UNIVERSITY POLICY
| SUBJECT: | HEALTH AND SAFETY | TITLE: | BLOODBORNE PATHOGENS |
| CODING: | 00-01-45-50:00 | ADOPTED: | 07/15/94 | AMENDED: | 01/21/00 |
I. PURPOSE
The purpose of this policy
is to establish procedures that will ensure compliance with the
Occupational Safety and
Health Administration's (OSHA) "Bloodborne Pathogens Standard"
(29 CFR 1910.1030) as promulgated
by the New Jersey Public Employees Occupational
Safety and Health Act (PEOSHA).
II. ACCOUNTABILITY
Under the direction of the
President, the Senior Vice President for Academic Affairs, the
Deans, Vice Presidents and
Associate Vice Presidents shall ensure compliance and
implement this policy. The
Director of Environmental and Occupational Health and Safety
Services (EOHSS) shall assist
with implementation of this policy by providing guidance and
technical assistance to
all UMDNJ schools and patient care facilities.
III. APPLICABILITY
A. This
Bloodborne Pathogens policy applies to the following Potentially Infectious
Materials:
1. Human body fluids: blood, semen, vaginal secretions, cerebrospinal
fluid, synovial
fluid, pericardial fluid, pleural 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.
2. Any unfixed tissue or organ (other than intact skin) from a human (living or dead).
3. HIV or HBV-containing cell or tissue cultures, organ
cultures, and HIV or
HBV-containing culture medium or other solutions; and blood, organs, or
other
tissues from experimental animals infected with HIV or HBV. (Bloodborne
pathogens as they relate to the use of animal blood may also be covered
by the
policies of the University's research animal care facilities).
IV. DEFINITIONS
A.
Bloodborne pathogens shall refer to pathogenic micro-organisms that are
present in
human blood and can cause disease in humans. These pathogens shall
include, but not
limited to, hepatitis B virus (HBV) and human immunodeficiency virus (HIV).
B.
Engineering Controls shall mean controls, which by design, isolate or remove
the
bloodborne pathogen hazard from the workplace (e.g. sharps disposal containers,
self-sheathing needles).
C.
Occupational Exposure shall be used to refer to reasonably anticipated
or inadvertent
skin, eye, mucous membrane, or parenteral contact with blood or other potentially
infectious materials that may result from the performance of an employee's
duties.
V. POLICY
A. Requirements:
The primary focus of this policy is to establish procedures, in accordance
with OSHA's
"Bloodborne Pathogens Standard" (29 CFR 1910.1030), that will protect UMDNJ
staff and employees from the hazards related to occupational exposures
to bloodborne
pathogens and other potentially infectious materials. As such, this
policy will
supplement, not supersede, the existing University Policy on HIV, HBV and
HCV
(00-01-45-52:00) developed to provide a safe
work and learning environment for
University staff, students, faculty, and house staff.
1. Each UMDNJ school and patient care facility shall
be responsible for developing
standard operating procedures which will establish compliance with this
policy.
For the purposes of this policy, these standard operating procedures shall
be
known as an “exposure control plan”.
2. This policy shall be reviewed on an annual basis,
or more frequently as new
information arises.
B. Procedures:
1. Exposure Control Plan:
a. Each school and patient care facility shall ensure
that a written "Exposure
Control Plan" is developed and implemented. This plan will function
as a
standard operating procedure; describing the procedures and/or programs
established by that specific school or unit to eliminate or minimize employee
exposure to bloodborne pathogens and other potentially infectious materials.
In some cases, departmental "exposure control plans" may have to be
developed. This would especially be the case for those departments whose
risk of exposure is moderate, high and/or unique. In those cases
where
departmental "exposure control plans" are developed, it is recommended
that
they be modeled after the school/facility plan.
b. The Exposure Control Plan shall minimally consist
of the following
components:
i. An Exposure Determination for those titles within that school/facility:
(a) including a list of all job titles in which all employees
have
occupational exposure (as defined in this policy).
(b) including a list of all job titles in which some
employees in that title
have occupational exposure. For these titles, a list of all tasks
and
procedures (or groups of closely related tasks and procedures) in
which occupational exposure occurs shall also be included.
ii. Descriptions or copies of specific programs, policies,
or procedures
implemented at each school or patient care facility to address the
requirements in this policy.
c. Each school/unit shall ensure that the Exposure
Control Plan is accessible to
its employees for examination.
d. The Exposure Control Plan shall be reviewed
and updated, by
representatives of the schools/units (e.g., school/unit safety committee)
at
least annually and, whenever tasks, procedures, or titles are modified
such
that risk of exposure to bloodborne pathogens change.
2. Universal Precautions:
a. As required by the existing University Policy on HIV,
HBV, and HCV each
school and patient care facility and all employees shall comply with the
Universal Precautions Guidelines as established by the Centers for Disease
Control and the New Jersey Department of Health Infection Control
Standards for Hospitals (NJAC 8:43G-14.1(b)2).
3. Engineering Controls:
a. Each school/unit will be responsible for reviewing
and implementing available
engineering controls. Engineering Controls refer to controls, which
by design,
isolate or remove bloodborne pathogen hazard from the workplace (e.g.
sharps disposal containers, self-sheathing needles). In those cases
where
engineering controls have been implemented to the extent feasible and
occupational exposure risk remains, other methods of controlling or
minimizing occupational exposure, including personal protective equipment
shall also be used.
b. Engineering controls shall be maintained and evaluated
periodically to ensure
their continued effectiveness.
4. Work Practices and Hygiene:
Each school/unit shall establish general work practices that will eliminate
or
minimize employee exposures. These may include, but not limited to:
a. Hand washing techniques and requirements;
b. Procedures for handling and disposal of contaminated needles and sharps;
c. Lists of prohibited activities. (For example,
eating, drinking, and handling
contact lenses in those work areas where there is potential for exposure,
or
storage of food in locations where blood or other potentially infectious
material are present.);
d. Procedures to minimize splashing, spraying, spattering,
generation of
droplets, etc. during tasks which involve blood or other potentially infectious
materials; and
e. Procedures for decontamination of contaminated equipment
before
servicing, shipping or disposal.
5. Personal Protective Equipment:
a. Each school/unit shall identify the specific procedures
and/or tasks where
personal protective equipment is required to prevent exposure to
bloodborne pathogens. Specific descriptions of the personal protective
equipment required for each task or procedure shall be included in
the
school's or patient care facility's Exposure Control Plan. For example,
employees who transport specimens from clinics or patient care areas to
laboratories may be required to wear gloves and laboratory coats.
This
requirement should be specified in the facility's Plan.
b. Each school/unit shall be responsible for providing
personal protective
equipment identified as essential to job performance at no cost to the
employee. Personal protective equipment may include, but not limited to,
gloves, gowns, laboratory coats, face shields and eye protection,
mouthpieces, and resuscitation bags.
c. Each school/unit shall ensure that personal protective
equipment is accessible
and available in sufficient quantities and appropriate sizes.
d. Each school/unit shall be responsible for cleaning,
laundering, replacing and
disposing of personal protective equipment as necessary.
6. Housekeeping:
a. Each school/unit shall ensure that an appropriate
written schedule for
cleaning and decontaminating different work areas and surfaces, based
upon the location within the facility, type of surface to be cleaned, types
of
contamination present, and tasks or procedures being performed in the
area, is established and implemented in each of their departments.
b. Each school/unit shall ensure that all equipment and
environmental and
working surfaces are cleaned and decontaminated appropriately after
contact with blood or other potentially infectious materials.
c. Each school/unit shall ensure that regulated waste
is maintained, labeled,
and disposed of in accordance with the University Regulated Medical
Waste policy (00-01-45-15:00).
7. Hepatitis B Vaccination and Post-Exposure Evaluation:
a. As required by the University Policy on HIV, HBV and
HCV
(00-01-45-52:00), all house staff, faculty
and staff who have direct patient
contact, (as defined in the University Policy on HIV, HBV and HCV), or
who have contact with potentially infectious body fluids or laboratory
materials must be immunized against hepatitis B or be able to demonstrate
immunity. In accordance with the standard, each school/unit shall
be
responsible for establishing procedures such that all employees who have
occupational exposure can obtain hepatitis B vaccinations at no cost to
them. The vaccination shall be made available after the employee
has
received training in accordance with this policy (see Section 9 of this
policy)
and, within 10 working days of assignment to duty, unless immunity has
been
established or the vaccine is contraindicated for medical reasons.
b. Confidential medical evaluation and follow-up shall
be made immediately
available to employees after an exposure incident is reported.
8. Labels and Signs:
a. Warning labels in accordance with the PEOSH/OSHA Bloodborne
Pathogens standard shall be affixed to containers or regulated waste,
refrigerators and freezers containing blood or other potentially infectious
materials Exhibit A.
b. PEOSH/OSHA bloodborne pathogens labels/signs must also be
posted at
the entrances to work areas conducting HBV and HIV research.
9. Training:
a. Each school/unit shall ensure that all employees with
occupational exposure
participate in a training program on Bloodborne Pathogens with the following
frequency:
i. At initial assignment;
ii. Annually;
iii When changes that affect the employee's occupational exposure occur.
b. Training shall include as a minimum:
i. An explanation of the contents of the PEOSH/OSHA Bloodborne
Pathogens Standard and information on how a copy of the standard may
be obtained if requested;
ii. A general explanation of the epidemiology and symptoms
of bloodborne
diseases;
iii. An explanation of the modes of disease transmission;
iv. A review of the school's/unit's Exposure Control Plan and the
steps that
the employee can take to obtain a copy of it;
v. An explanation of the appropriate methods that can be used
to
recognize and evaluate tasks and activities with potential exposure;
vi. An explanation of the use and limitations of the different methods
of
control including, but not limited to, engineering controls, work practices
and personal protective equipment;
vii. Information on the types, proper use, location, removal, handling
and
disposal of personal protective equipment and the basis for selection of
the different types of equipment;
viii. Information on the appropriate actions and procedures to follow if
an
exposure occurs;
ix. Information on the hepatitis B vaccine including efficacy, safety,
and that
the vaccine will be free of charge;
x. An explanation of the signs and labels required by the standard;
xi. An opportunity for interactive questions and answers; and
xii. Additional training for employees in HIV and HBV research laboratories
which is specific to the practices and operations of the laboratory.
10. Recordkeeping:
a. Each school/unit shall ensure that medical records for each
employee with
occupational exposure are maintained for the duration of employment and
30
years thereafter. Each school/unit shall ensure confidentiality of
employee
medical records. The medical records shall include:
i. Hepatitis B vaccination status; including the dates of vaccination.
ii. A copy of all results of post-exposure medical evaluations.
iii. Copies of any information provided to the physician(s)
performing
medical evaluations related to this policy and the PEOSH/OSHA
bloodborne pathogens standard.
b. Training records shall be maintained by each school and
patient care unit and
EOHSS. The records shall include training dates, contents of training,
names
and qualifications of instructors, and names and titles of the employees
attending the training. These training records shall be maintained
a minimum
of 3 years.
11. HIV and HBV Research:
Each school/unit engaged in the culture, production, concentration,
experimentation and manipulation of HIV and HBV shall comply with the
requirements outlined for HIV and HBV research laboratories in
PEOSH/OSHA's "Bloodborne Pathogens Standard" (29 CFR 1910.1030,
paragraph (e)). These requirements, including mandates for hand
and eye washing facilities as well as autoclaves for decontamination of
regulated
waste, shall be adhered to in addition to the requirements already outlined
in this
policy.
VI. EXHIBITS
A.
Occupational Exposure to Bloodborne Pathogens
By Direction of the President:
___________________________
Vice President for Administration
Occupational Exposure to Bloodborne Pathogens
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