36C24719Q0050-003.pdf

CHARLIE NORWOOD VETERANS AFFAIRS MEDICAL CENTER POLICY

MEDICAL CENTER MEMORANDUM NO. 235-12-01

AUGUSTA, GEORGIA FEBRUARY 24, 2012

BLOODBORNE PATHOGEN EXPOSURE CONTROL PLAN

1. PURPOSE: To identify employees at risk for occupational exposure to bloodborne pathogens and to establish standards of practice designed to reduce exposures.

2. POLICY:

A. The Medical Center Bloodborne Pathogen (BBP) Exposure Control Plan complies with the requirements of the Occupational Safety & Health Administration (OSHA) Final Bloodborne Pathogen Standard.

B. A copy of the OSHA Final Bloodborne Pathogen Standard is available to any employee upon request.

C. Standard Precautions are a component of the Medical Center BBP Exposure Control Plan. Other policies and guidelines that support this plan are referenced herein. All relevant documents are in the Infection Control Manual.

3. DELEGATION OF AUTHORITY AND RESPONSIBILITY:

A. The Infection Control Department is responsible for development and annual review of the Exposure Control Plan through the Infection Control Committee.

B. Each Service Line/Department is responsible for developing methods for monitoring compliance to this policy. Provision will be made for identifying failure to follow recommended precautions and for providing counseling, education, training or disciplinary action.

C. Each healthcare worker is responsible for being familiar with the Bloodborne Pathogen Exposure Control Plan and for following standard precautions whenever there is a potential for occupational exposure to blood and other body substances.

D. Employee Health Department, Primary Care Service Line is responsible for providing Hepatitis B vaccine, post-exposure medical follow-up of employee and related record keeping.

E. Safety Department, Facility Management Service Line is responsible for tracking, maintaining the automated Safety Incident Surveillance Tracking System (ASIST), follow-up on injury and illness reports as appropriate and monitoring and evaluating incident rates and trends.

4. ACTION/PROCEDURES:

A. Definition:

1) Standard Precautions: A standard of practice that incorporates the major features of Universal Precautions and applies whenever an employee may contact or handle 1) blood, 2) body fluids, secretions and excretions (except sweat), regardless of whether they contain visible blood, 3) non-intact skin, and 4) mucous membranes.

2) Engineering Controls: Controls that isolate or remove the bloodborne pathogen hazard from the workplace, i.e., sharps disposal containers and safer medical devices, such as sharps with engineered sharps injury protections and need leless systems.

3) Personal Protective Equipment (PPE): Specialized clothing or equipment worn or used by an employee for protection against an infectious hazard, i.e, gloves, gowns, masks and protective eyewear.

4) Work Practice Controls: Controls that reduce the likelihood of exposure to infectious agents by changing the manner in which a task is performed, i.e., prohibiting recapping of needles by a two-handed technique.

B. Exposure Determination:

1) Body Substances: The focus of this Exposure Control Plan is to reduce the risk of occupational exposure to the following body substances which may contain blood borne pathogens such as Human Immunodeficiency Virus (HIV) and Hepatitis B and C Viruses:

a. Blood, b lood products;

b. Body fluids (i.e., amniotic, cerebrospinal, pericardial, peritoneal, pleural, synovial) or any body fluid which cannot be identified;

c. Any body f luid with visible blood;

d. Semen and vaginal secret ions;

e. S a l i v a ;

f . Any unfixed tissue or organ from a human (living or dead).

2) Risk Determination List: Employees in the following jobs are reasonably anticipated to be at-risk of occupational exposure to blood borne pathogens during the performance of their routine duties or during performance of specified tasks/procedures.

a. Nurse (RN, LPN, NA);

b . Physician, Physician’s Assistant;

c. Anesthesia provider, CRNA, Technician;

d . Pathology/clinical Laboratory Technician/Technologist;

e . Respiratory Therapist ;

f . P h l e b o t o m i s t ;

g. Dent ist , Dental Technician;

h . Surgery Technic ian ;

i . Cardiac Catherization, EEG, Endoscopy, EKG, Radiology, Nuclear Medicine, Treadmill and other Diagnostic Technician/Technologist when in contact with patients, specimens or used instruments/equipment;

j . Sterile Processing Department or other employee when handling, servicing, cleaning or disposing of contaminated equipment, instruments, supplies and other items;

k . Housekeeper or others when participating in environmental sanitation (usually in patient care, laboratory or medical waste management areas);

l . Laundry worker, Patient Effects Clerk, or others when handling soiled linen;

m. Clerks or others when labeling, bagging and handling laboratory specimens;

n . Physical, Occupational, Speech, Audiology, Blind Rehabilitation Therapist/Specialist when testing/training patients and handling used instruments/equipment;

o . Research Laboratory Scientist/Technicians when handling human specimen/tissue;

p . Facility Engineering employee when servicing patient care equipment (eg., Biomedical Engineer/Technician) or when in contact with body substances (eg., Pipefitter, Energy Plant, Mechanical Systems);

q. Security employee when collecting contaminated evidence, or managing disruptive or uncooperative individuals;

r . Medical Media employee when handling human tissue/organ s . Clinical Pharmacists, Dieticians when collecting or handling blood specimens

3) Each Service Line/Department will notify at-risk employees of their occupational exposure risk and the availability of, and need for, Hepatitis B vaccination. This notification is to be documented (see Appendix A).

4) Each Service Line/Department is to conduct an annual review of all working conditions and tasks performed by their employees. Any changes in the Risk Determination List are to be reported to and evaluated by Infection Control.

C. Engineering Controls:

1) Engineering controls are to be used whenever possible to remove a blood borne hazard from the workplace. These controls include both safe medical devices and non-medical devices.

2) Safe medical devices. Use of safer medical devices will be implemented whenever the device is appropriate, effective and commercially available.

a. Appropriate medical device. Definition: devices whose use, based on reasonable judgment in individual cases, will not jeopardize patient or employee safety or be medically contraindicated.

b. Effective medical device. Definition: a device that, based on reasonable judgment, will make an exposure incident involving a contaminated sharp less likely to occur in the application in which it is used.

3) Safer medical devices include but are not limited to:

a. Sharps with engineered sharps injury protection. Definition:

a 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. Examples: syringes with a sliding sheath that shields 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; and intravenous medication delivery systems that administer medication or fluids through a catheter port or connector site using a needle that is housed in a protective covering.

b. Needleless systems. Definition: a device that does not use needles for: a) the collection of bodily fluids or withdrawal of body fluids after initial venous or arterial access is established; b) the administration of medication or fluids; or

c) any other procedure involving the potential for occupational exposure to bloodborne pathogens due to percutaneous injuries from contaminated sharps. Examples:

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

c. Other medical devices such as blunt suture needles and plastic or mylar-wrapped glass capillary tubes.

4) Non-medical devices include, but are not limited to: sharps disposal containers, biosafety cabinets, plexiglass shields and autoclaves.

5) Sharps use and disposal practices are outlined in MCPM #509-04- 23 5/04.

D. Work Practice Controls:

1) Standard Operating Procedures (SOPs) are to identify the minimum personal protective equipment, engineering or work practice controls (or combinations) which will reduce risk of exposure.

2) Appropriate Personal Protective Equipment (gloves, gowns, masks, eye protection and resuscitation bags/ventilation devices) will be available for use in areas where the need is reasonably predictable. Employees are required to use PPE and properly dispose of PPE before leaving the area where contact with blood or body substances occurred.

3) Only fluid repellent gowns/aprons will be worn during procedures likely to generate splashes of blood or body substances. Uniforms or lab coats will not be worn as protective gowns.

4) Any clothing (personal, scrubs, gowns, etc.) splashed with blood or body substances will be removed immediately. The clothing is to be laundered by this medical center laundry.

5) Environmental barriers against contact with blood and other potentially infectious material (e.g., protective coverings like plastic wrap, tongs, forceps, broom and dustpan) are to be available within user departments. Employees are required to use such barriers when indicated by the potential for contact with blood and other body substances.

6) Procedures are to be performed in a manner which minimizes splashing, spraying, splattering and generation of droplets of blood or other body substances.

7) Handwashing is performed immediately before applying gloves and as soon as feasible after removal of gloves or other personal protective equipment.

8) Hands and other skin are to be washed with soap and water, or mucous membranes flushed with water, immediately or as soon as feasible after contact with blood or other potentially infectious body substances.

9) Eating, drinking, applying cosmetics or lip balm, handling contact lenses is prohibited in work areas where there is reasonable likelihood of occupational exposure (e.g., patient care, laboratory, any area designated for soiled linen and equipment, or waste).

10) Mouth pipetting of any type of body substance is prohibited.

11) Food and drink are not to be stored in refrigerators, freezers, shelves, cabinets or on countertops or benchtops where blood or other potentially infectious material is likely to be present.

12) An employee with badly compromised skin is not permitted to work in direct contact with patients, the blood or body fluids of patients or with sterile instrument or supply preparation or handling. The employee must report to Employee Health.

Definition: an infected or draining lesion, extensive dermatitis or damage that potentially exposes dermal or subcutaneous layer tissues to the environment.

E. Labeling Requirements:

1) The color red or orange, the word "BIOHAZARD" or the universal biohazard symbol identifies potentially infectious materials.

2) Labeling and management of linens, laboratory specimens, contaminated equipment/articles is outlined in the Standard Precautions policy.

F. Environmental:

1) All equipment and environmental and working surfaces will be cleaned and disinfected after contact with blood and other potentially infectious body substances.

2) Contaminated work surfaces will be disinfected using the hospital approved disinfecting solution after completion of procedures, immediately or as soon as feasible when surfaces are overly contaminated or after any spills of blood or other potentially infectious body substance, and at the end of the work shift if the surface may have become contaminated since the last cleaning.

3) Spills of blood or other potentially infectious body substances are to be cleaned and disinfected using the Medical Center approved disinfectant.

a. Gloves are to be worn during the clean-up procedure.

b. Environmental Department will clean-up/disinfect areas of major spills.

4) Environmental Management will perform routine cleaning/ disinfection of surfaces and the environment according to their written standard operating procedures.

G . W aste Management :

Bagging, removal, transport and disposal of regulated medical waste will be in accordance with applicable federal, state and local regulations and MCPM #509-02-137/09, Waste Management Program.

H . Educat ion/Tra in ing:

1) Initial and annual education/training of all at-risk employees is required and will be documented. (Ref: Infection Control Orientation and Continuing Education of all Personnel, MCPM# 509-04-235/09).

2) New employees are to receive general training related to Standard Precautions, risk of bloodborne disease and associated procedures during hospital-wide orientation.

3) Service Line/Departments are to provide new at-risk employees specific training on Standard Precautions in their respective work area before independent assignment to tasks where occupational exposure may occur.

4) At risk employees are to participate in a hospital-wide educational activity related to Standard Precautions each year.

5) At risk employees are to receive additional "risk -oriented" education as defined by their Service Line/Department. Risk-oriented education is determined by additions or changes in tasks and procedures which may affect an employee's potential for exposure and by review of observations, data or recommendations from Supervisory, Employee Health, Workers' Compensation, Safety-Industrial Hygiene or Infection Control staffs.

I. Hepatitis B Virus (HBV) Vaccine:

1) HBV vaccine is available to all employees without charge, via Employee Health.

a. To at risk employees, within 10 days of assignment.

Employees are strongly advised to receive the vaccine.

Written consent/declination is required (see Appendix B).

b. To other employees, during hospital orientation and upon request. Written consent is required.

c. To any employee who has a potentially significant occupational exposure to blood or other potentially infectious material, at the time of exposure; percutaneous (e.g., needlestick or sharps injury, human bite); or mucosal (e.g., splattering into eyes, nose, mouth, or onto skin lesions).

2) An employee who declines vaccine but then changes his/her mind may report to the Employee Health Office for vaccination during its regular hours.

J. Exposure Incidents:

1) An incident/injury report is required after any employee sustains a percutaneous or mucosal exposure to blood or other potentially infectious material. Chapter 1.2, Environment of Care Manual outlines processes and responsibilities for filing reports and follow-up related to the injury.

2) Medical evaluation and post-exposure follow up. After a potentially significant percutaneous or mucosal occupational exposure, Employee Health Department will provide free medical evaluation, follow-up and prophylaxis. During the hours of 0730-1600, report to Employee Health if you are exposed. After hours, report to the Emergency Department Downtown. (Ref: Management of Infections in Healthcare Personnel

MCPM #509-06-235/1 3).

3) Records related to an incident/injury will be maintained for duration of employment plus 30 years.

K. Review and Evaluation:

1) There will be a subcommittee appointed and approved by the Infection Control Committee to identify, evaluate and select appropriate and effective engineering and work practice controls.

a. The subcommittee will be comprised of managerial and non-managerial employees who are involved in direct patient care and are at risk of occupational exposure to blood borne pathogens.

b. This subcommittee will document findings and present to the Infection Control Committee.

2) An annual review of the Exposure Control Plan will be conducted by the Infection Control Committee. The review will:

a. Reflect changes in technology that eliminate or reduce exposure to blood borne pathogens.

b. Document annual consideration and implementation of appropriate and effective safer medical devices designed to eliminate or minimize occupational exposure.

5. REFERENCES.

A. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis. MMWR, Centers for Disease Control, Vol 54, September 30, 2005.

B. Postexposure Prophylaxis for HIV Infection, N. Engl. J. Med. 361:18, October 29, 2009

C. www.cdc.gov/OralHealth/infectioncontrol/faq/bloodborne exposures. htm Accessed on 11/21/2011

D. www.cdc.gov/hicpac/Isolation2007.pdf http://www.cdc.gov/OralHealth/infectioncontrol/faq/bloodborne http://www.cdc.gov/hicpac/Isolation2007.pdf

6. RESCISSION. Medical Center Policy Memorandum 509-01-235/01 dated 9/1/06.

/s/ Carolyn L. Adams Acting Director

Attachments: 2

MEDICAL CENTER MEMORANDUM NO. 235-12-01

AUGUSTA, GEORGIA FEBRUARY 24, 2012

ATTACHMENT A

ACKNOWLEDGEMENT OF RISK DETERMINATION

EMPLOYEE: ___________________________________ TITLE: ________________

SERVICE LINE/DEPARTMENT ____________________ ROUTING ____________

I have reviewed the tasks required to perform my job.

I understand that during the performance of my duties that I am potentially at-risk for occupational exposure to bloodborne pathogens.

I have been advised that Hepatitis B vaccine is available to me free of charge through Employee Health.

EMPLOYEE SIGNATURE: _______________________________ DATE:

SUPERVISOR SIGNATURE: _____________________________ DATE:

SERVICE LINE EXECUTIVE:________________________________ DATE:

(Maintain in Employee's Personnel file within the Service)

MEDICAL CENTER MEMORANDUM NO. 235-12-01

AUGUSTA, GEORGIA FEBRUARY 24, 2012

ATTACHMENT B

HEPATITIS B VACCINE DECLINATION (Mandatory)

I understand that due to my occupational exposure to blood, or other potentially infectious materials, I may be at risk of acquiring HBV (Hepatitis B Virus) infection. I have been given the opportunity to be vaccinated with Hepatitis B Vaccine, at no charge to myself. However, if I decline Hepatitis B vaccination at this time I understand that 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 Hepatitis B Vaccine, I can receive the vaccination series at no charge to me.

Signature of Employee Date

(name of employee) has been offered the

Hepatitis B Vaccine on ________________ (date) and has declined vaccination at this time.

The employee also chooses not to sign the Hepatitis B Vaccine Declination Form.

Signature and Title Date

(Maintain in Employee's Employee Health Record)

Reference: Federal Register, Vol 56, No. 235, page 64182, Friday, December 6, 1991.

VA Form 1 0-5549d April 1993