Bloodborne Pathogens

EXPOSURE CONTROL PLAN
POLICY STATEMENT

Hennepin Technical College will eliminate or minimize employee occupational exposure to blood or other body fluids and comply with the OSHA Bloodborne Pathogens Standard, 29 CFR 1910.1030

IMPLEMENTATION PROCEDURE

BLOOD means human blood, human blood components, and products made from human blood.

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.

EXPOSURE INCIDENT means a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee's duties.

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.

PARENTERAL:  Piercing mucous membranes or skin barriers through such events as needle sticks, human bites, cuts, and abrasions.

PERSONAL PROTECTIVE EQUIPMENT (PPE) AND SUPPLIES:  specialized clothing or equipment worn by an employee for protection against a hazard.

Exposure Determination
OSHA requires employers to perform an exposure determination concerning which employees may incur occupation exposure to blood or other potentially infectious materials.  The exposure determination is made without regard to the use of personal protective equipment.  This exposure determination is required to list all job classifications in which all employees may be expected to incur routinely such occupational exposure, regardless of frequency.

The following job classifications are in this category:

School nurses and employees responsible for first aid, and any other employees who are individually assessed as likely to  incur  routinely occupational exposure.

Implementation Schedule and Methodology

1. Compliance Methods
Universal precautions will be observed 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 within  Hennepin Technical College.  Where occupational exposure remains after  institution of these controls, personal protective equipment shall also be utilized.  The following engineering controls will be utilized: sharps containers and accessible handwashing facilities.

The sharps containers will be examined and maintained on a regular schedule.

Hand washing facilities shall be made available to all employees including those who incur exposure to blood or other potentially infectious materials.  The handwashing facility shall include warm water, antibacterial soap, and disposable paper towels or air-dry equipment.

2. Needles
Contaminated needles and other contaminated sharps will not be bent, recapped, removed, sheared, or purposely broken.

3. Containers for Sharps
Contaminated sharps are to be placed immediately, or as soon as possible, after use into appropriate sharps containers. The containers are to be puncture resistant, leak proof, and labeled with a biohazard label. Sharps containers will be located in appropriate places as identified by the college. When the containers are one-half full, the sharps containers will be disposed of as per OSHA and college guidelines.

4. Disposal of Sharps Containers
When the sharps containers are one-half full  the maintenance department will be responsible for pick up and proper disposal according to college guidelines.

5. Personal Protective Equipment (PPE)
Gloves - The college will be responsible for ensuring that disposable gloves will be available for all employees.  Gloves shall be worn when it is "reasonably anticipated" that employees will have contact with blood, other potentially infectious materials, non-intact skin, mucous membranes, or when handling or touching contaminated items or surfaces.  Disposable gloves are not to be washed or decontaminated for re-use and are to be replaced as soon as practical when they become contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised.  Employees are instructed to place used gloves in lined wastebaskets and to wash hands immediately after use.  Utility gloves may be decontaminated or re-used provided that integrity of the glove is not compromised.  Utility gloves (leather, cloth, or latex) will be discarded if they are cracked, torn, punctured, or exhibit other signs of deterioration or when their ability to function as a barrier is compromised.

6. Housekeeping or Environmental Surfaces
Routine cleaning and soil removal from furniture and floors is sufficient for inactivation of microorganisms.  Cleaning of walls, blinds, and curtains is recommended only if they are visibly soiled by blood or other potentially infectious materials.

7. Regulated Waste Disposal
Disposable sharps - Contaminated sharps shall be discarded immediately or as soon as feasible in containers that are closable, puncture-resistant, leak proof on sides and bottom,  labeled,  and color-coded red.  Containers shall be maintained upright throughout use and replaced as needed.  When moving containers of contaminated sharps from the area of use, the containers shall be closed immediately prior to    removal or replacement to prevent spillage or protrusion of contents during handling, storage, transport, or  shipping.

Other regulated waste - Trash waste and disposable articles soiled with blood or other infectious body fluids will be bagged and labeled to identify the contents as "biohazardous" for proper transport and disposal purposes.

8. Laundry Procedures
Laundry contaminated with blood or other potentially infectious materials will be handled as little as possible.  Such laundry will be handled with protective gloves and placed in appropriately marked bags at the location where it is used.  Such laundry will not be sorted or rinsed in the area of use.

9. Hepatitis B Vaccine and Post-Exposure Evaluation and Follow-Up
The  College  shall make available the Hepatitis B vaccine and vaccination series to all employees who have occupational exposure, and post exposure follow-up, including prophylaxis. The vaccination shall be:

1. Made available at no cost to the employee;

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

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

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

All laboratory tests shall be conducted by an accredited laboratory.

Hepatitis B vaccinations shall be made available to those 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. This vaccination shall be made available at no cost to the employee.

The college is not responsible for antibody screening.

If the employee initially declines Hepatitis B vaccination but at a later date decides to accept the vaccination, the vaccination shall then be made available.  All employees who decline the Hepatitis B vaccination offered shall sign the OSHA/College Waiver indicating their refusal.

If a routine booster dose of Hepatitis B vaccine is recommended by the U.S. Public Health Service at a future date, such booster doses shall be made available at no expense to the employee.

Post Exposure Evaluation and Follow-Up - All exposure incidents shall be reported immediately, investigated, and documented.  When the employee incurs an exposure incident, it shall be reported to his/her dean or dean's office and to the Human Resource Department. Following a report of an exposure incident, the exposed employee shall receive a confidential medical evaluation and follow-up including at least the following elements:

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

2. Identification  and documentation of the source individual, when possible;

3. The source individual's blood shall be tested as soon as feasible and after consent is obtained in order to determine HBV and HIV infectivity.  If consent is not obtained, the Director of Human Resources shall establish that legally required consent cannot be obtained;

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

5. Results of the source individual's testing shall be made available to the exposed employee, and the employee shall be informed of the 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 blood status will comply as follows:

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

2. The employee will be offered the option of having his/her blood collected for testing of the employee's HIV/HBV blood status.  The blood sample will be preserved for up to 90 days to allow the employee to decide if the blood should be tested for HIV serological status.

All post exposure follow-up will be performed by the employee's health care provider.  The Director of   Human Resources shall ensure that the health care provider is provided with the following:

1. A  copy 29 CFR 1910.1030; (which outlines privacy requirements);

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

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

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

The Health Care Provider's Written Opinion - The Director of Human Resources shall obtain and provide the employee with a copy of the evaluation health care provider's written opinion within 15 days upon completion of the evaluation.

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

The health care provider's written opinion for post exposure follow-up shall be limited to the following information:  (All other findings for diagnosis shall remain confidential and shall not be included in the written report.)

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

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

10.  Labels and Signs
The Building and Grounds Supervisors shall ensure that biohazard labels shall be affixed to containers of regulated waste.  Red bags or the universal biohazard symbol shall be used.

11.  Information and Training
The Office of Human Resources shall ensure that training is provided at the time of initial assignment to   tasks where occupational exposure may occur and that it shall be repeated annually.  The person(s) conducting the training shall be knowledgeable in the subject matter.  Training shall be tailored to the education and language level of the employee and offered during the normal work shift.  The training will be interactive and cover the following:

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

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

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

4. An explanation of the college’s Bloodborne Pathogen Exposure Control Plan and a method of obtaining a copy;

5. The recognition of tasks that may involve exposure;

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

7. Information on the types, use, location, removal, handling, decontamination, and disposal of personal protective equipment;    

8. An explanation of the basis of selection of personal protective equipment;

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

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

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

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

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

All faculty will be informed of basic Bloodborne Pathogens Information, personal protective equipment, and the importance of post-exposure follow-up.

12.  Record Keeping
Medical records - The Director of Human Resources is responsible for maintaining medical records. These records will be kept  in accordance with OSHA Standard 29 CFR 1910.20.  These records shall be kept private and must be maintained for at least the duration of employment plus 30 years.  The records shall include the following:

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

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

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

4. A copy of the information provided to the health care provider, including a description of the employee's duties as they related to the exposure incident, and documentation of routes of exposure and circumstances of the exposure.

Training Records - The Office of Human Resources is responsible for maintaining training records. They will be maintained for three years from the date of the training.  The following information shall be documented and maintained:

1. The dates of the training sessions;

2. The outlines describing the material presented;

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

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

Availability - All employee records shall be made available to the employee in accordance with 29 CFR 1910.20.  All employee records shall be made available to the Assistant Secretary of Labor for the Occupational Safety and Health Administration and Director of the National Institute for Occupational Safety and Health upon request.

13.  Evaluation and Review
The Exposure Control Officer  (Director of Human Resources) is responsible for annually reviewing this program and its effectiveness and for updating the program as needed.

Contact HTC at 952-995-1300 or info@hennepintech.edu

Copyright © 2008 by Hennepin Technical College