Purpose

Trinity University is committed to providing a safe and healthful work environment for our entire staff. In pursuit of this endeavor, the following exposure control plan (ECP) is provided to eliminate or minimize occupational exposure to bloodborne pathogens in accordance with OSHA standard 29 CFR 1910.1030, "Occupational Exposure to Bloodborne Pathogens."

The ECP is a key document to assist our University in implementing and ensuring compliance with the standard, thereby protecting our employees. This ECP includes:

The methods of implementation of these elements of the standard are discussed in the subsequent pages of this ECP.

References

                    STP 2-1.166 Occupational Exposure to Bloodborne Pathogens; Final Rule

Administrative Duties

The Trinity University Environmental Safety Coordinator is responsible for the implementation of the University’s ECP. Each department/office that has employees with occupational exposure to bloodborne pathogens or other potentially infectious materials shall establish written polices/procedures as an annex to this ECP. The University Environmental Safety Coordinator will maintain, review, and update this ECP at least annually, and whenever necessary to include new or modified tasks and procedures. Contact location/phone number: University Environmental Safety Office, (210) 999-8375.

Those employees who are determined to have occupational exposure to blood or other potentially infectious materials (OPIM) must comply with the procedures and work practices outlined in this ECP.

The administrator of the department/office, or their designee, will maintain and provide all necessary personal protective equipment (PPE), engineering controls (e.g., sharps containers), labels, and red bags as required by the standard. The administrator of the department/office, or their designee, will ensure that adequate supplies of the aforementioned equipment are available in the appropriate sizes

The Health Services department will be responsible for ensuring that all medical actions required are performed and that appropriate employee health and OSHA records are maintained. Contact location/phone number: Trinity University Health Services, Myrtle Hall (lower level), (210) 999-8111.

The administrator of the using department/office, or their designee, will be responsible for training, documentation of training, and making the written ECP available to employees, OSHA, and NIOSH representatives.

Employee Exposure Determination

The following is a list of departments in which some employees at the University have occupational exposure. Each department/office administrator responsible for these employees shall augment this ECP with a list of tasks and procedures, or groups of closely related tasks and procedures, in which occupational exposure may occur for these individuals:

Health Services personnel, University Environmental Safety Office personnel, Department of Campus Security personnel, Department of Biology personnel, Animal Facility, Physical Plant plumbers, third party housekeeping and food service provider personnel, athletic trainers, and athletic lifeguards.

Definitions

Administrator means department/office supervisor, director, academic chair, principal research investigator and third party contractors.

Blood means human blood components, and products made from human blood.

Bloodborne Pathogens means pathogenic microorganisms that are present in human blood and cause disease in humans. These pathogens include, but are not limited to, hepatitis B, C, and HIV.

Contaminated means the presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.

Contaminated Sharps means any contaminated object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires.

Decontaminated means the use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal.

Engineering Controls means controls that isolate or remove the bloodborne pathogens hazard from the workplace.

HBV means hepatitis B virus.

HCV means hepatitis C virus.

HIV means human immunodeficiency virus.

Occupational Exposure means reasonably anticipated 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.

Other Potentially Infectious Material (OPIM) means the following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluids, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and any body fluids in situations where it is difficult or impossible to differentiate between body fluids.

Parenteral means piercing mucous membranes or the skin barrier through such events as needle sticks, human bites, cuts, and abrasions.

Personal Protective Equipment (PPE) means specialized clothing or equipment worn by an employee for protection against a hazard. General work clothing is not intended to function as personal protective equipment.

Regulated Waste means liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.

Source Individual means any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to an employee.

Sterilize means the use of a physical or chemical procedure to destroy all microbial life including highly resistant bacterial endospores.

Universal Precautions is an approach to infection control. According to the concept of universal precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, HCV, and other bloodborne pathogens.

Work Practice Controls means controls that reduce the likelihood of exposure by altering the manner in which a task is preformed.

Methods of Implementation and Control

Universal precautions shall be observed to prevent contact with blood or other potentially infectious materials. Under circumstances in which differentiation between body fluid types is difficult or impossible, all body fluids shall be considered potentially infectious.

Employees covered by the bloodborne pathogens standard receive an explanation of this ECP during their initial training session by their respective department. It will also be reviewed in their department’s annual refresher training. All employees have an opportunity to review this plan at any time during their work shifts via the Trinity University website. If requested, the University Environmental Safety Coordinator will provide an employee with a printed copy of the ECP free of charge and within 15 days of the request.

The Health Services department is responsible for reviewing and providing updates for the ECP annually (or more frequently if necessary) to reflect any new or modified tasks and procedures that may affect occupational exposure, and to reflect any new or revised employee positions with occupational exposure; to the University Environmental Safety Coordinator.

The review and update of such plans must also:

Table 1 lists the safer devices that have been identified as candidates in the last annual review.

Health Services and the University Environmental Safety Coordinator solicits input from non-managerial employees with occupational exposure to bloodborne pathogens or other potentially infectious materials in the identification, evaluation, and selection of effective engineering and work practice controls. Only those employees with occupational exposure to bloodborne pathogens or other potentially infectious materials need be contacted. Our solicitation method involves the following: safety audits, inspections, investigations, analysis of data, pilot testing, and safety committees. Health Services and the University Environmental Safety Coordinator document all solicitation in the ECP.

Table 2 lists the engineering and work practice controls identified during solicitation in the last annual review.

Engineering and work practice controls will be used to prevent or minimize exposure to bloodborne pathogens. When occupational exposure remains after institution of these controls, personal protective equipment shall also be used.

Engineering and work practice controls shall be established by each department’s administrator.

Each department/office shall make it the responsibility of a department/office administrator to examine and maintain or replace engineering or work practice controls on a regular schedule to ensure their effectiveness.

Hand washing facilities shall be provided by each department that will be readily accessible to employees.

Employees shall wash their hands and other exposed skin with soap and water immediately or as soon as feasible after removal of gloves or other personal protective equipment. Mucous membranes will be flushed with water, if they have been exposed to blood or other potentially infectious materials.

Contaminated sharps shall not be bent, recapped, or removed unless it can be shown that no other alternative is feasible or that such action is required by a specific medical procedure. Shearing or breaking of contaminated needles is also prohibited.

Contaminated sharps shall be immediately disposed of after use in a designated, marked disposal container.

These containers shall be puncture resistant, leak proof, and labeled or color-coded in accordance with the OSHA standard.

Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where blood is a reasonable likelihood of occupational exposure.

Food and drink shall not be kept in refrigerators, freezers, shelves, and cabinets or on countertops or bench tops where blood or other potentially infectious materials are present.

All procedures involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets of these materials.

Mouth pipetting/suctioning of blood or other potentially infectious materials shall be prohibited.

The University identifies the need for changes in engineering control and work practices through: review of OSHA records, employee interviews; Security, Safety and Health Committee recommendations. The University evaluates the need for new procedures or new products by Security, Safety and Health Committee recommendations.

The University Environmental Safety Coordinator will ensure effective implementation of these recommendations.

Where there is occupational exposure, the University shall provide at no cost to the employee, appropriate personal protective equipment such as, but not limited to: gloves, gowns, face shields or masks and eye protection, and mouthpieces, resuscitation bags, pocket masks, or other ventilation devices. Personal protective equipment will be considered "appropriate" only if it does not permit blood or other potentially infectious materials to pass through to or reach the employee’s work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used.

Each department/office shall ensure that the employees use appropriate personal protective equipment, unless the supervisor can show that the employee temporarily and briefly declined to use personal protective equipment when, under rare and extraordinary circumstances, it was the employee’s professional judgment that in the specific instances its use would have prevented the delivery of health care or public safety services or would have posed an increased hazard to the safety of the worker or co-worker. When the employee makes this judgment, the University and the department administrator will conduct an investigation and document the results, in order to determine whether changes can be instituted to prevent such concurrences in the future.

The department/office administrator shall ensure that appropriate personal protective equipment in the appropriate sizes is readily available at the worksite or is issued to employees.

The department shall clean, launder, and/or dispose of contaminated personal protective equipment as required by regulation or as suggested by the manufacturer at no cost to the employee.

The department shall repair or replace personal protective equipment as needed to maintain its effectiveness, at no cost to the employee.

If a garment is penetrated by blood or other potentially infectious materials, the garment shall be removed immediately or as soon as feasible.

All personal protective equipment shall be removed prior to leaving the work area. When PPE is removed, it will be placed in an appropriately designated area or container for storage, washing, decontamination, or disposal.

Gloves shall be worn when it can be reasonably anticipated that the employee may have hand contact with blood, other potentially infectious material, mucous membranes, non-intact skin, and when handling or touching contaminated items or surfaces.

Disposable gloves (one time use only), such as surgical or examination gloves shall be replaced as soon as practical when contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised.

Disposable glove shall not be washed or decontaminated for re-use.

Utility gloves (multiple-use) may be decontaminated for re-use if the integrity of the gloves is not compromised. However, they must be discarded if they are cracked, peeling, torn, punctured, or exhibits other signs of deterioration or when their ability to function as a barrier is compromised.

Masks in combination with eye protection devices, such as goggles or glasses with solid side shields, or chin-length face shields, shall be worn whenever splashes, spray, spatter, or droplets of blood or other potentially infectious materials may be generated and eyes, nose, or mouth contamination can be reasonably anticipated.

Departments/offices will ensure the worksite is maintained in a clean and sanitary condition. The departments/offices will 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 in the area.

All equipment and environmental and working surfaces shall be cleaned and decontaminated after contact with blood or other potentially infectious materials.

Contaminated work surfaces shall be decontaminated with an appropriate disinfectant immediately or as soon as feasible when surfaces are overly contaminated or after any spill of blood or other potentially infectious materials.

Broken glassware that may be contaminated is picked up using mechanical means, such as a brush and dust pan.

Contaminated Sharps Discarding and Containment:

Contaminated sharps shall be discarded immediately, or as soon as feasible, in containers that are closeable, puncture resistant, leak proof and properly labeled or color-coded.

During use, containers for contaminated sharps shall be easily accessible and located as close as feasible to the immediate area where sharps are used or can be reasonably anticipated to be found; maintained upright throughout their use; and replaced routinely and not be allowed to over fill.

When moving containers of contaminated sharps from the area of use, the containers shall be closed immediately prior to removal or replacement to prevent spillage or protrusion of contents during storage, transport, or shipping.

Containers shall be placed in a secondary container if leakage is possible. The secondary container shall be closable, and labeled or color-coded as required.

Disposable containers shall not be opened, or cleaned manually or in other manner that would expose employees to the risk of injury.

Contaminated laundry shall be handled as little as possible with a minimum of agitation. It shall be bagged or containerized at the location where it was used and shall not be sorted or rinsed in the location of use.

Contaminated laundry shall be placed in bags or containers labeled or color-coded.

When contaminated laundry is wet and presents a reasonable likelihood of soak-through of or leakage from the bag or container, the laundry shall be placed and transported in bags or containers which prevent soak-through and/or leakage of fluids to the exterior.

The University shall ensure that the employees who have contact with the contaminated laundry wear protective gloves and other appropriate personal protective equipment.

Uniforms worn by Department of Campus Security personnel that are contaminated by blood or other potentially infectious materials shall be properly discarded and replaced, at no cost to the employee. Other equipment that can be properly decontaminated shall be handled as other contaminated, re-useable equipment.

The following labeling method(s) is used in this University:

The University Environmental Safety Coordinator will ensure that departments/offices affix warning labels or use red bags as required if regulated waste or contaminated equipment is brought into the University. Employees are to notify the University Environmental Safety Coordinator if they discover regulated waste containers, refrigerators containing blood or OPIM, contaminated equipment, etc., without proper labels.

Hepatitis B Vaccination

The department/office administrator, or their designee, will provide training to employees on hepatitis B vaccinations, addressing the safety, benefits, efficacy, methods of administration, and availability.

The hepatitis B vaccination series is available at no cost after training and within 10 days of initial assignment to employees identified in the exposure determination section of this plan. Vaccination is encouraged unless:

1. Documentation exists that the employee has previously received the series;

2. Antibody testing reveals that the employee is immune; or

3. Medical evaluation shows that vaccination is contraindicated.

However, if an employee chooses to decline vaccination, the employee must sign a declination form. Employees who decline may request and obtain the vaccination at a later date at no cost. Documentation of refusal of the vaccination is kept at Health Services.

Vaccination will be provided by Health Services located in Myrtle Hall (lower level).

Post-exposure Evaluation and Follow-Up

Should an exposure incident occur during business hours, contact Health Services, Myrtle Hall (lower level) at the following telephone number (210) 999-8111.

Should an exposure incident occur when Health Services is closed, the individual is to seek immediate attention from an emergency room and notify Health Services either in person or by telephone the next business day.

An immediately available confidential medical evaluation and follow-up may be obtained by contacting the Health Services, Myrtle Hall (lower level), (210) 999-8111.

Following the initial first aid (clean the wound, flush eyes or other mucous membranes, etc.), the following activities will be performed by the health care professional:

Health Services ensures that health care professional(s) responsible for employee's hepatitis B vaccination and post-exposure evaluation and follow-up are given a copy of OSHA's bloodborne pathogens standard.

Health Services ensures that the health care professional evaluating an employee after an exposure incident receives the following:

The medical office that performed the post-exposure evaluation should provide the employee with a copy of the evaluating health care professional's written opinion within 15 days after completion of the evaluation.

The University Environmental Safety Office will review the circumstances of all exposure incidents to determine:

If it is determined that revisions need to be made, the University Environmental Safety Coordinator will ensure that appropriate changes are made to this ECP. Changes include: evaluation of safer devices, adding employees to the exposure determination list, etc.

Employee Training

All employees who have occupational exposure to bloodborne pathogens receive training conducted by the administrator of the using department/office, or their designee.

All employees who have occupational exposure to bloodborne pathogens receive training on the epidemiology, symptoms, and transmission of bloodborne pathogen diseases. In addition, the training program covers, at a minimum, the following elements:

The University Environmental Safety Office will assist departments in obtaining training materials, as necessary.

Recordkeeping

Training records are completed for each employee upon completion of training. These documents will be kept at the employees’ department/office for at least three years.

The training records include:

Employee training records are provided upon request to the employee or the employee's authorized representative within 15 working days. Such requests should be addressed to administrator of the department/office, or their designee.

Medical records are maintained for each employee with occupational exposure in accordance with 29 CFR 1910.1020, "Access to Employee Exposure and Medical Records."

Human Resources (Northrup Hall, Room 108, 210-999-7507) will maintain the confidential post-exposure medical report for at least the duration of employment plus 30 years.

Employee medical records are provided upon request of the employee or to anyone having written consent of the employee within 15 working days. Such requests should be sent to Health Services or the medical office that performed the post-exposure evaluation.

An exposure incident is evaluated to determine if the case meets OSHA's Recordkeeping Requirements (29 CFR 1904). This determination and the recording activities are done by Human Resources.

Human Resources establishes and maintains a sharps injury log to record percutaneous injuries from contaminated sharps. The information in the sharps injury log is recorded and maintained: OSHA 300 Log and OSHA 301 Report forms. (1) enter the type and brand of the device on either the 300 or 301 form, and (2) maintain the records in a way (i.e., a separate page or a quick computer printout) that segregates sharps injuries from other types of work-related injuries and illnesses, or allow sharps injuries to be easily separated. This protects the confidentiality of the injured employee. Health Services will closely coordinate with Human Resources for Sharps Injury Log information for OSHA reporting. Our sharps injury log contains:

Human Resources will maintain the log 5 years following the end of the calendar year that these records cover.

Hepatitis B Vaccine Consent/Declination (Mandatory)

Every employee subject to occupational exposure will complete a Hepatitis B Vaccine Consent/Declination form. This form will be maintained in the employee’s health records in Health Services. A copy of this form is attached to this ECP.

                                                                  TABLE 1

Date of Review: ______________ By: _______________________________________

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Date of Review: ______________ By: _______________________________________