Bloodborne Pathogens Exposure Control Plan

Bloodborne Pathogens Exposure Control Plan

REFERENCE 29 CFR §1910.1030, OCCUPATIONAL EXPOSURE TO BLOODBORNE PATHOGENS

SCOPE AND APPLICATION

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:

  • It is prudent to minimize all exposure to bloodborne pathogens
  • Risk of exposure to bloodborne pathogens should never be underestimated
  • YSU should institute as many work practices and engineering controls as possible to eliminate or minimize employee exposure to bloodborne pathogens.
  • YSU has implemented the Exposure Control Plan to meet the letter and intent of the OSHA Bloodborne Pathogen Standard. The objective of this plan is:
    • To protect employees from the health hazards associated with bloodborne pathogens
    • To provide appropriate treatment and counseling should an employee be exposed to bloodborne pathogens

DEFINITIONS

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)

 

GENERAL PROGRAM MANAGEMENT

EXPOSURE CONTROL OFFICER

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.

  • Overall responsibility for implementing the Exposure Control Plan for YSU
  • Revision and updating of the plan on a yearly basis and as necessary if circumstances dictate
  • Maintain information on the Bloodborne Pathogen Standard and bloodborne pathogen safety and health information
  • Act as facility liaison during OSHA inspections
  • Know current legal requirements concerning bloodborne pathogens
  • Conduct periodic facility audits to maintain an up-to-date Exposure Control Plan

The Director of Environmental, Health and Safety (EHS) will act as YSU’s Exposure Control Officer.

 

DEPARTMENT DIRECTORS AND SUPERVISORS

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.

 

EMPLOYEES

YSU realizes employees have the most important role in the bloodborne pathogen compliance program. Employees are responsible for the following.

  • Knowing which tasks they perform have a potential for occupational exposure
  • Attending the bloodborne pathogen training sessions
  • Planning and conducting all operations in accordance with universal precautions and work practice controls
  • Developing good personal hygiene habits

 

AVAILABILITY OF THE EXPOSURE CONTROL PLAN TO EMPLOYEES

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.

  • Department of Environmental Health and Safety, 2303 Cushwa Hall.
  • YSU Police Department.

Individual departments which are covered by the University’s Bloodborne Pathogen Standard:

  • Athletics
  • Biology
  • Dean’s Office - Engineering & Science
  • Environmental, Health and Safety (EHS)
  • Health Professions
  • Human Performance and Exercise Science (HPES)
  • Nursing
  • Physical Therapy
  • YSU Police

 

REVIEW AND UPDATE OF THE PLAN

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.

  • Annually
  • Whenever new or modified tasks and procedures are implemented which affect occupational exposure of our employees
  • Whenever employees’ jobs are revised such that new instances of occupational exposure may occur
  • Whenever we establish new positions that may involve exposure to bloodborne pathogens

 

EXPOSURE DETERMINATION

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.

 

JOB CLASSIFICATIONS IN WHICH ALL EMPLOYEES HAVE EXPOSURE TO BLOODBORNE PATHOGENS

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

  • Health Services

JOB TITLE

  • Nurse Supervisor Student
  • Nurse Student

DEPARTMENT

  • Police Department

JOB TITLE

  • Chief YSU
  • Lieutenant YSU
  • Sergeant YSU
  • Police Officer YSU

 

JOB CLASSIFICATIONS IN WHICH SOME EMPLOYEES HAVE EXPOSURE TO BLOODBORNE PATHOGENS

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

  • Health Professions

JOB TITLE

  • Professor
  • Associate Professor
  • Assistant Professor
  • Instructor
  • Student Assistant

DEPARTMENT

  • Nursing

JOB TITLE

  • Professor
  • Associate Professor
  • Assistant Professor
  • Instructor

WORK ACTIVITIES INVOLVING POTENTIAL EXPOSURE TO BLOODBORNE PATHOGENS

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.

Work Activities involving Potential 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

METHODS OF COMPLIANCE

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.

  • The use of Universal Precautions
  • Establishing appropriate Engineering Controls
  • Using necessary Personal Protective Equipment
  • Implementing appropriate Housekeeping Procedures
  • Implementing appropriate Work Practice Controls

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.

 

UNIVERSAL PRECAUTIONS

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.

 

ENGINEERING CONTROLS

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.

 

ENGINEERING CONTROL EQUIPMENT

The following operations have, or should have, Engineering Control Equipment to eliminate or minimize employee exposure to bloodborne pathogens.

DEPARTMENT OPERATION CONTROL EQUIPMENT

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.

  • Hand washing facilities are readily accessible.
  • Where hand washing facilities are not readily available, antiseptic towelettes are provided until the person can go to a hand washing facility.
  • Containers for sharps are puncture-resistant, color coded or labeled with the biohazard warning label and are leak proof on the sides and bottom.
  • Containers for contaminated materials, other than sharps, are color coded or labeled with the biohazard warning label.
  • Specimen containers are leak proof, color coded with the biohazard warning label and are puncture resistant when necessary.
  • Secondary containers are leak proof, color coded or labeled with the biohazard warning label and are puncture resistant when necessary.
  • Bloodborne Pathogen Exposure Kits are provided in the areas where there is a potential risk of bloodborne pathogens or other infectious materials.
WORK PRACTICE CONTROLS

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.

  • Employees wash their hands immediately, or as soon as feasible, after removal of potentially contaminated gloves or other personal protective equipment.
  • Following any contact of body area with blood or any other infectious materials, employees wash their hands and any other exposed skin with soap and water as soon as possible. They also flush exposed mucous membranes with water.
  • Contaminated needles and other contaminated sharps are not bent, recapped or removed unless the action is required by a specific medical procedure. If this is necessary, recapping or needle removal is accomplished through the use of a mechanical device or a one-handed technique.
  • Contaminated sharps are placed in appropriate containers immediately or as soon as possible after use.
  • Eating, drinking, smoking, applying cosmetics or lip balm and handling contact lenses is prohibited in work areas where there is a potential for exposure to bloodborne pathogens.
  • Food and drink is not kept in refrigerators, freezers, on countertops or in other storage areas where blood or other potentially infectious materials are present.
  • Mouth pipeting/suctioning of blood or other infectious materials is strictly prohibited.
  • All procedures involving blood or other infectious materials minimize splashing, spraying or other actions generating droplets of these materials.
  • Specimens of blood or other materials are placed in designated leak proof containers appropriately labeled for handling and storage.
  • If outside contamination of primary specimen container occurs, the contaminated container is placed within a second leak proof container appropriately labeled for handling and storage. If a specimen can puncture the primary container, the secondary container must be puncture resistant as well.
  • Equipment which becomes contaminated is examined prior to servicing or shipping and decontaminated as necessary unless it can be demonstrated that decontamination is not feasible.
    • An appropriate biohazard warning label identifying contaminated portions is attached to any contaminated equipment
    • Information regarding the remaining contamination is conveyed to all affected employees, the equipment manufacturer and the equipment service representative prior to handling, servicing or shipping
  • Biohazard bags containing contaminated materials will not be allowed to overflow. All contaminated material should be brought to Environmental Health and Safety (#2205 Cushwa Hall) as soon as the container becomes full.
  • Sharps containers that are (3/4) full should be brought to EHS Lab #2205, Cushwa Hall for proper decontamination and disposal.

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

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.

  • All personal protective equipment is inspected prior to wearing and is repaired or replaced if necessary.
  • Reusable personal protective equipment is cleaned and decontaminated as needed.
  • Single use personal protective equipment or equipment which cannot be decontaminated, is disposed of by transporting to the EHS Lab in #2205, Cushwa Hall.

To assure the personal protective equipment is used as effectively as possible, employees adhere to the following practices:

  • Any garment penetrated by blood or other infectious material is removed immediately or as soon as feasible and is placed in appropriate biohazardous containers
  • Only disposable outer garments are permitted to be worn when working with blood
  • Cloth outer garments are permitted in the Dental Hygiene Clinic and are laundered by University employees who are part of the Bloodborne Pathogen Standard.
  • All potentially contaminated personal protective equipment is removed prior to leaving the work area
  • Gloves are worn in the following circumstances.
    • Whenever employees anticipate hand contact with potentially infectious materials
    • When handling or touching contaminated items or surfaces
  • Disposable gloves are replaced as soon as practical after contamination or if they are torn, punctured or otherwise lose their ability to function as an “exposure barrier”
  • Utility gloves are decontaminated for reuse unless they are cracked, peeling, torn or exhibit other signs of deterioration, at which time they are discarded
  • Masks and eye protection (goggles, face shields, etc.) are used whenever splashes or spray may generate droplets of infectious materials
  • Protective clothing (such as coats) is worn whenever potential exposure to the body is anticipated

HOUSEKEEPING

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:

  • After contact with blood or other potentially infectious materials
  • After the completion of medical or research procedures
  • Immediately (or as soon as feasible) when surfaces are overtly contaminated
  • After any spill or blood or infectious materials
  • At the end of the work shift or procedure

Protective coverings (such as plastic trash bags or wrap, aluminum foil or absorbent paper) are removed and replaced:

  • As soon as it is feasible when overtly contaminated
  • At the end of the work shift if they may have been contaminated during the shift

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.

  • Potentially infectious materials are “bagged” in containers that are:
    • Closeable
    • Puncture resistant if the discarded materials have the potential to penetrate the container
    • Leak proof if the potential for fluid spill or leakage exists
    • Red/Orange in color or labeled with the appropriate biohazard warning label
  • Containers for infectious waste are placed in appropriate locations within laboratories or medical facilities that are easily accessible to employees and are as close as possible to the source of waste.
  • Waste containers are maintained upright, are replaced when necessary and are not allowed to overflow.
  • Contaminated laundry is handled as little as possible and is not sorted or rinsed where it is used. Contaminated laundry is placed immediately in the appropriate biohazard container. Wet contaminated laundry will be placed in containers which are leak proof to prevent any leakage of fluids to the exterior.
  • Whenever containers of regulated waste are moved from one area to the disposal area, the containers are immediately closed and placed inside an appropriate secondary container if leakage is possible from the first container.
  • Protective clothing, such as disposable coats and gloves are worn whenever potential exposure to the body is anticipated.

 

HEPATITIS B VACCINATION, POST EXPOSURE EVALUATION AND FOLLOW UP

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.

 

VACCINATION PROGRAM

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.

 

POST EXPOSURE EVALUATION AND FOLLOW UP

If an employee is involved in an incident where exposure to bloodborne pathogens may have occurred, two things will immediately be focused on.

  • Investigating the circumstances surrounding the exposure incident
  • Making sure the employee receives medical consultation and treatment, if required, as expeditiously as possible

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.

  • When the incident occurred (date and time)
  • Where the incident occurred (location)
  • What potentially infectious materials were involved in the incident (type of material, i.e., blood)
  • Source of material
  • Under what circumstances the incident occurred (type of work being performed)
  • How the incident was caused (accident)
  • Unusual circumstances such as equipment malfunction, power outage, etc.
  • Personal protective equipment being used at the time of the incident
  • Actions taken as a result of the incident (employee decontamination, cleanup, notifications made)

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.

  • Documentation regarding the routes of exposure and circumstances under which the exposure incident occurred
  • Identification of the source individual unless infeasible or prohibited by law

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.

 

INFORMATION PROVIDED TO THE HEALTHCARE PROFESSIONAL

To assist the healthcare professional, a number of documents are forwarded, including the following.

  • A copy of the Bloodborne Pathogen Standard.
  • A description of the exposure incident
  • The exposed employee’s relevant medical records
  • Other pertinent information

 

HEALTHCARE PROFESSIONAL’S WRITTEN OPINION

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.

 

MEDICAL RECORDKEEPING

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.

  • Name of employee
  • Social Security number of the employee
  • A copy of the employee’s Hepatitis B vaccination status including the dates of any vaccinations and medical records relative to the employee’s ability to receive the vaccination
  • Copies of the results of the examinations, medical testing and follow up procedures which took place as a result of an employee’s exposure to bloodborne pathogens
  • A copy of the information provided to the consulting healthcare professional as a result of any exposure to bloodborne pathogens

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.

 

LABELS AND SIGNS

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.

  • Containers of regulated waste
  • Refrigerators/Freezers containing blood or other potentially infectious materials
  • Sharps disposal containers
  • Other containers used to store, transport or ship blood and other infectious materials
  • Contaminated equipment
  • Laundry containers

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.

 

INFORMATION AND TRAINING

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.

 

TRAINING TOPICS

The following are the topics covered in our training program.

  • The Bloodborne Pathogen Standard
  • The epidemiology and symptoms of bloodborne diseases
  • The modes of transmission of bloodborne pathogens
  • Our facility’s Exposure Control Plan and the location of the plan
  • Appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials.
  • A review of the use and limitations of methods that will prevent or reduce exposure including:
    • Engineering controls
    • Work practice controls
    • Personal protective equipment
  • Selection and use of personal protective equipment including:
    • Types available
    • Proper use
    • Location within the facility
    • Removal
    • Handling
    • Decontamination
    • Disposal
  • Visual warning of biohazards including labels, signs and color-coded containers.
  • Information on the Hepatitis B Vaccine including its:
    • Efficacy
    • Safety
    • Method of Administration
    • Benefits of Vaccination
    • Free vaccination program
  • Actions to take and persons to contact in an emergency involving blood or other potentially infectious materials
  • The procedures to follow if an exposure incident occurs, including reporting
  • Information on the post exposure evaluation and follow up including medical consultation
  •  

TRAINING METHODS

Training presentations will be conducted using one or more of the following training techniques.

  • Classroom type atmosphere with personal instruction
  • Videotape programs
  • Training manuals/employee handouts
  • Individual training
  • Online course

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).

 

RECORDKEEPING

To document the training process, the following information is contained in our records.

  • Dates of all training sessions
  • Contents/summary of the training sessions
  • Names and qualifications of the instructors
  • Names and job titles of employees attending the training sessions

These training records are available to our employees and their representatives as well as OSHA and its representatives for examination and copying.