To protect employees against exposure to human bloodborne pathogenic diseases the following exposure control steps will be undertaken. First, "Standard/Universal Precautions" will be observed to prevent contact with blood or other potentially infectious materials. Second, engineering and work practice controls will be followed to prevent contact with potentially infectious materials. Third, specimens and equipment will be handled under strict guidelines. Finally, a hazard communication procedure will be followed to alert all employees to the possibility that pathogenic materials are present.

• A. Standard / Universal Precautions
• B. Engineering and Work Practice Controls
• C. Housekeeping
• D. Specimens and Equipment
• E. Hazard Communication

It will be the policy of the University of Wisconsin-Milwaukee to utilize Standard Precautions. Standard Precautions, formerly referred to as Universal Precautions, is a system of infection control which assumes that all human blood and certain body fluids are treated as if known to be infectious for HIV, HBV and other bloodborne pathogens. Standard Precautions shall be consistently used for all individuals. Implementation of Standard Precautions does not eliminate the need for other category or disease-specific isolation precautions.

Body fluids which are directly linked to the transmission of HBV and/or HIV to which Standard Precautions apply are blood, blood products, semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid, saliva in dental procedures and concentrated HIV and/or HVB viruses. Standard Precautions also apply to body tissues and any other human body fluids visibly contaminated with blood.

Although salvia has not been implicated in HBV and/or HIV transmission, to minimize the need for emergency mouth to mouth resuscitation, mouthpieces, resuscitation bags, and other ventilation devices will be available for use in areas in which the need for resuscitation is predictable.

All health care workers and emergency response personnel shall routinely use appropriate barrier precautions to prevent skin and mucous membrane exposure when contact with blood or other body fluids are anticipated.

A supply of nonsterile gloves will be made available by the departments employing these personnel and this equipment shall be worn when it is apparent that contact with blood or body fluids is reasonably expected. Other items such as long sleeve gowns, aprons, masks, shoe covers, and eye shields will also be available to health care and emergency response employees.

These protective barriers shall be examined by the supervisor on at least a monthly basis and shall be maintained or replaced on at least an annual basis to ensure their effectiveness.

The type of barrier chosen depends on the situation. In general, the selection of the type of protective barrier or equipment or work practice will include the consideration of the probability of exposure, the type and amount of blood or body fluid, as well as the route of transmission.

If a procedure or situation is likely to generate splashing, spraying, splattering and generation of droplets of blood and/or body fluids beyond the protective barrier provided by gloves, then it is left to the individual employees discretion (after appropriate training) to obtain the needed protective equipment prior to undertaking the procedure.

In the event that unexpected splashing occurs in an unprotected situation, a change of clothing and shower facilities shall be made available for the employee.

Hands and other skin surfaces shall be washed immediately and thoroughly if contaminated with blood or other body fluids. Hands shall be washed immediately after gloves are removed. It is not acceptable to wash gloves instead of removing gloves, washing hands, and applying clean gloves.

To prevent needlestick injury, contaminated needles or other sharps must not purposely be bent, sheared, broken, recapped, removed from disposable syringes, or otherwise manipulated by hand. They shall be disposed of in sharps containers.

All health care workers and emergency response personnel shall take precautions to prevent injuries caused by needles, scalpels, and other sharp instruments during procedures; when cleaning used instruments or during disposal of used needles; and when handling sharp instruments after procedures. After use, disposable syringes and needles, scalpel blades, and other sharp items shall be placed in puncture-resistant sharps containers for disposal. The puncture-resistant container should be located as close as practical to the use area and identified as biohazardous.

Gloves must be worn if the hands of the caregiver are not intact. Employees who have exudative lesions or weeping dermatitis shall refrain from all direct contact with patients or victims and from handling patient care equipment until the condition resolves.

Implementation of Universal Precautions will be accomplished as follows:

1. Gloves shall be worn when direct contact with blood and visibly blood tinged body substances can reasonably be expected including contact with blood and body fluids, mucous membranes, non-intact skin of individuals, handling of items or surfaces soiled with blood or body fluids, and for performing venipuncture and other vascular access procedures. Gloves shall be changed after contact with each patient or victim.
2. Gloves should be put on prior to beginning a task and removed when the task is complete. Hands must be washed after removal of gloves or other personal protective equipment. Sterile gloves should be worn for invasive aseptic procedures.
3. Gloves shall be worn for all procedures where a potential exists for exposure to blood or body fluids. The procedures will include, but not be limited to:

   • Perineal care

   • Catheter care
   • Oral care
   • Suctioning
   • Treatment/dressing changes
   • Venipuncture
   • Handling of contaminated trash
   • Handling of soiled laundry/linens
   • Cleaning body fluids spills
   • Cleaning blood spills
4. Handwashing with soap and water is mandatory between each patient or victim contact and should be done whenever hands are visibly soiled. Hand cleanser and clean cloth/paper towels or antiseptic towelettes will be provided by the employees department. When antiseptic hand cleanser or towelettes are used, hands must be washed with soap and running water as soon as feasible.
5. Gowns and disposable aprons are only needed when it is likely that blood and visibly blood substance will soil clothing or skin.
6. Masks are only needed when it is likely that nose and mouth will be splashed with moist body substances or when personnel are working directly in or around areas of large open wounds.
7. Eye shields, goggles, or face shields are only needed when there is a likelihood that the eyes may be splashed with body fluids.
8. Contaminated needles or other sharps must not be bent, sheared, broken or recapped by hand. Needles and other sharps must be discarded in rigid, leak proof puncture resistant containers for disposal. The puncture-resistant sharps container should be located as close as practical to the use area, and identified as biohazardous. To prevent recapping by hand, resheathing of needles may be accomplished with the aid of a resheathing instrument, self-sheathing needles or forceps.
9. Linen soiled with blood or blood tinged body fluids must be gathered without undue agitation and placed in a leak-proof bag for transportation to the laundry soiled linen area. Bagging should occur at the location where it was used, however double bagging is not necessary.
10. Containers used for waste containment must be large enough to hold all contents and must prevent leakage of fluids during handling, storage, transport or shipping. If outside contamination of the container occurs, a second container shall be used to encase the first.
11. Housekeeping - Environmental surfaces such as walls, floors, and other surfaces are not associated with transmission of infections to either patients/victims or employees, therefore, attempts to disinfect or sterilize is not necessary. However, changing and removal of soil should be done routinely using products that, according to the manufacturers instructions are effective for the required sanitation outcome and are registered with the EPA.
12. Laundry- Because the risks of disease transmission from soiled linen is negligible, hygienic, and common-sense storage and processing of clean and soiled linen is recommended. Soiled linens should be handled as little as possible. Linens should be washed with detergent and hot water (at least 60 degrees C for 25 minutes) or if lower temperature cycles are used, with chemicals suitable for low temperature washing at proper use concentration.
13. If an employee has an exposure incident, the employee shall file an accident report with his/her supervisor as soon as feasible and the individual shall be encouraged to be tested for HBV and HIV at the Norris Health Center as soon as feasible and then at intervals of six (6) weeks, twelve (12) weeks, and six (6) months following the incident.
14. An evaluation of any incident that exposed or potentially exposed an employee (or student or volunteer) to infection with bloodborne pathogens shall be undertaken collaboratively by the Department of University Safety and Assurances, the Norris Health Center and Risk Management Office and a description of the corrective action taken to prevent recurrence of similar exposures shall be recorded.
15. For each incidence of mucous membrane or parenteral exposure to body fluids or tissue, a description of the exposure and any corrective action taken to prevent recurrence shall be documented by the Department of University Safety and Assurances in collaboration with the Norris Health Center. Progressive discipline will occur for any employee that fails to comply with Universal Precautions. Documentation will include the employee infraction and the corrective action taken by the facility to bring the employee into compliance. Standard University disciplinary procedures will be followed.

Engineering and work practice controls will be used to eliminate or minimize employee exposure. Where occupational exposure remains after institution of these controls, personal protective equipment will also be used. Engineering controls shall be examined at least monthly and shall be maintained or replaced at least annually to ensure their effectiveness. The area supervisor shall be responsible for inspections.

The employing department will provide handwashing facilities which are readily accessible to employees. When provision of handwashing facilities is not feasible, the employing department will provide either an appropriate antiseptic hand cleanser in conjunction with clean cloth/paper towels or antiseptic towelettes. When antiseptic hand cleansers or towelettes are used, hands will be washed with soap and running water as soon as feasible.

The supervisor will ensure that employees wash their hands immediately or as soon as feasible after the removal of gloves or other personal protective equipment.

The supervisor will ensure that employees wash hands and any other skin with soap and water, or flush mucous membranes with water immediately or as soon as feasible following contact of such body areas with blood or other potentially infectious materials.

The University of Wisconsin-Milwaukee, through its employing departments, will ensure that worksites involving bloodborne pathogenic materials are maintained in a clean and sanitary condition. For example, the Norris Health Center, UWM Police Department, School of Allied Health (Medical Technology Program), School of Nursing and all research laboratories utilizing blood and other potentially infectious materials shall prepare written schedules (e.g. infection control plans) for cleaning and the method of decontamination based upon the location in the facility, type of surface to be cleaned, type of soil present, and tasks or procedures being performed in the area. The schedule shall be followed and it shall be made accessible to employees.

All equipment, environmental and working surfaces will be cleaned and decontaminated after contact with blood or potentially infectious materials.

Contaminated work surfaces will be decontaminated with an appropriate disinfectant after completion of a procedure; immediately or as soon as feasible when surfaces are overtly contaminated, or after any spill of blood or other potentially infectious materials; and at the end of the work shift if the surface has become contaminated since the last cleaning.

Protective coverings, such as plastic wrap, aluminum foil, or imperviously-backed absorbent paper used to cover equipment and environmental surfaces shall be removed and replaced at the end of the workshift if they became contaminated during the shift. Heavily contaminated coverings may need to be replaced several times during a shift.

All bins, pails, cans, and similar receptacles intended for reuse, which have a reasonable likelihood for becoming contaminated with blood or other potentially infectious materials, shall be inspected and decontaminated at least weekly and cleaned and decontaminated immediately, or as soon as feasible, upon visible contamination.

Broken glassware which may be contaminated shall not be picked up directly with the hands. It shall be cleaned up by mechanical means, such as brush and dustpan, tongs or forceps and be disposed of in an appropriate sharps container.

All procedures involving blood or other potentially infectious materials will be performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets of these substances.

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

Specimens of blood or other potentially infectious materials must be placed in a container which prevents leakage during collection, handling, processing, storage, transport, or shipping.

The container for storage, transport or shipping shall be labeled biohazardous or color- coded and closed prior to being stored, transported or shipped. When using Universal Precautions in the handling of all specimens, the label/color-coding of specimens is not necessary provided the containers are recognizable as containing specimens and so long as the specimen remains in the facility. Biohazardous labeling or color-coding is required if and when the specimen container leaves a UWM facility.

If there is outside contamination of the primary container, the primary container must be placed within a secondary container that is puncture-resistant in addition to the above characteristics.

Equipment that may become contaminated with blood or other potentially infectious material must be examined prior to servicing or shipping and must be decontaminated as needed, unless it can be demonstrated that the decontamination of such equipment or portions of such equipment is not feasible. If the equipment can't be decontaminated, then a readily observable biohazard label must be attached to the equipment stating which portion(s) remains contaminated.

It is the responsibility of all employing departments of the University to ensure that this information is conveyed to all affected employees, to all service representatives, and/or all manufacturer representatives, as appropriate, prior to the handling, servicing, or shipping of contaminated materials, so that appropriate actions can be taken.

Warning labels must be affixed to containers of regulated waste, refrigerators and freezers containing blood or other potentially infectious materials, and other containers used to store, transport or ship blood or other potentially infectious materials.

Labels required include the international biohazard symbol.

The Biohazard label shall be fluorescent orange or orange-red with lettering or symbols in a contrasting color.

Labels must be affixed as close as feasible to the container by string, wire, adhesive or other method that prevents their loss or unintentional removal.

Red bags or red containers may be substituted for labels.

Containers of blood, blood components or blood products that are labeled as to their contents and have been released for transfusion or other clinical use are exempted from the labeling requirements.

Individual containers of blood or other potentially infectious materials that are placed in a labeled container during storage, transport, shipment or disposal are exempted from the labeling requirement.

Contaminated equipment shall be labeled and state which portions of the equipment remain contaminated.

Regulated waste that has been decontaminated need not be labeled or color-coded.