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POLICY 08:18:00

BLOODBORNE PATHOGENS CONTROL PLAN

  1. Purpose and Scope
    The purpose of this plan is to establish guidelines and precautions for the handling of materials which are likely to contain infectious components. The provisions of this plan extend to all Pellissippi State employees, students, and visitors who have a risk or occupational exposure to human blood or other potentially infectious body fluids.
  2. Policy
    Occupational exposure to bloodborne diseases may occur in many ways. Health care workers and emergency responders are generally assumed to be at high risk for bloodborne infections due to their routine exposure to body fluids from potentially infected individuals. These workers are not the only type of employees who have been identified as either group one or group two exposure risk (Attachment I). Other workers in an academic environment are also at risk for exposure and shall take special precautions to minimize the likelihood for exposure to blood and other body fluids from all possible contacts, including but not limited to the following: lab specimens, injured persons, or discarded materials. All discarded items collected, including but not limited to the following: lab specimens, used needles, clothing, or bed sheets, which contains blood or other body fluids, must be considered infectious for bloodborne diseases, including but not limited to following: HBV (hepatitis B) and HIV (the virus thought to cause Acquired Immune Deficiency Syndrome). It is the policy of Pellissippi State Community College to protect all employees, students, and visitors from potential occupational exposure to bloodborne diseases.
  3. Procedure
    The following guidelines should be followed to protect all employees, students, and visitors from occupational exposure to bloodborne diseases acquired through contact with blood or other body fluids either by direct contact or indirectly from laboratory samples, evidence, contaminated crime/accident scenes, or waste products. All outlined specific procedures are intended to comply with 29 CFR 1910.1030 and may require periodic revisions in order to protect the safety of all Pellissippi State employees.

    1. Universal Precautions
      1. Hand Washing
        1. Wash hands with soap and water after each contact or as soon as reasonably possible after an exposure. When conditions prohibit immediate washing, a suitable chemical antiseptic alternative will be used and will be provided by the college, at no cost to the employee. If the chemical is used, the employee must wash with soap and water as soon as possible
        2. Always wash hands after removing gloves.
      2. Gloves
        1. Gloves must be worn by the employee anytime there is a reasonable possibility that the employee will be exposed to blood or body fluids.
        2. Gloves shall be of appropriate material, either intact latex or intact vinyl, and provided by the college at no cost to the employee.
        3. Reusable gloves may be used for activities which do not involve direct contact with another individual (i.e., equipment cleaning, specimen handling, and others). Reusable gloves must be in good condition and free of tears or other evidence of deterioration and shall be disinfected with an approved disinfectant solution daily.
      3. Gowns
        1. Gowns must be worn by the employee at any time that there is a reasonable possibility that blood or body fluids will be splashed on the employee or when a soak through of the exterior clothing is likely.
        2. Gowns should be made of a fluid-proof material and offer protection of exposed skin, and provided by the college at no cost to the employee.
      4. Mask
        1. A mask must be worn when there is a reasonable possibility that the employee may be exposed to facial spattering which may contact the mucus membranes of the nose and mouth.
        2. Masks should be the disposable filter type, and provided by the college at no cost to the employee.
      5. Protective Eyeware
        1. Protective glasses or goggles should be worn when there is a reasonable possibility that the employee may be exposed to spattering which may contact the eyes.
        2. Protective eyewear should be American National Standard Index (ANSI) approved and provided by the College at no cost to the employee.
      6. Resuscitation Equipment
        1. Mechanical ventilation devices shall be used, as opposed to mouth-to-mouth contact, in cases of cardiac or respiratory arrest.
        2. The mechanical ventilation devices shall be the disposable type and provided by the college at no cost to the employee.
      7. Hepatitis B Vaccine
        1. The Hepatitis B vaccination will be offered at no cost to all employees whose jobs involve potential risk of exposure to bloodborne diseases (Attachment I).
        2. The vaccination should be provided by an appropriate vendor in conjunction with the Pellissippi State Human Resources office.
        3. Employees who elect to refuse the vaccination must sign the Hepatitis B Vaccination Declination Form (Attachment II). A copy of this form must be maintained in the Human Resources office.
      8. Bloodborne Pathogens Education/Training
        1. All employees, in classifications which have occupational exposure, will receive initial training during orientation. The training will follow the training outline provided in 29 CFR 1910.1030
        2. Training records must be maintained by the Human Resources office on all employee training including the name and qualifications of the person conducting the training, the dates of training, content summary, and the names and titles of others attending the training.
      9. Record Keeping
        1. Each affected employee shall have a record maintained containing:
          1. name and social security number;
          2. a copy of the employees hepatitis B vaccination status including the dates of vaccinations;
          3. a copy of the refusal form if applicable (Attachment III);
          4. a copy of results from all examinations, testing, and follow-ups of exposures; and
          5. a copy of all medical reports relating to exposures.
        2. Records must be kept confidential and released only with the expressed written consent of the employee.
        3. Records must be maintained for the duration of employment plus thirty years, except training records which must be maintained for at least three years from the date of the training.
    2. Response
      1. Accident Scene Response
        All accidents must be reported immediately to the Safety and Security Office at 694-6649.

        1. Employees responding to accident scenes which present risk of exposure to blood or body fluids will, as soon as reasonably possible, secure the scene and clearly mark it to allow other employees to easily recognize that blood or body fluid exposure risk is possible. Employees must take all reasonable precautions to prevent public exposure to such scenes.
        2. If the scene is confined to a room it should be marked from the outside with a biohazard warning sign. In addition, a supply of personal protective equipment (i.e., gloves, mask, goggles, and gowns) should be made available to all employees who must enter the scene.
        3. If the scene is an outdoor area or an uncontrolled indoor area, it should be marked as clearly as possible utilizing biohazard caution tape.
      2. Lab Samples
        1. Universal precautions will be utilized when lab samples are collected/used which contains blood or body fluids. Samples should be collected in the recommended fashion.
        2. Samples which are potentially infectious shall be in a leak proof container and marked with the red biohazard symbol. When the biohazard emblem is not available, a red bag or container may be used.
      3. Needles/Sharps
        1. Employees must use extreme caution when dealing with needles or sharp objects (i.e., knives, screwdrivers, ice picks, etc.).
        2. Needles which are found and not considered evidence should be brought to the attention of the Safety & Security Office for disposal. Needles should not be broken, bent, or recapped. Needles must be disposed of in an approved sharps container.
      4. House Keeping
        An EPA approved disinfectant must be used to decontaminate spills of blood or body fluids. The spill must first be wiped up wearing gloves, then the surface must be decontaminated. When a vehicle is exposed to blood or body fluids it should not be used until it has been thoroughly disinfected. A 1:10 dilution of Clorox Bleach or equivalent strength hypochlorite solution shall be used for this purpose.
      5. Waste Disposal
        1. Used personal protective equipment should be placed in approved and labeled biohazard containers and picked up by the Safety and Security Office as soon as reasonably possible for proper disposal.
        2. Cleaning waste shall be handled in a similar fashion.
        3. Waste will not be disposed of in any other manner.
        4. Waste must be handled by the duty shift which creates the waste in order to protect all employees.
        5. All biohazard waste will be picked up and incinerated by an approved vendor.
      6. Follow-up Procedures
        1. Follow-up procedures will be initiated when any of the following accidents occur:
          1. If an employee receives a needle-stick or is cut with a sharp instrument of unknown origin;
          2. If an employee receives a splash of blood or body fluid to the eyes, nose, or mouth; or
          3. If the employee contacts blood or body fluid with chapped or abraded shin.
        2. Follow-up procedures will be conducted as outlined below. If the affected employee refuses follow-up care the refusal of follow-up form must be completed.
          1. Documentation (Attachment IV) of the following:
            1. route of exposure;
            2. the identity of the source of the body fluid; and
            3. the circumstances of the exposure.
          2. Collection and testing of the source person’s blood for HIV and HBV if possible.
          3. Collection and testing of the exposed person’s blood for HIV and HBV immediately
          4. Medical evaluation of the exposed person by a physician.
          5. Further follow-up of the exposed person including counseling.
          6. If the initial HIV test of the exposed person is negative, further testing for HIV six weeks, twelve weeks, and six months post exposure.
          7. If the employee or student has not been vaccinated against HBV or the antibody response is not adequate, post exposure prophylaxis including treatment with immune globulins and Hepatitis B Vaccine, under the direction of a physician shall be administered.
          8. Records of employee exposure to infectious agents shall be maintained for 30 years following the last date of employment.
          9. A Safety and Security Office incident report will be completed and forwarded to the Human Resources office.

Source: 29 CFR 1910.1030(b) as printed in the Federal register Vol.56. 235, Friday, December 6, 1991. Pages 64175-64182.
Occupational Exposure to Bloodborne Pathogens. OSHA #3127 U.S., Department of Labor. 1992. Entire Document

Attachments 08:18:00

 

Approved: Executive Council, March 4, 1991
Editorial Changes, May 4, 1993
Approved: President Allen G. Edwards, October 22, 2001
Reviewed/Recommended: President’s Staff, March 26, 2007
Approved: President Allen G. Edwards, March 26, 2007
Editorial Changes: July 1, 2009
Reviewed/Recommended: President’s Council. April 30, 2012
Approved: President Anthony Wise, Jr., April 30, 2012
Reviewed/Recommended: President’s Council, March 28, 2022
Approved: President L. Anthony Wise Jr., March 28, 2022