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Exposure Control Plan

SOP Number: 9.003
Review Date: Feb. 8, 2007
Replaces: 9.002
Review by: Darlene Heller

The State University of New York College at Plattsburgh is committed to providing a safe and healthful workplace for its staff and faculty. The following Exposure Control Plan has been developed to eliminate where possible or at least minimize the occupational exposure to blood-borne pathogens in accordance with the OSHA Blood-borne Pathogens Standard, Title 29 Code of Federal Regulations 1910.1030

Table of Contents

Definitions

Blood - Human blood, human blood components, and products made from human blood.

Blood-borne pathogens - Pathogenic microorganisms that are present in the human blood and can infect and cause disease in humans. These pathogens include but are not limited to, Hepatitis B virus (HBV), and Human Immunodeficiency Virus (HIV).

Contaminated - the presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.

Exposure Incident - a specific eye, mouth or other mucous membrane, non-intact skin or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee's duties.

Occupational Exposure - reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee's duties.

Other Potentially Infectious Materials (OPIM)

  1. The following human body fluids
    1. Semen
    2. Vaginal secretions
    3. Cerebrospinal fluid
    4. Synovial fluid
    5. Pleural fluid
    6. Pericardial fluid
    7. Peritoneal fluid
    8. Amniotic fluid
    9. Saliva in dental procedures
    10. Any body fluid visibly contaminated with blood
    11. All body fluids in situations where it is difficult or impossible to differentiate between body fluids
  2. Any unfixed tissue or organs (other than intact skin) from a human (dead or alive)
  3. HIV-containing cells or tissue cultures, organ cultures, and HIV and HBV-containing culture medium or other solutions.
  4. Blood, organs, or other tissue from experimental animals infected with HIV or HBV.

Regulated Waste

  1. Liquid or semi-liquid blood or other potentially infectious materials;
  2. Contaminated items that would release blood or other potentially infectious materials in the liquid or semi-liquid state if compressed.
  3. Items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling.
  4. Contaminated sharps.
  5. Pathological and microbiological wastes containing blood or other potentially infectious materials.

Methods of Implementation and Control

Universal Precautions

As of March 6, 1992 all employees will treat all human body fluids as infectious. Employees will use the appropriate personal protective equipment when the possibility of coming in contact with body fluids is present.

Exposure Control Plan

Employees covered by the Blood borne Pathogens Standard will receive an explanation of the ECP during their initial training, and will have it reviewed in their annual refresher training. All employees will have the opportunity to review this Plan at any time during their work shifts by contacting the supervisor, or Environmental Health Office at 5009 from 8am till 4:30 pm Monday thru Friday or by contacting the University Police at 2022 at other times. A copy of the plan will be made available free of charge within five days of the request. The Department Supervisor will be responsible for reviewing and updating the ECP annually or sooner if necessary to reflect any new or modified tasks and procedures which affect occupational exposure and to reflect new or revised employee positions with occupational exposure.

Engineering Controls and Work Practices

Engineering controls and work practice controls will be used to prevent or minimize exposure to blood borne pathogens. The specific engineering controls and work practice controls that will be used are:

  1. Puncture resistant disposable containers for contaminated sharps and broken glassware.
  2. Ventilated laboratory hoods
  3. Readily accessible hand washing facilities
  4. Emergency eye wash and deluge showers
  5. Safety guidelines for working with needles
  6. Prohibiting eating, drinking, smoking in areas where there is a likelihood of occupational exposure.
  7. Requiring that all procedures involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing, splattering, and generation of droplets of these substances.
  8. Placing specimens of blood or other potentially infectious materials in a container, which prevents leakage during collection, handling, processing, storage, transport or shipping.
  9. Examining equipment, which may become contaminated with blood or other potentially infectious materials prior to servicing or shipping and decontaminating such equipment as necessary. New technology for needle and sharps will be evacuated and implemented whenever possible to further prevent accidental needle sticks and cuts. Our engineering controls will be inspected and maintained or replaced by:
Area Responsibility Inspection
Student Health Center Director Daily
University Police Officers Chief Daily
University Police Students Chief Daily
Nursing Chairman Daily
Custodial Custodial Supervisor Daily
Phys. Ed. Athletic Director Weekly
Maintenance Maintenance Supervisor Weekly
Fieldhouse Fieldhouse Director Weekly
Student First Aiders Athletic Director Weekly
Residence Hall Staff Director Weekly

Personal Protective Equipment

Personal protective equipment must be used if occupational exposure remains after instituting engineering and work practice controls or if controls are not feasible. Training will be provided by the Environmental Health Office in the use of appropriate personal protective equipment for employee's specific job tasks or procedures they will perform.

Appropriate personal protective equipment is required for the following tasks:

Task Equipment
Physical Exam Gloves, clothing protection
First Aid Gloves, clothing protection, mask or Face shield (if appropriate)
Body Fluid clean up Gloves, mask (if chance of aerosol)
Injections Gloves, mask, eye protection
Laundry Gloves, clothing protection
Plumbing Leak repair Gloves, clothing protection
Toilet repair Gloves, clothing protection
Blood Lab Work Gloves, movable shield
Sewage Station Maintenance Gloves, mask, clothing protection

All personal protective equipment will be made readily accessible to all employees through their immediate supervisor or the office of Environmental Health and Safety. Employees will be issued equipment appropriate to the task and risk of exposure.

Personal Protective Equipment Available

General

  1. Wear appropriate gloves when it can be reasonably anticipated that you may have contact with blood or other potentially infectious materials and when handling or touching contaminated items or surfaces. Replace gloves if torn or punctured, contaminated, or if their ability to function as a barrier is compromised.
  2. Following any contact of body areas with blood or any other infectious materials, you must wash your hands and any exposed skin with soap and water as soon as possible. Employees must also flush exposed mucous membranes with water.
  3. Utility gloves may be decontaminated for reuse if their integrity is not compromised. The decontamination procedure will consist of washing the hands with gloves on in a disinfectant solution. Discard utility gloves when they show signs of cracking, peeling, tearing, puncturing, or deterioration.
  4. Never wash or decontaminate disposable gloves for reuse before disposal.
  5. Wear appropriate face and eye protection such as mask with glasses with solid side shields or a chin-length shield when splashes, sprays, splatters, or droplets of blood or other potentially infectious material pose a hazard to the eye, nose, or mouth.
  6. If a garment is penetrated by blood and other potentially infectious materials, the garments must be removed immediately or as soon as feasible.
  7. Repair and/or replacement of Personal Protective Equipment will be at no cost to the employees.
  8. All employees using Personal Protective Equipment must:
    1. Wash hands immediately or as soon as feasible after removal of gloves or other personal protective equipment.
    2. Remove protective equipment before leaving the work area and after the garment becomes contaminated.
    3. Place used protective equipment in appropriately designated areas or containers when being stored, washed, decontaminated, or discarded.

Container Areas

Biohazard waste containers will be set up in the training rooms and supervisor rooms at Memorial Hall and the Fieldhouse.

The Nursing Department will have containers on skills laboratories.

The Student Health Services will have containers set up in each examination room, and health laboratory.

For removal of waste call Environmental Health and Safety Office at 5009.

Training

All employees who have or are reasonably anticipated to have occupational exposure to blood borne pathogens will receive training consisting of information on the epidemiology of blood borne pathogens diseases. The training program will cover the following elements:

  1. A copy and explanation of the standard
  2. Epidemiology and symptoms to blood borne pathogens
  3. This Exposure Control Plan and how to obtain a copy
  4. Methods to recognize exposure tasks and other activities that may involve exposure to blood.
  5. Use and limitations of Engineering Controls, Work Practices, and Personal Protective Equipment.
  6. Personal Protective Equipment - types, use, location, removal, handling, decontamination, and disposal
  7. PPE-basis for selection
  8. Hepatitis B Vaccine - offered free of charge. Training will be given prior to vaccination on its safety, effectiveness, benefits, and methods of administration. (See Appendix O)
  9. Emergency procedures - for blood and other potentially infectious materials
  10. Exposure incident procedures.
  11. Post - exposure evaluation and follow up
  12. Signs and labels - and color coding
  13. Questions and answers

Training Records

Employee training records will be kept at the Environmental Health Office. All records will be kept for thirty years after an employee's separation of service.

Hepatitis B Vaccination

The Environmental Health Office will provide information on Hepatitis B Vaccinations addressing its safety, benefits, efficacy, methods of administration and availability.

The Hepatitis B Vaccination series will be made available at no cost to the employees who have exposure to blood or other potentially infectious materials:

If an employee chooses not to receive the vaccination he or she must sign a statement to the effect.

Employees who decline may request and obtain the vaccination at a later date at no cost.

Documentation of refusal of the HB vaccination will be kept in the Environmental Health Office.

Post Exposure Evaluation

Post Exposure Evaluation and Follow-up and Procedures for Reporting, Documenting and Evaluating the Exposure

Should an exposure incident occur contact the Environmental Health Office or University Police immediately. Each exposure must be documented by the employee on an "Exposure Report Form". The employee should inform their supervisor and go to the Emergency Room if necessary. During business hours, treatment may be available from the On the Job Network office at CVPH.

The following elements will be performed:

  1. Document the routes of exposure and how exposure occurred.
  2. Identify and document the source of individual (see Appendix E), unless the employer can establish that identification is not feasible or prohibited by State or local law.
  3. Obtain consent and test source individual's blood as soon as possible to determine HIV and HBV infectivity and document the source's blood test results.
  4. If the source individual is known to be infected with either HIV or HBV, testing does not needed to be repeated to determine the known infectivity.
  5. Provide the exposed employee with the source individual test results and information about applicable disclosure laws and regulation concerning the source identity and infectious status.
  6. After obtaining consent, collect exposed employee's blood as soon as feasible after exposure incident and test blood for HBV and HIV serological status.
  7. If the employee does not give consent for HIV serological testing during the collection of blood for baseline testing, preserve the baseline blood sample for at least 90 days.

Health Care Professionals

The Environmental Health Office will ensure that health care professionals responsible for employee's HB vaccination and post-exposure evaluation and follow-up be given a copy of the OSHA Blood Borne Pathogen Standard. The Environmental Health Officer will ensure that the health care professional evaluating an employee after an exposure incident receives the following:

  1. description of the employee's jobs duties relevant to the exposure incident.
  2. Route of exposure
  3. Circumstances of exposure
  4. Relevant employee records including vaccination status

Healthcare Professional's Written Opinion

The examining physician will provide the employee with a copy of his written opinion within 15 days after completion of the evaluation.

For HB vaccinations, the healthcare professional's written opinion will be limited to whether the employee requires or has received the HB vaccination.

The written opinion for post-exposure evaluation and follow-up will be limited to whether or not the employee has been informed of the results of the medical evaluation and any medical conditions, which may require further evaluation and treatment.

All other diagnoses must remain confidential and are not to be included in the written report.

Housekeeping

  1. Decontaminate work surfaces with an appropriate disinfectant after completion of procedure, immediately when overtly contaminated, after any spill of blood or other potentially infectious materials, and at the end of the work shift when surfaces have become contaminated since the last cleaning.
  2. Remove and replace protective coverings such as plastic wrap and aluminum foil when contaminated.
  3. Inspect and decontaminate on a regular basis, reusable receptacles such as bins, pails, and cans that have likelihood of becoming contaminated. When contamination is visible, clean and decontaminate receptacles immediately, or as soon as feasible.
  4. Always use mechanical means such as tongs, forceps, or a brush and a dust pan to pick up contaminated broken glassware; never pick up with hands even if gloves are worn.
  5. Store or process reusable sharps and in a way that ensures safe handling.
  6. Place regulated waste in closeable and labeled color-coded containers. When storing, handling, transporting or shipping, place all regulated waste in leak-proof containers.
  7. All sharps should be discarded in appropriate rigid, leak-proof containers.
  8. Sharps containers will be picked up for disposal by the Environmental Health Office and disposed of with the regulated medical waste.
  9. Never manually open, empty, or clean reusable contaminated sharps disposal containers.
  10. All regulated waste will be disposed of through the medical waste contactor and coordinated by the Environmental Health Office.

Laundry

The Fieldhouse Staff is responsible for the laundry and care of the athletic uniforms and equipment. The following requirements must be met, with respect to contaminated laundry:

  1. Handle contaminated laundry as little as possible and with a minimum of agitation
  2. Use appropriate personal protective equipment when handling contaminated laundry.
  3. Place wet contaminated laundry in leak-proof, labeled or color coded containers before transporting.
  4. Bag contaminated laundry at its location of use.
  5. Never rinse contaminated laundry in areas of its use.
  6. Use red bags or those marked with the biohazard symbol unless universal precautions are in use at the facility and all employees recognize the bags as contaminated and have been trained in handling the bags.
  7. When handling or sorting contaminated laundry, utility gloves and other personal protective equipment shall be worn

Labeling

All contaminated waste shall be disposed of in red leak-proof bags identified with a biohazard symbol on it.

Contaminated waste will be collected by Safeguard Biomed.

Recordkeeping

Medical Records

Medical Records are maintained for each employee with occupational exposure in accordance with 29 CFR Part 1910.20

The Personnel Office is responsible for maintenance of the required medical records and they are kept at that office.

In addition to the requirements of 29 CFR Part 1910.20, the medical record will include:

  1. The name and social security number of the employee;
  2. A copy of the employee's Hepatitis B vaccinations and any medical records relative to the employee's ability to receive vaccinations;
  3. A copy of all the results of examinations, medical testing, and follow-up procedures as required by the standard;
  4. A copy of all healthcare professional's written opinions as required by the standard.

All employee medical records will be kept confidential and will not be disclosed or reported without the employee's express written consent to any person within or outside the workplace except as required by the standard or as may be required by law.

Employee medical records shall be maintained for at least the duration of employment plus 30 years in accordance with 29 CFR Part 1910.20,

Employee medical records shall be provided upon request to the employee or anyone having written consent of the employee within 15 working days.

Training Records

The Environmental Health Officer will maintain Blood borne Pathogen training records at the office. The training records will consist of:

  1. The dates of the training sessions;
  2. The contents or a summary of the training sessions;
  3. The names and qualifications of persons conducting the training;
  4. The names and job titles of all persons attending the training sessions

Training records will be maintained for a minimum of three years from the date on which the training occurred.

Employee training records will be provided upon request to the employee or the employee's authorized representative within 15 working days.

Appendix A

Job Classifications In Which Employees May Have Occupational Exposure To Blood Borne Pathogens

Job Title Department
Medical Doctor Student Health Service
Physicians Assistant Student Health Service
Medical Technician Student Health Service
Registered Nurse Student Health Service
Licensed Practical Nurse Student Health Service
University Police Officer University Police
Athletic Trainer Physical Education
Equipment Manager Physical Education
Athletic coach Physical Education
Lifeguard Physical Education
Student Supervisor Physical Education
Security Fieldhouse
Janitor/Cleaner Janitorial
Maintenance Mechanic Maintenance & Operations
Nursing Faculty Nursing on hospital Assignment
Environmental Health & Safety Staff

Appendix B

Job Classifications And Work Practices In Which Some Employees Have Occupational Exposure To Blood Borne Pathogens

Job Title Department/Location Task Procedure
Custodian Academic Area Body Fluid Cleanup
Custodian Residence Hall Area Body Fluid Cleanup
Residence Assistants Campus Life Floor Supervision
Residence Director Campus Life Dorm supervision
Maintenance Mechanic M&O Plumbing Repair
Stationary Engineer M&O Plumbing Repair

Contact Information

Keith Tait, Director
Office: Beaumont Hall-207C
Phone: 564-3290
Fax: 564-5082
E-mail: ktait001@plattsburgh.edu

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