VETERANS AFFAIRS MEDICAL CENTER\
Houston, Texas

MEDICAL CENTER POLICY May 25, 2000\
MEMORANDUM NO. 111G1-002

EXPOSURE CONTROL PLAN FOR PREVENTION OF OCCUPATIONAL EXPOSURES TO
BLOODBORNE PATHOGENS

I. [PURPOSE]{.underline}

A. This document sets forth policies and procedures for bloodborne
pathogen exposure prevention and control as instituted at the Houston VA
Medical Center (HVAMC) and its affiliate clinics.

B. The objective of this program is to eliminate or minimize employee
exposure to bloodborne pathogens through the use of appropriate
engineering controls, safe work practices, and personal protective
barriers.

II\. [DEFINITIONS]{.underline}

See Attachment A for standard definitions.

III\. [PROCEDURES]{.underline}

A. The scope of this Bloodborne Pathogen Exposure Control Plan
encompasses all working facilities (treatment areas, clinics and
research areas, both on grounds and free-standing) administered,
staffed, and managed by the HVAMC.

B. The stipulations of this document apply generally to all full-time,
part-time, and temporary personnel, without compensation (WOC)
appointments, and volunteers and specifically to all tasks, activities,
jobs, or positions that have potential for exposure to bloodborne
pathogens and the employees who perform those tasks and activities or
occupy those jobs and positions.

C. In keeping with the stated mission of the HVAMC and in order to
protect the health and well-being of the employees, patients, and
community in its care, the standards and guidelines set forth in Title
29 Code of Federal Regulations, Part 1910.1030, Occupational Exposure to
Bloodborne Pathogens; Final Rule, shall be applied and followed at this
facility.

D. Exposure Risk Determinations.

> 1\. The major determinants for relative risk of occupational exposure
> in any job or position are the tasks that must be performed by the
> employee engaged in that job or position. The exposure risk
> determination identifies who has had occupational exposure to
> bloodborne pathogens and is made without regard to the use of personal
> protective clothing or equipment. The exposure risk categories
> include:
>
> a\. Jobs or positions in which [all]{.underline} employees perform
> at-risk tasks (Attachment B)
>
> b\. Jobs or positions in which [some]{.underline} employees, but not
> all employees in those job classifications perform at-risk tasks
> (Attachment C)
>
> c\. A list of all tasks and procedures or groups of closely related
> tasks and procedures in which occupational exposure occurs and that
> are performed by employees in job classifications listed above.
> (Attachment D)
>
> 2\. When a new employee enters on duty or an employee changes jobs
> within the facility, the following process will take place to ensure
> that the employee is trained in the appropriate work practices:
>
> a\. The service chief or supervisor will assure that employee\'s job
> classification and the tasks and procedures that they will perform are
> checked against the Job Classifications and Task Lists that identify
> those jobs in which occupational exposure occurs.
>
> b\. If the employee is transferring from one job to another within the
> facility, the job classification and tasks/procedures pertaining to
> their previous position are checked against these lists.
>
> c\. Based on this \"cross-checking\" the new job classifications and
> or tasks and procedures, which will bring the employee into
> occupational exposure situations, are identified.
>
> d\. Any change in the employee\'s job classification should be
> communicated to Human Resources Management Service (HRMS).

E. Methods of Compliance.

> 1\. Standard Precautions.
>
> a\. The dominant element in bloodborne pathogen exposure prevention is
> the practice of Standard Precautions. Originally adopted and
> implemented as Universal Precautions, the measures are consistently
> used with all patients regardless of their known or perceived
> bloodborne infection status in order to prevent contact with blood or
> other potentially infectious materials.
>
> b\. The guiding premise of the Standard Precautions methodology is the
> avoidance of contact with all human blood and certain human body
> fluids through the use of mechanical safety devices, modifications in
> performance of procedures/techniques and/or wearing of physical
> barriers to exposure.
>
> c\. The human body fluids and materials to which Standard Precautions
> applies include:
>
> \(1\) Human blood, human blood components, and products made from
> blood.
>
> \(2\) Semen, vaginal secretions, cerebrospinal fluid, synovial fluid,
> pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid,
> saliva in dental procedures, and wound exudates.
>
> \(3\) Any body fluid that is visibly contaminated with blood.
>
> \(4\) All body fluids in situations where it is difficult or
> impossible to differentiate between body fluid types.
>
> \(5\) Any unfixed tissue or organ (other than intact skin) from a
> human (living or dead).
>
> d\. In addition, Standard Precautions will be observed when handling
> the following materials:
>
> \(1\) HIV-containing cell or tissue cultures, organ cultures, and HIV-
> or HBV-containing culture medium or other solutions.
>
> \(2\) Any blood, organs, or other tissues from experimental animals
> infected with HIV or HBV.
>
> 2\. Engineering Controls.
>
> a\. Engineering Controls are generally mechanical safety devices that
> provide an alternative means to accomplish a task while minimizing or
> eliminating exposure potential inherent in using devices that do not
> provide protective apparatus.
>
> b\. The following Engineering Controls are standardized throughout the
> facility:
>
> \(1\) Handwashing facilities include a sink with running water and the
> provision of an adequate supply of soap and paper towels in a
> dispensing unit. Handwashing facilities are available in each patient
> room, isolation anteroom, bathroom, restroom, examination and
> treatment room, utility room, laboratory workstation, and research
> laboratory.
>
> \(2\) Antiseptic hand cleanser (antimicrobial soap) is provided in all
> patient-care areas. Alcohol gel hand cleanser products are available
> as an interim method of hand cleansing in locations lacking adequate
> handwashing facilities.
>
> \(3\) Safety needles, mechanical recapping devices, and needleless
> intravenous fluid administration systems are available in all patient
> care areas.
>
> \(4\) Sharps disposal containers are provided as in-room wall mounted
> units, tabletop units, floor units, and small hand-held (portable)
> units. All containers are designed to be closed, puncture-resistant,
> leak-proof on the sides and bottoms, and not intended for reuse. All
> containers are labeled with the Universal Biohazard symbol and are
> color (red) coded. Sharps disposal units are made available in all
> areas where sharps are used, e.g., clinical areas, as well as those
> areas where sharps may be found although not routinely used, e.g.,
> laundry and dish room.
>
> \(5\) Specimen transport containers are identified as plastic zip-lock
> bags with side pocket for laboratory test request slips. All
> containers are labeled with the Universal Biohazard symbol.
>
> \(6\) Certified biological safety cabinets/hoods with local exhaust
> are available in clinical and research laboratories.
>
> \(7\) Mechanical pipetting devices are available in clinical and
> research laboratories.
>
> \(8\) Specialized containers for collection and transport of regulated
> waste are available in all patient care areas and clinical and
> research laboratories.
>
> \(9\) Specialized containers for the collection, transport, and
> processing of reusable devices or instruments are available in all
> patient care areas
>
> \(10\) Resuscitator devices are made readily available and include
> devices such as masks, mouthpieces, Ambubags, and shields.
>
> \(11\) Local ventilation provides negative air pressure in specified
> laboratories and isolation rooms. Air is exhausted to the outside
> rather than recirculated through the building.
>
> \(12\) Storage for food and drink is separate and removed from those
> used for storage of blood, biological specimens, reagents, and
> pharmaceutical agents.
>
> b\. Engineering Controls are reviewed for proper function and
> maintained or replaced on a regular schedule to ensure their
> effectiveness.
>
> c\. Periodic review of existing engineering controls will be
> accomplished by representatives of the Infection Control and Safety
> Programs in conjunction with the service chief or supervisor where the
> equipment is located. The aim of the inspection process is to
> validate:
>
> \(1\) Areas where engineering controls are currently used
>
> \(2\) Areas not employing engineering controls, but where engineering
> controls would be beneficial.
>
> \(3\) Working condition of engineering controls and protective
> equipment

F. Work Practice Controls.

> 1\. Work practice controls are modifications or alterations in the
> performance of procedures that minimize employee exposure potential.
> Together with Engineering Controls, work practice controls constitute
> the primary means of eliminating or minimizing employee exposures.
> Where occupational exposure remains after institution of these
> controls, personal protective equipment will be utilized.
>
> 2\. Management of Sharps.
>
> a\. The single procedure that presents the greatest risk of exposure
> through the inoculation route is the use of a needle and syringe.
> Because of the imminent hazard of self-inoculation, the following
> practices are mandatory when handling sharp items:
>
> \(1\) Contaminated needles and other sharps will not be bent, sheared
> or purposely broken. Used needles will not be removed from disposable
> syringes or unnecessarily manipulated.
>
> \(2\) Used needles will not be reinserted into their sheaths by hand.
>
> b\. Employees requesting an exemption to recap needles must identify
> the specific situations requiring the action and must demonstrate that
> no alternative is feasible or that such action is essential and
> required by a specific medical procedure.
>
> c\. Recapping or needle removal may, in limited situations, be
> accomplished through the use of a mechanical device or a one-handed
> \"scoop\" technique.
>
> \(1\) The one-hand technique is performed using the needle itself to
> pick up the cap from a flat surface, then pushing the cap and sharp
> together against a hard surface to ensure a tight fit. The use of the
> properly performed one-hand scoop technique for recapping is a
> recognized and acceptable method for recapping of used needles in
> specific situations.
>
> \(2\) The one-handed scoop method is limited to the following
> situations: obtaining blood specimens for blood gas analyses,
> administering incremental doses of a medication such as an anesthetic
> to the same patient, or removing the needle from a phlebotomy
> collection apparatus (Vacutainer holder).
>
> d\. All disposable contaminated sharps will be managed as follows:
>
> \(1\) Immediately, or as soon as possible after use, sharps will be
> discarded intact, directly into designated sharps containers.
>
> \(2\) Sharps containers will not be allowed to overfill. Disposal
> units will be inspected daily for fill level and replaced when 2/3
> full. All bedside wall-mounted sharps containers will be maintained by
> the housekeeping aid; all other containers will be maintained by the
> using service.
>
> \(3\) Sharps containers will not be opened and contents emptied for
> reuse. Tape may be used to secure the lid of a sharps container as
> long as the tape does not serve as the lid itself. Once the lid is
> secured, filled sharps containers will be removed from the use area by
> the housekeeping aid.
>
> \(4\) Sharps containers will be maintained upright throughout use,
> transport, and disposal to prevent spillage or leakage of the
> contents.
>
> e\. Reusable contaminated sharps will be placed immediately, or as
> soon as possible after use, into appropriate instrument containers
> provided by Materiels Management Section (MMS). The containers used to
> store and transport reusable sharps are puncture resistant, leak-proof
> and labeled with the Universal Biohazard symbol. Daily removal of
> soiled instruments, from the clinical areas is accomplished by MMS.
>
> 3\. Handwashing.
>
> a\. The control of occupational exposure by the contact route requires
> that procedures be conducted in a manner that avoids contamination of
> body and work surfaces. It is recognized that dispersal of
> contaminants to other surfaces can occur by their transfer on the
> gloves of the healthcare worker.
>
> b\. To minimize or prevent contact transmission, employees will wash
> their hands between patient contacts and immediately or as soon as
> feasible after removal of gloves or other personal protective
> equipment.
>
> c\. Employees will wash their hands and any other unprotected skin
> surface 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.
>
> d\. Liquid antiseptic hand cleansers (alcohol foams or gels) are
> acceptable handwashing alternatives when soap, running water and
> towels are not available. Such products are available through the
> Pharmacy Service upon written request.
>
> e\. Hand cream application is permitted, although not encouraged as
> routine practice, in the work area provided the hands are thoroughly
> washed immediately prior to application. Care should be taken not to
> contaminate hand creams during application.
>
> f\. Employees who have exudative lesions or weeping dermatitis will
> refrain from all direct patient care and from handling patient care
> equipment and devices used in performing invasive procedures until the
> condition resolves. Such cases will be referred to the Employee Health
> Physician for evaluation and work recommendations.
>
> 4\. Clinical Specimens.
>
> a\. Specimens of blood and other potentially infectious materials from
> all patients are considered a biohazard. Standard precautions will be
> observed in handling all clinical specimens.
>
> b\. Specimens of blood or other potentially infectious materials will
> be placed in an appropriate primary container that prevents leakage
> during the collection, handling, processing, storage, and transport.
>
> c\. The primary containers used for this purpose are exempt from
> Biohazard labeling requirements providing the containers are
> recognizable as containing specimens and do not leave the facility.
> Labeling of the primary container is required when specimens are
> transported outside the facility for processing.
>
> d\. During collection, care is taken not to contaminate the outside of
> the primary specimen container. The primary specimen container will be
> placed into a specimen transport bag (impervious, plastic zip-lock bag
> labeled with the Universal Biohazard symbol).
>
> e\. Gloves will be worn when handling all specimen containers to
> eliminate or minimize the possibility of inadvertent contact with
> blood or other potentially infectious materials.
>
> 5\. Equipment Repair and Decontamination.
>
> a\. All equipment that is visibly soiled with blood or other
> potentially infectious materials will be examined and decontaminated
> as necessary prior to servicing by Biomedical repair personnel,
> servicing representatives, or the manufacturer.
>
> b\. The manufacturer\'s recommended procedures for cleaning and
> decontamination will be followed. If questions remain after review of
> the manufacturer\'s written guidelines, consultation with MMS will be
> sought.
>
> c\. When it is not possible to decontaminate equipment prior to
> servicing or shipping (e.g. highly technical or sensitive equipment
> and/or limited access to contaminated parts), at least partial
> decontamination, such as flushing lines and wiping the exterior, will
> be accomplished.
>
> d\. If complete decontamination is not possible, a readily observable
> biohazard label will be attached to the equipment specifically
> identifying the portions that remain contaminated. Additionally, this
> information will be conveyed verbally to all affected employees, the
> service representative, and/or the manufacturer, as appropriate, prior
> to handling, servicing, or shipping.
>
> 6\. To minimize or prevent transmission by either the oral or ocular
> route, strict adherence to the following work practices are mandatory:
>
> a\. Eating, drinking, smoking, applying cosmetics or lip balm, and
> handling of contact lenses are prohibited in work areas where there is
> a reasonable likelihood of occupational exposure.
>
> b\. The storage of food and drink in refrigerators, freezers,
> cabinets, or on shelves, countertops, or benchtops where blood and
> other potentially infectious materials are present is strictly
> prohibited.
>
> c\. Mouth pipetting/suctioning of blood or other potentially
> infectious materials is prohibited.
>
> 7\. To minimize or prevent exposure by the respiratory route all
> procedures involving blood or other potentially infectious materials
> will be performed in such a manner as to minimize splashing, spraying,
> spattering, and generation of droplets of these substances.

G. Personal Protective Equipment (PPE).

> 1\. Personal protective equipment (PPE) is any specialized clothing or
> equipment worn by an employee for protection against contact with
> blood or other potentially infectious materials. PPE is provided at no
> cost to the employee. Appropriate PPE includes, but is not limited to
> gloves, gowns, fluid resistant aprons, laboratory coats, head and foot
> coverings; face shields or masks and protective eyewear.
>
> 2\. The employees are required to use PPE each time any task with
> exposure potential is performed unless extenuating circumstances
> exist.
>
> a\. A limited exemption to the requirement for PPE is granted if an
> employee temporarily and briefly, under rare and extraordinary
> circumstances, declines to use personal protective equipment.
>
> b\. It must be the employee\'s professional judgment that its use in a
> specific situation would have prevented the delivery of health care
> (e.g., delay in administering CPR) or would have posed an increased
> hazard to personal safety.
>
> c\. All such excepted situations will be reviewed on a case-by-case
> basis by the service chief. The circumstances surrounding the incident
> will be documented and evaluated to determine whether prevention of a
> similar occurrence in the future is possible.
>
> d\. The exemption from the use of protective barriers is limited and
> does not apply to recurring tasks or particular work areas.
> Interference with proper performance of a procedure or improper fit
> are not considered legitimate or acceptable reasons to disregard the
> use of protective barriers.
>
> 3\. PPE in the appropriate sizes will be provided to employees.
> Special equipment or attire may be authorized by the Employee Health
> Physician if medically indicated. These provisions may include the
> issue of powderless gloves or glove liners. Protective equipment is
> provided in the following manner:
>
> a\. MMS distributes: Vinyl or neoprene examination and latex sterile
> gloves, disposable surgical gowns, plastic aprons, disposable shoe
> covers, surgical caps, surgical masks, face shields and protective
> eyewear (goggles), ventilation devices.
>
> b\. The Textile Care Section of Facilities Management Service (FMS)
> distributes: laboratory coats, clinic jackets, cover/isolation gowns,
> scrub attire.
>
> 4\. All HVAMC-issued laboratory coats, gowns, uniforms, and the like
> that are used as PPE will be cleaned and laundered by the facility.
> Home laundering is not permitted.
>
> 5\. All PPE will be repaired and replaced as needed to maintain its
> effectiveness.
>
> 6\. Under the performance-oriented standard, PPE is considered
> appropriate only if it does not permit blood or other potentially
> infectious materials to pass through or reach 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.
>
> a\. An employee may select any combination of appropriate PPE as long
> as they are sufficient to protect the employee from the types of
> exposure reasonably anticipated during performance of the employee\'s
> duties.
>
> b\. All garments which are penetrated by blood or other potentially
> infectious materials will be removed immediately or as soon as
> possible.
>
> c\. To prevent contamination beyond the work area, employees must
> remove all protective clothing prior to leaving the immediate work
> area and place them in an appropriately designated area or containers
> for storage, washing, decontamination or disposal.
>
> 7\. Gloves must be worn when there is reasonable likelihood of hand
> contact with blood or other potentially infectious material, mucous
> membranes, or non-intact skin, when performing vascular access and
> phlebotomy procedures, and when handling contaminated items or
> surfaces.
>
> a\. Disposable (single-use) gloves must be changed between contact
> with different patients or during the care of a single patient when
> moving from a contaminated to a clean body site.
>
> b\. Disposable gloves, such as surgical and examination gloves, will
> not be washed or decontaminated for re-use and must be replaced as
> soon as practical when they become contaminated, torn, punctured, or
> when their ability to function as a barrier is compromised. Hands must
> be washed after gloves are removed.
>
> c\. Surgical latex or polyvinyl gloves should be inspected for
> punctures before use. Double gloving to decrease the risk of exposure
> by penetration is recommended for exposure prone procedures if it does
> not interfere with the task.
>
> d\. The use of petroleum-based hand creams under latex gloves is not
> recommended since such creams or lotions can adversely affect glove
> integrity.
>
> e\. Utility gloves may be decontaminated for re-use provided that the
> integrity of the glove is not compromised. Utility gloves will 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.
>
> f\. If an employee is allergic to the gloves that are normally
> provided, the employee will be provided an alternative. Requests for
> alternative gloves will be initiated and approved by the Employee
> Health Physician.
>
> 8\. Masks in combination with eye protection devices, such as goggles
> or glasses with solid side shields, or chin length face shields, will
> be worn whenever splashes, spray, splatter or droplets of blood or
> other potentially infectious material may be generated and eye, nose,
> or mouth contamination can reasonably be anticipated.
>
> a\. Prescription glasses may be used as protective eyewear as long as
> they are equipped with solid side shields that are permanently affixed
> or of the \"add-on\" type.
>
> b\. If protective eyewear is chosen over the use of a face shield, the
> eyewear must be worn in combination with a mask to protect the nose
> and mouth.
>
> c\. The only exception to the use of protective eyewear when
> performing surgical procedures is during microsurgery, when it is not
> reasonably anticipated that there would be splattering or splashing of
> blood and protective eyewear may not be necessary.
>
> 9\. Gowns, aprons, and other protective clothing will be chosen based
> on the anticipated exposure to blood or other potentially infectious
> materials.
>
> a\. Although reusable cloth or disposable paper cover gowns generally
> will not prevent gross liquid from soaking through to the skin, these
> cover gowns are considered adequate protection for common bedside care
> procedures and in those situations when gross liquid/blood
> contamination is not likely.
>
> b\. The use of surgical caps or hoods, and shoe covers are required
> when overt contamination of the head or feet can be reasonably
> anticipated.
>
> c\. Laboratory coats and scrubs that are commonly used for convenience
> and usually worn in a manner similar to street clothes are not
> considered personal protective clothing. When used in ways other than
> to comply with the Standard, the HVAMC is not obligated to provide or
> clean such garments.
>
> d\. If an employee chooses to wear and maintain his/her own laboratory
> coat or scrubs, then s/he will need to don additional
> HVAMC-handled/controlled PPE when performing tasks where it is
> reasonable to anticipate exposure to blood or other potentially
> infectious materials.

H. Housekeeping.

> 1\. The HVAMC is maintained in a clean and sanitary condition and
> there is a written schedule for cleaning and decontamination
> appropriate to the area, the work surface to be cleaned, the type of
> soil present, and the tasks and procedures being performed.
>
> 2\. All equipment and work surfaces are cleaned and decontaminated
> after contact with blood or other potentially infectious material.
> Surfaces that are overtly contaminated or after any spill of blood or
> other potentially infectious materials are decontaminated immediately
> or as soon as feasible.
>
> 3\. In those situations where procedures are performed on a continual
> basis throughout a shift, it is not necessary to clean and
> decontaminate work surfaces between procedures except for overt
> contamination or spills. However, if the employee leaves the area
> unattended for a period of time, for a break or lunch, the
> contaminated work surfaces must be cleaned. Work surfaces in patient
> care areas are cleaned after any patient care procedures that actually
> result in surface contamination.
>
> 4\. Protective coverings, such as plastic wrap, aluminum foil, or
> imperviously-backed absorbent paper used to cover equipment and
> environmental surfaces will be removed or replaced as soon as possible
> when they become contaminated or at the end of the work shift if they
> have become contaminated during the work shift.
>
> 5\. Bins, pails, cans, and similar receptacles that are reused and
> have a reasonable likelihood of contamination with blood or other
> potentially infectious material are inspected and decontaminated on a
> regularly scheduled basis, and cleaned and decontaminated immediately
> or as soon as possible when visibly contaminated.
>
> 6\. Broken glassware that may be contaminated will be cleaned up using
> a mechanical means such as a brush and dustpan or tongs or forceps.

I. Regulated Waste.

> 1\. Biological waste that is regulated is characterized principally as
> waste that contains microorganisms capable of causing infection in a
> healthy susceptible host. For purposes of the Bloodborne Pathogen
> Standard, the term \"regulated waste\" refers to the following
> categories of waste which require special handling, at a minimum:
>
> a\. Liquid or semi-liquid blood or other potentially infectious
> materials.
>
> b\. Items contaminated with blood or other potentially infectious
> materials and which would release (drip) these substances in a liquid
> or semi-liquid state if compressed.
>
> c\. Items that are caked with dried blood or other potentially
> infectious materials and are capable of releasing (flaking or falling
> off) these materials during handling.
>
> d\. Contaminated sharps.
>
> e\. Pathological and microbiological wastes containing blood or other
> potentially infectious materials.
>
> 2\. The responsibility for safe handling and proper disposal of
> regulated waste materials resides with the individual who generates
> the waste.
>
> 3\. Needles and sharps, including broken glass are discarded and
> contained in rigid sharps disposal containers. Other regulated wastes
> are placed in containers that are closable and appropriately labeled.
>
> 4\. All regulated waste containers used for the transfer, storage,
> transport, or off-site shipment will be labeled with the Universal
> Biohazard symbol.
>
> 5\. All regulated waste containers will be closed prior to removal to
> prevent spillage during handling, transport, or shipping. Under no
> circumstances will a bag of regulated waste be squeezed, compressed,
> shaken or placed into the trash chute system.
>
> 6\. Disposal of infectious (Special Medical) waste is in accordance
> with applicable Federal, State, and local regulations.

J. Laundry.

> 1\. Standard Precautions is used consistently in the handling of
> soiled linen. Soiled laundry is handled as little as possible with a
> minimum of agitation.
>
> 2\. Soiled laundry is bagged or placed in containers at the location
> where it is used. The sorting or rinsing of hospital laundry
> contaminated with blood or other potentially infectious materials in
> the use area is strictly prohibited.
>
> 3\. Soiled laundry is placed and transported in cloth bags which are
> color coded. Only laundry wet enough to leak or soak-through a cloth
> bag will be placed in a plastic bag.
>
> 4\. Employees having direct contact with soiled laundry must wear
> protective gloves as minimum protection. Other personal protective
> equipment may be necessary in order to prevent or reduce contact
> exposure to blood or other potentially infectious materials.

K. Medical Surveillance.

> 1\. Hepatitis B vaccination and postexposure evaluation and treatment
> are provided without cost to the employee through the Employee Health
> Clinic during regularly scheduled clinic hours. Evaluation of exposure
> incidents after clinic hours is provided by the Emergency Room with
> follow-up in the Employee Health Clinic.
>
> 2\. Hepatitis B vaccination will be offered to all employees who have
> been identified as having occupational exposure to blood or other
> potentially infectious materials.
>
> a\. The vaccine is offered subsequent to training and within 10
> working days of initial assignment to work involving the potential for
> occupational exposure unless:
>
> \(1\) The employee has previously received the complete Hepatitis B
> vaccination series, or
>
> \(2\) Antibody testing has revealed that the employee has sufficient
> immunity, or
>
> \(3\) The vaccine is contraindicated for medical reasons.
>
> b\. Participation in a prescreening program is not a prerequisite for
> receiving the Hepatitis B vaccine.
>
> c\. Any employee who declines the Hepatitis B vaccine will sign a
> waiver that uses the OSHA mandated wording. Employees who initially
> decline the vaccine but at a later date while still covered under the
> Standard, decide to accept the vaccination, will be provided Hepatitis
> B vaccination at no cost.
>
> d\. Routine booster doses of the Hepatitis B vaccine will be available
> at no cost to the employee if such booster doses are recommended by
> the US Public Health Service.
>
> 3\. Medical evaluation of exposure incidents is provided by Employee
> Health Clinic during regularly scheduled clinic hours. Evaluation and
> treatment for incidents after clinic hours is provided by the
> Emergency Room with follow-up in the Employee Health Clinic.
>
> a\. All medical evaluations and procedures are performed by or under
> the supervision of a licensed physician and laboratory tests are
> conducted by an accredited laboratory.
>
> b\. Exposure incidents will be reported promptly to the employee\'s
> immediate supervisor and to the Employee Health Physician.
>
> c\. A confidential medical evaluation and follow-up is made available
> to any employee following the report of an exposure incident and
> includes the following:
>
> \(1\) Documentation of the routes of exposure and the circumstances
> under which the exposure incident occurred.
>
> \(2\) If possible, the identification and documentation of the source
> individual and, if possible, the status of the source individual. The
> source individual\'s blood will be tested for HIV/HBV/HCV infectivity,
> after consent is obtained.
>
> \(3\) Results of testing of the source individual will be made
> available to the exposed employee with the exposed employee informed
> about the applicable laws and regulations concerning confidentiality
> and disclosure of the identity and infectivity of the source
> individual.
>
> \(4\) The exposed employee\'s blood will be collected as soon as
> feasible and after consent is obtained.
>
> d\. If the employee consents to baseline blood collection but does not
> consent to HIV serologic testing, the blood sample will be preserved
> for up to 90 days to allow the employee to decide if the blood should
> be tested.
>
> e\. If within ninety days of the exposure incident the employee elects
> to have the baseline sample tested, such testing will be conducted as
> soon as feasible; otherwise, the sample will be discarded after ninety
> days.
>
> f\. The employee will be offered post exposure prophylaxis in
> accordance with the recommendations of the US Public Health Service.
>
> g\. The employee will be given appropriate counseling concerning
> precautions to take during the period after the exposure incident. The
> employee will also be given information on what potential illnesses to
> be alert for and to report any related experiences to the Employee
> Health Physician.
>
> h\. The Employee Health Physician has been designated to assure that
> the policy outlined here is effectively carried out as well as to
> maintain records related to this policy.
>
> 4\. Interaction with Evaluating Healthcare Professionals.
>
> a\. A written opinion will be obtained from the Employee Health
> Physician or other healthcare professionals who evaluate employees of
> this facility. Written opinions will be obtained in the following
> instances:
>
> \(1\) When the employee is sent to obtain the Hepatitis B vaccine.
>
> \(2\) Whenever the employee is sent to the Employee Health Physician
> or other healthcare professional following an exposure incident.
>
> b\. Healthcare professionals will be instructed to limit their
> opinions to:
>
> \(1\) Whether the Hepatitis B vaccine is indicated and if the employee
> has received the vaccine, or for evaluation following an incident.
>
> \(2\) That the employee has been informed of the results of the
> evaluation and that the employee has been told about any medical
> conditions resulting from exposure to blood or other potentially
> infectious materials. The written opinion is not to reference any
> personal medical information.

L. Evaluation of Exposure Incidents.

> 1\. The circumstances surrounding an exposure incident will be
> documented. The procedure for evaluating the circumstances surrounding
> an exposure incident will include:
>
> a\. Evaluation of policies and failures of \"control\" at the time of
> the exposure incident.
>
> b\. Engineering controls and work practices in place at the time of
> the exposure incident.
>
> c\. Protective equipment or clothing used at the time of the exposure
> incident.
>
> 2\. Recording of Exposure Incidents. For OSHA 200 record-keeping
> purposes, an occupational bloodborne pathogens exposure incident will
> be classified and recorded as an injury if the incident results in:
>
> a\. Recommendations for medical treatment beyond first aid (e.g.,
> gamma globulin, Hepatitis B immune globulin, Hepatitis B vaccine, or
> zidovudine) regardless of the dosage, or
>
> b\. Diagnosis of seroconversion. The seroconversion will be recorded
> as an injury and the serological status of the employee will not be
> recorded on the OSHA 200.
>
> 3\. The Safety Manager reviews reports of all incidents.

M. Communication of Hazards To Employees.

> 1\. Biohazard warning labels will be affixed to containers of
> regulated waste, refrigerators, and freezers containing blood and
> other potentially infectious materials; and other containers used to
> store, transport or ship blood or other potentially infectious
> materials.
>
> 2\. Warning labels will include the universal biohazard symbol
> followed by the term \"biohazard.\" The biohazard label must be
> fluorescent orange or orange-red with lettering or symbols in a
> contrasting color. Labels are securely affixed to prevent their loss
> or unintentional removal.
>
> 3\. Label Exemptions.
>
> a\. 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 because they have been screened for HBV and HIV
> prior to their release are exempt from the biohazard warning label
> requirements.
>
> b\. Individual containers of blood or other potentially infectious
> materials that are placed in labeled secondary containers during
> storage, transport, shipment or disposal are exempt from the biohazard
> warning label requirements.
>
> c\. Regulated waste that has been appropriately decontaminated does
> not require biohazard warning labels or color-coding of containers.
>
> d\. Laundry bags or containers do not require labeling or color-coding
> since Universal Precautions are observed for handling all linen.
>
> 4\. Signs. Signs that bear the biohazard legend will be posted at the
> entrance to all HIV and HBV research laboratories. Additionally, the
> sign will include the following information:
>
> • Name of the infectious agent
>
> • Special requirements for entering the area
>
> • Name, telephone number of the laboratory director or other
> responsible person.

N. Information and Training.

> 1\. The training program on occupational exposure to bloodborne
> pathogens is provided to all employees (including house staff,
> students, trainees, and volunteers) with occupational exposure.
> Training will be conducted during work hours and will be provided at
> the time of initial assignment to tasks where occupational exposure
> may occur and at least annually thereafter.
>
> 2\. Additional training will be provided to employees when new tasks
> or procedures are instituted or changes, such as modification of tasks
> or procedures affect the employee\'s occupational exposure.
>
> 3\. The training program on occupational exposure to bloodborne
> pathogens will contain at a minimum the following elements:
>
> a\. An accessible copy of the regulatory text of the OSHA Bloodborne
> Pathogen Standard and an explanation of the regulatory text content.
>
> b\. A general explanation of the epidemiology and symptoms of
> bloodborne diseases.
>
> c\. An explanation of the modes of transmission of bloodborne
> pathogens.
>
> d\. An explanation of this Exposure Control Plan and the means that
> the employee can obtain a copy of the written plan.
>
> e\. An explanation of the appropriate methods for recognizing tasks
> and other activities that may involve exposure to blood and other
> potentially infectious materials.
>
> f\. An explanation of the use and limitations of methods that will
> prevent or reduce exposure, i.e., engineering controls, work
> practices, and personal protective equipment.
>
> g\. Information on the types, proper use, location, removal, handling,
> decontamination, and disposal of personal protective equipment.
>
> h\. An explanation of the basis for selection of personal protective
> equipment.
>
> i\. Information on the Hepatitis B vaccine, including information on
> its efficacy, safety, method of administration, the benefits of being
> vaccinated.
>
> j\. Information on the appropriate actions to take and persons to
> contact in an emergency involving blood or other potentially
> infectious materials.
>
> k\. An explanation of the procedures to follow if an exposure incident
> occurs, including the method of reporting the incident and the medical
> follow-up that will be made available.
>
> l\. Information on the postexposure evaluation and follow-up that the
> Employee Health Clinic provides following an exposure incident.
>
> m\. An explanation of the signs and labels and/or color-coding of
> biohazard labels and containers.
>
> n\. A questions and answers session between the trainer and employees
> will be provided with each training program.
>
> 4\. Prior to initial assignment, employees in HIV and HBV research
> laboratories will receive additional training commensurate with prior
> experience in the handling of human pathogens or tissue cultures and
> demonstrated proficiency in standard microbiological practices and
> techniques and in the operations specific to the laboratory facility.
>
> 5\. Employees who have no prior experience in handling human pathogens
> will be assigned a progression of work activities as techniques are
> learned and proficiency is developed.

O. Record Keeping.

> 1 A confidential Employee Health medical record is maintained for each
> employee with occupational exposure. The employee\'s medical records
> will be maintained for the duration of employment plus 30 years. This
> record includes, but is not limited to the following:
>
> a\. Employee name and social security number
>
> b\. A copy of the employee\'s Hepatitis B vaccination status including
> dates of all the Hepatitis B vaccinations and any medical records
> relative to the employee\'s ability to receive vaccination.
>
> c\. A copy of all results of examination, medical testing, and
> follow-up procedures relevant to the postexposure evaluation and
> follow-up.
>
> d\. A copy of the healthcare professional\'s written opinion for
> Hepatitis B vaccination and for postexposure evaluation and follow-up.
>
> e\. A copy of the description of an employee\'s duties as they relate
> to an exposure incident, documentation of the routes of exposure and
> circumstances under which the exposure occurred, and results of the
> source individual\'s blood testing.
>
> 2\. Training records will be maintained for three years from the date
> on which the training occurred. The training records will include the
> following information:
>
> a\. Date of training session.
>
> b\. Content or a summary of the training session.
>
> c\. Names and qualifications of persons conducting the training
> session.
>
> d\. Names and job titles of all persons attending the training
> sessions.
>
> 3\. Availability of Records.
>
> a\. Employee medical records will be provided upon request for
> examination and copying to:
>
> \(1\) The Director of NIOSH or designated representative and the
> Assistant Secretary of Labor or designated representative.
>
> \(2\) The employee.
>
> \(3\) To anyone having written consent of the employee.
>
> b\. Employee training records will be provided upon request for
> examination and copying to:
>
> \(1\) The Director of NIOSH or designated representative and the
> Assistant Secretary of Labor or designated representative.
>
> \(2\) The employee.
>
> \(3\) To anyone having written consent of the employee.

IV\. [RESPONSIBILITIES]{.underline}

A. The Medical Center Director, with recommendations from the Infection
Control Committee and the Safety Management Committee, has the overall
responsibility for implementing a program to assure compliance with
occupational safety and health regulations. The Medical Center Director
is ultimately responsible for the maintenance of the Bloodborne Pathogen
Exposure Control Plan through allocation of resources necessary to
fulfill the requirements of the Standard. S/he is the final approving
authority on recommendations that will impact medical center policies,
programs, and operations.

B. Service chiefs and supervisors will:

> 1\. Establish and maintain working knowledge of provisions of the
> Standard and the Exposure Control Plan.
>
> 2\. Evaluate work-related tasks for potential exposure to bloodborne
> pathogens based on scientific knowledge.
>
> 3\. Notify HRMS whenever new or modified tasks and procedures are
> implemented which affect the occupational exposure category for an
> employee and maintenance of appropriate exposure determination
> documentation.
>
> 4\. Review and update relevant internal policies and procedures as
> necessary to maintain Standard compliance. Communicate changes to
> employees and assure compliance
>
> 5\. Assure copies of the Bloodborne Pathogen Standard and the HVAMC's
> exposure control plan are available for employees covered by the
> Standard.
>
> 6\. Assure that initial and annual training is provided to all
> employees who perform routine high-risk tasks.
>
> 7\. Monitor personnel work practices to ensure compliance with
> Standard Precautions and other exposure control procedures.
>
> 8\. Provide readily accessible and adequate supplies of appropriate
> engineering devices and personal protective equipment within the
> immediate work environment for employee protection and use.
>
> 9\. Refer all employees who may have sustained a significant blood or
> body fluid exposure to the Employee Health Clinic.
>
> 10\. Investigating conditions of known or suspected employee exposures
> to improve training, work practices or protective equipment as needed
> to prevent recurrences.

C. Employee Health Clinic will:

> 1\. Establish and maintain a working knowledge of provisions of the
> Bloodborne Pathogen Standard.
>
> 2\. Provide appropriate Hepatitis B vaccine training and immunization
> to employees in accordance with manufacturer\'s guidelines and the
> provisions of the Bloodborne Pathogen Standard.
>
> 3\. Provide examination, treatment, follow-up and counseling for
> employees significantly exposed to blood or other potentially
> infectious material.
>
> 4\. Maintain the prescribed documentation for Hepatitis B vaccinations
> and post exposure evaluations.

D. Facilities Management Service will:

> 1\. Establish and maintain a working knowledge of provisions of the
> Bloodborne Pathogen Standard.
>
> 2\. Maintain a clean and sanitary work environment.
>
> 3\. Maintain written schedules and methods for cleaning and
> decontamination of environmental surfaces. Written sanitation
> schedules will be approved by the Infection Control Committee.

E. The Facilities Management Service Line Executive will ensure
engineering controls are inspected and tested in accordance with
prescribed preventive maintenance standards. Inspections and testing
will be made of equipment, systems, and devices such as, but not limited
to, emergency showers, biosafety cabinets, and local ventilation and
exhaust systems.

F. The review and evaluation of engineering controls for their efficacy,
appropriateness, and feasibility will be accomplished jointly by the
Infection Control, Safety Management and Materials Standards Committees.

G. The Infection Control Committee is responsible for annual review of
the Exposure Control Plan. The Plan will be revised whenever necessary
to reflect new or revised job classifications, new tasks or new
procedures. The addition of new or modified procedures in situations
where employees performing those new or modified procedures are already
included in the exposure control plan will not require plan revision.

H. The Chief, Human Resources Management Service (HRMS) is responsible
for communicating all personnel changes and changes in job
classification that affect an employee\'s occupational exposure category
to the Employee Health Clinic and the Infection Control Program.

I. Infection Control practitioners will provide initial training to all
employees covered by the OSHA Standard. The Infection Control
practitioners and the Safety Manager will provide, upon request, the
required annual training classes for all employees covered by the
Standard.

J. Employee responsibilities include:

> 1\. Know the exposure determination category for their job title and
> strictly adhere to the accompanying work practice controls.
>
> 2\. Develop and maintain safe work practices.
>
> 3\. Routinely apply Standard Precautions and infection control
> procedures to each task they perform.
>
> 4\. Maintain a clean and sanitary work environment.
>
> 5\. Report any job-related injury or illness to the supervisor and
> promptly seek medical evaluation following any exposure incident.

V. [REFERENCES]{.underline}

> OSHA. 29 CFR 1910.1030. Occupational Exposure To Bloodborne Pathogens.
> [Federal]{.underline} [Register]{.underline}, Vol 56, No. 235, Friday,
> December 6, 1991.
>
> OSHA Instruction CPL 2-2.44, November 5, 1999, Enforcement Procedures
> for the Occupational Exposure to Bloodborne Pathogens.

VI\. [RESCISSIONS]{.underline}

> Medical Center Policy Memorandum No. 374, *Exposure Control Plan for
> Prevention of Occupational Exposure to Bloodborne Pathogens*, dated
> March 9, 1998.
>
> Professional Services Memorandum No. 9, *Hepatitis B Vaccination
> Program*, dated March 31, 1992.

\\es\\

DAVID WHATLEY\
Medical Center Director

Attachment A Standard Definitions

Attachment B Job Classifications in Which All Employees have Exposure to
Bloodborne Pathogens

Attachment C Job Classifications in Which Some Employees have Exposure
to Bloodborne Pathogens

Attachment D Tasks that have a Potential for Occupational Exposure to
Bloodborne Pathogens

Attachment E Bloodborne Pathogens Rules and Regulations for RCAHI

Attachment F Schedule and Method of Implementation

**Standard Definitions**

A. **Blood** means human blood, human blood components (including
plasma, platelets, and serosanguineous fluids, e.g., exudate from
wounds) and products made from blood, such as immune globulins, albumin,
and factors 8 and 9.

B. **Bloodborne Pathogens** means any pathogenic microorganism that is
present in human blood and can infect and cause disease in persons who
are exposed to blood containing the pathogen. Bloodborne diseases
include HIV, Hepatitis B, Hepatitis C, malaria, syphilis, babesiosis,
brucellosis, leptospirosis, arboviral infections, relapsing fever,
Creutzfeldt-Jakob disease, Human Lymphotropic Virus Type 1 associated
lymphoma/leukemia and myelopathy, and viral hemorrhagic fever.

C. **Contaminated** means the presence or the reasonably anticipated
presence of blood or other potentially infectious materials.

D. **Contaminated laundry** means laundry that has been soiled with
blood or other potentially infectious materials or may contain sharps.

E. **Decontamination** means the use of physical or chemical means to
remove, inactivate, or destroy bloodborne pathogens on a surface or item
to the point where they are no longer capable of transmitting infectious
particles and the surface or item is rendered safe for handling, use, or
disposal.

F. **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.

G. **Non-intact skin** includes skin with dermatitis, hangnails, cuts,
abrasions, chafing, acne, etc.

H. **Occupational exposure** means reasonably anticipated skin, eye,
mucous membrane, or parenteral contact with blood or other potentially
infectious materials that [may]{.underline} result from the performance
of an employee\'s duties.

I. **Other Potentially Infectious Materials (OPIM)** includes the
following:

> 1\. Human body fluids: semen, vaginal secretions, synovial fluid,
> cerebrospinal fluid, pleural fluid, pericardial fluid, peritoneal
> fluid, amniotic fluid, saliva in dental procedures, any body fluid
> that is visibly contaminated with blood, and all body fluids in
> situations where it is difficult or impossible to differentiate
> between body fluids;
>
> 2\. Any unfixed tissue or organ (other than intact skin) from a human
> (living or dead); and
>
> 3\. HIV-containing cell or tissue cultures, organ cultures, and HIV-
> or HBV-containing culture medium or other solutions as well as blood,
> organs or other tissues from experimental animals deliberately
> infected with HIV or HBV.

J. **Parenteral** means piercing mucous membranes or the skin barrier
through such events as needle-sticks, human bites that break the skin,
cuts, and abrasions.

K. **Regulated waste** means liquid or semi-liquid blood or other
potentially infectious materials; contaminated items that would release
blood or OPIM in a liquid or semi-liquid state if compressed; items that
are caked with dried blood or OPIM and are capable of releasing these
materials during handling; contaminated sharps; and pathological and
microbiological wastes containing blood or OPIM.

L. **Standard Precautions** refers to an approach to infection control
in which all human blood and OPIM are treated as if known to be
infectious for HIV, HBV, or other bloodborne pathogens regardless of the
perceived \"low risk\" of a patient or patient population. Standard
Precautions do not apply to feces, nasal secretions, sputum, sweat,
tears, urine, or vomitus, unless they contain visible blood.

**Job Classifications\
in Which All Employees have Exposure to Bloodborne Pathogens**

The Exposure Determination lists job classifications in which
[all]{.underline} employees may be expected to incur occupational
exposure to blood or other potentially infectious materials, regardless
of frequency. At the HVAMC, the following job classifications are in
this category:

+------------------------------+------+-------------------------------+
| **Position Title**           | **O  | **Service**                   |
|                              | cc.\ |                               |
|                              | Seri |                               |
|                              | es** |                               |
+------------------------------+------+-------------------------------+
| Physician                    | 0602 | Anesthesiology                |
|                              |      |                               |
| Nurse Anesthetist            | 0605 |                               |
|                              |      |                               |
| Medical Instrument Tech      | 0649 |                               |
+------------------------------+------+-------------------------------+
| Incinerator Operator         | 5403 | Facilities Management         |
|                              |      |                               |
| Laundry Supervisor           | 7301 |                               |
|                              |      |                               |
| Laundry Worker               | 7304 |                               |
|                              |      |                               |
| Laundry Machine Operator     | 7305 |                               |
+------------------------------+------+-------------------------------+
| Physician                    | 0602 | Chief of Staff                |
|                              |      |                               |
| Nurse                        | 0610 |                               |
|                              |      |                               |
| Nursing Assistant            | 0621 |                               |
|                              |      |                               |
| Physician Assistant          | 0603 |                               |
+------------------------------+------+-------------------------------+
| Dentist                      | 0680 | Dental                        |
|                              |      |                               |
| Dentist/Resident             | 0680 |                               |
|                              |      |                               |
| Dental Assistant             | 0681 |                               |
|                              |      |                               |
| Dental Hygienist             | 0682 |                               |
+------------------------------+------+-------------------------------+
| Physician                    | 0602 | Dermatology                   |
+------------------------------+------+-------------------------------+
| Physician                    | 0602 | Extended Care                 |
|                              |      |                               |
| Physician Assistant          | 0603 |                               |
+------------------------------+------+-------------------------------+
| Physician                    | 0602 | Medical                       |
|                              |      |                               |
| Physician Assistant          | 0603 |                               |
|                              |      |                               |
| Nurse                        | 0610 |                               |
|                              |      |                               |
| Registered Respiratory       | 0601 |                               |
| Therapist                    |      |                               |
|                              | 0601 |                               |
| Certified Respiratory        |      |                               |
| Therapy Tech                 | 0640 |                               |
|                              |      |                               |
| Respiratory Therapist        | 0649 |                               |
|                              |      |                               |
| Medical Instrument Tech      | 0645 |                               |
|                              |      |                               |
| Medical Technician           | 0601 |                               |
|                              |      |                               |
| Health Science Specialist    | 0640 |                               |
|                              |      |                               |
| Health Technician            |      |                               |
+------------------------------+------+-------------------------------+
| Physician                    | 0602 | Nuclear Medicine              |
|                              |      |                               |
| Physician Assistant          | 0603 |                               |
|                              |      |                               |
| Nuclear Medicine             | 0601 |                               |
| Technologist                 |      |                               |
+------------------------------+------+-------------------------------+

+------------------------------+------+-------------------------------+
| **Position Title**           | **O  | **Service**                   |
|                              | cc.\ |                               |
|                              | Seri |                               |
|                              | es** |                               |
+------------------------------+------+-------------------------------+
| Physician                    | 0602 | Neurology                     |
|                              |      |                               |
| Physician Assistant          | 0603 |                               |
+------------------------------+------+-------------------------------+
| Nurse                        | 0610 | Nursing                       |
|                              |      |                               |
| Vocational Nurse             | 0620 |                               |
|                              |      |                               |
| Graduate Vocational Nurse    | 0620 |                               |
|                              |      |                               |
| Psychiatric Vocational Nurse | 0620 |                               |
|                              |      |                               |
| Nursing Assistant            | 0621 |                               |
|                              |      |                               |
| Psychiatric Nursing          | 0621 |                               |
| Assistant                    |      |                               |
+------------------------------+------+-------------------------------+
| Physician                    | 0602 | Ophthalmology                 |
+------------------------------+------+-------------------------------+
| Physician                    | 0602 | Pathology & Laboratory        |
|                              |      | Medicine                      |
| Medical Technologist         | 0644 |                               |
|                              |      |                               |
| Cytotechnologist             | 0601 |                               |
|                              |      |                               |
| Histopathology Technician    | 0646 |                               |
|                              |      |                               |
| Medical Technician           | 0645 |                               |
|                              |      |                               |
| Microbiologist               | 0403 |                               |
|                              |      |                               |
| Chemist                      | 1320 |                               |
+------------------------------+------+-------------------------------+
| Physician                    | 0602 | Physical Medicine &           |
|                              |      | Rehabilitation                |
| Physician Assistant          | 0603 |                               |
+------------------------------+------+-------------------------------+
| Physician                    | 0602 | Psychiatry                    |
|                              |      |                               |
| Physician Assistant          | 0603 |                               |
+------------------------------+------+-------------------------------+
| Physician                    | 0602 | Radiology                     |
+------------------------------+------+-------------------------------+
| Physician                    | 0602 | Radiotherapy                  |
+------------------------------+------+-------------------------------+
| Volunteer - ER               | \-\  | Recreation Therapy/Voluntary  |
|                              | -\-- |                               |
| Volunteer -- Lab             |      |                               |
+------------------------------+------+-------------------------------+
| Physician                    | 0602 | Research                      |
|                              |      |                               |
| Nurse                        | 0610 |                               |
|                              |      |                               |
| Physician Assistant          | 0603 |                               |
+------------------------------+------+-------------------------------+
| Physician                    | 0602 | Spinal Cord Injury            |
|                              |      |                               |
| Physician Assistant          | 0603 |                               |
+------------------------------+------+-------------------------------+
| Physician                    | 0602 | Surgical                      |
|                              |      |                               |
| Physician Assistant          | 0603 |                               |
|                              |      |                               |
| Nurse                        | 0610 |                               |
|                              |      |                               |
| Health Technician            | 0640 |                               |
+------------------------------+------+-------------------------------+

**Job Classifications\
in Which Some Employees have Exposure to Bloodborne pathogens**

The Exposure Determination additionally lists HVAMC job classifications
in the which **some** employees may have occupational exposure to blood
or other potentially infectious materials. Since not all the employees
in these categories would be expected to incur exposure to blood or
other potentially infectious materials, tasks or procedures that would
cause these employees to have occupational exposure are also listed in
order to clearly understand which employees in these categories are
considered to have occupational exposure. The job classifications and
associated tasks for these categories are as follows:

+------------------------------+------+-------------------------------+
| **Position Title**           | **O  | **Service**                   |
|                              | cc.\ |                               |
|                              | Seri |                               |
|                              | es** |                               |
+------------------------------+------+-------------------------------+
| Medical Supply Technician    | 0622 | Acquisition & Materiel        |
|                              |      |                               |
|                              |      | Management                    |
+------------------------------+------+-------------------------------+
| Audiologist                  | 0665 | Audiology & Speech Pathology  |
|                              |      |                               |
| Speech Pathologist           | 0665 |                               |
+------------------------------+------+-------------------------------+
| Barber                       | 7603 | Canteen                       |
+------------------------------+------+-------------------------------+
| Dental Lab Technician        | 0683 | Dental                        |
+------------------------------+------+-------------------------------+
| Safety & Occupational Health | 0018 | Facilities Management         |
|                              |      |                               |
| Health Physicist             | 1306 |                               |
|                              |      |                               |
| Physical Science Tech        | 1311 |                               |
|                              |      |                               |
| Environmental Health Tech    | 0698 |                               |
|                              |      |                               |
| Safety Technician            | 0019 |                               |
|                              |      |                               |
| Biomedical Engineer          | 0858 |                               |
|                              |      |                               |
| Biomedical Engineering Tech  | 0802 |                               |
|                              |      |                               |
| Police Officer               | 0083 |                               |
|                              |      |                               |
| Plumber                      | 4206 |                               |
|                              |      |                               |
| Housekeeping Aid             | 3566 |                               |
+------------------------------+------+-------------------------------+
| Program Support Clerk        | 0303 | Fiscal                        |
+------------------------------+------+-------------------------------+
| Photographer                 | 1060 | Medical Media Production      |
+------------------------------+------+-------------------------------+
| Medical Instrument Tech      | 0649 | Medical                       |
|                              |      |                               |
| EKG Technician               | 0649 |                               |
+------------------------------+------+-------------------------------+
| Medical Instrument Tech      | 0649 | Neurology                     |
+------------------------------+------+-------------------------------+
| Food Service Worker          | 7408 | Nutrition & Food              |
+------------------------------+------+-------------------------------+
| Medical Clerk                | 0679 | Nursing                       |
+------------------------------+------+-------------------------------+
| Patient Representative       | 0301 | Office of the Director        |
+------------------------------+------+-------------------------------+
| Optometrist                  | 0662 | Ophthalmology                 |
|                              |      |                               |
| Health Technician            | 0640 |                               |
+------------------------------+------+-------------------------------+
| Pharmacist (Clinical)        | 0660 | Pharmacy                      |
+------------------------------+------+-------------------------------+

+------------------------------+------+-------------------------------+
| **Position Title**           | **O  | **Service**                   |
|                              | cc.\ |                               |
|                              | Seri |                               |
|                              | es** |                               |
+------------------------------+------+-------------------------------+
| Supervisory Rehabilitation   | 0601 | Physical Medicine &           |
| Therapist Physical Therapist |      | Rehabilitation                |
|                              | 0633 |                               |
| Physical Therapy Assistant   |      |                               |
|                              | 0636 |                               |
| Corrective Therapist         |      |                               |
|                              | 0635 |                               |
| Occupational Therapist       |      |                               |
|                              | 0631 |                               |
| Vocational Rehabilitation    |      |                               |
| Specialist                   | 1715 |                               |
|                              |      |                               |
| Research Health Science      | 0601 |                               |
| Specialist                   |      |                               |
+------------------------------+------+-------------------------------+
| Orthotist/Prosthetist        | 0667 | Prosthetic Treatment Center   |
|                              |      |                               |
| Prosthetist                  | 0667 |                               |
|                              |      |                               |
| Orthotist                    | 0667 |                               |
|                              |      |                               |
| Medical Equipment Repairer   | 4805 |                               |
+------------------------------+------+-------------------------------+
| Psychologist                 | 0180 | Psychiatry                    |
|                              |      |                               |
| Psychology Technician        | 0181 |                               |
+------------------------------+------+-------------------------------+
| Psychologist                 | 0180 | Psychology                    |
|                              |      |                               |
| Vocational Rehabilitation    | 1715 |                               |
| Specialist                   |      |                               |
+------------------------------+------+-------------------------------+
| Diagnostic Radiology Tech    | 0647 | Radiology                     |
|                              |      |                               |
| Health Technician            | 0640 |                               |
|                              |      |                               |
| Medical Instrument Tech      | 0649 |                               |
| (Diag)                       |      |                               |
+------------------------------+------+-------------------------------+
| Supv Ther Rad Tech           | 0648 | Radiotherapy                  |
|                              |      |                               |
| Ther Rad Tech                | 0648 |                               |
|                              |      |                               |
| Diagnostic Radiology         | 0647 |                               |
| Technologist                 |      |                               |
+------------------------------+------+-------------------------------+
| Volunteer \-- ER             | \-\  | Recreation Therapy/Voluntary  |
|                              | -\-- |                               |
| Volunteer -- Lab             |      |                               |
+------------------------------+------+-------------------------------+
| Research Microbiologist      | 0403 | Research                      |
|                              |      |                               |
| Microbiologist               | 0403 |                               |
|                              |      |                               |
| Research Health Science      | 0601 |                               |
| Specialist                   |      |                               |
|                              | 0601 |                               |
| Health Science Specialist    |      |                               |
|                              | 0640 |                               |
| Health Technician            |      |                               |
|                              | 0404 |                               |
| Biological Science Lab Tech  |      |                               |
|                              | 1320 |                               |
| Chemist                      |      |                               |
+------------------------------+------+-------------------------------+
| Social Worker                | 0185 | Social Work                   |
+------------------------------+------+-------------------------------+
| Health Technician            | 0640 | Surgical                      |
|                              |      |                               |
| Orthopedic Technician        | 0640 |                               |
|                              |      |                               |
| Physiologist                 | 0413 |                               |
+------------------------------+------+-------------------------------+

**Tasks That Have a Potential for\
Occupational Exposure to Bloodborne Pathogens**

The major determinants for relative risk of occupational exposure in any
job or position are the tasks that must be performed by the employee
engaged in that job/position. The first major tenant in determining if
an employee is covered by the standard would be if the employee is
trained in first aid and is identified as responsible for rendering
medical assistance as part of his/her job/duties. Other tasks that have
a potential for occupational exposure to bloodborne pathogens include,
but are not limited to:

> 1\. Performing and/or assisting with direct patient assessment, care,
> and/or transport.
>
> 2\. Performing or assisting with invasive medical, surgical, or dental
> procedures.
>
> 3\. Involvement in emergency or life-saving situations, code arrests
> and patient restraints.
>
> 4\. Environmental cleaning and/or decontamination and the clean up of
> spills involving blood or other body fluids.
>
> 5\. Decontamination, cleaning, and/or maintenance of contaminated
> (used) patient equipment and/or instruments.
>
> 6\. Collecting, handling or sorting soiled laundry.
>
> 7\. Collecting, handling or sorting infectious (special medical) waste
> prior to disposal.
>
> 8\. Handling, transporting, or receiving human biological specimens.
>
> 9\. Collecting or handling dietary trays in patient care areas or in
> the dishroom.
>
> 10\. Subdue or assist in the control of persons with violent,
> combative, or psychotic behavior.
>
> 11\. Performing maintenance, repairs, or service on potentially
> contaminated equipment, plumbing, piping, or vacuum lines.
>
> 12\. Isolation and purification of whole HIV and HBV, cells infected
> with these viruses or virus sub-components.
>
> 13\. Research operations using human blood or blood components,
> unfixed tissues or organs, or preparing reagents from human blood or
> blood components.

**Bloodborne Pathogens Rules and Regulations for RCAHI**

The Research Center on AIDS and HIV Infection (RCAHI) is a research
facility engaged in the culture, experimentation, and manipulation of
HIV and HBV. The RCAHI has about 2500 square feet of laboratory space
and is located on the first floor of the Research and Education Building
at the HVAMC in a completely contained annex. The facility has two main
entrances and two emergency exits. The east entrance is
access-controlled by a key. The west entrance is open during work hours
to permit access by persons not engaged in research activities in the
RCAHI. During non-working hours this door is automatically locked and
can only be opened by authorized personnel. The corridors are considered
\"clean areas\". Access to the laboratories of the facility are through
doors opening off of the corridor. The corridor door to the BL2/BL3 work
area is access-controlled by a key provided to authorized personnel
working in the facility.

Within the facility are two cell culture rooms. The first is a BL2/BL3
containment facility equipped with three laminar flow hoods, a
unidirectional pass-through autoclave, a refrigerator, a double-chamber
CO~2~ incubator, an inverted phase-contrast microscope, a standard
microscope, a Beckman ultracentrifuge with rotors, and a moderate speed,
table-top centrifuge. This room is reserved for activities involving
other potentially infectious material, and is heretofore designated as
the \"work area\". The second room is a BL2 containment facility
equipped with a laminar flow hood, double-chamber incubator, and
moderate-speed centrifuge and rotors. No HBV or HIV activities are
conducted in this area. Within the RCAHI is a glassware preparation
facility equipped with an autoclave, dishwasher, sterilizing oven, and
water purification system.

The RCAHI has established the following work practice for
experimentation with bloodborne pathogens

A. Standard microbiological practices. All regulated waste will be
decontaminated, as defined in the Standard, by autoclaving or by
treatment with at least 0.5% sodium hypochlorite solution to effectively
destroy bloodborne pathogens. In certain cases, when equipment may be
damaged by 0.5% sodium hypochlorite, decontamination with 2% NP40
solution followed by 80% ethanol will be used.

B. Special practices.

> 1\. Laboratory doors will be kept closed when work involving HIV or
> HBV is in progress.
>
> 2\. Contaminated materials that are to be decontaminated at a site
> away from the work area will be placed in a durable, leak-proof,
> color-coded (red) container that is closed before being removed from
> the work area.
>
> 3\. Access to the work area will be limited to authorized persons
> certifiably trained to work with biohazardous material. Only persons
> who have been advised of the potential biohazard, who meet specific
> entry requirements, and who comply with all entry and exit procedures
> will be allowed to enter the work areas.
>
> 4\. A hazard warning sign incorporating the universal biohazard symbol
> will be posted on all access doors into the facility as well as on the
> doors into the working area.
>
> 5\. All activities involving other potentially infectious materials
> will be conducted in biological safety cabinets or other
> physical-containment devices within the containment module. No work
> with these other potentially infectious materials will be conducted on
> the open bench.
>
> 6\. Laboratory coats, gowns, smocks, uniforms, or other appropriate
> protective clothing will not be worn outside of the work area. In the
> event of a spill on the protective clothing, the soiled area will be
> treated for fifteen minutes with 0.5% sodium hypochlorite and placed
> in a biohazardous bag prior to being sent to the laundry.
>
> 7\. Special care will be taken to avoid skin contact with other
> potentially infectious materials. Gloves will be worn when handling
> infected animals and when making hand contact with other potentially
> infectious materials is unavoidable.
>
> 8\. Before disposal, all waste from the BL2/BL3 work area will be
> decontaminated by autoclaving or by treatment with at least 0.5%
> sodium hypochlorite (final concentration) for at least five minutes
> (e.g. when decontaminating radioactively- labeled infectious waste) to
> effectively destroy bloodborne pathogens.
>
> 9\. Vacuum lines will be protected with liquid disinfectant traps
> connected in series and containing sodium hypochlorite at a
> concentration exceeding 0.5%. We have requested installation of high
> efficiency, particulate air (HEPA) filters or filters of equivalent or
> superior efficiency which can trap particulates \<0.2µ in size in
> these lines. These lines will be checked routinely and maintained or
> replaced as necessary.
>
> 10\. Syringes with hypodermic needles will be used only for parenteral
> injection and aspiration of fluids from laboratory animals and
> diaphragm bottles or in experimental situations where a safer approach
> is not available. Only needle-locking syringes or disposable
> syringe-needle units (i.e., the needle is integral to the syringe)
> will be used for the injection or aspiration of other potentially
> infectious materials. Extreme caution will be used when handling
> needles and syringes. A needle will not be bent, sheared, replaced in
> the sheath or guard, or removed from the syringe following use. The
> needle and syringe will be promptly placed in a puncture-resistant
> container and autoclaved or decontaminated before reuse or disposal.
>
> 11\. Procedures for biohazardous spills and accidents are specifically
> described in the VAMC Biohazard Safety Manual for Research and
> Development Service. All spills will be immediately contained and
> cleaned up by appropriate professional staff or others properly
> trained and equipped to work with potentially concentrated infectious
> materials.
>
> 12\. A spill or accident that results in an exposure incident will be
> immediately reported to the laboratory director and responsible
> supervisor and recorded in the RCAHI incident book.
>
> 13\. A Biohazard Safety Manual for Research and Development Service is
> available and periodically reviewed and updated at least annually or
> more often when necessary. Personnel will be advised of potential
> hazards, shall be required to read instructions on practices and
> procedures, and will be required to follow them.

C. Containment equipment.

> 1\. Certified biological safety cabinets (Class I, II, or III) or
> other appropriate combinations of personal protection or physical
> containment devices, such as special protective clothing, respirators,
> centrifuge safety cups, sealed centrifuge rotors, and containment
> caging for animals, will be used for all activities with other
> potentially infectious materials that pose a threat of exposure to
> droplets, splashes, spills, or aerosols.
>
> 2\. Biological safety cabinets will be certified when installed,
> whenever they are moved and at least annually.
>
> 3\. A facility for hand washing is readily available within the work
> area. An approved eye wash facility is readily available.
>
> 4\. A unidirectional autoclave for decontamination of regulated waste
> is available.
>
> 5\. The RCAHI facility is under \"unidirectional air flow.\"

D. Communication of hazards to employees.

> 1\. Labels and signs.
>
> a\. Warning labels will be affixed to containers of regulated 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 noted
> below.
>
> b\. Labels required by this section will include the universal
> biohazard label (Standard Form 420).
>
> c\. Labels will be fluorescent orange or orange-red or predominantly
> so, with lettering or symbols in a contrasting color.
>
> d\. Labels will 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\. 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.
>
> g\. Labels required for contaminated equipment shall be in accordance
> with this paragraph and shall also state which portions of the
> equipment remain contaminated.
>
> h\. Regulated waste that has been decontaminated need not be labeled
> or color-coded.
>
> 2\. Signs
>
> a\. Biohazard signs will be posted at the entrance to the BL2/BL3 work
> areas. These signs will include the following information:
>
> 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.

E. Information and Training for Employees in the RCAHI. To assist us in
the training program for all new employees of the RCAHI, we will require
employees to read the VAMC Biohazard Safety Manual for Research and
Development Service and Biosafety in the Laboratory: Practices for the
Handling and Disposal of Infectious Materials, National Academy Press,
1989. Concurrent with this program, we will offer the following:

> 1\. Discussion sessions
>
> a\. The concept of \"Standard Precautions\"
>
> b\. HIV and HBV biology (including survival in the environment, signs
> and symptoms of disease), virology and epidemiology (including modes
> of transmission)
>
> c\. Methods of containment for the management of infectious agents
>
> d\. Management of parenteral or mucous membrane exposure to body
> fluids
>
> 2\. Training sessions
>
> a\. Aseptic techniques
>
> b\. BSL2 practices (standard microbiological practices, required
> protective clothing and devices, procedures for the decontamination of
> all infectious waste, equipment and work surfaces, limited access to
> containment laboratory, biohazard warning signs)
>
> c\. Handling, transport and storage of potentially infectious agents
>
> d\. Use of manual and automatic pipetting devices
>
> e\. Proper use and maintenance of instrumentation and equipment
> especially the laminar flow hood, vacuum suction devices, incubator,
> autoclave, low and high speed centrifuges and ultracentrifuges.
>
> f\. Procedures for decontamination and sterilization of equipment and
> apparatus.
>
> g\. Procedures for cleaning and decontaminating biohazardous spills
> including those involving radioisotopes
>
> h\. Treatment and disposal of infectious waste
>
> i\. Procedures to follow if an exposure incident occurs, including the
> method of reporting the incident.
>
> 3\. The Medical and Scientific Directors to the RCAHI will assure that
> employees demonstrate proficiency in standard microbiological
> practices and techniques and in the practices and operations specific
> to the RCAHI facility before being allowed to work with HIV or HBV.
> The employee\'s proficiency in standard microbiological practices will
> be determined by evaluating his/her cell culture techniques. The
> employee will be considered proficient if s/he is able to passage an
> uninfected human T-cell or peripheral blood mononuclear cell line in
> the absence of antibiotics at least two times/week for a total of four
> weeks without bacterial or fungal contamination.
>
> The employee\'s proficiency in the practices and operations specific
> to the RCAHI will be determined by observing and evaluating his/her
> laboratory practices and by monitoring for radioactive contamination
> on the various work surfaces after the cultures of uninfected cells
> are passaged in media containing 3H-thymidine or 125I.
>
> 4\. The Medical and Scientific Directors of the RCAHI will assure that
> employees have prior experience in the handling of human pathogens or
> tissue cultures before working with HIV or HBV.
>
> 5\. An employee with no prior experience in handling human pathogens
> will be trained in all procedures or techniques relevant to his/her
> job description. Initial work activities shall not include the
> handling of infectious agents. A progression of work activities shall
> be assigned as techniques are learned and proficiency is developed.
> The employer shall assure that employees participate in work
> activities involving infectious agents only after proficiency has been
> demonstrated.
>
> 6\. The employee\'s proficiency in standard microbiological practices
> and in the practices and operations specific to the RCAHI will be
> evaluated as described above. To assure that the employee has prior
> experience in the handling of human pathogens and tissue culture
> cells, the employee will passage the EBV - producing human B-cell line
> or similar pathogen of low infectivity as described above.
>
> 7\. The employee will be required to take and pass a written exam
> testing his/her comprehension of the general and specific principles
> and practices of working with HIV and HBV.
>
> 8\. A record of the specialized training given to individual RCAHI
> employees and written exam results will be maintained in the RCAHI.

**Schedule and Method of Implementation**

This section outlines the schedule and methods of implementation
requirements of the Standard. Most provisions required by the Standard
are already in place.

A. Schedule.

> 1\. The Provisions listed below were implemented by June 4, 1992:
>
> a\. Communication of hazards to employees (Information and Training)
>
> b\. Record-keeping
>
> 2\. The Provisions listed below were implemented by July 6, 1992:
>
> a\. Compliance Methods
>
> \(1\) Standard Precautions
>
> \(2\) Engineering Controls and Work Practice Controls
>
> \(3\) Personal Protective Equipment
>
> \(4\) Written housekeeping schedule and procedures
>
> b\. Hazard Communication (signs and labels)
>
> c\. Hepatitis B Vaccination
>
> d\. Post-exposure Evaluation and Follow-up
>
> e\. HIV and HBV Research Laboratories and Production Facilities

B. Method. The Bloodborne Pathogen Standard Task Force was appointed in
February 1992 to address the implementation of the provisions of the
Standard. The goal of the team along with the Infection Control
Committee was to implement the mandatory provisions of the Standard by
the effective dates. The mechanisms used included:

> 1\. Evaluation of current policy, procedures, and work practices with
> regards to level of compliance.
>
> 2\. Development or revision of policies and procedures to address
> compliance to the Standard.
>
> 3\. Complete education for all employees identified in the exposure
> determination that meet the occupational exposure definition.
>
> 4\. Implementation of policies and procedures.
>
> 5\. Annual program evaluation.