1. Methods of Compliance
2. Standard Precautions
3. Engineering Controls
4. Work Practice Controls
5. Personal Protective
METHODS OF COMPLIANCE
We understand that there are a number of areas that must be
addressed in order to effectively eliminate or minimize exposure to bloodborne
pathogens in our facility. The first five areas we deal with in our plan
- The use of Universal Precautions
- Establishing appropriate Engineering Controls
- Implementing appropriate Work Practice Controls
- Using necessary Personal Protective Equipment
- Implementing appropriate Housekeeping Procedures
By rigorously following the requirements of OSHA's Bloodborne
Pathogens Standard in these five areas, we feel that we will eliminate or minimize
our employees exposure to bloodborne pathogens as much as possible.
In our facility, we have observed the practice of "Universal Precautions"
to prevent contact with blood and other potentially infectious materials since
August 1, 1992. As a result, we treat all human blood and the following
body fluids as if they are known to be infectious for HBV, HIV, and other bloodborne
- Vaginal secretions
- Cerebrospinal fluid
- Synovial fluid
- Pleural fluid
- Pericardial fluid
- Peritoneal fluid
- Amniotic fluid
In circumstances where it is difficult or impossible to differentiate
body fluid types (i.e., blood tinged fluids), we assume all body fluids to be
One of the key aspects to our Exposure Control Plan is the use
of Engineering Controls to eliminate or minimize employee exposure to bloodborne
pathogens. As a result, our facility employs equipment, such as sharps
disposal containers, and ventilating laboratory hoods as appropriate.
The following engineering controls are used, when needed, throughout
- Handwashing facilities are readily accessible
to all employees who have the potential for exposure. Antiseptic hand cleaners and clean towels or antiseptic towelettes may be used temporarily, as long as hands are washed with soap and running water as soon as feasible.
- Containers for contaminated sharps having the
- Color-coded or labeled with a biohazard
- Leak proof on the sides and bottom
- Sharps containers must be replaced periodically, (i.e.,
when they are approximately 3/4 full.)
- Specimen containers which are:
- Color-coded or labeled with a biohazard
- Puncture resistant when necessary
- Biological Safety Cabinets to provide containment
of infectious aerosols. Cabinets must be certified annually or whenever
- Mechanical pipetting devices. Mouth pipetting
- Splash guards or plastic-backed absorbent pads must be used to contain the
spread of blood and potentially infectious material in the laboratory.
- When the elimination of needle-bearing devices is not possible, needle devices
with safety features should be utilized. (Sharps injury protections) Examples of Safe Needle Devices
(See procedures for the
safe disposal of biohazardous waste)
WORK PRACTICE CONTROLS
In addition to engineering controls, our facility uses a number
of Work Practice Controls to help eliminate or minimize employee exposure to
bloodborne pathogens. Many of these Work Practice Controls have been
in effect for some time.
Our facility has adopted the following Work Practice
Controls as part of our Bloodborne Pathogens Compliance Program:
- Employees wash their hands immediately, or
as soon as feasible, after removal of gloves or other personal protective
- Following any contact of body areas with blood or any other potentially
infectious material, employees wash their hands and any other exposed skin
with soap and water as soon as possible. They also flush exposed mucous
membranes with water.
- Contaminated needles and other contaminated
sharps are not bent, recapped or removed unless:
- It can be demonstrated that there
is no feasible alternative.
- The action is required by a specific
medical or research procedure.
- In the two situations above, the
recapping or needle removal is accomplished through the use of
a mechanical device or a one-handed scoop
- Contaminated sharps are placed in appropriate
containers immediately, or as soon as possible after use. Containers
should be disposed of when approximately 3/4 full.
- Mixed waste sharps contaminated with carcinogens or
mutagens must be separated from other sharps. Label these containers
as "Carcinogen Contaminated Sharps."
- Sharps contaminated with radionuclides must be separated from other
sharps, and labeled with a proper "radioactive materials" label.
- Eating, drinking, smoking, applying cosmetics
or lip balm and handling contact lenses are prohibited in work areas where
there is potential for exposure to bloodborne pathogens.
- Remote handling devices (e.g., tongs, shovels, etc.) and
gloves will be provided for Facilities Services employees when improperly
discarded sharps are found on campus. These will immediately be placed into
appropriate sharps containers.
- Food and drink are not kept in refrigerators,
freezers, on countertops or in other storage areas where blood or other
potentially infectious materials are present.
- Mouth Pipetting/suctioning of blood or other
infectious materials is prohibited.
- All procedures involving blood or other infectious
materials minimize splashing, spraying or other actions generating droplets
of these materials.
- Specimens of blood or other materials are placed
in designated leak-proof containers, appropriately labeled, for handling
- If outside contamination of a primary specimen
container occurs, that container is placed within a second leak-proof container,
appropriately labeled, for handling and storage. (If the specimen
can puncture the primary container, the secondary container must be puncture-resistant
- Equipment which becomes contaminated is examined
prior to servicing or shipping, and decontaminated as necessary unless it
can be demonstrated that decontamination is not feasible.
- An appropriate biohazard warning
label is attached to any contaminated equipment identifying the contaminated portions.
- Information regarding the remaining
contamination is conveyed to all affected employees, the equipment manufacturer, and the equipment service representative prior to handling, shipping or servicing.
Engineering controls and work practice controls will be examined and
maintained or replaced on a regular schedule. The schedule for reviewing
the effectiveness of the controls is the responsibility of Laboratory
Supervisors/Department Supervisors. This facility will also identify
the need for changes in these controls through OSHA logs and accident reviews
and investigations. Evaluations will identify:
- Areas where engineering or work practice controls are currently
- Areas where engineering or work practice controls can be
- Areas currently not employing engineering or work practice
controls, but where these controls could be beneficial.
Sharps with engineered sharps injury protection and needleless
systems are required by OSHA when there is the potential for a bloodborne pathogens
exposure. When necessary, University personnel or departments evaluate devices
for effectiveness in reducing the risk of exposure incidents. Where possible,
alternatives must be utilized and if the elimination of needle-bearing devices
is not possible, needle devices with safety features will be evaluated. Methods
for evaluation may include interviews, questionnaires or trial runs. Examples of Safe Needle Devices
(See procedures for biohazard
control in our Biosafety Manual)
Personal protective equipment is our employees' "last line
of defense" against bloodborne pathogens. Because of this, our facility
provides (at no cost to our employees) the Personal Protective Equipment that
they need to protect themselves against such exposure. This equipment
includes, but is not limited to:
- Laboratory Coats
- Face Shields/Masks
- Safety Glasses
- Resuscitation bags
- Pocket Masks
- Shoe Covers
Hypoallergenic gloves, glove liners and similar alternatives will be made available
to employees who are allergic to the gloves our facility normally provides.
Laboratory Supervisors and Department Supervisors will ensure that personal
protective equipment is provided and worn by employees as needed and that training
in the proper wearing and use of such equipment is provided. Contact
the EHRS Department if additional help is required. Supervisors must consult
with the EHRS Department for assistance with the selection and training of employees
for the use of non-routine personal protective equipment such as respirators.
To ensure that personal protective equipment is not contaminated
and is in the appropriate condition to protect employees from potential exposure,
our facility adheres to the following practices:
- All personal protective equipment is inspected
periodically and repaired or replaced as needed to maintain its effectiveness.
- Reusable personal protective equipment is cleaned and decontaminated as
- Single-use personal protective equipment (or
equipment that cannot, for whatever reason, be decontaminated) is disposed
of as biohazardous waste.
To make sure that this equipment is used as effectively as possible,
our employees adhere to the following practices when using their personal protective
- Any garments penetrated by blood or other infectious
materials are removed immediately, or as soon as feasible.
- All personal protective equipment is removed
prior to leaving the work area.
- Gloves are worn in the following circumstances:
- Whenever employees anticipate hand contact
with potentially infectious materials.
- When performing vascular access procedures.
- When handling or touching contaminated items
- Disposable gloves are replaced as soon as practical
after contamination or if they are torn, punctured, or otherwise lose their
ability to function as an exposure barrier.
- Utility gloves are decontaminated for reuse
unless they are cracked, peeling, torn or exhibit other signs of deterioration,
at which time they are disposed of.
- Masks and eye protection (such as goggles,
face shields, etc.) are used whenever splashes or sprays may generate droplets
of infectious material.
- Protective clothing (such as gowns or aprons)
is worn whenever potential exposure to the body is anticipated.
(See additional information on
Personal Protective Equipment in the Safety Manual)
Maintaining our facility in a clean and sanitary condition is an important
part of our Bloodborne Pathogens Compliance Program. The schedule for
cleaning floors, bathrooms, hallways, residence halls, offices and general use
areas is maintained by the Facilities Services Department.
Special use areas, i.e., the laboratory or chemical, radioactive
and biohazard storage areas, are cleaned only after consultation with the individual
responsible for that area.
The following practices will be carried out by the individuals
directly responsible for the laboratory and hazardous substance storage areas.
- All equipment and surfaces are cleaned and
decontaminated after contact with blood or other potentially infectious
- After the completion of medical procedures.
- Immediately (or as soon as feasible) when surfaces
are overtly contaminated.
- After any spill of blood or other infectious
- At the end of the work shift if the surface
is contaminated during that shift.
- Coverings (such as plastic wrap, aluminum foil
or plastic-backed absorbent paper) are removed and replaced:
- As soon as it is feasible when overtly contaminated.
- At the end of the work shift if they may have
been contaminated during the work shift.
- All pails, bins, cans and other receptacles
are inspected, cleaned and decontaminated as soon as possible if visibly
- Potentially contaminated broken glassware is
picked up using mechanical means (such as a dustpan and brush, tongs, forceps,
- Contaminated sharps are stored in containers
that do not require hand processing.
- Splatters or spills of blood or other infectious
agents on the floor, sides of benches or elsewhere are immediately decontaminated.
The Laboratory Supervisor/Department Supervisor shall ensure that the laboratory
or area of responsibility is maintained in a clean and sanitary fashion and
shall establish decontamination procedures. A 1:10 or 1:100 dilution
of household bleach made fresh daily may be used. However, this may be corrosive
to some equipment and environmental surfaces and therefore, may not be an appropriate
choice for all situations. Call the EHRS Department if further assistance
We are also very careful in our facility in handling regulated waste, including
contaminated sharps, used bandages and other potentially infectious material.
The following procedures are used with all of these types of wastes:
- They are discarded or bagged in containers
- Leak-proof if the potential for fluid spill
or leakage exists
- Red in color or labeled with the appropriate
biohazard warning label
- Containers for the regulated waste are located
throughout the facility within easy access of our employees and as close
as possible to the sources of the waste.
- Waste containers are maintained upright, routinely
replaced and not allowed to overfill.
- Whenever our employees move containers
of regulated waste from one area to another, the containers are immediately
closed and placed inside an appropriate secondary container if leakage is
possible from the first container.
The EHRS Department is responsible for the collection and disposal of our facility's
(See additional information
on biohazardous waste from the Biosafety Manual)