S02 - Attch - D.9. Blood Borne Pathogen Exposure Control Plan.pdf

Department of Veterans Affairs Policy IP-008 Nebraska-Western Iowa Health Care System December 5, 2018

BLOOD BORNE PATHOGEN EXPOSURE CONTROL PLAN

1. PURPOSE: One of the major goals of the Occupational Safety and Health Administration (OSHA) is to regulate facilities where work is carried out and to promote safe work practices in an effort to minimize the incidence of illness and employee injury experience. Relative to this goal, OSHA has enacted the Blood borne Pathogens (BBP) Standard to "reduce occupational exposure to Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), Human Immunodeficiency Virus (HIV) and other Blood borne Pathogens" that employees may encounter in their workplace.

2. POLICY:

a. This Exposure Control Plan has been implemented to comply with the OSHA Occupational Exposure to BBP Standard, Needle-sticks and Other Sharp Injuries, 29 CFR 1910.1030. The objective of this plan includes:

1) To protect employees from occupational exposure to BBP by eliminating or minimizing, to the extent possible, occupational exposure;

2) To provide appropriate post-exposure evaluation and follow-up if an employee is exposed to BBP;

b. To provide a method for evaluation of exposure incidents that allows appropriate corrective action to be taken;

c. To provide a method for on-going evaluation and implementation of safe medical devices designed to reduce needle-stick injuries.

3. RESPONSIBILITIES:

a. The INFECTION PREVENTION COMMITTEE (IP) is responsible for overall oversight and support of the Blood Borne Pathogens Exposure Control Plan, to include studying and evaluating each reported exposure incident, and making recommendations to prevent recurrence.

b. SERVICE CHIEFS AND SUPERVISORS are responsible for the proper implementation of the Exposure Control Plan in their respective services and areas. Specific responsibilities include:

1) Evaluating tasks and exposure risks;

2) Evaluating whether employees need Hepatitis B vaccination;

3) Providing exposure control training;

4) Verifying that employees have received BBP training at the time of initial assignment to tasks where occupational exposure may take place;

5) Provision and use of engineering controls and personal protective equipment (PPE);

6) Assuring employee compliance with exposure control practices prescribed in this plan;

7) Evaluating new safety devices and informing the IPC and Safety Committees when new devices are trialed.

8) Responsible for completing employee incident report (CA-1) and assuring that all required information is included.

c. EMPLOYEES are responsible for:

1) Being knowledgeable of job tasks in which exposure to BBP may occur;

2) Participating in exposure control/blood borne pathogen training programs;

3) Following the exposure control precautions as presented in the training programs, this Exposure Control Plan and the NWIHCS policies;

4) Using the proper personal protective equipment, safety devices and engineering controls;

5) Developing good personal hygiene habits;

6) Immediately reporting all exposure incidents to ensure that chemoprophylaxis may be started within one-two hours of exposure (if appropriate);

7) Getting the HBV vaccination series or signing declination form;

8) Evaluating and recommending new safety devices.

d. OCCUPATIONAL HEALTH PERSONNEL will assure that the procedures outlined in the Exposure Control Plan for Hepatitis B vaccination, post-exposure follow-up, and employee medical record-keeping, are effectively carried out.

e. INFECTION PREVENTION AND SAFETY PERSONNEL will help and coordinate with Employee Education to conduct training regarding the Exposure Control Plan. Employee Education will keep training records at least three years.

4. PROCEDURES:

a. AVAILABILITY OF THE EXPOSURE CONTROL PLAN TO EMPLOYEES: The NWIHCS Exposure Control Plan (Policy IC-008) is available to employees at any time on the intranet web site. Employees are advised of this availability during education/training programs. Hard copies of the Exposure Control Plan are maintained with the Safety Department and Infection Prevention.

b. EXPOSURE DETERMINATION:

1) Job codes and job titles have been identified as those employees/volunteers who are at risk for exposure to blood and body fluids. The list was derived by reviewing job titles and job descriptions and by consulting with Supervisors about specific job duties. The particular type(s) of duties that puts each job code at risk for exposure is also identified (See Appendix A Job Classifications having potential Occupational Exposure).

2) All employees having potential exposure will receive BBP training and be offered the Hepatitis B vaccinations within ten working days of initial assignment. See specific job descriptions for tasks and procedures in which potential exposures could occur.

c. METHODS OF COMPLIANCE: There are a number of areas that must be addressed in order to effectively eliminate or minimize exposure to BBP in VA Nebraska-Western Iowa Health Care System (NWIHCS).

1) Use of Standard Precautions.

2) Engineering controls and implementation of new technology as it becomes available.

3) Implementing appropriate Work Practice Controls.

4) Using necessary Personal Protective Equipment.

5) Implementing appropriate Housekeeping Procedures.

6) Reporting and follow-up of exposure incidents.

Each of these areas is reviewed with employees during BBP-related training. By rigorously following the requirements of OSHA's BBP Standard in these six areas, the employees' occupational exposure to BBP will be eliminated or minimized.

a) STANDARD PRECAUTIONS: A policy of using Standard Precautions is practiced at NWIHCS. All body fluids are treated as possibly infectious andappropriate barriers (PPE) are used to prevent exposure. In addition, all human blood and the following body fluids are treated as if they are known to be infectious for HBV, HIV, HCV, and other blood borne pathogens:

(1) Semen

(2) Vaginal secretions

(3) Cerebrospinal fluid

(4) Synovial fluid

(5) Pleural fluid

(6) Pericardial fluid

(7) Peritoneal fluid

(8) Amniotic fluid

(9) Saliva only when visibly bloody

(10) Any body fluids containing visible blood

(11) All body fluid in situations where it is difficult or impossible to differentiate between body fluids.

b) ENGINEERING CONTROLS:

(1) One of the key aspects to the Exposure Control Plan is the use of engineering controls to eliminate or minimize employee exposure to BBP. The term "engineering controls" includes all control measures that isolate or remove a hazard from the workplace, encompassing not only sharps with engineered sharps injury protections and needle-less systems, but also other medical devices designed to reduce the risk of percutaneous exposure to BBP.

(2) The IPC and Safety Committees continually solicit input from managerial and non-managerial employees responsible for direct patient care who are potentially exposed to injuries from contaminated sharps in the identification, evaluation and election of effective engineering and work practice controls.

(3) The following engineering controls are available:

(a) Hand hygiene/disinfection facilities that are readily accessible to all employees who have the potential for exposure.

(b) Eye Wash Stations in high risk areas such as Laboratory and Pharmacy.

(c) Ventilating Laboratory hoods

(d) Safety Syringes, IV Catheters, Safety Lancets, Safety Scalpels, and blood collection devices.

(e) Needleless IV Administration Set

(f) Solidifier for body fluid spills

(g) Containers for contaminated sharps, specimens, and secondary containers having the following characteristics:

1. Puncture-resistant if necessary;

2. Color-coded or labeled with a biohazard warning label;

3. Leak-proof

c) WORK PRACTICE CONTROLS: In addition to engineering controls, NWIHCS uses a number of work practice controls to help eliminate or minimize employee exposure to blood borne pathogens. The following work practice controls have been adopted as part of the Blood borne Pathogens Exposure Control Plan:

(1) Employees wash their hands immediately after removal of gloves or other personal protective equipment.

(2) Following any contact of body areas with blood or any other infectious materials, employees wash their hands and any other exposed skin with antibacterial soap and water. They also flush exposed mucous membranes with water.

(3) Contaminated reusable and non-reusable sharps are not bent, recapped or removed unless:

- It can be demonstrated that there is no feasible alternative;

- The action is required by specific medical procedure;

- In the two situations above the recapping or needle removal is accomplished through the use of a medical device or a one-handed technique.

(4) Contaminated reusable and non-reusable sharps are placed in appropriate containers as soon as possible after use.

(5) Eating, drinking, smoking, applying cosmetics or lip balm and handling contact lenses is prohibited in patient care and clinical areas where there is reasonably likelihood for exposure to blood borne pathogens.

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

(7) Mouth pipetting/suctioning of blood or other infectious materials are prohibited.

(8) All procedures involving blood or other infectious materials minimize splashing, spraying, or other actions generating droplets of these materials.

(9) Specimens of blood or other materials are placed in designated leak-proof containers and appropriately labeled for handling and storage.

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

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

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

(b) 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.

d) PERSONAL PROTECTIVE EQUIPMENT:

(1) Personal protective equipment is the employees' "last line of defense" against blood borne pathogens. Because of this, NWIHCS provides (at no cost to employees) the personal protective equipment that they need to protect themselves against such exposure. This equipment includes, but is not limited to:

(a) Gloves

(b) Gowns

(c) Laboratory coats

(d) Face shields/masks

(e) Safety glasses

(f) Goggles

(g) Pocket masks

(h) Hoods (Laboratory)

(i) Shoe covers

(j) Caps

(2) All listed equipment is available in clean supply closets. If supplies are depleted during non-administrative hours, the charge nurse can ask VA Police to provide access to SPS.

(3) Hypoallergenic gloves, glove-liners, and similar alternatives are readily available to employees who are allergic to the gloves the facility normally uses.

(4) The Infection Prevention Committee and Safety Committee, working with Service Chiefs and Supervisors, are responsible for ensuring that all departments and work areas have appropriate personal protective equipment available to employees.

(5) Employees are trained regarding the use of the appropriate personal protective equipment for their job classifications and tasks/procedures they perform and are included in the selection/evaluation of personal protective equipment items.

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

(a) The user is responsible for visual inspection of personal protective equipment prior to use;

(b) All reusable personal protective equipment is inspected by the individual it is assigned to. If an item is not working properly, it will be replaced;

(c) Reusable personal protective equipment is cleaned, laundered and decontaminated as needed;

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

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

(a) Any garments penetrated by blood or other infectious materials are removed immediately, or as soon as possible;

(b) All personal protective equipment is removed prior to leaving a work area;

(c) Gloves are worn:

(d) Whenever employees anticipate hand contact with potentially infectious materials;

(e) When handling or touching contaminated items or surfaces;

(f) 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";

(g) Utility gloves are decontaminated for reuse unless they are cracked, peeling, torn or exhibit other signs of deterioration, at which times they are discarded;

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

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

(j) Surgical caps/hoods and/or shoe covers/boots are used in any instances where "gross contamination" is expected;

(k) All protective clothing will be removed as soon as possible after becoming soiled. Reusable items will be laundered by NWIHCS.

(l) Employee uniforms which become soiled with blood or body fluids will be removed as soon as possible and sent to the laundry for processing.

e) HOUSEKEEPING:

(1) Maintaining the Nebraska-Western Iowa Health Care

System in a clean and sanitary condition is an important part of the Blood borne Pathogens Exposure Control Plan. To facilitate this, a written schedule for cleaning and decontamination has been developed (see EMS Operating Manual for details). Using this schedule, the Housekeeping staff employs the following practices:

(a) All equipment and surfaces are cleaned and decontaminated with chemicals that are EPA registered and approved against HIV and HBV;

(b) After the completion of medical procedures;

(c) Immediately (or as soon as feasible) when surfaces are grossly contaminated;

(d) After any spill of blood or infectious materials;

(e) At the end of the work shift if the surface may have been contaminated during that shift;

(f) During daily scheduled cleaning;

(g) All pails, bins, cans, and other receptacles intended for use routinely are inspected, cleaned, and decontaminated as soon as possible if visibly contaminated;

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

(i) Contaminated reusable sharps are stored in containers that do not require "hand processing";

(j) Sharps containers are checked routinely as used and changed when three-quarters full.

(2) The Environmental Program Manager is responsible for setting up cleaning/decontamination procedures based on CDC requirements. These schedules are kept in the EMS Supervisor's office. Service-specific cleaning requirements, training, and schedules will be maintained by the Service.

(3) When bleach is used for decontamination purposes, a mixture of 10 percent bleach and 90 percent water is utilized. This mixture is lightly applied to the contaminated area and left to evaporate.

Bleach solutions must be mixed fresh daily.

f) BLOOD OR BODY FLUID CLEAN-UP PROCEDURES: The following clean-up procedures will be used when a blood or body fluid spill occurs.

(1) During regular housekeeping hours, housekeeping staff will be notified to disinfect and clean up any blood or body fluid spill unless other standard operating procedures are in place for individual services/situations.

(2) During hours when housekeeping staff is not available, the following procedure will be used to clean up and disinfect a blood or body fluid spill.

(3) STEPS:

(a) Obtain spill clean-up kit/supplies from the nearest housekeeping closet and take to the spill site. Supplies are stored in a labeled caddy in the housekeeping closet and are as follows:

1. Disinfectant and solidifying agent (combination product for wet spills)

2. Liquid disinfectant spray solution (for dried spills)

3. Personal protective equipment (gloves, face shield if splashing is likely, etc.)

4. Broom

5. Dustpan

6. Forceps (use for broken glass)

7. Putty knife

8. Red biohazard waste bag xxx

(b) Assess situation and apply appropriate personal protective equipment for the situation. (This always includes gloves.)

(c) Wet Spill: Sprinkle the disinfectant and solidifying agent over the spill. The spill will then be disinfected and changed to a solid. If the spill is on carpeting, wait five minutes before removing the disinfected material, otherwise the material may be removed immediately.

(d) Dry Spill: Spray the liquid disinfectant spray solution on the dried spill. The spill will then be disinfected. The wet material can then be wiped up with a paper towel and disposed of in the red biohazard waste bag. Another method would be to use the disinfectant and solidifying agent to change the liquid to a solid.

(e) Remove the disinfected material with the appropriate equipment (broom, dust pan, etc.) and place the disinfected material in the red biohazard waste bag. If broken glass or sharps are involved, use the forceps to pick up the sharps and dispose of in a puncture-resistant sharps container.

(f) Dispose of the red biohazard waste bag in the appropriate receptacle in the nearest dirty utility room.

(g) Remove gloves and wash hands.

(h) Return the equipment in the caddy to the housekeeping closet.

(i) Housekeeping staff will routinely check the equipment and clean and replace needed supplies.

g) REGULATED MEDICAL WASTE: The following procedures are used when handling regulated medical waste:

(1) Regulated medical waste materials are discarded or "bagged" in containers that are:

(a) Closeable

(b) Puncture-resistant

(c) Leak-proof if the potential for fluid spill or leakage exists

(d) Red in color or labeled with the appropriate biohazard warning label

(2) Containers for this regulated waste are located throughout

NWIHCS within easy access for employees and as close as possible to the sources of the waste.

(3) Waste containers are maintained upright, routinely replaced, and not allowed to overfill.

(4) Whenever employees move containers of regulated waste from one area to another the containers are immediately closed and placed inside an appropriate secondary container if leakage is possible from the first container.

(5) Employees are required to wear protective equipment such as gloves, gowns, and eye protection, as necessary, while working with regulated medical waste.

(6) Facilities Support Service is responsible for the collection, treatment, and disposal of the regulated waste of NWIHCS.

h) SOILED LINENS: The following procedures are used when handling . soiled linens:

(1) Contaminated laundry is handled as little as possible and is not sorted or rinsed where it is used.

(2) All soiled linens, including uniforms and protective clothing will be treated as contaminated for handling purposes.

(3) Linen items that are wet with blood/body fluids and present a reasonable likelihood of soak-through or leakage from the normal laundry bag will be placed and transported in bags or containers that prevent soak-through and/or leakage of fluids to the exterior.

(4) Employees are required to wear protective equipment such as gloves, gowns, and eye protection, as necessary, while working with soiled linen.

i) EXPOSURE INCIDENT PROCEDURES: All incidents of exposure (direct unprotected contact of skin and/or mucous membranes) to blood or other potentially infectious material and will be reported to his/her immediate supervisor at the time of the incident. Employees presenting themselves to Employee Occupational Health after sustaining this type of exposure will be seen by the Employee Occupational Health Medical Staff who will assess the exposure and intiate blood testing for source and employee as needed and record the data in the Employee Medical File (EMF). If after hours and Employee Occupational Health is not available, Omaha employees will go to the Emergency Room.

GrandIsland employees will report to their supervisor after hours and then contact the ER Phycian on call at 402-995-5217. They will follow-up on the next business day with Employee Occupational Health in Grand Island to complete the process.

Lincoln employees will do same as Grand Island employees, but will contact Employee Occupational Health in Omaha on next business day.

(1) Responsibility:

(a) Employee

1. If an occupational exposure to blood borne pathogens occurs, the exposed employee has the ultimate responsibility for promptly reporting the incident and seeking the necessary follow-

up. The exposed employee will immediately wash or flush the area for three minutes. The individual reports the incident to his/her supervisor who then contacts Omaha Employee Occupational Health, or Grand Island EOH.Lincoln employees during the day should call Omaha EOH. Employees should obtain the source patients name and contact information as well as request the source patient to remain at the facility until the appropriate screening lab work is obtained.

2. The employee may opt to seek care from their personal physician rather than through Occupational Health. If employee elects this option, the EOH nurse or physician should document this in the Employee Medical File (EMF).

(b) Occupational Health Personnel

1. Complete the NWIHCS "Body Fluid Exposure

Follow-up" form or the "Body Fluid Initial Exposure Note" in CPRS which can be located in the NWIHCS shared templates, Occupational/Employee Health folder, which will then be placed in the Employee Medical File.

2. Remind the employee who is at risk for Hepatitis B, C, and/or HIV seroconversion, to report to Occupational Health for scheduled follow-up testing. (We do complete a form outlining when future lab is due if necessary, but we ask the employee to maintain responsibility in following up).

3. The employee, if exposed to HIV, hepatitis B (if not immune) or hepatitis C is counseled to refrain from donating blood, semen, or organs, the implications of pregnancy, and to use protective measures to prevent BBP transmission during sexual intercourse during the period of follow-up (the time which seroconversion would be expected to occur).

4. Review the exposure history, epidemiological data on the exposure source, physical findings, and available lab.

5. Order any additional tests or therapy that may be indicated per current CDC recommendations (See Appendix B)

6. Document findings, vaccinations, and recommendations in the Employee Medical File.

Provide employee with a copy, and file original in Employee Medical File. If vaccination is recommended and refused, a declination form will be completed.

(2) HIV Testing:

(a) Verbal consent will be obtained per current VA directives. The individual also has the right to refuse testing. If the employee wishes anonymous testing for HIV, he/she is instructed to contact their public health department.

(b) If the employee consents to baseline blood collection but does not give consent at that time for HIV serologic testing, the lab should preserve the sample for at least ninety days. If, within ninety days of the exposure incident, the employee elects to have the sample tested, such testing should be done as soon as feasible.

(3) Medical Records: Under no circumstances should the exposure source, individual's name, or identifying information be placed in the employee medical file, unless written permission has been obtained from the source individual. The results of HIV testing, Hepatitis B testing, etc. should be relayed to the exposed employee and should be recorded without using the source individual's name.

(4) Treatment:

(a) Treatment will be advised by the Employee Occupational . Health Physician and/or the employee's private physician . based upon individual circumstances and per current . CDC guidelines.

(b) Employee Occupational Health may, as appropriate, consult appropriate specialists for guidance.

(5) Hepatitis B Vaccination Program:

(a) Hepatitis B (HB) Vaccination Program is available at no cost to all employees in positions that put them at risk of occupational exposure to blood borne pathogens.

(b) The program consists of a series of three injections over a six-month period. A titer will be checked two months after HB Vaccination series is completed. Employees are required to sign a written consent form to receive the series. If the employee decides to decline the vaccine, they must sign a "Vaccination Declination Form." This form will be maintained in the employee's medical records.

(c) Employee Occupational Health Service is responsible for the operation of the vaccination program under the direction of a licensed physician or other health care professional. Occupational Health is responsible for documenting individual employee health records for all employees receiving the vaccination. Employee awareness of the program is accomplished through orientation, training, and annual mandatory review.

Employees are also informed at the time of declination that they can elect to participate in the vaccination program at any time.

(d) The program for Hepatitis B vaccination of employees is initiated at time of employment and continued throughout employment at no cost to the employee.

(e) The vaccination program will be made available upon hire to a position that has been determined to place the employee at risk for occupational exposure to Hepatitis B.

(f) Each employee participating in the Hepatitis B Vaccination Program will be responsible for keeping follow-up visits for completion of the vaccination series and for rescheduling missed appointments.

d. LABELS AND SIGNS

1) The most obvious warning of possible exposure to blood borne pathogens is biohazard labels. A comprehensive biohazard warning labeling program has been implemented. The Environmental Program Manager is responsible for setting up and maintaining this program in our facilities.

2) The following items are labeled with biohazard labels or red in color:

a) Containers of regulated waste.

b) Refrigerators/freezers containing blood or other potentially infectious materials.

c) Sharps disposal containers.

d) Other containers used to store, transport, or ship blood and other infectious materials.

3) Biohazard labels are also affixed to contaminated equipment.

The labels will clearly indicate which portions of the equipment are contaminated. Facilities Support will provide biohazard labels to Services that have contaminated equipment in need of repair.

e. INFORMATION AND TRAINING: Training will be provided at the time of initial assignment and at least annually thereafter for employees who have the potential for exposure to BBP (see exposure determination list). Employees who change jobs or job functions will be given any additional training their new position requires at the time of their new job assignment.

Service Chiefs and Supervisors are responsible to provide training for new job assignments and/or contact Employee Education to arrange for training. Employee Education is responsible to provide initial orientation training to new employees with the assistance of Infection Prevention and the Safety Department. Service- and job-specific training will be provided by the employee's supervisor.

1) Employee Training: When a new employee or volunteer reports for duty, or an employee changes jobs, the following process takes place to ensure they are trained in the appropriate work practice controls:

a) The employee's job classification and the tasks and procedures that they will perform are checked against the Job Classifications and Task Lists identified in the Exposure Control Plan as those in which occupational exposure occurs.

b] If the employee is transferring from one job to another within the NWIHCS the job classifications and tasks/procedures pertaining to their previous position are also checked against these lists.

c] Based on this "cross-checking" the new job classifications and/or tasks and procedures that will bring the employee into occupational exposure situations are identified. The Supervisor receiving the employee notifies Employee Health if the Hepatitis B vaccination is needed.

d] The employee is then trained regarding any work practice controls that the employee is not experienced with.

2) Training Topics:

a] OSHA's Blood borne Pathogens Standard;

b] Examples of blood borne diseases;

c] Blood borne Pathogen modes of transmission;

d] NWIHCS Exposure Control Plan and how to obtain a copy;

e] How to identify tasks and activities that may involve exposure to blood and other potentially infectious materials;

f] Use and limitations of methods that will prevent or reduce exposure, including engineering controls, personal protective equipment, and work practices;

g] Selection and use of personal protective equipment including types available, location, removal, handling, decontamination, and disposal;

h] Hepatitis B vaccination information;

i] Appropriate actions to take, persons to contact, and method of reporting an exposure to blood borne pathogens;

j] Information on post-exposure evaluation and follow-up;

k] An explanation of signs, labels, and color-coding;

l] Interactive questions and answers following the training session.

3] Training Records: Training records will be maintained at Employee Education for a minimum of three years and will contain:

a] Dates of training programs;

b] Summary of the training program;

c] Names and qualifications of the persons who developed the program;

d] Names and job titles of persons participating in the training program.

f. RECORD KEEPING

1] General: The VA Nebraska-Western Iowa Health Care System will establish and maintain a Sharps Injury Log for the recording of percutaneous injuries from contaminated sharps. The information in the Sharps Injury Log will be recorded and maintained in such a manner as to protect the confidentiality of the injured employee. The Sharps Injury Log is maintained through the ASISTS program.

2] Responsibilities: The Occupational Health staff will be responsible for maintaining the Sharps Injury Log.

3] Specific Requirements: The Sharps Injury Log will contain at a minimum:

a) The type and brand of device involved in the incident;

b) The Department of work area where the exposure incident occurred;

c) An explanation of how the incident occurred, including a brief description of events that resulted in this injury;

d) The body part affected;

e) The objects or substances involved.

g. ANNUAL REVIEW AND UPDATE OF THE EXPOSURE CONTROL PLAN: The VA

Nebraska-Western Iowa Health Care System Exposure Control Plan will be reviewed and updated as necessary annually. The review and update of the plan will include the following:

1) Implementation of changes in technology that eliminates or reduces exposure to blood borne pathogens;

2) Documentation of consideration and implementation of safer medical devices designed to eliminate or minimize occupational exposure;

3) Evaluation methods used to evaluate devices and the results of the evaluations;

4) Justification for selection/non-selection decisions.

5. REFERENCES:

a. Compliance with Occupational Safety and Health Administration Standards on Occupational Exposure to Blood borne Pathogens, VHA Directive 96-024, March 27, 2001.

b. Employee Health Follow-up for HIV and Hepatitis B Virus (HBV) After and Accidental Occupational Exposure Incident Involving Blood and Other Potentially Infectious Material (OPIM), VHA Directive 10-95-105, October 19, 2000

c. Federal Register, Vol. 56, No. 235, December 6, 1991, Rules and Regulations for Blood borne Pathogens; Final Rule.

d. Federal Register, Vol. 66, No. 12, January 18, 2002, Occupational Exposure to Blood borne Pathogens, Needlestick, and Other

Sharps Injuries; Final Rule.

e. MMWR, Updated US Public Health Guidelines for the Management of Occupational

Exposures to HIV and Recommendations for Postexposure Prophylaxis. 54(RR09);1-17, Sept 30, 2005.

f. Case Reporting of Acquired Immune Deficiency Syndrome (RCS 10-0116), VHA Directive 96-013, February 20, 2001.

g. Informed consent for clinical treatments and procedures. VHA Handbook 1004.01, August 14, 2009.

h. Testing for human immunodeficiency virus in Veterans Health Administration facilities.

VHA Directive 2009-036, May 5, 2015.

i. MMWR, Updated US Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. 50(RR11);1-42, June 29, 2001.

j. US Public Health Service Working Group 2013 Recommendations. Kuhar, DT;

Henderson. DK; Struble. KA, et al. Updated Public Health Service Guidelines for the Management Occupational Exposures to Human Immunodeficiency Virus and recommendations for Post exposure Prophylaxis. Infection Control and Hospital Epidemiology 2013; 34 (9):875-892. Available at http://www.jstor.org/stable/10.1086/672271

k. APIC Text of Infection Control and Epidemiolgoy; Copyright dated 4th edition June 2014.

l. Schillie S, Vellozzi C, Reingold A, et al. Prevention of Hepatitis B Virus Infection in the

United Stated: Recommendations of the Advisory Committee on Immunization Practices.

MMWR Recomm Rep 2018: 67 (RR-1): 1-31.

6. RESCISSION: Policy IC-008. January 8, 2016.

7. FOLLOW-UP RESPONSIBILITY: Infection Prevention Committee Chief & Chief of Staff

8. NEEDED CONCURRENCES:

XCOM

INFECTION PREVENTION

CHIEF OF STAFF

ASSOCIATE DIRECTOR

OCCUPATIONAL HEALTH

CHIEF OF SAFETY

AFGE 2601 (GI)

AFGE 2270 (OM)

AFGE 2219 (LN)

CHIEF OF ENIVORMENTAL MANAGEMENT SERVICES

PRIVACY OFFICER

9. KEY WORDS:

BIOHAZARD

BLOOD OR BODY FLUID CLEANUP

BLOODBORNE PATHOGENS

CLEAN UP

DECONTAMINATION

DISINFECTION

EXPOSURE CONTROL

EXPOSURE PROCEDURES

HBV

HCV

HEPATITIS B VIRUS

HEPATITIS C VIRUS

http://www.jstor.org/stable/10.1086/672271

HIV

HUMAN IMMUNODEFICIENCY VIRUS

INFECTION CONTROL

NEEDLE STICKS

PERSONAL PROTECTIVE EQUIPMENT

SAFE MEDICAL PRACTICES

SAFETY

SHARPS INJURIES

/es/

DAVID A. WILLIAMS, M.D., MBA

Chief of Staff

/es/

B. DON BURMAN MHA

Director

ATTACHMENTS (3)

ATTACHMENT A

Job Classifications Having Potential Occupational Exposure to Bloodborne Pathogens

1 = Direct Patient Contact 2 = Contact with Contaminated Equipment/Environment 3 = Repair of Contaminated Equipment

Job Code-Job Title-Type of Duties

0060-Chaplain-1 0602-Physician-1 & 2 0610-QA Nurse-1 & 2 0622-Medical Supply Technician 0301-Patient Representative-1 0680-Dentist-1 & 2 0683-Dental Lab Tech-1 & 2 0682-Dental Hygienist-1 & 2 0681-Dental Assistant-1 & 2 7408-Food Service Worker-2 0630-Dietitian-1 3566-Housekeeping Aid-2 7304-Laundry Worker-2 7311-Laundry Machine Operator-2 5402-Boiler Plant Operator-2 4204-Pipefitter-2 2805-Electrician-2 4805-Bio-Med Engineering Technician-3 4749-Maintenance Mechanic-3 5306-Air Conditioning Equipment Mechanic-2 5703-Motor Vehicle Operator-2 0602-Physician-1 & 2 0644-Medical Technologist-1 & 2 & 3 0403-Microbiologist-1 & 2 & 3 1320-Chemist-1 & 2 & 3 0645-Medical Technician-1 & 2 & 3 0646-Histopathology Technologist/Technician-1 & 2 & 3 0318-Secretary 0303-Administrative Officer of the Day-1 & 2 0856-Electronic Technician-2 & 3 0610-Nurse Practitioner-1 & 2 0602-Physician-1 & 2 0603-Physician Assistant-1 & 2 0601-Registered Respiratory Therapist-1 & 2 0640-Certified Respiratory Therapist-1 & 2 0649-Medical Instrument Tech-1 & 2 0610-Chief, Nursing-1 & 2 0610-Assistant Chief, Nursing-1 & 2 0610-Community Health Nurse-1 & 2 0610-ADP Coordinator-1 & 2 0610-QA Nurse Coordinator-1 & 2 0610-Associate Chief, Nursing Education-1 & 2 0610-Clinical Manager, Ambulatory Care-1 & 2 0610-Nurse Manager, Hemodialysis-1 & 2 0610-Nurse Manager-1 & 2 0610-Nurse-1 & 2

0610-Nursing Valor Student-1 & 2 0620-Practical Nurse-1 & 2 0621-O.R. Nursing Assistant-1 & 2 0621-Nursing Assistant-1 & 2 0621-Psych Nursing Assistant-1 & 2 0660-Pharmacist-1 & 2 0661-Pharmacist Tech-1 & 2 0083-Police Officer-1 & 2 0672-Prosthetic Representative-1 & 2 1105-Purchasing Agent-1 & 2 0602-Physician-1 & 2 0638-Recreation Therapist-2 0101-Addiction Therapist-1 0180-Clinical Psychologist-1 0181-Psychology Technician-1 0602-Physician-1 & 2 0647-Diagnostic Radiology Tech-1 & 2 0601-Nuclear Medicine Tech-1 & 2 0649-Medical Instrument Tech-1 & 2 0633-Physical Therapist-1 & 2 0636-Physical Therapist Assistant-1 & 2 0631-Occupational Therapist-1 & 2 0636-Occupational Therapy Assistant-1 & 2 0185-Social Worker-1 0102-Readjustment Counselor-1 0602-Physician-1 & 2 0602-Physician Assistant-1 & 2 0602-Medical Student-1 & 2 0605-Nurse Anesthetist-1 & 2 0602-Physician/Resident-1 & 2 Escort-1 & 2 Clinic Assistant-1 & 2 Driver-1 & 2 0640-Health Technician-1 & 2

ATTACHMENT B

Selecting Drugs for prevention of HIV infection after Occupational Exposure

Treatment Guideline:

Based largely on US Public Health Service Working Group 2013 recommendations. Kuhar DT, Henderson DK, Struble KA, et al. Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis. Infect Control Hosp Epidemiol 2013;34:875- 892.

Step 1. To what kind of material was the healthcare worker exposed?

*Was it material that has been implicated in occupational transmission of HIV?

Blood Visibly bloody body fluids

*Was it potentially infectious material which has been implicated in sexual transmission of HIV?

Nonbloody semen Nonbloody vaginal secretions

*Was it potentially infectious material which has NOT been implicated in sexual transmission of HIV?

Nonbloody cerebrospinal fluid Nonbloody synovial fluid Nonbloody pleural fluid Nonbloody peritoneal fluid Nonbloody pericardial fluid Nonbloody amniotic fluid

*Was it a human bite?

Yes, a human bite

*Was it material not considered infectious for transmission of HIV?

Nonbloody feces Nonbloody nasal secretions Nonbloody saliva Nonbloody sputum Nonbloody sweat Nonbloody tears Nonbloody urine Nonbloody vomitus

Step 2. What kind of exposure did the healthcare worker experience?

*Was it one of the following percutaneous injuries classified as “more severe”?

Large bore hollow needle Deep puncture

Puncture with visible blood on device From needle used in patient’s artery or vein

*Was it the following percutaneous injury classified as “less severe”?

Solid needle AND the injury was superficial

*Was it an exposure to nonintact skin or to a mucous membrane that is classified as “large volume”?

A major blood splash

*Was it an exposure to nonintact skin or to a mucous membrane that is classified as “small volume”?

A few drops

*Was it an exposure to intact skin (not chapped; not abraded; not affected with dermatitis; no open wound)?

Intact skin

Step 3. What is known about the source of the exposure? If testing of the source is pending, do not wait for results. Start drugs within 1 hr of exposure. In any event, start drugs as soon as possible.

*Was it from a so-called “Class 2” patient known to be HIV positive with one of the following characteristics?

Known to have symptomatic HIV infection Known to have an AIDS diagnosis Currently is acutely seroconverting from HIV-negative to HIV-positive Known to have a high viral load (> 1500 RNA copies/ml)

*Was it from a so-called “Class 1” patient known to be HIV positive with one of the following characteristics?

Known to have asymptomatic HIV infection Known to have a low viral load (< 1500 RNA copies/ml)

*Was it from a patient with unknown HIV status, but who is known to have an HIV risk factor, such as?

Illicit drug use history Man who has had sex with men?

Sex partner of HIV patient Sex partner of injection drug user History of multiple sex partners

*Was it from a patient whose HIV status is unknown?

Currently unknown HIV status, not known to have HIV risk factor

*Was it from an unknown source, but where HIV exposure was likely?

Such as a needle from a sharps disposal container used in an HIV clinic

*Was it from an unknown source where HIV exposure was not likely?

Such as an ordinary sharps disposal container Such as inappropriately disposed blood

Step 4. Is there a special situation?

Check here if the exposed healthcare worker is pregnant (or might be). Do not delay starting drugs.

Check here if the exposed healthcare worker is breast feeding. Do not delay starting drugs.

Check here if the exposed healthcare worker is taking other medications

* Check here if the source of the exposure is a patient with HIV who is known to be taking HIV drugs. Do not delay starting drugs.

Check here if the exposure occurred more than 72 hr ago Check here if the source is unknown (for example, needle in a sharps disposal container or laundry)

Step 5. Using the information collected, the provider must decide what is the situation

There is a special situation, as noted in Step 4.

• Get expert consultation. Call the PEP line (888-448-4911) or infectious diseases (VA operator)

• Pregnancy limits the choice of drugs. If there is uncertainty about pregnancy, consider doing a test.

• There may be drug interactions with other medications.

• There may be resistance issues if the source patient was on HIV drugs

• Do not delay starting drugs in pregnancy, breast feeding, or exposure to a patient with

HIV who is known to be taking HIV drugs.

There is a more severe exposure, a less severe exposure, or a large volume exposure, as noted in Step 2.

If the patient is HIV positive, recommend the 3-drug regimen (see Step 6) If the patient is not known to be HIV positive (but has an HIV risk factor), consider the 3-drug regimen (see Step 6) If the source is unknown but HIV exposure was likely, consider the 3-drug regimen (see Step 6) If the HIV status of the source patient is unknown (and the patient is not known to have an HIV risk factor), don’t give any drugs If the source is unknown and HIV exposure is not likely, don’t give any drugs. But get expert consultation.

If the source patient is known to be HIV-negative, don’t give any drugs

There is a small volume exposure, as noted in Step 2.

If the patient is HIV positive and Class 2 (see Step 3), recommend the 3-drug regimen (see Step 6) If the patient is HIV positive and Class 1 (see Step 3), consider the 3-drug regimen (see Step 6) If the patient is not known to be HIV positive (but has an HIV risk factor), consider the 3-drug regimen (see step 6) If the source is unknown but HIV exposure was likely, consider the 3-drug regimen (see Step 6) If the HIV status of the source patient is unknown (and the patient is not known to have an HIV risk factor), don’t give any drugs

If the source is unknown and HIV exposure is not likely, don’t give any drugs. But get expert consultation.

If the source patient is known to be HIV-negative, don’t give any drugs

There is exposure to intact skin, as noted in Step 2. Don’t give any drugs

Summary of recommendations for drugs

Source of exposure

More severe exposure; less severe exposure; or large volume exposure

Small volume exposure

Expo-sure to Intact skin

HIV positive patient, class 2

Recommend 3-drug regimen

Recommend 3-drug regimen

No drugs

HIV positive patient, class 1

Recommend 3-drug regimen

Consider 3-drug regimen

No drugs

Patient not known to have HIV, has an HIV risk factor

Consider 3-drug regimen

Consider 3-drug regimen

No drugs

Source is unknown but HIV exposure was likely

Consider 3-drug regimen

Consider 3-drug regimen

No drugs

Patient not known to have HIV; no HIV risk factor

No drugs No drugs No drugs

Source is unknown but HIV exposure was not likely

No drugs No drugs No drugs

Source patient is known to be HIV negative

No drugs No drugs No drugs

Step 6. Select a drug regimen

3-drug regimen

• Truvada (tenofovir 300 mg and emtricitabine 200 mg) one pill once daily for four weeks

AND

• Isentress (raltegravir) 400 mg one pill twice daily for four weeks

Step 7. Plan laboratory monitoring of the exposed healthcare worker

Timing HIV serology

CBC

with diff

Liver tests

BUN,

Creatinine

Baseline 2 wk 6 wk 12 wk 6 mo

12 mo If pt became Infected with hepatitis C

Step 8. Plan additional follow-up

Education about drugs, risk, avoiding further transmission Follow-up with occupational health or the infectious diseases clinic within 72 hr In some case, alteration of drug regimen may be needed as more results are available

Approved For CPRS Template:

Yes

Approved by Pharmacy & Therapeutics Committee:

September 3, 2013

Concurrences:

Infectious Disease Medicine/Primary Care Patient Care Services Medical Executive Committee

ATTACHMENT C

Prevention of hepatitis B infection after occupational exposure, revised May 15, 2018 Based largely on CDC 2018 recommendations. Schillie S, Vellozzi C, Reingold A, et al. Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep 2018;67(RR-1):1-31. Also, Schillie S, Harris A, Link-Gelles R, Romero J, Ward J, Nelson N. Recommendations of the Advisory Committee on Immunization Practices for Use of a Hepatitis B Vaccine with a Novel Adjuvant. MMWR Morb Mortal Wkly Rep 2018;67:455–458.

DOI: http://dx.doi.org/10.15585/mmwr.mm6715a5.

Step 1. Determine if exposed healthcare worker was already protected against hepatitis B. Advice: If necessary, contact occupational health. The number:

(402)995-5823. Their confidential employee database may contain information about the exposed healthcare worker’s hepatitis B immunization and titer status.

Has the exposed healthcare worker received a 3-dose series of Hepatitis B vaccine (or, after November 2017, a 2-dose series of Heplisav-B (HepB-CpG), a single-antigen HepB vaccine with a novel immunostimulatory sequence adjuvant)?

Yes No Unsure

Was a titer of anti-HBs ≥10 mIU/mL documented in the exposed healthcare worker after Hepatitis B vaccination?

Yes No Unsure Other

If the answer to both Step 1 questions is “Yes” then STOP. No medical intervention is needed. The exposed healthcare worker must report to occupational health to document the injury.

Step 2. For the exposed healthcare worker, determine what hepatitis B vaccinations were received.

Did the exposed healthcare worker receive any hepatitis B vaccine?

Yes No Unsure Other. Specify:

If the answer to the previous question is “yes,” how many doses of hepatitis B vaccine did the exposed healthcare worker receive?

6 or more Unsure Does not apply, Answer to the previous question was not “yes” Other. Specify:

If the answer to the previous question is 1 or 2, why hasn’t the exposed healthcare worker received at least 3?

After November 2017, received a complete 2-dose series of Heplisav-B (HepB-CpG), a single-antigen HepB vaccine with a novel immunostimulatory sequence adjuvant Initial immunization in progress Started series but failed to adhere to recommendations to complete it Unsure Does not apply, Answer to the previous question was not 1 or 2 Other. Specify:

Step 3. For the exposed healthcare worker, determine what is known about a titer to hepatitis B surface antigen (anti-HBs).

Has the exposed healthcare worker been tested for antibody against the hepatitis B surface antigen (anti-HBs)?

Yes No Unsure Other. Specify:

If the answer to the previous question is “yes,” is information about the test results available?

Yes No Unsure Does not apply, Answer to the previous question was not “yes” Other. Specify:

If the answer to the previous question is “yes,” has the exposed healthcare worker ever been documented to have a titer to hepatitis B surface antigen (anti-HBs) of at least 10 mIU?

Yes No Unsure Does not apply, Answer to the previous question was not “yes” Other. Specify:

If test results for a titer to hepatitis B surface antigen (anti-HBs) for the exposed healthcare worker are not available now, can they be obtained within 7 days?

Yes. Blood can be drawn and a result obtained within 7 days. Do the test.

Yes. Medical records can be reviewed and a result obtained within 7 days. Get the results No Unsure Does not apply. Results for a titer to hepatitis B surface antigen (anti-HBs) are available now Other. Specify:

Step 4. For the exposed healthcare worker, summarize the hepatitis B immunization and anti-HBs titer status, based on the previous steps.

Received at least 3 doses of hepatitis B vaccine (or, after Nov 2017, received a complete 2-dose series of Heplisav-B (HepB-CpG)) according to written documentation and documented to have an anti-HBs titer of at least 10 miU/ml. “Documented responder” Received at least 6 doses of hepatitis B vaccine (or, after Nov 2017, at least 4 doses of Heplisv-B (HepB-CpG)) and documented to have an anti-HBs titer of less than 10 mIU/ml. “Documented nonresponder” Received at least 3 doses of hepatitis B vaccine (and, after Nov 2017, at least 2 doses of Heplisv-B (HepB-CpG)) and documented to have an anti-HBs titer of less than 10 mIU/ml. “Documented nonresponder” Received at least 3 doses of hepatitis B (or, after Nov 2017, a complete 2-dose series of of Heplisav-B (HepB-CpG)) vaccine but anti-HBs titer unknown. “Response unknown after 3 doses” Did not receive any doses of hepatitis B vaccine Received hepatitis B vaccine, but less than 3 doses (or less than 2 doses if had been given Heplisav-B (HepB-CPG)) Refused hepatitis B vaccine.

Other. Specify

Step 5. To what kind of material was the healthcare worker exposed?

Was it material that is considered potentially infectious?

Blood Visibly bloody body fluids Nonbloody cerebrospinal fluid Nonbloody synovial fluid Nonbloody pleural fluid Nonbloody peritoneal fluid Nonbloody pericardial fluid Nonbloody amniotic fluid

Was it material that has not been implicated in occupational transmission of hepatitis B virus (although it might transmit hepatitis B virus if contaminated with blood, even such a small amount of blood that it would not be visibly bloody)?

Nonbloody saliva Nonbloody tears

Was it material that has not been implicated in…