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
3. Personal Protective Equipment (PPE)

The use of Personal Protective Equipment places a barrier between the employee and the potentially infectious materials to which he/she may be exposed. In accordance with Universal Precautions, blood, body fluids, and tissues of all persons are considered potentially infectious. PPE must be utilized based on the particular task performed, regardless of the patient involved or the source of blood or other specimen involved. PPE will be considered appropriate only if it does not permit blood or other potentially infectious materials to pass through to or reach the employee's work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use. Job hazard assessments must be conducted prior to issuance of personal protective equipment to employees. This assessment is performed by the supervisor of the area for job titles being supervised.

The following directives apply to most areas of occupational exposures:

Personal protective equipment must be worn in all cases where there is the potential for exposure to blood or body fluids. The only exemption from the use of protective equipment is on rare and extraordinary occasions when its use would prevent the proper delivery of health care or would pose an increased hazard to the personal safety of the worker. An employee's decision not to use PPE is to be made on a case-by-case basis, prompted by legitimate and truly extenuating circumstances. In these cases, whether or not an exposure occurred, an incident report must be filled out explaining the event.

1. General
1. Provision - The University provides appropriate PPE at no cost to employees. Employees with special PPE requirements may receive alternative PPE types by contacting UHS (for example, gloving alternatives including glove liners and different gloving materials).
2. Use - Each Department Head or Supervisor will ensure the provided PPE is used appropriately by employees under his/her direction. In the event that PPE is not used when indicated, the circumstances shall be investigated and documented by the Supervisor. Any unusual or extraordinary events are to be documented on an incident report form.
3. Accessibility - Each supervisor will ensure that appropriate PPE, in appropriate sizes, is readily accessible at worksite or issued directly to all employees working in the area under their authority.
4. The upkeep of PPE is the responsibility of the University. Cleaning, laundering, disposal, repair and replacement of PPE shall be done as specified by each department to maintain its effectiveness.
5. If a garment(s) is penetrated by blood or other potentially infectious material, the garment(s) shall be removed immediately or as soon as feasible.
6. All PPE shall be removed prior to leaving the work area.
7. When PPE is removed it, shall be placed in an appropriately designated area or container for storage, washing, decontamination, or disposal.
2. Gloves

Gloves are selected on the basis of material and intended use. Vinyl gloves are typically less durable and more prone to tears and leakage than are latex or nitrile gloves. Use of vinyl gloves is recommended when minimal or no direct contact with wet blood or potentially infectious body fluids is anticipated. Use of nitrile gloves is recommended for moderate to high risk tasks that involve direct, heavier contact with body fluids, i.e. sufficient contact to wet the glove. See APPENDIX 11, Glove Recommendations for additional selection criteria and examples. "Universal Gloving" is required for all healthcare workers; this means taht gloves must be worn for ALL contact with patients and their environments

1. Gloves are required to be worn for all anticipated hand contact with human blood, body fluids, tissues, or mucous membranes and when handling items or surfaces suspected to be contaminated with blood or other potentially infectious materials.
2. Gloves must be worn during all invasive procedures.
3. Gloves must be worn during all vascular access procedures, including all phlebotomies and insertions of IV's or other vascular catheters.
4. Gloves must be worn during any examination of wounds, non-intact skin, mucous membranes, or areas of active bleeding, and during instrument examination of the oropharynx, respiratory tract, gastrointestinal tract, and genitourinary tract.
5. Gloves must be worn during all clean-up of blood/body fluids and during decontamination of instruments and equipment.
6. Gloves shall be replaced as soon as practical when contaminated or as soon as feasible if they are torn, punctured or when their ability to function as a barrier is compromised.
7. Gloves are to be worn only in the area of suspected exposure and must be discarded prior to leaving the room.
8. Disposable / single use gloves shall not be washed and reused.
3. Face Protection
1. Masks
1. Masks covering both the nose and mouth must be worn (in addition to eye protection) whenever spray, splash, spatter or aerosols of blood or body fluids may be generated, and contamination of the mouth or face can be reasonably anticipated. Masks must be worn during all major surgical procedures, all obstetrical procedures, and all insertions of arterial catheters and central vascular catheters.
2. To be effective, masks must be worn correctly with the metal band fitted to the nose, the top ties at the crown of the head, the bottom of the mask under the chin, and the bottom ties at the nape of the neck.
3. A mask is either on or off: it is never to be allowed to dangle around the neck where it can become heavily contaminated with microorganisms.
4. A mask should be changed if it becomes moist, regardless of how long it has been worn.
5. Used masks must be discarded prior to leaving the room. They should never be carried in pockets. (For exceptions see Ribaviran administration in the SMH Policy Book and Tuberculosis Control Plan in the SMH Infection Control Manual.)
2. Face shields

Face shields are an alternative to safety goggles and masks. Face shields combine protection for the eyes, nose, and mouth. Face shields must be at least chin length and may be worn over prescription glasses.

4. Eye Protection
1. Eye protection includes goggles or glasses with solid side shield (ordinary glasses are not acceptable).
2. Protective eyewear (in addition to a mask) must be worn whenever spray, splash, or aerosols of blood, body fluids, or tissue/bone particles may be generated, and contamination of eyes or face can be reasonably anticipated. Protective eyewear shall be worn during all major surgical procedures, deliveries, and during placement of arterial catheters.
3. Masks which incorporate a shield covering the eye area may be utilized.
4. When soiled, protective eyewear is to be decontaminated per manufacturer's directions.
5. Protective eyewear shall be discarded when defective or broken and not able to be repaired.
6. Safety glasses with solid side shields are only appropriate when fluids quantities are small and the likelihood of splashing or spraying is low.
5. Gowns and Aprons
1. Regular work clothes, surgical scrubs, and uniforms are not considered protective attire. Proper use of protective attire is intended to prevent contamination of skin, mucous membranes, and work clothing.
2. A water-resistant cloth isolation gown shall be worn whenever splashing, spattering, or spraying of blood or body fluids is anticipated or when blood/body fluid contamination of the arms is anticipated.
3. Disposable plastic apron shall be worn if clothing is likely to become soiled with blood or body fluid but the requirement for an isolation gown is not met.
4. Surgical, Obstetrical, and Post-mortem Procedures - the standard, fluid-resistant surgical gown is appropriate for most procedures. During those procedures in which heavy contamination or soak-through of a gown with blood or body fluids is reasonably anticipated, a fluid-proof or highly-fluid-resistant gown shall be worn. An isolation gown or surgical gown shall be worn when performing any obstetrical delivery in SMH.
5. All protective clothing must be removed after each use and prior to leaving the room. Gowns/aprons are not to be hung-up for reuse; a new gown is used for each contact.
6. Laboratory Coats

Lab coats are not made of impervious materials. Therefore lab coats only protect against 'nuisance' contact (unlikely to cause exposures). Additional barriers may be required based on individual tasks.

1. All personnel in SMH Clinical Laboratories shall wear buttoned laboratory coats at all times when present in the laboratory. Personnel in other laboratories of the University shall wear buttoned laboratory coats whenever procedures involving human blood, body fluids, tissues, or bloodborne pathogens are being performed.
2. All protective clothing must be removed after each use and prior to leaving the room. Laboratory Coats may be worn throughout a period of work (unless visibly contaminated with blood or other infectious material) but must be removed before leaving the laboratory area.
3. Laboratory coats which are used to prevent nuisance contact are to be laundered by the University. Purchasing can be contacted for help in arranging laundry service. The Eastman Institute for Oral Health employees are to check with their supervisors for procedures concerning drop off and pick up of laboratory coats for laundering.
7. Surgical caps/hoods

Surgical caps/hoods shall be worn when gross contamination of the head due to spraying of blood or body fluid is reasonably anticipated. Most such situations involve surgical operations in which caps or hoods are already required for reasons of sterility. These should be discarded before leaving the location.

8. Shoe covers, leg covers, or boots

Shoe covers, leg covers, or boots shall be worn when gross contamination of the lower legs and/or feet with blood or infectious body fluid is reasonably anticipated. Such procedures include, but are not limited to, orthopedic surgery, cardiovascular surgery, certain intra-abdominal surgery, and autopsies. Protective footwear shall be removed before leaving the room.

9. Resuscitation Equipment

Pocket masks, resuscitation bags, or other ventilation devices shall be provided in strategic locations as well as to key personnel where the need for resuscitation is likely. This will minimize the need for emergency mouth-to-mouth resuscitation.

Continue to Section IV, Part D - Housekeeping Practices

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

This page last updated 8/22/2019. Disclaimer