BLOODBORNE PATHOGENS

EXPOSURE CONTROL PLAN

Benaroya Research Institute at Virginia Mason

Revised 1.7.15

Page 2 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

TABLE OF CONTENTS

I. Purpose…………………………………………………………………….….…3

II. Administration & Compliance……………………………………..….….3

III. Definitions……………………………………………………………..……..4

IV. Exposure Determination……………………………………………………7

V. Controlling Exposures to BBP…………………………………….………..9

VI. Personal Protective Equipment ……….…………………………………13

VII. Housekeeping & Spill Response ………………………………………..15

VIII. General Tissue Culture Procedures & Precautions………………..22

IX. Hepatitis B Vaccine …………..…………………….………………………24

X. Exposure Incidents ……………………………….…………………….……24

XI. Evaluation & Management of Exposure Incidents …………………..24

XII. Personnel Training ……..…………………………………..…………….26

XIII. Safer Sharps Program …………………………………………...………29

XIV. Accessibility and Updates of This Plan ………………………………30

Page 3 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

BLOODBORNE PATHOGENS EXPOSURE CONTROL

PLAN

Benaroya Research Institute at Virginia Mason

I. Purpose

In accordance with the WISHA Bloodborne Pathogens standard WAC 296-62-08001, Benaroya

Research Institute has developed the following exposure control plan to eliminate or minimize

employee occupational exposure to blood or other potentially infectious materials as detailed in the

Bloodborne Pathogens standard. This manual also contains guidance on lab-specific procedures for

working with specific Risk Group 2 agents.

II. Administration and Compliance

The Benaroya Research Institute Safety Officer is the administrator of this plan and is responsible

for its implementation. Employees who are identified as having occupational exposure are required

to comply with the procedures and work practices outlined in this exposure control plan. Failure to

follow these procedures can result in disciplinary action.

The BRI Institutional Biosafety Committees (IBC) has been established under the NIH Guidelines

and currently provides local review and oversight of nearly all forms of research utilizing recombinant

or synthetic nucleic acid molecules. All new BRI protocols must first be reviewed by the IBC to

ensure proper oversight. The BRI Biohazard Assessment Form shall be completed for each new

protocol, to assess the level of oversight (if any) required. Because BRI receives funding from

federal agencies, all laboratories at BRI are subject to the NIH Guidelines for Research Involving

Recombinant or Synthetic Nucleic Acid Molecules. (NIH Guidelines)

The NIH Guidelines place much of the authority, responsibility, and accountability for the safe

conduct of the research at the local level. More specifically, each institution conducting or sponsoring

research involving recombinant or synthetic nucleic acid molecules that is covered by the NIH

Guidelines is responsible for:

Establishing an IBC;

Ensuring that the IBC has adequate expertise and training (using ad hoc consultants as

necessary);

Providing appropriate training for the IBC chair and members, Biological Safety Officer

(BSO), principal investigators (PI), and laboratory staff;

Filing an annual report with the NIH OBA that includes (1) a roster of IBC members clearly

indicating the chair, contact person and, as applicable, the BSO, plant expert, animal expert,

and human gene transfer expert or ad hoc consultant; and (2) biographical sketches (e.g.,

curricula vitae or résumé) of all IBC members, including community members;

Establishing procedures that the IBC shall follow in its initial and continuing review and

approval of applications, proposals, and activities; and making available to the public, upon

Page 4 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

request, all IBC meeting minutes and any documents submitted to or received from funding

agencies that those agencies must make available to the public.

III. Definitions

For purposes of this section, the following definitions from the OSHA Standard shall apply:

“Blood” means human blood, human blood components, and products made from human blood.

“Biosafety Level” is level of containment for biohazardous materials. The CDC ranks Biosafety

levels as 1-4, with 4 identifying the most stringent degree of containment and personal protection.

“Biohazardous waste,” also called regulated waste, infectious waste or biomedical waste, is

any waste containing infectious materials or potentially infectious substances such as blood. This

includes liquid or semi-liquid blood or other potentially infectious materials; contaminated items that

would release blood or other potentially infectious materials in a liquid or semi-liquid state if

compressed; items that are caked with dried blood or other potentially infectious materials and are

capable of releasing these materials during handling; contaminated sharps; and pathological and

microbiological wastes containing blood or other potentially infectious materials.

“Animal Biosafety Level” is the biosafety designation used in animal facilities and parallels

standard biosafety procedures and containment used in the research labs. BRI has BSL1, BSL2,

ABSL1 and ABSL2 labs.

“Bloodborne pathogens” means pathogenic microorganisms that are present in human blood

and can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus

(HBV) and human immunodeficiency virus (HIV).

“Clinical laboratory” means a workplace where diagnostic or other screening procedures are

performed on blood or other potentially infectious materials.

“Contaminated,” means the presence or the reasonably anticipated presence of blood or other

potentially infectious materials on an item or surface.

“Contaminated laundry,” means laundry which has been soiled with blood or other potentially

infectious materials or may contain contaminated sharps.

“Contaminated sharps” means any contaminated object that can penetrate the skin including,

but not limited to, needles, scalpels, broken glass, broken capillary tubes, and exposed ends of

dental wires.

“Decontamination” means 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 the surface or item is rendered safe for handling, use, or

disposal.

“Engineering controls,” means controls (e.g., sharps disposal containers, self-sheathing

needles, biosafety cabinets, etc.) that isolate or remove the bloodborne pathogens hazard from the

workplace.

Page 5 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

“Exposure incident” means a specific eye, mouth, other mucous membrane, non-intact skin, or

parenteral contact with blood or other potentially infectious materials that result from the

performance of a staff member’s duties.

“Handwashing facilities” means a facility providing an adequate supply of running potable water,

soap and single use towels or hot air drying machines.

“Hazardous location” Defined as any location where hazardous materials (chemical, biological,

physical) are used, stored, or received.

“HBV” means hepatitis B virus.

“HCV” means hepatitis C virus.

“HIV” means human immunodeficiency virus.

“Needleless systems” means a device that does not use needles for:

• The collection of bodily fluids or withdrawal of body fluids after initial venous or arterial access is

established;

• The administration of medication or fluids; or

• Any other procedure involving the potential for occupational exposure to bloodborne pathogens

due to percutaneous injuries from contaminated sharps.

“Occupational exposure” means reasonably anticipated skin, eye, mucous membrane, or

parenteral contact with blood or other potentially infectious materials that may result from the

performance of an employee’s duties.

“Other potentially infectious materials (OPIM)” means:

(a) 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;

(b) Any unfixed tissue or organ (other than intact skin) from a human (living or dead);

(c) HIV-containing cell or tissue cultures, organ cultures, and HIV- or HBV-containing culture

medium or other solutions; and blood, organs, or other tissues from experimental animals infected

with HIV or HBV.

Additionally, since there are many infectious agents in use at BRI, “OPIM” also includes

these agents. Section IV of this document provides a more complete list of OPIM.

“Parenteral” means piercing mucous membranes or the skin barrier through such events as

needlesticks, human bites, cuts, and abrasions.

“Personal protective equipment (PPE)” is specialized clothing or equipment worn by an

employee for protection against a hazard. General work clothes (e.g., uniforms, pants, shirts, or

blouses) not intended to function as protection against a hazard are not considered to be personal

protective equipment.

“Risk Group” Risk group classifications are primarily used in the research environment as part of

a comprehensive biosafety risk assessment. Each country classifies the agents in that country by

Page 6 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

risk group based on pathogenicity of the organism, modes of transmission and host range of the

organism. These may be influenced by existing levels of immunity, density and movement of host

population presence of appropriate vectors and standards of environmental hygiene. Risk groups

correlate, but do not equate to biosafety levels.

“Sharps with engineered sharps injury protections,” means a non-needle sharp or a needle

device used for withdrawing body fluids, accessing a vein or artery, or administering medications or

other fluids, with a built-in safety feature or mechanism that effectively reduces the risk of an

exposure incident.

“Source individual” means any individual, living or dead, whose blood or other potentially

infectious materials may be a source of occupational exposure to the employee. Examples include,

but are not limited to, hospital and clinic patients; clients in institutions for the developmentally

disabled; trauma victims; clients of drug and alcohol treatment facilities; residents of hospices and

nursing homes; human remains; and individuals who donate or sell blood or blood components.

“Sterilize,” means the use of a physical or chemical procedure to destroy all microbial life

including highly resistant bacterial endospores.

“Universal precautions” are an approach to infection control. According to the concept of

universal precautions, all human blood and certain human body fluids are treated as if known to be

infectious for HIV, HBV, and other bloodborne pathogens.

“Work practice controls” means controls that reduce the likelihood of exposure by altering the

manner in which a task is performed (e.g., prohibiting recapping of needles by a two-handed

technique).

Page 7 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

IV. Exposure Determination

All new staff at BRI, upon hire, report to Virginia Mason Employee Occupational Safety & Health

Dept. to meet their “fit for duty” requirements. Included in this visit is the required annual influenza

vaccine and the Hepatitis B vaccine is offered (series begins, is declined, or vaccine from another

provider is noted).

WISHA requires employers to perform an exposure determination to identify staff members who

have occupational exposure to blood or other potentially infectious materials. Occupational exposure

means “reasonably anticipated skin, eye, mucous membrane or parenteral contact with blood or

other potentially infectious material that may result from the performance of an employee’s duties.”

For purposes of the determination, staff is considered to have occupational exposure even if they

utilize PPE while performing duties that put them at risk for exposure.

The following are job classifications in our establishment which have potential occupational exposure

to bloodborne pathogens, or supervise those who do:

Clinical research staff

Laboratory research staff

Principal Investigators

Facilities, shipping/receiving, safety, IT staff

Workers located in laboratory areas where blood or OPIM is handled

All BRI staff with reasonably anticipated potential for exposure to human blood and its components,

human tissue, all human cell lines, human source materials, as well as medications derived from

blood (e.g., immunoglobulins, albumin), and OPIM are required to comply with the BRI BBP

Program. OPIM includes all of the following:

Human cells (including all human cell lines) tissue, or organ cultures

Saliva during dental procedures

Peritoneal fluid

Culture supernatant

Vaginal secretions

Cerebrospinal fluid

Amniotic fluid

Pericardial fluid

Semen

Synovial fluid

Any unfixed tissue or organ (other than intact skin) from a human (living or dead)

Pleural fluid

Any solutions containing HIV/HBV/HCV, other BBP

Blood, organs, or tissues from animals infected with HIV/HCV/HBV or other BBP

Any body fluid visibly contaminated with blood or OPIM

Any fluid where it is difficult to identify the presence or absence of blood

Urine, feces, vomit, sweat, tears, and saliva are not regulated under the BBP rule because they are

not considered to present a risk for BBP transmission unless there is visible blood in them. However,

they should still be approached with caution; personnel should use latex or nitrile gloves and/or other

PPE as needed when handling.

Page 8 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

PIs /supervisors are responsible for assessing activities in the workplace, determining if employees

have a potential for occupational exposure, and documenting any additional training for handling

specific biohazardous agents in the Agent Information Sheets and/or Lab Specific Biosafety Manual.

Individual exposure determinations must be made for existing workers on an on-going basis and

prior to assigning or reassigning workers to job classifications with potential for exposure. The

exposure determination must be made without regard to the use of PPE.

V. Controlling Exposures to BBP

A. Universal Precautions: Universal precautions will be observed at this facility in order to

prevent contact with blood or other potentially infectious materials. This means that all blood or

OPIM will be considered infectious regardless of the perceived status of the source individual.

UNIVERSAL PRECAUTIONS ARE TO BE FOLLOWED FOR ANY MANIPULATIONS OF BLOOD,

BODY SUBSTANCES OR OTHER POTENTIALLY INFECTIOUS MATERIAL.

UNIVERSAL PRECAUTIONS INCLUDE:

1. Hand Washing

Hands are to be thoroughly washed with water and soap under the following situations:

● Before gloving

● After removing gloves

● After each patient procedure

● Before leaving the work area

● Before eating

● After hands have touched a contaminated (or possibly contaminated) surface

2. Gloves (Personal Protective Equipment)

Wear disposable latex gloves (or gloves of other approved material) for contact with blood

and other potentially infectious material.

Wash hands after removing gloves.

Gloves should be changed frequently; always change gloves immediately after

contamination.

Dispose of gloves in container (biohazard bag) that is placed in work area.

3. Lab Coats (Personal Protective Equipment)

Wear lab coats (buttoned) to protect clothing during normal working conditions.

Remove lab coats after working with blood or other potentially infectious material,

and hang or store the coats in the area where such work is done.

4. Masks, Glasses, Face Shields (Personal Protective Equipment)

Masks and glasses must be worn if splashing or aerosols are produced during a

procedure. Glasses must have solid side protectors.

Face shields should be worn if splashing or aerosols are produced during a

procedure, in place of the mask/glasses combination, when engineering controls

are insufficient.

Page 9 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

5. Personal Protective Equipment (PPE)

All equipment listed above is supplied by BRI at no cost to the employee.

Notify your supervisor if any equipment needs repair, replacement, or cleaning.

B. Engineering Controls

Benaroya Research Institute conducts ongoing evaluation of tasks and medical devices that carry a

risk of exposure and implements safer medical devices whenever feasible. A representative sample

of non-managerial employees is included in all evaluations. BRI has developed the following

engineering controls to prevent or minimize exposure to bloodborne pathogens. New technology will

be implemented and evaluated whenever possible. Our engineering controls are evaluated and

maintained as described in the table below:

Controls in Use

Location Evaluation/Service Interval

Controls Evaluated

Sharps Containers

All laboratory areas

Autoclave and dispose of as needed

Evaluated during annual inspections

Biosafety Cabinet

All tissue culture rooms and some main labs

Twice per year. Certified and serviced by Technical Safety Services. Records of certification maintained by BRI Facilities Dept.

Biohazard Waste Container

All laboratory areas where work with blood or OPIM is performed

Consists of doubled biohazard bags or plastic beaker lined with biohazard bag. Should be closed inside hood and transferred to Safety Transfer Device.

Evaluated during annual inspections.

Safety Transfer Device (bin)

All laboratory areas

For holding bags of potentially infectious waste prior to autoclaving. Decontaminate as necessary using Coverage.

Evaluated during annual inspections

Autoclaves Rooms G38, G68, 113, 207, 3116, 4072

For sterilizing potentially infectious waste and sharps. Any biohazardous waste is monitored using biological test strips to assure proper sterilization.

Quarterly preventive maintenance performed by Omega Medical Mechtronics.

Closed centrifuge cups and/or rotors

All laboratory areas

For containment of biohazardous agents during centrifugation outside of the biosafety cabinet

Evaluated during annual inspections, centrifuges serviced annually by Lab Performance Specialists.

Page 10 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

We have identified the following tasks and devices that utilize non-safer devices or allow

exceptions to defined work practice controls:

Exempted task or device Justification

Bench top blood handling areas in Blackford

Hall and the CRC in VMMC. Absorbent pads

and a bench top shield (front and sides) are

used to prevent contamination. Lab coat and

gloves must be worn. Staff in Blackford Hall

now has access to a fume hood, which can

protect from splashes, spills, and aerosols. A

fume hood does not protect the sample being

processed. See “Blackford Hall Biosafety

Manual” on BRInet.

Neither location currently has a biosafety

cabinet, this been determined by the Safety

Committee to be the next safest approach,

as it protects eyes, mucous membranes,

and skin from possible exposure.

C. Work Practice Controls The following work rules apply where there is a potential for contact with blood or OPIM. Procedures

for work in the Blackford Hall laboratories are described the Blackford Hall Biological Safety Manual

on BRInet. Additional work practice controls may be required for certain agents, based on risk

assessment. These are described in the lab specific biosafety manuals.

1. Hands and Body Washing

Hand washing facilities are available to employees who are exposed to blood or other potentially

infectious materials.

Employees shall wash hands after removal of personal protective gloves and whenever

there is a likelihood of contamination. In addition, any contaminated skin area will be

washed as soon as possible.

When hand-washing facilities are not readily available. The use of waterless hand

washing products is permitted as an interim means of washing the hands or other parts

of the body after contamination with blood or OPIM.

If blood or other potentially infectious material contacts mucous membranes then those

areas shall be washed or flushed with water as appropriate as soon as possible following

contact.

2. Other Work Practices

Contaminated needles may not be recapped, bent or broken off. Shearing or breaking of

contaminated needles is prohibited. They must be deposited in a sharps container

immediately or as soon as possible after use.

Sharps containers must be closed and taped shut with autoclave tape prior to removal or

replacement to prevent spilling or protrusion of the contents during handling or storage.

Page 11 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses

are prohibited in hazardous locations or labs.

Food and drink must not be kept in refrigerators, freezers, shelves, and cabinets or on

countertops or bench tops in hazardous locations or labs.

All procedures will be conducted in a manner, which will minimize splashing, spraying,

splattering, and generation of droplets of blood or other potentially infectious materials.

Mouth pipetting/suctioning of blood or other potentially infectious materials is prohibited.

Specimens of blood or other potentially infectious materials must be placed in fluid proof,

biohazard labeled, secondary transport containers. If the outside of the containers

becomes contaminated, then it must be placed in a second container.

Regulated waste material must be placed in a biohazard labeled container, which is to be

closed before removal to prevent spillage or protrusion of contents. If the outside of the

container becomes contaminated, then it must be placed in a second biohazard labeled

container.

Equipment, which may be contaminated with blood or infectious materials, must be

examined prior to service or shipping and shall be decontaminated as necessary. If

decontamination is not feasible then a readily observable biohazard label shall be

attached to the equipment and the contaminated portions documented. Employees shall

observe universal precautions and utilize appropriate PPE when handling such

equipment.

Hand to hand transfer of contaminated sharps is prohibited.

3. Additional Normal Handling Procedures

All blood, blood by-products, Risk Group 2 agents, and body substance materials are to

be clearly labeled with the biohazard warning symbol. No open containers of blood,

blood by-products, Risk Group 2 agents, or body substances shall be left unattended.

Centrifugation of blood or Risk Group 2 agents must be done in anti-aerosol centrifuge

carriers. Centrifuge tubes (orange capped, plug seal tubes or equivalent ones only) are

to be covered during centrifuging (each tube with its own top) and placed inside the anti-

aerosol containers. These containers must be loaded and unloaded in the biosafety

cabinet, following any other specific procedures for the agent in use.

Do not eat, drink, smoke, apply cosmetics or lip balm, or handle contact lenses in areas

where hazardous locations or labs.

4. Blood manipulations are to be carried out in defined areas

Blood draws: There is currently only one approved blood-draw area in BRI (room 274).

Blood is also drawn for BRI in the CRC, main lab and exam rooms at VMMC. Each unit

provides its own supplies for draws at VMMC. Dispose of needles in the small sharps

container on the bench, then autoclave the container and dispose of it when full. Needle

disposal at VMMC is according to procedures as per the VMMC safety program. Do not

recap needles. Underlay the blood draw area with absorbent underpads. These and

any other potentially contaminated material should be collected in an autoclave bag and

Page 12 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

autoclaved. Inspect area for spills or spatters; clean with approved disinfectant as

indicated.

Normal handling of samples: After they have been obtained from a subject/patient, blood

and/or body substances may be handled only in biosafety hoods except for VMMC and

Blackford Hall locations, where procedures specific to these locations must be followed.

Clean and disinfect the area when a procedure is completed and you are ready to vacate

the hood.

VI. Personal Protective Equipment (PPE)

All PPE used at this facility will be provided without cost to employees. PPE will be chosen based on

the anticipated exposure to blood or other potentially infectious materials. The PPE will be

considered appropriate only if it does not permit blood or other potentially infectious materials to

pass through or reach the employees’ clothing, skin, eyes, mouth, or other mucous membranes

under normal conditions of use and for the duration of time which the protective equipment will be

used. Employees will receive training on the appropriate use of PPE provided for specific tasks.

The following personal protective equipment is provided for workers:

PPE Use Guidelines

Gloves 1. Wear disposable gloves of approved material for contact with blood and other potentially infectious material. 2. Wash hands after removing gloves. 3. Gloves should be changed frequently; always change gloves immediately after contamination. 4. Dispose of gloves in container (biohazard bag) that is placed in work area. 5. CryoGloves must be worn when adding or removing cryovials from liquid nitrogen storage.

Lab Coats 1. Wear lab coats (buttoned) to protect clothing during normal working conditions.

2. Remove lab coats after working with blood or other potentially infectious material, and hang or store the coats in the area where such work is done.

Page 13 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

Face Shields, Safety Glasses 1. Face shields and safety glasses must be worn if splashing or aerosols are produced during a procedure that does not occur in a biosafety hood. Glasses must have solid side protectors. 2. Face shields must be worn when adding or removing cryovials from liquid nitrogen storage.

Gowns, aprons, surgical caps, shoe covers, scrubs, Tyvek suits

1. Gowns and aprons are to be worn whenever there is a risk of a splash to the body 2. Surgical caps, shoe covers, scrubs, Tyvek suits are to be worn when gross contamination is anticipated. These are also required attire for working in the vivarium.

Refer to department policies and procedures for instructions on the use of PPE for specific tasks that

may expose workers to blood or other potentially infectious material.

If required PPE is not available, contact your supervisor who will ensure that supplies are

replenished.

A. Gloves

Gloves shall be worn where it is reasonably anticipated that employees will have hand

contact with blood, other potentially infectious materials, non-intact skin, and mucous

membranes.

Disposable gloves used at this facility are not to be washed or decontaminated for re-use

and are to be replaced as soon as practical when they become contaminated or as soon

as possible if they are torn, punctured, or when their ability to function as a barrier is

compromised.

Utility gloves may be decontaminated for re-use provided that the integrity of the glove is

not compromised. Utility gloves will be discarded if they are cracked, peeling, torn,

punctured, or exhibits other signs of deterioration or when their ability to function as a

barrier is compromised.

B. Other PPE

Appropriate face and eye protection must be worn when splashes, sprays, spatters, or

droplets of blood or other potentially infectious materials pose a hazard to the eyes, nose

or mouth.

Gowns, aprons, and other protective body clothing shall be worn whenever there is a risk

of splash to the body.

Surgical caps or hoods and shoe covers or booties shall be worn when gross

contamination can be reasonably anticipated.

Page 14 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

All garments, which are penetrated by blood, shall be removed immediately or as soon

as possible. All personal protective equipment will be removed and placed in a

designated area or container prior to leaving the work area.

VII. Housekeeping & Spill Response

Work surfaces must be decontaminated with an approved disinfectant as soon as possible after

contamination with blood or OPIM and at the end of the work shift if the surface may have become

contaminated since the last cleaning.

A. Protocols for cleaning/decontamination/disposal

1. The area in which blood was handled is to be decontaminated after each procedure.

Surfaces are to be wiped down with an approved disinfectant following the wet-wait time

specific to that disinfectant before rinsing with distilled water, drying, and wiping with

alcohol.

2. Any equipment used in blood or body substance procedures is to be decontaminated

after every use. For example, the centrifuge anti-aerosol containers and tube carriers

are to be cleaned even if there are no visible signs of contamination. Each submersible

item should be soaked following the manufacturer’s instructions, in an approved

disinfectant, and then rinsed with water and air-dried. (The diluted disinfectant may be

poured down the sink.) Decontaminate manual and electric pipettors by wiping with an

approved disinfectant on a gauze sponge; leave wet for 10 minutes in hood. Then, wipe

with water, followed by 70% alcohol, and air dry.

3. Liquid generated as a by-product of manipulations of blood or body substances is to be

collected in a (doubled) autoclave bag that has been filled with sufficient absorbent

material (e.g., animal bedding) to absorb it completely. The absorbent should be pre-

wetted with an approved disinfectant. These bags should be sealed before being

removed from the hood and autoclaved on a tray or in a supporting container. Do not

use vacuum pumps, lines, and traps to collect liquids from blood, body substance or

infectious materials.

4. All disposable materials that come into direct contact with blood or body substances will

be collected in an autoclavable bag. Separate out glass waste; hold the bag in a rigid

container, and autoclave it separately

5. All containers that held blood must be discarded immediately after use in doubled

autoclave bags. These bags are to be closed with autoclave tape before removing them

from the hood, whenever possible. The bags are to be taken to the autoclave room and

autoclaved on the appropriate cycle (either “biohaz” or “infectio”, depending on the

autoclave) preferably that day. Do not leave autoclave bags in hallways, the shared

equipment room or other locations. The gray bins in the labs are for holding the waste

until there is an autoclave available for use.

6. After autoclaving waste that contains glass, dispose of the bag in the glass disposal

container in the autoclave room. If no glass is present in the autoclaved waste, it may be

discarded in a regular, lined trash can.

7. Contaminated sharps are to be placed in small red sharps containers labeled "infectious

waste." Do not recap needles. If sharps are contaminated with blood or infectious

material, autoclave the sharps container at least once a week. Partially filled and

Page 15 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

autoclaved sharps containers may be returned to the lab and used until full. Filled

sharps containers should be taped shut with autoclave tape, autoclaved, then set beside

a trashcan for collection and disposal.

8. Cells, serum, and other products of blood or body substance processing are still

potentially infectious and should be treated and disposed of by autoclaving on the

appropriate cycle.

B. Procedures for handling a spill

This section provides spill clean-up procedures for BSL-1 and BSL-2 laboratories. These procedures

apply to biohazardous agents and all rDNA. For BSL-2 laboratories where particularly hazardous

agents are in use, refer to your laboratory specific biosafety manuals for specific spill clean-up

procedures.

1) Responsibility

The OH&S Specialist, in conjunction with the BRI Safety Officer and PI, is

responsible for developing spill clean-up procedures appropriate for the materials

used in the laboratory, as well as assuring that a spill kit is assembled and placed in

a strategic location in or near the area where a spill could occur.

Furthermore, anyone working with biological materials must receive training in spill

clean-up appropriate for the materials routinely used.

2) Biohazard Spill Kit

The following items should be assembled in a single container that can be easily

moved to the spill area. A large bucket is practical for the container as it can double

as the secondary container for transporting waste away from the spill. See the

Biohazard Spill Kit checklist for more information.

The spill kit contains:

A broad-based chemical decontaminant appropriate for most agents handled in

the lab.

Materials to absorb liquids after decontamination: This could include paper

towels, absorbent lab pads, or special materials designed to absorb large

volumes of liquid.

Appropriate PPE to wear during clean-up: Nitrile or heavy duty gloves, a long-

sleeve laboratory coat or gown, shoe covers, and face shields. Facial protection

should be considered for large spills as well as protection against splash and

splatter of the chemical decontaminant and aerosols.

A mechanical means for handling broken glass: Tweezers and mini

brooms/dustpans are provided in the kits for this purpose.

Biohazard bags, sharps containers, and/or other containers: The containers are

used to hold the material for further treatment and disposal.

Notification signs: biohazard stickers and laminated door signs to be used around

the spill zone to warn others in the area.

Page 16 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

Spill instructions: a laminated version of standard BRI biohazard spill instructions

are included in each spill kit.

3) Spill Advice

For biohazardous spill advice contact the people who are listed as the emergency

contacts for that specific room or agent. These signs are posted on all BSL2 laboratory

doors and include work and after-hours phone numbers. You may also contact the

OH&S Specialist or the Biosafety Officer during normal business hours (Monday –

Friday; 9:00 a.m. – 5:00 p.m.).

4) Biohazardous Spill inside the BSC

In case of a spill in the hood, decontamination will be carried out using an approved

disinfectant. Continue to operate hood blower to prevent escape of contaminants from

the cabinet. Spill cleanup procedures should be initiated immediately while the cabinet

continues to operate:

Spill inside a BSC that stays contained on the work surface:

Remove any sharp, contaminated objects from the spill area using mechanical

means (like tongs or forceps) and never with hands. Discard contaminated

sharps in a sturdy, leak-proof, biohazard labeled sharps container.

Cover the spill with Kimwipes, towels, or gauze sponges and saturate them with

diluted disinfectant.

Place blue pad on top (blue side up)

Leave sitting wet for 10 minutes, or according to disinfectant manufacturer’s

directions.

Wipe up the spill, work surfaces, walls, and any equipment in the cabinet with

paper towels dampened with decontaminant. Do not place your head in the

cabinet to clean the spill; keep your face behind the sash.

Gather and dispose of solids in a biohazard bag inside hood, then remove and

place the spill cleanup materials into the biohazardous waste containment bin in

the main lab for autoclaving as soon as possible.

Dispose of any spill cleanup PPE along with the rest of the solid biohazardous

spill waste, prior to resuming work in the BSC.

Decontaminate and clean the BSC (again) as usual, before leaving the BSC for

the next user.

Spill inside a BSC that flows past the work surface through the front or rear grills:

A large spill inside a BSC that flows past the work surface through the front or rear grilles

requires more extensive decontamination. To prevent escape of contaminants from the

cabinet, spill clean-up procedures should be initiated at once while the cabinet continues

to operate.

Ensure the drain valve under the BSC is closed.

Page 17 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

Remove any sharp, contaminated objects from the spill area using mechanical

means (like tongs or forceps) and never with hands. Discard contaminated

sharps in a sturdy, leak-proof, biohazard labeled sharps container.

Flood the top work surface tray and, if a Class II BSC, the drain pans and catch

basins below the work surface with a decontaminating solution that is appropriate

for the agent involved (see Section 4.E), and leave wet for 10 minutes, or for the

length of time the manufacturer of the disinfectant recommends.

Remove excess decontaminant from the work surface tray by wiping with a

sponge or cloth. For Class II BSCs, drain the tray into the catch basin below the

work surface, lift the tray and take out the removable front intake grille. Wipe the

top and bottom (underside) surfaces of the grille with a sponge or cloth soaked in

the decontaminant. Then place the tray in position, drain the decontaminant from

the cabinet base into an appropriate container, and dispose of the decontaminant

in the lab sink.

Wipe up the rest of the spill, work surfaces, walls, and any equipment in the

cabinet with paper towels dampened with decontaminant. Do not place your

head in the cabinet to clean the spill; keep your face behind the sash.

Place spill clean-up materials (e.g., contaminated gloves, cloth and/or sponge) in

biohazard bags and place in the biohazard containment bin in the lab, to be

autoclaved as soon as possible.

Dispose of any spill cleanup PPE along with the rest of the solid biohazardous

spill waste, prior to resuming work in the BSC.

Decontaminate and clean the BSC (again) as usual, before leaving the BSC for

the next user.

5) Biohazardous Spill Outside the BSC:

Know which agents you are working with that can be transmitted via aerosol. This

procedure is for small and medium sized spills. For spills of 250ml or larger, more spill

supplies may be required, and can be found in the main lab.

1. Hold your breath and leave the room immediately. Ask other lab occupants to also

leave the room and close the door.

2. Warn others not to enter the contaminated area and post a sign on the door.

3. Remove contaminated garments and put into a container for autoclaving, or wet

contaminated areas with disinfectant. Thoroughly wash any exposed areas of the

body.

4. Wait 30 minutes to allow dissipation of aerosols created by the spill.

5. Clean up spill following standard biohazard spill cleanup procedures (these

procedures are also included in the spill kits):

Don heavy gloves over regular disposable lab gloves (these are available in the

spill kit along with the other supplies described here).

Page 18 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

Put on the disposable lab coat, shoe covers, and face shield.

Mark the area with biohazard warning labels, or mark the room in which the spill

occurred with the spill warning door sign---whichever is more appropriate for the

situation.

Using the forceps/tweezers, put any broken glass or other sharps waste into

sharps container.

Cover the entire spill area with the yellow or gray absorbent pad

Saturate the spill area and pad with the disinfectant mixture and leave it wet for

10 minutes, or following manufacturer’s instructions

Use an absorbent blue pad (blue side up) to lift the other absorbent pad and spill

into the autoclave bag.

Spray down the spill area with water to remove any residual disinfectant, and

wipe it dry with another blue pad or towels.

Place this, along with the gloves, gown, shoe covers, and face shield, into the

autoclave bag with the rest of the spill cleanup materials.

Put this bag into another autoclave bag, tape it shut, and place all spill cleanup

supplies in the biohazard containment bin in the lab to be autoclaved as soon as

possible.

6) Spills Outside the Laboratory in Public Spaces

Samples must be transported in secondary, leak-proof containers to minimize the

potential for spills. However, if a spill does occur in a common hallway or public space

and cannot be immediately decontaminated, cordon off the area, restrict access using

the “do not enter” tape from the chemical spill cabinet located on your floor, and contact

the Safety Officer or EH&S Specialist for assistance.

7) Radioactive Biohazardous Spill

Anyone working with both radioactive and biohazardous materials should develop a spill

clean-up plan appropriate for all materials used. Some general principles should apply:

contain the spill,

prevent spreading the contamination

choose methods for decontamination that do not create “mixed waste”

Radioactive biohazards must be decontaminated prior to disposal by saturating with

approved disinfectant for the recommended length of time; material can then be

disposed of as radioactive liquid waste.

8) In case of a spill or splash on a lab coat or other clothing

Remove the contaminated garment promptly. Wet the affected area with an approved

disinfectant. Deposit it in the laundry bin in the shipping and receiving area on Grade

level, in a plastic bag if it is still wet.

Page 19 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

9) Spill Reporting and Follow-Up

All spills of biohazardous materials must be reported immediately to a supervisor or

safety representative, as well as via a BRI Incident Report. Notify the BRI Safety and

Facilities Dept. to replenish the spill kit supplies.

C. Handling of Waste Material

Biomedical hazardous waste should be treated the same day it is generated, in

accordance with BRI Standard Operating Procedures.

Put this waste (except for sharps & glass) in doubled autoclave bags, secure them

loosely with tape.

Contaminated sharps should be segregated in a rigid sharps container and

autoclaved when the container is full. Place the autoclaved sharps container next to

the trash can

Contaminated glass should be bagged separately, and after being autoclaved,

placed in the glass waste containers for pickup by Environmental Services

Transport biohazard waste to the autoclave in a leak-proof bin or tray that is labeled

with a biohazard symbol.

All biological waste being collected in lab areas shall be marked with a biohazard

symbol to avoid any confusion of Environmental Services staff about which waste to

pick up.

Do not leave any unsterilized biomedical waste unattended in the shared equipment

rooms.

To autoclave biomedical waste, refer to instructions posted on autoclave for the type

of waste being processed.

Report any failed runs to the Facilities Dept. immediately. Do not dispose of any

waste you suspect may not have been successfully autoclaved! (Return it to a

designated short-term storage area in your lab & get help from Facilities, or call

Omega Medical for service [425-392-9193].)

D. Laundry Laundry services for BRI are contracted through a private vendor in Seattle, currently

Medicleanse/Service Linen. Laundry drop off/pick up is located on the grade level of BRI, adjacent

to the elevator. Only lab coats and shower towels are laundered.

1) Handling Contaminated Laundry

Soak any contaminated area with approved disinfectant.

Place wet laundry that has been decontaminated with an approved product in leak-

proof, plastic bags before transporting to the laundry drop off/pick up point.

Wear appropriate PPE when handling contaminated laundry.

Page 20 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

Home laundering of contaminated clothing is prohibited.

E. Signs and Labels Warning labels are placed on containers of regulated waste, refrigerators containing blood or other

potentially infectious materials and other containers used to store or transport blood or infectious

materials. The label will be a fluorescent orange or orange-red biohazard label as illustrated with

lettering in a contrasting color (see example below).

Warning signs are placed on laboratory doors where work with Risk Group 2 agents is performed. The door signs provide the name of the agent,

VIII. BRI General Tissue Culture Procedures & Precautions

In addition to the procedures described below, staff will be trained on any other specific procedures

required when working with biohazardous agents. These details can be found in the BRI Biosafety

Manual and Laboratory Specific Biosafety Manual specific to that lab.

A. Universal Precautions Should be followed for any manipulations of blood, body substances, Risk Group 2 agents, or

other potentially infectious material.

Hand Washing: Wash with soap and water before and after working in the laboratory.

Gloves: Wear disposable latex gloves (or gloves of another approved material) and

change immediately after contamination. Do not touch phone, door handles, or any

clean surface with contaminated gloves. Dispose of contaminated gloves in biohazard

solid waste. After removing gloves, wash hands thoroughly.

Page 21 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

Lab Coats: Always wear a closed-front lab coat to protect clothing during normal

working conditions.

Masks, Glasses, Face Shields: Masks and glasses or a face shield must be worn if

splashing or aerosols are produced during a procedure which cannot be performed in a

biosafety cabinet. Glasses must have solid side protectors.

All Personal Protective Equipment is supplied by BRI at no cost to the employee.

Your supervisor should be notified of any equipment that needs repair, replacement,

or cleaning.

C. Working in a Tissue Culture Hood Before beginning:

Turn off UV lamp and be certain that the blower is on. (If blower is not on, turn it on

and wait at least 5 minutes before beginning to work in the hood)

Always wipe down work area with 70% ethanol before beginning work.

If needed, empty aspirator trap, rinse; then add concentrated disinfectant.

Upon completion:

Decontaminate all work surfaces by wiping down with disinfectant, followed by a

water rinse, 70% ethanol rinse, and allowed to air dry.

Clean hemocytometers by wiping off excess fluid with a Kimwipe or gauze, dispose

of Kimwipe or gauze in biohazard bag, then rinse hemocytometer with water or 70%

alcohol.

Check all equipment used during laboratory procedures (i.e. centrifuges, pipettors,

etc.) for spills or contamination. Wipe off all contaminated equipment with

disinfectant followed by a water rinse and 70% alcohol as soon as practical and put

them away.

Close biohazard solid waste bags loosely with autoclave tape, and place it in the

gray bin (safety transfer device). Re-line the solid waste container with double bags.

Glass waste should be segregated, autoclaved, then disposed of in the glass waste

container in the shared equipment room or lab.

Contaminated sharps should be placed in the small red sharps containers labeled

“infectious waste”.

Turn off blower, close hood sash, and turn on UV lamp for a minimum of 10 minutes.

D. Working with viral stocks BRI uses the “Biosafety in Microbiological and Biomedical Laboratories” as the guide for working

with viral stocks.

Precautions should be taken when working with viral stocks to minimize the

generation of aerosols.

Page 22 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

Use anti-aerosol containers for centrifugation steps. Soak in disinfectant and rinse

with distilled water to clean after use.

If applicable, use only designated hoods and/or incubators for viral work.

Additional information can be found in Laboratory Specific Biosafety Manuals

E. Working with radionuclides in tissue culture Only those individuals who have completed radiation safety training and task-specific training

with a qualified lab member may handle radionuclides, and only in designated areas.

All radioactive biological materials should be decontaminated with disinfectant prior

to disposal as radioactive waste.

Samples should be properly labeled and placed on a tray or in a secondary container

during work, transport, and incubator storage to minimize contamination of work or

incubator surfaces.

Wipe tests should be performed on all equipment (i.e. pipetman, pipettors,

centrifuges) and in the workspace upon completion of work. Any contaminated

equipment or workspace should be decontaminated immediately, and then the wipe

test should be repeated to document decontamination.

F. Adding or removing vials from Cryostorage Always wear a face shield and cryogloves when opening liquid nitrogen (LN2) storage and

adding or removing vials.

Transport frozen vials in a closed or shielded container from liquid nitrogen storage to work area.

Be especially cautious when handling vials removed from storage boxes that were below the

level of the liquid nitrogen in the tank, as they can explode as the pressure tries to equalize.

IX. Hepatitis B Vaccine

All personnel working at BRI must have a “Fitness for Duty” appointment at VM Employee Health

Services (VMEH). There, they are offered Hepatitis B vaccine, and a TB test and Influenza vaccine

are administered.

All personnel who have been identified as having exposure to blood or OPIM through the exposure

determination described in Section 4 of this plan must be offered the Hepatitis B vaccine series at no

cost to the employee within 10 days of initial assignment unless:

The staff member has previously received the series

Antibody testing reveals that the employee is immune

Medical reasons prevent taking the vaccination; or

The staff member chooses not to participate

Staff will be provided with information on Hepatitis B vaccinations addressing its safety, benefits,

efficacy, methods of administration and availability. The vaccination series is available to you

free of charge from VMMC’s Employee Health Service.

Page 23 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

All occupationally exposed employees are strongly encouraged to receive the Hepatitis B

vaccination series and post-vaccination antibody testing. However, if a staff member chooses to

decline this vaccination, that person must sign the declination section of the “Hepatitis B Vaccine

Record.” The form will be kept in the staff member’s confidential Employee Occupational Health file.

Employees who decline may request and obtain the vaccination at a later date at no cost.

Other vaccinations and medical surveillance are also available in VMEH. This is described more

fully in the BRI Biosafety Manual, Occupational Health and Safety Section.

X. Exposure Incidents

An exposure incident is defined as specific eye, mouth, other mucous membrane, non-intact skin

or parenteral contact with blood or potentially infectious materials. Examples of exposure incidents

include needle sticks, splash/spatter to the mucous membranes of the face, and any other incident

that involves contact between blood or potentially infectious materials and non-intact skin (cuts,

scratches, chapped skin, etc.)

In case of exposure, immediately wash your hands and any other skin with soap and water, or flush

mucous membranes with water, and if applicable, milk a cut or puncture wound until it bleeds.

Inform your supervisor, lab safety rep., and the BRI Safety Officer promptly.

Report as soon as possible to the VMMC Emergency Department or Employee Health for the

bloodborne pathogens exposure protocol. You must also report this incident on the BRI Incident

Report, which is forwarded to the OH&S Specialist.

XI. Evaluation and Management of Exposure Incidents:

A. Post-Exposure Management Wounds and skin sites that have been in contact with blood or OPIM should be washed

with soap and water; mucous membranes should be flushed with water.

Immediately report all exposure incidents to your supervisor, your department safety

representative, and BRI Safety Officer or OH&S Specialist.

BRI will provide a confidential medical evaluation to all exposed employees. It is

important that employees receive a prompt medical evaluation because HBIG, hepatitis

B vaccine, and HIV post –exposure prophylaxis (PEP) are most likely to be effective if

administered as soon after exposure as possible.

Medical Evaluations will be performed at the Virginia Mason Medical Center in

accordance with VMMC standard procedures at no cost to the staff member.

If the staff member does not give consent for HIV serological testing during collection of

blood for baseline testing, preserve the baseline blood sample for at least 90 days; if the

exposed staff member elects to have the baseline sample tested during this waiting

period, perform testing as soon as feasible.

Page 24 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

B. Source Testing The following applies only when source testing is permitted of study subject samples, due to the

specificity of individual consent forms.

The person (if known) whose blood or body fluid is the source of an exposure will be

tested for HBV, HCV, and HIV infection as soon as feasible. When the source is already

known to be infected with HBV, HCV, or HIV then testing need not be repeated.

Information from the medical record at the time of the exposure (e.g., laboratory test

results, admitting diagnosis, or previous medical history) of the source person will be

gathered to help confirm or exclude bloodborne infection. The BRI Safety Officer will

oversee this procedure.

HBV, HCV, and/or HIV testing shall be performed if the infection status of the source

person is unknown in accordance with VMMC standard procedures.

Results of source testing shall be provided to the staff member, and that person shall be

informed of all applicable laws and regulations concerning disclosure of the identity and

infectious status of the source.

The public health department will be consulted in the event that consent for source

testing cannot be obtained. King County Department of Public Health phone number is:

206-296-4755.

C. Health Care Professional’s Follow-Up The BRI Safety Officer will ensure that health care professionals responsible for the exposed

staff member’s hepatitis B vaccination, post-exposure evaluation, and follow-up are given a copy

of WISHA’s bloodborne pathogens standard.

1) The staff member will ensure that the health care professional evaluating an employee

after an exposure incident receives the following:

A description of the employee’s job duties relevant to the exposure incident

Route(s) of exposure

Circumstances of exposure

If possible, results of the source individual’s blood test

Relevant employee medical records, including vaccination status

Agent Information Sheet for the specific agent to which the staff member was exposed

(available for Risk Group 2 agents and biological toxins)

2) Post-exposure evaluation and follow-up procedures will include the following:

Documentation of the circumstances under which exposure occurred.

Identification of the source material (or individual) unless not feasible or prohibited by

law.

Collection and testing of blood and any post-exposure prophylaxis required.

Counseling and evaluation of reported illnesses.

Page 25 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

3) VMMC Employee Health will provide the employee with a copy of the evaluating health-

care professional’s written opinion within 15 days after completion of the evaluation

4) The written opinion for post-exposure evaluation and follow-up will be limited to

whether or not the employee has been informed of the results of the health evaluation and

of any health conditions which may require further evaluation and treatment.

5) All other diagnoses must remain confidential and are not to be included in the written

report to BRI.

D. Review of Exposure Incidents The Benaroya Research Institute Safety Committee will review the Incident Report for all

exposure incidents to determine:

Why the exposure incident occurred.

Type and brand of device involved

If procedures were being followed

If procedures, protocols, or training need to be revised

If it is determined that revisions need to be made, the BRI Safety Officer or EH&S

Specialist will ensure that appropriate changes are made to this exposure control plan.

Documentation of this evaluation should accompany the Incident Report.

XII. Personnel Training

All personnel who have occupational exposure to bloodborne pathogens will receive training at the

time of initial assignment and at least annually thereafter. Additional training may be required if work

is being overseen by the IBC. Principal Investigators and supervisors are responsible for oversight

of their staff’s training.

Staff who will work with whole blood or human tissue must receive a hands-on training with an

experienced member of the lab who performs this type of work, consulting with their safety

representative if blood is processed in their lab, CRC, or in Blackford Hall.

Agent Information Sheets for specific Risk Group 2 agents are supplemental to the BBP training, and

all staff working with those agents must read, understand, and sign them prior to working with those

Risk Group 2 agents. These sheets are created by the OH&S Specialist in conjunction with the PI,

and current, signed copies are in the folder found in each BSL2 lab. They can also be located on

BRInet Safety.

A. Training will include: Information on the epidemiology, symptoms, and transmission of bloodborne pathogen

diseases.

Access to a copy and explanation of the BBP standard.

An explanation of our exposure control plan and how to obtain a copy.

An explanation of methods to recognize tasks and other activities that may involve

exposure to blood and OPIM, including what constitutes an exposure incident.

Page 26 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

An explanation of the use and limitations of engineering controls, work practices, and

PPE

An explanation of the types, uses, location, removal, handling, decontamination, and

disposal of PPE.

An explanation of the basis for PPE selection.

Information on the hepatitis B vaccine, including information on its efficacy, safety,

method of administration, the benefits of being vaccinated, and that the vaccine will be

offered free of charge.

Information on the appropriate actions to take and persons to contact in an emergency

involving blood or OPIM 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 staff member following an exposure incident.

An explanation of the signs and labels and/or color coding required by the standard and

used at this facility.

An opportunity to pose questions and receive answers from the person presenting the

training.

B. Training Records

BBP Training records will be completed for each staff member upon completion of training.

These documents will be kept in the staff member’s safety file and will include:

Dates of the training sessions

Contents or a summary of the training sessions

Names and qualifications of persons conducting the training

Names and job titles of all persons attending the training sessions

Training records will be maintained for a minimum of three (3) years from the date on which the

training occurred.

Employee training records will be provided upon request to the employee or the employee’s

authorized representative within 15 working days.

The BRI Facilities & Safety department is responsible for maintenance of the required training

records.

C. Certification for the Handling of Blood, Body Substances, and Infectious Materials at BRI 1) First-time users

First-time users must receive training on safe handling practices and policies at BRI prior to their

first use of blood, body substances, and other potentially infectious materials (OPIM). This

Page 27 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

training includes the WISHA-mandated BBP training, currently a PowerPoint presentation in the

Safety section of BRInet.

Staff who will work with whole blood or human tissue must also receive a hands-on training with

an experienced member of the lab who performs this type of work, consulting with their safety

representative if blood is processed in their unit or in Blackford Hall.

2) Annual re-certification

Individuals who handle blood, body substances, and OPIM must receive annual refresher

training. This training program is available to all staff via the Safety section of BRInet.

3) Acknowledgment

Users at BRI will be asked to take a brief quiz after training to assess their understanding of

procedures before they will be permitted to work with blood or OPIM. Additionally, those working

with specific Risk Group 2 agents read and sign the Agent Information Sheet for the agents they

are using prior to working with these agents.

4) Infractions/violations of safe handling practices

BRI has adopted a progressive discipline process to assist supervisors and staff members in

resolving unsatisfactory job performance or misconduct. The progressive discipline process may

involve, but is not limited to: warnings (verbal or written), suspension, or termination. The

supervisor has the responsibility to accurately document and issue discipline in a timely manner.

Disciplinary actions should be discussed in a face-to-face meeting which provides the

opportunity for the staff member to understand the area of concern, present their perspective on

what occurred, fully discuss and understand specific corrective action, and understand the

consequences if the behavior is not corrected. Please refer to the BRI Progessive Discipline

Policy in the Human Resources section of Sharepoint for further information.

D. Medical Record Keeping Virginia Mason Medical Center (VMMC) is responsible for maintenance of the required medical

records. These records are maintained in Virginia Mason Employee Health, and VMEH manages

the annual sharps injury reporting to OSHA.

Medical records are maintained for each staff member with occupational exposure in compliance

with WAC 296-62-052, “Access to Employee Exposure and Medical Records” and will include:

The name and social security number of the staff member.

A copy of the employee’s Hepatitis B vaccinations and any medical records relevant to

the employee’s ability to receive vaccination

A copy of all results of examinations, medical testing, and follow-up procedures as

required by the Bloodborne Pathogens Standard

A copy of all health care professionals’ written opinions as required by the Bloodborne

Pathogens Standard

All personnel medical records will be kept confidential and will not be disclosed or reported

without the staff member’s express written consent to any person within or outside the

workplace, except as required by the Standard or other legal provisions.

Page 28 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

Personnel medical records shall be maintained for at least the duration of employment plus

30 years. If the BRI ceases to do business within that time and there is no successor

employer to receive and retain the records for the prescribed period, the BRI shall notify the

director of the Washington State OSHA office. The director will be contacted at least three

months prior to record disposal so that records can be transferred to the director, if required.

Personnel medical records will be provided upon request of the employee or to anyone

having written consent of the staff member within 15 working days. An exception is

disclosure without consent for viewing and copying by the Assistant secretary of Labor for

Occupational Safety and Health, Department of Health and Human Services, or where

required by law.

XIII. Safer Sharps Program

The use of safer medical devices and sharps is an integral part of the BRI exposure control plan.

The Safety Committee will evaluate safer medical devices as they become available to reduce the

risk of injuries and contaminations due to sharps mishaps. Devices will be reevaluated as potential

replacements become available. A listing of approved safer sharps devices are provided in the

“Resources” section of Safety on BRInet.

Whenever possible, engineered safer sharps shall be used. If safer sharps are not available, other

methods shall be evaluated to reduce the risk of injury and contamination.

All sharps injuries involving contaminated sharps will be documented on a Sharps Injury Log and a

BRI Incident Report. These will be maintained for a period of 5 years from the date of exposure.

An evaluation of the Safer Sharps Plan will occur yearly, or as new options become available. This

evaluation will include the Sharps Injury Log, new safer sharps devices, and a revision of current

safer sharps in use if deemed necessary.

A. Safer Sharps Evaluation Safer sharps evaluation will be documented using the Safety Device Evaluation Form. (found in

the “Resources” section of Safety on Sharepoint).

Two or three staff members shall evaluate and approve the device prior to its being used in the

labs.

B. Sharps Injury Report The BRI OH&S Specialist is responsible for maintenance of the confidential Incident Reports

which describe the details of the sharps injury.

The Incident Report (confidential) shall contain, at a minimum:

The route(s) of exposure

An explanation of and circumstances under which the incident occurred

The type and brand of device involved in the incident

The department or work area where the exposure occurred

Staff members involved

C. Sharps Injury Log The Bloodborne Pathogen rule requires that BRI establish and maintain a Sharps Injury Log to

record all contaminated sharps injuries in a facility. The purpose of this log is to help evaluate

Page 29 of 29

BRI OCCUPATIONAL HEALTH & SAFETY

and identify problem devices or procedures that require attention. The VMEH dept. is

responsible for maintaining the Sharps Injury Log, which is submitted to OSHA annually, as all

sharps injuries must be reported to VMEH or VM Emergency Dept.

The Sharps Injury Log will contain the date of the injury, the department the injury occurred,

the type of device being used at the time of the injury, and a brief description of the

occurrence. This log is retained for 5 years after the completion of the calendar year.

XIV. Accessibility and Update of this Plan

A. Accessibility Each PI/supervisor is responsible for ensuring that laboratory staff and workers can access

and consult the BRI Bloodborne Pathogens Exposure Control Plan (BBP ECP) and Agent

Information Sheets at any time as it is available on BRInet.

A copy of this exposure plan must be available to the Director of the Washington State

Department of Labor and Industries upon request for examination and copying.

B. Update The BRI BBP ECP will be reviewed and updated when necessary and at least annually. The

PI/supervisor is responsible for reviewing the lab’s Site-Specific Agent Information Sheets

annually and whenever necessary to reflect new agents or modified tasks and procedures

that affect the potential for occupational exposure.