Exposure Control | Bloodborne Pathogens

Q. What is an exposure control plan?

A. The exposure control plan is the employers written program that outlines the protective measures an employer will take to eliminate or minimize employee exposure to blood and OPIM.

The exposure control plan must contain at a minimum: (1) the exposure determination which identifies job classifications and, in some cases, tasks and procedures where there is occupational exposure to blood and OPIM; (2) the procedures for evaluating the circumstances surrounding an exposure incident; and (3) a schedule of how and when other provisions of the standard will be implemented, including methods of compliance, HIV and HBV research laboratories and production facilities requirements, hepatitis B vaccination and post-exposure follow-up, communication of hazards to employees, and recordkeeping.

Q. In the exposure control plan, are employers required to list specific tasks that place the employee at risk for all job classifications?

A. No. If all the employees within a specific job classification perform duties where occupational exposure occurs, then a list of specific tasks and procedures is not required for that job classification. However, the job classification (e.g., “nurse”) must be listed in the plans exposure determination and all employees within the job classification must be included under the requirements of the standard.

Q. Can tasks and procedures be grouped for certain job classifications?

A. Yes. Tasks and procedures that are closely related may be grouped. However, they must share a common activity, such as “vascular access procedure,” or “handling of contaminated sharps.”

Q. Does the exposure control plan need to be a separate document?

A. No. The exposure control plan may be part of another document, such as the facility’s health and safety manual, as long as all components are included. However, in order for the plan to be accessible to employees, it must be a cohesive entity by itself or there must be a guiding document which states the overall policy and goals and references the elements of existing separate policies that comprise the plan. For small facilities, the plans schedule and method of implementation of the standard may be an annotated copy of the final standard that states on the document when and how the provisions of the standard will be implemented. Larger facilities could develop a broad facility program, incorporating provisions from the standard that apply to their establishments.

Q. How often must the exposure control plan be reviewed?

A. The standard requires an annual review of the exposure control plan. In addition, whenever changes in tasks, procedures, or employee positions affect or create new occupational exposure, the existing plan must be reviewed and updated accordingly.

Q. Must the exposure control plan be accessible to employees?

A. Yes, the exposure control plan must be accessible to employees, as well as to OSHA and NIOSH representatives. The location of the plan may be adapted to the circumstances of a particular workplace, provided that employees can access a copy at the workplace during the workshift. If the plan is maintained solely on computer, employees must be trained to operate the computer.

A hard copy of the exposure control plan must be provided within 15 working days of the employees request in accordance with 29 CFR 1910.1020.

Q. What should be included in the procedure for evaluating an exposure incident?

A. The procedure for evaluating an exposure incident shall include:

• the engineering controls and work practices in place,

• the protective equipment or clothing used at the time of the exposure incident,

• an evaluation of the policies and “failures of control” at the time of the exposure incident.

Bloodborne Pathogens: Questions and Answers

Revision 12/05 On December 6, 1991, OSHA issued the Occupational Exposure to Bloodborne Pathogens standard, §1910.1030. This standard is designed to protect workers in the health care and related occupations from the risk of exposure to bloodborne pathogens such as HIV and HBV.

Through its enactment, OSHA received numerous questions regarding how to implement the provisions of the standard. The following information provides answers to many of those questions; however, it is not intended to be used as a substitute for the standard’s requirements. Please refer to §1910.1030 for the complete text.

Scope

Q. Who is covered by the standard?

A. The standard applies to all employees who have occupational exposure to blood or other potentially infectious materials (OPIM).

• Occupational exposure is defined as “reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or OPIM that may result from the performance of the employees duties.”

• Blood is defined as human blood, human blood components, and products made from human blood.

• OPIM is defined as the following human body fluids: saliva in dental procedures, semen, vaginal secretions, cerebrospinal, synovial, pleural, pericardial, peritoneal, and amniotic fluids; body fluids visibly contaminated with blood; along with all body fluids in situations where it is difficult or impossible to differentiate between body fluids; unfixed human tissues or organs (other than intact skin); HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV- containing culture media or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.

Q. Will the bloodborne pathogens standard apply to employees in agriculture, maritime, and construction industries?

A. The standard will not apply to agriculture. The standard applies to maritime in shipyards and boatyards (where 29 CFR 1910 applies), in commercial fishing vessels, towboats, barges, tugs and other vessels where OSHA has jurisdiction. However, the standard does not apply to longshoring and marine terminals. The construction industry is not covered by the standard. However, the General Duty Clause (Section 5(a)(1) of the OSH Act) will be used to enforce bloodborne hazards in construction.

Q. Are volunteers and students covered by the standard?

A. Volunteers and students may be covered by the standard depending on a variety of factors including compensation.

Q. Are physicians who are not employees of the hospital in which they work covered by the standard?

A. Physicians of professional corporations are considered employees of that corporation. The corporation which employs these physicians may be cited by OSHA for violations affecting those physicians. The hospital where the physician practices may also be held responsible as the employer who created or controlled the hazard. Physicians who are sole practitioners or partners are not considered employees under the OSH Act, and therefore, are not covered by the protections of the standard. However, if a non-incorporated physician were to create a hazard to which hospital employees were exposed, it would be consistent with current OSHA policy to cite the employer of the exposed employees for failure to provide the protections of the Bloodborne Pathogens Standard.

Q. We have employees who are designated to render first aid. Are they covered by the standard?

A. Yes. If employees are trained and designated as responsible for rendering first aid or medical assistance as part of their job duties, they are covered by the protections of the standard. However, OSHA will consider it a de minimis violation — a technical violation carrying no penalties — if employees, who administer first aid as a collateral duty to their routine work assignments, are not offered the pre-exposure hepatitis B vaccination, provided that a number of conditions are met. In these circumstances no citations will be issued.

The de minimis classification for failure to offer hepatitis B vaccination in advance of exposure does not apply to personnel who provide first aid at a first aid station, clinic, or dispensary, or to the health care, emergency response or public safety personnel expected to render first aid in the course of their work.

Exceptions are limited to persons who render first aid only as a collateral duty, responding solely to injuries resulting from workplace incidents, generally at the location where the incident occurred. To merit the de minimis classification, the following conditions also must be met:

• Reporting procedures must be in place under the exposure control plan to ensure that all first aid incidents involving exposure are reported to the employer before the end of the work shift during which the incident occurs.

• Reports of first aid incidents must include the names of all first aid providers and a description of the circumstances of the accident, including date and time, as well as a determination of whether an exposure incident, as defined in the standard, has occurred.

• Exposure reports must be included on a list of such first aid incidents that is readily available to all employees and provided to OSHA upon request.

• First aid providers must receive training under the Bloodborne Pathogens Standard that covers the specifics of the reporting procedures.

• All first aid providers who render assistance in any situation involving the presence of blood or other potentially infectious materials, regardless of whether or not a specific exposure incident occurs, must have the vaccine made available to them as soon as possible but in no event later than 24 hours after the exposure incident. If an exposure incident as defined in the standard has taken place, other post-exposure follow-up procedures must be initiated immediately, per the requirements of the standard.

Q. Are employees such as housekeepers, maintenance workers, or janitors covered by the standard?

A. Housekeeping workers in health care facilities may have occupational exposure to bloodborne pathogens, as defined by the standard. Individuals who perform housekeeping duties, particularly in patient care and laboratory areas, may perform tasks, such as cleaning blood spills and handling regulated wastes, which constitute occupational exposure.

While OSHA does not generally consider maintenance personnel and janitorial staff employed in non-health care facilities to have occupational exposure, it is the employers responsibility to determine which job classifications or specific tasks and procedures involve occupational exposure. For example, OSHA expects products such as discarded sanitary napkins to be discarded into waste containers which are lined in such a way as to prevent contact with the contents. But at the same time, the employer must determine if employees can come into contact with blood during the normal handling of such products from initial pick-up through disposal in the outgoing trash. If OSHA determines, on a case-by-case basis, that sufficient evidence of reasonably anticipated exposure exists, the employer will be held responsible for providing the protections of 29 CFR 1910.1030 to the employees with occupational exposure.

Recordkeeping | Bloodborne Pathogens

OSHA requires that all needlestick and sharps injuries and illnesses that result from bloodborne pathogens exposure be recorded on the OSHA 300 Log, the sharps injury log, and employee-related medical and training records.

OSHA 300 Log

Revision 12/05 All occupational bloodborne pathogens exposure incidents that are work-related and involve contamination with another person’s blood or potentially infectious material, such as needlesticks and lacerations, must be recorded on the OSHA 300 Log as an injury. However, to protect an employee’s privacy, do not enter the name on the Log.

Medical records

A confidential medical record for each employee with potential for exposure must be preserved and maintained according to OSHA’s standard governing access to employee exposure and medical records at §1910.1020. This standard requires that medical records must be kept confidential and maintained for at least the duration of employment plus 30 years. Also, if you contract with a healthcare provider, the medical records may be kept at their worksite.

In addition, under the bloodborne pathogens standard, medical records also must include the following information:

• Employee’s name and social security number;

• Employee’s hepatitis B vaccination status, including dates of all hepatitis B vaccinations and any medical records related to the employee’s ability to receive vaccinations;

• Results of examinations, medical testing, and post-exposure evaluation and follow-up procedures;

• The employer’s copy of the health care professional’s written opinion; and

• A copy of information provided to healthcare professional.

Sharps injury log

Employers having workers with occupational exposure to BBP must establish and maintain a sharps injury log for the recording of percutaneous injuries from contaminated sharps. The information in the sharps injury log has to be recorded and maintained in such manner as to protect the confidentiality of the injured employee. The sharps injury log need to contain, at a minimum:

• The type and brand of device involved in the incident,

• The department or work area where the exposure incident occurred, and

• An explanation of how the incident occurred.

Revision 12/05 This applies to any employer who is required to maintain a log of occupational injuries and illnesses under OSHA’s injury and illness recordkeeping standard, part 1904. However, employers may use the OSHA 300 Log and 301 incident report to meet the sharps injury log requirements. To use the recordkeeping forms, the type and brand of the device has to be entered on either the 300 or 301 form, and the records must be maintained in a way that segregates sharps injuries from other types of work injuries. However, if you prefer to maintain a separate sharps injury log, there is a sample form on page 77 of this chapter.

Training records

The bloodborne pathogens standard also requires you to maintain and to keep accurate training records. Training records are not considered to be confidential and may be stored onsite where they are easily accessible. They must be retained for three years from the training date. Employee training records must include the following:

• Training dates,

• Content or a summary of the training,

• Names and qualifications of trainer(s), and

• Names and job titles of trainees.

Records access

Upon request, both medical and training records must be made available to both NIOSH and OSHA officials. Training records must be available to employees or employee representatives upon request. Medical records can be obtained only by the employee or anyone having the employee’s written consent.

Also, if an employer ceases to do business, medical and training records must be transferred to the successor employer. If there is no successor employer, the employer must notify the director of NIOSH for specific directions regarding disposition of the records at least three months prior to intended disposal.