BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN

DEPARTMENT OF THE ARMY
HEADQUARTERS, WALTER REED ARMY MEDICAL CENTER
WASHINGTON, DC 20307-5001

1. Purpose: To prescribe policies, responsibilities and procedures for implementation of the Bloodborne Pathogen Exposure Control Plan (BBPECP) to meet the letter and intent of the OSHA Bloodborne Pathogens Standard (29 CFR 1910.1030). OSHA has enacted this standard to "reduce occupational exposure to Hepatitis B Virus (HBV), Human Immunodeficiency Virus (HIV) and other bloodborne pathogens". This plan details measures WRAMC and its employees will take to decrease the risk of transmission of bloodborne pathogens and provide appropriate treatment and counseling should an employee be exposed to bloodborne pathogens. This regulation supercedes WRAMC Regulation dated, 26 Aug 1996.

2. Applicability: This plan is applicable to all personnel working in all of Walter Reed Army Medical Center's (WRAMC) clinical and administrative activities. Tenant units will comply with applicable portions of this plan and supplement it with their own plan as necessary. Any tenant having employees with occupational exposure to bloodborne pathogens as defined in this regulation is required to develop an exposure control plan in accordance with 29 CFR 1910.1030. This plan also applies to medical care for bloodborne pathogen exposure provided to non-employee, military health-care beneficiaries not covered under 29 CFR 1910.1030.

3. References: Required and related references are listed in Appendix A. Prescribed and referenced forms are also listed in Appendix A.

4. Abbreviations/Terms: Abbreviations and special terms used in this regulation are explained in the glossary.

5. Joint Commission Standards: Standards IC.1 through IC.6 of the Commission on Accreditation of Healthcare Organizations Accreditation Manual for Hospitals apply throughout this publication.

6. General Philosophy: There are a number of "good general principles" that should be followed when working with bloodborne pathogens. These include:

a. It is prudent to minimize all exposure to blood and other potentially infectious materials.

c. WRAMC will institute as many engineering and work practice controls as possible to eliminate or minimize employee exposure to bloodborne pathogens.

a. Commander, WRAMC will issue a command policy statement demonstrating support for full compliance with the BBPECP.

b. Deputy Commander for Clinical Services will monitor the overall compliance with the BBPECP.

c. Department and service chiefs and all supervisory personnel will ensure that:

(1) All personnel in positions listed in the Exposure Determination section of this plan receive training as outlined in the Information and Training section of this plan annually.

(2) All personnel undergo immunization review and latex allergy screening on initial employment and annually thereafter.

(3) The hepatitis B vaccine immunization program is implemented in accordance with (IAW) the provisions of this regulation.

(4) Required personal protective equipment (PPE) and engineering controls are available to all personnel at no cost to the employee. This will also include low or no latex supplies and equipment for those employees who are latex sensitive.

(6) Compliance is monitored and evidence of results and actions taken to correct problems is maintained.

(7) Employees are supervised in the related practices, the need for further training is evaluated, and remedial action is taken as needed.

(8) Policies and procedures in the department support compliance with the provisions of this plan.

(10) Employees who have had exposure incidents report to the ER for initial evaluation and to the Occupational Health Clinic (OHC) for evaluation and follow-up.

(11) The source of the BBP exposure is evaluated in accordance with this plan if the source is still present in their area of responsibility.

(12) All personnel are oriented as required in the Information and Training section of this plan before they begin work.

(1) Have their immunization status and latex allergy screening reviewed on initial employment and annually thereafter.

(2) Comply with the hepatitis B vaccine immunization program as specified in this regulation.

(3) Know what tasks they perform that have occupational exposure to bloodborne pathogens.

(5) Plan and conduct all operations including use of PPE in accordance with this BBPECP and departmental infection control policies.

(6) Use good personal hygiene practices and report or correct any unsafe practices that may lead to bloodborne pathogen exposure.

(7) Report all exposure incidents to their supervisor and follow evaluation guidelines as per this document, to include periodic follow-up through the OHC.

(1) Provide consultation and assistance with equipment, policies, and practices as requested.

(2) In cooperation with the Occupational Health Section, provide initial and annual refresher training for all employees to meet the provisions of the BBP Standard and maintain the training records required by the BBP Standard.

(4) Assist departments in meeting the orientation provisions of the Information and Training section of this plan when requested.

(5) Annually, or as required, review and if necessary update this plan with the Occupational Health Section.

(6) Monitor implementation and compliance with this plan in conjunction with the Preventive Medicine Service and the Safety Office.

(7) Review the feasibility and testing of new engineering controls as they become available.

(8) In coordination with the Occupational Health Section, analyze BBP incident data to identify trends and propose preventive measures. Data analysis will be presented to the appropriate department for implementation/action as indicated.

coordination with the Infection Control Service ensure its annual review and revision whenever necessary.

(2) Monitor implementation and compliance with the BBPECP in conjunction with the Infection Control Service and with the Safety Office.

(2) Manage the hepatitis B vaccination, post-exposure evaluation, and follow-up provisions of this plan in conjunction with the Department of Allergy and Immunology.

(3) With the Infection Control Service, provide training for all employees to meet the provisions of the BBP Standard.

(4) Report all exposure incidents to the Safety office for documentation in OSHA Log 200 or Federal log equivalent for reporting occupational injuries and illnesses. Work with Safety Office to develop preventive strategies to reduce exposure incidents.

(5) Screen all employees on initial employment and annually thereafter for latex sensitivity. Those employees who have possible sensitivity to latex will be referred to the Allergy and/or Dermatology Clinic for further evaluation and will be placed on low or no latex exposure precaution.

(6) Provide initial orientation during inprocessing to all employees who may be exposed to BBP.

(7) Coordinate the review of the BBPECP annually or as required and update if necessary.

(1) Provide follow-up counseling to employees involved in exposure incidents with high risks for HIV or hepatitis, upon referral from the Occupational Health Clinic.

(2) Provide follow-up evaluation and counseling of non- employee military health care beneficiaries exposed to BBP who seek care at WRAMC.

(1) Collect data on all exposure incidents to bloodborne pathogens and develop or recommend remedial actions to reduce exposures. Data collected will be reported to the Safety Committee.

(2) Ensure all exposure incidents are properly documented on the OSHA 200 or Federal Log equivalent for reporting occupational injuries and illnesses.

(3) Investigate reports of circumstances in which an employee declines to use Personal Protective Equipment IAW para. 11.c.(1)(d) of this document.

(1) Implement the Hepatitis B Vaccine Immunization Program IAW the provisions of this regulation.

(2) Provide consultation and guidance on need and timing for checking immune titers and/or re-vaccination.

(3) Provide evaluation (and definitive diagnosis if possible) to all employees who may have an allergic latex sensitivity.

(1) Provide consultation for employees who sustain high-risk exposures or need HIV prophylaxis as per current published medical guidelines.

(2) Provide evaluation and treatment for all active duty employees who develop a subsequent infection after an exposure incident.

(3) Provide evaluation and offer treatment for all Department of the Army civilian employees who develop a subsequent infection after an exposure incident. Long-term care will be on a case by case basis.

(1) Ensure that all emergency room staff are trained and knowledgeable on the evaluation and treatment, required for employees who sustain an exposure incident as defined in this document.

(2) Provide evaluation, treatment, referral and consultation for employees who sustain an exposure incident as defined in this document.

(3) Ensure that copies of the evaluation, treatment, and consultation for employees who sustain an exposure incident are available or forwarded to the OHC.

(1) Adequately stock levels of personal protective clothing and equipment to include low or no latex items.

(l) Ensure military health records are maintained IAW AR 40-66, Medical Record Administration.

(2) Provide a copy of the information to consulting health-care professionals as a result of any exposure to bloodborne pathogen upon request.

<3> Keep the information in these medical records confidential. Information will not be disclosed to anyone without employees written consent, except as required by law or regulation.

(1) Coordinate a program for initial and annual training which meets the provisions of the BBP Standards.

(2) Collect written verification of attendance at training sessions and provide to Infection Control Service and NESD Training Database Manager.

p. Nursing Education and Staff Development will ensure that the list of attendees at training sessions provided by the Quality Improvement Office is computerized by the NESD Training Database Manager and a monthly report of attendance is provided to each department chief.

(2) Provide pre-placement BBP and CDC Standard Precautions training and hepatitis B vaccine immunization prior to working at WRAMC and BBP and CDC Standard Precaution training annually to all personnel identified in the contract as having occupational exposure as defined in Appendix B of this regulation.

(3) Maintain training and immunization records for contract personnel and students with occupational exposure.

(5) Contractors with personnel identified by the contract as having occupational exposure as defined in this regulation will have their own BBPECP which will be compatible with this regulation and submitted as part of the contract.

(1) Ensure that contracts for personnel identified as having occupational exposure to BBP contain the requirement to comply with all provisions of this regulation and 29 CFR 1910.1030 including hepatitis B immunization, BBP training, BBP exposure incident follow-up, records maintenance and BBPECP.

(3) Ensure that any BBPECP is reviewed by the Occupational Health Section and Infection Control Service.

(2) Be medically screened by the OHC and receive pre-placement immunization review and receive, or decline in writing, the hepatitis B vaccine immunization in accordance with the provision of this regulation.

Precautions training provided by WRAMC prior to volunteering and annually thereafter.

t. Resource Management Division will ensure that Memorandums of Agreement for all civilian training programs in which students will have occupational exposure to BBP as defined in this regulation contain the requirement to comply with all provisions of this regulation and 29 CFR 1910.1030, including hepatitis B vaccine immunization, BBP training, BBP exposure incident follow-up and records maintenance.

(1) Monitor compliance by students in civilian training programs with the hepatitis B vaccine immunization and BBP training provisions of this regulation.

(2) Notify the civilian training program regarding any student who has not complied with the requirement.

8. Availability of the BBPECP: A copy of the BBPECP will be available on every shift in work areas where there is the potential for blood and body fluid exposure.

9. Review And Update of the BBPECP: The Preventive Medicine Service and the Infection Control Service are responsible for reviewing the plan annually and for revising it whenever necessary.

a. All employee positions within the Medical Treatment Facility have been evaluated for occupational exposure to bloodborne pathogens as defined as "reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of the employee’s duties", regardless of the use of personal protective equipment.

b. The resulting exposure determination and the hepatitis B vaccine immunization policy are contained in

(1) The BBP Standard which was published in 1987 called for The implementation of Universal Precautions to prevent contact with blood or other potentially infectious materials. Universal Precautions required all employees to treat blood, body fluids and tissues of all patients as potentially infectious with HBV, HIV, and other bloodborne pathogens. Precautions were intended to prevent parenteral, mucous membrane and skin exposure to blood and body fluids.

(2) The Centers for Disease Control and Prevention revised their isolation guidelines and have replaced the category of Universal Precautions with Standard Precautions.

(3) Standard Precautions combines the major features of Universal Precautions, designed to reduce the risk of transmission of bloodborne pathogens, and Body Substance Isolation, designed to reduce the risk of transmission of pathogens from moist body substances.

(b) All body fluids, secretions, and excretions except sweat, regardless of whether or not they contain visible blood. Sweat is not considered to be infectious unless contaminated by visible blood.

(5) Standard Precautions will be used in the care of all patients regardless of their diagnosis or presumed infection status to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infections.

(6) Standard Precautions include: hand washing, use of PPE, handling patient-care equipment, environmental control, handling of linen, patient placement, and occupational methods for reducing the risk of bloodborne pathogen exposure.

(a) Engineering and work practice controls will be implemented as the primary means of eliminating or minimizing employee exposure to blood and body fluids. When occupational exposure remains after institution of engineering and work practice controls, PPE will be used.

(b) Engineering controls are controls that either isolate the employee from the hazard or remove the hazard from the workplace. Examples include sharps disposal containers, bio-safety cabinets, splash guards, and needleless IV systems.

(c) Work practice controls are those that reduce the likelihood of exposure by altering the manner in which a task is performed. An example of a required work practice control is prohibiting recapping of needles with a two-handed technique.

(d) All employees will be trained by their supervisor in the use of any engineering control before they are required to use it.

(a) Handwashing facilities will be readily accessible to employees. Approved alcohol based waterless hand cleansers and paper towels must be used in all areas where sinks are not readily available.

(b) Handwashing technique: Wet hands and apply soap; lather for 10-15 seconds insuring that fingernails and areas between fingers are washed; rinse thoroughly; dry hands with individual paper towels; and turn off faucet using a clean, dry paper towel.

(c) Employees will wash their hands immediately or as soon as feasible after removal of gloves or other personal protective equipment.

(d) Employees using a waterless hand cleaner must wash hands with soap and running water as soon as feasible.

(e) Employees will wash hands and any other skin with soap and water, or flush mucous membranes with water, immediately or as soon as feasible following contact of such body areas with blood or other potentially infectious materials.

(f) Hand cream application is permitted if the hands are thoroughly washed immediately prior to application. Hand creams must be from small, individual, nonrefillable containers and not shared between individuals.

(a) Contaminated needles and other contaminated sharps will not be bent, sheared, or broken.

(b) Contaminated needles will not be recapped or removed from syringes unless it can be demonstrated that there is no feasible alternative or the action is required by specific medical procedure. The two exceptions where recapping the needle is permitted are: performing a blood gas and administering incremental doses of a medication such as an anesthetic to the same patient. Removing the needle from a vacutainer sleeve is permitted only in the phlebotomy room of the laboratory. Other areas should use disposable vacutainer sleeves. Recapping with the traditional two-handed method is prohibited. Recapping, when permitted, will be performed with the one-hand scoop method (the hand holding the sharp is used to scoop up the cap from a flat surface) or by using forceps to replace the cap. Removing the needle from a vacutainer sleeve will be done using the special area on the sharps container where the needle is inserted and the vacutainer is used to unscrew the needle and the needle drops into the sharps container or using another device such as forceps. (NOTE: Other exceptions must be submitted to the Infection Control Committee for approval. Applications must include a justification for the need to recap or remove a needle.)

(c) Immediately, or as soon as feasible after use, contaminated needles or other sharps will be placed in leakproof, puncture resistant sharps containers by the person using the sharps. Sharps containers are located in patient rooms and in other areas as close to where sharps are used as feasible. Sharps containers in patient rooms are in a wall cabinet. This cabinet and the disposable sharps liners are to be labeled with a biohazard symbol IAW the Labels and Signs section of this plan. Chemotherapy sharps containers will be labeled IAW the Labels and Signs section of this plan. All other sharps containers will be red in color.

(e) Disposable sharps containers will be removed and replaced with a new one when 3/4 full. They will be closed off by securely locking the closure mechanism and placed in the Regulated Medical Waste area for pick-up by housekeeping. If a sharps container is found to be leaking, it must be placed in a larger sharps container which will then be labeled and sealed. The OIC in each work area is responsible for insuring that sharps containers are replaced when 3/4 full and are not overfilled.

(f) Contaminated reusable sharps will be placed in containers until properly processed. The containers are puncture-resistant, leakproof on the sides and bottom, and labeled with a biohazard label IAW the Labels and Signs section of this plan. The containers need not be closable. Employees will not reach by hand into these containers. Employees will not reach into a water-filled sink or pan to retrieve contaminated instruments. Instead a perforated tray can be used or the instruments can be retrieved with a reliable hand-held device (e.g. forceps). A closed container for reusable sharps will also be available in the Fabric Care Facility.

(g) Instrument pans or other reusable containers used for sharp instruments will be cleaned with soap and water and then disinfected with a 1:10 solution of bleach or sterilized after each use.

(h) Where there are no in-room sharps containers(e.g. in psychiatric units), needle users have two options: Carry a small sharps container to the room to immediately discard the sharp or use a self-sheathing needle/syringe unit.

(i) A needleless IV system will be used for access into IV lines. Stopcocks may also be used.

(k) Sharps containers must be mounted on solid surfaces unless under constant observation.

(a) Bio-safety cabinets and splash guards will be used in laboratories to minimize splashing, spraying, splattering, and generation of droplets.

(b) Engineering controls will be examined and maintained or replaced on a regular schedule to insure their effectiveness i.e. that they have not been removed or broken, that ventilation systems of bio-safety cabinets are functioning properly, and that filters are replaced frequently enough. The OIC in each work area will establish a written inspection and routine maintenance schedule for the engineering controls in that area.

(c) The Hospital Product Committee will review the feasibility of testing engineering controls as new ones enter the market.

(5) Handling and Packaging. All specimens of blood, body fluids, and tissues will be handled using CDC Standard Precautions and will be transported in sealed clear plastic bags. Specimen containers will be securely closed before placing in the bag. If outside contamination of the bag or primary container occurs, the bag or primary container shall be placed within a second container which prevents leakage during handling, processing, storage, transport, or shipping. If the specimen could puncture the primary container, the primary container will be placed within a second container which is puncture resistant. Containers used for transporting or shipping specimens outside the facility will be puncture resistant and will be labeled with a biohazard label IAW the Labels and Signs section of this plan.

(6) Contaminated Equipment. Equipment which may be contaminated with blood or body fluids will be examined prior to servicing or shipping and will be decontaminated as necessary. If decontamination of the equipment is not possible (personnel do not have training to take apart technologically advanced equipment or equipment design prohibits cleaning), a readily observable label will be attached to the equipment stating which portion may be contaminated and this information will be conveyed to all affected employees, the servicing representative, and/or the manufacturer, as appropriate, prior to handling, servicing, or shipping so that appropriate precautions will be taken. See section on Labels and Signs for required label characteristics. See Section on Housekeeping for instructions on decontamination. Biomedical maintenance personnel will be instructed in precautions to practice during decontamination of equipment.

(a) All procedures involving blood or other body fluids shall be performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets of these substances.

(c) Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in all work areas where there is a reasonable likelihood of occupational exposure. Eating or drinking are permitted only in designated areas separate from contaminated areas. Employees must remove any contaminated clothing or protective barriers prior to entering the clean area.

(d) Food and drink shall not be placed in refrigerators, freezers, shelves, cabinets, or on countertops or benchtops where blood or other potentially infectious materials are present or where specimens have been placed.

(e) Employees who have exudative lesions or weeping dermatitis will not perform or assist in invasive procedures or other direct patient care activities or handle equipment used for patient care.

(a) Supervisors will ensure that personal protective equipment in the appropriate sizes is readily available to employees in each work area that requires it. Supervisors will insure that employees are trained in its use and use it as required.

(b) PPE is provided at no cost to the employee and includes, but is not limited to, gloves, gowns, laboratory coats, face shields, masks, eye protection, and mouthpieces, resuscitation bags, pocket masks, or other ventilation devices.

(c) PPE is considered appropriate only if it does not permit blood or other potentially infectious materials 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 which the PPE will be used.

appropriate PPE, unless the supervisor can show 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 its use would have prevented the delivery or health care or public safety services or would have posed an increased hazard to the safety of the worker or a co-worker. When an employee makes this judgment, the supervisor will investigate and document the circumstances. The documentation will be forwarded to the Safety Manager no later than the next duty day. The supervisor and the Safety Manager will determine whether changes need to be instituted to prevent such occurrences in the future. A decision not to use protective barriers will not be applied to a particular work area or a recurring task. Neither interference with ease of performance of a procedure nor improper fit are acceptable reasons to not use PPE.

(e) Failure to use PPE, except under the circumstances listed above, may result in disciplinary action.

(f) Supervisors will ensure that PPE in the appropriate sizes is readily accessible at the worksite or is issued to employees. Hypoallergenic gloves, glove liners, powderless gloves, or other similar alternatives will be readily accessible to those employees who are allergic to gloves normally provided. Allergy/

sensitivity to gloves provided must be documented by the OHC. Once documented, the supervisor will obtain the alternative recommended by the OHC.

(g) PPE will be cleaned, laundered, or disposed of by WRAMC at no cost to personnel. Laboratory coats that are used as PPE will be laundered by the hospital and not taken home for laundering. Personal clothing contaminated by blood or body fluids will be laundered by the hospital laundry at no cost to the employee. Supervisors will contact the contracting officer's representative for the Fabric Care Facility, Bldg. 606, at (301) 295-7630/31 to make arrangements for laundering personal clothing when contaminated.

(h) Supervisors will ensure repair or replacement of all reusable equipment as needed to maintain effectiveness.

(i) If PPE items are penetrated by blood or other potentially infectious materials, the item will be removed immediately or as soon as is feasible.

(j) All PPE will be removed prior to leaving the work area. PPE will not be worn into designated break areas.

(a) Proper fitting latex gloves will be worn when it can be reasonably anticipated that the employee may have hand contact with blood, other body fluids, mucous membranes, and non-intact skin; when performing vascular access procedures; and when handling or touching contaminated items or surfaces.

(b) Examples of tasks where gloves will be worn are: phlebotomy, performing finger or heel sticks; during instrumental examination of the oropharynx, gastrointestinal tract, and genitourinary tract; during invasive procedures; during all cleaning up of body fluids and decontaminating procedures; while handling and cleaning processing blood, body fluid and tissue specimens; when examining abraided or non-intact skin or patients with active bleeding; when emptying drains and foley-catheter bags; and when rendering emergency medical assistance to individuals with traumatic injury.

(c) Single use disposable latex gloves shall be replaced as soon as practical when contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised.

(d) Gloves will be changed and hands washed between patients or during the care of a single patient when moving from a contaminated to a clean body site or from one contaminated site to another contaminated site.

(g) Disposable gloves such as surgical or examination gloves will not be re-used.

(h) Sterile surgical gloves will be used for procedures involving contact with normally sterile areas of the body.

(i) Latex examination gloves will be used for procedures involving contact with mucous membranes, unless otherwise indicated, and for other patient care or diagnostic procedures that do not require the use of sterile gloves.

(j) Double gloving may be used for invasive surgical procedures where prolonged contact with blood may be expected.

(k) Used gloves will not be used to touch telephones, computers keyboards, charts, elevator buttons, or other uncontaminated surfaces.

(l) Personnel engaged in non-patient care services should use gloves appropriate to their type of work. Heavy duty utility gloves may be preferable for housekeeping personnel. Utility gloves may also be worn for cleaning instruments. These gloves may be washed and disinfected for reuse if the integrity of the glove is not compromised. If gloves are cracked, peeling, torn, or punctured, they will be discarded.

(m) Hypoallergenic gloves, low or no latex gloves, glove liners, powderless gloves or other alternatives will be provided to those workers who have documented allergies to the gloves normally provided. For employees involved in high risk procedures double gloving with an inner vinyl and outer latex glove may be considered.

(b) Masks in combination with eye protection devices, such as goggles or glasses with solid side shields, or chin-length face shields shall be worn whenever splashes, spray, spatter, or droplets of blood or other body fluids may be generated and eye, nose, or mouth contamination can be reasonably anticipated.

(c) Prescription glasses may be used as protective eyewear as long as they are equipped with solid side shields that are permanently affixed or of the "add-on" type.

(d) Procedures requiring masks and eye protection include endotracheal intubation, bronchoscopy, GI endoscopy, gastric tube placement, dental procedures that splatter, autopsy, certain surgical and other invasive procedures, emptying containers of fluids, and irrigation’s.

(e) During microsurgery, when it is not reasonably anticipated that there would be any splattering, it would not constitute a violation for the surgeon, while observing surgery through a microscope, not to wear other eye protection.

(i) Reusable goggles and face shields will be washed with an approved detergent and water and disinfected with a 1:10 solution of bleach after each use.

(a) Gowns, aprons, laboratory coats, or clinic jackets must be worn when there is the potential for reasonably anticipated soiling of clothing with blood or other potentially infectious materials.

(b) A cover garment is appropriate only if it does not permit blood or other body fluids to pass through to or reach the employee's work clothes, street clothes, or undergarments.

(d) A long-sleeved cover will be worn when arms are likely to become contaminated.

(e) Scrubs are not considered PPE and will be covered by appropriate gowns, aprons, or laboratory coats when splashes to skin or clothing are anticipated.

(f) A gown which is frequently ripped or falls apart under normal use would not be considered appropriate PPE.

(g) A cloth gown or disposable cover gown will not generally prevent gross liquid contamination from soaking through to the skin, but they are adequate protection for common bedside patient care procedures in situations when gross liquid/blood contamination is not likely.

(h) Examples of activities requiring gowns or aprons are: caring for a bleeding patient, changing the bed of an incontinent patient, lifting or moving a patient with draining wounds, diagnostic and therapeutic procedures that may cause splattering or aerosolization, and autopsy.

(i) Gowns and aprons should be worn only once and then be removed and placed in the appropriate receptacle. These items will not be worn out of the work area.

(j) Cloth gowns and lab coats will be placed in the hospital laundry containers (or turned in as appropriate).

(k) Paper or plastic gowns/aprons will be discarded in the appropriate waste receptacle.

(5) Head and Foot Covers. Surgical caps or hoods and/or shoe covers or boots will be worn during surgical procedures, autopsies, or other situations when gross contamination can be reasonably anticipated. Shoe covers must be removed prior to leaving the work area to limit migration of contamination via shoes into other areas. Shoe covers must be removed prior to leaving the operating area. Wearing the shoe covers throughout the 4^th floor is no longer acceptable.

(6) Resuscitative Devices. Seal-easy masks are available in each patient room and in other areas of the hospital where patients and staff are located for use during mouth-to-mouth resuscitation to prevent direct contact between the employee and the patient. Ambu-bags are at each bedside in critical care areas and on each crash cart in the hospital. The seal-easy masks are disposable and will be discarded after each use. Ambu-bags that are reusable will be bagged and sent to CMS for high-level disinfection or sterilization. Disposable ambu-bags are available.

(1) General housekeeping services in the Heaton Pavilion will be provided through the Environmental Services Branch of the Hospital Logistics Division.

(2) Each section in the hospital has specific cleaning procedures to be performed by each section’s personnel that are prescribed in the section’s Infection Control Standing Operating Procedures. Supervisors will ensure that the work area is maintained in a clean and sanitary condition.

(3) All cleaning supplies and disinfectants used at WRAMC will be approved by the Infection Control Committee.

(4) All equipment and environmental and working surfaces will be properly cleaned and disinfected after contact with blood or other potentially infectious materials and on a regular schedule with an appropriate disinfectant.

(5) Contaminated work surfaces will be cleaned and disinfected with an appropriate disinfectant after completion of procedures; immediately or as soon as feasible when surfaces are overtly contaminated or after any spill of blood or other body fluids; and at the end of the work shift if the surface may have become contaminated since the last cleaning. A phenolic disinfectant approved by the Infection Control Committee and used according to the manufacturer's directions will be used in the laboratory, and the operating rooms. The dialysis unit uses bleach for same purposes.

(6) Blood spills will be cleaned up immediately with a hospital approved disinfectant/detergent and water and the area disinfected with a 1:10 solution of household bleach or an approved phenolic disinfectant. Wards and clinics with infrequent or small spills may use Cavicide® cleaner disinfectant: Clean up the spill using Cavicide®, then spray Cavicide® on the area, wipe over it, and allow the area to dry.

(7) Protective coverings such as plastic wrap, aluminum foil, or imperviously-backed absorbent paper may be used to cover equipment and environmental surfaces. These shall be removed and replaced as soon as feasible when they become overtly contaminated and between patients.

(8) All bins, pails, cans, and similar waste receptacles intended for reuse which have a potential for becoming contaminated with blood or other body fluids shall be inspected on a weekly basis and cleaned with an approved detergent and water, and decontaminated with a 1:10 solution of bleach or cleaned/decontaminated with a phenolic detergent/disinfectant immediately or as soon as possible after visible contamination and at least monthly.

(9) Reusable items contaminated with blood or other body fluids will be managed as follows:

(a) Items returned to CMS: Instruments and items returned to CMS in the red container soaking system should be placed into the enzymatic soak immediately or as soon as feasible after use. Items too large or not appropriate for red containers must be cleaned, rinsed, and placed in a plastic bag transport (the bag should be clear and labeled IAW the Labels and Signs section of this plan).

(b) Items to remain in the clinical area: These should be cleaned with detergent and water and wiped down with 1:10 solution of bleach, phenolic disinfectant, or Cavicide®.

(10) Broken glassware which may be contaminated will not be picked up directly with the hands. It will be cleaned up using mechanical means, such as a brush and dust pan, tongs, or forceps.

Location	Frequency	Cleaners And Disinfectants Used
Patient room	Daily	Approved quaternary ammonium disinfectant
Patient bathroom	Daily	Approved quaternary ammonium disinfectant
Exam room	Daily; weekly if exam table is covered during use and procedures are not done.	Approved quaternary ammonium disinfectant
Procedure room	Between procedures	Approved quaternary ammonium disinfectant
Operating Room	Between cases	Approved phenolic disinfectant
Dialysis	Between patients	Approved phenolic disinfectant or approved detergent and 1:10 bleach solution
Laboratory	When contaminated and/or daily	Approved phenolic disinfectant

(1) Regulated Medical Waste (RMW), including sharps, will be disposed of IAW WRAMC Reg 40-2. This regulation should be available in every work area where RMW is generated.

(2) When moving containers of contaminated sharps from the area of use, the containers will be closed immediately prior to removal or replacement to prevent spillage or protrusion of contents during handling, storage, transport, or shipping. If leakage is possible, the container will be placed in a secondary container that is closable, constructed to contain all contents and prevent leakage during handling, storage, transport, or shipping and labeled or red in color IAW the Labels and Signs section of this plan.

(3) Other regulated medical waste is placed in red plastic bags that line containers or are on stands which are labeled IAW the Labels and Signs section of this plan. When 3/4 full, the bags are closed, the box is sealed. If outside contamination of the box occurs, the waste is placed in a second bag inside another labeled box.

(4) Appropriate PPE will be used when handling containers of RMW as described in the Personal Protective Equipment section.

(2) All soiled linen will be handled using CDC Standard Precautions. Personnel handling linen soiled with blood or other body fluids will use appropriate PPE as described in the Personal Protective Equipment section.

(4) Soiled linen will be collected in the hospital-approved laundry bags at the location where it was used. If linen is excessively wet, it should be placed in an impervious laundry bag.

(5) Laundry from WRAMC is sent to the Fabric Care Facility at Forest Glenn Annex for cleaning.

(1) The Department of Defense (DOD) hepatitis B vaccination policy was established in October 1996 for DOD employees, students, volunteers and contract employees who provide care within DOD medical and dental treatment facilities. The policy is in Appendix B.

(2) 29 CFR 1910.1030, the OSHA Bloodborne Pathogen Standard states that "the employer shall make available the hepatitis B vaccine and vaccination series to all employees who have occupational exposure". Occupational exposure is defined as "reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties".

(3) Based on the guidelines detailed above, WRAMC has established the policy for implementation of the hepatitis B vaccine immunization program which is contained in Appendix B. Each employee to which this policy applies will be given the hepatitis B vaccination after receiving training as detailed in the Information and Training section of this regulation and within 10 working days of initial assignment unless exempt as listed above.

(4) Pre-vaccination screening to determine immunity to the hepatitis B virus will be performed upon request but is not a prerequisite for receiving the hepatitis B vaccination.

(5) The vaccination will be provided at no cost to DOD employees and any other personnel when included in a written agreement/contract.

(6) The Hepatitis B vaccine Immunization program consists of a series of three inoculations over a six month period. The OHC in conjunction with Allergy/Immunization Clinic is responsible for setting up and operating the vaccination program. Vaccinations are performed under the supervision of a licensed physician or other health care professional. Hepatitis B vaccine is administered IAW United States Public Health Service recommendations. If at a future date a routine booster of hepatitis B vaccine is recommended, it will be made available to employees.

(7) Employees will be evaluated by the OHC for initiation of the hepatitis B vaccination series at the time of employment. During the evaluation, the OHN will provide the employee with information on the hepatitis B vaccine. In accordance with the OSHA Bloodborne Pathogens Standard, within 15 days of the completion of the evaluation, the OHN will provide the employee with a provider’s written opinion, on WRAMC Overprint 611 (Health Care Provider’s Written Opinion for Hepatitis B Vaccination) of whether hepatitis B vaccination is indicated for the employee. A copy of the form will be placed in the employee’s medical record and a copy will be sent to the employee’s supervisor.

(8) A record of the vaccination status of all civilian employees will be maintained by the OHC. This database will be reviewed and updated annually on all employees through the Birth Month Annual Review (BMAR), and Soldier Readiness Processing(SRP) program. Any currently employed civilian employee hired prior to January 1, 1997, having declined to be vaccinated will have a signed declination statement WRAMC Overprint 602, (Hepatitis B Vaccination Declination) on file IAW 29 CFR 1910.1030. A notation will be made if employee declines to sign the declination form. This statement will be maintained in the employee’s medical record. Employees who initially decline the hepatitis B vaccination can receive the vaccine at a later date upon request.

(9) In addition to hepatitis B vaccination status screening, the OHC will screen employees on initial employment and annually thereafter for latex sensitivity. Those employees who have possible sensitivity to latex will be referred to the Allergy and/or Dermatology Clinic for further evaluation and will be placed on low or no latex exposure precautions.

(1) General. Needlesticks, cuts and splashes to the eye or mouth involving blood or other potentially infectious materials are serious occurrences. Because they may result in exposure to bloodborne pathogens such as HIV, hepatitis B virus and hepatitis C virus, they must be handled thoughtfully and expeditiously.

(2) Self aid. Immediately after an exposure incident, the employee should administer self aid. Self aid should be completed prior to all other activities.

(a) Needlesticks. Allow the area to bleed freely. Wash the area with a bacterial solution or at a minimum with soap and water.

(b) Non-intact skin exposure. Wash the area with a bacteriocidal solution or soap and water.

(a) After self aid, the employee will immediately notify the immediate supervisor that a BBP exposure has occurred.

(b) The supervisor will ensure that the injured employee reports immediately to the ER for initial evaluation and treatment and to the OHC for follow-up. Evaluations must be initiated immediately so that the post-exposure prophylaxis may be administered as soon as possible after the exposure.

(For high risk HIV exposure, the CDC recommends anti- retroviral prophylaxis within the first one to two hours following exposure.)

(c) WRAMC has the right to evaluate employees who are injured on the job and are filing a Form CA-1 Federal Employee’s Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation or Form CA-2 Notice of Occupational Disease and Claim of Compensation. Employees with suspected BBP exposure should report to the ER for evaluation as soon as possible after the exposure incident. After evaluation by the ER, the employee has the right to choose a civilian physician for treatment or to accept treatment by WRAMC. If the employee has initiated a CA-1/CA-2 claim and desires treatment by a private physician, the employee may obtain the necessary Department of Labor forms from the WRAMC FECA office requesting private physician treatment.

(a) The immediate supervisor will identify the source of the exposure, if possible.

(b) If the source is available, the supervisor will explain the importance of assisting the injured employee by agreeing to be evaluated for potential bloodborne pathogens.

(c) If the source is an outpatient who is still in the clinic, he/she will be requested to accompany the employee and supervisor to the ER for evaluation.

(d) If the source is an ambulatory surgery patient or an outpatient who has already left the clinic, the supervisor will contact the source’s physician and inform the physician that he/she must contact the ER to coordinate evaluation of the source.

(e) If the source is an inpatient, the ER will contact the source’s physician, physician coverage, or ward head nurse to coordinate evaluation of the source.

(a) The ER will immediately triage the employee and source if present and initiate evaluation and treatment IAW the algorithm at Appendix C.

(b) The ER will document the evaluation on WRAMC Overprint 594 (Needlestick or Blood/Body Fluid Exposure) (see Appendix C) and WRAMC Form 2072 (WRAMC Uniform Needlestick, Sharp Injury, and Blood/Body Fluid Exposure Report.)

(c) Evaluation of the source will be completed by the source’s physician or the ER and documented on WRAMC Overprint 593 (Blood and Body Fluid Exposure: Risk Assessment of Known Source) (see Appendix C). The risk assessment of the source will be used by the ER to determine the testing and treatment required by the employee.

(d) The ER will provide the injured employee with a copy of the Information Sheet for Patients Who Have Sustained a Needlestick Injury or Other Body Fluid Exposure (See Appendix C)and review contents with the employee.

(e) Testing for active duty military is mandatory. Prior to obtaining blood samples for HIV and other testing, a civilian employee or civilian source must be counseled by a health care provider. Consent for HIV testing for civilians must be documented in their medical record on WRAMC Form 2076 (Informed Consent and Agreement to HIV Testing). If the civilian employee or source refuses to be tested, this fact must be documented on WRAMC Form 2076. If the employee consents to baseline blood collection but does not give consent at that time for HIV serologic testing, the sample shall be preserved for at least 90 days. If within 90 days of the exposure incident the employee elects to have the baseline sample tested, he/she will notify the OHC. The OHC will then notify the Laboratory to test the blood sample as soon as possible.

(f) If the source is known to be HIV positive or is determined to be high risk for being HIV positive at the time of the exposure, the employee shall be counseled and given the option of anti-retroviral prophylaxis. The ER will coordinate with the Infectious Disease Service for counseling and initiation of treatment.

(g) The ER will send the injured employee to the OHC immediately (next duty day if evening, holiday or weekend) after evaluation and treatment in the ER for completion of OSHA regulated documentation. The ER will place the original of WRAMC Overprint 594, WRAMC Overprint 593, WRAMC Form 2072 and WRAMC Form 2076(for civilian employees) in the OHC box in the ER. The ER will keep the pink copy of the WRAMC Overprint 594 and 593 and give the yellow copy of WRAMC Overprint 594 to the employees (See Appendix C).

(h) If a civilian employee chooses to be treated by a private Health-care professional after the initial evaluation, the OHC will forward the following documentation: description of the exposure incident; results of the source’s risk assessment and blood testing, if available; and all medical records relevant to the evaluation and treatment of the employee including vaccination status.

(i) Contractors, students and volunteers will seek follow-up care from the source of medical care identified in their contract or agreement. The contracting company/volunteer agency/school will be provided a letter informing them of the exposure incident.

prophylaxis for hepatitis B, hepatitis C and HIV IAW CDC guidelines and the protocol in Appendix C. Documentation of test results will be made on WRAMC Overprint 600 (Results of Bloodborne Pathogen Exposure Incident Evaluation) and placed in the employee’s medical record. A copy will be maintained in the OHC. If employee declines to participate in the recommended follow-up and tests, this will be documented in the medical record.

(b) IAW the BBP Standard, the OHC will ensure that the employee has been informed of the results of their testing and the results of the source’s testing and acting as the employee’s representative, will provide the employee with the Healthcare Professional’s Written Opinion within 15 days of the completion of the evaluation with emphasis on confidentiality, the written opinion will be limited to the following: a statement that the employee has been informed of the results of the evaluation; and a statement that the employee has been told about any medical conditions resulting from the exposure incident which require further evaluation or treatment. All other findings or diagnoses will remain confidential and will not be included in the written report. The opinion will be documented on WRAMC Overprint 601 (Healthcare Provider’s Written Opinion for Bloodborne Pathogen Exposure) by the OHC. The original form will be given to the employee, a copy will be sent to the employee’s supervisor, a copy will be placed in the employee’s medical record, and a copy will be filed in the OHC.

(c) In order to make sure that employees receive the standard of care and timely treatment if exposed to a bloodborne pathogen, a post-exposure evaluation and follow-up checklist will be completed by the OHC. QA review of the checklist will verify that all the steps in the process have been completed.

circumstances surrounding the exposure incident. The supervisor will initiate the following forms: WRAMC Form 1332, Supervisors Report of Occupational Accident which will be forwarded to the Safety Office; DA Form 1811 (Risk Management/Quality Improvement Report) which will be forwarded to the Quality Improvement Office. For civilian employees, the supervisor will instruct the employees where to obtain a DOL Form CA-1 (Notification of Traumatic Injury and Claim for Continuation of Pay/Compensation), or CA-2 Notice of Occupational Disease and Claim for Compensation. The CA-1/CA-2 forms will be forwarded to the WRAMC FECA office by the supervisor with a copy to the Safety Office.

(b) The Safety Office will investigate every exposure incident that occurs in this facility. This investigation involves gathering information. The Safety Office will document all recordable exposure incidents on the OSHA 200 Log.

(c) The OHC will collect data on the types and circumstances of BBP incidents and provide the data to the Infection Control Service which will analyze the data to identify trends and propose preventive measures.

(8) BBP Incident Evaluation Forms. All WRAMC forms referenced in this regulation can be obtained through WRAMC publication supply channels.

(1) The OHC will establish and maintain an accurate record for each civilian employee with occupational exposure, in accordance with 29 CFR 1910.1020.

(2) Active duty employees’ personal health record will also serve as their record for occupational exposure. This record will be maintained by Patient Administration Directorate.

(e) Results of the examinations, medical testing, counseling and follow-up procedures which took place as a result of an employee's exposure to bloodborne pathogens.

medical records is confidential and will not be disclosed or reported to anyone without the employee's written consent, except as required by regulation or law.

treatment facility during the time of employment and are kept permanently at the National Records Center after the civilian employee/active duty member retires or leaves federal/military service.

(2) Refrigerators/freezers containing blood or other potentially infectious materials.

(3) The clear sharps container liners and the wall cabinets for the sharps containers.

(4) Containers used to store, transport, or ship blood and other potentially infectious materials outside of the facility (Individual specimen containers do not require a label nor do the clear plastic sealed bags used to transport specimens within the hospital).

b. Labels will be fluorescent orange or orange-red with letters or symbols in a contrasting color. The label will include the following legend:

c. Labels used to identify contaminated equipment will have a space for indicating which portion of the equipment is contaminated and, if known the containment.

identified in Appendix B will participate in initial training, annual training within one year of their previous initial or annual training, and training whenever changes in procedures or tasks occur which may affect occupational exposure.

(3) Training must be appropriate in content, language, and vocabulary to the educational, literacy, and language background of the employees.

(4) The Quality Improvement Office will coordinate the initial and annual training at WRAMC as described below to meet the provisions of the BBP Standard.

(1) All employees with occupational exposure as identified in the Exposure Determination section of this plan will participate in orientation prior to being placed in positions where occupational exposure may take place. Infection Control Service provides this orientation to inprocessing personnel during the Command Newcomer's Orientation. Supervisors in each work area must provide orientation to the use and location of engineering controls, PPE, cleaning and disinfection supplies, RMW containers, laundry bags, and this BBPECP in that area.

(2) Individuals who start work which may expose them to bloodborne pathogens prior to attending Command Orientation must be thoroughly oriented to this plan by the supervisors in their work area.