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:

• PDF Version of Exposure Control Plan for Bloodborne Pathogens
• PDF Version of Appendices

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4. Methods of Compliance
2. Engineering and Work Practice Controls

Engineering and work practice controls are designed to minimize or eliminate employee exposure to bloodborne pathogens. Physical means to isolate the hazard, such as sharps disposal containers and self-sheathing needles, are called engineering controls. Work practice controls are standard methods by which tasks are performed in an effort to improve safety, such as by prohibiting recapping of needles. Both engineering and work practice controls are effective if each employee develops good working habits.

1. Handwashing:
1. Even if there is no known exposure, all employees are required to wash their hands immediately or as soon as feasible after removal of gloves or other personal protective equipment. Alcohol based hand sanitizer (for example, Purell) may be used for disinfection if hands are not visibly soiled.
2. Following exposure to blood or other potentially infectious materials, employees shall wash hands and any other exposed skin with soap and water, or flush mucous membranes with water immediately or as soon as feasible.
3. Eye wash stations are to be provided in all areas where there is a potential for contamination of the eyes or face.
4. Hand washing facilities with soap and running water will be readily accessible to employees. When provision of handwashing facilities is not feasible an appropriate antiseptic hand cleanser and paper towels or antiseptic towelettes will be provided. After use of such antiseptic cleansing, hands should be washed with soap and running water as soon as feasible.
2. Sharps, Sharps Disposal, and Sharps Containers:
1. Needles, lancets, scalpel blades, sharp pipettes, slides, broken/contaminated glass, surgical staples, orthodontic wires, wooden applicator sticks or any other item likely to puncture a bag are considered sharps and must be disposed of in an approved sharps container. Everyone is responsible for the proper disposal of sharps that they have used. Sharps are never to be left on bedside tables, bracket table, procedure trays, or dining trays for someone else to pick up. Sharps are never to be discarded into the trash.
2. Bending, shearing, or breaking of used needles is strictly prohibited.
3. Approved sharps containers are puncture-resistant hard plastic, leak-proof on the sides and bottom, and biohazard-labeled. Sharps containers are wall-mounted in most patient rooms of SMH (except where they constitute a risk to the patient); larger free-standing, plastic sharps containers are used in high-volume clinical areas and laboratories.
4. The height at which sharps containers are mounted on walls plays a key role in allowing for proper sharps disposal and the prevention of avoidable sharps injuries at the University. Frequently, sharps injuries associated with mounted sharps containers result from inappropriately disposed of needles and bouncing back of a needle during disposal. These types of incidents are more easily prevented if the opening of the sharps container is visible to the individual disposing of the sharp. Thus the height of sharps containers must be such that the container opening is visible to the vast majority of the users. Environmental Health & Safety has also reviewed data taken from studies logging the height of patient caregivers on various units. Environmental Health & Safety has concluded that the opening of the sharps containers should be mounted between 48 inches and 54 inches from the floor. This height will accommodate most shorter individuals and allow everyone to see the container opening while disposing of their sharps. This height will also balance the need to keep sharps containers from the reach of curious children. Sharps containers should be mounted away from areas where children can climb up and reach the containers, and should not be installed in areas where children may be unsupervised.
3. Sharps Safety Devices:
1. Safety butterflies, syringes, lancets and straight needles must be employed when ever possible. Appropriate hospital committees, prior to purchasing, evaluate all safety devices for ease of use and protection afforded to staff. A passive system is preferred to a staff activated system. Safety devices require staff understanding of the technology and activation system. In-servicing on the safety device is required prior to using the device. All used devices are disposed of in the sharps receptacle. Refer to Appendix 2 for lists of sharps safety devices. Appropriate hospital committees continue to review needle safety technology for advancements in the needle safety systems.
2. Entry into an IV system is to be done only through a needleless device whenever a needleless device is available. Needleless access devices are employed on all central lines and on intermittent injection sites. Entry into IV systems is accomplished either through an existing needleless port in the IV line or by applying a needleless access pin to the IV port.
3. Engineering controls used to prevent sharps injuries are reviewed and recommended for trial by the University’s Occupational and Employee Health Blood Exposure Committee and the SMH Value Analysis Advisory Board. Reviews are conducted as technology in sharps safety advances and as injury trends are identified. Appendices 2, 8 and 9 outline the review process for sharps safety devices and a list of devices in use. All employees are encouraged to participate in the selection of engineering controls addressed at eliminating blood exposures. Employees may participate by contacting their supervisor, their committee representative, the Occupational Safety Unit of Environmental Health & Safety (x5-3241), or University Health Service (x5-1164).
4. Research laboratories staffed by non-clinical personnel (i.e. those that receive Institutional Biosafety Committee approval), alternatively may consult the Biosafety Officer (x5-3014) for device selection and training.
4. Recapping Policy:
1. Needles are not to be recapped or disassembled from syringes before disposal.
2. For disposal, a needle-syringe assembly is deposited as a unit directly into a sharps container. Needles attached to IV tubing should be cut off, with the end of the tubing, directly into the sharps container. The remainder of the IV tubing should not be discarded into the sharps container.
3. Exception: If recapping must be done for procedural or safety reasons, a specifically designed recapping device or the one-handed technique is employed for safe recapping of the needle. (For example, a needle must be removed from a blood gas syringe before sending the syringe to the laboratory, and the needle must be recapped before it can be safely removed.)
One-handed re-capping technique:
• place needle-cap on counter-top or table
• take hand away from cap and away from needle
• holding only the syringe, guide needle into cap
• lift up syringe so cap is sitting on needle hub
• secure needle-cap into place
5. Reusable Sharps:

Immediately, or as soon as feasible, contaminated reusable sharps are to be placed in appropriate containers until properly reprocessed. Containers shall be puncture resistant, biohazard-labeled or color-coded, and leak-proof on the sides and bottom.

6. Biological Safety Cabinets:
1. Biological safety cabinets provide employee, environmental, and product protection against potential hazards that are presented as an airborne particulate. This protection is achieved through HEPA (High Efficiency Particulate Air) filtration. Biological safety cabinets are used in laboratories to provide employee protection from splashing, spraying, and inhalation of potentially infectious materials.
2. Certification of biological safety cabinets is required regardless of its usage:
• Following cabinet relocation
• Following HEPA filter replacement
• Following repair or maintenance on any sealed portion of the cabinet
3. All newly installed biological safety cabinets must be certified in place before initial use regardless of usage type.
4. Biological safety cabinets must be recertified annually if one or more of the following are used within the cabinet.
• Recombinant or synthetic nucleic acids
• Human products including but not limited to blood, body fluids, unfixed tissues, cells and cell lines
• Organisms requiring biosafety level 2 or higher containment
• Radioisotopes
• Carcinogens or other hazardous chemicals in particulate form
5. Certification must be performed by an outside contractor. All certifiers must have demonstrated knowledge in working with biological safety cabinets. This knowledge must include training from manufacturers of cabinets. All individual certifiers must be accredited by a nationally recognized accreditation program such as but not limited to the National Sanitation Foundation. The biological safety cabinet certification procedure must comply with the National Sanitation Foundation’s Standard Number 49: Class II (Laminar Flow) Biohazard Cabinetry.
6. Decontamination of biological safety cabinets is performed by an outside contractor as noted above. Biological safety cabinet decontamination procedure must comply with the National Sanitation Foundation’s Standard Number 49: Class II (Laminar Flow) Biohazard Cabinetry.
7. Decontamination using gaseous formaldehyde or Vaporized Hydrogen Peroxide (VHP) must be performed:
• Before moving the cabinet to another location
• Before HEPA filter replacement
• Before repair or maintenance involving access to a contaminated plenum of the cabinet.
8. Hazardous volatile chemicals must never be used in non-ducted Class II type A1 or A2 (formerly called A/B3) biological safety cabinets. Class II type A biological safety cabinets vent or discharge exhaust air directly into the laboratory. HEPA filters will not trap gases or vapors therefore only ducted biological safety cabinets (Class II type B) are appropriate for hazardous volatile chemicals.
9. Lab personnel are responsible for and required to empty and chemically disinfect the work surface of the biological safety cabinet upon completion of experiments. Contact the Biosafety Officer (x5-3014) for disinfectant recommendations. Research laboratories staffed by non-clinical personnel (i.e. those that receive Institutional Biosafety Committee approval) must use disinfectants listed in the laboratory's LAB/L form.
10. Contact the Laboratory Safety Unit (x5-3241) of Environmental Health & Safety with questions regarding biological safety cabinets, certification, decontamination, and qualified biosafety cabinet contractors.



7. Eating, drinking, smoking, applying cosmetics, or handling contact lenses:

Eating, drinking, smoking, applying cosmetics, or handling contact lenses are prohibited in work areas where there is a reasonable potential of occupational exposure to blood or body fluids (e.g., operating rooms, procedure rooms, and laboratories). Hand cream is not considered a cosmetic. Petroleum or mineral oil based hand creams may adversely affect glove integrity and should not be used. If petroleum or mineral oil based hand cream is used, it must be washed off prior to donning gloves.

8. Food and drink:

Food and drink are never to be kept in refrigerators, freezers, or cabinets which are, at any time, used for storage blood or other potentially infectious materials.

9. Laboratory Procedures:

All laboratory procedures involving blood or other potentially infectious materials shall be performed in a manner as to minimize splashing, spraying, spattering, and generation of droplets of these substances.

1. Laboratory procedures involving human blood or other potentially infectious body fluids which may generate aerosols or micro-droplets must be completed using the protective features of a class II biosafety cabinet. Laboratory procedures which may generate splashes, sprays or large droplets of blood or other potentially infectious body fluids are to be performed preferentially in a biological safety cabinet. If a biological safety cabinet is unavailable, protection may be achieved using a work station shield to protect the face of the laboratory worker. Note, if a work station is used, the risk of exposure to employees working adjacent or opposite the shield must be considered. If a biological safety cabinet or work station shield is not used, then personal protective equipment must be used to protect the laboratory worker’s mucous membranes and include a fluid resistant splash mask and goggles or, alternatively, a chin-length face shield. Such procedures include but are not limited to opening of vacutainers or other stoppered / pressurized specimen containers and pipetting.
2. When centrifuging potentially infectious body fluids, covers shall be used on carriers. A waiting period of 10 minutes after centrifuge has come to a full stop before opening and removing any specimens is required. If breakage is known to have occurred, the carrier should be opened in a biological safety cabinet. If a biological safety cabinet is not available, then a chemical fume hood could be used instead. If no local ventilation device is available, then wait 30 minutes after centrifuge has stopped and remove while wearing full face protection.
3. Mouth pipetting of blood or other potentially infectious materials is prohibited.
10. Patient Care Procedures:

All patient care procedures involving blood or other potentially infectious materials shall be performed in a manner as to minimize splashing, spraying, spattering, and generation of droplets of these substances.

1. Examples of patient care activities that may result in splashing or spraying of body fluids include but are not limited to:
• Moving ventilated patients
• Debriding wounds
• Changing soaked dressings
• Flushing ports of needleless IV system
• Suctioning ventilated patients
• Emptying drainage from patients tubes (i.e. chest tubes, Foleys, J-tubes)
• Insertion and removal of an arterial or central line
• Surgical procedures including bedside procedures
2. For those tasks, personal protective equipment must be worn to prevent fluid contact with face (especially eyes and mouth), skin, and clothing. (Refer to Section on Personal Protective Equipment for more information.)
3. Mouth suctioning of blood or other potentially infectious materials is prohibited.
11. Specimen containers & transport:
1. Specimens of blood or other potentially infectious materials shall be placed in a container, which prevents leakage during collection, handling, processing, storage, transport, or shipping.
2. All blood tubes, blood culture bottles, culturettes, screw-top plastic or glass specimen containers/vials containing any specimens are handled in accordance with Universal Precautions.
3. Gloves are worn when handling, transporting, or processing all specimen containers.
4. Biohazard labels are required on:
1. Any specimen known or suspected to be infected with one of the following (place biohazard label on specimen and on zip-lock bag):
• Creutzfeldt-Jakob Disease (write “CJD” on labels)
• Mycobacterium tuberculosis (TB)
• Lassa Fever, Ebola Virus, Marburg Virus, Hantavirus or other hemorrhagic fever viruses
• Anthrax
2. Specimen bags
3. Any outer container used to carry or enclose primary specimen containers
4. Any specimen container sent outside of the University (must be labeled on container, not on outside of package)
5. Containers which are leaking or which are visibly contaminated with blood/body fluids on the outside are placed inside a clear zip-lock bag and sealed or are placed inside another leak-proof container.
12. SMH pneumatic tube system:
1. All specimens sent through the SMH pneumatic tube system must be placed in a zip-lock bag and sealed. Requisition forms are not placed inside zip-lock bag. Please refer to the Strong Memorial Hospital Infection Prevention Program for specific information regarding using the tube system for laboratory specimens.
2. Contaminated pneumatic tube carriers are handled in accordance with Universal Precautions. Contaminated carriers are disinfected with bleach solution (see Housekeeping) or other disinfectant recommended by manufacturer and approved by SMH Infection Control Committee.
3. Employees who open tube carriers containing patient specimens must wear gloves.
4. Decontamination of the pneumatic tube system is done by Medical Center Facilities.
5. Problems with the pneumatic tube system must be directed immediately to the Tube Hot-Line (ext. 5-4949).
13. Equipment decontamination:
1. Any equipment which may become contaminated with blood or other potentially infectious materials shall be examined prior to servicing or shipping and shall be decontaminated as necessary, unless the employer can demonstrate that decontamination of such equipment or portions of such equipment is not feasible.
2. The equipment shall be labeled with a biohazard symbol stating which portions remain contaminated.
3. This information shall be conveyed to all affected employees, servicing representatives prior to handling, servicing, or shipping so that appropriate precautions will be taken.

Continue to Section IV, Part C - Personal Protective Equipment

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QUESTIONS? Contact EH&S at (585) 275-3241 or e-mail EH&S Questions.

This page last updated 8/12/2016. Disclaimer