AU Medical Center Policy Library Policy Owner: Epidemiology POLICY STATEMENT Augusta University Medical Center (AUMC) shall establish a written Exposure Control Plan (ECP) designed to eliminate or minimize occupational exposure to blood or other potentially infectious material (OPIM). The ECP and supporting documents will be reviewed and updated at least annually and as necessary. This document contains information for all levels of the Augusta University Medical Center organization and is applicable at all AUMC locations with a potential for occupational exposure to blood or OPIM. To effectively prevent, mitigate and respond to occupational exposures, the ECP will include the following components: Employee Exposure Determination Methods of Implementation and Control o Universal Precautions o Engineering and Work Practice Controls o Personal Protective Equipment o Hepatitis B Vaccination Post-exposure Evaluation and Follow-up Hazards Communication and Training Recordkeeping Exposure Incident Review for Contributing Factors AFFECTED STAKEHOLDERS Indicate all entities and persons within the Enterprise that are affected by this policy: Administrative Services Hired Staff Housestaff/Residents & Clinical Fellows Leased staff Medical Staff (includes Physicians, PAs, APNs) Patient Care Services (Nursing, PCT s, Unit Clerks) Professional Services (Laboratory, Radiology, Respiratory, Pharmacy; etc.) Vendors/Contractors Other: Office of Compliance and Enterprise Risk Management Use Only Policy No.: 914 Policy Sponsor: Chief Medical Officer Originally Issued: 07/01/1997 Last Revision: 08/19/2016 Last Review: 09/06/2016 Next Review: 09/06/2017
2 DEFINITIONS Blood Bloodborne Pathogens Clinical Laboratory Human blood, human blood components, and products made from human blood. Pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV) and human immunodeficiency virus (HIV). A workplace where diagnostic or other screening procedures are performed on blood or other potentially infectious materials (OPIM). Contaminated Presence or the reasonably anticipated presence of blood or OPIM on an item or surface. Contaminated Laundry Contaminated Sharps Laundry which has been soiled with blood or OPIM or may contain sharps. Any contaminated object that can penetrate the skin including, but not limited to, needles, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires. Decontaminati on Use of physical or chemical means to remove, inactivate, or destroy pathogens, including those bloodborne, on a surface or item to the point where they are no longer capable of transmitting infectious particles and the surface or item is rendered safe for handling, use, or disposal. Engineering Controls Exposure Incident Handwashing Facilities Licensed Independent Practitioner HBV Controls (e.g., sharps disposal containers, self-sheathing needles, safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the bloodborne pathogens hazard from the workplace. A specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or OPIM that results from the performance of an employee's duties. A facility providing an adequate supply of running potable water, soap, and single-use towels or air-drying machines. Any practitioner permitted by law and by the organization to provide care and services, without direction or supervision, within the scope of the practitioner license and consistent with individually assigned clinical responsibilities. Hepatitis B virus.
3 HIV Needleless systems Occupational Exposure Other Potentially Infectious Materials (OPIM) Parenteral Personal Protective Equipment Regulated Waste Sharps with Engineered Sharps Injury Protections Source Individual Human immunodeficiency virus. A device that does not use needles for: The collection of bodily fluids or withdrawal of body fluids after initial venous or arterial access is established; the administration of medication or fluids; or any other procedure involving the potential for occupational exposure to bloodborne pathogens due to percutaneous injuries from contaminated sharps. Reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or OPIM that may result from the performance of an employee's duties. The following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids; any unfixed tissue or organ (other than intact skin) from a human (living or dead); and HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV. Route of transmission through the piercing mucous membranes or the skin barrier through such events as needlesticks, human bites, cuts, and abrasions. Specialized clothing or equipment worn by an employee for protection against a hazard. General work clothes (e.g., uniforms, pants, shirts or blouses) not intended to function as protection against a hazard are not considered to be personal protective equipment. Liquid or semi-liquid blood or OPIM; contaminated items that would release blood or OPIM in a liquid or semi-liquid state if compressed; items that are caked with dried blood or OPIM and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or OPIM. A nonneedle sharp or a needle device used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids, with a built-in safety feature or mechanism that effectively reduces the risk of an exposure incident. Any individual, living or dead, whose blood or OPIM may be a source of occupational exposure to the employee. Examples include, but are not limited to, hospital and clinic patients; clients in institutions for the developmentally disabled; trauma victims; clients of drug and alcohol
4 treatment facilities; residents of hospices and nursing homes; human remains; and individuals who donate or sell blood or blood components. Standard Precautions Sterilize Universal Precautions Work Practice Controls Precautions for the care of all patients regardless of their diagnosis or presumed infection status. Use of a physical or chemical procedure to destroy all microbial life including highly resistant bacterial endospores. An infection control concept and approach that considers all human blood, certain human body fluids, and OPIM as if known to be infectious for HIV, HBV, and other bloodborne pathogens. Controls that reduce the likelihood of exposure by altering the manner in which a task is performed (e.g., prohibiting recapping of needles by a two-handed technique). PROCESS & PROCEDURES Employee Exposure Determination AUMC s Employee Health and Wellness identifies healthcare workers (HCWs) exposure determination, i.e. risk of exposure to blood and/or OPIM, based on job classification, tasks or procedures performed, without regard to the use of personal protective equipment (PPE) and regardless of employment status (i.e. full-time, part-time, per-diem, contract). Employee Health and Wellness screens for bloodborne pathogen risk on hire, upon new job creation, and as needed. Method of Implementation and Control A. The Exposure Control Plan (ECP) will be reviewed and updated when indicated, but at least annually. The ECP is readily available via hospital intranet for all employees to review. All employees and Healthcare Workers, including Licensed Independent Practitioners (LIPs), students, residents, and fellows, shall follow requirements outlined in the ECP. Hospital Epidemiology oversees compliance of the ECP ensuring OSHA compliance. B. Methods of Compliance Universal Precautions At AUMC, health-care workers, including LIPs, students, residents, and fellows, use Precautions when caring for all patients to prevent contact with blood and OPIM. Universal Precautions include Standard Precautions. It is an approach to infection prevention wherein the basic concept is that all human blood and human body fluids, except tears and sweat are treated as if known to be infectious for Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), and other bloodborne pathogens. Under circumstances
5 where it is difficult to differentiate between body fluids and other liquids, all body fluids are considered potentially infectious materials. Hand Hygiene AUMC shall provide handwashing facilities which are readily accessible to employees in areas where exposure to blood and OPIM is reasonably anticipated. This includes the provision of an approved soap and paper towels. When provisions of handwashing facilities are not feasible, AUMC provides an appropriate antiseptic hand sanitizer. AUMC ensures that employees wash their hands immediately or as soon as feasible after removal of gloves or other PPE. AUMC shall ensure that employees wash hands and any other skin with soap and water or flush mucous membranes with water immediately or soon as feasible following contact of such body areas with blood or OPIM. At AUMC, employees follow provisions within the Hand Hygiene policy. Engineering and Work Practice Controls Engineering and work practice controls are used to prevent or minimize employee exposure to bloodborne pathogens. Engineering Controls o The safe handling of needles and sharps is recognized as the single most important practice in preventing sharps injuries. All employees must take precautions to prevent injuries when using needles, scalpels, scissors, pipettes, and other sharp instruments or devices during procedures; when cleaning used instruments; during disposal of used needles and sharps; and when handling sharp instruments after procedures. o All employees must be trained on the availability and use of approved safety devices where appropriate for their work responsibilities. Employees are encouraged to report any hazards from needles / sharps that they observe in their work environment. Engineering controls used within AUMC include but are not limited to the following: Needleless intravenous system Blunt access devices Retractable fingerstick devices Retractable IV start needles Self-sheathing syringes Blood collection tubes Safety scalpels
6 Sharps containers o AUMC identifies the need for changes in engineering controls and work practices through evaluation of employee exposure data, employee interviews, and committee activities. Engineering controls are preferred to work practice when available and may be used in conjunction with work practices. The Safety Device Committee provides feedback on performance to Infections Committee and Safety Committee, evaluates the need for new products, and implements the use of the devices. These teams are comprised of non managerial employees responsible for direct patient care. o Safety Device Committee will review product alert recommendations and develop response plans. Work practice controls o Work practice controls used within AUMC include but are not limited to the following: Routine hand hygiene is conducted. Following any exposure, procedures within the Management of Occupational Exposure to Bloodborne Pathogens will be followed. Shearing, bending, or breaking of contaminated sharps is prohibited. Hand-to-hand recapping of needles is prohibited. If recapping is necessary, a mechanical device, recapping pad, or one handed scoop technique must be used. Syringes with or without sharps must be disposed of in sharps containers immediately, or as soon as possible. Safety devices must be engaged prior to disposal. Sharps containers are puncture resistant, color coded, and leakproof on side and bottom and must be replaced routinely and not allowed to overfill. Sharps containers are maintained in upright position throughout use. When moving contaminated sharps containers, the lids must be closed to prevent spillage or protrusion of contents. Sharps containers are easily accessible to personnel and located as close as is feasible to the immediate area where sharps are used or can be reasonably anticipated to be found. Needle boxes will be placed in each patient room and in every treatment room. At AUMC any item inadvertently placed in a waste receptacle is retrieved by emptying the contents and obtaining the item. If the item is a sharp, an intermediary tool (e.g. tongs or forceps) is used to pick up the item. A HCW with a minor, non-exudative, non-infected skin lesion (e.g., cuts, tear, abrasions, or breaks in skin) must cover the
7 lesion with a moisture-resistant dressing before contact with any body substances. No HCW with exudative lesions or weeping dermatitis performs or assists with operative procedures or other direct patient care activities. Additionally the HCW does not handle supplies, instruments or equipment used for patient care until the condition is evaluated by Employee Health and Wellness. The condition must have resolved or the HCW is counseled on appropriate barrier measures before performing the aforementioned tasks. Permission to return to work and barriers required are documented by Employee Health and Wellness and are submitted to the HCW s supervisor. See Employee Illness Policy and Work Restrictions Policy. Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a potential for exposure to bloodborne pathogens. Additionally food and drinks must not be used in patient areas, such as nursing stations. Additionally food and drinks are not allowed on transport carts used for transporting linen, pharmaceuticals, clean supplies, soiled items, etc. Food and drink must not be kept in refrigerators, freezers, on the counter tops, or in other storage areas where blood or OPIM are present. Breast milk is stored in refrigerators/freezers designated and labeled for breast milk only. Follow facility policies for use of employee breast pump room(s) and storage of breast milk in designated refrigerators. In the absence of officially designated refrigerators, employees will be responsible for the storage of the breast milk in a private container, its labeling, and cooling (by ice pack). Mouth pipetting/suctioning of blood or OPIM is prohibited. All procedures involving blood or OPIM shall be performed in such a manner as to minimize splashing, spraying, or other actions generating aerosols or droplets of these materials. Specimens of blood or OPIM are placed in designated leakproof containers for handling, storage, and transport. All specimen containers must have a biohazard label. At AUMC all waste is sorted at the point of generation. Biohazardous waste should be placed in closable containers which are collected and stored in soiled utility rooms or other designated areas while awaiting removal/disposal. If outside contamination of a primary specimen container occurs, or if the specimen could puncture the primary container, that container is placed within a second leak-proof and/or punctureresistant container, appropriately labeled for handling and storage.
8 Equipment that becomes contaminated is examined prior to servicing or shipping and decontaminated, as necessary, unless decontamination is not feasible. If the equipment cannot be decontaminated, a label must be attached to the equipment stating which portions remain contaminated. The pneumatic tube system is used to transport items such as laboratory specimens and pharmaceuticals. All laboratory specimens will be packaged in a leak-proof container and placed in a secondary biohazard bag. Personal Protective Equipment (PPE) Personal protective equipment is provided by AUMC, at no cost to the employee, when there is a chance of occupational exposure to blood or OPIM. PPE is readily available for use throughout AUMC to prevent blood or OPIM from passing through personal clothing, or contacting skin, eyes, mouth, and other mucous membranes. Appropriate PPE must be used, unless engineering and work practice controls have eliminated the potential for occupational exposure. Each department must assess the exposure potential from procedures performed by their employees and identify all procedures which necessitate routine use of personal protective equipment because of a probability of exposure. In addition, each employee should critically review their work responsibilities to make informed decisions regarding the appropriate use of personal protective equipment. o Gloves must be worn for touching blood or body fluids, mucous membranes, or non-intact skin of all patients, for handling items or surfaces soiled with blood and body fluids, and for performing venipuncture and other vascular access procedures. o Masks and protective eyewear or face shields must be worn to prevent exposure of mucous membranes of the mouth, nose, and eyes during procedures that are likely to generate splashes or splatters of blood or other body fluids. o Appropriate protective gowns or aprons must be worn during procedures that are likely to generate splashes of blood or other body fluids. For procedures during which you anticipate your clothing may become soaked, the aprons or gowns must be fluid resistant. o Surgical caps or hoods, shoe covers or boots must be worn in instances where gross contamination with blood/body fluids is reasonably anticipated (i.e. autopsy, surgery). o Resuscitation bags or other ventilation devices should be available in areas where resuscitation is predictable, in order to minimize the need for emergency mouth-to-mouth resuscitation. PPE that is contaminated must be removed immediately, or as soon as feasible, and prior to leaving the work area. Once removed PPE shall
9 be placed in appropriate container for storage, washing, decontamination or disposal. Cleaning & Spill Procedures (Housekeeping) Employees will follow departmental written policies/procedures for cleaning and decontaminating the environment, equipment, and work surfaces. Scheduled cleaning and decontamination of each unit or department will be performed, based on the location, type of surface to be cleaned, amount and type of contamination, and procedure/task performed in each area. At AUMC spills are subdivided into small (less than 500 ml) and large spills (greater than or equal to 500 ml). It is the responsibility of the department employees to clean small spills and Environmental Services to clean large spills. All contaminated equipment, environmental and work surfaces will be cleaned and decontaminated, as soon as possible, after contact with blood or OPIM. Reusable biohazard-labeled waste containers must be cleaned on a regular basis, in accordance with Environmental Services Policy/Procedure, and after contamination. Broken glassware shall be cleaned up using mechanical means such as a Swiffer and dustpan, tongs, or forceps; not with the hands. Reusable sharps that are contaminated with blood or OPIM shall not be stored or processed in a manner that requires employees to reach by hand into a container where sharps have been placed. When handling spills for blood, body fluids, or OPIM utilize the following procedures: o Wear disposable gloves. o Absorb fluids with disposable towels or use Isolyzer. o Clean area of all visible fluids with detergent (soap/water). o Decontaminate area with a premixed 1:10 bleach solution or approved hospital grade disinfectant. o Place all disposable materials in plastic, leak-proof bag. Handle as regulated medical waste. o Always use Standard Precautions when handling blood or OPIM Regulated Medical Waste Disposable Sharps o Contaminated sharps are placed in appropriate containers immediately, or as soon as possible. Safety devices must be engaged prior to disposal. o Containers for contaminated sharps shall be easily accessible to employees and located as close as feasible to the immediate area where sharps are used. o Sharps containers must be replaced when fill line is reached on container.
10 o When moving contaminated sharps containers, the lids must be closed to prevent spillage or protrusion of contents. o The container shall be placed in a secondary container if leakage of the primary container is possible. The secondary container shall be closeable, constructed to contain all contents and prevent leakage during handling, storage, transport, or shipping. The second container shall be labeled or color-coded to identify its contents. Other Regulated Waste (Biohazardous Waste) o Other regulated waste shall be placed in containers that are closeable and constructed to contain all contents and prevent leakage during handling, storage, transport, or shipping. The waste container must be labeled or color-coded and closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping. o At AUMC a biohazard-labeled carrier (i.e. specimen bag) is used to transport specimens to avoid accidental breakage. Gloves are not worn to transport specimens. Upon delivery of a specimen to the receiving area, hands are washed at the designated sink. o At AUMC each HWC who handles the specimen container and requisition form has the right and responsibility to refuse to handle the container if the container is improperly sealed or contaminated externally. The HCW who collected the specimen is responsible for correcting such problems. If a specimen container is leaking, the sample is transferred to a new container if possible or a new specimen is obtained. If these possibilities are not feasible, the specimen container is placed in a well-sealed, biohazard-labeled bag to avoid contamination of individuals and the environment. o All specimen testing performed on the patient care units are conducted in the patient s room or soiled utility room. o When handling biohazardous waste, health care workers at AUMC shall utilize standard precautions. Laundry An adequate supply of clean linen shall be maintained to meet the needs of AUMC facilities. Linen shall be transported and stored in a manner as to minimize microbial contamination from surface contact or airborne deposition. AUMC uses Standard Precautions for handling all soiled laundry. All used laundry is considered potentially contaminated with blood or OPIM. Employees shall follow written policies/procedures for identifying, bagging, and handling all contaminated laundry and protective clothing that must be worn to prevent occupational exposure. Impervious bags are used for all laundry. PPE is worn during contact with contaminated laundry.
11 Contaminated laundry shall be handled as little as possible and with minimum agitation. For example, all soiled linen shall be bagged and closed at the location where it is used. Soiled linen is not stored or rinsed at the location of use. Laundry and Linen will provide designated scrubs to employees who have contaminated personal clothing. Hepatitis B Vaccination AUMC employees with an occupational exposure are instructed during their post offer health assessment regarding the Hepatitis B vaccination program. These employees are eligible to receive the hepatitis B vaccine at no charge. The first shot of the vaccine series is usually administered during the health assessment or at least within 10 days of initial assignment unless: o The employee previously received the vaccination series and; o Antibody titer testing reveals immunity or sero-conversion documented at time of initial vaccination; o The vaccination is medically contraindicated; or o The employee declines and signs an annual declination statement. The vaccine shall be administered under the supervision of a physician or other licensed healthcare professional. For employees who complete the Hepatitis B vaccination series, a test for antibody to Hepatitis B surface antigen must be conducted 6-8 weeks after completion of the three dose series. Titers will be drawn in the Employee Health and Wellness clinic. Any eligible employee who declines the Hepatitis B titer must sign a declination statement. If a routine booster dose of hepatitis B vaccine is recommended at a future date, such booster dose shall be made available to the employee. Post Exposure Evaluation and Follow up Hospital Epidemiology conducts the initial investigation for employee, student, patient, and visitor exposure to BBP. Augusta University (AU) Student Health shall manage the postexposure evaluation process and follow-up for AU students, including counseling, file documentation, program review, update, and oversight to ensure OSHA compliance with the elements of the program. The sharps injury log includes the date, involved device type and brand, the department or work area where the exposure incident occurred, and an explanation of how the incident occurred. AU Student Health shall be responsible for determining necessity of and implementing postexposure prophylaxis to AU students in the event of an exposure. Risk Management provides oversight for patients and visitors (nonemployees, non-healthcare personnel) exposed to blood and OPIM,
12 contact the exposed non-employee, arrange for medical follow-up, and coordinate payment of medical charges as needed. Employee Health and Wellness shall manage the post-exposure evaluation process and follow-up for AUMC employees. Following a report of an exposure incident, the exposed employee shall immediately receive a confidential medical evaluation and follow-up, including at least the following elements: o Documentation of the route of exposure, and the circumstances under which the exposure incident occurred. o Identification and documentation of the source individual (unless it can be established that identification is infeasible or prohibited by state or local law). o The source individual s blood shall be tested as soon as feasible, and after consent is obtained, in order to determine HBV, HCV, and HIV infectivity. o If consent is not obtained, the employer shall establish that legally required consent cannot be obtained. When the source individual s consent is not required by law, the source individual s blood, if available, shall be tested and the results documented. o When the source individual is already known to be infected with HBV, HCV, or HIV, testing for the source individual s HCV/HBV/HIV status need not be repeated. o Results of the source individual s testing shall be made available to the exposed employee, and the employee shall be informed of applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual. o The exposed employee s blood shall be collected as soon as feasible and tested after consent is obtained. o The employee will be offered the option of testing her/his blood for their HIV serological status. o Post-exposure prophylaxis will be offered when medially indicated as recommended by the Centers for Disease Control and Prevention o Counseling will be provided to the exposed employee o Evaluation of reported illnesses will be done by Employee Health and Wellness. Employee Health and Wellness shall ensure that the Healthcare Worker (HCW) who evaluates an employee following an exposure incident is provided with the following: o Information on the OSHA Bloodborne Pathogens standard; o A description of the exposed employee s duties as they relate to the exposure incident; o Documentation of the route(s) of exposure and circumstances under which exposure occurred; o Results of the source individuals blood testing, if available; and
13 o All medical records relevant to the appropriate treatment of the employee including vaccination status. Employee Health shall obtain and provide the employee with a copy of their evaluation within 15 days of completion. For HBV vaccination, the HCW s written evaluation shall be limited to whether vaccination is indicated for an employee, and if the employee has received such vaccination. For post-exposure follow-up, the HCW s written evaluation shall be limited to the following: o A statement that the employee has been informed of the results of the evaluation; and o A statement that the employee has been told about any medical conditions resulting from exposure to blood or OPIM which may require further evaluation or treatment. NOTE: All other findings or diagnosis shall remain confidential and shall not be included in the written report. Labels Biohazard labels will be affixed to refrigerators, freezers and incubators containing blood or other potentially infectious material and other containers used to store, transport or ship blood or other potentially infectious materials. Biohazard labels are available from the AUMC distribution center. Labels will have a fluorescent orange or orange-red background, with lettering and symbol in black: the word BIOHAZARD and the universal biohazard symbol. Regulated wastes that have been decontaminated are not required to be labeled or color-coded and may be placed in the general waste stream. Information and Training Hospital Epidemiology, Employee Health and Wellness, Infections Committee, and the Safety Committee shall assist in the annual review and update of the Exposure Control Plan and training. All employees with potential for occupational exposure to blood or OPIM will receive training at the time of initial assignment. Such training will be provided during work hours and at no cost to the employee. Training will be provided annually thereafter. Employee Health and Wellness, Hospital Epidemiology, and Safety may be contacted for questions. Workforce Development partners with Hospital Epidemiology and Employee Health and Wellness to ensure that initial and annual continuing education is provided to healthcare personnel whose work may put them at risk of exposure to bloodborne pathogens Employers shall provide additional training when changes such as modification of tasks or procedures or institution of new tasks or procedures affect the employee s occupational exposure risk.
14 Training will include the following elements: Accessible copy of the regulatory text of the OSHA Bloodborne Pathogen Standard and an explanation of its contents. General explanation of the epidemiology and symptoms of bloodborne diseases. Explanation of transmission modes of bloodborne pathogens. Explanation of the AUMC ECP and the means by which the identified person can obtain a copy of the written plan. Explanation of the appropriate methods of recognizing procedures and other activities that may involve exposure to blood and OPIM, including what constitutes an exposure incident. Explanation of methods that will prevent or reduce exposure including engineering controls, work practice controls, and personal protective equipment (PPE). Information on the types, proper usage, disposal, location, removal, handling, and decontamination of PPE. Explanation of the basis for selection of PPE. Information on the Hepatitis B vaccine, including vaccine efficacy, safety, method of administration, the benefits of being vaccinated, and its availability at no charge to persons in positions exposed to bloodborne pathogens. Information on the appropriate actions to take and persons to contact if an emergency involving blood or OPIM occurs. Explanation of the procedures to follow if an exposure incident occurs, including the methods of reporting the incident and the medical followup that will be made available. Information on the post-exposure evaluation and follow-up that AUMC will provide for the identified person following an exposure incident. Explanation of the signs, labels, and color-coding used at AUMC as required by the OSHA Bloodborne Pathogen Standard. Opportunity for interactive questions and answers with the person conducting the training session. The person conducting the training shall be knowledgeable in the subject matter covered by the elements contained in the training program as it relates to the workplace that the training will address. Training records will be maintained in the employee s department. Recordkeeping All records regarding employee exposure to blood or OPIM as required by OSHA will be maintained by Employee Health and Wellness and will contain the minimum information. o Employee s name and social security number o Employee s hepatitis B vaccination status including the dates of all the hepatitis B vaccinations and any medical records relative to the
15 employees ability to receive vaccination or the employee s declination. o Employee s post-exposure examination, medical testing, and followup procedures. o Exposure Incident Evaluation. A copy of information provided to the employee Confidentiality o The employer shall ensure the employee medical records are kept confidential and not disclosed or reported without the employees expressed written consent to any person within or outside the workplace except as required by law. o The employer shall maintain the records for at least the duration of employment plus 30 years. Training Records o Training records shall include the following information Dates of training sessions Training contents or summary Names and qualifications of persons conducting the training Names and job titles of all persons attending the training session Training records shall be maintained for 3 years from the date on which the training occurred Employee Health and Wellness maintains a sharps injury log for recording of percutaneous injuries from contaminated sharps. This data is reported to Safety Committee and Infections Committee. The log is maintained in such a manner as to protect the confidentiality of the injured employee and will contain at a minimum: o Type and brand of the device involved in the incident. o Department or work area where the exposure occurred. o Explanation of how the incident occurred. The OSHA 300 log will be maintained by the Workers Compensation Manager in Employee Health and Wellness for five years following the end of the calendar year that these records cover. REFERENCES, SUPPORTING DOCUMENTS, AND TOOLS Occupational Safety and Health Standards Bloodborne Pathogen 1910.1030 Occupational Safety and Health Standards Recording and Reporting Occupational Injuries and Illness 1904.33 Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Post exposure Prophylaxis
16 RELATED POLICIES Safety Device Committee Employee Illness Policy Work Restrictions Policy APPROVED BY Chief Executive Officer, Augusta University Medical Center Date: 09/06/2016