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UVM Environmental Safety FacilityUVM Exposure Control Plan for Bloodborne Pathogens |
Table of Contents |
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| 1. Policy | 6. Hepatitis B Vaccination | Appendix A: Procedures for Accidents and Exposures to Chemicals, Blood or Biohazardous Material |
| 2. Program Administration and Responsibilities | 7. Post-Exposure Evaluation and Follow-Up | Appendix B: Description of OSHA Standard |
| 3. Determination of Employee Exposure | 8. Administration Of Post-Exposure Evaluation and Follow-Up | Appendix C: Definitions |
| 4. Methods of Implementation and Control:
A. Standard Precautions B. Exposure Control Plan C. Engineering and Work Control Practices D. Personal Protective Equipment E. Regulated Waste Disposal F. Handwashing Facilities G. Needles and Other Sharps H. Work Area Restrictions I. Specimen Handling and Transport J. Contaminated Equipment K. Housekeeping L. Laundry M. Labels |
9. Procedures for Evaluating the Circumstances Surrounding an Exposure Incident 10. Recordkeeping: |
Appendix D: Appendix E: Biosafety Precautions by Level Appendix F: Appendix G: Appendix H: |
| 5. Employee Training | Appendix I: |
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The ECP is a key document to assist UVM in implementing and ensuring compliance with the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard, thereby protecting our employees. All employees are expected to adhere to guidelines established in this document. Questions should be addressed to the supervisor, the department, or the Department of Risk Management (656-3242).
A. The Risk Management Department is responsible for the implementation of the ECP. Risk Management staff will maintain, review, and update the ECP and the Sharps Injury Log at least annually, and whenever necessary to maintain current information including new or modified tasks and procedures.
The Risk Management Department will be responsible for ensuring that all medical actions required are performed, that appropriate employee health and OSHA records are maintained, and making the written ECP available to employees, OSHA, and NIOSH representatives.
The Risk Management Department will periodically follow-up with departments regarding suggestions for safer sharps made by non-managerial employees and submitted to the departments and/or Risk Management.
You may contact the Risk Management Department, 109 S. Prospect St., 656-3242 or the Environmental Safety Facility (ESF), 667 Spear St., 656-5400 with any questions about this plan.
B. The Center for Health and Wellbeing is responsible for administering the vaccination series and titer to UVM employees who present a completed Risk Designation form from their supervisor and for sending notification through campus mail to the supervisor following the first shot and the titer. This notification constitutes adequate documentation for receipt of the first shot and titer. CHWB staff will also furnish documentation of receipt of the shots or titers to supervisors when a request is made for that information.
C. Supervisors or Departments (as per Department Policy) are responsible for the following:
Contact your supervisor, your department, or the Risk Management Department with questions about supervisors' responsibilities, to schedule background training which meets the OSHA requirements and to obtain a written copy of the ECP. The ECP can also be accessed on the web at http://esf.uvm.edu/uvmecp/index.html.
D. Employees who are determined to be "at risk" for occupational exposure to blood or OPIM (see Determination of Employee Exposure, below) must comply with the Methods of Implementation and Control, and Employee Training outlined in this ECP. Risk designation, the offer of the Hepatitis B vaccination and initial training must happen within 10 days of assignment to an "at risk" position. If consent was given for receipt of the Hepatitis B vaccination series the appointment for the fist shot should also be within that 10 day window. Employees may contact the responsible party above (Risk Management Department, Center for Health and Wellbeing, Supervisor or Department) with questions.
OSHA requires employers to perform an exposure determination concerning which employees may incur occupational exposure to blood or other potentially infectious materials (OPIM). UVM has designated the "supervisor" as the person who has the responsibility to make this determination according to the following guidelines. Please contact the ESF staff at 656-5400 if you have any questions about this process.
The "at risk" determination is made solely on the activities for which an employee receives a paycheck from UVM and is made without regard to the use of personal protective equipment (PPE) (i.e. for the purpose of "exposure determination" assume that PPE is not worn.) Employees include all faculty and staff in full, part time, temporary, contract or per diem positions. OSHA excludes Good Samaritan acts from this determination.
The "at risk" determination for exposure to bloodborne pathogens is based on the expected level of risk , as determined by the supervisor, inherent in assigned work duties:
1. Moderate to High Risk: Those employees who work directly with human blood or OPIM. These employees are designated as "at risk" and fall under the jurisdiction of the OSHA Bloodborne Pathogens Standard. According to the Standard and UVM policy this requires use of Standard Precautions, initial and annual training, and being offered the Hepatitis B vaccination series and titer. Initial training and the offer of the Hepatitis B vaccine must occur within 10 days of employment or assignment to a position in which they are considered to be "at risk". If consent is given for the vaccination series then the first shot must be scheduled within that 10 day window.
2. Low Risk: Those employees who may encounter blood or OPIM in the course of their work and all of the following situations exist:
3. No Risk: Those employees who are not reasonably expected to encounter human blood or OPIM in the course of their assigned duties and if they might inadvertently encounter such a situation there is no expectation that the employee clean it up or handle it in any way. There is no requirement for bloodborne pathogens safety training in this category.
Standard Precautions is the recommended work practice for protection from infection with a bloodborne pathogen or other biological agent in the workplace. This is the work practice of treating all human and primate blood and body fluids (with the exception of sweat) as if they are infectious and avoiding all direct contact with this material.
Employees covered by the Bloodborne Pathogens Standard receive an explanation of the ECP during their initial training session. It will also be reviewed in their annual refresher training. All employees have an opportunity to review this plan at any time during their work shifts by contacting the Environmental Safety Facility or accessing it on a computer at http://esf.uvm.edu/uvm free of charge and within 15 days of the request (656-5400).
The Risk Management Department is responsible for reviewing and updating the ECP annually or more frequently if necessary to reflect any new or modified tasks and procedures which affect occupational exposure.
Engineering controls and work practice controls will be used to prevent or minimize exposure to bloodborne pathogens. The specific engineering and work practice controls to be used are identified by the supervisor. When occupational exposure remains after institution of these controls, personal protective equipment (PPE) will also be used.
Examples of engineering controls are safer sharps devices, sharps disposal containers, biological safety cabinets, clean benches, laminar flow hoods, enclosed containers, mechanical pipetting devices, secondary leaf-proof containers for transport of material in biohazard bags for autoclaving, broken glass containers (cardboard) with leakproof liners, and splash shields.
See Appendix E: Biosafety Levels/Standard Microbiological Practices and Appendix F: Biohazardous Materials Spill Cleanup Procedures.
Sharps disposal containers are inspected on a regular basis, maintained, and replaced (whenever necessary to prevent overfilling) by the supervisor or department.
UVM identifies the need for changes in engineering controls and work practices through the supervisor. Supervisors and non-managerial employees evaluate new procedures or new products. Front line workers are involved in this process by use of the Questionnaires for evaluating sharps found in Appendix I. Return a copy to your department, the ESF (667 Spear St.) and to your supervisor.
Your department will ensure effective implementation of these recommendations.
PPE selection, purchase and maintenance are the responsibility of each department. PPE will be chosen based on the anticipated exposure to blood or other biological material. The protective equipment will be considered appropriate only if it does not permit blood or other biological material 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.
All PPE will be cleaned, laundered and disposed of through procedures established by the individual department at no cost to employees. All repairs and replacements will be made by the department at no cost to employees. Departments using outside contractors for laundry services must supply appropriately labeled bags for delivery or pickup of soiled laundry.
Training is provided by the supervisor or department in the use of the appropriate PPE for the tasks or procedures employees will perform.
Gloves will be worn where it is reasonably anticipated that employees will have hand contact with blood, other biological material, non-intact skin, or mucous membranes.
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 biological material may be generated and eye, nose, or mouth contamination can reasonably be anticipated.
Lab coats, gowns, aprons, clinic jackets or similar outer garments will be worn when it is reasonably anticipated that clothing may become contaminated with blood or other biological material.
Affected laboratories and all other affected areas on campus will be decontaminated
utilizing approved cleaning agents and according to the schedules developed
by departments. 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 biological material, as well as the end of the work shift
if the surface may have become contaminated since the last cleaning.
Each laboratory should have a "spill kit" consisting of gloves, dustpan,
spray disinfectant bottle containing a 10% bleach solution (made fresh at least
weekly), and a plastic/metal scoop for moving material onto the dust pan. See
Housekeeping.
PPE is located in your department and may be obtained through your supervisor.
All employees using PPE must observe the following precautions:
The procedure for handling used PPE is determined by the supervisor or department.
This policy is established to assure the safe disposal of the University's infectious waste. The key requirement with regard to infectious waste is that the waste be identified as such, that it be properly decontaminated, and segregated from the normal solid waste stream. This policy governs all University activities which involve any of the types of biological waste listed below:
Biological waste as defined above must be single-bagged into 3 ml polyethylene bags. Free draining blood and blood products and biotechnology effluents shall be stored in securely sealed leak-proof containers. All of these containers must have a biohazard symbol affixed to the bag or container.
In addition, a piece of autoclave tape must be affixed to the biohazard symbol on the bag or the neck of the bag. This is to act as a quick visual identifier of which waste has been autoclaved and which has not.
All biological waste must be segregated from regular trash and deposited in the specially designated biological waste containers labeled Decontaminated Biological Waste Only, located outside the Given medical complex loading dock, the Health Science Research Facility (HSRF) loading dock, Marsh Life Science loading dock, Carrigan or Colchester Research Facility. The dumpsters will be locked with access to the keys from the loading dock in Given and from the labs containing autoclaves in other buildings. A waste log entry must be made at the time of acquiring the key. Waste logs will be collected by Risk Management and centrally filed, after each biological waste disposal pickup.
Sharps must be segregated from other wastes and disposed of in leak-proof, rigid, puncture resistant, shatterproof containers. Sharps must be rendered non-infectious by autoclaving, chemical disinfection, or incineration if they are contaminated with infectious materials. All sharps must be disposed of in the Biological Waste Dumpsters.
When transferring such items to a steam sterilizer or incinerator, enclose specimen in a second container such as a sealed bag. All biological wastes governed by this policy must be transported from the generating laboratory to either the incinerator or the steam sterilizing unit by a member of the laboratory or a designated trained person from the generating department. Only animal carcasses and their packaging may be burned in the Given and Hills' crematory (when operational). University custodial personnel shall not be required to transport biological wastes from laboratories to the incinerator or steam sterilizers. When transporting biological waste in common areas, the lab personnel must ensure that the biohazard bag is in good condition (no rips or tears) and that it is sealed. Also, they must only hand-carry one bag at a time. If it is necessary to transport more than one bag at a time, a cart with at least one-inch raised, protected sides should be used.
The principal investigator shall determine the appropriate autoclave treatment conditions for each of the types of biological waste generated by her/his laboratory. Treatment conditions to achieve sterility will vary in relation to the volume of material treated, its contamination level, the moisture content, and other factors.
The following are general steam sterilization recommendations:
Monthly Testing: Autoclaves should be evaluated at least monthly using an indicator organism with a defined heat susceptibility pattern. It is recommended that commercially available vials containing Bacillus stearothermophilus spores be used to verify autoclave operations as they have a well defined heat susceptibility pattern. Risk Management's Environmental Safety Facility will provide these vials free of charge to all departments that request them (call 656 -5400).
Autoclave Certification: In addition to the monthly biological monitoring, it is recommended that an annual certification of the autoclave mechanical and monitoring systems be made. If the autoclave passes this inspection, a certification sticker should be attached to the autoclave. An autoclave is not permitted to be operated without a current certification sticker. The lab may make arrangements with the manufacturer to do this certification.
A log must be kept for all autoclaves used to process biological waste. A copy of the log must be sent to the Department of Risk Management monthly. The log must include the following information:
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. All handwashing facilities are maintained by the custodial staff of the University.
If handwashing facilities are not feasible, the supervisor 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. Supervisors, 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 then those areas shall be washed with soap and water for several minutes. If exposure occurs to the mucous membranes the area should be flushed immediately with running water as soon as feasible following contact. Seek medical attention in the case of an exposure incident.
Sharps are any items which can penetrate the skin including, but not limited to, needles, scalpels, Pasteur pipets, pointed or edged plastic, instruments, and broken glass.
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.
Contaminated sharps that are reusable are to be placed immediately, or as soon as possible, after use into appropriate sharps containers. The sharps containers should be puncture resistant, labeled with a biohazard label, and leak proof.
Sharps containers are placed in all laboratories deemed appropriate by the supervisor. A supervisor's designee in each laboratory is responsible for checking the integrity of these containers and for disposing of them as needed in the biohazardous waste stream.
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, on counter tops or bench tops, or in the same work area where blood or other potentially infectious materials are present.
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 to accomplish this goal are determined by each supervisor. Mouth pipetting/suctioning of blood or other potentially infectious materials is prohibited.
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 space. The container used for this purpose will be labeled or color coded in accordance with the requirements of the OSHA standard.
Any specimens which could puncture a primary container will be placed within a secondary container which is puncture resistant. 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.
Equipment which has become contaminated with blood or other potentially infectious materials shall be decontaminated as soon as possible following contamination. In addition this equipment shall be examined prior to servicing or shipping and shall be decontaminated as necessary unless the decontamination of the equipment is not feasible. If decontamination is not feasible then the equipment must be labeled as contaminated using, as a minimum, the universal symbol for biohazardous material. Decontamination may be done with a disinfectant such as sodium hypochlorite solution (1 part household bleach mixed with 9 parts water, made fresh weekly).
Regulated waste is placed in containers which are closable, constructed to contain all contents and prevent leakage, appropriately labeled or color-coded, and closed prior to removal to prevent spillage or protrusion of contents during handling.
The procedure for handling sharps disposal containers is to close and dispose of them when they are full. Do not empty the container and do not force or compact the contents in any way as this may cause the container to be punctured. UVM sharps containers are disposed of by incineration. They may be included in a "burn box" or call the ESF (656-5400) to arrange pick-up of the sharps container.
Contaminated sharps are discarded immediately or as soon as possible in containers that are closable, puncture-resistant, leakproof on sides and bottoms, and labeled or color-coded appropriately. Sharps disposal containers are available at your work area or department and may be ordered through the UVM ChemSource program (656-5400) or through commercial distributors.
Bins and pails (e.g., wash or emesis basins) are cleaned and decontaminated as soon as feasible after visible contamination.
Broken glassware which may be contaminated is picked up using mechanical means, such as a brush and dust pan.
See Appendix G: Biowaste Disposal
Supervisors have the responsibility to arrange for laundering of towels from athletic facilities and laboratory PPE (labcoats).
The following laundering requirements must be met:
The following labeling method is used at UVM:
Biohazardous material needs to be labeled with an appropriately sized (for visibility) biohazard warning symbol (and the word "biohazard" if space allows) in the red or orange red color scheme. In the workplace if such material is in common use, each container need not be labeled; however, if the material leaves the workplace it must have appropriate labeling. Biowaste will be contained in red biohazard bags or clear bags marked with the red biohazard symbol.
Supervisors will ensure warning labels are affixed or red bags are used as required if regulated waste, contaminated equipment or samples are removed from or brought into the facility. Employees are to notify the supervisor if they discover regulated waste containers, refrigerators containing blood or OPIM, contaminated equipment, etc. without proper labels.
See Appendix G: Biowaste Disposal
All employees who have occupational exposure to bloodborne pathogens receive initial training and annual refresher training conducted by the supervisor. General background training can be found at the Environmental Safety Facility web site at http://esf.uvm.edu/courses. Training specific to the laboratory must still be done by the lab supervisor
All employees who have occupational exposure to bloodborne pathogens receive training on the epidemiology, symptoms, and transmission of bloodborne pathogen diseases. In addition, the training program covers, at a minimum, the following elements:
Training materials for ESF trainings are available at the Environmental Safety Facility, 667 Spear Street, Burlington, VT 05405, phone 656-5400 and specific relevant material given by the supervisor is available from her or him in the workplace.
Supervisors will provide training to employees on hepatitis B vaccinations, addressing the safety, benefits, efficacy, methods of administration, and availability. This may be delegated to the ESF (656-5400). See http://esf.uvm.edu for training dates. ESF BBP safety training can also be scheduled and customized for your group.
The hepatitis B vaccination series is available at no cost after training and within 10 days of initial assignment to employees identified as "at risk" in the Determination of Employee Exposure section of this plan. Vaccination is encouraged unless: 1)the employee has previously received the series, 2) antibody testing reveals that the employee is immune, or 3) medical evaluation shows that vaccination is contraindicated.
If an employee chooses to decline vaccination, the employee must sign a declination form. (Appendix H of this ECP) Employees who decline may request and obtain the vaccination at a later date at no cost or penalty. Documentation of refusal of the vaccination is kept in the workplace by the supervisor and at the Environmental Safety Facility, 667 Spear Street, Burlington, VT 05405, phone 656-5400.
Vaccination will be provided by the UVM Center for Health & Wellbeing, DeGoesbriand Building, 425 Pearl Street, Burlington, VT 05405, 656-3350 or 656-0847. A copy of the Risk Designation Form taken to the first appointment will assure the employee of receiving the vaccine at no charge.
Following hepatitis B vaccinations, the health care professional's Written Opinion will be limited to whether the employee requires the hepatitis vaccine, and whether the vaccine was administered.
FOR EMERGENCIES see Appendix A "Procedures for Accidents and Exposures to Chemicals, Blood or Biohazardous Material". A confidential medical evaluation and follow-up will be conducted by Concentra Health Care, 110 Kimball South Burlington, VT (802) 658-5756.
Following the initial first aid (clean the wound, flush eyes or other mucous membrane, etc.), the following activities will be performed:
The Risk Management Department ensures that health care professional(s) responsible for employee's Hepatitis B vaccination and post-exposure evaluation and follow-up are given a copy of the OSHA Bloodborne Pathogens Standard.
The Risk Management Department ensures that the health care professional evaluating an employee after an exposure incident receives the following:
The Risk Management Department provides the employee with a copy of the evaluating health care professional's written opinion within 15 days after completion of the evaluation.
The Risk Management Department will review the circumstances of all exposure incidents to determine:
Training records are completed for each employee upon completion of training. These documents will be kept for an employee, for at least three years past that person's termination of employment, at the Environmental Safety Facility (656-5400) and in the workplace by the supervisor or department.
The training records include:
Employee training records are provided upon request to the employee or the employee's authorized representative within 15 working days. Such requests should be addressed to the Environmental Safety Facility (667 Spear St./656-5400) or to the supervisor or department.
When an employee is designated as "at risk" it is imperative that the appropriate paperwork be kept on file in the workplace and accessible to ESF staff and OSHA inspectors:
1. Infectious Materials Risk Designation Form (send copy to ESF, 667 Spear Street)
2. Hepatitis B Vaccination Consent/Dissent Form (send top two copies to ESF)
3. Training Documentation for both supervisor's training and ESF training
4. Medical records indicating receipt of all three shots for those who consented to have the series.
5. Medical records indicating receipt of the titer if the person consented to have the vaccination series during or after 1999.
Medical records are maintained for each employee with occupational exposure in accordance with 29 CFR 1910.1020, "Access to Employee Exposure and Medical Records." (http://www.osha-slc.gov/OshStd_data/1910_1020.html)
The Risk Management Department is responsible for maintenance of the required medical records. These confidential records are kept at 109 S. Prospect Street for at least the duration of employment plus 30 years.
Employee medical records are provided upon request of the employee or to anyone having written consent of the employee within 15 working days. Such requests should be sent to the Risk Management Department, 109 S. Prospect,Burlington, VT 05405.
An exposure incident is evaluated to determine if the case meets OSHA's Recordkeeping Requirements, 29 CFR 1904, (http://www.osha.gov/FedReg_osha_data/FED19960202.html). This determination and the recording activities are done by the Risk Management Department (656-3242).
In addition to the 1904 Recordkeeping Requirements, all percutaneous injuries from contaminated sharps are also recorded in the Sharps Injury Log, maintained by the Risk Management Department (656-5400). All incidents must include at least:
This log is reviewed at least annually as part of the annual evaluation of the program and is maintained for at least five years following the end of the calendar year that is covered. If a copy is requested by anyone, it must have any personal identifiers removed from the report.
If you have any questions about this Exposure Control Plan, the OSHA Bloodborne Pathogens Standard or their applicability to you or your workplace please contact one of the following: |
From the UVM ESF web site |
HTML by Ralph Stuart |
Version 6.0 Last Revised: May 3, 2006 |
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