Environmental Health and Safety

BLOODBORNE PATHOGENS EXPOSURE

CONTROL PLAN

Update #5 – August 2005

Table of Contents

Purpose

Applicability

Review

Exposure Determination

Implementation and Methodology

Hepatitis B Vaccine

Training

Recordkeeping

APPENDIX A - HEPATITIS B VACCINE DECLINATION STATEMENT

APPENDIX B - ASSESSMENT TOOL

Purpose

This exposure control plan is adopted as the minimum standard to implement the Bloodborne Pathogens Exposure Control Plan required in Health and Safety Code, §81.304. In accordance with Health and Safety Code, Chapter 81, Subchapter H, and analogous to OSHA Bloodborne Pathogens Standard, the following exposure control plan exists:

Applicability

The minimum standards contained within this exposure control plan apply to The University of Texas at Tyler (UT Tyler) employees who have a risk of exposure to blood or other material potentially containing bloodborne pathogens in connection with exposure to sharps.

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Review

UT Tyler will annually review the exposure control plan, update when necessary, and document when accomplished.

Exposure Determination

UT Tyler has performed an exposure determination of employees who have occupational exposure to blood or other potentially infectious materials. This exposure determination is made without regard to the use of personal protective equipment and lists all job classifications in which employees have occupational exposure, regardless of frequency. The following job classifications apply:

• Full-time licensed nursing faculty/staff

• Part-time licensed nursing faculty/staff

• Full-time faculty in Health & Kinesiology with responsibilities in designated programs

• UT Tyler Police and Guards

• Athletic coaches and trainer

• Pool Lifequards

The job descriptions for the above employees encompass the potential occupational exposure risks to bloodborne pathogens.

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Implementation and Methodology

Compliance Methods

Universal precautions are observed to prevent contact with blood or other potentially infectious materials. All blood or other potentially infectious materials are considered infectious regardless of the perceived status of the source individual.

Engineering and work practice controls are used to eliminate or minimize exposure to employees. Where occupational exposure remains after institution of these controls, personal protective equipment is used. Examples include safety design devices, sharps containers, needleless systems, sharps with engineered sharps injury protection for employees, passing instruments in a neutral zone, etc.

Supervisors and workers examine and maintain engineering and work practice controls within the work center on a regular schedule.

Hand washing facilities are available to employees who incur exposure to blood or other potentially infectious materials. These facilities are readily accessible after incurring exposure.

After removal of personal protective gloves, employees 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 are washed with soap and water or flushed with water as soon as feasible following contact.

Needles

Contaminated needles and other contaminated sharps are not bent, recapped, removed, sheared, or purposely broken. An exception to this is allowed if no alternative is feasible and the action is required by a specific medical procedure. If such action is required, then the recapping or removal of the needle must be done by the use of a device or a one-handed technique.

Contaminated Sharps Discarding and Containment

Contaminated sharps are discarded immediately or as soon as feasible in containers that are closable, puncture resistant, leak proof on sides and bottom, and biohazard labeled or color-coded. Sharps containers that are full are contained in biohazard boxes and then disposed of at designated sites.

 

During use, containers for contaminated sharps are easily accessible to personnel, located as close as feasible to the immediate area where sharps are used or can be reasonably anticipated to be found, maintained upright throughout use, are not allowed to overfill, and replaced routinely.

Work Area Restrictions

In work areas where there is a reasonable likelihood of exposure to blood or other potentially infectious materials, employees are not to eat, drink, apply cosmetics or lip balm, smoke, or handle contact lenses. Food and beverages are not to be kept in refrigerators, freezers, shelves, cabinets, or on counter/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 are conducted in a manner to minimize splashing, spraying, splattering, and generation of droplets of blood or other potentially infectious materials.

 

Specimens

Specimens of blood or other potentially infectious materials are placed in a container, which prevents leakage during the collection, handling, processing, storage, transport, or shipping of the specimens. The container used for this purpose is labeled with a biohazard label or color-coded and universal precautions are used throughout the procedure and the specimens and containers remain in the facility.

If outside contamination of the primary container occurs, the primary container is placed within a secondary container, which prevents leakage during the handling, processing, storage, transport, or shipping of the specimen. The secondary container is labeled with a biohazard label or color-coded.

Any specimen that could puncture a primary container is placed in a puncture proof secondary container.

Contaminated Equipment

Equipment that may become contaminated with blood or other potentially infectious materials is examined prior to servicing or shipping and decontaminated as necessary. UT Tyler places a biohazard label on all portions of contaminated equipment that remain to inform employees, service representatives, and/or the manufacturer, as appropriate.

Personal Protective Equipment

All personal protective equipment is provided without cost to employees. Personal protective equipment is chosen based on the anticipated exposure to blood or other potentially infectious materials. The protective equipment is considered appropriate only if it does not permit blood or other potentially infectious materials to pass through or reach the employee’s clothing, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of the time which the protective equipment is used. Examples of personal protective equipment include gloves, eyewear with side shields, gowns, lab coats, aprons, shoe covers, face shields, and masks. All personal protective equipment is fluid resistant.

All personal protective equipment is cleaned, laundered, or disposed of by UT Tyler at no cost to employees. UT Tyler makes all repairs and replacements at no cost to employees.

All garments, penetrated by blood are removed immediately or as soon as feasible and placed in the appropriate container. All personal protective equipment is removed prior to leaving the work area and placed in the designated receptacle.

Gloves are worn where it is reasonably anticipated that employees will have hand contact with blood, other potentially infectious materials, non-intact skin, and mucous membranes. Latex sensitive employees are provided with suitable alternative personal protective equipment.

Disposable gloves are not to be washed or decontaminated for re-use and are to be replaced as soon as practical when they become contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised.

Utility gloves may be decontaminated for re-use provided that the integrity of the glove is not compromised. Utility gloves are discarded if they are cracked, peeling, torn, punctured, 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, glasses with solid side shield, or chin length 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.

Surgical caps or hoods and/or fluid resistant shoe covers or boots are worn in instances when gross contamination can reasonably be anticipated.

Housekeeping

Applicable areas within UT Tyler facilities are cleaned and decontaminated with an Environmental Protection Agency (EPA) registered germicide to maintain an antiseptic clean environment at all times.

All contaminated work surfaces are decontaminated after completion of procedures, immediately or as soon as feasible after any spill of blood or other potentially infectious materials, and at the end of the work shift.

Protective coverings (e.g., plastic wrap, aluminum foil, etc.) used to cover equipment and environmental surfaces are removed and replaced as soon as feasible when they become contaminated or at the end of the work shift.

All bins, pails, cans, and similar receptacles are inspected and decontaminated on a regularly scheduled basis.

Any potentially contaminated, broken glassware is not picked up directly with the hands.

Regulated Waste Disposal

All contaminated sharps are discarded as soon as feasible in sharps containers located as close to the point of use as feasible in each work area.

Regulated waste (other than sharps) is placed in appropriate containers that are closable, leak resistant, labeled with a biohazard label or color-coded, and closed prior to removal. If outside contamination of the regulated waste container occurs, it is placed in a second container that is also closable, leak proof, labeled with a biohazard label or color-coded, and closed prior to removal.

All regulated waste is properly disposed of in accordance with federal, state, county, and local requirements.

Laundry Procedures

All used laundry is considered contaminated. Contaminated laundry is handled as little as possible and placed in appropriately marked bags or containers at the location where it was used.

Wet laundry is placed in leak resistant bags or containers, closed, and transported in leak proof containers. Such laundry is not sorted or rinsed in the area of use.

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

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Hepatitis B Vaccine

All employees who have been identified as having a potential occupational exposure to blood or other material potentially containing bloodborne pathogens in connection with exposure to sharps are offered the hepatitis B vaccine, at no cost to the employee, under the supervision of a licensed physician or licensed healthcare professional. The vaccine is offered after bloodborne pathogens training and within 10 working days of their initial assignment to work unless the employee has previously received the complete hepatitis B vaccination series; antibody testing has revealed that the employee is immune, or that the vaccine is contraindicated for medical reasons. Employees receive the vaccine at the Occupational Medicine Clinic at The University of Texas Health Center at Tyler.

Employees who decline the Hepatitis B vaccine sign a declination statement (See appendix A). A copy of the declination will be kept on file by the affected department(s).

Employees who initially decline the vaccine but later elect to receive it may then have the vaccine provided at no cost.

 

Post Exposure Evaluation and Follow up

When an employee incurs an exposure incident, the employee notifies her/his supervisor who arranges for the employee to be seen at the University of Texas Health Center at Tyler (UTHCT) where the employee will be offered a confidential medical evaluation and follow up as follows:

 

• Documentation of the route(s) of exposure and the circumstances related to the incident.
• If possible, the blood of the source individual is tested for HIV/HBV infectivity. Consent is obtained if required by law.
• The results of testing of the source individual are made available to the exposed employee with the employee informed about the applicable laws and regulations concerning disclosure of the identity and infectivity of the source individual.
• The employee is offered the option of having his/her blood collected for testing of the employee’s HIV/HBV serological status. The blood sample is preserved for at least 90 days to allow the employee to decide if the blood should be tested for HIV serological status. If the employee decides prior to that time that the testing will be conducted, then testing is done as soon as feasible.
• The employee is offered post exposure prophylaxis in accordance with the current recommendations of the U.S. Public Health Service.
• The employee is given appropriate counseling concerning infection status, results and interpretations of tests, and precautions to take during the period after the exposure incident.
• The employee is informed about what potential illnesses can develop and to seek early medical evaluation and subsequent treatment.
• UTHCT is designated to assure that the policy outlined here is effectively carried out and maintains records related to this policy.

Interaction with Healthcare Professionals

A written opinion is obtained from UTHCT when they evaluates employees of UT Tyler after an exposure incident. In order for UTHCT to adequately evaluate the employee, they must be provided with:

1. A copy of UT Tyler’s exposure control plan.
2. A description of the exposed employee’s duties as they relate to the exposure incident.
3. Documentation of the route(s) of exposure and circumstances under which the exposure occurred.
4. Results of the source individual’s blood tests (if available).
5. Medical records relevant to the appropriate treatment of the employee.

Written opinions are obtained from UTHCT in the following instances:

1. When the employee is sent to obtain the Hepatitis B vaccine, or
2. Whenever the employee is sent to a healthcare professional following an exposure incident.

UTHCT is instructed to limit their written opinions to:

1. Whether the Hepatitis B vaccine is indicated;
2. Whether the employee has received the vaccine;
3. The evaluation following an exposure incident;
4. Whether the employee has been informed of the results of the evaluation;
5. Whether the employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials (the written opinion to UT Tyler is not to reference any personal medical information); and
6. Whether the UTHCT written opinion was provided to the employee within15 days of completion of the evaluation.

Labels

 

Biohazard warning labels are affixed to containers of regulated waste, refrigerators and freezers containing blood or other potentially infectious materials, and other containers used to store, transport, or ship blood or other potentially infectious materials. Red bags or red containers may be substituted for labels.

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Training

Training for all employees is conducted prior to initial assignment to tasks where occupational exposure may occur, or for current employees immediately prior to assignment to tasks with risk of exposure. All employees also receive annual refresher training. This training is to be conducted within one year of the employee's previous training.

Training for employees is conducted by a person knowledgeable in the subject matter and includes an explanation of the following:

• OSHA Bloodborne Pathogen Final Rule;
• Epidemiology and symptomatology of bloodborne diseases;
• Modes of transmission of bloodborne pathogens;
• UT Tyler’s exposure control plan, lines of responsibility, how the plan will be implemented, where to access plan, etc.);
• Procedures that may cause exposure to blood or other potentially infectious materials at this facility;
• Control methods that are used at UT Tyler to control exposure to blood or other potentially infectious materials;
• Personal protective equipment available at UT Tyler (types, use, location, etc.);
• Hepatitis B vaccine program at UT Tyler;
• Procedures to follow in an emergency involving blood or other potentially infectious materials.
• Procedures to follow if an exposure incident occurs, to include U.S. Public Health Service Post Exposure Prophylaxis Guidelines;
• Post exposure evaluation and follow up;
• Signs and labels used at UT Tyler; and
• An opportunity to ask questions with the individual conducting the training.

Recordkeeping

UT Tyler’s Human Resources department maintains medical records and Environmental Health & Safety department training records for employees.

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