THE ORCBS > Biological Safety > Programs & Guidelines > Exposure Control Plan >

Methods of Compliance

Universal Precautions

Employees at Michigan State University will observe universal precautions. All human blood and other potentially infectious materials (OPIM) are treated as if they are known to be infectious for HBV, HIV and other bloodborne pathogens.

Universal precautions apply to blood and other potentially infectious body fluids including tissues, semen, vaginal secretions, cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids.

Universal precautions currently do not apply to feces, nasal secretions, sputum (spit), sweat, tears, urine, vomit, or saliva unless they are visibly contaminated with blood. In circumstances where it is difficult or impossible to differentiate between body fluid types, all fluids are assumed to be potentially infectious.

Engineering Controls

Where engineering controls such as hand washing facilities, eye wash stations, sharps disposal containers, biological safety cabinets, ventilating laboratory hoods, autoclaves, and safer sharps devices will reduce employee exposure either by eliminating or isolating the hazard, they must be used.

The ORCBS and departments will review tasks and procedures performed to determine where engineering controls can be implemented or updated. The Department Manager or Supervisor will ensure that employees are trained regarding the use of the engineering controls for their job classification and the tasks/procedures they perform. This training will be documented through the completion of the Site-specific Training Checklist form and a Task-Specific Assessment for Controlling BBP Exposure Risk form (see Appendix E).

The ORCBS will upon request inspect:

• areas where engineering controls are currently employed;
• areas where engineering controls can be updated;
• areas currently not employing engineering controls, but where engineering controls could be beneficial.

The following engineering controls are to be used throughout the University:

1. Safer sharps devices are to be used, where appropriate, in order to reduce the risk of injury from needlesticks and from other sharp medical instruments. (Refer to section on the Sharps Injury Protection Program)
   
   Note: Needles that will not become contaminated by blood or OPIM during use (such as those used to draw medication from vials) are not required to have engineering controls.
   
2. Hand washing facilities are readily accessible to all employees who have a potential for exposure. Waterless antiseptic hand cleansers or antiseptic towelettes must be available to employees at risk of exposure if running water is not readily available. If waterless cleansers or towelettes must be used, the employee must follow-up with a soap and water wash as soon as feasible.
   
3. Emergency eye wash stations are in close proximity to workstations where employees perform tasks that produce splashes of potentially infectious materials. Eyewash stations should meet the following ANSI requirements:
   
   • Provide at least 0.4 gallons of water per minute for 15 continuous minutes, flushing both eyes simultaneously with hands free to hold eyes open.
   • Eye wash facilities must not exceed 95 psi (pounds per square inch) water flow pressure.
   • It is recommended that the eye wash facility be flushed on a regular basis. A log documenting the recommended weekly five minute flush is encouraged.
   
   Note: Specifications for eyewash stations found in the MSU Chemical Hygiene Plan must be adhered to in areas where hazardous chemicals are used. Please direct your questions regarding the design of the eye wash facility specific for your laboratory to the ORCBS.
   
4. Autoclaves are available in many departments to decontaminate solid biohazardous waste. These departments will monitor this equipment to assure that proper sterilization occurs. Proper instrumentation will be used to verify that time, temperature, and steam are adequate. In addition, the ORCBS will provide an annual check of all autoclaves on campus that are used for decontaminating biological wastes. Please contact the ORCBS for specifics regarding the annual autoclave check.
   
5. Sharps containers are used to properly store and dispose of sharps. Approved sharps containers are designed to isolate the cut or puncture hazard associated with handling sharp items such as needles, scalpels, or Pasteur pipettes. Approved sharps containers are:
   
   • puncture-resistant
   • red in color or labeled with a biohazard warning label
   • leak-proof on the sides and bottom
   • closable
   
   Containers for reusable sharps must meet the same requirements as containers for disposable sharps, with the exception that they are not required to be closable. Reusable sharps will not be stored or processed in a manner that requires reaching into containers of contaminated sharps.
   
   Approved sharps containers are available from University Stores. Food containers such as coffee cans should not be used to dispose of contaminated sharp objects.
   
6. Storage containers are used to reduce the possibility for an environmental release of potentially infectious materials. Primary containers should be designed to be leak-proof, puncture-resistant, and capable of being closed. Single primary containers used for potentially infectious materials should be labeled with the biohazard symbol.
   
   Exceptions:
   
   • Containers of blood, blood components, or blood products which are labeled as to their contents and which have been released for transfusion or other clinical use are exempted from these labeling requirements.
   • Individual containers of blood or other potentially infectious materials that are placed in a labeled container during storage are exempted from labeling requirements.
     
   Examples of containers that must be labeled as biohazardous if storing blood or potentially infectious materials:
   
   • Refrigerator
   • Freezer
   • Liquid nitrogen tank
   • Incubator
     
7. Transport containers are secondary containers that are used to reduce the possibility for an environmental release of potentially infectious materials when transporting biological materials locally between campus facilities as well as over the local roadways.
   
   1. Use primary containers designed to contain the material to be stored (as described above).
   2. Place primary sample containers into a leak-resistant, securely covered secondary container for transport (i.e. cooler with a latchable lid)
   3. If sample materials contain liquids, place enough absorbent material (i.e. paper towels) in the secondary container to absorb all free liquids in the event of breakage or leakage.
   4. Package primary containers in the secondary container in a manner that will reduce shock and/or rupture. (Bubble wrap or similar shock-absorbing "spacer" materials may be used.)
   5. Label secondary containers with a brief description of the contents and an emergency contact name and phone number. Containers used for transporting blood specimens (regardless of source) or specimens known or suspected to contain a pathogen (affecting humans or animals) should be additionally labeled with the biohazard symbol.
   6. Use a University-owned vehicle whenever possible for transport. Store and secure the transport container in a location in the vehicle whereby if an accident were to occur, the container or its contents will not be an exposure risk to the driver or the environment.

Note: When shipping using a ground or air carrier (i.e. FedEx, UPS, DHL), contact the ORCBS biological safety team at 353-1877, 432-5262, or 355-1283.

Work Practices

Supervisors, working in conjunction with Deans, Directors, Chairpersons or designees will oversee the implementation of Work Practice Controls in cooperation with the ORCBS. The Department Manager or Supervisor will ensure that employees are trained to use work practice controls for their job classification and the tasks/procedures they perform. This training will be documented through the completion of the Site-specific Training Checklist form and a Task-Specific Assessment for Controlling BBP Exposure Risk form (see Appendix E).

The following Work Practice Controls are to be implemented:

1. Employees will wash their hands:
   
   • after removal of gloves or other personal protective equipment;
   • when visible contamination with blood, body fluids, or other potentially infectious materials are present;
   • when work is completed and before leaving the laboratory;
   • before eating, drinking, smoking, applying makeup, changing contact lenses, or using the bathroom;
   • before activities that entail hand contact with mucous membranes, eyes, or breaks in the skin.
     
   Note: Alcohol based hand rubs may be used by healthcare personnel for patient care. When health care personnel's hands are visibly soiled, they should wash with soap and water.
   
2. Contaminated needles and other contaminated sharps must not be bent, recapped or removed unless:
   
   • it can be demonstrated that there is no feasible alternative or
   • the action is required by a specific medical procedure.
   
   Removing the needle from a used blood-drawing/phlebotomy device is rarely, if ever, required by a medical procedure.
   
   When recapping or removal of needles is required because there are no alternatives, a mechanical device or a one handed method must be used.
   
3. Use mechanical means (i.e. tongs) when handling contaminated sharps when possible and eliminate hand-to-hand passing of sharp instruments.
   
4. Contaminated sharps must be placed in appropriate containers immediately, or as soon as possible after use.
   
5. Eating, drinking, smoking, applying cosmetics or lip balm and handling contact lenses is prohibited in work areas where there is potential for exposure to bloodborne pathogens.
   
6. Food and drink must not be kept in refrigerators, freezers, on countertops, or in other storage areas where blood or other potentially infectious materials are present (See Appendix C).
   
7. Mouth pipetting/suctioning of blood or other infectious materials is prohibited.
   
8. Minimize splashing, spraying or other actions generating droplets of blood or other potentially infectious materials during all procedures. At a minimum, Biosafety Level 2 precautions are required for laboratories working with specimens of blood or body fluids. Contact the ORCBS for further information and assistance regarding these requirements.
   
9. Specimens of blood or other materials must be placed in designated leak-proof containers, appropriately labeled for handling and storage. If outside contamination of a primary specimen container is likely, that container must be placed within a second leak-proof container, appropriately labeled, for handling and storage. If the specimen can puncture the primary container, the secondary container must be puncture-resistant.
   
10. Primary containers of potentially infectious materials must be placed in puncture-resistant, leak-proof, closable secondary containers for transportation outside of the work area (i.e. from lab to lab where a common hallway is used, etc.).
    
11. Perform disinfection and housekeeping procedures as outlined in "Housekeeping" section of this Exposure Control Plan.

Personal Protective Equipment (PPE)

Personal protective equipment will be provided by the employer at no cost to the employee with an occupational exposure to blood or potentially infectious material. This equipment may include: gloves, gowns, laboratory coats, face shield/masks, safety glasses, goggles, mouthpieces, resuscitation bags, pocket masks, hoods, and shoe covers.

The Department Manager or Supervisor will ensure that all work areas have appropriate personal protective equipment available to employees. Employees must be trained regarding the use of the appropriate personal protective equipment for their job classification and the tasks/procedures they perform. This training will be documented through the completion of the Site-specific Training Checklist form and a Task-Specific Assessment for Controlling BBP Exposure Risk form (see Appendix E).

Personal protective equipment is considered to be appropriate only if it does not permit blood or other potentially infectious material to pass through to or reach the employee's work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time that the protective equipment will be used.

An employer shall ensure that the personal protective equipment is available in appropriate sizes and accessible locations.

An employer shall ensure that an employee uses appropriate personal protective equipment unless the employer shows that the employee temporarily and briefly declined to use PPE when, under rare and extraordinary circumstances, it was the employee's professional judgment that in the specific instance the use of PPE would have:

• prevented the delivery of health care or public safety services or
• posed an increased hazard to the safety of the worker or coworker.

When the employee makes this judgment, the circumstances shall be investigated and documented to determine if changes can be made to prevent future occurrences.

1. All personal protective equipment must be inspected periodically by the department manager or supervisor and repaired or replaced as needed.
2. Reusable personal protective equipment is cleaned, laundered and decontaminated as needed.
3. Single-use personal protective equipment (or equipment that cannot, for whatever reason, be decontaminated) is disposed of through existing practices and procedures as outlined in the MSU Waste Disposal Guide.

Employees must adhere to the following practices when using personal protective equipment:

1. Any garments, including personal clothing, penetrated by blood or other infectious materials, must be removed as soon as possible. These garments are to be collected in biohazard bags and decontaminated by the MSU Laundry facility or an appropriate laundry service provider that is selected by the department or disposed of as biohazardous waste.
   
2. All personal protective equipment must be inspected prior to use to verify that it is in good working condition.
   
3. All personal protective equipment must be removed prior to leaving the work area.
   
4. Gloves must be worn when:
   • employees anticipate hand contact with potentially infectious materials;
   • performing vascular access procedures;
   • handling or touching contaminated items or surfaces.
     
5. Disposable gloves must be replaced as soon as possible after contamination or immediately when torn, punctured, or are otherwise rendered unable to function as an exposure barrier.
   
6. Non-latex gloves must be provided to employees who are allergic to the gloves normally provided.
   
7. Utility gloves must be decontaminated for reuse; if utility gloves are cracked, peeling, torn or exhibit other signs of deterioration, they must be disposed.
   
8. Masks and eye protection must be used whenever there is a chance that a splash or spray may generate droplets of infectious materials.
   
9. Protective clothing must be worn whenever potential exposure to the body is anticipated.
   
10. Surgical caps/hoods and shoe covers/boots must be used in any instances where gross contamination is anticipated.

Sharps Injury Protection Program

Supervisors of all departments who have employees with occupational exposure to bloodborne pathogens must:

• consider and, where appropriate, use effective engineering controls, including safer sharps devices, in order to reduce the risk of injury from needlesticks and from other sharp medical instruments.
  
  Note: An appropriate safer sharps device includes only devices whose use, based on reasonable judgment in individual cases, will not jeopardize patient or employee safety or be medically contraindicated.
  
• establish a program for evaluating safer sharps devices designed to eliminate or minimize occupational exposure. This program should include an identification process, an evaluation process and a selection process.
  
• review the sharps that are being used on an annual basis. (See Annual Review section below.)

Identification Process:

Supervisors shall identify all sharp devices that have available products with safer engineering features and determine which products are to be evaluated.

Evaluation Process:

1. Evaluation of the safer sharps devices must be documented on the "Safer Sharps Device Evaluation Form". See Appendix F.
2. Supervisors in departments that have direct patient care cannot evaluate and select the safer sharps devices alone; supervisors must choose members of non-managerial employees who perform tasks with sharps exposure risks to be involved in this process.
3. Supervisors must provide at least four or more test samples of each product being evaluated to each individual evaluating the product.
4. Supervisors will ensure that visual instructions and a demonstration of the proper use of each device is provided to all evaluators.
5. Supervisors will review the instructions and rating system on the evaluation form with each evaluator.
6. Supervisors should encourage each evaluator to comment on the forms. This will provide a useful decision making tool.
7. Supervisors will keep all records of completed evaluation forms in their department.

Note: If safer sharps devices are currently in use, the evaluation process must still be completed.

Note: If there is no safer option for a particular sharps device used where there is exposure to blood or OPIM, you are not required to use something other than the device that is normally used. This information must be documented. During your annual review of devices, you must inquire about new or prospective safer options.

Selection Process:

Once the evaluation process is complete and the safer sharp device has been chosen, supervisors must implement use of the safer sharps devices as soon as possible.

Note: The selection and implementation process cannot be postponed in order to use up supplies of non-safer sharps. Additionally, when the safer sharps are in place, supplies of the non-safer sharps may not be used. Contact the ORCBS for disposal assistance if needed. Do not put unused supplies in the trash or send to salvage.

Note: If the safety device is not available (due to supply shortages, back orders, shipping delays, etc.), this must be documented.

Annual Review:

All sharps that are being used where there is exposure to human blood or OPIM must be reviewed on an annual basis. This will be accomplished by completing a "Safer Sharps Devices Annual Review Form". (Appendix F) This form should be completed annually and kept with departmental records.

The purpose of this review form is to document annual consideration and implementation of appropriate commercially available and effective safer sharps devices designed to eliminate or minimize exposure.

The review and update must reflect innovations in procedure and technological developments that eliminate or reduce exposure to bloodborne pathogens. This includes, but is not limited to, newly available sharps devices designed to reduce the risk of percutaneous exposure to bloodborne pathogens.

Resources:

• For the latest EpiNet list of safety-engineered sharp devices and other products designed to prevent occupational exposures to bloodborne pathogens, log on to:
  
  http://www.healthsystem.virginia.edu/internet/epinet/safetydevice.cfm
  
  The International Healthcare Worker Safety Center at the University of Virginia Health System

• For more information of safer sharps devices and manufacturers, please contact University Stores at 355-1700, ext. 202 or the ORCBS at 355-0153.
  

Housekeeping

Departments and Units, together with Custodial Services or other assigned employees must do the following:

1. Clean and decontaminate all equipment and surfaces after contact with blood or other potentially infectious materials. Gross contamination must be removed before decontaminating to ensure the disinfectant is completely effective. Clean and decontaminate:
   
   • after the completion of medical procedures;
   • immediately (or as soon as feasible) when surfaces become contaminated;
   • after any spill of blood or infectious materials;
   • at the end of the work shift, especially if the surface may have become contaminated during that shift.
   
   Note: Decontamination must be performed with a disinfectant product that is EPA-registered as a tuberculocidal or effective for the destruction of Hepatitis B and HIV. Refer to the "Disinfection" section in Appendix D.
   
2. Ideally, equipment that becomes contaminated will be cleaned and disinfected prior to servicing or shipping. In addition, an Equipment Release Form must be attached. Please refer to the MSU Laboratory Close-out Procedures for more information (see Appendix C). If it can be demonstrated that decontamination is not possible, then the following steps need to be taken:
   
   • a biohazard warning label is attached to any contaminated equipment, identifying the contaminated portions;
   • all affected employees, the equipment manufacturer and the equipment service representative, are informed of remaining contamination prior to handling, servicing or shipping.
     
3. Clean up spills of infectious materials as soon as possible. The following considerations should be made when treating and removing a spill of infectious material:
   
   • Wear appropriate personal protective equipment when cleaning up spills;
   • Spills should be covered with an absorbent material, wiped up and disposed of in a biohazard bag;
   • Disinfectant must be applied to contaminated surfaces for the amount of time prescribed by the manufacturer to assure effective decontamination.
   
   Note: Any department that has a potential for a spill of potentially infectious materials should have a spill kit and a spill response procedure. An example of a general response procedure and items for assembling a departmental spill kit are included in Appendix D.
   
4. Remove and replace protective coverings as soon as possible when these become contaminated, and also at the end of the work shift.
   
5. Routinely inspect all pails, bins, cans and other receptacles for contamination. Clean these items on a routine basis and decontaminate whenever visibly contaminated.
   
6. Pick up potentially contaminated broken glassware using mechanical means (such as dustpan and brush) and dispose of in an appropriate sharps container.
   
7. Inspect laundry to verify that it is free of sharps and other hazardous materials prior to placement in the hamper and shipment to the laundry. Handle contaminated laundry as little as possible. Facilities with high volumes of contaminated laundry have red laundry carts that are leak proof and signify contamination. Facilities without red laundry carts should place any contaminated laundry in a biohazard bag. Attach a label to the bag listing contaminants (i.e. blood).
   
8. When disposing of biohazardous waste:
   
   • Place waste in a biohazard labeled secondary leakproof container with a lid that is lined with a biohazard bag.
   • If autoclaving, biohazard bags must be autoclaveable. After autoclaving, place bags in a non-transparent bag and dispose in the regular solid waste receptacle.
   • Place containers for regulated waste within easy access to employees and as close as possible to the source of the waste;
   • Maintain waste containers in an upright position, replace routinely, and do not overfill;
   • Close the containers of regulated waste after use and for disposal or transportation to the autoclave or waste collection site.
   • Blood and body fluids may be disposed of by pouring liquid wastes down the sanitary sewer system.
   
   Note: Biohazardous wastes are not to be held in the work area for more than 90 days. All biohazardous waste will be disposed of according to the procedures outlined in the MSU's Waste Disposal Guide and the MSU Biohazardous Waste Management Plan.

HIV and HBV Research Laboratories/Production Facilities

Exposure Control Plan Table of Contents