Policy 4119.42 - Exposure Control Plan for Bloodborne Pathogens

Exposure Control Plan for Bloodborne

Rule 4119.42

The Superintendent or designee shall use engineering and work practice controls to eliminate or minimize employee exposure, and shall regularly examine and update controls to ensure their effectiveness.

Universal precautions will be observed to prevent contact with blood and 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.

"Bloodborne Pathogens" means pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV).

"Engineering Controls" means controls (e.g., sharps disposal containers, needleless systems and sharps with engineered sharps injury protection) that isolate or remove the bloodborne pathogens hazard from the workplace.

"Engineered Sharps Injury Protection" means either:

(1) A physical attribute built into a needle device used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids, which effectively reduces the risk of an exposure incident by a mechanism such as barrier creation, blunting, encapsulation, withdrawal or other effective mechanisms; or

(2) A physical attribute built into any other type of needle device, or into a non-needle sharp, which effectively reduces the risk of an exposure incident.

"Exposure Incident" means a specific eye, mouth, other mucous membrane, non- intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee's duties.

"Hand Washing Facilities" means a facility providing an adequate supply of running potable water, soap and single use towels or hot air drying machines.

"HBV" means hepatitis B virus.

"HCV" means hepatitis C virus.

“HIV” means human immunodeficiency virus

"Needle" or "Needle Device" means a needle of any type, including, but not limited to, solid and hollow-bore needles.

"Needleless System" means a device that does not utilize needles for:

1. The withdrawal of body fluids after initial venous or arterial access is established;
2. The administration of medication or fluids; and
3. Any other procedure involving the potential for an exposure incident.

"Occupational Exposure" means reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee's duties.

"OPIM" means other potentially infectious materials.

"Other Potentially Infectious Materials" means: Any of the following, if known or reasonably likely to contain or be infected with HIV, HBV, or HCV:

1. Cell, tissue, or organ cultures from humans or experimental animals;
2. Blood, organs, or other tissues from experimental animals; or
3. Culture medium or other solutions.

"Parenteral Contact" means piercing mucous membranes or the skin barrier through such events as needle sticks, human bites, cuts, and abrasions.

"Personal Protective Equipment" is specialized clothing or equipment worn or used by an employee for protection against a hazard. General work clothes (e.g., uniforms, pants, shirts or blouses) not intended to function as protection against a hazard are not considered to be personal protective equipment.

"Regulated Waste" means waste that is any of the following:

1. Liquid or semi-liquid blood or OPIM;
2. Contaminated items that:
   1. (A) Contain liquid or semi-liquid blood, or are caked with dried blood or OPIM; and
   2. (B) Are capable of releasing these materials when handled or compressed.
3. Contaminated sharps.
4. Pathological and microbiological wastes containing blood or OPIM.

"Sharp" means any object used or encountered in the industries covered by subsection (a) that can be reasonably anticipated to penetrate the skin or any other part of the body, and to result in an exposure incident, including, but not limited to, needle devices, scalpels, lancets, broken glass, broken capillary tubes, exposed ends of dental wires and dental knives, drills and burs.

"Sharps Injury" means any injury caused by a sharp, including, but not limited to, cuts, abrasions, or needle sticks.

"Sharps Injury Log" means a written or electronic record satisfying the requirements of subsection (c) (2).

"Universal Precautions" is an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, HCV, and other bloodborne pathogens.

"Work Practice Controls" means controls that reduce the likelihood of exposure by defining the manner in which a task is performed (e.g., prohibiting recapping of needles by a twohanded technique and use of patient-handling techniques).

3. Exposure Response, Prevention and Control.
   1. Exposure Control Plan.
      1. The Exposure Control Plan is accessible to employees in accordance with Section 3204(e).
      2. The Exposure Control Plan shall be reviewed and updated at least annually and whenever necessary as follows:
         1. To reflect new or modified tasks and procedures which affect occupational exposure;
            1. To reflect changes in technology that eliminate or reduce exposure to bloodborne pathogens; and
            2. To document consideration and implementation of appropriate commercially available needleless systems and needle devices and sharps with engineered sharps injury protection;
         2. To include new or revised employee positions with occupational exposure;
         3. To review and evaluate the exposure incidents which occurred since the previous update; and
         4. To review and respond to information indicating that the Exposure Control Plan is deficient in any area.
   2. Sharps Injury Log. The employer shall establish and maintain a Sharps Injury Log, which is a record of each exposure incident involving a sharp. The information recorded shall include the following information, if known or reasonably available:
      1. Date and time of the exposure incident;
      2. Type and brand of sharp involved in the exposure incident;
      3. A description of the exposure incident which shall include:
         1. Job classification of the exposed employee;
         2. Department or work area where the exposure incident occurred;
         3. The procedure that the exposed employee was performing at the time of the incident;
         4. How the incident occurred;
         5. The body part involved in the exposure incident;
         6. If the sharp had engineered sharps injury protection, whether the protective mechanism was activated, and whether the injury occurred before the protective mechanism was activated, during activation of the mechanism or after activation of the mechanism, if applicable;
         7. If the sharp had no engineered sharps injury protection, the injured employee's opinion as to whether and how such a mechanism could have prevented the injury; and
         8. The employee's opinion about whether any engineering, administrative or work practice control could have prevented the injury.
      4. Each exposure incident shall be recorded on the Sharps Injury Log within 14 working days of the date the incident is reported to the employer.
      5. The information in the Sharps Injury Log shall be recorded and maintained in such a manner as to protect the confidentiality of the injured employee.
   3. Exposure Determination.
      1. Each employer who has an employee(s) with occupational exposure as defined by subsection (b) of this section shall prepare an exposure determination. This exposure determination shall contain the following:
         1. A list of all job classifications in which all employees in those job classifications have occupational exposure;
         2. A list of job classifications in which some employees have occupational exposure; and
         3. A list of all tasks and procedures or groups of closely related task and procedures in which occupational exposure occurs and that are performed by employees in job classifications listed in accordance with the provisions of subsection (c)(3)(A)2. of this standard.
      2. This exposure determination shall be made without regard to the use of personal protective equipment.
4. Methods of Compliance.
   1. General. Universal precautions shall be observed to prevent contact with blood or OPIM. Under circumstances in which differentiation between body fluid types is difficult or impossible, all body fluids shall be considered potentially infectious materials.
   2. Engineering and Work Practice Controls -General Requirements.
      1. Engineering and work practice controls shall be used to eliminate or minimize employee exposure.
      2. Engineering controls shall be examined and maintained or replaced on a regular schedule to ensure their effectiveness.
      3. Work practice controls shall be evaluated and updated on a regular schedule to ensure their effectiveness.
      4. All procedures involving blood or OPIM shall be performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets of these substances.
   3. Engineering and Work Practice Controls -Specific Requirements.
      1. Needleless Systems, Needle Devices and non-Needle Sharps.
         1. Needleless Systems. Needleless systems shall be used for:
            1. Withdrawal of body fluids after initial venous or arterial access is established;
            2. Administration of medications or fluids; and
            3. Any other procedure involving the potential for an exposure incident for which a needleless system is available as an alternative to the use of needle devices.
         2. Needle Devices. If needleless systems are not used, needles with engineered sharps injury protection shall be used for:
            1. Withdrawal of body fluids;
            2. Accessing a vein or artery;
            3. Administration of medications or fluids; and
            4. Any other procedure involving the potential for an exposure incident for which a needle device with engineered sharps injury protection is available.
         3. Non-Needle Sharps. If sharps other than needle devices are used, these items shall include engineered sharps injury protection.
         4. Exceptions. The following exceptions apply to the engineering controls required by subsections (d) (3) (A) 1.-3.:
            1. Market Availability. The engineering control is not required if it is not available in the marketplace.
            2. Patient Safety. The engineering control is not required if a licensed healthcare professional directly involved in a patient's care determines, in the reasonable exercise of clinical judgment, that use of the engineering control will jeopardize the patient's safety or the success of a medical, dental or nursing procedure involving the patient. The determination shall be documented according to the procedure required by (c) (1) (B) 7.
            3. Safety Performance. The engineering control is not required if the employer can demonstrate by means of objective product evaluation criteria that the engineering control is not more effective in preventing exposure incidents than the alternative used by the employer.
            4. Availability of Safety Performance Information. The engineering control is not required if the employer can demonstrate that reasonably specific and reliable information is not available on the safety performance of the engineering control for the employer's procedures, and that the employer is actively determining by means of objective product evaluation criteria whether use of the engineering control will reduce the risk of exposure incidents occurring in the employer's workplace.
      2. Prohibited Practices.
         1. Shearing or breaking of contaminated needles and other contaminated sharps is prohibited.
         2. Contaminated sharps shall not be bent, recapped, or removed f from devices. Exception: Contaminated sharps may be bent, recapped or removed from devices if: a) The employer can demonstrate that no alternative is feasible or that such action is required by a specific medical or dental procedure; and b) The procedure is performed using a mechanical device.
         3. Sharps that are contaminated with blood or OPIM 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.
         4. Disposable sharps shall not be reused.
         5. Broken Glassware. 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.
         6. The contents of sharps containers shall not be accessed unless properly reprocessed or decontaminated.
         7. Sharps containers shall not be opened, emptied, or cleaned manually or in any other manner which would expose employees to the risk of sharps injury.
         8. Mouth pipetting/suctioning of blood or OPIM is prohibited.
         9. 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.
         10. Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or on countertops or bench tops where blood or OPIM are present.
      3. Requirements for Handling Contaminated Sharps.
         1. All procedures involving the use of sharps in connection with patient care, such as withdrawing body fluids, accessing a vein or artery, or administering vaccines, medications or fluids, shall be performed using effective patient-handling techniques and other methods designed to minimize the risk of a sharps injury.
         2. Immediately or as soon as possible after use, contaminated sharps shall be placed in containers meeting the requirements of subsection (d) (3) (D) as applicable.
         3. At all-time during the use of sharps, containers for contaminated sharps shall be:
            1. 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., laundries);
            2. Maintained upright throughout use, where feasible; and
            3. Replaced as necessary to avoid overfilling.
      4. Sharps Containers for Contaminated Sharps.
         1. All sharps containers for contaminated sharps shall be:
            1. Rigid;
            2. Puncture resistant;
            3. Leak-proof on the sides and bottom;
            4. Portable, if portability is necessary to ensure easy access by the user as required by subsection (d) (3) (C) 3.a.; and
            5. Labeled in accordance with subsection (g) (1) (A) (2). 2. If discarded sharps are not to be reused, the sharps container shall also be closeable and sealable so that when sealed, the container is leak resistant and incapable of being reopened without great difficulty.
      5. Regulated Waste.
         1.  General. Handling, storage, treatment and disposal of all regulated waste shall be in accordance with Health and Safety Code Chapter 6.1, Sections 117600 through 118360, and other applicable regulations of the United States, the State, and political subdivisions of the State.
         2. Disposal of Sharps Containers. When any container of contaminated sharps is moved from the area of use for the purpose of disposal, the container shall be:
            1. Closed immediately prior to removal or replacement to prevent spillage or protrusion of contents during handling, storage, transport, or shipping; and
            2. Placed in a secondary container if leakage is possible. The second container shall be:
               1. i. Closable;
               2. ii. Constructed to contain all contents and prevent leakage during handling, storage, transport, or shipping; and
               3. iii. Labeled according to subsection (g) (1) (A) of this section.
         3. Disposal of Other Regulated Waste. Regulated waste not consisting of sharps shall be disposed of in containers which are:
            1. Closable;
            2. Constructed to contain all contents and prevent leakage during handling, storage, transport, or shipping;
            3. Labeled and color-coded in accordance with subsection (g) (1) (A) of this section; and
            4. Closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping.
      6. Cleaning and Decontamination of the Worksite.
         1. General Requirements.
            1. Employers shall ensure that the worksite is maintained in a clean and sanitary condition.
            2. Employers shall determine and implement appropriate written methods and schedules for cleaning and decontamination of the worksite.
            3. The method of cleaning or decontamination used shall be effective and shall be appropriate for the:
               1. i. Location within the facility;
               2. ii. Type of surface or equipment to be treated;
               3. iii. Type of soil or contamination present; and
               4. iv. Tasks or procedures being performed in the area.
            4. All equipment and environmental and work surfaces shall be cleaned and decontaminated after contact with blood or OPIM no later than at the end of the shift. Cleaning and decontamination of equipment and work surfaces is required more often as specified below.
         2. Specific Requirements.
            1. Contaminated Work Surfaces. Contaminated work surfaces shall be cleaned and decontaminated with an appropriate disinfectant immediately or as soon as feasible when:
               1. Surfaces become overtly contaminated;
               2. There is a spill of blood or OPIM;
               3. Procedures are completed; and
               4. At the end of the work shift if the surface may have become contaminated since the last cleaning.
            2. Receptacles. All bins, pails, cans, and similar receptacles intended for reuse which have a reasonable likelihood for becoming contaminated with blood or OPIM shall be inspected and decontaminated on a regularly scheduled basis and cleaned and decontaminated immediately or as soon as feasible upon visible contamination.
            3. Protective Coverings. 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 work shift if they may have become contaminated during the shift.
      7. Hygiene.
         1. Employers shall provide hand washing facilities which are readily accessible to employees.
         2. When provision of hand washing facilities is not feasible, the employer shall provide either an appropriate antiseptic hand cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes. When antiseptic hand cleansers or towelettes are used, hands shall be washed with soap and running water as soon as feasible.
         3. Employers shall ensure that employees wash their hands immediately or as soon as feasible after removal of non-latex gloves or other personal protective equipment.
         4. Employers 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 OPIM.
      8. Laundry.
         1. Contaminated laundry shall be handled as little as possible with a minimum of agitation.
            1. Contaminated laundry shall be bagged or containerized at the location where it was used and shall not be sorted or rinsed in the location of use.
   4. Personal Protective Equipment.
      1. Provision. Where occupational exposure remains after institution of engineering and work practice controls, the employer shall provide, at no cost to the employee, appropriate personal protective equipment such as, but not limited to, non-latex gloves, gowns, laboratory coats, face shields or masks and eye protection, and mouthpieces, resuscitation bags, pocket masks, or other ventilation devices. Personal protective equipment will be considered "appropriate" only if it does not permit blood or OPIM 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.
      2. Use. The employer shall ensure that the employee uses appropriate personal protective equipment unless the employer 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 circumstances shall be investigated and documented in order to determine whether changes can be instituted to prevent such occurrences in the future. The employer shall encourage employees to report all such instances without fear of reprisal in accordance with Section 3203.
      3. Accessibility. The employer shall ensure that appropriate personal protective equipment in the appropriate sizes is readily accessible at the worksite or is issued to employees. Hypoallergenic non-latex gloves, glove liners, powder less non-latex gloves, or other similar alternatives shall be readily accessible to those employees who are allergic to the non-latex gloves normally provided.
      4. Cleaning, Laundering, and Disposal. The employer shall clean, launder, and dispose of personal protective equipment required by subsections (d) and (e) of this standard, at no cost to the employee.
      5. Repair and Replacement. The employer shall repair or replace personal protective equipment as needed to maintain its effectiveness, at no cost to the employee.
      6. Removal.
         1. If a garment(s) is penetrated by blood or OPIM, the garment(s) shall be removed immediately or as soon as feasible.
         2. All personal protective equipment shall be removed prior to leaving the work area.
         3. When personal protective equipment is removed it shall be placed in an appropriately designated area or container for storage, washing, decontamination or disposal.
      7. (G) Non-latex gloves. Non-latex gloves shall be worn when it can be reasonably anticipated that the employee may have hand contact with blood, OPIM, mucous membranes, and non-intact skin; when performing vascular access procedures except as specified in subsection (d)(4)(G)4.; and when handling or touching contaminated items or surfaces. These requirements are in addition to the provisions of Section 3384.
         1. Disposable (single use) non-latex gloves such as surgical or examination non-latex 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) non-latex gloves shall not be washed or decontaminated for re-use.
         3. Utility non-latex 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.
      8. Masks, Eye Protection, Face Shields, and Respirators.
         1. 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 OPIM may be generated and eye, nose, or mouth contamination can be reasonably anticipated. These requirements are in addition to the provisions of Section 3382.
         2. Where respiratory protection is used, the provisions of Sections 5144 and 5147 are required as applicable. Note: Surgical masks are not respirators.
            1. (I) Gowns, Aprons, and Other Protective Body Clothing.
               1. Appropriate protective clothing such as, but not limited to, gowns, aprons, lab coats, clinic jackets, 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. These requirements are in addition to the provisions of Section 3383.