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Security and Public Safety > Environmental Health and Safety Policies > Exposure Control Plan (ECP) for Bloodborne Pathogens

Purpose
This document serves as the written procedures Bloodborne Pathogens Exposure Control Plan (ECP) for Lake Forest College Campus. These guidelines provide policy and safe practices to prevent the spread of disease resulting from handling blood or other potentially infectious materials (OPIM) during the course of work.  

This ECP has been developed in accordance with the OSHA Bloodborne Pathogens Standard, 29 CFR 1910.1030. The purpose of this ECP includes: 

• Eliminating or minimizing occupational exposure of employees to blood or certain other body fluids. 
• Complying with OSHA's Bloodborne Pathogens Standard, 29 CFR 1910.1030.

Administrative Duties
The Department of Security & Public Safety is responsible for developing and maintaining the program. A copy of the plan may be reviewed by employees. It is located in the office of Security & Public Safety (2nd floor Commons), or the Personnel office (1st floor North Hall). In addition, the Personnel office is responsible for maintaining any records related to the Exposure Control Plan. This plan is current as of 01/01/2000.

If after reading this program, you find that improvements can be made, please contact the Department of Security & Public Safety. We encourage all suggestions because we are committed to the success of our written ECP. We strive for clear understanding, safe behavior, and involvement from every level of the College.

All incidents of exposure shall be reported to the Department of Security & Public Safety.

Definition of Exposure
For the purpose of this plan:
Exposure: is defined as any exposure where there is a presence of blood or OPIM without regard to the use of personal protective equipment (i.e., employees are considered to be exposed even if they wear personal protective equipment {PPE}).

Direct contact exposure: is defined as any exposure where there is direct contact of blood or OPIM with the skin or any body parts of the employee. (i.e., the employee was not wearing personal protective equipment and made contact with blood or OPIM, or the blood or OPIM made contact outside the area protected by personal protective equipment{PPE}).

Exposure Determination
We have determined which employees may incur occupational exposure to blood or OPIM. 
Job Classes: Global Risk of Exposure
This exposure determination is required to list all job classifications in which all employees may be expected to incur such occupational exposure, regardless of frequency. At this facility the following job classifications are in this category: 

• Security Officers
• Athletic Trainer 
• Health Center receptionist 
• Athletic Department Equipment Manager
• Others (as designated by the Vice President of Business) 

• Facilities Management (custodians) for clean up (as designated by the Director of Facilities Management)
• Professional Personnel in the Science Departments
• Sports Center (student workers) for laundry service of uniforms (as designated by the Equipment Manager)
• Others (as designated by the Vice President of Business) 

Compliance Strategies
This plan includes a schedule and method of implementation for the various requirements of the standard.  Universal precaution techniques developed by the Centers for Disease Control and Prevention (CDC) will be observed at this facility to prevent contact with blood or OPIM. All blood or OPIM will be considered infectious regardless of the perceived status of the source individual.

Engineering and Work Practice Controls
Engineering and work practice controls will be used to eliminate or minimize exposure to employees at this facility. Where occupational exposure remains after institution of these controls, employees are required to wear personal protective equipment. At this facility the following engineering controls are used: 

• Placing sharp items (e.g., needles, scalpels, etc.) in puncture-resistant, leakproof, labeled containers. 
• Performing procedures so that splashing, spraying, splattering, and producing drops of blood or OPIM is minimized. 
• Removing soiled PPE as soon as possible. 
• Cleaning and disinfecting all equipment and work surfaces potentially contaminated with blood or OPIM. Note: We use a solution of 1/4 cup chlorine bleach per gallon of water. 
• Thorough hand washing with soap and water immediately after providing care or provision of antiseptic towelettes or hand cleanser where handwashing facilities are not available. 
• Prohibition of eating, drinking, smoking, applying cosmetics, handling contact lenses, and so on in work areas where exposure to infectious materials may occur. 
• Use of leak-proof, labeled containers for contaminated disposable waste or laundry. 
• All soiled or potentially exposed clothing, PPE, dressings, or other materials are to be disposed of in approved, labeled Bio-Hazard trash bags or other suitably labeled containers.
• Employees may not wear soiled or exposed clothing to another assignment following the exposure.
• Employees may not launder such clothing at home. The College will provide laundering service through a licensed cleaner. 
• Soiled athletic uniforms will be laundered by the Head Athletic Trainer.

The above controls are examined and maintained on a regular schedule. 

Handwashing Facilities
Hand washing facilities are available to employees who have exposure to blood or OPIM. Sinks for washing hands after occupational exposure are near locations where exposure to bloodborne pathogens could occur.

At this facility hand washing facilities are located:  throughout each building. 

Supervisors make sure that employees wash their hands and any other contaminated skin after immediately removing personal protective gloves, or as soon as feasible with soap and water.

Supervisors also ensure that if employees' skin or mucous membranes become contaminated with blood or OPIM, then those areas are washed or flushed with water as soon as feasible following contact.

Work Area Restrictions
In work areas where there is a reasonable likelihood of exposure to blood or OPIM, employees are not to eat, drink, apply cosmetics or lip balm, smoke, or handle contact lenses. Food and beverages are not to be kept in refrigerators, freezers, shelves, cabinets, or on counter tops or bench tops where blood or OPIM are present. Mouth pipetting/suctioning of blood or OPIM is prohibited. All procedures will be conducted in a manner which will minimize splashing, spraying, splattering, and generation of droplets of blood or OPIM.

Personal Protective Equipment
All personal protective equipment (PPE) used at this facility is provided without cost to employees. PPE is chosen based on the anticipated exposure to blood or OPIM. The protective equipment is considered appropriate only if it does not permit blood or OPIM to pass through or reach the employees' clothing, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used.

Lake Forest College makes sure that appropriate PPE in the appropriate sizes is readily accessible at the work site or is issued without cost to employees by: 

• Each individual Department, as deemed necessary 
• Hypoallergenic gloves, glove liners, powderless gloves, or other similar alternatives are readily accessible to those employees who are allergic to the gloves normally provided.

• Each Department as needed 
• All repairs and replacements are made by Lake Forest College

Employees must remove all garments which are penetrated by blood immediately or as soon as possible.  They must remove all PPE before leaving the work area. When PPE is removed, employees place it in a designated container for disposal, storage, washing, or decontamination. 

Gloves
Employees must wear gloves when they anticipate hand contact with blood, OPIM, nonintact skin, and mucous membranes; when performing vascular access procedures, and when handling or touching contaminated items or surfaces. Disposable gloves used at this facility are not to be washed or decontaminated for re-use and are to be replaced as soon as practical when they become contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised.

Utility gloves may be decontaminated for re-use provided that the integrity of the glove is not compromised.  Utility gloves will be discarded if they are cracked, peeling, torn, punctured, or exhibit other signs of deterioration or when their ability to function as a barrier is compromised.  Hypoallergenic gloves, glove liners, powderless gloves, or other similar alternatives shall be readily accessible to those employees who are allergic to the gloves normally provided.  Routinely this facility does not follow Universal Precautions in the handling of all laundry, therefore, contaminated laundry must be placed in bags or containers which are labeled or color-coded. The Head Athletic Trainer will be responsible for the laundering of all soiled athletic uniforms, following the proper precautions.

Information and Training
Lake Forest College ensures that bloodborne pathogens trainers are knowledgeable in the required subject matter. We make sure that employees covered by the bloodborne pathogens standard are trained at the time of initial assignment to tasks where occupational exposure may occur, and every year thereafter by the following methods:   

• Annual training through the Department of Security & Public Safety 

• The standard and its contents. 
• The epidemiology and symptoms of bloodborne diseases. 
• The modes of transmission of bloodborne pathogens. 
• Lake Forest College Bloodborne Pathogen ECP, and a method for obtaining a copy. 
• The recognition of tasks that may involve exposure. 
• The use and limitations of methods to reduce exposure, for example engineering controls, work practices and personal protective equipment (PPE). 
• The types, use, location, removal, handling, decontamination, and disposal of PPEs. 
• The basis of selection of PPEs. 
• The Hepatitis B vaccination (HBV), including efficacy, safety, method of administration, benefits, and that it will be offered free of charge. 
• The appropriate actions to take and persons to contact in an emergency involving blood or OPIM. 
• The procedures to follow if an exposure incident occurs, including the method of reporting and medical follow-up. 
• The evaluation and follow-up required after an employee exposure incident. 
• The signs, labels, and color coding systems. 

Additional training is provided to employees when there are any changes of tasks or procedures affecting the employee's occupational exposure. Employees who have received training on bloodborne pathogens in the 12 months preceding the effective date of this plan will only receive training in provisions of the plan that were not covered.

Recordkeeping
Training records shall be maintained for three years from the date of training. The following information shall be documented:  

• The dates of the training sessions; 
• An outline describing the material presented; 
• The names and qualifications of persons conducting the training; 
• The names and job titles of all persons attending the training sessions. 

• The name and social security number of the employee. 
• A copy of the employee's HBV vaccination status, including the dates of vaccination. 
• A copy of all results of examinations, medical testing, and follow-up procedures. 
• A copy of the information provided to the healthcare professional, including a description of the employee's duties as they relate to the exposure incident, and documentation of the routes of exposure and circumstances of the exposure. 

All current year medical records will be kept in the Business Office vault and all prior years will be kept in the College’s archives. 

Availability
All employee records shall be made available to the employee in accordance with 29 CFR 1910.20. All employee records shall be made available to the Assistant Secretary of Labor for the Occupational Safety and Health Administration and the Director of the National Institute for Occupational Safety and Health upon request.

Evaluation and Review
This program and its effectiveness is reviewed every year and updated as needed. All provisions required by this standard will be implemented by 1/1/2000.

Hepatitis B Vaccination Program
Lake Forest College offers the Hepatitis B vaccine and vaccination series to all employees who have occupational exposure to bloodborne pathogens, and post exposure follow-up to employees who have had a direct contact exposure incident. Any employee who has been exposed is eligible for the Hepatitis B Vaccination Program.

All medical evaluations and procedures including the Hepatitis B vaccine and vaccination series and post exposure follow up, including prophylaxis are:  

• Made available at no cost to the employee. 
• Made available to the employee at a reasonable time and place. 
• Performed by or under the supervision of a licensed physician or by or under the supervision of another licensed healthcare professional. 
• Provided according to the recommendations of the U.S. Public Health Service. 

• After employees have been trained in occupational exposure (see Information and Training). 
• Within 10 working days of initial assignment. 
• To all employees who have occupational exposure unless a given employee has previously received the complete Hepatitis B vaccination series, antibody testing has revealed that the employee is immune, or the vaccine is contraindicated for medical reasons. 
• Can be received at the College’s Health Center with prior notification

Participation in a pre-screening program is not a prerequisite for receiving Hepatitis B vaccination. If the employee initially declines Hepatitis B vaccination but at a later date while still covered under the standard decides to accept the vaccination, the vaccination will be made available. All employees who decline the Hepatitis B vaccination offered must sign the OSHA-required waiver indicating their refusal. If a routine booster dose of Hepatitis B vaccine is recommended by the U.S. Public Health Service at a future date, such booster doses will be made available under the same criteria as the initial series. 

Post-Exposure Evaluation and Follow-Up
All exposure incidents are reported, investigated, and documented. When the employee is exposed to blood or OPIM, the incident is reported to the Director of Security & Public Safety immediately if possible, or at most within 24 hours. When an employee has a direct contact exposure, he or she will receive a confidential medical evaluation and follow-up, including at least the following elements:  

• Documentation of the route of exposure, and the circumstances under which the exposure occurred. 
• Identification and documentation of the source individual, unless it can be established that identification is infeasible or prohibited by state or local law.
• The source individual's blood shall be tested as soon as feasible and after consent is obtained in order to determine HBV and HIV infectivity. If consent is not obtained, the Director of Security & Public Safety establishes that legally required consent cannot be obtained. When the source individual's consent is not required by law, the source individual's blood, if available, will be tested and the results documented. 
• When the source individual is already known to be infected with HBV or HIV, testing for the source individual's known HBV or HIV status need not be repeated. 
• Results of the source individual's testing are made available to the exposed employee, and the employee is informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual. 

• The exposed employee's blood is collected as soon as possible and tested after consent is obtained; 
• The employee will be offered the option of having their blood collected for testing of the employee's HIV/HBV serological status. The blood sample will be preserved for up to 90 days to allow the employee to decide if the blood should be tested for HIV serological status. 

• A copy of 29 CFR 1910.1030. 
• A written description of the exposed employee's duties as they relate to the exposure incident. 
• Written documentation of the route of exposure and circumstances under which exposure occurred. 
• Results of the source individuals blood testing, if available. 
• All medical records relevant to the appropriate treatment of the employee including vaccination status. 

• A statement that the employee has been informed of the results of the evaluation. 
• A statement that the employee has been told about any medical conditions resulting from exposure to blood or OPIM which require further evaluation or treatment. 

Note: All other findings or diagnosis shall remain confidential and will not be included in the written report.

Biohazard labels are affixed to containers of regulated waste, refrigerators and freezers containing blood or OPIM, and other containers used to store, transport or ship blood or OPIM. The universal biohazard symbol is used. The label is fluorescent orange or orange-red. Red bags or other approved containers may be substituted for labels. Only licensed blood donor organizations shall be used for any blood drives on campus. It is expected that these outside agencies will follow all appropriate procedures.