Universal
precautions shall be observed to prevent contact with blood or other potentially
infectious materials. Under
circumstances in which differentiation between body fluid types is difficult or
impossible, all body fluids shall be considered potentially infectious
materials. Except as indicated below,
these methods of compliance are a responsibility of both the employee and
supervisor. Supervisors are encouraged
to consider employee compliance with these requirements an important aspect of
job performance. Disciplinary action, up
to and including discharge, may be appropriate for failure of the
employee/supervisor to comply with the Health Center Policy and/or the OSHA
Standard. Such disciplinary action will
be coordinated in advance with Human Resources.
2.
Engineering
and Work Practice Controls
a.
Engineering and work practice controls shall be used
to eliminate or minimize employee exposures. Where occupational exposure remains after institution of
these controls, personal protective equipment shall also be used.
b. Engineering controls shall be examined and maintained
or replaced on a regular schedule to ensure their effectiveness.
c.
Supervisors shall verify that handwashing facilities
are readily accessible to employees.
d. When provision of handwashing facilities is not feasible,
the supervisor will verify that either an appropriate waterless hand sanitizer, antiseptic hand cleanser
in conjunction with clean cloth/paper towels or antiseptic towelettes have been
made available. When antiseptic hand
cleaners or towelettes are used, hands shall be washed with soap and running
water as soon as feasible.
e.
Supervisors shall ensure that employees wash their
hands immediately or as soon as feasible after removal of gloves or other personal protective equipment.
f. Supervisors shall ensure that employees wash hands and
any other skin with soap and water, or flush mucous membranes with water immediately or as soon as
feasible following contact of such body areas with blood or other potentially
infectious materials.
g. The use of “safe” syringes/ or needleless devices
are strongly recommended. Such devices
have engineered safety mechanisms, such as self-sheathing needle, or are
needleless. Contaminated needles and other contaminated sharps shall not be
bent, recapped, or removed except as noted below. Shearing or breaking of contaminated needles
is prohibited.
(1)
Contaminated needles and other contaminated sharps
shall not be recapped or removed unless it has been demonstrated to the
supervisor that no alternative is feasible or that such action is required by a
specific medical procedure and the supervisor has approved the procedure.
(2) Such recapping or needle removal must be accomplished
through the use of a mechanical device or a one-handed technique.
h. Immediately or as soon as possible after use, contaminated
reusable sharps shall be placed in appropriate containers until properly
reprocessed. These containers will be
ordered from the Warehouse and shall be:
(1)
Puncture resistant;
(2)
Labeled or color-coded in accordance with the
Standard and the Health Center's Regulated Medical Waste Policy (biohazard
symbol, name, address, location);
(3) Leakproof on the sides and bottom; and
(4) In accordance with the requirements set forth in
paragraph 4b(5) below.
i.
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.
j. Food and drink shall not be kept in refrigerators,
freezers, shelves, cabinets or on countertops or benchtops where blood or other
potentially infectious materials are present.
k.
All procedures involving blood or other potentially
infectious materials shall be performed in such a manner as to minimize
splashing, spraying, spattering, and generation of droplets of these
substances.
l. Mouth pipetting/suctioning of blood or other
potentially infectious materials is prohibited.
m. Specimens of blood or other potentially infectious
materials shall be placed in a container which prevents leakage during
collection, handling, processing, storage, transport, or shipping.
(1)
The Health Center's policy is that "universal
precautions" will be used for all human specimens. Thus, color-coding of such specimens
remaining within the Health Center and recognizable as containing specimens do
not have to be specially color coded/labeled.
Note: When such containers
leave the facility the full labeling/color-coding and packaging requirements of
paragraph 5 apply.
(2)
The container for storage, transport, or shipping
shall be closed prior to being stored, transported or shipped.
(3)
If outside contamination of the primary container
occurs, the primary container shall be placed, using protective gloves, within
a second container which prevents leakage during handling, processing, storage,
transport, or shipping and is labeled or color-coded according to the
requirements of this standard.
(4)
If the specimen could puncture the primary container,
the primary container shall be placed within a secondary container which is
puncture-resistant in addition to the above characteristics.
n. Equipment which may become contaminated with blood or
other potentially infectious materials shall be examined prior to servicing or
shipping and shall be decontaminated as necessary, unless the supervisor can
demonstrate to Clinical Engineering, Infection Control or the Office of Research Safety, as
applicable, that decontamination of such equipment or portions of such
equipment is not feasible.
(1)
A readily observable label in accordance with
paragraph 5 shall be attached to the equipment stating which portions remain
contaminated.
(2) The supervisor shall ensure that this information is
conveyed to all affected employees, the servicing employees or representative, and/or
the manufacturer, as appropriate, prior to handling, servicing, or shipping so
that appropriate precautions will be taken.
3.
Personal
Protective Equipment
a. Provision. When there is occupational exposure or
potential for occupational exposure the supervisor shall make sure that at no
cost to the employee, appropriate personal protective equipment is available
such as, but not limited to, gloves, gowns, laboratory coats, face shields or
masks and eye protection, mouthpieces, resuscitation bags, pocket masks, or
other ventilation devices. Personal
protective equipment will be considered "appropriate" only if it does
not permit blood or other potentially infectious materials to pass through to
or reach the employee's work clothes, street clothes, undergarments, 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.
b. Use.
The supervisor shall ensure that the employees properly use appropriate
personal protective equipment unless the supervisor shows that the employee
temporarily and briefly declined to use personal protective equipment when,
under rare and extraordinary circumstances, it was the employee's
professional judgment that in the specific instance its use would have
prevented the delivery of health care or public safety services or would have
posed an increased hazard to the safety of the worker or co-worker. When the employee makes this judgment, the employee
will report it promptly to the supervisor.
The supervisor shall investigate the circumstances in order to document
and then determine whether changes can be instituted to prevent such
occurrences in the future. A written
copy of each such determination shall be provided by the supervisor to both the
Department of Epidemiology and the Office of Research Safety.
c. Accessibility. The supervisor shall ensure that appropriate
personal protective equipment in the appropriate sizes is readily accessible at
the worksite or is issued to employees.
Hypoallergenic gloves, glove liners, powderless gloves, or other similar
alternatives shall be readily accessible to those employees who are allergic to
the gloves normally provided.
d. Cleaning, Laundering, and
Disposal. The supervisor shall make
available services to clean, launder, and dispose of personal protective
equipment required by this standard, at no cost to the employee and require
that the employee use these services Note: Uniforms, lab coats and
other items of clothing provided and functioning as personal protective
equipment under this Policy must be provided, cleaned, repaired or disposed of
by the Health Center. Home laundering is
not allowable. See paragraph 4d on
laundering. Disposal of such items will
be in accordance with the Health Center's Medical Waste Policy.
e. Repair and Replacement. Employees will properly maintain, store and
dispose of such equipment, as appropriate.
The supervisor shall repair or replace personal protective equipment as
needed to maintain its effectiveness, at no cost to the employee.
f. If a garment(s) is penetrated by blood
or other potentially infectious materials, the garment(s) shall be removed by
the employee immediately or as soon as feasible.
g. All personal protective equipment shall
be removed by the employee prior to leaving the work area.
h. When personal protective equipment is
removed it shall be placed by the employee in an appropriately designated area
or container for storage, washing, decontamination or disposal. The supervisor will designate such
areas/containers.
i. Gloves. Gloves shall be worn when it can be
reasonably anticipated that the employee may have hand contact with blood,
other potentially infectious materials, mucous membranes, and non-intact skin;
when performing vascular access procedures; and when handling or touching
contaminated items or surfaces.
(1) 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.
(2) Disposable (single use) gloves shall "not"
be washed or decontaminated for re-use.
(3) Utility gloves may be decontaminated for
re-use if the integrity of the glove is not compromised. However, they must 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.
j. Masks, Eye Protection, and Face
Shields. Masks in combination with eye
protection devices, such as goggles or glasses with solid side shields, or
chin-length face shields, shall be worn whenever splashes, spray, spatter or
droplets of blood or other potentially infectious materials may be generated
and eye, nose, or mouth contamination can be reasonably anticipated. Note:
Surgical masks provide no protection against chemical overexposure. If chemical protection is needed, any
respiratory protection for the chemical will be selected by the Office of
Research Safety and utilized by the employee in accordance with the
Health Center's Respirator Policy.
k. Gowns, Aprons, and Other Protective
Body Clothing. Appropriate protective clothing
such as, but not limited to, gowns, aprons or similar outer garments shall be
worn in occupational exposure situations.
The type and characteristics will depend upon the task and degree of
exposure anticipated. Note: The end point to be achieved is for the
chosen personal protective equipment to adequately protect the employee's skin,
clothing and mucous membranes against contact with blood or other potentially
infectious materials under normal conditions of use and for the duration of
time the protective equipment will be used.
l. Surgical caps or hoods and/or shoe covers or boots shall be worn in instances when gross contamination can reasonably be anticipated (e.g., autopsies, orthopaedic surgery).
m. White lab coats are considered professional attire. If an individual uses a white lab coat for protection, it must be removed prior to leaving the immediate work area. Whie lab coats used as personal protective equipment is not permitted in public areas such as the cafeteria, etc.
4. Housekeeping
a. Written Schedule for Cleaning/Decontamination. Department supervisors shall ensure that
their work areas are maintained in a clean and sanitary condition. The supervisor shall determine and implement
an appropriate written schedule for cleaning and method of decontamination based
upon the location within the facility, type of surface to be cleaned, type of
soil present, and tasks or procedures being performed in the area. The supervisor may use for the areas cleaned
by Housekeeping, a copy of the cleaning schedule used by Facilities Management,
provided the supervisor concurs that the schedule is adequate and provided that
areas not covered by Facilities Management are covered by a local (department)
schedule.
b. Decontamination. Supervisors will ensure that all equipment and
environmental and working surfaces are cleaned and decontaminated after contact
with blood or other potentially infectious materials.
(1) Contaminated work surfaces shall be
decontaminated with an appropriate disinfectant after completion of procedures;
immediately or as soon as feasible when surfaces are overtly contaminated or
after any spill of blood or other potentially infectious materials; and at the
end of the work shift if the surface may have become contaminated since the
last cleaning. For laboratories, a
freshly prepared solution of one part household bleach to ten parts of water or
70% alcohol are examples of suitable disinfectants. In the Health System, the decontaminating
agent should be one approved by the Department of Epidemiology.
(2) Protective coverings, such as plastic
wrap, aluminum foil, or imperviously-backed absorbent paper used to cover
equipment and environmental surfaces, shall be removed and replaced as soon as
feasible when they become overtly contaminated or at the end of the workshift
if they may have become contaminated during the shift. Such contaminated items shall be disposed of
as Regulated Medical (Red Bag) Waste.
(3) All bins, pails, cans, and similar
receptacles intended for reuse which have a reasonable likelihood for becoming
contaminated with blood or other potentially infectious materials shall be
inspected and decontaminated on a regularly scheduled basis and cleaned and
decontaminated immediately or as soon as feasible upon visible contamination. In laboratories the examples of disinfectants
given in 4(b)(1) apply.
(4) Broken glassware which may be
contaminated shall not be picked up directly with the hands. It shall be cleaned up using mechanical
means, such as a brush and dust pan, tongs, or forceps (with the hands further
protected from direct contact by impervious gloves).
(5) Reusable sharps that are contaminated
with blood or other potentially infectious materials shall not be stored or
processed in a manner that requires employees to reach by hand into the
containers where these sharps have been placed.
c. Regulated
Medical Waste (Red Bag Waste).
(1) General.
(a) All activities will follow the Health
Center's Regulated Medical Waste Policy.
This is necessary for compliance with environmental regulations.
(2) Contaminated Sharps, Discarding and
Containment.
(a) Contaminated sharps shall be discarded
immediately or as soon as feasible into the sharps containers obtained from the
Warehouse that are: closable; puncture resistant; leakproof on sides and
bottom; and labeled or color-coded in accordance with paragraph 5. Note:
Needles in I.V. tubing are a medical waste that must go into the sharps
container.
(b) During use, containers for contaminated
sharps shall be: Easily accessible to
personnel and located as close as is feasible to the immediate area where
sharps are used or can be reasonably anticipated to be found (e.g., treatment
rooms); maintained upright throughout use; and replaced routinely and changed
frequently enough so that the container never becomes overfilled.
(c) When moving containers of contaminated
sharps from the area of use, the containers shall be: carefully closed
immediately prior to removal or replacement to prevent spillage or protrusion
of contents during handling, storage, transport, or shipping; placed in a
secondary container if leakage is possible.
The second container shall be: closable; constructed to contain all
contents and prevent leakage during handling, storage, transport, or shipping;
and labeled or color-coded according to paragraph 5.
(d) Reusable containers shall not be opened,
emptied, or cleaned manually or in any other manner which would expose
employees to the risk of percutaneous injury.
(3) Other Regulated Medical Waste (RMW)
Containment.
(a) Other regulated wastes which are not
sharps shall be placed in the RMW containers which are provided by and
collected by Facilities Management.
These are closable; constructed to contain all contents and prevent
leakage of fluids during handling, storage, transport or shipping; labeled or
color-coded in accordance with paragraph 5; and closed prior to removal to
prevent spillage or protrusion of contents during handling, storage, transport,
or shipping. Closed sharps containers,
not containing liquid, should also be placed in these RMW containers.
(b) If outside contamination of the regulated waste container
occurs, Facilities Management will be notified so that arrangements are made to
have it placed in a second container (carefully and using gloves). The second container shall be: closable;
constructed to contain all contents and prevent leakage of fluids during
handling, storage, transport or shipping; labeled or color-coded accordance with
paragraph 5; and closed prior to removal to prevent spillage or protrusion of
contents during handling, storage, transport, or shipping.
(4) Disposal of all regulated waste shall be
by Facilities Management in accordance with existing Health Center Policy. Off-site facilities will have their own
disposal program in accordance with the Health Center's Regulated Medical Waste
Policy.
d. Laundry.
(1) Contaminated laundry, for purposes of
this Health Center Policy/Plan, is all laundry from patient care activities or
laundry from other activities that has been soiled with blood or other
potentially infectious materials or may contain such materials or contaminated
sharps. Such contaminated laundry shall
be handled as little as possible and with a minimum of agitation.
(a) Contaminated laundry shall be bagged or
containerized at the location where it was used. It shall not be sorted or rinsed in the
location of use.
(b) Whenever contaminated laundry is wet and
presents a reasonable likelihood of soak-through of or leakage from the bag or
container, the item shall be placed and transported in closed bags or
containers which prevent soak-through and/or leakage of fluids to the
exterior. These bags/containers will be
immediately placed in the general laundry bag.
(c) All items in bagged laundry, from
patient care and other activities, will be considered contaminated. When direct contact with such contaminated
items is possible, appropriate protective clothing will be worn to include, as
a minimum, protective gloves. Thus,
since all bagged laundry items are considered contaminated as a matter of
policy, the bags/containers do not require special "Universal
Precautions" marking.
(d) Supervisor shall ensure that their
employees who have direct contact with contaminated laundry including all
laundry items that have been bagged/containerized wear protective gloves and
other appropriate personal protective equipment.
(e) Purchasing/Warehouse will require the
off-site facility receiving such bagged laundry to utilize Universal
Precautions as required by the OSHA Standard when handling such items.
(f) Doctor coats, laboratory coats, etc.,
that become contaminated will be placed by the employee in a plastic bag prior
to the item leaving the facility. The
contractor laundering such items will be required by Purchasing/Warehouse to
follow Universal Precautions as required by OSHA when handling such
contaminated items. Note: Items
such as physician coats, surgical scrubs are to be protected from the risk of
liquid contact in the same manner as personal clothing (e.g., use of
appropriate personal protective equipment over these garments are required).
5. Communication of Hazards to Employees
a. Labels and Signs
(1) Labels
(a) Warning labels shall be affixed to
containers of regulated medical waste, refrigerators and freezers containing
blood or other potentially infectious material; and other containers used to store,
transport or ship blood or other potentially infectious materials, except as
provided in paragraph 5a(1)(e),(f) and (g). [Note: Sharps
containers provided by the Warehouse [may not be labeled. However, labels
are provided and must be placed on the sharps container in a visible location.] Regulated Medical Waste disposal containers
provided by Facilities Management are pre-labeled.
(b)
Labels required by this section are available from
the Warehouse and must include the following legend:
BIOHAZARD
(c) These labels shall be fluorescent orange
or orange-red or predominantly so, with lettering or symbols in a contrasting
color.
(d) Labels required must be affixed as close
as feasible to the container by string, wire, adhesive, or other method that
prevents their loss or unintentional removal.
(e) Red bags or red containers may be
substituted for labels.
(f) Unless specific infectious agent
information is placed on the biohazard label, the label will be assumed by
supervisors and employees to indicate human materials and that universal
precautions must be followed.
(g) Containers of blood, blood components,
or blood products that are labeled as to their contents and have been released
for transfusion or other clinical use are exempted from the labeling
requirements of this paragraph.
(h) Individual containers of blood or other
potentially infectious materials that are placed in a labeled container during
storage, transport, shipment or disposal are exempted from the labeling
requirement.
(i) Labels required for contaminated
equipment shall be in accordance with this paragraph and shall also state which
portions of the equipment that remain contaminated.
(j) Labeled waste, even when
decontaminated, will be disposed of as Regulated Medical Waste as required by
the Health Center's Medical Waste Policy.
(2) Signs
(a) The supervisor shall post signs at the entrance
to work areas specified in paragraph (e) (HIV and HBV Research Laboratory and
Production Facilities) of the OSHA Standard, which shall bear the following
legend and other information as required by the written safety protocol that
shall be approved by the Institutional Biosafety Committee (The Office of
Research Safety will provide the investigator, upon request, a source where the
signs can be ordered.):
BIOHAZARD
(Name of the
Infectious Agent)
(Special
requirements for entering the area)
(Name,
telephone number of the laboratory director or other responsible person.)
(b) These signs shall be fluorescent
orange-red or predominantly so, with lettering or symbols in a contrasting
color.
b. Information and Training
(1) Activity heads and supervisors shall
ensure that all their employees with occupational exposure complete initial and
annual training as required by this Policy and the OSHA Standard. This training is mandatory for every
occupationally exposed employee and shall be provided at no cost to the
employee during working hours.
(2) Training shall be provided as follows:
(a) At the time of initial assignment to
tasks having the potential for bloodborne pathogen exposure (tasks with the
potential for such exposure shall not be accomplished until such training has
been completed) and;
(b) Whenever new changes effect the
employee’s occupational exposure and at least yearly.
(3) Initial bloodborne pathogen training is
provided as part of New Employee Orientation or by special arrangements with
the Department of Epidemiology, Office of Research Safety or Organization and
Staff Development. Annual training for
all employees shall be provided within one year of their previous comprehensive
(initial) training. Such annual training
is offered through the Healthstream computer based training program or the
Office of Research Safety Homepage.
(4) Supervisors shall provide additional
training when changes such as modification of tasks or procedures or
institution of new tasks or procedures affect their employee's occupational
exposure. For employees already current
in their training, the additional training may be limited to addressing the new
exposures created.
(5) For the training, material appropriate
in content and vocabulary to educational level, literacy, and language of
employees shall be used.
(6) The supervisor will, as a minimum, have
the course content cover elements g(2)(vii) (A) through (N) of the OSHA
Standard.
(7) For employees in HIV or HBV research
laboratories and HIV or HBV production facilities the supervisor will have the
initial training course also cover the additional training requirements as
listed in g(2)(ix)(A) through (C) of the OSHA Standard, as applicable. Note: See also paragraph IV of the Policy that
outlines responsibilities of Activity Heads and the Environmental Health and
Safety Subcommittee.
(8) Supervisors will have their
occupationally exposed employees trained in accordance with one of the Health
Center procedures described below. These
procedures are necessary for the Health Center to document compliance with the
training requirements listed above.
Other training requirements of the OSHA Standard including paragraphs
(g)(2)(vii)(N) {requirement for the opportunity of interactive questions with
the trainer} and (g)(2)(viii) (knowledge of the trainer); and the
"Recordkeeping Requirements for training in (h)(2) and (3), of the OSHA
Standard.
(9) All employees occupationally exposed. The initial and annual training will be
provided by completion of training sessions provided by:
Department
of Epidemiology/Office of Research Safety/Organization and Staff Development
Offered Sessions: - Normally, these sessions are offered every two
weeks as part of New Employee Orientation.
In limited cases, by prior arrangement/agreement with the Department
additional sessions may be provided. The
trainer for these sessions will provide the appropriate documentation of such
training to the Research Safety Office who will maintain copies of the records for at least three
years. (See "Note" below).
Major
Activity/Department Training - Employee Health Service,
Department of Epidemiology, the Office of Research Safety and Organization and
Staff Development recognize that the broad range of knowledge among Health
Center employees requires that education and training be geared to differing
levels of skill. This is allowed by OSHA
(see paragraph 5b(5) above). A major
activity, department, or division, may conduct their own training using the
materials described in the "Note"
below or by using their own training format provided clear documentation is
provided to the Office of Research Safety on the proper forms and the
Department maintains records showing full compliance including:
·
every prescribed training requirement is
appropriately covered;
·
the program provides for questions and answers with
the qualified trainer (physician, dentist, nurse, etc.);
·
the trainer immediately completes and maintains the written
training records required by the Standard {(h)(2)};
·
upon completion of the training, the trainer provides
the Office of Research Safety a list of attendees, containing their signature,
printed name, job title, department, and telephone extension on the appropriate
form;
·
the supervisor or department of the employee
maintains the originals of the training records required by paragraph (h)(2) of
the OSHA Standard for at least three years in a manner so that they will be
readily available.
Note: To facilitate
major activity/department conducted training as allowed above, training
materials,
copies of the available standard and written summaries of the video are
available for loan from the Department of Epidemiology and the
Office of
Research Safety.
6.
Hepatitis B Vaccination (HBV):
The
supervisor’s determination that an employee is occupationally exposed to human
blood and other potentially infectious determination results in the employee being
offered the HBV vaccination by Employee Health Service (EHS) at no cost to the
employee. The immunization will be offered
within ten work days and is normally provided for such new employees during
their processing through EHS. If
declined, the employee must sign the OSHA mandated declination form.
7.
Packaging
and Shipping of Specimens:
Federal
regulations provide specific packaging and shipping instructions for biomedical
materials. Such materials being shipped
must be packaged in such a way that the contents will not leak and will arrive
in good condition. The package and
shipping requirements are very specific and vary depending on whether the
substance can be classified a diagnostic specimen or infectious substance. In all cases, the primary sample container
must be placed in a leakproof secondary container with enough absorbent
material to contain all the liquid in the primary container. These containers must be then placed in a
sturdy shipping container. Volume limits
apply and in both cases labels, primary and secondary containers and shipping
papers must meet prescribed standards.
Ice and dry ice shipments result in added requirements. Activities/individuals shipping such
materials routinely from the Health Center shall be trained so that they are
familiar with the specific requirements and shall strictly conform with such
label, packing and shipping requirements.
This training is provided by the Office of Research Safety. Individuals requesting
shipments of such materials to the Health Center should be aware of the
specific requirement and instruct the sender to comply. You
are required to contact the Office of Research Safety, X2723 prior
to shipping or ordering any biological material.
All
imports and exports must comply with EPA’s Toxic Substance and Control
Act.