sop 2.7: bloodborne pathogen control plan€¦ · web viewengineering controls: controls that...

Household Hazardous Waste

SOP 2.7: Bloodborne Pathogen Control Plan

Contents1. Introduction..............................................................................12. Regulatory and contractual requirements................................13. Training………………………………………………………………………………………..14. Applicability/staff exposure determination...............................25. ECP implementaion and control................................................36. Hepatitis B vaccination.............................................................47. Labels and recordkeeping…………………………………................6AttachmentsA. ECP definitions.............................................................................8B. Hand-washing technique……………………………….………………….………… 9C. Removal of contaminated disposable gloves...............................10D. Blood clean-up……………………………………………………………………………. 11E. Hepatitis B vaccine declination....................................................13F. Bloodborne pathogen exposure incident form..............................14

1.IntroductionThe purpose of an exposure control plan (ECP) is to eliminate or minimize occupational exposure to blood

or other potentially infectious materials (OPIM) in accordance with the OSHA Bloodborne Pathogens

Standard. For ECP definitions, see Attachment A of this SOP.

2.Regulatory and contractual requirementsBloodborne pathogen policy is governed by the requirements established in the HHW program and state

agency contract (Exhibit A, part B), Minn. Statute § 116.78, sub. 2, and OSHA 29 CFR 1910.1020,

1910.1030, 1910.1030(f), 1910.1030(g)(2)(i).

3.Training3.1 The ECP Administrator is responsible for coordinating training, which shall be conducted by a

qualified individual who has knowledge of the required subject matter. The Program Manager is the

ECP Administrator and is responsible for implementing this HHW Facility’s plan. ECP training

shall be:

2.7 Bloodborne Pathogen Control Plan 1

conducted before assignment to a task where occupational exposure to blood may take place

and at least annually thereafter.

provided when changes (e.g., modification of tasks or procedures, new or revised staff

positions, change in technology) affect the occupational exposure.

provided at no cost.

3.2 ECP training is an opportunity for interactive questions and answers with the person conducting the

session. The ECP training program shall include the following explanations, at a minimum:

OSHA Bloodborne Pathogen Standard text and how to access a copy during working hours.

epidemiology, modes of transmission, and symptoms of bloodborne diseases.

the process staff can use to access or obtain a copy of this Facility’s ECP written plan.

appropriate methods for recognizing tasks and other activities that may involve exposure to

blood or other potentially infectious materials.

proper Personal Protective Equipment (PPE) use (e.g., types, location, removal, handling,

selection basis, decontamination, disposal).

use and limitations of methods that prevent or reduce exposure (e.g., appropriate engineering

controls, work practices, PPE).

appropriate actions to take and contact information for an emergency involving blood or OPIM.

Hepatitis B vaccine information (e.g., efficacy, safety, administration method, benefits, offered

at no charge, declination process).

procedures following an exposure incident (e.g., reporting methods, medical follow-up).

the follow-up evaluation process required after an exposure incident occurs.

clean-up procedures for blood and OPIM.

recognition of biohazard markings (e.g., signs, labels, color coding to denote biohazards).

4.Applicability/staff exposure determination4.1 Applicability

This Program shall have a bloodborne pathogen ECP or be covered by the employer’s existing

program, if it could be “reasonably anticipated” (as a result of performing job duties) that staff could

be exposed to blood or OPIM. This applies to staff performing any of the following functions:

accepts or handles needles

is expected to perform first aid

cleans up blood spills

4.2 ECP componentsThe exposure determination shall be made without regard to the use of PPE. The ECP shall include:


1.an exposure determination

2.methods of compliance

3.Hepatitis B vaccination

4.post-exposure evaluation procedures

5.training

4.3 AdministrativeThe ECP Administrator shall be review the plan at least annually, update as needed, and make it

available for staff to review. Safer devices shall be selected as they become available.

5.ECP implementation and control5.1 Universal precautions

According to universal (or standard) precautions, all blood or OPIM shall be considered potentially

infectious regardless of the perceived status of the source.

5.2 Engineering and work practice controlsEngineering and work practice controls shall be utilized to minimize or eliminate exposure for

Facility staff. Where the potential for occupational exposure remains after institution of these

controls, these practices shall be followed:

5.2.1 Sharps container

No sharps are accepted at this facility. If sharps are inadvertently accepted, they shall be

stored in acceptable sharps containers. Staff shall NOT directly handle sharps at any time.

5.2.2 Hand/body washing

The purpose of hand washing is to remove any pathogens from the surface of the

skin. For hand-washing instructions, see Attachment B of this SOP.

Hands shall be washed as soon as feasible after removal of gloves and other PPE.

Interim hand-washing measures (e.g., antiseptic hand cleansers, towelettes) shall be

used where hand-washing facilities are not immediately available. For glove removal

procedures, see Attachment C of this SOP.

Wash exposed skin as soon as possible after any incident (e.g., skin contact with

blood or OPIM).

Immediately following contact with blood or OPIM, eye and mucous membranes

shall be flushed with water.


5.3 PPEWhere occupational exposure remains after institution of engineering and work controls, PPE shall

be:

utilized and properly disposed of

provided at no cost to staff

purchased in appropriate sizes

maintained and made available for use while administering first aid or cleaning up blood

5.3.1 Selection and use

PPE shall be chosen based on the anticipated exposure to blood or OPIM. The protective

equipment shall be considered appropriate only if it does not allow blood or OPIM to pass

through or reach clothing, skin, eyes, mouth, or mucous membranes under normal

conditions of use and for the duration of time for which the PPE is used.

5.3.2 PPE general precautions

utilize PPE in occupational exposure situations; see SOP 2.4 PPE.

remove and replace all equipment or protective clothing that is torn, punctured, or

has lost its ability to function as a barrier against bloodborne pathogens.

remove all PPE before leaving the work area.

protective gloves are to be used if there is potential for contact with blood or OPIM.

alternative gloves shall be provided for staff with glove allergies (latex).

never wash or decontaminate disposable gloves for reuse or before disposal; for

glove removal procedures, see Attachment C of this SOP.

eye protection shall be worn to prevent exposure.

5.4 Housekeeping and maintenance5.4.1 Blood clean-up

To review blood clean-up procedures, see Attachment D of this SOP.

5.4.2 Decontamination and disinfecting

Surfaces or equipment contaminated with blood or OPIM shall be cleaned and

decontaminated as soon as possible, using one of the following methods:

household bleach diluted between 1:10 to 1:100 with water; dispose of unused

solution following the decontamination process.

EPA-registered tuberculocidal disinfectants or products registered against Hepatitis B

virus (HBV), used according to label instructions.


5.4.3 Broken glassware clean-up

Mechanical means shall be used (e.g., brush and dustpan) to clean up broken glassware.

Never pick up broken glassware by hand.

6.Hepatitis B vaccination6.1 Availability

The Hepatitis B vaccine shall be:

made available at no cost to staff covered by this ECP.

offered after staff has received training and within 10 days of initial assignment of job

involving potential for blood exposure.

6.2 DeclinationIf staff chooses to decline the Hepatitis B vaccine, they may later obtain it following the initial

declination. The following procedure shall be followed to document the initial declination:

complete the “Hepatitis B Declination Form”; see Attachment E of this SOP.

declination forms shall be maintained by the ECP Administrator.

6.3 General Vaccines shall be administered by a licensed healthcare professional (LHCP).

The vaccine shall be administered in accordance with U.S. Public Health Service (USPHS)

recommendations.

Hepatitis B booster dose shall be made available if/when recommended by USPHS.

6.4 Post-exposure evaluation and follow-up6.4.1 Staff responsibilities

Immediately clean the exposed body area, removing any contaminated clothing.

Thoroughly wash the affected body area with soap and water. Exposed mucous

membranes shall be thoroughly rinsed.

Notify the ECP Administrator of any exposure incident.

6.4.2 ECP Administrator responsibilities

If possible, investigate and document the incident before the end of the work shift.

Complete the “First Report of Injury” form (provided by employer) and the

supplemental “Bloodborne Pathogen Exposure Incident Form”; see Attachment F of

this SOP.


Offer staff a post-exposure evaluation and follow-up within 24 hours of the incident.

Post-exposure evaluations shall be performed at a designated clinic that provides this

type of service. Submit a copy of the completed forms to the clinic.

6.4.3 Testing of source and exposed individual

Identify the source individual and document their identity, unless identification is not

feasible.

If the source individual is already known to be infected, it is not necessary to repeat

the testing of that individual’s blood.

Obtain consent to arrange for collection of exposed staff’s blood as soon as feasible

after the exposure incident and test for HBV and HIV serological status.

Make arrangements to have the source individual tested as soon as possible to

determine HIV, HCV, and HBV status.

If the exposed staff does not give consent for HIV serological testing during the

collection of the blood for baseline testing, preserve the sample for at least 90 days. If

the exposed staff elects to have the baseline sample tested during this waiting period,

perform the testing as soon as feasible.

Results of the source individual’s testing shall be made available to the exposed staff.

Inform the affected staff of all applicable laws and regulations concerning disclosure of

the identity and infectious status of the source individual.

6.4.4 Clinic responsibilities

The clinic shall offer post-exposure prophylaxis in accordance with the current

recommendations of the USPHS.

The clinic shall provide appropriate counseling concerning precautions to take during

the period following the exposure incident.

The clinic shall provide instruction on which potential illnesses to be alert for and to

report any related experiences.

6.4.5 Information

The following information shall be provided to the clinic by the employer or any other

designated person:

A copy of 29 CFR 1910.1030 (if needed)—ECP for anyone responsible for rendering

first aid or CPR on the job.

A written description of the exposed staff’s duties as they relate to the exposure

incident.

Written documentation of the route and circumstances of the exposure.

A result of the source individual’s blood test (if available).

A copy of the completed “Bloodborne Pathogen Exposure Incident Form.”


The affected staff’s Hepatitis B vaccine status.

6.4.6 Healthcare professional’s written opinion

The employer or other designated person shall obtain and provide affected staff with

a copy of the evaluating healthcare professional’s written opinion within 15 days of the

evaluation.

The written opinion for HBV vaccination shall be limited to whether HBV

vaccination is needed and if the staff has received such a vaccine. The healthcare

professional’s written opinion for the post-exposure follow-up shall be limited to the

following information:

A statement that the staff has been informed about any medical conditions resulting

from exposure to blood or OPIM which would require further evaluation or treatment.

A statement that the staff had been informed of the results of the evaluation.

All other findings of diagnosis shall remain coincidental and shall not be included in

written report.

7.Labels and recordkeeping7.1 Labels

Affix labels or mark containers of regulated/infectious waste with:

a biohazard symbol

the words “Biohazard” or “Infectious Waste”

colors of fluorescent orange or orange-red with lettering or symbols in a contrasting color

7.2 Medical recordsStaff records shall be kept confidential and be maintained for the duration of employment plus 30

years by the employer or other designated person, including the;

1. name and social security number

2. HBV vaccination status, including the vaccination date

3. results of examinations, medical testing, and post-exposure evaluation follow-up

4. a copy of the information provided to the healthcare professional

5. a copy of the healthcare professional’s written opinion limited to information, as described

above


7.3 Training recordsTraining records shall be maintained by the ECP Administrator for at least 3 years and contain the

following training session information:

date and outline describing the material presented

name and qualifications of the trainer

names and job titles of all staff persons attending the training session

for additional information; see SOP 1.4 HHW Training Requirements.

7.4 OSHA 300Each exposure incident shall be evaluated by the ECP Administrator to determine if the case meets

OSHA’s recordkeeping (recordable) requirements. The incident shall be recorded on the log if it

meets one of these requirements:

involves loss of consciousness, transfer to another job, or restriction of work or motion.

results in the recommendation of medical treatment beyond first aid (e.g. gamma globulin,

hepatitis B immune globulin, hepatitis B vaccine, zidovudine (AZT)), regardless of dosage.

results in a diagnosis of seroconversion; the case shall not be recorded on the OSHA 300 as

seroconversion, but as an injury (e.g., needle stick, laceration); see SOP 2.2 OSHA

Recordkeeping/postings/checklist.

7.5 Sharps injury logIf accepting sharps, this facility shall maintain a sharps injury log for the recording of needle sticks.

The information shall be recorded and maintained in a manner to protect the confidentiality of the

injured staff. The log shall be maintained by the facility manager and follow the same retention

requirements as the OSHA 300 forms; see SOP 2.2 OSHA Recordkeeping/postings/checklist. The

log shall include:

Type and brand of device involved.

Work area where incident occurred.

Explanation of how incident occurred.

7.6 Availability All records shall be made available to staff upon request.

All records shall be made available to OSHA upon request for examination and

copying.


Attachment AECP definitions

Blood: human blood, human components, and products made from human blood.

Bloodborne pathogens: pathogenic microorganisms present in human blood that can infect and cause disease

in humans. These pathogens include, but are not limited to, Hepatitis B virus (HBV), Hepatitis C virus (HCV),

and Human Immunodeficiency Virus (HIV).

Contaminated: the presence or the reasonably anticipated presence of blood or other potentially infectious

materials on items or surfaces.

Decontamination: 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 transporting infectious particles

and the surface or item is rendered safe for handling, use, or disposal.

Engineering controls: controls that isolate or remove the bloodborne pathogens hazard from the workplace:

e.g., sharps disposal containers, or self-sheathing needles.

Exposure incident: a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with

blood or other potentially infectious materials resulting from the performance of a staff member’s duties.

Hand-washing facilities: a facility providing an adequate supply of running potable water, soap, and single-

use towels or hot-air drying machines.

Licensed healthcare professional: a person whose legally permitted scope of practice allows him or her to

independently perform Hepatitis B vaccinations and post-exposure evaluation and follow-up.

Occupational exposure: reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood

or other potentially infectious material that may result from the performance of a staff member’s duties.

Other potentially infectious materials (OPIM): includes human body fluids—semen, vaginal secretions,

cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures,

any body fluid visibly contaminated with blood, and all body fluids in situations where it is difficult or

impossible to differentiate between body fluids. Unless visibly contaminated with blood, saliva (except in

dental operations), feces, vomit, and urine are not considered to be OPIM.

Parenteral: piercing mucous membranes or the skin barrier through such events as needle sticks, human bites,

cuts, and abrasions.

Regulated waste: includes (1) liquid or semi-liquid blood or OPIM; (2) contaminated items that would

release blood or OPIM in a liquid or semi-liquid state if compressed; (3) items caked with dried blood or

OPIM that are capable of releasing these materials during handling; (4) contaminated sharps and used needles;


and (5) pathological and microbiological waste containing blood or OPIM.

Sharps: any object that can penetrate or cut the skin and produce an opening in the skin or a puncture wound

that would expose staff to blood or OPIM.

Source individual: any individual, living or dead, whose blood or other potentially infectious materials may be

a source of occupational exposure to the staff.

Universal precautions: an approach to infection control. According to the concept of Universal Precautions,

all human blood and certain human body fluids (OPIM) are treated as if known to be infectious for HIV, HBV,

HCV, and other bloodborne pathogens.


Attachment BHand-washing technique

Remove rings and watches before washing.

Hands shall be positioned lower than arms to prevent back flow contamination.

Running water is necessary to carry away dirt and debris.

Wet hands with warm running water, apply soap, and lather well.

Rub hands together in a circular motion applying light friction. Include front and back of both hands, between fingers and knuckles, around and under fingernails, and the wrist area.

Rinse hands under running water.

Dry hands with clean dry paper towel or air dryer.

Avoid direct contact of washed hands with faucet. If foot, elbow or knee controls are unavailable, drape paper towel over faucet handle prior to turning off.

Discard soiled paper towel in waste receptacle.

Attachment CRemoval of contaminated disposable gloves

Use two fingers to pinch the outside of one glove (near the inner wrist) with the other gloved hand.

Turn the glove inside out as it is pulled off.

Use gloved hand to loosely hold removed glove.

Reach inside second glove with two fingers of the bare hand and pinch it.

Turn the glove inside out as it is removed, enclosing the first glove.

Properly discard the entire package in waste receptacle.

Wash hands.


Attachment D

Blood clean–up

Wear impervious gloves and other PPE as deemed appropriate.

Use absorbent material (rag, paper towel, etc.) or item covered with absorbent solidifier to wipe up

blood.

Place contaminated items in a plastic bag (not red) and dispose of in the garbage (as long as they do

not meet the definition of a regulated waste).

Wash the surface with detergent and water.

Disinfect the surface using a bleach solution, letting it air dry (approximately 10 minutes), or use an

appropriate commercial disinfectant according to manufacturer directions.

Attachment EHepatitis B Declination Statement

The following statement of declination of Hepatitis B vaccination must be signed by a staff person who

chooses not to accept the vaccine. The statement can only be signed by the staff following appropriate training

regarding Hepatitis B, Hepatitis B vaccination, the efficacy, safety, method of administration, and benefits of

vaccination, and that the vaccine and vaccination are provided to staff free of charge. The statement is not a

waiver; staff is able to request and receive the Hepatitis B vaccination at a later date if they remain

occupationally at risk for Hepatitis B.

Declination StatementI 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 me; 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.

Staff signature: _________________________________________ Date: ____________________


Attachment FBloodborne pathogen exposure incident form

To be completed by Employee and reviewed with the Supervisor

Date: _____________________________________

Employee name:____________________________ Soc. Sec. #: _______________________________________

Job title:___________________________________ Date of birth: ______________________________________

Home phone: _______________________________ Work phone:_______________________________________

Exposure date: _____________________________ Exposure time:_____________________________________

Where did the incident occur? _____________________________________________________________________

Nature of incident (contaminated needle stick; splash to exposed membrane or non-intact skin)

______________________________________________________________________________________________

______________________________________________________________________________________________

Describe what task(s) were being performed when the exposure occurred:

______________________________________________________________________________________________

______________________________________________________________________________________________

Were you wearing Personal Protective Equipment (PPE)? Yes No If yes, list: __________________________

______________________________________________________________________________________________

Did the PPE fail? Yes No If yes, explain how: ____________________________________________________

To what fluids were you exposed? __________________________________________________________________

What parts of your body became exposed? ___________________________________________________________

Was this a puncture wound? Yes No If yes, what was the object? ____________________________________

Where did it penetrate your body? __________________________________________________________________

Was any fluid injected into your body? Yes No If yes, what fluid?_____________________________________

How much?_____________________________________________________________________________________

Did you receive medical attention? Yes No If yes, where?__________________________________________

When?____________________________________ By whom? ________________________________________

Identification of source individual(s) _________________________________________________________________

______________________________________________________________________________________________

Signature __________________________________ Date_____________________________________________

Reviewed by date________________________________________________________________________________


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