Exposure Control Plan, Island County

This information is brought to you by the Island County Health Department (ICPH)

1. Purpose
In accordance with the WISHA Bloodborne Pathogens standard WAC 296-62-08001, Island County has developed the following exposure control plan to eliminate or minimize employee occupational exposure to blood or other potentially infectious materials as detailed in the Bloodborne Pathogens standard.

2. Administration and Compliance
Vickie Chambers, Assistant Director GSA/Safety Coordinator, is the administrator of this plan and is responsible for its implementation. Employees who are identified as having occupational exposure are required to comply with the procedures and work practices outlined in this exposure control plan. Failure to follow these procedures can result in disciplinary action.

3. Definitions
For purposes of this section, the following shall apply:

"Blood" means human blood, human blood components, and products made from human blood.

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

"Clinical laboratory" means a workplace where diagnostic or other screening procedures are performed on blood or other potentially infectious materials.

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

"Contaminated laundry" means laundry that has been soiled with blood or other potentially infectious materials or that may contain contaminated sharps.

"Contaminated sharps" means any contaminated object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires.

"Decontamination" means the use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal.

"Director" means the director of the Washington State Department of Labor and Industries — the state designee for the Washington State plan.

"Engineering controls" means controls (e.g., sharps disposal containers, self-sheathing needles, safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the bloodborne pathogens hazard from the workplace.

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

"Handwashing facilities" means a facility providing an adequate supply of running potable water, soap and single use towels or hot air drying machines.

"Licensed healthcare professional" is a person whose legally permitted scope of practice allows him or her to independently perform the activities required by subsection (6) of this section, entitled Hepatitis B vaccination and post-exposure evaluation and follow-up.

"HBV" means hepatitis B virus.

"HIV" means human immunodeficiency virus.

"Needleless systems" means a device that does not use needles for:
• The collection of bodily fluids or withdrawal of body fluids after initial venous or arterial access is established;
• The administration of medication or fluids; or
• Any other procedure involving the potential for occupational exposure to bloodborne pathogens due to percutaneous injuries from contaminated sharps.

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

"Other Potentially Infectious Materials" (OPIM) means:

(a) The following human body fluids: Semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids;
(b) Any unfixed tissue or organ (other than intact skin) from a human (living or dead); and
(c) HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.

"Parenteral" means piercing mucous membranes or the skin barrier through such events as needle sticks, human bites, cuts, and abrasions.

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

"Production facility" means a facility engaged in industrial-scale, large-volume or high concentration production of HIV or HBV.

"Regulated waste" means liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.

"Research laboratory" means a laboratory producing or using research-laboratory-scale amounts of HIV or HBV. Research laboratories may produce high concentrations of HIV or HBV but not in the volume found in production facilities.

"Sharps with engineered sharps injury protections" means 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.

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

"Sterilize" means the use of a physical or chemical procedure to destroy all microbial life including highly resistant bacterial endospores.

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

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

4. Exposure Determination
WISHA requires employers to perform an exposure determination to identify employees who have occupational exposure to blood or other potentially infectious materials. Occupational exposure means “reasonably anticipated skin, eye, mucous membrane or parenteral contact with blood or other potentially infectious material that may result from the performance of an employee’s duties.” For purposes of the determination, employees are considered to have occupational exposure even if they utilize PPE while performing duties that put them at risk for exposure. Below, is a list of all job classifications and tasks in which employees may be expected to incur such occupational exposure, regardless of frequency.

Job Classification	Tasks With Exposure
Public Health Nurse I, II and III, Nursing Director, and certified health care assistants	Vaccine administration
	Blood draw or other blood test
	Disposal of syringes/needles/lancets/ gloves, or other items contaminated with bloodborne pathogens
	Giving first aid or CPR
	Oral Health exam
	Cleaning clinic surfaces
	Cleaning breast pumps
Administrative Assistant	Oral Health exam
	Cleaning breast pumps
Nutritionist	Hematocrits
	Cleaning breast pumps
	Oral Health exams
Coroner/Deputy Coroners	Medico-legal death investigation
Sheriff’s Office Commissioned Personnel	All physical contact with prisoners and the public which result in intentional or unintentional injury and subsequent exposure to blood or other bodily fluids
Maintenance Personnel	Disposal of waste unintentionally contaminated with blood borne pathogens
Solid Waste Personnel	Unintentional exposure to improperly discarded needles and other contaminated material
Parks Personnel	Unintentional exposure due to improperly discarded needles and other contaminated material

5. Compliance

a. Universal Precautions

Universal precautions will be observed at this facility in order to prevent contact with blood or other potentially infectious materials. This means that all blood or OPIM will be considered infectious regardless of the perceived status of the source individual. (See appendix D.)

b. Engineering Controls

Island County conducts ongoing evaluation of tasks and medical devices that carry a risk of exposure and implements safer medical devices whenever feasible. A Committee made up of managerial and non-managerial health department staff will evaluate tasks and devices on a yearly basis. A checklist for each mechanical device will be utilized, and is included in this policy. (See appendices A and B)

A representative sample of non-managerial employees is included in all evaluations. We have developed the following engineering controls to prevent or minimize exposure to bloodborne pathogens. New technology will be implemented and evaluated whenever possible. Our engineering controls will be evaluated and maintained as described below:

Controls in Use	Location	Evaluation/ Service Interval	Controls Evaluated
VanishPoint syringes	All Immunization clinic rooms All remote sites for special clinics	Yearly/June	{list all engineering controls/safer medical devices evaluated in the past year}
Self-sheathing butterfly needles for blood draws	All clinic rooms where venipuncture is performed	Yearly/June
Hemocue system with disposable plastic cuvette	All WIC clinic sites	Yearly/June
Sharps containers	All clinic Immunization rooms, remote clinic sites, needle exchange and HIV test sites	Yearly/June
Personal protective Latex and vinyl gloves	All Immunization rooms and county automobiles, including sheriff’s cars and offices	Yearly/June
Biohazard waste containers	All clinic immunization rooms	Picked up monthly
CPR mask	All immunization rooms and county automobiles	Yearly/June
Raincoats	Sheriff’s cars	yearly
Face shields, booties	Sheriff’s Evidence room, Coroner’s office	yearly

We have identified the following tasks and devices that utilize non-safer devices or allow exceptions to defined work practice controls:

Exempted task or device	Justification
Vaccines in pre-filled syringes	No other efficient or available option
Lancets	No other acceptable option

c. Work Practice Controls

The following work rules apply where there is a potential for contact with blood or OPIM:

Hand and Body Washing

Handwashing facilities are available to employees who are exposed to blood or other potentially infectious materials.
Employees shall wash hands after removal of personal protective gloves and whenever there is a likelihood of contamination. In addition, any contaminated skin area will be washed as soon as possible.
When handwashing facilities are not readily available. The use of waterless handwashing products is permitted as an interim means of washing the hands or other parts of the body after contamination with blood or OPIM.
If blood or other potentially infectious material contacts mucous membranes then those areas shall be washed or flushed with water as appropriate as soon as possible following contact.

Other Work Practices

Contaminated needles may not be recapped, bent or broken off. Shearing or breaking of contaminated needles is prohibited. They must be deposited in a sharps container immediately or as soon as possible after use. If recapping is a necessary part of a procedure, such recapping must be accomplished through the use of a recapping device or a one-handed technique.
Sharps containers must be closed prior to removal or replacement to prevent spilling or protrusion of the contents during handling or storage.
Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure.
Food and drink must not be kept in refrigerators, freezers, shelves, and cabinets or on countertops or bench tops where blood or other potentially infectious materials are present.
All procedures will be conducted in a manner that will minimize splashing, spraying, splattering, and generation of droplets of blood or other potentially infectious materials.
Mouth pipetting/suctioning of blood or other potentially infectious materials is prohibited.
Specimens of blood or other potentially infectious materials must be placed fluid proof, biohazard labeled shipping containers. If the outside of the containers becomes contaminated, then it must be placed in a second container.
Regulated waste material must be placed in a biohazard labeled container, which is to be closed before removal to prevent spillage or protrusion of contents. If the outside of the container becomes contaminated, then it must be placed in a second bio-hazard labeled container
Equipment, which may be contaminated with blood or infectious materials, must be examined prior to service or shipping and shall be decontaminated as necessary. If decontamination is not feasible then a readily observable biohazard label shall be attached to the equipment and the contaminated portions documented. Employees shall observe universal precautions and utilize appropriate PPE when handling such equipment.

d. Personal Protective Equipment (PPE)

All PPE used at this facility will be provided without cost to employees. PPE will be chosen based on the anticipated exposure to blood or other potentially infectious materials. The PPE 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. Employees will receive training on the appropriate use of PPE provided for specific tasks.

(See Universal Precautions Policy, appendix D)

The following personal protective equipment is provided for workers:

Tasks Requiring PPE	PPE Provided
Blood draws	Disposable gloves
Hemoglobin measurement	Disposable gloves
Cleaning breast pumps	Disposable gloves
Cleaning clinic surfaces	Disposable gloves
Handling used gloves	Disposable gloves
Oral health exams	Disposable gloves
First Aid, CPR	Disposable gloves, disposable microshields
Autopsies	Face shield, surgical caps, gowns gloves, shoe covers
Care and Custody of Inmates	Gloves, masks
Crime Scene Investigations	Gloves, gowns, face shields, booties, etc.
Contaminated materials handling	Leather gloves, aprons, face shields

If required PPE is not available, contact appropriate department head, elected official, or supervisor who will insure that supplies are replenished.

Gloves

Gloves shall be worn where it is reasonable anticipated that employees will have hand contact with blood, other potentially infectious materials, non-intact skin, and mucous membranes.
Disposable gloves used at this facility are not be washed or decontaminated for re-use and are to be replaced as soon as practical when they become contaminated or as soon as possible if they are torn, punctured, or when their ability to function as a barrier is compromised.
Utility gloves may be decontaminated for re-use if 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.

Other PPE

Appropriate face and eye protection is worn when splashes, sprays, spatters, or droplets of blood or other potentially infectious materials pose a hazard to the eyes, nose or mouth.
Gowns, aprons, and other protective body clothing are worn whenever there is a risk of splash to the body.
Surgical caps or hoods and shoe covers or booties are worn when gross contamination can be reasonably anticipated.
All garments, which are penetrated by blood, are removed immediately or as soon as possible. All personal protective equipment are removed and placed in a designated area or container prior to leaving the work area.

e. Housekeeping

Work surfaces must be decontaminated with an approved disinfectant as soon as possible after contamination with blood or OPIM, and at the end of the work shift if the surface may have become contaminated since the last cleaning.

The following locations require cleaning and decontamination on a scheduled basis:

Area	Scheduled Cleaning (Day/Time)	Cleaners and Disinfectants Used	Specific Instructions
Venipuncture surfaces	After each use	Approved germicidal solution
Clinic counters, exam tables and other surfaces	End of day after clinic	Approved germicidal solution
Toilets, inside and out	Every work day	Approved germicidal solution
Sinks, inside and out	Every work day	Approved germicidal solution
Floors in clinic rooms, bathrooms and lab	Every work day	Approved germicidal solution
Toys	Every work day	10% bleach solution
Coroner’s Van	After each use	Approved germicidal solution
Sheriff’s patrol cars	After each incident	Contract with biohazard response team

Handling of Waste Material

Used sharps containers are to be closed and transported to the nearest Immunization room, where it is to be placed in the Infectious waste disposal container furnished by “Stericycle”. Stericycle will pick up bio-hazardous waste once per month. Never manually open, empty, or clean reusable contaminated sharps disposal containers. They must be cleaned according to the manufacturer’s instructions.
Other infectious waste shall be placed in a red bag and placed in the Infectious waste disposal container furnished by “Stericycle”.
Always use mechanical means such as tongs, forceps or a brush and dustpan to pick up contaminated broken glassware. Never pick up with hands – even if gloves are worn!

f. Laundry

Handle contaminated laundry as little as possible, with minimal agitation.
Place wet contaminated laundry in leak-proof, labeled or color-coded containers before transporting to the laundry facility.
Wear appropriate PPE when handling and/or sorting contaminated laundry.
Contaminated linens should be washed with detergent in water at least 140F – 160F for 25 minutes. If low temperature laundry cycles are used, chemicals suitable for low temperature washing at proper use concentration must be used.
If clothing is contaminated, staff will change clothes, bag soiled clothing in a biohazard bag, and take clothing home to launder per above instructions. (Exception is for Sheriff’s Office: refer to “Jail Procedures Manual”)

6. Signs and Labels

Warning labels will be placed on containers of regulated waste, refrigerators containing blood or other potentially infectious materials and other containers used to store or transport blood or infectious materials. The label will be a fluorescent orange or orange-red biohazard label as illustrated with lettering in a contrasting color. (See above biohazard label)

7. Hepatitis B Vaccine

All employees who have been identified as having exposure to blood or OPIM through the exposure determination described in section 4 of this plan will be offered the Hepatitis B vaccine series at no cost to the employee within 10 days of initial assignment and after training has been received, unless:

the employee has previously received the series
antibody testing reveals that the employee is immune
medical reasons prevent taking the vaccination; or
the employee chooses not to participate

Employees will be provided with information on Hepatitis B vaccinations addressing its safety, benefits, efficacy, methods of administration and availability. Employees will access vaccinations through the health department at a clinic convenient to the employee’s worksite

All occupationally exposed employees are strongly encouraged to receive the Hepatitis B vaccination series and post-vaccination antibody testing. However, if an employee chooses to decline HB vaccination, then the employee must sign a copy of the declination statement. (See Appendix C) The copy will be kept in the employee’s confidential medical record. Employees who decline may request and obtain the vaccination later, and at no cost.

8. Evaluation and Management of Exposure Incidents:

a. Post-Exposure Management

· Wounds and skin sites that have been in contact with blood or OPIM should be washed with soap and water; mucous membranes should be flushed with water.

· Immediately report all exposure incidents to your supervisor.

· It is important that employees receive a prompt medical evaluation because HBIG, hepatitis B vaccine, and HIV post –exposure prophylaxis (PEP) are most likely to be effective if administered as soon after exposure as possible. Whidbey General Hospital Emergency Room in Coupeville, or Skagit Valley Hospital Emergency Room in Mt. Vernon, (if incident occurs on Camano Island) will provide a confidential medical evaluation to all exposed employees. If HIV or other blood testing is recommended, the employee will receive this service free of charge.

· Employees will complete an “Island County Incident/Accident” form as soon as possible after the exposure. Follow-up after the consultation and evaluation will be provided by health department personnel trained in this area.

· If the employee does not give consent for HIV serological testing during collection of blood for baseline testing, preserve the baseline blood sample for at least 90 days; if the exposed employee elects to have the baseline sample tested during this waiting period, perform testing as soon as feasible

b. Source Testing

· The person (if known) whose blood or body fluid is the source of an exposure will be tested for HBV, HCV, and HIV infection as soon as feasible. When the source is already known to be infected with HBV, HCV, or HIV then testing need not be repeated.

· Information from the medical record (e.g., laboratory test results, admitting diagnosis, or previous medical history) of the source person will be gathered at the time of the exposure to confirm or exclude bloodborne infection. The Health Officer will supervise this activity.

· HBV, HCV, and/or HIV testing shall be performed if the infection status of the source person is unknown. (see PP Manual under “HIV Counseling and Testing”.)

· Results of source testing shall be provided to the employee, and the employee shall be informed of all applicable laws and regulations concerning disclosure of the identity and infectious status of the source.

· The health department will be consulted in the event that consent for source testing cannot be obtained. Roger Case, MD, Health Officer, will supervise this activity. He can be reached at 360 914-0840

c. Review of Exposure Incidents

· The circumstances of all exposure incidents will be reviewed by the employee’s supervisor to determine:

o Why the exposure incident occurred;

o Type and brand of device involved (if any)

o If procedures were being followed; and

o If procedures, protocols, and/or training need to be revised.

· If it is determined that revisions need to be made, the plan administrator will ensure that appropriate changes are made to this exposure control plan.

· Documentation of this evaluation should accompany the exposure report.

9. Employee Training

All employees who have occupational exposure to bloodborne pathogens will receive training at the time of initial assignment and at least annually thereafter. Training will be provided by licensed staff from the Health Department upon referral by the Safety Director.

Training will include:

· Information as to the epidemiology, symptoms, and transmission of bloodborne pathogen diseases

· a copy and explanation of the standard

· an explanation of our exposure control plan and how to obtain a copy

· an explanation of methods to recognize tasks and other activities that may involve exposure to blood and OPIM, including what constitutes an exposure incident

· an explanation of the use and limitations of engineering controls, work practices, and PPE

· an explanation of the types, uses, location, removal, handling, decontamination, and disposal of PPE

· an explanation of the basis for PPE selection

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

· information on the appropriate actions to take and persons to contact in an emergency involving blood or OPIM an explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available

· information on the post-exposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident

· an explanation of the signs and labels and/or color coding required by the standard and used at this facility

· an opportunity for interactive questions and answers with the person conducting the training session

Training records will be completed for each employee upon completion of training. These documents will be kept with the employee’s records and will include:

· dates of the training sessions

· contents or a summary of the training sessions

· names and qualifications of persons conducting the training

· names and job titles of all persons attending the training sessions

Training records will be maintained for a minimum of three (3) years from the date on which the training occurred.

Employee training records will be provided upon request to the employee or the employee’s authorized representative within 15 working days.

10. Record Keeping

a. Medical Records

The Human Resources department is responsible for maintenance of the required medical records. They are kept in a locked file drawer in the Human Resources office. Medical Records of civil service employees are kept in locked files in the Sheriff’s Office.

Medical records are maintained for each employee with occupational exposure in compliance with WAC 296-62-052, "Access to Employee Exposure and Medical Records" and will include:

· the name and social security number of the employee

· a copy of the employee’s hepatitis B vaccinations and any medical records relative to the employee’s ability to receive vaccination

· a copy of all results of examinations, medical testing, and follow-up procedures as required by the bloodborne pathogens standard

· a copy of all health care professional’s written opinion(s) as required by the bloodborne pathogens standard

All employee medical records will be kept confidential and will not be disclosed or reported without the employee’s express written consent to any person within or outside the workplace except as required by the standard or other legal provisions.

Employee medical records shall be maintained for at least the duration of employment plus 30 years.

Employee medical records will be provided upon request of the employee or to anyone having written consent of the employee within 15 working days.

b. Sharps Injury Log

Risk Management is responsible for maintenance of the confidential Sharps Injury Log. The log is located a locked file drawer in the Risk Management Office in Coupeville.

The Sharps Injury Log shall contain, at a minimum:

o The routes of exposure;

o An explanation of and circumstance under which the incident occurred,

o The type and brand of device involved in the incident, and

o The department or work area where the exposure occurred

reviewed-3-12-09

ICPH

Index

App A

App B

App C

App D

Location

Exempted task or device

Justification