1.    Methods of Compliance
2.    Standard Precautions
3.    Engineering Controls
4.    Work Practice Controls
5.    Personal Protective Equipment
6.    Housekeeping

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 are:

• 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.

UNIVERSAL PRECAUTIONS

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 pathogens:

• Semen
• Vaginal secretions
• Cerebrospinal fluid
• Synovial fluid
• Pleural fluid
• Pericardial fluid
• Peritoneal fluid
• Amniotic fluid
• Saliva

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 potentially infectious.

ENGINEERING CONTROLS

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 the facility.

• 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 following characteristics:
  • Puncture-resistant
  • Color-coded or labeled with a biohazard warning label
  • 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:
  • Leak-proof
  • Color-coded or labeled with a biohazard warning label
  • Puncture resistant when necessary
• Biological Safety Cabinets to provide containment of infectious aerosols.  Cabinets must be certified annually or whenever moved.
• Mechanical pipetting devices.  Mouth pipetting is prohibited.
• 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 equipment.
• 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 technique.
• 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 and storage.
• 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 as well).
• 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 employed.
• Areas where engineering or work practice controls can be updated.
• 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

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:

• Gloves
• Gowns
• Laboratory Coats
• Face Shields/Masks
• Safety Glasses
• Goggles
• Mouthpieces
• Resuscitation bags
• Pocket Masks
• Hoods
• 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 needed.
• 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 equipment:

• 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 or surfaces.
• 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)

HOUSEKEEPING

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 materials:
  • 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 material.
  • 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 contaminated.
• Potentially contaminated broken glassware is picked up using mechanical means (such as a dustpan and brush, tongs, forceps, etc.).
• 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 is needed. 

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 that are:
  • Closable
  • Puncture-resistant
  • 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 contaminated waste.

(See additional information on biohazardous waste from the Biosafety Manual)