Download Exposure Control Plan - Westfield State University

Office of Environmental Health & Safety - Exposure Control Plan
Westfield State University
Exposure Control Plan
Bloodborne Pathogens
May 2012
In accordance with the requirements of OSHA 29 CFR 1910.1030 and the Westfield State University
Facilities and Operations Health & Safety Policy, the following guidelines have been established to
reduce the risk of exposure to bloodborne pathogens for our faculty, staff, and students. Westfield
State University has developed this plan to mitigate the hazards of blood, body fluids, sewage, and
other similar materials that may pose a risk to employees at occupational risk and to the campus
community.
Through engineering controls, safe practices, personal protective equipment, housekeeping,
immunizations, and training, Westfield State University is committed to take necessary steps to
protect employees and the campus community from the risk of exposure.
Definitions:
 Bloodborne Pathogens – microorganisms that are present in human blood that can cause
disease
 Hepatitis B Virus (HBV) – bloodborne pathogen that causes inflammation of the liver
 Hepatitis A Virus (HAV) – highly contagious, known to spread through the breakdown of
sanitary conditions such as floods or other natural disasters, person-to-person
contamination, poor hygiene habits (not washing hands thoroughly after using the
bathroom), Infected food handlers, contaminated food or water.
 Human Immunodeficiency Virus (HIV) – bloodborne pathogen that attacks the body’s
immune system, causing the disease known as AIDS.
 Personal Protective Equipment – Equipment that is required to protect employees from
exposure to blood and body fluids or other hazards. It may include but is not limited to:
- Aprons, gowns and lab coats
- face shields and/or goggles
- gloves
- masks for protection
 Potentially Infectious Human Body Fluids – fluids in which
bloodborne pathogens may be present.
- blood
- semen
- vaginal secretions
- cerebral spinal fluid
- any other body fluid contaminated with blood
 Potentially Infectious Materials – tissue and organs (other than intact skin) from dead or
living humans, cell or tissue cultures that contain HIV or HBV and any contaminated
sharp object that can penetrate the skin
 Sharps Container(s) – Red, labeled leak-proof, puncture resistant closeable containers used
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to discard (contaminated, presumed contaminated or non-contaminated) sharps.
Universal Precautions – guidelines that require faculty and staff to treat all blood, body
fluids, sewage and similar materials as infected with HBV, HIV or other bloodborne
diseases.
Affected Employees:
Westfield State University employees that have been identified as those for whom the risk of
exposure is a possibility must not only acquire the appropriate training, but are encouraged to seek
(through their supervisor) immunizations for Hepatitis B and Hepatitis A .
The vaccine is available at no cost to all Westfield State University employees in the positions
identified below:
Those employees for whom a risk assessment has been done, include;
1. Westfield State University, Department of Public Safety
Police Officers/ISO
First Aid / CPR
Crime scene analysis
Exposure to animal and human bites
2. Facilities and Operations Staff
Environmental Services Staff
First Aid / CPR Certified Employees
Housekeeping/maintenance of restrooms and common areas
Grounds and Trades employees
Landscapers
Plumbers
sewage, sink and toilet maintenance
other trades staff based on risk assessment
3. Departments of Athletics and Movement Science
Faculty, Coaches, Trainers,Staff
Administering First Aid/CPR
4. Department of Residential Life
Residence Directors
First Aid/CPR
4. Department of Health Services
5. Department of Biology , Faculty and Staff
If the employee does not wish to take advantage of the free immunization provided for by the
university, they will be required to sign a waiver that indicates they were made aware of such a
vaccination but chose not to participate. In the instance where those employees who had previously
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declined the inoculation now opt to take advantage of the program for the free shot(s) at a later date,
Westfield State University will make it available to the employee at no cost provided they contact the
Office of Environmental Health and Safety in advance.
Vaccinations are available as a new hire , during employment and immediately after exposure
Workplace Transmission:
Bloodborne pathogens are transmitted in the workplace the same ways, HBV, HIV and other
pathogens are transmitted elsewhere, through blood, body fluids, unfixed tissues or organs
other than intact skin. The primary routes of disease transmission into the body are;
1. Accidentally cutting yourself with a sharp object or glass that is contaminated with
infected blood and body fluids
2. Getting infected blood or body fluids on your skin, especially if your skin has open
sores, nicks, acne, dermatitis, broken cuticles and/or cuts
3. Getting infected blood or body fluids in the mucous membranes of your eyes, nose
and mouth
4. Sharing or otherwise coming in contact with infected needles
5. Sexual contact with an infected partner
Universal Precautions:
All blood, body fluids and sources of potentially infectious human body fluids including
sewage shall be considered infectious until proven otherwise. Since Westfield State University
staff cannot identify a person(s) who may be infected, they shall not take unnecessary chances.
It can take just one exposure to become infected.
Therefore, any employee who has been assigned the responsibility of providing First Aid /
CPR care, clean up or other tasks dealing with blood, body fluids, needles, and sewage should
take the following protective action;
First Aid
 if not trained in first aid / CPR - call the Department of Public Safety at 5262
 if trained, provide care and/or call the Department of Public Safety at 5262
assess the scene…
- is it safe to enter ?
- if no personal protective equipment available (gloves, face shields masks), then…
- give the patient the first aid supplies so that they may treat (if possible) their own
wound
- if personal protective equipment is available, then…
b. provide care utilize…
- gloves (non latex if possible)
- face mask or shields
- resuscitation mask or shield
c. clean-up
handwashing is required regardless of whether or not gloves and other personal
protective equipment was utilized.
- wash affected areas for a minimum of 30 seconds, use…
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antibacterial / antiseptic soap and water, or
disposable antibacterial / antiseptic waterless cleaner if no soap and water
Personal Protective Equipment (PPE)
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Eye and face shields, gloves, masks, disposable shoe covers and other similar items
must be located within all department, shop and vehicle first aid and biohazard kits.
PPE may also include (when applicable) aprons, gowns, laboratory coats and
mouthpieces
Gloves should be durable and doubled up when necessary to prevent exposures through
rips and tears. In addition, it is recommended that the gloves be non-latex for staff who
might be latex sensitive.
The appropriate type of Personal Protective Equipment depends on the type of work
and degree of exposure anticipated. Its purpose is to protect the workers and their
clothes from possible exposure and the spread of contamination.
blood soaked clothing should not be brought home for laundering.
- contaminated clothing should be disposed of or laundered by an outside firm
- disposable clothing should be discarded into a red biohazard bag for proper disposal
the red bag for disposal must be brought to the Hazardous Storage building by
authorized personnel. Contact your supervisor or call the Office of Environmental
Health and Safety at 5209. Red bags are readily available in Central Receiving,
however, Environmental Services staff should keep a supply ready in an area that is
immediately available(in their respective work areas) in the event of an emergency
Gloves
 are required to be durable and double layered (if necessary).
 they should fit properly and should not be so tight as to become easily ripped.
 if damaged, ripped or torn, discard gloves/ the eye and face protection, and replace them
with an appropriate PPE that is free from deficiency
- Contaminated gloves must not come in contact with equipment, items or surfaces that
were not contaminated or infected. Often gloves used to treat a patient remain in use
until the patient has been relocated out of the building. Hence, door handles,
refrigerators and lights that were previously not a problem have become so. Gloves are
inexpensive. Personnel should not feel as though the gloves should be reused. Dispose
of them whenever blood and body fluid is a potential or known concern.
- Gloves should be removed one at a time.
- as you remove your hand from the glove, turn it inside out.
- take the other hand out of the 2nd glove, turning it inside out and place them into the
1st glove for disposal. Those gloves must be red-bagged for correct disposal.
Blood and Body Fluid Clean-Up:
As soon as a blood and body fluid spill has occurred, the first issue is to deal with the victim
and any necessary first aid that is required. Once the victim has been attended, the clean-up
must begin.
 In accordance with prudent practice, products like 3-M quat disinfectant / phenolic should
be used to disinfect any blood /body fluids that may have been released. Pre-treatment
with 3-M brand heavy- duty ready-to-use Multi-Surface cleaner may be required as needed.
Environmental Services staff has been trained with regard to established cleanup
procedures.
 If a complete clean-up of the spilled 4
blood and body fluid(s) will be delayed,
then the Westfield State University Department of Public Safety or other initial response
staff should begin the initial decontamination process. Application of a recognized
disinfecting solution or spray can be applied until Environmental Services staff can
completely mitigate the hazard
After a blood and body fluid incident, and before the arrival of either Environmental Services
staff, it may become necessary for the Westfield State University Department of Public Safety
to start the decontamination process by applying a disinfectant or granular solidifier. This
recommendation shall not imply or require that it is their responsibility to completely clean-up
the area. Simply, the responding officers are protecting other unsuspecting persons from
exposure by covering the blood and/or body fluids with the needed means of disinfectant.
Sewage and Sewer Back-up
The Center for Disease Control (CDC) has warned of the hazards associated with the
inadequate cleaning of business, home, and other properties as a result of a sewer malfunction.
This can also occur during local flooding.
Our first goal is to protect the staff whose responsibility it is to clean up the spill. Sewer
back-ups may be building specific or a back up from the street that has come from one or more
homes and businesses. Since we are unable to tell the difference, we must assume the worst,
this is sewage and the potential for blood and body fluid exposure is significant. Boots that can
be properly disinfected and washed should be utilized only in the room or hall of origin. These
boots like the gloves should not move from place to place because this may spread the
contamination. Other types of PPE should be used during the cleanup process (such as the
disposable boot covers available in the cleanup kits).
Therefore, all pervious and semi-pervious materials that have been contaminated will
most likely have to be discarded. Shoes, leather, furniture, sheet-rock, wood and similar pieces
will retain water and trace amounts of waste from the sewage which will make them
impossible to adequately clean. Impervious materials such as the concrete floor, block walls
and the like can be disinfected using the 3-M products described earlier in this document.
Safe Housekeeping:
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Gloves are required.
- Westfield State University recommends at least two pairs
Use an apron/ Tyvek coveralls when necessary
- these items can be obtained from the office of Environmental Health & Safety or
through the area supervisors
Restrict access to the area
- WSU Department of Public Safety Police Officers should protect a hazardous area
until…
- A trained Environmental Services staff member arrives
- They have applied the necessary disinfectant to prevent any potential exposure
Do not pick up broken pieces of glass or sharps with gloved or bare hands.
- use tongs, shovels, scoops or brush and dust pan
Needles and syringes (if discovered) should be reported to the WSU Department of Public
Safety.
- do not pick up the needles or attempt to re-cap
- The needles and syringes will be
removed by the WSU Department
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of Public Safety Police Officers or the Office Environmental Health & Safety.
Use disposable towels and rags to soak up most of the blood and body fluids
Place all contaminated material into a red “labeled” biohazard bag for proper relocation
and disposal. Westfield State University has a Hazardous Waste Storage building with a
segregated bay for this purpose. Do not overfill the containers
Clean all work areas at the end of each shift. Use the appropriate
disinfectant.
Discard as red-bag all bio-hazard waste - all mops and any other used cleaning items.
Red bag waste will be kept at the Hazardous Waste Storage building until time of
transport.
Laundry:
When dealing with or handling bags of laundry that could contain blood
or body fluids, it is recommended that…
a. always lift the bag (double bag for bio-hazard waste) from the top
this will minimize your risk of exposure, since most hazards such as the needles and
other sharps will drop to the bottom of the bag
Needles and Syringes
Needle sticks could pose a significant health risk for the recipient of any contaminated or
potentially contaminated needle. Precautions must be taken to minimize the hazard. Regardless
of who you are and what you do…
a. do not bend, recap, shear or otherwise break a needle used for any purpose
b. always dispose of any needle into a puncture resistant, leak-proof “Biohazard”
labeled container, as soon as possible. Sharps containers are present in the Office
of Health Services
c. Report any full or damaged containers to your supervisor for repair or replacement
General Practices
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Do not eat, drink, smoke or apply cosmetics or lip balms or handle contact lenses where
personnel may be exposed to blood and body fluids
Avoid all petroleum-based lubricants that may dissolve or breakdown the latex gloves
Always wash your hands thoroughly (at least 30 seconds) before applying hand cream
Do not keep food and drinks in refrigerators, freezers or cabinets, or on shelves,
countertops or bench-tops where blood or other potentially hazardous material may be kept
Avoid splashing, splattering or spraying of blood
- when necessary use the aprons, eye and face protection, gowns and other PPE
Never mouth-pipette or suction blood or other potentially hazardous materials
All containers used for the disposal of bio-hazardous materials must be red in color and
shall be labeled “Biohazard” as required. Access to the Hazardous Waste Storage
building can be coordinated through the Office of Environmental Health and Safety or the
Department of Facilities and Operations.
Remember to inform your supervisor that a response kit has been used and needs
immediate replenishment
Biohazard / Infection Control Kits:
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Biohazard and Infection Control kits, in addition to First Aid Kits should be located in each
Westfield State University Police Car, the applicable Biology Department Laboratories,
Dining Services, Health Services, and the Departments of Athletics and Movement
Science.
Bodily Fluid Disposal Kit(s) should be located in at least (1) main custodial closet in each
building that is staffed by Facilities and Operations (Environmental Services) personnel
As a minimum the Infection Control and Bodily Fluid Disposal kits shall have;
 Disinfectant cleaner
 Gloves (adequate in size and number)
 Handwash (waterless antibacterial / antiseptic)
 Red “Biohazard” labeled bags
 Paper or other type towels
 Labels
 Masks
It shall be the responsibility of each departmental supervisor to
make certain the kits are inspected and refilled as necessary to
ensure adequate means of handling a bio-hazardous incident. Environmental Services
personnel must notify the area supervisor when they have used a spill response kit to ensure a
replacement kit is always and immediately available.
Additional kits will be purchased as necessary through the Office of Environmental Health and
Safety.
Training:
Training shall be provided to all WSU employees at occupational risk on an annual
basis. Additional training will be given if changes to the rules, regulations or policies have
changed. Employees who may not deal with this type of situation on a routine basis may (if
needed) request additional or follow-up training from the office of Environmental Health and
Safety.
Training will incorporate the following;
1. The OSHA Standard and General Duty Clause
2. Epidemiology, signs and symptoms and transmission of bloodborne
pathogens
3. The Exposure Control Plan
4. Procedures that may cause occupational exposure to blood, body fluids and
infectious diseases
5. Methods used to control exposures to blood and infectious diseases
6. Personal Protective Equipment available
7. Hepatitis B Vaccine Program/waiver form
8. Procedures to be followed when an exposure to blood and body fluids
occurs, and
9. Explanation of required labels and signs
Recordkeeping Requirements
Confidential Medical Records will be maintained on all Westfield State University employees
with an occupational exposure. These
records will include the following information;
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1.
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3.
4.
Employee’s Name and Social Security Number
Hepatitis B Vaccine status or waiver form
Copy of Health Care Professional(s) written opinion following an exposure, and
Any information provided by the employer to the health care professional following
an exposure incident.
Medical Records shall be kept for the duration of the worker’s employment plus 30 years.
These records mill be kept in confidential files located in the Department of Human Resources.
They will not be disclosed without written permission from the employee.
Training Records shall include the following;
1. Date of training session
2. Contents or summary of training session
3. Names and qualifications of trainers
4. Names and job titles of all persons attending the training
Training Records shall be maintained for three (3) years from the date of training and will be
kept in Office of Environmental Health and Safety. These records shall be available to
employees, employees’ representatives, and all other agencies charged with employee safety at
the state or federal level.
Incident Exposure Reporting:
Incident Exposure Report
An Accident Investigation Report shall be completed within 24 hours of an exposure
incident. The employee’s supervisor, the Facilities and Opertations Safety Officer and/or
Human Resources shall conduct a detailed investigation of the exposure incident and complete
all sections of the investigation report. The department head will then review the incident and
sign the investigation report in order to prevent a recurrence.
Post-Exposure Evaluation
Following a report of an exposure incident, Westfield State University will make
immediately available to the exposed employee a confidential medical evaluation and followup. Either the employee’s personal physician or a university appointed physician may conduct
the medical evaluation. Documentation of an exposure incident will include the following:
1. Circumstances of the exposure
2. Route of exposure
3. Identification of source individual, if feasible
4. Result of source individual’s blood testing, if feasible; and
5. Result of medical records relevant to appropriate treatment of employee, including
vaccination status.
Follow-Up
Follow up will include post exposure prophylaxis as recommended by the United States
Public Health Service, testing of blood for HBV and HIV status, counseling, and evaluation of
reported illness
Health Care Professional – Provided Information:
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The following information will be provided to the healthcare professional performing
the medical evaluation:
1.
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5.
Copy of OSHA standard
Description of exposed employee’s duties as they relate to the exposure incident
Documentation of the route of exposure
Results of source individual’s blood testing; and
Medical records relevant to appropriate treatment of employee, including
vaccination status.
Healthcare Professionals – Written Opinion:
Within 15 days of the completion of the medical evaluation, a written opinion from the
healthcare professional shall be given to the employee. The opinion will provide the following
information:
1. Whether HBV vaccination is indicated and if the employee received the vaccination
2. That the employee has been informed of the results of the evaluation; and
3. That the employee has been told about any medical conditions resulting from the
exposure that require further evaluation and treatment
All other information is confidential and shall not be in the written report.
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