Policy

RESPONSIBILITIES

The Director of Health and Wellness Programs and Human Resources are responsible for the implementation of this policy and will maintain, review, and update the regularly to include new or modified tasks and procedures. 

Those employees who are determined to have occupational exposure to blood or other potentially infectious materials (OPIM) must comply with the procedures and work practices outlined in this policy. 

Departments will  be responsible for the purchase and maintenance of necessary (PPE), engineering controls (e.g., sharps containers), labels, and red bags (biohazard bag) as required by the standard. 

The Director, in coordination with Human Resources, will be responsible for ensuring that all medical actions required are performed and that appropriate employee health and OSHA records are maintained. 

Contact location: Health & Wellness Programs

Phone number: 920.403.3259

Human Resources will be responsible for training, documentation of training, and making the policy available to employees, OSHA, and NIOSH representatives. 

Contact location: Human Resources

Phone number: 920.403.3211

EMPLOYEE EXPOSURE DETERMINATION

The Director of Health & Wellness Programs, in coordination with Human Resources, have performed an exposure determination for all common job classifications which may be expected to incur occupational exposures to blood or other potentially infectious materials. This exposure determination is made without regard to use of PPE (Personal Protective Equipment).  The following is a list of those job classifications in this category:

• Athletic Trainers contracted through Prevea
• Equipment Managers and Student Workers
• Housekeeping including Kress Inn Employees
• Campus Safety Officers
• Laundry and Equipment Managers and Student Workers

The following is a list of job classifications in which some employees may have occupational exposures. Not all of these employees are considered to be at risk for exposure to blood or OPIM. The job classification, tasks, and procedures are listed below:

Athletics

*Athletic Trainers oversight and management is authorized through Prevea Health.

PPE:  

1. Use of appropriate sized gloves, face masks, pocket masks, and shields as indicated with the type of potential exposure.

Engineering Work Practice Controls: 

1. Soap and water readily available or use of hand sanitizer if no water is available.
2. Sharps containers for contaminated sharps.
3. Self-sheathing needles and syringes.
4. Policy for no recapping of needles or re-sheathing of scalpels.
5. Tongs, broom, dust pan available for sharps pick up and disposal.
6. Biomedical waste containers labeled with Biohazard Insignia, lined with red biohazard bags; disposed of in a certified biohazard waste removal process.
7. Routinely clean surfaces of the treatment table with a biomedical solution that will kill blood-borne pathogens on surfaces.
8. Bloodborne Pathogens Protection and Clean-Up Kit.

PPE: 

1. Use of appropriate sized gloves in collecting and placing used towels, uniforms and other garments into the washing machine.

Engineering Work Practice Controls: 

1. Routinely clean laundering machines, collection baskets and any other equipment utilized in the laundering of athletic wear.
2. Bloodborne Pathogens Protection and Clean-Up Kit.

Housekeeping

PPE:

1. Use of appropriate sized and rubber type gloves when cleaning surfaces and equipment, including floors, walls, light fixtures, bathrooms, sinks etc.

Engineering Work Practice Controls: 

1.  Visible blood or body fluids will be treated with a biochemical solution that will ensure decontamination specific to blood borne pathogens.
2. Do not remove single waste items from the insides of garbage cans.
3. Bloodborne Pathogens Protection and Clean-Up Kit.

Campus Safety

PPE:  

1. Use of appropriate sized gloves, face masks, and pocket masks as indicated with the type of potential exposure.

Engineering Work Practice Controls: 

1. Soap and water readily available or use of hand sanitizer if no water is available.
2. Sharps containers for contaminated sharps.
3. Plastic cover for vehicle seat.
4. Bloodborne Pathogens Protection and Clean-Up Kit.

Procedures

IMPLEMENTATON AND CONTROL

Universal Precautions

“Universal Precautions” recognizes all body fluids as though they are infected with bloodborne pathogens. This method of infection control requires the employer and employee to assume that all human blood and specified human body fluids are infectious for HIV, HBV, HCV, and other bloodborne pathogens. Where differentiation of types of body fluids is difficult or impossible, all body fluids are to be considered as potentially infectious regardless of the perceived status of the source individual.

Engineering Controls and Work Practices

Engineering and Work Practice Controls will be used by all employees to eliminate or minimize occupational exposures at this facility. The Engineering Controls are:

1. Hand washing facilities are available.  Single use towels or air dryers will be used for drying. If sinks are not readily available, the use of alcohol based hand sanitizer is provided.
   1. Wash hands or other skin surfaces immediately after contact with bodily fluids.
   2. Wash hands after removing gloves or other protective equipment.
2. Gloves, masks, goggles, gowns and lab coats.
   1. N95 masks fit tested and provided for substances requiring this level of protection.
   2. CPR face shield or pocket mask.
3. Needle design to protect from needle stick injury.
4. Sharps container in all areas where needle use occurs.
5. Waste containers with lids and insignia signage/ color denoting hazardous material.
6. Air filters with variable air exchanges in rooms with communicable disease/ airborne particles.
7. Centrifuge with lid for specimen reduction.

The following PPE will be provided at no cost to employees:

Body Protection:

1. Gloves, masks, face shields and isolation gown or lab coat.  Gloves and Masks:  Gloves for all specimen collection/injections, wound care, procedures and clean up. Face Shields, masks, and/or pocket masks for assessments related to illness, specimen collection, tissue cultures, procedures such as ear lavage, wound irrigation, treatment applications, CPR, or clean up. 

Special PPE:

1.  N95 respiratory masks for airborne or droplet communicable disease secretions and specimen     collections. 
2. Gloves for biological waste disposal and containment.

Departments are assigned the responsibility to provide appropriate and readily accessible PPE.

• Hypoallergenic gloves, glove liners, powderless gloves, or other similar alternatives shall be readily accessible to those employees who are allergic to the gloves normally provided.  All PPE will be removed prior to leaving the work area.
• All PPE will be cleaned, laundered, and disposed of accordingly.
• PPE, when removed, will be discarded in general waste containers, unless “saturated” with potential Blood Borne Pathogens.  “Saturated” items will be disposed of in the waste container scheduled for professional waste disposal.

These facilities will be cleaned and decontaminated according to the following schedule:

Contaminated Laundry

Contaminated laundry in Athletics will be cleaned by the Athletic department by an individual with OSHA Bloodborne pathogen training.

Regulated Waste

The following procedures will be followed:

Sharps containers will be closed between uses and when full, the top will be locked and placed in the biohazard red bag lined container, sealed and given to Prevea in the Health & Wellness Center.

Hepatitis B Vaccine and Post Exposure Evaluation and Follow-up

Prevea will administer, at no cost to employees, the hepatitis B vaccination series within 10 working days after receiving the initial job assignment.  The hepatitis B series will be:

1. Made available at no cost to the employee at a reasonable place and time.
2. Performed or supervised by a licensed healthcare professional according to federal guidance.

However, if after being trained, the employee declines to get the vaccination at that time may request and obtain the vaccination at a later date at no cost.

Post exposure Evaluation and Follow-up

When an employee has an exposure incident, it will be reported to the employee’s supervisor in accordance with St. Norbert College’s workers compensation injury reporting procedure.  Following a reported exposure incident, the exposed employee will receive a confidential medical evaluation as soon as possible. The individual will be referred to the Health and Wellness Center for medical evaluation. All employees who incur an exposure incident considered to be a high risk exposure will be offered post exposure evaluation and follow-up in accordance with the OSHA Blood-borne Pathogen standard. All post exposure evaluations will be performed by Prevea Health in the Health and Wellness Center or the healthcare system of the employee’s choice.

Information Provided to the Healthcare Professional

Prevea Health (onsite clinic) will assist the employee with access to hepatitis B vaccination or records to support off campus evaluation and treatment. This may include:

• Dates of Hepatitis B vaccination series.
• Notification if documentation of vaccination has been refused.

Prevea Health or the employee’s provider of choice, will provide the employee with a copy of the evaluating healthcare professional’s written opinion within 15 days of the completion of the evaluation.  The healthcare professional’s written opinion for post exposure follow-up will be limited to the following information:

• Status of HIV testing and results of tests.
• Status of testing for HCV and results of tests.

The healthcare professional’s written opinion for HBV vaccination will be limited to whether HBV is indicated for an employee, and if the employee has received such vaccination.

Information and Training

Human Resources will ensure training is provided to the designated job classifications at the time of initial assignment and that it shall be repeated within 12 months of the previous training.  The training program will be tailored to the education and language level of the employee, and offered during the normal work shift. The training will contain the following information:

• How working in any environment with a high concentration of people can increase the risk of exposure to germs and infectious agents on a daily basis. 
• How bodily fluids can put you in danger of infection. Bloodborne pathogens are infectious microorganisms in human blood that can cause disease. 
• Training will provide an overview of the dangers posed by bloodborne pathogens and steps workers can take to protect themselves and others from exposure. 
• Topics covered include exposure risk, OSHA guidelines, universal precautions, personal protective equipment, and safe cleanup and disposal practices.
• The link to this policy.
• Review of Declination and Waiver of Hepatitis B Vaccine.

Additional training will be given to employees when there are any changes of tasks or procedures affecting the employee’s occupational exposure.

Recordkeeping

Prevea Health (onsite clinic) is responsible for maintaining employee medical records. 

Training Records

Human Resources is responsible for maintaining training records. These records will be kept electronically in Workday. All employee records will be made available to the employee as needed or requested.

Evaluation and Review

The Director of Health and Wellness Programs, in coordination with Human Resources, is responsible for reviewing this program, its effectiveness, and for updating as needed.