The Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Exposure Control Standard (29 CFR 1910.1030) requires that employers who have employees who are occupationally exposed to human blood or other potentially infectious materials develop a program to eliminate or minimize such exposures. This Bloodborne Pathogen Exposure Control Plan describes that program at Hampshire College. This plan is reviewed annually or more frequently as needed. The environmental health and safety office coordinates the review.
The program includes all employees who have occupational exposure to bloodborne pathogens. OSHA defines occupational exposure as "reasonably anticipated skin, eye, mucous membrane, or parenteral (under the skin) contact with blood or other potentially infectious materials that may result from the performance of an employee's duties". The OSHA Standard does not cover "good Samaritan" assistance provided in an emergency; however, should an employee be exposed while providing such assistance in the workplace, the College offers post-exposure evaluation and follow-up as described in Section VI.
This plan is maintained as an online document on the College intranet system. Paper copies are available upon request from the environmental health and safety office.
Employees in the following job classifications have occupational exposure to bloodborne pathogens. The environmental health and safety office maintains a list of employees with occupational exposure.
List of all job classifications in which all employees have occupational exposure:
List of job classifications in which some of the employees have occupational exposure:
List of task and procedures performed in which occupational exposure occurs and that are performed by the employee classifications listed above in 1 and 2:
Hampshire College Health Services health care providers are employees of the University of Massachusetts and are covered under that control plan.
Universal precautions must be observed to prevent contact with blood and other potentially infectious materials. Under the concept of universal precautions, all blood and certain human body fluids are always handled as if they are infectious. Blood is the single most important source of bloodborne pathogens in occupational settings. As defined by OSHA, other "potentially infectious materials" include tissue, semen, vaginal secretions, and the following fluids(surrounding the): cerebral (brain), spinal (spine), synovial (joints), pleural (lungs), peritoneal (abdomen), pericardial (heart), and amniotic (fetus). Feces, nasal secretions, sputum, saliva, sweat, tears, urine, and vomit are not included unless they are visibly contaminated with blood.
Under circumstances in which it is difficult to distinguish between infectious and noninfectious body fluids, all body fluids shall be considered "potentially infectious materials." If any of the exposure control methods are not feasible for a certain operation, permission to use alternate methods must be obtained from the department head.
Departments are responsible for providing all materials and equipment necessary to comply with the requirements of this plan.
A. Engineering and Work Practice Controls
The following engineering and work practice controls must be used in all applicable operations with potential exposure.
Material Handling Procedures
B. Personal Protective Equipment
Hampshire College provides appropriate personal protective equipment (PPE) to all employees. The employee must use the equipment provided. Departments are responsible for providing the necessary PPE. If under unusual circumstances, it is the employee's professional judgment that use of the equipment would prevent the delivery of health care or campus police services or pose an increased risk to the worker or co-worker, the employee should petition the director of environmental health and safety.
If the employee's judgment is made in an emergency situation, the circumstances will be investigated by the director of environmental health and safety, and documented to determine whether changes can be instituted to prevent future occurrences.
Campus police has gloves, masks, eye protection, a gown, and resuscitation devices in each vehicle and in the main office. Officers also carry gloves on their person. OPRA keeps with first aid supplies. The children’s center keeps gloves with first aid supplies and in each classroom. Facilities and grounds personnel keep gloves with their cleaning or material handling supplies. Cole Science Center has supplies gloves and eye protection to every lab.
The work site must be maintained in a clean and sanitary condition. A bleach solution (1/4 cup per 1 gallon), or hospital disinfectant, is used for cleaning all surfaces visibly contaminated with blood. A general-purpose disinfectant is used for other surfaces. Gloves are worn during all cleaning procedures.
D. Waste Disposal
Biomedical waste is stored in the waste storage building behind Cole Science Center. Waste can be brought to the storage area by: campus police, the Cole Science Center laboratory manager, custodial supervisors, or the environmental health and safety staff. Waste transport by a vendor to a licensed incinerator is coordinated by the environmental health and safety office.
E. Contaminated Laundry
In addition to the specific engineering and work practice controls described above for handling needles, OSHA requires evaluation and implementation of commercially available and effective safer medical devices. Since, Health Services health care providers are University of Massachusetts employees, there is no or minimal use of needles or other medical devices by Hampshire College employees. Should a situation arise where needles or other medical devices will be used with potentially infectious materials, alternatives will be reviewed on a case-by-case basis.
Hepatitis B vaccination is available to all employees who have occupational exposure at no cost to the employee. The vaccine is offered to employees with occupational exposure after initial training and within 10 days of assignment to a position with occupational exposure. Vaccination records are maintained at health services as part of the employee’s medical record.
Vaccines are administered by health services, or, when health services is closed, other arrangements are made with a local care provider. Appointments with health services can be made directly by the employee. When health services is closed, the employee should contact environmental health and safety.
Occupationally exposed employees are given a fact sheet (Appendix B) describing the vaccination series and are asked to elect to have the series or sign the mandatory declination (Appendix C). Declination statements are returned to the environmental health and safety office. The environmental health and safety office records that a declination statement has been received and forwards the signed statement to health services to be maintained as part of the employee’s medical record. Should an employee who continues to work in a position with occupational exposure and who has signed a declination wish to have the vaccination at a later time, it will be provided upon request from health services or environmental health and safety.
Upon skin contact, the area should be washed immediately with soap and water. If soap and water is not available, an antiseptic towelette should be used, and soap and water used as soon as possible.
Upon eye or other mucous membrane contact, the area should be flushed immediately with water or saline solution, whichever is available.
Employees must immediately report all exposure incidents to their immediate supervisor, who will notify the department head. An exposure incident is "a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral (under the skin) contact with blood or other potentially infectious material that results from the performance of an employee's duties."
The department head is responsible for initial investigation of the incident, and notification of human resources and the environmental health and safety office within 24 hours. The department head may designate these duties to a supervisor who has attended the bloodborne pathogen training.
An exposure incident report (see Appendix E) should be attached to the employee accident report form submitted to human resources. A copy should be sent to the environmental health and safety office. The investigation must document:
Following a report of an exposure incident to the department head, the employee will be offered a confidential evaluation and follow-up. The employee and the source individual, if identified, will be immediately referred to the Cooley Dickinson Hospital by the department head, environmental health and safety, or human resources. If the exposed employee or source individual is a student, they will be referred to health services. The employee will be advised that post-exposure evaluation is recommended within 24 hours of exposure.
The college has confirmed that Cooley Dickinson Hospital has a copy of the OSHA Standard that describes the requirements for exposure evaluation and follow-up, and will provide, at the time of the incident, the results of the investigation of exposure. Cooley Dickinson Hospital will follow the procedures established by OSHA and the Center for Disease Control for post-exposure medical evaluation and provide human resources a written opinion within 15 days of completion of the evaluation as prescribed by the OSHA Standard.
Medical records required by the OSHA Standard are kept at health services. Those records include for all employees with occupational exposure:
All medical records are kept confidential and are not be disclosed without the employee's express written consent to any person within or outside the workplace except as required by the OSHA Standard or as may be required by law.
Human resources maintains the sharps injury log required by OSHA in 29 CFR 1910 as part of the OSHA 300 log.
A. Signs and Labels
B. Information and Training
All employees with occupational exposure are trained during working hours at no cost to the employee. All new or transferred employees with occupational exposure are trained at the time of initial assignment to tasks where occupational exposure may take place. Appendix D includes an attendance form.
Training is updated at least annually and whenever a modification of tasks or procedures affects occupational exposure. There is opportunity for the employee to ask questions during the training session.
On-line training customized to include Hampshire College policies may be used. When online training is used, the environmental health and safety office will follow up with the employees to answer any questions they may have.
Employee training is coordinated by the environmental health and safety office or campus police (campus police employees and EMTs). All supervisors with occupationally exposed staff must also attend training. Departments are responsible for scheduling new employee training with the environmental health and safety office. The environmental health and safety office maintains training records for at least three years.
A. Procedure for Cleaning Bodily Fluids Contamination
B. Hepatitis B Vaccine [Recombinant] Employee Information Sheet
C. Declination of Hepatitis B Vaccination
D. Training Record
E. Incident Report Form