Download Infection Control - Exposure Control Plan

FHC Policy & Procedure Manual
Date of Original Policy:
2003
Effective Date:
January, 2004
Revision
# ______________
INFECTION CONTROL / EXPOSURE
CONTROL PLAN
Page 1 of 5
POLICY:
INFECTION CONTROL / EXPOSURE CONTROL
PLAN
SECTION:
Infection Control
PURPOSE:
To eliminate or minimize employee exposure to human blood and
other potentially infectious materials; to comply with OSHA
standards PART 1910.1030 concerning Occupational Exposure to
Bloodborne Pathogens; and to ensure each employee with
occupational exposure becomes familiar with and adheres to the
Exposure Control Plan. The Director of Operations has the
overall responsibility for the Exposure Control Plan and has the
full support of the Board of Directors and the authority to ensure
compliance is maintained throughout the organization. OSHA
compliance is a condition of employment.
Scope of Standard Practice
1.
The intent of the policy is to protect employees by reducing occupational exposure
to bloodborne pathogens including but not limited to Hepatitis B (HBV), and Human
Immunodeficiency Virus (HIV). Other preventable diseases include Hepatitis C
(HCV), Delta Hepatitis, and Syphilis.
2.
Employees with potential exposure to bloodborne pathogens will be identified and
categorized according to their potential risk. Job duties including the handling of
blood or body fluids will be outlined and proper personal protective equipment to be
used during these procedures will be identified. In addition, employees will be
trained in universal precautions and proper use of protective barrier equipment.
3.
Employees will be trained in proper handwashing and safe handling of sharp
objects to enhance the use of protective barriers. In addition, employees will be
expected to observe restrictions on eating, drinking and applying cosmetics in the
laboratory and in the patient care areas.
4.
Environmental controls to remove the bloodborne pathogens hazard from the work
place will also be implemented.
Proper patient care protocols, laboratory
procedures, housekeeping practices and bio-hazardous waste removal procedures
will be summarized in the plan.
5.
The hepatitis B vaccine will continue to be offered to all employees with potential
exposure to bloodborne pathogens at no cost. The administration procedures and
D:\582750797.doc; 5/6/2017
FHC Policy & Procedure Manual
Date of Original Policy:
2003
Effective Date:
January, 2004
Revision
# ______________
INFECTION CONTROL / EXPOSURE
CONTROL PLAN
Page 2 of 5
delineation process will be outlined in the plan. In the event of an accidental
exposure to a potentially infectious material, documentation and post exposure
management will be the responsibility of the Medical Director. A written medical
opinion will be prepared and presented to the employee. A copy will be maintained
confidentially in the employee health file(not to be confused with medical record).
6.
Other records including training activities, on site inspections and ongoing
monitoring practices will be maintained by the Director of Operations, as well as,
with each supervisor and HR for individual employee.
7.
Employees will be informed of other risks to potentially hazardous substances
through the use of material safety data sheets (MSDS) and by periodic in-service
programs.
8.
An annual review of all policies and procedures outlined in the exposure control
plan will be performed by the Director of Operations and Safety Committee
representatives.
*The OSHA standard on bloodborne pathogens defines certain terms.
Blood: Human blood, human blood components and products made from human blood.
Bloodborne Pathogens: Pathogenic microorganisms that are present in human blood
and can cause disease in humans. These pathogens include, but are not limited to,
Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV).
Clinical Laboratory: A workplace where diagnostic or other screening procedures are
performed on blood or other potentially infectious materials.
Contaminated: The presence or the reasonably anticipated presence of blood or other
potentially infectious materials on an item or surface.
Contaminated Laundry: Laundry which has been soiled with blood or other potentially
infectious materials or which may contain sharps.
Contaminated Sharps: Any contaminated object that can penetrate the skin including, but
not limited to, needles, scalpels, broken glass, broken capillary tubes.
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 transmitting infectious particles and the surface or item is rendered safe for
handling, use or disposal.
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FHC Policy & Procedure Manual
Date of Original Policy:
2003
Effective Date:
January, 2004
Revision
# ______________
INFECTION CONTROL / EXPOSURE
CONTROL PLAN
Page 3 of 5
Engineering Controls: Controls (e.g., sharps disposal containers, self-sheathing needles)
that isolate or remove the bloodborne pathogens hazard from the workplace.
Exposure Incident: A specific eye, mouth, other mucous membrane, non-intact skin, or
parenteral contact with blood or other potentially infectious materials that results from the
performance of an employee’s duties.
Handwashing Facilities: A facility providing an adequate supply of running potable water,
soap and single use towels or hot air drying machine.
Licensed Health Care Professionals: Persons whose legally permitted scope of practice
allows them to independently administer the Hepatitis B vaccination and post-exposure
evaluation and follow-up.
HBV: The Hepatitis B Virus.
HIV: The Human Immunmodeficiency Virus.
Infectious Conditions: Infection needs four simultaneous conditions to exist, which are:
-
a sufficiently large dose to constitute a dangerous quantity
-
a sufficient virulence to be dangerous
-
a portal of entry into a host, such as through an open cut or nasal passages
-
a susceptible resistance level of the host
Reducing or removing any of these conditions prevents infectious diseases such as:
-
the use of gloves and masks will eliminate portals of entry
-
regular handwashing and the use of disinfectants will remove or reduce the
dose and virulence of the disease
-
the placement of sharps and needles into a commercial sharps container and
the avoidance of recapping needles will reduce needlestick injuries
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.
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FHC Policy & Procedure Manual
Date of Original Policy:
2003
Effective Date:
January, 2004
Revision
# ______________
INFECTION CONTROL / EXPOSURE
CONTROL PLAN
Page 4 of 5
Other Potentially Infectious Materials: 1) The following human body fluids: semen,
vaginal secretions, cerebrospinal fluid, pleural fluid, pericardial fluid, peritoneal fluid,
amniotic fluid, saliva, any body fluid that is visibly contaminated with blood, and all body
fluids in situations where it is difficult or impossible to differentiate between body fluids; 2)
any unfixed tissue or organ (other than intact skin) from a human (living or dead) and 3)
HIV or HBV containing cell or tissue cultures, organ cultures and culture medium or other
solutions; and blood, organs or tissues from experimental animals infected with HIV or
HBV.
Parenteral: Piercing mucous membranes or the skin barrier through such events as
needlestick, human bites, cuts and abrasions.
Personal Protective Equipment: Specialized clothing or equipment worn by an employee
for protection against a hazard. General work clothes (e.g., uniforms, pants, shirts or
blouses) not intended to function as protection against a hazard are not considered to be
personal protective equipment. The use of protective equipment is an OSHA requirement.
Regulated Waste: Liquid or semi-liquid blood or other potentially infectious materials;
contaminated items that would release blood or other liquid or semi-liquid infectious
materials in a liquid or semi-liquid state if compressed; items that are caked with dried
blood or other potentially infectious materials and are capable of releasing these materials
during handling; contaminated sharps; and pathological and microbiological wastes
containing blood or other potentially infectious materials.
Research Laboratory: A laboratory producing research-laboratory-scale amounts of HIV
or HBV. Research laboratories may produce high concentrations of HIV or HBV but not in
the volume found in production facilities.
Source Individual: Any individual, living or dead, whose blood or other potentially
infectious materials may be a source of occupational exposure to the employee.
Examples include, but are not limited to, hospital and clinic patients, clients in institutions
for the developmentally disabled, trauma victims, clients of drug and alcohol facilities,
residents of hospices and nursing homes, human remains, and individuals who donate or
sell blood or blood components.
Sterilize: The use of a physical or chemical procedure to destroy all microbial life including
highly resistant bacterial endoscopes.
Universal Precautions: An approach to infection control. According to the concept of
Universal Precautions, all human blood and certain human body fluids are treated as if
known to be infectious for HIV, HBV and other bloodborne pathogens.
D:\582750797.doc; 5/6/2017
FHC Policy & Procedure Manual
Date of Original Policy:
2003
Effective Date:
January, 2004
Revision
# ______________
INFECTION CONTROL / EXPOSURE
CONTROL PLAN
Page 5 of 5
Work Practice Controls: Controls that reduce the likelihood of exposure by altering the
manner in which a task is performed (e.g., prohibiting recapping of needles by a twohanded technique.)
APPROVAL: ___________________________________
Chief Executive Officer
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Date