Bloodborne Pathogen Exposure Control Plan
Bloodborne Pathogen Exposure Control Plan
Montcalm Area Intermediate
School District
August 2024
MONTCALM AREA INTERMEDIATE SCHOOL DISTARICT
EXPOSURE CONTROL PLAN
TABLE OF CONTENTS
I. Purpose. 1
II. General Program Management 2
A. Responsible Persons 2
1. Exposure Control Officer 2
2. Directors, Supervisors and Principals 3
3. Employees 3
B. Availability of the Exposure Control Plan to 3
C. Review and Update of the 3
III. Exposure Determination 4
IV. Methods of Compliance 4
A. Universal Precautions 4
B. Work Practice Controls 5
C. Personal Protective Equipment 7
D. Infectious Waste Disposal 8
V. Hepatitis B Vaccination, Post-Exposure Evaluation and Follow-Up 9
A. Vaccination Program & Antibody Screening 9
B. Post-Exposure Evaluation and Follow-Up 9
C. Information Provided to the Healthcare Professional 10
D. Healthcare Professional’s Written Opinion 10
E. Medical Recordkeeping 11
VI. Training 11
A. Training Methods 11
B. Record Keeping 11
Appendices
Appendix A - “Rip and Run” 12
Appendix B – Glossary 13
Appendix C – Employee Exposure Determination 16
Appendix D – Exposure Determination Form for Individuals 17
Appendix E – Consent for Hepatitis B Vaccination or Declination Statement 18
Appendix F – Health Care Professional Written Opinion for Hep B Vaccination 19
Appendix G – Exposure Investigation Form 20 & 21
Guidelines and Procedures for the Prevention of Transmission of
Bloodborne Pathogens in the School Setting
EXPOSURE CONTROL PLAN
I. PURPOSE
One of the major goals of the Michigan Occupational Safety and Health Administration
(MIOSHA) is to regulate facilities where work is carried out and to promote safe work practices in an effort to minimize the incidence of illness and injury experienced by employees. Relative to this goal, MIOSHA has enacted the Bloodborne Pathogens Standard, codified as Rule 325.70001-.70018. The purpose of the Bloodborne Pathogens Standard is to reduce occupational exposure to Hepatitis B Virus (HBV), Human Immunodeficiency Virus (HIV) and other bloodborne pathogens that employees may encounter in their workplace.
The Montcalm Area Intermediate School District (MAISD) believes that there are a number of good general principles that should be followed when working with students. These include:
Risk of exposure to bloodborne pathogens should never be underestimated.
It is prudent to minimize all exposure to bloodborne pathogens.
The ISD should institute as many work practice controls as possible to eliminate or minimize employee exposure to bloodborne pathogens.
The Montcalm Area Intermediate School District has implemented this Exposure Control Plan to meet the requirements of the OSHA Bloodborne Pathogens Standard and also to assure that all MAISD employees have a safe workplace environment.
The objectives of the Exposure Control Plan are:
To protect employees from the health hazards associated with bloodborne pathogens.
To provide appropriate treatment and counseling in the event that an employee is
exposed to bloodborne pathogens.
II. GENERAL PROGRAM MANAGEMENT
RESPONSIBLE PERSONS
There are major categories of responsibility that are crucial to the effective
implementation of the Exposure Control Plan. They include:
The Exposure Control Officer (Sarah Reeber/Jess Dora)
Superintendent, Directors, Supervisors and Principals
The following sections define the roles played by each of these groups in carrying out the
plan. Throughout this written plan, employees with specific responsibilities are identified. If, because of a promotion or other responsibilities, the employee can no longer fill this duty, then the superintendent is to be notified so the records may be updated.
Exposure Control Officer
The Exposure Control Officer will be responsible for overall management and
support of the Bloodborne Pathogens Compliance Program. Activities which are delegated to the Exposure Control Officer include, but are not limited to:
Overall responsibility for implementing the Exposure Control Plan for the ISD.
Working with administrators and other employees to develop and administer any additional bloodborne pathogens related policies and practices needed to support the effective implementation of the Exposure Control Plan.
Seeking ways to improve the Exposure Control Plan, as well as to revise and update it when necessary.
Knowing current legal requirements regarding bloodborne pathogens.
Conducting periodic organization audits to maintain an up-to-date Exposure Control Plan.
Acting as a liaison during MIOSHA inspections.
To assist the Exposure Control Officer, the MAISD has created an Exposure Control Committee consisting of Sarah Reeber (nurse), Don Thompson (Facilities Director), Kim Iverson, (Associate Superintendent of Special Education) and Shannon Tripp, (Associate Superintendent of Career Technical Education).
Directors, Supervisors and Principals
Directors, Supervisors and Principals are responsible for exposure control in their respective areas. They work directly with the Exposure Control Officer, the Exposure Control Committee and the department’s employees to ensure that proper exposure control procedures are followed.
Employees
The employees have the most important role in the bloodborne pathogens compliance program, for the ultimate effectiveness of the Exposure Control Plan rests in their hands. Employee responsibilities include:
Knowing what tasks they perform that have occupational exposure.
Attending the bloodborne pathogens training programs.
Planning and conducting all operations in accordance with the work practice controls.
Developing and maintaining good personal hygiene habits, such as hand washing.
B. AVAILABILITY OF THE EXPOSURE CONTROL PLAN TO EMPLOYEES
To help employees with their efforts, Montcalm Area Intermediate School District Exposure Control Plan is available to employees at any time. Employees are advised of this availability during their education/training sessions. Copies of the Exposure Control Plan are kept at the reception desk of all ISD operated buildings.
C. REVIEW AND UPDATE OF THE PLAN
It is important to keep the Exposure Control Plan up-to-date. To ensure this, the plan will be reviewed and updated under the following circumstances:
Annually
Whenever new or modified tasks and procedures are implemented which affect the occupational exposure of employees to bloodborne pathogens.
III. EXPOSURE DETERMINATION
The Exposure Control Plan has identified exposure situations the employees may encounter:
Job classifications in which all or some employees have occupational exposure to
bloodborne pathogens. (Appendix C)
Job classifications in which employees do not have occupational exposure to bloodborne pathogens. (Leanne Bush maintains the employee exposure determination forms)
IV. METHODS OF COMPLIANCE
There are a number of areas that must be addressed in order to effectively eliminate or minimize exposure to bloodborne pathogens in the departments. These include:
Following Universal Precautions.
Implementing appropriate Work Practice Controls.
Using necessary Personal Protective Equipment.
Properly disposing of infectious waste.
A. UNIVERSAL PRECAUTIONS
The term "Universal Precautions" refers to a method of infection control developed by the Centers for Disease Control and the National Institute of Health in which blood and body fluids of all people are handled as if they contain bloodborne pathogens.
Body fluids to which Universal Precautions apply:
Blood and other body fluids containing visible blood. (Blood is the single most important source of HIV, HBV, and other bloodborne pathogens in the occupational setting.)
Semen and vaginal secretions.
Body fluids. (Spinal fluid, joint fluid, fluid surrounding the heart and lungs, or amniotic fluid.)
Any undetermined body fluid. (In circumstances where it is difficult or impossible to differentiate between body fluid types, we assume all body fluids to be potentially infectious.)
In the Montcalm Area ISD, we observe the practice of Universal Precautions to prevent contact with blood and other potentially infectious materials. All human blood and body fluids are treated as if they are known to be infectious for HBV,
HIV and other bloodborne pathogens.
Within the Intermediate School District, the Directors, Supervisors and Principal are responsible for overseeing the Universal Precautions program in their departments.
Body fluids that do not transmit bloodborne diseases unless contaminated with blood are listed below. Because these fluids can transmit other infection, Universal Precautions still apply at the Intermediate School District and must be followed.
urine
feces
sputum, phlegm (lung secretions)
tears
vomitus
saliva
sweat
B. WORK PRACTICE CONTROLS
In addition to engineering controls, a number of Work Practice Controls help eliminate or minimize employee exposure to bloodborne pathogens. All employees are responsible for implementing Work Practice Controls.
The following Work Practice Controls are part of the Bloodborne Pathogens Compliance Program:
1. Eating, drinking, smoking, applying cosmetics or lip balm or handling contact lenses are prohibited in work areas that carry an inherent potential for contamination.
2. Hands and other skin surfaces contaminated with potentially biohazardous material must be washed immediately and thoroughly with soap and water. Hands must be washed immediately after gloves are removed, even if the gloves appear to be intact.
3. Blood spills shall be cleaned up promptly with a disinfectant solution such as a fresh 1:10 dilution (1 part bleach to 10 parts water) of liquid chlorine bleach (5.25% sodium hypochlorite), or an approved hospital disinfectant. Studies have shown that HIV is inactivated rapidly after being exposed to commonly used chemical germicides. Germicides vary in their activity against infectious agents and in the time needed for disinfection. Manufacturers guidelines shall be followed. Isolate the area until it is properly cleaned and disinfected.
4. Contaminated laundry shall be placed in labeled or color-coded, leak proof containers at the location where it was contaminated. Employees who have contact with contaminated laundry must wear appropriate personal protective equipment.
5. HBV vaccine shall be offered, at MAISD expense, to all persons whose occupational tasks place them at risk of exposure to blood or other potentially infectious materials.
6. All supervisors/instructors shall be responsible for informing persons of any special precautions pertinent to their area.
When a new employee enters the department or an employee changes jobs within the department, the following process takes place to ensure that they are trained in the appropriate work practice controls:.
1. The employee’s job classification, the task and procedures that they will perform are determined by the employee’s immediate supervisor and an exposure determination form is completed.
2. If the employee is transferring from one job to another within the department, the supervisor will review the exposure determination form.
3. Employee training is then offered through the nurse regarding any work practice controls that the employees are not familiar with.
C. PERSONAL PROTECTIVE EQUIPMENT
Personal protective equipment is the employee's last line of defense against bloodborne pathogens. Personal protective equipment must be provided at no cost to employees to protect them against such exposure. This equipment includes, but is not limited to:
gloves
impervious gowns
mouth to mouth items
masks with wraparound splashguard visor
splashguard visor
head bouffant cap
shoe covers
The supervisor is responsible for ensuring that all work areas have appropriate personal protective equipment available to employees.
Employees are trained regarding the use of appropriate personal protective equipment for their job classifications and tasks/procedures they perform. Initial training about personal protective equipment is completed prior to the beginning their job duties. Additional training is provided when necessary, if an employee takes a new position or new job functions are added to their current position.
To determine whether additional training is needed, the employee’s supervisor, along with the nurse (as necessary) will compare the employee's previous job classification and tasks versus those for any new job or function that they undertake.
Protective barriers reduce the risk of exposure of a person’s skin or mucous membranes to fluids that require Universal Precautions. To make sure that this equipment is used as effectively as possible, employees will adhere to the practices they are taught, including use of the following protective barriers.
1. Gloves shall be worn for touching human blood, body fluid, mucous membranes, or skin with open wounds or weeping rashes; for touching items or surfaces soiled with blood or body fluids.
Only vinyl exam gloves shall be used. Hands shall be washed and gloves changed between contacts. Vinyl gloves shall NOT be washed. Use of soap compromises their ability to protect. All gloves shall be latex free due to allergy risk of both students and staff. Disposable gloves are replaced as soon as practical after contamination or if they are torn, punctured or otherwise lose their ability to function as an exposure barrier.
2. Any garments penetrated by blood or other infectious materials are to be removed immediately if feasible, or as soon as possible.
3. Disposable personal protective equipment shall be disposed of properly and not reused. Reusable equipment shall be decontaminated properly soon after use.
D. INFECTIOUS WASTE DISPOSAL
Infectious waste is defined as follows:
Liquid human, including blood and blood products, and body fluids (as defined under Universal Precautions). This includes materials crusted or soaked with blood or body fluids, but does not include urine.
Medical, biological, and other infectious wastes must be disposed of in designated containers or bags that are color-coded, labeled, and tagged as "biohazard". Bags may be obtained through the building custodian. Once filled, items are discarded and "bagged" in containers that are:
Closeable.
Puncture-resistant.
Leak-proof, if potential for fluid spill or leakage exists.
Red in color or labeled with the appropriate biohazard warning label.
Also note the following:
Waste containers are maintained upright, routinely replaced and not allowed to overfill.
Contaminated laundry is handled as little as possible and is not sorted or rinsed where it is used.
Whenever the employees move containers of regulated waste from one area to another, the containers are immediately closed and placed inside an appropriate secondary container if leakage is possible from the first container.
The building’s custodial staff is responsible for placing a new biohazard bag in the covered labeled waste container as soon as it’s full.
V. HEPATITIS B VACCINATION, POST-EXPOSURE EVALUATION AND
FOLLOW-UP
Everyone in the Montcalm Area Intermediate School District recognizes that exposure incidents can occur even with good adherence to exposure prevention practice. A Hepatitis B Vaccination Program and procedure for post-exposure evaluation and follow-up have been established.
VACCINATION PROGRAM & ANTIBODY SCREENING
The Montcalm Area Intermediate School District has implemented a vaccination program at the Mid Michigan Health Department. This program is offered at no cost to all employees who have occupational exposure to bloodborne pathogens.
The vaccination program consists of a series of three inoculations over a six-month period. As part of their bloodborne pathogens training, the employees will receive information regarding hepatitis B vaccination, including its safety and effectiveness. (Appendix C, D, E, F)
POST-EXPOSURE EVALUATION AND FOLLOW-UP
If a Montcalm Area Intermediate School employee is involved in an incident where exposure to bloodborne pathogens may have occurred, efforts should be focused on getting medical consultation and treatment expeditiously. The following procedure should be initiated:
1. Wash the exposed area immediately.
2. The employee must report the incident to the supervisor and the supervisor will then refer the exposed employee and the source, if available, to a local hospital for immediate evaluation and treatment. A supervisor must report the incident to the school nurse if a student is involved.
3. The treating physician will schedule follow-up appointments to monitor the employees’ post exposure medical status.
The building principal or program supervisor investigates every exposure incident. The investigation is initiated within 24 hours after the incident occurs. The Exposure Incident Investigation Forms can be found in the binder kept at every ISD building’s reception desk.
In order to make sure that the employees receive the best and most timely
treatment if an exposure to bloodborne pathogens should occur, the ISD has set up a comprehensive post-exposure evaluation and follow-up process which includes the following (Appendix G):
Actions taken as a result of the incident
Employee decontamination; care of injury
Cleanup
Notifications made
Much of the information involved in this process must remain confidential and every
effort will be taken to protect the privacy of the people involved.
C. INFORMATION PROVIDED TO THE HEALTHCARE PROFESSIONAL
To assist the healthcare professional the following documents will be forwarded to them in the event of an exposure: Exposure Investigation Form (G)
Employees are expected to be able to answer questions about their Hepatitis B Vaccination status.
D. HEALTHCARE PROFESSIONAL’S WRITTEN OPINION
After the consultation, the healthcare professional provides the Worker’s Compensation Office with a written opinion evaluating the exposed employee’s situation. The exposed employee will receive a copy of this (Appendix H). In keeping with this process’ emphasis on confidentiality, the written opinion will contain only the following information:
Whether Hepatitis B Vaccination is indicated for the employee
Whether the employee has received the Hepatitis B Vaccination.
Confirmation that the employee has been informed of the results of the evaluation.
Confirmation that the employee has been told about any medical conditions resulting from the exposure incident, which require further evaluation or treatment.
All other findings or diagnoses will remain confidential and will not be included in the written report.
E. MEDICAL RECORDKEEPING
Montcalm Area Intermediate School District is responsible for establishing and maintaining employee medical records related to bloodborne pathogen potential exposure incidents. These records include the following:
Name of the employee.
Social security number of the employee.
Copies of the results of the examinations, medical testing and follow-up
procedures that took place as a result of the employee’s exposure to bloodborne pathogens. (Appendix I)
A copy of the information provided to the consulting healthcare
professional as a result of any exposure to bloodborne pathogens.
The Intermediate School District is also responsible for keeping a copy of the
employee’s Hepatitis B vaccination status and dates the vaccinations were given.
As with all medical information, the information is confidential. Information is disclosed
only with the employee’s signed consent or in accordance with applicable state or federal
law.
VI. TRAINING
A. Training is required for all staff on an annual basis. Montcalm Area Intermediate School District uses Global Compliance Network for its training.
B. Safe Schools data base will be used to track employees who have been trained. Certificates can be printed form the Safe Schools system, stamped by the ISD employee who supervised the administration of training, and then stored at the ISD Central Office.
Appendix A
“Rip and Run”
MONTCALM AREA INTERMEDIATE SCHOOL DISTRICT
BLOODBORNE PATHOGEN EXPOSURE CONTROL PLAN
1. General Principles
There are a number of good general principles that should be followed when
Working with bloodborne pathogens. These include:
a. Risk of exposure should never be underestimated.
b. It is prudent to minimize all exposure.
c. Use universal precautions.
2. Universal Precautions
Universal precautions refers to the method of handling human blood and certain human body fluids. According to this concept all human blood and certain human body fluids are treated as if they are known to be infected with pathogens.
3. The following controls are to be used throughout the MAISD:
Hand washing (or antiseptic hand cleaners and towels or antiseptic
towelettes), which is readily available to all employees who have the potential
for exposure.
4. Personal Protective Equipment is the employee’s last line of defense against
bloodborne pathogens. PPE includes, but is not limited to: gloves, gowns, laboratory coats, goggles, hoods, face shields/masks, safety glasses, mouthpieces, resuscitation bags, pocket masks, shoe covers.
5. Accidental Exposure
If you are exposed you should:
Report exposure to your supervisor. The supervisor will contact the nurse.
The nurse will send you to the nearest hospital
6. Disinfection
Any contaminated or potentially contaminated surface should be disinfected. A 1:10 bleach to water solution (must be a fresh solution) may be used.
Appendix B
GLOSSARY
Blood: human blood components and products made from human blood.
Bloodborne Pathogens: pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to hepatitis B virus (HBV) and human immunodeficiency virus (HIV).
Contaminated: the presence or the reasonably anticipated presence of blood or potentially infectious materials or sharps.
Contaminated Laundry: laundry that has been soiled with blood or other potentially infectious materials or sharps.
Contaminated Sharps: any contaminated object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires.
Decontamination: 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. The surface of the item is rendered safe for handling, use, or disposal.
Department: the Department of Consumer and Industry Services.
Director: the Director of the National Institute of Occupational Safety and Health, U.S.
Department of Health and Human Services, or designated representative.
Disinfect: means to inactivate virtually all recognized pathogenic microorganisms, but not necessarily all microbial forms, on inanimate objects.
Engineering Controls: controls (e.g. sharps disposal containers, self-sheathing needles) that isolate or remove the bloodborne pathogens hazard from the workplace.
Exposure: reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties. This definition excludes incidental exposures that may take place on the job that are neither reasonably nor routinely expected in the normal course of employment.
Exposure Incident: a specific eye, mouth, other mucous membrane, non-intact skin, or
parentral contact with blood or other potentially infectious materials that results from the
performance of an employee’s duties.
Hand washing Facility: a facility providing an adequate supply of running water, soap and single use towels or hot air drying machines.
HBV: hepatitis B virus.
HIV: human immunodeficiency virus.
Occupational Exposure: reasonable anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties.
Other Potentially Infectious Materials: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal 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. Any unfixed tissues or organ (other than intact skin) from a human (living or dead). HIV-contaminated cell or tissue cultures, organ cultures, and HIV or HBV-containing medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.
Parenteral: piercing of mucous membranes or the skin barrier through such events as
needlesticks, human bites, cuts, and abrasions.
Personal Protective Equipment: specialized clothing or equipment worn by an employee for protecting against a hazard.
Production Facility: facility engaged in industrial-scale, large volume or high concentration production of HIV or HBV.
Regulated Waste: liquid or semi-liquid blood or other potentially infectious materials;
contaminated items that would release blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; pathological and microbiological wastes containing blood or other potentially infectious materials.
Source Individual: any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to the employee.
Standard Operating Procedures (SOPs): any of the following which address the performance of work activities so as to reduce the risk of exposure to blood and other potentially infectious material:
(i) Written policies
(ii) Written procedures
(iii) Written directives
(iv) Written standard of practice
(v) Written protocols
(vi) Written system of practice
(vii) Elements of an infection control program
Sterilize: the use of a physical or chemical procedure to destroy all microbial life including highly resistant bacterial endospores..
Universal Precautions: an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens.
