BCTC Bloodborne Pathogen Exposure Control Manual

Policy Statement

Bluegrass Community and Technical College (BCTC) is committed to providing a safe and healthful work environment for all employees and students within its facilities. In pursuit of this goal, the following Exposure Control Plan (ECP) is provided to eliminate or minimize occupational exposure to bloodborne pathogens as defined by, and in accordance with, OSHA standard 29 CFR 1910.1030, “Occupational Exposure to Bloodborne Pathogens.”

Program Description

The purpose of this ECP is to make available a source of information for all individuals who might have occupational exposure to bloodborne pathogens and to provide a description of the program. Individuals of primary concern for BCTC include employees, students, contractors, emergency responders, essentially anyone within BCTC with the potential to incur exposure.

The ECP is a key document to assist our organization in implementing and ensuring compliance with the standard, thereby protecting our employees and addresses the following topics:  

• Determination of employee exposure,
• Implementation of various methods of exposure control (i.e. universal precautions, engineering and work practice controls, personal protective equipment, housekeeping),
• Hepatitis B vaccination,
• Post-exposure evaluation and follow-up,
• Communication of hazards to employees and training,
• Recordkeeping, and
• Procedures for evaluating circumstances surrounding exposure incidents.

Program Administration

BCTC is responsible for implementation of the ECP and maintains, reviews, and updates the ECP at least annually to include new or modified tasks and procedures. 

Those employees who have been 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 Bloodborne Pathogens Officer is to assure the provision and maintenance of all necessary personal protective equipment (PPE), engineering controls (e.g., sharps containers), labels, and red bags as required by the standard. They are also tasked with ensuring that adequate employee health and OSHA records are maintained.  The Bloodborne Pathogens Officer is also responsible for training, documentation of training, and making the written ECP available to employees, OSHA, and NIOSH representatives.

Additional Assistance

For information concerning the occupational safety and health standards, regulations, interpretations and actions of the Kentucky Occupational Safety and Health Standards Board, contact:

OSH Regulations Development and Interpretations Office
Kentucky Labor Cabinet
Frankfort, Kentucky 40601
502.564.2778

For information concerning Occupational Safety and Health training, consultation, technical assistance, publications and OSH recordkeeping forms, contact:

Division of Education and Training
Kentucky Occupational Safety and Health Program
Kentucky Labor Cabinet
Frankfort, Kentucky 40601
502.564.4102

For information concerning this Exposure Control Plan for Bluegrass Community and Technical College contact:

Bloodborne Pathogens Officer
Bluegrass Community and Technical College
500 Newtown Pike
Lexington, Kentucky 40508
(859) 246-6200

OSHA requires employers to perform an exposure determination concerning which employees may incur occupational exposure to blood or other potentially infectious materials. This determination, specific to BCTC, includes the following:

1. Category I employees: A list of all job classifications in which all employees in those job classifications have occupational exposure to blood or potentially infectious materials.
2. Category II employees: A list of job classifications in which some employees have occupational exposure to blood and potentially infectious materials. This must include a list of all tasks and procedures, or groups of closely related tasks or procedures, in which occupational exposure may occur and that are performed by Category II employees.

Many BCTC employees associated with healthcare programs have occupational exposure at clinical affiliation sites. The burden of training that the Bloodborne Pathogen standard requires is the sole responsibility of BCTC. Clinical affiliation sites are not responsible because BCTC personnel are not their employees.

Although the clinical affiliation sites are not legally required to provide training under the OSHA Bloodborne Pathogen standard, other legal and civil issues dictate that there must be a shared responsibility of providing site-specific training, personal protective equipment, and controlling of potential exposure conditions. Contracts between BCTC and clinical affiliation sites should clearly describe the training responsibilities of both parties in order to ensure that all training requirements of the standard are met and that all BCTC employees are safe.

As required, the exposure determination described in the following tables has been made without regard to the use of personal protective equipment.

Category II: Tasks and Procedures

For Maintenance and Operations employees occupational exposure is unlikely but may occur during building maintenance procedures in laboratory facilities and the dental hygiene clinic, during bathroom facility repair and cleaning, repair of contaminated equipment, waste disposal procedures, and cleaning of blood spills in the event of a medical emergency or accident on campus. The nature of maintenance operations lends itself to causing many minor scrapes and cuts that can potentially cause an exposure to another employee if not properly handled.

29 CFR Part 1910.1030 Occupational Exposure to Bloodborne Pathogens; Final Rule became effective on March 6, 1992. The final implementation deadline for all components of the federal standard was July 6, 1992. However, Kentucky is a “state plan” state that has adopted its own OSHA approved Bloodborne Pathogen standard, which must be “at least as effective” as the Federal OSHA standard. The Kentucky deadline for full implementation was October 4,1992.

The Bloodborne Pathogens standard was revised in conformance with the requirements of the Needlestick Safety and Prevention Act effective April 18, 2001.

This exposure control plan must be reviewed and updated at least annually. In addition, whenever changes in tasks, procedures, or employee positions affect or create new occupational exposure, the existing plan must be reviewed and updated accordingly.

Standard precautions are intended to prevent transmission of infection, as well as decrease the risk of exposure for employees of BCTC. It is impossible to identify all infected persons, so it is necessary to treat every person as potentially infected with a bloodborne pathogen. Employees must protect themselves from blood or other body fluids that are not their own. Employees should anticipate possible exposures both in emergency situations and routine tasks they perform in a normal workday. Employees must be knowledgeable about the use of personal protective equipment such as latex gloves, proper handwashing techniques, proper disposal and cleanup techniques, and other important skills.

Standard precautions pertain to blood and other potentially infectious materials as defined in the definitions section of this Exposure Control Plan. When differentiation of types of body fluids is difficult or impossible, all body fluids are to be considered potentially infectious.

Engineering controls are designed to isolate or remove the bloodborne pathogens hazard from the workplace so that employee exposure is limited. Where occupational exposure remains after institution of these controls, personal protective equipment must also be used.  Examples of engineering controls may include sharps disposal containers, self-sheathing needles, sharps with engineered sharps injury protections, shields, vented hoods, and high speed vacuum systems.

OSHA requires that BCTC periodically examine and maintain or replace engineering controls on a regular schedule to ensure their effectiveness. Program coordinators and area supervisors or their designees are responsible for ensuring that supplies and controls for their own program/area are ordered and stocked so they can be replaced as necessary. They are responsible for ensuring that employees in their program/area are using the engineering controls properly. The effectiveness of these controls should be periodically reviewed and appropriate changes made if necessary. Faculty and staff classified as category I or II who work in areas that utilize engineering controls are responsible for the day-to-day monitoring and replacement of engineering controls that are mechanical or replacement dependent.

Problems with repair or replacement must be immediately brought to the attention of the Bloodborne Pathogen Officer and the appropriate program coordinator or area supervisor.

Work practice controls reduce the likelihood of exposure by altering the manner in which a task is performed. Many times they work with engineering controls to eliminate or minimize employee exposures. Examples of work practice controls include handwashing practices, avoiding, recapping of needles, refraining from eating, drinking, or storing food in restricted areas, and others.

Program coordinators and area supervisors or their designees are responsible for ensuring that employees in their program/area are practicing proper work practice controls. The effectiveness of these controls should be periodically reviewed and appropriate changes made if necessary.

Handwashing

Handwashing facilities, which are readily accessible, must be provided to employees of BCTC. There are handwashing facilities located in all laboratory and clinic areas. These handwashing stations have hot and cold running water, germicidal handwashing detergent, and paper towels. In addition, each building has public restrooms on every floor that are available to all staff and students. Laboratory and clinic areas are also provided with emergency showers and eyewash stations.

In some areas an appropriate antiseptic hand cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes may be provided. When antiseptic hand cleansers or towelettes are used, hands should be washed with soap and running water as soon as feasible.

It is BCTC policy that:

• Employees wash their hands immediately, or as soon as feasible, after removal of gloves or other personal protective equipment.
• Employees wash hands and any other affected skin with soap and water, or flush mucous membranes with water, immediately, or as soon as feasible, following contact with blood or other potentially infectious materials.

Needles and Sharps

Contaminated needles and other contaminated sharps must not be bent, recapped, or removed except as noted below. Shearing or breaking of contaminated needles is prohibited.

• Contaminated needles and other contaminated sharps must not be bent, recapped or removed unless it can be demonstrated that no alternative is feasible or that such action is required by a specific medical procedure.
• Bending, recapping, or needle removal must be accomplished through the use of a mechanical device or a one-handed technique.

Immediately or as soon as possible after use, contaminated reusable sharps must be placed in appropriately-identified containers until properly reprocessed. These containers must be:

• Closable,
• Puncture resistant,
• Labeled or color-coded in compliance with the Bloodborne Pathogen Standard, and
• Leak proof.

Reusable sharps that are contaminated with blood or other potentially infectious materials must not be stored or processed in a manner that requires employees to reach by hand into the containers where these sharps have been placed.

Work Area Restrictions

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 may not be kept in laboratory or clinic areas, including in refrigerators, freezers, shelves, 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 must be performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets of these substances.

Mouth pipetting/suctioning of blood or other potentially infectious materials is strictly prohibited.

Specimens

Specimens of blood or other potentially infectious materials must be placed in a container which prevents leakage during collection, handling, processing, storage, transport, or shipping.

• The container for storage, transport, or shipping must be labeled or color-coded and closed prior to being stored, transported, or shipped.  When a facility utilizes standard precautions in the handling of all specimens, the labeling/color-coding of specimens is not necessary provided containers are recognizable as containing specimens. This exemption only applies while such specimens/containers remain within the facility. Labeling or color-coding is required when such specimens/containers leave the facility.
• If outside contamination of the primary container occurs, the primary container must be placed within a second container which prevents leakage during handling, processing, storage, transport, or shipping, and is labeled or color-coded according to the requirements of this standard.
• If the specimen has the potential puncture the primary container, the primary container must be placed within a secondary container, which is puncture-resistant in addition to the above characteristics.

Equipment Servicing or Shipping

Equipment which may become contaminated with blood or other potentially infectious materials must be examined prior to servicing or shipping and be decontaminated as necessary unless it can be demonstrated that decontamination of such equipment or portions of such equipment is not feasible.

• A readily observable label must be attached to the equipment stating which portions remain contaminated.
• It is BCTC policy that this information be conveyed to all affected employees, the servicing representative, and/or the manufacturer, as appropriate, prior to handling, servicing, or shipping so that appropriate precautions are taken.

Personal protective equipment (PPE) is specialized clothing or equipment worn by an employee for protection against a hazard. General work clothes (e.g., uniforms, pants, shirts or blouses) not intended to function as protection against a hazard are not considered to be PPE.

Program coordinators and area supervisors or their designees are responsible for ensuring that PPE is readily accessible in all areas where it may be needed, and that it is properly used. They are also responsible for making sure that ample supplies are ordered and stocked so PPE can be replaced as necessary. The effectiveness of the required PPE should be periodically reviewed and appropriate changes made if necessary.

Faculty and staff classified as Category I or II who perform tasks that require PPE are responsible for the day-to-day monitoring and replacement of PPE.  The Dental Hygiene and Dental Laboratory Technology programs have individual exposure control plans that have detailed instructions on the use of PPE.

The Nursing program and maintenance employees have minimal occupational exposure at BCTC. When/if they handle or utilize potentially infectious needles, PPE and Biohazard containers are employed.

Exposure at Clinical Affiliation Sites

It is possible that some faculty in the healthcare programs do not have occupational exposure to bloodborne pathogens while at BCTC but go to off-campus sites where they perform tasks that put them at risk.  Faculty must follow the Exposure Control Plan protocols of the clinical affiliation site in which they are teaching.

The clinical affiliation site must provide PPE whenever there is the possibility of occupational exposure to bloodborne pathogens or other potentially infectious materials.  Faculty should wear their personal clothing and should cover that clothing with the appropriate PPE based on the type of exposure anticipated.  If a BCTC employee’s own clothing is exposed to blood or other potentially infectious materials, they should remove that clothing as soon as possible and wear replacement clothing provided by the clinical affiliation site.  The employee’s personal clothing should be placed in a red biohazard bag and brought to the BCTC Maintenance and Operations office where it will be transported off-site by a commercial laundry facility that BCTC has contracted to decontaminate and clean employee clothing. There will be no cost to the employee for this service.

Use of Personal Protective Equipment

In the case of potential occupational exposure, BCTC will provide, at no cost to the employee, appropriate PPE such as, but not limited to, gloves, gowns, laboratory coats, face shields or masks, eye protection, mouthpieces, resuscitation bags, pocket masks, or other ventilation devices.  PPE will be chosen based on the anticipated exposure to blood or other potentially infectious materials. PPE 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 PPE will be used.

Declination of Personal Protective Equipment

It is BCTC policy that an employee use appropriate PPE unless it can be demonstrated that the employee temporarily and briefly declined to use PPE when, under rare and extraordinary circumstances, it was the employee’s professional judgment that in the specific instance 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 circumstances will be investigated and documented in order to determine whether changes can be instituted to prevent such occurrences in the future.

Accessibility

It is BCTC policy to provide appropriate PPE in the appropriate sizes and is readily accessible at the worksite or is issued to employees. Hypoallergenic gloves, glove liners, powderless gloves, or other similar alternatives will be readily accessible to those employees who are allergic to the gloves normally provided.

Cleaning, Laundering, and Disposal

BCTC will provide cleaning, laundering, and disposal of required PPE, at no cost to the employee. Employees may not take personal protective clothing home to clean. PPE will be repaired or replaced 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) must be removed immediately or as soon as feasible, placed in a red biohazard bag and presented to BCTC for cleaning.

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

Gloves

Gloves must 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.

• Disposable (single use) gloves such as surgical or examination gloves must 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 (single use) gloves may not be washed or decontaminated for re-use.
• Utility gloves may be decontaminated for re-use if the integrity of the glove is not compromised.  However, they must be discarded if they are cracked, peeling, torn, punctured, or exhibit other signs of deterioration or when their ability to function as a barrier is compromised.

Masks, Eye Protection, and Face Shields

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

Other Protective Clothing

Appropriate protective clothing such as, but not limited to, gowns, aprons, lab coats, clinic jackets, or similar outer garments must be worn in occupational exposure situations. The type and characteristics will depend upon the task and degree of exposure anticipated.

It is BCTC policy that the worksite be maintained in a clean and sanitary condition.  BCTC determines and implements an appropriate schedule for cleaning and methods 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.

Category I and II employees of BCTC who perform tasks and procedures that contaminate work surfaces or equipment are responsible for cleaning and decontaminating those surfaces or equipment.  This cleaning and decontamination must occur after completion of each patient’s care and any other task involving blood or other potentially infectious material.  If surfaces or equipment are accidentally contaminated or a spill of blood or other potentially infectious material has occurred, it is to be cleaned and disinfected immediately.  Emergency biological spill kits are available at all campuses.

A detailed written schedule for cleaning and disinfection of the Dental Hygiene Clinic is found in their exposure control plan.

Acceptable disinfectants used throughout BCTC for housekeeping are:

• Fresh bleach solutions mixed to a 1:10 ratio with water.
• EPA-registered tuberculocidal disinfectants
• EPA-registered disinfectants that are labeled as effective against both HIV and HBV

Designated BCTC employees are responsible for the daily cleaning of environmental surfaces such as floors, walls, counters, sinks, and bathroom facilities and the disposal of all non-regulated waste.  BCTC provides training in the proper procedures to follow to minimize their exposure to bloodborne pathogens and other potentially infectious materials.

Cleaning and Disinfection

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

Contaminated work surfaces must be decontaminated with an appropriate disinfectant after completion of procedures; immediately or as soon as feasible when surfaces are overtly contaminated or after any spill of blood or other potentially infectious materials; 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 must be removed and replaced as soon as feasible when they become overtly contaminated or at the end of the work shift if they may have become contaminated during the shift.

All bins, pails, cans, and similar receptacles intended for reuse which have a reasonable likelihood for becoming contaminated with blood or other potentially infectious materials are to be inspected and decontaminated on a regularly scheduled basis; and cleaned and decontaminated immediately, or as soon as feasible, upon visible contamination.

Broken glassware, which may be contaminated, must not be picked up directly with the hands.  It must be collected and disposed of using mechanical means, such as a brush and dustpan, tongs, or forceps.

Reusable sharps that are contaminated with blood or other potentially infectious materials may not be stored or processed in a manner that requires employees to reach by hand into the containers where these sharps have been placed.

Handling of Regulated Waste

Federal OSHA guidelines dictate how contaminated wastes must be handled while the employee has occupational exposure to it. OSHA does not attempt to determine how infectious the medical waste may be, thus it uses the term, regulated waste. Regulated waste refers to the following five categories of waste which require special handling at a minimum:

• 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 are capable of releasing these materials during handling.
• Contaminated sharps.
• Pathological and microbiological wastes containing blood or other potentially infectious materials.

Treatment and Disposal Methods of Regulated Waste

Approved containers for regulated waste will be provided in all areas where they are reasonably anticipated to be needed. Employees will place all regulated waste into these containers and they will be stored until they are picked up for proper disposal. BCTC contracts with an outside agency, which specializes in the treatment, and disposal of regulated waste to ensure that all laws and regulations are followed. 

Contaminated Sharps Discarding and Containment

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

• Closable.
• Puncture resistant.
• Leak-proof.
• Labeled or color-coded in accordance with the Bloodborne Pathogen standard.

During use, containers for contaminated sharps must be:

• Easily accessible to personnel and located as close as is feasible to the immediate area where sharps are used or can be reasonably anticipated to be found.
• Maintained upright though out use.
• Replaced routinely and not allowed to overfill.

When moving containers of contaminated sharps from the area of use, the containers must be: 

• Closed immediately prior to removal or replacement to prevent spillage or protrusion of contents during handling, storage, transport, or shipping.
• Placed in a secondary container if leakage is possible. The second container must be:
  • Closable.
  • Constructed to contain all contents and prevent leakage during handling, storage, transport, or shipping.
  • Labeled or color-coded in accordance with the Bloodborne Pathogen Standard.

Reusable containers must not be opened, emptied, or cleaned manually or in any other manner, which would expose employees to the risk of percutaneous injury. 

Other Regulated Waste Containment

Regulated waste must be placed in containers, which are:

• Closable.
• Constructed to contain all contents and prevent leakage of fluids during handling, storage, transport, or shipping.
• Labeled or color-coded in accordance with the Bloodborne Pathogen Standard.
• Closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping.

If outside contamination of the regulated waste container occurs, it must be placed in a second container. The second container must also be: 

• Closable.
• Constructed to contain all contents and prevent leakage of fluids during handling, storage, transport, or shipping.
• Labeled or color-coded in accordance with the Bloodborne Pathogen Standard.
• Closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping.

Disposal of all regulated waste must be in accordance with applicable regulations of the United States, States and Territories, and political subdivisions of States and Territories.

Laboratory coats or other contaminated PPE laundry will be picked up and transported off-site by a commercial laundry facility that BCTC has contracted. Contaminated laundry should be handled as little as possible, with minimum agitation to prevent gross microbial contamination of the air and personnel handling the linen.  Also, contaminated laundry must be bagged or containerized at the location where it was used and not be sorted or rinsed in the location of use.

Contaminated laundry must be placed and transported in bags or containers labeled or color-coded as described in this document. When a facility utilizes standard precautions in the handling of soiled laundry, alternative labeling or color-coding is sufficient if it permits all employees to recognize the containers as requiring compliance with standard precautions.

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

It is BCTC policy that employees coming in contact with contaminated laundry wear protective gloves and other appropriate personal protective equipment.  If contaminated laundry is sent off-site to a second facility, which does not utilize standard precautions in the handling of all laundry, laundry must be placed in bags or containers which are properly labeled or color-coded.

There are no HIV/HBV research laboratories or production facilities at Bluegrass Community and Technical College.

For employees who have the potential for occupational exposure to Hepatitis B, BCTC must ensure that all medical evaluations and procedures including the hepatitis B vaccine and vaccination series and post-exposure evaluation and follow-up, including prophylaxis are made available at no cost to the employee. These shall be conducted at a reasonable time and place, and according to current standard recommendations for medical practice by the U.S. Public Health Service at the time these evaluations and procedures occur. All medical evaluations and procedures to be performed will be under the supervision of a licensed physician or by or under the supervision of another licensed healthcare professional and all laboratory tests conducted by an accredited laboratory.

The Hepatitis B vaccination shall be made available after the employee has received the training required in the Bloodborne Pathogen standard and within 10 working days of initial assignment to all employees who have occupational exposure unless the employee has:

• Previously received the complete hepatitis B vaccination series.
• Antibody testing reveals that the employee is immune.
• Medical reasons, which contraindicate the vaccine.

Participation in a prescreening program is not a prerequisite for receiving hepatitis B vaccination. Employees who decline to accept the Hepatitis B vaccination offered will sign a declination statement. If the employee initially declines the Hepatitis B vaccination but at a later date while still covered under the standard decides to accept the vaccination, BCTC will make the vaccination available at that time.

If a routine booster dose(s) of Hepatitis B vaccine is recommended by the U.S. Public Health Service at a future date, the booster dose(s) will be made available at no cost to the employee, within a reasonable time and place and performed under the supervision of a licensed physician or by or under the supervision of another licensed healthcare professional.

When an employee has an exposure incident, they should immediately or as soon as feasible, report the incident to their supervisor and to the BCTC Director of Safety and Security, who is responsible for assuring that the policy is effectively carried out, as well as maintaining records related to this policy. Employees will be informed of the procedures to follow and given assistance in filling out the proper recordkeeping forms.

Following a report of an exposure incident, BCTC will make immediately available to the exposed employee a confidential medical evaluation 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, unless the employer 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 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 the source individual is already known to be infected with HBV or HIV, testing for the source individual’s known HBV or HIV status need not be repeated.
  • Results of the source individual’s testing shall be made available to the exposed employee, and the employee shall be informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual.  The employee will be required to fill out and sign a confidentiality statement before being given the source individual’s test results.
• Collection and testing of employee’s blood for HBV and HIV serological status:
  • The exposed employee’s blood shall be collected as soon as feasible and tested after consent if obtain.
  • If the employee consents to baseline blood collection but does not give consent at that time for HIV serologic 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, when medically indicated, as recommended by the U.S. Public Health Service.
• Counseling - The employee will be given appropriate counseling concerning precautions to take during the period after the exposure incident to protect themselves as well as others they have contact with. The employee will also be given information on what potential illnesses to be alert for and to report any related experiences to appropriate personnel.
• Evaluation of reported illnesses.

Information Provided to the Healthcare Professional

The healthcare professional responsible for the employee’s Hepatitis B vaccination will be provided with a copy of the OSHA Standard on Occupational Exposure to Bloodborne Pathogens (29 CFR Part 1910.1030) and:

• A description of the exposed employee’s duties as they relate to the exposure incident.
• Documentation of the route(s) of exposure and circumstances under which exposure occurred.
• Results of the source individual’s blood testing, if available.
• All medical records relevant to the appropriate treatment of the employee including vaccination status, which, are the employer’s responsibility to maintain.

Healthcare Professional’s Written Opinion

BCTC will obtain and provide the employee with a copy of the evaluating healthcare professional’s written opinion within 15 days of the completion of the evaluation. The healthcare professional’s written opinion for Hepatitis B vaccination will 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 will be limited to:

• Assurance that the employee has been informed of the results of the evaluation.
• Assurance that the employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials which require further evaluation or treatment.
• Assurance that all other findings or diagnoses will remain confidential and not be included in the written report. 

Medical Recordkeeping

Medical records will be maintained in accordance with recordkeeping requirements of the Bloodborne Pathogen Standard.

Employee Exposure Incident Procedures

Exposure incident means a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee’s duties.

In the event of an exposure incident, the following procedures will be followed:

1. Wash exposed areas of the body as soon as possible.
2. Clean and disinfect contaminated surfaces if necessary.
3. Notify the following individuals:
   • The exposed employee’s immediate supervisor
   • BCTC Safety and Security Manager

   These individuals will explain the risks involved with exposure to bloodborne pathogens and the importance of evaluation and follow-up by a healthcare professional.  They will also assist the exposed employee with completion of all necessary forms.

4. Complete the following forms:
   • Worker’s Compensation Claim form I.A. – 1
   • Exposure Incident Report and Evaluation
   • Post-Exposure Evaluation Consent/Refusal
5. Determine if the source individual can be identified and complete the following forms:
   • Source Individual Informed Consent/Refusal
   • Employee Confidentiality Statement
6. Complete the Post-Exposure Report to Healthcare Professional form if the employee consents to evaluation and follow-up. Attach the above forms along with the exposed employee’s Hepatitis B Vaccine Informed Consent or Informed Refusal form and forward them to the healthcare professional who will be examining the exposed employee.

All invoices for employee or source individual expenses should be forwarded to the BCTC Safety and Security Manager.

Warning labels are to be affixed to containers of infectious waste, refrigerators and freezers containing blood or other potentially infectious material, or other containers used to store or transport blood or other potentially infectious materials. The labels shall be fluorescent orange or orange-red or predominately so, with lettering and symbols in contrasting colors, using the accepted biohazard label.  The label must either be an integral part of the container or affixed as closely as safely possible to the container by string, wire, adhesive, or other method that prevents their loss or unintentional removal.  Red bags or containers may be substituted for labels on containers of infectious waste.  Regulated waste that has been decontaminated need not comply.

Labels required by this section must include the biohazard symbol. as shown.

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Requirements for Training 

BCTC requires all employees with the potential for occupational exposure to participate in at least an annual training program, which must be provided at no cost to the employee and during working hours. Training will be provided as follows:

• At the time of initial assignment to tasks where occupational exposure may take place.
• Within 90 days after the effective date of the standard.
• Within one year of their previous training.
• When changes such as modification of tasks or procedures to institution of new tasks or procedures affect the employee’s occupational exposure (additional training may be limited to addressing the new exposures created).

For employees who have received training on bloodborne pathogens in the year preceding the effective date of the standard, only training with respect to the provisions of the standard which were not included need be provided.

Annual training for all employees will be provided within one year of their previous training.

Material appropriate in content and vocabulary to educational level, literacy, and language of employees shall be used.

The training program must contain the following elements:

• An accessible copy of the regulatory text of this standard and an explanation of its contents.
• A general explanation of the epidemiology and symptoms of bloodborne diseases.
• An explanation of the modes of transmission of bloodborne pathogens.
• An explanation of the employer’s exposure control plan and the means by which the employee can obtain a copy of the written plan.
• An explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious material.
• An explanation of the use and limitations of methods that will prevent or reduce exposure including appropriate engineering controls, work practices, and personal protective equipment.
• An explanation of the basis for selection of personal protective equipment.
• Information on the Hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine and vaccination will be offered free of charge.
• Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious material.
• An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available.
• Information on the post-exposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident.
• An explanation of the signs and labels and/or color-coding required by the Bloodborne Pathogen Standard.
• An opportunity for interactive questions and answers with the person conducting the training session.

Qualifications of Person Conducting the Training

The person conducting the training must be knowledgeable in the subject matter covered by the elements contained in the training program as it relates to BCTC.  Bloodborne Pathogen training is available through the KCTCS system at www.kctcsbest.com.

All medical records and training records required by OSHA will be maintained in a confidential manner by BCTC Human Resources Office and the yearly bloodborne pathogens training records kept in the office of the Bloodborne Pathogens Officer for three years from the date on which the training occurred.

Medical Records

BCTC will establish and maintain an accurate record for each employee with occupational exposure, for at least the duration of employment plus 30 years in accordance with 29 CFR 1910.20.  

This record will include:

• The name and social security number of the employee.
• A copy of the employee’s Hepatitis B vaccination status including the dates of all the Hepatitis B vaccinations and any medical records relative to the employee’s ability to receive vaccination as required by the Bloodborne Pathogen Standard.
• A copy of all results of examinations, medical testing, and follow-up procedures as required by the Bloodborne Pathogen Standard.
• BCTC’s copy of the healthcare professional’s written opinion as required by the Bloodborne Pathogen Standard.
• A copy of the information provided to the healthcare professional as required by the Bloodborne Pathogen Standard.

Confidentiality

BCTC will ensure that employee medical records required by the Bloodborne Pathogen Standard are kept confidential and are not disclosed or reported without the employee’s express written consent to any person within or outside the workplace except as required by this section or as may be required by law.

Training Records

Training records include the following information:

• The dates of the training sessions.
• The contents or a summary of the training sessions.
• The names and qualifications of persons conducting the training.
• The names and job titles of all persons attending the training session.

Availability

BCTC ensures that all records required to be maintained will be provided upon specific request for examination and copying to the subject employee, to anyone having written consent of the subject employee, to the Director of the National Institute for Occupational Safety and Health, and/or to the Assistant Secretary of Labor for Occupational Safety and Health in accordance with 29 CFR 1910.20.

Transfer of Records

BCTC will comply with the requirements involving transfer of records set forth in 29 CFR 1910.20(h). If BCTC ceases to do business and there is no successor employer to receive and retain the records for the prescribed period, BCTC will notify the Director, at least three months prior to their disposal and transmit them to the Director, if required by the Director to do so, within that three-month period.

Assistant Secretary - the Assistant Secretary of Labor for Occupational Safety and Health, or designated representative.

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

Bloodborne Pathogens - pathogenic microorganisms that are present in human blood and can cause disease in humans.  These pathogens include, but are not limited to, hepatitis B virus (HBV) and human immunodeficiency virus (HIV).

Clinical Laboratory - a workplace where diagnostic or other screening procedures are performed on blood or other potentially infectious materials.

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

Contaminated Laundry - laundry which has been soiled with blood or other potentially infectious materials or may contain sharps.

Contaminated Sharps - 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.

Decontamination - 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.

Director - the Director of the National Institute for Occupational Safety and Health, U.S. Department of Health and Human Services, or designated representative.

Engineering Controls - controls (e.g., sharps disposal containers, self-sheathing needles, safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the bloodborne pathogens hazard from the workplace.

Exposure Incident - a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee’s duties.

Handwashing Facilities - a facility providing an adequate supply of running potable water, soap, and single-use towels or air-drying machines.

Licensed Healthcare Professional - a person whose legally permitted scope of practice allows him or her to independently perform the activities required by paragraph (f) Hepatitis B Vaccination and Post-exposure Evaluation and Follow-up.

HBV - Hepatitis B virus.

HVC - Hepatitis C virus.

HIV - Human Immunodeficiency Virus.

Needleless systems - a device that does not use needles for:  

1. The collection of bodily fluids or withdrawal of body fluids after initial venous or arterial access is established;
2. The administration of medication or fluids; or
3. Any other procedure involving the potential for occupational exposure to bloodborne pathogens due to percutaneous injuries from contaminated sharps.

Occupational Exposure - 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.

OSHA - Occupational and Safety Health Administration

Other Potentially Infectious Materials - (1) 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- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.

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

Personal Protective Equipment - specialized clothing or equipment worn by an employee for protection against a hazard.  General work clothes (e.g., uniforms, pants, shirts or blouses) not intended to function as protection against a hazard are not considered to be personal protective equipment.

Production Facility - a facility engaged in industrial-scale, large-volume or high concentration production of HIV or HBV.

Regulated Waste - liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid 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.

Research Laboratory - a laboratory producing or using research-laboratory-scale amounts of HIV or HBV. Research laboratories may produce high concentrations of HIV or HBV but not in the volume found in production facilities.

Sharps with engineered sharps injury protections - a 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.

Sterilize - a physical or chemical procedure to destroy all microbial life including highly resistant bacterial endospores.

Universal Precautions (Standard 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 - 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).