Environmental Health and Safety
Exposure Control Plan
Bowling Green State University has classified its employees into two main categories based on the potential for exposure to bloodborne pathogens. Activities associated with compliance to the Bloodborne Pathogen Standard will be based upon exposure potentials described under the following categories:
|Category 1 -||Employees who, through the course of their delegated work activities, are reasonably expected to come into contact with blood or other potentially infectious materials (OPIM)|
|Category 2 -||Employees who may periodically or infrequently come into contact with blood or OPIM during the performance of their delegated work activities.|
The following employee work classifications that were determined to meet the given criteria are listed below:
- Physicians, nurses, and other medical staff of the University's Student Health Service who provide medical treatment to University students
- First Aid Responders (BGSU University Police - main campus) who respond to emergency calls for assistance
- Athletic trainers with the Department of Athletics and specifically designated personnel with Recreational Sports who respond to injuries occurring during recreational or athletic events
- Custodial personnel (both main and Firelands campuses) who clean areas contaminated with blood and/or OPIM as a part of their delegated work activities
- Maintenance Repair Workers I (Firelands) who clean areas contaminated with blood or OPIM as a part of their delegated work activities
All other University departments/areas including:
- Dining Services personnel
- Resident Advisors, House and Hall Directors, and other staff of Student Housing and Residential Programs who would respond to injuries occurring within University residential buildings
- Personnel from the School of Art who aid injured students or staff
- Child Development Specialist with the Child Development Center (School of Family and Consumer Sciences) responsible for assisting injured children enrolled at the Center
- Maintenance staff who periodically come into contact with blood and/or OPIM as part of their job duties
- Office workers, graduate students, and any other University employee who respond as Good Samaritans to assist individuals who are injured
Each department/area identified in Category 1 is responsible for categorizing specific employees under their jurisdiction in conjunction with Standard Operating Procedures developed as indicated above.
All University employees considered at high risk for exposure (Category 1) shall be offered Hepatitis B vaccine on a pre-exposure basis. Such vaccinations shall be provided at no cost to the employee. Procedures for the administration of the vaccine shall be determined by the department/area of the employee(s) in question and be incorporated as a part of the department/area SOP.
Departments/areas not at high risk for exposure (Category 2) may provide pre-exposure vaccinations to their employee(s) if desired. Arrangements for the administration of the vaccine shall be the responsibility of the applicable department/area. The vaccinations, if mandated by the department/area shall be of no cost to the employee.
Should any Category 1 employee decline the pre-exposure vaccine, he/she will be offered a waiver of vaccination. This waiver shall be signed by the employee refusing the vaccine (See Appendix I). The waiver shall be kept in the employee's personnel file. One copy of the signed waiver will be given to the employee and another copy will be kept in file in the department of Environmental Health and Safety.
An employee who has declined vaccination may reconsider this decision and choose to be vaccinated. To initiate the vaccination process, the employee must make arrangements through his/her department in conjunction with department/area Standard Operating Procedures.
All records of pre-exposure vaccinations, waivers of vaccination, etc. shall be maintained by the department/area in conjunction with other records as specified in a later section.
Methods of Control
Universal precautions will be observed at Bowling Green State University in order to prevent contact with blood or other potentially infectious materials. All blood or other potentially infectious material will be considered infectious regardless of the perceived status of the source individual.
Engineering and work practice controls will be utilized to eliminate or minimize exposure to employees. Where occupational exposure remains after implementation of these controls, personal protective equipment shall also be utilized. Engineering controls such as the use of sharps containers and the proper handling of reusable sharps will be utilized.
The above controls will be examined and maintained on a schedule determined by each department/area. A schedule for reviewing the effectiveness of the controls will be made by an individual or individuals selected by the department/area.
Handwashing facilities are considered workplace controls and are available to the employees to insure exposure to blood or other potentially infectious materials is minimized. OSHA requires that these facilities be readily accessible after incurring exposure. Handwashing facilities are located within building restrooms, janitor's closets, and other specific locations identified by the department/area. Handwashing procedures shall be described in the department/area SOP.
After removal of personal protective gloves, employees shall wash hands and any other potentially contaminated skin area immediately or as soon as feasible with soap and water.
If employees incur exposure to their skin or mucous membranes then those areas shall be washed or flushed with water as appropriate or as soon as feasible following contact. Procedures for reporting exposure incidents will be provided in an upcoming section.
Contaminated needles and other contaminated sharps from University departments/areas will not be bent, recapped, removed, sheared or purposely broken. All contaminated needles/sharps will be placed in approved sharps containers provided by the department/area. Procedures for the disposal of sharps containers will follow BGSU's Infectious Waste Management Program.
Whenever possible, the use of needleless systems will be utilized in place of syringe/needle units. The use of needleless systems is preferred in all applicable situations and will be encouraged by pertinent University departments/areas to minimize inadvertent puncture injuries.
Containers for Reusable Sharps
Contaminated sharps that are reusable are to be placed immediately, or as soon as possible, after use into appropriate sharps containers. All sharps containers shall be puncture resistant, labeled with a biohazard label, and be leak proof. Sharps containers will be placed in locations identified by the department/area.
Work Area Restrictions
In work areas where there is a reasonable likelihood of exposure to blood or other potentially infectious materials, 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 other potentially infectious materials are present.
Mouth pipetting/suctioning of blood or other potentially infectious materials is prohibited.
All procedures will be conducted in a manner which will minimize splashing, spraying, splattering, and generation of droplets of blood or other potentially infectious materials. Methods which will be employed to accomplish this goal will be specified by appropriate departments/areas within their Standard Operating Procedures.
Departments/areas using specimens of blood or other potentially infectious materials will place them in containers which prevents leakage during the collection, handling, processing, storage, and transport of the specimens.
Any container used for this purpose will be labeled or color coded in accordance with the requirements of the OSHA standard.
Any specimens which could puncture a primary container will be placed within a secondary container which is puncture resistant.
If outside contamination of the primary container occurs, the primary container shall be placed within a secondary container which prevents leakage during the handling, processing, storage, transport, or shipping of the specimen.
Equipment which has become contaminated with blood or other potentially infectious materials shall be examined prior to servicing or shipping and shall be decontaminated as necessary unless the decontamination of the equipment is not feasible. Contaminated equipment that cannot be adequately decontaminated shall be disposed of in accordance with BGSU's Infectious Waste Management Program.
Personal Protective Equipment
All personal protective equipment used at Bowling Green State University will be provided without cost to employees. Personal protective equipment will be chosen based on the anticipated exposure to blood or other potentially infectious materials. The protective equipment will be considered appropriate only if it does not permit blood or other potentially infectious materials 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. Protective clothing will be provided to employees in conjunction with BGSU's Personal Protective Equipment Policy and Standard Operating Procedures developed by applicable departments/areas.
All personal protective equipment will be properly managed by the employer at no cost to employees. All repairs and replacement will be made by the employer at no cost to employees.
All garments that are penetrated by blood shall be removed immediately or as soon as feasible. All personal protective equipment will be removed prior to leaving the work area. All personal protective equipment removed will be placed in a room location designated by the applicable department/area.
Gloves shall be worn where it is reasonably anticipated that employees will have hand contact with blood or other potentially infectious materials, or if non-intact skin is present. Gloves will be available from the appropriate department/area in conjunction with their designated Standard Operating Procedures.
Disposable gloves 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.
Masks in combination with eye protection devices, such as goggles or glasses with solid side shield, or chin length face shields, are required to be worn whenever splashes, spray splatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can reasonably be anticipated.
Lab coats, gowns, aprons, clinic jackets, or similar outer garments will be worn if so designated by the applicable department/area.
Departments/areas will be cleaned and decontaminated according to a schedule specified by the applicable department/area.
Decontamination of surfaces will be accomplished by utilizing any of the following materials: a 1:10 mixture of bleach and water freshly prepared as needed; other EPA registered germicides.
All contaminated work surfaces will be decontaminated after completion of procedures and immediately or as soon as feasible after any spill of blood or other potentially infectious material, as well as the end of the work shift if the surface had become contaminated since the last cleaning.
All bins, pails, cans, and similar receptacles shall be inspected and decontaminated according to Standard Operating Procedures developed by the departments/area.
Any broken glassware should not be picked up directly by hand. Employees should use appropriate equipment (i.e. broom and dust pan) for removal. Broken glass shall be placed in acceptable containers to minimize the potential for injuring individuals responsible for waste disposal.
Regulated Waste Disposal
All contaminated sharps shall be discarded as soon as feasibly possible in sharps containers placed in locations designated by the department/area.
Regulated waste other than sharps shall be placed in appropriate containers provided in locations specified by the departments/area. All regulated waste will be handled according to BGSU's Infectious Waste Management Procedures.
Laundry contaminated with blood or other potentially infectious materials will be handled as little as possible. If at all possible, such laundry will be removed and maintained in the area where the contamination occurred. Appropriately marked bags will be used for storage of the laundry until removed for further handling. Contaminated laundry will not be sorted or rinsed in the area of use.
Management of contaminated personal clothing will be the responsibility of the department/area in conjunction with established SOPs or instruction from the Department of Environmental Health and Safety.
All employees who handle contaminated laundry will utilize personal protective equipment to prevent contact with blood or other potentially infectious materials.
Procedures Following an Exposure
Following an unprotected exposure, the individual exposed shall immediately inform his/her supervisor and complete a standardized University Injury Report Form (See Appendix II). The employee who is exposed needs to submit the completed forms to the University's Department of Environmental Health and Safety as soon as feasibly possible (preferably within 24 hours). In cases where a supervisor is not present (i.e. after normal working hours), the exposed employee shall report the incident to Public Safety.
The exposed individual will be contacted by the University which will provide follow-up information and explain the post-exposure procedures. The individual will be instructed to discuss post-exposure medical options with his/her physician or other medical personnel. Medical evaluations following a potential exposure incident must be performed by a physician within 24 hours of the incident. Prior to the physician evaluation, the University, if possible, will provide a standardized evaluation form to the exposed employee that is to be completed by the physician (See Appendix III). The individual exposed may elect to decline a post-exposure medical evaluation. If so, the individual shall complete a medical evaluation declination form (See Appendix IV).
Post-Exposure Evaluation and Follow-Up
All employees who experience an exposure incident will be offered post-exposure evaluation and follow-up in accordance with the OSHA standard.
The follow-up will include the following:
|-||Documentation of the route of exposure and the circumstances related to the incident.|
|-||If possible, the identification of the source individual and, if possible, the status of the source individual. The blood of the source individual will be tested (after consent is obtained by the physician performing the medical evaluation) for HIV/HBV infectivity.|
|-||Results of testing of the source individual will be made available to the exposed employee with the exposed employee informed about the applicable laws and regulations concerning disclosure of the identity and infectivity of the source individual.|
|-||The exposed employee will be offered the option of having his/her blood collected for testing of the 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.|
|-||The employee will be given appropriate counseling concerning precautions to take during the period after the exposure incident. The employee will also be given information on what potential symptoms might occur and will be instructed to report any related experiences to appropriate personnel.|
The University will offer the exposed employee a post-exposure vaccination, if necessary, at no cost to the employee. The employee has the right to refuse this vaccination. Should the employee decline the post-exposure vaccine, he/she will be offered a waiver of vaccination. This waiver shall be signed by the employee refusing the vaccine (See Appendix I). The waiver shall be kept in the employee's personnel file. One copy of the signed waiver will be given to the employee and another copy will be kept on file in the Department of Environmental Health and Safety.
Interaction with Health Care Professionals
A written opinion shall be provided to the exposed employee and Environmental Health and Safety by the health care professional who evaluated the employee following a post-exposure evaluation. Written opinions will be obtained in the following instances:
|1.||Whenever the employee is sent to a health care professional following a potential exposure incident|
|2.||When the employee is sent to obtain the Hepatitis B vaccine.|
The health care professional shall complete an evaluation form provided by the University following an assessment of the exposed employee. Copies of the signed form shall be provided to the employee and to the Department of Environmental Health and Safety.
Training for all employees will be conducted within ten days of initial assignment to tasks where occupational exposure may occur. BGSU employees will be trained at least annually in the following areas:
|1.||The OSHA standard for Bloodborne Pathogens|
|2.||The causes and symptoms of bloodborne diseases|
|3.||Modes of transmission of bloodborne pathogens|
|4.||BGSU's Exposure Control Plan (i.e. points of the plan, lines of responsibility, how the plan will be implemented, etc.)|
|5.||Procedures which might cause exposure to blood or other potentially infectious materials at this facility|
|6.||Control methods which will be used at the facility to control exposure to blood or other potentially infectious materials|
|7.||Personal protective equipment available and who should be contacted to obtain them|
|8.||Post exposure evaluation and follow-up|
|9.||Signs and labels used|
|10.||Hepatitis B vaccine program|
All outlines used in bloodborne pathogen training for employees will be maintained by the University's Safety and Health Coordinator in the Department of Environmental Health and Safety. Training materials utilized by individual departments/areas shall be kept according to the department/area SOP.
All records required by the OSHA standard as well as pertinent Standard Operating Procedures will be maintained by each applicable department/area. All records (with the exception of training records) shall be kept for each individual having occupational exposure for a period of 30 years following the employment of the employee. Training records shall be maintained for a period of three years from the date of the training. Each department/area maintaining records will submit a copy to the Department of Environmental Health and Safety.
A Sharps Injury Form Needlestick Report and Sharps Injury Log forms shall be available and utilized by relevant University departments for the recording of percutaneous injuries from contaminated sharps (see Appendix V and Appendix VI). The information in the sharps injury log shall be recorded and maintained in such manner as to protect the confidentiality of the injured employee. The sharps injury log shall contain, at a minimum--
(A) the type and brand of device involved in the incident,
(B) the department or work area where the exposure incident occurred, and
(C) an explanation of how the incident occurred.
Standard Operating Procedures
Each department/area identified in Category I (exposure determination) shall develop specific standard operating procedures for exposures to bloodborne pathogens. Other departments/areas having a potential for exposure to blood or other body fluids are encouraged to develop SOPs of their own to assist in minimizing problems should a potential exposure incident occur.
It is encouraged that the Standard Operating Procedures developed should follow the structure of the University's Exposure Control Plan. Specific department/area information should be incorporated under the headings outlined in the University's Plan. Nonapplicable topics should be designated as such under the appropriate headings (i.e. "Laundry Procedures").
Assistance for the development of department/area Standard Operating Procedures can be obtained from the Department of Environmental Health and Safety.
As stated above, all SOPs are to be kept in the appropriate department/area with a copy sent to the Department of Environmental Health and Safety.