Risk Management
Employee Safety Manual
Bloodborne Pathogens Exposure Control Plan
May 2007

Bloodborne Pathogens Exposure Control Plan

1.         PURPOSE:

1.1       The purpose of the John Wood Community College Bloodborne Pathogens Exposure Control Plan is to eliminate or minimize employee occupational exposure to blood or other potentially infectious bodily fluids or materials.  Other potentially infectious bodily fluids or materials include: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, amniotic fluid, saliva, and any body fluid visibly contaminated with blood.

2.         RESPONSIBILITY:

2.1       All John Wood Community College supervisors shall be responsible for ensuring their employees comply with the provisions of this plan.  The college is responsible for providing all necessary supplies such as personal protective equipment, soap, bleach, Hepatitis B Virus (HBV) vaccinations, etc.  Most of these supplies are available through the Physical Plant.  Any employee requiring supplies or personal protective equipment should contact their supervisor.  HBV vaccinations are available through the Office of Human Resources.  The Office of Campus Safety and Security is responsible for training JWCC employees.  The Physical Plant is responsible for disposing of bio-hazardous waste contained in biohazard bags.

3.         ENGINEERING AND WORK PRACTICE CONTROLS:

3.1       Universal precautions will be observed by all JWCC employees 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.  Engineering and work practice controls will be utilized to eliminate or minimize exposure to JWCC employees.

3.1.1    Employees must wash their hands or other skin with soap and water, or flush mucous membranes with water, as soon as feasible following an exposure incident (e.g. splash of blood to the eyes or accidental needle stick).

3.1.2    Employees must wash their hands with soap and water immediately or as soon as feasible after removal or gloves or other personal protective equipment.  Employees should familiarize themselves with the nearest hand washing facilities for the buildings in which they work.

3.1.3    JWCC employees who encounter improperly disposed needles shall notify Campus Safety and Security of the location of the needle(s).  Needles shall be disposed of in labeled sharps containers available through Campus Safety and Security.  If sharps containers are not immediately available at the location where the needle(s) was found, Campus Safety and Security will pick up and dispose of the needle(s) in an appropriate labeled sharps container.

3.1.3.1             Needles should never be recapped.

3.1.3.2             Needles may be moved or picked up only by using a mechanical device or tool (e.g. forceps, pliers, broom and dust pan).

3.1.4    Breaking or shearing needles is prohibited.

3.1.5    No eating, drinking, smoking, applying cosmetics or lip balm, or handling contact lenses is allowed in a work area where there is a reasonable likelihood of occupational exposure.

3.1.6    No food or drinks shall be kept in refrigerators, freezers, cabinets, shelves, or on counter tops or bench tops where blood or other potentially infectious materials are present.

3.1.7    Employees performing procedures involving blood or other potentially infectious materials must do so in such a manner as to minimize splashing, spraying, splattering, and generation of droplets of these substances.

4.         HOUSEKEEPING:

4.1       Decontamination will be accomplished by utilizing the following materials:

4.1.1    10% (minimum) solution of chlorine bleach

4.1.2    Lysol or other EPA registered disinfectants

4.2       All contaminated work surfaces, tools, objects, etc. will be decontaminated immediately or as soon as feasible after any spill of blood or other potentially infectious materials.  The bleach solution or disinfectant must be left in contact with contaminated work surfaces, tools, objects, or other potentially infectious materials for at least ten (10) minutes before cleaning.

4.3       Equipment that may become contaminated with blood or other potentially infectious materials will be examined and decontaminated before servicing or use.

4.4       Broken glassware will not be picked up directly with the hands.  Employees should sweep or brush material into a dustpan.

4.5       Known or suspected contaminated sharps shall be discarded immediately or as soon as feasible in a container that is closable, puncture-resistant, leak-proof on sides and bottom, and marked with an appropriate biohazard label.

4.6       When containers of contaminated sharps are being moved from the area of use or discovery, the containers shall be closed immediately before removal or replacement to prevent spillage or protrusion of contents during handling, storage, transport, or shipping.

4.7       Reusable containers shall not be opened, emptied, or cleaned manually or in any other manner that would expose employees to the risk of percutaneous injury.

5.         OTHER REGULATED WASTE:

5.1       Other regulated waste shall be placed in containers that are closable, constructed to contain all contents and prevent leakage of fluids during handling, storage, transportation, or shipping.

5.2       The waste must be labeled and closed before removal to prevent spillage or protrusion of contents during handling, storage, or transport.

5.3       Biohazard bags and labels are available from Campus Safety and Security.

5.4       Removal of bio-hazardous waste shall be handled by the Physical Plant.  Employees requiring removal of properly discarded bio-hazardous waste should contact the Physical Plant to arrange for its removal.

6.         LAUNDRY PROCEDURES:

6.1       Laundry contaminated with blood or other potentially infectious materials will be handled as little as possible.  Such laundry will not be sorted or rinsed in the area of use.  The Physical Plant will coordinate cleaning or disposal of contaminated laundry.

7.         PERSONAL PROTECTIVE EQUIPMENT:

7.1       Where occupational exposure remains after the institution of engineering and work controls, personal protective equipment shall also be utilized in accordance with the college’s procedure titled Personal Protective Equipment (PPE).

7.2       The college will provide gloves, face shields, masks, eye protection, and aprons at no cost to employees.  Employees requiring personal protective equipment should contact their supervisor.

7.3       All personal protective equipment will be chosen based on the anticipated exposure to blood or other potentially infectious materials.  The personal protective equipment will be considered appropriate only if it does not permit blood or other potentially infectious materials to pass through or reach the employee’s clothing, skin, eyes, mouth, or mucous membranes under normal conditions of use and for the duration of time for which the personal protective equipment will be used.

7.4       Employees must:

7.4.1    Utilize personal protective equipment in occupational exposure situations.

7.4.2    Remove garments that become penetrated by blood or other potentially infectious materials immediately or as soon as feasible.

7.4.3    Replace all garments that are torn or punctured, or that lose their ability to function as a barrier to bloodborne pathogens.

7.4.5    Remove all personal protective equipment before leaving the work area.

7.4.6    Place all garments in the appropriate designated area or container for storage, cleaning, decontamination, or disposal and notify the Physical Plant.

8.         HEPATITIS B VIRUS (HBV) VACCINE:

8.1       The Hepatitis B Virus (HBV) vaccination shall be made available after the employee has received the training in occupational exposure and within ten (10) working days of initial assignment.  Employees accepting the HBV vaccination will sign the Hepatitis B Virus (HBV) Vaccine Acceptance Form (Appendix A).

The HBV vaccination shall be made available to all employees who have potential occupational exposure unless the employee has previously received the complete HBV vaccination series, antibody testing has revealed that the employee is immune, or the vaccine is contraindicated for medical reasons.  Employees who have already received the HBV vaccine must sign the Hepatitis B Virus (HBV) Vaccine Confirmation Form (Appendix B).

8.2       If the employee initially declines the HBV vaccination, but at a later date decides to accept the vaccination, the vaccination shall then be made available.

8.3       All employees who decline the HBV vaccination shall sign the required Hepatitis B Virus (HBV) Vaccine Declination Form (Appendix C) indicating their refusal.

8.4       If a routine booster dose of the HBV vaccine is recommended at a future date, such booster doses shall also be made available at no cost to the employee.

8.5       The HBV vaccination shall be offered to all employees in the Physical Plant and Campus Safety and Security, Health Sciences Faculty, volunteer first responders, and any other positions deemed appropriate to receive the vaccination.

9.         POST-EXPOSURE EVALUATION AND FOLLOW-UP:

9.1       All exposure incidents shall be reported, investigated, and documented in accordance with the college’s procedure titled Accident Investigation.  When the employee incurs an exposure incident, the employee should immediately report the incident to their supervisor and to Campus Safety and Security.

9.2       Following a report of an exposure incident, the exposed employee shall go to the Office of Human Resources to get information on receiving a confidential medical evaluation and follow-up, including at least the following elements:

9.2.1    Documentation of the route(s) of exposure.

9.2.2    A description of the circumstances under which the exposure occurred.

9.2.3    If possible and within legal limits, the identification and documentation of the source individual.

9.2.4    The collection and testing of the source individual’s blood for HBV and HIV serological status.

9.2.5    When medically indicated, post-exposure treatment for the employee.

9.2.6    Counseling.

9.2.7    Evaluation of any reported illness.

9.3       The Healthcare professional evaluating the exposed employee will be provided with the following information:

9.3.1    A copy of this Bloodborne Pathogens Exposure Control Plan.

9.3.2    A copy of the OSHA Bloodborne Pathogens Standard (29 CFR 1910.1030).

9.3.3    Documentation of the route(s) of exposure.

9.3.4    A description of the circumstances under which the exposure occurred.

9.3.5    Results of the source individual’s blood testing, if available.

9.3.6    All medical records applicable to treatment of the employee, including vaccination status.

9.4       The employee will receive a copy of the evaluating healthcare professional’s written opinion within fifteen (15) days of the completion of the evaluation.

9.5       The healthcare professional’s written opinion for HBV vaccination is limited to the following:

9.5.1    Whether the employee needs the HBV vaccination.

9.5.2    Whether the employee has received such a vaccination.

9.6       The healthcare professional’s written opinion for post-exposure evaluation and follow-up is limited to the following information:

9.6.1    That the employee was informed of the results of the evaluation.

9.6.2    That the employee was informed about any medical conditions resulting from exposure to blood or other potentially infectious materials that require further evaluation or treatment.

9.7       All other findings or diagnoses will remain confidential and will not be in a written report.

9.8       All medical evaluations shall be made by or under the supervision of a licensed physician or by or under the supervision of another licensed healthcare professional.  All laboratory tests must be conducted by an accredited laboratory at no cost to the employee.  All medical records will be maintained by the Office of Human Resources in accordance with 29 CFR 1910.1020.

10.       TRAINING:

10.1     All JWCC employees are required to participate in a training program.  JWCC conducts its Bloodborne Pathogens training online using the college’s intranet.  Training will occur at orientation, before assignment to a task where occupational exposure may take place, and at least annually thereafter.  Additional training will be provided when changes such as modification of tasks or procedures affect the employee’s occupational exposure.

10.2     Any employee with the potential for being exposed to blood or other potentially infectious materials shall receive training, even if the employee was allowed to receive the HBV vaccination after exposure.

10.3     The training program will include at least the following elements:

10.3.1  An accessible copy of the regulatory text of 29 CFR 1910.1030 and an explanation of its contents.

10.3.2  A general explanation of the epidemiology and symptoms of bloodborne diseases.

10.3.3  An explanation of the modes of transmission of bloodborne pathogens.

10.3.4  An explanation of the college’s exposure control plan and the means by which the employee can obtain a copy of the written plan.

10.3.5  An explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood or other potentially infectious materials.

10.3.6  An explanation of the use and limitations of methods that will prevent or reduce exposure, including appropriate engineering and work controls, work practices, and personal protective equipment.

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

10.3.8  An explanation of the basis for selection of personal protective equipment.