Here is an example exposure control plan.
This video gives an overview of the different components of what the exposure control plan
encompasses.
This sample plan is available to download on the resource page or through the Oregon
OSHA website.
The purpose of a written program is not just to meet OSHA regulations, but to make sure
that you’ve accounted for all of the variables and that when the person who is in charge
of your exposure control plan leaves, their replacement knows exactly what to do.
As with any example of a written program, there are fields that need to be filled out.
This is very important to make sure that you go through and fill in all the blanks.
Starting with the Program administration section, we get into the nuts and bolts of identifying
who is in charge of what, which makes this an area that is especially important to pay
close attention to.
Sometimes you will want to fill in the name of the person, but you also want to make sure
if that person no longer has those responsibilities, that you change your program to reflect that.
Or you can identify a position so that it remains current, even if the person in that
position changes.
Next we have the Exposure Determination.
When you do your initial determination, you’re identifying which employees are always exposed
to Bloodborne Pathogens … You’re identifying employees who are sometimes exposed to Bloodborne
Pathogens … and you are also identifying tasks that can expose employees to Bloodborne
Pathogens.
So here’s where you would want to include the job titles of people that could have that
type of exposure potential.
For example, a phlebotomist, can’t draw blood without being exposed to blood.
In Methods of Implementation and Control you begin by stating what level of precautions
your program is following.
Whether you are following universal precautions, standard precautions or body substance isolation,
this is where you say that.
You want to identify who is responsible for keeping this program up to date, and who is
responsible for reviewing it annually.
The exposure control plan talks about the person, job title, department or whoever is
responsible for making sure that the initial training for employees is completed and that
the plan is annually reviewed, especially for smaller sites and larger hospitals.
For example, a hospital with an infection control department.
They’re probably going to be the same department doing both training and infection control.
In engineering controls and work practices you identify which engineering controls your
company uses.
And that’s also going to include your SHARPS devices and your safer medical devices.
This is going to include what you are going to do with SHARPS containers for used SHARPS.
So if there is a specific work process that needs to be followed for a particular task
this is where you would want to identify that.
This section deals with Personal Protective Equipment.
What kind of PPE do your workers use?
Clearly with this, it depends on what tasks your employees doing.
This can be just be an overview of the program of what PPE is available, and then when you
get to what the task is.
You don’t necessarily need to say “for phlebotomy we use this kind of PPE, for housekeeping
we use this kind of PPE”.
You don’t have to drill it down that far.
That can just be something you can do locally.
What’s important is that you list all of the PPE that will be used and available on
site.
You want to say where it is, and who you speak with to obtain the correct PPE.
And then you have your specific practices for how you use it.
How are you going to dispose of that equipment when needed, especially when it is soiled
or contaminated?
Because that’s not something that you can necessarily dispose of in the normal garbage.
You may need to clean and decontaminate it first, or you may need to have specific biohazard
containers.
If it can break or if it’s sharp it may need to go into a SHARPS container.
There isn’t a lot of PPE that would need that, but you’ve got to consider it.
The housekeeping section mainly deals with regulated waste.
What do you do with your used sharps and regulated waste?
Where does that go?
Housekeeping is concentrated on waste and cleanup.
And in laundry, what articles are going to be laundered regularly by an employer.
Whether you sent it out or remain on-site, you need to identify that.
For example; if employees wear scrubs and those scrubs stay on site to be laundered
or if you contract an offsite facility to launder contaminated laundry, you’ll want
to state that.
And in the event that there is no laundry facility, and the PPE is all throw away, you
would want to state that as well.
If it is all disposable then you don’t have to worry about laundry.
But again, say so, so your program clearly identifies the protocol.
The labeling section covers who are responsible for making sure that contaminated or infectious
items are clearly identified as such.
Some instances will require biohazard tags and others just a label saying what is in
the container.
That’s going to depend on what the facility policy is, for example, a site may use red
bags for all the infectious waste.
Depending on the complexity of having different bags for different things, OSHA is only interested
with materials that are infectious and regulated.
But if there is a potential for confusion on what something is, you’ll definitely
want to make sure that it is labeled.
For storage areas you would want to make sure that it is clearly identified, so you don’t
put infectious waste some place else; for example, specimens and contaminated laundry.
Contaminated laundry is handled differently than all of your other laundry, especially
in a hospital setting.
So you want to make sure that you have two clearly identified places of what goes where,
so everyone is on the same page.
And whoever is responsible for making sure that those things are done so that if there
is a problem, your written program clearly identifies who you need to talk with.
With the Hepatitis B Vaccine, you want to ensure that someone is in charge of administering
it.
So making sure there is someone who’s responsible for getting everyone informed of the vaccination
is essential.
Whether they decline or accept, you will have accounted for every person and it will be
documented.
Where are they supposed to go to get the vaccination?
You want to identify that here.
When an employee declines a vaccination they need to sign a form “declination statement”,
which is attached the end of this document.
You can download a sample declination statement from the Oregon OSHA website.
Who is going to keep those forms, where are they going to be kept, also needs to be identified.
Possibly one of the most important sections of the written program is the post exposure
evaluation and follow up.
Any time that there is a needle stick, there are steps that must take place at the earliest
convenience.
If somebody has a needle stick that may carry HIV, they need to start treatment within 2
hours of that exposure.
That gives them the best possible outcome.
The timeliness on this is critical.
Again, it is very important to identify who is responsible for reporting needle sticks
and where the injured are going for treatment is also imperative.
There are specific things that need to happen, as part of the post exposure evaluation; the
employer is responsible for making sure that all of this happens.
They don’t necessarily do every step, but they do need to make sure that every step
is followed.
There are other aspects to this also, like counseling, and source individual testing.
In essence, the post exposure evaluation and the administration of that clearly needs to
identify who, what, where, and when.
In post-evaluation evaluation and follow-up, you must establish who is responsible for
ensuring proper procedures are followed after an exposure.
Now if there is an exposure incident you need to understand why.
You want to know how did this happen, why did this happen, and how do we keep this from
happening again.
So evaluating all of the different particulars of what was being used, were engineering controls
in use, was it a safe medical devise or not.
If it was a safer medical device, what model was it?
Have there been other issues with this particular devise?
If it the injury wasn’t caused by an engineered devise, are there engineered devises that
could overcome future occurrences?
These are things you are looking at in-depth.
The person who is responsible for making those changes is identified as well.
If changes need to happen, who is responsible for this evaluation?
Is
it
a person, a title, or
is
it a department.