Safety Manual:
Bloodborne Pathogens (BBP) Exposure Control Plan 

Human Immunodeficiency Virus (HIV), Hepatitis B virus (HBV), Hepatitis C, and other blood-borne pathogens have long been recognized as a hazard for health care workers who are exposed to blood. In the mid-1980’s, reports documenting the transmission of HIV to health care workers were published. Several other diseases carry varying but lesser risk. In response to these concerns, on December 6, 1991, the Occupational Safety and Health Administration published a final standard on the prevention of occupational exposure to blood-borne pathogens. 

On November 6, 2000, President Clinton signed the Needlestick Safety and Prevention Act. This act directed OSHA to revise the blood-borne pathogens standards. OSHA subsequently implemented federal regulations (29 Code of Federal Regulations Part 1910 Occupational Exposure to Blood-borne Pathogens Needlesticks and Other Sharps Injuries Final Rule) on January 18, 2001.

The purpose of this plan is to comply with these regulations and to identify and practice measures which protect healthcare workers from new threats as the threats are identified.

This plan applies to all NKY Health staff.

In order to ensure the safest possible work environment, staff will be trained as follows:

• All staff will be trained in the procedures and information presented in this plan at the time of hire , any time the plan changes and annually thereafter.

• Staff who are affected under a plan change will be trained at the time the plan changes.

• Annual updates will be coordinated by the Employee Health Nurse.

• Training records for NKY Health employees are maintained in a learning management system and/or personnel files

Jobs are classified into three categories as follows:

A.    Positions that usually do have occupational exposure

B.    Positions that may have occupational exposure

C.   Positions that usually do not have occupational exposure

In all three classifications, the individual responsibilities of EACH staff must still be reviewed to determine the potential for exposure to blood-borne pathogens.

Staff in non-classified and/or contract positions will be evaluated on a case-by-case basis.

In the following job classifications, all employees have occupational exposure as part of their normal work routine.

• Advance Practice Registered Nurse (APRN)

• Clinic Licensed Practical Nurse (Clinic LPN)

• Clinic Manager

• Clinic Registered Nurse (Clinic RN) - (I and II)

• Clinic Supervisor II

• Community Licensed Practical Nurse (Community LPN)

• Community Registered Nurse (Community RN) - (I and II)

• Director of Clinical Services

• Health Educator for HIV/Prevention and Harm Reduction

• Medical Director

• Oral Health Program Coordinator

• Oral Health Program Manager

• Programs Manager

• Programs Supervisor (I and II)

• Public Health Registered Dental Hygienist (Public Health RDH)

• Registered Dental Hygienist (RDH)

In the following job classification, some employees may have occupational exposure as part of their normal work routine:

• Case Manager

• Clinic Registered Dietitian (Clinic RD)

• Community Registered Dietitian (Community RD)

• Director of Environmental Health and Safety

• Director of Population Health

• Disease Intervention Specialist (DIS)

• Disaster Preparedness Specialist

• Environmental Health Manager

• Environmental Health Supervisor II

• Environmental Health Worker

• Epidemiology Manager

• Epidemiologist

• Health Educator

• Nutrition Manager

• Nutrition Supervisor

• Programs Manager

• Programs Supervisor

• Registered Environmental Health Specialist (REHS) (I and II)

In the following job classifications, employees do not have occupational exposure as part of their normal work routine:

• Accounting Coordinator

• Accounting Specialist

• Accounting Supervisor

• Administrative Office Associate

• Administrative Office Associate/Interpreter

• Budget and Grants Manager

• Buildings and Accounting Administrator

• Case Manager

• Clinic Clerk

• Data Analyst

• Deputy Director of Health

• District Director of Health

• District Executive Assistant

• Division Executive Assistant

• Environmental Health Assistant

• Environmental Health Worker

• Front Office Associate

• Front Office Associate/Interpreter

• Front Office Supervisor

• Health Educator

• Human Resources Administrator (HR Administrator)

• Human Resources Coordinator (HR Coordinator)

• Human Resources Specialist (HR Specialist)

• Information Systems Analyst (IS Analyst)

• Public Information Coordinator (PI Coordinator)

• Public Information Officer (PIO)

• Public Information Specialist (PI Specialist)

• Planner

• Public Health Impacts Administrator

• Support Services Supervisor

The following tasks and procedures or groups of closely related tasks and procedures may be/are performed by employees in job classifications listed in “A: Positions that Usually Do Have Occupational Exposure” and “B: Positions that May Have Occupational Exposure” above, and may result in occupational exposure to bloodborne pathogens: 

• The performance of venipuncture, heelsticks or fingersticks.

• The performance of intravenous, intramuscular, subcutaneous or intradermal administration of vaccine or medications.

• The use and handling of needles, sharp instruments, scalpels or similar devices during routine clinical procedures or diagnostic examinations. The cleaning of used instruments, and the disposal of needles, blades and other sharps.

• The collection and handling of all smears, cultures and specimens of all bodily fluids (whether or not they contain visible blood). The collection and handling of unfixed tissue from a human, living or deceased.

• The physical examination of the pelvis, rectum and genitalia; contact with all mucous membranes, including the nose and mouth.

• The performance of invasive procedures; the manipulation, cutting or removal of any oral tissue including tooth structure in which bleeding occurs; the handling of intra-oral devices; contraceptive implant and insertion.

• The performance or assistance in vaginal delivery; and in handling the placenta or newborn infant’s skin.

• The performance of wound care, tracheostomy or enterostomy care, dressing changes, enemas, removing of impactions or catheter care. 

Professional judgment must be used in all situations to determine the level of protection required. 

Standard orange fluorescent biohazard warning labels must be affixed to all regulated waste containers, refrigerators containing blood or other potentially infectious material, and any other containers used to store, transport or ship blood or other potentially infectious materials. Containers or vacutainers of blood or blood products that are labeled as to their contents and are being clinically tested within the facility are exempt from labeling requirements. Red bags or red containers may be substituted for labels. Individual containers that are placed in a larger labeled container for storage, transport or shipment need not be individually labeled.

The labels on regulated waste will have an A or B underneath the biohazard symbol indicating the class of infectious waste. If the container has a mixture of types, the letter A will be used. Labels must be affixed as closely as feasible to containers by string, wire, adhesive or another method to assure that labels are not lost or unintentionally removed.

Labels are also required for any contaminated laboratory equipment and must state which portion(s) of the equipment is contaminated. Regulated waste that has been decontaminated does not need to be labeled.

NKY Health will ensure that all staff identified as having the potential for an occupational exposure participate in an annual training program provided at no cost to staff and during work hours. 

New staff identified as having the potential for exposure must receive training during the orientation period or prior to undertaking tasks where exposure may take place. Additional training will be provided if a staff’s change in duties increases the chance of exposure.

An instructor familiar with infection control theory and practice will be responsible for providing and assessing the effectiveness of the training. Initial and annual training programs must contain (at a minimum) the following components:

• A general explanation of the epidemiology, modes of transmission and symptoms of infection with bloodborne pathogens.

• An explanation of NKY Health's exposure control plan, the location of the plan, and how staff can obtain a copy.

• An explanation of the appropriate methods of recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials.

• An explanation of the use and limitations of methods that will prevent or reduce exposure including appropriate engineering controls, work practices and personal protective equipment.

• Information on the types, proper use, location, removal, handling, decontamination and disposal of personal protective equipment.

• An explanation of the basis for selection of personal protective equipment.

• Information on the Hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine, vaccination, and blood testing will be offered free of charge.

• Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials.

• An explanation of the procedures to follow if an exposure incident occurs , including the method of reporting the incident and the medical follow-up that will be made available. (Note: the blood of the source patient may be sent for testing immediately after an exposure incident if the patient signed form CH 22a Consent for Health Services and the NKY Health Post-exposure Incident Consent Form, Source Individual.)

• Information on the post-exposure evaluation and follow-up that NKY Health provides for staff following an exposure incident.

• An explanation of the signs, labels and/or color coding in use by NKY Health.

• Ample opportunity for questions and answers.

Additionally, copies of federal OSHA regulations (29 CFR 1910.1030, Occupational Exposure to Blood-borne Pathogens) outlining the requirements for employers and NKY Health’s exposure control compliance plan must be available and easily accessible to each trainee.