VA Ann Arbor Healthcare System Policy Memorandum S-4

August 1, 2003

[EXPOSURE CONTROL PLAN FOR BLOODBORNE PATHOGENS]{.underline}

1\. [PURPOSE]{.underline}: To describe an Exposure Control Plan as it
relates to bloodborne pathogens. This plan is intended to provide an
optimally safe environment for all employees.

2\. [POLICY]{.underline}: The VA Ann Arbor Healthcare System (VAAAHS)
will protect its employees from exposure to infection from bloodborne
pathogens in the workplace.

3\. [PROCEDURES]{.underline}:

a\. [Exposure Determination]{.underline}. The following is a list of job
classifications in which employees have potential occupational exposure
to blood or hazardous body fluids (semen, vaginal secretions,
cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid,
peritoneal fluid, amniotic fluid, and any body fluid visibly
contaminated with blood).

Audiologist

Autopsy Assistant

Biological Aide

Biomedical Equipment Technician

Chemist

Companion

Cytologist

Dental Assistant

Dental Hygienist

Dentist

Dietitian (Blood Glucose Monitoring/Training)\*

Health Technician (Decontamination and/or Specimen Transport)\*

Histopathology Technician

Housekeeping Aide

Industrial Equipment Mechanic

Laboratory Aide

Medical Illustrator

Medical Instrument Technician

Medical Media Office Assistant

Medical Photographer

Medical Supply Technician (Decontamination)\*

Medical Technologist & Technician

Motor Vehicle Operator (Specimen Transport and/or Patient Transport)\*

Nuclear Medicine Technologist

Nurse ‑ All categories

Occupational Therapist (Splinting Wounds)\*

Pharmacist (Code Responding, Injection Training, Ostomy Fitting)\*

Physical Therapist

2\.

VA Ann Arbor Healthcare System Policy Memorandum S-4

August 1, 2003

Physical Therapist Assistant & Aide

Physician

Physician Assistant

Pipefitter

Police Officer

Prosthetics, Chief (Decontamination)\*

Prosthetics, Clerk (Decontamination)\*

Psychologist

PV Technician

Radiologist

Radiology Technician

Research Technician & Assistant (Human Research)\*

Respiratory Therapist

Social Worker (Specimen Transport)\*

Speech Pathologist

Toledo Van Driver

Unit Maintenance Provider

Utility System Repairers/Operator

Volunteer (Specimen and/or Patient Transport)\*

\* = Indicates that only employees with this job classification who
perform this task are exposed.

b\. [Methods of Compliance]{.underline}.

\(1\) Standard Precautions will be used, per the Infection Control
Manual, to prevent contact with blood or hazardous body fluids.

\(2\) All available engineering controls will be utilized. The
Engineering Controls for Bloodborne Pathogens Subcommittee will meet at
least annually. It will make recommendations to the Commodity Standards
Committee with input from nonmanagerial employees throughout the
facility.

\(3\) Employees will wash their hands after personal protective
equipment (PPE) is removed. A waterless hand sanitizer is available when
running water and soap are not available.

\(4\) Needle Stick Prevention: All sharps will be disposed of in
designated sharps containers only. They shall never be bent or sheared
off prior to disposal. Situations which require recapping must utilize
either a resheathing device or the one‑handed slide technique.

\(5\) All equipment, environmental and working surfaces will be cleaned
and decontaminated after contact with blood or hazardous body fluids per
the Infection Control Manual.

3\.

VA Ann Arbor Healthcare System Policy Memorandum S-4

August 1, 2003

\(6\) Contaminated laundry will be placed in an impervious linen bag for
decontamination.

c\. [HIV and HBV Research Labs]{.underline}. These labs use research
scale amounts and are specially regulated by OSHA. The Industrial
Hygienist will be notified by Research Service

prior to any HIV or HBV research to certify that the lab meets all
requirements of OSHA\'s Bloodborne Pathogens Standard.

d\. [Hepatitis B Vaccination]{.underline}. Within 10 working days of
initial assignment, all new hires identified in 3.a., \"Exposure
Determination,\" will be offered a Hepatitis B vaccination, free of
charge. Employees who refuse vaccination must sign the declination
statement.

e\. [Post-Exposure Evaluation & Follow-up]{.underline}. Following an
exposure incident (parenteral or mucous membrane exposure to potentially
infectious body fluids, tissues, or materials):

\(1\) The exposed person will report to Employee Health or the Emergency
Treatment Room during non‑administrative hours.

\(2\) An accident report will be filled out in the ASISTS Program by the
exposed person's supervisor.

\(3\) The source individual\'s and exposed person's blood will be tested
for HBV, HCV, and HIV. HIV testing is only done after consent is
obtained.

\(4\) Post‑exposure prophylaxis for HBV, HIV, and/or vaccination for HBV
will be given as recommended per U. S. Public Health Service guidelines.

\(5\) Evaluation of the incident and counseling will be made available
to the exposed person through Employee Health.

\(6\) The exposed person will be provided with a healthcare
professional\'s written opinion within 15 days of the healthcare
professional\'s completion of evaluation. It will indicate the
following:

\(a\) Whether Hepatitis B vaccination is indicated for the employee and
if it was received by the employee.

\(b\) That the exposed person has been informed of the source
individual\'s testing results as well as their own.

\(c\) That the exposed person has been informed of the evaluation
results.

4\.

VA Ann Arbor Healthcare System Policy Memorandum S-4

August 1, 2003

\(d\) That the exposed person has been told of any medical condition
resulting from exposure to blood and hazardous body fluids which
requires follow-up.

f\. [Communication of Hazards to Employees]{.underline}.

\(1\) Biohazard symbols will be affixed to all containers,
refrigerators, and freezers containing blood and/or hazardous body
fluids. Red bags for infectious waste do not require biohazard symbols
because they are internationally recognized as a biohazard.

\(2\) Training for all employees and their supervisors identified in
3.a., \"Exposure Determination,\" will be provided annually by Infection
Control. New hires will receive the information during New Employee
Orientation.

\(3\) All equipment surfaces must be thoroughly disinfected prior to
being turned in for repairs. If blood or hazardous body fluids have
leaked down inside the device, it will be noted on the work order. The
device should be covered with a red bag to alert repair technicians of
the need for internal disinfection.

g\. [Record Keeping]{.underline}.

\(1\) All medical records concerning occupational exposures will be
confidentially maintained by Employee Health per the Employee Health
Manual.

\(2\) Training records for all new employees will be maintained by the
Safety Office. Annual training records will be maintained by Education.

\(3\) This plan will reviewed on an annual basis through the Safety
Committee.

4\. [RESPONSIBILITIES]{.underline}:

a\. [Industrial Hygienist]{.underline}. Certifies labs for HIV and HBV
research. He/she ensures compliance with the Exposure Control Plan on a
medical center-wide basis.

b\. [Employee Health]{.underline}. Coordinates all Hepatitis B
vaccinations, post‑exposure evaluations, and follow‑ups. Also counsels
persons involved in an exposure incident with blood-borne pathogens.

c\. [Infection Control]{.underline}. Educates all new employees and
updates current employees.

d\. [Education]{.underline}. Conducts annual training for employees.

5\.

VA Ann Arbor Healthcare System Policy Memorandum S-4

August 1, 2003

e\. [Social Work Service]{.underline}. Obtains permission from source
individual to have HIV testing performed. Social Work Service obtains
consent during business hours. MOD obtains consent during off tours.

f\. [Supervisors]{.underline}. Familiarize themselves with the content
of this publication to ensure compliance with this policy in their
departments.

g\. [Employees]{.underline}. All employees must comply with the
requirements of this memorandum for their own safety and protection.
Failure to comply may result in appropriate disciplinary action in
accordance with local and agency policies.

5\. [REFERENCES]{.underline}:

29 CFR 1910.1030

VAAAHS Infection Control Manual

Protection against viral hepatitis: Recommendations of the Immunization

Practices Advisory Committee. MMWR 1990;39 (No RR‑2): 17‑22

Hepatitis B Virus: A comprehensive strategy for eliminating transmission

in the United States through universal childhood vaccinations; Appendix
A

Post‑exposure prophylaxis for Hepatitis B. MMWR 1991;40 (No RR‑13):
21‑25.

IL-10-98-009: Needle Stick Prevention Program

Employee Health Manual

JCAHO Comprehensive Accreditation Manual for Hospitals, Surveillance,
Prevention & Control of Infection, Section 2

6\. [RESCISSION]{.underline}: Policy Memorandum S-4, dated August 1,
2001

7\. [EXPIRATION]{.underline}: August 2006

8\. [FOLLOW‑UP RESPONSIBILITY]{.underline}: Industrial Hygienist (50IH)

James W. Roseborough

JAMES W. ROSEBOROUGH

Director

Distribution: A + 26 for 30