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701 - Blood-Borne Pathogens (Prevention of Exposure)

Legal References: OSHA Blood-Borne Pathogens Standard, 29 CFP 1910.1030 

Universal precautions will be observed at the College to prevent contact with blood or other potentially infectious agents/materials. All blood or potentially infectious materials will be treated as infectious regardless of the perceived status of the individual/circumstance.

Appropriate work practices, as described in the Implementation Procedures below, will be used by those employees who potentially may be exposed to blood-borne or other infectious pathogens in the routine execution of their assignments. Exposure determination is found in the Blood-Borne Pathogens Procedures below.

Employees and students are to contact a Building Maintenance Supervisor should an emergency situation require immediate containment and prevention measures. All Maintenance employees should know where the necessary protective equipment is stored, and Personal Protection Equipment Procedures to be used, in the event that a Building Maintenance Supervisor is not available.

Blood-Borne Pathogens Procedures

Exposure Determination

At the College, the following are job classifications/programs in which employees/students may incur occupational exposure to blood or other potentially infectious materials (OPIM) such as non-intact skin and mucous membranes.

Job Classification/Program

  • Nursing Instructor
  • Custodial/Maintenance
  • E-Team

Tasks/Procedures

  • Hospital Instruction/Sharps
  • Instruction/Injury Response
  • Spill Clean-up (approved kit)
  • First Aid/Injury Response

All college personnel may have some chance of exposure during emergency situations. However, personnel, except for the above, are strongly discouraged from administering the elements of this plan. Instead, the procedure is to contact one of the employees listed above for further action; specifically, or an alternate in their absence. In emergency situations, however, if above personnel are not immediately available to assist, employees must take prompt action in accordance with this plan.

Implementation Schedule and Methodology

1. Compliance Methods

Universal Precautions will be observed at the College in order to prevent contact with blood /OPIM. All blood/OPIM will be considered infectious regardless of the perceived status of the source individual.

Engineering and work practice controls will be used to eliminate or minimize exposure to employees/students at this facility. Where occupational exposure remains after institution of these controls, personal protective equipment shall also be used. At the College, appropriate sharps containers (puncture resistant, biohazard labeled, and leak proof) and approved spill clean-up kits are available as engineering controls. These controls will be examined and maintained on a regular schedule by the Building Maintenance Supervisors.

Hand-washing facilities are available to individuals who incur exposure to blood/OPIM. OSHA requires that these facilities be readily accessible; therefore, at the College all labs and restrooms are equipped with hand-washing facilities. After removal of personal protective gloves, individuals will wash hands and any other potentially contaminated skin area immediately with soap and water. If mucous membranes are exposed, the individual(s) will wash or flush with water.

2. Needles

Contaminated needles and other contaminated sharps will not be bent, recapped, removed, sheared or purposely broken.

3. Containers for Sharps

Contaminated sharps will be placed immediately into appropriate sharps containers located in the nursing labs and restrooms. The nursing instructors will contact Maintenance when the containers are ready for proper disposal. Maintenance employees will monitor sharps containers that are located in restrooms.

4. Work Area Restrictions

Individuals are not to eat, drink, apply cosmetics or lip balm, or handle contact lenses in areas where blood/OPIM are present.

5. Contaminated Equipment

Equipment that has become contaminated with blood/OPIM will be de-contaminated by using EPA registered germicides. Equipment that cannot be de-contaminated will be disposed of properly by Maintenance employees.

6. Personal Protective Equipment

OSHA standards require appropriate protective clothing (e.g. gloves, lab coats, gowns, aprons, clinic jackets, face shields, utility gloves, protective eyewear with solid side shields, shoe covers, etc.) be worn during labs where patients and/or specimens are present. At a minimum, gloves will be worn where it is reasonably anticipated that individuals will have hand contact with blood/OPIM.

All required personal protective equipment will be provided without cost to employees based on the anticipated exposure to blood/OPIM. Appropriate equipment will not allow passage to clothing, skin, eyes, mouth or other mucous membranes under normal conditions for use and for the duration of time in use.

All personal protective equipment will be used as directed by supervisors, and then it will be removed before leaving the work area. Contaminated garments are to be removed immediately, placed in a red plastic bag available in spill clean-up kits and custodial supply storage areas and sealed. Contaminated materials should not be sorted in areas of use. The employee should notify maintenance staff for removal. The College, at no cost to the employee, will clean, launder, dispose of and/or replace the equipment, as needed. Disposable gloves are not to be washed or decontaminated for reuse. They will be replaced as soon as compromised. Utility gloves will be decontaminated for reuse if their integrity is not compromised; otherwise they will be discarded.

The College will be cleaned routinely and de-contaminated after spills using EPA registered germicides. All work surfaces will be decontaminated after completion of these procedures (immediately after any spill) as well as at the end of the work shift if surfaces have been used since prior cleaning. All bins, pails, cans and similar receptacles will be inspected and decontaminated routinely and after possible exposure has occurred. Hands, gloved or not, will not be used to pick up broken glassware.

7. Regulated Waste Disposal

All sharps will be placed as soon as possible in sharps containers located in the nursing labs. The contents are periodically disposed of, as per agreement, at Community Memorial Hospital, Winona, Minnesota and at Fairview Red Wing Regional Home Health, Red Wing, Minnesota, for respective campuses. Regulated waste, other than sharps, is to be placed in red plastic bags and placed in appropriate containers.

8. Laundry Procedures

Contaminated items are to be handled as little as possible and only when wearing personal protective equipment. It will be placed in appropriately marked bags in areas of use and then laundered off site (in Winona at Leaf’s Cleaners and Launderers and in Red Wing at Red Wing Cleaners and Launderers).

9. Hepatitis B Vaccine

Vaccine will be offered to employees in job classifications that may incur occupational exposure and to any individuals who have been exposed to blood/OPIM at no cost to the individual. If declining the vaccine, the individual must sign a waiver with wording from Appendix A of the OSHA standard. Individuals who initially decline the vaccine, but who later wish to have it, while still covered under standard, may then have the vaccine provided at no cost. The Human Resources office at the Red Wing Campus (Vanessa Harstad) and the Maintenance office at the Winona Campus ( Nicki Adank) will assure that the vaccine is offered and make arrangements for those who wish to have the vaccine or that waivers are signed and filed for those that decline.

10. Post-Exposure Evaluation and Follow-up and/or Interaction with Health Care Professionals

Post-exposure services will be provided to all individuals who incur an exposure incident. All exposures must be reported immediately to the Human Resources office at the Red Wing Campus (Vanessa Harstad) and the Maintenance office at the Winona Campus (Nicki Adank). The individual will be given an exposure Incident Report to take to the health care facility.

Blood-borne Pathogen Post-Exposure Evaluation and Follow-up Procedures: When an employee incurs an exposure incident, it must be reported to the Human Resources office at the Red Wing Campus (Vanessa Harstad) and the Maintenance office at the Winona Campus ( Nicki Adank).

All employees who incur an exposure incident will be offered post-exposure evaluation and follow-up in accordance with the OSHA standard.

This follow-up will include the following.

  • Documentation of the route of exposure and the circumstances related to the incident
  • If possible, the identification of the source individual and, if possible, the status of the source individual. The blood of the source individual will be tested (after consent is obtained for HIV/HBV infectivity).
  • 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 disclosure of the identity and infectivity of the source individual.
  • The employee will be offered the option of having their blood collected for testing of the employee’s HIV/HBV serological status. The blood sample will be preserved for up to 90 days to allow the employee to decide if the blood should be tested for HIV serological status. However, if the employee decides before that time that testing will or will not be conducted, then the appropriate action can be taken and the blood sample discarded.
  • The employee will be offered post-exposure prophylaxis in accordance with the current recommendations of the U.S. Public Health Service.
  • 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 illness to be alert for and to report any related experiences to appropriate personnel.

Interaction with Health Care Professionals: A written opinion shall be obtained from the health care professional who evaluates employees of this facility. Written opinions will be obtained in the following instances:

  • When the employee is sent to obtain the Hepatitis B vaccine.
  • Whenever the employee is sent to a health care professional following the exposure incident. Health care professionals shall be instructed to limit their options to:
  • Whether the Hepatitis B vaccine is indicated and if the employee has received the vaccine.
    • that the employee has been informed of the results of the evaluation
    • that the employee has been told about any medical conditions resulting from exposure to blood or other potentially infectious materials. (Note that the written opinion to the employer is not to reference any personal medical information.)  

11.  Training

Training will be provided to all individuals before their initial assignment to tasks where occupational or training exposure may occur. It will include the following:

  • The OSHA Standard for Blood-borne Pathogens,
  • Epidemiology and symptomatology of blood-borne diseases,
  • Modes of transmission,
  • Orientation to exposure control procedures/policy, i.e. policy points, lines of responsibility, and procedural implementation, including identification of exposure risks, control methods to limit/reduce exposure, personal protective equipment, contact information, post-exposure evaluation and follow-up, Hepatitis B vaccine program,
  • Signs and labels used
  • Training will be conducted using videotapes, written materials and instruction per OSHA standards. Employees will receive annual refresher training.

12.  Record-Keeping

The Academic Affairs Office on Winona Homer Road campus will maintain all medical records required under the OSHA standards.

Approved: April 10, 1997
Reviewed: December 28, 2010; October 23, 2013
Revised: February 15, 2000; June 30, 2004