Bloodborne Pathogens Exposure Control Policy

Initiated: January 13, 1993
Approved: June 1, 1993
Revised: August 21, 1998
Revised: January 21, 2002

Purpose

To ensure that Northern Michigan University is in compliance with the requirements of the OSHA Bloodborne Pathogens Standard, Title 29 Code of Federal Regulations Part 1910 Section 1030. The "Compliance Officer" for Northern Michigan University is the University Safety Director (Director, Public Safety and Police Services).

Applicability

All University employees, full time, part time, temporary, casual labor, students, who may incur occupational exposure to blood or other potentially infectious materials. The risk of exposure is made without regard to the use of personal protective equipment.

Policy

It is the policy of Northern Michigan University to comply with the requirements of the Bloodborne Pathogens Standards. All employees, full and part, who may incur occupational exposure to blood or other potentially infectious materials are covered by this policy. Personal Protective Equipment will be provided to covered employees at no cost to the employee. In addition all covered employees will be offered the Hepatitis B Vaccine at no cost to the employee.

References

OSHA Bloodborne Pathogens Standard, Title 29 Code of Federal Regulations Part 1910 Section 1030 and Section 24, Act 154 of Public Acts of 1974 as amended, Rule 325.7001-70017 and amendments.

Initiating Department/Division

Public Safety and Police Services, 227-2152.

Department

Job Classification

Athletics*

Athletic Trainer/Coordinator

Athletics

Athletic Trainer - Coordinator Training Services

Athletics

Graduate Work Assistants

Consumer & Family Studies

Teacher, Director, Child Development Center

Consumer & Family Studies

Master Crafts,am/Instructor

Consumer & Family Studies

Instructor TAS

Consumer & Family Studies

Professor TAS

Consumer & Family Studies

Associate Professor TAS

Consumer & Family Studies

Assistant Professor TAS

Consumer & Family Studies

Adjunct NMUFA

Consumer & Family Studies

Overload NMUFA

Dining Services

Building/Grounds Attendants

Dining Services

Identified Food Service Employees

Health Center*

Chief of Staff - Physician

Health Center

Staff Nurse

Health Center

Clinical Nurse Specialist

Health Center

Medical Technologist

Health Center

Nurse Practioner

Health Center

Physician's Assistant

Health Physical Education and Recreation*

Exercise Physiology Lab Service Coordinator

Health Physical Education and Recreation

Graduate Assistants

Health Physical Education and Recreation

Identified Student Employees

Health Physical Education and Recreation

Building/Grounds Attendants

Housing & Residence Life

Building/Grounds Attendants

Housing & Residence Life

Resident Directors

Medical Technology*

Professor

Medical Technology

Associate Professor

Medical Technology

Adjunct Faculty

Medical Technology

Overload Faculty

Nursing*

Head and Professor

Nursing

Associate Professor

Nursing

Assistant Professor

Nursing

Adjunct Faculty

Nursing

Overload Faculty

Nursing

Graduate Clinical Assistant

Nursing

AAUP Faculty

Nursing

Graduate Assistant

Plant Operations

Building/Grounds Attendants

Plant Operations

Plumbers

Plant Operations

Housekeepers

Public Safety & Police Services*

Director

Public Safety & Police Services

Assistant Director - Public Safety

Public Safety & Police Services

Assistant Director - Police Services

Public Safety & Police Services

Crime Prevention & Security Specialist

Public Safety & Police Services

Investigator

Public Safety & Police Services

Police Officer

Tasks/Procedures

The tasks/procedures for the job classifications listed above are maintained in individual departments and the department of Personnel & Staff Benefits. In addition, those departments indicated with a * have developed and maintain an individualized Bloodborne Pathogen Exposure Control Plan covering activities unique to the area. Copies of individualized plans are attachments to this document. All other departments are covered by this plan.

Definitions:

The following provides clarifications of some terms used in this plan:

A. Blood: Human blood, human blood components, and products made from human blood. The term "Human Blood Components" includes plasma, platelets, and serosanguineous fluids (e.g., exudates from wounds).

B. Bloodborne Pathogens: Any pathogenic microorganism that is present in human blood and can infect and cause disease in persons who are exposed to blood containing the pathogen. Examples include: HIV, Hepatitis B, Hepatitis C, malaria, syphilis, babesiosis, brucellosis, leptospirosis, arboviral infections, relapsing fever, viral hemorrhagic fever, etc.

C. Clinical Laboratory: A work place where diagnostic or other screening procedures are performed on blood or other potentially infectious materials.

D. Contaminated: The presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.

E. Contaminated Laundry: Laundry which has been soiled with blood or other potentially infectious materials or may contain sharps.

F. Contaminated Sharps: Any contaminated object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broken capillary tubes, knifes, saw blades and exposed ends of dental wire.

G. Decontamination: The use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use or disposal.

H. Engineering Controls: Controls that isolate or remove the bloodborne pathogen hazard from the work place, e.g., sharps disposal containers, self sheathing needles.

I. Exposure Incident: A specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee duties. Non-intact skin includes skin with dermatitis, hang nails, cuts, abrasions, chafing, etc., when used in the context of "exposure incident".

J. Hand Washing Facilities: A facility providing an adequate supply of running potable water, soap and single use towels or hot air drying machines. The facility must be located a reasonable distance from the worksite.

K. Licensed Health Care Professional: Is a person whose legally permitted scope of practice allows him or her to independently perform the activities required in Hepatitis B Vaccination and Post-exposure evaluations.

L. HBV: Hepatitis B Virus.

M.HIV: Human immunodeficiency virus.

N. Occupational Exposure: Reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employees duties. Reasonably anticipated when used in the context of "occupational exposure", includes the potential for exposure as well as the actual exposure.

O. Other Potentially Infectious Material (Opim): The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids. It also extends to blood and tissues of animals who are deliberately infected with HIV or Hepatitis B.

P. Parenteral: Piercing mucous membranes or the skin barrier through such events as needle sticks, human bites, cuts and abrasions. This includes human bites that break the skin, which are most likely to occur in violent situations such as may be encountered by police in emergency situations.

Q. Personal Protective Equipment: Is specialized clothing or equipment worn by an employee for protection against a hazard. General work clothes (e.g., uniforms, pants, shirts or blouses) not intended to function as protection against a hazard are not considered to be personal protective equipment.

R. Regulated Waste: Liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.

S. Source Individual: Any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to the employee.

T. Sterilize: The use of a physical or chemical procedure to destroy all microbial life including highly resistant bacterial endospore.

U. Universal Precautions: That all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens.

V. Work Practice Controls: Controls that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., prohibiting recapping of needles by a two-handed technique).

Compliance Methods:

Northern Michigan University will observe universal precautions 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 University. Where occupational exposure remains after institution of these controls, personal protective equipment shall also be utilized. At Northern Michigan University the following engineering controls will be utilized:

A. Hand washing facilities are available to the employees who incur exposure to blood or other potentially infectious materials.

1. Handwashing facilities are readily accessible.

2. Handwashing is done as soon as feasible after removal of gloves. Employees are required to wash with soap and running water.

3. Following contact with blood or other potentially infectious material, handwashing is done as soon as feasible, skin that was in contact is washed, and mucous membranes in contact are flushed with water.

4. In those cases where employees are working in an area where handwashing facilities are not immediately available, the University will provide either an antiseptic cleanser with paper towels or antiseptic towelettes.

5. The Supervisor is responsible for ensuring maintenance and accessibility of the items.

B. Needles and Sharps: Contaminated needles and other contaminated sharps will not be bent, recapped, removed, sheared or purposely broken.

1. Needles and sharps:

a. Disposable needles and sharps are not bent, recapped, sheared, broken or removed.

b. Disposable needles and sharps are placed in closable, puncture resistant containers which are leak proof on the sides and bottom, and are either red in color or have a red biohazard label affixed to them.

c. Reusable needles and sharps are removed with a mechanical device or by using the one hand technique.

d. Reusable needles and sharps are placed in closable, puncture resistant containers which are leakproof on the sides and bottom, and are either red or have a red biohazard label affixed to them.

e. During use, containers for contaminated sharps are easily accessible to personnel and as close as feasible to the immediate area where sharps are used, maintained upright throughout use, replaced routinely and not allowed to overflow and closed immediately prior to removal or replacement.

f. Sharps instruments are not passed from hand to hand.

2. The above controls will be examined and maintained on a regular schedule. There will be a set schedule for reviewing the effectiveness of the controls. Those departments identified in Section II of this plan are responsible for setting the schedule of inspections and identifying the position responsible for conducting the inspection.

C. Containers for Reusable Sharps: Contaminated sharps that are reusable are to be placed immediately, or as soon as possible, after use into an appropriate sharps container. This container must meet the criteria of a sharps disposal container.

1. Containers must be puncture resistant, labeled with a biohazard label, and leak proof.

2. Sharps containers will be located in all work areas where contaminated sharps or contaminated needles are routinely used. The person responsible for the work area shall be responsible for removing the sharps from the container and establishing the schedule for removal.

3. If sharps containers contain residual liquids and the container cannot be sealed to prevent leakage, the container must be placed in a secondary container.

D. Work Area Restrictions: In work areas where there is a reasonable likelihood of exposure to blood or other potentially infectious materials, employees are not permitted to eat, drink, apply cosmetics or lip balm, or handle contact lenses.

1. Food and beverages will not be kept in refrigerators, freezers, shelves, cabinets, or on counter tops or bench tops where blood or other potentially infectious materials are present.

2. Employee who are provided designated lunchrooms or break rooms will wash up and change any contaminated clothing prior to entry.

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

4. 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.

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

1. The container used for this purpose will be labeled or color coded.

2. Any specimens which could puncture a primary container will be placed within a secondary container which is puncture resistant.

3. 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.

F. 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.

G. Personal Protective Equipment. (PPE)

1. Personal protective equipment used at Northern Michigan University shall be provided without cost to the employee. Prescription glasses will be covered by the University Eye Protection Policy. The University will provide PPE in appropriate sizes and at accessible locations.

2. PPE will be chosen based on the anticipated exposure to blood or other potentially infectious materials. Employees are required to wear PPE provided by the University.

3. PPE will only be considered appropriate 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.

4. PPE will be provided by each department covered by this plan. The department head or other designated individual will be responsible for the development of procedures governing the use of PPE within there department. The specific procedures will be attached to this document. the provided, who has responsibility for providing it, which procedures the use of what PPE.

5. PPE will be cleaned, laundered, repaired and/or disposed of the University, at no cost to the employee.

6. All garments which are penetrated by blood shall be removed immediately or as soon as feasible.

7. All PPE will be removed prior to leaving the work area. Each department head or designated individual is responsible for identifying an area where employees will leave PPE and the development of any other procedures.

8. Gloves shall be worn where it is reasonably anticipated that employees will have hand contact with blood, or other potentially infectious materials, non-intact skin, and mucous membranes.

a. Gloves will be used for the following procedures:

1)As a minimum gloves shall be used where there is reasonable anticipation of employee hand contact with blood, or other potentially infectious materials, mucous membranes, or non-intact skin, when handling or touching contaminated surfaces or items.

2) Department Heads or other designated individuals will be responsible for development of any other procedures or tasks which will require the use of gloves.

b. Disposable gloves will not be washed or decontaminated for re-use, and shall be replaced where there ability to function as a barrier is compromised or they become contaminated.

c. Utility gloves may be decontaminated for re-use provided that the integrity of the glove is not compromised.

d. Utility gloves will be discarded if they are cracked, peeling, torn, punctured, or their ability to function as a barrier is compromised.

e. Hypoallergenic gloves, glove liners, powderless gloves, or other similar alternatives shall be provided to those employees who are allergic to the gloves normally provided.

f. Hand washing after glove removal is required. Studies have shown that although gloves provide a barrier they are not completely impermeable.

9. 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, splatters, or droplets of blood or other potentially infectious materials may be generated, and eye, nose, or mouth contamination can reasonably be anticipated. Department Heads or other designated individuals are responsible for the identification of those situations were these requirements exist.

10. The use of Lab coats, gowns, aprons, clinic jackets, or a similar outer garment will be worn as determined by Department Heads or other designated individuals. The department Head or other designated individual will evaluate the task and type of exposure expected and based on that determination select the appropriate PPE.

H. The University will ensure that the worksite is maintained in a clean and sanitary condition.

1. The term worksite refers not only to permanent fixed facilities, but also covers temporary non-fixed work places. For example the inside of a Public Safety vehicle or any other non-fixed work site which has a reasonable possibility of becoming contaminated with blood or other potentially infectious material.

a. The Department Head or other designated individual will develop a written cleaning schedule, describe the decontamination method based on the location with the facility, type of surface to be cleaned, type of soil present, and tasks and procedures being performed in the area.

2. All equipment and environmental and working surfaces shall be cleaned and decontaminated after contact with blood or other potentially infectious materials.

3. Contaminated work surfaces shall be decontaminated with an appropriate disinfectant after completion of the procedure and immediately or as soon as feasible after any spill of blood or other potentially infectious material.

4. Work surfaces will be cleaned at the end of the work shift, if the surface may have become contaminated since the last cleaning.

5. All bins, pails, cans, and similar receptacles shall be inspected and decontaminated on a regularly scheduled basis.

6. Broken glass will not be picked up directly with the hands. A broom and dust pan must be used, and the material placed in a puncture proof container. The tools used for clean up must be decontaminated or properly disposed of after use. Vacuum cleaners will not be used to pick up broken glass.

I. Regulated Waste Disposal

1. Under this plan regulated waste is:

a. Liquid or semi-liquid blood or other potentially infectious materials.

b. Items contaminated with blood or other potentially infectious materials and which would release these substances in a liquid or semi-liquid state if compressed.

c. Items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling.

d. Contaminated sharps. A needle sheath is not to be considered a waste container, self-sheathing needle products must be disposed of in a sharps container. Sharps containers will be located as close as feasible to where sharps are used.

e. Pathological and microbiological wastes containing blood or other potentially infectious materials.

2. Regulated waste containers will be labeled with the biohazard symbol or color coded to warn employees who may have contact with the containers of the potential hazard posed by their contents.

3. If the regulated waste container has been contaminated on the outside, it must be placed inside another regulated waste container.

4. All contaminated sharps shall be discarded as soon as feasible in sharps containers which are located in the department. The Department Head or other designated individual is responsible for determining the location of the sharps containers, and a schedule for emptying the containers.

5. Other regulated waste shall be placed in appropriate containers. The Department Head or other designated individual is responsible for determining the location of the sharps containers, and a schedule for emptying the containers.

6. Disposal of regulated waste shall meet the current requirements of the Environmental Protection Agency.

J. Laundry Procedures

1. Laundry contaminated with blood or other potentially infectious material will be handled as little as possible. Employees required to handle contaminated laundry will wear protective gloves and other PPE as appropriate, in order to prevent contact exposure to blood or other potentially infectious materials.

a. Such laundry will be placed in appropriately marked bags at the location were it was used.

1) Appropriately marked means that the container will have the biohazard label or be color coded.

2) The material used for laundry bags or containers must prevent soak through or leakage of fluids to the exterior, if the contaminated laundry is wet and presents a reasonable likelihood of soak through or leakage.

b. Such laundry will not be sorted or rinsed in the area of use.

2. Employees who handle contaminated laundry will use personal protective equipment to prevent contact with blood or other potentially infectious material.

3. Each department head or other designated individual will identify the laundry facility being used and ensure that the laundry uses universal precautions.

4. Home laundering is not permitted since the University cannot guarantee that proper handling or laundering procedures are being followed; it could also lead to the migration of contaminants to the home.

Hepatitis B Vaccine:

A. All employees (full and part time) 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.

1. The vaccine will be offered within 10 days of the initial assignment to work involving the potential for occupation exposure to blood or other potentially infectious materials (unless the employees has previously had the vaccine or wishes to submit to antibody testing which shows the employee to have sufficient immunity.

2. Employees who decline the Hepatitis B vaccine with sign a waiver containing the following wording:

a. "I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me."

b. The Department Head or other designated individual is responsible for assuring that the vaccine is offered, the waiver is signed, and who will administer the vaccine.

3. Employees who initially decline the Hepatitis B vaccine but who later wish to have it may then have the vaccine provided at no cost to the employee.

Post Exposure Evaluation And Follow Up:

A. When an employee incurs an exposure incident, it must be reported to the University Safety Director (Director, Public Safety & Police Services). The University Accident/Injury/Illness Report will be used for this purpose.

B. The University Safety Director will evaluate the circumstances surrounding the exposure incident, including an evaluation of the policies and "failures of control" at the time of the exposure incident. The engineering controls and work practices in place, as well as protective equipment or clothing used at the time of the incident will also be evaluated.

C. Employees who incur an exposure incident shall be referred to the University Health Center and will be offered post-exposure evaluation and follow-up that will include the following:

1. Documentation of the route of exposure and the circumstances related to the incident.

2. If possible, the identification of the source individual, and if possible, the status of the source individual.

3. If consent is obtained, the blood of the source individual will be tested for HIV/HBV infectivity.

4. The results of the testing of the source individual will be made available to the exposed employee and the employee will be informed about the applicable laws and regulations concerning disclosure of the identity of the source individual.

5. The employee will be offered the option of having their blood collected for testing of the employees HIV/HBV serological status by the University Physician.

a. The blood sample will be preserved for at least 90 days to allow the employee to decide if the blood should be tested for HIV Serological status.

b. If the employee decides prior to that time that testing will be conducted then the appropriate action can be taken and the blood sample discarded.

c. The employee will be offered post exposure prophylaxis in accordance with the current recommendations of the U.S. Public Health Service.

6. The employee will be given appropriate counseling concerning precautions to taken during the period after the exposure incident by the University Physician.

7. The employee will be given information on what potential illnesses to be alert for and to report any related experience to the University Physician.

8. The University Safety Director and the University Physician are responsible for maintaining all appropriate records required by this plan.

9. If an employee not covered by this plan has an occupational exposure they will be provided the same opportunities as a covered employee. (e.g., good samaritan acts or unanticipated exposure).

D. For the purpose of this plan, police officers and supervisors at Public Safety will use the Body Substance Isolation (BSI) method. This method defines all body fluids and substances as infectious. Exposure to any body fluid will be treated as an occupational exposure incident, and appropriate procedures will be followed as outlined in this plan.

Health Care Requirements:

A. Written opinions from the Health Care Provider will be provided to the employer in the following circumstances:

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.

B. The Health Care Provider will limit their opinions to:

1. Whether the Hepatitis B vaccine is indicated and if the employee has received the vaccine, or for an 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.

4. The written opinion will not contain any personal medical information.

Employee Information And Training Requirements:

A. Labels must be provided on containers of regulated waste, on refrigerators and freezers that are used to store blood or other potentially infectious materials, and on containers used to store, dispose of, transport, or ship blood or other potentially infectious materials.

1. This requirement does not preempt either the US Postal Service or the Department of Transportation's Hazardous Material Regulations labeling requirements.

2. Individual containers used when blood is being drawn or laboratory procedures are being performed on blood samples are not required to have labels on the individual containers, provided that the larger container into which they are placed is labeled.

B. All employees covered by this plan will be trained prior to initial assignment to tasks where occupational exposure may occur.

C. Required training will include the following:

1. The OSHA Standard for Bloodborne Pathogens

2. Epidemiology and symptomatology of bloodborne diseases

3. Modes of transmission of bloodborne pathogens

4. The University Exposure Control Plan

5. Procedures which might cause exposure to blood or other potentially infectious materials at the University

6. Control methods which are used at the University to control exposure to blood or other potentially infectious materials.

7. Personal protective equipment available at the University

8. Who to contact in the event of an exposure

9. Post exposure evaluation and follow up

10. Signs and labels used at the University

11. Hepatitis B vaccine program at the University

D. There must be an opportunity for personal interaction between the employee and the trainer/s. Employee training will be conducted by the University Safety Director and the University Physician. The method of training will include the use of videotapes, written materials, and lecture.

E. All employees covered by this plan will receive an annual refresher training, or when changes in procedures or tasks occur which affect occupation exposure.

F. The outline for the training program is maintained at the University Safety Department and University Health Center.

Record Keeping:

All records required by OSHA Bloodborne Pathogens standard 29 CFR 1910.1030 will be maintained at the University Safety Department under the supervision of the University Safety Director (Director, Public Safety & Police Services).

Review Of Plan:

This plan will be reviewed on an annual basis by the University Safety Director, and updated as required.

Approved June 1993

References

OSHA Bloodborne Pathogens Standard, Title 29 Code of Federal Regulations Part 1910 Section 1030 and Section 24, Act 154 of Public Acts of 1974 as amended, Rule 325.7001-70017 and amendments.

Initiating Department/Division

Public Safety and Police Services, 227-2152.