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Bloodborne
Pathogens Standard
Exposure Control Plan (ECP) for Bloodborne
Pathogens Mich. Occupational Health Standard 325.70001 Federal OSHA
(29 CFR 1910.1030)
PURPOSE
This document serves as the written procedures Bloodborne Pathogens
Exposure Control Plan (ECP) for Hope College. These guidelines provide
policy and safe practices to prevent the spread of disease resulting
from handling blood or other potentially infectious materials (OPIM)
during the course of work.
This ECP has been developed in accordance with the OSHA Bloodborne
Pathogens Standard, Michigan Health Standared 325.70001 and Federal OSHA
29 CFR 1910.1030. The purpose of this ECP includes:
- Eliminating or minimizing occupational exposure of employees to blood
or certain other body fluids.
- Complying with OSHA's Bloodborne Pathogens Standard, 29 CFR 1910.1030.
ADMINISTRATIVE DUTIES
The Department of Occupatational Health and Fire Safety is responsible
for developing and maintaining the program. A copy of the plan may be
reviewed by employees. It is located in the Occupational Health and Fire
Safety Office(H&FS). In addition, the H&FS office is responsible for
maintaining any records related to the Exposure Control Plan.
This plan is current as of 1/7/2007
If after reading this program, you find that improvements can be made,
please contact the H&FS office. We encourage all suggestions because
we are committed to the success of our written ECP. We strive for clear
understanding, safe behavior, and involvement from every level of the
college.
EXPOSURE DETERMINATION
We have determined which employees may incur occupational exposure
to blood or OPIM. 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).
Job Classes: Global Risk of Exposure
This exposure determination is required to list all job classifications
in which all employees may be expected to incur such occupational exposure,
regardless of frequency. At this facility the following job classifications
are in this category:
- Athletic Trainers, Athletic Training Students, Life Guards.
- Biology Lab Directors
- Health Clinic Staff
- Housekeeping /Plumbers
- Nursing Faculty, Lab/Media Coordinator, & Student Lab Assistants.
- First Aid /CPR Providers - Campus Safety Officers.
Job Classes: Site Specific Risk of Exposure
The job classifications and associated tasks for these categories are
explained in each departmental policy and procedure. Each of these departments
has a site specific policy which can be obtained from the departmental
representative. They are:
| Athletic Trainers |
Rich Ray |
Kinesiology |
X7708
DeVos Field House |
| Biology Lab Director |
Lori Hertel |
Biology |
X7722
Schaap Science Center |
| Physical Plant Director |
Jerry Rademaker |
Physical Plant |
X7835
Physical Plant Office |
| Health Clinic Coordinator |
Cindy Sabo |
Health Clinic |
X7585
Dow Center |
| Nursing Dept Lab Coordinator |
Vicki Slot |
Nursing Dept |
X7422
Schaap Science Center |
| CS Patrol Supervisor |
Chad Wolters |
Campus Safety |
X7770
Campus Safety |
COMPLIANCE STRATEGIES
- This plan includes an overview and method of implementation for departmental
site specific requirements of this standard.
- Universal precautions techniques developed by the Centers
for Disease Control and Prevention (CDC) will be observed at
this facility to prevent contact with blood or OPIM. All blood
or OPIM will be considered infectious regardless of the perceived
status of the source individual.
ENGINEERING AND WORK PRACTICE CONTROLS
- Engineering and work practice controls will be used to eliminate
or minimize exposure to employees at this facility. Where occupational
exposure remains after institution of these controls, employees are
required to wear personal protective equipment. At this facility the
following engineering controls are used:
- Placing sharp items (e.g., needles, scalpels, etc.) in puncture-resistant,
leakproof, labeled containers.
- Performing procedures so that splashing, spraying, splattering,
and producing drops of blood or OPIM is minimized.
- Removing soiled PPE as soon as possible.
- Cleaning and disinfecting all equipment and work surfaces potentially
contaminated with blood or OPIM. Note: We use a solution of 1/4
cup chlorine bleach per gallon of water which should be used
to wipe down the surface and allowed to air dry.
- Towelettes or hand cleanser where handwashing facilities are
not available.
- Prohibition of eating, drinking, smoking, applying cosmetics,
handling contact lenses, and so on in work areas where exposure
to infectious materials may occur.
- Use of leak-proof, labeled containers for contaminated disposable
waste or laundry.
- Use of protective gloves in all instances of handling raw sewage.
The above controls are examined and maintained on a regular schedule.
Each department containing category A employees has specific departmental
plans, containing specific procedures, planning, and equipment
that shall be consulted and understood by the effected employees
on the above listed controls.
HANDWASHING FACILITIES
- Handwashing facilities are available to employees who have exposure
to blood or OPIM. Sinks for washing hands after occupational exposure
are near locations where exposure to bloodborne pathogens could occur.
At Hope College handwashing facilities are located:
- In any public restroom located on the campus of Hope College.
- When circumstances require handwashing and facilities are
not available, either an antiseptic cleanser and paper towels
or antiseptic towelettes are provided. Employees must then
wash their hands with soap and water as soon as possible. Employees
can find these hand-washing supplies:
- Supervisors make sure that employees wash
their hands and any other contaminated skin
after immediately removing personal protective
gloves, or as soon as feasible with soap and
water.
- Supervisors
also ensure
that if employees'
skin or mucous
membranes become
contaminated
with blood
or OPIM, then
those areas
are washed
or flushed
with water
as soon as
feasible following
contact.
CONTAMINATED EQUIPMENT
- Hope College requires that equipment which has become contaminated
with blood or OPIM must be decontaminated before servicing or shipping
as necessary unless the decontamination of the equipment is not feasible.
Our procedures for equipment decontamination are as follows:
- Flush equipment with a bleach/water solution @ 10% Bleach and
allow to air dry.
- Use of other products manufactured to kill HBV or HIV virus.
PERSONAL PROTECTIVE EQUIPMENT
- All personal protective equipment (PPE) used at this facility is
provided without cost to employees. PPE is chosen based on the anticipated
exposure to blood or OPIM. The protective equipment is 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 and for the duration of time which the protective
equipment will be used.
- Hope College makes sure that appropriate PPE in the appropriate
sizes is readily accessible at the work site or is issued without
cost to employees by: Contacting the H&FS office at X7999
- Synthetic, powder-free gloves, glove liners,
powderless gloves, or other similar alternatives
are readily accessible to those employees who
are allergic to the gloves normally provided.
- We purchase
(when consumable),
clean, launder,
and dispose
of personal
protective
equipment as
needed by:
- All
contaminated
PPE which
cannot
be cleaned
such
as gloves
must
be placed
in (red)
Bio-hazard
bags
and secured
in an
area
not accessible
to the
general
public.
Bags
can be
brought
over
to the Dow
Center
Health
Clinic or the Chemical Stock Room in Schaap Science Center for
disposal.
- Items
needing
laundering
can
be
brought
over
to
the
Dow
Center
Equipment
room
to
be
laundered.
All
repairs
and
replacements
are
made
by
Hope
College
at
no
cost
to employees.
- Employees
must
remove
all
garments
which
are
penetrated
by
blood immediately or
as
soon
as
possible.
They
must
remove
all
PPE
before
leaving
the
work
area.
When
PPE
is
removed,
employees
place
it
in
a
designated
container
for
disposal,
storage,
washing,
or
decontamination.
Employees
may
not
bring
contaminated
laundry
home.
- Employees must
wear
gloves when
they
anticipate
hand
contact
with
blood,
OPIM,
nonintact
skin,
and
mucous
membranes;
when
handling
or
touching
contaminated
items
or
surfaces.
Disposable
gloves
used
at
this
facility
are not to
be
washed
or
decontaminated
for
re-use
and
are
to
be
replaced
as
soon
as
practical
when
they
become
contaminated
or
as
soon
as
feasible
if
they
are
torn,
punctured,
or
when
their
ability
to
function
as
a
barrier
is
compromised.
Utility
gloves
may
be
decontaminated
for
re-use
provided
that
the
gloves
are
not
torn,
punctured,
or
when
their
ability
to
function
as
a
barrier
is
compromised.
- Synthetic,
powder-free
gloves
,
glove
liners,
powderless
gloves,
vinyl
gloves
or
other
similar
alternatives
shall
be
readily
accessible
to
those
employees
who
are
allergic
to
the
gloves
normally
provided.
- Employees
must
wear
masks
in
combination
with
eye
protective
devices,
such
as
goggles
or
glasses
with
solid
side
shield,
or
chin
length
face
shields,
whenever
splashes,
splatter,
or
droplets
of
blood
or
OPIM
may
be
generated
and
reasonably
anticipated
to
contaminate
eye,
nose,
or
mouth.
Those
situations
and
the
corresponding
eye
and
face
protection
include:
- Contact
your
supervisor
or
look
at
your
departmental
policy.
HOUSEKEEPING
- All bins, pails, cans, and similar receptacles are inspected and
decontaminated on a regularly scheduled basis: Each department should
include in their site specific plans whom and how often this is to
be done.
- Contaminated equipment should be kept separate from other equipment.
Decontamination should be done daily or as needed.
- Additional housekeeping requirements to prevent the spread
of bloodborne pathogens include:
- Broken glassware that may be contaminated shall not
be picked up directly with hands. It shall be cleaned
up using mechanical means and disposed of in closable,
leakproof, puncture-resistant, disposable containers.
HANDLING REGULATED WASTES
When handling regulated wastes, other than contaminated needles and
sharps, we make sure it is:
- Placed in containers which are closeable, constructed to contain
all contents, and prevent fluid leaks during handling, storage, transportation,
or shipping. Containers can be obtained from the OH&FS office. X7999.
- Labeled or color coded and closed prior to removal to prevent spillage
or protrusion of contents during handling, storage, transport, or shipping.
Note: Disposal of all regulated waste is in accordance with applicable
United States, state and local regulations. Regulated medical waste is
picked up at the Dow Center Health Clinic or the Schaap Science Center
Biology Department by a licensed medical waste hauler. Hope College uses
Stericycle, Inc. 1040 Market St. SW Grand Rapids, MI 49503 to pick-up
it's medical waste. Phone (616) 454-9405. All medical pick-ups can be
scheduled by calling the Occupational Health and Fire Safety office at
X7999.
HANDLING CONTAMINATED LAUNDRY
Laundry contaminated with blood or OPIM is handled as little as possible.
Such laundry is placed in appropriately marked (biohazard labeled, or
color coded red bag) bags at the location where it was used. Such laundry
is not sorted or rinsed in the area of use.
Employees must remove all garments which are penetrated by blood immediately or
as soon as possible. They must remove all PPE before leaving the work
area. When PPE is removed, employees place it in a designated container
for disposal, storage, washing, or decontamination. Employees may not
bring contaminated laundry home.
The contaminated laundry must be transported to the Dow Center Equipment
Room and turned over to the Physical Education and Athletic Equipment
Manager for washing. The Hope College Athletic Equipment Manager is Gordon
Vander Yacht X7917.
INFORMATION AND TRAINING
- Hope College ensures that bloodborne pathogens trainers are knowledgeable
in the required subject matter. We make sure that employees covered
by the bloodborne pathogens standard are trained at the time of initial
assignment to tasks where occupational exposure may occur, and every
year thereafter by the following methods:
- Video training program
- Supervisor information and training in the work area and review
of site specific policies and procedures.
- training is 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:
- The standard and its contents.
- The epidemiology and symptoms of bloodborne diseases.
- The modes of transmission of bloodborne pathogens.
- Hope College Bloodborne Pathogen ECP, and a method
for obtaining a copy.
- The recognition of tasks that may involve exposure.
- The use and limitations of methods to reduce exposure,
for example engineering controls, work practices and
personal protective equipment (PPE).
- The types, use, location, removal, handling, decontamination,
and disposal of PPE
- The basis of selection of PPEs.
- The Hepatitis B vaccination, including efficacy, safety,
method of administration, benefits, and that it will
be offered free of charge.
- The appropriate actions to take and persons to contact
in an emergency involving blood or OPIM.
- The procedures to follow if an exposure incident occurs,
including the method of reporting and medical follow-up.
- The evaluation and follow-up required after an employee
exposure incident.
- The signs, labels, and color coding systems.
All trained employees must sign a Document of Training
sign up sheet that is dated and indicates the training
received and the name and title of the instructor. A copy
of this sign up sheet should be filed with the OH&FS office
at 178 East 11th street Holland, MI 49423. (See Document
of Training record.)
- Additional training is provided to employees
when there are any changes of tasks or procedures
affecting the employee's occupational exposure.
Employees who have received training on bloodborne
pathogens in the 12 months preceding the effective
date of this plan will only receive training
in provisions of the plan that were not covered.
RECORD KEEPING
- Training records shall be maintained for three years from the date
of training. The following information shall be documented:
- The dates of the training sessions;
- An outline describing the material presented;
- The names and qualifications of persons conducting the training;
- The names and job titles of all persons attending the training
sessions.
- Training records shall be kept in the employees file at the
Human Resources Office for three years. A copy of the training
record shall be forwarded to the Occupational Health and Fire
Safety office (See Document of Training Record )
- Medical records shall be maintained in accordance with OSHA
Standard 29 CFR 1910.20. These records shall be kept confidential,
and must be maintained for at least the duration of employment
plus 30 years. The records shall include the following:
- The name and social security number of the employee.
- A copy of the employee's HBV vaccination status, including
the dates of vaccination.
- A copy of all results of examinations, medical testing,
and follow-up procedures.
- A copy of the information provided to the health care
professional, including a description of the employee's
duties as they relate to the exposure incident, and documentation
of the routes of exposure and circumstances of the exposure.
- Medical records on vaccinations and post exposure
follow-ups will be kept at the Holland MediCenter 175
S. Waverly Rd, Holland, MI 49423.
AVAILABILITY
All employee records shall be made available to the employee in accordance
with 29 CFR 1910.20. All employee records shall be made available to
the Assistant Secretary of Labor for the Occupational Safety and Health
Administration and the Director of the National Institute for Occupational
Safety and Health upon request.
HEPATITIS B VACCINATION PROGRAM
- Hope College offers the Hepatitis B vaccine and vaccination series
to all employees who have occupational exposure to bloodborne pathogens,
and post exposure follow-up to employees who have had an exposure incident.
- All medical evaluations and procedures including the Hepatitis
B vaccine and vaccination series and post-exposure follow-up,
including prophylaxis are:
- Made available at no cost to the employee.
- Made available to the employee at a reasonable time
and place.
- Hepatitus B Vaccinations at the Holland MediCenter .
- Post exposure follow-up and prophylaxis at the Holland
MediCenter 175 S. Waverly, Holland, MI PH392-5222
6:30 AM to 7:30 PM. After 6:00PM Holland Community
Hospital PH394-3202.
- Performed by or under the supervision of a licensed
physician or by or under the supervision of another licensed
health care professional.
- Provided according to the recommendations of the U.S.
Public Health Service.
- All laboratory tests are conducted by an
accredited laboratory at no cost to the employee.
Hepatitis B vaccination is made available:
- After employees have been trained in
occupational exposure (see Information
and Training).
- Within 10 working days of initial assignment.
- To all employees who have occupational
exposure unless a given employee has
previously received the complete Hepatitis
B vaccination series, antibody testing
has revealed that the employee is immune,
or the vaccine is contraindicated for
medical reasons.
- Provider
documented
proof of Hepatitis
B vaccination
status is required
to be on file
with the current
employer. Each
department
should keep
a record on
file of their
employees vaccination
record. A copy
can be sent
to the Dow
Center Health
Clinic.
- If
the
employee
initially
declines
Hepatitis
B
vaccination
but
at
a
later
date
while
still
covered
under
the
standard
decides
to
accept
the
vaccination,
the
vaccination
will
be
made
available.
All
employees
who
decline
the
Hepatitis
B
vaccination
offered
must
sign
the
OSHA-required
waiver
indicating
their
refusal.
(See
Hepatitis
B
Vaccination
Declination
Form)
- If
a
routine
booster
dose
of
Hepatitis
B
vaccine
is
recommended
by
the
U.S.
Public
Health
Service
at
a
future
date,
such
booster
doses
will
be
made
available
at
the
Dow
Center
Health
Clinic. Current
CDC
guidelines recommends
that
employees
who
have
ongoing
contact
with
patients
or
blood
and
are
at
on
going
risk
for
injuries
with
sharp
instruments
or
needlesticks
be
tested
for
antibody
to
Hepatitis
B
surface
antigen
one
to
two
months
after
the
completion
of
the
three-dose
vaccination
series.
Employees
who
do
not
respond
to
the
primary
vaccination
series
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