Environmental Health & Safety
In Compliance with 29 CFR 1910.1030 OSHA Standard for Occupational Exposure to Bloodborne Pathogens
Bloodborne Pathogens Exposure Control Plan
Printable files are available in two parts with Adobe Acrobat Reader:
- University Health Service Occupational Health Nurse -- ext. 5-2662
- University Health Service Occupational Health Program -- ext. 5-4955
- Infection Prevention, SMH -- ext. 5-7716
- Infection Control, Eastman Institute for Oral Health -- ext. 5-2662
- SMH Employee Health Blood Exposure Hotline -- 275-1164
- Environmental Health & Safety -- ext. 5-3241
- University Biosafety Officer -- ext. 5-3241 or ext. 5-3014
- Occupational Safety Unit -- ext. 5-3241
- University Sanitarian -- ext. 5-8405
- Environmental Services
- Strong Memorial Hospital (SMH) -- ext. 5-6255
- School of Medicine & Dentistry (SMD) -- ext. 5-9203
- River Campus -- ext. 3-4567
- Public Safety
- Emergency -- ext. 13
- Non-emergency -- ext. 5-3333
HIV/HBV Research Laboratories -- Special Instructions
This section applies to research laboratories engaged in the culture, production, concentration, experimentation, and manipulation of HIV or HBV. It does not apply to clinical or diagnostic laboratories engaged solely in the analysis of blood, tissues, or organs.
These requirements apply in addition to the other requirements of the standard and of the Institutional Biosafety Committee. All research with potential biohazardous materials, including HIV and HBV, must be approved by the Institutional Biosafety Committee prior to initiating such experiments. Contact the University Biosafety Officer at ext. 5-3014 or ext. 5-3241 for more information.
- Standard Microbiological Procedures.
- All regulated waste shall be decontaminated by a method such as autoclaving known to effectively destroy bloodborne pathogens.
- Special Practices:
- Laboratory doors shall be kept closed when work involving HIV or HBV is in progress.
- An autoclave for decontamination of regulated waste shall be available. Contaminated materials that are to be decontaminated at a site away from the work area shall be placed in a durable, leakproof, labeled, or color-coded container that is closed before being removed from the work area.
- Access to work area shall be limited to authorized persons. Written policies and procedures shall be established whereby only persons who have been advised of the potential biohazard, who meet any specific entry requirements, and who comply with all entry and exit procedures shall be allowed to enter the work areas and animal rooms.
- When other potentially infectious materials or infected animals are present in the work area or containment module, a hazard warning sign shall be posted on all access doors.
- All activities involving other potentially infectious materials shall be conducted in biological safety cabinets or other physical containment devices within the containment module. No work with these other potentially infectious materials shall be conducted on the open bench.
- Laboratory coats, gowns, smocks, uniforms, or other appropriate protective clothing shall be used in the work area and animal rooms. Protective clothing shall not be worn outside of the work area and shall be decontaminated before being laundered.
- Special care shall be taken to avoid skin contact with other potentially infectious materials. Gloves shall be worn when handling infected animals and when making hand contact with other potentially infectious materials is unavoidable.
- Each laboratory shall contain a facility for hand washing and an eye wash facility, which is readily available within the work area.
- Before disposal, all waste from work areas and from animal rooms shall either be incinerated or decontaminated by a method such as autoclaving known to effectively destroy bloodborne pathogens.
- Vacuum lines shall be protected with liquid disinfectant traps and high-efficiency particulate air (HEPA) filters or filters of equivalent or superior efficiency and which are checked routinely and maintained or replaced as necessary.
- Hypodermic needles and syringes shall be used only for parenteral injection and aspiration of fluids from laboratory animals and diaphragm bottles. Safety needles or needles having an integral engineered safety device to prevent needlesticks as they become available shall be used for the injection or aspiration of other potentially infectious materials. Extreme caution shall be used when handling needles and syringes. A needle shall not be bent, sheared, replaced in the sheath or guard, or removed from the syringe following use. The needle and syringe shall be promptly placed in a puncture-resistant container and autoclaved or decontaminated before reuse or disposal.
- All spills shall be immediately contained and cleaned up by appropriate professional staff or others properly trained and equipped to work with potentially concentrated infectious materials.
- A spill or accident that results in an exposure incident shall be immediately reported to the laboratory director or other responsible person.
- A biosafety manual shall be prepared or adopted and periodically reviewed and updated at least annually or more often if necessary. Personnel shall be advised of potential hazards, shall be required to read instructions on practices and procedures, and shall be required to follow them.
- Containment Equipment:
- Certified biological safety cabinets (Class I, II, or III) or other appropriate combinations of personal protection or physical containment devices such as special protective clothing, respirators, centrifuge safety cups, sealed centrifuge rotor, and containment caging for animals shall be used for all activities with potentially infectious materials that pose a threat of exposure to droplets, splashes, spills, or aerosols.
- Biological safety cabinets shall be certified when installed, whenever they are moved and at least annually.
- Signs:
- Signs shall be posted at the entrance to HIV and HBV Research Laboratory Facilities that bear the following legend:
- Biohazard symbol and name of infectious agent
- Special requirements for entering the area
- Name, telephone number of the lab director or other responsible person.
- These signs shall be fluorescent orange-red with lettering or symbols in a contrasting color.
- Additional initial training for employees in HIV and HBV laboratories:
- Supervisors will require new employees to demonstrate proficiency in standard microbiological practices and techniques and in the practices and operations specific to the facility before being allowed to work with HIV or HBV.
- Employees shall have prior experience in the handling of human pathogens or tissue cultures before working with HIV or HBV.
- The supervisor of a new employee who has no prior experience in handling human pathogens shall provide a training period. Initial work activities shall not include the handling of infectious agents. A progression of work activities shall be assigned as techniques are learned and proficiency is developed. The employer shall assure that employees participate in work activities involving infectious agents only after proficiency has been demonstrated.
An alternative to posting personal telephone numbers is to ensure that Public Safety has the contact information for the lab director and other responsible persons and then direct responders to contact Public Safety at x13 in the event of an emergency.
Appendix 8 Occupational & Employee Health Blood Exposure Committee
- Mission
- Evaluation Process
- Committee Representation
- SMH Employee Health Clinicians - provide clinical expertise about institutional post-exposure follow-up, including medical evaluation / treatment / follow-up of all blood exposures.
- Environmental Health & Safety - is responsible for maintaining the Blood Exposure Control Plan, provides guidance for research laboratory situations, acts as a liaison for employee/student safety and provides data analysis of all blood/body fluid exposures.
- Hospital Epidemiologist - MD clinical expert and liaison to MD leadership groups for changes in practice, education or safety engineered equipment.
- Nursing Education - clinical experience, liaison with nursing educators to ensure that any educational changes are incorporated in nursing practice and policies.
- Nursing - clinical experience, provides guidance on day-to-day unit tasks and safety engineered issues.
- Surgery/OR - clinical experience, provides guidance on surgical issues, how safety engineered equipment can be implemented, and educational opportunities.
- Nursing Management - clinical experience, liaison with nursing leadership.
- SMH Value Analysis Advisory Board - clinical experience, liaison for trial process, primarily responsible for introducing new products for evaluation and institutional conversion of products.
- Physician/Surgeon - Orthopedic Trauma Surgeon provides guidance and expertise for changes in practice in acute care settings for providers.
- GME/Residents - third or fourth year resident/trainee represents the day-to-day clinical responsiblities and safety equipment issues for the residents group.
- Employee Participation
- Evaluation Checklist
- Sharps Safety Devices
- Sharps Safety Device Training
- Training for existing employees is conducted initially by the manufacturer and their representatives. Records of general education on new products are kept at the unit level.
- Annual Competencies on using phlebotomy safety engineered sharps are done at the unit level and records are maintained by the Nurse Managers.
- Training for new employees is conducted upon hire by Nursing Education Office during orientation. Records of training from orientation are kept in individual personnel files on Masters Competency checklists.
The mission of the Occupational & Employee Health Blood Exposure Committee is to prevent blood and body fluid exposures among the University of Rochester/Strong Memorial Hospital staff and student population through the use of engineering and work practice administrative controls, work practices, education and training. The committee meets on a regular basis to carry out its mission. Documentation of committee activities and deliberations are recorded and distributed to committee participants, and to those groups charged with protecting the health and safety of the University Community.
Engineering controls used to prevent sharps injuries are initially evaluated by the University’s Occupational & Employee Health Blood Exposure Committee. On the basis of this review, a recommendation for trial is forwarded to the SMH Value Analysis Advisory Board for consideration.
This committee includes representation from the following departments and disciplines:
All University employees are actively encouraged to participate in the evaluation process through their committee representative, through their supervisor, or through UHS Occupational Heath, SMH Employee Health and the Occupational Safety Unit of Environmental Health & Safety.
A checklist was developed to assist with the evaluation process. This checklist was developed according to the NIOSH (National Institutes of Occupational Safety and Health) recommendations for preventing needlestick injuries.
- For a printable version of the checklist - click here Checklist
See Appendix 2 for sharps safety devices addressing needlestick prevention that are currently in use at SMH.
Continue to Appendix 9 Product Evaluation Worksheet
QUESTIONS? Contact EH&S at (585) 275-3241 or e-mail EH&S Questions.
This page last updated 8/23/2019. Disclaimer
