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Table of Contents

Introduction
Policy
Program Administration
Employee Exposure Determination
Exposure Control Plan

1.0 Universal Precautions
2.0 Availability of Exposure Control Plan
3.0 Engineering Controls and Work Practices
4.0 Personal Protective Equipment (PPE)
5.0 Training
6.0 Hepatitis B Vaccination

Highlights of hepatitis B Vaccination

7.0 Post Exposure Evaluation and Follow-up

Post Exposure Evaluation Highlights

8.0 Health Care Professionals
9.0 Housekeeping
10.0 Labeling
11.0 Medical Records

  APPENDIX SECTION  

A - Bloodborne Pathogens Standard 29 CFR 1910.1030
B - Definitions
C - DCEMS Bloodborne Pathogen Policy
D - Declination Statement
E - DCEMS Chemoprophylaxis After Potential Occupational/Educational Exposure to HIV
F - DCEMS HIV and HBV Policy
G - Exposure Incident Report Form
H - DCEMS Regulated Medical Waste Policy
 I - Biohazard Illustration

INTRODUCTION

Acquired Immune Deficiency Syndrome (AIDS) and hepatitis B warrant serious concern for workers occupationally exposed to blood and certain other body fluids that could be contaminated with bloodborne pathogens. It is estimated nationally that more than 5.6 million workers in health care and public safety occupations could be potentially exposed. In recognition of these potential hazards, DCEMS has adopted the Occupational Safety and Health Administration (OSHA) regulation [Bloodborne Pathogens 29 Code of Federal Regulations (CFR) 1910.1030] to help protect personnel from these health hazards. A copy of this regulation is included in Appendix A.

 The major intent of this regulation is to prevent the transmission of bloodborne diseases within potentially exposed workplace occupations. The standard is expected to reduce and prevent employee exposure to the Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and other Bloodborne diseases. The Occupational Safety and Health Administration (OSHA) estimates the standard could prevent more than 200 deaths and about 9,000 infections per year from HBV alone. The standard requires that employers follow universal precautions, which means that all blood or other potentially infectious materials must be treated as being infectious for HIV and HBV. Each employer must determine the application of universal precautions by performing an employee exposure evaluation. If employee exposure is recognized, as defined by the standard, then the standard mandates a number of requirements. One of the major requirements is the development of an Exposure Control Plan, which mandates engineering controls, work practices, personal protective equipment, HBV vaccinations and training. The standard also mandates practices and procedures for housekeeping, medical evaluations, hazard communication, and record keeping. A list of definitions for terms used in this Exposure Control Plan, as well as the Bloodborne Pathogen Regulation is included in Appendix B.

POLICY

In accordance with the DCEMS Bloodborne Pathogens Policy (Appendix C), DCEMS is committed to providing a safe and healthful work environment for our entire staff. In pursuit of this endeavor, the following Exposure Control Plan (ECP) is provided to eliminate or minimize occupational exposure to bloodborne pathogens in accordance with the OSHA Bloodborne Pathogens Standard, Title 29 Code of Federal Regulations 1910.1030.

The Exposure Control Plan (ECP) is a key document to assist clinics, laboratories and departments in implementing and ensuring compliance with the standard, thereby protecting our employees. This ECP includes:  

1. Employee exposure determination
2. The procedures for evaluating the circumstances surrounding and exposure incident, and
3. The schedule and method for implementing the specific sections of the standard, including:

1. Methods of compliance
2. Hepatitis B vaccination and post-exposure follow-up
3. Training and communication of hazards to employees

PROGRAM ADMINISTRATION

• The Departmental Safety Officer and Operations Officers are responsible for the overseeing implementation of the provisions of this Exposure Control Plan (ECP). A Shift Safety Representative may be selected who will be responsible for the day-to-day implementation of the requirements of this ECP under the direction of the Departmental Safety Officer. This ECP will be reviewed and revised at least annually and whenever necessary to include new or modified tasks and procedures.

• Those employees who are reasonably anticipated to have contact with, or exposure to blood or other potentially infectious materials are required to comply with the procedures and work practices outlined in this ECP.

• The DCEMS Safety Officer and Station Officers will have the responsibility for written housekeeping protocols and will ensure that effective disinfectants are purchased and available.

• The Operations Supervisors under the direction of the Departmental Safety Officer will be responsible for ensuring that all required medical actions are performed and that appropriate records are maintained.

• The Operation Supervisors under the direction of the Departmental Safety Officer will be responsible for ensuring that each employee attends required training, for maintaining documentation of training, and for making the written ECP available to employees, OSHA and NIOSH representatives.
  
• The Departmental Safety Officer will ensure that all necessary personal protective equipment (PPE), engineering controls (i.e., sharp containers, etc.), labels and red bags, as required by the standard, are available.

• The Station Officers under the direction of the Departmental Safety Officer will ensure that adequate supplies of the aforementioned equipment are available.

EMPLOYEE EXPOSURE DETERMINATION

All employees in the following job classifications are involved with patient care and have duties that place them at occupational risk of exposure to blood or body fluids while performing their work: 

• EMT-B
• EMT-I
• EMT-P
• Administrative staff - Director & Deputy Directors
• Students
• MICN's
• Pilots

In the following non-clinical job classifications listed below, certain persons may enter treatment rooms or handle clinical specimens and are considered to have potential for exposure to blood or body fluids while performing their work:

• receptionist/secretary

Examples of procedures which may result in personnel exposure to blood or body fluids includes:

•  Drawing blood
• Resuscitation
• caring for persons who may bite
• Surgical/Medical/Invasive procedures
• packaging diagnostic/biological specimens for transport
• clinical laboratory handling and analysis of diagnostic specimens
• cleaning up spills of blood or body fluids
• handling/cleaning equipment contaminated with blood or body fluids
• inserting an IV
• suctioning

Note: "Good Samaritan" acts which result in exposure to blood or other potentially infectious materials from assisting a fellow employee (i.e., assisting a co-worker with nosebleed, giving CPR or first aid) are not covered by the Bloodborne Pathogens Standard. However, Post-Exposure Evaluation and Follow-up should be provided in such cases.  

 EXPOSURE CONTROL PLAN:
METHODS OF IMPLEMENTATION AND CONTROL

1.0 Universal Precautions

1.1 All employees will utilize Universal Precautions. Universal Precautions is an infection control method which requires employees to assume that all human blood and specified human body fluids are infectious for HIV, HBV and other bloodborne pathogens (see definition for Universal Precautions in Appendix B) and must be treated accordingly.

2.0 Availability of Exposure Control Plan

2.1 Employees covered by the Bloodborne Pathogens Standard will receive an explanation of this ECP during their initial training session. It will also be reviewed during annual refresher training. All employees will have an opportunity to review and/or photocopy this Plan at any time during their work shifts by contacting the Departmental Safety Officer.  

2.2 The Departmental Safety Officer will be responsible for reviewing and updating the ECP annually or sooner, with input from Department Supervisors,  County Safety Representatives,  or other persons if necessary to reflect any new or modified tasks and procedures which affect occupational exposure and to reflect new or revised employee positions with occupational exposure.

3.0 Engineering Controls and Work Practices

3.1 Engineering controls and work practice controls will be used to prevent or minimize exposure to bloodborne pathogens. Examples of engineering and work practice controls we will use are listed below:

• Self-sheathing needles in certain high-risk locations
• Puncture-resistant disposal containers for contaminated sharps or broken glass wherever there is a potential for contaminated sharps or glass
• Mechanical needle recapping devices

New technology for needles and sharps will be periodically evaluated by Departmental Safety Officer as well as other County Safety Representatives. These will be employed whenever there is substantial evidence that their use will significantly prevent accidental needle sticks and cuts. Each sharps container will be replaced by the Supply Officer when it is two thirds full.

Work practice controls which will be implemented by personnel include, but are not limited to:

• Providing readily accessible hand washing facilities

• Washing hands immediately or as soon as feasible after removal of gloves

• At non-fixed sites (i.e., emergency scenes, mobile blood collection sites) which lack hand washing facilities, providing interim hand washing measures, such as antiseptic towelettes and paper towels. Employees can later wash their hands with soap and water as soon as feasible

• Washing body parts as soon as possible after skin contact with blood or other potentially infectious materials occurs

• Prohibiting the recapping or bending of needles

• Shearing or breaking contaminated needles is prohibited

• Labeling containers with a biohazard sticker

• Equipment and surface decontamination

• Prohibiting eating, drinking, smoking, applying cosmetics or lip balm and handling contact lenses in work areas where there is a likelihood of occupational exposure

• Prohibiting food and drink from being kept in refrigerators, freezers, shelves, cabinets or on counter or bench tops where blood or other potentially infectious materials are present

• Requiring that all procedures involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing, splattering, and generation of droplets of these substances

• Placing specimens of blood or other potentially infectious materials in a container which prevents leakage during collection, handling, processing, storage, transport or shipping

• Ensuring that equipment which may become contaminated with blood or other potentially infectious materials are decontaminated prior to servicing or shipping. Items not completely decontaminated will be labeled per section (g)(1)(i)(H) of the OSHA Bloodborne Pathogen Standard (Appendix A).

• A plumbed, readily accessible, and uncluttered eyewash station must be available where necessary. Eyewashes in DCEMS buildings will be activated monthly to ensure proper functioning. An inspection log will be kept by the Station Officer or another person who has been designated by the Departmental Safety Officer.

4.0 Personal Protective Equipment (PPE)

4.1 Personal protective equipment must be used if potential for occupational exposure remains after engineering and work practice controls have been instituted, or if controls are not feasible. Training sessions will cover the use of appropriate personal protective equipment for employees' specific job classifications and tasks/procedures. 

PPE items include:

• Disposable gloves for tasks where employees may have hand contact with blood or other potentially infectious materials
• Gowns or other protective body covering shall be worn in occupational exposure situations. The type shall be appropriate for the tasks being performed.
• Face shields, Masks and Eye Protection. PPE such as goggles or glasses with solid side shields or chin length face shields shall be worn whenever splashes, spray, spatter or droplets of blood or other potentially infectious materials may be generated, and eye nose or mouth contamination can be reasonably anticipated
• Resuscitation bags and mouthpieces

Additional training on personal protective equipment will be provided whenever necessary, such as, if a new device is used, if an employee takes a new position, or if new duties are added to their current positions.

PPE will be kept "readily accessible" for employees' use. The Departmental Safety Officer is responsible for ensuring that the appropriate equipment is issued and that staff are in-serviced in how, when, and who will provide the PPE.  It is imperative that employees wear appropriate protective body coverings such as gowns, gloves, coats, pants and boots when occupational exposure is possible. The type and characteristics will depend upon the task and degree of exposure anticipated.

First aid responders must have quick access to kits containing impervious gloves, resuscitation bags or mouthpieces, eye protection, aprons, disinfectant towelettes for hand washing, and red bags or biohazard bags.

4.2 All employees using PPE must observe the following precautions:

• Wash hands immediately or as soon as feasible after removal of gloves or other personal protective equipment
• Remove protective equipment before leaving the work area and after a garment becomes contaminated
• Place used protective equipment in appropriately designated areas or containers when being stored, washed, decontaminated, or discarded. 

Note: Areas or containers which are to be used for contaminated PPE should be designated in each station and employees should be familiar with their location.

Wear appropriate gloves when it can be reasonably anticipated that you may have contact with blood or other potentially infectious materials and when handling or touching contaminated items or surfaces. Replace gloves if torn, punctured, contaminated, or if their ability to function as a barrier is compromised.

Following any contact of body areas with blood or any other infectious materials, you must wash your hands and any other exposed skin with soap and water as soon as possible. Employees must also flush exposed mucous membranes (eyes, mouth, etc.) with water.

Utility gloves may be decontaminated for reuse if their integrity is not compromised. The decontamination procedure will consist of washing with a solution of bleach and water. Discard utility gloves when they show signs of cracking, peeling, tearing, puncturing, or deterioration.

Never wash or decontaminate disposable gloves, either for reuse or before disposal. 

Wear appropriate face and eye protection when splashes, sprays, spatters, or droplets of blood or other potentially infectious materials pose a potential hazard to the eye, nose, or mouth. 

If a garment(s) is contaminated by blood or other potentially infectious materials, the garment(s) must be removed immediately or as soon as feasible. If a pull-over shirt becomes minimally contaminated, employees should be trained to remove the pull-over shirt in such a way as to avoid contact with the outer surface; e.g., rolling up the garment as it is pulled toward the head for removal. However, if the amount of blood exposure is such that the blood penetrates the scrub and contaminates the inner surface, not only is it impossible to remove the shirt without exposure to blood, but the penetration itself constitutes exposure. Employees shall be trained to cut such a contaminated shirt to aid removal and prevent exposure to the face.

Repair and/or replacement of PPE will be at no cost to employees.

5.0. Training

5.1 All employees who have or are reasonably anticipated to have occupational exposure to bloodborne pathogens will receive annual training conducted by DCEMS. Alternatively, a DCEMS Supervisor or Safety Representative may also provide the training as long as they have attended an DCEMS training on the topic. At a minimum, training sessions shall include the following topics. 

• An explanation of the contents of the OSHA Bloodborne Pathogens Standard (Appendix A) and information on how a copy of the standard may be obtained if requested;
• A general explanation of the epidemiology and symptoms of bloodborne diseases;
• An explanation of the modes of disease transmission;
• A review of this Exposure Control Plan and the steps that the employee can take to obtain a copy of it;
• An explanation of the appropriate methods that can be used to recognize and evaluate tasks and activities with potential exposure;
• An explanation of the use and limitations of the different methods of control including, but not limited to, engineering controls, work practices and personal protective equipment;
• Information on the types, proper use, location, removal, handling and disposal of personal protective equipment and the basis for selection of the different types of equipment;
• Information on the appropriate actions and procedures to follow if an exposure occurs;
• Information on the Hepatitis B vaccine including efficacy, safety, and that the vaccine will be free of charge;
• An explanation of the signs and labels required by the standard;
• An opportunity for interactive questions and answers; and
• Additional training for employees in HIV and HBV research laboratories which is specific to the practices and operations of the laboratory.

5.2  Location of Training Records

A record of each employee's training will be kept at the EMS Station 1 - Kill Devil Hills, NC

6.0 Hepatitis B Vaccination

6.1 Training sessions will include information on hepatitis B vaccinations, addressing its safety, benefits, efficacy, methods of administration and availability.

The hepatitis B vaccination series will be made available to employees from  Health Department at no charge to the employee. The employee's supervisor should arrange to have the vaccination provided within 10 days of initial assignment to employees who have occupational exposure to blood or other potentially infectious materials unless:  

• the employee has previously received the series
• antibody testing reveals that the employee is immune
• medical reasons prevent taking the vaccination; or
• the employee chooses not to participate  

The employee's supervisor is responsible for making arrangements for new employees to receive Hepatitis B titers and/or vaccines. All employees who are potentially exposed to Bloodborne Pathogens are strongly encouraged to receive the hepatitis B vaccination series. However, if an employee chooses to decline hepatitis B vaccination, then the employee must sign a Declination Statement to this effect (A form is included in Appendix D).

Hepatitis B vaccines (and antibody testing) are currently being given to employees at the Dare County Health Department unless other arrangements have been made. If other arrangements have been made, the Departmental Safety Officer shall send copies of the medical records to the The Outer Banks Hospital for filing. The employee's supervisor is responsible for scheduling appointments. 

Employees who decline may request and obtain the vaccination at a later date at no cost. Documentation of refusal of the hepatitis B vaccination (see Appendix D) shall be sent to Employee Health Services where they will be filed along with the employee's other medical records.

Highlights of Hepatitis B Vaccination - Other Requirements

Participation in pre-screening is not a prerequisite for receiving hepatitis B vaccination

Hepatitis B vaccination is to be provided even for employee who initially declined but later accepts treatment

The employee must sign a Declination Statement when declining the hepatitis B vaccination

The vaccination is administered in accordance with the United States Public Health Service (USPHS) recommended protocol

Hepatitis B vaccination booster doses must be available to employees if recommended by the United States Public Health Service.

7.0 Post Exposure Evaluation and Follow-up: Procedures for Reporting, Documenting and Evaluating the Exposure

7.1 Decontamination

Should an exposure incident occur, decontamination should be performed if necessary at the nearest eyewash or safety shower. Soap and water should be used.

7.2 Protocol for Obtaining Medical Treatment, counseling, baseline blood testing and prophylaxis 

• The protocol for obtaining post-exposure counseling, treatment, baseline blood testing, and (if necessary and agreed) prophylaxis, is listed below. 
• The person who has been exposed will immediately notify their supervisor and medical personnel as follows: 
• Contact the Operations Supervisor immediately.  Employees will be seen initially  at  Outer Banks Hospital or at the closest affiliated Hospital and will receive follow-up care and counseling, as well as medications.  Initial evaluation will be according to the protocol of the affiliated hospital and CDC guidelines for Occupational Exposure of HCP. 
• Each exposure must also be documented on a DCEMS Exposure Report form AND appropriate WORKERS' COMPENSATION documents which should be available from any EMS Station. An appointment for medical care should be as soon as possible following exposure, and should be no longer than 24 hours after the exposure so that prophylaxis can be provided, if indicated.
• Post-exposure medical follow-up procedures are outlined in the DCEMS Policy.  A copy is included in Appendix E of this document. The DCEMS HIV and HBV Policy is included in Appendix F. 

7.3 Serological testing of exposed employees and students

The exposed student or employee's consent is required for collection and testing of blood for HBV and HIV serological status. If consent for baseline serological testing is denied, the exposed employee or student should be requested to provide consent to have blood drawn and stored, usually for a three month period. This leaves the option open for the person to provide consent for serological testing in the future. If, during this time, the exposed employee elects to have the baseline sample tested, testing shall be done as soon as feasible.

7.4 Source patient consent to have blood drawn and analyzed for HIV and HBV 

It is usually easier to obtain consent from the source patient for a blood sample to be drawn and analyzed for HIV or HBV if the request is made at the time of the incident before the patient leaves the medical facility. The clinical site supervisor where the incident may have occurred is responsible for contacting, obtaining consent and testing the source patient. If the clinic is not an Dare County facility, it is recommended that the site supervisor still contact, obtain consent and test the source patient otherwise the person supervising the employee or student supervisor must be contacted and alternative arrangements must be made. The site supervisor has the responsibility for ensuring that these provisions are implemented. Requesting consent from the source patient is mandatory unless it can be established that identification is not feasible or if it is already known that the source patient is positive for HIV and HBV.  As soon as infectivity information is determined, this information shall be provided to the treating physician and shall also be forwarded to Employee Health Services for employees or Family Practice Center, Department of Family Practice for students. 

7.5 Medical Follow-up

The facility which provides counseling, baseline testing, prophylaxis and/or treatment of exposed employees or students shall forward data and results to the Outer Banks Hospital,  within 24 hours of seeing the patient. The Medical facility will obtain information about the infectivity of the source patient's blood. The OB Hospital will provide additional treatment and counseling for employees or students, respectively, as necessary. Counseling regarding exposure to blood which has been confirmed to be infective shall be performed in person, whenever possible. 

7.6 Custodian of Records

Outer Banks Hospital will be the custodian of DCEMS employee and student records pertaining to bloodborne pathogen exposure and follow-up.

7.7 Accident/incident review

The Departmental Safety Officer will review the circumstances of the exposure incident to determine if procedures, protocols and/or training need to be repeated or revised to prevent a reoccurrence of the incident. The completed "Exposure Incident Report Form," (Appendix H) should be filled out by the employee's or student's supervisor and returned to Departmental Safety Officer to initiate this process. 

Notes: