Exposure Control Plan

For Buena Vista University


Table of Contents


Section I
: Purpose of the Plan

Section II
: General Program Management
  1. Responsible Persons
  2. Availability to Employees
  3. Review and Update
Section III: Exposure Determination

Section IV
: Methods of Compliance
  1. General
  2. Engineering Controls
  3. Work Practice Controls
  4. Personal Protective Equipment
  5. Housekeeping
Section V: HIV and HBV Research Laboratories and Production Facilities

Section VI
: Hepatitis B Vaccination, Post-Exposure Evaluation and Follow-up
  1. Hepatitis B Vaccination
  2. Post-Exposure Evaluation and Follow-up
  3. Information provided to the Healthcare Professional
  4. Healthcare Professional's Written Opinion
  5. Medical Record keeping
Section VII: Labels and Signs

Section VIII
: Information and Training
  1. Training and Topics
  2. Training Methods
  3. Record keeping

Section I: Purpose of the Plan

One of the major goals of the Occupational Safety and Health Administration (OSHA) is to regulate facilities where work is carried out...to promote safe work practices in an effort to minimize the incidence of illness and injury experienced by employees. Relative to this goal, OSHA has enacted the Bloodborne Pathogens Standard, codified as 29 CFR 191030. The purpose of the Bloodborne Pathogens Standard is to "reduce occupational exposure to Hepatitis B Virus (HBV), Human Immunodeficiency Virus (HIV) and other bloodborne pathogens" that employees may encounter in their workplace.

Buena Vista University believes that there are a number of "good general principles" that should be followed when working with bloodborne pathogens. These include that:

  • It is prudent to minimize all exposure to bloodborne pathogens.
  • Risk of exposure to bloodborne pathogens should never be underestimated.
  • Our facility should institute as many work practices and engineering controls as possible to eliminate or minimize employee exposure to bloodborne pathogens.

We have implemented this Exposure Control Plan to meet the letter and intent of the OSHA Bloodborne Pathogens Standard. The objective of this plan is twofold:

  • To protect our employees from the health hazards associated with bloodborne pathogens.
  • To provide appropriate treatment and counseling should an employee be exposed to bloodborne pathogens.

Section II: General Program Management


1. Responsible Persons

There are four major "Categories of Responsibility" that are central to the effective implementation of our Exposure Control Plan. These are:

  • The "Exposure Control Officer."
  • Department Managers and Supervisors.
  • Education/Training Instructors
  • Our Employees.

The following sections define the roles played by each of these groups in carrying out our plan. (Throughout this written plan, employees with specific responsibilities are identified. If, because of promotion or other reasons, a new employee is assigned any of these responsibilities, Human Resources Kendra is to be notified of the change, so that they can update their records.)

Exposure Control Officer

The "Exposure Control Officer" will be responsible for overall management and support of our facility's Bloodborne Pathogens Compliance Program. Activities which are delegated to the Exposure Control Officer typically include, but are not limited to:

  • Overall responsibility for implementing the Exposure Control Plan for the entire facility
  • Working with management and other employees to develop and administer any additional bloodborne pathogens related policies and practices needed to support the effective implementation of this plan.
  • Looking for ways to improve the Exposure Control Plan, as well as to revise and update the plan when necessary.
  • Collecting and maintaining a suitable reference library on the Bloodborne Pathogens Standard and bloodborne pathogens safety and health information.
  • Knowing current legal requirements concerning bloodborne pathogens.
  • Acting as facility liaison during OSHA inspections.
  • Conducting periodic facility audits to maintain an up-to-date Exposure Control Plan.

Director of Health Services and Human Resources has been appointed as the facility's Exposure Control Officer.

We have determined that the Exposure Control Officer will require assistance in fulfilling their responsibilities. To assist them in carrying out their duties, we have created an Exposure Control Committee composed of the following people:

Exposure Control Committee 
  • Director of Physical Plant
  • Associate Director of Physical Plant
  • Human Resources
  • Director of Health Services
  • Athletic Director
  • Dean of School of Science
  • Director of Siebens Forum
  • Director of Security

Department Managers and Supervisors

Department Managers and Supervisors are responsible for exposure control in their respective areas. They work directly with the Exposure Control Officer and our employees to ensure that proper exposure control procedures are followed.

Education/Training Coordinator

Our Education/Training Coordinator will be responsible for providing information and training to all employees who have the potential for exposure to bloodborne pathogens. Activities falling under the direction of the Coordinator include:

  • Maintaining an up-to-date list of facility personnel requiring training (in conjunction with facility management).
  • Developing suitable education/training programs.
  • Scheduling (2) classroom training seminars for employees every August.
  • Maintaining appropriate training documentation records.
  • Maintaining on-line training tool.
  • Periodically reviewing the training programs with the Exposure Control Committee.

All new employees requiring bloodborne pathogen training will be trained by the Education Coordinator during the orientation period. All other employees requiring bloodborne pathogen training will be offered (2) classroom presentation every August or may use the on-line training tool. All yearly trainings must be complete by September 1st. Failure to comply with the training will result in notification of Vice President of Student Services & Dean of Students who will notify proper supervisors and Vice Presidents to ensure that the annual training is complete.

Health Services has been selected to be the facility's Education/Training Coordinator.

Employees

As with all of our facility's activities, our employees have the most important role in our bloodborne pathogens compliance program, for the ultimate execution of much of our Exposure Control Plan rests in their hands. In this role they must do things such as:

  • Know what tasks they perform that have occupational exposure.
  • Attend the bloodborne pathogens training sessions.
  • Plan and conduct all operations in accordance with our work practice controls.
  • Develop good personal hygiene habits.

2. Availability of the Exposure Control Plan To Employees

To help them with their efforts, our facility's Exposure Control Plan is available to our employees at any time. Employees are advised of this availability during their education/training sessions. Copies of the Exposure Control Plan are kept in the following locations:

  • Stadium Maintenance
  • Health Services
  • Human Resources
  • Athletic Director Office
  • Science Department
  • Forum Office
  • Buena Vista University's Centers
  • Security Office
  • Lamberti Recreation Center Reception Desk
  • Resident Hall Director(s) Offices (4)
  • Custodial Supervisor(s) (2)
  • Web Page @ Human Resources: http://www.bvu.edu/hr/ 

3. Review and Update of the Plan

We recognize that it is important to keep our Exposure Control Plan up-to-date. To ensure this, the plan will be reviewed and updated under the following circumstances:

  • Annually, on or before June 1st of each year.
  • Whenever new or modified tasks and procedures are implemented which affect occupational exposure of our employees.
  • Whenever our employees' jobs are revised such that new instances of occupational exposure may occur.
  • Whenever we establish new functional positions within our facility that may involve exposure to bloodborne pathogens.

Section III: Exposure Determination

One of the keys to implementing a successful Exposure Control Plan is to identify exposure situations employees may encounter. To facilitate this in our facility, we have prepared the following lists:

  • Job classifications in which all employees have occupational exposure to bloodborne pathogens.
  • Job classifications in which some employees have occupational exposure to bloodborne pathogens.

The initial lists were compiled on or before May 5, 1992. The Human Resources will work with department managers and supervisors to revise and update these lists as our tasks, procedures, and classifications change. It is the responsibility of the supervisor to ensure that employees are trained annually.

All new employees requiring bloodborne pathogen training will be trained by the Education Coordinator during the orientation period. All other employees requiring bloodborne pathogen training will be offered two classroom presentations every August or may use the on-line training tool. All yearly trainings must be completed by September 1st. Failure to comply with training will result in notification of Vice President of Student Services & Dean of Students who will notify proper supervisors and Vice Presidents to ensure that the annual training is complete.

Job Classifications In Which All Employees Have Exposure To Bloodborne Pathogens

Below are listed the job classifications in our facility where all employees may come into contact with human blood or other potentially infectious materials, which may result in possible exposure to bloodborne pathogens.

Job Title Department/Location/Trainer
Custodians Maintenance/Stadium/Forum/Education Coord.
Maintenance Maintenance/Stadium/Forum/Education Coord.
Campus Security Student Services/ Forum/Education Coord.
Science Professors and students in chemistry, biology, or physics labs School of Science/ Science Center/Professors and EPA Safety Coord. Bloodborne Pathogen Training included in class syllabus.
Athletic Trainers Athletics/ Fieldhouse/Assist Prof. Exercise Sc.
Director of Residence Life and Director of Housing Student Services/ 5 dorms, 3 suites, cottages/Education Coord.
Health Services Student Services/ Fieldhouse/Education Coord.
Coaches Athletics/ Fieldhouse/Education Coord and/or Assist Prof Exercise Sci
Resident Hall Directors (4) Student Services/ Resident Halls/Education Coord.
Assistant Resident Director Student Services/ Resident Halls/Education Coord.
Resident Advisors Student Services/ Resident Halls/Education Coord.
Laundry & Athletic Equipment Manager Fieldhouse/Education Coord.
Athletic Trainer (s) and AT students Athletics/Fieldhouse/Assist Prof. Exercise Sc.


Job Classifications In Which Some Employees Have Exposure To Bloodborne Pathogens

Below are listed the job classifications in our facility where some employees may come into contact with human blood or other potentially infectious materials, which may result in possible exposure to bloodborne pathogens.

Job Title Department/Location/Trainer
Conference Assistant(s) Forum/Education Coord.
Science professors and academic assistant and work-study students in chemistry, biology, or physics labs. Science Center/EPA Safety Coord.


Work Activities Involving Potential Exposure To bloodborne Pathogens

Below are listed the tasks and procedures in our facility where employees may come into contact with human blood or other potentially infectious materials which may result in exposure to bloodborne pathogens.

Task/Procedure Job Classification Department/Location
Handling equipment trash or linen  all contaminated with body fluids Coaches, Trainers, Custodians, Maintenance/Work-study/ Professors/Students Gym, Athletic Fields, buildings & work areas
Sanitary napkin disposal Custodians All female dorms  restrooms
First Aid-lacerations, wound debridement Health Services/Athletic Trainers, Coaches, Supervisors, Professors, Science Professors/Students/AA

Health Services/Field-house
Athletics/Fieldhouse Campus Athletic fields
Science Department

Chemistry Lab-glassware use  Science Professors/Students/AA Science Department
Physics Lab-mechanical equipment  Science Professors/Students/AA Science Department
Biology Lab-scalpels, scissors, lancets, needles, other cutting devices  Science Professors/Students/AA Science Department

Section IV: Methods of Compliance

We understand that there are a number of areas that must be addressed in order to effectively eliminate or minimize exposure to bloodborne pathogens in our facility. The first five areas we deal with in our plan are:

  • The use of Universal Precautions
  • Establishing appropriate Engineering Controls
  • Implementing appropriate Work Practice Controls
  • Using necessary Personal Protective Equipment
  • Implementing appropriate Housekeeping Procedures 

Each of these areas is reviewed with our employees during their bloodborne pathogens related training (see the "Information and Training" section of this plan for additional information). By rigorously following the requirements of OSHA's Bloodborne Pathogens Standard in these five areas, we feel that we will eliminate or minimize our employees' occupational exposure to bloodborne pathogens as much as possible.

1. Universal Precautions

In our facility we have begun the practice of "Universal Precautions" on November 1, 1992. As a result, we treat all human blood and body fluids as semen and vaginal secretions as if they are known to be infectious for HBV, HIV, and other bloodborne pathogens.

In circumstances where it is difficult or impossible to differentiate between body fluid types, we assume all body fluids to be potentially infectious.

Health Services/Human Resources is responsible for overseeing our Universal Precautions Program.

 
2. Engineering Controls

One of the key aspects to our Exposure Control Plan is the use of Engineering Controls to eliminate or minimize employee exposure to bloodborne pathogens. As a result, employees use cleaning, maintenance, and other equipment that is designed to prevent contact with blood or other potentially infectious materials.

Exposure Control Committee periodically works with department managers and supervisors to review tasks and procedures performed in our facility where engineering controls can be implemented or updated. As part of this effort, a facility survey was completed on November 1, 1992 identifying three things:

  • Operations where engineering controls are currently employed.
  • Operations where engineering controls can be updated.
  • Operations currently not employing engineering controls, but where engineering controls could be beneficial.

The results of this survey can be found on the following pages.

Each of these lists is reexamined during our annual Exposure Control Plan review and opportunities for new or improved engineering controls are identified. Any existing engineering control equipment is also reviewed for proper function and needed repair or replacement every 12 months, in conjunction with the department manager or supervisor where the equipment is located.

Engineering Control Equipment

The following operations have, or should have, Engineering Control Equipment to eliminate or minimize our employees' exposure to bloodborne pathogens. If equipment is needed but not yet available "None" is indicated in the "Control Equipment" column.

Department

Athletic Training Room, Fitness Center, Health Services

Control Equipment

Reusable equipment exposed to body fluids should be soaked in 10% Sodium Hypochlorite solution for 10 minutes, washed in Clean-A-Septic solution, rinsed, dried, and sterilized for use.

Department

Athletic Training Room, Health Services, Maintenance, Science Department

Control Equipment

Disposable items exposed to body fluids must be placed in a puncture-proof container or red bag with the biohazard emblem. The container will be transported for incineration.

Department

Athletic Training Room, Athletic Laundry Department, Housekeeping Conference Assistants

  • Laundry shall be handled as little as possible with minimal agitation.
  • Contaminated laundry shall be bagged or containerized at the location where it was used and must not be sorted or rinsed at the location of use.
  • Contaminated laundry to be laundered at athletic campus laundry department must be placed in a red or yellow bio-hazard bag and transported to campus laundry site designated by Athletic Director.
  • Whenever contaminated laundry is wet and presents a reasonable likelihood of soak-through or leakage from the red/yellow bag,
  • The laundry bag must be placed and transported in plastic can liner bag or container which prevent soak-through and/or leakage of fluids to the exterior.
  • Contaminated laundry is soaked in a 10% bleach solution for 24 hours and then laundered by the University.

Custodial/Laundry ~Employees who have contact with contaminated laundry shall wear protective gloves and other appropriate personal protective equipment. All laundry is considered contaminated by the off campus site and there-fore does not need to be placed in a special color coded bag or container, unless totally saturated and leakage is potential.

Our facility has adopted the following Work Practice Controls as part of our Bloodborne Pathogens Compliance Program:

  • Employees wash their hands immediately, or as soon as feasible, after removal of potentially contaminated gloves or other personal protective equipment.
  • Following any contact of body areas with blood or any other infectious material, employees wash their hands and any other exposed mucous membranes with water.
  • Contaminated needles and other contaminated sharps are not bent, recapped, or removed unless:
  • It can be demonstrated that there is no feasible alternative.
  • The action is required by specific medical procedure.
  • In the two situations above the recapping or needle removal is accomplished through the use of a medical device or a one-handed technique. (medical)
  • Contaminated reusable sharps are placed in appropriate containers immediately, or as soon as possible, after use. (Medical)
  • Eating, drinking, smoking, applying cosmetics or lip balm and handling contact lenses is prohibited in work areas where there is potential for exposure to bloodborne pathogens.
  • Food and drink is not kept in refrigerators, freezers, on counter tops or in other storage areas where blood or other potentially infectious materials are present. (Medical)
  • Mouth pipetting/suctioning of blood or infectious materials is prohibited. (Medical)
  • All procedures involving blood or other infectious materials minimize splashing, spraying or other actions generating droplets of these materials. (Medical)
  • Specimens of blood or other materials are placed in designated leak-proof container, appropriately labeled, for handling and storage. (Medical)
  • If outside contamination of a primary specimen container occurs, that container is placed within a second leak-proof container, appropriately labeled, for handling and storage. (If specimen can puncture the primary container, the secondary container must be puncture-resistant as well.) (Medical)
  • Equipment which becomes contaminated is examined prior to servicing or shipping, and decontaminated as necessary (unless it can be demonstrated that decontamination is not feasible.)
  • An appropriate biohazard warning label is attached to any contaminate equipment, identifying the contaminated portions.
  • Information regarding the remaining contamination is conveyed to all affected employees, the equipment manufacturer and the equipment service representative prior to handling, servicing, or shipping.

When a new employee comes to our facility, or an employee changes jobs with the facility, the following process takes place to ensure that they are trained in the appropriate work practice controls:

  • The employee's job classification and the tasks and procedures that they will perform are checked against the Job Classifications and Task Lists which we have identified in our Exposure Control Plan as those in which occupational exposure occurs.
  • If the employee is transferring from one job to another within our facility, the job classifications and tasks/procedures pertaining to their previous position are also checked against these lists.
  • Based on this "cross-checking" the new job classifications and/or tasks and procedures which will bring the employee into occupational exposure situation are identified.
  • The employee is then trained by the facility Training Coordinator or another instructor regarding any work practice controls that the employee is not experienced with.

In addition to the engineering controls identified on these lists, the following engineering controls are used through our facility:

  • Hand washing facilities (or antiseptic hand cleansers and towels or antiseptic towelettes), which are readily accessible to all employees who have the potential for exposure
  • Self-sheathing needles (Medical)
  • Containers for contaminated reusable sharps having the following characteristics:
  • Puncture-resistant
  • Color-coded or labeled with a biohazard warning label
  • Leak-proof on the sides and bottom (Medical)
  • Specimen Containers are:
  • Leak-proof
  • Color-coded or labeled with a biohazard warning label
  • Puncture-resistant, when necessary (Medical)
  • Secondary Containers which are:
  • Leak-proof
  • Color-coded or labeled with a biohazard warning label
  • Puncture-resistant, if necessary (Medical)

3. Work Practice Controls

In addition to engineering controls, our facility uses a number of Work Practice Controls to help eliminate or minimize employee exposure to bloodborne pathogens. Many of these Work Practice Controls have been in effect for some time. Any controls that we are using for the first time will be fully implemented before July 6, 1992.

The person in our facility who is responsible for overseeing the implementation of these Work Practice Controls is Human Resources. They work in conjunction with department managers, supervisors, and our facility's training coordinators to effect this implementation.

4. Personal Protective Equipment

Personal Protective Equipment is our employees' "last line of defense" against bloodborne pathogens. Because of this, our facility provides (at no cost to our employees) the Personal Protective Equipment that they need to protect themselves against such exposure. The equipment includes, but is not limited to:

  • Gloves
  • Safety glasses
  • Goggles
  • Face shields/masks

Hypoallergenic gloves; glove liners, and similar alternatives are readily available to employees who are allergic to the gloves our facility normally uses.

Human Resources, working with department managers and supervisors, is responsible for ensuring that all departments and work areas have appropriate personal protective equipment available to employees.

Our employees are trained regarding the use of the appropriate personal protective equipment for their job classifications and tasks/procedures they perform. Initial training about personal protective equipment was completed in our facility on or before June 4, 1992. Additional training is provided, when necessary, if an employee takes a new position or new job functions are added to their current position.

To determine whether additional training is needed the employee's previous job classification and tasks are compared to those for any new job or function that they undertake. Any needed training is provided by their department manager or supervisor working with our facility's Training Coordinator.

To ensure that personal protective equipment is not contaminated and is in the appropriate condition to protect employees from potential exposure, our facility adheres to the following practices:

  • All personal protective equipment is inspected periodically and repaired or replaced as need to maintain its effectiveness.
  • Reusable personal protective equipment is cleaned, laundered, and decontaminated as needed.
  • Single-use personal protective equipment (or equipment that cannot, for whatever reason, be decontaminated) is disposed of by forwarding that equipment to designated biohazard disposal area.

To make sure that this equipment is used as effectively as possible, our employees adhere to the following practices when using their personal protective equipment:

  • Any garments penetrated by blood or other infectious materials are removed immediately, or as soon as feasible.
  • All potentially contaminated personal protective equipment is removed prior to leaving a work area.
  • Gloves are worn in the following circumstances:
  • Whenever employees anticipate hand contact with potentially infectious materials.
  • When 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 gloves are decontaminated for reuse unless they are cracked, peeling, torn, or exhibit other signs of deterioration, at which time they are disposed of.
  • Masks and eye protection (such as goggles, face shields, etc.) are used whenever splashed or sprays may generate droplets of infectious materials.
  • Protective clothing (such as coats) is worn whenever potential exposure to the body is anticipated.

5. Housekeeping

Maintaining our facility in a clean and sanitary condition is an important part of our Bloodborne Pathogens Compliance Program. To facilitate this, we have set up a written

schedule for cleaning and decontamination of the appropriate areas of the facility. The schedule provides the following information (this schedule can be found on the following page):

  • The area to be cleaned/decontaminated
  • Day and time of scheduled work
  • Cleansers and disinfectants to be used
  • Any special instructions that are appropriate

Using this schedule, our janitorial/cleaning staff employs the following practices:

  • All equipment and surfaces are cleaned and decontaminated after contact with blood or other potentially infectious materials:
  • After the completion of medical procedures. (Medical)
  • Immediately (or as soon as feasible) when surfaces are overtly contaminated.
  • After any spill of blood or infectious materials. (Medical)
  • At the end of the work shift if the surface may have been contaminated during that shift.
  • Protective coverings (such as plastic trash bags or wrap, aluminum foil or absorbent paper) are removed and replaced:
  • As soon as it is feasible when overtly contaminated.
  • At the end of the work shift if they may have been contaminated during the shift.
  • All trash containers, pails, bins, and other receptacles intended for use routinely are inspected, cleaned and decontaminated as soon as possible if visible contaminated.
  •  Potentially contaminated broken glassware is picked up using mechanical means (such as dustpan and brush, tongs, forceps, etc.)
  • Contaminated reusable sharps are stored in containers that do not require "hand processing". (Medical)

Exposure Control Committee members are responsible for setting up our cleaning and decontamination schedule and making sure it is carried out within their respected area.

We are also very careful in our facility in handling regulated waste (including used bandages, feminine hygiene products and other potentially infectious materials). Starting on or before July 6, 1992, the following procedures are used with all of these types of wastes:

  • They are discarded or "bagged" in containers that are:
  • Closeable
  • Puncture-resistant if the discarded materials have the potential to penetrate for fluid spill or leakage exists.
  • Leak-proof if the potential for fluid spill or leakage exists.
  • Red in color or labeled with the appropriate biohazard warning label.
  • Containers for this regulated waste are placed in appropriate locations in our facility within easy access of our employees and as close as possible to the sources of the waste.
  • Waste containers are maintained upright, routinely replaced and not allowed to overfill.
  • Contaminated laundry is handled as little as possible and is not sorted or rinsed where it is used. All contaminated laundry is considered infectious by our off campus laundry service. No special bags or labeling is needed.
  • Whenever our employees move containers of regulated waste from one area to another the containers are immediately closed and placed inside an appropriate secondary container if leakage is possible from the first container.
  • The designated infectious waste pick up receptacle is located on the West side of the new Science Center. The receptacle is clearly marked and kept locked at all times. 

Director of Physical Plant and Associate Director of Physical Plant are responsible for the collection and handling of our facility's contaminated waste.

Cleaning Schedule

Equipment/Area

Scheduled Cleaning

Cleaners and Disinfectants Used

Special Instructions

Custodial Resident Hall

6am-3pm

Windex/Glass Cleaner, Tough Duty/degreaser cleaner, Damp Mop/cleaner, PST/bowl & RR cleaner, Crew/RR cleaner, PinelV/disinfectant cleaner, TSR/soap & scum cleaner, LS-25/soap & scum cleaner, Spring Green/enzyme cleaner, Foamy Q&A/disinfectant cleaner, Comet Spray/cleaner-whitener, Comet Cream/cleaner-whitener

Use according to manufactures

Custodial Academic Buildings

6am-3pm

3M #1L/glass cleaner, 3M #2L/multi-cleaner, 3M #3H/neutral cleaner, 3M #4L/bathroom cleaner, 3M #5L/quaternary disinfectant, 3M # 8L/general cleaner, Consume eco lyzer/enzyme-disinfectant cleaner, Spring Green/enzyme cleaner, Foamy Q&A/disinfectant cleaner

According to instructions

Maintenance

7am-4pm

Tough Duty/degreaser cleaner,

According to instructions

Vionexx/anti-microbial liquid soap

Fitness Center

Hourly or as needed

3M Quat Cleaner

According to instructions

Athletic Training Room

Twice daily or as needed

3M Quat Cleaner + Clorox

According to instructions

Locker Rooms

Daily

3M Quat Cleaner + Clorox

According to instructions

Whirlpools

Daily

Cavicide

Scrub with dish soap the use Cavicide

Athletic Training Laundry

As needed

10% + solution of Clorox

Soak immediately for 12 hours

Athletic Uniforms

As needed

Biozide Cleaner

According to instructions

Laundry

As needed

Puritan Cleaner

According to instructions

Wrestling Room

Daily or as needed

Pioneer Checkmate Mat Cleaner

According to instructions

Fieldhouse

4am-3pm

10pm-7am

3M #1L/glass cleaner, 3M #2L/multi-cleaner, 3M #3H/neutral cleaner, 3M #4L/bathroom cleaner, 3M #5L/quaternary disinfectant, 3M # 8L/general cleaner, Consume eco lyzer/enzyme-disinfectant cleaner, Spring Green/enzyme cleaner, Foamy Q&A/disinfectant cleaner

According to instructions

Health Services

Daily and as needed

Cavicide Disinfectant

According to instructions



Section V: HIV and HBV Research Laboratories and Production Facilities

We recognize that there are special requirements for HIV and HBV research laboratories and production facilities in the areas of construction, engineering controls, work practices, the use of containment equipment as well as employee education and training. However, since we do not have these types of operations in our facility, these special requirements do not apply. THEREFORE, OUR EXPOSURE CONTROL PLAN DOES NOT ADDRESS THESE REQUIREMENTS.

(If your facility includes HIV or HBV research laboratories or production facilities you can find a listing of the special requirements the Standard imposes by consulting the Bloodborne Pathogens Standard in the "Attachments" section of this manual. In this case, to complete your Exposure Control Plan you will need to document the methods you will use to comply with these special requirements, as well as your implementation schedule.)


Section VI: Hepatitis B Vaccination, Post-Exposure Evaluation and Follow-Up

Everyone in our facility recognizes that even with good adherence to all of our exposure prevention practices, exposure incidents can occur. As a result, we have implemented a Hepatitis B Vaccination Program, as well as set up procedures for post-exposure evaluation and follow-up should exposure to bloodborne pathogens occur.

1. Vaccination Program

To protect our employees as much as possible from the possibility of Hepatitis B infection, our facility has implemented a vaccination program. This program is available, at no cost, to all employees who have occupational exposure to bloodborne pathogens within 90 days of employment. If an employee does not wish to receive the vaccine they must sign the waiver statement declining the vaccine.

The vaccination program consists of a series of three inoculations over a six-month period. As part of their bloodborne pathogens training, our employees have received information regarding Hepatitis vaccination, including its safety and effectiveness.

Health Services Director and Human Resources are responsible for setting up and operating our vaccination program, which has been in effect since November 1, 1992.

Vaccinations are performed under the supervision of a licensed physician or other healthcare professional. Lists of employees taking part in the vaccination program and who have declined to take part in the program are maintained by the education coordinator in the office of Health Services. Those who have declined also have a "Vaccination Declination Form" on file.

To ensure that all employees are aware of our vaccination program, it is thoroughly discussed in our bloodborne pathogens training.  

Consent and Release

Buena Vista University and the undersigned hereby agree as follows:

  1. The undersigned acknowledges that he/she is a student at Buena Vista University, having its main office located at 610 West 4th Street, Storm Lake, Iowa.
  2. Buena Vista University has offered a program whereby Hepatitis B immunization (series of three injections) is offered to each student identified as having possible risk of exposure to bloodborne pathogens.
  3. The Hepatitis B immunization will be conducted by the employer's nurses, Kim Carver, RN and Tami Laursen, RN, BSN. The student must have first attended an educational session addressing the OSHA standards related to bloodborne pathogens.
  4. The undersigned acknowledges and understands that there is no guarantee regarding the success of the immunization with regard to avoidance of Hepatitis B.
  5. The immunization offered by Buena Vista University in not a condition of enrollment and the undersigned's involvement in said immunization is strictly voluntary.

In consideration of the immunization to be performed as described above, the undersigned, fully realizing that such immunization may not be successful, hereby requests that such immunization be performed and expressly consents thereto. The participating physician, Jonathon Hruska, M.D. and the Trimark Physician's Group, Family Health Center, of Storm Lake, IA, and any other persons connected with immunization from all claims, damages and causes of action that may arise from the immunization herein described and from other medical care arising therefrom.

The undersigned agree that this release shall be binding upon himself/herself, his/her spouse, heirs, legal representatives and assigns.

The undersigned has read all of the terms of this instrument and understands that he/she is signing a complete release and bar to any claim resulting from the immunization herein described.

Dated this_____________________________day of _____________________

___________________________________ Employee/Student Signature

 

HEPATITIS VACCINE

Buena Vista University Employees

I request that I be given the vaccine for Hepatitis B. I have been provided with information concerning possible side effects of the vaccine and I release Buena Vista University of responsibility for any untoward reactions that may occur. I further state that I am not to my knowledge pregnant (requires permission of primary OB physician prior to administration). I do not have any allergies to yeast or yeast products.

DATE:______________________ SIGNATURE:_____________________________

Print Name________________________________

WITNESS:________________________________

DATE:______________________ Hepatitis B Vaccine 1.0ml, Intramuscular at 0, 1, and 6 months.

_________________________________________ Physician

DATE:______________________ Recombivax HB, 1.0ml, Intramuscularly

LOT:_____________EXP.______ _______________________________________RN

DATE:______________________ Recombivax HB, 1.0ml, Intramuscularly

LOT:_____________EXP.______ _______________________________________RN

DATE:______________________ Recombivax HB, 1.0ml, Intramuscularly

LOT:_____________EXP.______ _______________________________________RN

DATE:____________ HEPATITIS B SURFACE ANTIBODY:____________________

DATE:____________ Recombivax HB Booster, 1.0ml Intramuscularly

LOT:_____________EXP._______ _______________________________________RN

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me.

DATE:______________ SIGNATURE:___________________________________

WITNESS:______________________________________

DECLINATION STATEMENT: I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me.

DATE:______________ SIGNATURE:________________________________

DATE: _____________ WITNESS:__________________________________

 

HEALTH SERVICES

610 W. Fourth Street,

Storm Lake, Iowa 50588

PHONE: 712.749.1238

FAX: 712.749.1467

2. Post-Exposure Evaluation and Follow-up

If one of our employees is involved in an incident where exposure to bloodborne pathogens may have occurred there are two things that we immediately focus our efforts on:

  • Report immediately to Supervisor, Supervisor to Human Resources.
  • Investigating the circumstances surrounding the exposure incident.
  • Making sure that our employees receive medical consultation and treatment (if required) as expeditiously as possible.

Human Resources investigate every exposure incident that occurs in our facility. This investigation is initiated within 24 hours after the incident occurs and involves gathering the following information:

  • When the incident occurred.
  • Date and time.
  • Where the incident occurred.
  •  Location within facility
  • What potentially infectious materials were involved in the incident.
  •  Type of material (blood, etc.)
  • Source of the material.
  • Under what circumstances the incident occurred.
  • Type of work being performed.
  • How the incident was caused.
  • Accident
  • Unusual circumstances (such as equipment malfunction, power outage, etc.).
  • Personal protective equipment being used at the time of the incident.
  • Actions taken as a result of the incident.
  • Employee decontamination
  • Cleanup.
  • Notifications made.

After this information is gathered it is evaluated, a written summary of the incident and its causes is prepared and recommendations are made for avoiding similar incidents in the future (to help with this, we use the "Incident Investigation Form" found at the end of this section).

In order to make sure that our employees receive the best and most timely treatment if an exposure to bloodborne pathogens should occur, our facility has set up a comprehensive post-exposure evaluation and follow-up process. We use the "checklist" at the end of this section to verify that all the steps in the process have been taken correctly. This process was implemented on or before July 6, 1992 and is overseen by the following people:

  • Director of Health Services
  • Human Resources
  • Associate Director of Physical Plant
  • Athletic Director

We recognize that much of the information involved in this process must remain confidential, and will do everything possible to protect the privacy of the people involved.

As the first step in this process we provide an exposed employee with the following confidential information:

  • Documentation regarding the routes of exposure and circumstances under which the exposure incident occurred.
  • Identification of the source individual (unless infeasible or prohibited by law).  

An appointment is then arranged for the exposed employee with a qualified healthcare professional to discuss the employee's medical status. This includes an evaluation of any reported illnesses, as well as any recommended treatment.

On recommendation of the healthcare professional, the source individual's blood is tested to determine HBV and HIV infectivity. This information will also be made available to 

the exposed employee, if it is obtained. At that time, the employee will be make aware of any applicable laws and regulations concerning disclosure of the identity and infectious status of a source individual.

3. Information Provided to the Healthcare Professional

To assist the healthcare professional we forward a number of documents to them, including the following:

  • A copy of the Bloodborne Pathogens Standard
  • A description of the exposure incident.
  • The exposed employee's relevant medical records.
  • Other pertinent information.

4. Healthcare Professionals Written Opinion

After the consultation, the healthcare professional provides our facility with a written opinion evaluating the exposed employee's situation. We, in turn, furnish a copy of this opinion to the exposed employee.

In keeping with this process' emphasis on confidentiality, the written opinion will contain only the following information:

  • Whether Hepatitis B Vaccination is indicated for the employee.
  • Whether the employee has received the Hepatitis B Vaccination.
  • Confirmation that the employee has been informed of the results of the evaluation.
  • Confirmation that the employee has been told about any medical conditions resulting from the exposure incident which require further evaluation or treatment.

All other findings or diagnoses will remain confidential and will not be included in the written report.
 

5. Medical Recordkeeping

To make sure that we have as much medical information available to the participating healthcare professional as possible, our facility maintains comprehensive medical records on our employees. Director of Health Services is responsible for setting up and maintaining these records, which include the following information:

  • Name of the employee
  • A copy of the employee's Hepatitis B Vaccination status.
  • Dates of any vaccinations
  • Medical records relative to the employee's ability to receive vaccination.
  • Copies of the results of the examinations, medical testing and follow-up procedures which took place as a result of an employee's exposure to bloodborne pathogens.
  • A copy of the information provided to the consulting healthcare professional as a result of any exposure to bloodborne pathogens.

As with all information in these areas, we recognize that it is important to keep the information in these medical records confidential. We will not disclose or report this information to anyone without our employee's written consent (except as required by law).

Exposure Incident Investigation Form

Date of Incident:_________________ Time of Incident:_________________

Location: ____________________________________________________

Potentially Infectious Materials Involved:

Type: ____________________ Source:___________________

____________________ ___________________

Circumstances (work being performed, etc.):____________________________________________________

How incident was caused (accident, equipment malfunction, etc.): ____________________________________________________

Personal Protective Equipment being used: ____________________________________________________

Actions Taken (decontamination, clean-up, reporting, etc.): ____________________________________________________

Recommendations for Avoiding Repetition: ____________________________________________________

 

Post-Exposure Evaluation and Follow-Up Checklist

The following steps must be taken, and information transmitted, in the case of an employee's exposure to Bloodborne Pathogens:

Activity Completion Date

  • Employee furnished with documentation

Regarding exposure incident. _________________

  • Source individual indentified.  

(_____________________________) __________________

Source Individual

  • Source individual's blood tested and  

Results given to exposed employee. __________________

____Consent has not been able to be

obtained

  • Exposed employee's blood collected and

Tested. __________________

  • Appointment arranged for employee with  

Healthcare professional.

(___________________________) __________________

Professional's Name

  • Documentation forwarded to healthcare

Professional. __________________

____Bloodborne Pathogens Standard

____Description of exposed employee's

duties.

____Description of exposure incident, including

routes of exposure.

____Result of source individual's blood

testing.

____Employee's medical records.

Section VII: Labels and Signs

For our employees, one of the most obvious warnings of possible exposure to bloodborne pathogens is biohazard labels. Because of this, we have implemented a comprehensive biohazard warning labeling program in our facility using labels of the type shown on the following page, or when appropriate, using red "color-coded" containers. Exposure Control Committee is responsible for setting up and maintaining this program in their respected areas.

On or before July 6, 1992 the following items in our facility were labeled:

  • Containers of regulated waste.
  • Refrigerators/freezers containing blood or other potentially infectious materials. (Medical)
  • Sharps disposal containers. (Medical)
  • Other containers used to store, transport, or ship blood and other infectious materials.
  • Contaminated equipment.

On labels affixed to contaminated equipment we have also indicated which portions of the equipment are contaminated.

We recognize that biohazard signs must be posted at entrances to HIV and HBV research laboratories and production facilities. However, we do not have these types of operations in our facility, so we are not affected by these special signage requirements.

(If your facility has HIV and HBV research laboratory and production operations see the copy of the Bloodborne Pathogens Standard section (g)(1)(ii) for signage requirements.

Biohazard Labels

  • Label will appear as black on red or red on white for infectious waste (bag or hard sharps container)
  • Label will appear as black on yellow for infectious laundry (if used)

* Note: BVU does not special bag laundry. Our off- site service considers all our laundry to be infectious.


Section VIII: Information and Training

Having well informed and educated employees is extremely important when attempting to eliminate or minimize our employees' exposure to bloodborne pathogens. Because of this, all employees who have the potential for exposure to bloodborne pathogens are put through a comprehensive training program and furnished with as much information as possible on this issue.

This program was set up so that employees would receive the required training on or before June 4, 1992. Employees will be retrained at least annually to keep their knowledge current. Additionally, all new employees, as well as employees changing jobs or job functions, will be given any additional training their new position requires at the time of their new job assignment.

Human Resources is responsible for seeing that all employees who have potential exposure to bloodborne pathogens receive this training. They will be assisted by the following instructors:

  • Education Training Coordinator
  • ECC Members
  • Head Athletic Trainer
  • Science Center Stockroom Supervisor/EPA and Safety Coordinator
  • Supervisors and Vice Presidents

1. Training Topics

The topics covered in our training program include, but are not limited to, the following:

  • The Bloodborne Pathogens Standard itself.
  • The epidemiology and symptoms of bloodborne diseases.
  • The modes of transmission of bloodborne pathogens.
  • Our facility's Exposure Control Plan (and where employees can obtain a copy or view on-line).
  • Appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials.
  • A review of the use and limitations of methods that will prevent of reduce exposure, including:
  • Engineering controls.
  • Work Practice controls.
  • Personal protective equipment.
  • Selection and use of personal protective equipment including:
  • Types available.
  • Proper use.
  • Location within the facility.
  • Removal.
  • Handling.
  • Decontamination.
  • Disposal.
  • Visual warnings of biohazards within our facility including labels, signs, and "color-coded" containers.
  • Information on the Hepatitis B Vaccine, including its:
  • Efficacy.
  • Safety.
  • Method of Administration.
  • Benefits of Vaccination.
  • Our facility's free vaccination program within 90 days of hire.
  • Actions to take and persons to contact in an emergency involving blood or other potentially infectious materials.
  • The procedures to follow if an exposure incident occurs, including incident reporting.
  • Information on the post-exposure evaluation and follow-up, including medical consultation, that our facility will provide.

2. Training Methods

Our facility's training presentations make use of several training techniques including, but not limited to, those checked below:

__X__ Classroom type atmosphere with personal instruction.

__X___ Videotape programs.

__X___ Training manuals/employee handouts.

__X___ Employee Review Sessions.

__X___ Power Point Presentation

__X___ Other ___________________________________(Specify)

Because we feel that employees need an opportunity to ask questions and interact with their instructors, time is specifically allotted for these activities in each training session.

3. Recordkeeping

To facilitate the training of our employees, as well as to document the training process, we maintain training records containing the following information:

  • Date of all training sessions.
  • Contents/summary of the training sessions.
  • Names and qualifications of the instructors.
  • Names and job titles of employees attending the training sessions. 

We use an Excel spread sheet as our computer systems to facilitate this recordkeeping.

These training records are available for examination and copying to our employees and their representatives, as well as OSHA and its representatives.

Buena Vista University Exposure Control Plan

Written

1-10-92

Reviewed

Jan 02

Revised

May 02
December 02
May 03
May 04
June 04
August 05
October 05
August 06
March 07
May 07