CHANGE HISTORY
GN470086, SNL Bloodborne Pathogens Exposure Control Plan

Administrative Changes Only
May 20, 2010

This supplement was revised to:

• Change: The Subject Matter Expert (SME) from Nancy Vrabel to Linda Manke.

February 16, 2010

Summary: Substantive and administrative changes to this document were made for its annual update.

• Under topic, “Minimizing Occupational Exposure”:
  • Added: The requirement for Members of the Workforce who start the Hepatitis B vaccination series to sign a Hepatitis B acceptance form.
  • Deleted: Guidance for Members of the Workforce to consult the bloodborne pathogens contact to determine if contractors are eligible to receive the Hepatitis B vaccine.
  • Clarified: That managers must require non-medical Members of the Workforce to complete MED113, and medical Members of the Workforce to complete MED115. Also clarified that non-medical Members of the Workforce must initially take the course with a live instructor; they may take a computer-based course annually thereafter.

• Under topic, “Storing And Disposing of Infectious Waste,” under requirements for Members of the Workforce:
  • Changed: “At SNL/NM, store waste in the designated holding area for no more than 45 days”: changed to 90 days.

• Under topic, “Organization Specific Procedures":
  • Moved: Requirements into topic “Minimizing Occupational Exposure” (Step 5 in the table).

October 13, 2009

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

October 31, 2008

Global Change to insert requirement for managers to ensure that training is accomplished. See detailed change history for ES&H Manual, 10/31/08.

Administrative Changes Only
April 11, 2008

Global change to insert appropriate reference to Corporate training requirements and documentation. See detailed change history for ES&H Manual, 4/11/08

December 14, 2007

Global Change to insert appropriate reference to 10 CFR 851. See detailed change history for ES&H Manaul, 12/14/07.

October 16, 2007

Note: (*) asterisk denotes substantive change.

This ES&H Manual Supplement was revised to:

• Under topic, “Storing and Disposing of Infectious Waste”
• *Change: The requirement

from

• At SNL/CA, infectious medical waste shall not be stored at room temperature for longer than seven days or, if frozen, for longer than 90 days.

to

• At SNL/CA, infectious medical waste shall not be stored at room temperature for longer than 30 days

Administrative Changes Only
December 13, 2006

This supplement was revised to:

• Change: The Subject Matter Expert (SME) from "Mickey Fitzpatrick" to "Nancy Vrabel."
• Change: The NM SME in the Direct Access Services (DAS) list under the heading "Bloodborne Pathogens" from "Mickey Fitzpatrick" to "Nancy Vrabel," and also make this change under the heading "Health Services."

September 11, 2006

Note: (*) asterisk denotes substantive change.

This chapter was revised to:

• Add: The Review Date to the header to indicate that an ES&H Manual Self-Assessment (SA) was completed on this section.
• Add: The following statement under the header: “Note: This document is reviewed annually.”
• Change: The heading “Applicability and Ownership” to “Applicability.”
• Under topic, “Applicability”:
• Add: The following bullet to the list of ES&H Manual Sections which this document supplements:
• Section 19F , "Other Waste," - the material titled “Infectious Waste.”
• Delete: The heading titled “Ownership” and the subordinate sentence “The director of the Health, Benefits and Employee Services (HBE) Center (3300) owns this document.”
• Under topic, “Personal Protective Equipment”:
• Change: The first bullet under “Guidance” from “Purchase and use disposable PPE whenever possible” to “Use disposable PPE whenever possible.”
• Under topic, “Generating Infectious Waste”:
• Add: The following general note:
• Note: These requirements supplement those listed in Section 19F, "Other Waste," under the heading “Infectious Waste.”
• *Change: The first bullet listed in “Requirements” under the subtopic “Tracking and Segregating” from “Tracking infectious waste from the time it...” to “At SNL/NM, tracking infectious waste from the time it...” to indicate that this requirement is specific to SNL/NM.
• *Change: The first bullet listed in “Requirements” under the subtopic “Segregating Other Infectious Waste” from “Place liquid infectious waste in unbreakable...” to “At SNL/NM, place liquid infectious waste in unbreakable ...” to indicate that this requirement is specific to SNL/NM.
• *Add: The following SNL/CA requirement as a bullet under the subtopic "Segregating Other Infectious Waste”:
• 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.
• *Add: The following requirement as a bullet under the subtopic “Segregating Other Infectious Waste”:
• Upon collection for disposal, replace rigid containers with clean containers.
• Under topic, “Storing and Disposing of Infectious Waste”:
• Add: The following general note:
• Note: These requirements supplement those listed in Section 19F, "Other Waste," under the heading “Infectious Waste.”
• Add: The following SNL/CA requirement as a bullet:
• At SNL/CA, infectious medical waste shall not be stored at room temperature for longer than seven days or, if frozen, for longer than 90 days.
• *Add: The following SNL/CA requirement as a bullet:
• 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.
• *Change: The former fourth bullet from “Store waste in the designated holding area for no more than 45 days” to “At SNL/NM, store waste in the designated holding area for no more than 45 days” to indicate that this requirement is specific to SNL/NM.
• Under topic, “Handling Contaminated Laundry”:
• *Change: The first bullet under “Requirements” from “Handle contaminated laundry as little as possible” to “Handle contaminated laundry as little as possible with minimum of agitation.”
• *Add:The following bullet under Requirements:
• Wear protective gloves and other appropriate PPE when handling contaminated laundry.
• Change: The first sentence under “Guidance” from “Members of the Workforce are encouraged to purchase and use disposable items whenever possible” to “Members of the Workforce are encouraged to use disposable items whenever possible.”
• Change: The last bullet under “Guidance” from “At SNL/CA, contact health services department personnel” to “At SNL/CA, contact health services department personnel at 294-2700.”
• Under topic, “Housekeeping”:
• *Change: The first subordinate bullet under the first bullet listed under “Requirements” from “Solution (made fresh every week) of one part household bleach to 10 parts water” to “Solution (made fresh every week) of one part household bleach to 9 parts water.”
• *Change: Step 1 in the first Table listed under “Requirements” from “Don disposable gloves and remove visible material by wiping it up with disposable towels” to “Don disposable gloves, lab coat, and eye protection, and remove visible material by wiping it up with disposable towels.”
• *Change: Step 3 in the first Table listed under “Requirements” from “Saturate area with appropriate chemical germicide, let it stand for at least 10 minutes, and wipe it up with disposable towels” to “Saturate area with appropriate chemical germicide, let it stand for at least 20 minutes, and wipe it up with disposable towels.”
• *Change: Step 2 in the second Table listed under “Requirements” from “ Place in a rigid puncture resistant disposal container that is labeled as a biohazard ” to “Place in a rigid puncture resistant sharps container that is labeled as a biohazard.”
• Under topic, “References”:
• *Add: The following requirement under “Requirement Source Documents”:
• California Medical Waste Management Act, California Health and Safety Code Sections 117600 - 118360.
• Add: The following document under “Implementing Documents”:
• Section 19F, "Other Waste."

Administrative Changes Only
November 3, 2005

This document was administratively revised to:

• Change: The SME from Renee Wood, RN to Mickey Fitzpatrick, RN COHN.
• Change: CA Counterpart: Gail Bachman, from RN to NP
• Under the subtopic “Ownership,” under the topic “Applicability and Ownership:"
  • Change: “The director of the Benefits and Health Services” to “The director of the Health, Benefits and Employee Services (HBE) Center (3300) owns this document.”
• Under the subtopic “Guidance,” under the topic “Minimizing Occupational Exposure:”
• Change: The first SNL/NM Hepatitis B Vaccination Contact from “Medical Clinic Department” to “International Travel Clinic.”
• Under the email contact information on the bottom of the page:
• Change: “Renee Wood, rvwood@sandia.gov” to “Mickey Fitzpatrick, mfitzp@sandia.gov.”

Administrative Changes Only
June 29, 2005

This document was administratively revised to:

• Change: Executive Policy Sponsor from Les Shephard to Frank Figueroa

Administrative Changes Only
February 19, 2003

This section was administratively revised to:

• Change:
• A new SNL/NM subject matter expert and a new CA Counterpart
• Under the topic, "In Case of Exposure," Step 4, was changed to read, "Isolate any contaminated work area and alert Members of the Workforce in the immediate vicinty to notify the Incident Commander (or the ES&H Hotline at SNL/CA) to arrange for decontamination.

December 4, 2001

This document has been revised to:

• Add:
• To the Section "Minimizing Occupational Exposure, Requirements" to Step 4, managers to "request SME to review biotechnical and bioengineering literature at least annually to select the safest controls as they become available" and "involve employees in the identification and selection of new control devices."
• To the Section "Minimizing Occupational Exposure, Guidance," managers should inform the SME of the Members of the Workforce identified in Step 1, so that the SME is aware of the various job duties and PPE needs of organization personnel."
• To the Section "Generating Infectious Waste, Guidance," bloodborne pathogens contact.
• To the Section "Organization-Specific Procedures, Requirements":
• The requirement to include "organization specific instructions for generating, storing, and disposing of infectious waste."
• The requirement to track sharps injuries and a heads-up about a procedure change that will be effective January 1, 2002.
• Change:
• In Section "Minimizing Occupational Exposure, Requirements," in Step 2, specify that the required training is MED113, Bloodborne Pathogens Training for Non-Medical Personnel."
• In Section "Minimizing Occupational Exposure, Requirements," simplify Step 5 to "establish and document their organization-specific procedure for mitigating exposure."
• In Section "Generating Infectious Waste, Requirements, Tracking and Segregating," clarify the requirements for Members of the Workforce.
• In Section "Housekeeping, Guidance," replaced the table that directed the reader to custodians and incident commanders for clean up of blood spills and other potentially infectious material (OPIM) with a link to the phone number list in Chapter 15, "Emergency Preparedness and Management."
• In Section "Organization-Specific Procedures, Requirements," revised as follows:
  • Clarify the schedule as "annually."
  • Reword the requirement to review and update organization-specific procedures whenever necessary to "account for the consideration and implementation of any technological developments that would reduce the risk of exposure incidents.
• To the Section "References," include new regulations regarding needle stick and other sharps injuries.
• Delete:
• From Section "Minimizing Occupational Exposure, Requirements," Step 1, "certain custodial tasks (i.e., bloodborne pathogen spill clean up)," because custodial personnel no longer clean up spills of bloodborne pathogens.
• From Section "Generating Infectious Waste, Requirements, Disposing of Sharps," "see Using Disposal Containers for Contaminated Sharps," because that section follows immediately.
• From the Section "References," the subsection "Related Documents," because the information is in this document.

GLOSSARY

• Add: the term "biohazardous waste" and point to the definition for "infectious waste."
• Delete the definition for “medical waste” and point to the definition for "infectious waste."

Nancy Vrabel, nvrabel@sandia.gov
Gail Bachman, glbachm@sandia.gov
Al Bendure, aobendu@sandia.gov

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