Bloodborne Pathogens Exposure Control Plan
Walla Walla University is committed to providing a safe and healthful work environment. This is our plan to eliminate or minimize occupational exposure to bloodborne pathogens (BBP). Individual departments may be requested to provide supplemental information to act as addenda to this written program.
The program applies to all Walla Walla University employees at risk of occupational exposure to potentially infectious materials as defined below (see Definitions). In addition, the post-exposure plan in this program applies to any employee who experiences an exposure as a result of the performance of their duties. Employees may review this plan at any time during their work shift. A copy will be provided free of charge to any employee within 15 days of request.
- Make all employees aware of the BBP program and how it impacts them
- Ensure that employees comply with the program
- Report any exposure to Campus Security immediately, and assist the exposed employee in seeking medical attention
- Conduct investigation
- Must comply with procedures established by their supervisor and the BBP plan to minimize the risk of exposure
- Must report any incident of exposure immediately to their supervisor or Campus Security if supervisor is not available
- Maintain training records
- Ensure that at-risk employees receive required training
- Make recommendations for any necessary program revisions to Human Resources.
Human blood, human blood components, and products made from human blood.
The presence or the reasonably anticipated presence of blood or other potentially infectious materials (OPIM) on an item or surface.
Laundry which has been soiled with blood or other potentially infectious materials (OPIM) or may contain contaminated sharps.
Any contaminated object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires.
The use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal.
Controls (e.g., sharps disposal containers, self-sheathing needles, and safer medical devices such as sharps with engineered sharps injury protections and needle-less systems) that isolate or remove the bloodborne pathogen hazard from the workplace.
A specific eye, mouth, other mucous membrane, or non-intact skin contact with blood or other potentially infectious materials (OPIM) that results from the performance of an employee's duties.
The hepatitis B virus.
The human immunodeficiency virus.
A reasonably anticipated skin, eye, mucous membrane, or non-intact skin contact with blood or other potentially infectious materials (OPIM) that may result from the performance of an employee's normal duties.
The following body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any that is visibly contaminated with blood, and any where it is difficult or impossible to differentiate between body fluids. Any unfixed human tissue or organ. HIV-containing cells or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions and blood, organs, or other tissues from experimental animals. Blood and tissues of experimental animals infected with bloodborne pathogens
Liquid or semiliquid blood or OPIM in a liquid or semiliquid state if compressed, items that are caked with dried blood or OPIM and are capable of releasing these materials during handling, contaminated sharps, and pathological and microbiological wastes containing blood or OPIM. NOTE: Discarded feminine hygiene products, used to absorb menstrual flow, do not fall within the definition of regulated waste. These products should be discarded into lined waste containers.
Any individual, living or dead, whose blood or OPIM may be a source of occupational exposure to the employee. Examples include, but are not limited to, hospital and clinic patients, clients in institutions for the developmentally disabled, trauma victims, clients of drug and alcohol treatment facilities, residents of hospices and nursing homes, human remains, and individuals who donate or sell blood or blood components.
An approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious of HIV, HBV, and other bloodborne pathogens.
| Department | Who | How |
|---|---|---|
| Biology | Department Heads, Instructors, Lab Assistants | Rendering first aid/CPR, Cleaning contaminated areas, Use of medical sharps |
| Campus Clinic | Nurses and Nurses' Aides | Cleaning contaminated areas, Use of medical sharps, Patient care |
| Campus Security | Officers | Rendering first aid/CPR, Cleaning contaminated areas, Physical altercations, Transporting biohazard waste. |
| Chair Crew | Supervisors | Rendering first aid/CPR, Cleaning contaminated areas |
| Chemistry | Department Heads, Instructors, and Lab Assistants | Rendering first aid/CPR, Cleaning contaminated areas |
| Custodial | All Employees | Cleaning contaminated areas |
| Education | Pre-School Employees | Rendering first aid/CPR, Cleaning contaminated areas |
| Facility Services | Supervisors | Rendering first aid/CPR, Cleaning contaminated areas |
| Health and Physical Education | Associate Director, Athletic & Intramural Directors, Instructors, Lifeguards, Trainers, Coaches, Assistant Coaches, Cage workers, Soccer Field Landscape Specialist, and Student Employees | Rendering first aid/CPR, Cleaning contaminated areas, Laundry |
| Human Resources | Chemical Hygiene Officer | Pickup and disposal of biohazard waste, |
| Rental Properties | Custodial Employees | Cleaning contaminated areas |
| Residence Halls | Deans, Assistant Deans, and Resident Assistants | Rendering first aid/CPR, Cleaning contaminated areas |
| Rosario Beach Marine Laboratory | Manager | Rendering first aid/CPR, Cleaning contaminated areas |
| School of Nursing | Department Heads, Instructors, and Students | Cleaning contaminated areas, Use of medical sharps, Patient Care, Biohazard waste taken to Adventist Health: Portland for disposal |
| School of Social Work | Administrative Assistants | Rendering first aid/CPR, Cleaning contaminated areas |
| Winter Education Complex | Facility Director, Head Softball Coach | Rendering first aid/CPR, Cleaning contaminated areas |
Following the initial first aid treatment, such as cleaning the wound and flushing eyes or other mucous membranes for at least 5 minutes, the Bloodborne Pathogens Post-Exposure Control Plan will be followed.
- Walla Walla University provides to employees who have an occupational exposure a confidential medical evaluation and follow-up, if they so desire, and the cost will be covered by the University's Workers' Compensation insurance. Supervisors must obtain a Bloodborne Pathogens Exposure Packet from Campus Security. The packet contains:
- instructions for the supervisor,
- an Accident/Near Miss Report,
- a Walla Walla University Post-Exposure Form,
- a Medical File Report Form, and
- a copy of WAC 296-823.
For satellite campus sites (Portland, Missoula, Rosario, and Billings), please see the Satellite Campus Addendums for variances.
- Supervisors will:
- Immediately notify Campus Security of the occupational exposure incident. Campus Security will secure the area.
- Ensure the Accident/Near Miss Report is completed by the emploayee and returned to Human Resources within 24 hours after the incident.
- Complete the Accident/Near Miss Investigation Report and returned to Human Resources within 72 hours after the incident.
- Identify and document the route of exposure and how the exposure occurred
- Identify the source of any potentially infectious materials unless identification is not possible or is prohibited by state or local law.
- Complete the Post-Exposure Form with signatures, send a copy to Human Resources
- Send the original Post-Exposure Form along with the Medical File Report Form with the employee to the emergency department or other licensed health care provider of their choice (for best results, testing must be done within 20 minutes and prophylactic medicine administered within 2 hours of the exposure). Healthcare providers should complete the Medical File Report Form and return it to Human Resources within 15 days of the evaluation.
- If a source individual cannot be identified, is unavailable, or will not consent to testing, the exposed employee will be notified. If the source individual is known and is available, inquiries should be made to determine if the source individual is willing to have his/her blood tested for HIV and HBV. If a source individual refuses testing, the refusal must also be documented on the Post-Exposure Form in the source individual information section. If the source individual agrees to testing, he/she shall be referred to an emergency room or a health practitioner of his/her choice for pre-test counseling. If a source individual is already known to be HIV, HBV, or HCV-positive, new testing is not required.
Consent and record releases should be obtained by a licensed healthcare provider or other HIPAA-trained individual. DO NOT ATTEMPT TO GAIN CONSENT FROM THE SOURCE INDIVIDUAL BY COERCION. THE SOURCE INDIVIDUAL IS NOT LEGALLY REQUIRED TO SUBMIT TO TESTING.
- Walla Walla University and health care providers must provide the exposed employee with:
- results of the source individual's testing
- information about applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual
- the option to obtain an initial evaluation with appropriate lab studies, so that the employee is able to make an informed choice regarding post-exposure immunization
- counseling, if requested
- The exposed employee has the option to decline HIV testing. If the employee does not give consent for testing, the baseline blood sample must be preserved for at least 90 days. If the exposed employee decides to have the sample tested during this time, the testing must be performed as soon as feasible. A written copy of the healthcare provider opinion(s) will be provided to the employee.
Hepatitis B Employee Fact Sheet
The Hepatitis B vaccine series is available at no cost to all employees who have been identified in this plan as being at risk of occupational exposure. The vaccine series will be explained at the employee training session and made available within 10 days of initial assignment of the duties which may result in potential exposure. Departments will coordinate and cover the cost of the vaccinations through the employee's primary care provider.
Vaccination is encouraged unless
- documentation is provided stating the employee has previously received the vaccination series
- antibody testing reveals the employee is immune
- medical evaluation shows that vaccination is contraindicated, and a copy of the health care professional's written opinion will be provided to the employee
Employees who choose to decline the vaccination must sign Walla Walla University's Hepatitis B Vaccine Declination form. This form informs employees that should they decline the vaccine, yet experience continued occupational exposure, they may at any time and at no cost ask for and receive the vaccination series. Completed declination forms will be maintained by Human Resources in confidential personnel files.
For satellite campus sites (Billings, Missoula, Portland, and Rosario), please see the Satellite Campus Addendums for variances.
Controlling Employee Exposure to Bloodborne Pathogens
In an emergency situation involving blood or OPIM, employees should always use Universal Precautions or an equivalent exposure prevention strategy to protect themselves from bloodborne pathogens or OPIM.
Universal Precautions is the term used to describe a prevention strategy in which all blood or OPIM are treated as infectious, regardless of the perceived health status of the source individual. In other words, all blood and OPIM are assumed to be infected with bloodborne pathogens. This means that the appropriate exposure controls are to be used anytime an employee encounters blood or OPIM.
Whenever practical, engineering controls will be used to eliminate or minimize exposure to bloodborne pathogens or other potentially infectious materials. Engineering controls will be periodically reviewed by supervisors and staff to ensure their effectiveness. Self-sheathing needles, puncture-resistant disposal containers for contaminated sharps, resuscitation bags, and ventilation devices are examples of engineering controls.
When engineering controls are not available or feasible, work practice controls will be used to eliminate or minimize exposure to bloodborne pathogens or OPIM. Whenever possible, employees will be provided with easily accessible hand washing facilities. When this is not possible, employees will be provided with antiseptic hand cleanser in first aid kits for use until a sink with hot and cold running water, soap, and disposable towels is available.
- Employees will wash their hands immediately or as soon as feasible after removing gloves or other personal protective equipment (PPE). In the event of eye, nose, or mouth contact with blood or OPIM, those mucous membranes will be flushed with water immediately or as soon as feasible after.
- Needles will not be bent, sheared, or broken off. If needles must be recapped, it will be done using the one-hand scoop method or a recapping device.
- All contaminated sharps will be placed in appropriate containers immediately or as soon as possible after use. Containers will be puncture-resistant and leak-proof on the sides and bottoms and labeled or color-coded (per Washington Industrial Safety and Health Act of 1973 (WISHA) regulations). Sharps which are reusable shall not be stored in such a manner that employees will be required to reach into containers.
- Eating, drinking, smoking, applying cosmetics (including lip balm), or handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure.
- Food and drink are not allowed in refrigerators, freezers, or cabinets, or on shelves, counter tops, or bench tops where blood or OPIM are present.
- Procedures involving blood or OPIM shall be performed in such a manner as to minimize splashing, spraying, spattering, and generating droplets.
- Mouth pipetting or suctioning of blood or OPIM is prohibited.
- Specimens of blood or OPIM will be placed in containers which prevent leakage during collection, handling, processing, storage, transport, or shipping. The following items will be marked with a biohazard tag or be stored in a red bag or container (departments may choose to substitute orange or red bags or orange or red containers with labels):
- regulated waste that has not been decontaminated
- refrigerators or freezers used to store blood or OPIM
- contaminated equipment or containers used to store, transport, or ship blood or OPIM
- individual containers of blood or OPIM that are placed in colored containers during handling and storage
- If the primary container leaks or becomes contaminated, employees will put the container in a secondary container which meets the above criteria. Appropriate containers are available for purchase through medical and safety equipment suppliers.
- Equipment that may become contaminated with blood or OPIM will be examined prior to servicing or shipping and decontaminated, if necessary. If the equipment cannot be decontaminated, it shall be tagged with biohazard labels and all persons to come into contact with the equipment shall be informed of the hazard as well as which pieces of the equipment are contaminated.
Appropriate personal protective equipment (PPE) is selected and provided based upon hazard assessments conducted utilizing the Walla Walla University PPE Hazard Assessment Tool. Employees are required to use appropriate PPE except when, in the employee's professional judgment, use of the PPE would prevent the delivery of health care or pose an additional unacceptable hazard to the employee or co-workers. In this situation, the incident and circumstances will be investigated and documented to determine if changes should be made to avoid a similar future situation.
PPE is provided to employees at no cost. A variety of sizes are available to employees to ensure proper fit. When necessary, hypoallergenic gloves or similar alternatives are provided. Supervisors are responsible for insuring their employees are provided with appropriate PPE and trained to use it.
At a minimum, gloves and safety glasses/goggles will be used whenever there is reasonable anticipation of contact with blood or other potentially infectious materials.
Contaminated PPE shall be disposed of by placing it in a biohazard bag (available through the Custodial Department during working hours or Campus Security during all other hours) and then contacting the Chemical Hygiene Officer for pick up.
For satellite campus sites (Billings, Missoula, Portland, and Rosario), please see the Satellite Campus Addendums for variances.
Disposable Gloves
Disposable gloves will be available in these areas:
- All departmental first aid kits
- Biology Laboratory
- Campus Security office and on the person of officers
- Chemical Hygiene office
- Chemistry Laboratory
- Custodial Services: main office, custodial closets, and on carts
- Education: Pre-school
- Examination rooms
- Facility Services office
- Health and Physical Education office
- Nursing station
- Rental Properties: paint supply room
- Residence Halls: Conard, Foreman, Hansen, Meske, and Sittner front desks
- Residence Halls (Portland): Hansen Dean's office
- Risk and Safety Management office
- Rosario Beach Marine Laboratory: Manager's office and workshop, Lindgren Hall, biology labs, and academic office
- School of Nursing: skills labs at Portland and College Place sites
Face Protection
Masks, goggles, face shields, and ventilation devices will be available in the following areas:
- All first aid kits (CPR barrier)
- Biohazard response kits
- All patient care areas
- Campus Security office
Protective Gowns or Coats
Protective gowns or coats will be available in the following areas:
- Campus Security office (biohazard response kit)
Blood/Body Fluid Protection Kit
Each of the following areas will have a blood/body fluid protection kit available:
- Custodial office
- Fitness Centers
- Campus Security office
- Chemical Hygiene office
- Academic Buildings: in custodial closets on main floors
- Residence Halls: in custodial closets on main floors
- Rosario Beach Marine Laboratory: Manager's workshop and academic office
Each kit will contain:
- Absorbent material
- Biohazard disposal bag
- Disinfectant wipes
- Disposable gloves
- Mask/eye shield
- Scoop
- Towelettes
In order to maintain the workplace in a clean and sanitary condition, certain employees are trained and equipped to clean up bloodborne pathogen releases. Documentation of cleanup procedures must be kept and should include the type of surfaces to be cleaned, potential contaminants present, tasks or procedures performed in the area, and a cleaning/decontamination schedule (as appropriate).
Contaminated work surfaces must be decontaminated with an appropriate disinfectant after completion of procedures when surfaces are overtly contaminated, after any spill of blood or other potentially infectious materials, and at the end of the work shift if the surface may have become contaminated since the last cleaning.
- Contaminated laundry will be handled as little as possible and with the least amount of bodily contact. Contaminated laundry will be bagged at the location and identified as a biohazard. If a hazard of soaking-through exists, the laundry shall be double-bagged.
- Individual departments are responsible for making their own laundry arrangements, including documentation that the laundry facility uses Universal Precautions in handling the contaminated items.
For satellite campus sites (Billings, Missoula, Portland, and Rosario), please see the Satellite Campus Addendums for variances.
Regulated waste, other than sharps, must be disposed of in a marked biohazard bag or container. Bags and containers must be tightly closed in order to prevent leakage during handling, storage, and transportation. If there is potential for bag puncture or leakage, it must be placed in a marked, hard-sided container. Filled and closed bags will be disposed of by the Chemical Hygiene Officer.
- Sharps will be disposed of in an approved sharps container which will be closable, puncture-resistant, leak-proof on both sides and bottoms, and labeled to color codes as per this plan. During use, the container will be easily accessible to employees and located as close as is feasible to the immediate area where sharps are used or can be reasonably anticipated to be found.
- Sharps containers will be maintained in an upright position and routinely replaced to avoid overfill. When sharps containers are removed, they will be closed immediately prior to removal or replacement to prevent spilling or protrusion of the contents. If leaking is a possibility, a secondary container shall be provided which is closable, constructed to contain all contents, and labeled as per this plan. Sharps containers are available at medical supply companies as well as other commercial sources.
- Waste material not meeting the definition of regulated waste will be placed in a plastic bag, sealed, and disposed of as normal trash.
- Labels and signs - Warning labels will be affixed to containers of regulated waste, refrigerators and freezers containing blood or OPIM, and other containers used to store, transport, or ship blood or OPIM. Labels shall meet the requirements of WAC 296-823. Red or orange bags or containers may be substituted for labels.
For satellite campus sites (Billings, Missoula, Portland, and Rosario), please see the Satellite Campus Addendums for variances.
Decontamination of specialty equipment and the surrounding area is the responsibility of the owning department. However, in those situations where responsibility is unclear the Custodial Department will be contacted during their office hours and Campus Security after hours.
In cases of response by Emergency Medical Personnel, the Custodial Department is responsible for the area once the patient has been removed. In cases where immediate cleanup and decontamination is not possible, Campus Security will be notified and the area secured until it can be cleaned.
For satellite campus sites (Billings, Missoula, Portland, and Rosario), please see the Satellite Campus Addendums for variances.
Departments with employees at risk of occupational exposure will be responsible for insuring that their employees receive training on bloodborne pathogens. Training in compliance with the regulations is available through SafetySkills. Training will be conducted during working hours or the employee will be compensated for the time. Training must take place before initial assignment to tasks where occupational exposure may take place, annually thereafter, and when changes in tasks or procedures take place that affect occupational exposure.
Training will include:
- epidemiology, symptoms, and transmission of bloodborne pathogens
- copy and explanation of WAC 296-823, Occupational Exposure to Bloodborne Pathogens
- explanation of the University's Exposure Control Plan and how to obtain a copy
- methods used to identify tasks and other activities that may involve exposure to blood and OPIM
- what constitutes an exposure incident
- the use and limitations of controls, work practices, and personal protective equipment (PPE)
- the basics of PPE selection and explanation of:
- types
- uses
- location
- handling
- removal
- decontamination
- disposal
- information on the Hepatitis B vaccine including:
- effectiveness
- safety
- method of administration
- benefits of being vaccinated
- that the vaccination series is offered at no charge to employees
- actions to take and persons to contact in an emergency involving blood of OPIM
- procedures to follow if an exposure incident occurs, including:
- how to report an incident
- medical follow-up available
Walla Walla University recognizes the value of information on bloodborne pathogens; therefore, any interested employee may complete the bloodborne pathogens training provided. However, only designated "at-risk" employees will be eligible for HBV vaccinations at the University's expense.
Walla Walla University Employee Training Forms are available for use. These training forms will include a space for each participating employee's name, training date, and signature. Training records will be maintained by the individual departments.
For satellite campus sites (Billings, Missoula, Portland, and Rosario), please see the Satellite Campus Addendums for variances.
Medical records must be maintained for each employee who has an occupational exposure to bloodborne pathogens in accordance with WAC 296-802. Human Resources will establish a file for each employee identified in the exposure determination. This file will include the following:
- employee name
- employee social security number
- Hepatitis B immunization records with dates of injections and any medical records related to the employee's ability to receive vaccinations
- a copy of all results of examinations, medical testing, and follow-up care
- the employee's copy of the health care professional's written opinion as outlined in WAC 296-823
- a copy of all employer-generated exposure incident and accident reporting forms
Files related to employee exposure will be kept confidential and not disclosed or reported to any person within or outside the workplace without the employee's express written consent, except as required by law. These records shall be maintained for the duration of employment plus 30 years.
Employee training records will be recorded and maintained by individual departments. Documentation must include:
- date of training
- subject and source of training provided (e.g., Walla Walla University CLMI Training)
- name and job title of attendee(s)
- name and qualifications of trainer(s)
Training records must be maintained for length of employment plus six years. Documentation of training may be made available to employees or their representatives upon written request and as required by law.
The Director of Nursing will maintain a confidential record of percutaneous injuries from contaminated sharps and other mucus membrane exposures. A summary of the information will be provided to Human Resources. Information included in the log will include at a minimum:
- the type and brand of device involved in the incident
- the department or work area where the exposure incident occurred
- an explanation of how the incident occurred
The Needle-Stick/Sharps Injury Log will be maintained for five years following the year of the injuries to which they relate.
For satellite campus sites (Billings, Missoula, Portland, and Rosario), please see the Satellite Campus Addendums for variances.
Campus Security
(509) 527-2222
Director
Courtney Bryant
(509) 527-2613
courtney.bryant@wallawalla.edu
Office Hours
Monday-Thursday 9 a.m. - 5 p.m.
Friday 9 a.m. - 12 p.m.
Satellite Campus Addendums
Contaminated PPE shall be disposed of by placing it in a biohazard bag (available in the office) and contacting the Administrative Assistant who will coordinate pickup service.
Custodial services outsourced.
Filled and closed bags will be disposed of by contacting the Administrative Assistant who will coordinate the pickup of regulated waste through the Billings Clinic/Hospital.
Decontamination of specialty equipment and the surrounding area is the responsibility of the owning department.
In cases of response by emergency medical personnel, the outsourced custodial service is responsible for the area once the patient has been removed. In cases where immediate cleanup and decontamination is not possible, the Administrative Assistant will be notified and the area secured until it can be cleaned.
Hepatitis B Employee Fact Sheet
The Hepatitis B vaccine series is available at no cost to all employees who have been identified in this plan as being at risk of occupational exposure. The vaccine series will be explained at the employee training session and made available within 10 days of initial assignment of the duties which may result in potential exposure. Departments will coordinate and cover the cost of the vaccinations through the Billings Clinic/Hospital or the employee's primary care provider.
Vaccination is encouraged unless
- documentation is provided stating the employee has previously received the vaccination series
- antibody testing reveals the employee is immune
- medical evaluation shows that vaccination is contraindicated, and a copy of the health care professional's written opinion will be provided to the employee
Employees who choose to decline the vaccination must sign Walla Walla University's Hepatitis B Vaccine Declination form. This form informs employees that should they decline the vaccine yet experience continued occupational exposure, they may at any time and at no cost ask for and receive the vaccination series. Completed declination forms will be maintained by Human Resources in confidential personnel files.
Departments with employees at risk of occupational exposure will be responsible for insuring that their employees receive training on bloodborne pathogens. Training in compliance with the regulations is available through SafetySkills. Training will be conducted during working hours or the employee will be compensated for the time. Training must take place before initial assignment to tasks where occupational exposure may take place, annually thereafter, and when changes in tasks or procedures take place that affect occupational exposure.
Training will include:
- epidemiology, symptoms, and transmission of bloodborne pathogens
- copy and explanation of WAC 296-823, Occupational Exposure to Bloodborne Pathogens
- explanation of the University's Exposure Control Plan and how to obtain a copy
- methods used to identify tasks and other activities that may involve exposure to blood and OPIM
- what constitutes an exposure incident
- the use and limitations of controls, work practices, and PPE
- the basics of PPE selection and explanation of:
- types
- uses
- location
- handling
- removal
- decontamination
- disposal
- information on the Hepatitis B vaccine including:
- effectiveness
- safety
- method of administration
- benefits of being vaccinated
- that the vaccination series is offered at no charge to employees
- actions to take and persons to contact in an emergency involving blood of OPIM
- procedures to follow if an exposure incident occurs, including:
- how to report an incident
- medical follow-up available
Walla Walla University recognizes the value of information on bloodborne pathogens; therefore, any interested employee may complete the bloodborne pathogens training provided. However, only designated "at-risk" employees will be eligible for HBV vaccinations at the University's expense.
Walla Walla University Employee Training Forms are available for use. These training forms will include a space for each participating employee's name, training date, and signature. Training records will be maintained by the individual departments.
Following the initial first aid treatment, such as cleaning the wound and flushing eyes or other mucous membranes for at least 5 minutes, the Bloodborne Pathogens Post-Exposure Control Plan will be followed.
- Walla Walla University provides to employees who have an occupational exposure a confidential medical evaluation and follow-up, if they so desire, and the cost will be covered by the University's Workers' Compensation Insurance. Faculty/staff must obtain a Bloodborne Pathogens Exposure Packet from the Administrative Assistant. The packet contains:
- Faculty/staff will immediately notify the Administrative Assistant of the occupational exposure incident. The Administrative Assistant will secure the area.
- Supervisors will:
- Ensure that the Administrative Assistant has been notified of the occupations exposure incident
- Ensure the Accident/Near Miss Report is completed by the employee and returned to Human Resources within 24 hours after the incident.
- Complete the Accident/Near Miss Investigation Report and return to Human Resources within 72 hours after the incident.
- Identify and document the route of exposure and how the exposure occurred
- Identify the source of any potentially infectious materials, unless identification is not possible or is prohibited by state or local law
- Complete the Post-Exposure Form with signatures, and send a copy to Human Resources
- Send the original Post-Exposure Form along with the Medical File Report Form with the employee to the emergency department or other licensed health care provider of their choice (for best results, testing must be done within 20 minutes and prophylactic medicine administered within 2 hours of the exposure). Healthcare providers should complete the Medical File Report Form and return it to Human Resources within 15 days of the evaluation.
- If a source individual cannot be identified, is unavailable, or will not consent to testing, the exposed employee will be notified. If the source individual is known and is available, inquiries should be made to determine if the source individual is willing to have his/her blood tested for HIV and HBV. If a source individual refuses testing, the refusal must also be documented on the Post-Exposure Form in the source individual information section. If the source individual agrees to testing, he/she shall be referred to an emergency room or a health practitioner of his/her choice for pre-test counseling. If a source individual is already known to be HIV, HBV, or HCV-positive, new testing is not required.
Consent and record releases should be obtained by a licensed healthcare provider or other HIPAA-trained individual. DO NOT ATTEMPT TO GAIN CONSENT FROM THE SOURCE INDIVIDUAL BY COERCION. THE SOURCE INDIVIDUAL IS NOT LEGALLY REQUIRED TO SUBMIT TO TESTING.
- Walla Walla University and health care providers must provide the exposed employee with:
- results of the source individual's testing
- information about applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual
- the option to obtain an initial evaluation with appropriate lab studies, so that the employee is able to make an informed choice regarding post-exposure immunization
- counseling, if requested
- The exposed employee has the option to decline HIV testing. If the employee does not give consent for testing, the baseline blood sample must be preserved for at least 90 days. If the exposed employee decides to have the sample tested during this time, the testing must be performed as soon as feasible. A written copy of the healthcare provider opinion(s) will be provided to the employee.
Contaminated PPE shall be disposed of by placing it in a biohazard bag (available in the office) and contacting the Administrative Assistant who will coordinate pickup service.
Custodial services outsourced.
Filled and closed bags will be disposed of by contacting the Administrative Assistant who will coordinate pickup.
Decontamination of specialty equipment and the surrounding area is the responsibility of the owning department.
In cases of response by emergency medical personnel, the outsourced custodial service is responsible for the area once the patient has been removed. In cases where immediate cleanup and decontamination is not possible, the Administrative Assistant will be notified and the area secured until it can be cleaned.
Hepatitis B Employee Fact Sheet
The Hepatitis B vaccine series is available at no cost to all employees who have been identified in this plan as being at risk of occupational exposure. The vaccine series will be explained at the employee training session and made available within 10 days of initial assignment of the duties which may result in potential exposure. Departments will coordinate and cover the cost of the vaccinations through a Missoula Clinic/Hospital or the employee's primary care provider.
Vaccination is encouraged unless
documentation is provided stating the employee has previously received the vaccination series
antibody testing reveals the employee is immune
medical evaluation shows that vaccination is contraindicated, and a copy of the health care professional's written opinion will be provided to the employee
Employees who choose to decline the vaccination must sign Walla Walla University's Hepatitis B Vaccine Declination form. This form informs employees that should they decline the vaccine yet experience continued occupational exposure, they may at any time and at no cost ask for and receive the vaccination series. Completed declination forms will be maintained by Human Resources in confidential personnel files.
Departments with employees at risk of occupational exposure will be responsible for insuring that their employees receive training on bloodborne pathogens. Training in compliance with the regulations is available through SafetySkills. Training will be conducted during working hours or the employee will be compensated for the time. Training must take place before initial assignment to tasks where occupational exposure may take place, annually thereafter, and when changes in tasks or procedures take place that affect occupational exposure.
Training will include:
- epidemiology, symptoms, and transmission of bloodborne pathogens
- copy and explanation of WAC 296-823, Occupational Exposure to Bloodborne Pathogens
- explanation of the University's Exposure Control Plan and how to obtain a copy
- methods used to identify tasks and other activities that may involve exposure to blood and OPIM
- what constitutes an exposure incident
- the use and limitations of controls, work practices, and PPE
- the basics of PPE selection and explanation of:
- types
- uses
- location
- handling
- removal
- decontamination
- disposal
- information on the Hepatitis B vaccine including:
- effectiveness
- safety
- method of administration
- benefits of being vaccinated
- that the vaccination series is offered at no charge to employees
- actions to take and persons to contact in an emergency involving blood of OPIM
- procedures to follow if an exposure incident occurs, including:
- how to report an incident
- medical follow-up available
Walla Walla University recognizes the value of information on bloodborne pathogens; therefore, any interested employee may complete the bloodborne pathogens training provided. However, only designated "at-risk" employees will be eligible for HBV vaccinations at the University's expense.
Walla Walla University Employee Training Forms are available for use. These training forms will include a space for each participating employee's name, training date, and signature. Training records will be maintained by the individual departments.
Following the initial first aid treatment, such as cleaning the wound and flushing eyes or other mucous membranes for at least 5 minutes, the Bloodborne Pathogens Post-Exposure Control Plan will be followed.
- Walla Walla University provides to employees who have an occupational exposure a confidential medical evaluation and follow-up, if they so desire, and the cost will be covered by the University's Workers' Compensation Insurance. Faculty/staff must obtain a Bloodborne Pathogens Exposure Packet from the Administrative Assistant. The packet contains:
- Faculty/staff will immediately notify the Administrative Assistant of the occupational exposure incident. The Administrative Assistant will secure the area.
- Supervisors will:
- Ensure that the Administrative Assistant has been notified of the occupations exposure incident
- Ensure the Accident/Near Miss Report is completed by the employee and returned to Human Resources within 24 hours after the incident.
- Complete the Accident/Near Miss Investigation Report and return to Human Resources within 72 hours after the incident.
- Identify and document the route of exposure and how the exposure occurred
- Identify the source of any potentially infectious materials, unless identification is not possible or is prohibited by state or local law
- Complete the Post-Exposure Form with signatures, and send a copy to Human Resources
- Send the original Post-Exposure Form along with the Medical File Report Form with the employee to the emergency department or other licensed health care provider of their choice (for best results, testing must be done within 20 minutes and prophylactic medicine administered within 2 hours of the exposure). Healthcare providers should complete the Medical File Report Form and return it to Human Resources within 15 days of the evaluation.
- If a source individual cannot be identified, is unavailable, or will not consent to testing, the exposed employee will be notified. If the source individual is known and is available, inquiries should be made to determine if the source individual is willing to have his/her blood tested for HIV and HBV. If a source individual refuses testing, the refusal must also be documented on the Post-Exposure Form in the source individual information section. If the source individual agrees to testing, he/she shall be referred to an emergency room or a health practitioner of his/her choice for pre-test counseling. If a source individual is already known to be HIV, HBV, or HCV-positive, new testing is not required.
Consent and record releases should be obtained by a licensed healthcare provider or other HIPAA-trained individual. DO NOT ATTEMPT TO GAIN CONSENT FROM THE SOURCE INDIVIDUAL BY COERCION. THE SOURCE INDIVIDUAL IS NOT LEGALLY REQUIRED TO SUBMIT TO TESTING.
- Walla Walla University and health care providers must provide the exposed employee with:
- results of the source individual's testing
- information about applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual
- the option to obtain an initial evaluation with appropriate lab studies, so that the employee is able to make an informed choice regarding post-exposure immunization
- counseling, if requested
- The exposed employee has the option to decline HIV testing. If the employee does not give consent for testing, the baseline blood sample must be preserved for at least 90 days. If the exposed employee decides to have the sample tested during this time, the testing must be performed as soon as feasible. A written copy of the healthcare provider opinion(s) will be provided to the employee.
Contaminated PPE shall be disposed of by placing it in a biohazard bag located in the nursing skills lab and contacting the Office Manager for pickup.
Provided through Adventist Health: Portland custodial department.
Taken to Adventist Health: Portland for disposal.
Decontamination
Decontamination of specialty equipment and the surrounding area is the responsibility of the School of Nursing.
In cases of response by emergency medical personnel, the environmental services of Adventist Health: Portland is responsible for the area once the patient has been removed. In cases where immediate cleanup and decontamination is not possible, the Office Manager will be notified and the area secured until it can be cleaned.
Hepatitis B Employee Fact Sheet
The Hepatitis B vaccine series is available at no cost to all employees who have been identified in this plan as being at risk of occupational exposure. The vaccine series will be explained at the employee training session and made available within 10 days of initial assignment of the duties which may result in potential exposure. The School of Nursing will coordinate and cover the cost of the vaccinations through the Dean of the School of Nursing.
Vaccination is encouraged unless
- documentation is provided stating the employee has previously received the vaccination series
- antibody testing reveals the employee is immune
- medical evaluation shows that vaccination is contraindicated, and a copy of the health care professional's written opinion will be provided to the employee
Employees who choose to decline the vaccination must sign Walla Walla University's Hepatitis B Vaccine Declination form. This form informs employees that should they decline the vaccine yet experience continued occupational exposure, they may at any time and at no cost ask for and receive the vaccination series. Completed declination forms will be maintained by Human Resources in confidential personnel files.
Training for compliance with the regulation will be done through the Acemapp online training module at acemapp.org.
Following the initial first aid treatment, such as cleaning the wound and flushing eyes or other mucous membranes for at least 5 minutes, the Bloodborne Pathogens Post-Exposure Control Plan will be followed.
- Walla Walla University provides to employees who have an occupational exposure a confidential medical evaluation and follow-up, if they so desire, and the cost will be covered by the University's Workers' Compensation Insurance. Faculty/staff must obtain a Bloodborne Pathogens Exposure Packet from the Office Manager or Dean of the School of Nursing. The packet contains:
- Faculty/staff will immediately notify the Office Manager or the Dean of the School of Nursing of the occupational exposure incident, who will secure the area.
- Supervisors will:
- Ensure that the Office Manager or Dean of the School of Nursing has been notified of the occupations exposure incident
- Ensure the Accident/Near Miss Report is completed by the employee and returned to Human Resources within 24 hours after the incident.
- Complete the Accident/Near Miss Investigation Report and return to Human Resources within 72 hours after the incident.
- Identify and document the route of exposure and how the exposure occurred
- Identify the source of any potentially infectious materials, unless identification is not possible or is prohibited by state or local law
- Complete the Post-Exposure Form with signatures, and send a copy to Human Resources
- Send the original Post-Exposure Form along with the Medical File Report Form with the employee to the emergency department or other licensed health care provider of their choice (for best results, testing must be done within 20 minutes and prophylactic medicine administered within 2 hours of the exposure). Healthcare providers should complete the Medical File Report Form and return it to Human Resources within 15 days of the evaluation.
- If a source individual cannot be identified, is unavailable, or will not consent to testing, the exposed employee will be notified. If the source individual is known and is available, inquiries should be made to determine if the source individual is willing to have his/her blood tested for HIV and HBV. If a source individual refuses testing, the refusal must also be documented on the Post-Exposure Form in the source individual information section. If the source individual agrees to testing, he/she shall be referred to an emergency room or a health practitioner of his/her choice for pre-test counseling. If a source individual is already known to be HIV, HBV, or HCV-positive, new testing is not required.
Consent and record releases should be obtained by a licensed healthcare provider or other HIPAA-trained individual. DO NOT ATTEMPT TO GAIN CONSENT FROM THE SOURCE INDIVIDUAL BY COERCION. THE SOURCE INDIVIDUAL IS NOT LEGALLY REQUIRED TO SUBMIT TO TESTING.
- Walla Walla University and health care providers must provide the exposed employee with:
- results of the source individual's testing
- information about applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual
- the option to obtain an initial evaluation with appropriate lab studies, so that the employee is able to make an informed choice regarding post-exposure immunization
- counseling, if requested
- The exposed employee has the option to decline HIV testing. If the employee does not give consent for testing, the baseline blood sample must be preserved for at least 90 days. If the exposed employee decides to have the sample tested during this time, the testing must be performed as soon as feasible. A written copy of the healthcare provider opinion(s) will be provided to the employee.
The Dean of the School of Nursing will maintain a confidential record of percutaneous injuries from contaminated sharps and other mucus membrane exposures. A summary of the information will be provided to Human Resources. Information included in the log will include at a minimum:
- the type and brand of device involved in the incident
- the department or work area where the exposure incident occurred
- an explanation of how the incident occurred
The Needle-Stick/Sharps Injury Log will be maintained for five years following the year of the injuries to which they relate.
Contaminated PPE shall be disposed of by placing it in a biohazard bag available in the Manager's workshop and contacting the Manager for pickup.
Provided by the Manager, student employees, and an outsourced custodial service.
Filled and closed bags will be disposed of by the Manager.
Decontamination of specialty equipment and the surrounding area is the responsibility of the owning department.
In cases of response by emergency medical personnel, the outsourced custodial service is responsible for the area once the patient has been removed. In cases where immediate cleanup and decontamination is not possible, the Manager will be notified and the area secured until it can be cleaned.
Hepatitis B Employee Fact Sheet
The Hepatitis B vaccine series is available at no cost to all employees who have been identified in this plan as being at risk of occupational exposure. The vaccine series will be explained at the employee training session and made available within 10 days of initial assignment of the duties which may result in potential exposure. Departments will coordinate and cover the cost of the vaccinations through Island Hospital or the employee's primary care provider.
Vaccination is encouraged unless
- documentation is provided stating the employee has previously received the vaccination series
- antibody testing reveals the employee is immune
- medical evaluation shows that vaccination is contraindicated, and a copy of the health care professional's written opinion will be provided to the employee
Employees who choose to decline the vaccination must sign Walla Walla University's Hepatitis B Vaccine Declination form. This form informs employees that should they decline the vaccine yet experience continued occupational exposure, they may at any time and at no cost ask for and receive the vaccination series. Completed declination forms will be maintained by Human Resources in confidential personnel files.
Departments with employees at risk of occupational exposure will be responsible for insuring that their employees receive training on bloodborne pathogens. Training in compliance with the regulations is available through SafetySkills. Training will be conducted during working hours or the employee will be compensated for the time. Training must take place before initial assignment to tasks where occupational exposure may take place, annually thereafter, and when changes in tasks or procedures take place that affect occupational exposure.
Training will include:
- epidemiology, symptoms, and transmission of bloodborne pathogens
- copy and explanation of WAC 296-823, Occupational Exposure to Bloodborne Pathogens
- explanation of the University's Exposure Control Plan and how to obtain a copy
- methods used to identify tasks and other activities that may involve exposure to blood and OPIM
- what constitutes an exposure incident
- the use and limitations of controls, work practices, and PPE
- the basics of PPE selection and explanation of:
- types
- uses
- location
- handling
- removal
- decontamination
- disposal
- information on the Hepatitis B vaccine including:
- effectiveness
- safety
- method of administration
- benefits of being vaccinated
- that the vaccination series is offered at no charge to employees
- actions to take and persons to contact in an emergency involving blood of OPIM
- procedures to follow if an exposure incident occurs, including:
- how to report an incident
- medical follow-up available
Walla Walla University recognizes the value of information on bloodborne pathogens; therefore, any interested employee may complete the bloodborne pathogens training provided. However, only designated "at-risk" employees will be eligible for HBV vaccinations at the University's expense.
Walla Walla University Employee Training Forms are available for use. These training forms will include a space for each participating employee's name, training date, and signature. Training records will be maintained by the individual departments.
Following the initial first aid treatment, such as cleaning the wound and flushing eyes or other mucous membranes for at least 5 minutes, the Bloodborne Pathogens Post-Exposure Control Plan will be followed.
- Walla Walla University provides to employees who have an occupational exposure a confidential medical evaluation and follow-up, if they so desire, and the cost will be covered by the University's Workers' Compensation Insurance. Faculty/staff must obtain a Bloodborne Pathogens Exposure Packet from the Manager or Academic Office. The packet contains:
- Faculty/staff will immediately notify the Manager or the Academic Director of the occupational exposure incident, who will secure the area.
- Supervisors will:
- Ensure that the Manager or Academic Director has been notified of the occupations exposure incident
- Ensure the Accident/Near Miss Report is completed by the employee and returned to Human Resources within 24 hours after the incident.
- Complete the Accident/Near Miss Investigation Report and return to Human Resources within 72 hours after the incident.
- Identify and document the route of exposure and how the exposure occurred
- Identify the source of any potentially infectious materials, unless identification is not possible or is prohibited by state or local law
- Complete the Post-Exposure Form with signatures, and send a copy to Human Resources
- Send the original Post-Exposure Form along with the Medical File Report Form with the employee to the emergency department or other licensed health care provider of their choice (for best results, testing must be done within 20 minutes and prophylactic medicine administered within 2 hours of the exposure). Healthcare providers should complete the Medical File Report Form and return it to Human Resources within 15 days of the evaluation.
- If a source individual cannot be identified, is unavailable, or will not consent to testing, the exposed employee will be notified. If the source individual is known and is available, inquiries should be made to determine if the source individual is willing to have his/her blood tested for HIV and HBV. If a source individual refuses testing, the refusal must also be documented on the Post-Exposure Form in the source individual information section. If the source individual agrees to testing, he/she shall be referred to an emergency room or a health practitioner of his/her choice for pre-test counseling. If a source individual is already known to be HIV, HBV, or HCV-positive, new testing is not required.
Consent and record releases should be obtained by a licensed healthcare provider or other HIPAA-trained individual. DO NOT ATTEMPT TO GAIN CONSENT FROM THE SOURCE INDIVIDUAL BY COERCION. THE SOURCE INDIVIDUAL IS NOT LEGALLY REQUIRED TO SUBMIT TO TESTING.
- Walla Walla University and health care providers must provide the exposed employee with:
- results of the source individual's testing
- information about applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual
- the option to obtain an initial evaluation with appropriate lab studies, so that the employee is able to make an informed choice regarding post-exposure immunization
- counseling, if requested
- The exposed employee has the option to decline HIV testing. If the employee does not give consent for testing, the baseline blood sample must be preserved for at least 90 days. If the exposed employee decides to have the sample tested during this time, the testing must be performed as soon as feasible. A written copy of the healthcare provider opinion(s) will be provided to the employee.