials during the performance of their duties. The review identified job classifications in which all employees have occupational exposure and job classifications in which some employees have occupational exposure. In addition, for those job classifications in which some employees have occupational exposure, tasks and procedures or groups of closely related tasks and procedures in which occupational exposure occurs were identified. The exposure determination was conducted without regard to the use of personal protective equipment.
Job classifications in which all university employees in the specific job classification have occupational exposure pursuant to 29 CFR 1910. 1030:
- Athletic Trainers
- Hazardous Waste Specialists
- Medical Assistants
- Medical Technologists
- Nurse Practitioners
- Registered Nurses
Job classifications in which some university employees in the specific job classifications may have occupational exposure pursuant to 29 CFR 1910. 1030:
- Animal Car Personnel
- Custodial Personnel
- Full/Associate/Assistant/Adjunct Professors
- Health/Safety Specialists
- Health Services Clinic Manager
- Laboratory Coordinators
- Police Officers
- Research Faculty Associates
- Research Laboratory Assistants
- Research Specialists
- Research Technicians
- Student Workers
- Teaching Assistants
Tasks and procedures or groups of closely related tasks and procedures in which occupational exposure occurs in job classification in which some employees have occupational exposure is somewhat of a difficult task to document accurately. This belief is based, in part, on the specific nature and variety of exposure activities conducted at the university.
Whether an employee may have an occupational exposure to BPP is determined by the Budget Unit Head of the area in which those employees work, and is not determined by EHS, Human Resources, of Student Health. The reason for this is because the Budget Unit Head is the person who would assign these “high risk” duties and responsibilities to these personnel.
Universal precautions will be observed by all university employees to prevent contact with blood and other potentially infectious materials. Under circumstances in which differentiation between body fluid types is difficult or impossible, all body fluids will be considered potentially infectious.Universal precautions are methods of preventing disease by preventing transfer of blood and certain body fluids, e.g., semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, and saliva in dental procedures.
The underlying concept of universal precautions is that all blood and certain body fluids are considered to be vectors for bloodborne pathogens. In most situations, an employee will treat all blood and certain body fluids as though they contained bloodborne pathogens and will accomplish this through a variety of measures including, but not necessarily limited to:
The only exception to the use of universal precautions is in rare instances such as unexpected medical emergencies, where employees may not be able to put on gloves, don a gown, or tie on a face mask immediately. In those situations, to which leeway must be accorded the provider of health care or public safety services, the employees must neither ignore the underlying concept of universal precautions nor decline to use all the equipment appropriate to the task. Only under unexpected extraordinary circumstances will employees have the option of deciding not to use personal protective equipment if they feel such equipment will prevent the proper delivery of health care or public safety services or will create a greater hazard to their personal safety.
The universal precaution exemption provided in the standard does not apply to the general concept or universal precautions. It only applies to the use of personal protective equipment under rare and relatively limited circumstances.
Engineering and Work Practice Controls
Engineering and work practice controls serve to reduce employees’ exposure in the work place by either removing the hazard or isolating the worker from exposure. In fact, these control measures are viewed as the primary means of eliminating or minimizing employee exposure. These controls may include process or equipment redesign (e.g., self-sheathing needles), process equipment enclosure (e.g., biosafety cabinets), and employee isolation. In general, engineering controls act on the source of the hazard and eliminate or reduce employee exposure without reliance on the employee to take self-protective action. Once implemented, engineering controls protect the employee permanently, subject only, in some cases, to periodic replacement or preventative maintenance. By comparison, work practice controls reduce the likelihood of exposure through alteration of the manner in which a task is performed. While work practice controls also act on the source of the hazard, the protection they provide is based on employer and employee behavior rather than installation of a physical device such as a protective shield.
The two control methodologies frequently work in tandem because it is often necessary to employ work practice controls to assure effective operation of engineering controls.
Where occupational exposure remains after institution of these controls, departments must provide and ensure employees use personal protective equipment as supplemental protection. Primary reliance on engineering controls and work practices for controlling exposure is consistent with good industrial hygiene practice and with the OSHA traditional adherence to a hierarchy of controls. The hierarchy specifies that engineering controls and work practices are to be used in preference to personal protective equipment.
Engineering and work practice controls will be used by university facilities and employees to eliminate or minimize employee exposure. Where occupational exposure remains after institution of these controls, personal protective equipment will also be used. Engineering controls will be examined and maintained or replaced on a regular schedule to ensure their effectiveness. The following engineering and work practice controls have been designed and are in place at all university facilities that present potential bloodborne pathogen exposure issues.
Handwashing facilities are readily accessible in the work place to employees that are reasonably anticipated to contact blood or other potentially infectious materials during the performance of their duties. In the event that handwashing facilities are not feasible, provisions will be provided for the placement of either an appropriate antiseptic hand cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes. When antiseptic hand cleansers or towelettes are used, employees are instructed to wash their hands with soap and running water as soon as feasible.
Employees are required to wash their hands immediately or as soon as feasible after removal of gloves or other personal protective equipment. Most importantly, employees are required to wash their hands and any other skin with soap and water or flush mucous membranes with water immediately or as soon as feasible following contact with body areas contaminated with blood or other potentially infectious materials.
Contaminated needles and other contaminated sharps will not be recapped or removed unless it can be demonstrated by the department that no alternative is feasible or that such action is required by a specific medical procedure. Under these circumstances, recapping or needle removal shall be accomplished through the use of a mechanical device or a one-handed technique.
Immediately or as soon as possible after use, contaminated reusable sharps shall be placed in appropriate containers until properly reprocessed. These containers shall be:
- puncture resistant
- appropriately labeled or color-coded
- leakproof on the sides and bottoms
- shall not be handled in a manner that requires employees to reach by hand into containers where these sharps have been placed.
Eating, smoking, drinking, applying cosmetics or lip balm, and handling contact lenses is prohibited in work areas where there is reasonable likelihood of occupational exposure. Food and drink will not be stored in refrigerators, freezers, shelves, cabinets, cabinet tops, or bench tops where blood or other potentially infectious materials are present.
All procedures involving blood or other potentially infectious materials shall be performed in a manner to minimize splashing, spraying, spattering, and generation of droplets of these substances.
Mouth pipetting/suctioning of blood or other potentially infectious materials is strictly prohibited.
Specimens of blood or other potentially infectious materials shall be placed in a container which prevents leakage during collection, handling, processing, storage, transport, or shipping. The container for storage, transport or shipping shall be labeled or appropriately color-coded and closed prior to being stored, transported, or shipped. When universal precautions are utilized in the handling of specimens, the labeling/color-coding of specimens is not necessary provided containers are recognizable as containing specimens. This exception only applies while such specimens/containers remain within the faculty. Appropriate labeling/color-coding is required when such specimens/containers leave the facility.
In the event that outside contamination of the container occurs, the primary container will be placed within a second container which prevents leakage during handling, processing, storage, transport, or shipping and will be appropriately labeled or color-coded. If the specimen could puncture the primary container, in addition to the aforementioned required container characteristics, the primary container will be placed within a secondary container which is puncture-resistant.
Equipment which may become contaminated with blood or other potentially infectious materials will be examined prior to servicing or shipping and will be decontaminated as deemed necessary, unless it can be demonstrated that decontamination of such equipment or portions of such equipment is not feasible. An appropriate readily observable label will be attached to the equipment stating which portions remain contaminated. The department is responsible for ensuring this information is conveyed to all affected employees, the servicing representative, and/or the manufacturer as appropriate prior to handling, servicing, or shipping so that appropriate precautions will be taken.
Personal Protective Equipment
When there is occupational exposure, the department will provide at no cost to the employee, appropriate personal protective equipment such as, but not limited to the following: gloves, gowns, laboratory coats, face shields or masks and eye protection, mouthpieces, resuscitation bags, pocket masks, or other ventilation devices. Personal protective equipment will be considered “appropriate” only if it does not permit blood or other potentially infectious materials to reach or pass through to 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 in which the protective equipment will be used.
The department will ensure that the employee uses appropriate personal protective equipment unless it can be demonstrated that the employee temporarily and briefly declined to use personal protective equipment when, under rare circumstances, it was the employee’s professional judgement that in the specific instance its use would have prevented the delivery of health care or public safety services or would have posed an increased hazard to the safety of the worker or co-worker. When the employee makes this judgment, the circumstances shall be investigated and documented in order to determine whether changes can be instituted to prevent such occurrences in the future.The department will ensure that appropriate personal protective equipment in the appropriate sizes is readily accessible at the work site or is issued to employees. Hypo-allergenic gloves, glove liners, powderless gloves, or other similar alternatives will be readily accessible to those employees who are allergic to the glove normally provided.
The department will clean, launder, and dispose of personal protective equipment at no cost to the employee. The department will repair or replace personal protective equipment as needed to maintain its effectiveness at no cost to the employee.
If a garment is penetrated by blood or other potentially infectious materials, the garment will be removed immediately or as soon as feasible. All personal protective equipment will be removed prior to leaving the work area. When personal protective equipment is removed it will be placed in an appropriately designated area or container for storage, washing, decontamination or disposal.
Gloves shall be worn when it can be reasonably anticipated that the employee may have hand contact with blood, other potentially infectious materials, mucous membrane, and non-intact skin; when performing vascular access procedures; and when handling or touching contaminated items or surfaces.
Disposable, single-use gloves such as surgical or examination gloves, will be replaced as soon as practical when contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised. Disposable, single-use gloves will not be washed or decontaminated for reuse. Utility gloves may be decontaminated for reuse if the integrity of the glove is not compromised. However, they must 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.
Masks in combination with eye protection devices, such as goggles or glasses with solid side shields or chin-length face shields, will be worn whenever splashes, spray, spatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can be reasonably anticipated.
Appropriate protective clothing such as, but not limited to, gowns, aprons, lab coats, clinic jackets, or similar outer garments will be worn in occupational exposure situations. The type and characteristics will depend upon the task and degree of exposure anticipated. Surgical caps or hoods and/or shoe covers or boots will be worn in instances when gross contamination can reasonably be anticipated.
Departments will ensure the work-site is maintained in a clean and sanitary condition. The department will determine and implement an appropriate written schedule for cleaning and method of decontamination based upon the location within the facility, type of surface to be cleaned, type of soil present, and tasks or procedures being performed in the area.
All equipment and environmental and working surfaces will be cleaned and decontaminated after contact with blood or other potentially infectious materials. Contaminated work surfaces will be decontaminated with an appropriate disinfectant after completion of procedures, immediately or as soon as feasible when surfaces are overtly contaminated or after any spill of blood or other potentially infectious materials, and at the end of the work shift if the surface may have become contaminated following the last cleaning.
Protective coverings (e.g., plastic wrap, aluminum foil, or imperviously-backed absorbent paper) used to cover equipment and environmental surfaces, will be removed and replaced as soon as feasible when they become overtly contaminated or at the end of the work shift if they may have become contaminated during the shift.
All bins, pails, cans, and similar receptacles intended for reuse that have a reasonable likelihood for becoming contaminated with blood or other potentially infectious materials will be inspected and decontaminated on a regular basis and cleaned and decontaminated immediately or as soon as feasible upon visible contamination.
Broken glassware, which may be contaminated, will not be picked up directly with the hands. The spill and/or debris will be cleaned up using mechanical means such as a brush and dust pan, tongs, or forceps.
Reusable sharps that are contaminated with blood or other potentially infectious materials will not be stored or processed in a manner that requires employees to reach by hand into the containers where these sharps have been placed.
Contaminated sharps will be discarded immediately or as soon as feasible in containers that are:
- puncture resistant
- leakproof on sides and bottom
- appropriately labeled or color-coded
- During use, containers for contaminated sharps will be:
- easily accessible to personnel and located as close as feasible to the immediate area where sharps are used or can be reasonably anticipated to be found (e.g., laundries)
- maintained upright throughout use
- replaced routinely and not be allowed to overfill
When moving containers of contaminated sharps from the area of use, the containers will be:
- closed immediately prior to removal or replacement to prevent spillage or protrusion of contents during handling, storage, transport, or shipping
- place in a secondary container if leakage is possible. The second container will be:
- constructed to contain all contents and prevent leakage during handling, storage, transport, or shipping
- appropriately labeled or color-coded
Reusable containers will not be opened, emptied, or cleaned manually or in any other manner which would expose employees to the risk or percutaneous injury.
Regulated waste will be placed in containers which are:
- constructed to contain all contents and prevent leakage of fluids during handling, storage, transport, or shipping
- appropriately labeled or color-coded
- closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping
If outside contamination of the regulated waste container occurs, it will be placed in a second container. The second container will be:
- constructed to contain all contents and prevent leakage of fluids during handling, storage, transport or shipping
- appropriately labeled or color-coded
- closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping
Disposal of all regulated waste will be in accordance with applicable regulations of the United States, State of Louisiana, and political subdivisions of the state.Contaminated laundry will be handled as little as possible with a minimum of agitation.
Contaminated laundry will be bagged or containerized at the location where it was used and will not be sorted or rinsed in the location of use.
Contaminated laundry will be placed and transported in bags or containers appropriately labeled or color coded.
When a department utilizes universal precautions in the handling of all soiled laundry, alternative labeling or color-coding is sufficient if it permits all employees to recognize the containers as requiring compliance with universal precautions.
Whenever contaminated laundry is wet and presents a reasonable likelihood of soak-through of or leakage from the bag or container, the laundry will be placed and transported in bags or containers which prevent soak-through and/or leakage of fluids to the exterior.
The department will provide employees who have contact with contaminated laundry protective gloves and other appropriate personal protective equipment.When a department ships contaminated laundry off-site to a second facility that does not utilize universal precautions in the handling of all laundry, the department generating the contaminated laundry will place such laundry in bags or containers which are appropriately labeled or color-coded.
IF SPILL IS THE RESULT OF A PERSONAL INJURY TO A STAFF MEMBER, STUDENT, OR VISITOR, FOLLOW THE UNIVERSITY PROCEDURE FOR REPORTING AND ACCIDENT/INJURIES.
Only certain University personnel are authorized by the Louisiana Tech University Office of Environmental Health and Safety to clean up and decontaminate spills of blood and body fluids. These personnel include custodians, University Police, Office of Environmental Health personnel, and instructors/personnel in areas where blood and body fluids are routinely encountered in the course of work. These employees are classified as employees with “high risk” for exposure to bloodborne pathogens.
These personnel must receive documented training by the Office of Environmental Health and Safety when hired and must have training up-dates provided by this Office, each year. It is the responsibility of supervisors to notify the Office of Environmental Health and Safety when new personnel are hired in these areas. ONLY THESE DESIGNATED PERSONNEL WILL HAVE THE APPROPRIATE EQUIPMENT, SUPPLIES, AND TRAINING TO PROPERLY CLEANUP AND DECONTAMINATE THE SPILL. Do not attempt to clean up a spill unless authorized to do so.
“High Risk” areas at the University where contact with blood or body fluids can reasonably by encountered are: Student Health Center, specialty laboratories in nursing, biological sciences, biomedical engineering, speech/hearing clinic, kinesiology, and athletics, and with certain accidents involving injury.
ANY PERSON WHO ENCOUNTERS/OBSERVES SPILLED BLOOD OF BODY FLUIDS MUST, ALSO IMMEDIATELY CONTACT ONE OF THE FOLLOWING:
SPILL IN DORMITORIES: Contact the Director of Building Services and Facilities in the Housing Department at 257-4038
SPILL IN CAMPUS CLASSROOM/OFFICE BUILDING: Contact Superintendent, Support Service at 257-4161 or 257-3267
SPILL IN “HIGH RISK” AREAS– Contact Budget Unit Head over each area or their designee. (Consult departmental listing for phone #)
SPILL IN NEUTRAL AREAS OUTSIDE OF CAMPUS BUILDINGS– Contact University Police at 257-4018
IF THESE PERSONNEL ARE UNAVAILABLE– Contact Office of Environmental Health and Safety at 257-2120 (during regular work hours) or 4018 (after hours)
- Personal Protective Equipment (PPE)
- Disposable Gloves
- Protective Goggles
- Disposable Face Mask
- Disposable Gown or Apron
- Antiseptic Towelettes
- Spill Clean-Up Equipment
- Disposable Absorbent Material (e.g., Paper Towels or Lab Table Soakers)
- Red Medical Waste Bag for Disposal
- Appropriate Germicidal Solution
- Forceps or Other Mechanical Means for Picking-Up Broken Glass or items which have been contaminated with blood or body fluids
Authorized personnel may obtain Spill Kits may be obtained from their supervisor.
- Cleaning and Decontaminating Spills of Blood or Other Potentially Infectious Body Fluids
- Put on appropriate personal protective equipment (PPE) including double gloves, gown, protective goggles, and face mask.
- Control access to area. Prevent people from walking through affected area and thereby tracking the blood or other potentially infectious material to other areas.
- Contain spill. Use paper towels or other absorbent material to contain spill.
- Use forceps, plastic scoop, or other mechanical means to remove any broken glass or other sharp objects from the spill area. Take care not to create aerosols. Place these items into a small cardboard box, thick walled plastic bag, or other container that will prevent them from puncturing the red bag (or your hand). Place the contained sharp items into the red bag for disposal. Do not seal bag. Also use the forceps to pickup and bag items contaminated with blood or body fluids and place the contaminated items into a red bag.
- Apply appropriate disinfectant to decontaminate contaminated surfaces. To avoid creating aerosols, never spray disinfectant directly into spilled material. Instead, gently pour disinfectant on top of paper towels covering the spill or gently flood affected area first around the perimeter of the spill, then work disinfectant slowly into spilled material.
- Allow several minutes of contact time with disinfectant. (CRITICAL STEP!!!!)
- Pick-up all absorbent material and place carefully in red bag for disposal. Do not seal red bag.
- Clean affected area again with disinfectant and new paper towels. Place used paper towels in red bag for disposal. Do not seal red bag.
- Dry area. Place used paper towels in red bag for disposal. Do not seal red bag.
- Once spill is completely cleaned, place all used spill control equipment in the red bag for disposal. Do not seal red bag.
- Remove PPE and place in red bag for disposal. Remove PPE in the following order:
- Remove soiled gown.
- Remove outer pair of disposable gloves.
- Remove face mask and protective goggles.
- Do not remove PPE from face with soiled gloves. Remove soiled outer gloves first and place them in the red bag for disposal. Use clean inner glove to remove PPE from face. This prevents the introduction of blood or other potentially infectious material to the mucous membranes of the face via a contaminated glove.
- Once all used PPE, spill control equipment, and other potentially contaminated items are in the red bag seal bag securely for disposal. Contact the Louisiana Tech Office of Environmental Health and Safety to collect and dispose of this bagged material
- Wash hands.
The department will make available the Hepatitis B vaccine and vaccination series to all employees who have occupational exposure and post-exposure evaluation and follow-up to all employees who have had an exposure incident. The department will ensure that all medical evaluations and procedures including the Hepatitis B vaccine and vaccination series and post-exposure evaluation and follow-up, including prophylaxis, are:
- made available at no cost to employee
- made available to the employee at a reasonable time and place
- performed by or under the supervision of a licensed physician or by or under the supervision of another licensed healthcare professional
- provided according to recommendations of the U.S. Public Health Service current at the time these evaluations and procedures take place
All diagnostic laboratory tests will be conducted by an accredited laboratory at no cost to the employee.
Hepatitis B Vaccination
A Hepatitis B vaccination will be made available after the employee has received the required training 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.
The department will not make participation in a prescreening program 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 department will make available Hepatitis B vaccination at that time.
The department will require employees who decline to accept Hepatitis B vaccination offered by the department to sign the statement in Appendix 2. The original signed statement will be maintained in the employee’s permanent personnel file and copies will be provided to the employee, the employee’s department, and the Office of Environmental Health and Safety.If a routine booster dose(s) of Hepatitis B vaccine is recommended by the U.S. Public Health Service at a future date, such booster dose(s) will be available.
Following a report of this exposure incident, the Department for which the exposed employee works, will make immediately available to the exposed employee a confidential medical evaluation and follow-up, including at least the following requirements. The University Accident Form and DA-2000 shall be completed by the Supervisor and the medical investigation and evaluation shall be conducted by a qualified medical professional. Medical evaluations are coordinated through the Student Health Center.
INFORMATION PROVIDED TO THE EXPOSED EMPLOYEE
- Copies of the “University Accident Form” and DA-2000
- documentation of the route(s) of exposure and the circumstances under which the exposure incident occurred
- identification and documentation of the source individual, unless the employer can establish that identification is infeasible or prohibited by state or local law
- the source individual’s blood will 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 department will 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, will be tested and the results documented.
- 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
- 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
- the exposed employee’s blood will be collected as soon as feasible and tested after consent is obtained
- if the employee consents to baseline blood collection, but does not give consent at that time for HIV serologic testing, the sample will be preserved for at least 90 days. If within 90 days of the exposure incident, the employee elects to have the baseline sample tested, such testing will be done as soon as feasible.
- post-exposure prophylaxis, when medically indicated, as recommended by the U.S. Public Health Service
- evaluation of reported illness
Information Provided by the Healthcare Professional
The healthcare professional responsible for the employee’s Hepatitis B vaccination will be provided a copy of the bloodborne pathogen standard regulation. The department will provide the following information to the healthcare professional evaluating an employee after an exposure incident is provided the following information:
- a copy of the bloodborne pathogen standard regulation
- a description of the exposed employee’s duties as they relate to the exposure incident
- documentation of the route(s) of exposure and circumstances under which exposure occurred
- results of the source individual’s blood testing, if available
- all medical records relevant to the appropriate treatment of the employee including vaccination status that are the university’s responsibility to maintain
Healthcare Professionals Written Opinion
The department will obtain and provide the employee with a copy of the evaluation healthcare professional’s written opinion within 15 days of the completion of the evaluation. The healthcare professional’s written opinion for Hepatitis B vaccination will be limited to whether Hepatitis B vaccination is indicated for an employee, and if the employee has received such vaccination.
The healthcare professional’s written opinion for post-exposure evaluation and follow-up will be limited to the following information:
- the employee has been informed of the results of the evaluation
- the employee has been informed of any medical conditions resulting from exposure to blood or other potential infectious materials which require further evaluation or treatment
All other findings or diagnoses will remain confidential and will not be included in the written report.
the Student Health Center will establish and maintain an accurate record for each employee with occupational exposure, in accordance with 29 CFR 1910.20. The record shall include:
- name and social security number of the employee
- a copy of the employee’s Hepatitis B vaccination status including the dates of all the Hepatitis B vaccinations and any medical records relative to the employee’s ability to receive vaccinations
- a copy of all results of examinations, medical testing, and follow-up procedures required
- the copy of the healthcare professional’s written opinion as required
- a copy of the information provided to the healthcare professional as required
The Student Health Center will ensure the employee medical records required are:
- kept confidential
- are not disclosed or reported without the employee’s express written consent to any person within or outside the workplace except as required by the standard or as may be required by law
The Student Health Center will maintain the records required for at least the duration of employment plus thirty years in accordance with 29 CFR 1910.20.
Communication of Hazards to Employee
Efforts directed at communicating hazards of bloodborne pathogens to university employees through the use of labels, signs, and information and training are intended to provide employees with adequate warning to eliminate or minimize their exposure.
All university employees with occupational exposure to blood or other potentially infectious materials will participate in a bloodborne pathogen information and training program which is provided at no cost to the employee and conducted during their normal working hours. All high risk employees who are identified must attend this course annually and all other employees must attend this training once every three years.
Training will be provided at the time of initial assignment to tasks where occupational exposure must take place or within 90 days of employment or assignment to “high risk” tasks.
Employees who have received training on bloodborne pathogens in the year preceding the effective date of the standard, i.e., March 6, 1992, only need further training with respect to the provisions of the standard which were not included in previous training.
Employees will receive additional training when changes or modifications of tasks or procedures occur or when new tasks or procedures affect the employee’s occupational exposure. The additional training will be limited in scope by only addressing the new exposure created.
Material will be used that is appropriate in content and vocabulary to educational level, literacy and language of employees undergoing the training program.
The training program will contain the following elements:
- an accessible copy of the regulatory text of the bloodborne pathogen standard and an explanation of its contents
- a general explanation of the epidemiology and symptoms of bloodborne diseases
- an explanation of the modes of transmission of bloodborne pathogensan explanation of Louisiana Tech University’s Exposure Control Plan and the means by which the employee can obtain a copy of the written plan
- an explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials
- an explanation of the use and limitations of methods that will prevent or reduce exposure including appropriate engineering controls, work practices, and personal protective equipment
- information on the types, proper use, location, removal, handling, decontamination, and disposal of personal protective equipment
- an explanation of the basis for selection of personal protective equipment
- information on the Hepatitis B vaccine, including information on its efficiency, safety, method of administration, the benefits of being vaccinated, and that the vaccine and vaccination will be offered free of charge
- information on appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials
- an explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available
- information of the post-exposure evaluation and follow-up that the department is required to provide for the employee following an exposure incident
- an explanation of the signs and labels and/or color coding required by the standard
- an opportunity for interactive questions and answers with the person conducting the training session
Training will be conducted by individuals knowledgeable in the subject matter covered in the training program as it relates to the specific workplace being addressed.
Training records will include the following information:
- the dates of the training sessions
- the contents or a summary of the training sessions
- the names and qualifications of persons conducting the training
- the names and job titles of all persons attending the training s
All training records relative to the bloodborne pathogen standard will be maintained for a minimum of three years from the date on which the training occurred. The Office of Environmental Health and Safety will serve as the custodian of all bloodborne pathogen standard training records. All training records required by this standard will be provided upon request for examination and copying to all employees, employee representatives, the Director of the National Institute for Occupational Safety and Health (NIOSH), and the Assistant Secretary of the U.S. Department of Labor in accordance with 29 CFR 1910.20.
Louisiana Tech University must comply with the requirements involving transfer of records set forth in 29 CFR 1910.20(h). Should Louisiana Tech University cease to do business and there is no successor employer to receive or retain the records for the prescribed period, the university will notify the NIOSH Director at least three months prior to their disposal and transmit them to the NIOSH Director, if required by the Director to do so, within the three month period.
Warning labels will be affixed to containers of regulated waste, refrigerators, and freezers containing blood or other potentially infectious materials; There are several exemptions to the labeling requirement:
- containers of blood, blood components, or blood products that are labeled as to their contents and have been released for transfusion or other clinical use do not need to be labeled in accordance with the provisions outlined in this section
- individual containers of blood or other potentially infectious materials that are placed in a labeled container during storage, transport, shipment, or disposal do not need to be labeled in accordance with the provisions outlined in this section
- regulated waste that has been decontaminated does not need to be labeled
- red bags can be substituted for labels on bags or container of regulated waste
- The label will be fluorescent orange, orange-red, or predominantly so with lettering or symbols in a contrasting color. Labels will be affixed as close as feasible to the container by string, wire, adhesive, or other method.
- In order to maintain consistent labeling throughout the university, the Office of Environmental Health and Safety will provide all required labeling devices to individual departments upon request.
- Contaminated equipment scheduled for maintenance or repair will be labeled in accordance with the provisions in this section, and the label will also state which portions of the equipment remain contaminated