III. Exposure Control Plan [29 CFR 1910.1030 (c)]
IV. Methods of Compliance [29 CFR 1910.1030 (d)]
In order to limit occupational exposure to blood borne pathogens including,
but not restricted to, human immunodeficiency virus (HIV) and hepatitis
B virus (HBV), Occupational Health and Safety Administration (OSHA) promulgated
the blood borne pathogen standard 29 CFR 1910.1030. The Idaho Department
of Labor and Industrial Services adopted 29 CFR 1910.1030 in its entirety
(Appendix B). This policy sets forth the practices and procedures to be
followed in order to comply with 29 CFR 1910.1030. If there is a conflict
between the University of Idaho blood borne pathogen policy and OSHA 29
CFR 1910.1030, the more stringent of the two shall apply.
Affected personnel shall include any University of Idaho employee or student, who, through the course of undertaking his or her job or scholastic duties, may reasonably be expected to have skin, eye, mucous membrane or parenteral contact with human blood or other potentially infectious human materials. University of Idaho employees or students engaged in HIV or HBV research or production are covered by additional federal regulations [29 CFR 1910.1030 (e)] not discussed in this policy.
Ultimately, employees and students are responsible for complying with the Blood Borne Pathogen Policy, ensuring that hazards from potentially infectious materials are minimized through the use of safe work practices, engineering controls, appropriate personal protective equipment and prompt decontamination of spills. Supervisors are responsible for informing employees and students of the provisions of this policy, advising them of training opportunities available through Environmental Health and Safety, and supplying them with necessary personal protective equipment.
Environmental Health and Safety personnel shall oversee and manage the program, maintain records, and provide or arrange for training for all covered UI personnel. Questions regarding selection of decontamination agents, appropriate personal protective equipment, proper work methods, etc should be directed to the UI Industrial Hygienist. The UI Industrial Hygienist will investigate all possible exposure incidents.
Human Resource Services personnel shall update job descriptions to reflect the requirements of this policy and inform applicants of the provisions of this policy if the position requires possible contact with human body fluids.
Student Health Center physicians shall administer HBV vaccinations and conduct any necessary post exposure medical attention and counseling.
For the rest of this policy, both students and employees shall be collectively
referred to as employees. Job duties will comprise professional and academic
responsibilities.
III Exposure Control Plan
[29 CFR 1910.1030 (c)]
A. Exposure determination
Human Resource Services has compiled a list of job descriptions, tasks and procedures where employees may be at risk of occupational exposure to human blood or other infectious materials (Appendix C). The list shall be updated by Human Resource Services as needed or at least annually.
B. Schedule and method of implementation
As of the publication date, all sections of the University of Idaho Blood Borne Pathogen Policy will be adopted as an interim policy. On July 1, 1993 the University of Idaho Blood Borne Pathogen Policy will be adopted as a final policy.
C. Accessibility to policy
Copies of the Blood Borne Pathogen Policy will be available for employee inspection during normal University business hours at Student Health Center, Environmental Health and Safety, and Human Resource Services. Affected departments will be given a copy of the policy and are welcome to make additional copies as needed.
D. Review of policy
The policy shall be reviewed and updated at least annually and whenever
new or modified job descriptions, procedures or tasks have a reasonable
chance for occupational exposure to human blood or potentially infectious
materials. The University Industrial Hygienist, with the assistance of
Student Health Center and Human Resource Services, is responsible for reviewing
and revising the policy as necessary.
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IV Methods of Compliance [29 CFR 1910.1030 (d)]
A. Universal precautions
All employees covered by the policy shall assume that all human blood and other potentially infectious materials are infectious for HIV, HBV and other blood borne pathogens. Accordingly, personnel shall use appropriate personal protective equipment, work practices and engineering controls to eliminate or minimize exposure to blood borne pathogens.
B. Engineering and work practice controls
Engineering controls and modified work practices are the preferential methods of minimizing occupational exposure. If these are unable to eliminate the potential for occupational exposure, personal protective equipment will be used. Engineering controls would include conducting work in a biological safety cabinet. Engineering controls shall be regularly inspected and maintained in good working condition.
1. Hand washing
Employers shall make hand washing facilities readily accessible. In situations where this is not feasible, the employing department shall provide antiseptic cleaners and towels or antiseptic towelettes. If antiseptic cleaners or towelettes are used, employees shall wash their hands with soap and running water as soon as possible. Supervisors shall ensure that employees wash their hands as soon as possible after removing gloves or other personal protective devices. Supervisors shall also ensure that following contact with human blood or potentially infectious material, employees wash exposed skin with soap and water or flush mucous membranes with water as soon as feasible.
2. Needles
Contaminated needles and other contaminated sharps are prohibited from being shorn or broken. Contaminated needles and sharps may not be bent, recapped or removed except when the supervisor can demonstrate that no feasible alternative exists or that such action is required by a specific medical procedure. Needle removing or recapping must be accomplished by a mechanical device or by a one handed technique, such as pushing the needle cap on against a counter top or tray.
Contaminated sharps shall be placed in leak proof, puncture-resistant, color-coded containers as soon as possible after use.
3. Work practices
In work areas where there is a reasonable possibility of occupational exposure, eating, drinking, smoking, applying cosmetics or lip balm or handling contact lenses is prohibited. Food and drink may not be kept in refrigerators, freezers, cabinets, shelves or countertops where blood or other potentially infectious materials are present.
All procedures involving human blood or other potentially infectious materials shall be performed so as to minimize splashing, spraying, spattering or aerosoling of the materials. Human blood or other potentially infectious materials shall not be mouth pipetted/suctioned. A one valve device shall be used when performing mouth-to-mouth resuscitation.
4. Waste disposal
Human blood or other potentially infectious materials shall be placed in leak proof, puncture-resistant containers during collection, handling, processing, storage, transport or shipping. Containers shall be conveniently located in the work area and permanently marked with fluorescent orange or orange-red labels bearing the word "biohazard" and biohazard logo (Appendix D). Red bags or containers may be substituted for the labels. If a primary container becomes contaminated, it shall be placed in a secondary, leak proof, puncture-resistant, color-coded container. Containers shall be closed prior to storage, shipping or transport. Potentially infectious waste shall be decontaminated by autoclaving or incinerating prior to leaving the facility.
5. Contaminated equipment
Personnel shall decontaminate equipment prior to service or shipping.
If the supervisor can demonstrate that decontamination, either in whole
or part, is not feasible, the supervisor must affix a readily observable
label, fashioned in accordance with Appendix D, stating which parts of
the equipment may be contaminated. The supervisor must also ensure that
all people who may contact the contaminated equipment are informed of the
possible contamination so that appropriate protective measures may be taken.
C. Personal protective equipment
1. Provision
The employing department is responsible for supplying, at no cost to the employee, appropriate personal protective equipment to employees with occupational exposure. Personal protective equipment may include gloves, gowns, laboratory coats, face shields, masks, eye protection, mouthpieces, resuscitation bags or other ventilators. "Appropriate" protective equipment is that which, under normal use, does not allow blood or other potentially infectious materials to penetrate the protective equipment.
2. Use
The employee's supervisor is responsible for assuring that the employee uses appropriate personal protective equipment. Under very rare and unusual circumstances the employee may temporarily and briefly forego wearing personal protective equipment when, in the employee's professional opinion, wearing the personal protective equipment would prevent the delivery of necessary health care or public safety service or that using the personal protective equipment would increase the risk to either the employee or a co-worker. In making the decision to forgo personal protective equipment, either temporarily or briefly, the employee accepts the increased risk of exposure to blood borne pathogens including, but not limited to, HIV and HBV. Following such a situation, the employee, supervisor and EHS staff will investigate the circumstances and attempt to prevent it from re-occuring.
3. Accessibility
Supervisors shall ensure that appropriate personal protective equipment, in the correct size and type, is readily available to employees at all times, whether by locating stocks of protective equipment throughout the job site or by issuing supplies to each employee. For employees who cannot wear gloves normally provided, the supervisor shall make available hypo-allergenic gloves or other alternatives.
4. Cleaning, disposal, repair and replacement
The employing department shall pay for cleaning, laundering, disposal, repair and replacement of personal protective equipment at no cost to the employee. The employee shall remove all personal protective equipment as soon as it becomes contaminated or when leaving the work area, whichever comes first, and dispose in a designated labelled area or container.
5. Gloves
Gloves shall be worn when it can reasonably be expected that the employee may have hand contact with human blood or other potentially infectious materials, when performing vascular access procedures, or when touching or handling contaminated surfaces or objects. As an exception, personnel working at a voluntary blood donation center may elect to forgo gloving for routine phlebotomy. However under these circumstances the supervisor shall periodically re-evaluate this policy, make gloves available to those who wish to use them, and not discourage the use of gloves. Gloves shall be worn for phlebotomy when the employee has cuts, scratches or breaks in his or her skin, the donor is uncooperative or when the employee is being trained in phlebotomy.
All gloves shall be replaced and disposed as soon as their integrity is compromised. Gloves shall also be replaced as soon as possible when they become contaminated.
Disposable gloves (surgical, polyvinyl or latex gloves) are not to be re-used or decontaminated. Utility gloves may be decontaminated as long as they can function as an effective barrier.
6. Other protective clothing
Masks, eye protection, face protection, gowns, aprons, lab coats, caps or shoe covers shall be worn during procedures where there is a reasonable chance of spattering, spraying or splashing human blood or other potentially infectious materials. The type and characteristics will depend upon the task and degree of exposure expected. For example, masks and eye protection would be required when there is a chance of spraying possibly infectious materials. Gowns and/or aprons would be necessary when gross contamination is expected, such as during autopsy. If workers are unsure what level of protection may be needed, they should contact Environmental Health and Safety for more information.
D. Housekeeping
1. General
Supervisors shall ensure that the work area is kept clean and sanitary. Appendix E contains guidelines for decontaminating equipment and work areas.
2. Cleaning
All equipment and surfaces shall be cleaned and decontaminated immediately or as soon as feasible after completion of a procedure, contact with human blood or other potentially infectious materials, and at the end of the work shift if contamination may have occurred since the last cleaning.
Protective coverings (plastic wrap, aluminum foil, plastic backed absorbent paper, etc) on equipment and work surfaces shall be removed and disposed as soon as feasible after contamination and at the end of the work shift if they may have been contaminated since the last change.
All bins, pails, cans, etc. which are designated for reuse and which may become contaminated with human blood or other potentially infectious materials shall be cleaned and decontaminated after each use or as soon as feasible upon signs of obvious contamination.
Contaminated broken glassware or reusable sharps may not be picked up by hand. Mechanical devices such as tongs, forceps or dust pan and brush must be used. Re-usable equipment used to clean up contaminated debris shall also be cleaned and decontaminated after each use or as soon as feasible.
3. Medical waste
Contaminated sharps shall be discarded immediately or as soon as feasible into containers that are closeable, puncture resistant, leak proof on sides and bottom, and labelled according to Appendix D. Other medical waste shall be disposed of in containers that are closeable, leak proof, and labelled according to Appendix D. Potentially infectious waste shall be decontaminated by autoclaving, incinerating or other acceptable method prior to leaving the facility.
During use, disposal containers shall be accessible, upright, located in the work area and where needed; they shall not be allowed to overfill. Disposal containers shall be closed prior to moving. They shall also be placed in a secondary container if leakage from the original container is possible. The secondary container shall be closeable, able to contain all contents and labelled according to Appendix D.
Reusable containers shall not be opened, emptied or cleaned manually in any manner that would risk injury to any employee.
4. Laundry
Contaminated laundry shall be handled as little as possible with a minimum of agitation. Contaminated laundry shall be placed in appropriately labelled (see appendix D) bags or containers where it was used; do not sort or rinse. If contaminated laundry is wet, the container shall also be leak-proof in addition to the above requirements.
All employees who may contact contaminated laundry must wear gloves and other personal protective equipment.