Office of Security, Safety and Risk Management

Bloodborne Pathogen exposure control plan

In accordance with the OSHA BLOODBORNE PATHOGEN standard, 29 CFR 1910.1030, Denison University has developed the following Exposure Control Plan.

EXPOSURE DETERMINATION

OSHA requires us to perform an exposure determination concerning which employees may incur occupational exposure to blood or other potentially infectious materials. The exposure determination is made without regard to the use of personal protective equipment, (employees are considered to be exposed even if they wear personal protective equipment.) This exposure determination is required to list all job classifications in which employees may be expected to insure such occupational exposure regardless of frequency. At our facility the following job classifications are in this category:

JOB CLASSIFICATION

First Aid Responder -- In addition, OSHA requires a listing of job classifications in which some of our employees may have occupational exposure. Since not all employees in these categories would be expected to incur exposure to blood or other potentially infectious materials, tasks or procedures that would cause these employees to have occupational exposures are also required to be listed in order to clearly understand which employees in these categories are considered to have occupational exposure. The job classifications and the associated tasks for these categories are as follows:

JOB CLASSIFICATION TASKS/PROCEDURES

First Aid Responder -- Clean up of contaminated area or any exposure to blood or other potentially infectious materials.

IMPLEMENTATION SCHEDULE AND METHODOLOGY

OSHA also requires that this plan also include a schedule and method of implementation for the various requirements of the standard. The following complies with this requirement:

Compliance Methods -- Universal precautions will be observed at this facility 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 at this facility. Where occupational exposure remains after institution of these controls, personal protective equipment shall also be utilized.

At this facility the following engineering controls will be utilized:

Biohazard Containers -- The above controls will be examined and maintained on a regular schedule. The schedule for reviewing the effectiveness of the controls is as follows: Garret Moore Reviewing will be done Monthly

Hand washing facilities are also available to employees who incur exposure to blood or other potentially infectious materials. At our facility, hand washing facilities are located: Rest room facilities

If hand washing facilities are not available in the area, our facility will provide either an antiseptic cleanser in conjunction with a clean cloth/paper towels or antiseptic towels. If these alternatives are not used, then the hands are to be washed with soap and running water as soon as feasible. After removal of personal protective gloves, employees shall wash hands and any other potentially contaminated skin area immediately or as soon as feasible with soap and water. If employees incur exposure to their skin or mucous membranes, then those areas shall be washed or flushed with water as appropriate as soon as feasible following contact.

Needles Contaminated -- needles and other contaminated sharps will not be bent, recapped, removed, sheared or permanently broken. OSHA allows an exception to this if the procedure would require that the contaminated needle be recapped or removed and no alternative is feasible and the action is required then the recapping or removal of the needle must be done by the use of a mechanical device or a one handed technique. At our facility, recapping or removal is only permitted for the following procedures: Not applicable at this facility.

Containers for Reusable Sharps -- Contaminated sharps that are reusable are to be placed immediately, or as soon as possible, after use into appropriate sharps containers. At this facility, the sharps containers are puncture resistant, labeled with a biohazard label and are leak proof. These containers will be checked daily for sharps and removed by a competent person appointed by our facility.

Work Area Restrictions -- In the work areas where there is a reasonable likelihood of exposure to blood or other potentially infectious materials, employees have been instructed not to eat, drink, apply lip balm, smoke, or handle contact lenses. Food and beverages are not to be kept in refrigerators, freezers, shelves, cabinets or on counter tops or bench tops where blood or other potentially infectious materials are present.

Mouth pipetting/suctioning of blood or other potentially infectious materials is prohibited. All procedures will be conducted in a manner which will minimize splashing, spraying, splattering and generation of droplets of blood or other potentially infectious materials. Methods which will be employed at this facility to accomplish this goal are: (covers on centrifuges, dental dams, etc.) Not applicable at this facility.

Specimens -- Specimens of blood or other potentially infectious materials will be placed in a container which prevents leakage during the collection, handling, processing, storage, transport of the specimens. The container used for this purpose will be labeled or color coded in accordance with the requirements of OSHA standard. This standard provides for the labeling/color coding requirements of the standard provided that the facility utilizes universal precautions in the handling of all specimens and the containers are recognizable as containing specimens. This exemption applies only while the specimens remain in the facility. Our facility will use the label and/or color coded in accordance with the requirements of OSHA standard. Any specimens which could puncture a primary container will be placed within a secondary container which is puncture resistant. This facility has the following specimens that could puncture a primary container and may require a puncture resistant secondary container: Not app.

If outside contamination of the primary container occurs, the primary container shall be placed with in a secondary container which prevents leakage during the handling of the specimen.

Contaminated Equipment -- A readily observable Biohazard Label shall be affixed to and equipment that has any portions remaining contaminated. Our facility shall insure that this information is conveyed to all affected employees, the servicing representative, and or the manufacturer, as appropriate, and prior to handling servicing or shipping so that appropriate precautions will be taken. Equipment which has been contaminated with blood or other potentially infectious materials shall be decontaminated as necessary unless the decontamination of the equipment is not feasible.

This facility has the following equipment which can not be decontaminated prior to servicing or shipping: Not applicable at this facility.

Personal Protective Equipment -- Our facility shall insure that the employees use appropriate personal protective equipment unless we can show that the employee temporarily and briefly declined to use personal protective equipment when under rare and extraordinary circumstances. It is the employees’ professional judgment that in the specific instance its use would have prevented the delivery of health care or public safety services or would have posed an increased hazard to the safety of the worker or the co-worker. When the employee makes this judgment, the circumstances shall be investigated and documented in order to determine whether changes can be instituted to prevent such occurrences in the future.

All personal protective equipment used at this facility will be provided without cost to employees. Personal protective equipment will be chosen based on the anticipated exposure of blood or other potentially infectious materials. The protective equipment will be considered appropriate only if it does not permit blood or other potentially infectious materials to pass through or to reach the employees clothing, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used. This facility shall insure that the appropriate personal protective equipment in the appropriate sites is readily accessible at the work site or issued to the employees. Hypo-allergenic gloves, glove liners, powder-less gloves, or any similar alternatives shall be readily accessible to those employees who are allergic to the gloves normally provided. If our facility is involved in a volunteer blood donation center and judges that routine gloving for a

Periodically reevaluate this policy.
Make gloves available to all employees who wish to use them for phlebotomy.
Not discourage the use of gloves for phlebotomy.
Require that gloves be used for phlebotomy in the following circumstances.

(a) When the employees has cuts, scratches, or other breaks in his or her skin.
(b) When the employee judges that the hand contamination with blood may occur, for example, when performing phlebotomy on an uncooperative source individual, and
(c) When the employee is receiving training in phlebotomy.

Mr. Garret Moore will be responsible to insure all employees have the appropriate Personal Protective Equipment at their work place. Protective clothing will be provided to employees in the following manner:

Task Personal Protective Equipment Contaminated area clean up Protective gloves.

All personal protective equipment will be cleaned, laundered, and disposed of by Denison University at no cost to the employee.

All repairs and replacements will be made by Denison University at no cost to the employees.

All garments which are penetrated by blood shall be removed immediately or as soon as feasible.

All personal protective equipment will be removed prior to leaving the work area.

The following protocol has been developed to facilitate leaving the equipment at the work area.

Employees shall place their Personal Protective Equipment upon leaving the work area in the Biohazard Container.

Gloves shall be worn where it is reasonably anticipated that employees will have had contact with blood, other potentially infectious materials, non-intact skin, and mucous membranes.

Gloves will be available from: Locations Personal Responsible Nurses office and through Central stores and various (assigned) supervisors.

Gloves will be used for the following procedures:

Contaminated area clean up or any exposure to blood or other potentially infectious materials. Disposable gloves used at this facility are not to be washed or decontaminated for reuse and are to be replaced as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised.

Utility gloves will be discarded if they are cracked, peeling, torn, punctured, or exhibit other signs of deterioration or when their ability to function as a barrier is compromised.

Masks in combination with eye protection devices, such as goggles, or glasses with solid face shields are required to be worn whenever splashes, spray, splatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can reasonably be anticipated.

The following protective equipment will be utilized at this facility.
Masks and Safety glasses:

The OSHA standard also requires appropriate protective clothing to be used, such as lab coats, aprons, clinic jackets, or similar outer garments. The following protective clothing will be utilized at this facility:

Lab coats and Aprons

Housekeeping -- Denison University shall insure that the work site is maintained in a clean and sanitary condition. Our facility will determine and implement an appropriate written schedule for cleaning and method decontamination based upon the location within the facility, type of surface to be cleaned, type of soil present, and tasks or procedures being performed in the area.

This facility will be closed and decontaminated according to the following schedule: Area Schedule Any

When contamination occurs (non-routine basis) -- Decontamination will be accomplished by utilizing the following materials:
Phenol Based Decontamination Solution

All equipment and environmental and working surfaces shall be cleaned and decontaminated after contact with blood or other potentially infectious materials. All Contaminated work surfaces shall be decontaminated with an appropriate disinfectant after completion of procedure; immediately or as soon as feasible when the surfaces are overtly contaminated or after any spill of blood or other potentially infectious materials; and at the end of the work shift if the surface may have become contaminated since the last cleaning.

If our facility uses protective coverings such as plastic wrap, aluminum foil, or imperviously-backed absorbent paper used to cover equipment and environmental surfaces, they shall be removed and replaced as soon as feasible when they become overtly contaminated or at the end of the work shift if they may have been contaminated during the shift.

This facility uses the following protective covering to assist in keeping surfaces free of contamination:
Not applicable at this facility

We will insure that all bins, pails, cans, and similar receptacles intended for reuse which have a reasonable likelihood for becoming contaminated with blood or other potentially infectious materials, shall be inspected and decontaminated on a regular scheduled basis and cleaned and decontaminated immediately or as soon as feasible upon visible contamination. Schedule Inspector Daily Various supervisors

Our facility shall insure that all broken glassware which may be contaminated shall not be picked up directly with the hands. It shall be cleaned up using mechanical means, such as a brush, and dust pan, tongs, or forceps.

This facility will not store reusable sharps that are contaminated with blood or other potentially infectious materials that requires employees to reach by hand into the containers where these sharps have been placed.

Regulated Waste Disposal -- Denison University insures that all contaminated sharps or other related waste shall be discarded immediately or as soon as feasible in containers that are:

Closeable
Puncture resistant
Leak proof on sides and bottom; and
Labeled or color coded with appropriate biohazard label

During use the containers for contaminated sharps or other regulated waste shall be:

Easily accessible
Maintained upright
Replaced routinely and not to be allowed to overfill

When moving containers of contaminated sharps or other regulated waste from the area of use, the containers shall be:

Closed prior to removal
Placed in appropriate secondary container if leakage if possible Reusable containers shall not be opened, emptied, or cleaned manually or in any manner which would expose employees to the risk of percutaneous injury.

Disposal of all regulated waste shall be in accordance with applicable regulations of the United States, states and territories and political subdivisions of States and Territories. All contaminated sharps shall be discarded as soon as feasible in sharps containers which are located in the facility. Sharps containers are located in:

The Nurses Office and Custodial maintenance closets throughout the campus.

Regulated waste other than sharps shall be placed in appropriate containers. Such containers are located in:
Not applicable at this facility

Laundry Procedures -- Our facility will handle contaminated laundry as little as possible. The contaminated laundry:

Shall be bagged or containerized at the location where it was used and shall not be sorted or rinsed in the location or use.
Shall be placed and transported in bags or containers labeled or color coded appropriately with hazard requirements.
Shall be placed in bags or containers that prevent soak through or leakage.

We will insure that employees who have contact with contaminated laundry wear protective gloves and other appropriate personal protective equipment.

For all laundry the employer transports off-site, they shall insure the receiving facility is notified of the nature of contaminated laundry and that all Bags are appropriately labeled or color coded.

Laundry contaminated with blood or other potentially infectious materials will be handled as little as possible. Such laundry will be placed in appropriately marked bags at the location where it was used. Such laundry will not be stored or rinsed in the area of use.

All employees who handle contaminated laundry will utilize personal protective equipment to prevent contact with blood or other potentially infectious materials.

Laundry at this facility will be cleaned on site. If at any time laundry is sent off site, we will notify the accepting laundry in accordance with the section (d) of the standard.

HIV and HBV Research Laboratories and Production Facilities -- For all functions and work areas that serves as a research laboratory or production facility engaged in the culture of, production, concentration, experimentation, and manipulation of HIV and HBV the following requirements shall apply:

Standard microbiological practices shall be insured all regulated waste shall either be incinerated or decontaminated by a method such as autoclaving known to effectively destroy Bloodborne pathogens.
Laboratory doors shall be kept closed when work involving HIV or HBV is in progress.
Contaminated materials that are to be decontaminated at a site away from the work area shall be placed in a durable, leak proof, labeled or color-coded container that is closed before being removed from the work area.
Access to the work area shall be limited to authorized persons. Written policies have been established whereby only persons who have been advised of the potential biohazard, and who meet specific entry requirements, and who comply with all entry and exit procedures shall be allowed to enter the work areas and/or animal rooms.
A hazard warning sign incorporating the universal biohazard symbol has been posted on all access doors where potentially infectious materials or animals are present.
All activities involving potentially infectious material shall be conducted in biological safety cabinets or other physical containment devices.
Appropriate personal protective equipment shall be used in all work areas, shall not be worn outside of work area, and shall be decontaminated before being laundered.
Before disposal all waste from work areas, animal rooms shall be incinerated or decontaminated by a method such as autoclaving known to effectively destroy Bloodborne pathogens.
All vacuum lines are protected with liquid disinfectant traps and high-effectively particulate air filters (HEPA) or minimum equivalent filters.
Hypodermic needles and syringes shall only be used for parental injection and aspiration of fluids from laboratory animals and diaphragm bottles. ONLY needle-locking syringes or disposable syringes shall be used for the injection or aspiration of other potentially infectious materials. All needles and syringes shall be handled using appropriate hazard contaminated technique.
All spills shall be immediately contained and cleaned up by those trained and equipped to handle potentially concentrated infectious materials.
Any spill or accident that results in an exposure incident shall be immediately reported to the laboratory director or designed other.
A biosafety manual is available and reviewed and updated at least annually. Personal shall be advised of potential hazards, are required to read and follow proper practice and procedures.

For all containment equipment in our facility that is in service for the research or production and engaged in the culture, production, concentration, experimentation, and manipulation, of HIV and HBV the following requirements shall apply:

Certified biological safety cabinets (class 1, 2, 3,) or other appropriate combinations of personal protective equipment and physical containment devises shall be used for all activities with potentially infectious materials.

All biological safety cabinets shall be certified when installed, whenever moved, and at least annually.

For all activities and work areas in our facility that serves as a HIV and HBV research laboratory, the following requirements have been met:

Each laboratory has a facility for hand washing and eye wash facility within the area.
An autoclave for decontamination of regulated waste is available.

For all activities and work areas in our facility that serves as a HIV and HBV production facility, the following criteria have been met:

Work areas are separated from areas that area open to unrestricted traffic flow within the building. Passage through two sets of doors is required for entry into the work area from access corridors or other contiguous areas.
The surfaces of doors, walls, floors, and ceilings in the work areas are water resistant and can be easily cleaned.
Each work area has a sink for washing hands and an eye wash facility. The sinks are either foot, elbow, or automatically operated and are located near the exit door.
Access doors to working areas are self-closing.
An autoclave for decontamination of regulated waste is available.
There is a ducted exhaust air ventilation system that provides directional intake air flow to the work areas. The exhaust air is discharged directly to the outside and dispersed away from occupied areas and air intakes. The air flow direction has been verified.

Hepatitis B Vaccination Post Exposure Evaluation, and Follow-up -- Our facility has made available the Hepatitis B vaccine and vaccination series to all employees who have occupational exposure, post-exposure evaluation and follow-up to all employees who have had an exposure incident.

This facility has insured that all medical evaluations and procedures including the hepatitis B vaccine and vaccination series and post-exposure evaluation and follow-up, including prophylaxis are:

Available at no cost to employees.
Available at a reasonable time and place to employees.
Performed by or under the supervision of a licensed physician or licensed health care professional.
Provided according to the current recommendations for the US Public Health Services.
And that all laboratory tests are conducted by an accredited laboratory at no cost to the employee.

The Hepatitis B Vaccination The program should meet the following requirements:

The vaccination series is available to employees after the required employee training and within 10 working days of initial assignment to all employees who have occupational exposure unless the employee has previously received the complete Hepatitis B vaccination series, or that the vaccine is contraindicated for medical reason.
Any employee who has declined to accept the Hepatitis B vaccination has signed the waiver statement.
Any employee who has initially declined the Hepatitis B vaccination, but at a later date while still covered under the standard decides to accept the vaccination, this facility shall make available the Hepatitis B Vaccination at that time.
If a routine booster dose(s) of Hepatitis B vaccine is recommended by U.S. Public Health Service at a future date, such booster dose(s) shall be made available.

Denison University has a designated administrator for the Vaccination Program and also those who will administer the vaccine:

Administrator, Vaccine Administrator Sandra Jump, R.N. Post-Exposure Evaluation Follow-up -- Following a report of an exposure incident, Denison University shall make immediately available to the exposed employee a confidential medical evaluation and follow-up. All exposure incidents should be reported to:

Sandra Jump, R.N.

The following elements will be included in the evaluation and follow-up:

Documentation of the route(s) of exposure and the exposure incident circumstances.
Documentation and Identification of source individual, if possible, and if possible the status of the source individual.
The blood of the source individual will be tested and documented for HIV/HBV infectivity as the law allows.
Results of testing of the Source individual will be made available to the exposure employee and the employee shall be informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual.
The employee will be offered the option of having their blood collected for testing of the employees HIV/HBV serological status. The blood sample will be preserved for up to 90 days to allow the employee time to decide if the blood should be tested for HIV serological status.
The exposed employee will be offered post exposure prophylaxis in accordance with the current recommended actions of the U.S. Public Health Service.
The employee will be given appropriate counseling concerning precautions to take during the period after the exposure incident. The employee will also be given information on what potential illness to be alerted for and to report any related experiences to appropriate personnel.

The following person(s) have been designed to assure that the evaluation and follow-up policy outlined here is effectively carried out as well as to maintain records related to this policy.

Sandra Jump, R.N.

Health Care Professional -- The employee shall insure that the Health care professional responsible for the employees Hepatitis B vaccination is provided a copy of the regulation.

Denison University shall provide an employee after an exposure the following:

A copy of the regulation.
A description of the exposed employee's duties as they relate to the exposure incident.
Documentation of the route(s) of exposure and circumstances under which the exposure occurred.
Results of the Source individuals blood testing, if available.
All medical records relevant to the appropriate treatment of the employee including vaccination status which is our responsibility to maintain.

Our facility shall obtain and provide the employee with a copy of the evaluating health care professionals’ written opinion within 15 days of the completion of the evaluation.

The following shall apply to the written opinion:

The health care professional s written opinion for Hepatitis B vaccination shall be limited to whether Hepatitis B vaccination is indicated for an employee, and if the employee had received such vaccination.
The health care professional's written opinion for post-exposure evaluation and follow-up shall be limited to the following information:

(a) That the employee has been informed of the results of the evaluation; and

(b) 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.

Communication of Hazards Labels and Signs -- The employer shall insure that warning labels shall be affixed to containers of regulated waste, refrigerators and freezers containing blood or other potentially infectious material; and other containers used to store, transport, or ship blood or other potentially infectious materials:

The labels shall include the biohazard legend.
These labels shall be fluorescent orange or orange-red with lettering and symbols in contrasting color.
The labels shall be affixed as close as feasible to the container by string, wire, adhesive, or other method that prevents their loss or unintentional removal.
Contaminated equipment shall also be required to have appropriate Biohazard labeling.

The employer shall post signs at the entrance to work areas that function as research laboratories or production facilities engaged in the culture, production, concentration, experimentation, and manipulation of HIV and HBV.

These signs shall be fluorescent orange-red or predominantly so with lettering and symbols in a contrasting color.

Information and Training: Our facility will train all employees with occupational exposure to Bloodborne pathogens. This training will be provided at no cost to the employee and during working hours.

The training for all employees will be conducted prior to initial assignment to tasks where occupational exposure may occur.

The training shall be annual and within one year of previous training. The training program shall contain at minimum the following elements:

An explanation of the regulatory text of the OSHA Bloodborne Pathogen standard.
A general explanation of the epidemiology and symptoms of Bloodborne diseases.
An explanation of the modes of transportation of Bloodborne pathogens.
An explanation of the exposure control plan and how the employee can obtain a copy of the written plan.
An explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials.
An explanation of the use and limitations of methods that will prevent or reduce exposure including appropriate engineering controls, work practices, and personal protective equipment.
An explanation on the section use, decontamination, and disposal of personal protective equipment.
An explanation of the Hepatitis B Vaccination program available at the facility.
An explanation of the evaluation and follow-up program if an exposure incident occurs.
An explanation of the signs and labels and/or color coding required.
An opportunity for interactive question and answers with the person conducting the training session.

We will provide additional initial training for all employees in the HIV and HBV Laboratories and production facilities:

That employees demonstrate proficiency in standard microbiological practice and techniques and in the practices and operations specific to the facility before being allowed to work with HIV or HBV.
That employees have prior experience in the handling of human pathogens or tissue cultures before working with HIV or HBV.
That a training program be provided to employees who have no prior experience in handling human pathogens.

Initial work activities shall not include the handling of infectious agents. A progression of work activities shall be assigned as techniques are learned and proficiency is developed.

The employees shall participate in work activities involving infectious agents only after proficiency has been demonstrated.

Record Keeping: Our facility shall establish and maintain an accurate record for each employee with occupational exposure. This record shall include:

The name and Social Security number of the employee.
A copy of the employee s Hepatitis B vaccinations and any medical records relative to the employees’ ability to receive vaccinations.
A copy of all results of examinations, medical testing, and follow-up procedures.
A copy of the health care professionals’ written opinion.
A copy of the information provided to health care professionals.

The Medical records shall be kept confidential and shall not be disclosed or reported without the employees’ express written consent to any person within or outside of the workplace; except as required by law. The records shall be maintained for the duration of employment plus 30 years.

The training records shall include the following:

The dates of the training session.
The contents or summary of the training session.
The names and qualifications of persons conducting the sessions.
The names and job titles of all persons attending the training session.
Training records shall be maintained for 3 years from the date of training.

Denison University will provide all records required upon request to the assistant secretary and the director for examination and copying.

Employee training records required shall be provided upon request for examination and copying to employees, to employee representatives, to the director, and to the assistant secretary.
Employee medical records required shall be provided upon request for examination and copying to the subject employee, to anyone having written consent of the subject employee, to the director, and to the assistant secretary.
If our facility ceases to do business and their is no successor employer to receive and retain the records for the prescribed period, this facility shall notify the director at least 3 months prior to their disposal and transmit them to the director to do so, within that 3 month period.