University of Arkansas at Little Rock
Policy Name: Bloodborne Pathogens Exposure Control Plan
Policy Number: LR 701.4
Effective Date: January 1, 2006
Most Recent Review Date:
In accordance with the OSHA Bloodborne Pathogens Standard, 1910.1030, the following exposure control plan has been developed.
The Bloodborne Pathogens Exposure Program is to reduce occupational exposure to bloodborne pathogens or known infected blood or other potentially infectious materials (OPIM), including animal tissue infected for research.
Designated employees that may come into contact with human blood or other OPIM:
- First aid responders in all departments.
- Faculty, staff, and researchers working with or reasonably anticipated to have exposure to blood or OPIM as determined by the EH&S Office.
- Department of Public Safety
- Others as may be identified by a job hazard analysis.**(see Appendix A)
Methods of Compliance
Universal precautions will be utilized in the handling of all human blood and OPIMs.
Engineering Controls/Administrated Controls
- Hand sinks are located in all departments and are readily accessible to all employees who have the potential for exposure.
- Employees will wash their hands and any other exposed skin with soap and hot water immediately or as soon as possible after contact with blood or OPIM, for 15 seconds, in a manner causing friction on both the inner and outer surfaces of the hands.
- Employees will be provided with antiseptic hand cleaner and paper towels when hand washing is not feasible. However, hand washing must still take place as soon as possible after exposure.
- Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses is prohibited in work areas where there is the potential for exposure to bloodborne pathogens.
- If professional medical attention is required, a local ambulance will be the first choice; a personal car will be the second. If a personal car is taken, impervious material should be used to prevent contamination of the vehicle.
- New employees or employees being transferred to other sections will receive training about any potential exposure from the section manager.
Personal Protective Equipment (PPE)
All personal protective equipment used at this facility will be provided without cost to employees by the employees’ department. Personal protective equipment will be chosen based on the anticipated exposure to blood or OPIM. The protective equipment will be considered appropriate only if it does not permit blood or OPIM to pass through or reach the employees’ clothing, skin, eyes, mouth, or other mucous membranes under normal conditions of use. If any employee brings or purchases their own PPE it must be approved by the Environmental Health & Safety Office (EH&SO).
Disposal of Contaminated Items and Communication of Hazard
- Employees must:
- Use bleach or approved Environmental Protection Agency (EPA) listed disinfectant to disinfect any blood or OPIM.
- Apply the bleach or approved EPA listed disinfectant with single-use gloves and allow to sit for 15 minutes.
- Place any single-use gloves that have been contaminated in a biohazard garbage bag and cover.
- Dispose of the bag and contact the EH&SO if there are any questions about disposal.
- Regulated waste should be placed in appropriate containers, labeled and disposed of in accordance with applicable state, federal, and local laws.
- Employees will be warned of biohazard bags by labels attached to the disposal bags. Labels used will be orange-red and marked with the word BIOHAZARD or the biohazard symbol.
Maintaining our work areas in a clean and sanitary condition is an important part of the UA Little Rock Bloodborne Pathogens Compliance Program. Employees must decontaminate working surfaces and equipment with an appropriate disinfectant after completing procedures involving blood or OPIM.
All equipment, environmental surfaces, and work surfaces shall be decontaminated immediately or as soon as feasible after contamination.
- Employees must clean and disinfect when surfaces become contaminated and after any spill of blood or OPIM.
- Employees will use a solution of one part bleach to ten parts water for cleaning and disinfecting.
- Working surfaces and equipment will be routinely cleaned, disinfected, and maintained.
- Potentially contaminated broken glass will be picked up using mechanical means, such as dustpan and brush, tongs, etc.
- UALR uses universal precautions for handling of all soiled laundry.
- Laundry contaminated with blood or OPIM will be handled as little as possible. Employees who handle contaminated laundry will utilize personal protective equipment to prevent contact with blood or OPIM from coming into contact with skin or street clothes.
- Contaminated clothing will remain on the premises, or will be sent directly to a laundry facility for cleaning. Employees will be given the option of reimbursement for the cost of cleaning or replacing contaminated clothing, in some case the clothing will be disposed as Biohazard waste.
Hepatitis B Vaccination and Post-Exposure Evaluation and Follow-up
UALR shall make available within 10 days of possible exposure the Hepatitis B vaccine and vaccination series to all employees who have occupational exposure.
An exposure incident is any contact of blood or OPIMs with non-intact (broken) skin or mucous membranes. Any employee having an exposure incident shall contact the EH&SO (501-916-6351). All employees who have an exposure incident will be offered a confidential post-exposure evaluation and follow-up in accordance with the OSHA standard. This includes a visit to a physician selected by the employer. The healthcare professional written opinion will be provided to the employee within 15 days of the evaluation.
Training is provided at the time of initial assignment to tasks where occupational exposure may occur and shall be repeated within twelve months of the initial training. Training shall be tailored to the education and language level of the employee and offered during the normal work shift. The person conducting the training shall be knowledgeable in the subject matter pertaining to Bloodborne Pathogens (BBP). The training will be interactive and cover the following:
- A copy of the standard and an explanation of its contents.
- A discussion of the epidemiology and symptoms of bloodborne diseases.
- An explanation of the modes of transmission of bloodborne pathogens.
- An explanation of the UALR Bloodborne Pathogen Exposure Control Plan (this program) and a method for obtaining a copy.
- The recognition of tasks that may involve exposure.
- An explanation of the use and limitations of methods to reduce exposure, for example engineering controls, work practices and personal protective equipment.
- Information on the types, use, location, removal, handling, decontamination, and disposal of PPE.
- An explanation of the basis of selections of PPE.
- Information on the Hepatitis B vaccination (including efficacy, safety, method of administration, benefits) and the training will be offered free of charge.
- Information on the appropriate actions to take and persons to contact in an emergency involving blood or OPIM.
- An explanation of the procedures to follow if an exposure incident occurs, including the method of reporting and medical follow-up.
- Information on the evaluation and follow-up required after an employee exposure incident.
- An explanation of the signs, labels, and color-coding systems.
Medical records shall be maintained in accordance with OSHA standards. These records shall be kept confidential and must be maintained for at least the duration of employment plus 30 years.
Infection Control Plan/Universal Precautions/General Procedures
The purpose of the Infection Control Plan is to protect the health and safety of the persons directly involved in handling the materials, facility personnel and the general public by ensuring the safe handling, storage, use, processing, and disposal of infectious medical waste. This plan complies with OSHA requirement proposed for 29 CFR 1910.1030, Bloodborne Pathogens.
Universal precautions refers to a system of infectious disease control that assumes every direct contact with body fluids is infectious and requires every employee exposed to be protected as though such body fluids were infected with blood-borne pathogens. All infectious/medical material must be handled according to Universal Precautions (OSHA Instruction CPL 2-2.44A).
The following procedures must be followed by personnel when in medical rooms or laboratories:
- All supervisors must ensure that their staff is trained in proper work practices, the concept of universal precautions, the use of PPE, and in proper cleanup and disposal techniques. Resuscitation equipment, pocket masks, resuscitation bags, or other ventilation equipment must be provided to eliminate the need for direct mouth-to-mouth contact in all trained first responders groups where resuscitation is a part of their responsibilities.
- Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a potential for exposure to any health hazard. Food and drink must not be stored in refrigerators, freezers, or cabinets where blood or other potentially infectious material is stored or in other areas of possible contamination.
- According to the level of risk, wearing laboratory or protective clothing may be required for persons entering infectious disease laboratories. Likewise, showers with a germicidal soap may be required before exiting.
- Gowns, aprons, or lab coats must be worn whenever there is a possibility that body fluids could splash on skin or clothing. Gloves must be made of appropriate disposable material, usually intact latex or vinyl. They must be used in the following circumstances:
- When the employee has cuts, abraded skin, chapped hands, dermatitis, or similar conditions.
- When examining abraded or non-intact skin of a patient with active bleeding.
- While handling blood or blood products or other body secretions during routine laboratory procedures.
- Employees must wash their hands immediately, or as soon as possible, after removal of gloves or other personal protective equipment and after hand contact with blood or other potentially infectious materials. All personal protective equipment must be removed immediately upon leaving the work area, and if this equipment is overtly contaminated, it must be placed in an appropriate area or container for storage, washing, decontamination, or disposal. Contaminated clothing must not be worn in clean areas or outside the building. All procedures involving blood or other potentially infectious agents must be performed in a manner that will minimize splashing, spraying, and aerosolization.
- Medical/infectious waste must be segregated from other waste at the point of origin. Medical/infectious waste, except for sharps (i.e., razor blades, broken glass, needles, etc.) capable of puncturing or cutting, must be contained in double disposable red bags conspicuously labeled with the words “INFECTIOUS WASTE” and “BIOHAZARD.”
- Infectious sharps must be contained for disposal in leak-proof, rigid puncture-resistant containers. Infectious waste contained as described above must be placed in reusable or disposable leak-proof bins or barrels that are conspicuously labeled with the words “INFECTIOUS WASTE” and “BIOHAZARD.” These waste barrels are picked up regularly by an outside company licensed to handle infectious wastes.
- Used needles or other sharps (razor blades, broken glass, scalpels, etc.) must not be sheared, bent, broken, recapped, or re-sheathed.
- All infectious agents, equipment, or apparatus must be disinfected in an autoclave or otherwise disinfected before being washed or disposed of. Each individual working with infectious bio-hazardous agents is responsible for disinfection and disposal of these agents.
- Biological wastes that do not contain radioactive or hazardous substances may be disinfected by steam sterilization (autoclave) then disposed of in the regular trash.
- Liquid bio-hazardous waste may be disposed of in the sewage system following chemical decontamination.
- Reusable glassware must be decontaminated in sodium hypochlorite (household bleach) solution (1:9) prior to rinsing and acid washing. The glassware must then be sterilized in an autoclave.
- To minimize the hazard to firefighters or emergency response personnel, at the close of each work day and before the building is closed, all infectious or toxic material must not be placed in an autoclave and left overnight in anticipation of autoclaving the next day.
- Floors, laboratory benches, and other surfaces in buildings where infectious agents are handled must be disinfected with a suitable germicide, such as 1:9 sodium hypochlorite solution (household bleach) as often as necessary as determined by the supervisor.
- The surroundings must be disinfected after completion of operations involving planting, pipetting, centrifuging, and similar procedures with infectious agents.
- Infectious agents must not be dumped into the building drainage system without prior disinfection.
If employees has a needle stick, cut, or mucous membrane exposure to another person’s body fluids they must report the incident immediately to their supervisor, professor, or department chair.
All employees exposed to human blood and blood products must report to the EH&S Office for information and possible inclusion in the Hepatitis B Immunization Program.
Source: Environmental Health and Safety
Approved By: Environmental Health and Safety Committee, Jan. 1, 2006
Custodian: EHS Committee