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SOP 27 Bloodborne Pathogen Control Plan

By Tiffany Watson,2014-06-17 18:12
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SOP 27 Bloodborne Pathogen Control Plan ...

    SOP 2.7: Bloodborne Pathogen

    Household Control Plan Hazardous Waste

Contents

     1. Introduction .................................................................................. 1

    2. Regulatory and contractual requirements ......................................... 1

    3. Training………………………………………………………………………………………..1

    4. Applicability/staff exposure determination ........................................ 2

    5. ECP implementaion and control ....................................................... 3

    6. Hepatitis B vaccination ................................................................... 4

    7. Labels and recordkeeping………………………………… ............................. 6 Attachments

    A. ECP definitions .................................................................................. 8

    B. Hand-washing technique……………………………….………………….………… ...... 9

    C. Removal of contaminated disposable gloves ......................................... 10

    D. Blood clean-up……………………………………………………………………………. ..... 11

    E. Hepatitis B vaccine declination ............................................................ 13

    F. Bloodborne pathogen exposure incident form ....................................... 14

    1. Introduction

    The purpose of an exposure control plan (ECP) is to eliminate or minimize occupational exposure to blood

    or other potentially infectious materials (OPIM) in accordance with the OSHA Bloodborne Pathogens

    Standard. For ECP definitions, see Attachment A of this SOP.

    2. Regulatory and contractual requirements

    Bloodborne pathogen policy is governed by the requirements established in the HHW program and state

    agency contract (Exhibit A, part B), Minn. Statute ? 116.78, sub. 2, and OSHA 29 CFR 1910.1020,

    1910.1030, 1910.1030(f), 1910.1030(g)(2)(i).

    3. Training

    3.1 The ECP Administrator is responsible for coordinating training, which shall be conducted by a

    qualified individual who has knowledge of the required subject matter. The Program Manager is the

    ECP Administrator and is responsible for implementing this HHW Facility’s plan. ECP training

    shall be:

    ? conducted before assignment to a task where occupational exposure to blood may take place

    and at least annually thereafter.

    2.7 Bloodborne Pathogen Control Plan 1

    ? provided when changes (e.g., modification of tasks or procedures, new or revised staff positions,

    change in technology) affect the occupational exposure.

    ? provided at no cost.

    3.2 ECP training is an opportunity for interactive questions and answers with the person conducting the session. The ECP training program shall include the following explanations, at a minimum:

    ? OSHA Bloodborne Pathogen Standard text and how to access a copy during working hours. ? epidemiology, modes of transmission, and symptoms of bloodborne diseases. ? the process staff can use to access or obtain a copy of this Facility’s ECP written plan.

    ? appropriate methods for recognizing tasks and other activities that may involve exposure to

    blood or other potentially infectious materials.

    ? proper Personal Protective Equipment (PPE) use (e.g., types, location, removal, handling,

    selection basis, decontamination, disposal).

    ? use and limitations of methods that prevent or reduce exposure (e.g., appropriate engineering

    controls, work practices, PPE).

    ? appropriate actions to take and contact information for an emergency involving blood or OPIM. ? Hepatitis B vaccine information (e.g., efficacy, safety, administration method, benefits, offered

    at no charge, declination process).

    ? procedures following an exposure incident (e.g., reporting methods, medical follow-up). ? the follow-up evaluation process required after an exposure incident occurs. ? clean-up procedures for blood and OPIM.

    ? recognition of biohazard markings (e.g., signs, labels, color coding to denote biohazards).

    4. Applicability/staff exposure determination

    4.1 Applicability

    This Program shall have a bloodborne pathogen ECP or be covered by the employer’s existing

    program, if it could be “reasonably anticipated” (as a result of performing job duties) that staff could be exposed to blood or OPIM. This applies to staff performing any of the following functions:

    ? accepts or handles needles

    ? is expected to perform first aid

    ? cleans up blood spills

    4.2 ECP components

    The exposure determination shall be made without regard to the use of PPE. The ECP shall include: 1. an exposure determination

    2.7 Bloodborne Pathogen Control Plan 2

2. methods of compliance

    3. Hepatitis B vaccination

    4. post-exposure evaluation procedures

    5. training

    4.3 Administrative

    The ECP Administrator shall be review the plan at least annually, update as needed, and make it

    available for staff to review. Safer devices shall be selected as they become available.

    5. ECP implementation and control

    5.1 Universal precautions

    According to universal (or standard) precautions, all blood or OPIM shall be considered potentially

    infectious regardless of the perceived status of the source.

    5.2 Engineering and work practice controls

    Engineering and work practice controls shall be utilized to minimize or eliminate exposure for

    Facility staff. Where the potential for occupational exposure remains after institution of these

    controls, these practices shall be followed:

    5.2.1 Sharps container

    No sharps are accepted at this facility. If sharps are inadvertently accepted, they shall be

    stored in acceptable sharps containers. Staff shall NOT directly handle sharps at any time. 5.2.2 Hand/body washing

    ? The purpose of hand washing is to remove any pathogens from the surface of the skin.

    For hand-washing instructions, see Attachment B of this SOP.

    ? Hands shall be washed as soon as feasible after removal of gloves and other PPE.

    Interim hand-washing measures (e.g., antiseptic hand cleansers, towelettes) shall be

    used where hand-washing facilities are not immediately available. For glove removal

    procedures, see Attachment C of this SOP.

    ? Wash exposed skin as soon as possible after any incident (e.g., skin contact with blood

    or OPIM).

    ? Immediately following contact with blood or OPIM, eye and mucous membranes shall

    be flushed with water.

    2.7 Bloodborne Pathogen Control Plan 3

    5.3 PPE

    Where occupational exposure remains after institution of engineering and work controls, PPE shall

    be:

    ? utilized and properly disposed of

    ? provided at no cost to staff

    ? purchased in appropriate sizes

    ? maintained and made available for use while administering first aid or cleaning up blood

    5.3.1 Selection and use

    PPE shall be chosen based on the anticipated exposure to blood or OPIM. The protective

    equipment shall be considered appropriate only if it does not allow blood or OPIM to pass

    through or reach clothing, skin, eyes, mouth, or mucous membranes under normal

    conditions of use and for the duration of time for which the PPE is used.

    5.3.2 PPE general precautions

    ? utilize PPE in occupational exposure situations; see SOP 2.4 PPE.

    ? remove and replace all equipment or protective clothing that is torn, punctured, or has

    lost its ability to function as a barrier against bloodborne pathogens.

    ? remove all PPE before leaving the work area.

    ? protective gloves are to be used if there is potential for contact with blood or OPIM.

    ? alternative gloves shall be provided for staff with glove allergies (latex).

    ? never wash or decontaminate disposable gloves for reuse or before disposal; for glove

    removal procedures, see Attachment C of this SOP.

    ? eye protection shall be worn to prevent exposure.

    5.4 Housekeeping and maintenance

    5.4.1 Blood clean-up

    To review blood clean-up procedures, see Attachment D of this SOP.

    5.4.2 Decontamination and disinfecting

    Surfaces or equipment contaminated with blood or OPIM shall be cleaned and

    decontaminated as soon as possible, using one of the following methods:

    ? household bleach diluted between 1:10 to 1:100 with water; dispose of unused solution

    following the decontamination process.

    ? EPA-registered tuberculocidal disinfectants or products registered against Hepatitis B

    virus (HBV), used according to label instructions.

    2.7 Bloodborne Pathogen Control Plan 4

    5.4.3 Broken glassware clean-up

    Mechanical means shall be used (e.g., brush and dustpan) to clean up broken glassware.

    Never pick up broken glassware by hand.

    6. Hepatitis B vaccination

    6.1 Availability

    The Hepatitis B vaccine shall be:

    ? made available at no cost to staff covered by this ECP.

    ? offered after staff has received training and within 10 days of initial assignment of job involving

    potential for blood exposure.

    6.2 Declination

    If staff chooses to decline the Hepatitis B vaccine, they may later obtain it following the initial

    declination. The following procedure shall be followed to document the initial declination:

    ? complete the “Hepatitis B Declination Form”; see Attachment E of this SOP.

    ? declination forms shall be maintained by the ECP Administrator.

    6.3 General

    ? Vaccines shall be administered by a licensed healthcare professional (LHCP).

    ? The vaccine shall be administered in accordance with U.S. Public Health Service (USPHS)

    recommendations.

    ? Hepatitis B booster dose shall be made available if/when recommended by USPHS.

    6.4 Post-exposure evaluation and follow-up

    6.4.1 Staff responsibilities

    ? Immediately clean the exposed body area, removing any contaminated clothing.