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Bloodborne Pathogens Exposure Control Plan

TMCC Policy Statement

The TMCC Environmental Health and Safety Office's (EHS) mission is to support the Truckee Meadows Community College (TMCC) teaching and service functions. EHS assists organizational units in meeting their responsibility to protect the environment and to provide a safe and healthful place of employment and learning. This program has been developed in accordance with 29CFR 1910.1030 (Bloodborne Pathogens).

Purpose and Scope

The goal of the TMCC Bloodborne Pathogens Exposure Control Plan (ECP) is to outline the basic requirements of the OSHA Bloodborne Pathogens standard and procedures at Truckee Meadows Community College (TMCC). General requirements include:

  • A written exposure control plan, reviewed and updated annually;
  • Use of universal precautions;
  • Consideration, implementation, and use of safer engineered needles, sharps, and equipment;
  • Use of engineered and work practice controls and appropriate personal protective equipment (gloves, face and eye protection, gowns);
  • Hepatitis B vaccine offered to affected employees free of cost;
  • Medical follow-up in the event of exposure;
  • Use of labels or color-coding for items such as sharps disposal boxes and containers for regulated waste, contaminated laundry, and certain specimens;
  • Proper containment of all regulated waste; and
  • Employee training.

Roles and Responsibilities

  • The Environmental Health and Safety Office (EHS) shall have overall responsibility for the management, support, and implementation of the TMCC Bloodborne Pathogens ECP.
  • Departments, divisions, offices, or laboratories with employees anticipated to have potential occupational exposure to blood or other potentially infectious material (OPIM) are encouraged to develop a program-specific plan to address the specific hazards associated with the area of study / work. Plans shall be patterned after the TMCC Bloodborne Pathogens ECP.
  • It shall be the responsibility of all TMCC managers and supervisors to determine if their employees have potential occupational exposure as defined by the standard.
  • It shall be the responsibility of all supervisors to ensure proper exposure control procedures are disseminated and followed in their areas of control.
  • It shall be the responsibility of all instructors or designated lab assistants to ensure proper exposure control procedures are followed in the classroom and laboratory setting.

Scope of Coverage

OSHA's Bloodborne Pathogens 29CFR 1910.1030 standard applies to all employees with potential occupational exposure, i.e., reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials (OPIM) that may result from the performance of the employee's duties. The employer (TMCC) will implement the requirements set forth in the OSHA standard to include the requirements to update the Exposure Control Plan and to keep an exposure/sharps injury log.

Definitions

ECP: Exposure Control Plan

OPIM: Other Potentially Infectious Materials means (1) The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any bodily fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids; (2) Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and (3) HIV-containing cell or tissue cultures, organ cultures, and HIV-containing or HBV-containing culture medium or other solutions, blood, organs, or other tissues from experimental animals infected with HIV or HBV.

Pathogen: Any agent, especially a virus, bacterium, or other microorganism.

PPE: Personal Protective Equipment.

Safer Medical Devices: Effective commercially available safer medical devices designed to eliminate or minimize occupational exposure.

Sharps with engineered Injury Protections: Any non-needle sharp or a needle device used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids, with a built-in safety feature or mechanism that effectively reduces the risk of an exposure incident.

Source Individual: Any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to the employee. Examples include, but are not limited to:

  • Hospital and clinic patients;
  • Clients in institutions for the developmentally disabled;
  • Trauma victims;
  • Clients of drug and alcohol treatment facilities;
  • Residents of hospices and nursing homes;
  • Human remains; and individuals who donate or sell blood or blood components.

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, and other bloodborne pathogens.

Work Practice Controls: Means controls that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., prohibiting recapping of needles by a two-handed technique).

Exposure Determination

Exposure determination is made without regard to the use (or non-use) of PPE, since the employee is considered exposed even if PPE is being properly used.

Potentially infectious materials include, but are not limited to: blood and any bodily fluid visibly contaminated by blood, semen, vaginal secretions, possibly saliva, urine, vomitus and feces. Also included is any unfixed human tissue and organ other than intact skin, as well as HIV or HBV containing cultures and blood or organs from infected experimental animals. 

Compliance

  • Universal precautions will be observed at all times to prevent contact with blood or other potentially infectious materials. All blood or other potentially infectious materials will be considered infectious regardless of the perceived status of the source individual.
  • The Exposure Control Plan is available on the Environmental Health and Safety web page.
  • The ECP shall be reviewed annually and updated whenever necessary. Review and updates shall consider:
    • New or modified tasks and procedures, which affect occupational exposure.
    • Reflect changes in technology that eliminate or reduce exposure to bloodborne pathogens.
    • Document annually consideration and implementation of appropriate commercially available and effective safer medical devices designed to eliminate or minimize occupational exposure.
  • Engineering and work practice controls shall be used to eliminate or minimize employee exposure. Where occupational exposure remains after institution of these controls, personal protective equipment (PPE) shall also be used. Engineering controls shall be examined and maintained or replaced on a regular schedule to ensure their effectiveness.
  • Employers shall provide hand-washing facilities, which are readily accessible to employees. When provision of hand-washing facilities is not feasible, the employer shall provide either an appropriate antiseptic hand cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes.
  • Employers shall ensure that employees wash their hands immediately or as soon as feasible after removal of gloves or other personal protective equipment.
  • Contaminated needles and other contaminated sharps shall not be bent, or recapped. Shearing or breaking of contaminated needles is prohibited.
  • Warning labels shall be affixed to containers of regulated waste, refrigerators, and freezers containing blood or OPIM. Warning labels shall include the “biohazard” legend followed by the term “BIOHAZARD” and shall be fluorescent orange or orange-red with lettering and symbols in a contrasting color.
  • Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure. Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or on countertops or bench-tops where blood or other potentially infectious materials are present.
  • Mouth pipetting/suctioning of blood or other potentially infectious materials is prohibited.
  • Specimens of blood or other potentially infectious materials shall be placed in a container, which prevents leakage during collection, handling, processing, storage, transport, or shipping.
  • Employees with occupational exposure must be trained in the use and limitations of methods that will prevent or reduce exposure, including appropriate engineering controls, work practices and personal protective equipment.

Personal Protective Equipment

When there is the potential for occupational exposure, the employer shall provide, at no cost to the employee, appropriate personal protective equipment such as, but not limited to, gloves, gowns, laboratory coats, face shields or masks and eye protection, and mouthpieces, resuscitation bags, pocket masks, or other ventilation devices.

The employer shall ensure that appropriate personal protective equipment in the appropriate sizes is readily accessible at the worksite or is issued to employees.

The employer shall repair or replace PPE as needed to maintain its effectiveness, at no cost to the employee.

If a garment(s) is penetrated by blood or other potentially infectious materials, the garment(s) shall be removed immediately or as soon as feasible. When PPE is removed it shall 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 materials, mucous membranes, and non-intact skin; when performing vascular access procedures; and when handling or touching contaminated items or surfaces.

Housekeeping

Employers shall ensure that the worksite is maintained in a clean and sanitary condition.

  • All equipment and working surfaces shall be cleaned and decontaminated after contact with blood or other potentially infectious materials.
  • Broken glassware, which may be contaminated, 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.

Sharps Management

Contaminated sharps shall be discarded immediately or as soon as feasible in containers that are:

  • Closable;
  • Puncture resistant;
  • Leak-proof on sides and bottom; and
  • Labeled or color-coded in accordance with paragraph (g)(1)(i) of the OSHA standard.

Supervisory personnel shall ensure that a sharps injury log be maintained and retained for seven years.

  • The sharps injury log must contain, at a minimum, the type and brand of device involved in the injury (if known), the department or work area where the exposure incident occurred, and an explanation of how the incident occurred. The log must be recorded and maintained in a manner that protects the confidentiality of the injured worker (e.g., removal of personal identifiers).

Medical Treatment and Evaluation

First Aid Treatment of an Exposure Site: Wounds and skin sites that have been in contact with blood or body fluids should be washed with soap and water; mucous membranes should be flushed with water. No evidence exists that using antiseptics for wound care or expressing fluid by squeezing the wound further reduces the risk of bloodborne pathogen transmission; however, the use of antiseptics is not contraindicated. The application of caustic agents (e.g., bleach) or the injection of antiseptics or disinfectants into the wound is not recommended.

Post-exposure Evaluation and Follow-up: Following a report of an exposure incident, the employer shall make immediately available to the exposed employee a confidential medical evaluation and follow-up, including at least the following elements:

  • The source individual's blood shall be tested as soon as feasible and after consent is obtained in order to determine HBV and HIV infectivity.
  • If consent is not obtained, the employer shall establish that legally required consent cannot be obtained.
  • When the source individual's consent is not required by law, the source individual's blood, if available, shall be tested and the results documented.

When law does not require the source individual’s consent, the source individual's blood, if available, shall be tested and the results documented. Treatment shall be provided by the current NSHE medical provider:

  • Renown Occupational Health
    975 Ryland Street #100
    Reno, NV 89512
    775-982-4200
    Hours: M-F 7:30 a.m.–5 p.m.

  • After Hours: St. Mary's Urgent Care
    6180 Mae Anne Ave, Suite 1
    Reno, NV 89523
    775-284-5556
    Hours: M-F 8:30 a.m.–5 p.m., S-S 9 a.m.–5 p.m.
  • Alternative locations for treatment.

Training and Records

New employees designated as being at risk under this procedure shall be trained in compliance with 29CFR 1910.1030. Additionally, all employees of TMCC identified to be at risk shall be given an annual refresher course on bloodborne pathogens.

Some employees in the following job classifications performing proscribed tasks may have occupational exposure to blood of other potentially infectious materials.

  • Science, Nursing and Dental
    • Prep lab personnel
    • Instructors
    • Lab assistants
  • Facility Services
    • Custodial personnel
    • Maintenance personnel
    • EHS
  • ChildCare Center
    • All ChildCare Center personnel

Training records must be maintained for three years from the date on which training occurred, and shall include: Date of the training session, content summary of the training session, names and qualifications of persons conducting the training, and names and job titles of persons attending the training session.
Records of injury shall be kept for thirty years.

All individual training certificates shall be maintained in the department of ownership.