Bloodborne Pathogen Exposure Control Plan

Cuts, lacerations, punctures, and similar percutaneous injuries can be especially dangerous when the instrument that causes them is contaminated with blood and other bodily fluids or tissue that can cause hepatitis, HIV, COVID-19, and other significant and even life-threatening diseases. Exposure to so-called bloodborne pathogens (BBPs) is common among healthcare workers who handle needles, scalpels, and other “sharps” used to provide medical care. However, it’s also a concern at medical research facilities, labs, laundering and cleaning services, law enforcement offices, and any site in which staff provides first aid to ill or injured workers.

Employers at sites where BBP hazards exist are legally required to take measures to protect their workers against exposure. Several provinces and territories require employers to incorporate these measures into an exposure control plan. Even where not expressly required, having an exposure control plan for BBPs is highly advised as a best practice. Here’s a template form that you can adapt for your own use depending on your particular operations and province.

BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN

PURPOSE

In the course of work, ABC Healthcare Company (“ABC”) workers may be required to work with or near needles, lancets, scalpels, and other machinery, equipment, tools and objects with sharp blades or edges that may cut, lacerate, and puncture the skin. In addition to causing serious injury to skin, muscles, nerves, bones, and internal organs, wounds from sharps may transmit bloodborne pathogens that can pose a risk of harm to the worker’s health and safety. ABC has adopted this Plan to ensure that all workers understand these hazards and outline the measures that will be taken to control those hazards in accordance with the Human Pathogens and Toxins Act (“HPTA”), [insert jurisdiction] Occupational Health and Safety Regulations (“OHS Regulations”) and other applicable requirements and standards.

DEFINITIONS

For purposes of this Plan:

“Bloodborne Pathogens” (BBPs), as used in this Plan, refer to: i. pathogenic micro-organisms present in human blood that can cause diseases in humans, including but not limited to hepatitis B virus (HBV) and human immunodeficiency virus (HIV); and ii. Other Potentially Infectious Materials (OPIM) means other infectious materials including:

Bodily fluids, such as semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva, or any other body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to tell the difference between body fluids; and
Fixed tissues and organs, non-intact skin, or mucous membranes.

“Competent” means possessing knowledge, experience, and training to perform a specific duty safely and effectively.

“Contaminated sharp” means any contaminated object that can penetrate the skin including but not limited to needles, scalpels, broken glass, broken capillary tubes, dental wires and equipment, and edges of dirty equipment.

“Exposure incident” means any contact of blood or OPIMs with non-intact skin or mucous membranes.

“Needleless system” means a commercially available device approved as a medical device by Health Canada that replaces a hollow bore needle for use in medical procedures in which a worker could suffer a percutaneous injury with a contaminated hollow bore needle.

“Reasonably practicable” means a standard used to determine whether a specific safety measure or device is appropriate and viable for use by ABC to control BBP hazards at its workplace applied by ABC management on a case-by-case basis, which involves determination of: i. ‘Reasonableness,’ an evaluation that weighs factors such as degree of risk to workers, nature of the hazard, length and frequency of exposure, number of workers exposed, and severity of consequences the hazard can result in; and ii. ‘Practicability,’ an evaluation of whether a particular method of controlling the hazard is technologically feasible, affordable, cost-effective for the particular hazard, suited to the circumstances of the workplace, or otherwise viable. To be deemed not ‘reasonably practicable,’ a measure or device must be more than simply inconvenient or costly but impossible to adopt or adoptable only by investing time, energy, money, and other resources that are disproportionate to the safety benefits the measure or device would provide.

“Safety-engineered needle” means a hollow-bore needle that is: (a) designed to eliminate or minimize the risk of a skin puncture injury to the worker; and (b) and licensed as a medical device by Health Canada.

“Universal Precautions” refers to precautions developed by the U.S. Centers of Disease Control and Prevention and the Bureau of Communicable Disease Epidemiology in Canada that are designed to prevent the transmission of HIV, HBV, and other BBPs during delivery of first aid or health care. As outlined in Section 7 of this Plan, Universal Precautions include specific recommendations for use of gloves, gowns, masks, and protective eye wear when contact with blood or body secretions containing blood is anticipated.

POLICY STATEMENT

As part of its commitment to provide workers a safe and health working environment, the management of ABC will ensure that all reasonably practicable steps are taken to protect the health and safety of workers who work with or near or who are otherwise exposed to BBPs and contaminated sharps as required by the HPTA, OHS Regulations, and other applicable laws and standards.

WORKERS THIS POLICY IS INTENDED TO PROTECT

The intent of this Plan is to ensure that all workers exposed to illness and injury from contaminated sharps while working at ABC facilities and work sites are protected, regardless of who pays or employs those workers, including:

Full- or part-time workers employed by ABC;
Medical professionals and others who are self-employed or employed by third parties who work at ABC facilities;
Temporary employees placed by an outside agency to work at ABC facilities;
Contract labourers engaged to perform work at ABC facilities;
Volunteers or trainees who work at the site for free; and
Workers employed by prime contractors, contractors, and subcontractors to perform work at the site under a contract with ABC.

ROLES & RESPONSIBILITIES

5.1. Employer

Owners, corporate officers and directors, upper managers, and other representatives of ABC who may be defined as an “employer” under the [province] Occupational Health and Safety Act are responsible for overall implementation of this Plan, including ensuring that:

- The resources necessary to implement this Plan effectively are provided;
- The hazard assessment required by this Plan is appropriately carried out, reviewed, and revised;
- Appropriate measures are implemented to control BBP and contaminated sharps hazards identified, including reasonably practicable engineering controls, safe work procedures and other administrative controls, and personal protective equipment (“PPE”) and protective clothing;
- Workers are trained in and required to comply with the required safe work procedures and processes;
- Appropriate first aid facilities, equipment and personnel are in place to ensure immediate and effective treatment of contaminated sharps injuries;
- All exposed workers receive the information and training required by this Plan;
- This Plan is monitored, reviewed, and updated as necessary and at least once a year.

5.2. OHS Coordinator, Site Manager

The OHS coordinator, facility manager, or other person designated as being in charge of safety at the facility is responsible for ensuring the effective implementation of this Plan, including ensuring that:

- The hazard assessment required by this Plan is appropriately carried out, reviewed and revised;
- Appropriate measures are implemented to control BBP and contaminated sharps hazards identified, including reasonably practicable engineering controls, safe work procedures and other administrative controls, and PPE and protective clothing;
- Workers are trained in and required to comply with the required safe work procedures and processes;
- Appropriate first aid facilities, equipment, and personnel are in place to ensure immediate and effective treatment of sharps injuries;
- All exposed workers receive the information and training required by this Plan;
- This Plan and any administrative controls and safe work procedures developed under it are applied to prime contractors, contractors, and subcontractors hired to perform work at ABC facilities involving exposure to BBPs;
- The contaminated sharps injury log and other records required by this Plan are properly created and retained; and
- This Plan is monitored, reviewed and updated as necessary and at least once a year.

5.3. Supervisors

Supervisors are responsible for day-to-day implementation of many of the measures provided by this Plan, including ensuring that:

- All workers exposed to BBPs receive, understand, and follow their WHMIS or training or equivalent training provided under Section 16;
- Safe work procedures and processes for using, handling, storing, producing, and disposing of contaminated sharps are created and implemented;
- Workers are trained in and required to comply with safe work procedures and processes;
- Workers are held accountable for complying with this Policy and carrying out any applicable safe work procedures, including where necessary via the imposition of discipline for infractions;
- This Plan is properly applied to workers of prime contractors, contractors, and subcontractors hired to work at ABC sites where BBP hazards are present.

5.4. Workers

Workers are responsible for knowing, cooperating, and complying with this Plan, including by:

- Receiving, paying attention to, and applying the BBPs and contaminated sharps health and safety training and instructions they receive;
- Being aware of and carrying out safe work procedures for handling and working with and around contaminated sharps;
- Knowing how to immediately summon first aid;
- Wearing any supplied protective clothing;
- Properly using, inspecting, and storing any PPE they are required to use; and
- Reporting any contaminated sharps hazards, incidents, injuries or illnesses that they witness, experience, or are aware of to their supervisors.

5.5. Safety Committee/Safety Representative

ABC will consult with and secure the participation of the workplace Joint Health and Safety Committee (JHSC), Health and Safety Representative, or where no JHSC or Representative exists, the affected workers at the site in developing and implementing this Plan, including with regard to:

- Assessment of BBP hazards;
- Development and implementation of BBP health and safety training;
- Development and implementation of safe work procedures and processes;
- Selection and monitoring of hazard controls;
- Selection and installation of protective clothing and PPE;
- Investigation of contaminated sharps incidents; and
- Review of this Plan.

5.6. Visitors

Visitors to ABC workplaces and facilities covered by this Plan must stay away from areas of the work site where BBP hazards are present unless they:

- Are authorized to be in those areas;
- Follow all applicable safe work procedures while in those areas;
- Use all required PPE and protective clothing; and
- Comply with all safety instructions provided.

BBP HAZARD ASSESSMENT

ABC will designate a competent person to perform a hazard assessment to evaluate all job classifications and determine which workers face the risk of occupational exposure to BBPs. This determination will be made without regard to the use of PPE. The competent person will create a list of all job classifications and tasks or procedures that involve exposure to BBPs. The BBP hazard assessment will be reviewed at least once a year and immediately after:

Contaminated sharps incidents, injuries, and illnesses;
Significant changes to operations, technology, work methods, personnel, and other conditions affecting BBP and contaminated sharp hazards that were not addressed in the current hazard assessment; and
Indications that the current hazard assessment is not effective or responsive to current conditions.

UNIVERSAL PRECAUTIONS

ABC will observe Universal Precautions at its facilities to prevent contact with blood or OPIM. All blood or OPIM will be considered infectious regardless of the perceived status of the source individual.

Workers must wear appropriate PPE when performing work involving exposure to BBPs;
Workers must wash their hands or other skin surfaces immediately upon removal or gloves or contamination with blood or other body fluids;
Sharps must be disposed of in a puncture and leak-proof container labeled for disposal of such items;
Non-reflective breathers or other disposable aids must be used to minimize exposure to body fluids during CPR;
Clothing that becomes contaminated must be removed as soon as possible; and
Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in the first aid room.

SAFETY-ENGINEERED NEEDLES

ABC will, in consultation with the JHSC or safety representative, select and ensure the use of reasonably practicable engineering controls to eliminate or minimize worker exposure to BBPs.

8.1 Use of Safety-Engineered Needles & Needleless Systems

Where reasonably practicable, ABC will provide and ensure that workers use a self-sheathing needle device, retractable needle system, or other safety-engineered needle or needleless system for:

- Collecting bodily fluids;
- Withdrawing bodily fluids after establishing initial venous or arterial access;
- Administering medication or fluids; or
- Any other procedure in which it’s reasonably anticipated that a worker could suffer a percutaneous injury with a contaminated hollow bore needle.

8.2 Exceptions

Conventional hollow bore needles that are not safety-engineered or needleless systems may be provided and used if:

- After making reasonable efforts, ABC is unable to obtain a safety-engineered needle or needleless system that is appropriate for the work;
- ABC’s supply of safety-engineered needles or needleless systems has been exhausted and the risk of postponing the procedure until such a needle or system becomes available outweighs the risk of performing the procedures with a conventional hollow bore needle; or
- The location of the facility is subject to a public health emergency under [province] law.

[Add if you’re in Ontario]. In accordance with OHS regulations (O. Reg. 474/07, Section 4), workers may also use a hollow-bore needle that is not safety-engineered if they believe on reasonable grounds that, in the particular circumstances, the use of a safety-engineered needle would pose a greater risk of harm to themselves or another person than the use of the hollow-bore needle. ABC will develop and implement appropriate safety procedures for the use of non-safety-engineered needles in the event such circumstances arise.

PPE

ABC will provide PPE at no cost to workers, and workers must use gloves, gowns, lab coats, eye protection (including goggles and glasses with side shields), face masks and shields, and other PPE protecting against BBP exposure that is appropriate to the work. Workers must follow the protocols set out in the ABC PPE Policy in using, storing, inspecting, cleaning, and maintaining their PPE.

9.1 Gloves

Workers must wear disposable gloves when touching blood or other body fluids, mucus membranes or non-intact skin, or when handling items or surfaces soiled with blood or other body fluids;
Disposable gloves must be disposed of after a single use or immediately if they get torn, punctured or contaminated;
Workers who are allergic to latex gloves will be offered alternatives such as hypoallergenic gloves or glove liners.

9.2 Eye & Face Protection

Workers must wear goggles or face shields where droplets of blood or any body fluids may come in contact with the mucus membranes of their eyes, nose, or mouth. Regular safety glasses will not provide adequate protection if splashing occurs.

WHMIS LABELS

ABC will ensure that BBP hazards are clearly communicated to exposed workers in accordance with WHMIS requirements, including ensuring that the following items have warning labels bearing the WHMIS biohazard infectious materials symbol:

Containers of biological waste;
Contaminated equipment;
Refrigerators and freezers containing blood or OPIM;
Other containers used to store, transport, or ship blood or OPIM;
Sharps disposal containers; and
Bags and containers that contain or were in contact with blood or OPIM.

However, individual containers of blood or OPIM placed in a labeled container for storage, transport, shipment, or disposal need not be individually labeled. Labels are also not required for biological waste that has been decontaminated.

HANDLING OF SPECIMENS

The following protocols must be followed when handling specimens of blood or OPIM:

Specimens must be placed in a container that prevents leakage during specimen collection, handling, processing, storage, transport, or shipping;
Specimens that could puncture the primary container must be placed in a secondary, puncture-proof container;
The container for collecting, handling, processing, storing, transporting, or shipping blood or OPIM outside the facility must be labeled with a WHMIS BIOHAZARD label or colour-coded;
A BIOHAZARD labeled or colour-coded container must also be used for such specimens within the facility unless Universal Precautions are used throughout the procedure;
If outside contamination of the primary container occurs, the primary container must be placed in the secondary leak proof container that is labeled with a BIOHAZARD label or colour-coded;
Equipment that may become contaminated with blood or OPIM must be inspected and decontaminated as necessary before servicing or shipping;
If decontamination is not feasible, BIOHAZARD labels must be placed on all contaminated portions of the equipment to inform workers.

DISPOSAL OF CONTAMINATED SHARPS

The following protocols must be followed when discarding contaminated sharps and waste that may be contaminated with blood or OPIM:

When discarded as waste materials, needles, knives, scissors, scalpels, broken glass, or other sharp objects that are capable of cutting or penetrating the skin or any part of a worker’s body must be placed in puncture-resistant and leakproof sharps containers that are:
- Labeled or colour-coded as a BIOHAZARD;
- Easily accessible to personnel;
- Located as close as feasible to the immediate area where contaminated sharps are used or can be anticipated to be found;
- Maintained in the upright position;
- Emptied as often as necessary to prevent overfilling
[Add if you’re in Ontario] EXCEPTION: If such method of discarding needles is impracticable, ABC will provide a device or equipment selected by ABC, in consultation with the JHSC or safety representative, that protects workers from being accidentally punctured while recapping used needles and ensure that the needles are recapped using such device or equipment by workers who have received instruction and training in the use of that device or equipment;
Contaminated needles and other contaminated sharps must not be bent, recapped, removed, sheared, or purposely broken;
Broken glassware that may be contaminated must be collected using mechanical means that does not involve direct contact with the hands, such as tongs or brushes and a dustpan.

HOUSEKEEPING & SANITATION

Maintaining work areas in a clean and sanitary condition is essential to guarding against harmful BBP exposure:

Workers must decontaminate working surfaces and equipment with an appropriate disinfectant as soon as possible after completing procedures involving blood or OPIM;
All equipment, environmental surfaces, and work surfaces must be covered with protective coverings and decontaminated immediately or as soon as feasible after contamination;
In carrying out decontamination and cleaning, workers should normally use a solution of one part bleach to 10 parts water for cleaning and disinfecting;
All bins, pails, cans, and similar receptacles must be inspected and decontaminated on a regularly scheduled basis;
Food and beverages may not be kept in refrigerators, freezers, shelves, cabinets, or on countertops or bench tops where blood or OPIM are present;
Workers may not eat, drink, apply cosmetics or lip balm, smoke, or handle contact lenses in work areas where there is a reasonable likelihood of exposure to blood or OPIM;
Mouth piping/suctioning of blood or OPIM is prohibited; and
Universal Precautions must be followed for handling laundry that may be contaminated with blood or OPIM.

SPILLS

Universal Precautions and the measures set forth in this Plan must be implemented when responding to and cleaning spills of blood and OPIM:

Workers cleaning the spill must use appropriate PPE and discard or dispose of it as soon as possible after completing the operation;
Spills should be cleaned up before the area is cleaned since adding liquid to spills increases the spill’s size;
If broken glass or other sharps are present, workers must use a dustpan, forceps, or other mechanical devices for cleanup, and discard the waste into a biohazard container or sharps container as applicable; and
Towels, gloves, and other wastes must be discarded in a biohazard bag.

Workers should use the following protocols when cleaning spills:

Secure the spill area and notify the supervisor;
Contain the spill with inert absorbing material such as kitty litter or absorbent pads;
Remove the absorbed material with a scraper and pan and place it in a biohazard bag; and
Clean the spill with an approved disinfectant.

HANDWASHING

Workers who handle blood or OPIM must follow proper handwashing protocols:

Wash hands with soap and water or clean them with alcohol hand sanitizer promptly after touching blood or OPIM, regardless of whether the worker was wearing gloves;
Use approved soap and not alcohol sanitizers when washing hands or gloves that are grossly soiled with blood or OPIM;
Clean hands with soap and water or alcohol hand sanitizer between tasks and procedures on the same patient to prevent cross-contamination of different body sites;
Perform handwashing between uses of alcohol hand sanitizer or towelettes to prevent buildup of residue.

BBP SAFETY TRAINING

Workers exposed to BBPs must receive training from a competent person who is knowledgeable of the subject about the hazards they face and measures in place to control them at the time of initial assignment to tasks where occupational exposure may occur. Such training must cover:

BBPs hazards and symptoms;
The modes of transmission of BBPs;
An explanation of this BBP Exposure Control Plan and how to get a copy of it;
Job tasks that may involve exposure to BBPs;
A description of the engineering, work practices, and other measures used to reduce risk of BBP exposure;
The types, use, location, removal, handling, decontamination, and disposal of the required PPE;
An explanation of the signs, WHMIS labels, and colour-coding systems;
The appropriate actions to take and persons to contact in an emergency involving blood or OPIM;
The procedures to follow if an exposure incident occurs, including the method or reporting and medical follow-up;
Information on the evaluation and follow-up required after an exposure incident; and
[Include if you’re in BC] Information on the HBV vaccination, including its efficacy, safety, method of administration, benefits, and that it will be offered free of charge.

Training will be refreshed, repeated, and reinforced as necessary and no less often than once a year.

EXPOSURE INCIDENT REPORTING & RESPONSE

Workers must immediately notify their supervisor or another ABC official when they are involved in an exposure incident. ABC will maintain an injury log for all exposure incidents that lists:

The date and time of the exposure incident;
The department or work area in which the exposure incident occurred;
The type and brand of the device involved in the exposure incident; and
An explanation of how the exposure incident occurred.

ABC will ensure that protected health information listed in the incident exposure log report is kept confidential and not disclosed except as permitted or required by law.

MEDICAL EXAMINATIONS

ABC will permit workers to undergo medical examination by a qualified health professional after an exposure incident or where such examination is ordered by a government official in accordance with [province] OHS laws. Where practicable, such medical examinations will be carried out during the worker’s normal working hours. ABC will pay for required medical examinations and treat the time workers spend receiving and traveling to and from them as work hours with no deductions from salary or wages.

HBV VACCINATION

[Include if you’re in BC] ABC will offer vaccination against HBV to all workers who are at risk of occupational exposure to that virus at no cost to the worker. Workers who decline the offered HBV vaccine must sign the waiver form, which is attached to this Plan as Attachment A.

[Add if you’re in Alberta] ABC will offer workers involved in an exposure incident a confidential post-exposure evaluation and follow-up along with access to the appropriate vaccination and vaccination series, if any, for the particular pathogen to which the worker was exposed. Workers who decline the vaccine must sign the waiver form, which is attached to this Plan as Attachment A.

EVALUATION

ABC will review this Plan, in consultation with the JHSC or Safety Representative, if any, at least once a year and as necessary in response to:

Significant or repeated exposure incidents, illnesses, or injuries;
Significant changes to operations, technology, work methods, personnel, and other conditions affecting BBPs that were not addressed in the current hazard assessment; and
Indications that the current Plan is not effective or responsive to current conditions.