MENDOCINO COAST DISTRICT HOSPITAL INFECTION CONTROL POLICY AND PROCEDURE STATEMENT

NUMBER: 170.1021 PAGE: 1 OF 14

TITLE: EXPOSURE CONTROL PLAN

PURPOSE: This exposure control plan has been established in order to minimize, and to prevent, when possible, the exposure of our employees to disease causing microorganisms transmitted through human blood, and as a means of complying with the Blood borne Pathogen Standard, enacted by the Occupational Safety and Health Administration (OSHA), codified as Title 8, California Code of Regulations Section 5193 with revisions as per Assembly Bill 1208 (1998). All employees who are exposed to blood and other potentially infectious materials as a part of their job duties are included in this program. (See V. Exposure Determination for a discussion of job categories and tasks that have been identified as having exposure.)

REVIEW OF THE PLAN: This plan will be reviewed and updated at least annually and whenever necessary to reflect new or modified tasks and procedureswhich affect occupational exposure and to reflect new or revised employee positions with occupational exposure.

Review will be by the Integrated Quality Management Committee, and the Employee Health and Infection Control Coordinators, and other members of the hospital staff, as required.

EMPLOYEE ACCESS TO THE PLAN: Copies of this plan are available on the Hospital intranet in the Infection Control manual, in the office of the Employee Health and Infection Control Coordinators. An employee may obtain a copy of this plan within three days of his/her request to their Department Manager.

COMPONENTS OF THE PLAN: Basic components of this exposure control plan include: Exposure Determination Methods of Compliance Hepatitis B Vaccination Policy Procedures for Evaluation and Follow up of Exposure Incidents Employee Training Record Keeping Procedures

EXPOSURE DETERMINATION: All job categories in which it is reasonable to anticipate that an employee will have skin, eye, mucous membrane, or parental contact with blood or other

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NUMBER: 170.1021 PAGE: 2 OF 14 potentially infectious materials (OPIM) will be included in the exposure control plan.

Exposure determination is made without regard to the use of personal protective equipment (i.e. employees are considered to be exposed even if they wear personal protective equipment).

Other Potentially Infectious Materials (OPIM): Body fluids semen vaginal secretions cerebrospinal fluid pleural fluid pericardial fluid peritoneal fluid amniotic fluid any body fluid visibly contaminated with blood saliva in dental procedures

Other Materials any unfixed tissue or organ (except intact skin) from a human (living or dead)

LIST A: All employees in job categories listed here are included in the plan. Admitting Clerk Biomed Technician Cardiovascular Technician Certified Nurses Aide EEG Technician EKG Technician Emergency Medical Technician I Emergency Department Clerk Food Service Worker Home Health Aide Home Health Supervisor Housekeeper/Janitor Laboratory Assistant Laboratory Technologist Licensed Vocational Nurse Maintenance Technician I Maintenance Technician II Materials Management Employees Neurodiagnostic Technician Nuclear Medicine Technologist

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NUMBER: 170.1021 PAGE: 3 OF 14

Operating Room Technician Paramedic Pharmacist Pharmacy Technician Phlebotomist Radiology Technologist Registered Nurse Respiratory Therapist Sterile Processing Assistant Ultrasound Technologist Unit Ward Clerk

LIST B: Job classifications in which some employees may have occupational exposure are included on this list. Since not all employees in these categories are expected to incur exposure to blood or other potentially infectious materials, the tasks or procedures that would cause potential exposure are also listed. (See Addendums B,D,E,F,G,H)

METHODS OF COMPLIANCE: A. GENERAL: STANDARD PRECAUTIONS All body fluids shall be considered potentially infectious materials.

B. ENGINEERING CONTROLS:

GENERAL: Such controls shall be used to eliminate or minimize employee exposure.

The following engineering controls will be utilized: Automatic pipettes Biohazard labels Biosafety cabinets Centrifuge safety caps Safety syringes Secondary transport containers Self-sheathing needles Sharps containers Splash shields

The above controls will be maintained or replaced on a regular schedule to ensure their effectiveness.

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C. WORK PRACTICE CONTROLS: GENERAL: In addition to engineering controls, work practice controls will be used to help eliminate or minimize exposure to blood borne pathogens. All procedures involving blood or OPIM shall be performed in such a manner as to minimize splashing, spraying, spattering and generation of droplets of these substances.

The following work practice controls will be observed: • Employees will sanitize or wash their hands immediately or as soon as feasible after removal of gloves and/or personal protective equipment. • Following any contact of body areas with blood or OPIM employees will wash their hands and any other exposed skin with soap and water as soon as possible. They will also flush mucous membranes with copious amounts of water. Hand washing facilities are readily available in all patient care areas except for the ambulance and in some Home Health situations where water is not available. Ambulance personnel and Home Health personnel shall use alcohol based hand sanitizer and as soon as feasible wash their hands using soap and water. Home Health personnel shall also teach patient/caregiver hand washing techniques as appropriate. • Disposable sharps shall not be reused. Sharps containers shall be disposed of when 2/3 full. • Broken glassware which may be contaminated shall not be picked up directly with the hands. It shall be cleaned up using mechanical means, such as brush and dustpan, tongs or forceps. • The contents of sharps containers shall not be accessed unless properly reprocessed or decontaminated. • Sharps containers shall not be opened, emptied, or cleaned manually in a way which would expose employees to risk of sharps injury. • Contaminated needles and other contaminated sharps shall not be bent, recapped or removed from devices, unless the procedure performed is using a mechanical device or a one handed technique, and it can be demonstrated that no other alternative is feasible or that such action is required by a specific medical or dental procedure. • Eating, drinking, applying cosmetics or lip balm and handling contact lenses is prohibited in areas where there is the likelihood of occupational exposure. • Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or on counter tops or benches where blood or OPIM are present. • Mouth pipetting/suctioning of blood or OPIM is prohibited.

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• All procedures involving the use of sharps in connection with patient care such as withdrawing body fluids, accessing a vein or artery, administering vaccines, medications or fluids shall be performed using effective patient handling techniques to minimize the risk of a sharp injury.

D. ENGINEERING AND WORK PRACTICE CONTROLS- SPECIFIC REQUIREMENTS: • Needleless systems, needle safety devices and non needle sharps will be used as follows: 1. Withdrawal of body fluids after initial venous or arterial access is established. 2. Administration of medications or fluids. 3. Any other procedure involving the potential for an exposure incident for which a needless system is available as an alternative for the use of needle devices. • Needle devices--if needleless systems are not used, needles with engineered sharps protection shall be used for: 1. Withdrawal of body fluids. 2. Accessing a vein or artery. 3. Administration of medications or fluids. 4. Any other procedure involving the potential for an exposure incident for which a needle device with engineered sharps protection is available. • Non-needle sharps: if sharps other than needle devices are used, these items shall include engineered sharps protection. • Exceptions: The following exceptions apply to the required engineering controls: 1. Market availability. The engineering control is not required if it is not available in the marketplace. 2. Patient safety. The engineering control is not required if a licensed healthcare professional directly involved in a patient’s care determines, in the reasonable exercise of clinical judgment, that use of the engineering control will jeopardize the patient’s safety or the success of a medical, dental or nursing procedure involving the patient. 3. Safety performance. The engineering control is not required if the Organization can demonstrate by means of objective product evaluation criteria that the control is not more effective in preventing exposure than the alternative used by the employer. 4. Availability of Safety Performance Information. The engineering control is not required if the Organization can demonstrate that reasonably safe and reliable information is not available on the safety performance of the engineering control for the Organizations

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procedures, and that the Organization is actively determining by means of objective products evaluation criteria whether the use of the engineering control will reduce the risk of exposure incidents occurring in the workplace.

• Employee Input on Product Selection: 1. Employees who are responsible for direct patient care are required to provide input regarding the identification, evaluation and selection of effective engineering controls, including safer medical devices. 2. A “Sharps Product Evaluation” form or similar form will be provided to end- users as a tool to obtain their input. See Attachment A.

• Requirements for handling contaminated sharps: 1. All procedures involving the use of sharps in connection with patient care, such as withdrawing body fluids, accessing a vein or artery, or administering vaccines, medications or fluids, shall be performed using effective patient handling techniques and other methods designed to minimize the risk of a sharps injury. 2. Immediately or as soon as possible after use, contaminated sharps shall be placed in sharps containers. 3. At all time during the use of sharps, containers for contaminated sharps shall be: -Easily accessible to personnel and located as close as feasible to the immediate area where sharps are used or can be reasonably anticipated to be found. -Maintained upright throughout use, where feasible -Replaced as necessary to avoid overfilling. 4. Sharps containers for contaminated sharps shall be rigid, puncture resistant, leak proof on the sides and bottom, portable (if portability is necessary to ensure easy access by the user) and labeled. If discarded sharps are not to be reused, the sharps container shall also be closable and sealable so that when sealed, the container is leak resistant and incapable of being reopened without great difficulty.

E. REGULATED WASTE: 1. Disposal of sharps containers: When any container of contaminated sharps is moved from the area of use for the purpose of disposal, the container shall be closed immediately prior to removal or replacement to prevent spillage or protrusion of contents during handling, storage, transport or shipping and placed in a secondary container if leakage is possible. The second container shall be closable, constructed to contain all contents and prevent leakage

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NUMBER: 170.1021 PAGE: 7 OF 14

during handling, storage, transportation or shipping and be labeled appropriately. 2. Regulated waste not consisting of sharps shall be disposed of in containers which are closable, constructed to contain all contents, labeled and color coded and closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping. 3. If outside contamination of a container of regulated waste occurs, it shall be placed in a second container. The second container shall be closable, constructed to contain all contents and prevent leakage of fluids during handling, storage, transport, or shipping be labeled and color coded and closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping. 4. For Home Health/Hospice, see disposal of Medical Waste and Sharps in the home. Addendum A.

F. PERSONAL PROTECTIVE EQUIPMENT: 1. Where occupational exposure still remains after institution of engineering and work practice controls, the employee will be provided at no cost, personal protective equipment (PPE) such as, but not limited to: -Gloves -Gowns -Face shields/Masks -Safety glasses -Single use resuscitation devices (pocket masks) -Hoods -Shoe covers/ boots -Respirators 2. Personal protective equipment is considered appropriate only if it does not permit blood or OPIM to pass through or reach the employee’s work clothes, street clothes, undergarments, skin, eyes, nose, mouth or other mucous membranes under normal conditions of use and for the duration of time which the PPE will be used. Hypoallergenic gloves, glove liners and similar alternatives are available for employees who have sensitivity to latex products normally used. 3. Employees are trained regarding the use of appropriate PPE for their job classifications and tasks/procedures they perform. Additional training is performed when necessary (e.g. when an employee takes a new position or new job functions are added to a current position.)

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4. The following measures will be enforced to ensure that PPE is used correctly: • All personal protective equipment is inspected periodically and repaired or replaced as necessary to maintain its effectiveness. • Reusable personal protective equipment is cleaned and decontaminated as needed. • Single use disposable PPE shall be properly disposed of (in red trash bag if contaminated with blood or OPIM). • All garments penetrated by blood or OPIM shall be removed immediately or as soon as feasible. • All PPE is removed prior to leaving the work area. • Gloves will be worn in the following circumstances: -Whenever employees anticipate contact with blood, body fluids, body substances or non-intact skin -When performing any vascular access procedure. -When handling or touching any contaminated surface or equipment. -Disposable gloves are replaced as soon as practical after contamination or if they are torn, punctured, or otherwise lose their ability to function as a barrier to exposure. -Utility gloves are decontaminated for reuse unless they are cracked, peeling, torn, or exhibit other signs of deterioration, at which time they are to be discarded. • Whenever splashes or sprays may generate droplets of blood or OPIM. • Surgical caps, hoods, shoe covers or boots shall be used when gross contamination can be reasonably expected, such as orthopedic surgery or autopsies. 5. Home Health and Hospice- see personal protective equipment list for car supplies referred to in Addendum B. Clothing must be worn that is appropriate for the anticipated task.

G. HANDLING SPECIMENS OF BLOOD OR OPIM: • Specimens of blood or OPIM shall be placed in a container which prevents leakage during collection, handling, processing, storage, transport or shipping. • The container for storage, transport, or shipping shall be labeled or color coded appropriately and closed prior to being stored, transported, or shipped. • If outside contamination of the primary container occurs, the primary container shall be placed within a second container which

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prevents leakage during collection, handling, processing, storage, transport, or shipping and is labeled or color coded as appropriate. • If the specimen could puncture the primary container, the primary container shall be placed within a secondary container which is puncture resistant in addition to the above characteristics.

H. SERVICING OR SHIPPING CONTAMINATED EQUIPMENT: Equipment which may become contaminated with blood or OPIM shall be examined prior to servicing or shipping and shall be decontaminated as necessary, unless it can be demonstrated that the decontamination of such equipment or portions of such equipment is not feasible. • A readily observable label shall be attached to the equipment stating which portions remain contaminated. • Information concerning all remaining contamination shall be conveyed to all affected employees, the servicing representative, and or the manufacturer, as appropriate, prior to handling, servicing, or shipping so that appropriate precautions will be taken.

I. CLEANING AND DECONTAMINATION OF THE WORKSITE: GENERAL: Maintaining our facility in a clean and sanitary manner is an important part of our Blood borne Pathogens Compliance Program. All equipment and environmental and work surfaces shall be cleaned and decontaminated after contact with blood or OPIM no later than at the end of the shift. We have a written schedule for cleaning and decontamination of the various areas of the organization. The Housekeeping Supervisor is responsible for this schedule and making sure it is carried out. (See Addendum C.)

The cleaning schedule provides the following information: • The area to be cleaned/ decontaminated. • Day and time of scheduled work. • Any special instructions that are required.

SPECIFIC REQUIREMENTS: • Contaminated work surfaces shall be cleaned and decontaminated immediately or as soon as feasible when: 1. Surfaces become overly contaminated. 2. There is a spill of blood or OPIM. 3. Procedures are complete. 4. at the end of the work shift if the surface may have become contaminated since the last cleaning.

• Receptacles, including all bins, pails, cans and similar receptacles intended for reuse which have a reasonable likelihood for becoming

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contaminated with blood or OPIM shall be inspected and decontaminated on a regularly scheduled basis and cleaned and decontaminated immediately or as soon as feasible upon visible contamination. • Protective coverings, such as plastic wrap, aluminum foil, or imperviously-backed absorbent paper used to cover equipment and environmental surfaces, shall be removed and replaced as soon as feasible when they become overtly contaminated or at the end of the work shift if they may have become contaminated during the shift.

J. HYGIENE: • Hand washing facilities shall be provided which are readily accessible to employees. • When provision of hand washing facilities is not feasible, employees shall be provided with either an appropriate antiseptic hand cleanser. Hands visibly soiled shall be washed with soap and running water as soon as feasible. • Employees shall sanitize or wash their hands immediately or as soon as feasible after the removal of gloves or other personal protective equipment. • Employees shall wash their hands and any other skin with soap and water, or flush mucous membranes with water immediately or as soon as feasible following contact of such body with blood or OPIM.

K. LAUNDRY: • Contaminated laundry shall be handled as little as possible with a minimum of agitation. • Contaminated laundry shall be bagged or containerized at the location where it is used and shall not be sorted or rinsed in the location of use. • Wet contaminated laundry which may soak through or cause leakage from the bag or container must be placed and transported in bags which prevent soak through and or leakage of fluids to the exterior. • Employees who have contact with contaminated laundry shall wear protective gloves and other appropriate PPE. • Laundry for this facility is cleaned at contracted outside laundry service. This laundry operates an approved laundry as required by Title 22. • Home Health personnel shall refer to the Home Health Policy and Procedure regarding disposal of contaminated laundry.

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COMMUNICATION OF HAZARDS TO EMPLOYEES: Employees will be informed of hazards through a system of biohazard labels and/or color-coding. Labels shall be fluorescent orange or orange red with lettering or symbols in a contrasting color. The label is either an integral part of the container or affixed as close as feasible to the container by a method which prevents loss or unintentional removal of the label.

Included in this, but not limited to, are the following: - Containers of regulated waste (all medical waste in red bags or containers). - Refrigerators/freezers containing blood or OPIM.

- Sharps disposal containers. - Other containers used to store, transport, or ship blood or OPIM. - Contaminated equipment (on labels affixed to contaminated equipment it is also indicated which portions of the equipment are contaminated).

The labels and color coding described here are not required in the following instances: - When containers of blood, blood components or blood products are labeled as to their contents and have been released for transfusion or other clinical use. - When individual containers of blood or OPIM materials are placed in labeled containers during storage, transport, shipment or disposal. - When regulated waste has been decontaminated.

INFORMATION AND TRAINING: A. All employees with occupational exposure shall participate in a training program which will be provided at no cost to the employee and during working hours. B. The training will take place at the time of initial assignment to tasks where occupational exposure may take place and at least annually thereafter. C. Additional training will be provided when changes, such as introduction of new engineering, administrative or work practice controls, modification of tasks or procedures or institution of new tasks or procedures affect the employee’s occupational exposure. The additional training may be limited to addressing the new exposures created. D. The training program will be tailored to the educational level, literacy and language of the employee. The program will include an opportunity for employees to have questions answered by the trainer. E. The person conducting the training shall be knowledgeable in the subject matter covered by the elements contained in the training program as it relates to the workplace that the training will address. F. The training program shall contain at a minimum the following elements:

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• An accessible copy of the regulatory text of the Blood borne Pathogen Standard and an explanation of its contents shall be available to all employees. • A general explanation of the epidemiology and symptoms of blood borne diseases. • An explanation of the modes of transmission of blood borne pathogens. • An explanation of the exposure control plan and means by which an employee can obtain a copy of the written plan. • An explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and OPIM. • An explanation of the use and limitations of methods that will prevent or reduce exposure including appropriate engineering controls, administrative or work practice controls and PPE. • Information on the types, proper use, location, removal, handling, decontamination and disposal of PPE. • An explanation of the basis for selection of PPE. • Information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine and vaccination will be offered free of charge. • Information on the appropriate actions to take and persons to contact in an emergency involving blood or OPIM. • An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident, the medical follow-up that will be made available and the procedure for recording the incident on the sharps injury log. • Information on the post exposure evaluation and follow-up that is provided for the employee following an exposure incident. • An explanation of the signs and labels and/or color coding required. • An opportunity for interactive questions and answers with the person conducting the training session.

HEPATITIS B VACCINATION POLICY: See Employee Health Policy & Procedure # 2.013: Vaccine Program: Hepatits B Vaccine.

PROCEDURES FOR EVALUATION AND FOLLOW-UP OF EXPOSURE INCIDENTS: See Infection Control Policy & Procedure #2.022: Protocol for Exposure to Blood and Bodily Fluids Through Parental/Cutaneous Routes.

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RECORD KEEPING: A. Employee Medical Record keeping: See Infection Control Policy & Procedure# 2.022: Protocol for Exposure to Blood and Bodily Fluids Through Parental/Cutaneous Routes. B. Training Records: These records shall be maintained for 3 years from the date on which the training occurred. Training records shall include the following information: 1. The dates of the training session. 2. The contents or a summary of the training session. 3. The names and qualifications of persons conducting the training. 4. The names and job titles of all persons attending the training sessions. C. Sharps Injury Log: The sharps injury log shall be maintained 5 years from the date the exposure incident occurred. (See Addendum D.) D. Availability of Records: 1. All records required by this standard shall be made available upon request to the Chief and NIOSH for examination and copying. 2. Employee training records shall be provided upon request for examination and copying to employees, to employee’s representatives, to the Chief, and to NIOSH. 3. Employee medical records required by this standard shall be provided upon request for examination and copying to the subject employee, to the chief, and to NIOSH (in accordance with section 3204). 4. The Sharps Injury Log required by this standard shall be provided upon request for examination and copying to employees, to employee representatives, to the chief, to the Department of Health Services, and to NIOSH.

E. Transfer of Records: • The organization shall comply with the requirements of the Blood borne Pathogen Standard involving the transfer of records. • If the Organization ceases to do business and there is no successor employer to receive and retain the records for the prescribed period, the organization shall notify NIOSH, at least three months prior to their disposal and transmit them to the NIOSH, if required by the NIOSH to do so, within that three month period.

Reference: Blood borne Pathogens Standard, Title 8, California Code of Regulations, Section, 5193

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NUMBER: 170.1021 PAGE: 14 OF 14

New: 11/1994 Revised: 7/1999, 07/2004, 02/2005, 11/2008

Approval Signatures:

______Infection Control Coordinator Date

______Employee Health Coordinator Date

______Chairperson, Infection Control Advisory Committee Date

______Chairperson, Integrated Quality Management Committee Date

______Medical Chief of Staff Date

______Chief Executive Officer Date

______President, Board of Directors Date

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