Written Exposure Control Program

Revised 2/16/2012

WRITTEN EXPOSURE CONTROL PROGRAM

PURPOSE:

This written blood borne disease control program has been developed for BrownCounty. The purpose of this program is to inform all affected employees of the hazards concerning contact with blood or other body fluids. All aspects of this program are to be updated through a training program on a yearly basis and all procedures are to be followed daily or whenever there is an exposure to blood or body fluids. All blood and other potentially infectious materials (OPIM) will be handled as directed by this policy.

This program will be subject to change in order to remain in compliance with all Federal and State standards. However, if there is a change to this policy before the scheduled periodic training is presented, all affected employees will be notified of those changes in writing and when feasible, instructed in them.

REFERENCES:

Federal Register 29 CFR 1910.1030

DEFINITIONS:

See Appendix A

EXPOSURE DETERMINATION:

BrownCounty has identified employees with potential risk of occupational exposure. (See Appendix B)

UNIVERSAL PRECAUTIONS:

Universal precautions will be observed by BrownCounty employees with identified risk of exposure in order to prevent contact with blood or OPIM. All blood and OPIM will be considered infectious regardless of the perceived status of the source.

ENGINEERING and WORK PRACTICE CONTROLS:

Engineering and work practice controls will be utilized to eliminate or minimize employee exposure. Where occupational exposure remains after institution of these controls, personal protective equipment shall be utilized.

A list of specific engineering controls will be developed when appropriate by each affected department and a regular examination and maintenance schedule determined and reviewed for effectiveness by the supervisor. This list and schedule will be attached to the department copy of this Exposure Control Plan.

HAND-WASHING FACILITIES/PRACTICES:

Hand-washing facilities are available to employees at risk of occupational exposure. Employees will be made aware of locations of such facilities by their Supervisor.

Antiseptic towelettes will be provided to an employee at risk of occupational exposure to be used when hand-washing facilities are not readily accessible. Hands shall be washed with soap and running water as soon as feasible.

Employees must wash their hands immediately or as soon as feasible after removal of gloves or other personal protective equipment.

Employees must wash their hands or any other skin with soap and water immediately or as soon as feasible following contact with blood or OPIM.

NEEDLES & SHARPS:

Contaminated needles and other contaminated sharps are not to be bent, sheared, broken, recapped or removed except when no alternative is feasible or such action is required by a specific medical procedure. [A list or procedure(s) which require recapping under the previous stated restrictions are filed at the afflicted departments - Mental Health Center.]

Contaminated needles or sharps for disposal shall be discarded immediately or as soon as feasible in containers that are closable, puncture resistant and leak proof on the sides and bottom. These containers shall be red or have the required biohazard label affixed.

Contaminated reusable needles or sharps or those being held for evidence will be placed in containers that are puncture resistant, closable, leak proof on the sides and bottom and are red or affixed with the required biohazard label.

WORK AREA GUIDELINES:

Eating, drinking, smoking, applying cosmetics or lip balm, handling contact lenses are prohibited in work areas where there is reasonable likelihood of occupational exposure.

Food and drink is not to be kept in refrigerators, freezers, shelves, cabinets or on countertops or bench tops where blood or body substances are present.

All procedures involving blood or OPIM shall be performed in such a manner as to minimize splashing, spraying, spattering and generation of droplets of these substances.

SPECIMEN/BODY TISSUE HANDLING:

All specimens are to be considered as if they contain potentially infectious material.

Mouth pipetting/suctioning is prohibited.

Specimens of blood and body substances are to be placed in a container to prevent leakage during collection, handling, processing, storage, transport, or shipping.

A closed specimen container for storage, transport or shipping must be red or affixed with the required biohazard label.

If outside contamination or puncture of the primary container occurs or is anticipated, this container shall be placed within a second container which prevents leakage and/or is puncture resistant. The secondary container shall be red or have the required biohazard label affixed.

All refrigerators, etc. where blood or body substances are stored shall be identified and labeled with biohazard placards.

EQUIPMENT:

All equipment contaminated with blood/body substances will be decontaminated prior to servicing or shipping.

If decontamination is not feasible, a “biohazard” tag will be attached to the equipment with an explanation of portions remaining contaminated and the servicing representative or shipping receiver will be notified prior to shipping.

PERSONAL PROTECTIVE EQUIPMENT:

Personal protective equipment (PPE) will be provided at no cost to individuals who have risk of occupational exposure under BrownCounty employment. PPE may include but is not limited to gloves, gowns, laboratory coats, face shields or masks and eye protection and available resuscitation bags.

1.Individuals at risk for occupational exposure under BrownCounty employment will use the appropriate PPE based on the anticipated exposure. (See the chart appendix as a reference example of when PPE is to be used.)

2.Appropriate PPE will be readily available in areas where there is potential for occupational exposure.

3.Individuals at risk for occupational exposure are responsible for knowing where the PPE is obtained in their area.

4.Employees will inform the department responsible for restocking PPE when stock needs replacement.

5.PPE or clothing contaminated with blood or OPIM will be removed immediately or as soon as feasible. All contaminated clothing must be placed in a red bag or designated container and sealed. If machine washable, they must be delivered to the MHC laundry department done in the proper form. If dry cleanable, they must be delivered to Bay Towel, Webster Street Store. (See #8.)

6.All PPE will be removed prior to leaving the work area and appropriately discarded or stored.

7.Disposable PPE when saturated or caked with blood or body fluids will be placed in a red bag or designated trash container for regulated waste; otherwise, it will be disposed of in the regular trash.

8.BrownCounty will be responsible for cleaning or laundering any non disposable PPE or personal clothing which is contaminated with blood or body fluids. All contaminated clothing will be delivered to the appropriate drop off site by Facilities Bags with contaminated laundry must be stored in a designated area or removed from the work area. (See Appendix F)

9.Employees should have a change of uniform or access to cover gowns/scrubs if clothing becomes contaminated. BrownCounty will provide coveralls or scrubs for an employee to temporarily utilize.

GLOVES

Gloves will be worn when it can be reasonably anticipated that the employee may have hand contact with blood, other potentially infectious materials, mucous membranes, and non-intact skin; when performing vascular access procedures, and when handling contaminated items.

Disposable gloves such as surgical or examination gloves will be replaced as soon as practical when contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised.

Disposable gloves will not be washed or decontaminated for reuse.

Utility gloves will be decontaminated for reuse if the integrity of the gloves is not compromised. They must be discarded if they are cracked, peeling, torn, punctured, or exhibits other signs of deterioration or when their ability to function as a barrier is compromised.

MASK, EYE PROTECTION, AND FACE SHIELDS

Masks in combination with eye protection devices, such as goggles or glasses with solid side shields, or chin-length face shields, will be worn whenever a splash, spray, spatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can be reasonably anticipated.

GOWNS, APRONS, AND OTHER PROTECTIVE BODY CLOTHING

Appropriate protective clothing such as gowns, aprons, lab coats or similar outer garments will be worn in occupational exposure situations. The type and characteristics will depend upon the task and degree of exposure anticipated.

Surgical caps or hoods and/or shoe covers or boots will be worn in instances when gross contamination can reasonably be anticipated.

ENVIRONEMTAL GUIDELINES:

The work site will be maintained in a clean and sanitary condition. A written schedule for cleaning and method of decontamination is based on:

-the location

-type of surface to be cleaned

-type of soil present

-task or procedures being performed in the area

Equipment and environmental and work surfaces will be cleaned and decontaminated after contact with blood or other potentially infectious materials.

Contaminated work surfaces will be decontaminated with an approved disinfectant or with a mixture of one part bleach to ten parts of water.

-after completion of procedures

-immediately or as soon as feasible when surfaces are overtly contaminated

-at the end of the work shift if the surface may have become contaminated since last cleaning

Protective coverings used for equipment and surfaces will be removed and replaced as soon as feasible or when they become overtly contaminated.

All bins, pails, cans, intended for reuse will be inspected as they are emptied for contamination with blood or other potentially infectious materials. Housekeeping is responsible for the inspection and cleaning of these.

Broken glassware is not to be picked up directly with the hands. It will be cleaned by using a brush and dust pan, tongs or forceps.

Reusable sharps that are contaminated with blood or other potentially infectious materials are not to be stored or processed in a manner that requires employees to reach by hand into the containers where these sharps have been placed.

CONTAMINATED SHARPS DISCARDING:

Any disposable sharps (e.g., broken glass, needles, blades, etc.) contaminated with blood or OPIM will be discarded immediately or as soon as feasible in sharps container that is puncture and leak proof.

Sharps containers will be:

-located in the area where sharps are used or reasonably anticipated to be found

-maintained in an upright position at all times

-replaced routinely and not allowed to overfill

Sharps containers immediately prior to removal or replacement will be closed to prevent spillage or protrusion of contents during handling, and in addition, will be sealed prior to storage, transport or shipping.

LINEN:

Linen is considered contaminated when soiled with blood or body fluids.

Contaminated linen will be:

-handled as little as possible with a minimum of agitation

-placed in a laundry bag at the location of use without sorting or rinsing

Linen wet with blood or OPIM must be contained to prevent leakage or contamination during handling, storage, or transport.

Employees in contact with contaminated linen must wear the appropriate PPE.

REGULATED WASTE:

All waste contaminated by blood or OPIM which is saturated or caked will be discarded in a plastic bag which clearly indicates the contents are biohazardous. The bag may be red or affixed with a fluorescent orange or orange-red label with the biohazard symbol and the word biohazardous.

Small amounts of blood or OPIM may be carefully poured down a drain connected to a sanitary sewer system.

All biohazardous waste will be removed in sealed bags or containers. The bags must be discarded of in a designated area or at the MentalHealthCenter. (See Appendix E)

All bio-hazardous waste will be disposed of in accordance with all applicable federal, state and local regulations.

All biohazardous waste will be placed in the above appropriate devices in the manner describe as above.

IF WASTE IS BROUGHT TO THE DROP OFF SITE AND IS NOT CONTAINED AS INSTRUCTED ABOVE, THIS MATERIAL WILL THEN BE RETUNED TO THE DEPARTMENT IN WHICH IT CAME ORIGNALLY AND WILL NOT BE PROCESSED UNTIL THE ABOVE REQUIREMENTS OF PROPER DISOPSAL HAVE BEEN MET.

COMPLIANCE MONITORING:

Compliance with Universal Precautions is considered to be a standard of performance and is included in the annual performance evaluation for all employees who have a potential for occupational exposure.

Recommended practices are stated in this policy and located in each department.

Strategies for compliance monitoring:

a.Follow-up on the report of an employee's failure to comply with the required protective measures will be the responsibility of the employee's supervisory staff.

b.Follow-up of problems identified through informal reports, complaints from staff, quality assurance or safety reports, minutes from committees, employee questionnaires, staff logs, and comments received during evaluations of education and training programs will be the responsibility of the affected departments' supervisory staff.

Noncompliance will be dealt with by the responsible supervisor according to the disciplinary process.

HEPATITIS B VACCINATION PROGRAM:

The Hepatitis B Vaccine (HBV) is not mandatory.

HBV will be offered free of charge to all employees with “reasonably anticipated” risk of occupational exposure when performing their job duties (see Exposure Determination List, Appendix B).

The HBV program is under the supervision of the Medical Director and administered by the Occupational Health nurse.

Prior to vaccination the employee will be provided with information on the HBV, its efficacy, safety and method of administration.

The HBV will be made available within 10 working days of initial assignment to all employees who have risk of occupational exposure unless the employee has documentation of previously receiving the complete HBV series, verification of immune status, or if contraindicated for medical reasons.

Current employees at risk who decline the HBV can, at any time, decide to accept the vaccine which will then be made available at that time by the employer free of charge to the employee.

A Hepatitis B Vaccine Declination form will be signed by employee with occupational risk if he/she refuses the HBV. (See Appendix D).

The employer will maintain confidential record of the HBV administration for length of employment plus 30 years.

SIGNIFICANT EXPOSURE PROCEDURE:

Definition of aSignificant Exposure:

Significant exposure is defined as blood or bodily fluids in direct contact with NON-intact skin, needle stick and punctures, skin lacerations with bloody weapons, instruments, splashes of blood to eyes, mouth, or other mucous membranes, bites if the skin is broken. The source person’s salvia may or may not contain visible blood.

If you have an exposure at work, you MUST follow the procedure as listed below immediately!!!

• If you question whether or not an incident is a true significant exposure you should contact the Occupational Health Nurse Office at 448-4423 during regular business hours of 8-4. Monday through Friday.

• If the event occurs on the weekend or during the pm or night shift, or the nurse is not available you will need to callone of the local Emergency Rooms for guidance as the Significant Exposure follow up procedure is set up in all three area medical centers which includes Bellin, Aurora, and St. Vincent’s Hospital.

• If you need to seek medical attention you can contact your family physician, an UrgentCareCenter, or any Emergency Room. Both Prevea WorkMed and Aurora Occupational Health Clinics are set up to handle significant exposures.

Please complete this check list in the order it is listed:

1. Use Standard Precautions at all times when dealing with blood or bodily fluids
2. Exposed skin surfaces should be scrubbed immediately with soap and water
3. If splashed in the eye, mouth, or open lesion, flush immediately with large amounts of water
4. The exposed employee and their supervisor should determine if the exposure is a significant exposure * if unable to determine thenrefer to the above reference*.

YOU MUST COMPLETE THE BROWN COUNTYINCIDENT REPORT FORM AND THE BROWN COUNTYREPORT OF OCCUPAITONAL EXPOSURE FORM.

When the forms have been completed and signed by both employee and supervisor, you must send them to the Occupational Health Nurse.

1. Document who the source person is and how to contact them. If they are availableimmediately for testing, direct them to the place you have elected for your follow up care for testing. Your supervisor can assist in this process.

1. Go to any of the local ER centers or Occupational Clinics in the area for significant exposure follow-up testing procedure. (Bellin, Aurora, Prevea or St.Vincent’s)

CONTACT THE OCCUPATIONAL HEALTH NURSE INFORMING HER OF THE INCIDENT BY LEAVING A MESSAGE ON THE CONFIDENTIAL VOICE MAIL # 448-4423.

POST EXPOSURE EVALUATION AND FOLLOW-UP:

Any employee exposed to blood or OPIM will report the incident to their supervisor immediately or as soon as feasible.

The employee will document the route(s) of exposure, and the circumstances under which the exposure incident occurred.

When possible the source individual will be identified and documented.

First-aid will be administered immediately or as soon as feasible post exposure.

a.if exposure on non-intact skin, wash the area with soap and warm water for 15 minutes

b.if exposure to eyes or mucous membranes, flush area with tepid water for 15 minutes

c.if exposure resulted in a minor injury, e.g., cut or laceration requiring medical attention, the injury can be treated or assessed at any local clinic or emergency room; but if the injury requires moderate or major medical care, seek an emergency room for care provision.

Employees who have had a significant blood or body fluid exposure will follow the guidelines listed below for Significant Exposure Procedure and be sent to a local clinic or hospital for a confidential medical evaluation which will include blood collection and testing.

POST EXPOSURE EXAM AND FOLLOW-UP:

Brown County Occupational Health Services will obtain and provide the exposed employee with a copy of the evaluating healthcare professional’s written opinion within 15 days of the completion of the post exposure evaluation. The employee may make a direct request to obtain this report from the Healthcare Professional. If this is done the employee will contact the Brown County Occupational Health Nurse and report their post exposure status.