Exposure Control Plan

Program Reference

Purpose

The Public Employment Risk Reduction Program's (PERRP) Bloodborne Pathogens standard requires that Miami University develop a written Exposure Control Plan to eliminate or minimize employee exposure to bloodborne pathogens in the workplace. It identifies those tasks and procedures in which occupational exposure may occur and specifies the positions whose duties include those tasks and procedures identified with occupational exposure.

Scope and Application

Unless specified otherwise, all policies, provisions, and procedures listed in the ECP are the responsibility of EHSO.

The ECP applies to all job classifications listed in the Exposure Determination section. Employees in these job classifications are required to comply with all aspects of the ECP.

EHSO staff will conduct audits of records and work areas to ensure affected departments’ compliance with the ECP. Any employee who willfully violates or disregards provisions of the ECP will be subject to disciplinary action as specified by University policy. Any contractor who willfully violates or disregards provisions of the ECP will be subject to penalties up to and including removal from the job and/or loss of contract in accordance with the provisions of the contract.

References

EHSO has compiled information for this ECP from the sources listed below. Furthermore, this document has been reviewed by medical professionals and State of Ohio consultants to ensure technical accuracy and comprehensive coverage for the wide range of job duties at Miami University.

Only EHSO may add, delete, or modify any provisions in the ECP. Requests for changes in the ECP may be submitted in writing to EHSO. This document is updated at least annually.

  • Occupational Safety and Health Administration. Code of Federal Regulations. Chapter 29, Part 1910, Section 1030. “Bloodborne Pathogens.” 29 CFR 1910.1030.
  • OSHA. Interpretive Quips.
  • U.S. Department of Labor. Sample Exposure Control Plan.
  • U.S. Department of Labor. Office of Health Compliance Assistance.
  • U.S. Department of Health and Human Services. Public Health Service. Centers for Disease Control and Prevention.
  • American Liver Foundation.

ECP Accessibility

This document must be kept in a readily accessible location in each affected department. By law, employees must have access to this document and have a copy provided to them upon request.

Implementation Tasks and Methods

Exposure Determination

The BBP standard requires that Miami University determine which employees may reasonably anticipate occupational exposure to blood or Other Potentially Infectious Materials (OPIM). This determination is made without regard to the use of PPE (i.e., employees are considered to have potential occupational exposure even if they wear PPE). Guidelines for making these exposure determinations are contained in the Exposure Determination.

The table includes two types of reasonably anticipated exposure as they relate to job classification:

  • When the exposure potential of all employees is high and persons having those job descriptions are expected to incur such occupational exposure, regardless of frequency (e.g., health center nurses). These classifications are indicated with a “Yes” response in the “Reasonably Anticipated Exposure Potential” column.
  • When the exposure potential of some employees is remote to moderate and persons having those job descriptions are not likely to experience occupational exposure. Since not all the employees in a particular job description would be expected to incur exposure to blood or OPIM, a general description of duties (task description) is included.

Note: Individuals whose only anticipated exposure is in rendering first aid as a collateral duty need not be offered the Hepatitis B vaccine. Although departments are encouraged to offer pre-exposure prophylaxis to those individuals, a voluntary post-exposure medical evaluation may result in a physician’s recommendation to initiate the vaccination series.

Universal Precautions

Universal Precautions is a simple approach to infection control that assumes all human blood and certain human body fluids are treated as if known to be infected by bloodborne pathogens.

Tasks

  • Observe Universal Precautions to prevent contact with blood or OPIM. 
  • Use Universal Precautions in conjunction with all prevention measures listed in this plan.

Methods

  1. Employees will receive instruction on the Universal Precautions concept in his/her initial and annual BBP training.
  2. Incorporate this concept into departmental Standard Operating Procedures.
  3. Educate employees on this concept through employee orientation, department safety meetings, newsletters, handbooks, manuals; bulletin board postings; or any other safety fact sheets, publications, notices, etc.

Engineering Controls

Engineering controls are physical or mechanical means of isolating or removing bloodborne hazards from the work area.

Tasks

Implement engineering and work practice controls to eliminate or minimize employee exposure potential to blood or OPIM. Where exposure potential remains after implementing these controls, use PPE (see Work Practice Controls and Personal Protective Equipment for more information). 

Methods

  1. Select applicable engineering controls based on the exposure potential present in the work area or related to the job task. Examples of applicable engineering controls include:
    • Sharps containers
    • Red disposal bags
    • Handwashing facilities
    • Centrifuge covers
    • Needle guards and needle disposal
    • Biosafety cabinets Resuscitation Devices
  2. Learn and observe the following guidelines regarding specific engineering controls at Miami University. 
    • Sharps Containers: After use, place all contaminated sharps into appropriate sharps containers. Containers used for disposing of potentially contaminated sharps must be labeled with a biohazard label, puncture resistant, and leak proof on the sides and bottom.
      If applicable, place sharps containers in readily accessible locations in the work areas where sharps are likely to be used and disposed of in normal work operations.
      If an employee discovers a potentially contaminated sharp (e.g., syringe, broken glass with blood or OPIM on it, etc.) in a work area where sharps containers are not readily accessible, the employee must contact his or her supervisor and request that a sharps container be brought to the site. An employee should never transport a potentially contaminated sharp out of his or her immediate work area.
    • Needles: NEVER bend, recap, remove, shear, or purposely break contaminated needles or any other potentially contaminated sharps.
    • Handwashing Facilities: An appropriate handwashing facility must have an adequate supply of running potable water, soap, and single use towels or hot air drying machines. At Miami University, handwashing facilities are located in building restrooms and in most laboratories.
      Ensure that handwashing facilities are available to employees who have reasonable exposure potential to blood or OPIM (see Exposure Determination). The BBP standard requires that these facilities be readily accessible after incurring a potential exposure incident (see Exposure Incidents).
      If handwashing facilities are not feasible in a particular work area where potential exposure to blood or OPIM may occur, provide either an antiseptic cleanser in conjunction with a clean cloth/paper towels or antiseptic towelettes. If these temporary alternatives are used, handwashing with soap and running water should be conducted as soon as feasible.
    • Infectious Waste Containers: Infectious Waste Containers are provided by a licensed disposal company. Red bags, sharps containers, disposable items, or small items that cannot be decontaminated are placed in these containers. Departments that generate infectious waste must make arrangements to have access to an infectious waste container. (See Packaging of Infectious Materials)
  3. Ensure that the engineering controls are continuously maintained in the work area. “Maintained” in this context means that the supervisor and employee will routinely:
    • Check that there is an adequate stock of supplies (e.g., sharps containers, red bags, resuscitation devices, etc.). Note that:
      • Red bags and sharps containers may be purchased through EHSO with an appropriate account number.
      • Supply catalogs are available in EHSO.
      • EHSO offers consultation for selecting appropriate supplies.
    • Check the fill level of each sharps container and replace filled containers with new ones.
    • Check the fill level of infectious waste containers.
    • Ensure that stored infectious waste does not present a health risk.
    • Ensure that the controls are adequate for existing and new work tasks.
    • Ensure that controls are readily accessible to affected employees.
    • Implement countermeasures if necessary. For example, provide or arrange to have:
      • Antiseptic Towelettes if no handwashing facilities are accessible.
      • A sharps container brought to the site of a blood/OPIM spill involving sharps.
      • Blood/OPIM-contaminated waste transported to an infectious waste container.

Student Health Center and Needleless Systems

The Student Health Center is responsible for implementing needleless systems and sharps that are manufactured with engineered sharp injury protection see Needleless Systems: Sharps Injury Protection, for more information. New sharps engineered safety devices shall be evaluated by SHC using the Safety Feature Evaluation Form (or equivalent). The Needleless System of the ECP is updated annually to reflect progress in the implementation of new needleless systems and sharps manufactured with engineered sharps injury protection.

Work Practice Controls

Work practice controls are behavioral means of reducing an individual’s exposure potential by following established rules, procedures, or guidelines associated with a particular work task. Safe work practices used in conjunction with engineering controls and PPE may substantially decrease an individual’s risk of incurring an exposure to blood or OPIM on the job.

Tasks

Use work practice controls in conjunction with engineering controls to eliminate or minimize exposure potential to blood or OPIM. Where occupational exposure remains after implementing these controls, select and use appropriate PPE.

Methods

  1. Observe Universal Precautions at all times.
  2. Learn and observe the following Work Area Restrictions in areas where there is a reasonable likelihood of exposure to blood or OPIM (e.g., triage/medical facilities, holding areas for infectious waste and contaminated laundry, phlebotomy labs, etc.).
    • Affix a bio hazard sign or label at each entrance to the work area.
    • Prohibit eating, drinking, smoking, applying cosmetics, applying lip balm, or handling contact lenses.
    • Prohibit food and beverages in a laboratory, this includes storage in refrigerators, freezers, shelves, cabinets, countertops or bench tops.
  3. Use Spill Cleanup Kits and follow established procedures (see Spill Cleanup).
  4. Conduct work procedures in a manner that will minimize splashing, spraying, splattering, and generating droplets of blood or OPIM. For example: 
    • Attach appropriate covers to centrifuges.
    • Minimize the amount of water used during cleanup procedures.
    • Use paper towels instead of mops to absorb blood or OPIM residuals.
    • Saturate contaminated areas with appropriate de-contaminants in a “fog” or “mist” fashion in lieu of a pressurized stream.
  5. Contact University Police at 911 or a designated first aid person for immediate medical assistance. 
  6. Bare-hand pressure applied to another person’s open wound should be avoided.
  7. Remove and dispose of PPE (or decontaminate non-disposable PPE) before leaving the work area.
  8. Do not use sharp objects when working with specimens.
  9. NEVER use mouth pipetting or suctioning.
  10. Immediately wash any potentially contaminated skin area with soap and water.

Specimens

Specimens may include human blood or OPIM. The methods listed below apply to those work areas where these materials are collected or prepared for phlebotomy or laboratory analysis.

Tasks

  • Ensure work areas where specimens are collected, handled, processed, stored, or prepared for shipment are kept in a decontaminated condition. 
  • Prevent any release of blood or OPIM from specimen containers.

Methods

  1. Place specimens of blood or OPIM in a container that prevents leakage during the collection, handling, processing, storage, and transport of the specimens.
  2. Label or color-code containers appropriately (see Labeling of Infectious Materials).
  3. Place any specimens that could puncture a primary container in a puncture resistant secondary container.
  4. If outside contamination of the primary container occurs, place the primary container within a secondary container that will prevent leakage during the handling, processing, storage, transport, or shipping of the specimen. This could be as simple as placing the contaminated container in an uncompromised plastic trash bag.

Contaminated Equipment

Any department that is planning to have contaminated equipment serviced or disposed of is responsible for thoroughly cleaning and decontaminating such equipment. Equipment that becomes contaminated with blood or OPIM and is not, or cannot be, properly decontaminated may pose an exposure risk to personnel who handle or service the equipment (e.g., plumbers, electricians, movers, etc.). If the equipment cannot be thoroughly decontaminated, all personnel who are involved in the maintenance, service, repair, or shipment of the equipment must be informed of the potential contamination.

Tasks

Ensure that equipment that is, or may have been, contaminated with blood or OPIM is examined prior to service or shipping and thoroughly decontaminated, if feasible.

Methods

  1. Examine the equipment prior to servicing or shipping. 
  2. Arrange to have the equipment decontaminated as necessary unless the decontamination of the equipment is not feasible. 
  3. If decontamination of equipment or portions thereof is not feasible, affix readily observable bio hazard labels to the equipment that remains contaminated. 
  4. Ensure each label states which portion(s) of the equipment remain contaminated.
  5. BEFORE the equipment is dismantled, handled, or moved in any fashion, inform the shipping and service personnel that the equipment is contaminated and receive confirmation that the equipment can be shipped and serviced in its current condition. 

Personal Protective Equipment

Personal Protective Equipment, or PPE, is specialized clothing or equipment worn by an employee for protection against a hazard. General work clothes (e.g., uniforms, pants, shirts or blouses) will not adequately protect against a hazard and are not considered PPE. Departments are responsible for selecting, purchasing, and stocking an adequate supply of appropriate PPE and at no cost to employees. 

Tasks

  • Choose appropriate PPE based on the anticipated exposure potential to blood or OPIM. 
  • Ensure PPE is stocked and accessible to the affected employees. 

Methods

  1. PPE is considered appropriate only when, under normal conditions of use and for the duration of time that the protective equipment will be used, it does not permit blood or OPIM to pass through or reach the following:
    • Employee’s clothing (e.g., uniform, street clothes, undergarments, etc.).
    • Skin, eyes, mouth, and other mucous membranes.
  2. Use PPE selection guidelines to help you select the appropriate PPE for work tasks that may involve risk of exposure to blood or OPIM.
  3. If necessary, EHSO offers consultation to help you select PPE.

PPE Maintenance and Disposal

Reusable PPE (e.g., rubber gloves, goggles, etc.) is an effective barrier to blood or OPIM when it is properly maintained and decontaminated for reuse provided that the integrity of the PPE is not compromised. Disposable PPE is also an effective means of protection when the proper type is used and its integrity is maintained for the period of use. However, due to its design, disposable PPE can usually be easily torn, ripped, or its integrity compromised in some way. Therefore, it is extremely important that individuals examine all disposable PPE before and during use to ensure integrity and immediately remove and replace PPE if it becomes damaged.

Departments are responsible for purchasing, cleaning, repairing, laundering, and disposing of all personal protective equipment at no cost to employees.

Tasks

  • Ensure disposable PPE is inspected and discarded properly.
  • Ensure reusable PPE is properly decontaminated, inspected, maintained, and disposed of when necessary. 

Methods

  1. Learn and observe the following general requirements regarding gloves:
    • Ensure gloves are stocked and readily accessible to all employees who may need to use them.
    • Wear gloves for reasonably anticipated hand contact with blood, OPIM, non-intact skin, and mucous membranes.
    • Put on gloves BEFORE entering an area where blood or OPIM is reasonably anticipated to be present. 
    • Wash your hands after removing gloves. 
    • Dispose of reusable gloves if they are cracked, peeling, torn, punctured, or exhibit other signs of deterioration or when their ability to function as a barrier is compromised. 
  2. Learn and observe the following precautions regarding disposable gloves:
    • Recognize that single-use gloves (e.g., latex) are a good liquid barrier but are not puncture-proof.
    • Immediately replace disposable gloves if they become contaminated, torn, punctured, or when their ability to function as a barrier is compromised.
    • Inspect disposable gloves before use since they can be easily torn and may have small holes or defects in them right out of the box.
    • Remove rings before putting on gloves due to the tear potential.
    • Wear two pairs of gloves for hands with long or sharp fingernails.
    • Cover any recent wounds or non-intact skin with a bandage before putting on gloves to afford an additional level of protection in case the glove is torn during use. 
    • DO NOT wash or attempt to decontaminate disposable gloves for reuse.
  3. Learn and observe the following requirements regarding eye and face protection:
    • Any protective device(s) used must provide a complete splash barrier for the eyes, nose, and mouth.
    • Wear surgical-type face masks in combination with eye protection devices, such as chemical splash goggles or safety glasses with solid side shields, whenever blood or OPIM contact may result from splashing, spraying, splattering, etc.; or when the eye, nose, or mouth contamination can reasonably be anticipated.
    • Face shields are not a substitute for but must be used in conjunction with eye protection.
  4. Remove all PPE (i.e., disposable and reusable) prior to leaving any work area where blood or OPIM may be present. 
  5. Dispose of all single-use PPE (i.e., disposable) in a red bag. 
  6. Place all reusable PPE in a designated location for decontamination.
  7. Decontaminate reusable PPE according to appropriate methods (see Decontamination Methods).

Housekeeping

Proper and routine cleaning and decontamination of work areas is an integral part of preventing environmental transmission of diseases. Based on the frequency of contamination in your respective work area, establish a cleaning schedule and ensure it is being adhered to by inspecting work areas regularly. This section provides minimum requirements to implement for proper hygiene and inspections in work areas where blood or OPIM contamination may occur.

Cleaning Schedule

  1. Clean-up all visible blood, spills of blood, or OPIM immediately and decontaminate the area.
  2. Partition off the area for large releases of blood or OPIM until the area is cleaned and decontaminated.
  3. Decontaminate all work surfaces immediately or as soon as feasible after completion of procedures, as well as the end of the work shift.
  4. Clean and decontaminate work areas at the end of each shift, or more often as needed, where blood or OPIM is not visible, but where contamination may have occurred during the shift.
  5. Include permanent fixtures in the cleaning and decontamination schedule that could become contaminated with blood or OPIM from possible/occasional contact with contaminated gloves (e.g., door and desk handles, handles on lighting fixtures, handles on tools, etc.).
  6. Remove and replace protective coverings (e.g., plastic wrap, aluminum foil, or plastic-backed absorbent paper used to cover equipment and work surfaces) when they become overtly contaminated or at the end of the work shift if they may have become contaminated during the shift.
  7. Establish and maintain a checklist system for personnel to document that they have performed the required cleaning and decontamination.

Receptacles

  1. Decontaminate all bins, pails, cans, and similar receptacles that are used in conjunction with infectious materials on a regularly scheduled basis.
  2. Clean and decontaminate receptacles immediately or as soon as feasible if they are visibly contaminated with blood or OPIM.
  3. Designate personnel to inspect all bins, pails, cans, and similar receptacles to ensure proper decontamination at the end of their shift, or at least once a day.
  4. Establish and maintain a checklist system for personnel to document that they have performed the required inspections. 

Decontamination Methods

  1. Chemical Disinfection Options
    • Minimum 10% bleach solution for 15-minute contact time. Spill cleanup: minimum 1 to 10 dilution of household bleach and water. (1:10 solution = 1 part bleach and 10 parts water.)
    • Undiluted bleach solution for 30-second contact time.
  2. Other Chemicals:
    • Must be classified as an EPA registered sterilant or EPA registered tuberculocidal disinfectant.

Cleanup Kits

If employees in your charge are responsible for cleaning up spills of blood or OPIM, you need to select, order, stock, and maintain an adequate supply of disposable spill cleanup kits, or you may create your own kits. Whether you purchase or create spill cleanup kits, you need to ensure that they meet the minimum requirements listed below. EHSO offers consultation to help meet these requirements.

Tasks

  • Select and purchase an adequate supply of spill cleanup kits. 
  • Ensure spill cleanup kits meet the minimum requirements of the ECP. 

Methods

  1. Consult first aid, medical, or safety supply catalogs for commercial, disposable spill cleanup kits.
  2. If desired, create your own spill cleanup kits by buying items in bulk or “ala carte” and follow the guidelines listed below for minimum requirements.
  3. Designate someone to be responsible for checking on a regular basis that cleanup kits and supplies are kept stocked and readily accessible.
  4. Establish and maintain a recordkeeping system to document that the kits and supplies are being checked.
  5. Instruct staff to inform you if replacement kits are needed.
  6. Instruct employees in how to use the specific kit you select.

Minimum Requirements for Spill Kits

At a minimum, a spill clean-up kit should contain the following items:

  1. Eye protection (choose one):
    • Protective plastic face shield in conjunction with eye protection.
    • Glasses with solid side shields.
    • Chemical splash goggles.
  2. Hand protection (all of the following):
    • Disposable latex gloves (and hypo-allergenic gloves if necessary). 
    • Antiseptic towelettes or hand washing facilities.
  3. Non-permeable disposable clothing (choose one. May be kept separate from kits but must be accessible):
    • Gowns.
    • Aprons.
    • Body suits.
  4. Absorbent Material (choose one):
    • Paper towels.
    • Gel powder/pellets.
    • Absorbent pads/pillows.
  5. Tools for picking up sharps (choose one):
    • Plastic scoops.
    • Scrapers.
    • Pieces of stiff cardboard.
  6. Disposal Materials (all of the following): 
    • Disposable red or labeled bag(s) with twist ties.
    • Sharps container (may be kept separate from kits but must be accessible).
    • EPA-registered Tuberculocidal decontaminant or bleach (may be kept separate from kits but must be accessible).
  7. Optional Materials:
    • Shoe covers.
    • Surgical-type paper mask.
    • Reusable rubber gloves.

Spill Cleanup

The cleanup procedure listed below is a general guideline for spills of blood or OPIM following an injury or other bodily releases. EHSO has developed an instruction sheet for employees. Instruction sheets are included in spill kits purchased through EHSO and are available from EHSO upon request. A copy is included on the BBP Trainer CD-ROM.

Precautions

  • Observe universal precautions in the clean up of any soil or residue that is potentially contaminated with blood or OPIM.
  • Never use brushes or brooms to clean-up blood or OPIM residuals or for any items that are potentially contaminated with blood or OPIM.
  • Always use PPE.
  • Never attempt to pick-up glass with your hands, even if you have gloves on.
  • Never use a broom to collect blood or OPIM residuals as the bristles are absorbent and can contaminate other surfaces.
  • Never use a vacuum cleaner or shop vac to pick-up pieces of potentially contaminated glass.

Tips

  • Use items that are disposable or that can be decontaminated (e.g., stiff cardboard, plastic scoops, dust pans, tongs, etc.) to pick up broken glass or sharp objects potentially contaminated with blood or OPIM.
  • Use only as much liquid as you need to minimize the spread of spill. 
  • Avoid splashing or spraying. 
  • Assume your gloved hands are contaminated during cleanup procedures and do not touch any exposed skin. 

Cleanup Procedures

  1. Determine extent of the spill and block off area if necessary.
  2. Inspect and put on appropriate PPE (minimum: eyes, and hand protection).
  3. Open red bag and position so materials can be dropped in without contaminating outside of the bag.
  4. Carefully pour or spray only as much decontaminant or bleach solution as you need to cover spill area and cover with paper towels. A 15-minute contact time is preferable.
  5. For non-level surfaces, such as a wall, thoroughly clean the area with rag or paper towel soaked in 10% bleach solution (or other approved chemical in proper concentration) and allow to air dry.
  6. If any sharp objects are in the spill area, such as a syringe or broken glass, use only mechanical means to pick-up and place into a proper sharps container (example: use cardboard to scoop sharp object into dustpan, place object in a sharps container, and decontaminate dustpan with 10% bleach solution.) Do not transport the object to the sharps container, rather, have sharps container at the cleanup area. If the object will not fit into the container, do not force it! Use a larger container that is puncture resistant and leak proof.
  7. Place all materials in the red bag. Don’t overfill bags or containers. Decontaminate equipment and other non-disposable items.
  8. When cleanup is done, decontaminate area again with 10% bleach solution (or other approved chemical in proper concentration) and allow to air dry. Keep area barricaded until dry.
  9. Remove PPE and place in red or labeled bag. Remove gloves last using proper method.
  10. Close and secure bag. Touch outside of bag only! If outside becomes contaminated, put on a new pair of gloves and place bag and contents in a new red bag.
  11. Contact supervisor on shift and arrange for transport of bag to an infectious waste container.
  12. Wash your hands with soap and water.
  13. When the area is dry, open area to the public.

Contaminated Laundry

Although soiled linen has been identified as a source of large numbers of pathogenic microorganisms, the risk of actual disease transmission from soiled linen is negligible. However, to reduce the risk of employee exposure to blood or OPIM from contaminated laundry, implement and observe the measures listed below.

Tasks

Ensure employees know how to properly handle contaminated laundry.

Methods

  1. Always use appropriate PPE when handling potentially contaminated laundry. At a minimum, wear disposable gloves and thoroughly wash your hands following all such work tasks.
  2. Handle contaminated laundry as little as possible.
  3. Remove garments (including personal clothing) as soon as feasible if they become contaminated by blood or OPIM.
  4. If possible, arrange to have the garment laundered on-site.
  5. Place contaminated laundry in a red or labeled bag.
  6. Keep contaminated laundry separate from the non-contaminated laundry.
  7. Do not sort or rinse contaminated laundry in patient-care areas.
  8. Select, provide, and maintain an adequate stock of appropriate laundry bags and labels.
  9. Designate a holding location for the laundry until it is cleaned and decontaminated OR until a laundry service arrives to pick it up.
  10. Ensure all contaminated laundry holding locations have appropriate bio hazard labeling or signage at each entrance. 
  11. Select, provide, and maintain an adequate stock of appropriate chemical detergents for cleaning laundry (if laundry is handled internally). 

Contaminated Laundry Cleaning Options

  • Launder on-site:
    • If the water temperature is > 160°F (70°C): wash for a minimum of 25 minutes.
    • If the water temperature is < 160°F (70°C): use laundry chemicals suitable for low-temperature washing at proper use concentrations.
  • Launder off-site: Minimal handling, biohazard labeling, leak-proof container, notify outside personnel of biohazard, assure compliance with BBP standard. 
  • Disposal: Handle as infectious waste.

Labeling of Infectious Materials

Any individual who generates potentially infectious materials is responsible to properly label the receptacles. Note that labeling can include bio hazard labels or color-coding.

Tasks

  • Ensure availability of appropriate bio hazard labels or color-coding.
  • If applicable, ensure labels are affixed appropriately.

Methods

  1. Purchase and stock appropriate bio hazard labels, if applicable.
  2. Affix appropriate bio hazard labels to containers of regulated waste, refrigerators, and freezers containing blood or OPIM; and other containers used to store, transport, or ship blood or OPIM.
  3. Labeling Exemptions:
    • Blood or OPIM that is stored, transported or shipped in red bags or red containers.
    • Containers of blood, blood components, or blood products that are labeled as to their contents and have been released for transfusion or other clinical use.
    • Individual containers of blood or OPIM that are placed in a labeled container during storage, transport, shipment, or disposal.
    • Equipment that has been decontaminated does not need to be labeled or color-coded.
  4. Labels must include the universal bio hazard legend (symbol) and be fluorescent orange, orange-red, or predominantly so, with lettering and symbols in a contrasting color.
  5. Affix labels as close as feasible to containers by string, wire, adhesive, or other methods that prevent their loss or unintentional removal.

Packaging of Infectious Materials

If infectious materials are generated in your area of responsibility, you must ensure that such materials are properly handled and disposed of. In addition to the requirements of the BBP standard, the Ohio EPA regulates the disposal of infectious waste. EHSO offers consultation to help meet these requirements.

Tasks

Ensure proper handling, packaging, and disposal of all infectious materials.

Methods

  1. Observe Universal Precautions.
  2. Use appropriate PPE when handling infectious materials (e.g., disposable gloves, eye protection, etc.)
  3. Maintain an adequate supply of red or labeled bags and sharps containers.
  4. Designate a holding location to store infectious materials for pickup by a licensed disposal company or arrange to have infectious materials transported to one of the designated drop-off points on campus.
  5. Post an appropriate biohazard sign or label at all entrances to areas where infectious waste is stored.
  6. Do not place infectious materials in the regular trash.
  7. Place infectious materials in red disposal bags or appropriate containers and place them in a designated holding location for pickup and disposal by a licensed disposal company.
  8. Use appropriate bio hazard labels for non-red bags and other types of infectious waste containers.
  9. Discard all contaminated sharps as soon as feasible in sharps containers.

Containers

A contaminated sharp is any potentially contaminated object that can penetrate the skin (e.g., needles, razor blades, broken glass, etc.). Sharps containers are a type of engineering control that helps protect employees from being stuck or cut by a potentially contaminated sharp.

Tasks

  • Ensure proper disposal of all potentially contaminated sharps.
  • Provide an adequate number of sharps containers in the applicable work areas.
  • Ensure appropriate labeling of sharps containers.
  • Maintain sharps containers and replace as necessary.
  • Provide access to sharps containers for non-medical work areas.

Methods

  1. Discard all potentially contaminated sharps as soon as feasible in disposable sharps containers.
  2. Ensure that sharps containers are red or have appropriate bio hazard labeling.
  3. Ensure all sharps containers are closable, puncture-resistant, and leak proof on both the sides and bottom.
  4. Maintain sharps containers in an upright position throughout use.
  5. Place sharps containers in work areas where sharps would normally be used and disposed of in normal work operations.
  6. Locate sharps containers so that an employee will not have to carry a sharp across the room or in close proximity to other workers to dispose of it.
  7. Check the level of sharps containers regularly and do not allow them to overfill.
  8. Never force a sharp or attempt to “make it fit” into the opening of a sharps container.
  9. Close a sharps container before removing or replacing it. This will prevent spillage or protrusion of contents during handling, storage, transport, and shipping.
  10. Place all FULL sharps containers contaminated with blood or OPIM in a designated location for pickup by a licensed disposal company.
  11. Place the sharps container in a properly labeled secondary container whenever it is punctured, leaking, or its integrity is compromised in some way.
  12. Never carry a potentially contaminated sharp out of a work area to a sharps container in another work area, rather, have the sharps container brought to your location.
  13. Arrange a system in your area of responsibility to have sharps containers brought to work sites where sharps are not normally used.

Hepatitis B Vaccination Program

Program Administration

The Student Health Center (SHC) administers the vaccinations. Departments are responsible for training their staff and for the cost of pre- and post-exposure charges. Employees who consent to receive the vaccination but do not complete the series within six months will be responsible for an administrative fee equal to the cost of the vaccination series.

Determining Employee Eligibility

Employees who have received BBP training and have been identified in the Exposure Determination section as being reasonably anticipated exposure to blood or OPIM may be offered the HBvac series at no cost following his/her initial BBP training. The vaccine must be offered to eligible employees within ten working days of the employee’s initial assignment involving the potential for occupational exposure to blood or OPIM unless he or she has previously had the vaccine or wishes to submit to antibody testing which shows him or her to have sufficient immunity. An eligible employee who has completed any one of the three vaccinations outside of Miami University is responsible for submitting written documentation to SHC. It is extremely important that each supervisor keep a strict accounting of his or her staff to ensure that new or transferred employees who are eligible are trained by a BBP Trainer and offered the series within the required time frame relative to his or her date of hire. BBP Trainers are responsible for the following tasks:

Tasks

  • Determine which staff members are to be offered the pre-exposure HBvac program as part of the BBP training.
  • Inform consenting employees of their responsibility to take their completed Consent/Declination form to SHC to begin their HBvac series.

Methods

  1. Review the Exposure Determination.
  2. Determine which employees are eligible for the pre-exposure HBvac program. Employees whose only exposure is in rendering first aid as a collateral duty may be offered the vaccination at the discretion of the employee’s department.
  3. Submit the completed training attendance roster for file in BBP Trainer’s departmental records for three (3) years.
  4. Repeat this process as necessary.

HBvac Program Procedures

The HBvac is administered in three (3) doses over a six (6) month period.  The second and final vaccination must be administered within a specific time frame relative to when the first dose was received.

If an employee fails to receive a vaccination on his or her scheduled due date, a specific “window of opportunity” exists. Beyond this “window,” the prospect for optimum immunity decreases. Non-compliance with the HBvac program will result in administrative charges to the employee.

Tasks

Ensure eligible employees comply with the established procedures for HBvac consent or declination.

Methods

  1. Determine applicable employee’s disposition regarding vaccination (i.e., intends to consent or decline).
  2. Complete the steps for either consent or declination. 
    • Consent: If an eligible employee wants to receive the series, he or she must:
      1. Have completed Miami University’s BBP training course within the past year.
      2. Read the entire Consent/Declination Form, complete the Personal Information section, and sign the Consent section of the form.
      3. Report to the Student Health Center within ten (10) working days. Present the Consent/Declination Form and Miami University identification card to begin the vaccination series.
    • Declination: If an eligible employee does not want to receive the series at this time, he or she must: 
      1. Have completed Miami University’s BBP training course within the past year.
      2. Read the Consent/Declination Form, complete the Personal Information section, and sign the Declination section of the form. Return completed form to BBP trainer who will submit to the department for file in BBP Trainer’s departmental records for three (3) years.

Hepatitis B Vaccination Records

The Student Health Center maintains HBvac records under Miami University’s BBP program. An employee may request a copy of his/her medical records by contacting SHC.

HBvac Process

Employees initiate their HBvac series by reporting to the SHC with their completed and signed Consent/Declination Form. That form is received through the employee’s BBP Trainer. Ultimately, the employee and their department are responsible for compliance with the HBvac Program.

Tasks

Participating employees are responsible for remaining on-schedule with their initial, second, and final vaccinations. 

Methods

  1. BBP Trainers or supervisors should encourage participating employees to remain on-schedule with their vaccinations.
  2. BBP Trainers must remind participants that, although the vaccination series is available at no cost to them, the consenting employee may be held responsible for administrative fees equal to the cost of the series deductible as a Bursar payable if not completed within six months of consent.

Exposure Incidents

An exposure incident is a specific eye, mouth, other mucous membranes, non-intact skin, or parenteral contact with blood or OPIM that results from the performance of an employee’s duties.

Based on the confidentiality and potential implications of bloodborne exposures, it is critically important that administrators and employees be thoroughly familiar with the procedures outlined in this chapter.

Examples of potential exposure incidents include:

  • Blood or OPIM contact on non-intact skin (e.g., rash, recent cut, broken cuticles, chafed, scraped, chapped, etc.)
  • Blood or OPIM contact to mucous membranes of eyes, nose, or mouth through direct contact or splash.
  • Puncture injury with potentially contaminated sharp (e.g., used syringe, broken glass with blood or OPIM on it, etc.)

Exposure First Aid

  1. Immediately apply first aid as appropriate:
    • Needlestick or puncture injury: allow to bleed freely; clean with 70% alcohol; wash thoroughly with soap and water. 
    • Mucous membrane splash: flush thoroughly with water for 10 to 15 minutes.
    • Eyes: irrigate and flush thoroughly with water for 15 minutes. 
  2. Report the incident immediately to the supervisor in charge.
  3. Obtain professional medical care as appropriate.
  4. Supervisor: An exposure incident is defined by PERRP as a recordable accident. Complete an Injury/Illness Report Form and forward to EHSO.

Post-Exposure Records

The SHC maintains post-exposure medical records that include:

  • Maintenance of post-exposure incident records.
  • Maintenance of post-exposure test results.

Post-exposure records are kept for the duration of the employee’s employment, plus thirty (30) years. Medical records are not disclosed or reported without the employee’s express written consent.

Reporting Exposures

It is crucial that you report all potential exposures as soon as possible because certain medical treatments if medically indicated, must be administered within a short time frame following an exposure. For example, an employee who has not been vaccinated for HBV may need to receive the Hepatitis B Immune Globulin (HBIG) and start the HBvac series. The HBIG needs to be administered as soon as possible after exposure (best started within 48 hours). The HBvac should begin as soon as possible—but within seven (7) days of the exposure.

The employee is responsible for immediately reporting any potential exposure incident to his/her supervisor and for reporting to SHC.

The supervisor is responsible for reporting the incident to EHSO.

Normal Business Hours/After-Hours Procedures

According to the Centers for Disease Control, due to the long incubation period of the Hepatitis B virus, an approximate seven (7) day window of time exists to begin treatment following an exposure. However, the employee is required to immediately report a possible exposure incident to his or her supervisor and they both must follow the procedures outlined below.

Normal Business Hours: Report to Student Health Services 8 am to 6 pm Monday through Friday and 10 am to 2 pm Saturday. If the incident occurs after clinic hours Monday through Friday, begin post-exposure procedures the following morning. If the incident occurs between Saturday after 2 pm and Sunday night, begin post-exposure procedures promptly on Monday morning. Scheduling an appointment by calling the Student Health Service at 513-529-3000 will reduce waiting times.

Extending Periods: Miami’s Student Health Service is closed on all days of the year when Miami University is not open. If an incident occurs during this time period obtain the post-exposure paperwork and then report to one of the following locations: 

  • Oxford Campus: Urgent Care Unit at Ross. [Hours of operation: 10 am to 8 pm Monday –Friday, 10 am to 6 pm Saturday and Sunday. Appointments scheduled by calling 856-5944.
  • Hamilton Campus: Emergency Room at Fort Hamilton Hospital in Hamilton.
  • Middletown Campus: Emergency Room at Middletown Regional Hospital.

Post-Exposure Protocol

Following a report of a potential exposure incident:

  1. The employee’s supervisor shall direct the employee to Miami’s Convenient Care Clinic for a post-exposure evaluation at no cost to the employee. 
  2. The Convenient Care Clinic shall:
    • Evaluate the incident and, if medically indicated, conduct all required post-exposure evaluation and follow-up procedures listed in the BBP standard [reference OSHA Standard 1910.1030 paragraphs (f)(3), (f)(4), and (f)(5)].
      • The employee may refuse to undergo the medical evaluation and/or blood collection and testing, however, he/she must sign the appropriate declination forms in the presence of a medical professional.
      • If the employee consents to baseline blood collection but does not give consent at that time for HIV testing, the sample will be preserved for 90 days. The employee may elect to have this sample tested within 90 days of the exposure incident.
    • Provide the potentially exposed employee with a copy of the Physician’s Written Opinion within fifteen (15) days following the completion of the evaluation.
    • Coordinate with other evaluating medical professionals [reference PERR standard 1910.1030 paragraph (f)(4)].
  3. EHSO shall ensure that the evaluating physician has:
    • A copy of the Bloodborne Pathogens Standard.
    • A description of the potentially exposed employee’s duties as they relate to the incident.
    • Any occupational records maintained by EHSO that may be relevant to the appropriate treatment of the employee.

Employee Responsibility

If the employee consents to any part of the post-exposure protocol, he/she is responsible for following through with any recommended testing or treatment. If the employee decides to terminate his or her participation at any point, he/she is responsible for informing SHC and arranging to sign the appropriate declination forms. This applies to, but is not limited to, the following:

  • HBV blood test: initial.
  • HIV blood testing schedule (from date of incident): initial, 6 weeks, 12 weeks, 6 months, one year.
  • HBvac schedule: initial, second 30 days later, third (final) six months from initial.
  • Medical treatment: as prescribed by evaluating physician.

Training

Who Must Attend

Employees identified in the Exposure Determination as having potential occupational exposure to blood or OPIM must participate in BBP training. Supervisors with employees who must participate in training are also required to participate. This will keep the supervisor informed of the policies, procedures, and responsibilities under this program.

Tasks

  • Departments shall determine which staff members must participate in training.
  • BBP Trainers shall ensure that employees receive training before being assigned to tasks where occupational exposure may occur. 

Methods

  1. Compare the job classifications with the job classifications in your area of responsibility.
  2. Refer to the Exposure Determination section as it relates to the job duties performed by staff in your area of responsibility.
  3. Generate a list of names of all employees in those job classifications or with those job duties.
  4. Consolidate your list, if necessary, to include only those employees who have duties that may involve occupational exposure since employees may have the same job classification but have different duties.
  5. Train applicable employees initially and at least annually thereafter.
  6. Review and update your list at least annually or when new employees are assigned to your area of responsibility.
  7. Submit completed Bloodborne Training Attendance Roster to your department.

Training Records

Participating Departments maintain employee BBP training records. Those records are kept for a period of three (3) years beyond the date of training.

Scheduling

Supervisors, as well as BBP Trainers at Miami University, must take an active role in scheduling employees for training.

Tasks

  • Schedule employees for training.
  • Ensure affected staff members participate in training.

Methods

  1. BBP Trainers shall conduct training for their department.
  2. Contact EHSO regarding questions regarding regulatory interpretations or BBP program clarification.

Abbreviations

AIDS - Acquired Immunodeficiency Syndrome
BBP - Bloodborne Pathogens
ECP - Exposure Control Plan
EHSO - Environmental Health and Safety Offices
HBV - Hepatitis B Virus
HBvac - Hepatitis B Virus vaccination
HIV - Human Immunodeficiency Virus
IDC - Interdepartmental Charge
LPO - Limited Purchase Order
OPIM - Other Potentially Infectious Materials
OSHA - Occupational Safety and Health Administration
PPE - Personal Protective Equipment
PERRP - Public Employment Risk Reduction Program
SHC - Student Health Center