Bloodborne Pathogens Exposure Control Plan

Purpose

Bryant University is committed to the safety of all employees and aims to facilitate a safe, healthy working environment. The purpose of this Exposure Control Plan (ECP) is to eliminate or minimize employee occupational exposure to bloodborne pathogens in accordance with OSHA standard 29 CFR 1910.1030, Occupational Exposure to Bloodborne Pathogens.

Copies of the plan will be stored in the Risk Management and Safety office as well as the Bryant Shared Drive. Copies will be made available to an employee at any time.

Scope

This Bloodborne Pathogens (BBP) Exposure Control Plan (ECP) applies to all Bryant University employees University who, during the course of their employment, may come into contact with blood or other potentially infectious materials. Other potentially infectious materials (OPIM) include the following human body fluids: semen, vaginal secretions, cerebrospinal fluid, amniotic fluid, or 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.

This ECP includes the following:

• Implementation of various methods of exposure control, including:
  • Universal precautions;
  • Engineering and work practice controls;
  • Personal protective equipment;
  • Housekeeping;
• Hepatitis B vaccination;
• Post-exposure evaluation and follow-up;
• Communication of hazards to employees and annual training;
• Recordkeeping; and
• Procedures for evaluating circumstances surrounding exposure incidents.

Section 5 of this Plan designated some specific roles at the University that may have occupational exposure.

Definitions

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.

Contaminated Sharps means any contaminated object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires.

Decontamination means the use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal.

Engineering Controls means controls (e.g., sharps disposal containers, self-sheathing needles, safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the bloodborne pathogens hazard from the workplace.

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.

Handwashing Facilities means a facility providing an adequate supply of running potable water, soap, and single-use towels or air-drying machines.

Licensed Healthcare Professional is a person whose legally permitted scope of practice allows him or her to independently perform the activities required by paragraph (f) Hepatitis B Vaccination and Post-exposure Evaluation and Follow-up.

HBV means hepatitis B virus.

HIV means human immunodeficiency virus.

Needleless systems mean a device that does not use needles for:

1. The collection of bodily fluids or withdrawal of body fluids after initial venous or arterial access is established;
2. The administration of medication or fluids; or
3. Any other procedure involving the potential for occupational exposure to bloodborne pathogens due to percutaneous injuries from contaminated sharps.

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.

Parenteral means piercing mucous membranes or the skin barrier through such events as needlesticks, human bites, cuts, and abrasions.

Personal Protective Equipment (PPE) is specialized clothing or equipment worn by an employee for protection against a hazard. General work clothes (e.g., uniforms, pants, shirts or blouses) not intended to function as protection against a hazard are not considered to be personal protective equipment.

Regulated Waste means liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.

Research Laboratory means a laboratory producing or using research-laboratory-scale amounts of HIV or HBV. Research laboratories may produce high concentrations of HIV or HBV but not in the volume found in production facilities.

Sharps with engineered sharps injury protections means a non-needle sharp or a needle device used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids, with a built-in safety feature or mechanism that effectively reduces the risk of an exposure incident.

Sterilize means the use of a physical or chemical procedure to destroy all microbial life including highly resistant bacterial endospores.

Universal Precautions is an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens.

Work Practice Controls means controls that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., prohibiting recapping of needles by a two-handed technique).

Roles and Responsibilities

Risk Management & Safety (RMS)

At Bryant University, the Risk Management and Safety team oversees this ECP. The RMS team works with different departments within the University to ensure that occupationally exposed employees receive training, access to this Plan, and access to the Hep B vaccine or declination form.

Additional duties of the RMS group include:

• Assisting in carrying out provisions of this written Plan;
• Assisting in completing hazard assessments where necessary;
• Assisting in determining occupational exposure of employees;
• Assisting in personal protective equipment (PPE) selection;
• Facilitate training for all occupationally exposed employees;
• Facilitate medical exams, vaccinations, etc.;
• Review exposure incidents;
• Aid in the maintenance of records required by this Plan;
• Ensuring all occupationally exposed employees are offered the Hepatitis B vaccine; and
• Reviewing this written Plan at least annually, and updating as necessary.

Supervisors

Supervisors at the University oversee implementation of this ECP within their department(s). These duties include:

• Communicating with RMS when employees have occupational exposure & work with RMS to address concerns related to BBP and this ECP;
• Completing hazard assessments in their department or work area(s);
• Ensure appropriate engineering and administrative controls are implemented in their work area(s);
• Select and provide PPE;
• Ensuring all PPE is properly cleaned and maintained;
• Review exposure incidents in their department or work area;
• Ensure work areas are properly decontaminated; and
• Ensure employees are trained and have been offered the Hepatitis B vaccinations or completed a declination form.

Occupationally Exposed Employees

Occupationally exposed employees are defined in Section 5 of this Program. Employees who are determined to have occupational exposure to blood or OPIM have the following duties:

• Comply with the procedures and practices outline in this Exposure Control Plan;
• Attend and engage in all trainings on Bloodborne Pathogens;
• Accept Hepatitis B vaccination(s), provide proof of previous vaccination or titer test, or complete attached declination form;
• Utilize correct PPE and follow safe administrative and engineering controls; and
• Report all spills and exposures related to BBP.

Human Resources

Human Resources is responsible for completion of the Sharps Injury Log, OSHA 300 Log, and covering the cost(s) of medical treatment, vaccinations, etc.

Occupation Employee Exposure Determination

Occupational exposure is any reasonably anticipated skin, eye, mucous membrane or other contact with blood or potentially infectious materials as result of an employee’s duties. This includes accidental needle sticks, splashes of blood or bodily fluids, cuts from broken glass containers of body fluids, accidental skin contact with vomit, urine or feces possibly contaminated with blood. Other potentially infectious materials that may enter the body through routes of exposure include human body fluids, unfixed tissue, organ cultures, culture medium and other solutions, or HIV and HBV infected animals.

Below is a list of job titles Bryant University anticipates may have occupation exposure to blood or OPIM during the course of their employment. Please note that employees who have occupational exposure are not limited to the below list.

Methods of Implementation and Control

Universal Precautions

All employees must utilize universal precautions which is defined as treating all blood, bodily fluids, or other potentially infectious materials infectious regardless of the perceived status of the source/individual.

Universal precautions include washing hands before and after exposure to blood and other body fluids. Employees should also always wear gloves, masks, goggles, other personal protective equipment (PPE) and utilize engineering and administrative controls to limit exposure to potential bloodborne pathogens.

Engineering Controls

Engineering and administrative controls will be utilized to eliminate or minimize exposure to bloodborne pathogens.

While engineering controls may not be practical or feasible in all situations involving blood or OPIM, there are certain situations where they may prove helpful in minimizing or eliminating a hazard. Some examples of engineering controls include, but are not limited to:

• Splash guards
• Biological Safety Cabinets (BSC)
• Spill trays, decks, etc.
• Bench coats or diapers
• Mechanical pipetting device(s)
• Safety centrifuge(s)

Administrative Controls

• 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.
• 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.
• Employees must perform all procedures involving blood or other potentially infectious materials (OPIM) in such a manner as to minimize splashing, spraying, splattering, and generation of droplets of these substances.
• Appropriate clothing should be worn in work areas with blood or OPIM to minimize risk of exposure.
  • This includes shoes that cover all parts of the foot, long pants, and long sleeves or lab coats.
• Mouth pipetting is strictly prohibited at the University.

Handwashing

Employees must wash their hands or other skin with soap and water prior to any work with blood or OPIM and as soon as possible:

• Following removal of gloves or other PPE;
• Following any work with blood or OPIM;
• Following any exposure incident;
• Following any patient procedures;
• Prior to leaving the work area; and
• Prior to drinking or eating.

Where handwashing facilities are not immediately available, an alcohol-based hand rub (ABHR) with a minimum of 60% alcohol may be used as an intermediary until the individual may reach a handwashing facility. Effective handwashing requires scrubbing with soap for at least 20 seconds on all surfaces on the hands and wrist. Additionally, a thorough rinse and complete drying. Contaminated sink handles will require decontamination as soon as possible and should not be used by anyone until it is decontaminated.

Exposure incidents involving mucous membranes must be flushed with water for at least 15 minutes.

Labeling

All containers, refrigerators, freezers, etc. that contain blood or OPIM must be properly labeled with biohazardous signs and/or labels. Red or orange bags may also serve as indicators of blood or OPIM waste. All containers must be constructed of materials that prevent leakage during collection, storage, processing, transportation, and shipping.

Personal Protective Equipment (PPE)

Where occupational exposure remains after institution of engineering and administrative controls, personal protective equipment (PPE) shall also be utilized as a last line of defense. It will be provided to employees at no cost to them. Utilize the appropriate personal protective equipment in alignment with Bryant University’s Personal Protective Equipment Program.

Some examples of the types of PPE that may be made available to employees include, but are not limited to:

• Gloves
• Face shields
• Eye protection
• Disposable gowns or aprons
• Lab coats

All PPE 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 OPIM 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. PPE must be cleaned, repaired, or replaced as necessary. When damaged, defective, or contaminated and cannot effectively be decontaminated, it must be disposed of as regulated waste. All PPE must be removed prior to leaving the work area to minimize contamination.

When utilizing PPE all employees must observe the following precautions:

• Do not touch your face/body, door handles, cell phone, or other personal belongings when wearing gloves to avoid cross-contamination.
• Heavy, puncture-resistant gloves should be used when cleaning up sharps such as broken glass or loose needles.
  • These gloves may be decontaminated for reuse if their integrity is not compromised
  • Discard utility gloves if they show signs of cracking, peeling, tearing, puncturing, or deterioration.
• Never wash, decontaminate, or reuse disposable gloves.
• Remove garments that become penetrated by blood or OPIM immediately or as soon as feasible in such a way as to avoid contact with the outer surface.
  • Exposed clothing may need to be cut/ripped away to avoid exposing additional parts of your body.
• Remove all personal protective equipment before leaving the work area.
  • Place all garments in the appropriate designated area for disposal.
  • All contaminated that cannot or should not be decontaminated should be disposed of as regulated waste.
  • All re-usable PPE must be thoroughly decontaminated immediately after use.
• Wash hands immediately or as soon as feasible after removing gloves or other PPE.

Housekeeping

All contaminated work surfaces, tools, objects, etc. will be decontaminated immediately or as soon as feasible after any spill of blood or OPIM. Equipment that may become contaminated with blood or OPIM will be examined and decontaminated before servicing or future use. Protective coverings for work surfaces should be replaced or decontaminated regularly when contaminated, and at the end of each work shift. Only EPA registered disinfectants or a minimum 10% solution of chlorine bleach may be used to clean-up or decontaminate blood or OPIM. These solutions must be left in contact with contaminated work surfaces, tools, objects, etc. for a minimum of 10 minutes before proceeding with clean-up operations. Only individuals trained to the contents on this ECP are authorized to respond to or clean-up blood or OPIM, or decontaminate surfaces, equipment, etc. Biohazard spill/clean-up kits are available in the receiving department of the Unistructure.

Broken glassware and other sharps will not be picked up directly with the hands. Sweep or brush material into a dustpan or use tongs and utilize puncture-resistant gloves when cleaning up sharps. All sharps are to be disposed of in containers that are closable, puncture-resistant, leak-proof on sides and bottoms, and appropriately labeled or color-coded per Section 6.6 of this Plan. Other regulated waste must be placed in the appropriate waste container per Section 6.7 of this Plan prior to leaving the work area. Always wash hands with disinfectant soap immediately following any clean-up operations.

Appendix E contains a bodily fluids clean-up reference guide with additional procedures.

Sharps

Sharps include any material that can puncture the skin. This includes needles, scalpels, broken, glass, etc. Sharps that have had contact with blood or OPIM are considered contaminated sharps.

• Puncture-proof containers must be used for the disposal of needles and other contaminated sharps.
  • Never dispose of these in the regular trash.
  • Do not fill sharps containers more than ¾ so as to avoid overfilling.
• Do not leave uncapped needles or sharps out when not in use; dispose of immediately after use.
  • Needles should never be recapped; self-sheathing needles are used for all injections.
• Breaking or shearing of needles is prohibited.
• Known or suspected contaminated sharps shall be discarded immediately or as soon as feasible in containers that are closable; puncture-resistant; leak-proof on sides and bottom; and marked with an appropriate biohazard label.
• When containers of contaminated sharps are being moved the containers shall be closed immediately before removal or replacement to prevent spillage or protrusion of contents during handling, storage, transport, or shipping.
• There should never be any hand-to-hand transfer of contaminated sharps such as scalpels, picks, probes, etc.
• Utilize tools such as dustpans and brooms/brushes to clean up sharps such as broken glass or needles.

Any exposures or injuries involving sharps will be documented on the Sharps Injury Log in Appendix B and described in Section 10.

Regulated Waste

Regulated waste shall be placed in red or orange bags and containers that are closable, constructed to contain all contents and prevent leakage of fluids or protrusion of contents during handling, storage, transportation, or shipping. Biohazardous signs and labels must be on all sharps and regulated waste containers. Additional requirements for regulated waste containers include:

• Containers must be stored in locations that are easily accessible and as close and feasible to the area which the sharp or needle is being used.
• Sharps and biohazardous waste containers are inspected for leaks and punctures.
  • Containers are replaced regularly to prevent over-filling.
• All contaminated material(s), PPE, equipment, and sharps will be disposed of as regulated material in the appropriate containers.

Incineration of biohazardous waste shall be handled by a biological waste destructor. This shall be coordinated through the Risk Manager and Health Services.

Contaminated Laundry

Contaminated laundry should be handled as little as possible and placed in leak-proof containers if wet or saturated. These containers should also be appropriately labeled as biohazardous. All proper engineering and administrative controls should be followed, including use of PPE, when handling or cleaning any contaminated laundry.

Post-Exposure Evaluation and Follow-Up

Exposure

If an employee incurs a needle stick, sharps injury, or is exposed to blood or OPIM during the course of their job, the following steps should immediately be followed:

• Wash exposed or injured area with soap and water;
  • Flush exposed area with water if soap is not available;
  • Irrigate eyes with clean water, saline, or sterile irritants (ex. Emergency eyewash station, if available);
• Immediately seek medical treatment;
  • Staff members may be referred to an occupational health clinic that the University has agreements with for an evaluation for post exposure prophylaxis (PEP);
  • Student employees may be referred to Student Health Services (SHS);
  • If an employee is exposed outside of normal working hours, they must report the incident and immediately seek medical treatment;
• Report incident to Supervisor and RMS;
• Document the routes of exposure and how the exposure occurred;
  • Refer to Appendix C for the Injury Report Form.
• Obtain consent and make arrangements to have the source individual tested as soon as possible to determine HIV, HCV, and HBV infectivity;
  • Document that the source individual’s test results were conveyed to the employee’s health care provider.
  • If the source individual is already known to be HIV, HCV and/or HBV positive, new testing need not be performed.

Post-Exposure

Following a report of an exposure incident, the exposed employee is urged to have a confidential medical evaluation and follow-up, provided at no cost to the employee. If there is a source individual, identification, testing, and documentation of this individual is required, unless this is not feasible or there are state or local laws which prohibit this. If this individual does not consent to testing, this must be documented by the employer. Treatment must include at least the following elements:

1. Assure that the exposed employee is provided with the source individual’s test results (if applicable) and with information about applicable disclosure laws and regulations concerning the identity and infectious status of the source individual.
2. If the employee did not give consent for HIV serological testing during the collection of blood for baseline testing, ensure that the lab preserves the baseline blood sample for at least 90 days; if the exposed employee elects to have the baseline sample tested during this waiting period, perform testing as soon as feasible.

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

• A copy of this Exposure Control plan;
• A copy of the OSHA Bloodborne Pathogen regulations (29 CFR 1910.1030);
• Description of the employee’s job duties relevant to the exposure incident;
• Documentation of the route(s) of exposure;
• A description of the circumstances under which the exposure occurred;
• Results of the source individual's blood testing, if available or applicable; and
• All medical records relevant to treatment of the employee, including vaccination status. The employee will receive a copy of the evaluating healthcare professional's written opinion within 15 days of the completion of the evaluation.

Documentation and Evaluation of Exposure Incidents

Any percutaneous injuries will be recorded in a Sharps Injury Log per Section 10 of this Plan, available in Appendix B.

Risk Management and Safety and Supervisors will review the circumstances of all exposure incidents to determine:

• All engineering controls in use at the time;
• All administrative controls in use at the time;
• Description of the device(s) being used (including type and brand), if applicable;
• Personal protective equipment or clothing that was used at the time of the exposure incident (gloves, eye shield, etc.);
• Location of the incident;
• Procedure being performed when the incident occurred, if applicable; and
• Employee’s training;

Per 29 CFR 1910.1030, post-exposure evaluation, treatment, and follow-up is the responsibility of the medical facility or Primary Care Physician (PCP). The licensed healthcare professional (LHCP) will issue a written opinion limited to the following information:

• Confirmation that employee has been informed of results of their evaluation; and
• The employee has received communication about any and all medical conditions as a result of the exposure, including those that require additional evaluation or treatment.

All other findings, diagnoses, etc. must remain confidential and will not be included in the written report to the employer.

Hepatitis B Vaccine

The Hepatitis B vaccination series is available at no cost after initial employee training and within 10 days of initial assignment. This must be provided at no cost to the employee and during normal working hours. Individuals may elect not to get the vaccine for any reason, and documentation of declination will be kept on file. A copy of the declination form is included in Appendix A. If an employee initially declines Hepatitis B vaccination, but at a later date decides to accept the vaccination, the vaccination shall then be made available at no cost. The initial declination form must be retained on file.

Vaccination is encouraged unless:

1. Documentation exists that the employee has previously received the vaccination series;
2. Antibody testing (titer test) reveals that the employee is immune or already vaccinated; or
3. Medical evaluation shows that vaccination is contraindicated.

Records of employee vaccination will be kept on file, confidentially, for 30 years beyond the employees end of employment at Bryant University.

Training

All employees who have occupational exposure to bloodborne pathogens must be fully trained and demonstrate full competency in this ECP. Training will occur upon initial hire and take place at least annually thereafter. Additional training will be provided when changes such as modification of tasks or procedures affect the employee's occupational exposure. Training must be presented during normal working hours and in a language workers can understand.

The training program will include at least the following elements:

1. A copy and explanation of the OSHA bloodborne pathogen standard;
2. An explanation of the ECP at Bryant University and how an employee can obtain a copy of the written plan;
3. An explanation of the modes of transmission of bloodborne pathogens and what constitutes an exposure incident;
4. An explanation of the symptoms and epidemiology of HIV, HCV, and HBV;
5. An explanation of the use and limitations of engineering and administrative controls and PPE;
6. Information on hepatitis B vaccine, including efficacy, safety, method of administration, benefits of being vaccinated, and that the vaccine will be offered free of charge;
7. An explanation of the procedure to follow if an exposure incident occurs including reporting and medical follow-up that will be made available;
8. Information on the post-exposure evaluation and follow-up that the employer is required to provide for an employee following an exposure incident;
9. The opportunity for all employees to offer input and suggestions for improvement of the plan; and
10. The opportunity for employees to raise questions regarding this ECP.

Please direct all questions to Risk Management and Safety (jrix@bryant.edu).

Training records will include the following information:

• Dates of the training sessions;
• Contents or summary of the training sessions;
• Names and qualification of persons conducting the training; and
• Names and job titles of employees attending the training sessions.

Recordkeeping

Medical records are maintained for each employee with occupational exposure. These confidential records are kept for at least the duration of employment, plus 30 years. Employee medical records are provided upon request of the employee or an authorized representative within 15 working days. Such requests must be made to Risk Management and Safety.

OSHA Recordkeeping

An exposure incident is evaluated to determine if the case meets OSHA’s Recordkeeping Requirements (29CFR 1904). This determination and the recording activities are done by Human Resources.

Sharps Injury Log

In addition to the 1904 Recordkeeping Requirements, all percutaneous injuries from contaminated sharps are also recorded in a Sharps Injury Log found in Appendix B. All incidences must include at least:

• Date of injury;
• Type and brand of the device involved (syringe, scalpel, etc.);
• Work area where the incident occurred; and
• Explanation of how the incident occurred.

This log is reviewed during the annual evaluation of this ECP and maintained for at least five years following the end of the calendar year covered. If a copy is requested by anyone, it must have any personal identifiers removed from the report.