This document is no longer a CPR. This document implements the requirements of Corporate procedure ESH100.2.OTH.3, Control Exposure to Bloodborne Pathogens.

IMPORTANT NOTICE: A printed copy of this document may not be the document currently in effect. The official version is the online version located on the Sandia Restricted Network (SRN).

GN470086 – SNL BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN

Subject Matter Expert: Linda Manke, RN, COHN-S; CA Counterpart: Gail Bachman, NP
GN470086, Issue H
Revision Date: February 16, 2010; Replaces Document Dated: October 31, 2008
Review Date: August 8, 2006
Administrative Change: May 20, 2010

Note: This document is reviewed annually.

Change History

• Applicability
• Minimizing Occupational Exposure
• In Case of Exposure
• Communicating Hazards
• Engineering and Work Practice Controls
• Personal Protective Equipment (PPE)
• Generating Infectious Waste
• Storing and Disposing of Infectious Waste
• Handling Contaminated Laundry
• Housekeeping
• Organization-Specific Procedures
• References
• Form
• SF 2050-P, Report of Occupational Occurrences (Injury/Illness) (Word file/Acrobat file)

APPLICABILITY

For purposes of this document, Members of the Workforce are:

• Sandia employees.
• Sandia contractors.

This document applies to all Members of the Workforce whose job duties include performing tasks that involve an inherent potential for mucous membrane, skin, or parenteral contact with human blood or other potentially infectious material (OPIM). Tasks that may involve occupational exposure include performing medical procedures, medical emergency response activities, security emergency response activities, and some research and development activities.This document supplements:

• ESH100.2.IS.8, Assess Workplace Hazards and Provide and Maintain Personal Protective Equipment
• ESH100.2.IS.9, Apply Signs and Tags
• ESH100.2.IH.14, Procure and Work with Biological Agents
• ESH100.3.1, Prepare for and Manage Emergencies

• ESH100.4.RPT.2, Report Injuries and Illnesses
• HR100.4.5, Refer an Employee for Clinical Evaluation
• HR100.4.6, Prevent and Test for Workplace Substance Abuse
• HR100.4.7, Participate in Medical Monitoring/Surveillance
• HR100.4.8, Obtain Medical Restrictions
• HR100.4.11, Protect Human Research Subjects
• HR100.4.15, Manage Occupational Medicine Services for Contractors at all Tiers

• ESH100.2.ENV.26, Manage Other Waste at SNL/NM
• ESH100.2.GEN.3, Develop and Use Technical Work Documents

MINIMIZING OCCUPATIONAL EXPOSURE

Requirements

Managers shall ensure that Members of the Workforce complete the required training identified below prior to performing the indicated work activity or fulfilling the indicated role.

See HR100.2.1, Identify and Complete Sandia Required Training for all Members of the Workforce.

Guidance

Managers should inform the SME of the Members of the Workforce identified in Step 1, "Determine who is at risk...," so that the SME is aware of the various job duties and PPE needs of organization personnel.

Members of the Workforce should consult the bloodborne pathogens contact for:

• More information about controlling occupational exposure to bloodborne pathogens.

The following contacts provide free Hepatitis B vaccination, a series of three injections over a 6-month period to all Members of the Workforce (on a case-by-case basis) with potential occupational exposure to blood or other potentially infectious material (OPIM)

Members of the Workforce may start the Hepatitis B vaccination series after completing required training and within 10 working days of initial assignment to jobs with the potential for occupational exposure to bloodborne pathogens.

IN CASE OF EXPOSURE

Requirements

• Requiring that Members of the Workforce who sustain an occupational exposure incident to other potentially infectious material (OPIM) report to the site Medical office (or specified medical provider if off site) immediately.
• Completing SF 2050-P, Report of Occupational Injury/Illness (Word file/Acrobat file), for all occupational exposure incidents.
• Implementing any necessary changes to applicable work processes to mitigate future occupational exposure incidents.

Members of the Workforce shall follow the steps below when involved in an occupational exposure incident:

COMMUNICATING HAZARDS

Requirements

• Follow the requirements in ESH100.2.IS.9, Apply Signs and Tags, as they relate to bloodborne pathogens.
• Verify that all containers that hold blood or other potentially infectious material (OPIM) are red or bear the biohazard label (see Figure 1), which identifies the contents of the container as potentially infectious material.
• Affix biohazard labels as close as possible to containers with adhesive, string, wire, or another method that prevents loss or unintentional removal.

ENGINEERING AND WORK PRACTICE CONTROLS

Requirements

Universal Precautions

• Treat all human blood and OPIM as if potentially contaminated.

Engineering Controls

• Place contaminated sharps in appropriate containers located in area of use immediately after use. (See "Generating Infectious Waste" for more information.)
• Use appropriate safety engineered products such as self-sheathing needle/syringes

Work Practice Controls

• Wash hands with soap and water as soon as feasible after removing gloves or other PPE. Where hand washing facilities are not available, do the following:
1. Wash hands with either an appropriate antiseptic hand cleanser and a cloth or paper towel, or with antiseptic towelettes.
2. Upon having access to soap and running water, wash hands immediately.
• Perform all procedures involving blood or OPIM in a manner that minimizes splashing, spraying, spattering, and generation of droplets.
• Place specimens of blood or OPIM in containers that are labeled as biohazard and that prevent leakage during collection, handling, processing, storage, transportation, or shipping. If the outside of the container becomes contaminated, place the primary container in a secondary container labeled as biohazard. If the specimen could puncture the primary container, the secondary container shall also be puncture-resistant.
• Examine equipment that may become contaminated prior to servicing and/or shipping, and decontaminate it as necessary. If decontamination is not feasible, attach a readily observable label to contaminated equipment that bears the biohazard label and that states which portions of the equipment remain contaminated. Convey information about contaminated equipment to all affected Members of the Workforce, the servicing representative, or the manufacturer, as appropriate, prior to handling, servicing, or shipping so that appropriate precautions may be taken.

Members of the Workforce shall not:

• Bend, recap, shear, or remove contaminated needles or other contaminated sharps unless:
• No alternative is feasible.
• Such action is required by a medical procedure.
• Such action is accomplished through a mechanical device or a one-handed technique.
• Engage in the following activities in areas where there is a reasonable likelihood of occupational exposure:
  • Eating
  • Drinking
  • Handling contact lenses
  • Applying cosmetics or lip balm
• Perform mouth pipetting or mouth suctioning of blood or OPIM.
• Keep food or drink in refrigerators, freezers, shelves, or cabinets or on countertops or benchtops where blood or OPIM is stored.

PERSONAL PROTECTIVE EQUIPMENT (PPE)

Requirements

Members of the Workforce who still have a potential for occupational exposure to bloodborne pathogens after implementing universal precautions, engineering and work practice controls shall:

• Select and use PPE appropriate to risk of task(s) to be performed. PPE is appropriate only if it does not permit blood or OPIM to reach the worker's work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of the time that the equipment is used. In this context, PPE includes, but is not limited to, the following:
• Gloves (including single use, and utility gloves).
• Gowns.
• Lab coats.
• Eye and face protection devices, such as surgical masks, chin-length face shields, screen shields, goggles, and safety glasses with side shields.
• Ventilation devices with one way valves (for example, mouthpieces, resuscitation bags, and pocket masks).
• Wear gloves when:
• Hand contact with blood or other potentially infectious material (OPIM) can be reasonably anticipated.
• Performing vascular access procedures.
• Handling or touching contaminated items or surfaces.
• Replace disposable (single use) gloves as soon as practical when they become contaminated or as soon as feasible if they are torn or punctured or when their ability to function as a barrier is compromised. Do not wash or decontaminate single use/disposable gloves for reuse.
• Discard utility gloves if they are cracked, peeling, torn, punctured or exhibit other signs of deterioration or when their ability to function as a barrier is compromised. Utility gloves may be decontaminated for reuse.
• Decontaminate utility gloves following use.
• Always wear personal protective equipment (PPE) that protects all mucous membranes (eyes, nose, and mouth) whenever the possibility exists for splashes, spray, spatter, or droplets of blood or OPIM. (e.g., face shields or surgical masks in combination with goggles or safety glasses).
• Wear surgical caps or hoods and shoe covers or boots in instances where gross contamination is anticipated (e.g., during emergency response to injury involving arterial bleeding).
• Always wear gowns, aprons, lab coats, clinic jackets, or similar outer garments as needed in potential occupational exposure situations. The type and characteristics of garments depend upon the task and the degree of anticipated exposure.
• Use ventilation devices with one-way valves when performing rescue breathing.
• Use disposable PPE whenever possible.
• Remove garments that are penetrated by blood or OPIM as soon as practical.
• After removing PPE, place it in an appropriate designated area or biohazard container for storage, washing, decontamination, or disposal.

Members of the Workforce shall always use PPE during potential occupational exposure to blood and OPIM. In life-threatening situations, Members of the Workforce may decline to use PPE when its use would prevent the delivery of health care or public safety services or pose increased hazards to Members of the Workforce.

GENERATING INFECTIOUS WASTE

Requirements

Note: These requirements supplementthose listed in ESH100.2.ENV.26, Manage Other Waste at SNL/NM.

Tracking and Segregating

• At SNL/NM, tracking infectious waste from the time it is generated until it is picked up from the designated holding area by SNL Hazardous Waste Management Facility (HWMF) personnel.
• Segregating infectious waste from all other waste at the point of origin.
• Segregating, collecting, and labeling infectious waste according to the requirements in this document.

Disposing of Sharps

• No trecap needles, purposely bend or break them by hand, remove them from disposable syringes, or otherwise manipulate them by hand.
• Discard contaminated sharps as soon as possible in containers that are manufactured for the purpose of sharps containment.

Using Disposal Containers for Contaminated Sharps

Members of the Workforce shall use only containers for contaminated sharps that are:

• Rigid and puncture resistant.
• Labeled as biohazard.
• Leakproof on the sides and bottom.
• Designed in a way that does not require Members of the Workforce to reach by hand into the containers where these sharps are placed.
• Taped closed or have a tightly fitting lid to preclude loss of contents.
• Located in the immediate area of use and accessible to Members of the Workforce.
• Maintained upright.
• Replaced routinely to prevent overfill.

Segregating Other Infectious Waste

Members of the Workforce shall:

• At SNL/CA, liquid infectious medical waste shall be decontaminated using a 10% bleach solution for a 30-minute contact time and then disposed of down the drain with water per the California Medical Waste Management Act.
• Place infectious waste other than sharps in appropriately labeled biohazard disposal bags that are impervious to moisture and strong enough to preclude rupture.
• Close bags securely to prevent leakage during storage, handling, or transportation.
• Place biohazard disposal bags into rigid containers clearly labeled as biohazard in designated holding areas.
• Upon collection for disposal, replace rigid containers with clean containers.

Warning: Contaminated cardboard containers cannot be decontaminated and shall not be reused. All contaminated containers that cannot be decontaminated shall be treated as infectious waste.

• Close bags securely to prevent leakage during storage, handling, or transportation.

Members of the Workforce shall verify that any container used for the storage or transportation of infectious waste is only reused under the following conditions:

• The surfaces of the container were completely protected from contamination by disposable, un-punctured, and undamaged liners, bags, or other devices that were removed with the infectious waste.
• The surfaces of the container show no evidence of damage, puncture or contamination.
• The container was thoroughly washed and decontaminated according to the periodic schedule of cleaning or when visibly contaminated

Guidance

Members of the Workforce should call the waste management or bloodborne pathogens contact for more information on kinds of infectious waste and activities that generate such waste.

STORING AND DISPOSING OF INFECTIOUS WASTE

Requirements

Note: These requirements supplement those listed in ESH100.2.ENV.26, Manage Other Waste at SNL/NM.

• Store infectious waste, prior to offsite transportation and disposal, in an access-restricted, designated holding area that is ventilated to the outdoors, protected from water, rain, wind, animals, insects, rodents, and marked with prominent warning signs which can be easily read during daylight from a distance of 25 feet.
• At SNL/CA, infectious medical waste shall not be stored at room temperature for longer than 30 days.
• At SNL/CA, infectious medical waste shall be disposed of by either an approved medical waste vendor or by autoclaving in an approved medical waste autoclave.
• Dispose of puncture-resistant containers according to policies and procedures of the specific work area in which they are located. Place all biohazard disposal bags in rigid biohazard storage containers located in the designated holding area.
• At SNL/NM, store waste in the designated holding area for no more than 90 days.
• Not use compactors, grinders, or similar devices to reduce the volume of infectious waste.

Members of the Workforce shall call the waste management contact for offsite pick-up, offsite transportation, and disposal of infectious waste.

HANDLING CONTAMINATED LAUNDRY

Requirements

Members of the Workforce shall:

• Handle contaminated laundry as little as possible with minimum of agitation.
• Wear protective gloves and other appropriate PPE when handling contaminated laundry.
• Place contaminated laundry in biohazard bags or containers at the point of use.
• Place wet contaminated laundry in leakproof biohazard bags or containers.
• Not sort or rinse contaminated laundry.

Guidance

Members of the Workforce are encouraged to use disposable items whenever possible.

HOUSEKEEPING

Requirements

• Use one of the following solutions to decontaminate surfaces that are or that may be contaminated with blood or other potentially infectious material (OPIM):
• Solution (made fresh every week) of one part household bleach to 9 parts water
• Chemical germicides that are approved as "hospital disinfectants" and that are tuberculocidal when used at recommended dilutions

Note:Owner's manuals may provide procedures to decontaminate specific pieces of equipment.

• Follow this procedure when using the above solutions:

Step	Action
1	Don disposable gloves, lab coat, and eye protection, and remove visible material by wiping it up with disposable towels.
2	Place soiled toweling in a red, labeled biohazard disposal bag.
3	Saturate area with appropriate chemical germicide, let it stand for at least 20 minutes, and wipe it up with disposable towels.
4	Use clean disposable towels and a germicide to thoroughly wipe area. Let it air dry.
5	Remove gloves and place them in the red, labeled biohazard disposal bag.
6	Wash hands with soap and running water.

• Clean and decontaminate all equipment and working or environmental surfaces (countertops, walls, floors, ambulance seats, woodwork) at the following times:
• After completion of procedures.
• As soon as feasible when surfaces are overtly contaminated or after any spill of blood or OPIM.
• At the end of the work shift if the surface may have become contaminated since the last cleaning.
• Remove and replace protective coverings (for example, plastic wrap, aluminum foil, or imperviously backed absorbent paper) used to cover equipment and environmental surfaces as follows:
• As soon as feasible when overtly contaminated
• At the end of a workshift if coverings may have become contaminated during the shift
• On a regularly scheduled basis, inspect and decontaminate receptacles intended for reuse (for example, bins, cans, and pails) that have a reasonable likelihood for becoming contaminated with blood or OPIM. Clean and decontaminate receptacles intended for reuse as soon as feasible upon visible contamination.
• Dispose of disposable towels and other swabs used to decontaminate surfaces that may be contaminated with blood or OPIM as infectious waste, whether they are obviously contaminated or not.
• Follow this procedure to dispose of broken glassware that may be contaminated with blood or OPIM.

Step	Action
1	Use mechanical means such as brush and dust pan, tongs, or forceps to pick up contaminated broken glass. Do not pick up contaminated broken glass with hands.
2	Place in a rigid puncture resistant sharps container that is labeled as a biohazard.

Guidance

If the blood or OPIM is combined with other hazardous material, Members of the Workforce should call the appropriate emergency phone number.

ORGANIZATION-SPECIFIC PROCEDURES

Guidance

REFERENCES

Requirements Source Documents

10 CFR 851, Worker Safety and Health Program.

20 NMAC 9.1, New Mexico Administrative Code, Title 20, Chapter 9, Part I, "Solid Waste Management."

29 CFR 1910.1030, Bloodborne Pathogens.

66 FR 5317, Occupational Exposure to Bloodborne Pathogens; Needlestick and other Sharps Injuries.

California Environmental Protection Agency, Title 22, California Code of Regulations, Division 4.5, "Environmental Health Standards for the Management of Hazardous Waste."

California Medical Waste Management Act, California Health and Safety Code Sections 117600 - 118360.

Implementing Documents

Final Rule Analysis, FRA 01-04, "OSHA amends the BBP Standards," Environmental Regulatory Consultants, Lockheed Martin Corporation, 2/2/2001.

ESH100.2.GEN.3, Develop and Use Technical Work Documents.

ESH100.2.IS.8, Assess Workplace Hazards and Provide and Maintain Personal Protective Equipment.

ESH100.2.IS.9, Apply Signs and Tags.

ESH100.2.IH.14, Procure and Work with Biological Agents , Procure and Work with Biological Agents.

ESH100.3.1, Prepare for and Manage Emergencies.

ESH100.4.RPT.2, Report Injuries and Illnesses

HR100.4.5, Refer an Employee for Clinical Evaluation.

HR100.4.6, Prevent and Test for Workplace Substance Abuse.

HR100.4.7, Participate in Medical Monitoring/Surveillance.

HR100.4.8, Obtain Medical Restrictions.

HR100.4.11, Protect Human Research Subjects.

HR100.4.15, Manage Occupational Medicine Services for Contractors at all Tiers.

ESH100.2.ENV.26, Manage Other Waste at SNL/NM.

ESH100.2.GEN.3, Develop and Use Technical Work Documents.

ESH100.2.ENV.15, Manage Hazardous Waste at SNL/CA.

ESH100.2.ENV.20, Manage Other Waste at SNL/CA.

Linda Manke, lmmanke@sandia.gov
Gail Bachman, glbachm@sandia.gov
Al Bendure, aobendu@sandia.gov

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