Typical Problem:         

Typical Informant:       

Point Person:                Linda Shank

Team Members:            Linda Shank – Point Person Represents Marketing & Communications

                                     Willie Neal – First Responder, Chief of Police

                                     Adam White – Chaplain

                                     Cheryl Steele – Dean Co-Curricular Life & Director of Health Services

                                     Steve Bailey – Director of Physical Plant

                                     Director of the Local Health Department

EXPOSURE CONTROL PLAN FOR

BLOODBORNE PATHOGENS

POLICY

In accordance with federal, state and local regulations, Sweet Briar College has established work practice controls and precautions, engineering controls and employee training programs in order to eliminate and minimize occupational exposure to bloodborne pathogens.

PROCEDURE

I.      Definitions

A.    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), and hepatitis C virus.

B.    Exposure Incident -  A specific eye, mouth, or other mucous membrane, or non-intact skin contact with blood or other potentially infectious materials that results from the performance of an employeeÕs duties

C.    Source Individual - Any individual whose blood or other potentially infectious materials may be a source of occupational exposure to the employee.

II.     Scope and Application

A.    This plan applies to all occupational exposure to blood or other potentially infectious materials.

B.    Exposure Determination - Employees at Risk

1.     Employees risk exposure when providing treatment to an injured person or when cleaning up blood or body fluids.

III.   Methods of Controlling Exposure

A.    Exposure Control

1.     Employees who have received proper training in administering First Aid and CPR should be the front line of assistance to administer treatment to an injured person.

2.     All body fluids shall be considered potentially infectious materials, regardless of perceived Òlow riskÓ of a patient.

3.     Latex gloves and a CPR mask with one-way valve, suitable for administering treatment and providing protection from the patientÕs body fluids shall be stocked in first aid boxes.

4.     Gloves and masks shall be replaced as soon as possible when contaminated, torn, punctured, or otherwise deemed unusable or unprotective.  Gloves and masks shall not be washed or decontaminated for re-use.

5.     Handwashing facilities are readily accessible to all employees.  Employees shall wash their hands with soap and water immediately or as soon as feasible after removal of gloves.

B.       Housekeeping

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

2.     Any employee involved in the clean-up / decontamination of a potentially infected area shall wear gloves, and be instructed in their proper use and removal.

IV.   Exposure Incident

A.    In the event that an actual or potential exposure incident occurs, the employee shall immediately report the incident to their immediate supervisor.    The immediate supervisor is responsible for submitting the Exposure Incident Report to Pat James in Human Resources. 

B.    The Exposure Incident Report shall document the incident and include at least the following elements:

1.     Name of exposed employee.

2.     Name of source individual.

3.     Date and time of the incident.

4.     Duty being performed by the employee at the time of exposure.

5.     Details of exposure (including amount and type of body fluid, severity and risk of exposure, the extent and duration of the exposure, etc.).

6.     Use of protective equipment (i.e., in use, failed to protect, not in use etc.).

7.     Any other employees involved who may have been exposed.

8.     Determine whether changes can be instituted to prevent such occurrences in the future.

The Exposure Incident Report becomes a part of the exposed employeeÕs medical record and is kept completely confidential.

C.    Exposed Employee Counseling

The employee shall determine if the possibility of infection exists.  For instance, the employee may have had intact skin exposure, which may not constitute an actual exposure with potential for infection.  In such a case, the immediate supervisor must advise the exposed employee of the elements of the Post Exposure Evaluation and Follow-up (described in Section IV.D. below), and be offered the hepatitis B vaccine.  The hepatitis B vaccine will be available and can be administered at the College Health Center.  The employee may decline the evaluation and vaccine in such cases, if an actual exposure did not occur.  If declined, the employee must sign the Hepatitis B Vaccine Declination Form.  In these situations, the report shall be documented in the same manner as in Section B above, with a determination of ÒNon-Exposure IncidentÓ.

D.    Post-Exposure Evaluation and Follow-up

Following the report of an exposure incident, the immediate supervisor must offer the exposed employee a confidential medical evaluation and follow-up, including the following elements:

1.     The College panel of physicians for review by the employee.  The list is available in each department and posted outside Human Resources.  In addition, you can contact the Human Resources Department to obtain the panel of physicians.  The exposed employee may select the panel physician he/she wishes to consult.  An appointment shall immediately be made for the employee with the panel physician selected.

2.     Once the employee has selected the panel physician, the immediate supervisor should ensure that the physician is supplied with the following:

a)      A copy of the OSHA Standard for Bloodborne Pathogens (1910.1030) (available in the Human Resources Department).

b)     A copy of this plan.

c)      A description of the exposed employeeÕs duties as they relate to the exposure incident (detailed on the Exposure Incident Report).

d)     A copy of the Exposure Incident Report, documenting the route of exposure and the circumstances surrounding the exposure incident.

3.     The College shall request the source individual to consent to a blood test to determine HBV and HIV infectivity.  If consent is not obtained, documentation must reflect that required consent cannot be obtained.

4.     Results of the source individualÕs testing shall be made available to the exposed employee and the selected physician.  The results of the post-exposure evaluation are held in highest confidentiality. 

5.     The selected physician shall request the exposed employee to consent to a blood test to determine HBV and HIV infectivity.  If consent is not obtained, documentation must reflect that required consent cannot be obtained.

6.     The exposed employee may elect to consent to baseline blood collection, but delay testing for HIV for 90 days.  If so, the blood sample shall be preserved for 90 days, during which time the exposed employee may request testing.

7.     Results of the exposed employeeÕs testing shall be made available to the exposed employee and the selected physician.  The results of the testing shall not be made available to any other parties.  Confidentiality is of extreme importance.

8.     Within 15 days of the post-exposure evaluation, the selected physician shall provide the College with a copy of the physicianÕs written opinion, including the following elements:

a)      If Hepatitis B vaccination is indicated for the employee, and whether the vaccine was administered.

b)     Verification that the employee has been informed of the results of the evaluation.

c)      That the employee has been told about any medical conditions resulting from the exposure which requires further evaluation or treatment.

d)     All other findings or diagnoses shall remain confidential between the employee and physician, and shall not be included in the written report.

9.     The College shall maintain all records associated with the exposure incident in the exposed employeeÕs medical record.  Medical records shall be maintained for the duration of employment plus 30 years.

V.    Information and Training

A.    All employees with occupational exposure as designated in Section II.B.shall participate in a training program that will be conducted at least annually.  All new hires must be trained within 30 days of their date of hire.  The departmental supervisor is responsible for coordinating this training.  The Human Resources Department can assist with identification of resources, such as video library tapes and/or written reference material.  All training should be documented by completion of the Control of Bloodborne Pathogens Training Certificate.

B.    The training program shall include distribution and explanation of the OSHA Standard for Bloodborne Pathogens and this Exposure Control Plan.  Training will also cover the epidemiology and symptoms of bloodborne pathogens and how they are transmitted, the methods of preventing exposure, proper use and handling of personal protective equipment, information on the Hepatitis B vaccine, exposure incident reporting procedures, information on the post-exposure evaluation and follow-up. 

C.    Departmental supervisors shall maintain training records for 3 years.

D.    At least annually and following any exposure incident, the training program will be analyzed to determine if the program adequately addresses the risks involved in each job, and updated if necessary.

EXPOSURE INCIDENT REPORT

General Information

Name ____________________________     SSN:______________________

                        (exposed employee)

Date of Incident: ________________                      Time: ______ a.m. ______ p.m.

Date Reported: ______________                Reported to: _____________________

Source Individual (Name) ____________________________________________

Details of the Exposure

Brief description of events leading up to and events following exposure:

Duties being performed by the exposed employee: _______________________

Amount and type of body fluid exposed to: ______________________________

Route of exposure: ________________________________________________

Extent and duration of exposure: _____________________________________

Was protective equipment in use?  If not, why?  If so, did it fail to protect?

Any other employees involved who may have been exposed: _______________

How can this type of exposure be prevented:  ___________________________

Determination

___________ Exposure Incident (to follow with Post-Exposure Evaluation)

___________ Non-Exposure

Signatures

______________________________          ________________________________

Exposed Employee                                                           Safety Coordinator

HEPATITIS B VACCINE DECLINATION

I understand that due to occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B (HBV) infection.  I have been given the opportunity to be vaccinated with the 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 material and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.

_____________________________  Signature of exposed employee

_____________________________  Date

_____________________________  Signature of company official

_____________________________  Date