What to do if you've been exposed
BBP Spill Cleanup Procedures
Exposure Control Policy
Post-exposure Follow Up Procedures
BBP Exposure Incident Report Form
Hepatitis B Vaccine Declination Form
Person responsible for implementation and review of the Exposure Control Plan: Jill Fermanich
The University of Wisconsin-Green Bay is subject to the requirements of the U.S. Occupational Safety and Health Administration’s (OSHA) Bloodborne Pathogen Standard, 29 CFR 1910.1030. This standard has been adopted by the State of Wisconsin and is enforced by the Department of Commerce’s Safety and Buildings Division. The purpose of this Exposure Control Plan is to protect employees of UW-Green Bay from exposure to bloodborne pathogens and to meet requirements of 29 CFR 1910.1030.
- EXPOSURE DETERMINATION
- METHOD OF COMPLIANCE
- HEPATITIS B VACCINATION
- POST EXPOSURE EVALUATION AND FOLLOWUP
- COMMUNICATION ABOUT HAZARDS TO EMPLOYEES
- GOOD SAMARITAN ACTS BY EMPLOYEES
- Job Classifications
UW-Green Bay has identified the following job classifications as those in which employees of the campus could be exposed to bloodborne pathogens in the course of fulfilling their job requirements. The exposure determination has been made without regard to the use of personal protective equipment:
- Athletic Trainers
- Campus Police and Security Officers
- Phoenix Sports Center supervisors
- Student Health Center employees
- Custodial and housekeeping staff—lead workers will be designated with responsibility of cleaning up all spills of blood and OPIM; custodial staff assigned cleaning responsibilities in Health Services
- Instructors, researchers, and lab technicians where human blood and OPIM are used
- Nursing Program Instructors with clinical responsibilities
- Weidner Center staff with responsibility for responding for first aid or CPR incidents
- Summer Camp counselors designated to respond to first aid and CPR incidents
- Care of injured person during a sport activity
- Care of minor injuries that occur within the campus setting, i.e. bloody nose, scrape, minor cut
- Care of students with medical needs typical in a student health care center
- Cleaning and maintenance tasks associated with body fluid spills.
- Emergency first aid and/or CPR response.
- Police/security duties e.g. subduing a suspect, intervention in an altercation
- Set-up, supervision, break-down of laboratories where blood or OPIM are used
- Research activities where blood or OPIM are used.
- Supervision of clinical settings where blood or OPIM is present
- Universal Precautions
- Engineering/and Work Practice Controls
- The campus shall provide handwashing facilities which are readily accessible to employees, or when provision for handwashing facilities is not feasible, the campus will provide either an appropriate antiseptic hand cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes. Employees must wash hands (or other affected area) with soap and running water as soon as feasible thereafter.
- Employees shall wash hands or any other skin with soap and water, or flush mucous membranes with water immediately or as soon as feasible following contact of such body areas with blood or OPIM.
- Employees shall wash their hands immediately or as soon as feasible after removal of gloves or other personal protective equipment. When antiseptic hand cleaners or towelettes are used, hands shall be washed with soap and running water as soon as feasible. Do not reuse disposable gloves.
- Housekeeping and Waste Procedures
- The campus shall ensure that the worksite is maintained in a clean and sanitary condition. The campus shall determine and implement an appropriate written schedule for cleaning and method of decontamination based upon the location within the facility, type of surface to be cleaned, type of soil present, and tasks or procedures being performed. Persons responsible for doing this are the supervisor for each area covered by the campus plan. See Appendix A for a list of responsible supervisors.
- All equipment, materials, environmental and working surfaces shall be cleaned and decontaminated after contact with blood or OPIM.
- Contaminated work surfaces shall be decontaminated with an appropriate disinfectant immediately after completion of procedures/task/therapy, or as soon as feasible, when surfaces are overtly contaminated or after any spill of blood or OPIM, and at the end of the work shift if the surface may have become contaminated since the last cleaning.
- Protective coverings, such as plastic wrap, aluminum foil, or imperviously-backed absorbent paper used to cover equipment and environmental surfaces, shall be removed and replaced as soon as feasible when they become contaminated with blood or OPIM, or atthe end of the work shift if they have become contaminated since the last cleaning.
- All bins, pails, cans, and similar receptacles intended for reuse which have reasonable likelihood for becoming contaminated with blood or OPIM shall be inspected and decontaminated on a regularly scheduled basis and cleaned and decontaminated immediately or as soon as feasible upon visible contamination.
- Materials, such as paper towels, gauze squares or clothing, used in the treatment of blood or OPIM spills that are blood-soaked or caked with blood shall be bagged, tied and designated as a biohazard. The bag shall then be removed from the site as soon as feasible and replaced with a clean bag. On this campus, bags designated as biohazard (containing blood or OPIM contaminated materials) shall be either red in color or affixed with a biohazard label and shall be located in each area where generation of biohazardous material is possible.
For the purposes of this policy, biohazard waste will include liquid or semi-liquid blood or OPIM; items contaminated with blood or OPIM and which would release these substances in a liquid or semi-liquid state if compressed; items that are caked with dried blood or OPIM and are capable of releasing these materials during handling; contaminated sharps; pathological and microbiological wastes containing blood or OPIM.
- Designated custodial personnel shall respond immediately to any major blood or OPIM incident so that it can be cleaned, decontaminated, and removed immediately.
A major blood or OPIM incident is one in which there will be biohazardous material for disposal.
- In the event that regulated waste leaks from a bag or container, the waste shall be placed in a second container, and the area shall be cleaned and decontaminated.
- Disposal of regulated waste shall be in accordance with applicable regulations of the United States, the state of Wisconsin and its political subdivisions (currently the Department of Natural Resources regulates waste disposal in Wisconsin). On this campus, non-sharps biohazardous waste will be autoclaved. Once autoclaved, this waste will be handled as regular waste. Campus autoclaves are located in the Student Health Center and the Laboratory Science biology prep room. Supervisors should arrange for autoclaving biohazardous waste by contacting either the director of Student Health or the biology laboratory technician. Note: The largest autoclave bag which can be accommodated by campus autoclaves is 24 X 30.
- Broken glass contaminated with blood or OPIM shall not be picked up directly with the hands. It shall be cleaned up using mechanical means, such as a brush and dust pan, tongs, or forceps. Broken glass shall be containerized. The custodian shall be notified immediately or through verbal or written notification before scheduled cleaning.
- Contaminated sharps, broken glass, plastic or other sharp objects shall be placed into appropriate sharps containers. On this campus the sharps containers shall be closeable, puncture resistant, labeled with a biohazard label, and leak proof. Containers shall be maintained in an upright position. Containers shall be easily accessible to staff and located as close as feasible to the immediate area where sharps are used or can be reasonably anticipated to be found. If an incident occurs where there is contaminated material that is too large for sharps container, the supervisor shall be contacted immediately to obtain an appropriate biohazard container for this material.
- Reusable sharps that are contaminated with blood or OPIM shall not be stored or processed in a manner that requires employees to reach by hand in to the containers where these sharps have been placed.
- On this campus, the employee shall notify the supervisor when sharp containers become 3/4 full so that they can be disposed of properly. Sharps containers shall be brought to Health Services or the biology prep room for proper disposal. UWGB sends biohazardous sharps off campus for incineration.
- Contaminated needles shall not be bent, recapped, removed, sheared or purposely broken.
- Food and drink shall not be kept in refrigerators, freezers, cabinets, or on shelves, counter-tops or bench tops where blood or other potentially infectious materials are present.
- All procedures involving blood or OPIM shall be performed in such a manner as to minimize splashing, spraying, splattering, and generating droplets of these substances. Mouth pipetting/suctioning of blood or OPIM is prohibited; e.g., sucking out snake bites.
- Specimens of blood or OPIM shall be placed in containers which prevent leaking during collection, handling, processing, storage, transport, or shipping. These containers shall be labeled with a biohazard symbol or be colored red.
- Equipment which may become contaminated with blood or other potentially infectious material is to be examined prior to servicing and shipping and is to be decontaminated, if feasible. If not feasible, a readily observable biohazard label stating which portions are contaminated is to be affixed to the equipment. This information is to be conveyed to all affected employees, the service representative, and/or manufacturer, as appropriate, prior to handling, service or shipping. Equipment to consider: communication devices or equipment needing repair after an exposure incident.
- Contaminated laundry shall be handled as little as possible. Contaminated laundry is laundry which has been soiled with blood or OPIM or may contain sharps. Gloves must be worn when handling contaminated laundry. Contaminated laundry shall be bagged or containerized at the location where it was used and shall not be sorted or rinsed in the location of use. Containers must be leak-proof if there is reasonable likelihood of soak-through or leakage. All contaminated laundry shall be placed and transported in bags or containers that are biohazard-labeled or colored red.
- Personal Protective Equipment
- Where occupational exposure remains after institution of engineering and work controls, personal protective equipment shall be used. Forms of personal protective equipment available on this campus are gloves, masks, CPR masks, protective clothing such as laboratory coats/aprons and eye protection devices such as goggles and face shields.
- Gloves shall be worn when it can be reasonably anticipated that the employee may have hand contact with blood, OPIM, mucous membranes, and non-intact skin; and when handling or touching contaminated items or surfaces.
- Disposable gloves shall be replaced as soon as practical when contaminated or as soon as feasible if they are torn, punctured, or when the ability to function as a barrier is compromised. Disposable gloves shall not be washed or decontaminated for re-use (contaminated disposable gloves do not meet the DNR definition of infectious waste and do not need to be disposed of in red or specially labeled bags.)
- Hypoallergenic gloves, glove liners, powderless gloves, or other similar alternatives shall be readily accessible to those employees who are allergic to the gloves normally provided.
- Masks, in combination with eye protection devices, such as goggle or glasses with solid side shields, or chin-length face shields, shall be worn whenever splashes, spray, spatter, or droplets of blood or OPIM may be generated and eye, nose, or mouth contamination can be reasonably anticipated, i.e. custodian cleaning a clogged toilet, nurses performing suctioning.
- Appropriate PPE shall be used to perform resuscitation procedures. Emergency ventilation devices such as masks, mouthpieces , resuscitation bags, shields/overlay barriers will be provided as needed.
- Appropriate protective clothing shall be worn in occupational exposure situations. The types and characteristics shall depend upon the task, location, and degree of exposure anticipated.
- Campus supervisors with employees covered by the standard shall ensure that appropriate personal protective equipment is readily accessible at the worksite or is issued to the employees.
- This campus shall clean, launder and dispose of personal protective equipment at no cost to the employee.
- This campus shall repair or replace personal protective equipment as needed to maintain its effectiveness, at no cost to the employee.
- All personal protective equipment shall be removed prior to leaving the work area. When personal protective equipment/supplies are removed they shall be placed in an appropriately designated area or container for storage, washing, decontamination or disposal.
- If a garment(s) is penetrated by blood or OPIM infectious materials, the garment(s) shall be removed immediately, or as soon as feasible.
- Supervisors are responsible for ensuring that the employees use appropriate personal protective equipment. If an employee temporarily and briefly declines to use personal protective equipment because it is in his or her judgment that in that particular instance it would have posed an increased hazard to the employee or others, the campus shall investigate and document the circumstances in order to determine whether changes can be instituted to prevent such occurrences in the future.
On this campus universal precautions shall be observed in order to prevent contact with blood or other potentially infectious materials (OPIM). All blood or other potentially contaminated body fluids shall be considered to be infectious. Under circumstances in which differentiation among body fluid types is difficult or impossible, all body fluids shall be considered potentially infectious materials.
Engineering and work practice controls are designed to eliminate or minimize employee exposure. The Campus will utilize effective engineering controls to reduce needlesticks and other sharps injuries where appropriate. These engineering controls may include needleless devices, shielded needle devices, blunt needles, and plastic capillary tubes. Health Services will do an annual evaluation of available safe needle devices.
An exposure incident is defined as contact with blood or OPIM materials on an employee's non-intact skin, eye, mouth, and other mucous membrane or by piercing the skin or mucous membrane through such events as needlesticks. “Non-intact” skin includes skin with dermatitis, hangnails, cuts, abrasions, chafing, acne, etc.
A BBP Exposure Incident Report Form shall be completed each time an exposure incident occurs.
- Hepatitis B vaccine is available for employees whose designated job assignment includes the rendering of first aid, emergency response, or have occupational exposure to blood or OPIM.
- This campus shall make the hepatitis B vaccination series available to all employees who have occupational exposure after the employee(s) have been given information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, and the benefits of being vaccinated. The vaccine and vaccinations shall be offered free of charge.
- This campus shall make the hepatitis B vaccination series available after the training and within 10 working days of initial assignment to all employees who have occupational exposure.
- The hepatitis B vaccination series will be performed under the supervision of a licensed physician by the nursing staff of UWGB Student Health Center. All laboratory tests will be conducted by an accredited laboratory. The vaccine series will be offered at a reasonable time to all employees covered.
- Based on current CDC guidelines, post-vaccination testing for antibody to hepatitis B surface antigen response is indicated for healthcare workers who have blood or patient contact and are at ongoing risk for injuries with sharp instruments or needlesticks. Employees who do not respond to the primary vaccination series must be revaccinated with a second three-dose vaccine series and retested. Non-responders must be medically evaluated.
- The primary job assignment of such a designated first aid provider is not the rendering of first aid or other medical assistance.
- Any first aid rendered by such person is rendered only as a collateral duty, responding solely to injuries resulting from workplace incidents, generally at the location where the incident occurred.
- ALL first aid incidents involving the presence of blood or OPIM are reported to the employee's supervisor by the end of the work day/shift on which the incident occurred.
- The BBP Exposure Incident Report Form is used to report first aid incidents involving blood or OPIM. The incident description must include a determination of whether or not, in addition to the presence of blood or OPIM, an "exposure incident," as defined by the standard, occurred.This determination is necessary in order to ensure that the proper post-exposure evaluation, prophylaxis and follow-up procedures are made available immediately if there has been an exposure incident as defined by the standard.
- The Campus Post-Exposure Follow Up Procedure (Appendix B) is followed.
- The full hepatitis B vaccination series is made available as soon as possible, but in no event later than 24 hours, to all unvaccinated first aid providers who have rendered assistance in any situation involving the presence of blood or OPIM regardless of whether or not a specific "exposure incident," as defined by the standard, has occurred.
- A list of first aid incidents is maintained by the supervisor and is readily available to all employees.
- This reporting procedure is included in the training program.
- Following a report of an exposure incident, this campus shall make immediately available to the exposed employee a confidential medical examination and follow up, including at least the following elements
- Documentation of the route(s) of exposure, and the circumstances under which the exposure incident occurred;
- Identification and documentation of the source individual, if possible, or unless this campus can establish that identification is infeasible or prohibited by state or local law;
- The source individual's blood shall be tested as soon as feasible and after consent is obtained in order to determine BBP infectivity. If consent is not obtained, the campus shall establish that legally required consent cannot be obtained.
- Results of the source individual's testing shall be made available to the exposed employee only after consent is obtained, and the employee shall be informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual.
- The exposed employee's blood shall be collected as soon as feasible and tested after consent is obtained. If the employee consents to baseline blood collection, but does not consent at that time for HIV serological testing, the sample shall be preserved for at least 90 days. If, within 90 days of the exposure incident, the employee elects to have the baseline sample tested, such testing shall be done as soon as feasible;
- Post-exposure prophylaxis will follow the recommendations established by the U.S. Health Service;
- Counseling shall be made available by this campus at no cost to employees and their families on the implications of testing and post-exposure prophylaxis;
- There shall be an evaluation of reported illnesses.
- The campus shall ensure that all medical evaluations and procedures including prophylaxis, are made available at no cost, and at a reasonable time and place to the employee. UWGB has designated Prevea WorkMed to be the employee health care provider for post-exposure follow-up.
- Information provided to the healthcare professional who evaluates the employee shall include:
- A copy of 29 CFR 1910.1030 as needed
- A description of the employee's duties as they relate to the exposure incident;
- Documentation of the route of exposure and circumstances under which exposure occurred;
- Results of the source individual's blood testing, if consent was given and results are available;
- All medical records relevant to the appropriate treatment of the employee, including vaccination status which are this campus' responsibility to maintain.
- This campus shall obtain and provide the employee with a copy of the evaluating healthcare professional's written opinion within 15 working days of the completion of the evaluation.
- The healthcare professional's written opinion for hepatitis B vaccination shall be limited to whether hepatitis B vaccination is indicated for an employee, and if the employee has received such vaccination.
- The healthcare professional's written opinion for post-exposure evaluation and follow-up shall be limited to the following information:
- This employee has been informed of the results of the evaluation; and
- This employee has been told about any medical conditions resulting from exposure to blood or OPIM infectious materials which require further evaluation and or treatment.
- All other findings or diagnoses shall remain confidential and shall not be included in the written report.
- Warning labels shall be affixed to containers of regulated waste, refrigerators, and freezers containing blood or other potentially infectious material; and other containers used to store, transport or ship blood or OPIM. Exception: Red bags or red containers may be substituted for labels.
- Labels required by this section shall have a biohazard symbol on the label.
- These labels shall be fluorescent orange or orange-red or predominantly so, with lettering or symbols in a contrasting color.
- These labels shall be an integral part of the container or shall be affixed as close as feasible to the container by string, wire, adhesive, or other methods that prevent their loss or unintentional removal.
- Labels for contaminated equipment must follow the same labeling requirements. In addition, the labels shall also state which portions of the equipment remain contaminated.
- Supervisors are responsible for ensuring that containers and equipment are properly labeled.
- Information and Training
- This campus shall ensure that all employees with potential for occupational exposure participate in a training program at no cost to employees. Supervisors will identify employees who are covered by this standard, make arrangements for the training, and ensure that employees participate in the training. Documentation of training will be provided to supervisors when employee training is completed.
- Training shall be provided at the time of initial assignment to tasks when occupational exposure may take place and at least annually thereafter.
- For employees who have received training on bloodborne pathogens in the year preceding the effective date of this standard, only training with respect to the provisions of this standard which were not included need be provided.
- Annual training for all employees with potential for occupational exposure shall be provided within one year of their previous training.
- The campus shall provide additional training when changes such as modifications of tasks or procedures affect the employee's potential for occupational exposure. The additional training may be limited to addressing the new exposure created.
- Material appropriate in content and vocabulary to educational level, literacy, and language of employees shall be used.
- The person conducting the training shall be knowledgeable in the subject matter covered by the elements contained in the training program, as it relates to the workplace. Jill Fermanich currently has responsibility for providing this training.
- Medical Records
- This campus shall establish and maintain an accurate medical record for each employee with occupational exposure. This record shall include:
- Name and social security number of employee;
- Copy of employee's hepatitis B vaccination record or declination form and any additional medical records relative to hepatitis B;
- If exposure incident(s) have occurred, a copy of all results of examinations, medical testing, and follow-up procedures;
- If exposure incident(s) have occurred, the campus' copy of the healthcare professional's written opinion;
- If exposure incident(s) have occurred, the campus' copy of information provided to the healthcare professional: i.e., exposure incident report form and results of the source individual's blood testing, if available and consent has been obtained for release.
- This campus shall ensure that the employee's medical records are kept confidential and are NOT disclosed or reported without the employee's written consent to any person within or outside the campus except as required by law. These medical records shall be kept separate from other personnel records and will be maintained by Jill Fermanich, the person designated responsibility for administering the Exposure Control Plan.
- Campus medical records shall be maintained for the duration of employment plus 30 years.
- The Campus designated health care provider for post-exposure followup (Prevea WorkMed) shall maintain all other medical records.
- Training Records
- Training records shall include:
- The date of the training session;
- The contents or a summary of the training session;
- The names and qualifications of person(s) conducting the training;
- The name and job titles of all persons attending the training session.
- Training records shall be maintained for three years from the date the training occurred.
- Supervisors are responsible for ensuring that employees covered by the standard receive training. Supervisors will maintain training records for employees in his/her area. Jill Fermanich will maintain campus-wide training records.
- Availability of Records
- This campus shall ensure:
- All records to be maintained by this standard shall be made available upon request to Department of Commerce (or designee) for examination and copying.
- Employee training records required by this standard shall be provided upon request for examination and copying to employees, to employee representatives, and to the Department of Commerce (or designee).
- Employee medical records required by this standard shall be provided upon request for examination and copying to the subject employee and/or designee, to anyone having written consent of the subject employee and to the Department of Commerce.
- This campus shall comply with the requirements involving the transfer of records set forth in this standard.
Students who are not employees are not covered by the Bloodborne Pathogens Rule except for the parts pertaining to maintaining a safe place. However, UW-Green Bay will not allow a student to engage in a hazardous activity without risk communication, proper training or ensuring the use of appropriate personal protective equipment. Therefore, any UW-Green Bay student who is enrolled in a class that involves reasonably anticipated exposure of the student to blood or OPIM will be covered by the following policy. This would include blood typing procedures done once per semester in undergraduate biology laboratories and lab procedures which use screened blood.VIII. VOLUNTEERS
Of particular concern are students enrolled in the Professional Program in Nursing. Consult with the Chair of this program about their policy on student HBV immunizations.
- Department administrators must identify those courses that involve any reasonably anticipated exposure of students to blood or OPIM.
- Students who will be using blood or OPIM in their academic coursework must be informed of the epidemiology and transmissivity of HIV, HBV, HCV and other BBPs and trained in the safe work practices, including use of PPE, that will reduce the likelihood of their becoming exposed. This training must take place prior to any procedures where blood or OPIM is used. Faculty/staff supervising these laboratories are responsible for the training.
- Students must be trained and required to use appropriate PPE for any course activity involving blood or OPIM. Faculty/staff supervising students must ensure that safe work practices are followed and appropriate PPE used.
- Students who have reasonably anticipated exposure to blood or OPIM must be provided information about the Hepatitis B vaccination before they are permitted to participate in courses where exposure may occur. The campus will not cover the cost of student immunization.
- Students must be made aware of post-exposure follow up procedures as part of their training on bloodborne pathogens. Post-exposure follow up should be initiated by the faculty/staff supervisor. Costs for post-exposure follow up are the responsibility of the student. For curricula that involve an off-site internship or clinical experience with an affiliate health care institution, the procedure and responsibility for post-exposure followup should be clearly described in the affiliation agreement. The UW-Green Bay Student Health Center can provide post-exposure followup medical care of UW-Green Bay students, however, costs are still the responsibility of the student.
- Students who are not employees are prohibited from handling, treatment, or sewering of infectious waste, other than the handling required to immediately containerize infectious waste generated by their laboratory procedures. Students who are not employees are prohibited from the handling of contaminated laundry for University-related purposes other than handling required to containerize personally generated contaminated laundry.
Volunteers are not covered by the BBP Rule. It is campus policy that volunteers will not be asked to perform first aid duties as part of their volunteer activity. Volunteers and bystanders who opt to provide first aid or CPR chose to do so on their own and act as "Good Samaritans." The campus does not cover the cost of exposure followup for volunteers acting as Good Samaritans. It is recommended that volunteers consider their options for exposure followup before considering administering first aid/CPR as a Good Samaritan. Department supervisors are responsible for informing volunteers in their area of this campus policy at the time volunteers are recruited.-Top-
IX. GOOD SAMARITAN ACTS BY EMPLOYEES
Campus employees not covered by this policy who are exposed to a BBP while providing assistance, voluntarily performed, to an injured co-worker or the general public should follow the Post-exposure Follow Up Procedures in Appendix B.
Contact Jill Fermanich (ext. 2273) if you have further questions concerning this policy.