Kevin Ian Schmidt

Bloodborne Pathogen Exposure Control Plan

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An employer exposure control plan (ECP) is a requirement of 29 CFR 1910.1030(c) of the Bloodborne Pathogens Standard established by the Occupational Safety and Health Administration (OSHA). The purpose of the ECP is to establish procedures to eliminate or minimize employee exposure to bloodborne pathogens.

Bloodborne Pathogen Policy

Notice in the sample below, the policy is specific to a facility, not the business. This is because a business with multiple work-sites must have a separate Exposure Control Program for each site.

The policy establishes the required contents of the ECP.

Sample Policy

The (Your facility name) is committed to providing a safe and healthful work environment for our entire staff. In pursuit of this goal, the following exposure control plan (ECP) is provided to eliminate or minimize occupational exposure to bloodborne pathogens in accordance with OSHA standard 29 CFR 1910.1030, “Occupational Exposure to Bloodborne Pathogens.”

The ECP is a key document to assist our organization in implementing and ensuring compliance with the standard, thereby protecting our employees. This ECP includes:

  • determination of employee exposure
  • implementation of various methods of exposure control, including:
    • universal precautions
    • engineering and work practice controls
    • personal protective equipment
    • housekeeping
  • hepatitis B vaccination
  • post-exposure evaluation and follow-up
  • communication of hazards to employees and training
  • recordkeeping
  • procedures for evaluating circumstances surrounding exposure incidents

Implementation methods for these elements of the standard are discussed in the subsequent pages of this ECP.

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Program Administration

The program administration section of the Exposure Control Plan (ECP) is very important. Within this section of the ECP, the people and/or departments responsible for the various administrative functions are identified.

The program administrative section determines who will:

  • implement the ECP
  • maintain, review, and update the ECP
  • provide PPE and all necessary equipment or materials
  • ensure all medical actions required are performed and OSHA records are maintained
  • ensure training and document the training
  • make available the ECP to employees, OSHA and/or NIOSH representatives

 

Sample Program Administration

  • (Name of responsible person or department) is (are) responsible for implementation of the ECP. (Name of responsible person or department) will maintain, review, and update the ECP at least annually, and whenever necessary to include new or modified tasks and procedures. Contact location/phone number: __________.
  • Those employees who are determined to have occupational exposure to blood or other potentially infectious materials (OPIM) must comply with the procedures and work practices outlined in this ECP.
  • (Name of responsible person or department) will provide and maintain all necessary personal protective equipment (PPE), engineering controls (e.g., sharps containers), labels, and red bags as required by the standard. (Name of responsible person or department) will ensure that adequate supplies of the aforementioned equipment are available in the appropriate sizes. Contact location/phone number: __________.
  • (Name of responsible person or department) will be responsible for ensuring that all medical actions required by the standard are performed and that appropriate employee health and OSHA records are maintained. Contact location/phone number: __________.
  • (Name of responsible person or department) will be responsible for training, documentation of training, and making the written ECP available to employees, OSHA, and NIOSH representatives. Contact location/phone number: __________.
Check Out: Understanding OSHA Bloodborne Pathogens Standard

Employee Exposure Determination

One of the key elements of the Exposure Control Plan (ECP) is the employee exposure determination. This section of the plan lists all job classifications at the work-site with occupational exposure to bloodborne pathogens.

For example, in this section you might identify the job title “Housekeeper” within the department “Facility Maintenence”.

Notice that individual names are not used. Occupational exposure is classified by the job or task, not by the individual.

In addition to identifying the job classification and department, the ECP should also identify the procedures, or group of closely related tasks and procedures, in which occupational exposure may occur.

Adding to our previous example, the job title, location, and task would be identified as “Housekeeper / Facility Maintenence / Handling Regulated Waste”.

NOTE: Part-time, temporary, contract and per diem employees are covered by the bloodborne pathogens standard. The ECP should describe how the standard will be met for these employees.

Sample Employee Exposure Determination

The following is a list of all job classifications at our establishment in which all employees have occupational exposure:

Job Title Department/Location
(Example: Phlebotomists) (Clinical Lab)

Use as many lines as necessary.

The following is a list of job classifications in which some employees at our establishment have occupational exposure. Included is a list of tasks and procedures, or groups of closely related tasks and procedures, in which occupational exposure may occur for these individuals:

Job Title / Department – Location / Task – Procedure

(Example: Housekeeper / Environmental Services Handling / Regulated Waste)

Use as many lines as necessary.

 

What jobs are most at risk of exposure to bloodborne pathogens?

Occupations with a likely chance of occupational exposure include:

  • First aid providers
  • Teachers
  • Daycare workers
  • Housekeepers
  • Lab workers
  • Firefighters
  • Emergency Medical Technicians (EMTs) and paramedics
  • Law enforcement agents
  • Medical and dental personnel

An employer must review every job classification and make a determination of the potential occupational exposure for that position. Failure to properly identify potential occupational exposure can result in warnings or fines issued by OSHA.

If an occupational exposure does occur, it is important for you to follow the employer’s written procedures for handling medical self-care and evaluation, as well as documenting the circumstances of the exposure.

 

 

Methods of Implementation and Control

This section of the Exposure Control Plan (ECP) discusses the methods and controls the organization will use to prevent occupational exposure.

Topics included in this section of the ECP are:

  • Exposure Control Plan
  • Engineering Controls and Work Practices
  • Personal Protective Equipment (PPE)
  • Housekeeping
  • Laundry
  • Labels

Methods To Control The Risk Of Exposure

The recommended infection-control concept called “Universal Precautions” advocates everyone’s blood and body fluids be considered potentially infectious. This eliminates the difficulty in determining risk individually. Remember, although some bodily fluids have not been documented to transmit pathogens, it is sometimes impossible to tell if blood or another potentially infectious fluid is present.

PPE for Bloodborne Pathogens

Personal Protective Equipment (PPE) is specialized clothing or equipment that protects you from exposure to blood or other potentially infectious material.

Personal protective equipment is designed to keep blood and other potentially infectious material away from your skin, eyes, and mouth.

Examples of PPE include: disposable gloves, gowns, laboratory coats, protective face shields, resuscitation masks or shields, and mouth pieces. Any equipment necessary to prevent exposure to blood or other potentially infectious material is considered PPE.

Effective PPE

Effective personal protective equipment must not allow potentially infectious materials to pass through or reach your skin, eyes, mouth, or clothes under normal conditions of use.

General work clothes, such as uniforms, pants, shirts, or blouses, which are not intended to function as a protective barrier against hazards, are not considered to be PPE.

Employer responsibilities

An employer must ensure employees use appropriate personal protective equipment.

Your employer must make PPE available to you in the appropriate size and at no cost. Non-latex alternatives will also be made available to employees who have allergic sensitivity to latex. Employers must also properly clean, launder, repair, replace, or dispose of contaminated PPE as needed at no cost to the employee.

Employees should never take contaminated clothing home to be washed. This can increase the chance of accidental exposure to themselves and their family.

 

Sample Methods of Implementation and Control

Universal Precautions

All employees will utilize universal precautions.

Exposure Control Plan

Employees covered by the bloodborne pathogens standard receive an explanation of this ECP during their initial training session. It will also be reviewed in their annual refresher training. All employees can review this plan at any time during their work shifts by contacting (Name of responsible person or department). If requested, we will provide an employee with a copy of the ECP free of charge and within 15 days of the request.

(Name of responsible person or department) is responsible for reviewing and updating the ECP annually or more frequently if necessary to reflect any new or modified tasks and procedures that affect occupational exposure and to reflect new or revised employee positions with occupational exposure.

Engineering Controls and Work Practices

Engineering controls and work practice controls will be used to prevent or minimize exposure to bloodborne pathogens. The specific engineering controls and work practice controls used are listed below:

(For example: non-glass capillary tubes, SESIPs, needleless systems)

Sharps disposal containers are inspected and maintained or replaced by (Name of responsible person or department) every (list frequency) or whenever necessary to prevent overfilling.

This facility identifies the need for changes in engineering controls and work practices through __________ (Examples: Review of OSHA records, employee interviews, committee activities, etc.)

We evaluate new procedures and new products regularly by __________ (Describe the process, literature reviewed, supplier info, products considered)

Both front-line workers and management officials are involved in this process in the following manner: __________ (Describe employees’ involvement)

(Name of responsible person or department) is responsible for ensuring that these recommendations are implemented.

Personal Protective Equipment (PPE)

PPE is provided to our employees at no cost to them. Training in the use of the appropriate PPE for specific tasks or procedures is provided by (Name of responsible person or department).

The types of PPE available to employees are as follows: _________ (gloves, eye protection, etc.)

PPE is located (List location) and may be obtained through (Name of responsible person or department). (Specify how employees will obtain PPE and who is responsible for ensuring that PPE is available.)

All employees using PPE must observe the following precautions:

  • Wash hands immediately or as soon as feasible after removing gloves or other PPE.
  • Remove PPE after it becomes contaminated and before leaving the work area.
  • Used PPE may be disposed of in (List appropriate containers for storage, laundering, decontamination, or disposal.)
  • Wear appropriate gloves when it is reasonably anticipated that there may be hand contact with blood or OPIM, and when handling or touching contaminated items or surfaces; replace gloves if torn, punctured or contaminated, or if their ability to function as a barrier is compromised.
  • Utility gloves may be decontaminated for reuse if their integrity is not compromised; discard utility gloves if they show signs of cracking, peeling, tearing, puncturing, or deterioration.
  • Never wash or decontaminate disposable gloves for reuse.
  • Wear appropriate face and eye protection when splashes, sprays, spatters, or droplets of blood or OPIM pose a hazard to the eye, nose, or mouth.
  • Remove immediately or as soon as feasible any garment contaminated by blood or OPIM, in such a way as to avoid contact with the outer surface.

The procedure for handling used PPE is as follows: _________ (may refer to specific procedure by title or number and last date of review; include how and where to decontaminate face shields, eye protection, resuscitation equipment)

Housekeeping

Regulated waste is placed in containers which are closable, constructed to contain all contents and prevent leakage, appropriately labeled or color-coded (see the following section “Labels”), and closed prior to removal to prevent spillage or protrusion of contents during handling.

The procedure for handling sharps disposal containers is: (may refer to specific procedure by title or number and last date of review)

The procedure for handling other regulated waste is: (may refer to specific procedure by title or number and last date of review)

Contaminated sharps are discarded immediately or as soon as possible in containers that are closable, puncture-resistant, leak proof on sides and bottoms, and appropriately labeled or color-coded. Sharps disposal containers are available at (must be easily accessible and as close as feasible to the immediate area where sharps are used).

Bins and pails (e.g., wash or emesis basins) are cleaned and decontaminated as soon as feasible after visible contamination.

Broken glassware that may be contaminated is only picked up using mechanical means, such as a brush and dustpan.

Laundry

The following contaminated articles will be laundered by this company:

Laundering will be performed by (Name of responsible person or department) at (time and/or location).

The following laundering requirements must be met:

  • Handle contaminated laundry as little as possible, with minimal agitation
  • Place wet contaminated laundry in leak-proof, labeled or color-coded containers before transport. Use (specify either red bags or bags marked with the biohazard symbol) for this purpose.
  • Wear the following PPE when handling and/or sorting contaminated laundry: __________ (List appropriate PPE).

Labels

The following labeling methods are used in this facility:

Equipment to be Labeled: _________ (Label Type and Size, Color ) (specimens, contaminated laundry, etc.) (red bag, biohazard label)

(Name of responsible person or department) is responsible for ensuring that warning labels are affixed or red bags are used as required if regulated waste or contaminated equipment is brought into the facility. Employees are to notify (Name of responsible person or department) if they discover regulated waste containers, refrigerators containing blood or OPIM, contaminated equipment, etc., without proper labels.

 

Read: Understanding OSHA Bloodborne Pathogens Standard

Hepatitis B Vaccination

This section of the exposure control plan (ECP) establishes your organizations policy regarding hepatitis B (HBV) vaccinations.

Employers are required to provide the HBV vaccination to employess at no cost within 10 days of initial assignment.

It is important to note that “employers” includes both for-profit and non-profits organizations. Volunteers are considered employees for the purpose of the Bloodborne Pathogens standard. Also, if a school, requires students to perform tasks which exposes them to bloodborne pathogens, the school may be required to provide the HBV vaccination at no cost to the student.

The hepatitis B immunization series requires three separate injections.

The hepatitis B vaccine is very effective in protecting against the hepatitis B virus. Approximately 90 percent of people who receive the vaccine will become fully immune to the virus. It is given in a series of three shots. The entire series of shots is required to provide full immunity. The vaccine is safe with very few adverse reactions.

Typical Vaccination Schedule: The first injection can be administered at any given time. The second injection must be given at least one month after the first, and the third injection must be given six months after the first.

A licensed physician or other healthcare professional will perform or supervise the vaccinations.

Your employer does not have to offer you the vaccination series if you have previously received the complete series or have tested as immune to HBV.

You can decline the vaccination for hepatitis B after being informed of the risks and benefits.  To do this, you must sign a declination form. If you initially decline the vaccination for Hepatitis B, you can later request it from your employer at no charge.

There are currently two vaccines used to prevent hepatitis B infection in the United States. Neither vaccine contains blood products. You cannot get Hepatitis B from these vaccines.

Vaccination is encouraged unless:

  1. Documentation exists that the employee has previously received the series
  2. Antibody testing reveals that the employee is immune
  3. Medical evaluation shows that vaccination is contraindicated

Employees can decline the vaccination. If they do, the employee must sign a declination form. Employees who decline the vaccination may request and obtain the vaccination at a later date at no cost.

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Post-Exposure Evaluation and Follow-Up

OSHA expects employers to have a plan in place in the event an employee does have an occupational exposure.

This section of the Exposure Control Plan (ECP) must identify the person responsible for post-exposure follow-up.

Additionally, this section of the ECP must provide the post-exposure steps to be taken in the event of an occupational exposure. Remember, employees must be able to access the ECP for their personal review, even if an exposure has not occurred.

Sample Post-Exposure Evaluation and Follow-Up

Should an exposure incident occur, contact (Name of responsible person) at the following number __________.

An immediately available confidential medical evaluation and follow-up will be conducted by (name of licensed health care professional).

Following initial first aid (clean the wound, flush eyes or other mucous membrane, etc.), the following activities will be performed:

  • Document the routes of exposure and how the exposure occurred.
  • Identify and document the source individual (unless the employer can establish that identification is infeasible or prohibited by state or local law).
  • Obtain consent and make arrangements to have the source individual tested as soon as possible to determine HIV, HCV, and HBV infectivity; document that the source individual’s test results were conveyed to the employee’s health care provider.
  • If the source individual is already known to be HIV, HCV and/or HBV positive, new testing need not be performed.
  • Assure that the exposed employee is provided with the source individual’s test results and with information about applicable disclosure laws and regulations concerning the identity and infectious status of the source individual (e.g., laws protecting confidentiality).
  • After obtaining consent, collect exposed employee’s blood as soon as feasible after exposure incident, and test blood for HBV and HIV serological status
  • If the employee does not give consent for HIV serological testing during collection of blood for baseline testing, preserve the baseline blood sample for at least 90 days; if the exposed employee elects to have the baseline sample tested during this waiting period, perform testing as soon as feasible.

Administration of Post-Exposure Evaluation and Follow-Up

This section of the Exposure Control Plan (ECP) identifies the person or department responsible for ensuring the post-exposure evaluation and follow-up are performed.

After the post-exposure evaluation is completed, the employee must be provided a copy of the health care professional’s written opinion within 15 days after the evaluation is completed.

Sample Administration of Post-Exposure Evaluation and Follow-Up

(Name of responsible person or department) ensures that health care professional(s) responsible for employee’s hepatitis B vaccination and post-exposure evaluation and follow-up are given a copy of OSHA’s bloodborne pathogens standard.

(Name of responsible person or department) ensures that the health care professional evaluating an employee after an exposure incident receives the following:

  • A description of the employee’s job duties relevant to the exposure incident
  • Route(s) of exposure
  • Circumstances of exposure
  • If possible, results of the source individual’s blood test
  • Relevant employee medical records, including vaccination status

(Name of responsible person or department) provides the employee with a copy of the evaluating health care professional’s written opinion within 15 days after completion of the evaluation.

 

Procedures for Evaluating the Circumstances Surrounding an Exposure Incident

This section of the Exposure Control Plan (ECP) identifies who is responsible for evaluating an exposure incident. In addition, it should list what will be included as part of the evaluation process.

One important piece to this section is the recording of percutaneous injuries from contaminated sharps in a Sharps Injury Log. If your company is not required to maintain a Sharps Injury Log, then this can be excluded.

Sample Procedures for Evaluating the Circumstances Surrounding an Exposure Incident

(Name of responsible person or department) will review the circumstances of all exposure incidents to determine:

  • engineering controls in use at the time
  • work practices followed
  • a description of the device being used (including type and brand)
  • protective equipment or clothing that was used at the time of the exposure incident (gloves, eye shields, etc.)
  • location of the incident (O.R., E.R., patient room, etc.)
  • procedure being performed when the incident occurred
  • employee’s training

(Name of Responsible Person) will record all percutaneous injuries from contaminated sharps in a Sharps Injury Log.

If revisions to this ECP are necessary (Responsible person or department) will ensure that appropriate changes are made. (Changes may include an evaluation of safer devices, adding employees to the exposure determination list, etc.)

Employee Training

All employees who have been identified as having occupational exposure must receive initial and annual Bloodborne Pathogens training. Remember, you should have already identified all of the job classifications previously in your Exposure Control Plan.

Some companies put all of their employees through this training, regardless of their job classification, especially if an employee’s job classification can change. This can potentially save in training costs, by reducing the number of separate trainings that might need to be offered. For example, primary and secondary teachers are often given this training at the beginning of each school year.

Computer based training (CBT) can be used to provide this training if all of the criteria below are met. It is important to note that hands on training for personal protective equipment (PPE) will be required for bloodborne pathogens training. Employees must be able to practice putting on and taking off the PPE, as well as being instructed in it’s proper use.

Sample Employee Training

All employees who have occupational exposure to bloodborne pathogens receive initial and annual training conducted by (Name of responsible person or department). (Attach a brief description of their qualifications.)

All employees who have occupational exposure to bloodborne pathogens receive training on the epidemiology, symptoms, and transmission of bloodborne pathogen diseases. In addition, the training program covers, at a minimum, the following elements:

  • a copy and explanation of the OSHA bloodborne pathogen standard
  • an explanation of our ECP and how to obtain a copy
  • an explanation of methods to recognize tasks and other activities that may involve exposure to blood and OPIM, including what constitutes an exposure incident
  • an explanation of the use and limitations of engineering controls, work practices, and PPE
  • an explanation of the types, uses, location, removal, handling, decontamination, and disposal of PPE
  • an explanation of the basis for PPE selection
  • information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine will be offered free of charge
  • information on the appropriate actions to take and persons to contact in an emergency involving blood or OPIM
  • an explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available
  • information on the post-exposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident
  • an explanation of the signs and labels and/or color coding required by the standard and used at this facility
  • an opportunity for interactive questions and answers with the person conducting the training session

Training materials for this facility are available at (name location).

Recordkeeping

This section of the Exposure Control Plan (ECP) details what training records must be maintained in relation to:

  • Training
  • Medical Records
  • OSHA Recordkeeping
  • Sharps Injury Log

These documents must be maintained for at least three (3) years.

Additionally, an employee or their authorized representative may request a copy of the employee’s exposure and medical records.

Sample Recordkeeping

Training Records

Training records are completed for each employee upon completion of training. These documents will be kept for at least three years at (Location of records).

The training records include:

  • the dates of the training sessions
  • the contents or a summary of the training sessions
  • the names and qualifications of persons conducting the training
  • the names and job titles of all persons attending the training sessions

Employee training records are provided upon request to the employee or the employee’s authorized representative within 15 working days. Such requests should be addressed to (Name of responsible person or department).

Medical Records

Medical records are maintained for each employee with occupational exposure in accordance with 29 CFR 1910.1020, “Access to Employee Exposure and Medical Records.”

(Name of responsible person or department) is responsible for maintenance of the required medical records. These confidential records are kept in (List location) for at least the duration of employment plus 30 years.

Employee medical records are provided upon request of the employee or to anyone having written consent of the employee within 15 working days. Such requests should be sent to (Name of responsible person or department and address).

OSHA Recordkeeping

An exposure incident is evaluated to determine if the case meets OSHA’s Recordkeeping Requirements (29 CFR 1904). This determination and the recording activities are done by (Name of responsible person or department).

Sharps Injury Log

In addition to the 1904 Recordkeeping Requirements, all percutaneous injuries from contaminated sharps are also recorded in a Sharps Injury Log. All incidences must include at least:

  • Date of the injury
  • Type and brand of the device involved (syringe, suture needle)
  • Department or work area where the incident occurred
  • Explanation of how the incident occurred.

This log is reviewed as part of the annual program evaluation and maintained for at least five years following the end of the calendar year covered. If a copy is requested by anyone, it must have any personal identifiers removed from the report.

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