1 UNIVERSITY OF ROCHESTER BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN GUIDELINES FOR OFF-SITE LOCATIONS in compliance with 29 CFR OSHA Standard for Occupational Exposure to Bloodborne Pathogens I. Policy II. III. IV. Program Administration Employee Exposure Determination Implementation of Exposure Control Methods A. Universal Precautions B. Blood Exposure Reduction Committee Mission Evaluation Process Committee Representation Employee Participation C. Engineering Controls and Work Practices Handwashing Sharps Safety Devices Sharps, Sharps Disposal and Sharps Containers Recapping Policy Eating, Drinking, Smoking, Applying Cosmetics or Handling Contact Lenses Labels D. Personal Protective Equipment E. Housekeeping General Contaminated Items Contaminated Work Surfaces and Equipment Laundry F. Biohazard/Infectious Waste Disposal Definition of Biohazard Waste Infectious Waste o Unbroken Blood Tubes o Sharps o Guidelines
2 V. Hepatitis B Vaccination VI. VII. Post-Exposure Evaluation and Follow-Up A. Administration of Post-Exposure and Follow-Up B. Procedures for Evaluating the Circumstances Surrounding an Exposure Incident Employee Training VIII. Recordkeeping A. Training Records B. Medical Records C. Sharps Injury Log Appendix I: Sharps Safety Devices A. Safety Sharps Devices Approved by the Blood Exposure Reduction Committee B. Sharps Safety Device Training Appendix II: Biohazard Waste Disposal A. Point of Generation General Guidelines B. Proper Disposal Practices C. Infectious Waste Directory List Appendix III: Websites for Additional Information Appendix IV: Hepatitis B Vaccine Declination
3 I. POLICY (Enter Facility Name) 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 , "Occupational Exposure to Bloodborne Pathogens." The ECP is a key document to assist our organization 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: o Universal precautions o Engineering and work practice controls o Personal protective equipment o Housekeeping o Regulated waste disposal Hepatitis B vaccination requirements Post-exposure evaluation and follow-up Communication of hazards to employees and training Recordkeeping Procedures for evaluating circumstances surrounding an exposure incident OSHA recognizes that the potential for exposure to bloodborne pathogens extends beyond healthcare professionals and thus defines the scope of this standard to include all personnel at risk for occupational exposures to blood or other potentially infectious materials. This plan covers all healthcare professionals, laboratory personnel, housekeepers, facilities staff, and any other University employees with the potential for exposure to bloodborne pathogens. All employees identified in the Exposure Determination are required to comply with this policy. II. PROGRAM ADMINISTRATION (Enter name of responsible person or department) is responsible for the implementation of the ECP. (Enter name of responsible person or department) will maintain, review, and update the ECP at least annually, and whenever necessary to include new or modified tasks and procedures. Contact location/phone number: Those employees who have been classified in the Exposure Determination as having potential occupational exposure to blood or other potentially infectious materials (OPIM) must comply with the procedures and work practices outlined in this ECP.
4 (Enter name of responsible person or department) will maintain and provide all necessary personal protective equipment (PPE), engineering controls (e.g., sharps containers), labels, and red bags as required by the standard. (Enter name of responsible person or department) will ensure that adequate supplies of the aforementioned equipment are available in the appropriate sizes. Contact location/phone number: (Enter name of responsible person or department) will be responsible for ensuring that all medical actions required are performed and that appropriate employee health and OSHA records are maintained. Contact location/phone number: (Enter name of responsible person or department) will be responsible for training, documentation of training, and making the written ECP available to employees, OSHA, and NIOSH representatives. Contact location/phone number: III. EMPLOYEE EXPOSURE DETERMINATION This employee exposure determination applies to all employees and volunteers at risk of occupational exposure to bloodborne pathogens, including full-time and part-time employees, temporary services personnel, time-as-reported staff, graduate and undergraduate student employees. The following is a list of all job classifications at this establishment in which all employees may have occupational exposure: JOB TITLE (Example: Phlebotomists) DEPARTMENT/LOCATION (Example: Clinical Lab) The following is a list of job classifications in which some employees at this establishment may 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 (Example: Housekeeper Environmental Services Handling Biohazard Waste)
5 IV. IMPLEMENTATION OF EXPOSURE CONTROL METHODS Exposure control methods are the techniques and procedures to be followed in order to minimize the risk of exposure to bloodborne pathogens in the workplace. The methods outlined in this plan are written generically so they are applicable to most job classifications or job tasks that have potential exposure to blood or body fluids. For more specific procedures consult your supervisor. A. Universal Precautions All employees will utilize universal precautions. Universal precautions are an approach to infection control that assumes that the blood, body fluids and tissues of ALL persons are potentially infectious with bloodborne pathogens. These pathogens include human immunodeficiency virus (HIV), hepatitis B virus, hepatitis C virus, and other agents. Practicing universal precautions involves the use of applicable personal protective equipment such as gloves and face shields whenever contact with blood or body fluids can be anticipated. Infection may occur via the following types of occupational exposure to blood or other infectious body fluids: o Parenteral exposure (needlestick, injection, cut) o Mucous membrane exposure (eye, mouth) o Non-intact skin exposure (wounds, dermatitis) o Skin exposure involving prolonged contact with large amount of blood Definition of Potentially Infectious Materials (for bloodborne pathogens): o Human blood and blood products o Semen and vaginal secretions o Cerebrospinal fluid (CSF), synovial fluid, peritoneal fluid, pericardial fluid, amniotic fluid o Saliva in dental procedures (assume blood contamination) o Any unfixed human tissue or organ o HIV-containing cell, tissue, or organ cultures or solutions, and blood, organs, or other tissues from experimental animals infected with HIV or hepatitis B virus (HBV). Other body excretions such as saliva, urine, stool, vomitus and respiratory secretions are not included on this list (unless visibly contaminated with blood.) However, many of these excretions present other infectious hazards. As a practical matter, at the University of Rochester, UNIVERSAL PRECAUTIONS apply to ALL blood, body fluids, tissues and secretions.
6 B. Blood Exposure Reduction Committee Mission The mission of the Blood Exposure Reduction Committee is to prevent blood and body fluid exposures among the University of Rochester/Strong Memorial Hospital staff and student population through the use of engineering and administrative controls, work practices, education and training. The committee meets on a regular basis to carry out its mission. Documentation of committee activities and deliberations are recorded and distributed to committee participants, and to those groups charged with protecting the health and safety of the University Community. Employee Participation All University employees are actively encouraged to participate in the evaluation process through their committee representative, through their supervisor, or through the UHS Occupational Heath Unit ( ) or the Industrial Hygiene Unit of the Environmental Health & Safety Department ( ). Evaluation Process Engineering controls used to prevent sharps injuries are initially evaluated by the University s Blood Exposure Reduction Committee. The checklist used for evaluation of controls was developed according to the NIOSH (National Institutes of Occupational Safety and Health) recommendations for preventing needlestick injuries. On the basis of this review, a recommendation for trial is forwarded to the SMH Value Analysis Advisory Board for consideration. A list of sharps safety devises approved for use can be found in Appendix I. Committee Representation The Blood Exposure Reduction Committee includes representation from the following departments and disciplines: o University Health Services Occupational Health Unit - non-managerial clinical experience, provides institutional pre-exposure information and post-exposure follow-up including medical evaluation/ treatment/ followup and documentation o Environmental Health & Safety - maintenance of the Exposure Control Plan, provides guidance for research laboratory situations, liaison for employee/student safety o Hospital Epidemiologist - clinical experience as physician, liaison for physicians, provides guidance for exposure follow-up o Nursing Education - clinical experience, liaison with nursing educators o Surgery - clinical experience, provides guidance on surgical issues
7 o Nursing Management - clinical experience, liaison with nursing leadership o SMH Value Analysis Advisory Board - clinical experience, liaison for trial process, primarily responsible for introducing new products for evaluation C. Engineering Controls and Work Practices Engineering controls and work practice controls will be used to prevent or minimize exposure to bloodborne pathogens. The specific engineering controls and work practice controls used are listed below: Handwashing o Even if there is no known exposure, all employees are required to wash their hands immediately or as soon as feasible after removal of gloves or other personal protective equipment o Following exposure to blood or other potentially infectious materials, employees shall wash hands and any other exposed skin with soap and water, or flush mucous membranes with water immediately or as soon as feasible. After handwashing, pour 3% hydrogen peroxide over any nonintact skin or cleanse with chlorhexidine or iodophor. o Eye wash stations are to be provided in all areas where there is a potential for contamination of the eyes or face. o Handwashing facilities with soap and running water will be readily accessible to employees. When provision of handwashing facilities is not feasible an appropriate antiseptic hand cleanser and paper towels or antiseptic towelettes will be provided. After use of antiseptic cleansing, hands should be washed with soap and water as soon as feasible. Sharps Safety Devices o The use of safer medical devices, such as sharps with engineered sharp injury protection and needleless systems, must be implemented by employers whenever they are appropriate, commercially available and effective.
8 o The University s Blood Exposure Reduction Committee and the SMH Value Analysis Advisory Analysis Board evaluate sharps safety devices. A list of sharps safety devices approved for use can be found in Appendix I. Additional information about the evaluation process can be found in Section IV (B) Blood Exposure Reduction Committee. Sharps, Sharps Disposal, and Sharps Containers o Needles, lancets, scalpel blades, sharp pipettes, slides, broken/contaminated glass, surgical staples, orthodontic wires, wooden applicator sticks, or any other item likely to puncture a bag are considered sharps and must be disposed of in an approved sharps container. Everyone is personally responsible for the proper disposal of sharps that they have used. Sharps are never to be left on beds or bedside tables, bracket tables, procedure trays, or dining trays. Sharps are never to be discarded into trash bags. o Bending, shearing or breaking of used needles is strictly prohibited. o Sharps containers must be closable, puncture-resistant, leak proof on sides and bottoms, and labeled or color-coded appropriately. Sharps disposal containers are available at (fill in location where sharps containers are stored.) o Sharps containers must either be labeled with the universal biohazard symbol and the word "biohazard" or be color-coded red. Sharps containers shall be maintained upright throughout use, replaced routinely, and not be allowed to overfill. o Sharps containers must be easily accessible and as close as feasible to the immediate area where sharps are used. o Sharps containers should be mounted so that the opening of the containers is between 48 and 54 inches from the floor if possible. This height will allow everyone to see the container while disposing of sharps, while at the same time making it difficult for most children to reach into the containers. Sharps containers should also be mounted away from areas where children may be left unsupervised or where children can climb up and reach the containers.
9 Recapping Policy o Needles are not to be recapped or disassembled from syringes before disposal. o Exception: if recapping must be done for procedural or safety reasons, a specifically designed recapping device or the one-handed technique is employed for safe recapping of the needle. o One-handed re-capping technique: Place needle-cap on counter-top or table. Take hand away from cap and away from needle. Holding only the syringe, guide needle into cap. Lift up syringe so cap is sitting on needle hub. Secure needle-cap into place. Eating, Drinking, Smoking, Applying Cosmetics, or Handling Contact Lenses o Eating, drinking, smoking, applying cosmetics, or handling contact lenses are prohibited in work areas where there is a reasonable potential of occupational exposure to blood or body fluids (e.g. operating rooms, procedure rooms, and laboratories.) o Food and drink are never to be kept in refrigerators, freezers, or cabinets that are used for storage of blood or other potentially infectious materials. Labels o Warning labels shall be affixed to containers of biohazard 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. o (Enter name of responsible person or department) will ensure warning labels are affixed or red bags are used as required for biohazard waste or contaminated equipment.
10 D. Personal Protective Equipment (PPE) PPE is provided to employees at no cost to them. Training is provided by (Enter name of responsible person or department) in the use of the appropriate PPE for the tasks or procedures employees will perform. The types of PPE available to employees are as follows:(ex., gloves, eye protection, etc.) PPE is located (List location) and may be obtained through (Enter name of responsible person or department) All employees using PPE must observe the following precautions: o Wash hands immediately or as soon as feasible after removal of gloves or other PPE. o Remove PPE after it becomes contaminated, and before leaving the work area. o Used PPE may be disposed of in (List appropriate containers for storage, laundering, decontamination, or disposal.) o Wear appropriate gloves when it can be reasonably anticipated that there may be hand contact with blood or other potentially infectious material, and when handling or touching contaminated items or surfaces; replace gloves if torn, punctured, contaminated, or if their ability to function as a barrier is compromised. o Utility gloves may be decontaminated for reuse if their integrity is not compromised; discard utility gloves if they show signs of cracking, peeling, tearing, puncturing, or deterioration. o Never wash or decontaminate disposable gloves for reuse. o Wear appropriate face and eye protection when splashes, sprays, spatters, or droplets of blood or other potentially infectious material pose a hazard to the eye, nose, or mouth. o Remove immediately or as soon as feasible any garment contaminated by blood or other potentially infectious material, in such a way as to avoid contact with the outer surface.
11 E. Housekeeping General Supervisors shall assure that work sites are maintained in a clean and sanitary condition. Cleaning is performed in a manner to prevent potentially infectious material from splashing or becoming airborne. Contaminated Items All items that come in contact with potentially infectious materials will be cleaned on a regularly scheduled basis. In most cases this will be at least daily and after each known contamination. Contaminated Work Surfaces and Equipment All work surfaces shall be properly cleaned and disinfected after contact with blood or other potentially infectious materials as soon as feasible after visible contamination. Appropriate disinfectants include 10% diluted bleach solution, and EPA-registered tuberculocides (List B) or sterilants (List A), or products registered for use against HIV/HBV (List D). Contact time for bleach is generally considered to be the time it takes the product to air dry. Laundry o Universal precautions are used for handling all soiled laundry. o The following contaminated articles: will be laundered on-site by (Enter name of responsible person or department) OR Laundering will be performed offsite by (Enter name of laundry vendor.) o The following laundering requirements must be met: Handle contaminated laundry as little as possible, with minimal agitation. Place wet contaminated laundry in leak-proof, labeled or color-coded containers before transport. Use (color-coded bags or bags marked with biohazard symbol) for this purpose. Wear the following PPE when handling or sorting contaminated laundry (List appropriate PPE.)
12 F. Biohazard/Infectious Waste Disposal Definition of Biohazard Waste Any liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are capable of releasing blood or other potentially infectious materials during handling; used or unused sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials. Also included are cultures and stocks of infectious agents, contaminated animal carcasses, body parts, and bedding of animals known to have been exposed to infectious agents. (See Appendix II for additional disposal information.) Infectious Waste All infectious waste destined for disposal shall be placed in closable leak-proof containers or bags that are red in color. If outside contamination of the container or bag is likely to occur, then a second closable leak-proof container or bag shall be placed over the outside of the first and closed to prevent leakage during handling, storage, and transport. (This applies only to internal transportation of biohazard waste. External shipments are subject to additional requirements. Contact the University Sanitarian at ext for more information.) o Unbroken Blood Tubes All unbroken blood tubes shall be disposed of in a sharps shelter or in a plastic-lined cardboard box specifically approved for this purpose. o Sharps Immediately after use, sharps safety devices must be activated and sharps shall be disposed of in closable, puncture resistant, disposable containers. These containers shall be easily accessible to personnel and located in the immediate area of use. Sharps containers will be replaced when ¾ full. o Guidelines Guidelines for the disposal of biohazard waste can be found in Appendix II. Additional information can be obtained from the University Sanitarian at ext V. HEPATITIS B VACCINATION (Enter name of responsible person or department) will provide training to employees on hepatitis B vaccinations, addressing the safety, benefits, efficacy, methods of administration, and availability.
13 The hepatitis B vaccination series is available at no cost and within 10 days of initial assignment to employees identified in the exposure determination section of this plan. Vaccination is required unless: 1) documentation exists that the employee has previously received the series, 2) antibody testing reveals that the employee is immune, 3) medical evaluation shows that vaccination is contraindicated, or 4) the employee declines the vaccination. If an employee chooses to decline vaccination, the employee must sign a declination form. (see Appendix III for 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 (List location or person responsible for this documentation). Vaccination will be provided by (List responsible Health Care Professional.) VI. POST-EXPOSURE EVALUATION AND FOLLOW-UP The plan for post-exposure evaluation and follow-up will ensure that: measures are taken to minimize the risk of infection secondary to the exposure; that the circumstances surrounding the exposure are investigated and documented; and that the employee receives medical consultation, follow-up, and treatment if necessary, in a timely and expeditious fashion. Any employee sustaining skin, mucous membrane, or percutaneous contact with blood or other potentially infectious materials shall clean the affected areas as soon as possible as follows: Intact skin wash with soap and water. Non-intact skin and needlestick/scalpel cuts wash with soap and water, then pour 3% hydrogen peroxide over the cut/lesion or cleanse with chlorhexidine or iodophor. Intra-oral exposure rinse the mouth well with 3% hydrogen peroxide and then water. Eyes remove any contact lenses and rinse well with sterile saline or water. Should an exposure incident occur, contact (Name of responsible person) at the following number:. An immediately available confidential medical evaluation and follow-up will be conducted by (Licensed health care professional). Following the initial first aid (clean the wound, flush eyes or other mucous membrane, etc.), the following activities will be performed: 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).
14 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. Follow applicable state law for HIV testing. A sample NYS HIV release form can be found at: 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 (e.g., laws protecting confidentiality). After obtaining consent, collect exposed employee's blood as soon as feasible after exposure incident, and test blood for HBV, HCV and HIV serological status. Comprehensive post-exposure guidelines including postexposure prophylaxis can be found in the CDC document Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis at 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. A. Administration of Post-exposure Evaluation and Follow-up Administration of post-exposure evaluation and follow up should begin as soon as possible following an exposure incident. Ideally, post-exposure prophylaxis (PEP) should begin within two hours following exposure if determined necessary during risk assessment. (Enter name of responsible person or department) ensures that health care professional(s) responsible for employee's hepatitis B vaccination, post-exposure evaluation and follow-up are provided with access to OSHA's bloodborne pathogens standard and are familiar with the requirements of the standard.
15 (Enter name of responsible person or department) ensures that the health care professional evaluating an employee after an exposure incident receives the following: o a description of the employee's job duties relevant to the exposure incident o route(s) of exposure o circumstances of exposure o if possible, results of the source individual's blood test o relevant employee medical records, including vaccination status (Enter name of responsible person or department) provides the employee with a copy of the evaluating health care professional's written opinion within 15 days after completion of the evaluation. B. Procedures for Evaluating the Circumstances Surrounding an Exposure Incident (Name of responsible person or department) will review the circumstances of all exposure incidents to determine: o engineering controls in use at the time o work practices followed o a description of the device being used (including type, brand, and status of safety feature activation) o protective equipment or clothing that was used at the time of the exposure incident (gloves, eye shields, etc.) o location of the incident (O.R., E.R., patient room, etc.) o procedure being performed when the incident occurred o employee s training o any additional information concerning why the incident may have occurred. All work-related needlestick injuries and cuts from sharp objects that are contaminated with another person's blood or other potentially infectious material must be recorded on Employee Incident Forms (SMH115). The white copy should be sent to Worker s Compensation, Wallis Hall 19 RC Box The yellow copy should be mailed to Environmental Health & Safety, 300 East River Rd. Rm 23, Rochester NY This documentation is reviewed by both the department of Environmental Health & Safety and the department of Workers Compensation. Significant findings are reported to the Blood Exposure Reduction Committee.
16 VII. EMPLOYEE TRAINING Employees identified in the exposure determination as having potential occupational exposures shall participate in a training program that shall be provided at no cost to the employee and during working hours. Training will be provided for all new employees or current employees at the time of initial exposure determination. Annual training will be provided within one year of previous training. Trainers will be knowledgeable in the subjects of bloodborne pathogens, PPE, the content of this Exposure Control Plan, and the requirements of the OSHA standard. The training program covers, at a minimum, the following elements: o an accessible copy of the standard and an explanation of its contents o an explanation of the Exposure Control Plan and how to obtain a copy o a general explanation of the epidemiology and symptoms of bloodborne diseases o an explanation of methods to recognize tasks and other activities that may involve exposure to blood and other potentially infectious material, including what constitutes an exposure incident o an explanation of the use and limitations of engineering controls, work practices, and PPE o information on the types, uses, location, removal, handling, decontamination, and disposal of PPE o an explanation of the basis for PPE selection o information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine will be offered free of charge o information on the appropriate actions to take and persons to contact in an emergency involving exposure to blood or other potentially infectious materials o an explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available o information on the post-exposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident o an explanation of the signs and labels and/or color coding required by the standard and used at this facility o an opportunity for interactive questions and answers with the person conducting the training session.
17 VIII. RECORDKEEPING A. Training Records Training records shall include dates of the training sessions, contents of the training sessions, names and job titles of all persons attending the training sessions. These documents will be kept for at least three years at (Enter location of records or name of responsible person.) B. Medical Records For each employee with occupational exposure, the employer is required to establish and maintain an accurate record that includes the employee s name, social security number, hepatitis B vaccination status, and any information related to exposure follow-up. These records are confidential and will be retained for the duration of employment plus 30 years. (Enter name of responsible person or department) is responsible for maintenance of the required medical records. These confidential records are kept at (List location.) C. Sharps Injury Log All percutaneous injuries from contaminated sharps must also be recorded in the OSHA 300 Log and the Sharps Injury Log. Records of all instances must include at least: o the date of the injury o the type and brand of the device involved o the department or work area where the incident occurred o an explanation of how the incident occurred. Worker s Compensation is responsible for maintaining both the OSHA 300 Log and the Sharps Injury Log. The Sharps Injury Log is reviewed at least annually by Environmental Health and Safety, and entries in the Log are maintained for at least five years following the incidents they cover. If a copy of the Sharps Injury Log is requested by anyone, it must have any personal identifiers removed from the report. The source for the collection of sharps injury information for the University is the Employee Incident Form (SMH115). Employee Incident Forms must be filled out for all exposure incidents. The white copy of the SMH115 is sent to Worker s Compensation, Wallis Hall 19 RC Box The yellow copy is mailed to Environmental Health & Safety, 300 East River Road, Room 23, Rochester NY Employee Incident Forms are available from (Name of responsible person or department).
18 APPENDIX I: SHARPS SAFETY DEVICES A. Safety Sharps Devices Approved By The Blood Exposure Reduction Committee Sharps safety devices addressing needlestick prevention that are currently in use by the University of Rochester/Strong Memorial Hospital: Needless IV manufactured by Abbott Safety Butterfly manufactured by BD Clave connector manufactured by ICU Medical Genie Lancet manufactured by BD Plastic coated capillary tube manufactured by BD Safety Glide by BD Insyte AutoGuard by BD Angel Wing Safety Needle System by Kendall B. Sharps Safety Device Training Training for existing employees is conducted initially by the manufacturer and/or manufacturer representatives. (Enter name of person or department) is responsible for maintaining records of general education on new products. Training for new employees is conducted upon hire and re-training is conducted if injury occurs with sharps safety device. Training is conducted by (Enter name of person or department responsible for training. APPENDIX II, BIOHAZARD WASTE DISPOSAL A. Point of Generation - General Guidelines For legal and safety reasons, it is imperative that as potential generators of biohazard waste you handle and dispose of it properly. It should be realized that biohazard waste is a subset of, and includes, only certain categories of medical waste.
19 The following general categories are defined as biohazard waste: o o o o o Cultures and stocks of infectious agents and associated biologicals from medical, pharmaceutical or other research, commercial, or industrial laboratories including laboratory wastes that were in contact with these agents. Human pathological wastes including tissue, organs, body parts, body fluids and items saturated to the point of dripping with these fluids removed during surgery, autopsy or other medical procedures. Human blood and blood products including items saturated to the point of dripping with free flowing blood or blood products. Sharps that have been used in animal or human patient care or treatment or in medical, research or industrial laboratories as well as certain other unused sharps that are discarded. Contaminated animal carcasses, body parts and bedding of animals that were known to have been exposed to infectious agents. All feces unless submitted as a clinical specimen for laboratory tests is not Biohazard Waste. Urine unless submitted as a clinical specimen for laboratory tests or is from a patient known to have a disease which may be transmitted through urine is not Biohazard Waste. B. Proper Disposal Practices: Solid Biohazard Waste is deposited in red plastic bags for disposal by a permitted hauler. In some areas Biohazard Waste may be initially disposed of in a clear plastic bag with ultimate disposal in a red bag. Recombinant DNA wastes may require special handling (contact Biological Safety Officer). State law prohibits disposal of untreated biohazard waste in landfills. Liquid Biohazard Waste including blood can be deposited in the sewer by using a toilet or designated sink. However, public toilets or sinks should not be used nor should sinks be used that are designated for handwashing or instrument cleaning. If liquid Biohazard Waste will not be emptied, it must be disposed of in a leakproof container, ensuring that any lids or openings are sealed.
20 Sharps including needles, blades, sharp pipettes, slides, broken/contaminated glass or any other item that could puncture a bag must be deposited in sharps containers. Never place sharps in plastic bags or anywhere other than in approved sharps shelters. As a general rule, sharps shelters must not be overfilled and are replaced when ¾ full. Sharps shelters are replaced by area designee. Regular trash (non-regulated) is deposited in plastic bags and is placed in the compactor for land-filling. Hazardous chemical waste, Antineoplastic waste, and radioactive waste require detailed, special handling. Contracts must be arranged with permitted haulers. C. Infectious Waste Directory List University Sanitarian (Environmental Health & Safety) and Chair of the Medical Center's Materials and Waste Management Committee Infection Control (SMH) Infection Control (EDC) APPENDIX III: WEBSITES FOR ADDITIONAL INFORMATION Center for Disease Control and Prevention (CDC): CDC Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis: Occupational Safety and Health Administration (OSHA): OSHA Safety & Health Topics: Bloodborne Pathogens: New York State Department of Health: NYS Informed Consent form to perform HIV testing: SMH Infection Control Program:
21 APPENDIX IV: HEPATITIS B VACCINE DECLINATION I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me. Signed: (Employee Name) Date:
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