Policy No.

*SF-1373.6

POLICY & PROCEDURES MEMORANDUM

TITLE:

BLOODBORNE

PATHOGENS: EXPOSURE

CONTROL PLAN (ECP)

EFFECTIVE DATE:

November 25, 2002

(Title Updates 5/7/05)

CANCELLATION:

none

OFFICE:

Safety (SF)*

*Initially Distributed as AD-1373.6

POLICY STATEMENT

Delgado Community College is committed to providing a safe and healthy work

environment for our entire staff. In pursuit of this endeavor, the following Exposure Control

Plan (ECP) has been developed in accordance with the OSHA Bloodborne Pathogens

Standard, 29 CFR 1910.1030. The purpose of this ECP includes elimination or minimization

of employee occupational exposure to blood or certain other body fluids, compliance with

the OSHA Bloodborne Pathogens Standard, 29 CFR 1910.1030, and the protection of

Delgado Community College's students, faculty, staff, and visitors.

This memorandum, also described as the College’s Exposure Control Program

(ECP) is a key document to assist the College in implementing and ensuring compliance

with the standard, thereby protecting College employees.

PROCEDURES & SPECIFIC INFORMATION

the OSHA Bloodborne Pathogens Standard, 29 CFR 1910.1030, and the protection of

Delgado Community College's students, faculty, staff, and visitors.

This memorandum, also described as the College’s Exposure Control Program

(ECP) is a key document to assist the College in implementing and ensuring compliance

with the standard, thereby protecting College employees.

PROCEDURES & SPECIFIC INFORMATION

Purpose

To establish procedures for dealing with potential exposure to blood borne pathogens

at Delgado Community College.

Scope and Applicability

This policy and procedures memorandum applies to all College operating units and to

all employees, students and visitors of Delgado Community College.

SF-1373.6 November 25, 2002

(Title Updates 5/7/05)

Program Administration

The Health Services EMT-Paramedic is responsible for the implementation of the

Exposure Control Plan (ECP). This individual will maintain, review and update the ECP at

least annually and whenever necessary to recommend new or modified tasks and procedures.

Those employees who have occupational exposure to blood or other potentially

infectious materials (OPIM) must comply with the procedures and work practices outlined in

this memorandum.

The College Health Services EMT-Paramedic will maintain and provide all necessary

personal protective equipment (PPE), engineering controls (i.e., sharps containers), labels,

and red bags as required by the standard. He/she will also ensure that adequate supplies of

the aforementioned equipment are available in the appropriate sizes.

The College Health Services EMT-Paramedic in conjunction with the Human

Resources Department will be responsible for ensuring that all medical actions required are

performed and that appropriate employee health records are maintained.

The College Health Services EMT-Paramedic will be responsible for training,

documentation of training, and making the written ECP available to employees.

The Maintenance Department will be responsible for the proper disposal of all

medical waste produced by actions occurring on any campus in the pursuit of the proper

application of the Bloodborne Pathogen Program.

Employee Exposure Determination

The U.S. Occupational Safety Health Administration (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).

The exposure determination of

Ongoing Exposure Risk

includes all job

classifications in which employees will incur such occupational exposure, regardless of

frequency. At the College the following job classifications are in this category:

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(Title Updates 5/7/05)

College Health Services EMT-Paramedic

College personnel assisting with administering vaccinations

Nursing/Allied Heath Faculty with exposure to clinical settings

Any College personnel assisting with providing health services, clerical and

administrative staff working with the above mentioned classifications

Implementation of Methods of Exposure Control

This plan includes a schedule and method of implementation for the various

requirements of the standard. It is the College's policy to comply with this

requirement. Employees covered by the bloodborne pathogen standard receive an

explanation of this 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 shift by contacting the custodian of the Delgado Community College Loss

Prevention Manual in their departmental office. If requested, the College Health Services

EMT-Paramedic will provide an employee with a copy of the ECP.

Compliance Strategies

The Centers for Disease Control (CDC) Universal Precautions

: will be observed at

the College 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 the College. Where occupational exposure remains after

the institution of these controls, personal protective equipment shall also be utilized.

At the College the following engineering controls will be utilized:

Hand-Washing Facilities

Hand washing facilities are 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. In College lavatories employees should not have to open doors or

use stairs to access washing facilities in order to avoid further surface

contamination.

SF-1373.6 November 25, 2002

(Title Updates 5/7/05)

Supervisors shall ensure that after the 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.

Supervisors shall ensure that if employees incur exposure to their skin or

mucous membranes, then those areas shall be washed or flushed with water as

soon as feasible following contact.

Sharps, Contaminated Needles & Glassware

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.

Disposal of Sharps, Contaminated Needles & Glassware

All sharps must be placed in a labeled, biohazard sharps container. All

needles are to be placed in a labeled biohazard needles/sharps container.

Contaminated sharps shall be discarded immediately or as soon as feasible in

containers that are closable, puncture resistant, leak proof on sides and bottom

and labeled or color coded. Delgado Community College will provide leak-

proof containers for contaminated sharps capable of resisting punctures and

labeled as a biohazard. These containers are to be used for gathering and

storage of all contaminated sharps, including glassware.

During use, containers for contaminated sharps shall be easily

accessible to personnel and located as close as is feasible to the

immediate area where sharps are used or can be reasonably anticipated

to be found (i.e., Exam rooms, Laboratory, Nursing triage area,

Training room).

Employees are to use unwinders to separate needles from syringes and

vacutainers and are to be trained regarding proper removal of needles.

The containers shall be maintained upright throughout use, replaced

routinely and not be allowed to overfill. They are to be checked every

time there is a pickup of infectious waste and changed when they are

nearly full.

SF-1373.6 November 25, 2002

(Title Updates 5/7/05)

When moving containers of contaminated sharps from the area of use,

the containers shall be closed immediately prior to removal or

replacement to prevent spillage or protrusion of contents during

handling, storage, transport, or shipping.

The container shall be placed in a secondary container if leakage of

the primary container is possible. The second container shall be

closeable, constructed to contain all contents and prevent leakage

during handling, storage and transport, or shipping. The second

container shall be labeled or color-coded to identify its contents.

Other Regulated Waste

Delgado Community College will provide containers sufficient to contain

regulated wastes capable of resisting punctures and labeled as a biohazard

(as appropriate). Regulated Waste includes the following:

Liquid or semi-liquid blood or other potentially infectious material.

Items contaminated with blood or other potentially infectious material

that would release these substances in a liquid or semi liquid if

compressed.

Items that are caked with blood or other potentially infectious material

and are capable of releasing these substances during handling.

Pathologic and microbiological waste containing blood or other

potentially infectious material.

Other regulated waste shall be placed in containers, which are closeable,

constructed to contain all contents and prevent leakage of fluids during

handling, storage, transportation or shipping. The waste must be labeled

or color-coded and closed prior to removal to prevent spillage or protrusion of

contents during handling, storage, transport, or shipping. Disposal of all

regulated waste shall be in accordance with applicable Federal, State and

Local regulations.

Personal Protective Equipment (PPE)

PPE must be used to prevent blood or Other

Potentially Infectious Materials (OPIMs) from passing through to, or contacting the

employee’s work or street clothes, undergarments, skin, eyes, mouth, or other mucus

membranes, unless engineering controls and work practices have eliminated

occupational exposure. An employee may temporarily decline to wear PPE only

when, in a life-threatening situation, the use of protective equipment will prevent the

delivery of health care and public safety services or pose an increased hazard to

workers. Incidents during which an employee elects not to wear protective

SF-1373.6 November 25, 2002

(Title Updates 5/7/05)

equipment are to be documented in order to determine whether changes can be

instituted to prevent occurrences in the future.

Delgado Community College assumes the financial responsibility for purchasing PPE

that protects its employees against contact with blood or OPIM as can be reasonably

anticipated encountering in its setting. If laboratory coats and uniforms are to be

used as PPE, they will be laundered through Contract hire on a as needed basis, and

are not to be taken home for cleaning. The College Health Services EMT-Paramedic

will provide the PPE required by bloodborne first responder teams, in order to protect

them in the execution of their duties.

All PPE must be removed prior to leaving the work area, removed as soon as possible

following penetration by blood or OPIM and placed in a designated area or container

for storage, washing, decontamination or disposal.

Housekeeping Practices

Regulated Waste

Regulated waste is to be placed in containers, which are closable, constructed

to contain all contents and prevent leakage, appropriately labeled and color

coded, and closed prior to removal, to prevent spillage or protrusion of

contents during handling.

Work Surfaces

Work surfaces are to be decontaminated with a detergent or 10% bleach

solution after completion of procedures, immediately upon contamination by

any spill of blood or OPIM and at the end of each work shift.

Protective Coverings

Non-absorbent, protective coverings, are to be used to cover equipment and

surfaces when they have become overtly contaminated and at the end of a

work shift if they have become contaminated.

Reusable Receptacles

Reusable receptacles like bins, garbage receptacles, and pails will be

decontaminated weekly. When contamination is visible, receptacles should

be decontaminated immediately.

SF-1373.6 November 25, 2002

(Title Updates 5/7/05)

Broken Glassware

Broken glassware, which may be contaminated, must not be picked up

directly with the hands. Tools used in cleanup of broken glass are to be

decontaminated and broken glass discarded in a sharps container. Do not use

vacuum cleaner for cleanup of contaminated glass.

Laundry

Laundry contaminated with blood or other potentially infectious materials

will be handled as little as possible. Such laundry will be placed in

appropriately marked "A biohazard", labeled, or color-coded red bags at the

location where it was used. Such laundry will not be sorted or rinsed in the

area of use.

Labeling Procedures of Blood or OPIM

Labels to be used to warn employees who may have contact with containers, of the

potential hazard posed by their contents. Labels are to be attached to container of

regulated waste, to refrigerators containing blood and OPIM, and to other containers

used to store, transport, or ship blood or OPIM. The warning label must be

fluorescent orange or orange red, containing the biohazard symbol and the word

“biohazard” in a contrasting color and be attached to prevent loss or unintentional

removal of the label.

General Practices

Food and Drinks are not to be kept

in refrigerators, freezers, shelves,

cabinets, or on countertops where blood or OPIMs are present.

Applying cosmetics or contact lenses is prohibited in areas where blood or

OPIMs are present.

All procedures involving blood or OPIMs must be performed in such a

manner as to minimize splashing, spraying, splattering and generation of

droplets of these substances.

Hepatitis B Vaccine

The College Health Services EMT-Paramedic will provide training to employees on

Hepatitis B vaccinations, addressing the safety, benefits, efficacy, methods of

administration, and availability. The Hepatitis B vaccination series is available at no

cost after training and within (ten) 10 days of initial assignment to employees

identified in the exposure determination section of this plan.

SF-1373.6 November 25, 2002

(Title Updates 5/7/05)

Vaccination is encouraged

unless

Documentation exists that the employee has previously received the series.

Antibody testing reveals that the employee is immune.

Medical evaluation shows that vaccination is contraindicated.

However, if an employee chooses to decline vaccination, the employee must sign a

declination form. This declination form will be kept with the employee’s medical file

in the College Health Services EMT-Paramedic’s office. Employees who declined

the vaccine may request and obtain the vaccination at a later date at no cost. The

College Health Services EMT-Paramedic will provide the required

vaccinations in their office. Following Hepatitis B vaccinations, the health

care professional will provide a Written Opinion, which will be limited to whether

the employee required the hepatitis vaccine, and whether the vaccine was

administered. This Written Opinion will also be kept in the employee’s medical file

in the College Health Services EMT-Paramedic’s office.

If the U.S. Public Health Service recommends a routine booster dose of the Hepatitis

B vaccine at a future date, such booster doses shall be made available at no cost to the

employee.

Information and Training

All employees who have occupational exposure to bloodborne pathogens must receive

training on the epidemiology, symptoms, protection from, and transmission of bloodborne

pathogen diseases. The College Health Services EMT-Paramedic will provide this training.

This training will be provided at no cost to the employee and during the employees’ working

hours. The training will be as follows:

A. Will be provided by the College Health Services EMT-Paramedic. He/she shall

ensure that training is provided at the time of initial assignment to tasks where

occupational exposure may occur, and that it shall be repeated within twelve (12)

months of the previous training.

B. Training shall be tailored to the education and language level of the employee, and

offered during the normal work shift. 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.

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(Title Updates 5/7/05)

An explanation of the Delgado Community College Bloodborne Pathogen

ECP, 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 (PPE).

Information on the types, selection, use, location, removal, handling,

decontamination, and disposal of PPEs.

Information on the Hepatitis B vaccination, including efficacy, safety, method

of administration, benefits, and that it will be offered free of charge.

Information on the appropriate actions to take and persons to contact in an

emergency involving blood or other potentially infectious materials.

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.

C. Employees who have received training on bloodborne pathogens in the 12 months

preceding the effective date of this plan shall only receive training in provisions of

the plan that were not covered.

D. Additional training shall be provided to employees when there are any changes of

tasks or procedures affecting the employee's occupational exposure.

Recordkeeping

A. Medical Records are maintained for each employee with occupational exposure in

accordance with 29 CFR 1910.20, "Access to Employee Exposure and Medical

Records."

The College Health Services EMT-Paramedic is responsible for maintenance of the

required medical records. These confidential records are kept in these said offices 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. These medical records include:

SF-1373.6 November 25, 2002

(Title Updates 5/7/05)

Name and Social Security Number of the employee.

Employee Hepatitis B vaccination status including dates of vaccination and

the records relating to the employee’s ability to receive the vaccine and signed

declination form, if applicable.

A copy of all the results of examinations, medical testing, and follow-up

procedures.

B. Training records are completed for each employee upon completion of training.

These documents will be kept for at least three years at the College Health Services

EMT-Paramedic and the Senior Compliance Officer. The training records include:

The dates of the training sessions.

The contents or a summary of the training sessions.

The names and qualifications of persons conducting the training.

The names and job titles of all persons attending the training sessions.

C. The College Health Services EMT-Paramedic will maintain a log of occupational

injury or illness. Identifying information related to bloodborne pathogens will be

removed prior to granting access to the records. The log will document the

following:

Date of incident.

Name and Social Security number of the exposed individual.

Hepatitis B vaccination status.

Medical follow up, examination results, and medical testing.

Confidential medical information must be retained while the employee is

employed by Delgado Community College and for thirty (30) years thereafter.

Employee medical records will be provided upon request, for examination and

copying to the employee, the Director of NIOSH, the Assistant Secretary of

Occupational Safety and Health, and to anyone having the written consent of the

employee.

SF-1373.6 November 25, 2002

(Title Updates 5/7/05)

Post- Exposure Evaluation and Follow-Up

Should an exposure incident occur, employees must contact the College Health Services

EMT-Paramedic who will conduct an immediately available confidential medical evaluation

and follow-up. Following the initial first aid (clean the wound, flush eyes or other mucous

membrane, etc.), the following activities will be performed:

Document the routes of exposure and how the exposure occurred.

Identify and document the source individual (unless the employer can establish that

identification is infeasible or prohibited by state or local law).

Obtain consent and make arrangements to have the source individual tested as soon

as possible to determine Human Immune Deficiency Virus (HIV), Hepatitis C Virus

(HCV) and/or Hepatitis B Virus (HBV) infectivity. Document that the source

individual's test results were conveyed to the employee's health care provider.

If the source individual is already known

to be HIV, HCV and/or HBV positive, new

testing need not be performed.

Assure that the exposed employee is provided with the source individual's test results

and with information about applicable disclosure laws and regulations concerning the

identity and infectious status of the source individual (e.g., laws protecting

confidentiality).

After obtaining consent, collect exposed employee's blood as soon as feasible after

exposure incident, and test blood for HBV and HIV serological status.

If the employee does not give consent for HIV serological testing during collection of

blood for baseline testing, preserve the baseline blood sample for at least ninety (90)

days; if the exposed employee elects to have the baseline sample tested during this

waiting period, perform testing as soon as feasible.

Policy Reference:

Occupational Safety Health Administration (OSHA) Standard: Bloodborne Pathogens,

29 CFR 1910.1030

Occupational Safety Health Administration (OSHA) Standard: Access to Employee

Exposure and Medical Records, 29 CFR 1910.20

Review Process:

Safety Committee 3/14/02

Bloodborne Pathogen Policy Ad Hoc Review Committee 11/22/02

Executive Committee 11/25/02

Distribution:

Distributed Electronically Via the College’s Internet and Email Systems