division: - quia.com€¦ · web view... osha has enacted the bloodborne pathogens standard, ......

Gateway Surgery Center1025 Northeast Gateway Court, NEConcord, NC 28025

POLICIES AND PROCEDURES___________________________________________________________________________

TITLE: Exposure Control Plan

Index: IC 10.001.01

Prepared By:____________________________________ Authorized By:____________________________________

Endorsed By:____________________________________ Effective Date: 1/31/04

1. IntroductionOne of the major goals of the Occupational Safety and Health Administration (OSHA) is to regulate facilities where work is carried out...to promote safe work practices in an effort to minimize the incidence of illness and injury experienced by employees. Relative to this goal, OSHA has enacted the Bloodborne Pathogens Standard, codified as 29 CFR 2010.1030. The purpose of the Bloodborne Pathogens Standard is to "reduce occupational exposure to Hepatitis B Virus (HBV), Human Immunodeficiency Virus (HIV) and other bloodborne pathogens".

Gateway Surgery Center, L.L.C. believes that:

a. It is prudent to minimize all exposure to bloodborne pathogens.

b. Risk of exposure of bloodborne pathogens should never be underestimated.

c. The facility will institute appropriate engineering and work practice controls to eliminate or minimize employee’s exposure to bloodborne pathogens.

This exposure Control Plan has been implemented to meet the letter and intent of the OSHA Bloodborne Pathogens Standard. The Exposure Control Plan differs from the Infection Control Program by placing an emphasis on the center's responsibility as an employer for protecting healthcare workers and other employees from bloodborne infection as opposed to the prevention and management of general infection in and among patients.

2. Authority

a. Clinical Director/Designee has authority for the establishment, maintenance and allocation of necessary resources of the Center-wide Exposure Control Plan.

of 20

document.doc

b. The Quality Improvement Committee, as approved by the Clinical Director, has responsibility for the implementation of the Exposure Control Plan including employee training, inspections and investigation.

c. The Clinical Director/Designee has the authority to ensure employee compliance to this program.

3. ObjectivesThe objective of this plan is:a. To minimize employee risk of exposure to bloodborne pathogens.b. To protect our employees from the health hazard associated with bloodborne

pathogen.c. To provide appropriate treatment and counseling should an employee be

exposed to bloodborne pathogens.

4. Scope

The Exposure Control Plan is a Center wide program that includes all employees who may have exposure to blood or other potentially infectious materials as part of their job duties.

5. Policy

a. The Exposure Control Plan is to be followed by all employees with potential for occupational exposure.

b. The Clinical Director / Designee shall be responsible for achieving employee compliance with the Exposure Control Plan.

c. All employees will adhere to Universal Precautions/Body Substance Isolation.

d. An Exposure Control Plan training program will be provided at the time of hire, annually and as appropriate.

e. The program shall be evaluated annually by the Quality Improvement Committee and revised as necessary by the Clinical Director.

6. Purpose

a. To eliminate or minimize employee exposure to blood or body fluids.

b. To educate all employees about their risk and about risk reduction strategies.

of 20

document.doc

7. General Program Management

a. The Clinical Director shall be the Infection Control Nurse who will be responsible for exposure control in the Center. He/she works directly with the Medical Director and the staff to ensure that proper exposure control procedures are followed.

b. Responsibilities

1) The staff is responsible for adhering to the guidelines outlined in the Exposure Control Plan.

2) The Clinical Director or designee is responsible to ensure compliance with this program by:

Monitoring Body Substance Isolation/Exposure Control practice of staff;

Disciplinary action for non-compliance and follow-up. Identifying actual and potential infection control problems. Investigation and documenting the circumstances when an

employee elects to act without appropriate personal protective equipment, (PPE), to determine whether changes can be instituted to prevent such occurrences in the future.

Documentation shall be sent to the appropriate department:

Clinical Director

Quality Improvement Committee

3) The Clinical Director or Designee shall ensure that staff participate in training and education programs.

4) The Clinical Director will provide for annual Universal Precautions/Body Substance Isolation education.

5) The Clinical Director will facilitate and document an annual inservice of the Exposure Control Program.

of 20

document.doc

6) Clinical Director will provide the Hepatitis B program, post exposure determination, evaluation and follow-up.

7) The Quality Improvement Committee will be responsible for overall management and support of the facility's blood borne Compliance Program. Activities include, but are not limited to:

· Overall responsibility for implementing the Exposure Control Plan for the entire facility.

· Review, track and trend reports, make appropriate recommendations and monitor follow-ups.

· Know current legal requirements concerning bloodborne pathogens.

· Act as facility liaison during OSHA inspections.

· Revise and update the program annually and when necessary.

8. Definitions as Defined by OSHA

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

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

c. A Biohazard Label needs to be applied to containers of regulated waste, refrigerators/freezers and other containers used to store, transport, or ship blood and other potentially infectious materials. The label must be fluorescent orange-red in color with the biohazard symbol or the word biohazard.

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

of 20

document.doc

e. Contaminated sharps means any contaminated object that can penetrate the skin.

f. Engineering Controls means controls (e.g., sharps disposal containers, resheathing devices) that isolate or remove the bloodborne pathogens hazard from the workplace.

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

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

i. Other Potentially Infectious Materials means

1) The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids.

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

3) HIV-containing cell or tissue cultures, organ cultures, and HIV-or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.

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

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

of 20

document.doc

during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.

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

m. Universal Precautions is an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens.

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

9. Exposure Control Plana. Exposure determination

1) The following job classifications have employees with occupational exposure.

Registered NursesCS/Instrument room technicianSurgery TechnologistRadiology TechnologistAncillary Support Personnel

2) Tasks and Procedures

Tasks and procedures or groups of closely related tasks and procedures are classified according to the risk for occupational exposure as Category I, II, or III. The category is included in the nursing procedures and Infection Control Guidelines.The definition of the Categories is:

Category I – Tasks that involve exposure to blood, body fluids, or tissues.

of 20

document.doc

All procedures or other job related tasks that involve an inherent potential for mucous membrane or skin contact with blood, body fluids, or tissues, or a potential for spills or splashes of them, are Category I tasks. Those employees who are classified within this category include: All RN’s All Surgery Technologists All CS/Instrument room technicians Ancillary Support Personnel

Category II – Tasks that involve no exposure to blood, body fluids, or tissues, but employment may require performing unplanned Category I tasks. Those employees who are classified within this category include: Materials Coordinator

Equipment: Protective eyewear Mask Gloves Gown

Category III - Tasks that involve no exposure to blood, body fluids, or tissues and Category I tasks are not a condition of employment.

The normal work routine involves no exposure to blood, body fluids, or tissues (although situations can be imagined or hypothesized under which anyone, anywhere, might encounter potential exposure to body fluids). Persons who perform these duties are not called upon as part of their employment to perform or assist in emergency medical care or first or to be potentially exposed in some other way. Tasks that involve handling implements or utensils, use of public or shared bathroom facilities or telephones, and personal contacts such as handshaking are category III tasks. Those employees who are classified within this category: Administrative personnel Admitting and Business Office personnel

of 20

document.doc

Scheduler

Equipment: None

10. Methods of Compliance

a. Universal Precautions/Body Substance Isolation

Universal Precautions/Body Substance Isolation shall be observed to prevent contact with blood or potentially infectious materials. All body fluids shall be considered potentially infectious material. Refer to Universal Precautions/Body Substance Isolation Policy in the Policy and Procedure Manual.

b. Engineering and Work Practice Control

Engineering and work practice controls shall be used to eliminate or minimize employee exposure;

1) Engineering controls shall be examined and maintained or replaced on an on-going basis to ensure their effectiveness.

2) Gateway Ambulatory Surgery Center, L.L.C. identifies the need for changes in engineering control and work practices on an ongoing basis. Non-managerial staff at Gateway Ambulatory Surgery Center, L.L.C. evaluates new products and makes recommendations in the selection of these products.

3) Information regarding engineering and work practice controls may be found in the Infection Control section of the Policy and Procedure Manual. These include, but are not limited to:

· Handwashing technique· Needle and sharps safety· Employee Health policies· Work area specific guidelines

3) Applicable Work Practice Controls

· Employees wash their hands immediately, or as soon as feasible, after removal of gloves or other personal protective equipment.

of 20

document.doc

· Following any contact of body areas with blood or any other infectious materials, employees wash their hands and any other exposed skin with soap and water as soon as possible. They also flush exposed mucous membranes with water.

· Handle sharp objects carefully. Report immediately all needle stick accidents, mucosal splashes or contamination of open wounds with blood or body fluids.

· Contaminated reusable sharps are placed in appropriate containers immediately, or as soon as possible, after use.

· Eating, drinking, smoking, applying cosmetics or lip balm and handling contact lenses is prohibited in work areas where there is potential for exposure to bloodborne pathogens.

· Food and drink is not kept in refrigerators, freezers, on countertops or in other storage areas where blood or other potentially infectious materials are present.

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

· All procedures involving blood or other infectious materials will be performed to minimize splashing, spraying or other actions generating droplets of these materials.

· Specimens of blood or other materials are placed in designated leakproof containers and are appropriately labeled for handling and storage.

· If outside contamination of a primary specimen container occurs, that container is cleaned with an approved disinfectant and placed within a second leak-proof container, appropriately labeled, for handling and storage. (If the specimen can puncture the primary container, the second container must be puncture-resistant as well.)

· Equipment which becomes contaminated is examined prior to servicing or shipping, and is decontaminated as necessary (unless it can be demonstrated that decontamination is not feasible).

of 20

document.doc

An appropriate biohazard warning label is attached to any contaminated equipment, identifying the contaminated portions.

Information regarding the remaining contamination is conveyed to all affected employees, the equipment manufacturer and the equipment service representative prior to handling, servicing or shipping.

4) When a new employee comes to the facility or changes positions within the organization, the Clinical Director is responsible for ensuring that the employee receives instructions regarding any work practice controls that the employee is not experienced with.

c. Personal Protective Equipment (PPE)

1) The Center shall provide and maintain at no cost to the employee and physicians, appropriate personal protective equipment.

2) The employee is responsible for proper use and routine care of health safety devices and personal protective equipment. This equipment may include, but is not limited to:

· Gloves· Gowns/Aprons· Face Shields/Masks· Safety Glasses/Goggles· Mouthpieces· Resuscitation Bags· Pocket Masks· Surgical Caps/Hoods· Shoe Covers

3) To ensure that personal protective equipment is not contaminated and is in the appropriate condition to protect employees from potential exposure, our facility adheres to the following practices:

of 20

document.doc

· All personal protective equipment is inspected periodically and repaired or replaced as needed to maintain its effectiveness by the Clinical Director/designee.

· Reusable personal protective equipment is cleaned, laundered, and decontaminated as needed.

· Single-use personal protective equipment (or equipment that cannot, for whatever reason) be decontaminated is disposed of.

4) Employees are trained regarding the use of the appropriate equipment for their job classifications and tasks/procedures they perform.

· Masks and eye protection (such as goggles, face shields, etc.) are used whenever splashes or sprays may generate droplets of infectious materials.

· Protective clothing (such as gowns and aprons) is worn whenever potential exposure to the body is anticipated.

· Surgical caps/hoods and/or sheet covers/boots are used in any instances where "gross contamination" is anticipated.

5) To make sure that this equipment is used as effectively as possible, employees adhere to the following practices when using personal protective equipment.

· Personal protective garments penetrated by blood or other infectious materials are removed immediately or as soon as feasible.

· All personal protective equipment is removed prior to leaving a work area.

· Gloves are worn in the following circumstances.

Whenever employees anticipate hand contact with potentially infectious materials

When performing vascular access procedures

of 20

document.doc

When handling or touching contaminated items or surfaces.

· Disposable gloves are replaced as soon as practical after contamination or if they are torn, punctured or otherwise lose their ability to function as an "exposure barrier."

· Utility gloves are decontaminated for reuse unless they are cracked, peeling, or torn or exhibit other signs of deterioration, at which time they are disposed of.

· Hypoallergenic gloves, gloveliners and similar alternatives are readily available to employees who are allergic or sensitive to the gloves the facility normally uses.

6) Clinical Director/designee is responsible for ensuring that all units and work area are:

· provided with a sufficient quantity of personal protective equipment in appropriate sizes.

· monitored for appropriate inventory levels.

7) Clinical Director / designee shall insure that no employee at any time, is forced to choose between providing immediate patient attention without the benefit of protective equipment or waiting for appropriate equipment to be found.

8) Each employee is responsible for knowing the location and inventory level of appropriate and properly sized protective equipment and for advising Clinical Director / designee if adequate supplies are not available to them for the duration of the shift.

d. Housekeeping Practices

Clinical Director / designees shall ensure that the worksite is maintained in a clean and sanitary condition. For information regarding environmental cleaning and decontamination, regulated waste, and laundry, refer to the Policy / Procedure Manual and the Universal Precautions/Body Substance Isolation Policy.1) Employees engaged in cleaning equipment shall use personal protective

equipment that will ensure that there is no contact of potentially contaminated material with skin or personal clothing.

of 20

document.doc

2) General housekeeping practices involve the nursing staff.· All equipment and surfaces are cleaned and decontaminated after

contact with blood or other potentially infectious materials:

After the completion of surgical/invasive procedures

Immediately (or as soon as feasible) when surfaces are overtly contaminated.

After any spill of blood or infectious materials

At the end of the work shift if the surface may have been contaminated during that shift.

· All pails, bins, cans and other receptacles intended for use routinely are inspected, cleaned and decontaminated as soon as possible if visibly contaminated.

· Potentially contaminated broken glassware is picked up using mechanical means (such as dustpan and brush, tongs, forceps, etc.).

· Contaminated reusable sharps are stored in containers that do not require "hand processing”.

e. Hepatitis B Vaccination and Post Exposure Evaluation and Follow-up.

To protect the employees as much as possible from the possibility of Hepatitis B Infection, the Center has implemented a vaccination program. The program is available at no cost to all employees who have occupational exposure to bloodborne pathogens.

1) The Hepatitis B Program

· The Clinical Director and Infection Control Nurse are responsible for the Hepatitis B program.

· The vaccination consists of a series of three inoculations over a six-month period. As part of the bloodborne pathogens training, employees receive information regarding Hepatitis vaccination including its safety and effectiveness.

of 20

document.doc

· The Hepatitis B Vaccination Program consists of:

Hepatitis B Information Hepatitis B vaccine Post exposure determination, evaluation and follow-up

including HIV test information.

· The training prior to vaccination includes information on:

Hepatitis B Vaccine Safety of vaccine, efficacy and methods of administration Benefits of being vaccinated Right to decline vaccination and have it still be provided

upon request at a later date.

2) The Hepatitis B Vaccine

· Hepatitis B Vaccine shall be made available to all employees who have occupational exposure after the employee has received the training required and within 10 working days of initial assignment.

· The Center shall not make participation in a pre-screening program a prerequisite for receiving hepatitis B Vaccination.

· The vaccination shall be available to the employee at an alternative date if the employee initially declines at a reasonable time and place convenient to the employee.

· Employee must sign a statement of declination if he/she chooses to decline the vaccination.

3) Hepatitis B Vaccine Campaign

· To ensure that all employees are aware of the vaccination program, it is thoroughly discussed in any bloodborne pathogens training.

· The Immunizations Hepatitis B and Management of Health Care Worker Policy and exposure to Blood or Body Fluids procedure may be found in the Policy and Procedure Manual.

of 20

document.doc

4) Post-Exposure Evaluation and Follow-up

· The employee should report all needle stick injuries and blood exposures to the Clinical Director within one hour.

· The employee will complete an "Occurrence Report.”

· The Surgery Center shall make available to the employee, through contracted services with Employee Health, an immediate confidential medical evaluation and follow-up which includes the following:

See Employee Health Policy

· Clinical Director shall report trends or patterns identified from the "Departmental Investigation of Exposure to Blood/Body/Fluids" to the Quality Improvement Committee quarterly.

· Information provided to the Clinical Director

Copy of this regulation as well as any of the employee's personal data is given to the health professional or person administering the hepatitis B vaccine.

· Employee Health Service Written Opinion

The Clinical Director shall provide the employee with a copy of the health professional’s evaluation within 15 days of the completion of the evaluation.

The evaluation contains indications for vaccination; and any medical condition resulting from the exposure. All other findings or diagnoses shall remain confidential and excluded from the evaluation.

Confirmation that the employee has been informed of the results of the evaluation.

of 20

document.doc

· Medical Record keeping The Clinical Director shall maintain an accurate medical

record of the employee with an occupational exposure. This is to be kept confidential and cannot be disclosed without written consent from the employee. The following information should be included:

- Name of the employee

- Social Security number of the employee

- A copy of the employee's Hepatitis B vaccination status.

(1) Date of any vaccinations(2) Medical records relative to the employee's

ability to receive vaccination.

- Copies of the results of the examinations medical testing and follow-up procedures which took place as a result of an employee's exposure to bloodborne pathogens. HIV test results will be maintained in a separate confidential file identified by code.

- A copy of the information provided to the consulting healthcare professional as a result of any exposure to bloodborne pathogens.

f. Labels and Signs (Bio-Hazard Communication)

The Clinical Director is responsible for setting up and maintaining a comprehensive biohazard-labeling program.

1) Labels shall include the following legend: BIOHAZARD

Labels shall be fluorescent orange or orange-red or predominantly so, with lettering or symbols in a contrasting color.

of 20

document.doc

2) Biohazard warning labels shall be affixed to containers of regulated waste, refrigerators and freezers containing blood or other potentially infectious materials.

3) Labels are required to be affixed as close as feasible to the container by string, wire, adhesive, or other method that prevents their loss or unintentional removal.

4) Red bags or red containers may be substituted for labels.

5) The following are exempt from the labeling requirements.

· Red bags or red containers may be substituted for labels.

· Containers of blood, blood components, or blood products that are labeled as to their contents and have been released to transfusion or other clinical use.

· Individual containers of blood or other potentially infectious materials that are placed in a labeled container using storage transport, shipment or disposal.

· Regulated waste that has been decontaminated.

g. Information and Training

1) Having well informed and educated employees is extremely important when attempting to eliminate or minimize employees exposure to bloodborne pathogens. Because of this, all employees who have the potential for exposure to bloodborne pathogens are put through a comprehensive training program and furnished with as much information as possible on this issue.

2) This training was set up so the employees would receive the required training prior to patient care responsibilities assignment. Employees will be retrained at least annually to keep their knowledge current. Additionally, all new employees, as well as employees changing jobs or job functions, will be given any additional training their new position requires at the time of their new job assignment by Clinical Director/ Designee.

of 20

document.doc

3) Clinical Director is responsible for facilitating and documenting that all employees who have potential exposure to the bloodborne pathogens receive training.

4) The Center shall provide training to the employee at no cost and during working hours.

5) The training program shall contain at minimum the following elements:

· An accessible copy of the regulatory text of this standard and an explanation of its contents:

· A general explanation of the epidemiology and symptoms of bloodborne disease;

· An explanation of the transmission of bloodborne pathogens;

· An explanation of the Center's exposure control plan and the means by which the employee can obtain a copy of the written plan;

· An explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials.

· An explanation of the use and limitations of methods that will prevent or reduce exposure including appropriate engineering controls, work practices and personal protective equipment;

· Information on the types, proper use, location, removal, handling, decontamination and disposal of personal protective equipment.

· An explanation of the basis for selection of personal protective equipment;

· Information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine and vaccination will be offered free of charge;

of 20

document.doc

· Information on the appropriate actions to take and persons to

contact in an emergency involving blood or other potentially infectious materials;

· An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available;

· An explanation of the signs and labels, and/or color coding

· An opportunity for interactive questions and answers.

6) Training

Training may include but is not limited to the following:

· Orientation of New Employees

An Exposure Control Program handbook will be provided to each employee during the orientation process.

An acknowledgement of training statement will be signed by the employee and Clinical Director and placed in the employee file.

· The Clinical Director is responsible for the training of any employee not attending these annual education programs.

7) Training Records· To facilitate the training of employees, as well as to document the

training process, the Clinical Director/Designee shall maintain training records containing the following information:

Date of training session

Summary of the training session

Name and qualifications of the person(s) conducting the training

of 20

document.doc

Names and job titles of the employees attending the training session.

The training record shall be maintained for 3 years from the dates of training.

9) Transfer of RecordsIf the employer ceases to do business and there is no successor employer to receive and retain the records for the prescribed period, the employer shall notify the Director of the National Institute for Occupational Safety and Health, at least three months prior to their disposal and transmit them to the Director to do so, within the three-month period.

of 20

division: - quia.com€¦ · web view... osha has enacted the bloodborne pathogens standard, ......

Documents