Slide 1. Slide 2. Slide 3. Bloodborne Pathogens Exposure Control Plan Is Yours in Order?

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1 Slide 1 Bloodborne Pathogens Exposure Control Plan Is Yours in Order? Carol H. Eatman, RN, MSN, NCSN, LNC Student Health Coordinator Nash-Rocky Mount Public Schools Slide 2 Discuss the reasons that a bloodborne pathogens (BBP) exposure control plan is needed in schools. List the components of an OSHA-compliant BBP exposure control plan. Compare and contrast recommendations to your district s BBP exposure control plan. Slide 3 Unions representing healthcare employees petitioned OSHA for a standard to protect employees from occupational exposure to bloodborne diseases (September 1986). OSHA s reviews revealed significant risks related to occupational exposure to BBP and issued compliance instructions. (1/19/1998 CPL 2.244, 8/15/1988 CPL 2.244A, 2/27/1990 CPL 2.244B). OSHA published its final regulation on exposure to BBPs 29 CFR (12/6/1991). The standard and CPL C became effective (3/6/1992).

2 Slide 4 OSHA published a Request for Information (RFI) on engineering and work practice controls used to eliminate or minimize the risk of occupational exposure to bloodborne pathogens due to percutaneous injuries from contaminated sharps (9/9/1998). Summary from FRI: Safer medical devices along with training are the most effective means of reducing injury rates (3/1999). CPL D issued that incorporated information from the RFI, past interpretations, and several CDC guidelines on vaccination and post-exposure prophylaxis (11/5/1999). Slide 5 On November 6, 2000 the Needlestick Safety and Prevention Act was signed into law (Public Law ) directing OSHA to revise the BBP standard to: Include new examples in the definition of engineering controls; Require that exposure control plans reflect changes in technology that eliminate or reduce exposure to bloodborne pathogens; Require employers to document annually in the exposure control plans consideration and implementation of safer medical devices; Require employers to solicit input from non-managerial employees responsible for direct patient care in the identification, evaluation, and selection of engineering and work practice controls; Document this input in the exposure control plan; and, Establish and maintain a log of percutaneous injuries from contaminated sharps. Published revisions on January 18, 2001, with an effective date of April 18, Slide 6 A regulation that prescribes safeguards to protect workers against health hazards from occupational exposure to bloodborne pathogens. Occupational 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. Provisions in the standard address: An exposure control plan. Engineering and work practice controls. Hepatitis B vaccinations. Hazard communication and training. Recordkeeping.

3 Slide 7 Scope: Includes any employee who has occupational exposure to blood or other potentially infectious material. If an employee is trained in first aid and identified by the employer as responsible for rendering medical assistance as part of his/her job duties, that employee is covered by the standard. Part-time and temporary workers are also covered. Application: Includes any setting where employees are exposed to blood or other potentially infectious material. This is why schools must have a Bloodborne Pathogens Exposure Control Plan. Slide 8 It s the top of the list for OSHA citations. The top 5 OSHA citations: 1. Establishment of a written Exposure Control Plan. 2. Review* and update Exposure Control Plan. 3. Use of engineering and work practice controls. 4. Availability of HBV vaccination. 5. Employee training program. * Note: This review must reflect changes in technology and document annual consideration and implementation of safer medical devices. Slide 9 Responsibilities, definitions, and overview. Exposure determination. The procedure for the evaluation of circumstances surrounding exposure incidents. Methods of compliance and safe work practices. Universal precautions and hand-washing PPE Housekeeping Disposal of contaminated waste Contaminated Sharps Contaminated Laundry Hepatitis B Vaccination and Declination Form. Post-Exposure evaluation and follow-up. Communication of hazards to employees. Recordkeeping and surveillance. The 1 st thing OSHA will access, upon inspection.

4 Slide 10 Describe/state the following about the ECP: State that a copy is accessible to employees - state where is should be kept in each school, other ways to access (e.g., online, school nurse, etc.) The ECP shall be reviewed and updated at least annually and whenever necessary to reflect new or modified tasks and procedures which affect occupational exposure and to reflect new or revised employee positions with occupational exposure. The review and update of such plans shall also: Reflect changes in technology that eliminate or reduce exposure to bloodborne pathogens; and, Document annually consideration and implementation of appropriate commercially available and effective safer medical devices designed to eliminate or minimize occupational exposure. In your training, stress if OSHA inspects us, they will randomly select and ask employees: Does your school have an Exposure Control Plan? Where is it located / Can you easily access it? Questions to see if they are following guidelines in the ECP. Slide 11 Describe/state the following about the ECP State that the school system shall solicit input from non-managerial employees responsible for direct student healthcare who are potentially exposed to injuries from contaminated sharps in the identification, evaluation, and selection of effective engineering and work practice controls. State that this solicitation shall be documented in the Exposure Control Plan. Mention that the Exposure Control Plan shall be made available to the Assistant OSHA Secretary and the Director upon request for examination and copying. Note: The ECP may be part of a larger safety plan; however, the section addressing bloodborne pathogens must be pulled out. Slide 12 May be listed separately, e.g., before definitions. Each employee (as well as OSHA inspector) sees from the get-go who s responsible for what vs. wading through entire document. Very helpful for principals, school nurses, employees who have an occupational exposure, superintendent, and the district s BBP Coordinator, etc., to know their specific roles. May be described in each section. May format your plan, using both. Best choice: Reinforce one s understanding in deciphering medically-related jargon/material.

5 Slide 13 Use definitions as they are listed in the Bloodborne Pathogens Standard Add any definitions specific to your plan. OSHA inspectors use the definitions as a guide in their review of the Exposure Control Plan. Slide 14 Provide a general overview. Specify the employees for whom the exposure control plan applies. Describe where copies of the plan will be placed for easy accessibility by all employees. Mention the plan s review, update, and reflection of technology changes to eliminate/reduce exposure. Describe obtaining input for safest practices/ppe and request for safest needle devices. Describe processes for review of exposure reports, documentation, and follow-up. Slide 15 Describe process of evaluating the work environment to determine the actual and potential hazards for exposure to bloodborne pathogens (without regard to the use of PPE). E.g., exposure determination questionnaire completed by new hires, employees upon request, etc. Identify the job classifications in which all employees have occupational exposure and those in which some employees have occupational exposure. Identify the tasks/procedures causing risk. Describe protective barriers, engineering controls, and work practice controls to eliminate/minimize risk. Mention the HepB vaccine will be offered immediately and within 24 hrs. of the exposure incident to any unvaccinated employee in a collateral-risk job.

6 Slide 16 If employees are designated as responsible for rendering first aid as part of their job duties, they are covered by the protections of the standard. If employees render first aid as a collateral duty to their routine work assignments, OSHA considers it a de minimis violation ( a technical violation carrying no penalties) provided that a number of conditions are met. (In these circumstances, no citations will be issued.) Slide =interpretations&p_id= =INTERPRETATIONS&p_id=28835 Slide 18 The de minimis classification is limited to persons who render first aid only as a collateral duty, responding solely to injuries resulting from workplace incidents, generally at the location where the incident occurred. The de minimis classification for failure to offer hepatitis B vaccination in advance of exposure does not apply to personnel expected to render first aid in the course of their work. Nurses EMS Personnel Public Safety Workers

7 Slide 19 Reporting Procedures for First-Aid Incidents involving blood/opim must be in the Exposure Control Plan. Incident must be reported before the end of the work shift. The incident report must include: Names of all first-aid providers who rendered assistance; Description of the circumstances of the accident, including date and time; and, A determination of whether an exposure incident, as defined in the standard, has occurred. A report that lists all such first-aid incidents must be readily available to all employees and provided to OSHA upon request. Slide 20 Training The training for first-aid providers must cover specifics of the reporting procedures. Hepatitis B Vaccine All first-aid providers who render assistance in any situation involving the presence of blood or other potentially infectious materials, regardless of whether or not a specific exposure occurs, must have the vaccine made available to them as soon as possible - but in no event later than 24 hours - after the exposure incident. Post-exposure follow-up procedures Must be initiated immediately for any exposure incident. Slide 21 Universal Precautions Shall be observed to prevent contact with blood or other potentially infectious materials. All body fluids shall be considered potentially infectious materials. Engineering and Work Practice Controls Purpose: to eliminate/minimize employee exposure Readily accessible hand washing facilities. Management of contaminated sharps/equipment management. Removal of activities likely to produce self-contamination e.g., Keeping food and drink out of the work area. Procedures to handle blood/opim.

8 Slide 22 Personal Protective Equipment (PPE) Shall be used where exposure remains after institution of engineering and work practice controls. Employer shall provide appropriate PPE at no cost to employee. Describe: Provision and use Accessibility and ordering Cleaning, laundering, and disposal Repair and replacement Removal and disposal Types: gloves, eye protection, face shields/masks, gowns, aprons, other protective body clothing, and resuscitation devices Blood spill clean-up kits Slide 23 Housekeeping Worksite maintained in clean and sanitary condition. Cleaning and decontamination of items. Safe disposal of waste contaminated with blood/opim. Contaminated sharps discarding and containment: Approved sharp containers Easily accessible Upright Not allowed to overfill Container removal Close immediately prior to removal Place in secondary container if leakage is possible Reusable containers Not opened, emptied, or cleaned manually. Slide 24 Contaminated Laundry Shall be handled as little as possible. Bagged or containerized at the location where it was used. Containers labeled or color-coded. Leak proof bags or containers. Employees must wear protective gloves and other appropriate PPE, when handling.

9 Slide 25 Does an employer need to ensure the proper laundering of contaminated linen? Source Response: The Bloodborne Pathogens Standard covers the handling and transport of contaminated laundry for the protection of employees; however, OSHA regulations do not have specific requirements for actual laundering procedures for assuring patient-specific infection control. OSHA's authority is limited to the protection of workers. As you noted in your inquiry, there are existing infection control guidelines set by the CDC. In the 2003 Guidelines for Environmental Infection Control in Health-Care Facilities, the CDC provides guidance for the handling, cleaning, and disinfection of contaminated laundry. The document can be found at Slide 26 Is it permissible for employees to launder personal protective equipment like scrubs or other clothing worn next to the skin at home? Source Uniforms or scrubs which are usually worn in a manner similar to street clothes are generally not intended to be PPE and would not need to be handled in the same manner as contaminated laundry or contaminated PPE Is that same employer responsible for following the CDC guidelines for laundering contaminated laundry? The CDC guidelines are not mandatory. They are recommendations written with the intent of enhancing infection control measures in all healthcare facilities, including dental settings. Source Slide 27 Other regulated waste containment Closeable, constructed to contain all contents, labeled or color-coded, and closed prior to removal. If outside contamination of the container occurs, it shall be placed in a second container. Disposal of all regulated waste shall be in accordance with applicable regulations.

10 Slide 28 Made available after the employee has received the training required and within 10 working days of initial assignment to all employees who have occupational exposure unless the employee has previously received the complete hepatitis B vaccination series, antibody testing has revealed that the employee is immune, or the vaccine is contraindicated for medical reasons. Made available to employees who may have potential exposure as collateral duty (post-exposure). Provided at no cost to employees and during work time. Contract agency responsible for contract employees. Hepatitis B Vaccination Declination Form. Slide 29 Once employee has completed the 3-dose hepatitis B vaccination series, is there a requirement to obtain a test for hepatitis B antibodies? Yes According to OSHA s BBP standard, the hepatitis vaccination series is to be provided according to the most current recommendations of the U.S. Public Health Service at the time the vaccinations take place. At the time of this writing, the most current guidance is provided in the CDC s, CDC Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus Protection and for Administering Post-exposure Management, MMWR 2013:62 (No. RR-8), which states: Post-vaccination serologic testing for anti-hbs is recommended 1-2 months after the last vaccine dose for HCP [health-care personnel] at risk for occupational percutaneous or mucosal exposures. [29 CFR (f)(1)(ii)(D)] After an exposure incident, is the employer required to pay for the testing of the source patient? Yes Slide 30 When did the U.S. Public Health Service (USPHS) first recommend hepatitis B antibody (titer) testing after the hepatitis B vaccination series has been completed? Several of my employees were vaccinated shortly after the OSHA BBP standard went into effect in 1991, when there was no requirement for titer testing. The Centers for Disease Control and Prevention (CDC) is the United States Public Health Service agency responsible for issuing guidelines and making recommendations regarding infectious diseases. OSHA's BBP standard requires compliance with the CDC guidelines for hepatitis B vaccination, among other things, current at the time of the evaluation or procedure. [29 CFR (f)(1)(ii)(D)]The CDC made a recommendation as early as December 1997 that healthcare workers who have contact with patients or blood and are at ongoing risk for percutaneous injuries be tested for antibody to hepatitis B surface antigen (anti-hbs) 1-2 months after completion of the 3-dose vaccination series. See Immunization of Health-Care Workers: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC). [MMWR December 26, 1997 / Vol. 46 / No. RR-18]

11 Slide 31 If my employees received the HBV vaccine before the USPHS recommendations for titer testing went into effect, what do I do now? Do I offer titer testing or should I offer them revaccination? What if the employees were vaccinated after the titer testing recommendations became effective? Response: In a situation as you describe, where employees received the HBV vaccine several years prior to the CDC recommendations, there was no specific recommendation for additional vaccination or serologic testing to monitor antibody concentrations of those employees at that time. Therefore, the standard does not require titer testing after hepatitis B vaccinations given before December 26, [29 CFR (f)(1)(ii)(D)]. Slide 32 Response continued With regard to employees vaccinated after the 1997 guidance was issued, the recommendation for titer testing current at the time of this letter is in CDC Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus Protection and for Administering Post-exposure Management, MMWR (December 20, 2013 / Vol. 62 / No 10.). This document states on p. 12: "All HCP [health-care personnel] recently vaccinated or recently completing HBV vaccination who are at risk for occupational blood or body fluid exposure should undergo anti-hbs [titer] testing. Anti-HBs testing should be performed 1-2 months after administration of the latest dose of the vaccine series when possible." The recommendation about testing 1-2 months after the completion of the vaccination series is not a hard and fast deadline. For further guidance on whether titer testing should be conducted when more than 2 months has passed since the vaccination you should contact the CDC. Slide 33 Response continued Regardless of when your employees received the HBV vaccination, following an exposure incident you are still required by OSHA's BBP standard to "...make immediately available to the exposed employee a confidential medical evaluation and follow-up..."[29 CFR (f)(3)] The BBP standard has provisions on HBV and HIV testing after an exposure incident. Paragraph (f)(3)(ii) requires, among other provisions, the following HBV testing after an exposure incident: (ii) Identification and documentation of the source individual, unless the employer can establish that identification is infeasible or prohibited by state or local law; (A) The source individual's blood shall be tested as soon as feasible and after consent is obtained in order to determine HBV and HIV infectivity. If consent is not obtained, the employer shall establish that legally required consent cannot be obtained. When the source individual's consent is not required by law, the source individual's blood, if available, shall be tested and the results documented.

12 Slide 34 Response continued (B) When the source individual is already known to be infected with HBV or HIV, testing for the source individual's known HBV or HIV status need not be repeated. (C) Results of the source individual's testing shall be made available to the exposed employee, and the employee shall be informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual. (iii) Collection and testing of blood for HBV and HIV serological status; (A) The exposed employee's blood shall be collected as soon as feasible and tested after consent is obtained. Slide 35 Response continued After an exposure incident, the BBP standard also requires documentation of the route(s) of exposure and the circumstances under which the exposure incident occurred, counseling of the exposed employee, and evaluation of any reported illness, as well as prophylaxis, when medically indicated, in accordance with current CDC guidelines. [29 CFR (f)(3)(i) and (iv)-(vi)]. The 2013 CDC guidance referenced above provides guidance to manage postexposure prophylaxis for percutaneous exposure of your workers, even those with unknown HBV immunity. The CDC's post-exposure guidance is based on the HBV immunity status of the exposed employee (unvaccinated, incompletely vaccinated, or unknown). Please refer to that document for more information about type(s) and frequency of follow-up testing that should be done after the initial baseline testing of employees for HBV infection that is required by the OSHA standard. Treatment of the exposed employee must also follow the guidance provided by the 2013 CDC guidance document. Slide 36 State that immediately following an exposure incident, a confidential medical evaluation and follow-up will be made available. Description of procedure to include: Documentation of the route(s) of exposure. Identification of circumstances under which the exposure incident occurred. Identification and documentation of the source individual. Collection and testing of blood for HBV and HIV. Post-exposure prophylaxis and care. Counseling. Evaluation of reported illnesses. Employee receiving a copy of the medical report.

13 Slide 37 Training Records Shall be maintained for 3 years from the date of training. Medical Records Shall be maintained for duration of employment + 30 years. Surveillance Describe how schools will be monitored for compliance to the BBP Procedures/Exposure Control Plan. Sharps Injury Log For each incident, list type and brand of device involved, department/work area, and how the incident happened. State this log has been established and will be maintained. Slide 38 Over 70% unannounced. Each willful violation may be imposed for: Average fine $2, Penalties up to $70,000. A record of the violation will be listed in the OSHA database: Increases the likelihood of a re-inspection. A compliance officer will arrive, usually unannounced. If visit is to investigate a catastrophe or fatality, visit will be scheduled. Against law to announce a programmed inspection. No fines or penalties collected at time of inspection. Anyone who tries to collect money at an inspection is not an OSHA representative. Slide 39 The Compliance Officer may inspect the workplace for all OSHA standards, not just the Bloodborne Pathogens Standard. The Compliance Officer indicates any and all unsafe working conditions to the employer as they are observed during an inspection tour. After the inspection tour, there is a closing conference. All unsafe or unhealthful conditions are discussed, as well as all violations for which a citation may be issued or recommended. The Compliance Officer does not indicate any proposed penalties at the closing conference. Instead, the OSHA area director will issue penalties after reviewing a full report. The closing conference can also include employees or their representatives. Source

14 Slide 40 Issued and decided by the OSHA Area Director. Citations: Inform the employer and employees of the regulations and standards alleged to have been violated and of the proposed length of time they have to correct the problem(s). Sent by certified mail. Copy of each citation must be posted at or near the place the violation occurred. Must be posted for 3 days or until the violation is fixed, whichever is longer. Source Slide 41 Other than Serious Directly related to job safety and health, but one that would probably not cause death or serious physical harm. A penalty of up to $7,000 may be issued for each violation. Serious Violation Substantial probability that death or serious physical harm could result and one that the employer knew, or should have known, about. A mandatory penalty of $7,000 for each violation. Willful Violation Committed intentionally and knowingly by employer. Penalties up to $70,000 may be imposed for each, with a minimum penalty of $5,000 for each violation. If a willful violation results in the death of an employee, employers can also be punished by a court-imposed fine or by imprisonment for up to 6 months, or both. Source Slide 42 Repeat Violation A violation of a standard where, upon re- inspection, a similar violation is found. Repeat violations can bring a fine of up to $70,000 for each violation. Failure to Correct Prior Violation A civil penalty of up to $70,000 may be imposed for each day the violation continues beyond the prescribed date for its correction. At $70,000 per violation, it doesn't take long for recalcitrant organizations to reach several hundred thousand dollars worth of penalties and fines. Moreover, OSHA violations, fines and penalties are not confidential. They are often reported in the media. A news report that a major organization had a $250,000 OSHA violation for failing to follow safety regulations could, for instance, be a public relations disaster. Source

15 Slide 43 Slide 44 North Carolina Department of Labor ogram.pdf OSHA Nash-Rocky Mount Public Schools Slide 45 ctsheet-inspections.pdf OSHA s Bloodborne Pathogens Standard Appendix A OSHA s Compliance Directive for Bloodborne Pathogens OSHA s Enforcement Example: Online Training with Quiz NC Department of Labor OSHA Inspections

16 Slide 46 PowerPoint Presentation Click here for pdf version. Click here to download ppt version. Documents will be ed to you, upon request.