BCTC Bloodborne Pathogen Exposure Control Manual | BCTC

BCTC Bloodborne Pathogen Exposure Control Manual

Revised October, 2020

Policy Statement

It is the policy of Bluegrass Community and Technical College to safeguard the employees and students within this facility and to eliminate or reduce employee and student occupational exposure to human blood and/or certain body fluids that may contain infectious bloodborne pathogens or other potentially infectious materials.

Purpose

The purpose of the Exposure Control Manual is to provide a written description of the Exposure Control Plan in effect at Bluegrass Community and Technical College so that all individuals who might have occupational exposure to bloodborne pathogens will know and understand the infection control program. These individuals include employees, subcontractors, emergency responders, government officials, and inspectors of the Kentucky Labor Cabinet Occupational Safety and Health (OSH) Program.

Objectives

The objectives of Bluegrass Community and Technical College’s Exposure Control Plan are:

  1. To minimize or eliminate the exposure of our employees in the course of their work to infectious human bloodborne pathogens.
  2. To reduce or eliminate the potential exposure to infectious human bloodborne pathogens by the proper instruction on safe procedures and use of safety equipment and materials.
  3. To comply with the federal regulations in 20 CFR Section 1910.1030 of the Occupational Safety and health Act, 29 U.S.C. 655 & 657 (as applicable), as adopted by Kentucky standard 803 KAR 2:320, effective October 4, 1992.

Contents

The Exposure Control Plan of Bluegrass Community and Technical College will provide the specific components, information and training required to protect all employees from exposure to potentially infectious bloodborne pathogens. The program consists of the following main components:

  • Exposure Determination
  • Methods of Compliance
  • Engineering & Work Practice Controls
  • Medical & Training Records
  • Hepatitis B Vaccination Program
  • Use of Personal Protective Equipment
  • Reporting & Managing Exposure Incidents
  • Labeling & Waste Management

The Exposure Control Plan will be made available to all employees, their designated representative(s), emergency responders, and the Assistant Secretary of the Occupational Safety and Health Administration and representatives of the Kentucky Labor Cabinet OSH Program upon request.

Additional Help or Information

Kentucky is one of 23 states with an approved OSH plan, which, must be at least as effective as the final federal OSHA Bloodborne standard. Exposure Control Plans must be developed in accordance with 29 CFR 1910.1030 as adopted by Kentucky standard 803 KAR 2:320. Listed below are the two minor changes from the federal standard:

  • 29 CFR 1910.1030(d)(3)(ix) is amended to:
    Gloves shall be worn when it can be reasonably anticipated that the employees 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.
  • 29 CFR 1910.1030(d)(3)(ix)(D) is removed.

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:

Beecher McCarty
Dean of Operations
Bluegrass Community and Technical College
859.368.6738

 

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

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

Bloodborne Pathogens means 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 means a workplace where diagnostic or other screening procedures are performed on blood or other potentially infectious materials.

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

Contaminated Laundry 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.

Decontamination 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.

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

Engineering Controls means 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 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.

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

Licensed Healthcare Professional is 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 means hepatitis B virus.

HVC means hepatitis C virus.

HIV means human immunodeficiency virus.

Needleless systems means 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 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.

OSHA means Occupational and Safety Health Administration

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- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.

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

Personal Protective Equipment 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 personal protective equipment.

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

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 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 means 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 means a nonneedle 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 means 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 means the use of 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 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)

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 Bluegrass Community and Technical College, 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.
    1. A list of all tasks and procedures, or groups of closely related task or procedures, in which occupational exposure may occur and that are performed by Category II employees.

Many Bluegrass Community and Technical College 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 I: Exposure Determination
Job Title Program/Area

Faculty

  • Full-time
  • Part-time
  • Temporary
  • Cadaver Lab
  • Dental Hygiene
  • Medical Assisting & Phlebotomy
  • Nursing
  • Pharmacy Technology
  • Radiography
  • Respiratory
  • Medical Assisting
  • Surgical Technology
Staff Support Associate I Nursing, Dental Hygiene
Clinic Coordinator Dental Hygiene
Work-study, Work-ship, and Temp. Staff All Healthcare Programs
Category II: Exposure Determination
Job Title Program/Area
Maintenance and Operations Personnel Maintenance/Operations
Work-study, Work-ship, and Temp. Staff Maintenance/Operations

Category II: Tasks and Procedures

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.

The person responsible for updating the plan is the Bloodborne Pathogen Officer for the College. At the present time that person is:

Beecher McCarty
Dean of Operations
Bluegrass Community and Technical College
859.368.6738

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 appropriate program coordinator or area supervisor or the following:

Beecher McCarty
Dean of Operations
Bluegrass Community and Technical College
859.368.6738

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 laboratories and in the dental hygiene clinic. These handwashing stations have hot and cold running water, germicidal handwashing detergent, and paper towels. In addition, each building has public rest rooms on every floor that are available to all staff and students.

In addition, emergency showers and/or eyewash stations can be found at:

LOCATIONS: Emergency Showers and Eyewash Station
Campus Building/Room Eyewash Station Emergency Shower
Cooper Oswald Building - 244 X X
Cooper Oswald Building - 244 X  
Cooper Oswald Building - 245 X X
Cooper Oswald Building - 302 X  
Cooper Oswald Building - 322 X X
Cooper Oswald Building - 324 X  
Cooper Oswald Building - 326 X  
Cooper Oswald Building - 326C X  
Cooper Oswald Building - 331 X  
Cooper Oswald Building - 343 X  
Danville 129 X  
Danville 133 X  
Georgetown 119   X
Georgetown 125A X  
Georgetown 125K X  
Georgetown 128 X  
Georgetown 212 X  
Leestown A – 253 X  
Leestown B – 110 X  
Leestown M – 117 X  
Leestown M – 118 X  
Leestown M – 136 X  
Leestown M – 136A X  
Leestown M – 138A X  
Leestown M – 138B X  
Leestown M – 142 X  
Leestown M – 143 X  
Leestown M – 145 X  
Leestown N – 100 X  
Leestown N – 101 X  
Leestown N – 109B X  
Leestown S – 101 X  
Leestown S – 102 X  
Leestown S - 116 X  
Lawrenceburg Construction lab – 122 X X
Lawrenceburg Micro lab – 139 X X
Lawrenceburg Construction classroom – 129 X X
Lawrenceburg M&O Office – 130 X X
Lawrenceburg Nursing lab – 157 X X
Lawrenceburg A&P lab - 137 X  
Newtown Classroom Building
Science lab - 307
X X
Newtown Classroom Building
Prep-room - 309
X X
Newtown Science Building -
214
X X
Newtown Science Building - 216 X X
Newtown Science Building - 217 X X
Newtown Science Building - 219 X X
Newtown Science Building - 304 X X
Newtown Science Building - 305 X X
Newtown Science Building - 306 X X
Newtown Science Building - 307 X  
Newtown Science Building - 308 X X
Newtown Science Building - 309 X X
Newtown Science Building - 310 X  
Newtown Science Building - 311 X X
Newtown Science Building - 312 X X
Newtown Science Building - 312A X X
Winchester 216 X X

When the provision of handwashing facilities is not feasible, BCTC shall provide either an appropriate antiseptic hand cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes. When antiseptic hand cleansers or towelettes are used, hands are to be washed with soap and running water as soon as feasible.

BCTC shall ensure 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 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 other potentially infectious materials.

Needles and Sharps

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

  • Contaminated needles and other contaminated sharps shall not be bent, recapped or removed unless BCTC can demonstrate that no alternative is feasible or that such action is required by a specific medical procedure.
  • Such 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 shall be placed in appropriate containers until properly reprocessed. These containers shall be:

  • Closable
  • Puncture resistant
  • Labeled or color-coded in with the Bloodborne Pathogen standard
  • Leak proof on the sides and bottom

Reusable sharps that are contaminated with blood or other potentially infectious materials shall 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 shall not be kept 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 shall 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 prohibited.

Specimens

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.

  • The container for storage, transport, or shipping shall 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 shall be placed within a second container which prevents leakage during handling, processing, storage, transport, or shipping and is labeled or color-coded according the requirements of this standard.
  • If the specimen could puncture the primary container, the primary container shall 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 shall be examined prior to servicing or shipping and shall be decontaminated as necessary, unless BCTC can demonstrate that decontamination of such equipment or portions of such equipment is not feasible.

  • A readily observable label shall be attached to the equipment stating which portions remain contaminated.
  • BCTC shall ensure that this information is conveyed to all affected employees, the servicing representative, and/or the manufacturer, as appropriate, prior to handling, servicing, or shipping so that appropriate precautions will be 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 program has 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. They do utilize potentially infectious needles and handle them utilizing PPE and Biohazard containers.

Exposure at Clinical Affiliation Sites

Faculty in some of the healthcare programs do not have occupational exposure to bloodborne pathogens 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. Faculty should wear their personal clothing and should cover that clothing up 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 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

When there is occupational exposure, BCTC shall 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

BCTC shall ensure that an employee uses appropriate PPE unless BCTC can show 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 shall be investigated and documented in order to determine whether changes can be instituted to prevent such occurrences in the future.

Accessibility

BCTC shall ensure that appropriate PPE in the appropriate sizes is readily accessible at the worksite or is issued to employees. 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.

Cleaning, Laundering, and Disposal

BCTC shall clean, launder, and dispose of required PPE, at no cost to the employee. Employees are not allowed to take personal protective clothing home to clean.

BCTC 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.

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

Gloves

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.

  • Disposable (single use) gloves 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 (single use) gloves shall 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, shall be worn whenever splashes, spray, spatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can be reasonably anticipated.

Other Protective Clothing

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

General

BCTC shall ensure that the worksite is maintained in a clean and sanitary condition. BCTC 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 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 should 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 shall 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 to these employees so that they know the proper procedures to follow to minimize their exposure to bloodborne pathogens.

Cleaning and Disinfection

All equipment and environmental or 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 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 shall 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 shall 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, shall not be picked up directly with the hands. It shall be cleaned up using mechanical means, such as a brush and dustpan, tongs, or forceps.

Reusable sharps that are contaminated with blood or other potentially infectious materials shall 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 waste 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 and 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 shall be discarded immediately or as soon as feasible in containers that are:

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

During use, containers for contaminated sharps shall 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 throughout use.
  • Replaced routinely and not allowed to overfill.

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 handling, storage, transport, or shipping.
  • Placed in a secondary container if leakage is possible. The second container shall be:
    1. Closable
    2. Constructed to contain all contents and prevent leakage during handling, storage, transport, or shipping.
    3. Labeled or color-coded in accordance with the Bloodborne Pathogen standard.

Reusable containers shall 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 shall 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 shall be placed in a second container. The second container shall 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 shall 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 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 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 all 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 shall be placed and transported in bags or containers which prevent soak-through and/or leakage of fluids to the exterior.

BCTC shall ensure that employees who have contact with contaminated laundry will wear protective gloves and other appropriate personal protective equipment.

If BCTC ships contaminated laundry off-site to a second facility, which does not utilize standard precautions in the handling of all laundry, BCTC must place such laundry 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.

General

For employees who have occupational exposure, BCTC shall 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 take place. 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.

Hepatitis B Vaccination

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 that 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 shall make available the hepatitis B vaccination 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, booster dose(s) shall 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.

General

When an employee has an exposure incident, they should immediately or as soon as feasible, report the incident to their supervisor and to the Dean of Operations at the following number, 859.351.2060. They are 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.

Post-exposure Evaluation and Follow-up

Following a report of an exposure incident, BCTC shall 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.
    1. The source individual’s blood shall be tested as soon as feasible and after consent is obtain 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.
    2. 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.
    3. 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:
    1. The exposed employee’s blood shall be collected as soon as feasible and tested after consent if obtain.
    2. 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
    1. 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

BCTC shall ensure that the healthcare professional responsible for the employee’s Hepatitis B vaccination is provided a copy of the OSHA Standard on Occupational Exposure to Bloodborne Pathogens (29 CFR Part 1910.1030).

BCTC shall ensure that the healthcare professional evaluating an employee after an exposure incident is provided the follow information:

  • 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 shall 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 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:

  • That the employee has been informed of the results of the evaluation.
  • 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.
  • All other findings or diagnoses shall remain confidential and shall not be included in the written report.

Medical Recordkeeping

Medical records shall 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 up and disinfect contaminated surfaces if necessary.
  3. Notify the following individuals:
    • The exposed employee’s immediate supervisor
    • Dean of Operations

These individuals will explain the risks involved with an 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.

  1. Complete the following forms:
    • Worker’s Compensation Claim form I.A. – 1
    • Exposure Incident Report and Evaluation
    • Post-Exposure Evaluation Consent/Refusal
  2. Determine if the source individual can be identified and complete the following forms:
    • Source Individual Informed Consent/Refusal
    • Employee Confidentiality Statement
  3. 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 Dean of Operations.

Labels

Warning labels shall be affixed to containers of the 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 shall either be an integral part of the container or shall be 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 red 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 shall include the following legend:

Information and Training

BCTC shall ensure that all employees with occupational exposure participate in at least an annual training program, which must be provided at no cost to the employee and during working hours.

Training shall 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 shall be provided within one year of their previous training.

BCTC shall provide additional training when changes such as modification of tasks or procedures or institution of new tasks or procedures affect the employee’s occupational exposure. The additional training may be limited to addressing the new exposures created.

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

The training program shall contain at a minimum 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.

Name and Qualifications of Person Conducting the Training

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 that the training will address.

The Bloodborne Pathogen Officer offers online training yearly for employees at https://elearning.kctcs.edu located within the eCommunity.

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

Medical Records

BCTC shall 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 shall 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 shall 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 shall 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 shall ensure that all records required to be maintained shall be made available upon request to the Assistant Secretary and the Director for examination and copying.

Employee training records shall be provided upon request for examination and copying to employees, to employee representatives, to the Director, and to the Assistant Secretary.

Employee medical records shall be provided upon request for examination and copying to the subject employee, to anyone having written consent of the subject employee, to the Director, and to the Assistant Secretary in accordance with 29 CFR 1910.20.

Transfer of Records

BCTC shall 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, the employer shall 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.

This policy has been reviewed and revised on 09/27/19 by Beecher McCarty, Dean of Operations, Bluegrass Community and Technical College.

Purpose

Provide guidance for BCTC employees related to the management of needle sticks or sharps injuries and exposure incidents with potentially infectious materials.

Target Audience

BCTC employees and students involved in programs that handle needles or sharps for educational and instructional purposes.

Procedure

Any BCTC employee who sustains a needlestick or sharps injury shall immediately notify their direct supervisor. Any BCTC student who sustains a needlestick or sharps injury shall immediately notify their instructor. Upon notification, a review of the needlestick or sharps injury shall occur immediately to determine if any exposure to blood or other bodily fluids has occurred. If exposure has occurred or potentially occurred, the BCTC employee or student will be directed to immediately follow these CDC recommendations:

  • Wash needle sticks and cuts with soap and water
  • Flush splashes to the nose, mouth, or skin with water
  • Irrigate eyes with clean water, saline, or sterile irrigants
  • Report the incident to your supervisor
  • Immediately seek medical treatment

This information can be found on the CDC’s website

Training and Review

All BCTC employees involved in programs where needlesticks or sharps injuries may occur and M&O staff must complete the Safe Colleges training module titled “Bloodborne Pathogen Exposure Prevention”.

This training shall be repeated annually and training completion monitored by the BCTC Bloodborne Pathogen Officer.

Reporting

A report of all accidents / emergencies, etc., should be completed using form FM84 within 24 hours of occurrence and submitted to the campus Safety and Security Supervisor where the incident occurred. Contact information for all Safety and Security staff can be found at the BCTC website.

Form FM84 – Accident / Injury Report

Instructions for completing the FM84