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UNIVERSITY OF FLORIDA

Environmental Health And Safety

BLOOD BORNE PATHOGEN PROGRAM

EXPOSURE CONTROL PLAN

Universal Precautions Policy

According to the concept of Universal Precautions, all human blood, human blood components, products made from human blood and certain other materials are treated and handled as if known to be infectious for HIV, HBV and other bloodborne pathogens.

The other potentially infectious materials (OPIM) which require Universal Precautions include 1) 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; 2) any unfixed tissue or organ (other than intact skin) from a human (living or dead); 3) HIV-containing cell or tissue cultures, organ cultures and HIV-containing culture medium or other solutions; and 4) blood, organs or other tissues from experimental animals infected with HIV or HBV.

The following shall be observed:

Personal Protective Equipment (PPE)

Personal protective equipment shall be used to prevent skin and mucous membrane contact with blood and OPIM. These may include the use of gloves, masks, protective eye wear or face shields and gowns or aprons, as appropriate for the task.

Hand washing

Hands and other skin surfaces shall be washed immediately after contact with blood or OPIM. Hands shall be washed each time gloves are removed.

Sharps

All sharps (needles, scalpels and razor blades) shall be disposed of in labeled, leakproof, puncture-proof sharps containers. Needles shall not be bent, sheared or recapped. Sharps containers shall be available in the area where sharps are being used.

Dermatitis

Employees who have exudative lesions or weeping dermatitis shall refrain from handling blood or OPIM until the condition resolves.

Biological Safety Cabinets (BSC)

BSC are required for procedures that may generate an aerosol (vortexing, grinding, blending etc.).

Biological Waste Disposal Policy

This policy is intended to provide guidance and insure compliance with the NIH/CDC guidelines, the State of Florida Administrative Code 64E-16, and restrictions of the Alachua County Landfill.

Categories

Infectious/potentially infectious/R-DNA

a)human pathogens

b) animal pathogens

c) plant pathogens

d) recombinant DNA

e) human and primate blood, blood products and other body fluids

f) human and primate tissue

g) any material containing or contaminated with any of the above (test tubes, needles*, syringes, tubing, culture dishes, flasks, etc.)

This waste must be inactivated prior to disposal. The preferred method is steam sterilization (autoclaving), although chemical inactivation or incineration may be appropriate in some cases. Storage of non-inactivated waste is restricted to within the generating laboratory. The material may not be stored longer than 24 hours prior to inactivation.

Non-infectious waste

This category includes waste that is not contaminated with any of the biological wastes listed above. It includes solid waste and sharps generated in clinical or laboratory settings. Sterile or unopened biomedical materials that require disposal are also considered biological waste.

IV Packs Test Tubes Petri Dishes

Needles* Razor Blades* Tissue Culture Flasks

Syringes Culture Dishes

Scalpels* Flasks

Broken Glass and Pipettes

Plasticware

This material does not require sterilization prior to disposal.

*Must be packaged in plastic sharps boxes.

Mixed radioactive/biohazardous waste

The biohazardous component of mixed radioactive/biohazardous waste shall be inactivated prior to its release to radiation safety for disposal as radioactive waste. Steam-sterilization or chemical inactivation shall be employed as above. Although many radioactive materials can be autoclaved safely, please check with the Radiation Safety Office (392-7359) regarding the best method to employ with any given radionuclide.

Mixed chemical/biohazardous waste

The biohazardous component of mixed chemical/biohazardous waste shall be inactivated prior to its release for chemical disposal. Precautions should be taken to prevent the generation and release of toxic chemicals during the inactivation process. In general, autoclaving is not recommended because flammable or reactive compounds should not be autoclaved due to the explosion hazard. Please check with the Biological Safety Office (392-1591) for guidance regarding particular chemicals.

Animal carcasses and materials

The disposal of animal carcasses and other animal materials shall be through the Animal Resources or the Veterinary Medicine incinerators only. These incinerators are for animal materials only. Please contact Animal Resources (392-2977) for further information. No animal bodies or material shall be disposed of as regular trash or through the biomedical waste receptacle.

Human remains

Please contact the Department of Pathology and Laboratory Medicine, Autopsy Services (392-4051) or the State Anatomical Review Board (392-3588) for information regarding the final disposition of human remains and body parts.

Packaging

Biohazard bags

Used for the initial collection of certain biological wastes. All biohazard bags must meet impact resistance (165 grams), tearing resistance (480 grams), and heavy metal concentration (<100 PPM total of lead, mercury, chromium and cadmium) requirements. Written documentation (a test report) from the manufacturing regarding these requirements must be on file. These bags must be placed in cardboard boxes (as described below) prior to disposal.

Sharps

a)Needles, scalpels and razor blades are required to be containerized in red plastic sharps containers. These are provided by Building Services (392-4415) at the Health Center.

b)All other sharps (broken glass and plasticware, pipettes, etc.) shall be containerized in puncture-resistant cardboard boxes (as described below). These are also available from Building Services.

Corrugated cardboard boxes

All biological waste is required to be containerized in rigid, leak-proof, puncture resistant boxes as the terminal receptacle. They are available from Building Services at the JHMHC, 392-4415.

Labeling

All packages containing biological waste shall be labeled with indelible ink marker (i.e., Sharpie(~)) as follows:

Date

Biohazard bags shall be labeled with the date they were put into use. Please note that biohazard bags must be labeled even though they will be placed inside a secondary container for final disposal.

Sharps containers shall be labeled with the date the container is full.

Corrugated boxes (biomedical waste boxes) shall be labeled with the date the biohazardous waste was treated. Boxes used for non-biohazardous waste collection shall be dated when the box is sealed.

Name/Location

Generator's (principal investigator's name and lab location (room number) will be clearly printed on each container.

Biohazard sign

Only manufacturer containers with the preprinted universal biohazard symbol and the words "biomedical", "biohazardous", or "infectious" shall be used.

Transport

The transport of biohazardous waste outside of the laboratory (i.e., to an autoclave or incinerator) must be in a closed leakproof container that is labeled "biohazard". Only trained personnel may transport biomedical waste. Labeling may be accomplished by use of a red or orange biohazard bag or a biomedical waste box with the universal biohazard symbol. Only corrugated biomedical boxes and red plastic sharps containers may be used to transport biological waste to the biomedical waste receptacle. Waste receptacle personnel are instructed not to accept any other type of containers.

Training

All employees who handle biological waste shall be trained annually regarding the proper handling of biological waste. All new employees shall be trained before they are allowed to handle biological waste. Training may be accomplished through the UF Bloodborne Pathogen Training Program, informally in the lab setting, or through formal training programs set up by individual departments or divisions. For assistance, please call the Biological Safety Office at (392-1591). According to Florida Statute (Ch. 64E-16 F.A.C.), records of the training session shall be maintained for each employee, along with an outline of the training program.

Exposure Control Plan

Exposure Prevention

Universal Precautions

Universal Precautions shall be practiced to prevent employee exposure to blood and other potentially infectious materials (see policy).

Engineering and Work Practice Controls

Engineering and work practice controls shall be used to eliminate or minimize employee exposure. Personal protective equipment shall be used when occupational exposure may occur even though the engineering and work practice controls are in place.

Engineering controls shall be examined and maintained or replaced on a regular schedule.

1. Hand washing facilities shall be provided and maintained with adequate supplies.
2. Hand washing shall be performed after removal of gloves and after contact with blood or OPIM.
3. Employees who have exudative lesions or weeping dermatitis shall refrain from handling blood or OPIM until the condition resolves.
4. Contaminated sharps and needles shall not be bent, recapped, or sheared.
5. Contaminated sharps and needles shall be disposed of in puncture resistant, color-coded, or labeled, leak-proof containers.
6. Eating, drinking, smoking, handling contact lenses, and applying cosmetics are prohibited in work areas where there is a potential for blood or OPIM exposure.
7. Food and drink are prohibited in work areas where there is a potential for blood or OPIM exposure.
8. All procedures involving blood and OPIM shall be performed in such a manner to minimize splashing, spraying, spattering, generation of droplets, or aerosolization of these substances.
9. Mouth pipetting and suctioning are not allowed.
10. Resuscitation devices including mouthpieces or resuscitation bags shall be available for use in areas where the need for resuscitation is predictable.
11. All specimens of blood or OPIM shall be placed in closable, leak-proof containers prior to transport. If contamination of the outside of the primary container is likely, then a second container such as a plastic bag should be placed over the primary container to prevent contamination and/or leakage during handling, storage or transport.

Personal Protective Equipment (PPE)

Personal protective equipment, including gloves, gowns, laboratory coats, face shields, face masks, eye protection, foot coverings, resuscitation bags and other items shall be provided to employees, as appropriate, to prevent exposure to blood or OPIM. These items shall be worn selectively, as needed for the task involved. PPE shall be considered "appropriate" if it does not permit the passage of blood or

OPIM through to an employee's skin, mucous membranes or street clothes.

Gloves

1. Disposable, single use gloves shall be worn when it is reasonably anticipated that the employee will have hand contact with blood or OPIM. The gloves shall be replaced when worn, torn or contaminated. They shall not be washed or decontaminated for re-use.
2. Utility gloves may be decontaminated and re-used if not punctured.

Masks, eye protection, face shields

Masks in combination with eye protection devices shall be worn when there is a reasonably anticipated chance of exposure to blood or OPIM through splashes, sprays, spatters or droplets.

Gowns, gloves, aprons and other protective coverings

These shall be worn depending upon the task and the degree of exposure anticipated.

Surgical caps, hoods or boots

These shall be worn when gross contamination is reasonably anticipated.

There shall be a designated area in each work setting for the disposing, storage, cleaning and disposal of PPE. Contaminated PPE that is not immediately decontaminated shall be clearly designated and treated as biohazardous material.

Housekeeping

Cleaning, Disinfection, and Sterilization Practices

1. All environmental and work surfaces shall be properly cleaned and disinfected on a regular schedule and after contamination with blood or OPIM (see procedures).
2. Appropriate personal protective equipment (e.g. gloves) shall be worn to clean and disinfect blood and OPIM spills.
3. Cleaning, disinfection, and sterilization of equipment shall be performed, as appropriate, after contamination with blood and OPIM (see procedures).

All linens used in UF Health Care Facilities shall be considered to be contaminated and shall be handled using Universal Precautions.

All infectious wastes shall be managed according to UF Biological Waste Disposal Policy (see policy).

1. Gloves shall be worn by employees who have direct contact with contaminated waste.
2. All biohazardous and/ or biomedical waste designated for removal and incineration off-site shall be labeled according to Florida statutes.

Labels

1. Warning labels as specified by the bloodborne pathogen standard shall be used. Red bags or red containers may be substituted for labels.
2. The labels shall include the biohazard symbol and be fluorescent orange or orange red.
3. Warning labels shall be placed on containers of regulated waste, refrigerators and freezers containing blood or other potentially infectious materials. Other containers used to store, transport or ship blood and OPIM shall also be labeled.
4. Warning labels should be affixed to contaminated equipment and state which portions of the equipment are contaminated.

Exposure Management

Exposure management including post exposure prophylaxis shall be done according to Student Health Care Center (SHCC) Employee Health Policies, in compliance with OSHA standard 1919.1030 and Florida statutes.

UF employees who have been determined to be at risk shall receive education regarding the management of exposures to bloodborne pathogens that shall include the following:

1. Wound and skin exposures shall be immediately washed with soap and water.
2. Exposures shall be reported to the supervisor.
3. Exposed individuals shall go as soon as possible (within 1 to 24 hours) to the SHCC (or to Shands Emergency Room if SHCC is closed) for follow-up evaluation and treatment.

SHCC shall provide a confidential medical evaluation and follow-up of all exposure events to employees. The follow-up shall include these components:

1. The route and circumstances of the exposure shall be documented.
2. The identification of the source individual shall be documented unless it is unfeasible or prohibited by state law.
3. The source individual shall be tested for HIV or HBV according to Florida Statutes. Retesting is not necessary when the source individual is known to be positive for HIV or HBV. Those results shall be disclosed to the employee according to Florida statutes.
4. Serologic testing of the exposed employee shall be offered within the provisions of Florida statutes for HIV. If the employee consents to baseline blood collection, but chooses not to be tested for HIV at that time, the sample shall be held for 90 days after the incident enabling the employee to have HIV testing within the 90 days.

The evaluation and follow-up protocols are based upon U.S. Public Health Service recommendations. A written follow-up letter shall be provided to the exposed employee with 15 days of the completion of the evaluation. The letter shall document:

1. That the employee has been informed of the results of the evaluation.
2. That the employee has been informed about any medical conditions resulting from exposure to blood or other potentially infectious materials which require any further evaluations or treatment.
3. The hepatitis B immunization status and the need for immunization.
4. The letter shall not include any confidential material.
5. The medical personnel responsible for evaluation of exposures shall be knowledgeable about the OSHA Bloodborne Pathogen standard 1910.1030 and Florida Statute. SHCC shall provide the results of the source individual's blood testing and the immunization status to the medical evaluator. A description of the exposed employee's duties as they relate to the incident shall also be given to the evaluator.

HIV and HBV Research and/or Production Laboratories

There are special requirements for research laboratories and production facilities engaged in the culture, production, concentration, experimentation and manipulation of HIV and HBV (see procedures). These requirements apply in addition to the other requirements of this rule. These requirements DO NOT apply to clinical or diagnostic laboratories engaged solely in the analysis of blood, tissue or organs.

Assessment: Monitoring, Review and Update

Monitoring

1. Each department chairperson or director shall be responsible for monitoring his or her department's or division's compliance with the bloodborne pathogen standard.
2. EH&S shall assist departments in monitoring compliance with the bloodborne pathogen standard.

Review and Update

EH&S shall review and assess the Exposure Control Plan annually. Input from the departments and from campus-wide monitoring will be used to update this plan as needed.

Jan van der Aa
Hans van Oostrom
WebMasters

Department of Anesthesiology
University of Florida