DHHS POLICIES AND PROCEDURES
Safety and Benefits
Current Effective Date:
Original Effective Date:
To establish procedures and protocols designed to protect employees who are identified as occupationally exposed to blood and other infectious materials.
Division/Facility/School Directors shall ensure all Department employees receive formal Bloodborne Pathogens training as required by OSHA 1910/1926 Industry and Construction Standards and State Workplace Requirements Program Manual for Safety and Health.
Definitions (also see Safety and Benefits Policy, Establishment of the Safety and Health Program Definitions Section)
- Protection Definitions
- Administrative Controls - procedures and work rules developed for specific tasks which are designed to reduce the risk of employee exposure.
- Engineering Controls - physical devices which isolate or remove the bloodborne pathogen hazard from the workplace.
- Personal Protective Equipment - specialized clothing or equipment worn by an employee for protection against a hazard, which does not permit suspect material to pass through or reach the employee's street or work clothes, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time it is used.
- Universal Precautions - the practice of treating all human blood and certain human body fluids as if they were suspect materials.
- Work Practice Controls - devising procedures or altering the manner in which a task is performed to reduce the likelihood of exposure.
- Employee Definitions
- At-Risk Employees - employees who are assigned to perform an at-risk task and employees who may perform at-risk tasks as a normal function of the job.
- Direct-Risk Employee - an At-Risk Employee who is reasonably anticipated to perform one or more Direct-Risk Tasks as part of the employee's primary job responsibilities.
- Potential-Risk Employee - an At-Risk Employee who is reasonably anticipated to perform a Potential Risk Task, or perform a Direct-Risk Task as a corollary job function, or who volunteers to provide first aid, CPR, or automatic defibrillation care in the event of an emergency.
- Tasks and Activities Definitions
- At-Risk Task - any task, activity, or job duty which could expose an employee to contact with blood or other infectious materials, without regard to the frequency, duration, or risk of such potential exposure and without regard to any protection provided by personal protective equipment.
- Direct Risk Task - one of the following At-Risk Tasks
- Activities which involve contact with Non-Intact Skin or mucous membranes.
- Activities which involve penetration of the skin barrier or invasive procedures.
- Decontamination and sterilization of equipment and instruments covered by the scope of this policy.
- Blood/body fluid spills and stain clean-up.
- Provision of first aid and cardio-pulmonary resuscitation, if a designated job function.
- Potential-Risk Task - one of the following At-Risk Tasks
- Activities performed in locations where invasive procedures are performed.
- Activities performed in locations where blood and/or other infectious materials are or may be openly present.
- Collection of items visibly contaminated with blood or other infectious materials.
- Infectious Materials Definitions
- Blood - human blood, human blood components and products made from human blood.
- Bloodborne Pathogens - pathogenic microorganisms that are present in blood and can cause disease in humans.
- Other Potentially Infectious Materials.
- The following human body fluids'
- Vaginal secretions.
- Any body fluids which do not naturally leave the body or penetrate to the exterior of the skin barrier.
- Any body fluid which is visibly contaminated with blood.
- All body fluids in situations where it is difficult or impossible to differentiate between fluids.
- Any unfixed tissue or organ (other than intact skin) from a human, living or dead.
- Human Immunodeficiency Virus (HIV)- or Hepatitis B Virus (HBV)-containing cultures, culture media, or experimental animal parts.
- Suspect Material - blood or other potentially infectious materials, in liquid, semi-liquid, or solid (caked) form.
- Exposure Definitions
- Exposure - a specific contact with contamination to one or more of the following body parts.
- Other mucous membrane.
- Exposure Incident - a specific incident of exposure which results directly from the performance of the employee's duties.
- Non-Intact Skin - skin where the normal skin barrier is breached, allowing direct contact between the employee's circulatory system and suspect materials.
- Occupational Exposure - the reasonably anticipated exposure that may result from the performance of an employee's duties.
- Parenteral - piercing the mucous membranes or the skin barrier through such events as needle sticks, human bites, cuts, and abrasions.
- Source Individual - any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to an employee.
- Other Definitions
- Contaminated, Contamination - the presence or the reasonably anticipated presence of suspect materials on an item or surface.
- Decontamination - the use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles and to where the surface or item is rendered safe for handling, use, or disposal.
- Medical Waste - blood and body fluids in individual containers in volumes greater than 20 milliliters, microbiological waste and pathological waste.
- Suspect Materials.
- Medical Waste.
- Contaminated items that would release suspect materials if compressed (squeezed) without concern to amount.
- Items caked with dried suspect materials which would release such materials during handling.
- Contaminated sharps.
- Pathological and microbiological wastes containing suspect materials.
- Sharps - Any object that can penetrate the skin.
- Sterilize - The use of a physical or chemical procedure to destroy all microbial life, including highly resistant bacterial endospores.
- All blood and other potentially infectious materials shall be treated as, contaminated with bloodborne pathogens.
- No employee shall knowingly enter into an environment or perform job duties where a risk of bloodborne pathogens exposure exists, unless.
- The employee is performing directed job related duties and is covered under an Exposure Control Plan(OSHA Standard, 1910.1030(c) ) and is in full compliance with its requirements and this policy; or
- The employee is providing voluntary assistance or first aid care in an emergency situation which is not work or job related.
- The employee is participating in a voluntary workplace sanctioned first aid program (i.e. AED’s, CPR) and has completed BBP Awareness Training as outlined below; or
- Each division/facility/school with identified At-Risk Tasks shall develop and implement an Exposure Control Plan meeting the following requirements:
- Exposure Determination Lists
- The schedule and method of implementation for Methods of Compliance, Hepatitis B Vaccination and Post-Exposure Evaluation and Follow-up, Communication of Hazards to Employees, and Recordkeeping and
- The procedure for the evaluation of circumstances surrounding exposure incidents
- A copy of the Exposure Control Plan is accessible to employees
- The Exposure Control Plan shall be reviewed and updated at least annually and whenever necessary to reflect new or modified tasks and procedures which affect occupational exposure and to reflect new or revised employee positions with occupational exposure. The review and update of such plans shall also
- Reflect changes in technology that eliminate or reduce exposure to bloodborne pathogens; and
- Document annually consideration and implementation of appropriate commercially available and effective safer medical devices designed to eliminate or minimize occupational exposure.
- A process to solicit input from non-managerial employees responsible for direct patient care who are potentially exposed to injuries from contaminated sharps in the identification, evaluation, and selection of effective engineering and work practice controls and shall document the solicitation in the Exposure Control Plan
- Each division/facility/school shall determine if its employees perform tasks which involve or may involve contact with blood and/or other infectious materials through the Hazard Assessment process (Safety Job Analysis/PPE Hazard Assessment, or Exposure Control Plan).
- The division/facility/school Safety and Health Director/Safety Representative shall ensure the Exposure Control Plan is reviewed annually, or whenever necessary to reflect new or modified tasks and procedures which affect occupational exposure.
- Medical Records for each Direct-Risk Employee shall be maintained and include the following:
- The name and social security number of the employee.
- A copy of the employee's hepatitis B vaccination status including the dates of all the hepatitis B vaccinations and any medical records relative to the employee's ability to receive vaccination.
- A copy of all results of examinations, medical testing, and follow-up procedures.
- The employer's copy of the healthcare professional's written opinion.
- A copy of the information provided to the healthcare professional.
- Medical Records covered under this policy shall be kept confidential and not disclosed or reported without the employee’s express written consent; except as required by this policy and the law.
- Medical Records for Direct-Risk Employees shall be maintained for the duration of employment plus 30 years in accordance with 29 CFR 1910.1020.
- Training covered under this policy shall be documented in writing and contain, at a minimum, the following elements:
- Name of the employee’s division/facility/school and work unit
- Date of training.
- Employee’s printed/typed name.
- Trainer’s printed/typed name.
- Training topic.
- Statement that the employee “acknowledges participation in the training and has acquired the knowledge, skills and ability to safely perform the task trained, and has been given the opportunity to ask questions and have those questions satisfactorily answered.”
- Employee’s signature.
- Trainer’s signature.
- Any deadline for follow-up training and make-up procedures.
- Training records for Direct-Risk Employees shall be maintained for 3 years from the date on which the training occurred.
- Training records for employees without anticipated occupational exposure (non Direct-Risk) shall be maintained for the current and previous year in accordance with the guidance found in the DHHS Safety Training policy.
- Bloodborne Pathogen Awareness Training
- Employees, regardless of exposure determination, shall receive BBP Awareness training during new employee orientation and annually thereafter.
- BBP Awareness Training shall include the following elements:
- General explanation of epidemiology and symptoms of bloodborne pathogens.
- Explanation of the modes of transmission of bloodborne pathogens.
- Explanation of Universal Precautions.
- Explanation of what constitutes as exposure incident.
- Procedures for Post-Exposure Examination and follow-up.
- The Division/Facility/School Safety and Health Director/Safety Representative shall be responsible for ensuring the preparation and presentation of this training is in compliance with this policy.
- Employees participating in a voluntary workplace first aid program (i.e. AED, CPR) shall complete BBP Awareness Training prior to being allowed to participate in the program and annually thereafter.
- Bloodborne Pathogen Training for Direct-Risk Employees
- Direct-Risk Employees shall participate in a training program which must be provided at no cost to the employee and during normal working hours.
- Employees participating in directed (involuntary) first aid programs will be considered to be Direct-Risk Employees.
- Training shall be provided to Direct-Risk Employees at the time of initial assignment to tasks with occupational exposure and Annually thereafter.
- Annual training for Direct-Risk employees shall be provided within one year of their previous training.
- Divisions/facilities/school’s 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. The additional training may be limited to addressing the new exposures created.
- The BBP training program for Direct-Risk Employees shall contain at a minimum the following elements:
- An accessible copy of the regulatory text of 29CFR1910.1030 and an explanation of its contents.
- A general explanation of the epidemiology and symptoms of bloodborne diseases.
- An explanation of the modes of transmission of bloodborne pathogens.
- An explanation of the applicable exposure control plan and the means by which the employee can obtain a copy of the written plan.
- An explanation of the appropriate methods for recognizing tasks and other activities that may involve exposure to blood and other potentially infectious materials.
- An explanation of the use and limitations of methods that will prevent or reduce exposure including appropriate engineering controls, work practices, and personal protective equipment.
- Information on the types, proper use, location, removal, handling, decontamination and disposal of personal protective equipment.
- An explanation of the basis for selection of personal protective equipment.
- Information on the hepatitis B vaccine, including information on its efficacy, safety, method of administration, the benefits of being vaccinated, and that the vaccine and vaccination will be offered free of charge.
- Information on the appropriate actions to take and persons to contact in an emergency involving blood or other potentially infectious materials.
- An explanation of the procedure to follow if an exposure incident occurs, including the method of reporting the incident and the medical follow-up that will be made available.
- Information on the post-exposure evaluation and follow-up that the employer is required to provide for the employee following an exposure incident.
- An explanation of the signs and labels and/or color coding required by paragraph 29CFR1910.1030(g)(1).
- An opportunity for interactive questions and answers with the person conducting the training session.
- The competent 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.
- Any employee who experiences an exposure incident as defined in this policy shall be provided an immediate medical examination and follow up examinations if so ordered by the treating medical provider.
- Hepatitis B vaccination and post-exposure evaluation and follow-up.
- The division/facility/school shall make available the hepatitis B vaccine and vaccination series to all employees who have occupational exposure, and post-exposure evaluation and follow-up to all employees who have had an exposure incident.
- The division/facility/school shall ensure that all medical evaluations and procedures including the hepatitis B vaccine and vaccination series and post-exposure evaluation and follow-up, including prophylaxis, are:
- Made available at no cost to the employee;
- Made available to the employee at a reasonable time and place;
- Performed by or under the supervision of a licensed physician or by or under the supervision of another licensed healthcare professional; and
- Provided according to recommendations of the U.S. Public Health Service current at the time these evaluations and procedures take place.
- The division/facility/school shall ensure that all laboratory tests are conducted by an accredited laboratory at no cost to the employee.
- Hepatitis B Vaccination.
- Hepatitis B vaccination shall be made available after the employee has received the required training and within 10 working days of initial assignment to all employees who have occupational exposure unless the employee has previously received the complete hepatitis B vaccination series, antibody testing has revealed that the employee is immune, or the vaccine is contraindicated for medical reasons.
- The division/facility/school shall not make participation in a prescreening program a prerequisite for receiving hepatitis B vaccination.
- If the employee initially declines hepatitis B vaccination but at a later date while still covered under the standard decides to accept the vaccination, the division/facility/school shall make available hepatitis B vaccination at that time.
- The division/facility/school shall assure that employees who decline to accept hepatitis B vaccination offered by the division/facility/school sign the statement in CFR 1910.1030 Appendix A.
- If a routine booster dose(s) of hepatitis B vaccine is recommended by the U.S. Public Health Service at a future date, such booster dose(s) shall be made available.
- Post-exposure Evaluation and Follow-up
- The division/facility/school shall document the route(s) of exposure, and the circumstances under which the exposure incident occurred.
- The division/facility/school shall identify and document the source individual, unless the the division/facility/school can establish that identification is infeasible or prohibited by state or local law.
- The source individual's blood shall be tested as soon as feasible and after consent is obtained in order to determine HBV and HIV infectivity. If consent is not obtained, the the division/facility/school 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.
- When the source individual is already known to be infected with HBV or HIV, testing for the source individual's known HBV or HIV status need not be repeated.
- 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.
- Collection and testing of blood for HBV and HIV serological status.
- The exposed employee's blood shall be collected as soon as feasible and tested after consent is obtained.
- If the employee consents to baseline blood collection, but does not give consent at that time for HIV serologic testing, the sample shall be preserved for at least 90 days. If, within 90 days of the exposure incident, the employee elects to have the baseline sample tested, such testing shall be done as soon as feasible.
- The division/facility/school shall, when medically indicated provide Post-exposure prophylaxis, as recommended by the U.S. Public Health Service.
- The division/facility/school should evaluate the need for post exposure counseling.
- The division/facility/school shall evaluate the circumstances of each reported illnesses to determine any changes to policy or procedures.
- The Safety Program Manager shall develop general operating procedures for the implementation of this policy.
- Each division/facility/school with employees performing at-risk tasks shall develop an Exposure Control Plan and specific operating procedures for the implementation of that plan.
- Each supervisor/manager shall ensure that the requirements of this policy, the associated procedures and the Exposure Control Plan are followed.
- Each employee shall perform his/her job duties in accordance with the requirements of this policy and the associated procedures and where applicable the Exposure Control Plan.
North Carolina General Statutes
Chapter 95, Occupational Safety and Health Act of North Carolina: 95-129(2) and 95-148(1) and (2)
Chapter 130A: Public Health: Article 6 and 130A-309.26
Chapter 143, Article 63: State Employees Workplace Requirements Program for Safety and Health: 143-582(1) through (5)
North Carolina Administrative Code
25 NCAC 1N.0105 (a)
15 NCAC 13B.1200
North Carolina Occupational Safety and Health Standards for General Industry, 29 CFR 1910.1030
Workplace Requirements Program Manual for Safety and Health:
Section 2, Policy 2.2: Requirements 1.b., 1.e., 2.a., 4.a., and 7.a.
Section 5, Policy 5.2
For questions or clarification on any of the information contained in this policy, please contact Human Resources. For general questions about department-wide policies and procedures, contact the DHHS Policy Coordinator.