UCAR Safety Manual
 Bloodborne Pathogens
REFERENCE: 7-1
ISSUED: 2-7-93
EFFECTIVE: 2-7-93
SUPERSEDES: Generic
Bloodborne Pathogens and Exposure
Control Plan
0.0 Scope
Provides safe practices, policies, and procedures for protection against bloodborne pathogens and meets regulatory requirements of OSHA 29 CFR 1910.1030. The plan is to be implemented and adhered to by all personnel who by virtue of their job may reasonably anticipate occupational exposure to skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials during the course of their employment at UCAR.
1.0 Definitions
1.1 Blood
Human blood, components or products made from human blood.
1.2 Bloodborne Pathogens
Microorganisms present in blood that can cause disease including but not limited to hepatitis B (HBV) and human immunodeficiency virus (HIV).
1.3 Contaminated
Presence or reasonably anticipated presence of blood or other infectious materials. All body fluids and blood are assumed to be contaminated.
1.4 Medical Emergency Response Team Member
Official member of the UCAR "first aid" team. All members are volunteers.
1.5 Team Leader
Individual selected by Health and Environmental Manager to provide technical leadership to the medical emergency response team and to communicate with and help the Health and Environmental Services manager implement the medical emergency response program. Leader is selected for each site.
2.0 Responsibilities
2.1 Management
Assures that Medical Emergency Response Team Members are qualified, properly trained, and skilled in safe conduct, potential hazards, and emergency procedures for protection against bloodborne pathogens.
2.2 Health and Environmental Manger
Determines, designs, communicates, and administers safety programs. Monitors and audits compliance to policies, procedures, and regulations, and reports non-compliant conditions to appropriate management for correction. Writes, publishes, and up-dates generic safety policies and procedures. Provides generic safety training. Takes appropriate actions to abate unsafe conditions, practices or activities. Maintains and keeps all applicable records.
2.3 Medical Response Team Members
Conducts operations in safe manner compliant with organizational and regulatory policies, procedures, and requirements. Attends and participates in required training. Recognizes and understands potential hazards of operations. Reports out of tolerance conditions to team leader or Health and Environmental Manager.
2.4 Medical Response Team Leader
Provides technical direction to team and interfaces with and helps implement administrative aspects of program with Health and Environmental Services Manager.
3.0 Exposure Determination
The Health and Environmental Services manager shall perform and keep up-dated an exposure determination to identify which employees may incur occupational exposure to blood or other potentially infectious material.
3.1 Job Classification
Employees reasonably expected to have occupational exposure are limited to those members of the Medical Emergency Response Team. There are no other routine job activities or work requirements which would result in potential exposures to infectious materials.
3.2 Associated Tasks/Procedures
Team members may incur exposure while administering emergency medical treatment and during subsequent clean-up of medical emergencies.
4.0 Training
Team members receive training and information pertaining to bloodborne pathogens. Training is provided by the Health and Environmental Manger at the time of assignment to the team or effective date of OSHA regulation and annually thereafter. Training includes an explanation and copy of the OSHA standard, discussion of the mode of transmission, symptoms, warning signals relating to possible exposure, recognition of tasks which may involve exposure, procedures to prevent exposure, explanation of use and limitations of methods to prevent/reduce exposures, types, use, location, removal, handling, decontamination and disposal of personal protective equipment, information on hepatitis B vaccination and procedures to follow if exposure occurs. Training shall also include a copy and explanation of UCAR's exposure control plan.
4.1 Implementation Schedule and Compliance
Universal controls will be used at all facilities. All body fluids shall be considered as potentially infectious material. Compliance is immediate with operation of facility and/or establishment and participation on medical emergency response team. Engineering or work practice controls shall minimize employee exposure to bloodborne pathogens. Where occupational exposure remains after institution of these controls, personal protective equipment will be used.
5.0 Engineering Controls
Controls are limited by the nature of potential routes of exposure, medical emergency response, and are confined primarily to handwashing facilities. Said facilities are provided throughout all buildings as an integral part of the building structure and consist of mens and womens restrooms with sinks, hot and cold water, soap, and towels. Showers are available at the fitness centers in each location. Antiseptic soap will be provided in first aid rooms. Proper containers are provided for storage, transportation, and disposal of contaminated materials. The team does not engage in activities utilizing sharps and therefore engineering controls are not necessary for these objects.
6.0 Equipment
Equipment to protect against exposure to bloodborne pathogens is provided by the Health and Environmental manager. Monthly inspections shall be conducted to ensure adequate supply and proper condition of said equipment. All equipment and materials are furnished free of charge to team members. All equipment and materials are located in medical emergency response kits, first aid rooms and, where appropriate, in public first aid kits. Replacements are obtained through the Health and Environmental manager.
6.1 Gloves
Individual gloves are provided to each team member to be kept in their offices, are located in bulk in first aid rooms, in medical emergency response kits and in public first aid kits.
6.2 CPR masks
Individual masks are provided to each team member. Masks are also located in medical emergency response kits.
6.3 Eye protection
Goggles and face shields are located in medical emergency response kits, in first aid rooms and provided to individual members. OSHA approved safety glasses are also available to team members.
6.4 Clothing
Gowns, aprons, coats are provided in first aid rooms and in medical emergency medical response kits.
6.5 Decontamination kits
Equipment consisting of red waste bags, disinfectants, absorbents are located in each first aid room.
6.6 Soaps
Antiseptic soaps are located in each first aid room.
7.0 Procedures
All fluids shall be assumed to be contaminated and universal precautions utilized during medical emergency responses.
7.1 Protective equipment
Team members will don appropriate protective equipment for the situation and may consist of gloves, eye protection and clothing. Equipment shall also be worn during all subsequent decontamination and clean-up procedures and/or while handling or touching contaminated items or surfaces. Disposable gloves shall not be re-washed or re-used after contamination. Disposable gloves shall be replaced as soon as their protective ability is comprised, such as being torn or punctured. Utility gloves shall be used for handling contaminated waste and for cleanup procedures. Utility gloves shall be washed and decontaminated before re-use. Utility gloves shall be immediately discarded if observed to be cracking, peeling or are otherwise compromised. Hypoallergenic gloves will be provided free of cost to allergic team members.
7.2 CPR Masks
Team members will utilize CPR masks if CPR is required.
7.3 Site Decontamination
Following administration of emergency medical services team members shall decontaminate all surfaces and materials coming into contact with body fluids. Team members will don appropriate equipment including utility gloves, goggles, and protective clothing. Team members shall wipe down contaminated surfaces using decontamination kits and cleansing solutions provided. Wipe down continues until all visible fluids are removed. Then spray area with provided disinfectant. All waste materials are to be placed in red bags provided in decontamination kit.
7.4 Personnel Decontamination
Following administration of emergency medical services team members will immediately remove gloves. Place gloves and all other contaminated material in red bags. Immediately wash hands using hot water and antiseptic soaps. If site decontamination is required then don utility gloves and initiate clean-up. Following site decontamination remove gloves, using aseptic techniques, placing gloves and materials in red bags. Immediately wash hands with hot water and antiseptic soap.
7.5 Contaminated Clothing
Remove and place any/all contaminated clothing in separate red bag provided in decontamination kit.
7.6 Waste Disposal
All contaminated materials are to be placed in red bags and or rigid red containers and given to the Health and Environmental manager. Health and Environmental manager will dispose of material according to city, county, state and federal regulations and shall assure that all bags are properly labeled, handled, stored and transported to an approved disposal site.
7.7 General rules
Eating, drinking, smoking, applying cosmetics or lip balm, or handling contact lenses is prohibited during emergency procedures and decontamination.
8.0 Hepatitis B Vaccine
All employees are eligible to obtain vaccination, free of cost. Vaccinations are provided by an UCAR designated licensed physician. Employees declining the vaccination are asked to sign a declination form which is kept on file in the office of the Health and Environmental manager. Declining employees may change their minds and at anytime request and receive a vaccination. All vaccination procedures are administered by the Health and Environmental manager.
9.0 Exposure Procedures
All incidents in which an employee believes they may have been
exposed to contaminated fluids will result in a comprehensive
review of the incident and a medical follow-up will be
provided to the employee.
9.1 Reporting
Any exposure incident must be immediately reported to Health and Environmental Manager.
9.2 Post exposure evaluation and follow-up
The Health and Environmental manger shall assure proper follow-up and shall document the route of exposure and circumstances related to the incident. If possible, the source individual and the status of the source individual shall be determined. If consent is obtained, the blood of the source individual will be collected as soon as feasible and will be tested for HIV/HBV infection. If permission from the source individual is obtained the results will be made available to the exposed employee who will also be informed about the applicable laws and regulations concerning disclosure of the identity and infectivity of the source. If the exposed employee consents, blood will be drawn and tested. The employee will be offered post-exposure prophylaxis in accordance with the current recommendations of the U.S. Public Health Service. Appropriate counseling shall be provided by a licensed physician to the exposed employee at no cost to the employee.
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