Bloodborne Pathogen Exposure Control Plan Template
Bloodborne Pathogen Exposure Control Plan
Table of Contents
I. PURPOSE AND OBJECTIVE
II. DEFINITIONS
III. RESPONSIBILITIES
A. Plan Administrator
B. Management
C. Supervisors
D. Employees
E. Contractors
IV. PROCEDURE
A. Exposure Determination
B. Universal Precautions
C. Engineering and Work Practice Controls
D. Diabetic Supplies
E. Sharps and Needles
F. Hand Washing Facilities
G. Work Area Restrictions
H. Specimens
I. Contaminated Equipment
J. Personal Protective Equipment (PPE)
1. PPE Provision
2. PPE Use
3. PPE Availability
4. PPE Cleaning, Laundering and Disposal
5. Types of PPE
K. Housekeeping
L. Labels and Signs
M. Regulated Waste Disposal
1. Sharps
2. Other Regulated Waste
N. Laundry
O. Hepatitis B Vaccines
P. Post-Exposure Evaluation and Follow Up
Q. Information Provided to the Healthcare Professional
R. Healthcare Professional’s Written Opinion
S. Recordkeeping
T. Evaluation and Review of the Plan
V. TRAINING
A. General
B. Records
VI. REFERENCES
A. Regulatory references
B. NCH Policy reference
VII. APPENDICES
A. Category I Job Classification/Expected Exposure List
B. Category II Job Classification/Possible Exposure List
C. Sharps Injury Log
D. Personal Protective Equipment/Task List
E. Cleaning and Decontamination Schedule
F. Hepatitis B Vaccine Declination
G. International Biohazard Symbol/Label
VIII. DOCUMENT CONTROL
Bloodborne Pathogen Exposure Control Plan
for
[Company Name/Location]
I. PURPOSE AND OBJECTIVE
The Bloodborne Pathogen Exposure Control Plan is intended to provide guidance necessary to managers and other employees of [Company Name/Location] for them to eliminate or minimize the hazards to employees who may be exposed to blood, body fluids or other potentially infectious materials that may contain bloodborne pathogens while performing normal and/or emergency job responsibilities. Employees working in a microbiology or other laboratory may have potential exposure. Employees working in an industrial, warehouse, or office facility who may be exposed to blood or other potentially infectious materials include those who are trained to administer medical first aid to other employees, those who are designated to respond to medical emergencies on site and those who perform housekeeping or janitorial duties. This is to be accomplished by providing protection to employees in the form of engineering controls, personal protective equipment, training, and risk/hazard reduction to assist facility management in ensuring that operations will be conducted in a safe, healthful and environmentally sound manner.
Another objective of the [Company Name/Location] Bloodborne Pathogen Exposure Control Plan is to assist in compliance with applicable governmental regulations, such as the U.S. Occupational Safety and Health Administration’s (OSHA) Bloodborne Pathogens Standard, 29 CFR 1910.1030, and OSHA Access to Employee Exposure and Medical Records Standard, 29 CFR 1910.1020, for facilities located in the U.S.A. The procedures described in this Plan are intended to facilitate compliance with applicable governmental regulations. If there is a conflict between this Plan and a governmental regulation, the governmental regulation will apply and this Plan will be modified. However, all other requirements in this Plan apply even if more stringent than governmental regulations.
II. DEFINITIONS
Blood means human blood, human blood components, and products made from human blood.
Bloodborne pathogens means 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).
Body fluids means 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.
Contaminated means the presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.
Other potentially infectious materials (OPIM) means any unfixed tissue or organ (other than intact skin) from a human (living or dead), and human immunodeficiency virus (HIV)-containing cell or tissue cultures, organ cultures, and HIV- or hepatitis B virus (HBV)-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.
Universal Precautions means the practice by medical professionals or first aid responders, of considering all patients to be possible carriers of blood-borne pathogens, and of avoiding any contact with the patients' body fluids by means of the wearing of personal protective equipment, such as nonporous gloves, splash goggles and face shields. The practice of universal precautions requires:
A. wearing gloves when collecting or handling blood and body fluids contaminated with blood,
B. wearing face shields and goggles when there is danger of blood splashing on mucous membranes, and
- disposing of all contaminated needles and sharp objects in puncture-resistant containers.
III. RESPONSIBILITIES
A. Plan Administrator
[Responsible Person] shall manage the Bloodborne Pathogen Exposure Control Plan for [Company Name/Location] and ensure that all records pertaining to the Plan are maintained.
B. Management
[Company Name/Location] will provide adequate controls and equipment that, when used properly, will eliminate or minimize risk of occupational exposure to blood or other potentially infectious materials. These shall be provided at no cost to the employees. [Facility Manager Name], as Facility Manager, will ensure proper adherence to this Plan through periodic evaluations.
C. Supervisors
Supervisors shall themselves follow and ensure that their employees are trained in and utilize proper work practices, universal precautions, appropriate personal protective equipment and proper cleanup/disposal techniques.
D. Employees
Employees are responsible for following the procedures described in this Plan. Employees are also responsible for reporting all exposure incidents to [Responsible Person] immediately.
E. Third Party Contractors
Third Party Contractors are responsible for complying with this Plan, and shall ensure that their employees have the necessary training to comply with the Plan.
IV. PROCEDURE
A. Exposure Determination
All job classifications and locations in which employees may be expected to incur occupational exposure to blood or other potentially infections materials, based on the nature of the job or collateral duties, regardless of frequency, shall be identified, evaluated and documented on job classification lists by [Responsible Person]. Exposure determination shall be made without regard to the use of personal protective equipment (employees are considered to be exposed even if they normally wear personal protective equipment).
Category I
Job classifications in which employees are exposed to blood or other potentially infectious materials on a regular basis, and in which such exposures are considered a normal course of work, fall into Category I. [Responsible Person] shall maintain a list of Category I jobs and the locations in which the work will be performed (see Appendix A).
Category II
Job classifications in which employees may have an occasional exposure to blood or other potentially infectious materials, and in which such exposures occur only during certain tasks or procedures that are collateral to the normal job duties, fall into Category II. [Responsible Person] shall maintain a list of Category II jobs and the locations in which the work may be performed (see Appendix B).
The lists of Category I and II job classifications shall be updated as job classifications or work situations change.
B. Universal Precautions
Universal precautions shall be used at [Company Name/Location] to prevent contact with blood or other potentially infectious materials. All blood or other potentially infectious materials shall be considered infectious, regardless of the perceived status of the source individual.
C. Engineering and Work Practice Controls
The engineering and work practice controls listed below shall be used to minimize or eliminate exposure to employees at [Company Name/Location].
[List of the controls such as sharps containers, bio-safety cabinets, safety needles, needleless systems, etc.]
Reviews of new control equipment and/or technologies present in the workplace to evaluate effectiveness should be conducted upon installation. The following schedule shall be followed to periodically review and evaluate the effectiveness of engineering and work practice controls.
[List of the schedule (such as daily, once a week, etc.) that each control is to be reviewed, including the annual review, including who has the responsibility to review the effectiveness of each control, such as the department supervisor, etc.]
Where occupational exposure remains after the institution of a control, personal protective equipment shall also be used.
D. Diabetic Supplies
Any employee bringing or handling diabetic needles/syringes, blood testing devices or other potentially contaminated equipment or supplies on site must comply with the applicable requirements of this Plan. Applicable requirements include, but are not limited to, those in Section IV. E of the Plan (Sharps And Needles), those in Section IV. M (Regulated Waste Disposal) and those in Section IV. G (Work Area Restrictions). An employee who has a question about requirements of the Plan that are applicable to diabetic supplies must discuss it with his or her supervisor.
E. Sharps and Needles
1. Except as noted below, contaminated needles and other sharps shall not be bent, recapped, removed, sheared, or purposely broken. Contaminated sharps shall be placed immediately, or as soon as possible after use, into appropriate sharps containers. All disposable sharps containers shall be puncture resistant, labeled with a biohazard label and of leak-proof design.
2. At [Company Name/Location], the following procedure(s) require a contaminated needle to be recapped or removed with a mechanical device or one-handed technique, and no alternative is feasible:
[List the procedure(s) and the mechanical device(s) or one-handed technique to be used.]
3. Contaminated sharps that are reusable shall be placed immediately, or as soon as possible after use, into appropriate sharps containers. All reusable sharps containers shall be puncture resistant, labeled with a biohazard label, and leak-proof. The following are locations for reusable sharps containers:
[List the locations of reusable sharps containers, the person(s) responsible for removing sharps from each container and the frequency that the container shall be checked for fullness.
4. Sharps Injury Log: See Section IV. S, Recordkeeping, for sharps injury log requirements.
F. Hand Washing Facilities
Hand washing facilities shall be made available and readily accessible to all employees who may incur exposure to blood or other potentially infectious materials. Where hand washing facilities are not feasible, [Company Name/Location] will provide an antiseptic cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes. Such areas include:
[List locations, tasks, and responsibilities to ensure maintenance and accessibility of these alternative hand washing methods.]
When these alternatives are used, employees shall wash their hands with soap and running water as soon as feasible.
G. Work Area Restrictions
In work areas where there is a reasonable risk of exposure to blood or other potentially infectious materials, employees shall not eat, drink, apply cosmetics or lip balm, smoke, or handle contact lenses. Food and beverages shall not be kept in refrigerators, freezers, shelves, cabinets, or on counter tops or bench tops where blood or other potentially infectious materials may be present.
Mouth pipetting or suctioning of blood or other potentially infectious materials is prohibited.
All processes and procedures shall be conducted in a matter that will minimize splashing, spraying, splattering, and generation of droplets of blood or other potentially infectious materials. Methods utilized at [Company Name/Location] for minimizing exposure are:
[List methods for minimizing exposure, such as restricted entry into a specific area, covers on centrifuges, dental dams, etc.]
H. Specimens
Any specimen of blood or other potentially infectious material shall be placed in a container that will prevent leakage during the collection, handling, processing, storage, and transport of the specimen. Any specimens that could puncture a primary container shall be placed within a secondary container that is of puncture-resistant design. If outside contamination of the primary container occurs, the primary container shall be placed within a secondary container that will prevent leakage during handling, processing, storage, transport, or shipping of the specimen.
Specimen containers shall be labeled and/or color-coded in accordance with applicable requirements.
I. Contaminated Equipment
[Responsible Person] shall ensure that equipment that has become contaminated with blood or other potentially infectious materials is examined prior to servicing or shipping. Contaminated equipment shall be decontaminated, unless decontamination is not feasible. Contaminated equipment shall be tagged and labeled as such until decontamination is completed, with the international symbol for biohazardous material (see Appendix G).
J. Personal Protective Equipment (PPE)
1. PPE Provision
[Responsible Person] shall ensure that the provisions regarding personal protective equipment described in this plan are met and maintained.
Personal protective equipment shall be chosen based on the anticipated exposure to blood or other potentially infectious materials. Protective equipment shall be considered appropriate only if it does not permit blood or other potentially infectious materials to pass through or reach an employees’ clothing, skin, eyes, mouth, or other mucous membranes under normal and proper conditions of use and for the duration of time that the equipment will be used.
A list of personal protective equipment and associated tasks for Company Name can be found in Appendix D of this plan.
2. PPE Use
Responsible Person and supervisors shall ensure that employees use appropriate PPE. In cases where an employee temporarily and briefly declines to use PPE because, in the employee’s professional judgment, its use may prevent delivery of healthcare or pose an increased hazard to the safety of the worker or co-worker, then the supervisor shall investigate and document the situation to determine whether changes can be instituted to prevent such occurrences in the future.
3. PPE Availability
[Responsible Person] shall ensure that appropriate PPE in the necessary sizes is readily accessible at the work site and is issued at no cost to employees. Hypoallergenic gloves, glove liners, powderless gloves, or other similar alternatives shall be readily accessible to those employees who are allergic to the gloves normally provided.
4. PPE Cleaning, Laundering and Disposal
All PPE shall be cleaned, laundered, and disposed of by [Company Name/Location] at no cost to the employees. Company Name will also make all necessary repairs and replacements at no cost to employees.
All garments penetrated by blood or other potentially infectious materials shall be removed immediately or as soon as feasible. All PPE shall be removed before leaving the work area.