Bloodborne Pathogens: Exposure Control Plan (ECP)

Scope

This procedure applies to all college employees, including faculty, staff, and student workers, who have been identified as having occupational exposure to blood or Other Potentially Infectious Materials (OPIM). It also provides guidance for the immediate response to exposure incidents involving non-employees (students and visitors) on campus property.

Narrative

A. Responsibility and Identification

1. Exposure Determination: Human Resources (HR) maintains a master list of all positions with occupational exposure. This list is reviewed annually to reflect changes in job duties or technology.
2. Supervisory Duty: Supervisors must notify HR immediately when new employees are hired into covered positions or when job duties change to include potential exposure.
3. Vaccination: The college provides the Hepatitis B vaccine series at no cost to all employees on the master list.
   1. Employees who decline the vaccine must sign the OSHA-mandated Declination Statement.
   2. Employees who initially decline may choose to receive the vaccine at a later date at no cost.
4. High Risk Instructional Areas: In high-risk clinical environments, department-specific Safety and Infection Control Officers (SICO) manage day-to-day compliance, water line testing, and immediate incident response. These officers serve as the primary departmental point of contact and must coordinate all exposure records with Human Resources. Outside of high-risk instructional areas day-to-day compliance is managed by the OSHA Compliance Coordinator.

B. Standard Operating Procedures (Controls)

1. Universal Precautions: All employees shall observe Universal Precautions, treating all human blood and OPIM as known to be infectious.
2. Engineering Controls: Supervisors shall implement controls to isolate or remove hazards (e.g., sharps disposal containers, self-sheathing needles). These must be inspected and maintained regularly.
3. Work Practice Controls:
   1. Handwashing: Employees must wash hands immediately after removing gloves or other PPE.
   2. Prohibitions: Eating, drinking, smoking, and applying cosmetics are prohibited in areas of potential exposure.
4. Vaccination: For employees with occupational exposure the Hepatitis B Vaccination Record & Declination Form must be completed, and the Hepatitis B immunization protocol must begin within 10 days of employment or prior to the first day of exposure to ensure protection before occupational exposure occurs.
5. PPE: The college provides appropriate PPE (gloves, gowns, masks, eye protection) at no cost. Supervisors must ensure PPE is used, cleaned, or disposed of properly.
   1. Standard Operating Procedures in clinical settings may require higher-grade PPE than general workplace standards. For aerosol-generating procedures, N95 fitted masks and face shields are required. For non-aerosol clinical procedures, a minimum of Level 3 medical-grade masks with 98% filtration efficiency must be utilized.

C. Exposure Incidents and Post-Exposure Evaluation

An exposure incident is defined as a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or OPIM. Exposure incidents need to be medically evaluated within 2 hours of exposure.

1. For Staff Covered by Workers Compensation (SAIF):

Note: This includes all college employees, including faculty, staff, and student workers including Cooperative Work Experience (CWE), Workstudy, and Learn and Earn students.

• Immediate Action: Clean the wound with soap and water; flush mucous membranes with water for 15 minutes.
• Medical Evaluation: Call and report to Cascade Health Solutions (2650 Suzanne Way #200, Springfield; 541-228-3096) within 2 hours for prophylaxis. If unavailable, go to the nearest Emergency Room.
• Source Testing: The college will attempt to identify and test the source individual for HBV, HCV, and HIV, subject to state law and consent.
• Documentation: Complete a SAIF accident form. HR will ensure the employee receives the healthcare professional’s written opinion within 15 days of the evaluation.

2. For Persons Not Covered by Workers Compensation (Visitors/Students):

• Direct the individual to seek medical care at a hospital within 2 hours.
• Treatment costs are the responsibility of the individual.
• Staff must document the individual’s name, the nature of the incident, and the medical advice provided via a Non-Employee Incident Report.

Recordkeeping

• Training Records: HR maintains training records for 3 years, including dates, content summaries, and trainer qualifications.
• Medical Records: Confidential medical records for exposed employees are maintained for the duration of employment plus 30 years.
• Sharps Injury Log: HR maintains a log of all percutaneous injuries from contaminated sharps. This log is kept for 5 years and includes the device type/brand, location of incident, and a description of the event, maintaining employee confidentiality.
• Human Resources is responsible for maintaining training records.