Bloodborne Pathogens Exposure Control Policy

The College of Charleston (the College) is committed to providing a safe and healthful work environment for our entire staff. In pursuit of this endeavor, the following exposure control plan (ECP) is provided to eliminate or minimize occupational exposure to bloodborne pathogens in accordance with OSHA standard 29 CFR 1910.1030, "Occupational Exposure to Bloodborne Pathogens."

The ECP is a key document to assist the College in implementing and ensuring compliance with the standard, thereby protecting our employees. This ECP includes:

  • Determination of employee exposure
  • Implementation of various methods of exposure control including:
    • Universal precautions
    • Engineering and work practice controls
    • Personal protective equipment Housekeeping
  • Hepatitis B vaccination
  • Post-exposure evaluation and follow-up
  • Communication of hazards to employees and training
  • Recordkeeping
  • Procedures for evaluating circumstances surrounding an exposure incident

Every division/department of the College of Charleston determined to have employees whose occupational tasks or responsibilities include reasonable anticipated risk of occupational exposure to human blood or Other Potentially Infectious Material (OPIM) of human origin must have an ECP on file with the Office of Environmental Health & Safety. A template is provided for division/department ECPs.

Those departments/divisions with the potential only for non-routine exposure will be covered by the ECP for Non-Routine Exposure.

The methods of implementation of these elements of the standard are discussed in the subsequent pages of this ECP.

Scope and Application

The ECP covers all College of Charleston personnel (employees, including faculty, staff, student employees, contractors, volunteers etc.) whose occupational tasks or responsibilities include reasonable anticipated risk of occupational exposure to human blood or Other Potentially Infectious Material (OPIM) of human origin as well as those occupations with non-routine exposure.

Those employees who are determined to have occupational exposure to blood or OPIM must comply with the procedures and work practices outlined in their division/department ECP. They will receive an explanation of this ECP during their initial training session. It will also be reviewed in their annual refresher training. Each covered employee will be given access to a copy of their division/department plan. 

Definition

BBP: Bloodborne Pathogens: Pathogenic microorganisms that are present in human blood and can cause disease in humans. These disease causing organisms can be found in all body fluids, unfixed tissue, cell lines, and in situations where it is difficult or impossible to differentiate between body fluids and other materials.

Contamination: The presence, or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface.

Sharps: Any object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broken capillary tubes and pipettes.

Decontamination: 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.

Engineering Controls: Equipment and practices that isolate or remove the bloodborne pathogens hazard from the workplace.

Exposure Incident: An unanticipated event that involves specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials and results from the performance of an personnel duties.

HBV: Hepatitis B Virus:  The cause of a serious, potentially life threatening liver disease for which a vaccine is available to provide long-term protection. 

HCV: Hepatitis C Virus:  The cause of a serious, potentially life threatening liver disease for which no vaccine is available.

HIV: Human Immunodeficiency Virus:  May cause AIDS (Acquired Immuno-Deficiency Syndrome).

Occupational Exposure: Reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of personnel duties. Procedures are in place to prevent or minimize exposure.

OPIM: Other Potentially Infectious Material is any of the following: semen, vaginal secretions, amniotic fluid, cerebrospinal fluid, peritoneal fluid, pleural fluid, pericardial fluid, synovial fluid, and saliva in dental procedures; any body fluid that is visibly contaminated with blood; all body fluids in situations where it is difficult or impossible to differentiate between body fluids; any unfixed tissue or organ, other than intact skin, from a living or dead human; cell or tissue cultures that contain HIV, organ cultures, and culture medium or other solutions that contain HIV or HBV; blood, organs or other tissues from experimental animals infected with HIV, HBV or other bloodborne pathogen(s).

Non-routine Exposure: Incidental or accidental exposure to human blood or OPIM that is not likely to result from the performance of an employee’s duties.

Parenteral: Piercing mucous membranes or the skin barrier, such as exposure through subcutaneous, intramuscular, intravenous, or arterial routes resulting through such events as needle sticks, human bites, cuts, and abrasions.

PPE: Personal Protective Equipment: Specialized clothing or equipment worn by an employee for protection against a hazard.

Reasonably Anticipated Risk of Exposure: Skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that is likely to result from the performance of an employee's duties. 

Regulated Waste: Potentially infectious materials or contaminated items that are capable of releasing BBP or OPIM during handling.

Universal (Standard) Precautions: An approach to infection control in which all human blood and other body fluids are treated as if they are known to be infectious for HIV, HBV, and other bloodborne pathogens.

Program Administration

The Environmental Health and Safety Office (EHS) is responsible for

  • Implementation and compliance oversight of the ECP
  • Maintaining, reviewing, and updating the ECP at least annually, and whenever necessary to include new or modified tasks and procedures.
  • Ensuring that all medical actions required are performed and that appropriate employee health and OSHA records are maintained in collaboration with the Human Resources Office.
  • Making the written ECP available to employees, OSHA, and NIOSH representatives.
  • Assuring that training programs are available and that documentation of training is maintained by the relevant division or department manager, principal investigator or area supervisor.
  • Maintaining and providing necessary personal protective equipment (PPE), engineering controls (e.g., sharps containers), labels, and red bags as required by the standard and ensuring that adequate supplies are available.

Division or department managers, principal investigators or area supervisors are responsible for their laboratory or areas’ compliance with the College BBP ECP and specifically for:

  • Identifying those employment positions within their areas that fit the definition of “occupational exposure” described in this Plan and specify those tasks or procedures in which occupational exposure is likely to occur in consultation with EHS.
  • Ensuring that all personnel are informed of the hazards associated with the work performed.
  • Providing and documenting training covering the elements outlined in the training section of this document and making the written ECP available to all employees.
  • Establishing (where applicable) a program for evaluating sharps with safety devices designed to eliminate or minimize occupational exposure.
  • Enforcing all safety rules and policies within the work setting and initiate progressive disciplinary proceedings, when necessary, as outlined by Human Resources.
  • Ensuring the most up to date ECP is readily available to all personnel in their work area.

Personnel working with BBP and OCIM must accept a shared responsibility for conducting their work in a safe manner, specifically:

  • Not engaging in work for which they are not trained.
  • Reporting unsafe work conditions or practices.
  • Knowing which of their tasks have a potential occupational exposure to bloodborne pathogens;
  • Following guidance provided in the ECP;
  • Planning and conducting all operations in accordance with exposure control procedures and specific departmental, work area or laboratory safety procedures;
  • Completing the appropriate BBP training depending on job functions;
  • Reporting hazardous conditions to the PI/area supervisor and EHS;
  • Reporting job-related injuries or illnesses to the PI, supervisor, Office of Human Resources and EHS and seeking medical treatment immediately (see Office of Human Resources website for applicable forms)
  • Requesting information and training when unsure how to work with bloodborne pathogens;
  • Wearing and properly maintaining the PPE necessary to perform assigned job tasks;
  • Using engineering controls, including safe sharps technology and safety equipment properly.

Employee Exposure Determination

The following is a list of all job classifications in which all employees have routine occupational exposure:

JOB TITLE DEPARTMENT/LOCATION

Faculty/Athletic Training Student

Department of Health and Human Performance

Coach/Trainer/Physical Therapist

Athletics

Custodial/Building Services Staff

Facilities Maintenance
Residence Life
Contractors

Emergency Response Staff/CPR-trained Student Volunteer

Fire and EMS Department

Grounds Staff

Facilities Maintenance

Life Guard

Athletics

Physician/Nurse

Student Health Services

Plumber

Facilities Maintenance

Public Safety Officer

Public Safety Office

Resident Assistant

Residence Life

Teacher/Teacher Assistant/Student Teacher

Early Childhood Development Center
Department of Teacher Education


The following is a list of job classifications in which some employees have occupational exposure. Included is a list of tasks and procedures, or groups of closely related tasks and procedures, in which occupational exposure may occur for these individuals: 

JOB TITLE DEPARTMENT/LOCATION TASK/PROCEDURE
Counseling staff Counseling and Substance Abuse Services Student injury or illness
Laboratory Instructor (Professor/Associate Professor/Assistant Professor/Research Associate/Graduate Student/Laboratory Technician) Department of Biology Department of Chemistry Department of Health and Human Performance Department of Psychology Class exercises that involve the use of human blood, body fluids, unfixed tissue, or cell lines.
Librarian All College of Charleston Libraries Staff/student injury or illness
Maintenance Staff (non-plumber) Facilities Maintenance Repair of facilities, equipment, or fixtures that might be contaminated.
Principal Research Investigator/Laboratory Technician/Student Researcher Biology Department
Chemistry Department
Department of Health and Human Performance
Department of Psychology		 Research that involves the use of human blood, body fluids, unfixed tissue, or cell lines.

Part-time, temporary, contract and per diem employees are covered by the ECP.

Released: June 2013

Revised: August 2013, April 2014, July 2018

Bloodborne Pathogens

EXPOSURE CONTROL PLAN

NON-ROUTINE EXPOSURE

Point of Contact: Director of Environmental Health & Safety

This plan covers all personnel of the College of Charleston whose job responsibilities do not involve a reasonably anticipated risk of contact with human blood or other potentially infectious materials (OPIM) and whose division or department does not have a Blood Borne Pathogens Exposure Plan.

General health and safety precautions will reviewed with new employees at their orientation meeting. This presentation will include a brief review of the materials available on the EHS website, with an emphasis on timely reporting of accidents and incidents.

Annually all employees will receive a reminder of the importance of safety on the job.

Procedure if an employee comes in contact with human blood or OPIM:

  • Wash hands immediately or as soon as feasible after contact. When hand washing facilities are not possible, appropriate antiseptic hand cleanser or antiseptic towelettes may be used.
  • Remove immediately or as soon as feasible any garment contaminated by blood or OPIM, in such a way as to avoid contact with the outer surface.
  • Contact EHS or the building custodian for removal of any contaminated materials before leaving the area.
  • Submit an Accident/Incident Report form available on the EHS Webpage. Evaluation of the incident may require discussion with the employee about Hepatitis B vaccination. If deemed advisable, the vaccination will be provided to the employee at no cost. If the employee chooses to decline vaccination, the employee must sign a declination form. Employees who decline may request and obtain the vaccination at a later date at no cost. Documentation of refusal of the vaccination is kept at the EHS Office.

Employees are to notify EHS if they discover regulated waste containers, refrigerators containing blood or OPIM, contaminated equipment, etc. without proper labels.

RECORDKEEPING 

Training Records

Training records are completed for each employee upon completion of training. These documents will be kept in the EHS office for at least three years after the employee’s termination date. The training records 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

Employee training records are provided upon request to the employee or the employee's authorized representative within 15 working days. Such requests should be addressed to the Director of EHS.

Medical Records

Medical records are maintained for each employee with occupational exposure in accordance with 29 CFR 1910.1020, "Access to Employee Exposure and Medical Records."

The Office of Human Resources is responsible for maintenance of the required medical records. These confidential records are kept at [location] for at least the duration of employment plus 30 years.

Employee medical records are provided upon request of the employee or to anyone having written consent of the employee within 15 working days. Such requests should be sent to the Office of Human Resources.

OSHA Recordkeeping

An exposure incident is evaluated to determine if the case meets OSHA’s Recordkeeping Requirements (29 CFR 1904). This determination and the recording activities are done by EHS 

Sharps Injury Log

In addition to the 1904 Recordkeeping Requirements, all percutaneous injuries from contaminated sharps are also recorded in the Sharps Injury Log. All incidences must include at least:

  • the date of the injury
  • the type and brand of the device involved
  • the department or work area where the incident occurred
  • an explanation of how the incident occurred.

This log is reviewed at least annually as part of the annual evaluation of the program and is maintained for at least five years following the end of the calendar year that they cover. If a copy is requested by anyone, it must have any personal identifiers removed from the report.

EXPOSURE INCIDENT PROCEDURES

Post-Exposure Procedures

Following the initial first aid (clean the wound, flush eyes or other mucous membrane, etc.):

  • Document the routes of exposure and how the exposure occurred.
  • Identify and document the source individual (unless the employer can establish that identification is infeasible or prohibited by state or local law).
  • Obtain consent and make arrangements to have the source individual tested as soon as possible to determine HIV, HCV, and HBV infectivity; document that the source individual's test results were conveyed to the employee's health care provider.
  • If the source individual is already known to be HIV, HCV and/or HBV positive, new testing need not be performed.
  • Assure that the exposed employee is provided with the source individual's test results and with information about applicable disclosure laws and regulations concerning the identity and infectious status of the source individual.
  • After obtaining consent, collect exposed employee's blood as soon as feasible after exposure incident, and test blood for HBV and HIV serological status
  • 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.
  • Notify the Director of EHS.
  • Submit an Accident/Incident Report (available on the EHS webpage) within 24 hours of the incident.

Post-Exposure Evaluation and Follow-Up

The following post-exposure procedures are performed by the Director of EHS:

  • Ensure that health care professional(s) responsible for employee's hepatitis B vaccination and post-exposure evaluation and follow-up are given a copy of OSHA's bloodborne pathogens standard.
  • Ensure that the health care professional evaluating an employee after an exposure incident receives the following:
    • Description of the employee's job duties relevant to the exposure incident
    • Route(s) of exposure
    • Circumstances of exposure
    • Results of the source individual's blood test, if possible
    • Relevant employee medical records, including vaccination status
  • Provide the employee with a copy of the evaluating health care professional's written opinion within 15 days after completion of the evaluation.
  • Record all percutaneous injuries from contaminated sharps in the Sharps Injury Log.

Evaluation of the Circumstances of the Exposure Incident

EHS will review the circumstances of all exposure incidents to determine:

  • Engineering controls in use at the time
  • Work practices followed
  • Description of the device being used (including type and brand)
  • Protective equipment or clothing that was used at the time of the exposure incident (gloves, eye shields, etc.)
  • Location of the incident
  • Procedure being performed when the incident occurred
  • Employee’s training

If it is determined that revisions need to be made, the Director of EHS will ensure that appropriate changes are made to this ECP in consultation with the division/department head or designee.

EHS Approval Date:

Review Dates: