TABLE OF CONTENTS

 

1.0 POLICY STATEMENT

 

Departments that have employees falling within the scope of this program must ensure that all of the provisions outlined in this program are implemented within their department.

 

2.0 RESPONSIBILITIES

 

This program is intended to eliminate or minimize reasonably anticipated employee exposure to pathogens that may be found within blood or other potentially infectious body fluids, while performing work for Brigham Young University (BYU). To incorporate this program, the following parties have the following responsibilities:

2.1 Risk Management & Safety

• Provide training for “responsible person(s)”, when requested (train the trainer);
• Assist supervisors who request help in establishing Engineering Controls and Work Practices for their Exposure Control Plan (ECP);
• Investigate exposure incidents involving University employees as outlined in section 10.0 of this program;
• Risk Management & Safety shall ensure that the health care professional evaluating an exposed employee has been supplied with a copy of OSHA’s Bloodborne Pathogens standard, 29 CFR 1910.1030.

2.2 Departments

 

• Provide and/or maintain the appropriate engineering controls, personal protective equipment, and cleaning supplies for employees falling within the scope of this program;
• Departments must designate a responsible person to implement, review, and update their Exposure Control Plan;
• Identify the need for changes in engineering controls and work practices by reviewing accidents, near misses, and interviewing those employees involved;
• Make available Hepatitis B vaccinations to employees having reasonably anticipated exposure to blood or other potentially infectious material (OPIM);
• Give employees the opportunity to comment on the effectiveness of engineering controls. Comments should be directed to the responsible person; and
• Cleanup of spills involving blood or other potentially infectious material in facilities controlled by the department. This is not a normal custodial function unless there is a written agreement with Custodial Services to provide that function. Custodians can not normally clean up blood or other potentially infectious material because they do not have the training, vaccinations or equipment for that task. There is no written agreement with Custodial Services, it will be the responsibility of a trained, equipped, department employee to complete this task.
• Vomit, urine, fecal material, sweat, and saliva are not considered potentially infectious material unless there is visable contamination with human blood.

 

Note - Employees may refuse to undergo a Hepatitis B vaccination by signing a declination statement (Appendix D). Completed declination statements must be maintained in the department file for the employee.

 

2.3 Department Designated Responsible Person

 

• Complete exposure determinations as outlined in section 7.0 of this program;
• Review and update the exposure control plan (ECP) at least annually, and whenever necessary to include new or modified tasks and procedures (Appendix F has been provided to help with the review process);
• Ensure that personal protective equipment (PPE) assessments for job tasks pertaining to this program have been completed by following the procedures outlined in Appendix A of this program;
• Develop and maintain “Engineering Controls and Work Practice” documents in appendix E of this program (these account for part of a completed exposure control plan);
• Provide bloodborne pathogens training in accordance with, and pertaining to, this plan;;
• Ensure the proper use of labels and red bags as outlined in section 8.6;
• See that sharps disposal containers are inspected and maintained in accordance with section 8.5; &
• Evaluate procedures or new products, in the light of changes in technology that eliminate or reduce exposure to bloodborne pathogens, by checking online at www.cdc.gov for updates that pertain to the work being performed, and by comparing new products, designed by manufacturers to prevent bloodborne exposures, with those that are currently being used.
• Exposure Incident: If an exposure incident occurs
• If possible, obtain consent from the source individual and make arrangements to have the source individual 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.
• Assure that the exposed employee is provided with the source individual’s test results if allowed by current federal and state laws.
• Provide exposed individuals with a copy of the evaluating health care professional’s written opinion within 15 days after completion of the post-exposure evaluation.
• If the exposed employee consents to have their blood tested then have the employee sent to the Student Health Center to have the test performed immediately.
• If the exposed employee does not give their consent for HIV serological testing during collection of blood for baseline testing, have the baseline blood sample preserved for at least 90 days; if the exposed employee elects to have the baseline sample tested during this waiting period, have testing performed as soon as feasible.
• Following an exposure incident, and investigation of the incident, make revisions to the work being performed, based upon the exposure incident investigation findings;
• Following an exposure incident, ensure that the health care professional performing post exposure evaluation(s) receives the following information:
• A description of the employee’s job duties relevant to the exposure incident;
• The route(s) of exposure;
• Circumstances surrounding the exposure;
• If possible, the results of the source individual’s blood test; and relevant employee medical records, including vaccination status.

 

2.4 Supervisors

 

• Direct employees who have been exposed to blood or other potentially infectious material (OPIM) to the proper health care provider as outlined in section 10.0 of this program, and let the responsible person know of the exposure incident;
• Ensure that those employees falling within the scope of this program receive the proper training, as outlined in section 11.0 of this program, by coordinating this training through the responsible person;
• Maintain the most current training records for those individuals in your department who fall within the scope of this program; and
• Prior to initial job assignment, see that employees included in this program are provided the opportunity to receive the Hepatitis B vaccination series (see section 9.0 for details).

 

2.5 Employees

 

• Follow the guidelines, rules, and provisions found in this program, and use the appropriate personal protective equipment outlined on the completed “Engineering Controls and Work Practices” documents found in Appendix E and in accordance with your training.

 

3.0 PURPOSE

 

This program is designed and intended to help University employees eliminate or minimize their potential exposure to bloodborne pathogens.

 

Brigham Young University is committed to providing a safe and healthful work environment for our entire staff. In pursuit of this endeavor, this exposure control plan has been established to minimize occupational exposure to bloodborne pathogens in accordance with OSHA standard 29 CFR 1910.1030, “Occupational Exposure to Bloodborne Pathogens”.

 

4.0 SCOPE

 

This program applies to all Brigham Young University employees who have reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of their job duties.

 

5.0 APPLICABLE FORMS & DOCUMENTS

 

OSHA Standard 29 CFR 1910.1030	Online PPE Assessments
OSHA Standard 29 CFR 1910.132	Appendix B Declination Form for Hepatitis B Vaccination

 

6.0 GETTING STARTED

 

Once it is determined that an employee falls within the scope of this program, supervisors must ensure that these employees receive the appropriate training, as outlined in section 11.0 of this program.

 

Note: The responsible person is to see that the exposure control plan (ECP) is available for review at any time.

 

7.0 EXPOSURE DETERMINATIONS

 

Departments must determine if their employees have reasonably anticipated occupational exposure to blood or other potentially infectious materials (OPIM). If so, then the department must document this determination by including the job task performed by these workers in the Exposure Determination Log found in Appendix D. It is intended that this log include all individuals in your department having occupational exposure, which can be divided into three different groups:

 

• Job tasks where all of the employees performing their duties are expected to have occupational exposure
• Job tasks where only some of the employees have occupational exposure
• Job tasks where occupational exposure may occur every now and then for at least one of the workers performing the task.

 

If you need help making an exposure determination please contact Risk Management and Safety, and ask for the Research Safety Officer.

 

• CORE REQUIREMENTS

 

• Exposure Control Plan (ECP) - All departments having employees that fall within the scope of this program must ensure that they complete their exposure control plan (See Appendix A for a model exposure control plan). Engineering Controls and Work Practices must be developed for each type of job where employees have reasonably anticipated occupational exposure to blood or other potentially infectious material.

 

8.2 General Rules

 

• “Universal Precautions” - All blood and other potentially infectious materials must be treated as if they are infectious.
• Broken glassware is to be collected and disposed of using mechanical means, such as a dustpan and broom. Do not handle broken glassware with your hands.
• Always use the PPE, engineering controls and the safe work practices outlined in Appendix E of this program, when performing a job task that falls within the scope of this program.
• Food, drinks, or cosmetics shall not be consumed, stored, or used in areas where blood or other potentially infectious materials (OPIM) could be present.
• Mouth pipeting or suctioning is prohibited.

8.3 Sharps

 

• Do not handle needles, razor blades, or other sharps with your hands.
• Sharps are to be disposed of in a properly labeled, puncture resistant, & spill resistant container immediately after use, or when cleaned-up.
• Sharps must not be bent or broken.
• Needles are not to be recapped. Following use, needles are to be immediately disposed of in a properly labeled puncture resistant sharps container.
• Do not place any member of your body into a sharps container.

 

8.4 Personal Protective Equipment (PPE)

 

Each department provides PPE, for protection against bloodborne pathogens, to employees at no cost to them. The location of all necessary PPE needed to perform a task must be listed on the “Engineering Controls and Work Practices” document, created by the responsible person, and located in Appendix E of this program.

 

Use of PPE in accordance with the following requirements:

 

• Wash hands immediately or as soon as feasible after removing gloves;
• Remove PPE before leaving a contaminated work area;
• Used PPE must be disposed of as outlined by the responsible person on the “Engineering Controls and Work Practices” documents found in Appendix E of this program;
• Wear appropriate gloves when there is reasonably anticipated hand contact with blood or OPIM, and when handling or touching contaminated items or surfaces; replace gloves if torn, punctured, contaminated, or if the gloves ability to function as a barrier is compromised;
• Utility gloves may be decontaminated for reuse if their integrity is not compromised; discard utility gloves if they are of cracked, peeling, torn, punctured or otherwise deteriorated;
• Decontaminate gloves that will be reused, prior to removal;
• Never wash or decontaminate disposable gloves for reuse;
• Wear appropriate face and eye protection when splashes, sprays, spatters, or droplets of blood or OPIM pose a hazard to the eye, nose, or mouth; and
• Remove any garment contaminated by blood or OPIM in a manner that avoids, or minimizes, contact with the outer surface.

 

Note: The specific procedure for handling used personal protective equipment (PPE) must be outlined in the exposure control plan. Note: The “Engineering Controls and Work Practices” documents contain information such as, but not limited to, where and how to decontaminate eye protection.

 

• Housekeeping
• Regulated waste is placed in containers which are closable, constructed to contain all contents and prevent leakage, appropriately labeled or color-coded (see Labels), and closed prior to removal to prevent spillage or protrusion of contents during handling. Our contract with Stericycle does not permit the disposal of free liquids. Contaminated liquids (blood, CSF, plural fluid, pericardial fluid, synovial fluid) should be properly decontaminated and discarded to the sanitary sewer.
• must be placed in containers which are closable, constructed to contain all contents and prevent leakage, appropriately labeled or color-coded (see Labels), and closed prior to removal to prevent spillage or protrusion of contents during handling.
• Sharps container disposal is done in accordance with the instructions provided by the responsible person on the “Engineering Controls and Work Practices” documents found in Appendix E.
• Sharps containers are to be maintained upright throughout use, and replaced when 2/3 full.
• Contaminated Sharps must be discarded immediately or as soon as possible in containers that are closable, puncture-resistant, leak proof on sides and bottoms, and labeled or color-coded appropriately. Sharps disposal containers are obtained at the location designated on the “Engineering Controls and Work Practices” document located in Appendix E.
• Other regulated waste is placed in appropriately color coded or labeled bags and placed in a lined biowaste container as designated on the “Engineering Controls and Work Practices” document found in Appendix E of this program.
• Autoclaves used for the decontamination of regulated waste must be tested using a spore strip or equivalent means within one week of the date that a regulated material is autoclaved. In addition an autoclave log must be maintained showing the date, autoclave temperatures, duration of cycle and name of the individual responsible for operating the autoclave used to sterilize a load of regulated waste.
• Broken Glassware which may be contaminated, must be picked up using mechanical means, such as a brush and dustpan, or stick and tin can (we don’t care, just don’t touch it with your hands);
• Walls, tables, chairs, workbenches, and other work surfaces potentially contaminated with blood must be maintained as free as possible from all visible contamination. Contaminated surfaces are to be cleaned with a biocide, such as a solution consisting of 90% water and 10% bleach. The cleanup must be performed as outlined by an appropriate “Engineering Controls and Work Practices” document (see Appendix E). Note: These practices must minimize the potential for a splash or generation of contaminated aerosols.
• All bins, pails, cans, and similar receptacles that are potentially contaminated which are intended for reuse must be inspected daily and decontaminated on a weekly basis, or as soon as feasible if visible contamination is found.
• Protective coverings such as plastic wrap, aluminum foil, or imperviously backed absorbent paper are to be removed and replaced as soon as feasible following contamination.  Example: The protective paper covering exam tables must be changed following each use.
• Regulated Medical Waste containers must be emptied regularly, so as to prevent them from being overfilled.
• Tools and equipment must be stored in their proper location.
• Counters, floors, and other work surfaces which could be contaminated must be maintained free of unnecessary tools or equipment, magazines, paper, and other materials generalized as clutter.

 

8.6 Labels & Signs

 

All trash receptacles, sharp containers, bags, and vessels (including secondary containment vessels) used to hold or transport contaminated materials must be labeled with the biohazard sign and read BIOHAZARD.

 

 

Biohazard labels must be predominantly fluorescent orange or orange-red with lettering and symbols in a contrasting color (typically black). Red bags or containers may be substituted for the above label.

 

Labels must be affixed to containers, bags, or vessels using adhesive backed labels, or have the biohazard symbol and wording imprinted onto their surface.

 

The labeling methods that have been selected for this department are detailed on the “Engineering Controls and Work Practices” documents in Appendix E of this program.

 

The responsible person must ensure warning labels are affixed or red bags are used as required if regulated waste or contaminated equipment is brought into the facility. Employees are to notify the responsible person (listed on the front of this plan) if they discover regulated waste containers, refrigerators containing blood or OPIM, contaminated equipment etc. that is not properly labeled.

 

8.7 Containers

 

All biohazard containers must prevent leakage during collection, handling, processing, storage, or transport. In addition, “sharps” containers must be puncture resistant.

 

Biohazard containers used for storage, transport, or shipping must be labeled with the BIOHAZARD symbol and lined with a red biohazard bag.  The container is to be closed and sealed prior to being stored, transported, or shipped.

 

If outside contamination of the primary container occurs, the primary container is to be placed within a secondary container to prevent leakage during handling, processing, storage, transport, or shipping. The secondary container must be labeled with the BIOHAZARD symbol to indicate containment of potentially infectious materials.

 

8.8 Cleaning, Laundering, & Disposal of Contaminated Laundry and Other Reusable Items

 

Contaminated and potentially contaminated laundry must be handled as little as possible with a minimum of agitation while wearing protective gloves.

 

Laundry contaminated with blood or other potentially infectious material must be placed in a dissolvable plastic bag, which is then placed in a red bag and then taken to Textile Cleaning Services and laundered.

 

At the laundry facility, people handling red bag materials will wear gloves and place the dissolvable bags directly into the washing machines. Biohazard laundry bags shall be transported by designated persons, trained and authorized to transport such items.  

 

Removal of Bedding:

 

Bedding is to be removed carefully. While removing bedding, employees should watch for needles, razor blades, and other sharps. If a needle (or other sharp) is found within the bedding then the employee should have the room occupant remove and dispose of the sharp (if possible). If the room occupant is not available, use pliers or some other engineering control to remove the sharp. The sharp must then be placed into a sharps container. Employees are not to handle “sharps” with their hands.

 

8.9 Porous & Non-Porous Surface Cleanup

Cleanup of spills involving blood or other potentially infectious material is the responsibility of the department in which the spill occurs.

 

8.10 Engineering Controls and Work Practices

 

Engineering controls and work practice controls must be used to prevent or minimize exposure to bloodborne pathogens. The specific engineering controls and work practice controls used must be listed in Appendix E of this program.

 

-Engineering Controls and Work Practices Examples-

 

The following two examples are provided to help responsible persons understand how detailed the steps should be, in the main body of the “Engineering Controls and Work Practices” documents. The following examples are not intended to include all of the information needed on an “Engineering Controls and Work Practices” document.

 

Example 1- Suggested procedures for Appendix E, “Engineering Controls and Work Practices”, when cleaning porous and non-porous surfaces other than carpet, but should be altered (if necessary) when re-written in Appendix E to address the work being performed:

 

• Secure the area and inform others in the area about the contamination.
• Obtain all of the equipment and cleaning supplies necessary for the cleanup, prior to performing the cleanup. Note: Disinfectants, need to be capable of destroying Hepatitis B virus.
• Use the personal protective equipment (PPE) listed on the PPE assessment form, which addresses the work being performed.
• Remove any sharps and/or broken glass by using engineering controls such as pliers or tongs, and place the sharps and/or contaminated broken glass into a sharps container.
• If the blood or OPIM could spatter then absorb the excess blood or OPIM with paper towels or kitty litter prior to disinfecting the contaminated area, and dispose of contaminated absorbent materials in a proper biohazard bag.
• Apply a disinfectant to the contaminated surface(s), and allow contact time as designated by the disinfectant manufacturer. .
• Following proper disinfection, use a sponge or paper towels to wipe the treated surface clean, and dispose of the contaminated material(s) in a proper biohazard bag.
• Use a 10% bleach solution or a disinfectant capable of destroying Hepatitis B virus to clean your protective gloves, but do not remove the gloves yet.
• Using the 10% bleach solution or disinfectant, clean the reusable items of PPE as you remove them.
• While wearing the gloves, remove and properly dispose of the other disposable PPE.
• Decontaminate the protective gloves again, remove them and dispose of them properly.
• Properly seal the waste container(s) and bag(s), and dispose of them properly.

 

Example 2- The following steps are suggested when cleaning carpet, but should be altered (as necessary) when they are re-written in Appendix E to address the work being performed:

 

• If blood or OPIM has penetrated the carpet (not just surface contamination) then the carpet / carpet pad must be replaced.
• Secure the area and inform others in the area about the contamination.
• Obtain all of the equipment and cleaning supplies necessary for the cleanup, prior to performing the cleanup. Note: Disinfectants, including rug shampoos, need to be capable of destroying Hepatitis B virus.
• Use the personal protective equipment (PPE) listed on the PPE assessment form, which addresses the work being performed.
• Remove any sharps and/or broken glass by using engineering controls such as pliers or tongs, and place the sharps and/or contaminated broken glass into a sharps container.
• If the blood or OPIM could spatter then absorb the excess blood or OPIM with paper towels or kitty litter prior to disinfecting the contaminated area, and dispose of contaminated absorbent materials in a proper biohazard bag.
• Apply a disinfectant to the contaminated surface(s), and allow contact time as indicated by the disinfectant manufacturer. Note: The disinfectant must be powerful enough to destroy the Hepatitis B virus. The EPA requires testing to certify disinfectants for specific pathogens. The disinfectant should clearly state that it has been tested or is suitable for Hepatitus B virus and the Human Immunodeficiency Virus.
• Use a freshly prepared 10% bleach solution (0.5% hypochlorite is the diluted concentration) or a disinfectant capable of destroying Hepatitis B virus to clean your protective gloves, but do not remove the gloves yet. Note: dilute hypochlorite solutions will undergo chemical degradation that reduces the effective hypochlorite concentration over time. Once the bleach is diluted, it should be used within 24 hours.
• Using the 10% bleach solution or disinfectant, clean the reusable items of PPE as you remove them.
• While wearing the gloves, remove and properly dispose of the other disposable PPE.
• Decontaminate the protective gloves again, remove them and dispose of them properly.
• Properly seal the waste container(s) and bag(s), and dispose of them properly.
• Clean the carpet using a carpet cleaner and a disinfectant shampoo.
• Dump the waste contents from the carpet cleaner into the sewer.

 

9.0 HEPATITIS B VACCINATIONS

 

Hepatitis B vaccinations must be provided at no cost to employees working for the University who have occupational exposure to blood or other potentially infectious material (OPIM). The cost of the vaccine is the responsibility of the department who supervises the employee that has reasonably anticipated occupational exposure.

 

The hepatitis B vaccination series is available at no cost (after training) and within 10 days of initial assignment to employees identified as having occupational exposure. Vaccination is encouraged unless: 1) documentation exists that the employee has previously received the series, 2) antibody testing reveals that the employee is immune, or 3) medical evaluation shows that vaccination is contraindicated.

 

The vaccination series is to be administered during the employees work shift.

 

A licensed health care provider who is following current U.S. Public Health Service procedures must provide any vaccinations. The University designates the proper health care provider.

 

If the individual is considered to be at ‘high-risk’ of exposure to bloodborne pathogens, post-vaccine testing of the antibody titers elicited by the vaccine should follow vaccination. The ‘high-risk’ designation is found in Appendix D of this program. This post-vaccination testing must be completed within two months of the final dose of vaccine.

 

Individuals who do not want the Hepatitis B vaccination need to sign a copy of the declination statement located in Appendix B of this program. All signed declination statements must be kept in the employee’s department file(s).

 

If an employee, still performing duties that fall within the scope of this plan, initially declines the hepatitis B vaccination, but then decides to accept the vaccination; the department must make the vaccination available at the time of the latest decision.

 

If the U.S. Public Health Service recommends a routine booster dose(s) of hepatitis B vaccine at a future date, such booster dose(s) must be made available to employees.

 

Following administration of hepatitis B vaccinations, the health care professional’s Written Opinion must be limited to whether the employee requires the vaccine, and whether the vaccine was administered.

 

For people identified as having a ‘high-risk’ of exposure to blood or other potentially contaminated material as part of their routine duties, the HBV vaccine will be evaluated by testing the blood of the vaccinated person for HBV protective antibody titer within two months of completion of the vaccine series. The need for post-vaccination evaluation is determined by the responsible person and denoted on the Appendix D Exposure Determination Log.

 

10.0 EXPOSURE INCIDENTS

 

Following each occupational exposure, exposed individuals are to report the incident as soon as possible to their supervisor, and seek a consultation from a qualified physician or licensed health care provider. During normal working hours this will be provided by the BYU Health Center. After normal working hours the medical consultation will be provided through the Utah Valley Regional Medical Center Emergency Room. Supervisors must complete a Supervisor’s Incident Investigation Report for each exposure incident. Note: Risk Management and Safety will use completed Incident Investigation Reports to investigate exposures and, if necessary, recommend changes in work practices and controls.

 

The cost for post workplace exposure consultations and post workplace exposure treatment is the financial responsibility of the department supervising the exposed individual.

 

-Immediate Response to an Exposure Incident-

 

• Clean the wound, wash or flush the contaminated area thououghly.
• Contact Urgent Care at the Student Health Center at the following number when calling from a campus phone: 8-5128 from 8 AM to 6 PM. During the night or weekends, go directly to the Utah Valley Regional Medical Center for evaluation and post exposure follow-up.
• The following information must be provided to the responsible person designated on the front of this plan:
• The route(s) of exposure and how the exposure occurred; and
• The identity of the source individual, unless the employer can establish that identification of the source individual is not feasible or prohibited by law.

 

Note: The department will furnish post-exposure prophylaxis, for hepatitis B, and or HIV when medically indicated as recommended by the U.S. Public Health Service, counseling; and evaluation of the reported illnesses.

 

-Investigation of Exposure Incidents-

 

When investigating an exposure incident, determine:

• What engineering controls were in use at the time of the exposure;
• The work practices being followed at the time of the exposure;
• The type of devices being used at the time of exposure (document a description of the devices);
• What protective equipment or clothing was being used at the time of exposure;
• The location of the incident (O.R., E.R., patient room, etc.);
• The procedures being performed when the incident occurred; and
• Investigate the extent of the exposed employees training, and the training of those contributing to the exposure incident.

 

-Needlestick Injuries-

 

The following information must be collected and submitted to Risk Management and Safety for each percutaneous injury from a contaminated sharp on a standard Supervisors Report:

 

• The type and brand of device involved in the incident;
• The department or work area where the exposure incident occurred; and
• An explanation of how the incident occurred.

 

Exposure incidents are evaluated by Risk Management & Safety to determine if the case meets OSHA’s recordkeeping requirements.

 

Note: The health care professional's written opinion for post-exposure evaluation and follow-up shall be limited to the following information:

• That the employee has been informed of the results of the evaluation.
• 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.
• Whether or not Hepatitis B vaccine is indicated and if employee has received vaccine.
• Whether Post-Exposure Prophylaxis was evaluated for the employee

 

11.0 TRAINING

 

All employees falling within the scope of this program are to be trained upon initial job assignment and at least annually thereafter. Students, who perform work that is similar to employees covered by this program, must also receive the same training. Training must also be provided, when an existing job task is altered, or when an employee is required to perform a new job task that warrants such training.

 

The responsible person will provide training to the employees in their department, who have reasonably anticipated exposure to blood or OPIM. Employees are not required to participate in a prescreening program, as a prerequisite for receiving hepatitis B vaccinations.

 

Employee training must include at least the following elements:

1. Where to locate a copy of the regulatory text (OSHA standard 29 CFR 1910.1030 is available over the internet at www.osha.gov).
2. An explanation of the epidemiology and symptoms of bloodborne diseases.
3. An explanation of the modes of transmission.
4. Where to locate the Exposure Control Plan (ECP) and a description of the ECP.
5. An explanation of the methods to recognize tasks and other activities that may involve exposure to blood and OPIM, including what constitutes an exposure incident.
6. Use and limitations of the engineering and administrative (safe work practices) controls, and personal protective equipment that are to be used to eliminate or minimize exposures.
7. An explanation as to why the different types of PPE are needed.
8. How to select, locate, use, remove, handle, decontaminate, and properly dispose of PPE.
9. Information regarding the Hepatitis B vaccination (Its usefulness, efficacy, safety, administration, benefits, and availability).
10. The steps employees will need to take in the event of an emergency, or bloodborne pathogen exposure incident.
11. Information of the post-exposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident.
12. How to recognize bloodborne pathogen warning signs and labels, and the color-coding required by the standard and used by the department.
13. Specific engineering controls, work practices, precautions, and personal protective equipment required for each job task to be performed.

 

Note: The department of Risk Management & Safety has created a PowerPoint presentation, and have available a BBP video that can be used as tools to help achieve the training requirements.

 

*Employee questions are invited throughout each training session. Employees are expected to be proficient with this program and all training material.

 

12.0 RECORDKEEPING

Training records are to be completed for each employee upon completion of training. Training records will be kept for at least three years by the trained individuals department. The training records must include:

 

• The date, when training occurred;
• The contents or a summary of the training session;
• The names and qualifications of persons conducting the training; and
• The names, and job titles, of the individuals who received the training.

A record of employee training can be obtained by contacting the responsible person. The record will be provided to the employee or their authorized representative within 15 days of the initial request.

 

-Medical Records-

 

Medical records are maintained by the Student Health Center and/or Human Resource Services, in accordance with 29 CFR 1910.1020, a department having medical record should direct them to 124 TOMH. To request medical records please contact Human Resource Services.

 

 

APPENDIX A Personal Protective Equipment Assessments

 

To complete a PPE assessment please visit the Risk Management and Safety website, http://safety.byu.edu, and access the link called “PPE builder”, which is found under the Personal Protective Equipment program link. If you need help completing a PPE assessment please call Risk Management & Safety (422-4468). Once approved, completed assessments can be viewed online at the same web location.

 

Note: Once determined, please indicate what PPE is needed on the appropriate “Engineering Controls & Work Practices” form (Appendix E). It is important for individuals must know what PPE is needed and when to use it, therefore PPE needs to be documented on the “Engineering Controls & Work Practices” forms.

 

APPENDIX B Declination Statement For Hepatitis B Vaccination

 

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.

 

 

 

 

 

Name (Please Print)_______________________________________________________

 

I.D. #____________________________

 

Department___________________________________________________

 

Supervisor (Please Print)_________________________________________

 

Date_____________________________

 

 

Signature of Employee ____________________________________________________

APPENDIX C Definitions

 

Bloodborne Pathogens (BBP) – 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.

 

Exposure Control Plan – A plan designed to minimize employee exposure to blood and other potentially infectious materials. This plan includes:

• An exposure determination (in this program, the listing for the job task);
• The sections found in this program; and
• Methods to investigate exposure incidents.

 

Exposure Incident – A specific eye, mouth, mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious material that results from performing work for the University of Maine.

 

Parenteral – Means piercing mucous membranes or the skin barrier through such events as needle sticks, human bites, cuts, and abrasions.

 

Other Potentially Infectious Material (OPIM) – 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. Tissues can be considered OPIM also. Any unfixed tissue or organ (other than intact skin) from a human (living or dead) is considered OPIM; and 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.

 

The following materials are not considered other potentially contaminated material unless visably contaminated with blood: vomit, fecal material, saliva (except in dental procedures), sweat, and urine.

 

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.

 

Sharps – Needles, scalpels, or other sharp object that can penetrate the skin.

 

Universal Precautions - All human blood & other potentially infectious material (OPIM) are treated as if known to be infectious for HIV, HBV, or other bloodborne pathogens.

Appendix D Exposure Determination Log

 

The following is a list, pertaining to our department, of all job classifications where it is reasonably anticipated that employees performing this work may receive skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employees duties:

 

Instruction: Mark “Yes”, under “High Risk?” on this form for each job task where the employee(s) have a high risk of occupational exposure to blood or other potentially infectious material (OPIM). While a surgeon is the quintessential high risk job title and a custodian who cleans up a few drops of blood once every six to twelve months would represent the low risk category, the responsible person may have to make judgments on risk for many job titles. This assignment is the responsibility of the department but BYU Risk Management will give guidance to those departments desiring help with this designation.

 

Job Title		Department Location	High Risk?

Appendix E Engineering Controls & Work Practices

 

One of these forms needs to be completed and included in this Appendix for each job title/task listed in Appendix D

 

Job Title:						Date of Completion:
Engineering Controls Needed To Perform Task:
Work Practices Needed To Complete Task:
(For an example see section 8.9 of this program)
Personal Protective Equipment (PPE) Needed:					Location of PPE:
Proper Disposal Method for PPE:
Location of Sharps Container:
Location of Lined Biowaste Container:
The Following Labeling Methods Are Allowed To Be Used:

Appendix F Bloodborne Pathogens Program Evaluation Checklist

 

Evaluation by:

Date:

 

Section 1 – Training
1. Training is offered to all employees with potential exposure to BBP (annual)	Yes	No
2. The trainer is qualified	Yes	No
3. Trainer is available to answer questions	Yes	No
(The following topics are covered in training)
4. An explanation of the BBP standard	Yes	No
5. Epidemiology and symptoms of bloodborne disease	Yes	No
6. Explanation of modes of transmission of BBP	Yes	No
7. Explanation of the Exposure Control Plan	Yes	No
8. Identification of tasks that may involve exposure to BBP	Yes	No
9. An explanation of the use, value, and limitations of PPE, engineering controls, and work practices used at the facility.	Yes	No
10. Information on HBV vaccination	Yes	No
11. What to do if an exposure occurs, contacts, etc.	Yes	No
12. Post exposure follow-up	Yes	No
13. Signs, labels, and color codes	Yes	No
Section 2 ECP
1. Exposure determination is complete for all jobs in the department	Yes	No
2. Records indicating annual review of ECP are available	Yes	No
3. Procedure for evaluation of exposure incidents are included	Yes	No
4. The ECP is available to employees	Yes	No
5. The ECP Includes a list of tasks that could result in exposures	Yes	No
6. SOP’s for high risk tasks are included or referenced	Yes	No
Section 3 Methods of Compliance
1. Documentation of annual review of engineering controls with employee input is available.	Yes	No
2. Appropriate PPE is identified and made available by the department	Yes	No
3. Personal protective is maintained and cleaned by the department	Yes	No
4. Hand washing facilities are available	Yes	No
5. Sharps are not bent, recapped or removed	Yes	No
6. Appropriate sharps containers are available	Yes	No
7. Eating, drinking, applying cosmetics or lip balm and handling contact lenses are prohibited in the work area with likely exposure to BBP	Yes	No
8. Waste containers (regulated waste) are color coded or labeled	Yes	No
9. Contaminated equipment is labeled or decontaminated	Yes	No
10. Appropriate disinfectants are used (reviewed by EPA)	Yes	No
11. Regular cleaning and disinfection schedules for potentially contaminated areas are clearly defined and written, including responsible party (example: following patient exam the disposable bench cover is replaced by the orderly, lab benches are disinfected before lunch and at the end of the day by the microbiologist)	Yes	No
12. HBV vaccination is offered to all potentially exposed employees	Yes	No