PVCC Safety Manual - Section 6
6.1 Bloodborne Pathogens Exposure Control Plan - General
Piedmont Virginia Community College (PVCC) is committed to providing the safest possible work environment for all employees, including faculty, staff, and student employees.
The OSHA/VOSH 1910.1030 Bloodborne Pathogens Standard was issued to reduce the occupational transmission of infections caused by microorganisms sometimes found in human blood and certain other potentially infectious materials. Although a variety of harmful microorganisms may be transmitted through contact with infected human blood, Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV) have been shown to be responsible for infecting persons who were exposed in the course of their employment to human blood and certain other body fluids containing these viruses.
This exposure control plan has been established by PVCC to minimize and to prevent, when possible, the exposure of PVCC employees to disease-causing microorganisms transmitted through human blood and to meet the requirements of the OSHA Bloodborne Pathogens Standard.
This plan will be reviewed annually and updated as necessary by the vice president for finance and administrative services with the assistance of the human resources manager and the dean of the division of health and life sciences.
6.2 General Program Management
- The following offices and individuals shall have the responsibility for the effective implementation of PVCC's exposure control plan:
- Office of the vice president for finance & administrative services
- Human resources office
- Division deans and supervisors
- PVCC employees
2. The roles of each of these groups are defined below:
a. Vice President for Finance & Administrative Services
i. Maintaining overall responsibility for implementing the exposure control plan
ii. Working with the administrators and supervisors to develop and administer any additional policies and practices related to bloodborne pathogens.
iii. Reviewing and revising the exposure control plan as necessary
iv. Acting as facility liaison during OSHA inspections
b. Human Resources Office
c. Division Deans
Division deans and supervisors are responsible for exposure control in their respective areas. They shall work directly with the vice president for finance and administrative services and PVCC employees to ensure that proper exposure control procedures are followed. They are also responsible for assuring that all new employees receive orientation training for the bloodborne pathogens program.
PVCC employees have the most important role in PVCC's bloodborne pathogens compliance program because the ultimate execution of much of the exposure control plan rests in their hands. In this role they are responsible for the following activities:
- Knowing what tasks they perform that have occupational exposure;
- Attending the bloodborne pathogens training sessions;
- Planning and conducting all operations in accordance with PVCC policies and procedures and work practice controls;
- Developing good personal hygiene habits.
B. Availability of Bloodborne Pathogens Exposure Control Plan
The plan will be made readily available to employees who have the potential for exposure due to the nature of their job duties. Such employees will be briefed on the plan during the new employee orientation. Copies of the plan will be maintained in the Office of the Vice President for Finance and Administrative Services; Human Resources Office; Office of the Vice President for Instruction and Student Services; Division of Math, Science, and Human Services; Facilities Department; Nursing Department; Public Safety Office; the Betty Sue Jessup Library, and on the PVCC website.
C. Review and Update of the Plan
The plan shall be reviewed and updated by the vice president for finance and administrative services in coordination with human resources and the dean of the division of health and life sciences as follows:
- Annually, on or before May 30 of each year;
- Whenever new or modified tasks and procedures are implemented which affect occupational exposure of employees;
- Whenever any tasks of any position are revised such that new instances of occupational exposure may occur;
- Whenever new functional positions are established at PVCC that may involve exposure to bloodborne pathogens.
6.3 Exposure Determination
A. General Determination
All job categories in which it is reasonable to anticipate that an employee will have skin, eye, mucous membrane or parenteral contact with blood or other potentially infectious materials (listed below) shall be governed by this plan. Exposure determination is made without regard to the use of personal protective equipment.
Other Potentially Infectious Materials (OPIM) as defined by OSHA
- Vaginal secretions
- Cerebrospinal fluid
- Pericardial fluid
- Peritoneal fluid
- Amniotic fluid
- Any body fluid visibly contaminated with blood
- Any unfixed tissue or organ (other than intact skin) from a human (living or dead);
- HIV/HBV containing cell or tissue cultures, organ cultures and culture medium;
- Blood, organs or other tissues from experimental animals infected with HIV or HBV;
- Unless they contain blood, OSHA does not list the following body fluids as HIV/HVB transmission sources: urine, feces, mother's milk, vomit, or tears.
B. Job Categories
- All employees who have the potential of being exposed to bloodborne pathogens due to the nature of their employment duties are subject to the exposure control plan. The plan does not include students other than those employed by the college.
- The job categories that fall under this plan include, but are not limited to:
- Maintenance and housekeeping personnel;
- Faculty members, instructional assistants, lab managers, and student employees in health sciences, biology and natural science, chemistry, and physical education;
- Public safety officers;
- Any other faculty member, staff member, or student employee who may be exposed to body fluids as a result of his/her occupational duties.
- Division deans and supervisors are responsible for identifying their at-risk positions and informing the human resources office.
6.4 Methods of Compliance
A. Universal Precautions
At PVCC, all blood or other potentially infectious materials (as described in Part II, Exposure Determination) shall be handled as if contaminated by a bloodborne pathogen. When circumstances prevail which makes the differentiation between body fluid types difficult or impossible, all body fluids shall be considered potentially infectious materials.
B. Engineering Controls
The following engineering controls are used throughout the college where there is the possibility of exposure to bloodborne pathogens.
- Handwashing facilities are easily accessible to the areas where there is the possibility of exposure to bloodborne pathogens. Where handwashing facilities are not available, germicidal towelettes or other disinfecting controls will be available.
- Containers for contaminated sharps that are: Puncture-resistant; leak-proof on the sides and bottom; color-coded or labeled with a biohazard label.
- Specimen containers that are: Puncture-resistant when necessary; peak-proof; color-coded or labeled with a biohazard label.
- The college shall use equipment such as sharps disposal containers, ventilating laboratory hoods, and biologic safety cabinets as appropriate. Personal protective equipment shall also be used when appropriate.
- A representative from the safety committee will conduct periodic inspections to identify: Areas where engineering controls are currently used; areas where engineering controls can be updated; areas that are not using engineering controls currently, but where they would be beneficial.
C. Work Practice Controls
In addition to engineering controls, work practice controls shall be used to eliminate or minimize employee exposure to bloodborne pathogens. The vice president for finance and administrative services, deans, and supervisors shall ensure that employees have adopted the following work practice controls.
- Handwashing and Other Hygiene Measures.
- Employees shall wash their hands thoroughly using soap and water or germicidal towelettes whenever hands become contaminated and as soon as possible after removing gloves or other personal protective equipment.
- When other skin areas or mucous membranes come in contact with blood or other potentially infectious materials, the skin shall be washed with soap and water, and the mucous membrane shall be flushed with water as soon as possible.
- Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a potential for exposure to bloodborne pathogens.
- Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or on countertops or benchtops where blood or other potentially infectious materials are present.
- Mouth pipetting/suctioning of blood or other potentially infectious materials are prohibited.
- Employees shall use practices to minimize splashing, spraying, spattering, and generation of droplets during procedures involving blood or other potentially infectious materials.
Management of Sharp Objects
- Shearing or breaking of contaminated needles is prohibited. Contaminated needles and other contaminated sharp objects shall not be bent, recapped or removed unless;
- Recapping or needle removal is accomplished only through the use of a mechanical device or a one-handed technique only when appropriate for medical procedures.
- Sharp object containers shall be closable, puncture-resistant, labeled with a biohazard label or color-coded in red, leakproof on the sides and bottom, and maintained upright as long as they are in use. The containers shall be located where they are easily accessible to personnel and as close as is feasible to the immediate area where sharps are used.
- Contaminated disposable sharp objects and contaminated broken glass shall be discarded as soon as possible after use in disposable sharp object containers, sealed and disposed of by cremation or other effective means.
- Reusable contaminated sharp objects shall be placed in a reusable sharps container and will be decontaminated by autoclaving or otherwise properly processed as soon as feasible.
- Maintenance and housekeeping personnel will be advised not to handle or empty sharp object containers.
3. Handling Specimens
- Specimens of blood or OPIM shall be placed in a container that prevents leakage during collection, handling, processing, storage, transport, or shipping. The container must be closed before being stored, transported, or shipped. Containers shall be labeled with a biohazard label. All specimens at PVCC shall be handled using universal precautions.
- If the outside of the primary specimen container becomes contaminated or punctured, it shall be placed inside a secondary container which prevents leakage and resists puncture during handling, processing, storage, transport, or shipping.
4. Management of Contaminated Equipment
- Equipment will be assessed for contamination and decontamination, if possible, before servicing or shipping. Any equipment that has not been fully decontaminated will be labeled as to which parts remain contaminated. The facilities manager will be responsible for assuring that equipment is assessed and decontaminated and the procedure that is to be used.
D. Personal Protective Equipment
Division deans and supervisors will identify and provide personal protective equipment for employees in their respective areas and will inform their respective vice presidents of personal protective equipment needs.
All personal protective equipment will be provided, repaired, cleaned, and disposed of by PVCC at no cost to the employees. This equipment includes, but is not limited to:
- Laboratory Coats
- Face Shields
- Eye Protection
- Pocket Masks
Employees will wear personal protective equipment when performing procedures in which exposure to the skin, eyes, mouth, or other mucous membrane is anticipated.
Employees shall be instructed during their initial training session in the use of appropriate personal protective equipment for their job classifications and tasks or procedures they perform. Additional training shall be provided for new employees if an employee takes a new position or new job functions are added to his/her current position. To determine whether additional training is needed, the employee's previous job classification and tasks shall be compared to those for any new job or function that they shall undertake. Additional training shall be provided by the employee's supervisor.
To ensure that personal protective equipment is used as effectively as possible, employees shall adhere to the following practices.
- All personal protective equipment shall be inspected periodically by supervisors and repaired or replaced as needed;
- All garments or equipment penetrated by blood or other potentially infectious materials shall be removed immediately, or as soon as feasible;
- All personal protective equipment shall be removed prior to leaving the work area and will be disposed of or laundered at the facility.
Gloves shall be worn when:
- There is a possibility of hand contact with blood or OPIM;
- Employees perform vascular access procedures;
- Handling or touching contaminated items or surfaces.
Disposable gloves are replaced as soon as practical after contamination or if they are torn, punctured, or otherwise lose their ability to function as an "exposure barrier."
Utility (reusable) gloves shall be decontaminated for reuse unless they are cracked, peeling, torn, or exhibit other signs of deterioration, in which case they will be disposed of properly.
Masks and eye protection or face shields shall be used whenever there is the possibility of splashes, sprays, or droplets of blood or OPIM.
Protective clothing shall be worn whenever potential exposure to the body is anticipated.
E. Maintenance and Housekeeping
Maintaining facilities in a clean and sanitary condition is an important component of an effective exposure control program. In addition to the information below, the PVCC Maintenance Plan contains routine procedures that custodial and maintenance personnel are to follow in order to meet this objective on a continual basis. Supervisors are also responsible for assuring that employees maintain the workplace in a clean and sanitary condition.
- Equipment and working surfaces
Equipment and working surfaces that are contaminated will be cleaned with an appropriate disinfectant:
a. After completing procedures;
b. Immediately or as soon as feasible after any spill of blood or other possible contaminated material; and
c. At the end of the work shift if the surface may have become contaminated since the last cleaning.
- Special Sharp Object Precautions
Broken glass which may be contaminated will be cleaned up using mechanical means, such as a brush and dustpan, tongs, or forceps.
Employees SHALL NOT pick up sharp objects directly with their hands.
Reusable containers shall not be opened, emptied, or cleaned manually or in any other manner which could expose employees to the risk of percutaneous injury. Employees SHALL NOT reach by hand into a container of reusable contaminated sharp objects.
- Regulated Waste
Regulated waste includes:
- Liquid or semi-liquid blood or other potentially infectious materials;
- Contaminated items that would release blood or other potentially 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.
These substances will be placed in containers that are closeable, puncture-resistant, leakproof, if necessary, and labeled with the biohazard label or color-coded in red. The containers will be maintained upright and not allowed to overfill.
Waste containers will be disposed of in accordance with the Virginia's Department of Waste Management's Infectious Waste Management Regulations.
Employees who handle contaminated laundry will wear protective gloves and other personal protective equipment. It will be handled as little as possible and will not be sorted or rinsed where it is used.
Employees will not take contaminated laundry home for cleaning.
Contaminated laundry will be cleaned by a contractor as designated by the business office.
6.5 Labels and Signs
The most obvious warning of possible exposure to bloodborne pathogens is the use of labels and signs. PVCC will use biohazard labels (red-orange or fluorescent orange in color with the biohazard symbol and the text "BIOHAZARD" in a contrasting color) where appropriate, and bags and equipment that are color-coded in red.
Warning labels will be attached firmly to containers of regulated waste, refrigerators, and freezers containing blood or other potentially infectious materials, and any other containers used to store, transport or ship blood or other potentially infectious materials.
6.6 Hepatitis B Vaccination Exposure Incident Procedures
PVCC recognizes that exposure incidents can occur even though all exposure prevention practices are strictly followed. Therefore, the college will implement a Hepatitis B vaccination program, as well as procedures for post-exposure evaluation and follow-up, should exposure to bloodborne pathogens occur.
A. Hepatitis B Program
All employees who have been identified as having exposure to bloodborne pathogens will be counseled regarding bloodborne pathogen and Hepatitis B and C vaccination series. The vaccination consists of a series of three injections over six months. If a routine booster dose of Hepatitis B vaccine is recommended or required, it will also be made available to the identified employees.
The vaccination will be made available to the appropriate employees after they have attended training on bloodborne pathogens and within ten working days of assignment to a job category with exposure.
The vaccination series will not be made available to:
(a) Employees who have previously received the complete Hepatitis B series;
(b) Any employee who has demonstrated immunity through antibody testing;
(c) Any employee for whom the vaccine is medically contraindicated.
B. Exposure Incident Procedures
An exposure incident is a specific eye, mouth, other mucous membranes, non-intact skin, or parenteral contact with blood or other potentially infectious materials resulting from the performance of an employee's duties. A list of the procedures to follow in the case of an exposure incident is provided in Appendix H and is to be posted in all areas where there is the possibility of an exposure incident.
C. Post-Exposure Evaluation and Follow-Up
The division dean or appropriate supervisor shall investigate every exposure incident that occurs at PVCC within 24 hours of the incident and shall report the incident and the results to the vice president for finance and administrative services on the appropriate form (Appendix B). This investigation will include:
- The date and time that the incident occurred;
- Where the incident occurred;
- What potentially infectious materials were involved in the incident (blood, amniotic fluid, etc.);
- Identification and documentation of the source individual, if possible;
- Under what circumstances the incident occurred, including the type of work being performed;
- The cause of the incident, whether by accident or an unusual circumstance such as an equipment malfunction, power outage, etc.;
- The type of personal protective equipment being used at the time; and
- The actions taken as a result of the incident.
If the infectivity status of the source individual is unknown, the blood will be tested as soon as feasible after the individual's consent is obtained. If the source individual's blood is available and the individual's consent is not required by law, the blood shall be tested and the results documented. The exposed employee shall be informed of the results of the testing.
The exposed employee's blood will be collected as soon as feasible after consent is obtained and will be tested for HBV and HIV serological status. If the employee does not give consent at the time for HIV serologic testing, the sample shall be preserved for at least 90 days. If, within 90 days of the exposure incident, the employee elects to have the baseline sample tested, such testing shall be done as soon as possible.
The exposed employee shall be offered post-exposure prophylaxis, when medically indicated, as well as counseling and medical evaluation of any reported illnesses.
Blood collection, testing, post-exposure prophylaxis, counseling, and medical evaluation will be provided by a designated healthcare facility within reasonable proximity to the campus where the employee works. These services will be provided under Worker's Compensation.
The following information will be provided to the healthcare professional evaluating an employee after an exposure:
- A copy of the bloodborne pathogens standard;
- A description of the exposed employee's duties as they relate to the exposure incident;
- The documentation of the route of exposure and the circumstances under which the exposure occurred;
- The results of the source individual's blood testing, if available;
- All medical records relevant to the appropriate treatment of the employee, including vaccination status.
The human resources office will obtain and provide the employee with a copy of the evaluating healthcare professional's written opinion within 15 days of the completion of the evaluation. The written opinion will be limited to the following information:
i. The results of the evaluation;
ii. Any medical conditions resulting from exposure to the blood or other potentially infectious materials which require further evaluation or treatment.
NOTE: All other findings are confidential and shall not be included in the written report.
D. Medical Recordkeeping
The human resources office is responsible for keeping all medical records pertaining to the Bloodborne Pathogens Exposure Control Plan. The records include:
- Name of the employee;
- Social security number of employee;
- Employee's Hepatitis B vaccination status;
- Copies of the results of examinations, medical testing, and follow-up procedures which took place as a result of the employee's exposure to bloodborne pathogens.
- The records shall be maintained for the duration of employment plus 30 years.
6.7 Employee Training
Employees of the college who are assigned tasks where exposure may occur will receive periodic training as outlined below. Training will also be conducted for new employees as appropriate during their orientation. Additional training will be provided by supervisors whenever there are changes in tasks or procedures which affect an employee's occupational exposure.
The training approach will be tailored to the needs of the employees. Each training session shall include an opportunity for employees to have their questions answered by the trainer. The appropriate dean or supervisor is responsible for scheduling and providing the appropriate training & maintaining training records.
A. Training Topics
The topics covered in the employee training programs will include, but are not limited to:
- An explanation of the Bloodborne Pathogens Standard;
- The epidemiology, modes of transmission and symptoms of bloodborne diseases;
- PVCC's Exposure Control Plan;
- Procedures which may expose employees to blood or other potentially infectious materials;
- Engineering controls and work practice controls to be used at PVCC;
- Selection and use of personal protective equipment, including the types available, proper use, location within the facility, removal, handling, decontamination, and disposal;
- Visual warnings of biohazards, including labels, signs and color-coded containers;
- Information on the Hepatitis B vaccination program, including the benefits and safety of vaccination;
- Information on procedures to use in an emergency involving blood or other potentially infectious materials;
- The procedures to follow if an exposure incident occurs;
- An explanation of post-exposure evaluation and follow-up procedures;
- How to inspect equipment for contamination and how to decontaminate it.
B. Training Methods
- Several training techniques shall be used during the training sessions including, but not limited to:
- An interactive classroom atmosphere providing ample opportunity for employees to ask questions;
- Videotape programs;
- Training manuals and employee handouts;
- Overhead slides
C. Dean or supervisor
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