Bloodborne Pathogens Program
Fisher Scientific
Bloodborne Pathogens Program
Program 200.09
2000 Park Lane
Pittsburgh, Pennsylvania 15275
Phone 412.490.8300 • Fax 412.490.8930
Regulatory Affairs Manual Series 200
Bloodborne Pathogens Program Program 200.09
Table of Contents
X Mandatory Discretionary
Effective Date: May 1998 Rev. # 1 Page 4 of 16
Revision Date: August 2004
Regulatory Affairs Manual Series 200
Bloodborne Pathogens Program Program 200.09
1 General 1-1
1.1 Bloodborne Pathogens 1-1
1.2 Program 1-1
1.2.1 Exposure Control Plan 1-1
1.2.2 Methods of Compliance 1-2
1.2.3 Hepatitis B Vaccination 1-2
1.2.4 Post-Exposure Evaluation and Follow-up 1-2
1.2.5 Hazard Communication 1-2
1.2.6 Training 1-2
1.2.7 Regulated Waste Disposal 1-2
1.2.8 Recordkeeping 1-2
1.3 Application 1-2
2 Exposure Control Plan 2-1
2.1 Exposure Determination 2-1
2.2 Methods of Compliance 2-1
2.2.1 General 2-1
2.2.2 Engineering Controls 2-2
2.2.3 Work Practice Controls 2-2
2.3 Personal Protective Equipment (PPE) 2-3
2.4 Housekeeping 2-3
2.4.1 General 2-3
2.4.2 Contaminated Laundry 2-4
2.5 Biohazard Contamination and Cleanup 2-5
2.5.1 Personnel 2-5
2.5.2 Biohazard Cleanup 2-5
2.6 Medical Surveillance 2-6
2.6.1 Hepatitis B Vaccination 2-6
2.7 Exposure Incident 2-6
2.8 Post Exposure Evaluation 2-7
2.8.1 Exposure to Uncontaminated Sharps 2-7
2.8.2 Exposure from Known Source 2-7
2.8.3 Exposure from Unknown Source 2-8
2.9 Medical Provider 2-8
2.9.1 Medical Information 2-8
2.9.2 Medical Opinion 2-8
2.10 Employee Communication 2-9
2.10.1 Labels and Signs 2-9
2.10.2 Training 2-9
2.11 Recordkeeping 2-10
Appendices – See the Appendix Section of the Regulatory Affairs Manual
Appendix A200.09.01 - Laundry Notification Letter
Appendix A200.09.02 - BBP Standard
Forms – See the Forms Section of the Regulatory Affairs Manual
Form F105.07 - Record of ESH Training
Form F200.09.01 – Exposure Incident Report
Form F200.09.02 - Declination of Hepatitis B Vaccination
X Mandatory Discretionary
Effective Date: May 1998 Rev. # 1 Page 4 of 16
Revision Date: August 2004
Regulatory Affairs Manual Series 200
Bloodborne Pathogens Program Program 200.09
1 General
The Fisher Scientific Bloodborne Pathogens Program is designed to limit occupational exposure to blood and other potentially infectious materials since exposure could result in transmission of bloodborne pathogens which can have a serious impact on employee health. The Bloodborne Pathogens Program is required at each Fisher facility where employees can reasonably be anticipated, as the result of performing their job duties, to contact blood or other potentially infectious materials. Where exposure to human blood may occur, adherence to the controls, decontamination and disposal sections of this program is mandatory.
1.1 Bloodborne Pathogens
The Occupational Safety and Health Administration (OSHA) issued regulations governing potential exposure to bloodborne pathogens in the workplace. Because of the technical nature of the standard, the following are a few key definitions to aid in understanding:
Bloodborne Pathogens-Microorganisms present in human blood that can cause disease in humans. These include, but not limited to, hepatitis B virus (HBV) and human immunodeficiency virus (HIV).
Exposure Incident-Any potentially infectious bodily fluid that comes in contact with employee eyes, mouth, mucus membrane, non-intact skin or parenteral contact while performing a job function.
Occupational Exposure-A reasonably anticipated skin, eye, mucus membrane or parenteral contact with any potentially infectious bodily fluid while performing a job function.
Parenteral-A piercing of mucus membranes or the skin by means of a needlestick, human bite and/or abrasion.
Potentially Infectious Bodily Fluid-Fluids that maybe present in a first aid emergency including: blood, urine, bodily fluids and vomit containing blood.
Universal Precautions - refers to a method of infection control in which all human blood and other potentially infectious materials are treated as if known to be infectious for HIV and HBV. It does not apply to feces, nasal secretions, sputum, sweat, tears, urine or vomit unless they contain visible blood.
1.2 Program
1.2.1 Exposure Control Plan
Each Fisher Scientific facility that has a potential employee exposure to bloodborne pathogens must have a written Exposure Control Plan to minimize exposure. At a minimum, the plan must list tasks and procedures as well as job classification where occupational exposure occurs. It must include the schedule for implementing provisions of the standard and the procedure for evaluating circumstances surrounding exposure incidents. Exposure Control Plans must be reviewed annually.
1.2.2 Methods of Compliance
Universal precautions will be used when encountering a biohazard. Engineering and work practice controls must be implemented to minimize the potential of an event that can result in a possible biohazard exposure. Personal protective equipment must be used in conjunction with these controls to assure employee exposure is minimized.
1.2.3 Hepatitis B Vaccination
Vaccinations shall be made available to all employees who have occupational exposure to blood within 10 working days of assignment, at no cost to them.
1.2.4 Post-Exposure Evaluation and Follow-up
Following any exposure incident, the individual must immediately wash the effected area. The incident must be reported to the supervisor who must investigate. The supervisor must document the circumstances and measures to prevent recurrence. A confidential medical evaluation and follow-up must be made available to the employee, at no cost.
1.2.5 Hazard Communication
Biohazard materials must be labeled and disposed of properly.
1.2.6 Training
Training must be accomplished prior to beginning duties and repeated at least annually. At a minimum it must consist of access to a copy of the OSHA Bloodborne Pathogen Standard and an explanation of its contents, a general explanation of epidemiology, symptoms and mode of transportation of bloodborne pathogens, an explanation of the Exposure Control Plan as well as an opportunity for interactive questions and answers.
1.2.7 Regulated Waste Disposal
Waste materials contaminated with bodily fluids of potential bloodborne pathogens are to be disposed in containers labeled as biohazard waste and isolated from the general waste stream for proper disposal.
1.2.8 Recordkeeping
Medical records must be maintained for the duration of employment plus 30 years. Records of training are to be maintained for at least 3 years past the training date.
1.3 Application
First aid responders, janitorial personnel and workers handling plasma-based products may face the risk of exposure to human blood during performance of their duties. Although the only documented occupational risks of HIV and HBV infection are associated with injection, inoculation (including contamination of broken skin) or mucous membrane exposure to blood and other potentially infectious body fluids. As a precautionary measure because differentiating between fluid types is difficult, Fisher Scientific employees will treat all bodily fluids as if contaminated with human blood containing the HIV or HBV.
X Mandatory Discretionary
Effective Date: May 1998 Rev. # 1 Page 6 of 16
Revision Date: August 2004
Regulatory Affairs Manual Series 200
Bloodborne Pathogens Program Program 200.09
2 Exposure Control Plan
2.1 Exposure Determination
Identifying employees who have a potential exposure to bloodborne pathogens is the first step when implementing an exposure control program. The following job classifications at the (your Fisher facility) that have a potential occupational exposure to bloodborne pathogens:
1. First-aid/CPR Responders
2. Janitorial Services
3. Spill Team Responders
4. ______
5. ______
The employees in above referenced job classifications perform the following tasks and procedures in which a potential occupational exposure may occur:
1. CPR
2. Treatment for wounds to skin involving tears to skin tissue.
3. Removal of foreign bodies from eyes or skin tissue.
4. Disposal of contaminated sharps.
5. Clean up of injury scene.
6. Disposal of biohazard waste from first aid room and women’s restrooms.
7. ______
8. ______
2.2 Methods of Compliance
2.2.1 General
Universal precautions shall be observed to prevent contact with blood or other potentially infectious materials. Under circumstances in which differentiation between body fluid types is difficult or impossible, all body fluids shall be considered potentially infectious materials.
2.2.2 Engineering Controls
Engineering controls shall be used to eliminate or minimize employee exposure. Where occupational exposure remains after institution of these controls, personal protective equipment shall also be used. Engineering controls shall be examined and maintained or replaced on a regular schedule to ensure their effectiveness.
2.2.3 Work Practice Controls
Work practice controls will be used to eliminate or minimize employee exposure. Where occupational exposure remains after institution of these controls, personal protective equipment shall be used.
The following work place controls and procedures are part of the standard operating procedures:
· Fisher Scientific will provide handwashing facilities that are readily accessible to employees.
· When provision of handwashing facilities is not feasible, an appropriate hand cleanser in conjunction with clean cloth/paper towels or antiseptic towelette will be provided. When antiseptic cleansers or towelette are used, 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 and any other skin with soap and water, or flush mucous membranes with water immediately or as soon as feasible following contact of such body areas with blood or other potentially infectious materials.
· Contaminated needles or other contaminated sharps shall not be bent, recapped, or removed. Shearing or breaking of contaminated needles or other contaminated sharps is prohibited.
· Immediately or as soon as possible after use, contaminated sharps shall be placed in appropriate containers. The containers shall be:
o Puncture resistant.
o Labeled or color coded in accordance with this standard.
o Leak-proof on the sides and bottom.
· Eating, drinking, smoking, applying cosmetics, or lip balm, and handling contact lenses are prohibited in first-aid and restroom areas where there is reasonable likelihood of occupational exposure.
· Food and drink shall not be kept in refrigerator, freezer, shelves, cabinets, or on countertops where blood or other infectious materials are present.
· All procedures involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing, spraying, splattering, and generation of droplets of these substances.
2.3 Personal Protective Equipment (PPE)
Personal protective equipment will be provided in accordance to the PPE Hazard Assessment and PPE Requirement Matrix (Appendices A and B of the Fisher PPE Program). PPE must prohibit blood or other potentially infectious materials from passing through or reach employee's work clothes, street clothes, undergarments, skin, eyes, mouth or other mucous membranes under normal conditions of use and for the duration of time for which the protective equipment will be used.
Personal Protective Equipment will be readily accessible at the work area or issued to the affected employee. Employee will be trained on the proper use, care, maintenance and limitations of specified PPE. Training on use of PPE will be documented in writing (Appendices C and D of the Fisher PPE Program). PPE will be cleaned, repaired or replaced at no cost to the employee
If garment(s) or PPE is penetrated by blood or other potentially infectious materials, the garment(s) shall be removed as soon as feasible and placed in an appropriately designed area or container for storage, washing, decontamination or disposal.
Gloves shall be worn when it can be reasonably anticipated that the employee may have contact with blood, other potentially infectious materials, mucous membranes, non-intact skin, when performing vascular access procedures such as removing foreign bodies, and when handling or touching contaminated items or surfaces. Disposable (single use) gloves shall be replaced as soon as feasible if they tear, are punctured, or when their ability to function as a barrier is compromised.
Masks, eye protection, and face shields, masks in combination with eye protective devices such as goggles or glasses with solid side shields, or chin-length face shields, shall be worn whenever splashes, sprays, splatters, or droplets of blood or potentially infectious materials may be generated and eye, nose, or mouth contamination can reasonably be expected.
Appropriate protective clothing such as, but not limited to, gowns, aprons, lab coats, clinic jackets or similar outer garments shall be worn in occupational exposure situations. The type and characteristics will depend upon the task and degree of occupational exposure anticipated.
All PPE will be removed upon completion of work shift or when visibly contaminated. Equipment must be inspected, cleaned and routinely replaced to maintain its effectiveness. Employees will be responsible for proper inspection, storage, decontamination, proper disposal and request for replacement of all PPE. Fisher will provide the equipment and replacements as well as training in the use and maintenance of PPE.
2.4 Housekeeping
2.4.1 General
Decontamination procedures can be conducted in several ways, depending on the surface or material to be cleaned. The preferred method of decontamination is the use of a hypochlorite solution with 500 ppm of chlorine. The solution can be made with a 1:100 dilution of common household bleach and water (approximately ¼ cup bleach per one gallon of water). When a hypochlorite solution is not available, decontaminating with hot water of at least 180 degrees Fahrenheit for a minimum of 15 seconds.
All equipment and environmental working surfaces shall be cleaned and decontaminated after contact with blood and other potentially infectious materials. Contaminated work surfaces shall be decontaminated after completion of procures, immediately or as soon as feasible when surfaces are overtly contaminated or after any spill of any other potentially infectious materials; and at the end of the work shift if the surface may have become contaminated since the last cleaning.
All bins, pails, cans, and similar receptacles intended for reuse which have a reasonable likelihood for contamination with blood or other potentially infectious materials shall be inspected and decontaminated on a regularly scheduled basis and cleaned and decontaminated or, as feasible, upon visible contamination. A written schedule for cleaning and decontamination shall be established for each facility with contamination possibilities.
Waste materials are to be picked up by a mechanical means, i.e. tongs and not by hand. Regulated waste and contaminated sharps shall be discarded immediately or as soon as feasible in containers that are:
· Lidded
· Puncture resistant
· Leak-proof on sides and bottom
· Labeled in container colored fluorescent orange, orange/red or red