No./Title: Exposure Control Plan
Resp. Office: Campus Safety and Emergency Management
Effective Date: 2/10/2021
Category: General Safety
Last Review: 4/1/2021
Next Review: 3/1/2023
Contact: Ramesh Ray, Institutional Biosafety Officer
Related Policies: RS002 – Office of Research Safety Affairs Exposure Control Plan GME Policy #360 – Infection Control for Immunizations for Medical and Dental Residents GME Policy #361 – Infection Control for Tuberculosis for Medical and Dental Residents Policy on Infection Control for Tuberculosis for UTHSC Employees, Faculty and Staff Security Plan for the Transportation of Hazardous Materials
Forms: Hepatitis B Declination
PURPOSE, APPLICABILITY, AND SCOPE:
This Bloodborne Pathogens Exposure Control Plan (ECP) has been developed and implemented to meet the requirements of the Occupational Safety and Health Administration’s (OSHA) Bloodborne Pathogens Standard (29 CFR 1910.1030). This federal standard has been adopted by the State of Tennessee with minor additional provisions. This standard was originally promulgated and continues to address occupational exposure risk to human body fluids that may contain bloodborne pathogens such as human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) in human healthcare settings. University of Tennessee Health Science Center (UTHSC) is required by OSHA to have an Exposure Control Plan (ECP).
This plan is applicable to all UTHSC faculty, staff, students, residents and fellows. In this plan the term “employee” means all faculty, staff, students, residents and fellows. All employees who have the potential for occupational exposure to blood, bodily fluids and Other Potentially Infectious Material (OPIM) must comply with the procedures and work practices outlined in the ECP.
- Bloodborne Pathogens (BBP)
- Biosafety Level (BSL)
- Biosafety Officer (BSO)
- Center for Disease Control (CDC)
- Hepatitis B Virus (HBV)
- Hepatitis C Virus (HCV)
- Human Immunodeficiency Virus (HIV)
- Institutional Animal Care and Use Committee (IACUC)
- Institutional Biosafety Committee (IBC)
- International Air Transport Association (IATA)
- Other Potentially Infectious Materials (OPIM)
- Occupational Health and Safety Administration (OSHA)
- Principal Investigator (PI)
- Personal Protective Equipment (PPE)
- Office of Research Safety Affairs (RSA)
- Standard Operating Procedure (SOP)
- Tuberculosis (TB)
- United States Department of Transportation (US DOT)
- University Health Services (UHS)
- University of Tennessee Health Science Center (UTHSC)
This Exposure Control Plan describes UTHSC’s efforts to eliminate or minimize occupational exposure to bloodborne pathogens, infectious agents, and Other Potentially Infectious Materials (OPIM). It contains information concerning the regulations and procedures for:
General Program Management
- Availability of the Exposure Control Plan to Employees
- Exposure Determination
- Standard precautions
- Engineering Controls
- Work Practices
- Personnel Protective Equipment
Bloodborne Pathogen Communication
- Labeling and Signs
- Information and Training
Hepatitis B Virus (HBV) Vaccination, Post-Exposure Evaluation and Follow-up
- Hepatitis B Vaccination
- Exposure Response, Post-Exposure Evaluation and Follow-up
- UTHSC Affiliate Sites
- Medical Recordkeeping
- Sharps Injury Prevention Program
- Shipping human materials including blood and OPIM
- Appendix A: Hepatitis Declination Form
- Appendix B: First Aid and Human Blood Spill Responders’ Exposure Control Guide
- Appendix C: Infection Control Awareness for Employees Exposed to Wastewater
- Appendix D: Safer Sharps Device Initial Evaluation Form
- Appendix E: Safer Sharps Device Annual Review Form
- Appendix F: Bloodborne Pathogen Exposure/Sharps Injury Report
GENERAL PROGRAM MANAGEMENT
The six primary areas of responsibility for the Exposure Control Plan (ECP) are:
- UTHSC Campus Safety and Emergency Management
- University of Tennessee Office of Risk Management
- UTHSC University Health Services
- Supervisory Personnel (including Principal Investigators, Managers and Supervisors)
University of Tennessee Office of Risk Management
Risk management is responsible for maintaining the OSHA 300 log.
UTHSC University Health Services
University Health Services or the designated health care provider shall be responsible for:
- Maintenance of medical records relative to this program.
- Post-exposure evaluation and follow-up, including medical consultation.
Supervisory Personnel (including Principal Investigators, Managers and Supervisors)
Supervisory personnel are responsible for compliance in their areas. They shall work with the Exposure Control Coordinators and their employees to ensure that:
- Overseeing the implantation of the Exposure Control Plan in their work area.
- All employees under their supervision who are at risk of exposure to bloodborne pathogens receive initial training (including site-specific training which must be completed in conjunction with an experienced person in the employee’s work environment). This training must be completed before the supervisor permits the employee to engage in work procedures with a BBP exposure risk.
- All employees under their supervision who are at risk of exposure to BBPs complete annual retraining in bloodborne pathogens as outlined in the “Training” section of this document.
- All volunteer personnel in their area who are at risk for exposure to bloodborne pathogens receive training and follow safe work practices commensurate with that of employees performing the same duties.
- Proper exposure control procedures are followed as outlined in the “Methods of Compliance” section of this document.
- Appropriate personal protective equipment is available and in good working condition for all employees at risk of exposure to bloodborne pathogens; this includes alternatives if an employee is allergic to the gloves normally provided.
- Any employee who experiences an occupational exposure incident to blood or other potentially infectious materials is provided with post-exposure medical services as outlined in the “Post-Exposure Evaluation and Follow-Up” section of this document.
- Conducting periodic audits and inspections of environments where occupational exposure risk is present to verify regulatory compliance.
- Program-related documentation (i.e., training records, written procedures, sharps evaluation forms, equipment maintenance records) is available at the work site and is current with regulatory requirements.
Employees who have occupational exposure risk for BBPs are responsible for following procedures and practices, as outlined in the Exposure Control Plan. This includes but is not limited to:
- Completing bloodborne pathogens initial training and annual refresher training.
- Understanding which tasks have potential occupational exposure to bloodborne pathogens.
- Conducting all operations in accordance with established work practice controls, including use of Standard Precautions.
- Developing and maintaining good personal hygiene habits.
- Reporting all exposure incidents.
AVAILABILITY OF THE EXPOSURE CONTROL PLAN TO EMPLOYEES
All supervisors with personnel who have occupational exposure to BBPs should maintain a copy of the Exposure Control Plan and have it readily available to their employees. This Exposure Control Plan can also be accessed by employees and the general public at the following website: https://www.uthsc.edu/campus-safety/procedures-policies.php.
Review and Update of the Plan
This Exposure Control Plan will be reviewed and updated at least annually by the UTHSC Safety Committee with input from other Exposure Control Coordinators and supervisors of personnel who have occupational exposure risk for BBPs.
Supervisors are responsible for determining which employees have potential for occupational exposure to bloodborne pathogens, infectious agents or OPIM, and for providing these individuals with proper training. Training must include:
- The identification of activities or tasks associated with risk of exposure to Bloodborne Pathogens (BBP)
- Instructions for performing procedures associated with risk of exposure to BBP
- Completion of a BBP training program that meets content requirements established by OSHA, such as BBP training provided by UTHSC Campus Safety
The following list of job classifications and exposure risk tasks are identified as having potential for occupational exposure to BBP.
- Anatomy Bequest Program Staff: Handling and preparation of Anatomy Bequest Program specimens.
- Campus Police: Required to administer first aid or perform human blood/ OPIM spill response as part of job duties.
- Clinical Laboratory Staff: Handling blood, OPIM and other patient specimens.
- Clinical Research Staff: Collection or handling of patient specimens.
- College of Dentistry: Dental procedures, providing dental hygiene and other related healthcare practices involving interaction with patients, devices or equipment that have contacted blood or OPIM.
- College of Medicine: Faculty, students, residents and fellows, providing healthcare to patients.
- Custodial Services: Spill response involving human blood or OPIM; accidental contact with improperly disposed sharps.
- Forensic Center Technicians: Handling of human materials.
- Lab Animal Care Unit Staff: Care of animals that have been challenged with a BBP; care of animals that have been implanted with human derived materials where there is a possibility of leakage or seepage of these materials from the implant site.
- Lifeguards: Required to administer first aid or perform human blood/OPIM spill response as part of job responsibilities.
- Maintenance Workers: Maintenance/repair of laboratory or clinical care facility plumbing.
- Principal Investigator/Research Associate: Manipulation of human derived materials including cells and materials contaminated with such materials.
- Research Assistant/Research Technician: Manipulation of human derived materials including cells and materials contaminated with such materials. Spill response involving human blood or other human-derived material.
- University Health Services Staff: Contact with blood or OPIM during interaction with patients, handling of specimens and other healthcare activities.
- Any Other Job Classification: Required to administer first aid or perform human blood/ OPIM spill response as part of job duties.
METHODS OF COMPLIANCE:
All human blood* and other potentially infectious materials must be treated as if known to be infectious for HBV, HCV, HIV and other bloodborne pathogens. OPIMs include:
- Body fluids containing visible blood
- Semen and vaginal secretions
- Cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids
- Human cell, tissue, or organ cultures not shown to be free of bloodborne pathogens.
*Note: “Blood” includes human blood products such as serum, plasma, albumin, etc.
Equipment such as hand washing facilities, eye wash stations, sharps disposal containers, biological safety cabinets, autoclaves, and safer sharps devices are to be used when appropriate. Examples of safer sharps devices include needleless systems and sharps with engineered sharps injury protection (e. g., self-sheathing syringe needles).
The UTHSC safety professionals, in conjunction with appropriate supervisors, will review tasks and procedures performed to determine where engineering controls can be implemented or updated.
Engineering controls to be used for work with potentially infectious materials include:
- Hand washing facilities must be accessible to all employees who have a potential for exposure. Waterless antiseptic hand cleansers or antiseptic towelettes must be available to employees at risk of exposure if running water is not readily available. If waterless cleansers or towelettes must be used, the employee must follow up with a soap and water wash as soon as feasible.
- Emergency eye wash stations must be near workstations or work areas where employees perform tasks that may produce splashes of potentially infectious materials. Eye wash stations must be kept clear of items that hinder accessibility or proper function and must be flushed regularly.
- Biosafety Cabinets (BSC) must be used for manipulations of blood or OPIM (including human cells) that will generate aerosols. BSCs are designed to provide personal, environmental and product protection when appropriate practices and procedures are followed. Biosafety cabinets use high efficiency particulate air (HEPA) filters in their exhaust and/or supply systems. Biosafety cabinets must not be confused with other laminar flow devices or “clean benches”; in particular, horizontal flow cabinets which direct air towards the operator should never be used for handling potentially infectious, toxic or sensitizing materials. BSCs used for manipulation of human-derived materials or infectious agents must be certified (i.e., leak tested and inspected, using criteria of National Sanitation Foundation 49 Standard) when initially installed, moved, or at least annually.
- Safe Sharps Devices (or sharps with engineered sharps injury protections) should be used for any lab manipulations involving human blood or blood products and human cell or tissue cultures whenever feasible. Whenever a sharp device will be used for procedures on a living human (i.e., phlebotomy, vaccine administration), an engineered safer sharps device MUST be used. The use of sharps for procedures on living humans must be documented initially and annually as outlined in the Sharps Injury Protection Program section of this Exposure Control Plan. Safe sharps devices include, but are not limited to:
- Self-sheathing needles/syringes.
- Hypodermic syringes with retractable technology safety features.
- Phlebotomy needles with self-blunting safety features.
- Retracting lancets with safety features; or
- Disposable scalpels with shields and other safety features.
- Biohazardous sharps containers must be used to properly store and dispose of contaminated sharps. Disposable biohazardous sharps containers must isolate the cut or puncture hazard associated with handling sharp items such as needles, scalpels, or Pasteur pipettes. Therefore, containers used for collection and disposal of contaminated sharps must be designed and manufactured for that specific purpose and used in accordance with the manufacturer’s instructions. Disposable biohazardous sharps containers must be:
- Red in color or labeled with a biohazard warning label.
- Leak-proof on the sides and bottom.
Containers for reusable contaminated sharps must meet the same requirements as containers for disposable sharps; however, they are not required to be closable, and do not have to be manufactured specifically for that purpose. Reusable sharps must not be stored or processed in a manner that requires reaching into containers of contaminated sharps. Food containers, such as coffee cans, are not acceptable containers for sharps collection or disposal.
- Storage and/or transport containers must be used to reduce the potential for an environmental release of potentially infectious materials. Primary containers should be designed to be leak-proof, puncture-resistant, and capable of being closed. Single primary containers used for potentially infectious materials should be labeled with the biohazard symbol. If multiple primary containers are stored in a secondary container (such as a rack of specimen tubes contained in a cooler for transport), only the secondary container must be labeled with the biohazard symbol. Secondary containers are used for additional protection against an environmental release and therefore must be leak-proof, puncture-resistant and capable of being closed. Use of secondary containers are required for any transportation or long-term storage of all potentially infectious materials.
Supervisors are responsible for ensuring that all personnel with occupational exposure risk complete training regarding applicable work practices to reduce exposure risk, and for assuring that these work practices are adopted and followed on the job.
The following work practice controls are to be implemented.
General Practices and Rules
- Eating, drinking, smoking, applying cosmetics or lip balm, handling contact lenses, and food/drink storage is prohibited in all laboratory areas.
- Mouth pipetting/suctioning of blood or other infectious materials is always prohibited.
- Minimize splashing, spraying or other actions generating droplets of blood or other potentially infectious materials during all procedures.
- At a minimum, Biosafety Level 2 containment practices are required for laboratories working with specimens of blood or body fluids.
- Specimens of blood or other potentially infectious materials must be placed in designated leak-proof containers, appropriately labeled for handling and storage.
- Primary containers of potentially infectious materials must be placed in puncture-resistant, leak-proof, closable secondary containers for transportation outside of the work area (e.g., from lab to lab where a common hallway is used, etc.).
Hand washing* must be performed:
- After removal of gloves or other personal protective equipment.
- When visible contamination with blood, body fluids, or other potentially infectious materials is present.
- When work is completed and before leaving the patient care area or laboratory.
- Before eating, drinking, smoking, applying makeup, changing contact lenses, or using the bathroom.
Note: Soap and water are the most effective means for hand washing. If a waterless hand cleanser or antiseptic towelettes are used due to lack of available running water, the employee must follow up with soap and water as soon as feasible.
Contaminated Needles and Other Contaminated Sharps
Contaminated needles and other contaminated sharps must not be bent, recapped or removed unless it can be demonstrated that there is no feasible alternative. In this event, such bending, recapping or needle removal must be accomplished using a mechanical device or one-handed technique.
Use of Sharps Containers
Immediately or as soon as possible after use, contaminated reusable sharps shall be placed in appropriate containers until properly reprocessed. These containers must be:
- Labeled with the biohazard symbol or color-coded in red
- Leak-proof on the sides and bottom
- Designed and used in such a manner that does NOT require employees to reach by hand into the containers.
Disposable contaminated sharps must be placed in appropriate containers (as described under “Engineering Controls”) immediately, or as soon as possible, after use. These containers must be:
- Leak-proof on the sides and bottom
- Labeled with the biohazard symbol or color-coded in red.
During use, containers must be:
- Located as close as feasible to the immediate area where sharps are used, or otherwise can be reasonably found.
- Maintained upright throughout use.
- Replaced routinely and not overfilled. Containers must be permanently closed and replaced either upon reaching the maximum capacity indicator or they are ¾ full.
Proper use of sharps container lids is required. These practices include:
- Lids must be properly installed before a disposable biohazardous sharps container is put into use.
- When not in use, or when moving a container from one location to another, sharps container lids must be closed to further eliminate the potential for exposure.
- Container lids must be permanently closed before handling containers for disposal.
Work Surface and Waste Container Cleaning and Disinfecting
Employees working with potentially infectious materials must:
- Clean and decontaminate all equipment and surfaces after contact with blood or other potentially infectious materials. Visible contamination must be removed before applying disinfectants to surfaces to ensure product efficacy. Disinfectants must be EPA-registered and capable of inactivating HIV and HBV. Freshly made 1:10 (vol:vol) bleach solutions are also acceptable.
Clean and disinfect:
- Immediately (or as soon as feasible) when surfaces become contaminated.
- After any spill of blood or potentially infectious materials.
- At the end of the work shift, especially if the surface may have become contaminated during that shift.
Examine contaminated equipment prior to servicing or shipping. If it can be demonstrated that decontamination is not possible, then the following steps need to be taken:
- Attach a biohazard warning label to any contaminated equipment, identifying the contaminated portions.
- Inform affected employees, equipment manufacturer and the equipment service representative of remaining contamination prior to handling, servicing, or shipping.
- If equipment must be shipped, contact Campus Safety before shipping.
- Routinely inspect and clean all pails, bins, cans, and other receptacles. These items must be properly decontaminated whenever visibly contaminated.
- Pick up potentially contaminated broken glassware using mechanical means (such as tongs, forceps, or a dustpan and brush) and dispose of in a proper sharps container. Do not handle broken contaminated glass with your hands!
- Immediately clean up spills of blood, body fluids, or any other potentially infectious materials.
When disposing of contaminated biological waste:
- Discard in a biohazard bag placed inside a secondary biohazard waste container.
- Locate containers for regulated waste so that they are readily accessible to employees and as close as possible to the source of the waste.
- Maintain waste containers in an upright position and do not overfill.
- Close containers when not actively in use and at the end of the day.
- Contain and store waste in accordance with procedures outlined by the medical waste contractor when applicable.
PERSONAL PROTECTIVE EQUIPMENT
Personal protective equipment is available at no cost to all employees with an occupational exposure to blood or other potentially infectious materials. PPE items include gloves, gowns, laboratory coats, face shield/masks, safety glasses, goggles, mouthpieces, resuscitation bags, pocket masks, hoods, and shoe covers. Assignment of PPE for a given task must be based on the potential for exposure risk and the nature of that exposure. The UTHSC safety professionals should be consulted for assistance with PPE selection.
Principal Investigators (PI) or supervisors must ensure that PPE of appropriate type and size is available and easily accessible to employees. Employees must be trained, regarding the use of appropriate PPE for their job classification and the tasks/procedures they perform. This training must be documented through the completion of a Job Hazard Assessment, Bloodborne Pathogens training record, or other means determined by the supervisor.
PIs and supervisors shall ensure that employees use appropriate PPE. If an employee declines to use PPE, the PI/supervisor must show that it was the employee’s professional judgment that the use of PPE would have posed an increased hazard to the safety of himself/herself or a coworker. When the employee makes this judgment, the circumstances shall be investigated and documented to determine if changes can be made to prevent future occurrences.
Types of Personal Protective Equipment (PPE)
Gloves shall be worn:
- When it can be reasonably anticipated that the employee may have hand contact with blood or OPIM, mucous membranes, and non- intact skin
- When performing vascular access procedures,
- When handling or touching contaminated items or surfaces.
Disposable (single use) gloves such as surgical or examination gloves, shall be replaced as soon as practical when contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised.
Disposable (single use) gloves shall not be washed or decontaminated for re-use.
Utility gloves shall be discarded if cracked, peeling, torn, punctured, or otherwise exhibit signs of deterioration, or when their ability to function as a barrier is compromised.
Gloves should not be worn in public areas outside the laboratory, including hallways and offices. Individuals must use a disinfected secondary container or use the “one glove” technique when transporting hazardous materials between work areas.
• Masks, eye protection and face shields
Masks shall be worn alone or in combination with eye protection devices such as goggles or glasses, side shields, face shields, etc. whenever splashes, spray, splatter or droplets of blood or OPIM may be generated and eye, nose, or mouth contamination can be reasonably anticipated.
• Gowns and other protective body clothing
Appropriate protective clothing such as, but not limited to, long-sleeved gowns, aprons, long sleeved lab coats, long- sleeved clinical jackets, or similar outer garments shall be worn when occupational exposure may occur. The type and characteristics of such protective clothing must be appropriate to the task and degree of exposure anticipated.
The supervisor is responsible for designating the appropriate PPE that employees should wear during specific treatments or tasks depending on the degree of exposure anticipated. Campus Safety personnel are available to provide technical assistance to supervisors making PPE selections.
Surgical caps, hoods and/or covers or boots shall be worn in instances when gross contamination can reasonably be anticipated (e.g., autopsies, orthopedic surgery, etc.)
The following practices must be utilized to ensure that PPE is not contaminated and is in appropriate condition to protect employees from potential exposure:
- All PPE must be inspected periodically by the PI/supervisor and repaired or replaced as needed.
- Reusable PPE (lab coats, safety glasses, face shields, etc.) must be cleaned or laundered and decontaminated as needed. Lab coats (and any personal clothing that becomes contaminated with blood or OPIM) must not be sent home with employees for laundering. For assistance with identifying on-site laundry or commercial laundry services, contact your departmental office or campus safety officer.
- Single-use PPE that is contaminated with blood or OPIM to the extent where the material can drip or flake off the item will be disposed of as biohazardous waste.
When using PPE, employees must:
- Inspect PPE prior to use to verify that it is in good condition.
- Remove all PPE before leaving the work area.
Wear gloves when:
- Hand contact with potentially infectious materials is anticipated.
- Handling or touching contaminated items or surfaces.
- Working with or performing any procedures with lab animals.
- Replace disposable gloves as soon as possible after contamination or immediately when torn, punctured or otherwise rendered unable to function as an exposure barrier.
- Report any adverse reactions to glove material, or any known latex allergy to your supervisor so that appropriate alternative protective devices can be provided.
- Decontaminate reusable gloves (i.e., heavy gauge nitrile or vinyl) before reuse; if utility gloves are cracked, peeling, torn or exhibit other signs of deterioration, they must be discarded.
- Wear eye protection and masks whenever there is a chance that a splash or spray may generate droplets of infectious materials.
- Wear protective clothing (e.g., lab coat) whenever splashes or aerosols of human blood or OPIM are anticipated.
- Wear fluid-resistant body covering (i.e., coated Tyvek coveralls) and shoe covers/boots in any instance where gross contamination is anticipated.
- Remove and replace compromised or moderately contaminated PPE as soon as feasible.
- Wash hands after removal of PPE.
BLOODBORNE PATHOGEN COMMUNICATION:
LABELS AND SIGNS
Biohazard labels consist of a red or fluorescent orange colored background with the traditional biohazard symbol in a contrasting color. Campus Safety and the Office of Research Safety Affairs will keep a supply of labels meeting these criteria and these will be available upon request.
The following items must be labeled:
- Entrances to all laboratory areas where blood, cell cultures, or other potentially infectious materials are used.
- Containers of regulated waste.
- Refrigerators, freezers, incubators, or other equipment containing blood, cell cultures, or other potentially infectious materials.
- Sharps disposal containers.
- Containers used to store, transport or ship blood and other potentially infectious materials. When a primary container holds several smaller items containing the same potentially infectious substance, only the primary container needs to be labeled. All employees handling these containers must be informed of their contents and the need to use Standard Precautions when handling such items. Items that are transported or shipped need to comply with local and federal transportation regulations. Contact the Campus Safety prior to shipping any potentially infectious materials.
- Laundry bags/containers holding contaminated items. Alternately, laundry may be placed in a biohazard bag. Employees handling laundry must be informed of the potential for contamination and/or infectivity of the biohazard bags.
- Contaminated equipment.
INFORMATION AND TRAINING
All employees who have occupational exposure to human blood or OPIM are required to complete bloodborne pathogens training before engaging in job tasks with an exposure risk.
Employees must complete annual refresher training to keep their knowledge current. Other training must be conducted as needed to address new tasks or procedures that affect occupational exposure. Volunteers who are performing tasks that put them at risk for BBP exposure should be provided with the same level of training and information as employees.
The UTHSC Campus Safety and Emergency Management has prepared online Bloodborne Pathogens training that addresses campus specific procedures. This general training must be supplemented with task-specific training to be provided by an individual experienced in the specific tasks expected to be carried out by the work group. Upon request, Campus Safety will provide in-person training for UTHSC personnel. All sessions conducted by Campus Safety will be tailored for the audience’s learning needs and will offer an opportunity for employees to ask questions.
Initial Training Topics
Per the minimum requirements of the OSHA BBP Standard, bloodborne pathogens training for new employees who will have occupational exposure to human blood or OPIM will include the following mandatory topics:
- OSHA’s Bloodborne Pathogens Standard and its availability.
- Epidemiology, symptoms and modes of transmission of bloodborne diseases including HIV, HBV and HCV; existence of other bloodborne diseases.
- UTHSC Exposure Control Plan and its availability.
- Methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials.
Review of use and limitations of methods that will prevent or reduce exposure, including:
- Engineering controls
- Work practice controls
- Personal protective equipment (PPE).
- Proper selection, use and disposal of PPE.
- Visual warning of biohazards including labels, signs and color-coded containers.
- Information on the Hepatitis B vaccine, including its availability, efficacy, safety, benefits, administration, and HBV Vaccination Program.
- Emergency actions for incidents involving blood or other potentially infectious materials.
- Incident reporting
- Post-exposure evaluation and follow-up including medical consultation.
If a supervisor chooses to perform their own training, he or she must ensure that all these topics, as well as site-specific training information are included. This training must be conducted in a manner that includes an interactive question and answer component. The supervisor must document the training event as outlined under the “Training Documentation” section.
Update and Annual Refresher training
Supervisors must provide a brief update training anytime that a new task or procedure is adopted that affects occupational exposure risk. This training should be documented as outlined in the next section. Annual refresher must be completed, regardless of any procedural changes. Training shall reiterate and emphasize key training components of the bloodborne pathogen standard as well as any new information related to exposure control.
Whenever BBP training is conducted, the following information must be documented:
- Dates of all training sessions
- Contents/summary of the training sessions
- Names and qualifications of the instructors
- Names and job titles of employees attending the training sessions.
Although the UTHSC health & safety professionals will maintain records of the training sessions that they provide and completion of online training obtained through UTHSC Campus Safety, this does not constitute a complete training record. Therefore, supervisors must maintain records for their personnel in their workplace. These records must be available for inspection upon request. Training records must be maintained for at least three years from the date of the event.
HEPATITIS B VACCINATION, POST-EXPOSURE EVALUATION AND FOLLOW-UP:
A hepatitis B vaccination program and procedure for post-exposure evaluation and follow-up has been established by University Health Services.
HEPATITIS B VACCINATION
Vaccination for the Hepatitis B virus (HBV) is available, at no cost to the individual, for all employees who have the potential for occupational exposure. The vaccine is administered through UTHSC University Health Service (UHS). The vaccination program consists of a series of three inoculations over a six-month period and a post-vaccine titer. Information addressing the safety, benefits, efficacy, and methods of administration are available from UHS. At the time of the bloodborne pathogens training, employees will receive information about the availability of the vaccine and its benefits and risks. Employees must be trained before they are offered the vaccine.
If a person decides to decline the Hepatitis B vaccination, they must sign the Hepatitis B Vaccine Declination form (Appendix A). The vaccination requirement is waived if the employee provides documentation that he or she has previously received the complete HBV vaccination series, or if antibody testing reveals that the employee is immune, or if the vaccine is contraindicated for medical reasons.
EXPOSURE RESPONSE, POST-EXPOSURE EVALUATION AND FOLLOW-UP
Employees of UTHSC work in a variety of environments at different sites throughout State of Tennessee. It is important that ALL employees know what to do and who to contact in the event an exposure occurs. This information shall be communicated during initial and annual training. Supervisors or academic program leaders will facilitate all post-exposure treatment protocols detailed in campus procedures, plans and the CDC guidelines for handling Bloodborne Pathogens.
If an employee sustains an exposure to biological materials considered to be a bloodborne pathogens risk, the employee should seek medical consultation and treatment immediately.
First aid response includes the following (Appendix B):
- If contact with blood or other potentially infectious material occurs on skin with cuts, rashes, acne or dermatitis, wash the area for 15 minutes with soap and water.
- If blood or other potentially infectious material splashes in the eyes or on mucous membranes, flush the area for 15 minutes with water or normal saline.
- If there is a cut or puncture with a contaminated object (broken glass, needle, etc.), wash the area for 15 minutes with soap and water.
Exposures must be reported as follows:
- Notify the supervisor or instructor of the work area or academic program where the exposure occurred.
- UTHSC faculty and staff exposures must be reported by calling the CorVel 24/7 nurse line at 1-866-245-8588 within 48 hours of the incident and before seeking follow-up medical care. Faculty members with joint appointments at UTHSC and affiliate locations shall only call CorVel if the exposure occurred during the performance of UTHSC-related job responsibilities
- Student exposures must be reported by completing the online Incident Report Form accessible on the UTHSC Campus Safety website.
Follow-up care should be obtained as soon as possible after an exposure.
- Employees located at the UTHSC Memphis campus may report University Health Services (UHS) for follow up care. UHS is located at 910 Madison Avenue, 9th floor. UHS may be contacted during regular business hours by calling 901-448-5630. UHS may be contacted afterhours and on weekends by calling 901-541-5654.
- Follow affiliate location procedures for exposures that occur off-campus.
Exposures involving College of Pharmacy students or staff should seek follow-up care as follows:
- Memphis: UTHSC University Health Services at 910 Madison Avenue, Memphis, Tennessee.
- Nashville: Vanderbilt University Medical Center at 1211 Medical Center Drive, Nashville, Tennessee
- Knoxville: University of Tennessee Medical Center at 1924 Alcoa Highway, Knoxville, Tennessee
- Campus Safety will follow up on injuries and exposures that occur on the Memphis campus to investigate and document if changes can be made to prevent future occurrences. This will include collection of Sharps Injury Log information.
UTHSC AFFILIATE SITES
Affiliate Site Daytime After Hours
University Health Services
UHS Medical Provider: (901) 541-5654
BAPTIST HOSPITAL (East)
Employee Health (8am-4pm)
Emergency Room (901) 226-5000
EAST TENNESSEE CHILDREN’S HOSPITAL
Erlanger Work Force Corporate Health Office (8am-4pm)
Associate Health (8am-4pm)
Emergency Room (866) 870-5570
JACKSON-MADISON COUNTY HOSPITAL
MEMPHIS MENTAL HEALTH INSTITUTE (MMHI)
METHODIST UNIVERSITY HOSPITAL
Associate Health (7am-4pm)
MOCCASIN BEND MENTAL HEALTH INSTITUTE
REGIONAL ONE MEDICAL CENTER (THE MED)
(7am-5pm) (901) 545-7166
Emergency Room (901) 545-7826
ST. FRANCIS HOSPITAL
Emergency Room (901) 765-2180
ST. JUDE CHILDREN’S RESEARCH HOSPITAL
ST. THOMAS HOSPITAL
UT MEDICAL CENTER (KNOXVILLE)
Employee Health (8am-5pm)
Vanderbilt University Medical Center
Operator: (615) 322-5000
Operator: (615) 322-5000
UTHSC University Health Services (UHS) maintains confidential employee medical records. Information will not be disclosed without the employee’s written consent, except as required or permitted by law. These records will be maintained for, at least, the duration of the employee’s employment plus 30 years.
SHARPS INJURY PREVENTION PROGRAM:
All sharp devices at UTHSC that are used in healthcare setting procedures where device contamination with blood or OPIM is anticipated must be safe sharp devices as described in the Methods of Compliance section (Engineering controls, Safe Sharps Devices). Selection and use of safer sharps must be documented initially and annually. If no safe sharp option exists for the device in question, this must be documented, as well.
UTHSC research laboratories at the Memphis campus that plan to use human blood or OPIM in their applications must register their use of such materials with the Institutional Biosafety Committee (IBC). Through this registration process, the IBC will work with PIs/supervisors to evaluate procedures for exposure risk including the use of sharps and to identify procedure changes that can reduce exposure risk. If procedures will require collection of blood or OPIM from a living human source, and collection will be performed by lab personnel a safe sharp devise must be used.
When replacing a conventional sharp device with a safe sharp device, supervisors must ensure that the safe sharp device is properly evaluated before implementing the use of the device. Front line employees must be included in the evaluation process and the evaluation must be documented. Selection decisions must be based on employee acceptance, product reliability and safety. A sample initial evaluation form that can be used or adapted for as needed is included with this plan. A sample annual evaluation form that can be used or adapted for UTHSC needs is also included.
UTHSC Campus Safety maintains a sharps injury log for the recording of percutaneous injuries from contaminated sharps that occur at UTHSC Memphis campus. Information about sharps injuries that occur at affiliate healthcare settings off campus are maintained in the sharps injury log for that location. The information in the sharps injury log is recorded and maintained in such manner as to protect the confidentiality of the injured employee. A copy of the Sharps Injury Investigation form used by Campus Safety is included with this plan.
SHIPPING HUMAN MATERIALS INCLUDING BLOOD AND OTHER POTENTIALLY INFECTIOUS MATERIALS
Individuals shipping potentially infectious substances including human blood and OPIM must do so in accordance with the requirements of the United States Department of Transportation, the International Air Transport Association (IATA) and the UTHSC Security Plan for the Security Plan for the Transportation of Hazardous Materials. Training is provided by the Office of Research Safety Affairs and must be renewed at least every two years as required by regulation.