bloodborne pathogens exposure control plan · finance & operations policy library bloodborne...

of 29

UNIVERSITY of NORTH DAKOTA FINANCE & OPERATIONS POLICY LIBRARY

BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN

POLICY STATEMENT

The University of North Dakota (UND) is committed to providing a safe and healthful work environment for its entire faculty, staff, and students. In pursuit of this goal, the following exposure control plan (ECP) is provided to eliminate or minimize occupational exposure to bloodborne pathogens in accordance with Occupational Safety and Health Administration (OSHA) Standard 29 CFR 1910.1030 and its amendment and amendments thereto, Occupational Exposure to Bloodborne Pathogens.

REASON FOR POLICY

The ECP is a key document to assist our organization in implementing and ensuring compliance with the Bloodborne Pathogens Standard 29 CFR 1910.1030 and its amendment and amendments thereto, thereby protecting our employees/students. This ECP includes determination of employee/student exposure; implementation of various methods of exposure control, including universal precautions, engineering and work practice controls, personal protective equipment, and housekeeping; Hepatitis B vaccination, post-exposure evaluation and follow-up; communication of hazards to employees/students and training; recordkeeping; and procedures for evaluating circumstances surrounding exposure incidents.

SCOPE OF POLICY

This policy applies to:

President Vice Presidents Deans, Directors & Department Heads Area Managers & Supervisors

Faculty Staff Students Others/Affiliates

WEB SITE REFERENCES

This policy: http://UND.edu/finance-operations/_files/docs/6-27-bloodborne-pathogens-ecp.pdf Policy Office: http://und.edu/finance-operations/policy-office/index.cfm Vice President for Finance & Operations: http://UND.edu/finance-operations/

Section 6, Public Safety

Policy 6.27, Bloodborne Pathogens Exposure Control Plan

Responsible Executive: VP Finance & Operations

Responsible Office: Office of Safety

Issued: April 11, 2016

Latest Review / Revision: September 9, 2016

UND Finance & Operations Policy Library Section 6, Public Safety Title 6.27 Bloodborne Pathogens Exposure Control Plan

of 29

CONTENTS

Policy Statement 1

Reason for Policy 1

Scope of Policy 2

Web Site References 2

Related Information 3

Contacts 3

Definitions 3

Principles (overview) 7

Procedures 7

Administration 7 Bloodborne Pathogens and Other Potentially Infectious Material (OPIM) 10 ECP Implementation and Control 11 Biohazardous Waste Management Program 20 Hepatitis B Vaccination 21 Post-Exposure Evaluation and Follow-Up 22 Procedures for evaluating the circumstances surrounding and Exposure Incident 23 Employee/Student Training 24 Summary: Requirements prior to assignment to duties with Occupational Exposure 24 Recordkeeping 25

Responsibilities 26

Forms 28

Appendices (list) 28

Revision Record 29


of 29

RELATED INFORMATION

29 CFR § 1910.1030 – Occupational Safety and Health Standards: Bloodborne Pathogens

http://www.ecfr.gov/cgi-bin/retrieveECFR?gp=&SID=d0a3d4bf728be183be0fc517eebfc337&n=pt29.6.1910&r=PART&ty=HTML#se29.6.1910_11030

A Guide to Understanding North Dakota’s Infectious Waste Regulations

https://www.ndhealth.gov/wm/Publications/AGuideToUnderstandingNorthDakotasInfectiousWasteRegulations.pdf

EPA Registered Tuberculocidal Products Effective Against Mycobacterium Tuberculosis

https://www.epa.gov/pesticide-registration/list-b-epas-registered-tuberculocide-products-effective-against-mycobacterium

North Dakota Department of Health Waste Management: Household Infectious Waste

http://www.ndhealth.gov/wm/InfectiousWaste/HouseholdInfectiousWaste.htm

OSHA Bloodborne Pathogens Standard https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051

UND Biological Safety Cabinet Policy http://www.UND.edu/finance-operations/_files/docs/6-25-biological-safety-cabinet.pdf

UND Communicable Disease Policy http://UND.edu/finance-operations/_files/docs/lc-communicable-diseases.pdf

UND Incident Reporting Policy https://cio.UND.edu/public-safety/_files/docs/incident-reporting-policy-7-15.pdf

UND Institutional Biosafety Manual https://UND.edu/research/resources/institutional-biosafety-committee.cfm

UND Lab Specific Safety Manual http://UND.edu/public-safety/public-safety/biological.cfm

UND Laboratory Access Door Signs http://UND.edu/public-safety/public-safety/biological.cfm

UND Sharps Policy http://www.UND.edu/finance-operations/_files/docs/6-29-sharps.pdf

UND Workers’ Compensation and Claims Management Procedures

http://UND.edu/finance-operations/human-resources-payroll/_files/docs/workers-comp-and-claims-policy.pdf

CONTACTS

Specific questions should be directed to the following:

Subject Contact Telephone Office or Department E-Mail / Web Address

Policy Clarification Office of Safety (701) 777-3341 http://und.edu/public-safety/public-safety/index.cfm

Report Accidents Office of Safety (701) 777-3341 http://und.edu/public-safety/public-safety/index.cfm


of 29

DEFINITIONS

Biological waste Biological waste is any material that contains or has been contaminated by a biohazardous agent.

Biohazardous agent Biohazardous agent refers to an agent that is biological in nature, capable of self-replication, and has the capacity to produce deleterious effects upon biological organisms. Biohazardous agents include, but are not limited to; bacteria, fungi, viruses, rickettsiae, chlamydia, prion, parasites, recombinant products, allergens, cultured human and animal cells and the potentially biohazardous agents these cells may contain, infected clinical specimens, tissue from experimental animals, plant viruses, bacteria and fungi, toxins, and other biohazardous agents as defined by State and Federal regulations.

Blood Human blood, blood components, and other potentially infectious materials (OPIM).

Bloodborne Pathogens Pathogenic microorganisms that are present in human blood that can cause disease in humans, such as Hepatitis B virus (HBV), Hepatitis C virus (HCV), and Human immunodeficiency virus (HIV).

Body Substance Precautions

Body substance precautions take universal precautions one more step and require the same barrier precautions for all moist body substances, not just those associated with transmission of HIV and HBV (i.e., would include respiratory secretions, urine, etc.). Since many patients’ secretions become colonized with organisms (often resistant organisms) prior to any symptoms of illness, this practice can decrease transmission before a patient is isolated for an infection.

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

Contaminated Laundry Laundry that has been contaminated with blood or other potentially infectious materials or may contain sharps.

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.

Disinfect The use of a physical or chemical procedure to destroy certain microbial life. Levels of disinfection include low, intermediate, and high. Unlike sterilization, even high-level disinfection does not kill bacterial endospores. Surface disinfectants are ranked as either low or intermediate. These include EPA registered tuberculocidal disinfectants or 1:10 freshly mixed bleach and water. If blood or other potentially infectious materials are to be disinfected from a contaminated surface, one of these intermediate-level disinfectants is required to be used.

Designated Medical Provider (DMP)

A medical professional or a facility selected by the employer to treat work related injuries. All employers in North Dakota have the option of selecting a DMP.

Employee For the purposes of this document, includes UND faculty, staff, and student employees.

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


of 29

Exposure Incident An exposure incident is a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact (subcutaneous or intravenous injection) with blood or other potentially infectious materials (OPIM), as defined in the standard that results from the performance of a worker’s duties.

Hepatitis B Virus (HBV) A viral infection that attacks the liver and can cause both acute and chronic disease. The virus is transmitted through contact with the blood or other body fluids of an infected person.

Hepatitis C Virus (HCV) An infectious disease affecting primarily the liver. The infection is often asymptomatic, but chronic infection can lead to scarring of the liver and ultimately to cirrhosis, which is generally apparent after many years.

Human Immunodeficiency Virus (HIV)

A lentivirus (a subgroup of retrovirus) that causes HIV infection and acquired immunodeficiency syndrome (AIDS). AIDS is a condition in humans in which progressive failure of the immune system allows life-threatening opportunistic infections and cancers to thrive.

Hand Washing Facilities A facility providing an adequate supply of running potable water, soap, and single use towels or hot-air drying machines.

Infectious Waste NDCC 23-29-03.5 defines infectious waste as solid waste that may contain pathogens with sufficient virulence and in sufficient quantity that exposure of a susceptible human or animal to the solid waste could cause the human or animal to contract an infectious disease. Regulated infectious waste includes but is not limited to:

Sharps Cultures and stocks Human blood and blood products Pathological waste Animal waste Isolation waste Unused sharps

The majority of waste produced at any medical facility is not classified as infectious waste. Materials such as office waste, paper from examination tables, gauze, packaging, and band-aids are not considered infectious waste and may be disposed of as regular solid waste. North Dakota does not have a separate definition for medical waste.

Institutional Biosafety Committee (IBC)

An institutional committee created under the NIH guidelines to review research involving recombinant or synthetic nucleic acid molecules. The role of IBCs has evolved and UND’s committee also reviews other forms of research, as well as instructional activity that entail biohazardous risks as part of their institutionally assigned responsibilities.

Licensed Healthcare Professional

A person whose legally permitted scope of practice allows him or her to independently perform the activities required by the program, Hepatitis B vaccination and post-exposure evaluation and follow-up.

Needleless Systems Devices that do not use needles for: The collection of body fluids or withdrawal of body fluids after

initial venous or arterial access is established; The administration of medication or fluids; or Any other procedure involving the potential for occupational

exposure to bloodborne pathogens due to percutaneous injury involving contaminated sharps. Examples of needleless systems include, but are not limited to, intravenous medication delivery systems that administer medication or fluids through a catheter port or connector site using a blunt cannula or other non-needle connection, and jet injection systems that deliver subcutaneous or


of 29

intramuscular injections of liquid medication through the skin without use of a needle.

Near Miss An unplanned event that did not result in injury, illness, or damage – but had the potential to do so.

Occupational Exposure Reasonable anticipated skin, eye mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties.

Other Potentially Infectious Materials (OPIM)

OPIM refers to: Human blood, semen, vaginal secretions, cerebrospinal fluid,

synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, and any body fluid visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids;

Any unfixed tissue or organ (other than intact skin) from a human (living or dead);

All human derived cell cultures, including well established cell lines as described above;

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

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

Personal Protective Equipment (PPE)

Protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer’s body from injury or infection. The hazards addressed by protective equipment include physical, electrical, heat, chemicals, biohazards, and airborne particulate matter.

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

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

Sharps Sharp instruments that have been used in animal or human patient care or treatment or in medical, research, or industrial laboratories, including hypodermic needles, syringes (with or without the attached needle if contaminated), Pasteur pipettes, scalpel blades, blood vials, needles with attached tubing, and glass culture dishes (regardless of presence of infectious agents). Also included are other types of broken or unbroken glassware that were in contact with infectious agents, such as used slides and cover slips.

Sharps with Engineered Sharps Injury Protections (SESIPs)

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. These may include: syringes with guards or sliding sheaths that shield the attached needle after use; needles that retract into a syringe after use; shielded or retracting catheters used to access the bloodstream for intravenous administration of medication or fluids; intravenous medication delivery systems that administer medication or fluids through a catheter port or connector site using a needle that is housed in a


of 29

protective covering, blunt suture needles; and plastic capillary and blood tubes.

Standard Precautions The general concept that all patients and all laboratory specimens should be handled as if they were infectious, capable of transmitting disease.

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

Student Student, for the purposes of this document, means an individual matriculating at an institution of higher education who is at UND for academic purposes only. Students who are also hired as an employee will function under the guidelines for employees when acting as an employee.

Soiled Dirty; not contaminated with blood or OPIM. An employee’s/student’s uniform may be soiled with dirt and sweat from the day’s work. The uniform would be contaminated if blood or OPIM were on the uniform.

Source Individual Any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to the employee/student. Examples include, but are not limited to: hospital and clinic patients; clients in institutions for the developmentally disabled; trauma victims; clients of drug and alcohol treatment facilities; residents of hospices and nursing homes; human remains; and individuals who donate or sell blood or blood components.

Universal Precautions An approach to infection control in which human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, HCV or 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. handling medical waste with gloves). [see also Engineering Controls]

PRINCIPLES

OVERVIEW – UND is committed to providing a safe and healthful work environment for our entire faculty, staff, and students. In pursuit of this goal, the following exposure control plan (ECP) is provided to eliminate or minimize occupational exposure to bloodborne pathogens in accordance with OSHA Standard 29 CFR 1910.1030 and its amendment and amendments thereto, Occupational Exposure to Bloodborne Pathogens.

The ECP is a key document to assist our organization in implementing and ensuring compliance with the Bloodborne Pathogens Standard 29 CFR 1910.1030 and its amendment and amendments thereto, thereby protecting our employees/students. This ECP includes determination of employee/student exposure; implementation of various methods of exposure control, including universal precautions, engineering and work practice controls, personal protective equipment, and housekeeping; Hepatitis B vaccination, post-exposure evaluation and follow-up; communication of hazards to employees/students and training; recordkeeping; and procedures for evaluating circumstances surrounding exposure incidents.

PROCEDURES

Administration

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


of 29

TASK RESPONSIBLE DEPARTMENT AND CONTACT INFORMATION

Implementation of the exposure control plan Office of Safety, Associate Director for Safety 3851 Campus Rd, Stop 9031 Grand Forks, ND 58202-9031 Phone: 701-777-3341

Maintain, review, and update the ECP at least annually and whenever necessary to include new or modified tasks and procedures

Office of Safety, Associate Director for Safety 3851 Campus Rd, Stop 9031 Grand Forks, ND 58202-9031 Phone: 701-777-3341

Maintain and provide all necessary personal protective equipment (PPE), engineering controls (e.g., sharps containers), labels, and red bags as required by the standard

The affected department principal investigators, supervisors, chairs, directors

Ensure that all medical actions required are performed

Designated Medical Provider, Licensed Health Care provider, Student Health Services (Only UND Students)

Responsible for making the written ECP available to employees, students, OSHA, and NIOSH representatives


Responsible for training and documentation The affected department principal investigators, supervisors, chairs, directors and the Office of Safety

Maintenance of training records The affected department principal investigators, supervisors, chairs, directors, and office of safety. (Office of Safety will only maintain records for trainings conducted by them.)

Ensure reports from an employee’s/student’s primary health care provider are maintained by the department principal investigators, supervisors, chairs, directors. Note: Actual health care records should not be retained by the department.


Supply post-exposure evaluation written opinion to employee/student and Office of Safety

Occupational healthcare provider or Licensed health care provider or Student Health Services

Adhere to the requirements of the ECP; Develop good personal exposure control work habits; Complete all safety training requirements and comply with documentation procedures; and Report all suspected exposure incidents.

University employees and students with occupational exposure to human blood or OPIM

EXPOSURE DETERMINATION – Each employee/student must have an exposure evaluation based upon the job description and assigned tasks. The evaluation shall be reviewed with the employee at time of hire or within 90 days of the establishment of this program. Similarly, the evaluation shall be reviewed with the student within 90 days of the establishment of this program. Exposure evaluation shall be based upon a reasonably anticipated contact (skin, eye, mucous membrane, parenteral contact, etc.) with blood or OPIM that may result from the performance of an employee's/students duties. As required by OSHA, exposure evaluations will be performed in accordance with a categorization scheme based on the potential of job-related tasks leading to exposure. The three categories used are:

1. Category 1 – Tasks that involve routine occupational exposure to blood, body fluids or tissues. 2. Category 2 – Tasks that involve no routine occupational exposure to blood, body fluids or tissues, but

work may require performing unplanned Category 1 procedures.


of 29

3. Category 3 – Tasks that involve no occupational exposure to blood, body fluids or tissues and Category 1 tasks are not a condition for employment.

Table 1 presents a listing of job classifications identified to date that may be assigned to categories 1 or 2. This list can be used as a guideline for categorization. Actual determinations for specific employees/students must be performed by the applicable supervisor/department. Table 1. Employee/Student Assignments Qualifying as Category 1 or 2 for Purposes of Bloodborne Pathogen Control

College and Departments Employee/Student Assignment

Guideline Category

College and Academic Departments are listed below: -Arts and Sciences -Basic Sciences -Biology -Center for Family Medicine (Bismarck and Minot) -Center for Health Promotion & Prevention Research -Chemistry -Cyclotron -Family & Community Medicine -Forensic Science -Geriatrics -INMED -International Medicine (Bismarck, Fargo) -Master of Public Health -Medical Laboratory Science -ND Simulation, Teaching, and Research Center -Neurology -Nursing -Obstetrics & Gynecology (Bismarck, Fargo, Grand Forks, Minot) -Occupational Therapy -Pathology -Pediatrics (Bismarck, Fargo, Grand Forks) -Physical Therapy -Physician Assistant Program -Population Health -Psychiatry and Behavioral Science (Bismarck, Fargo, Grand Forks) -Radiology (Bismarck) -School of Medical and Health Sciences -Sports Medicine -Surgery (Bismarck, Fargo, Grand Forks)

Assistant Professor Research Assistant Professor Associate Professor Research Assistant Graduate Assistant Graduate Student Postdoctoral Fellow Predoctoral Fellow Professor Research Associate Research Scientist Students MD RN MLS

1-2

Athletics Head Athletic Trainer Trainers (including paid student trainers), Equipment Manager

1-2

Childcare Teachers Child Care Providers Assistants (including Student Assistants)

2

Dining Services Food Service Manager Maintenance Staff Servers Cook

2

Facilities Management Associate Vice President Facilities Supervisor Operations Director

2


of 29

Director Custodial Services Plumbers Maintenance Workers Electricians Grounds

Office of Safety Associate Director of Safety EHS Manager Biological Safety Officer Fire Prevention Officer Worker Safety and Insurance Coordinator Student Employees Safety Assistants

1-2

Residence Halls Director Housekeeper Residence Assistants Plumber Electricians

2

Student Health Services Nurse Physician Assistant Physician Nurse Practitioner Medical Technologist Laboratory Technician Phlebotomist Housekeeper Radiation Technologist

1-2

Transportation Auto Service Mechanics Fleet Drivers

2

University Police and Public Safety Chief of Police Emergency Manager Police Officers Detectives Lieutenants

1

Note: Part-time, temporary, contract, and per diem employees are covered by the BBP standard. All other departments are to follow the Communicable Disease Policy exposure evaluation based upon the job description and assigned tasks (See Related Information).

NEAR MISSES – Changing an unsafe behavior is the best method of preventing an accident. Identifying near misses is crucial in order to reevaluate procedures and re-train individuals. Accidents, near misses, unsafe behaviors, and unsafe situations must immediately be reported to the Office of Safety. Methods for reporting unsafe behaviors established by UND may include:

1. Confidential meetings with the Office of Safety 2. Reporting forms

Bloodborne Pathogens and Other Potentially Infectious Material

BLOODBORNE PATHOGENS – Bloodborne pathogens are microorganisms found in human blood that can infect and cause disease when persons are exposed to blood that contain microorganisms. While there are many bloodborne pathogens, the 3 specifically covered in this ECP are:

1. Human Immunodeficiency Virus (HIV) – Cause Acquired Immunodeficiency Syndrome (AIDS)


of 29

2. Hepatitis B Virus (HBV) 3. Hepatitis C Virus (HCV)

OTHER POTENTIALLY INFECTIOUS MATERIAL (OPIM) – Materials that can contain pathogens. OPIMs include:

1. Human blood and blood products 2. Semen or vaginal secretions 3. Internal human body fluids, including cerebrospinal fluid, and fluids from joints, chest cavity, heart sac

or abdomen 4. Breast milk (only if ingested) 5. Unfixed human tissues or organs (both living and dead) 6. Human cell lines not documented to be free of bloodborne pathogens 7. Blood, tissues, or cell lines from animals experimentally infected with bloodborne pathogens 8. Cultures or any liquid containing bloodborne pathogens (this includes culture media) 9. Equipment contaminated with human blood or OPIMs 10. Any body fluid visibly contaminated with human blood 11. Any body fluid that is difficult to differentiate from other fluids

The following are not considered to be OPIMs unless they are visibly contaminated with blood, or it is difficult or impossible to distinguish:

1. Tears 2. Sweat 3. Saliva (except during dental procedures) 4. Vomit 5. Feces 6. Urine 7. Nose fluids 8. Intact human skin (from living or dead source)

HOW ARE BLOODBORNE PATHOGENS TRANSMITTED – Pathogens, which are contained in blood and OPIM, must be introduced into the body for an employee/student to become exposed. An exposure potential task is a task that could potentially expose the employee/student in one of the following ways:

1. Parenteral exposure from needles, scalpels, broken glass, sharp instruments, or anything that can pierce, puncture or cut your skin that is contaminated with blood or OPIM

2. Non-intact skin such as an existing wound, eczema, broken cuticle, or rash coming in contact with blood or OPIM

3. Mucous membranes such as the eyes, nose, and mouth becoming splashed, sprayed, or touched with blood or OPIM

Remember, touching contaminated surfaces can be a mode of spreading disease. The HBV virus can survive on environmental surfaces and objects dried and at room temperature for as long as a week. More about decontamination of surfaces is discussed later in this document (See Procedures: ECP Implementation and Control: Housekeeping).

ECP Implementation and Control

The bloodborne pathogen exposure control at UND employs three major strategies:

1. Administrative controls and training 2. Engineering and work practice controls 3. Personal Protective Equipment

ADMINISTRATIVE CONTROLS AND TRAINING – Employees/Students covered by the bloodborne pathogens standard receive an explanation of this ECP during their initial training session. This plan is also to be reviewed in their annual refresher training. All employees/students have an opportunity to view this plan at any time during their work by contacting their supervisor. If requested, Office of Safety will provide an employee/student with a copy of the ECP free of charge within 15 days of the request. The Office of Safety is responsible for reviewing and updating the ECP annually or more frequently if necessary to reflect any new or


of 29

modified tasks and procedures that affect occupational exposure and to reflect new or revised employee positions with occupational exposure.

ENGINEERING AND WORK PRACTICE CONTROLS – Engineering and work practices designed to eliminate or minimize employee/student exposure shall be used when performing exposure potential tasks. All procedures involving blood and OPIM will be performed in a way that prevents or minimizes splashing, spraying, spattering, and generation of droplets. Where occupational exposure remains, personal protective equipment shall also be used. Engineering and work practice controls will be evaluated, maintained, and/or replaced on a regular schedule to ensure their continued effectiveness. The principal investigator, supervisor, or department identifies the need for changes in engineering controls and work practices through review of incident records, use of checklists, evaluation forms and employee/student interviews. Should an exposure incident occur while using these controls, the controls will be evaluated as to the reason for the failure, corrected, and changes will be made to this exposure control plan in order to prevent future incidents. Training of employees/students will occur immediately, reflecting the new changes. Examples of engineering and work practice controls used to eliminate or minimize employee/student exposure to bloodborne pathogens include but may not be limited to:

1. Universal Precautions or Standard Precautions 2. Use of biological safety cabinets 3. Hand washing 4. Sharps with engineered sharps injury prevention (SESIPs) 5. Sharps containers

Universal Precautions and Standard Precautions UND as well as OSHA requires that universal precautions or standard precautions be observed to prevent contact with blood or body fluids. The difference between universal precautions and standard precautions is as follows: Universal Precautions – All blood and OPIM are treated as if known to be infectious for HIV, HBV, HCV and other bloodborne pathogens, regardless of the perceived low or high risk of the patient/person from whom they came. Universal precautions include the following practices:

1. Wear gloves when hands may come into contact with human blood or OPIM. 2. Replace gloves when they become torn or contaminated. 3. To prevent exposure of mucous membranes of the mouth, nose and eyes, wear masks and protective

eyewear whenever splashes, spray, or spatter of blood or potentially infectious materials are likely to occur.

4. Wear protective suits, gowns or aprons during procedures that are likely to generate splashing of potentially infectious materials.

5. Wash hands and other skin surfaces immediately following contact with human blood or OPIM, and after gloves are removed.

6. Use care when handling needles, scalpels, razors and other sharp objects contaminated with blood or OPIM. Use tongs or forceps if possible.

7. Use appropriately-labeled and constructed containers for disposal, storage, and transport of any potentially infectious material.

8. Employees responsible for first aid should use protective resuscitation masks for mouth-to-mouth resuscitation.

9. Health care workers or first aid providers must cover skin lesions and wear gloves when treating patients or when handling health-care equipment.

10. Do not eat, drink, apply cosmetics or lip balm, smoke, or handle contact lenses in work areas where there is likelihood of occupational exposure. Do not keep food and beverages in refrigerators, freezers, shelves, cabinets, or on countertops where human blood or OPIM are present.

At a minimum, all employees/students at this institution will practice universal precautions.


of 29

Standard Precautions – Incorporates the major features of universal precautions and body substance precautions and applies these principles to all individuals regardless if their diagnosis is presumed infection status. Standard precautions apply to:

1. Blood, 2. All body substances, secretions, and excretions (except sweat) regardless of whether or not these

substances contain visible blood, 3. Non-intact skin, 4. Mucous membranes, and 5. Non-preserved tissues.

Standard precautions are designed to reduce the risk of transmitting of microorganisms from both known and unknown sources of infection in the hospital setting.

Biological Safety Cabinets (BSCs) BSCs will be used when there is a possibility for direct hand contact with human blood or OPIM based on risk assessment. It is the responsibility of the supervisor, principal investigator, or department to ensure that the BSCs are certified annually from a NSF Field Certifier. The supervisor, principal investigator, or the department is responsible for covering the cost and maintaining the documentation for the BSC certification as per the UND Biological Safety Cabinet policy (see Related Information).

Hand Washing

1. Employees/Students will wash their hands for approximately 20 seconds with soap and tepid running water immediately or as soon as possible after all glove or other personal protective equipment removal. Hand sanitizers (greater than 62% alcohol) may be used in situations if there are no means to wash (i.e., health fair). This procedure must be followed by washing with soap and water as soon as feasible.

2. Employees/Students will wash skin with soap and water or flush mucous membranes with water immediately following contact with blood or OPIM (refer to appendix 2 for hand washing procedures during an exposure incident).

3. Workers who have exudative lesions or weeping dermatitis should refrain from all direct patient care and from handling other patient care equipment until the condition resolves.

Handling Sharps with Engineered Sharps Injury Protections (SESIPs) Medical devices with sharps injury prevention features that are cleared by the FDA [510(k)] will be used whenever possible. Devices should have design features with the following characteristics:

1. A fixed safety feature that provides a barrier between the hands and needle after use; 2. The safety feature should allow or require the worker’s hands to remain behind the needle at all times; 3. The safety feature is an integral part of the device and not an accessory; 4. The safety feature is in effect before disassembly and remains in effect after disposal to protect users,

trash handlers, and for environmental safety; 5. The safety feature is as simple as possible, and requires little or no training to use effectively; 6. The device will not jeopardize patient or employee/student safety or be medically inadvisable; 7. The device will make an exposure incident involving a contaminated sharp less likely to occur.

Examples of such devices include:

1. Needle-protected systems 2. Needleless systems 3. Self-sheathing needles 4. Safety phlebotomy needles 5. Retracting lancets 6. Plastic blood tubes and plastic or mylar-coated capillary tubes 7. Blood transfer devices 8. Blunt suture needles

Engineering Controls and SESIPs Evaluation – Evidence to ensure engineering controls and sharps-injury protection effectiveness, sharps and engineering controls will be evaluated on a regular basis by the evaluation team (Office of Safety and Principal Investigators or Supervisors). Identification, evaluation and selection of effective engineering controls shall be accomplished through:


of 29

1. Review of materials provided by research entities, government regulations, industry associations, and product manufacturers.

2. Use of evaluation forms and hands-on assessment of devices. 3. Following the procedures for new technology, SESIPs, and ECP evaluation. 4. Annual review of new technology.

Specific SESIPs Evaluated

Device Name Device Use Manufacturer Date Evaluated

Procedures for New Technology, SESIPs, and Exposure Control Plan Evaluation and Update

1. Research will be assessed on products through available data from a variety of sources which may include the State Medical Association, American Medical Association, American Nurses’ Association, Association for Professionals in Infection Control and Epidemiology, and websites of prospective safety device manufacturers.

2. Suppliers or manufacturers may be contacted for samples of new safety devices. Instructional materials such as videos and data on proper use will be requested.

3. A staff meeting will be scheduled to discuss the new regulations and plans for evaluating products. Clinical employees or job classifications asked to volunteer to participate in the evaluation of any safety device that will replace a device they currently use will be identified in this ECP.

4. The evaluation team comprising of the principal investigator or supervisor and the Office of Safety will meet to review evaluations and discuss the pros and cons of each device evaluated. The team will decide, using the objective data gathered, what devices will be implemented. If safety devices for certain procedures are not to be implemented, the team will justify in writing why and how this decision was made. The following criteria may justify not switching to a safety device from a traditional device:

a. No safety device on the market for the particular procedure b. Less safe for the operator than your traditional device c. Interfered with patient care delivery d. Was less safe for the patient

5. The final step is to fully implement the safety devices, as well as any other new engineering devices and procedures determined to be good choices to prevent the potential for sharps injuries.

6. The exposure control plan, procedures and new technology will be reviewed at least annually. As required by UND, safety policies and procedures will be enforced. Compliance by employees and students to the safety policies and procedures is required and enforceable. Any violation of this policy can result in discipline up to and including termination in accordance with North Dakota University System and UND human resource policies.

Sharps Containers for Disposable and Reusable Sharps – Disposable sharps shall be discarded immediately or as soon as feasible in containers that are:

1. Able to be closed prior to removal 2. No more than two-thirds Full 3. Puncture resistant 4. Leak-proof on sides and bottom 5. Labeled biohazard or color-coded red 6. Easily accessible to personnel and located as close as possible to the point of use, or where sharps might

be found. 7. Maintained upright throughout use 8. Replaced routinely and may not be overfilled 9. Appropriate in size for devices placed in them 10. Designed with visible opening, below eye level, if wall-mounted 11. Designed with an unobstructed opening that allows devices to drop in easily


of 29

Note: Sharps container must be closed prior to transport. If it is necessary to transport sharps containers to other location for autoclaving it must be placed in a secondary container prior to transport. Reusable Sharps Reusable sharps such as scissors that are contaminated shall be placed as soon as possible after use in appropriate containers with liquid disinfectant until properly reprocessed. These containers must be:

1. Puncture resistant 2. Labeled with biohazard or red 3. Leak-proof on the sides and bottom 4. Designed so sharps are not stored or processed in a manner that requires employees/students to reach by

hand into the containers where the sharps have been placed. Sharps containers are purchased by the principal investigators, supervisors, chairs, or directors. Once the sharps containers are filled up to three-quarters full, the Office of Safety must be contacted for pick up. Note: Fill the waste disposal form/manifest (see Forms) and call the Office of Safety at 701-777-3341 to pick up the sharps container for disposal. UND has a contract with a licensed vendor, that removes sharps for disposal by incineration.

Sharps must be handled and disposed using following precautions:

1. Extreme caution must be used when working with sharp objects such as needles, scalpels, razor blades, or broken glass and properly dispose of the sharps in appropriate sharps containers;

2. Syringes and Needles shall be disposed of in labeled sharps containers; 3. Needles should not be re-sheathed. Some applications may require re-sheathing. In those cases, the use of

re-sheathing needles or mechanical re-capping devices are strongly recommended. If these alternatives are not feasible, then the one-handed scoop method for re-sheathing should be employed;

4. Needles and other sharps should be handled as little as possible. Handling sharps for transport, cleanup or disposal must be done using a mechanical device or tool (forceps, pliers, broom, and dust pan);

5. Breaking or shearing needles is prohibited; 6. Controls should be used to prevent needlestick injuries, and include specially engineered sharps injury

protection (e.g. leur-lock syringes, permanent needle and syringe combination, self-sheathing needles, needle-less systems, etc.);

7. University employees/students who encounter improperly disposed needles shall notify Office of Safety of the location of the needle(s). The appropriate authorities (e.g., lab manager, principle investigator, supervisor) must also be notified;

8. Office of Safety should be contacted to dispose of properly decontaminated sharps or glassware.

Sharps Injury Log UND has elected to establish and maintain a sharps injury log for the recording of percutaneous injuries from contaminated sharps (See Related Information: UND Sharps Policy). This may help UND to identify the need to eliminate identified unsafe engineering devices. The information in the sharps injury log shall be recorded and maintained as to protect the confidentiality of the injured employee/student according to the procedures of the sharps policy by the supervisor, principal investigator, or department. The sharps injury log shall contain, at a minimum:

1. The type and brand of device involved in the incident 2. The department or work area where the exposure incident occurred and an explanation of how the

incident occurred Note: Students/Employees working at medical centers or clinical affiliate locations outside of the main campus must adhere to the medical center or clinical affiliate policies related to sharps injury log. UND will not establish and maintain a sharps injury log for locations outside of the main campus. PERSONAL PROTECTIVE EQUIPMENT – Personal protective equipment (PPE) will be provided to the employees at no cost from their supervisors, principal investigators, or department. Training in the use of the appropriate PPE for specific tasks or procedures is provided by the affected principal investigator, supervisor, chair or the Office of Safety (if requested). All employees/students who have potential skin, eye, mouth,


of 29

mucous membrane, or parenteral contact with human blood or OPIM must wear PPE that will act as a barrier to these materials. PPE will consist of, but may not be limited to, gloves, masks, fluid resistant gowns, lab coats, face shields, eye protection, and resuscitation devices. The type(s) of protective clothing or equipment used in a specific instance will depend on the job being performed. The following protective clothing and equipment will be made available for use depending upon the activity performed and based on risk assessment:

Gloves Gloves are worn when there is a possibility for direct hand contact with human blood or OPIM. There are several types of gloves available, and selection should be based upon the job being performed:

1. Thin latex or nitrile gloves are used for operations involving delicate manipulations. These gloves are designed to fit tightly against the skin. The proper size should be selected to fit the worker's hands. Latex and nitrile gloves are available either powdered or powder-free. If an employee/student has a skin reaction from the gloves, hypo-allergenic and/or powder-free types must be provided. All such gloves are disposable and are not to be reused.

2. Polyvinyl chloride (PVC) gloves are also disposable and should not be reused. They do not fit tightly against the skin and should not be used for activities requiring delicate manipulations. PVC gloves may be powdered or powder-free, and are available in a variety of sizes. PVC gloves are not recommended for work with human blood or OPIM because they do not always provide a leak-proof barrier.

3. Rubber, neoprene or other thicker reusable gloves are more durable and are generally used for more strenuous activities, such as cleaning blood spills. They may be re-used if properly decontaminated following contact with potentially infectious materials. Reusable gloves should be periodically inspected to ensure there are no cracks, holes or breaks in the material; if any are found, they must be discarded.

Safety Glasses Eyewear goggles with solid side shields or chin-length face shields must be worn when there is a risk of splashing human blood or OPIM. This protective equipment reduces the potential for contact with the mucous membranes of the eyes. Masks The use of protective masks is intended to reduce the risk of splashing human blood or OPIM onto the mucous membranes of the nose and mouth. If masks are disposable, they must be removed immediately following use and not be reused. Reusable masks and face shields must be properly handled, cleaned and decontaminated prior to reuse. Protective Clothing Protective clothing must be worn when there is a risk of human blood or OPIM spattering a worker’s skin or clothing. There are various types of suits, gowns and aprons available for this purpose. The type of protective clothing selected will depend upon the task and degree of exposure anticipated. Protective clothing should be resistant to fluids, and may be disposable or reusable. Reusable clothing must be properly laundered prior to reuse. Resuscitation Masks Personnel who perform cardiopulmonary resuscitation (CPR) should have resuscitation masks on hand for use in an emergency. Most resuscitation masks are disposable and should be handled as contaminated waste following use. The resuscitation mask allows for effective CPR without mouth-to-mouth contact. Most masks are also fitted with a one way valve which prevents the flow of materials from victim to rescuer.

All employees/students using PPE must observe the following precautions:

1. Wash hands immediately or as soon as feasible after removal of gloves or other PPE; 2. Remove PPE after it becomes contaminated, and before leaving the work area; 3. Used PPE may be disposed of in plastic bags, then incinerated or autoclaved; 4. Wear appropriate gloves when it can be reasonably anticipated that there may be hand contact with blood

or OPIM, and when handling or touching contaminated items or surfaces; 5. Replace gloves if torn, punctured, contaminated, or if their ability to function as a barrier is

compromised;


of 29

6. Utility gloves may be decontaminated for reuse if their integrity is not compromised; 7. Discard utility gloves if they show signs of cracking, peeling, tearing, puncturing, or deterioration. 8. Never wash or decontaminate disposable gloves for reuse; 9. Wear appropriate face and eye protection when splashes, sprays, spatters, or droplets of blood or OPIM

pose a hazard to the eye, nose, or mouth; 10. Remove immediately or as soon as feasible any garment contaminated by blood or OPIM, in such a way

as to avoid contact with the outer surface.

All contaminated PPE are thrown in red or orange biohazard bags/containers. The individual departments, principal investigators, or supervisors are responsible for maintaining appropriate biohazard containers.

The decision as to the type of PPE must be based upon the potential for exposure to uniform, eyes, nose, mouth, hands, or non-intact skin. Always assess the situation or perform a risk assessment carefully prior to making a decision regarding PPE. The following are examples of minimal PPE to be worn for exposure potential tasks:

Check if Task Performed

TASK PPE (Add additional PPE as Required)

Picking up and disposing of contaminated sharps

Gloves

Cleaning up body fluid spills Gloves, mask, eye protection, gown

Disinfecting contaminated objects Gloves, mask, eye protection, gown

Handling contaminated laundry (blood or OPIM on it)

Gloves, mask, eye protection, gown

Handling contaminated waste (blood or OPIM on it)

Gloves, mask, eye protection, gown

Performing CPR Resuscitation device. Depends on the severity of the injury and presence of blood or OPIM.

Performing first aid Depends on the severity of the injury and presence of blood or OPIM. Gloves at a minimum.

Finger and/or heel sticks Gloves

Injections Gloves

Vascular access Gloves

Dressing removal Gloves

Suturing/stapling Gloves

Suture/staple removal Gloves

Foreign body removal Gloves

Biopsy Gloves


of 29

Surgical procedures with potential for splash or splatter Sterile gloves, mask, eyewear, gown

Surgical procedures without potential for splash or splatter

Sterile gloves, mask

Specimen handling Gloves

Throat culture Gloves

Cryosurgery Gloves, mask

Lab procedures dealing with blood or OPIM Gloves

Lab procedures dealing with blood or OPIM with potential for splash or splatter

Gloves, mask &/or eyewear (or appropriate barrier), gown

Lab procedures dealing with non-blood or OPIM body fluids

Gloves

Vaginal sonogram Gloves

Pelvic and rectal exams Gloves

Penile and/or vaginal collection Gloves

Urinary catheter placement and removal Gloves

Clip skin tags Gloves

Arthrocentesis Gloves

The supervisor/principal investigator/department will be responsible for the hazard assessment, selection, training, and compliance on the use of appropriate PPE for the tasks or procedures employees/students will perform. If guidance is needed contact Office of Safety (701-777-3341). Faculty, Staff and Students must be retrained:

1. If there is near miss incident or lack of understanding of usage 2. If there is a change in task or PPE

LABELS – The following labeling methods are used at UND:

1. Biohazard label for all equipment used with or to store infectious material (sharps container, refrigerators, biohazardous trash).

2. Biohazard bag for spill clean-up materials that have not been disinfected. The bag must be bright orange or red, and must have the biohazard symbol (See Figure 1).


of 29

Figure 1

Supervisors, principal investigators, or department are responsible for ensuring that the biohazard label and symbol is affixed on orange or red bags as required if regulated waste or contaminated equipment is brought into or taken out of the facility. Employees/Students are to notify Office of Safety if they discover regulated waste containers, refrigerators containing blood or OPIM, contaminated equipment, etc., without proper labels.

HOUSEKEEPING – Facilities and other UND custodial or maintenance staff must work together with each department to ensure that the following conditions are met:

1. Decontamination must be performed with an EPA registered tuberculocidal cleaner and disinfectant for destruction of HBV, HCV, and HIV;

2. Equipment and surfaces must be clean and decontaminated after contact with blood or OPIM; 3. Bins/pails (e.g. wash basins) need to be cleaned and decontaminated as soon as feasible after visible

contamination; 4. Spills of blood or OPIM should be cleaned up as soon as possible by personnel specifically trained for

bloodborne pathogen spill response; 5. Regulated waste needs to be placed in containers which are closable, constructed to contain all contents

and prevent leakage, appropriately labeled or color coded and closed prior to removal to prevent spillage or protrusion of contents during handling;

6. Broken glassware must be picked up using mechanical means (e.g. tongs, dustpan and brush) and disposed of in an appropriate sharps container;

7. Contaminated sharps are discarded as soon as possible into containers that are closable, puncture-resistant, leak proof on sides and bottoms, and appropriately labeled or color coded. Sharps disposal containers are available through supervisors, principal investigators, or department and must be located where sharps are being used.

Disposing of biohazardous waste:

1. Supervisors must instruct employees/students in the proper disposal and procedures when using biohazard bags.

2. Biohazard bags must be autoclaved and over bagged with a translucent covering before they can be disposed of in the regular trash (e.g., black trash bag).

3. Waste containers must be in an upright position and replaced routinely. 4. Containers with blood or OPIM must be closed after use, for disposal or for transfer to an autoclave.

LAUNDRY

1. Contaminated laundry (if contaminated with blood or OPIM) shall include: a. Reusable PPE b. Reusable coverings such as towels, lab coats, etc. contaminated with blood or OPIM c. Any employee/student clothing or uniform contaminated with blood or OPIM

2. Contaminated laundry shall not be: a. Sorted or rinsed at the location of use b. Taken home for laundering by employees/students

3. Contaminated laundry shall be: a. Handled as little as possible and with a minimum of agitation b. Bagged or containerized at the location where it was used c. Placed in plastic bags if there is a chance of soaking or leaking through the bag d. Handled with a minimum PPE of gloves


of 29

Handling of contaminated laundry will be as follows: 1. Soiled (simply dirty) laundry is segregated from laundry contaminated with blood or OPIM, or 2. All laundry is treated with universal precautions (as if all contaminated)

Laundry items should be containerized appropriately using these examples as guides:

1. Lab coats, scrub jackets, patient drape, towels, bedding and other laundry that has been contaminated with blood or OPIM shall be placed into a biohazard bag in a designated area.

2. Items not contaminated, but simply soiled shall be placed in a separate laundry bag for washing separate from any contaminated laundry.

3. If contaminated items are laundered on-site, they shall be cleaned in the following manner: (Residence Halls, Wellness Center, School of Medicine and Health Sciences, Biology, Chemistry, etc.)

a. Use gloves and gown (additional PPE if determined necessary) b. Wash at 150 degrees Fahrenheit (hot) c. Use bleach if uncertain of the temperature d. Dry at 200 degrees Fahrenheit (hot) e. Discard any blood or OPIM-contaminated plastic bags f. Laundry is to be handled only by trained employees

Note: The UND Facilities Management laundry service picks up contaminated laundry in secondary containment (color coded appropriate) from approximately 50 departments. UND treats all laundry universally (as if all contaminated). Some departments have an external vendor pick up their contaminated laundry. The external vendor also treats all laundry universally.

RESEARCH LABORATORIES

Additional Considerations for Researchers Handling Human Blood, OPIM, Bloodborne Pathogens, or Human Derived Tissue Cultures Principle investigators, supervisors, and departments must provide additional appropriate administrative controls, protective equipment, information and training as appropriate for all employees/students engaged in:

1. Culture, concentration or research of HIV, HBV, or HCV and/or other bloodborne pathogens; 2. Work with human or animal cell lines potentially infected with bloodborne pathogens;

Note: Certain cell lines may be exempt from this requirement. Principle investigators must consult with the biological safety officer (701-777-2444) to determine specific exemptions;

3. Manipulation of human blood or OPIM; 4. Manipulation of animal blood or tissue cultures experimentally infected with HIV, HBV, or HCV.

Additional requirements that may exceed those for research laboratories not involved in the above activities include: Security

1. Closed, locked when not attended, laboratory doors and limited lab access 2. Appropriately labeled laboratory access doors (See Related Information for fillable door signs)

Work Practices and Administration – Site-specific training must document that personnel have:

1. Read the UND Institutional Biosafety Manual (See Related Information) 2. Read the Lab Specific Safety Manual (See Related Information) 3. Been informed of the risks associated with their job 4. All spills must be contained or cleaned up immediately by trained personnel 5. All spills and accidents must be reported immediately to the supervisor and the Office of Safety 6. All waste from the work area and animal rooms must be decontaminated appropriately 7. Transportation of contaminated materials for decontamination must be performed in closed, leak-proof,

labeled containers Engineering Controls

1. Certified biosafety cabinets 2. Centrifuge containment devices to prevent aerosols 3. Autoclave or other effective decontaminating method for decontamination of waste


of 29

4. High-Efficiency Particulate Arrestance (HEPA) filters for vacuum lines 5. Use of leak-proof and appropriately labeled containers for transporting contaminated materials 6. Hand washing sink 7. Eyewash station

Sharps

1. Safety needles/syringes will be used whenever possible 2. Extreme caution is to be used whenever performing procedures with sharps 3. Needles/syringes should not be recapped, bent, or removed from syringe after use 4. Sharps will be placed in sharps container immediately after use and autoclaved prior to disposal or

reusing

Personal Protective Equipment 1. Lab coats/gowns or other appropriate clothing must be worn at all times in the laboratory and animal

handling facility 2. Gloves must be worn when manipulating potentially infected materials or animals 3. Protective clothing must not be worn outside of the work area

Biohazardous Waste Management Program

North Dakota Department of Health defines regulated waste (commonly called infectious waste) as: 1. Liquid or semi-liquid blood, or other potentially infectious materials (OPIM) 2. Contaminated items that would release blood, or OPIM in a liquid or semi-liquid state if compressed 3. Items that are caked with dried blood, or OPIM and are capable of releasing these materials during

handling 4. Contaminated sharps 5. Pathological and microbiological wastes containing blood or OPIM

TYPES OF REGULATED WASTE Sharps Waste Please refer to Procedures: ECP Implementation and Control: Engineering and Work Practice Controls in this plan for the proper handling of contaminated sharps and sharps container criteria, transport, and usage. Always place the sharps container into a secondary container if leakage is possible. This container shall meet the same criteria as the original container.

Other Regulated Waste Other regulated waste (soft waste, such as blood soaked gauze) must be placed in containers, which are:

1. Closable 2. Constructed to contain all contents and prevent leakage of fluids during handling, storage, transport or

shipping 3. Appropriate in size for devices placed in them 4. Designed with a visible opening, below eye level, if wall-mounted 5. Designed with an unobstructed opening that allows devices to drop in easily 6. Labeled with a biohazard label or color coded red 7. Closed prior to removal 8. Placed into a secondary container that meets the same criteria as the primary container, if outside

contamination of the primary container occurs

Disposal of all regulated waste shall be in accordance with applicable regulations of the state of North Dakota (see Related Information: A Guide to Understanding North Dakota’s Infectious Waste Regulations).

WASTE CONTAINMENT, TRANSPORT AND TREATMENT – Only trained employees/students, utilizing universal precautions, will store regulated infectious waste until Office of Safety picks it up. A waste disposal manifest form (see Forms) must be filled out and signed by the principle investigator or designee prior to pick up and disposal.


of 29

Regulated waste is contained, transported, and treated in the following manner:

1. Red bag-lined containers: The containers should be hard-walled, leak-proof with a lid. The container needs to be closed during transport and when not in use.

a. Removal Frequency: When three-quarters full, the waste shall be removed and transported for disinfection or incineration.

b. Documentation: Disinfection by immediately transferring the waste to autoclave facilities within the laboratory buildings is processed by the individual departments without Office of Safety involvement. For items needing disposal through a licensed vendor, a waste manifest form is used. The original remains with the generating department. The second copy is retained by the Office of Safety and a copy is held by the licensed vendor.

Manifests, waste use evaluation, and procedure performance shall be evaluated annually. Management of the regulated waste program including maintenance of the documentation for UND is coordinated by the Office of Safety.

For all regulated infectious waste:

1. Proof of regulated waste destruction shall be filed and maintained for a minimum of three years by the Office of Safety or time required by state and local jurisdictions.

2. Documentation of infectious waste destruction shall be maintained for the time required by state and local regulations, and at a minimum of three years by Office of Safety.

3. Each department/principal investigator/supervisor will be responsible for covering the costs associated with regulated infectious waste disposal.

REGULATED WASTE LABELING FOR TRANSPORT – Prior to transport from this facility it is typically required from state environmental agencies that the waste container be labeled. The generator (UND) has a cradle to grave liability for the waste leaving this facility; and it is crucial that correct handling and labeling of waste be performed to protect employees/students, the public, and the environment. Labeling should typically consist of half inch high letters written in indelible ink and including:

1. Name and address of the generator (this facility) and 2. Identification number (waste transporter account number) or 3. Date of shipment

Hepatitis B Vaccination

The principal investigators, supervisors, department, or Office of Safety will provide annual training to employees/students that will include information about the Hepatitis B vaccine, addressing its safety, benefits, efficacy, methods of administration, and availability. The Hepatitis B vaccination series is available at no cost, after training and within ten days of initial assignment, to employees (including student employees) identified in the exposure determination section of this plan by a licensed healthcare provider or designated medical provider. All other students are responsible for following policies within their academic field of study for Hepatitis B vaccination. Students not functioning under the definition of employees are responsible for covering the cost associated with their vaccinations. Vaccination is encouraged unless:

1. Documentation exists that the employee/student has previously received the series; 2. Antibody testing reveals that the employee/student is immune; or 3. Medical evaluation shows that vaccination is contraindicated.

However, if an employee/student chooses to decline vaccination, the employee/student must sign a declination form (see appendix 1). Employees/students who decline may request and obtain the vaccination at a later date. Employees will be offered the vaccination at no cost. Documentation of refusal of the vaccination is kept by the principal investigator, supervisor, or department. Vaccination for the ECP must be provided by the designated medical provider or licensed health care provider or Student Health Services (only students) who will provide a written opinion.


of 29

Post-Exposure Evaluation and Follow-Up

All occupational exposures to human blood and body substances will be regarded as serious, reported promptly, and be evaluated by a trained healthcare professional.

1. Upon injury from a suspected exposure source, the supervisor/employee/student will attempt to determine the nature of the exposure and any biohazardous material associated with it.

2. The employee/student will also attempt to carefully retain the exposure source and any biohazardous materials that may have constituted an exposure.

SOURCE INDIVIDUAL IDENTIFICATION – If possible, the unit head should determine and document the identity of the source individual (see appendix 6), who should be referred for testing to the healthcare professional that is treating the exposed employee/student. The source individual's blood must be tested as soon as feasible after consent is obtained to determine HIV/HBV/HCV infection status. The unit head shall document any issues related to obtaining consent, and note if consent cannot be obtained (see appendix 9). The unit head shall ensure that the exposed employee/student is informed about the applicable laws and regulations concerning disclosure of the identity and infection status of the source individual. If a source individual can be identified, the supervisor overseeing the exposure shall complete the UND occupational exposure to bloodborne pathogens source identification form (see appendix 6). The source individual identification form shall be transmitted to the healthcare professional as soon as the form is completed. If possible, the form should be faxed. If the form cannot be faxed, contact the healthcare professional by phone to alert them that a source individual has been referred. If phone contact is made, a hard copy of this form shall be mailed or carried to the healthcare professional as soon as feasible. The unit shall retain a copy of the source identification form for unit records.

1. If necessary, first-aid should be administered immediately for any cuts or punctures and any exposed skin should be washed with soap and water.

2. The employee/student should report the injury to their supervisor within one hour. a. The supervisor will then locate and complete any necessary incident report forms (as per the

requirements of the UND Incident Reporting Policy (see Related Information) and will refer the employee/student to the UND designated medical provider or licensed health care provider. Students will be referred to Student Health Services. Note: If the employee/student refuses to receive medical care the employee/student needs to fill the employee/student bloodborne/other potential infectious material exposure release form (see appendix 7).

3. In off campus sites (Clinical Locations, Hospitals etc.) the employee/student should report the injury to their immediate supervisor within one hour.

a. The supervisor will then locate and complete any necessary incident report forms and will refer the employee/student to the designated medical provider or licensed health care provider. In such instances, the student/employee will follow the procedures and policies of the off campus site if the UND department does not require them to follow the UND Exposure Control Plan requirements.

b. If the UND department requires the off campus site to follow the UND Exposure Control Plan requirements, the immediate supervisor at the off campus site location will be responsible to locate and complete any necessary UND Incident Reporting Requirements for the student/employee (see Related Information).

4. The employee/student will provide details on their injury to the licensed health care provider or designated medical provider (see appendix 8):

a. The type of injury the employee/student received b. The type and samples of any biohazardous material the employee/student was exposed to c. Circumstances under which the exposure occurred d. The hepatitis immunization status of the employee/student

5. The licensed health care provider or designated medical provider will provide the employee/student with a confidential medical evaluation and follow-up of the incident:

a. Evaluation of the exposure risk of the incident based on the exposure source, providing the employee/student with a written list of recommended options for testing and preventative treatment. Note: The medical care provider will collect the exposed employee's/student’s blood as


of 29

soon as feasible, and test for HIV, HBV, and HCV serological status after consent is obtained. The collected blood must be retained for 90 days or until consent to test is obtained, whichever period of time is shorter.

b. Explaining to the employee/student the rationale and benefits of these tests and treatments. 6. Employee (including student employees) acceptance of the tests/treatments will be on a completely

voluntary basis and services will be provided at no cost to them. 7. Student acceptance of the tests/treatments will be on a completely voluntary basis. Students not

functioning under the definition of employees are responsible for covering the cost associated with their tests/treatments.

8. The medical provider will provide the University with a written opinion (see appendix 8 or its equivalent form), within 15 days of the exposure incident. The report will summarize:

a. That the employee/student has been informed of the results of the evaluation and has been told about any medical conditions resulting from exposure to blood or other biohazardous materials that require further evaluation and treatment

b. Whether HBV vaccine was indicated for the employee/student, and if the employee has received such treatment.

c. All other findings or diagnoses will remain confidential and will not be included in the report. 9. The Office of Safety will provide the employee/student a copy of the licensed health care provider or the

designated medical provider’s determination within 15 days of the exposure incident. A copy of the report will be included in the employee’s/students permanent medical records with the Office of Safety.

10. If the employee/student eventually becomes ill or seroconverts (develops antibodies to the virus) as a direct result of occupational exposure to a bloodborne pathogen, the medical provider will file a complete report with the University Office of Safety, which handles workers’ compensation (see Related Information).

a. The report will be confidential and will be sent to no other organization within the University. b. If the exposure source sample is positive or not available and the employee/student is negative for

HBV, HCV, and HIV, follow up testing will be made available to them at three months and six months.

c. If occupational exposure of the employee/student to a bloodborne pathogen is confirmed, the University shall provide, through the healthcare service, confidential counseling and evaluation of any consequent illness that the employee/student reports. Students not functioning under the definition of employees need to follow up on their own with the healthcare provider.

Note: Please refer to appendix 2 for post-exposure incident checklist. This checklist summarizes the steps that must be taken in the event of an employee’s/student’s exposure to blood or other potentially infectious material.

Procedures for Evaluating the Circumstances Surrounding an Exposure Incident

The Office of Safety will investigate and review the circumstances of all exposure incidents to determine: 1. Has a risk assessment been completed (Contact the biological safety officer if assistance is needed with

risk assessment) 2. Engineering controls in use at the time 3. Work practices followed 4. A description of the device being used (including type and brand) 5. Protective equipment or clothing that was used at the time of the exposure incident (gloves, eye shields,

etc.) 6. Location of the incident 7. Procedure being performed when the incident occurred 8. Employee’s/student’s training

The supervisor, principal investigator, or department will investigate and fill out the incident reporting form and a sharps injury log (see appendix 3) for all percutaneous injuries from sharps at UND. If revisions to this ECP are necessary the Office of Safety will ensure that appropriate changes are made and retraining. (Changes may include an evaluation of safer devices, adding employees/students to the exposure determination list, etc.)

Employee/Student Training


of 29

INITIAL TRAINING AND ANNUAL RETRAINING – All employees/students required to participate in the ECP must have initial training and annual retraining. Initial training must be completed before performing duties by which occupational exposure could occur. Students who may have occupational exposure to bloodborne pathogens or exposure to OPIM are also required to complete training according to the requirements of their academic field of study and coursework. Several training techniques may be used, as approved by Office of Safety, include, but are not limited to:

1. Instructor led (by Office of Safety or Personnel designated by Office of Safety) 2. Videotape programs 3. Computer aided interactive training 4. Training manuals/employee/student handouts 5. Employee/Student review sessions

Training must cover, at a minimum, the following elements:

1. A copy and explanation of the OSHA bloodborne pathogen standard 2. An explanation of the ECP and how to obtain a copy 3. Epidemiology, symptoms, and transmission of bloodborne pathogen diseases 4. An explanation of methods to recognize tasks and other activities that may involve exposure to blood and

OPIM, including what constitutes an exposure incident 5. An explanation of the use and limitations of engineering controls, work practices and PPE 6. An explanation of the types, uses, location, removal, handling, decontamination, and disposal of PPE 7. An explanation of the basis for PPE selection 8. Information on the Hepatitis B vaccine, including information on its efficacy, safety, method of

administration, the benefits of being vaccinated, and that the vaccine is free of charge for employees/student employees

9. Information on the appropriate actions to take, and persons to contact, in an emergency involving blood or OPIM

10. Spill cleanup procedures 11. An explanation of the procedure to follow if an exposure incident occurs, including the method of

reporting the incident and the medical follow-up available 12. Information on the post exposure evaluation and follow-up that the employer is required to provide for

the employee/student following an exposure incident 13. An explanation of the signs and label and/or color coding required by the standard and uses at the

University 14. An opportunity for interactive questions and answers with the person conducting the training session

Additionally, principal investigators or supervisors must provide lab specific training for researchers handling any cultures or other materials potentially containing human blood/bloodborne pathogens, OPIM or human derived tissue cultures. Training must include safety training specific for the duties, equipment, and protocols relative to each employee/student. Training must ensure that employees/students have sufficient proficiency in working with human pathogens or tissue cultures prior to being allowed to work with any materials potentially containing human bloodborne pathogens. The employee/student must not participate in work involving infectious agents until proficiency is demonstrated to the satisfaction of the principal investigator or supervisor. This training needs to be documented in the lab specific safety manual (see Related Information). Note: Refer to appendix 4 to review the bloodborne pathogens site-specific training checklist.

Requirements Prior To Assignment to Duties with Occupational Exposure

It is the principal investigator’s or supervisor’s responsibility to ensure that prior to assignment to duties with occupational exposure:

1. Initial training is completed, to include spill clean-up 2. Site-specific training is completed 3. Hepatitis B vaccination, if requested, has been initiated 4. Hepatitis B declination form, if declined (see appendix 1 form) is filed with the principal investigator,

supervisor, or department, and Office of Safety


of 29

5. Employees/students are re-trained annually

Recordkeeping

TRAINING RECORDS – Records of training conducted by Office of Safety are maintained according to UND’s Record Retention Policy. Principal investigators, supervisors, or department are responsible for maintaining records of training done on-site according to UND’s Record Retention Policy. The training records include:

1. The dates of the training sessions 2. The contents or a summary of the training sessions 3. The names and qualifications of the persons conducting the training 4. The names and job duties of all persons attending the training sessions

Employee/student training records will be provided upon request to the employee/student or the employee’s authorized representative within 15 working days. Such requests should be addressed to the employee’s/student’s supervisor, principal investigators or department.

OSHA RECORDKEEPING – An exposure incident is evaluated to determine if the case meets OSHA’s Recordkeeping Requirements (29 CFR 1904). This determination and the recording activities are done by supervisor, principal investigator, or department. SHARPS INJURY LOG – In addition to the 1904 Recordkeeping Requirements, all percutaneous injuries from contaminated sharps are also recorded in a sharps injury log at UND campus. All incidences must include:

1. Date of the injury 2. Type and brand of the device involved (syringe, suture needle) 3. Department or work area where the incident occurred 4. Explanation of how the incident occurred

This log is reviewed as part of the annual program evaluation and maintained for at least five years following the end of the calendar year covered. If a copy is requested, it must have any personal identifiers removed from the report. For all off campus incidents UND will not keep a log for sharps injury. MEDICAL RECORDS – Medical records are maintained for each employee/student with occupational exposure in accordance with 29 CFR 1910.1020 and its amendment and amendments thereto, “Access to Employee/Student Exposure and Medical Records.” The Occupational Health Provider or designee is responsible for maintenance of the required medical records. These confidential records are kept for at least the duration of employment/enrollment plus 30 years. Employee/student medical records are provided upon request of the employee/student or to anyone having written consent of the employee/student within 15 working days. Such requests should be sent to the occupational health provider or designee. PROGRAM EVALUATION – Each department is required to comply with the bloodborne pathogens standard. UND expects its employees/students to adhere to all aspects of this ECP. These procedures have been established to eliminate or reduce exposure to bloodborne pathogens. Without commitment of both employer and employees to safety and health in this workplace, employees are likely to suffer injury and illness. It is procedure of the Office of Safety to evaluate the effectiveness of this bloodborne pathogen program on a regular basis. It may accomplish these evaluations in a variety of ways including:

1. Management and evaluation of engineering controls and personal protective equipment 2. Management and evaluation of employee/student training programs 3. Employee/Student self-evaluations and safety recommendations 4. Safety audits

RESPONSIBILITIES

Departments Ensure compliance with the contents of the ECP.


of 29

Identify departmental personnel governed by the ECP. Meet training requirements. Ensure proper record maintenance. Ensure the cost associated with tests/services associated with the ECP

program are covered.

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

Healthcare Professional Responsibilities (Designated Medical Provider or Licensed Healthcare Professional)

Healthcare professionals contracted by UND to provide the Hepatitis B vaccination series and/or post-exposure care must: Provide services in compliance with applicable OSHA regulations

regarding bloodborne pathogens and in accordance with current U.S. Public Health Service recommendations;

Administer Hepatitis B vaccinations as recommended by the U.S. Public Health Service;

If providing post-exposure care, conduct a confidential medical post-exposure evaluation in accordance with current U.S. Public Health Service recommendations, including:

Obtain consent for testing of source individual; Make results of the testing of the source individual available to the

exposed employee/student; Collect the exposed employee's/student’s blood as soon as feasible, and

test for HIV, HBV, and HCV serological status after consent is obtained. The collected blood must be retained for 90 days or until consent to test is obtained, whichever period of time is shorter;

Advise the exposed employee/student of post-exposure preventive and protective measures when medically indicated, as recommended by the U.S. Public Health Service;

Provide the exposed employee/student with appropriate treatment and counseling concerning precautions to take during the period after the exposure incident;

Give the employee/student information regarding which potential illnesses to be alert for and instructions for reporting any related experiences.

Provide all written documentation specified in the UND Bloodborne Pathogen Exposure Control Plan.

UND Student Health Services

UND Student Health Services providing the Hepatitis B vaccination series and/or post-exposure care to students (not student employees) must: Provide services in compliance with applicable OSHA regulations

regarding bloodborne pathogens and in accordance with current U.S. Public Health Service recommendations;

Administer Hepatitis B vaccinations as recommended by the U.S. Public Health Service;

If providing post-exposure care, conduct a confidential medical post-exposure evaluation in accordance with current U.S. Public Health Service recommendations, including:

Obtain consent for testing of source individual; Make results of the testing of the source individual available to the

exposed student; Collect the exposed student’s blood as soon as feasible, and test for HIV,

HBV, and HCV serological status after consent is obtained. The collected blood must be retained for 90 days or until consent to test is obtained, whichever period of time is shorter;

Advise the exposed student of post-exposure preventive and protective measures when medically indicated, as recommended by the U.S. Public Health Service;


of 29

Provide the exposed student with appropriate treatment and counseling concerning precautions to take during the period after the exposure incident;

Give the student information regarding which potential illnesses to be alert for and instructions for reporting any related experiences.

Office of Safety Oversee and implement ECP. Develop, in cooperation with administrators and departmental authorities,

any additional policies and practices needed to support the implementation of the ECP.

Work with principal investigators or supervisors in the evaluation of employee exposure potential.

Review the ECP at least annually and whenever necessary to reflect new or changed exposure potential tasks and procedures.

Responsible for training, documentation of training, and making the written ECP available to employees, students, OSHA, and NIOSH representatives.

Periodically review and update training programs.

Principal Investigators/Supervisors

Perform exposure evaluation of students/employees based upon the job description and assigned tasks.

Ensure that guidelines established in this manual are strictly followed by all persons under their jurisdiction.

Follow and ensure that their employees are trained in and use proper work practices, universal precautions, the use of personal protective equipment, and proper cleanup and disposal techniques.

Maintain records of all site-specific training and declaration of vaccination preference with employee records, and submitting a copy to Office of Safety.

Provide all necessary personal protective equipment (PPE), engineering controls (e.g., sharps containers), labels, and red bags as required by the standard.

Ensure that the cost associated with tests/services associated with the ECP program are covered.

Students Utilize proper work practices, universal precautions, personal protective equipment and cleanup/disposal techniques as described in this plan.

FORMS

Employee/Student Bloodborne/OPIM Exposure Release Form (Refusal of Care)

See Appendix 7

Hepatitis B Vaccine Declination Form See Appendix 1

Incident Investigation Form-Part 1 http://UND.edu/public-safety/_files/docs/incident-investigation-form-part-one.pdf

Incident Investigation Form-Part 2 http://UND.edu/public-safety/_files/docs/incident-investigation-form-part-two.pdf

Incident Reporting Form http://UND.edu/public-safety/_files/docs/incident-reporting-form.pdf

Source Individual Consent Form (HIV, Hepatitis B And C Virus Blood Testing)

See Appendix 9

Waste Disposal Form/Manifest http://UND.edu/public-safety/_files/docs/waste-disposal-manifest-form.pdf


of 29

APPENDICES

Appendix 1 – Hepatitis B Vaccine Declination Form

Appendix 2 – Post-exposure Incident Checklist

Appendix 3 – Sharps Injury Log

Appendix 4 – Bloodborne Pathogens Site-Specific Training Checklist

Appendix 5 – Blood and Other Potentially Infectious Material Spill Clean Up

Appendix 6 – Occupational Exposure to Bloodborne Pathogens Source Identification

Appendix 7 – Employee/Student Bloodborne/OPIM Exposure Release Form (Refusal of Care)

Appendix 8 – Report of Exposure to Blood or OPIM Request for Treatment

Appendix 9 - Source Individual Consent Form (HIV, Hepatitis B And C Virus Blood Testing)

REVISION RECORD

04/11/2016 – Policy Implementation President Edward T. Schafer

09/09/2016 – Revision Updated Web links throughout document Updated content in Appendix 4 – Bloodborne

Pathogens Site-Specific Training Checklist

APPENDIX 1: HEPATITIS B VACCINE DECLINATION FORM (MANDATORY) University of North Dakota offers the Hepatitis B vaccine to employees, students, and volunteers who work in areas where their duties may involve exposure to blood or other potentially infectious materials. The vaccination is free of charge to all employees (including student employees), and consists of three (3) immunizations. NOTE: Students not functioning under the definition of employees are responsible for covering the cost associated with their vaccinations. I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with the Hepatitis B vaccine, I can receive the vaccination series at no charge to me. Employee/Student Name: (printed) ______________________________________________ Date: ________________ Signed: ___________________________________________________________________________________________

APPENDIX 2: POST-EXPOSURE INCIDENT CHECKLIST

The following steps must be taken, and information provided, in the event of an employee's/student’s exposure to blood or other potentially infectious material at UND. (This section needs to be completed by the Immediate Supervisor). DATE OF EXPOSURE INCIDENT: _______________________________ ACTIVITY COMPLETION

Contaminated area was washed with soap and water (or eyewash if the eye) for at least 15 minutes.

Employee/Student furnished with documentation regarding exposure incident. Employee/Student Employee referred to Designated Medical Provider/Licensed Healthcare Provider/Emergency Room/

Occupational Health within 2 hours of incident (following washing/flushing described above)

Student referred to Student Health Center/Licensed Healthcare Provider within 2 hours of incident (following washing/flushing described above)

The following documentation was forwarded to a Healthcare Professional who is evaluating employee/student:

Bloodborne Pathogens Standard Report of Exposure to Blood or OPIM Materials (Appendix H)

The following documentation was forwarded to the Office of Safety:

Incident Reporting Form (Completed by the individual involved or on his/her behalf) within 24 hours of the incident (http://und.edu/finance-operations/office-of-safety/_files/docs/incident-reporting-form.pdf)

Incident Investigation Form Part 1 completed by the immediate supervisor (within 24 hours) (https://und.edu/finance-operations/office-of-safety/_files/docs/incident-investigation-form-part-one.pdf)

Incident Investigation Form Part 2 completed within one week of incident (https://und.edu/finance-operations/office-of-safety/_files/docs/incident-investigation-form-part-two.pdf)

Source Individual:

Identified OR it was determined that ID was not feasible (Appendix F) Authorization to collect blood requested (Appendix I) Blood tested OR authorization refused (Appendix I)

Source individual’s blood results given to exposed employee/student

Employee informed that any/all follow-up care shall be at no cost to him/her

Students not functioning under the definition of employees informed that they are responsible for covering the cost associated with their vaccinations and follow-up

Note: Student/employee will follow the procedures and policies of the off campus site if the UND department does not require them to follow the UND Exposure Control Plan requirements.

APPENDIX 3: SHARPS INJURY LOG FOR UNIVERSITY OF NORTH DAKOTA Complete all sections of this form. A copy of this form will be kept on file by the supervisor for a minimum of 5 years after the incident.

Case/Report number: __________ Date filed: ____________

Injured Employee/Student: Department: Phone:

Date and Time of Injury: Job title of Employee/Student:

Location where incident occurred:

Body Part Injured:

Type of Device (e.g. syringe, suture needle) and Brand and Model:

Brief Description of How the Incident Occurred [i.e., action being performed (disposal, injection, etc.), substances involved, body part injured]: a) Did device have engineered sharps protection?

b) Was protection mechanism activated at time of injury?

c) Exposure occurred: Before, During, After safety device activation.

If the sharp did not have engineered sharps protection, describe employee’s/students opinion as to whether and how such a mechanism could have prevented this injury:

Injured employee’s/students opinion as to whether there are any other work practice controls or sharps devices that could have prevented this injury: Did employee/student receive medical consultation and follow up?

Other comments:

Employee/Student Signature: ________________________________ Date: ____________________ Supervisor Signature: ____________________________ Date: ____________________

Retain a copy for the employee/student file, and submit a copy to UND Office of Safety 3851 Campus Rd, Stop 9031 Grand Forks, ND 58202-9031

Email: [email protected]

APPENDIX 4: BLOODBORNE PATHOGENS SITE-SPECIFIC TRAINING CHECKLIST In order to complete the training requirements please review the site-specific training items listed below with the employee/student. Check each item as it is reviewed or write N/A if it is not applicable to your work area. Administrative: These Items MUST be completed _______Ensure that Risk Assessment, Initial BBP training techniques approved by Office of Safety, quiz etc. have been completed. _______Declaration of Vaccination Preference (Appendix 1- Must be signed and submitted) Spill Kits and Personal Protective Equipment (PPE): Gloves, eye protection, ventilation devices, etc. _______Location and availability of spill kits and review of kit contents _______Location of PPE, and maintenance of reusable PPE, if applicable (cleaning, storage and inspection) Engineering Controls _______Location, operation, and use of eyewash facilities _______Explanation of engineering controls that are specific to the work environment (examples: eyewash stations, sharps containers, biological safety cabinets, mechanical pipettors, safer sharps devices, etc.). Biohazardous Waste Handling _______Discussion and clarification of which wastes generated in the work area are considered biohazardous and how those items are to be segregated, stored, transported, treated and disposed of _______Review of hazardous waste pick-up procedures if applicable to the work area _______Disinfection & Spill Response/Exposure Incident Response/Exposure Control Plan _______Review of the UND procedure for handling spills of potentially infectious materials _______Reminder that non-disposable items that were touched with dirty gloves must be decontaminated before being put back into the spill cleanup kit _______Who to contact for spill cleanup supplies, and for reporting Other Site Specific Check Points (List as needed) __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Additional Requirements for HIV, HBV, and HCV Research Laboratories: _________ Read the UND Institutional Biosafety Manual _________ Read the UND Lab Specific Biosafety Manual _________ Informed of the job associated risks, and provide an opportunity to ask questions _________ Review departmental security access procedures _________ Lab specific procedures associated with BBP and OPIM

DEPARTMENT: DATE OF TRAINING

TRAINER (PRINTED NAME) TRAINER (SIGNATURE)

LIST OF TASKS OR PROCEDURES THAT MAY POSE RISK OF EXPOSURE TO HUMAN BLOODBORNE PATHOGENS: EMPLOYEE/STUDENT PRINTED NAME

EMPLOYEE/STUDENT ID NUMBER

EMPLOYEE/STUDENT SIGNATURE

Retain a copy for the employee/student file, and submit a copy to UND Office of Safety

APPENDIX 5. BLOOD AND OTHER POTENTIALLY INFECTIOUS MATERIAL SPILL CLEAN UP Spill clean-up kit will consist of absorbent, dustpan and broom/scoop (for this use only), PPE, and plastic bag. Blood or OPIM spills are to be cleaned up immediately or as soon as feasible by utilizing the following procedure: Determine what PPE is to be used, depending on size and location of spill (utility gloves and mask at a minimum). If the fluid spill is only on a hard surface, place paper towels over the spill to absorb fluid. If it is a large spill, or if

the spill contains broken glass, place absorbent beads over spill, follow manufacturer directions and sweep into dustpan. Never pick up glass with your hands. If the spill has dried, soak the spill with a disinfectant first.

Place paper towels (or material in dustpan) into plastic bag. Spray contaminated surface with freshly prepared 10% Bleach (1 Parts Bleach + 9 parts water) or EPA registered

tuberculocidal disinfectant and wipe with a clean paper towel. Spray again with disinfectant and let sit according to manufacturer’s directions in order to disinfect. Be sure to

block off the area to reduce potential of slips and falls. If spill is on carpeting, sprinkle with disinfecting absorbent, allow to absorb, sweep or scoop up. Clean area with

appropriate cleaner using gloves and any other PPE determined necessary. Never vacuum area or the absorbent on the spill. Follow above steps and completely clean area prior to any vacuuming.

Immediately dispose of plastic bag in medical waste receptacle or in a biohazard container. Dispose of PPE in medical waste receptacle or in a biohazard container if considered regulated waste. Review procedures to determine the cause of this spill and if procedural changes need to occur. Call the Office of Safety (701-777-3341) for guidelines on pick up of biohazardous waste.

BLOOD AND BODY FLUID SPILL KITS ARE LOCATED DEPARTMNE/FACILITY NAME: ___________________________________________________________________ LOCATION TO BE POSTED: _______________________________________________________________________

APPENDIX 6: UNIVERSITY OF NORTH DAKOTA OCCUPATIONAL EXPOSURE TO BLOODBORNE PATHOGENS SOURCE IDENTIFICATION

Supervisor: Please complete this form to the best of your knowledge if a source individual can be identified in an exposure incident involving human blood or other potentially infectious materials (OPIM). Transmit this form as soon as possible to the Licensed Healthcare Provider, the Designated Medical Provider that is treating the exposed Employee/Student Employee. Transmit this form as soon as possible to the UND Student Health Services that is treating the exposed student. Note: The student/employee will follow the procedures and policies of the off campus site if the UND department does not require them to follow the UND Exposure Control Plan requirements.

CAMPUS UNIT Unit Name: ___________________________________ Unit Head/Title: _____________________________________ Unit Address (incl. mail code): _______________________________________________________________________ Unit Head Work Phone: ________________________________ Unit Emergency Phone: _______________________

EXPOSED EMPLOYEE/STUDENT Name: _________________________________________ Title: _____________________________________________ Home Phone: _______________________________________________ Work Phone: __________________________ Date and Time of Exposure: ___________________________________

SOURCE INDIVIDUAL The human blood or other potentially infectious material involved in the exposure referred to above came from the following individual: Name: ________________________________________ Work Phone: _______________________________________ Home Address: _________________________________ Home Phone: ______________________________________ City: _________________________ State: ________________________________ Zip Code: ____________________ The above-named source individual has has not been referred to the Licensed Healthcare Provider, the Designated Medical Provider or UND Student Health Services for testing.

Source individual declined to be tested

Above-named source individual cannot be located Unit Representative Signature: _________________________ Title: ________________________________________ Date: _______________________________________________

APPENDIX 7: EMPLOYEE/STUDENT BLOODBORNE/OTHER POTENTIAL INFECTIOUS MATERIAL EXPOSURE RELEASE FORM

(REFUSAL OF CARE)

I understand that due to my bloodborne or other potential infectious material exposure I may be at risk of acquiring HIV, HBV, HCV, or other potential infectious pathogens. I have been informed that it is the standard procedure after an exposure incident to be tested for HIV, HBV and HCV infection immediately. However, I decline to be tested for HIV, HBV and HCV at this time. I am signing this release form in full recognition and appreciation of the dangers, hazards and risks of not being tested for bloodborne pathogen infection.

I understand by signing this release, I am releasing and holding harmless the affiliation site _______________________ or the University of North Dakota, their governing boards, officers, employees and agents from any and all liability, claims and actions arising out of this incident.

I recognize that this release means that I am giving up, among other things, rights to take legal action against the affiliation site __________________ or the University of North Dakota, their governing boards, officers, employees and agents for injuries, damages or losses I may incur. I also understand that this release bind my heirs, executors, administrator, and assigns, as well as myself.

____________________________________ __________ Employee/Student Signature Date ____________________________________ Employee/Student Name (print) ____________________________________ _________ Witness 1. Signature Date ____________________________________ Witness 1. Name (print) ____________________________________ _________ Witness 2. Signature Date ____________________________________ Witness 2. Name (print) Standard: Bloodborne Pathogens Exposure Control Plan Reviewed By Supervisor: _________________________ Date: ______________

Note: The student/employee will follow the procedures and policies of the off campus site if the UND department does not require them to follow the UND Exposure Control Plan requirements.

APPENDIX 8: UNIVERSITY OF NORTH DAKOTA REPORT OF EXPOSURE TO BLOOD OR OTHER POTENTIALLY INFECTIOUS MATERIALS

An exposure incident is defined by the OSHA Bloodborne Pathogen Standard (29 CFR 1910.1030) as a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral (skin-piercing wound) contact with blood or other potentially infectious materials (OPIM) (any body fluid containing visible blood, semen, vaginal secretions, fluids surrounding internal organs, the brain, or a fetus, any unfixed human organs or tissues, and cultures containing HIV, HBV, or HCV) that results from the performance of an employee/student duties. Any employee/student so exposed must be referred to a healthcare professional for post-exposure care and counseling. Please use this form and the Campus-wide Exposure Control Plan as guidance for ensuring post-exposure follow-up and care at UND campus. Please use this form or its equivalent for all off campus post-exposure follow-up and care. Please direct questions to the Office of Safety at (701) 777-3341. Note: The student/employee will follow the procedures and policies of the off campus site if the UND department does not require them to follow the UND Exposure Control Plan requirements.

EXPOSED EMPLOYEE/STUDENT

1. Wash the exposed area thoroughly. Use soap for skin; use only water if eyes, nose or mouth. 2. Notify your supervisor of this exposure. He/she can answer your questions. 3. Please complete this section.

Name: ___________________________________________ Title: _______________________________________ Home Address: __________________________________Home Phone: ________________________________ City: __________________State: __________________Zip: ____________Work Phone: ___________________ Exposed on _______________(date) at ______AM/PM, at ______________________ (Location: bldg, room #) I received an exposure to: blood other potentially infectious material (OPIM) Specify type of OPIM if possible: _______________________________________________________________

This material came into contact with my:

right/left/both eye(s) nose mouth cut/scratched/damaged/punctured skin Was a sharp involved? (Needle, syringe, scalpel/razor blade, contaminated glass etc.) Yes No Describe how this exposure occurred? _________________________________________________ __________________________________________________________________________________ I was wearing: gloves protective clothing face protection protective eyewear no PPE

Immediately after I received the exposure…. I washed the exposed area thoroughly I reported the exposure to my supervisor I have I have not been vaccinated against the Hepatitis B virus I can I cannot identify the individual to whose blood or body fluid I was exposed: Source Name: _________________________________________________________________________________ Address: _______________________________________________________ Phone: _______________________ When you are finished, sign and date this section and give this report to your supervisor. Promptly report to the licensed healthcare provider or designated healthcare provider.

Signature of Exposed Employee/Student: ______________________________ Date: _________________________

SUPERVISOR

1. Confirm that the employee/student has washed the exposed area and has submitted a completed form. 2. Provide the following information. If you have any questions, please ask your PI or unit head. Your Name: _____________________ Title: ______________________ Phone: _________________________ On (date) __________________ at _________ AM/PM, the above-named employee/student reported this exposure to me: as described above. According to unit records, the exposed employee/student:

has received Hepatitis B vaccinations has not received Hepatitis B vaccination has has not received training in Occupational Exposure to Bloodborne Pathogens has has not signed a Declination of HBV Vaccination Form

Source Individual identification cannot can be confirmed. Complete a Source Individual ID form (Appendix F).

Photocopy this form for your unit's records. Send the original form and a copy of the employee's/student’s task description with the

employee/student to the healthcare professional. If the identity of the source individual can be confirmed, complete the Source Individual

Identification Form (Appendix F). Signature of Supervisor: ______________________________ Date: _________________________________

HEALTHCARE PROFESSIONAL

1. Complete the following section after completing your evaluation of the exposed employee/student. Name: ________________________________ Title: _____________________ Phone: ____________________ On _____________ (date) at ___________AM/PM, the above-named employee/student reported this exposure to me: as described above. The employee/student has been given the 1st 2nd 3rd vaccination in the Hepatitis B vaccination series as a part of post- exposure care. Remaining vaccinations should be arranged through the employee's/student’s unit. I have evaluated and treated the employee/student in accordance with U.S. Public Health Service recommendations current at this date. I have informed the employee/student of the results of my medical evaluation and provided the employee/student information regarding necessary precautions, further medical evaluations and/or treatment, and potential illnesses that might result from the exposure. All other medical information regarding this exposure incident is confidential and will not be reported to the employee's/student’s unit Signature of Healthcare Professional: ___________________________Date: __________________________ Please return this completed evaluation form or equivalent documentation within 15 days to: Facility Name: University of North Dakota Facility Address: Office of Safety 3851 Campus Rd Stop 9031 Grand Forks, ND 58202-9031 Facility Phone: 701-777-3341 To the Attention of: Office of Safety

NOTE: The designated healthcare provider is responsible for collecting the exposed employee's/student’s blood as soon as feasible and testing for HIV/HBV/HCV serological status after consent is obtained. The collected blood must be retained for 90 days or until consent to test is obtained, whichever period of time is shorter.

APPENDIX 9: SOURCE INDIVIDUAL CONSENT FORM (HIV, HEPATITIS B AND C VIRUS BLOOD TESTING)

I have been informed that my blood will be tested in order to detect whether or not I have antibodies and/or antigens in my blood to the Human Immunodeficiency Virus - HIV (which is the probable causative agent of Acquired Immune Deficiency Syndrome - AIDS), and Hepatitis B and C. I understand that the tests are performed by withdrawing blood and using a substance to test the blood.

I have been informed that the HIV test results may, in some cases, indicate that a person has antibodies and/or antigens to the virus when the person does not (false positive), or that it may fail to detect that a person has antibodies to the virus when the person has antibodies (false negative). I understand that in order to diagnose AIDS, other means must be used in conjunction with this blood test.

I have been informed that if I have any questions regarding the nature of the blood tests, its expected benefits, its risks and alternative tests, I may ask those questions before I decide to consent to the blood tests.

I understand that the results of these blood tests are confidential and will only be released to those health care practitioners directly responsible for my care and treatment and to others, as required by law.

By my signature below, I acknowledge that I have been given all of the information I desire concerning the blood tests and release of results and have had all of my questions answered.

I give permission for my blood to be tested for HIV, Hepatitis B and Hepatitis C antibodies and antigens.

Source Individual Signature: _______________________________________ Date: ________________________________

I do not give my permission for my blood to be tested for HIV, Hepatitis B and Hepatitis C antibodies and antigens. Source Individual Signature: _______________________________________ Date: ________________________________

Witness Name: ___________________________________________________ Date: ________________________________

Witness Signature: ________________________________________________

Supervisor Name: ___________________________________________________ Date: ______________________________

Supervisor Signature: ________________________________________________

Note: The student/employee will follow the procedures and policies of the off campus site if the UND department does not require them to follow the UND Exposure Control Plan requirements.

bloodborne pathogens exposure control plan · finance & operations policy library bloodborne...

Documents