Section 3 Table of Contents
UNIVERSAL PRECAUTIONS
Universal Precautions provide the first line of defense for
employees against the risks of exposure to bloodborne pathogens.
Universal Precautions shall be practiced at all times to reduce
the risk to workers in the vicinity of an exposure. Since there is
no way to know the status of body fluids from an unknown source,
Universal Precautions must be consistently used. This relates to
all activities involving contact with blood, tissue, body fluids,
or equipment and materials which may have been contaminated by
these substances.
- A. At a minimum, the following precautions are required of all
employees when attending to an injured worker or working with
equipment or materials which may have been contaminated with
infectious material. These universal guidelines do not relieve
personnel of responsibility for knowing and complying with
more detailed policies included in this Exposure Control
Plan which must be consulted and followed routinely.
- 1. WASH HANDS with antiseptic towelettes if there is any
possibility of contact with blood, body fluids or human
tissue. Wash hands with soap and water as soon as
possible.
- 2. WEAR GLOVES when anticipating contact with blood, body
fluid, tissues, mucous membranes or contaminated surfaces,
or if breaks in the skin are present.
- 3. WEAR AN IMPERVIOUS GOWN OR APRON if splattering of
clothing is likely.
- 4. WEAR A MASK if there is to be contact with an infectious
disease spread by splatter droplets.
- 5. WEAR APPROPRIATE PROTECTIVE EQUIPMENT at all times,
including a mask and eye protection if splattering is
likely to occur when attending to an injured worker.
- 6. USE MOUTHPIECES, RESUSCITATION BAGS AND OTHER VENTILATION
DEVICES during emergency resuscitation if this is a part
of the job duties.
- 7. HANDLE SHARP OBJECTS CAREFULLY:
- a. Do not cut, bend, break or reinsert used needles into
original sheath by hand.
- b. Discard sharp objects intact, immediately after use or
finding, into an impervious sharps disposal box.
- c. Report immediately all needle stick accidents, mucosal
splashes or contamination open wounds with blood or
body fluids.
- 8. DISPOSE OF ALL SPILLS which contain, or may contain,
biological contaminants in accordance with policies for
infectious waste disposal. Until clean-up is complete, the
area should be roped off to other workers.
- 9. POST UNIVERSAL PRECAUTION SIGNS in all areas designated
for first aid and on emergency response boxes and first-
aid kits.
- B. Again, we must always assume that every situation involving
unknown body fluids is a potential exposure to bloodborne
pathogens. PPE is our first line of defense. This equipment
is a physical barrier preventing skin or mucous membrane
contact with potentially contaminated fluids or tissues. Wear
gloves for most tasks. Always wear safety glasses with splash
guards or goggles if splashing may occur in body fluid
cleanups. If other protective clothing is necessary to
prevent contact, use it. Your health and safety are our
primary concern.
Section 3 Table of Contents
ENGINEERING CONTROLS AND WORK PRACTICES
- A. In spite of continual improvements in the design and
manufacture of safety devices to protect employees from all
types of environmental threats to their safety and health,
many threats remain. St. Olaf College acknowledges the
significant contribution made by these devices in protecting
employees from occupational hazards associated with bloodborne
pathogens and will insist that they be used on our job sites.
- B. Most BBP threats can be minimized greatly through engineering
controls and modified work practices. An engineering control
is a device which isolates or removes BBPs from the work
place. Sharps containers in the health service would be an
example. Work practice controls reduce a BBP threat by
changing the manner in which we perform a task. Blotting
large amounts of fluid with disposable toweling instead of
scooping up quantities with a dust type pan might be an
example. This would reduce the possibility of splashing.
When engineering controls and work practices cannot ensure
safety from an exposure incident, personal protective
equipment must be used.
- C. The following applies to all classification I and II employees
when attending to a situation which presents any risk of
exposure to a bloodborne disease:
- 1. Classification I and II employees are responsible for
proper use and routine care of health safety devices and
personal protective equipment.
- 2. Each employee must recognize the possibility of failure of
a safety device. Accordingly, employees shall adhere to
the tenants of Universal Precautions, always working with
care and without placing unjustifiable reliance on
mechanical devices as the sole means of avoiding the risk
of personal contamination.
- 3. Each classification I and II employee is responsible for
reporting observed deficiencies in existing devices to
supervisors or the maintenance staff.
- 4. Engineering safety controls and devices shall be
maintained in working order consistent with manufacturer's
specifications and common sense, which ever offers the
greater degree of worker protection.
- 5. Administrators and professional staff shall be alert to
the availability of new or improved protective devices.
Section 3 Table of Contents
HANDWASHING
- A. All employees must wash hands and any other skin with soap and
water and flush exposed mucous membranes with water
immediately or as soon as possible following contact with
blood or other potentially infectious materials.
- B. Employees must advise supervisors directly of any locations
where contamination could reasonably be expected to occur and
hands cannot be cleaned in accordance with the following
standards so that corrective action can be taken.
- C. It is vitally important to clean hands thoroughly after
contact with possible infectious material. This helps to
protect you, but is very important in preventing the
hand-to-hand spread of contamination to your fellow employees.
Inability to clean hands in accordance with the following
standard prior to possible contamination of self or others
which could result in transmitting a bloodborne disease must
be reported and evaluated as a possible exposure incident.
- D. Handwashing is the single most important means of preventing
the spread of infection. The principle of good handwashing is
that of using friction to mechanically remove micro-organisms.
- E. After possible exposure:
- 1. Wash hands with non-abrasive soap and running water.
- 2. Rinse hands under running water.
- 3. Dry hands well with paper towel.
- 4. Use paper towel to turn off faucet. All manually
controlled faucets are considered contaminated.
- 5. Dispose of single use or linen towels in appropriately
marked closable containers.
- 6. Apply hand cream after frequent handwashing. Use lotion to
prevent skin irritation, breakdown and subsequent
infection.
Section 3 Table of Contents
NEEDLES AND SHARPS
- A. Classification I and II employees do not usually use needles
or sharps shcu as scalpels. These implements, however, may be
used in the health service in unusual circumstances. If
contaminated by use, sharps must be safely contained in proper
sharps containers at the use location.
- B. Do not cut, bend, break ot routinely re-insert used needles
into original sheath by hand.
- C. Discard sharp objects intact immediately after use into an
impervious needle disposal box which should be conveniently
placed in appropriate work areas.
- D. Report immediately all accidents, including needlesticks,
mucosal splashes or contamination of open wound with blood or
body fluids.
- E. Employees must adher to the following Standard of Practice
when working with uncapped needles, syringes or IV tubing:
- 1. Place needle cap on flat surface, such as a table top.
- 2. Thread unprotected needle into cap, holding syringe or
tubing at needle juncture, securing firmly over the
needle.
- 3. Discard capped needle and syringe into designated sharps
disposal container.
- F. For needle attached to IV tubing:
- 1. Remove the capped needle from tubing and discard the
needle into an approved sharps disposal container.
Section 3 Table of Contents
INGESTION OF BLOODBORNE PATHOGENS
- A. Eating, drinking, smoking, applying cosmetics or lip balm and
handling contact lenses are prohibited in work areas where
there is a reasonable likelihood of occupational exposure.
- B. Food and drink shall not be kept in refrigerators, freezers,
shelves, cabinets, on countertops or bench tops where blood or
other potentially infectious materials are present.
- C. To every extent possible these cautions shall be communicated
to the general work force through routine first aid or other
safety training events and through written information
distributed or posted as a part of normal employee general
information dissemination.
- D. Employees who have been working at a site where the
possibility of contamination exists shall avoid any behavior
that could result in ingesting contaminated materials until
they have washed their hands with soap and running water as
described in the Exposure Control Plan's policy on
handwashing.
Section 3 Table of Contents
AVAILABILITY AND ACCESSIBILITY OF PERSONAL PROTECTIVE
EQUIPMENT
- A. Personal Protective Equipment includes but is not limited to
gloves, gowns, laboratory coats, face shields, masks, eye
protection, mouthpieces, resuscitation bags, pocket masks and
other ventilation devices.
- B. Appropriate equipment is that which does not permit blood or
other potentially infectious materials to pass through to or
reach the employee's work clothes, street clothes,
undergarments, skin, eyes, mouth or other mucous membranes
under normal conditions and for the duration of use.
- C. Each Classification I and II employee is responsible for
knowing the location and inventory level of appropriate and
properly sized protective equipment, and for advising
supervisors if adequate supplies are not available.
- D. Each Classification I and II employee is responsible for
inspecting protective equipment before use and for placing
defective pieces in the reject container located in each
storage area.
- E. To reduce the risk of exposure, PPE should not be handled
excessively for the purpose of inspection after use. Pieces
observed to be damaged should be placed in a separate
contaminated laundry container which is tagged defective.
- F. Incidence of possible exposure resulting from non-availability
of appropriate personal protective equipment is a serious flaw
in job performance for all involved.
- G. All Classification I and II employees shall use appropriate
personal protective equipment to the extent judged appropriate
based on any possibility of contracting an infection from
bloodborne pathogens at work.
- H. Employees shall wear protective caps or hoods and shoe covers
or boots in addition to routine personal protective equipment
when there is reasonable anticipation of gross contamination,
such as at the scene of a major accident.
- I. Employees shall remove immediately, or as soon as feasible,
any garment that is penetrated by blood or other potentially
infectious material. All personal protective equipment shall
be removed prior to leaving the scene and shall be placed in a
designated container for storage, washing, decontamination or
disposal.
- J. Each employee is responsible for inspecting protective
equipment before use. Defective pieces should be placed in the
reject container located in each storage area.
- K All employees are responsible for identifying pieces of
protective equipment that have been damaged during use.
However, to reduce the risk of personal exposure when removing
protective equipment, pieces should not be handled excessively
during inspection. Pieces known to have been damaged during
use should be placed in a separate contaminated laundry
container, and the container should then be tagged
accordingly.
Section 3 Table of Contents
SPECIFIC USE OF PERSONAL PROTECTIVE EQUIPMENT
- A. Masks, eye protection and face shield combinations shall be
worn whenever splashes, spray, splatter or droplets of blood
or other potentially infectious materials may be generated and
eye, nose or mouth contamination can be reasonably
anticipated.
- B. Employees shall wear gloves when it can be reasonably
anticipated that the employee may have hand contact with
blood, other potentially infectious materials, mucous
membranes, non-intact skin.
- C. Protective body clothing such as, but not limited to, gowns,
aprons, lab coats, clinic jackets or similar outergarments
shall be worn in occupational exposure situations. The type
and characteristics will depend upon the task and degree of
exposure anticipated.
- D. Employees shall wear protective caps or hoods and shoe covers
or boots when there is reasonable anticipation of gross
contamination in mass injury situations with extensive blood
loss or body fragmentation, or when gaining access to the
victim could result in exposure to blood or other potentially
contaminated fluids.
Section 3 Table of Contents
EYE PROTECTION
- A. Eye protection such as goggles, eye glasses or a face shield
will be worn when there is a possibility of contamination of
the mucous membranes through splashing.
- B. To properly apply eye protection:
- 1. Wash hands
- 2. Apply eye protectors
- 3. Glove
- 4. Perform procedure
- 5. Remove gloves
- 6. Remove eye protectors
- 7. Wash eye protectors with soap and water
- 8. Wash hands.
- 9. Keep eye protectors in a convenient, clean, dry area.
- C. Use this same procedure for putting on protective masks, head
wear, footwear, gloves and gowns or aprons.
Section 3 Table of Contents
GLOVES
- A. Gloves must be worn when it can be reasonably anticipated that
the employee may have hand contact with infectious material.
- B. Utility (reusable) gloves may be reused if they are in good
condition. If they are cracked, peeling or torn, they must be
properly disposed of.
- C. Disposable (single use) gloves must be replaced as soon as
possible if contaminated, or their integrity is compromised.
- D. After putting gloves on, reinspect for damage.
- E. When removing disposable gloves, pull down from the cuff. This
will leave the glove inside out, but minimizes potential
contamination of your hands. Place this first glove in the
palm of the other hand and remove the second glove in the same
manner.
- F. When removing reusable gloves, pull down from the
cuff. This
will leave the glove inside out, but minimizes potential
contamination of your hands. Disinfect, dry and reinspect for
damage. Discard if damaged in any way.
Section 3 Table of Contents
REMOVAL OF PPE
- A. To take off masks, headwear, footwear, gloves and gown:
- 1. Remove, headwear, footwear and then gloves and discard
into a waste container or place into an approved, properly
marked laundry container located within the space where
the task or procedure has been performed.
- 2. Remove gown, turning it inside out. Handle only the inside
of the gown. Place it into an approved, properly marked
laundry container located within the space where the
procedure has been performed.
- 3. Wash hands and flush mucous membranes if there is any
possibility that membrane exposure to blood or other
infectious fluids or materials occurred.
Section 3 Table of Contents
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