Bloodborne Pathogen Exposure Control Plan

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HUMAN RESOURCES POLICY MANUAL

TOPIC:                       Bloodborne Pathogen Exposure Control Plan
EFFECTIVE DATE:     1 November 2009
Reviewed/Revised Date:
Approved By:            B. Reissenweber, VP for Finance
Policy Number:         212

Developed in accordance with the OSHA Bloodborne Pathogens Standard, 29 CFR 1910.1030

POLICY: 

Aurora University is committed to providing a safe and healthful work environment for faculty, staff and students.  In pursuit of this goal, the Bloodborne Pathogen Exposure Control Plan is provided to eliminate or minimize employee occupational exposure to blood or other potentially infectious materials (OPIM). 
The plan also includes provisions for employees at risk of occupational exposure to receive Hepatitis B vaccinations, training, and if necessary confidential medical evaluations.

EXPOSURE DETERMINATION:

The following Aurora University employees have been determined to be at risk for occupational exposure to blood or OPIM and as such must comply with the procedures and work practices outlined in this Bloodborne Pathogen Exposure Control Plan. 

  • Wellness Center Staff (AUR)
  • Campus Safety (AUR and GWC)
  • Athletics and Physical Education  (Athletic Trainers, Coaches, Faculty)
  • Health Science Lab Faculty and Lab Assistants
  • Recreation Administration (GWC Faculty, Graduate Assistants)
  • Residence Life (Professional Staff)
  • Lifeguards (GWC)

UNIVERSAL PRECAUTIONS:

All employees will observe universal precautions when performing any task which may result in occupational exposure to blood or other potentially infectious body fluid.  Universal precautions treat all blood and certain body fluids as if they were infected with bloodborne pathogens.

OPIM include: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid visibly contaminated with blood, and all body fluids where it is difficult to differentiate between body fluids. 

RESPONSIBILITY:

Responsibility for implementing and carrying out this policy is shared by several areas:

  • Departmental supervisors shall be responsible for ensuring their employees comply with the provisions of this plan. 
  • Human Resources (Aurora/GWC) and the Director of Facilities (GWC) shall be responsible for training employees.
  • Physical Properties is responsible for providing necessary supplies such as personal protective equipment, spill kits, soap, bleach, etc.  Supplies are available in the Physical Properties Supply Department.
  • Human Resources arranges for Hepatitis B vaccinations which are available through the local Occupational Health services.
  • Human Resources tracks and maintains appropriate training records, Hepatitis B vaccination records and declinations, and exposure records and reporting.
  • Physical Properties shall be responsible for disposing of biohazardous waste contained in biohazard bags. 

ENGINEERING AND WORK PRACTICE CONTROLS:

The following engineering and work practice controls will be utilized to minimize exposure to employees working at Aurora University. 

  1. Employees must wash their hands or other skin with soap and water, or flush mucous membranes with water, as soon as possible following an exposure incident (such as a splash of blood to the eyes or an accidental needle stick). **
  2. Employees must wash their hands immediately (or as soon as feasible) after removal of gloves or other personal protective equipment.**
    **Employees shall familiarize themselves with the nearest hand washing facilities for the buildings in which they work.  Most AU buildings will have available hand washing facilities in restrooms and custodial/janitorial closets. 
    (If hand washing facilities are not readily available, Physical Properties will provide either an antiseptic cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes.  If these alternatives are used, then the hands are to be washed with soap and water as soon as feasible.)
  3. Spill kits with sharps containers are available to Campus Safety, Residence Life, the Head Athletic Trainer, Laboratories, and the Wellness Center.  The director of each department is to notify Physical Properties as needed for replenishment of supplies.  Spill kits will be checked by Physical Properties (Aurora Campus and GWC) annually and on an as needed basis.
  4. Employees or students who encounter improperly disposed needles, blood and/or OPIM shall notify the following departments immediately: Campus Safety on the Aurora Campus, and the appropriate department as follows on the George Williams Campus (Physical Properties Department during the day and Campus Safety during the night).
  5. Campus Safety and/or Physical Properties will dispose of needles in the following manner:
    1. Needles shall be disposed of in labeled sharps containers provided at the location. 
    2. Needles should never be recapped.
    3. Needles may be moved or picked up only by using a mechanical device or tool (forceps, pliers, broom and dust pan).
    4. Breaking or shearing of needles is prohibited.
    5. If sharps containers are not available at that location, needles or other sharps will be disposed of in an appropriate, labeled sharps container supplied in Spill kits.
      Additionally, the appropriate authorities at the location shall be notified (i.e., Director of the School of Nursing, Dean of Student Life (AUR and GWC)).
  6. 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.
  7. No food or drinks shall be kept in refrigerators, freezers, cabinets, shelves, or on counter tops or bench tops where blood or OPIM are present.
  8. Employees must perform all procedures involving blood or other potentially infectious materials in such a manner as to minimize splashing, spraying, splattering, and generation of droplets of these substances.

Blood & OPIM Clean Up

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.  Decontamination will be accomplished by utilizing 10% bleach solution or other EPA-registered disinfectant.  The bleach solution or disinfectant must be left in contact with contaminated work surfaces, tools, objects, or potentially infectious materials for at least 10 minutes before cleaning, or per product instructions.

Clean Up Procedure

  • Avoid splashing.  Do not spray or pour decontamination solution directly on blood or OPIM.
  • Open up a red biohazard bag with edges turned down; put on gloves and appropriate personal protective equipment; place paper towels over the spill and allow fluid to be absorbed.  Do not pat.  Dispose of used paper towels in the red biohazard bag.  Repeat until the fluid residue is absorbed.
  • Pour decontamination solution on paper towels and allow it to be absorbed to wipe up any remaining residue.  Lastly, rinse the area with the decontamination solution.
  • Remove gloves and any other personal protective equipment.  Place them in the red biohazard bag and close without touching the inside surface.  Double bag with an additional red biohazard bag if the outside of the bag is contaminated or if leaking.
  • Place red biohazard bag in approved biohazard containers.  Approved biohazard containers are located within the Wellness Center, janitor closet in each residence hall, Nursing Department Lab, and Athletic Training room.  In the event that a red biohazard bag is placed within biohazard container in the janitor closet, the individual placing the bag in such location, will send an e-mail to Physical Properties, informing of the need to remove filled container for incineration.  All biohazard bags should be placed in an approved container within the building in which biohazard material was found.
  • If biohazard material is found outside of a building, or within a building for which there is no approved biohazard container, then Physical Properties and/or Campus Safety should be notified for proper clean up and removal of biohazard waste/bag to appropriate receptacle.
  • Wash hands with soap and water immediately or as soon as feasible. 

Management of Contaminated Sharps

  • Secure the area.
  • Broken glassware will not be picked up directly with the hands, even when wearing gloves.  Sweep or brush material into a dustpan and/or use plastic scoopers from spill kits.
  • Known or suspected contaminated sharps shall be discarded immediately or as soon as feasible in approved red biohazard puncture resistant containers located in campus spill kits. Do not force contaminated sharps into red biohazard containers; if contaminated sharps are too large to fit into red biohazard container, notify Campus Safety immediately for further advisement.
  • 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.
  • Reusable, portable red biohazard puncture resistant containers shall not be opened, emptied, or cleaned manually or in any other manner that would expose employees to the risk of percutaneous/exposure injury.

REMOVAL OF CONTAMINATED WASTE

Incineration of biohazardous waste shall be handled by a biological waste destructor.  This shall be coordinated through the Physical Properties department.

LAUNDRY PROCEDURES

  1. Contaminated clothing will be handled as little as possible.  Workers who handle potentially infectious clothing will wear appropriate personal protective equipment such as gloves.  Gowns and eye protection will be worn if gross contamination is present.
  2. Contaminated clothing will be bagged at the location where it was used and transported in leakproof containers labeled with the biohazard symbol.  Laundry will not be sorted or rinsed at the location of use.
  3. Contaminated laundry will be laundered by properly trained personnel or picked up by a commercial laundry service.  Dry cleaning is acceptable.
  4. For handling/management of laundry contaminated in relation to intercollegiate athletic participation, please reference the Athletics procedures located in the Athletics office.

ARTIFICIAL TURF PROCEDURES (VAGO FIELD, AURORA CAMPUS)

  1. The synthetic field is rinsed once per week during the sports season if sufficient rain does not occur in that time period.  Rinsing is completed before 7AM on the scheduled day. 
  2. Any bloodborne pathogens are spot cleaned using a 4 parts water to 1 part bleach ratio per Prograss recommendations. 
    1. The solution is sprayed directly on turf fibers, and the fibers wiped down. 
    2. The infill is removed with a shop vac and replaced with sand rubber equivalent to what was removed. 
  3. Bleach solution needs to be mixed at the time of use so that the bleach does not lose its effectiveness.

PERSONAL PROTECTIVE EQUIPMENT

Where occupational exposure remains after institution of engineering and work controls, personal protective equipment shall also be utilized. 

Physical Properties or the academic area will provide gloves, face shields, masks, eye protection, and gowns at no cost to employees in jobs that include occupational exposure.  Personal protective equipment will be replaced or repaired as necessary at no cost to employees.

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

Employees must:

  • Utilize protective equipment in occupational exposure situations.
  • Remove garments that become penetrated by blood or OPIM as soon as feasible.
  • Notify their supervisor of any protective equipment/garments that are torn or punctured, or that lose their ability to function as a barrier to bloodborne pathogens, and must wear only protective equipment that is functional.
  • Remove all personal protective equipment before leaving the work area.
  • Place all garments in the appropriate designated area or container for storage, cleaning, decontamination, or disposal as determined by the department.
  • Notify department supervisor of spill kit use and need for replenishment of supplies as indicated.
  • Home laundering is not permitted.

HEPATITIS B VACCINE (HBV)

The Hepatitis B vaccine shall be made available at no cost to employees who have potential 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 Hepatitis B vaccination shall be made available after the employee has received the training in occupational exposure and within 10 working days of initial assignment.  Human Resources will provide verbal and written notice of Hepatitis B vaccination availability to at risk employees upon hire. 

Employees may initially decline the Hepatitis B vaccination, but can change their mind at a later date   and receive the vaccination.

All employees who decline the Hepatitis B vaccination shall sign the OSHA-required Hepatitis B declination statement.

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

POST-EXPOSURE EVALUATION AND FOLLOW-UP

Involving a needle stick or other potential exposure to a bloodborne pathogen by an employee:

  1. Cleanse the wound and surrounding area with soap and water (for a needle stick), or flush eyes, nose, or mouth with copious amounts of tap water (for a splash to the face or non-intact skin). 
  2. Notify your supervisor immediately
  3. Report to local Occupational Health service, or to the emergency room if Occupational Health Services is closed.  Inform front desk staff that you experienced an occupational blood or body fluid exposure covered by Aurora University’s Workers Compensation Insurance. 
  4. Complete the Aurora University Occupational Bloodborne Pathogen Exposure Incident form (available linked to this policy, in Campus Safety and in Human Resources) within 24-hours of your exposure, and send a copy to Human Resources. 

Following an exposure incident, the exposed employee shall go to the designated Occupational Health Provider for a confidential medical evaluation and documentation of the following:

  1. The route(s) of exposure.
  2. A description of the circumstances under which the exposure occurred.
  3. Post-exposure treatment for the employee, when medically indicated in accordance with the U.S. Public Health Service.
  4. The identification and documentation of the source individual.  (The identification is not required if the employer can establish that identification is impossible or prohibited by state or local law.)
  5. The collection and testing of the source individual's blood for HBV and HIV serological status.
  6. Counseling.
  7. Evaluation of any reported illness.

TRAINING

All at-risk employees shall participate in a training program upon hire and annually thereafter in accordance with OSHA standard 1910.1030(g)(2).  Training will occur before assignment to a task where occupational exposure is present.  Additional training will be provided when changes such as modification of tasks or procedures affect the employee's occupational exposure. Training is considered valid for one year from training date. 

Any employee who is exposed to infectious materials shall receive training, even if the employee was allowed to receive the HBV vaccine after exposure.

Training Outline

New Hire (identified as “at-risk”)

Within 10 working days of date of hire:

  • The employee will make an appointment for a training session with a member of Human Resources as part of the new hire orientation process.
  • Complete the Bloodborne Pathogen training session. 
  • As part of the training program, the Hepatitis B vaccine information along with acceptance and declination forms, and a copy of this policy shall be provided to each participant.
  • Receive a copy of a “certificate of completion,” and informed that the certificate should be shown to their supervisor.
  • A copy of the certificate of completion shall be placed in the employee’s Personnel file, and information entered into the employee’s records. 

Annual Training

  • Training sessions will be held on each campus during fall semester of each year.
  • Human Resources will notify supervisors of employees covered by the Blood Borne Pathogens program who are required to attend.
  • Each employee must sign a training log to indicate attendance.  Records will be maintained in Human Resources.
  • Employees who are not covered by this policy are welcomed to attend training.

Bloodborne Pathogen Trainer Responsibilities

The following is a list of approved Bloodborne Pathogen Trainers:

  • Director, Associate Director of Human Resources, and Human Resources Assistant
  • Director of Athletics
  • Dean of Student Life (GWC)
  • Director of Facilities, Facilities Manager, Sodexo Services

The following information will be addressed by the assigned trainer during the training session:

  • Review of Aurora University’s Bloodborne Pathogen Exposure Plan and the OSHA fact sheets.
  • Information on types, proper use, location, and disposal of personal protective equipment at Aurora University.
  • Application of knowledge through scenario discussion.
  • Review Hepatitis B vaccine information.
  • Opportunity for questions and answers.

Oversight & Enforcement

Tracking and enforcement of employee bloodborne pathogen training is the responsibility of Human Resources.  Human Resources will train new hires during their new hire process. In addition, Human Resources will notify at-risk employees of need for renewal of annual training session.  

For previously identified at-risk employees that fail to complete the training upon hire and/or annually, Human Resources will at 30-days and at 60-days provide a written notice to both the employee and their supervisor indicating that training has not been completed.  Sessions will be held as needed to complete training.

Forms

Exposure Incident Report

Hepatitis B Vaccine Acceptance Statement

Hepatitis B Vaccine Declination Statement