Department
Perioperative Services
Policy / Procedure
Bloodborne Pathogen Exposure Control Plan
Section / Number
Infection Prevention
Original date:
Reviewed/Revised date(s):
For prior revision descriptions, contact dept manager/admin specialist.
Substantive Revisions 4/12: Eliminate A.6. Airborne Diseases.
Under B.5., added b. Surgical masks will not be left hanging around the neck.
POLICY:
Added B.6. Scrubs and Personal Clothing
Exposure to blood and body fluids will be minimized by following Policy D-07-
009 Standard and Transmission Based Precautions and other applicable Infection
Prevention/Control Policies and Procedures.
PURPOSE: To protect employees from occupational exposure to bloodborne pathogens.
REFERENCES: Perioperative Standards and Recommended Practices, Vol. 1, 2012 Edition.
AORN, Inc. Chapter 21. Recommended Practices for Prevention of Transmissible
Infections in the Perioperative Setting. Retrieved from: http://aornstandards.org/content/1/SEC21.body
Perioperative Standards and Recommended Practices, Vol. 1, 2012 Edition.
AORN, Inc. Chapter 47. AORN Guidance Statement: Sharps Injury Prevention in the Perioperative Setting. Retrieved from: http://aornstandards.org/content/1/SEC47.body
Blood Borne Pathogens Standard OSHA 29CFR Blood borne pathogens. -
1910.1030
Blood Borne Pathogens WAC 296-62-08001 WAC 296 - 62 CHAPTER.htm -
Washington State Legislature
Infection Prevention/Control and Employee Health Operational Policy
Implementation D-07-015: Blood borne Pathogen Exposure Control Plan
Infection Prevention/Control and Employee Health Operational Policy
Implementation: D-07-009: Standard and Transmission Based Precautions
Infection Prevention/Control and Employee Health Operational Policy
Implementation F-07-016: Biomedical Waste Management Plan
Infection Prevention/Control and Employee Health Operational Policy D-07-013:
Hand Hygiene
Surgical Services Policy 7.4: Surgical Hand Antisepsis
Infection Prevention/Control and Employee Health Operational Policy
Implementation D-07-01: Sharp Object Handling & Disposal
Infection Prevention/Control and Employee Health Procedure: Personal Protective
Equipment Availability and Use
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Infection Prevention/Control and Employee Health Procedure: Personal Protective
Equipment Donning and Removal
Infection Prevention/Control and Employee Health Procedure: Soiled Laundry
Handling
RESPONSIBILITIES: Perioperative Services Leadership Team
INSTRUCTIONS:
A.
Engineering/Work Practice Controls
1.
Sharps: a.
Sharps containers will be readily accessible throughout the surgery center. b.
Sharps will be handled in a manner that prevents contact with the hands. c.
On the surgical field:
 The practice of the "no touch technique" or "neutral zone" must be used to avoid hand to hand passing of sharps.
 Sharps will be counted with an instrument, never fingers. d.
Contaminated sharps are not to be recapped unless required by a specific medical procedure.
 If recapping is required, use of a recapping device or a one hand scoop method will be used.
 When available, staff must use and activate safe sharp products per Infection Prevention/Control
 and Employee Health Operational Policy Implementation D-07-01: Sharp Object Handling &
Disposal .
When disposing of syringes or vials with medication –go into the blue and white pharmaceutical waste container.
2.
Sponge Counts: a.
Will be performed in a manner to minimize contamination of the environment and employees.
 Sponges will come off the surgical field fully extended.
 Sponges will be confined, contained and located below the level of the sterile field and out of the traffic pattern.


The circulating nurse will wear appropriate personal protective equipment while counting.
Sponges will be bagged per count procedure. b.
At the end of the case, saturated sponges which drip upon compression will be placed in a red bag and then into a biohazard waste container.
3.
Suction: a.
When transferring operative site suction tubing from a full container to an empty one, suction will be turned off to prevent splash back from a full container. b.
Suction canisters with a collection of blood or body fluids, will be discarded into a biohazard container. c.
Personal Protective Equipment (PPE) consisting of gloves and a mask with face shield should be worn when:


Emptying suction canisters into sanitary sewers
Securing closings for disposal in the biomedical waste containers. d.
Suction catheters and tips will be changed after use. e.
At BASC the Dornoch, closed suction system will primarily be used for procedures with large volumes of irrigation. f.
If suction solidifiers or other products are used they must be a product approved by the ICC committee.
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4.
Irrigation Fluid: a.
Will be managed on the sterile field through collection devices, i.e., suction, drain pouches, and absorbable linen to prevent spillage from the field to the floor. b.
Suction mats and other means will be used to trap and collect irrigation fluid on the floor on procedures such as arthroscopies when large amounts of irrigation fluid may be spilled. c.
Avoid use of forced irrigation due to aerosolization and potential contamination.
5.
Specimens: a.
To prevent spillage and contamination of personnel, pathology tissue specimens, lab specimens, and blood gas specimens will be placed in biohazard plastic bags for transportation outside of the department b.
If it is not feasible to bag a specimen, it will be covered and transported in a sealed, leak- proof container labeled “BIOHAZARD.”
B.
Personnel Protective Equipment (PPE). See Infection Prevention/Control and Employee Health
Operational Policy Implementation: D-07-009: Standard and Transmission Based Precautions and Infection
Prevention/Control and Employee Health Procedure: Personal Protective Equipment Availability and Use :
1.
Face protection (eye and surgical mask): a.
Will be worn by all personnel at the surgical field and throughout the procedure. b.
Face protection includes:
 Eye protection, i.e. safety glasses or safety goggles with solid side shields worn with a surgical mask covering the nose and mouth.
 Or a surgical mask covering the nose and mouth with a shield covering the eyes. c.
In addition, personnel will wear face (mask and eye) protection when there is a potential risk for splash to the face, i.e. emptying collection containers, washing soiled instruments and equipment, transfer of specimens, incision and drainage. d.
During microsurgery, eye protection may be removed to accommodate eye loops, microscopes, etc. e.
Masks will be removed immediately upon exit of the OR suite and discarded f.
Masks will not be hung around the neck and reused.
2.
Shoe covers: a.
Will not be worn outside of the surgery center. a.
May be worn outside of the OR suite, but:
 If torn or soiled with body fluids, will be removed before leaving the OR suite
 Hand hygiene must be done after removing shoe covers b.
Boots or long/knee high shoe covers will be worn when large volumes of irrigation fluid are used, i.e. arthroscopic surgery, and gross contamination is anticipated.
3.
Surgical gowns: a.
Will be fluid resistant. b.
Extra protection gowns and aprons will be available for use as needed if strike through blood or other body fluids is anticipated.
4.
Gloves and hand hygiene: a.
Hand hygiene will be done prior to donning gloves. b.
Gloves will be worn when contamination of hands with body substances is anticipated. c.
Gloves will be removed immediately after use, followed by hand hygiene, to prevent contamination of the environment.
5.
All PPE, including masks, gloves, and torn or soiled shoe covers used for protection during a procedure or in a practice setting:
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a.
Will be removed prior to leaving the operating room or other work area. b.
Masks will be removed after each surgery and discarded when soiled or wet, and will not be saved by hanging around the neck, putting in a pocket, or worn on top of the head.
6.
Scrubs or Personal Clothing: a.
If scrubs or personal clothing become contaminated with blood or other body substance, request relief and change clothes. b.
Cleanse skin with an approved non-antimicrobial soap to remove soilage and reduce microorganism content.
C.
Biomedical Waste Disposal:
1.
Linen/laundry: a.
When contaminated with blood or other body substances, will be considered a biohazard and will be bagged with a fluid resistant bag. b.
It is not necessary to place laundry contaminated with blood or other body substances in a red bag when placing it in a designated soiled laundry container. c.
Linen bags should be 1/2 to 1/3 full to prevent back injuries and will be emptied between each case.
2.
Disposable drapes, sponges, and other items: a.
If soaked or caked with blood in such a manner that when compressed will drip or splash, will be placed in a red biohazard bag in the operating room. b.
Will be disposed of in the biohazard waste container in the soiled utility area.
3.
Trash will be bagged in plastic and emptied between each case.
4.
Spilled body fluids: a.
Will be confined and contained, then cleaned as soon as possible. b.
The operating room will be cleaned after each case with a approved disinfectant according to
Environmental Services procedure (EVS-0146).
Reviewed by:
APPROVAL:
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