March 25, 1992

MEMORANDUM FOR:     ASSISTANT REGIONAL ADMINISTRATORS
                   AREA DIRECTORS DISTRICT OFFICE SUPERVISORS

FROM:               WILLIAM Q. WIEHRDT ARA - T/S

SUBJECT:            SAMPLE BLOOODBORNE PATHOGENS EXPOSURE CONTROL PLAN

The attached document, which is being provided for your information, is a copy of a sample bloodborne pathogens exposure control plan developed by the Philadelphia Regional Office of Technical Support to assist employers in developing an exposure control plan as required by 29 CFR 1910.1030(c).

If you have any questions with regard to this document or with regard to the bloodborne pathogen standard please contact Mr. Arthur Gomez or Ms. Leslie Ptak of my staff at FTS 353-2220.

Attachment

Note: This sample plan is provided only as a guide to assist in complying with 29 CFR 1910.1030, OSHA's Bloodborne Pathogens standard. It is not intended to supersede the requirements detailed in the standard. Employers should review the standard for particular requirements which are applicable to their specific situation. It should be noted that this model program does not include provisions for HIV/HBV laboratories and research facilities which are addressed in section (e) of the standard. Employers operating these laboratories need to include provisions as required by the standard. Employers will need to add information relevant to their particular facility in order to develop an effective, comprehensive exposure control plan. Employers should note that the exposure control plan is expected to be reviewed at least on an annual basis and updated when necessary.

BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN

Facility Name: _________________________________

Date of Preparation: ___________________________

In accordance with the OSHA Bloodborne Pathogens standard, 29 CFR 1910.1030, the following exposure control plan has been developed:

1. Exposure Determination

OSHA requires employers to perform an exposure determination concerning which employees may incur occupational exposure to blood or other potentially infectious materials. The exposure determination is made without regard to the use of personal protective equipment (i.e. employees are considered to be exposed even if they wear personal protective equipment.) This exposure determination is required to list all job classifications in which all employees may be expected to incur such occupational exposure, regardless of frequency. At this facility the following job classifications are in this category:

In addition, OSHA requires a listing of job classifications in which some employees may have occupational exposure. Since not all the employees in these categories would be expected to incur exposure to blood or other potentially infectious materials, tasks or procedures that would cause these employees to have occupational exposure are also required to be listed in order to clearly understand which employees in these categories are considered to have occupational exposure. The job classifications and associated tasks for these categories are as follows:

Job Classification Tasks/Procedures

2. Implementation Schedule and Methodology

OSHA also requires that this plan also include a schedule and method of implementation for the various requirements of the standard. The following complies with this requirement:

Compliance Methods

Universal precautions will be observed at this facility in order to prevent contact with blood or other potentially infectious materials. All blood or other potentially infectious material will be considered infectious regardless of the perceived status of the source individual.

Engineering and work practice controls will be utilized to eliminate or minimize exposure to employees at this facility. Where occupational exposure remains after institution of these controls, personal protective equipment shall also be utilized. At this facility the following engineering controls will be utilized: (list controls, such as sharps containers, etc.)

The above controls will be examined and maintained on a regular schedule. The schedule for reviewing the effectiveness of the controls is a follows: (list schedule such as daily, once/week, etc. as well as list who has the responsibility to review the effectiveness of the individual controls, such as the supervisor for each department, etc.)

Handwashing facilities are also available to the employees who incur exposure to blood or other potentially infectious materials. OSHA requires that these facilities be readily accessible after incurring exposure. At this facility handwashing facilities are located: (list locations, such as patient rooms, procedure area, etc. If handwashing facilities are not feasible, the employer is required to provide either an antiseptic cleanser in conjunction with a clean cloth/paper towels or antiseptic towelettes. If these alternatives are used then the hands are to be washed with soap and running water as soon as feasible. Employers who must provide alternatives to readily accessible handwashing facilities should list the location, tasks, and responsibilities to ensure maintenance and accessibility of these alternatives.)

After removal of personal protective gloves, employees shall wash hands and any other potentially contaminated skin area immediately or as soon as feasible with soap and water.

If employees incur exposure to their skin or mucous membranes than those areas shall be washed or flushed with water as appropriate as soon as feasible following contact.

Needles

Contaminated needles and other contaminated sharps will not be bent, recapped, removed, sheared or purposely broken. OSHA allows an exception to this if the procedure would require that the contaminated needle be recapped or removed and no alternative is feasible and the action is required by the medical procedure. If such action is required then the recapping or removal of the needle must be done by the use of a mechanical device or a one- handed technique. At this facility recapping or removal is only permitted for the following procedures: (list the procedures and also list the mechanical device to be used or alternately if a one-handed technique will be used)

Containers for Reusable Sharps

Contaminated sharps that are reusable are to be placed immediately, or as soon as possible, after use into appropriate sharps containers. At this facility the sharps containers are puncture resistant, labeled with a biohazard label, and are leak proof. (Employers should list here where sharps containers are located as well as who has responsibility for removing sharps from containers and how often the containers will be checked to remove the sharps.)

Work Area Restrictions

In work areas where there is a reasonable likelihood of exposure to blood or other potentially infectious materials, employees are not to eat, drink, apply cosmetics or lip balm, smoke, or handle contact lenses. Food and beverages are not to be kept in refrigerators, freezers, shelves, cabinets, or on counter tops or bench tops where blood or other potentially infectious materials are present.

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

All procedures will be conducted in a manner which will minimize splashing, spraying, splattering, and generation of droplets of blood or other potentially infectious materials. Methods which will be employed at this facility to accomplish this goal are: (list methods, such as covers on centrifuges, usage of dental dams if appropriate, etc.)

Specimens

Specimens of blood or other potentially infectious materials will be placed in a container which prevents leakage during the collection, handling, processing, storage, and transport of the specimens.

The container used for this purpose will be labeled or color coded in accordance with the requirements of the OSHA standard. (Employers should note that the standard provides for an exemption for specimens from the labeling/color coding requirement of the standard provided that the facility utilizes universal precautions in the handling of all specimens and the containers are recognizable as containing specimens. This exemption applies only while the specimens remain in the facility. If the employer chooses to use this exemption then it should be stated here. _______________________________________)

Any specimens which could puncture a primary container will be placed within a secondary container which is puncture resistant. (The employer should list here how this will be carried out, e.g. which specimens, if any, could puncture a primary container, which containers can be used as secondary containers and where the secondary containers are located at the facility.)

If outside contamination of the primary container occurs, the primary container shall be placed within a secondary container which prevents leakage during the handling, processing, storage, transport, or shipping of the specimen.

Contaminated Equipment

Equipment which has become contaminated with blood or other potentially infectious materials shall be examined prior to servicing or shipping and shall be decontaminated as necessary unless the decontamination of the equipment is not feasible. (Employers should list here any equipment which it is felt can not be decontaminated prior to servicing or shipping. __________

_________________________________________)

Personal Protective Equipment

All personal protective equipment used at this facility will be provided without cost to employees. Personal protective equipment will be chosen based on the anticipated exposure to blood or other potentially infectious materials. The protective equipment will be considered appropriate only if it does not permit blood or other potentially infectious materials to pass through or reach the employees' clothing, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used.

Protective clothing will be provided to employees in the following manner: (list how the clothing will be provided to employees, e.g. who has responsibility for distribution, etc. and also list which procedures would require the protective clothing and the type of protection required, this could also be listed as an appendix to this program)

(The employer could use a checklist as follows:

Personal Protective Equipment Task

Gloves:

Lab Coat

Face Shield

Clinic jacket

              Protective eyewear
                   (with solid side shield)

Surgical Gown

Shoe Covers

Utility Gloves

Examination Gloves

Other PPE (list)

All personal protective equipment will be cleaned, laundered, and disposed of by the employer at no cost to employees. All repairs and replacements will be made by the employer at no cost to employees.

All garments which are penetrated by blood shall be removed immediately or as soon as feasible. All personal protective equipment will be removed prior to leaving the work area. The following protocol has been developed to facilitate leaving the equipment at the work area: (list where employees are expected to place the personal protective equipment upon leaving the work area, and other protocols, etc.)________________________________

Gloves shall be worn where it is reasonably anticipated that employees will have hand contact with blood, other potentially infectious materials, non-intact skin, and mucous membranes. Gloves will be available from (state location and/or person who will be responsible for distribution of gloves) ________________

Gloves will be used for the following procedures: _____________

_______________________________________

Disposable gloves used at this facility are not to be washed or decontaminated for re-use and are to be replaced as soon as practical when they become contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised. Utility gloves may be decontaminated for re-use provided that the integrity of the glove is not compromised. Utility gloves will be discarded if they are cracked, peeling, torn, punctured, or exhibit other signs of deterioration or when their ability to function as a barrier is compromised.

Masks in combination with eye protection devices, such as goggles or glasses with solid side shield, or chin length face shields, are required to be worn whenever splashes, spray, splatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can reasonable be anticipated. Situations at this facility which would require such protection are as follows:

The OSHA standard also requires appropriate protective clothing to be used, such as lab coats, gowns, aprons, clinic jackets, or similar outer garments. The following situations require that such protective clothing be utilized:

This facility will be cleaned and decontaminated according to the following schedule: (list area and schedule)

Decontamination will be accomplished by utilizing the following materials: (list the materials which will be utilized, such as bleach solutions or EPA registered germicides)

All contaminated work surfaces will be decontaminated after completion of procedures and immediately or as soon as feasible after any spill of blood or other potentially infectious materials, as well as the end of the work shift if the surface may have become contaminated since the last cleaning. (employers should add in any information concerning the usage of protective coverings, such as plastic wrap which they may be using to assist in keeping surfaces free of contamination.)

All bins, pails, cans, and similar receptacles shall be inspected and decontaminated on a regularly scheduled basis (list frequency and by whom ________________________________)

Any broken glassware which may be contaminated will not be picked up directly with the hands. The following procedures will be used:

Regulated Waste Disposal

All contaminated sharps shall be discarded as soon as feasible in sharps containers which are located in the facility. Sharps containers are located in (specify locations of sharps containers.)

Regulated waste other than sharps shall be placed in appropriate containers. Such containers are located in (specify locations of containers.)

Laundry Procedures

Laundry contaminated with blood or other potentially infectious materials will be handled as little as possible. Such laundry will be placed in appropriately marked bags at the location where it was used. Such laundry will not be sorted or rinsed in the area of use.

All employees who handle contaminated laundry will utilize personal protective equipment to prevent contact with blood or other potentially infectious materials.

Laundry at this facility will be cleaned at __________________. (Employers should note here if the laundry is being sent off site. If the laundry is being sent off site, then the laundry service accepting the laundry is to be notified, in accordance with section (d) of the standard.)

Hepatitis B Vaccine

All employees who have been identified as having exposure to blood or other potentially infectious materials will be offered the Hepatitis B vaccine, at no cost to the employee. The vaccine will be offered within 10 working days of their initial assignment to work involving the potential for occupational exposure to blood or other potentially infectious materials unless the employee has previously had the vaccine or who wishes to submit to antibody testing which shows the employee to have sufficient immunity.

Employees who decline the Hepatitis B vaccine will sign a waiver which uses the wording in Appendix A of the OSHA standard.

Employees who initially decline the vaccine but who later wish to have it may then have the vaccine provided at no cost. (Employers should list here who has responsibility for assuring that the vaccine is offered, the waivers are signed, etc. Also the employer should list who will administer the vaccine)

Post-Exposure Evaluation and Follow-up

When the employee incurs an exposure incident, it should be reported to (list who has responsibility to maintain records of exposure incidents): __________________________________________

All employees who incur an exposure incident will be offered post-exposure evaluation and follow-up in accordance with the OSHA standard.

This follow-up will include the following:

- documentation of the route of exposure and the circumstances related to the incident

- if possible, the identification of the source individual and, if possible, the status of the source individual. The blood of the source individual will be tested (after consent is obtained) for HIV/HBV infectivity.

- results of testing of the source individual will be made available to the exposed employee with the exposed employee informed about the applicable laws and regulations concerning disclosure of the identity and infectivity of the source individual. (Employers made need to modify this provision in accordance with applicable local laws on this subject. Modifications should be listed here: _____________

____________________________________________________________

____________________________________________________________

- The employee will be offered the option of having their blood collected for testing of the employees HIV/HBV serological status. The blood sample will be preserved for up to 90 days to allow the employee to decide if the blood should be tested for HIV serological status. However, if the employee decides prior to that time that testing will or will not be conducted then the appropriate action can be taken and the blood sample discarded.

- The employee will be offered post exposure prophylaxis in accordance with the current recommendations of the U.S. Public Health Services. These recommendations are currently as follows: (these recommendations may be listed as an appendix to the plan)

- The employee will be given appropriate counseling concerning precautions to take during the period after the exposure incident. The employee will also be given information on what potential illnesses to be alert for and to report any related experiences to appropriate personnel.

- The following person(s) has been designated to assure that the policy outlined here is effectively carried out as well as to maintain records related to this policy: _____________________

Interaction with Health Care Professionals

A written opinion shall be obtained from the health care professional who evaluates employees of this facility. Written opinions will be obtained in the following instances:

1) When the employee is sent to obtain the Hepatitis B vaccine.

2) Whenever the employee is sent to a health care professional following an exposure incident.

Health care professionals shall be instructed to limit their opinions to:

1) Whether the Hepatitis B vaccine is indicated and if the employee has received the vaccine, or for evaluation following an incident

2) That the employee has been informed of the results of the evaluation, and

3) That the employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials. (Note that the written opinion to the employer is not to reference any personal medical information)

Training

Training for all employees will be conducted to initial assignment to tasks where occupational exposure may occur. Training will be conducted in the following manner:

Training for employees will include the following an explanation of: 1) the OSHA standard for Bloodborne Pathogens 2) Epidemiology and symptomatology of bloodborne diseases 3) Modes of transmission of bloodborne pathogens 4) this Exposure Control Plan, i.e. points of the plan, lines of responsibility, how the plan will be implemented, etc) 5) Procedures which might cause exposure to blood or other potentially infectious materials at this facility 6) Control methods which will be used at the facility to control exposure to blood or other potentially infectious materials. 7) Personal protective equipment available at this facility and who should be contacted concerning 8) Post Exposure evaluation and follow-up 9) Signs and labels used at the facility 10) Hepatitis B vaccine program at the facility

Recordkeeping

All records required by the OSHA standard will be maintained by (insert name or department responsible for maintaining records):

__________________________________

Dates

All provisions required by the standard will be implemented by: (insert date for implementation of the provisions of the standard)

(employers should list here if training will be conducted using videotapes, written material, etc. Also the employer should indicate who is responsible for conducting the training.)

All employees will receive annual refresher training. (Note that this training is to be conducted within one year of the employee's previous training.)

The outline for the training material is located (list where the training materials are located.)