BAY de NOC COMMUNITY COLLEGE PERSONNEL POLICIES AND PROCEDURES  

Originator:  Revision Date:

Subject:        Work Areas

607                 BLOODBORNE PATHOGENS EXPOSURE CONTROL POLICY

It shall be the policy of the Bay de Noc Community College Board of Trustees to require instruction concerning bloodborne pathogens and recommended exposure controls.  Such instruction shall include employees with a likelihood of occupational exposure to Bloodborne Pathogens.

PROCEDURE:

Exposure Control Plan for Bloodborne Pathogens

607.1  Definitions for the purpose of this procedure are as follows: 

A.      Occupational exposure: Reasonably anticipated eye, mouth, mucous membrane, non-intact skin, or parenteral (subcutaneous, intramuscular, or intravenous) contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties. 

B.      Potentially infectious materials: Includes the following: human body fluids but is not limited to blood, semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate among body fluids.  In addition, any unfixed tissue of organ (other than intact skin) from a human (living or dead); and any human immunodeficiency virus (HIV) cultures or hepatitis B virus (HBV) cultures. 

C.       Universal precautions: An approach to infection control in which all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens.

607.2  Bay de Noc Community College will identify in writing jobs where occupational exposure to blood and/or other potentially infectious material can occur.  (See Attachment A.)

607.3    Bay de Noc Community College will identify in writing those tasks or procedures or groups of closely related tasks and procedures in which occupational exposure occurs by employees in job classifications where occupational exposure to blood and/or other potentially infectious material can occur.  (See Attachment B.)

607.4  Methods of Compliance 

A.       Universal Precautions will be used by employees to prevent contact with blood or other potentially infectious material. 

B.      Engineering and work practice controls shall be used to eliminate, limit, or minimize employee exposures.  Where occupational exposure remains after institution of these controls, personal protective equipment shall be used. 

1.        Housekeeping if there is a situation in which body fluids must be cleaned up, the procedure is as follows. 

a. Clean up any broken glass or sharp objects using mechanical means, such as a broom and dustpan while wearing gloves.  Discard soiled materials in a nonpermeable container (e.g. plastic or cardboard box depending on type of soiled material).  Place container inside second plastic bag and tie or seal shut for final disposal. 

b. If an absorbent material is needed to clean up body fluids such as blood or vomit, sprinkle the absorbent over and around the area.  After absorption has occurred, use a putty knife, broom or other tool to scrape material into a plastic bag.  Tie the bag shut, and dispose into a second plastic bag for final disposal. 

                                    c.  Wipe area clean, while wearing gloves. 

d.  Spray contaminated area with approved disinfectant. (Must be tuberculocidal.)  Let air dry.           

e.  Disinfect tools used in cleanup with an approved tuberculocidadisinfectant following manufacturer’s directions. 

f.  Discard any disposable materials used in the cleanup, such as paper towels, rags, and disposable gloves, in a plastic bag.  Tie bag shut and discard into a second plastic bag.

g. If wearing nondisposable gloves during cleanup, wash gloves with soap and water, dry, spray with disinfectant and air dry. 

h. Wash hands carefully and thoroughly with soap and water at end of cleanup. 

2.                  First-aid situations: In assisting an individual in a first-aid situation, where the possibility of exposure to blood or other infectious body fluids exists, the following procedures shall be followed. 

a. If possible, first apply disposable gloves, which are found in all first-aid boxes at college-managed campus sites, prior to giving direct assistance.  In most situations, care is not significantly impaired by asking the person to wait a moment while you apply gloves. 

If gloves are not immediately available, hand the person some sort of a barrier and ask them to apply pressure themselves.  A barrier may be a scarf, a paper towel, a Kleenex, or handkerchief.  Most bleeding victims can follow directions to apply direct pressure to a bleeding area, while the rescuer applies protective gear.  If exposure to potentially infectious materials occurs, follow the procedure for treatment of exposure. 

b. If CPR is needed, use CPR face shields which are found in all first-aid boxes at college-managed campus sites when giving CPR.  If CPR is started without protective gear, apply the protective gear as soon as it is brought to the site and then follow the procedure for treatment of exposure. 

3.       Clinical nursing faculty will follow the infection control and exposure control plans at their affiliating health care agency. 

                        4.         General work practices: 

a. Contaminated needles/sharps shall not be recapped, purposefully bent or broken by hand, removed from disposable syringe, or otherwise manipulated by hand. Contaminated needles/sharps shall be disposed of promptly in puncture resistant collection containers. 

b. Contaminated needles/sharps shall be placed in puncture resistant leak proof containers that are labeled and disposed according to the college’s Waste Disposal Plan Policy. 

c. Eating, drinking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is reasonable likelihood of occupational exposure to blood and/or other potentially infectious material. 

d. Food and beverages shall not be stored in refrigerators, freezers, shelves, cabinets, or on counter/bench tops where blood and other potentially infectious materials are present. 

e. All procedures involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets of these substances. 

f.  Mouth pipetting/suctioning of blood or other potentially infectious materials is prohibited. 

C.     Personal protective equipment, including gloves, cover gowns, aprons, face shields or masks and eye protection, surgical caps or hoods and/or shoe covers or boots, mouthpieces and resuscitation bags shall be provided by Bay de Noc Community College or the affiliating clinical agency to prevent or minimize occupational exposure to blood and/or other potentially infectious materials while performing job tasks or procedures. 

                        1.         Gloves: 

a. Gloves shall be worn when it can be reasonably anticipated that the employee will have contact with blood and other potentially infectious materials. 

b. Hypoallergenic gloves or glove liners will be made available upon request for those employees who are allergic to vinyl or latex gloves. 

c. Gloves shall be replaced as soon as practical when contaminated, torn or punctured. 

d.  Disposable gloves shall not be washed for reuse.

e. Hands shall be washed after removing gloves. 

            D.        Treatment of exposure: 

1.       Employees shall wash the exposed areas of their hands with soap and water immediately or as soon as feasible when exposed to blood or other potentially infectious body fluids, and always after removing contaminated gloves. 

2.        Employees who have an exposure of blood or other potentially infectious material to skin and/or mucous membranes shall flush the area with water immediately. Exposed skin areas shall also be washed with soap and water. 

3.      Clinical nursing faculty sustaining an exposure at an affiliating clinical agency shall seek initial risk assessment, counseling, and treatment at the agency according to the agency’s Exposure Control Plan.  The affiliating agency usually assumes the cost of this initial assessment and treatment. If it does not, it will be assumed by Bay de Noc Community College. 

4.       Other employees exposed to potentially infectious bodily fluids shall follow-up with his/her personal health care provider for risk assessment, counseling, and treatment. Employees may seek this care at the local hospital emergency department if unable to receive this care from his/her personal care provider in a timely manner.  The cost of this initial assessment and treatment will be assumed by Bay de Noc Community College. 

Prophylaxis and vaccination for hepatitis B exposure to an unvaccinated person is best performed within 24-48 hours of the exposure, though it may be given as long as 7 days post exposure.  Booster vaccinations may be given to already vaccinated people.  Timely assessment and treatment are important.           

            E.        Disposal of infectious waste 

Regulated infectious medical waste, including sharps, needles, syringes, blood and other potentially infectious material shall be disposed of in nonpermeable containers labeled as bio-hazardous and disposed of according to the Bay de Noc Community College Waste Management Plan. 

607.5  Communication of Hazards to Employees 

A.        Biohazard labels are affixed to regulated infectious waste containers, refrigerators and freezers containing blood or other potentially infectious material.  Red bags or red containers may be substituted for bio-hazardous labels. 

607.6  Training 

A.        Information and training for all employees with occupational exposure to blood or other potentially infectious material will be made available at time of initial assignment and annually thereafter. Additional training shall be provided by the employer when changes, modifications or additional procedures or tasks affect the employee’s occupational exposure.  The person conducting the training shall be knowledgeable in the area of bloodborne pathogens, as well as the subject matter in the training program as it relates to the work place. Additional training specific to the affiliating clinical agency and unit of practice will be offered by the affiliating agency at the start of each clinical rotation.

B.        Information the training shall include but is not limited    to:  

1.  An explanation of the Exposure Control Plan; 

2.  Where to find a copy of the regulatory text of the Bloodborne Pathogen Standards from OSHA; 

3. The epidemology and symptoms of bloodborne disease;

4. Modes of transmission of bloodborne pathogens; 

5. Methods for recognizing tasks and other activitiesthat may involve exposure to blood and other potentially infectious materials. 

6.  Use and limitations of methods that will prevent or reduce exposure including appropriate engineering controls, work practices, and personal protective equipment; 

7.  Information on the types, proper use, location, removal, handling, decontamination and disposal of personal protective equipment; 

8. Information on Hepatitis B vaccine, including information on its efficacy, safety, method of administration, benefits of being vaccinated, and that the vaccine and vaccination are free of charge; 

9. Information on appropriate action to take and persons to contact in the event of exposure to blood or other potentially infectious material; 

10. Information on procedures to follow if an exposure incident occurs including method of reporting the incident and the available medical follow-up that will be made available; 

11. Information on the post-exposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident; 

12. Explanation of bio-hazardous signs and labels. 

607.7  Medical Record Keeping 

A.       Employee medical records will be established and maintained by Human Resources.  The medical record shall include: the employee’s name, social security number, copy of employee’s Hepatitis B vaccination status when applicable, a copy of all results of examinations, medical testing, and follow-up procedures, employer’s copy of the health care professional’s written opinion, and a copy of the information provided to the health care professional required.   

B.           The employee medical record will be confidential and cannot be disclosed or reported without the employee’s written consent to any person within or outside the work place except as required by law, or to the Director and to Assistant Secretary of National Institute for OSHA or designated representative.  The employee medical record shall be maintained for the duration of the employee’s employment plus 30 years. 

C.          Training records shall include: Dates of the training sessions, contents or a summary of the training session; name and qualifications of persons conducting the training, names and job titles of persons attending the training sessions.  Training records shall be maintained for 3 years from the date on which training occurred.  Training records will be maintained for each employee by the Property Assistant. 

607.8  Controls 

A.       The Exposure Control Plan shall be reviewed and/or revised at least annually by the Safety Committee and whenever necessary to reflect new or modified tasks and procedures which affect occupational exposure and to reflect new or revised employee positions with occupational exposure.