Site-Specific Bloodborne Pathogen
Site-Specific Bloodborne Pathogen
Non-Laboratory Exposure Control Plan
Program Scope
The Northeastern University Exposure Control Plan (ECP) describes how to eliminate or minimize the exposure of personnel to human blood, blood products and other potentially infectious material (OPIM) that may contain bloodborne pathogens (BBP). The ECP is available on the Office of Environmental Health and Safety website for review and downloading. This document provides site-specific information about how the ECP will be carried out in specific areas and supplements the university ECP.
Responsibilities: Each supervisor of non-laboratory environments will:
- Complete this site-specific ECP based on the activities performed in his/her facilities. The plan will remain on file in a central location within the workplace along with other safety documents. A copy will be submitted to the Biosafety Program Manager each year to ensure the plan is updated annually.
- Consider sharps safety devices annually. A review of devices must be completed every year and should involve staff members that work with the sharps. The “Safety Needle/Sharps Annual Review Form” and “Sharps Safety Device Evaluation Form” should be completed each year and retained for record keeping purposes.
- Assure that faculty, staff and students are referred to complete the Bloodborne Pathogens training provided by EHS at the time of initial assignment and annually thereafter.
- All eligible faculty, staff and students will be offered the hepatitis B vaccine. Each employee must fill out a “Hepatitis B Vaccination Verification/Declination Form”. This form will be kept on file in the Office of Environmental Health and Safety.
- Refer employees who would like to get the hepatitis B vaccine to contact the Office of Environmental Health and Safety. Employees may choose to accept the hepatitis B vaccine at any time.
Prepared by / Date Completed
Phone
Number / Date of annual review and update
Building / Room Number(s)
Principal
Investigator / Department
Person Responsible for ECP / Location of
ECP
Category I
This includes workers with job related tasks or procedures that have the potential to involve contact or exposure to mucous membranes with blood or OPIM. This can include the potential for spills or splashes. Activities include research, teaching and clinical work that involves the use of human blood or OPIM.
Personnel and/or job title with expected occupational exposureCategory II
This includes workers with job related tasks or procedures that do not normally involve planned exposure to human blood or OPIM. Potential exposure may result from unplanned tasks and may be a condition of employment.
Personnel and/or job title with possible exposureCheck all material used in your work area that may result in employee exposure to bloodborne pathogens.
Source Material of Potential Bloodborne ExposureHuman Blood / Cells/Tissues/Organ Cultures – Human
Human Blood Components / Body fluids with blood (e.g. saliva, vomitus)
Human Blood Products / All body fluids-can’t differentiate fluids
Unfixed Human Tissues / Other:
Unfixed Human Organs / Other:
Culture Growth Media Solutions / Other:
Experimental Animal Blood/Tissues / Other:
Procedures/tasks with potential exposure / Personal Protective Equipment (PPE) required
Safety glasses Goggles Face shield
Lab coat Disposable gown Coveralls
Surgical Mask
Gloves: Click here to select typeNitrile - single layerNitrile - double layerLatex - single layerLatex - double layerUtility gloves
Safety glasses Goggles Face shield
Lab coat Disposable gown Coveralls
Surgical Mask
Gloves: Click here to select typeNitrile - single layerNitrile - double layerLatex - single layerLatex - double layerUtility gloves
Safety glasses Goggles Face shield
Lab coat Disposable gown Coveralls
Surgical Mask
Gloves: Click here to select typeNitrile - single layerNitrile - double layerLatex - single layerLatex - double layerUtility gloves
Safety glasses Goggles Face shield
Lab coat Disposable gown Coveralls
Surgical Mask
Gloves: Click here to select typeNitrile - single layerNitrile - double layerLatex - single layerLatex - double layerUtility gloves
Safety glasses Goggles Face shield
Lab coat Disposable gown Coveralls
Surgical Mask
Gloves: Click here to select typeNitrile - single layerNitrile - double layerLatex - single layerLatex - double layerUtility gloves
Safety glasses Goggles Face shield
Lab coat Disposable gown Coveralls
Surgical Mask
Gloves: Click here to select typeNitrile - single layerNitrile - double layerLatex - single layerLatex - double layerUtility gloves
Safety glasses Goggles Face shield
Lab coat Disposable gown Coveralls
Surgical Mask
Gloves: Click here to select typeNitrile - single layerNitrile - double layerLatex - single layerLatex - double layerUtility gloves
Engineering and Work Practice Controls
Please check the appropriate methods of compliance below.
Engineering controls – Specify when each is usedIncineration box lined with 2 red biohazard bags covered with a plastic lid
Sharps container:
Tongs or forceps to handle broken glass:
Other (describe):
Sharps containers are inspected, maintained and replaced: / Whenever necessary to prevent
overfilling (no more than 2/3 full)
By:
Every:
Sharps container decontamination and disposal procedure:
Containers for reusable sharps information and protocol for securing and removing
Sharps injury log / See Appendix A
Work practice controls used to minimize exposure; in conjunction with universal precautions
No eating or drinking, applying cosmetics or contact lenses in areas with human materials (blood and/or OPIM)
Wear protective footwear
No capping, bending or shearing
needles
Contaminated sharps are
immediately placed in sharps container
No mouth pipetting
Change gloves whenever soiled, torn or punctured
Remove gloves before exiting the lab or clinical environment
Follow procedures for proper removal and disposal of PPE
Training on use of engineering controls required prior to working in area
Specimens are transported in secondary, non-breakable, leak proof, sealed and labeled containers when taken outside of the lab
Wash hands when gloves are removed or changed, whenever gloves become soiled or contaminated and before leaving the work area / Reusable sharps are secured immediately when not in use (explain how and where these are stored):
Additional work practice controls (explain):
How are all personnel and supervisors involved in identifying changes in engineering controls and work practices and evaluating new products or process improvements?
Employee feedback (explain):
Exposure incident investigation:
Other (specify and explain):
Name of person responsible for implementing engineering controls and work practice recommendations
Personal Protective Equipment (PPE)
Please indicate the appropriate methods of compliance below.
Location of PPEPerson responsible for providing PPE
Procedure for removal and handling of used PPE
List articles that are laundered
Person responsible for laundry name of company
How are articles prepare for laundry and what is the laundry schedule?
Decontamination Procedure
Potentially contaminated surfaces and equipment shall be decontaminated at the end of each work shift. Use the table below to identify your laboratory/workplace cleaning schedule.
Area (equipment, etc.) / Frequency / Disinfectant (concentration) / Contact time (minutes)Spill and decontamination procedures (specify disinfectant and contact time)
Handwashing Facilities
Hand washing facilities shall be made available and readily accessible however where handwashing facilities are not feasible, antiseptic cleanser with clean paper towels will be available. When antiseptic cleanser is used, employee shall wash his/her hand with soap and running water as soon as feasible.
Location of handwashing facilities and/or antiseptic cleanerPerson responsible for maintaining supplies and handwashing facility
Waste Disposal
Bloodborne pathogen waste procedure - explain how waste is handled and disposed of (include PPE):Person responsible for providing site-specific BBP training (required before working with BBP – includes on proper use of engineering controls)
Person responsible for reviewing exposure incidents
Emergency Procedures
Wash area immediately
· Wounds and needlestick: Thoroughly scrub the area for 15 minutes with warm water and soap.
· Eye and mucous membrane exposure: Flush immediately at nearest eyewash station for 15 minutes.
Seek care immediately
· While you are treating your exposure area, have a co-worker contact campus police at (617) 373 – 3333 for help. They will triage you and get you to a medical care facility for further treatment if necessary.
· Be prepared with information for the healthcare providers. Bring information about the agent and/or animal or material involved in your injury or exposure. This information should include agent description, route of exposure, dose and concentration, and any unusual characteristics of the agent
· Notify your supervisor, PI and the Office of Environmental Health and Safety
______
Signature of PI or Lab Manager Date reviewed & updated
(must be within 12 months of last review/update)
Appendix A
Sharps Injury Log
PI/Supervisor:
Dates:
Date Entered / Date/Time of Incident / Type/Brand of Device / Department/ Work Area Incident Occurred / Description of IncidentRetain until ______(Five years after end of log year)
Safety Needle / Sharps Annual Review Form
All sharps that are being used where there is potential for exposure to bloodborne pathogens must be reviewed on an annual basis. During your annual review of devices, you must inquire about new or prospective safer options.
Principal Investigator / Supervisor ______
Date ______Department ______Extension ______Address ______
Please fill out the table below with the appropriate information for documentation of:
1. Annual consideration of new safer sharps devices;
2. To determine which sharp devices are currently in use;
3. To document the criteria used in the selection of the safer sharp deice in use.
Sharps Currently in Use
Name of Sharp / Manufacturer / Size(s) in Use / Is it a Safety Sharp? / Are there evaluation forms (or exclusion memos) on file? / Justification for selection of device (enter N/A if no device is currently available)Principal Investigator / Supervisor Signature ______
Date ______
Sharps Safety Device Evaluation Form
Principal Investigator / Supervisor:______Evaluation Date:______
Evaluator’s Name:______Job Title:______
Department:______Extension:______
Name of Device:______
Name of Manufacturer:______
Applications of Device:______
Number of times used:______
Please circle the most appropriate answer for each question. Not Applicable (N/A) maybe used if the question does not apply to this product. Please explain all problems with the device in the comments section.
Agree….Disagree
1. The safety feature can be activated using a one-handed technique. 1 2 3 4 5 N/A
2. The safety feature does not interfere with the normal use of this 1 2 3 4 5 N/A
product.
3. Use of this product requires you to use the safety feature. 1 2 3 4 5 N/A
4. The user’s hands remain behind the needle/sharp until activation 1 2 3 4 5 N/A
of the safety mechanism is complete.
5. A clear and unmistakable change (either audible or visible) occurs 1 2 3 4 5 N/A
when the safety feature is activated.
6. This product does not require more time to use than a non-safety 1 2 3 4 5 N/A
device.
7. The device is easy to handle while wearing gloves. 1 2 3 4 5 N/A
8. The device is easy to handle when wet. 1 2 3 4 5 N/A
9. The safety feature works well with a wide variety of hand sizes. 1 2 3 4 5 N/A
10. The safety feature operates reliably. 1 2 3 4 5 N/A
11. The exposed sharp is permanently blunted or covered after use 1 2 3 4 5 N/A
and prior to disposal.
12. This device will work with all required syringe and needle sizes. 1 2 3 4 5 N/A
13. Use of this product does not increase the number of sticks to 1 2 3 4 5 N/A
the patient.
14. The user does not need extensive training for correct operation. 1 2 3 4 5 N/A
15. The device can be used without causing more patient discomfort 1 2 3 4 5 N/A
than a conventional device.
Sharps Safety Device Evaluation Form
Agree….Disagree
16. This device offers a good view of any aspirated fluid. 1 2 3 4 5 N/A
17. The product stops the flow of blood after the needle is removed 1 2 3 4 5 N/A
from the catheter (or after the butterfly is inserted) and just prior
to the line connections or the hep-lock capping.
18. It is not easy to skip a crucial step in proper use of the device. 1 2 3 4 5 N/A
Additional Questions for I.V. Connectors:
19. Use of this connector eliminates the need to exposed needles in 1 2 3 4 5 N/A
connections.
20. The safety feature allows you to collect blood directly into a vacuum 1 2 3 4 5 N/A
tube, eliminating the need for needles.
21. The connector can be secured (locked) to Y-sites, hep-locks, and 1 2 3 4 5 N/A
central lines.
Additional Questions for Vacuum Tube Blood Collection Systems:
22. The safety feature works with a butterfly. 1 2 3 4 5 N/A
23. The inner vacuum tube needle (rubber sleeved needle) does not 1 2 3 4 5 N/A
present a danger of exposure.
Would you recommend using this device? Yes No
Comments (describe problems, list incompatibilities):______
______
1