One of the major goals of the Occupational Safety and Health Administration (OSHA) is to promote safe work practices in an effort to minimize the incidence of illness and injury experienced by employees. Relative to this goal, OSHA enacted the Occupational Exposure To Bloodborne Pathogens Standard, codified as 29 CFR §1910.1030. The purpose of the Bloodborne Pathogen Standard is to “reduce occupational exposure to Hepatitis B Virus (HBV), Human Immunodeficiency Virus (HIV) and other bloodborne pathogens” that employees may encounter in their workplace.
Youngstown State University (YSU) realizes occupational exposure to blood or other potentially infectious materials can occur to its employees. Therefore, in order to protect the health and welfare of its employees, the University has established certain precautions and safeguards for all employees who may come into contact with blood or blood products. Under this rule, other potentially infectious materials as defined on page 4 of this document will also be subject to this standard.
YSU believes there are a number of “good general principles” that should be followed when working with bloodborne pathogens. These include:
In order to better understand the function of the Bloodborne Standard, it is important employees have a clear understanding of the definitions used by OSHA. The following is a list of the most important definitions.
BLOOD - Human blood, human blood components and products made from human blood.
BLOODBORNE PATHOGENS - Pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, Hepatitis B Virus (HBV) and Human Immunodeficiency Virus (HIV).
CONTAMINATED - The presence of the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.
CONTAMINATED SHARPS - Any contaminated object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broken capillary tubes and exposed ends of dental wires.
CONTAMINATED LAUNDRY - Laundry which has been soiled with blood or other potentially infectious materials, or may contain sharps.
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.
ENGINEERING CONTROLS - Controls (e.g., sharps disposal containers, self-sheathing needles, etc.) that isolate or remove the bloodborne pathogens hazard from the workplace.
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’s duties.
HANDWASHING FACILITIES - A facility providing an adequate supply of running potable water, soap and single use towels or hot air drying machines.
HBV - Hepatitis B Virus
HCV - Hepatitis C Virus
HIV - Human Immunodeficiency Virus
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 employee’s duties.
OTHER POTENTIALLY INFECTIOUS MATERIALS - (1) 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 that is visibly contaminated with blood and all body fluids in situations where it is difficult or impossible to differentiate between body fluids. (2) Any unfixed tissue or organ (other than intact skin) from a human (living or dead). (30 HIV-containing cell or tissue cultures, organ cultures and HIV or HBV-containing culture medium or other solutions and blood, organs or other tissues from experimental animals infected with HIV or HBV.
PERSONAL PROTECTIVE EQUIPMENT - 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.
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.
SOURCE INDIVIDUAL - any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to an employee. Examples include, but are not limited to, hospital and clinic patients, clients in institutions for the developmentally disabled, trauma victims, clients of drug and alcohol treatment facilities, residents of hospices and nursing homes, human remains and individuals who donate or sell blood or blood components.
UNIVERSAL PRECAUTIONS - Treating all blood and certain human body fluids as if they are known to be infectious for HIV, HBV and other bloodborne pathogens.
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)
The “Exposure Control Officer” will be responsible for the overall management of YSU’s Bloodborne Pathogens Compliance Program. Activities which are delegated to the Exposure Control Officer will include the following.
The Director of Environmental, Health and Safety (EHS) will act as YSU’s Exposure Control Officer.
Department chairpersons, department directors, immediate supervisors and faculty are responsible for exposure control in their respective areas. They work directly with the Exposure Control Officer and employees to ensure the proper exposure control procedures are followed. Although students are not covered by the Exposure Control Plan, it will be the responsibility of individual faculty to inform students of any hazard associated with the use of blood, blood products or any other infectious materials that may be used in the teaching environment.
YSU realizes employees have the most important role in the bloodborne pathogen compliance program. Employees are responsible for the following.
The Exposure Control Plan is available to employees. Employees are advised of the location of the plan during their education/training sessions. Copies of the Exposure Control Plan are available in the following locations.
Individual departments which are covered by the University’s Bloodborne Pathogen Standard:
We recognize it is important to keep our Exposure Control Plan up to date. To ensure this, the plan will be reviewed and updated by the Exposure Control Officer under the following circumstances.
The key to implementing a successful Exposure Control Plan is to identify exposure situations employees may encounter. To facilitate this, we have prepared the following lists.
Job classifications in which all employees in these classifications may have occupational exposure to bloodborne pathogens.
Job classifications in which some employees in these classifications may have occupational exposure to bloodborne pathogens.
Tasks and procedures in which occupational exposure to bloodborne pathogens occurs (these tasks and procedures are performed by employees in the job classifications shown on the two previous lists).
The initial lists were compiled on June 28, 1994. The Exposure Control officer will work with department heads to revise and update these lists as tasks, procedures and classification change.
Below are listed the job classifications in our facility where all employees in these job classifications may come into contact with human blood or other potentially infectious materials, which may result in possible exposure to bloodborne pathogens.
DEPARTMENT
JOB TITLE
DEPARTMENT
JOB TITLE
Below are listed the job classifications where some employees with these job classifications may come into contact with human blood or other potentially infectious materials which may result in possible exposure to bloodborne pathogens.
DEPARTMENT
JOB TITLE
DEPARTMENT
JOB TITLE
Below are listed the tasks and procedures where employees may come into contact with human blood or other potentially infectious materials which may result in exposure to bloodborne pathogens.
| TASK | JOB CLASSIFICATION | DEPARTMENT |
|---|---|---|
| Dental Clinic | Professor | Health Professions |
| Dental Clinic | Associate Professor | Health Professions |
| Dental Clinic | Associate Professor | Health Professions |
| Dental Clinic | Instructor | Health Professions |
| Emergency Care | Professor | Health Professions |
| Emergency Care | Associate Professor | Health Professions |
| Emergency Care | Assistant Professor | Health Professions |
| Emergency Care | Instructor | Health Professions |
| Lab Instruction | Professor | Health Professions |
| Lab Instruction | Associate Professor | Health Professions |
| Lab Instruction | Assistant Professor | Health Professions |
| Lab Instruction | Instructor | Health Professions |
| First Aid/Patient Care | Nurse | Student Health Services |
| Patient Care | Professor | Nursing |
| Patient Care | Associate Professor | Nursing |
| Patient Care | Assistant Professor | Nursing |
| Patient Care | Instructor | Nursing |
There are a number of areas that must be addresses in order to effectively eliminate or minimize exposure to bloodborne pathogens. The following is a list of how YSU intends to comply with the bloodborne standard.
Each of these areas is reviewed with employees during their bloodborne pathogen related training. By following the requirements of OSHA’s Bloodborne Pathogen Standard in these five areas, we feel we will eliminate or substantially minimize employee’s occupational exposure to bloodborne pathogens as much as possible.
YSU began a program of Universal Precautions on June 30, 1994. As a result, we treat all human blood and other potentially infectious material (OPIM) as if they are known to be infectious for HBV, HIV or other bloodborne pathogens. In circumstances where it is difficult or impossible to differentiate between body fluid types, we assume all body fluids to be potentially infectious. The Exposure Control Officer is responsible for overseeing our Universal Precautions Program.
One aspect of the Exposure Control Plan is the use of Engineering Controls to eliminate or minimize employee exposure to bloodborne pathogens. As a result, employees use cleaning, maintenance and other equipment designed to prevent contact with blood or other potentially infectious materials. The Exposure Control Officer works with department heads to review tasks and procedures performed where engineering controls can be implemented or updated. Engineering controls are reexamined during the annual Exposure Control Plan review and when additional tasks are added that require the use of engineering controls. Existing engineering control equipment is reviewed for proper function and needed repair or replacement by the appropriate department head where the equipment is located.
The following operations have, or should have, Engineering Control Equipment to eliminate or minimize employee exposure to bloodborne pathogens.
EHS Spill Cleanup: Tongs, Brush, Dustpan
Janitorial Services: Dustpan, Brush, Broom
Biology Research Involving Blood: Plexiglass Shields
Chemistry Research Involving Blood: Plexiglass Shields
Health Professions Lab, Analysis of Blood: Plexiglass Shields
In addition to the engineering controls identified on the previous list, the following engineering controls are used throughout our facility.
In addition to engineering controls, a number of Work Practice Controls to help eliminate or minimize employee exposure to bloodborne pathogens have been implemented. The Exposure Control Officer is responsible for overseeing the implementation of Work Practice Controls. The Exposure Control Officer works closely with the department directors to assure proper and effective implementation.
The following Work Practice Controls have been adopted as part of the Bloodborne pathogen Compliance Program.
If a new employee is hired or if an existing employee changes job descriptions in which the potential for exposure to bloodborne pathogens is present, he/she will be trained at the time of employment in the appropriate work practice controls.
Personal protective equipment is the “last line of defense” against bloodborne pathogens. YSU provides (at no cost to employee) the personal protective equipment necessary to protect employees against any exposures. This equipment includes, but is not limited to, the following.
Gloves - Safety Glasses
Goggles - Face Shield/Mask
Respirators - Bloodborne Pathogen Kits
The Exposure Control Officer, working with department heads, is responsible for ensuring all departments and work areas have appropriate personal protective equipment available to employees.
Employees are trained regarding the use of the appropriate personal protective equipment for their job classifications and tasks/procedures they perform. Initial training on personal protective equipment was completed on January 10, 1995. Additional training is provided, when necessary, if an employee takes a new position or new job functions are added to their current position. Any needed training is provided by their department supervisor or staff from EHS.
To ensure personal protective equipment is not contaminated and is in the appropriate condition to protect employees from potential exposure, YSU adheres to the following practices.
To assure the personal protective equipment is used as effectively as possible, employees adhere to the following practices:
Maintaining our facility in a clean and sanitary manner is an important part of the Bloodborne Pathogen Compliance Program. Cleaning and decontamination of appropriate areas will be conducted by the person who has been using or processing the potentially infectious body fluid.
All equipment and surfaces are cleaned and decontaminated:
Protective coverings (such as plastic trash bags or wrap, aluminum foil or absorbent paper) are removed and replaced:
All biohazard containers intended for disposal of infectious materials are inspected, cleaned and decontaminated as soon as possible if visibly contaminated.
Potentially contaminated broken glassware or sharps are picked up using mechanical means such as a dustpan and brush, tongs, forceps, etc.
Our facility is very careful in the handling of regulated waste and other potentially infectious materials. Starting on or before May 1, 1990 the following procedures are used with all of these types of waste.
Youngstown State University recognizes even with strict adherence to all exposure prevention practices, exposure incidents can occur. As a result, YSU has implemented a Hepatitis B Vaccination Program, as well as set procedures for post exposure evaluation and follow up should exposure to bloodborne pathogens occur.
To protect our employees from the possibility of Hepatitis B infection, YSU has implemented a vaccination program. This program is available, at no cost, to all employees who may have occupational exposure to bloodborne pathogens.
The vaccination program consists of a series of three inoculations over a six-month period. As part of their bloodborne pathogen training, employees have received information regarding the Hepatitis B vaccination, including its safety and effectiveness.
The Exposure Control Officer is responsible for setting up the vaccination program through YSU’s Student Health Clinic. Employees can schedule an appointment with the Clinic to receive all three inoculations.
Vaccinations are performed under the supervision of a licensed physician or other healthcare professional. Employees taking part in the vaccination program are listed on file in the department of EHS. Employees who have declined to take part in the program have been informed of their right to receive the vaccination at a later date if they so choose. Those who have refused to vaccination have a signed “Hepatitis B Declination Form”. A listing of those who have refused the vaccination can be found on file in the Department of EHS.
If a routine booster of Hepatitis B Vaccine is recommend by the U.S. Public Health Service at a future date, such booster dose will be made available to employees at no cost.
In accordance with Center for Disease Control recommendations, titer check will be conducted one to two months after an employee received their third vaccination. If the employee does not show an adequate titer, they will be given additional vaccination as deemed necessary by the health care professional.
To ensure all employees are aware of our vaccination program memos explaining the program were sent to all departments who have employees that may have an exposure to bloodborne pathogens. Copies of these memos can be found on file in the Department of EHS.
If an employee is involved in an incident where exposure to bloodborne pathogens may have occurred, two things will immediately be focused on.
The Exposure Control Officer, or designee, investigates every exposure incident. The investigation is initiated within 24 hours of notice of the incident and involves gathering the following information.
After this information is gathered and evaluated, a written summary of the incident and its cause is prepared and recommendations are made for avoiding similar incidents in the future. A copy of the “Incident Investigation Form” is found at the end of this document.
In order to assure employees receive the best and most timely treatment if an exposure to bloodborne pathogens should occur; YSU has set up a comprehensive post exposure evaluation and follow up process. The Exposure Control Officer will oversee this process.
Much of the information involved in the process must remain confidential and everything will be done to protect the privacy of the people involved.
The first step in the process will be to provide the exposed employee with the following confidential information.
Next, if possible, we will have the source individual’s blood tested to determine HBV, HCV and HIV infectivity. This information will be made available to the exposed employee, if obtained. At that time, the employee will be made aware of any applicable laws and regulations concerning disclosure of the identity and infectious status of a source individual.
In the meantime, the employee is advised to arrange for an appointment with a qualified healthcare professional to discuss the employee’s medical status. The blood of the exposed individual will be tested for HBV, HCV and HIV status. An evaluation of any reported medical illness, as well as any recommended treatment will be discussed with the physician. The cost of this examination will be charged to the University.
To assist the healthcare professional, a number of documents are forwarded, including the following.
After consultation, the healthcare professional provides YSU with a written opinion within fifteen days evaluating the exposed employee’s situation. We in turn furnish a copy of this opinion to the exposed employee.
In keeping with this process’ emphasis on confidentiality, the written opinion will contain only the following information.
Whether Hepatitis B Vaccination is indicated for the employee
Whether the employee has received the Hepatitis B Vaccination
Confirmation the employee has been informed of the results of the evaluation
Confirmation the employee has been told about any medical conditions resulting from the exposure incident which require further evaluation or treatment
All other findings or diagnoses will remain confidential and will not be included in the written report.
To assure as much medical information is available to the participating healthcare professional as possible, YSU maintains comprehensive medical records on our employees who have had an occupational exposure. The Exposure Control Officer is responsible for maintaining these records, which include the following information.
As with all information in these areas, it is recognized that it is important to keep the information in these medical records confidential. YSU will not disclose or report this information to anyone without the employee’s written consent, except as required by law.
One of the most obvious warnings of possible exposure to bloodborne pathogens are biohazard labels. Because of this, YSU has implemented a comprehensive biohazard warning labeling program using labels of the type shown on the following page, or when appropriate, using red “color coded” containers. The Exposure Control Officer is responsible for maintaining this program.
The following items in our facility are labeled with the biohazard symbol.
On labels affixed to contaminated equipment, we have also indicated which portions of the equipment are contaminated.
YSU recognizes that biohazard signs must be posted at entrances to HIV and HBV research laboratories and production facilities. Since YSU does not have these types of operations in its facility, it is not affected by these special signage requirements.
In order to minimize employee exposure to bloodborne pathogens, it is extremely important to have well-informed and educated employees. Therefore, all employees who have the potential for exposure to bloodborne pathogens are required to attend a comprehensive training program. This program provides employees with as much information as possible on bloodborne pathogens.
Employees receive initial training and will be required to attend annual refresher training sessions. Additionally, all new employees, as well as employees changing jobs or job functions, will be given any additional training their new position requires at the time of their new job assignment.
The Education/Training Coordinator is responsible for seeing all employees who have potential exposure to bloodborne pathogens receive training.
The following are the topics covered in our training program.
Training presentations will be conducted using one or more of the following training techniques.
Time is allotted at the end of each training session for employees to have an opportunity to ask questions. Employees can also contact the Exposure Control Officer at any time if questions arise. He can be reached by contacting the Department of Environmental Health and Safety (ext. 3700) during regular business hours. After hours, he can be reached by contacting the University Police Department (ext. 3527).
To document the training process, the following information is contained in our records.
These training records are available to our employees and their representatives as well as OSHA and its representatives for examination and copying.
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