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The Fred Hutchinson Cancer Research Center is committed to providing a safe and healthful work environment for all staff. The Exposure Control Plan (ECP) contains details on how Fred Hutch eliminates or minimizes occupational exposure to bloodborne pathogens. This plan is in compliance with the Washington Industrial Safety and Health Act Standard titled "Occupational Exposure to Bloodborne Pathogens" (Chapter 296-823 WAC, January 2013 edition).

Workers can review the Exposure Control Plan at any time during their work shifts. EH&S maintains the detailed ECP. Because the plan is updated annually, it is not included in this manual, but the latest version can be found online at the EH&S website, or you may request a copy, free of charge, from EH&S.

Workers who have occupational exposure to human blood or other potentially infectious material (OPIM) must follow the procedures and work practices in this plan. Other potentially infectious materials include all of the following:

  1. 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;
  2. Any unfixed tissue or organ (other than intact skin) from a human (living or dead);
  3. Human cell lines;
  4. 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; or
  5. Blood and tissues of experimental animals infected with bloodborne pathogens.

7.1 Exposure Control Plan

EH&S is responsible for oversight of the Exposure Control Plan. The ECP is reviewed and updated at least annually whenever necessary to:

  1. Reflect new or modified tasks and procedures that affect occupational exposure;
  2. Reflect new or revised job classifications with occupational exposure;
  3. Reflect changes in technology that eliminate or reduce exposure to bloodborne pathogens; or
  4. Document consideration and implementation of appropriate commercially available and effective safer medical devices designed to eliminate or minimize occupational exposure.

The Exposure Control Plan includes:

  1. The overview;
  2. Identification of workers who are at risk for exposure;
  3. Controlling worker exposure to bloodborne pathogens;
  4. Worker training and hazard communication;
  5. Post-exposure evaluation and follow-up; and
  6. Recordkeeping.

The exposure control plan is available from EH&S or on the EH&S website.

EH&S is responsible for:

  1. Implementing the exposure control plan
  2. Maintaining, reviewing, and updating the exposure control plan at least annually, and whenever necessary to include new or modified tasks and procedures
  3. Making this plan available to employees, and DOSH (Division of Occupational Safety and Health) representatives
  4. Making sure all medical actions required are performed, and that appropriate employee medical records are maintained
  5. Making sure this list is kept up-to-date.

7.2 Identification of Workers at Risk for Exposure

The Hazard Exposure Assessment (HEA) form is used to determine if workers have the potential for exposure to bloodborne pathogens (BBPs) or other potentially infected materials (OPIM) during the course of their work. Completion of the HEA occurs upon hire, on an annual basis, and if job changes occur. An exposure determination list of workers having reasonably anticipated exposure to BBPs or OPIM is maintained in the detailed Exposure Control Plan maintained by EH&S. It contains:

  1. A list of job classifications in the center in which all staff have occupational exposure to bloodborne pathogens.
  2. A list of job classifications in the center in which some staff have occupational exposure to bloodborne pathogens, along with a description of all tasks and procedures.

7.3 Controlling Staff Exposure to Bloodborne Pathogens (BBP)

The Center uses a combination of methods to control staff exposure to bloodborne pathogens.

7.3.1 Universal Precautions

Universal precautions is the name given to an infection control system that requires staff to handle all blood or OPIM as potentially infectious for human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other bloodborne pathogens. It is intended to prevent parenteral, mucous membrane, and nonintact skin exposures to blood or OPIM.

7.3.2 Safer Medical Devices and Equipment Used to Minimize Occupational Exposure

Universal precautions is the name given to an infection control system that requires staff to handle all blood or OPIM as potentially infectious for human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other bloodborne pathogens. It is intended to prevent parenteral, mucous membrane, and nonintact skin exposures to blood or OPIM.

7.3.3 Personal Protective Equipment (PPE)

Personal protective equipment includes devices worn by staff to protect them against bloodborne pathogen exposures. The Center provides PPE to staff at no cost. Department supervisors are responsible for purchasing, distributing, and maintaining PPE.

The types of PPE available to staff are gloves, gowns, lab coats, and face shields (or a combination of masks and eye protection). It is the responsibility of the department supervisor to maintain PPE and to inform staff of the location where PPE is stored.

All staff using PPE must observe the following precautions:

  1. Wear appropriate face and eye protection when splashes, sprays, spatters, or droplets of blood or OPIM pose a hazard to the eye, nose, or mouth.
  2. Wear appropriate gloves when you can reasonably anticipate hand contact with blood or OPIM, or handle or touch contaminated items or surfaces.
  3. Replace gloves if torn, punctured, contaminated, or otherwise damaged.
  4. Decontaminate reusable gloves if they don't show signs of cracking, peeling, tearing, puncturing, or other deterioration.
  5. Never wash or decontaminate disposable gloves for reuse.
  6. Wash hands immediately or as soon as feasible after removal of gloves or other PPE.
  7. Remove PPE after it becomes contaminated, and before leaving the work area.
  8. Dispose of contaminated PPE in designated containers.
  9. Remove blood- or OPIM-contaminated garments immediately or as soon as feasible, in a manner that avoids contact with the contaminated surface.

For specific details on the types of PPE used at the center and how to handle used PPE, please see Chapter III, Section 6, Personal Protective Equipment.

For more information on lab coats, please see Chapter III, Section 6.2.

7.3.4 Work Practices Used to Minimize Occupational Exposure

The Center uses the following work practices to eliminate or minimize staff exposure to bloodborne pathogens:

  1. Handle contaminated sharps properly and safely:
    1. Don't bend, recap, or remove contaminated needles or other contaminated sharps unless it can be demonstrated that there is no feasible alternative or that it's required by a specific procedure. If bending, recapping, or needle removal is necessary, it must be done using a mechanical device or a one-handed technique.
    2. Don't shear or break contaminated needles.
  2. Handle reusable sharps properly and safely:
    1. Place contaminated reusable sharps immediately, or as soon as possible after use, in appropriate containers until properly contaminated.
    2. Store or process contaminated reusable sharps so that staff aren't required to reach into the container or sink by hand.
    3. Ensure reusable sharps containers aren't opened, emptied, or cleaned manually or in any other manner that would exposure staff to contaminated sharps.
  3. Ensure all procedures involving blood or OPIM are performed so splashing, spraying, spattering, and generation of droplets are minimized.
  4. Ensure that staff clean their hands regularly and properly:
    1. Provide hand washing facilities that are readily accessible to staff, wherever feasible. If hand washing facilities aren't feasible, provide either antiseptic towelettes or antiseptic hand rub product along with clean cloth/paper towels.
    2. Ensure that staff clean their hands as soon as feasible after removing gloves and whenever there is the potential for contact with blood or OPIM.
    3. Ensure that staff wash any skin with soap and water, or flush mucous membranes with water as soon as feasible following contact with blood or OPIM.
  5. Prohibit food, drink, and other personal activities in the work area:
    1. Ensure eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is occupational exposure.
    2. Ensure food and drink aren't kept in refrigerators, freezers, shelves, cabinets, or on countertops or bench tops where there is a potential for exposure to blood or OPIM.
  6. Prohibit mouth pipetting and suctioning of blood or OPIM by mouth.

7.3.5 Housekeeping

All equipment and working surfaces in which handling of blood or OPIM occur must be decontaminated:

  1. After completion of a procedure;
  2. Immediately or as soon as possible when surfaces are clearly contaminated or after any spill of blood or OPIM; and
  3. At the end of the workshift, if the surface could have been contaminated since the last cleaning.

Bins, cans and pails intended for reuse must be cleaned and decontaminated as soon as feasible after visible contamination. Broken glassware that may be contaminated must be picked up using mechanical means, such as a brush and dustpan, tongs, forceps, or other mechanical means. Decontamination of blood or OPIM must be conducted using an appropriate disinfectant that is effective against tuberculosis, HBV and HIV, such as a diluted bleach solution. It is the responsibility of the individual causing the contamination to clean and disinfect the area.

Regulated waste is placed in containers which:

  • Contain all contents
  • Do not leak
  • Are appropriately labeled or color-coded
  • Are closed prior to removal to prevent contact spilling or protruding during handling.

Contaminated sharps are discarded immediately after use in containers that are:

  • Closable
  • Puncture-resistant
  • Leak-proof on sides and bottoms
  • Labeled or color-coded appropriately
  • Easily accessible to personnel
  • Located as close as feasible to the immediate area where sharps are used or areas sharps can reasonably anticipated to be found
  • Maintained upright throughout use
  • Replaced routinely and not allowed to overfill.

For more information on blood or OPIM spill response, see Section 6.

For more information on the handling of biohazardous waste, see Chapter VI, Section 8.

For more information on sharps disposal containers and the handling of sharps waste, see Chapter VI, Section 9.

7.3.6 Laundry

Lab coats are available for all staff whose jobs involve exposure to blood or OPIM. A vendor provides weekly laundry service for all lab coats.

For information on the Center's lab coat policy, lab coat station locations, and what to do with contaminated lab coats, see Chapter III, Section 6.2.

7.3.7 Using Labels

Appropriate labels must be attached to:

  1. Containers used to store, transport, or ship blood or OPIM including refrigerators and freezers;
  2. Sharps containers;
  3. Contaminated equipment (e.g., centrifuges, incubators, refrigerators);
  4. Laundry bags and containers;
  5. Specimen containers; and
  6. Regulated waste containers.

Labels are all or mostly fluorescent orange or orange-red with the lettering and biohazard symbol in a contrasting color, and are attached to containers using methods which do not allow them to become lost or accidentally removed. Red bags or red containers may be substituted for labels.

For more information on labeling of biohazardous waste, see Chapter VI, Section 8.

7.3.8 Hepatitis B Vaccinations

The Hepatitis B vaccination series is available within 10 days of initial assignment to all workers who are identified as having potential exposure to blood or OPIM. The vaccination is free of charge. Vaccination is encouraged unless documentation is received that shows the worker has previously received the series, antibody testing reveals that the worker is immune, or medical evaluation shows that vaccination is contraindicated. A worker who chooses to decline the vaccination must sign a declination form. They may, however, request and obtain the vaccination at a later date, at no cost.

Vaccinations are provided by an occupational health nurse (OHN) at the conclusion of new employee bloodborne pathogens training, during employee health clinics (see the EH&S web page for the schedule), or via individual appointments.

7.3.9 Staff Training

All workers who have occupational exposure to bloodborne pathogens receive training conducted by the Environmental Health & Safety Department. Training is provided annually, before initial assignment to a task in which occupational exposure may take place, and when changes in task or procedures take place that affect occupational exposure.

Bloodborne pathogen training includes:

  1. Epidemiology, symptoms, and transmission of bloodborne pathogens;
  2. Explanation of WAC 296-823, Occupational Exposure to Bloodborne Pathogens; copies of WAC provided upon request;
  3. Explanation of the Center's Exposure Control Plan and how to obtain a copy;
  4. Methods used to identify tasks and other activities that may involve exposure to blood and OPIM;
  5. What constitutes an exposure incident;
  6. The use and limitations of controls, work practices, and PPE;
  7. The basis for PPE selection and an explanation of:
    1. Types
    2. Uses
    3. Location
    4. Handling
    5. Removal
    6. Decontamination
    7. Disposal
  8. Information on the hepatitis B vaccine, including:
    1. Effectiveness
    2. Safety
    3. Method of administration
    4. Benefits of being vaccinated
    5. Vaccine is offered free of charge
  9. Actions to take and persons to contact in an emergency involving blood or OPIM;
  10. Procedures to follow if an exposure incident occurs, including:
    1. How to report the incident;
    2. Available follow-up medical attention; and
    3. Worker's evaluation and follow-up after an exposure incident;
  11. Signs, labels, and color coding used; and
  12. Interactive question and answer time with the trainer.

Training records are maintained for each worker upon completion of training. These documents are kept for at least three years in the Environmental Health & Safety Department. Training records are provided to staff or their authorized representatives within 15 working days of a request. Requests for training records should be addressed to the EH&S Dept.

7.4 Post-Exposure Evaluation and Follow-up

7.4.1

South Lake Union Campus

First Aid for a Potential Bloodborne Pathogen Exposure

  1. Eye or mouth exposures: If your eyes are splattered with blood or OPIM, immediately flush with water or saline eyewash for five minutes. If blood or OPIM is splashed on your face or in your mouth, rinse with water for five minutes.
  2. Needle stick or puncture wound exposures: If you sustain a sharps injury from an item potentially contaminated with a bloodborne pathogen, or if you sustain a bite or scratch from an animal potentially infected with human bloodborne pathogens, wash the wound thoroughly with soap and water for five minutes. Do not squeeze the wound to induce bleeding, and do not use caustic agents such as bleach to clean the injury. Cover the injury with a band-aid or sterile dressing.

Do the following after initial first aid is given:

  1. Contact an EH&S occupational health nurse (OHN) at 206.667.4866.
  2. If an OHN is not available, or if the incident occurs after business hours (Monday-Friday, 8 a.m.-4 p.m.), call the 24-Hour Physician Help Line at 800.927.8770 and follow the physician's recommendation. If post-exposure prophylactic medications are needed, you will be referred to Harborview Medical Center. If transportation to the treating facility is needed, call Security at 206.288.1111 to obtain cab vouchers.
  3. SOURCE PATIENT - The OHN will contact the source patient to counsel and obtain consent for HIV, Hep B and Hep B testing. Please have the source patient information readily available to provide to the OHN.
  4. Complete an Accident-Illness Report (AIR) Form and return it to the OHN at J3-200 or fax to 206.667.4048.
Northwest Hospital Site

First Aid for a Potential Bloodborne Pathogen Exposure

  1. Eye or mouth exposures: If your eyes are splattered with blood or OPIM, immediately flush with water or saline eyewash for five minutes. If blood or OPIM is splashed on your face or in your mouth, rinse with water for five minutes.
  2. Needle stick or puncture wound exposures: If you sustain a sharps injury from an item potentially contaminated with a bloodborne pathogen, or if you sustain a bite or scratch from an animal potentially infected with human bloodborne pathogens, wash the wound thoroughly with soap and water for five minutes. Do not squeeze the wound to induce bleeding, and do not use caustic agents such as bleach to clean the injury. Cover the injury with a band-aid or sterile dressing.

Do the following after initial first aid is given:

  1. Call the Occupational Health Nurse (OHN) at 206.667.4866.
  2. If an OHN is not available, or if the incident occurs after business hours (Monday through Friday, 8 a.m. to 4 p.m.), call the 24-Hour Physician Help Line at 800.927.8770 and follow the physician's recommendation. If post-exposure prophylactic medications are needed, you will be referred to Harborview Medical Center.
  3. Obtain an injury packet for BLOODBORNE PATHOGEN EXPOSURES (RED FILE FOLDER)

SOURCE PATIENT:

  1. The source patient's healthcare provider or designee should immediately counsel and obtain consent for HIV, Hep B and Hep C testing from the source patient, or obtain consent from spouse/power of attorney if patient is unable . If underage, obtain consent from parents/guardian. Explain to the patient that an employee has been injured and how. Counsel the patient that all testing is confidential. There is no charge for the lab work and the SCCA Occupational Health Nurse will notify them of the results .Complete "Source Patient Consent for Testing Following an Employee Exposure"; fax completed form to Occupational Health at 206.667.3467 or email to OHN at Mailstop J3-200.
  2. Arrange for an SCCA LPN/MA to draw the source patient's blood sample
    1. Use the DYNACARE lab requisition included in the exposure packet; complete the following sections: last name, first name, birthdate, collection date/time
    2. Label the sticker with source patient's last name, first name
    3. Draw one red-top tube and label it with the sticker
    4. Place tube in a lab sample bag with the requisition form
    5. Place lab sample bag in the SCCA Lab Courier pickup location for transport back to SCCA Lab

EXPOSED EMPLOYEE

  1. If you need transportation to the treating facility (Harborview Medical Center, 325 Ninth Ave, Seattle WA 98104, 206.744.3000), use the cab vouchers included in the packet; call the number on the voucher and provide the cab service with the location you are going to; use the return cab voucher for your trip back to work or to your residence if it is after work hours
  2. Complete the "Accident/Illness Report" form and return according to instructions
  3. An Occupational Health Nurse will follow up with you and answer any questions you may have about your injury and worker's compensation claim
EvergreenHealth Site

First Aid for a Potential Bloodborne Pathogen Exposure

  1. Eye or mouth exposures: If your eyes are splattered with blood or Other Potentially Infectious Material (OPIM), immediately flush with water or saline eyewash for five minutes. If blood or OPIM is splashed on your face or in your mouth, rinse with water for five minutes.
  2. Needle stick or puncture wound exposures: If you sustain a sharps injury from an item potentially contaminated with a bloodborne pathogen, wash the wound thoroughly with soap and water for five minutes. Do not squeeze the wound to induce bleeding, and do not use caustic agents such as bleach to clean the injury. Cover the injury with a band-aid or sterile dressing.

Do the following after initial first aid is given:

  1. Report incident to Evergreen Employee Health Services at 425.899.2278 immediately (between the hours of 7:30am–4:00pm); if unavailable or after hours, report to the Nursing Supervisor at 425.890.4328.
  2. Immediately report to the Emergency Department for:
    1. Exposure to known HIV positive or high risk patient
    2. An injury that requires medical attention
  3. Also report the incident to the Occupational Health Nurse (OHN) at 206.667.4866. Evergreen Employee Health will handle all bloodborne pathogen exposures, however notification to the OHN is important for recordkeeping and coordination of follow-up care, if needed.
  4. Obtain an injury packet for BLOODBORNE PATHOGEN EXPOSURES (RED FILE FOLDER) which contains the Evergreen Employee Health packet "Needlestick/Exposure Quick Checklist".

SOURCE PATIENT:

  1. The source patient's healthcare provider or designee should immediately counsel and obtain consent for HIV, Hep B and Hep C testing from the source patient, or obtain consent from spouse/power of attorney if patient is unable (see "Consent for HIV Antibody Test" marked SOURCE PATIENT). If underage, obtain consent from parents/guardian. Explain to the patient that an employee has been injured and how. Counsel the patient that all testing is confidential, and their name is not used. There is no charge for the lab work and the Evergreen employee health coordinator will notify them of the results. If the patient refuses, see EvergreenHealth Policy 2.1 Attachment B for how to notify the Department of Health to obtain consent.
  2. Call extension 3898 and arrange for the lab to draw source patient's blood STAT. If time is an issue and the Evergreen lab is unable to send a staff member to the SCCA clinic before the patient leaves, arrange for an SCCA LPN/MA to draw the blood sample.
    1. Use the lab requisition that is included in the exposure packet (include Birthdate and Sex).
    2. Label the tube with the Enumber sticker from the lab requisition, initial, time and date collected).
    3. Place the sample in the bin for Evergreen Lab pickup.

7.4.2 Reviewing the Circumstances of an Exposure Incident

The occupational health nurses conduct evaluations of all potential bloodborne pathogen exposures by:

  1. Documenting the route of exposure and how the exposure occurred;
  2. Identifying and documenting the source individual, unless that's not possible or is prohibited by state or local law;
  3. Obtaining consent and arranging to test the source individual as soon as possible to determine HIV, HCV, and HBV infectivity (but if the source individual is already known to be HIV, HCV, and/or HBV positive, new testing is not needed);
  4. Documenting that the source individual's test results were conveyed to the worker's health care provider;
  5. Providing the exposed worker with the source individual's test results;
  6. Providing the exposed worker with information about laws on confidentiality for the source individual;
  7. Obtaining consent and providing a blood test for the exposed worker to determine whether he or she was infected with HBV, HCV, and HIV as soon as possible; and
  8. Providing the exposed worker with a copy of the healthcare professional's written opinion.

The Environmental Health & Safety Department conducts an investigation of all exposure incidents to determine:

  1. Controls in use at the time;
  2. Work practices that were followed;
  3. Description of the device used (including type and brand);
  4. Protective equipment or clothing in use at the time;
  5. Location of the incident;
  6. Procedure being performed when the incident occurred; and
  7. Worker's training.

Corrective actions are reviewed with the worker and supervisor to prevent a recurrence of the exposure.

7.4.3 Recordkeeping

7.4.3.1 Medical Records

Medical records are maintained for each worker who has an occupational exposure to bloodborne pathogens in accordance with WAC 296-62-052, Access to Records. The Occupational Health Program is responsible for maintaining medical records. These confidential records are kept in the Environmental Health & Safety Department, or in archives at a separate location, for at least 30 years beyond the length of employment.

7.4.3.2 Sharps Injury Log

In addition to WAC 296-27, Recordkeeping Requirements, all percutaneous injuries from contaminated sharps are also recorded in the Sharps Injury Log. This log includes the following information:

  1. Date of injury;
  2. Type and brand of the device involved;
  3. Where the incident occurred; and
  4. How the incident occurred.

This log is reviewed during the Center's Health and Safety Committee meetings and is kept for at least five years following the end of the calendar year. Copies are provided upon request, but such copies have any personal identifiers removed.

References

7.5 Approval

Author: Judith Davies
Name/Title of Reviewer(s):
Bruce Busby, Don Wang, Danielle Parette
Institutional Biosafety Committee
Date Written: 1/26/16
Date Reviewed: 1/26/16