BLOODBORNE PATHOGENS

EXPOSURE CONTROL PLAN

PRINCETON UNIVERSITY

[DEPARTMENT]

(GROUP/LAB)

 

I. INTRODUCTION

Princeton University maintains an ongoing effort to provide a safe working environment. As part of that effort, the [ DEPARTMENT] has implemented this plan which is intended to reduce the risk of exposure to bloodborne pathogens for all those working in the [DEPARTMENT] who may have such exposure as part of their official duties. This written plan is intended to comply with the requirements of the federal Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard (29CFR 1910.1030).

 

II. REVIEW OF EXPOSURE CONTROL PLAN

The [DEPARTMENT] is responsible for the review and updating of this Exposure Control Plan at least annually and whenever necessary to reflect new or modified tasks that have an impact on individual exposure. A copy of this plan is maintained [ where Plan can be found ] for access by individuals in the [DEPARTMENT] and for representatives of OSHA upon request.

Date of Preparation____________________

Revision Date_________________________

Reviewed/Revised by __________________

III. DEFINITIONS

A. Exposure:

Reasonably anticipated skin, eye, mucous membrane, or parenteral (injection or puncture) contact with blood or other potentially infectious materials (OPIM) as a result of performing official duties.

B. Other Potentially Infectious Materials (OPIM):

    1. These 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 tell the difference between body fluids.

    2. Any unfixed tissue or organ (other than intact skin) from a human (living or dead)

    3. HIV(Human Immunodeficiency Virus)-containing cell or tissue

C. In the text of the Plan that follows, when the term "blood" is used, it includes human blood and OPIM as defined above.

D. "Good Samaritan" acts, such as helping a fellow worker with a nosebleed or cut finger, are not considered official duties or exposures covered under this plan.

 

IV. EXPOSURE DETERMINATION

Each department or affected group must determine if there are job classifications and work activities in which there are possible exposure to bloodborne pathogens. The [DEPARTMENT] has determined that the following job classifications and tasks have the potential for reasonably anticipated exposure to bloodborne pathogens, regardless of whether protective equipment is used by the employee.

A. Job classifications which include employees whom all have occupational exposure:

(i.e. nurse, proctor)

 

 

 

B. Job classifications which include employees some of whom have occupational exposure:

(i.e. janitor )

 

 

 

1. Tasks, procedures, or groups of closely-related tasks/procedures in which occupational exposure occurs to some of those in the jobs listed in B above: (i.e. janitorial duties in McCosh Health Center )

 

V. METHODS OF COMPLIANCE

The following practices, procedures and control measures are used or have been instituted to minimize or eliminate exposure to blood.

A. UNIVERSAL PRECAUTIONS - All blood is assumed to be and is treated as if infected. Individuals exposed to direct contact with blood must take the necessary precautions to protect themselves from infection.
  1. WORK PRACTICE AND ENGINEERING CONTROLS

1. Accessible handwashing facilities with soap and disposable towels or antiseptic towelettes are available and used after removing gloves, following patient care, or after any other contamination of the hands. If disposable towelettes are used, handwashing with soap and running water is done as soon as practical.

2. After direct contact with blood or after patient contact, touching of the mouth, eyes, or other mucous membranes is avoided until hands have been thoroughly washed.

    1. Contaminated needles are not bent, recapped, removed, sheared, or broken. If circumstances call for recapping, only a one-handed "scoop" technique or mechanical device is used.

[Specify any known need to recap or remove needles.]

4. There is no eating, drinking, smoking, applying cosmetics or lip balm, or handling contact lenses in work areas with possible exposure.

5. Food or drink is not stored or kept in areas with blood exposure.

6. Procedures involving blood or blood exposure are done in a way to minimize splash, spray, spattering, or generation of droplets.

7. Mouth pipetting is not allowed.

C. PERSONAL PROTECTIVE EQUIPMENT

    1. Personal protective equipment (PPE) appropriate to the tasks being performed is provided and must be used. PPE is made available in the appropriate sizes and is readily accessible. For those allergic to the normal gloves provided, alternatives such as hypoallergenic gloves or glove liners, are made available.

2. Any cleaning, laundering, repairing, replacing, and disposing of PPE is the responsibility of the [DEPARTMENT]. If an outside laundry service is contracted, the [DEPARTMENT] informs the service that the laundry is a potential biohazard and the service must, therefore, be capable of handling such laundry.

3. The PPE equipment checked below is provided: [Check those that are provided and list any additional items under "other"]

_____ Gloves _____ Gowns _____Lab Coats _____Face Shields/Masks _____ Eye Protection

_____ Eye Protection _____ Mouth Pieces _____ Resuscitation Bags _____ Pocket Masks

_____Other Ventilation Devices _____Other __________________________________________

4. PPE Use

 

D. HOUSEKEEPING

    1. The worksite is kept in a clean and sanitary condition.

2. A written schedule and procedure for cleaning and decontamination of blood-soiled surfaces is in place and is followed. Minimally, equipment, environmental, and working surfaces are cleaned and decontaminated after a spill or procedure resulting in contamination. [Indicate the cleaning schedule and measures in use by revising and/or adding to the examples listed in the table below:]

SCHEDULE FOR CLEANING AND METHOD OF DECONTAMINATION

ITEM OR AREA

METHOD OF DECONTAMINATION

CLEANING SCHEDULE

COMMENTS

Work Surfaces

Wash with 1:10 bleach solution.

After the completion of procedures or end of work shift which involved contamination. When surfaces become obviously contaminated.

  

Reuseable Resuscitation Mask

Wash with hot soap and water. After each use disinfect with alcohol.

After each use

  

 

      

 

 

      

 

 

      

 

 

      

 

 

      

 

3. Housekeeping Procedures

 

VI. HEPATITIS B VACCINATION

After determination of those who are potentially exposed, those individuals are offered, at department expense, vaccination for the prevention of hepatitis B. New employees assigned to positions with exposure are offered this vaccination within 10 working days. McCosh Health Center administers the vaccination. If a health care professional from outside the University provides the hepatitis B vaccination to the exposed individual, McCosh Health Center gives a copy of the OSHA Standard to the health care provider.

If declining to receive the offered vaccination, the individual signs a hepatitis B declination form available from Occupational Medicine. If the individual later decides to accept the vaccination, it is provided at that time. Except for an individual declining the hepatitis B vaccination, the only acceptable circumstances for not providing this vaccination are that 1) the individual has previously received the complete hepatitis B vaccination series, or 2) antibody testing has revealed that the individual is immune, or 3) the vaccination is not recommended for medical reasons.

 

VII. POST EXPOSURE EVALUATION AND FOLLOW-UP

In the event of an exposure incident, the post exposure procedures as outlined below are followed.

The exposed individual’s blood is collected as soon as feasible and tested, provided consent is received. Collected blood is held for up to 90 days awaiting consent for HIV testing if consent is not given initially. Testing of the baseline sample is done if consent is given within the 90-day period.

During the post exposure evaluation and examination at McCosh, the route and circumstance of exposure is determined and recorded. An accident investigation is conducted by Environmental Health and Safety, as necessary. Every attempt is made to determine the source of the blood and have it tested for HBV and HIV infection and document the results of testing. The results of the source blood testing is made available to the exposed individual along with information about the laws concerning disclosure of the identity and infectious status of the source individual.

Post-exposure prophylactic treatment, when medically indicated; counseling; and evaluation of reported illnesses is provided by McCosh Health Center and documented in the individual’s medical record.

 

XIII. INFORMATION PROVIDED FOR AND BY THE HEALTH CARE PROFESSIONAL

A. If a health care professional from outside the University provides post-exposure evaluation, the following information is given to that person by McCosh Health Center:

1. A description of the exposed individual’s duties as they relate to the exposure incident.

2. Documentation of the route(s) of exposure and circumstances under which exposure occurred.

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

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

B. The health care professional’s written opinion (whether from an outside source or McCosh staff )is provided by McCosh Health Center to the exposed individual within 15 days of the completion of the evaluation and included in the patient chart. The written opinion regarding hepatitis B vaccination is limited to whether hepatitis B vaccination is indicated for the exposed person and if the person has received such vaccination. The written opinion for post-exposure follow-up is limited to the following information:

1. That the individual has been informed of the results of the evaluation, and

2. That the individual has been told about any medical conditions resulting from exposure to blood which require further evaluation or treatment.

C. All other findings or diagnoses remain confidential and are not included in the written report.

 

IX. COMMUNICATION OF HAZARDS

A. Warning Labels

    1. Warning labels using the standard biohazard symbol, wording, and coloration are provided on containers of regulated waste; contaminated equipment; refrigerators and freezers containing blood; other containers used to store, transport, or ship blood, except that:

    2. Red bags or red containers may be used instead of labels.

    3. Individual containers of blood placed in a labeled container for storage, transport, shipment, or disposal need not be individually labeled.

    4. Regulated waste that has been decontaminated need not be labeled.

B. Information and Training

Initial training is provided to all individuals upon assignment to tasks involving determined exposure and is supplemented when there are changes in tasks or procedures that will affect exposure.

Annual training is provided to individuals within one year of previous training. The [DEPARTMENT] arranges for the general training (Initial and Annual) which is given by Environmental Health and Safety and/or Occupational Medicine. The [DEPARTMENT] is responsible for providing the more task-specific training and supervision.

Interim training is arranged through and provided by Occupational Medicine at McCosh Health Center and is designed to accommodate individuals who begin exposure-related work assignments between the times when formal training is scheduled. This training is documented on Interim Training Form, Appendix D.

The elements of the general training program are outlined in Appendix C.

 

X. RECORDKEEPING

A. Medical records for all exposed individuals are maintained by McCosh Health Center for the duration of the individual’s employment plus 30 years. These records include:

    1. The name and social security number of the individual

    2. The individual’s hepatitis B vaccine status

    3. A copy of information provided to the outside health care professional

    4. A copy of all results of examinations, medical testing, and follow-up procedures

    5. A copy of the health care professional’s written opinion

B. Medical records are available upon request for examination and copying to the subject individual, anyone having the written consent of the subject individual, and representatives of OSHA.

C. Training records are maintained for a minimum of 3 years from the training date by the [DEPARTMENT]. These records include the following information:

    1. The date of the training

    2. The content or summary of the training

    3. The names and qualifications of persons conducting the training

    4. The names, signatures, and job titles of all individuals attending the training session

D. Training records are provided upon request for examination and copying to the subject individual, employee representatives, and representatives of OSHA.

 

XI. Administrative Responsibilities

A. Department

    1. Determine those at risk of exposure.
    2. Complete and implement Exposure Control Plan

2. Provide for annual review and revisions of Plan, as necessary

3. Ensure that those exposed attend the required initial and annual training

4. Maintain a copy of the current Exposure Control Plan and training records

5. Offer and encourage hepatitis B vaccination for all exposed

6. Provide the necessary PPE and engineering controls to eliminate or reduce exposure

B. Supervisor

1. Ensure that those exposed attend the required training

2. Provide the task specific training for individuals

3. Complete Report of Accidental Injury or Occupational Illness following exposure events

4. Ensure that those exposed have available and use the appropriate personal protective equipment and that "Universal Precautions" are followed

C. EHS/Occupational Medicine
    1. Conduct initial, annual, and interim training
    2. Provide copies to training records to the Department

D. EHS

1. Provide assistance in meeting OSHA standard

2. Investigate exposure incidents, as necessary

3. Audit department program periodically

E. McCosh Health Center
    1. Maintain medical records of those exposed
    2. Provide interim training, as necessary
    3. Provide medical surveillance to include administration of hepatitis B vaccine and medical follow-up for exposures
    4. Provide treating health care professional with a copy of the OSHA standard and all required information and records regarding the patients exposure
    5. Provide the exposed individual with the health care professional’s written opinion and place copy in the patient’s chart

F. Individual

1. Attend the provided training and understand the risk associated with the job

2. Consider seriously the offer of hepatitis B vaccination

3. Follow the appropriate practices and procedures established for the work environment to limit or prevent exposures, and adopt the principle of "Universal Precautions"

4. Report any exposures to supervisory personnel and undertake any necessary medical review or treatment

 

APPENDICES

Appendix A - Text of the OSHA Bloodborne Pathogens Standard

Appendix B - Informed Consent/Waiver Form

Appendix C - Training Program Elements

Appendix D - Interim Training Form (EHS-SAN Form #13)

Appendix E - Completed Training Attendance List (EHS-SAN Form #14)