Texas Woman's University
University Regulations and Procedure
Regulation and Procedure Name: Bloodborne Pathogens
Regulation and Procedure Number: I.05.05.d
Applicable Regent Policy: A.05.05 Risk Management
STATEMENT OF PURPOSE
The Texas Woman’s University Bloodborne Pathogen Regulation and Procedures are
established to protect faculty, staff, students, and guests who are exposed to blood or other
potentially infectious materials in the course of their occupation or education at Texas
Woman's University (TWU).
DEFINITIONS
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Blood: Human blood, human blood components, and products made from human
blood
Bloodborne Pathogen: Pathogenic microorganisms that are present in human
blood and other potentially infectious materials and can cause disease in humans.
These pathogens include, but are not limited to: Hepatitis B virus (HBV), Hepatitis C
Virus (HCV) and Human Immunodeficiency Virus (HIV).
Bloodborne Pathogen Exposure Control Plan (ECP): A plan to protect faculty,
staff, students, and guests from bloodborne pathogens. The ECP covers:
○ Responsibilities
○ Exposure determination
○ Methods of Compliance including universal precautions, engineering and work
practice controls, personal protective equipment, and waste handling/disposal
○ Hepatitis B and other vaccinations
○ Prevention of transmission while providing health care services where
applicable
○ Evaluation and follow-up following accidental exposure to bloodborne
pathogens
○ Communication of hazards to employees (warning labeling)
○ Training
○ Annual plan reviews
○ See: http://www.twu.edu/rm/Bloodborne-Pathogens.asp
Exposure Control Plan (ECP): The procedures for what to do if exposed to
bloodborne pathogens. See Bloodborne Pathogen Exposure Control Plan (ECP).
Other Potentially Infectious Materials (OPIM): OPIMs include:
○ Human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial
fluid (joint lubricant), pleural fluid (around lungs), pericardial fluid (around
heart), peritoneal fluid (around abdomen), amniotic fluid, breast milk, saliva
in dental procedures, human cell lines (that are not documented to be free of
bloodborne pathogens), any body fluid visibly contaminated with blood, and
all body fluids in situations where it is difficult or impossible to differentiate
between body fluids.
○ Any unfixed tissue or organ (other than intact skin) from a human, living or
dead
HIV-containing cell or tissue cultures, organ cultures, and HIV, HBV or HBC
containing culture medium or other solutions; and blood, organs, or other
tissues from experimental animals infected with HIV, HBV or HBC.
APPLICABILITY
○
☒ TWU Students, Faculty, Staff, and Guest
☐ TWU Student
☐ TWU Faculty
☐ TWU Staff
☐ TWU Guest
Exposure Incident Procedure Summary
The following is a summary of the required procedures when an employee or student has an
“exposure incident” (a specific eye, mouth, other mucous membrane, non-intact skin, or
parenteral contact with blood or other potentially infectious materials that results from the
performance of an employee’s duties or as part of a student’s education). For complete
instructions, refer to the Post Exposure Evaluation and Follow-Up section of the TWU
Bloodborne Pathogen Exposure Control Plan: http://www.twu.edu/rm/BloodbornePathogens.asp
Following an exposure incident all of the following must be completed:
1. Cleanse the wound and surrounding area with soap and water (for a puncture,
cut or similar incident), and/or flush eyes, nose or mouth with copious amounts of
tap water (for a splash to the face).
2. Report the incident to exposed individual’s supervisor immediately.
3. Exposure incidents are to be considered urgent medical concerns. The
supervisor of the exposed individual must ensure that he/she receive medical
attention promptly. The CDC states that post exposure preventive medications are
most likely to be effective if administered as soon as possible after the exposure
(within hours of the incident, not days). The exposed individual must immediately
be sent to a nearby hospital or clinic to receive the postexposure evaluation
described below. Students may be sent to Student Health Services in Denton, or to a
local clinic or hospital. Employees must be sent to a clinic or hospital within the IMO
Med-Select Network if available in the area (call 888-466-6381 or visit
www.injurymanagement.com to find a provider).
a. The exposed individual must receive a confidential medical evaluation
and follow up including identification and documentation of source
individual, collection and testing of blood, post-exposure prophylaxis when
medically indicated, and appropriate counseling regarding infection
status/results of tests/necessary precautions.
b. The information on the Exposure Incident Reporting Form (see
Bloodborne Pathogen website: http://www.twu.edu/rm/BloodbornePathogens.asp ) must be provided to the healthcare professional providing
the medical evaluation as soon as possible (but do not delay sending the
exposed individual for treatment). This may be accomplished verbally or by
using the form, but all information on the form must be provided.
4. The exposed individual’s supervisor must obtain and provide the individual with
a copy of the medical provider’s written opinion within 15 days of completion
of the evaluation. This opinion must be limited to the items listed on the Medical
Provider’s Written Opinion Form (see Bloodborne Pathogen website for form).
5. The exposed individual and his/her supervisor must complete the “Employee’s Report
of Injury” form (SORM-29) and the “Supervisor’s Report of Incident, Injury or
Illness” form (SORM-703) and submit them to TWU Human Resources as soon as
possible after the employee receives medical care. see Bloodborne Pathogen website
for forms.
6. If the incident involved a percutaneous injury from contaminated sharps, the DSHS
“Contaminated Sharps Injury Reporting Form” must be completed by the supervisor
and mailed to the local health department and a copy provided to Risk Management
within 10 days of the incident. See Bloodborne Pathogen website for form.
SPECIAL NOTES
The University shall endeavor to comply with the intent of appropriate federal and state
legislation and regulations, including the U.S. Occupational Health and Safety Administration
regulations (including 29 CFR 1910.1030), Texas Department of State Health Services
regulations (including 25 TAC 96 and 25 TAC 97), the Texas Health and Safety Code
(including Chapter 81 Subchapter H and Chapter 85 Subchapter I), and the State Board of
Dental Examiners regulations (including 22 TAC 108).
These acts, along with supporting University guidelines, rules, and procedures; as outlined
in the TWU Exposure Control Plan (ECP); will provide the standards under which the
University will conduct its bloodborne pathogen program. A copy of the ECP is available in
the Risk Management office and on the Risk Management website for inspection and use.
Employees who are exposed to blood or other potentially infectious materials will be offered
the Hepatitis B vaccine at no cost within 10 working days of initial assignment. Employees
would not be offered the vaccine if the employee has previously received the complete
Hepatitis B vaccination series, antibody testing has revealed that the employee is immune,
or that the vaccine is contraindicated for medical reasons. Any employee who declines to
receive the Hepatitis B vaccine must sign a Hepatitis B Vaccine Declination Form. For
individuals who decline to receive the vaccination, but later decide to accept the vaccination
and are still exposed to blood or other potentially infectious materials, TWU will provide the
vaccine at no cost.
Health Professional Students who are exposed to blood or other potentially infectious
materials are required to obtain Hepatitis B and other vaccinations, at their own expense, as
necessary to protect student health in accordance with the ECP.
Texas Woman's University does not require HIV testing of its employees or students.
However, such testing may be required by some health care agencies with which the
University affiliates for clinical education. Policies related to students and faculty with HIV
infection are described in TWU Policy 6.04 – “HIV Infection/AIDS Among TWU Students and
Employees”.
Faculty, staff and students who are exposed to blood or other potentially infectious
materials are required to use personal protective equipment (PPE) in accordance with the
ECP. PPE required by the ECP will be provided to employees at no cost.
Faculty, staff and students who are exposed to blood or other potentially infectious
materials are required to complete training as required by the ECP. Appropriate training will
be provided by the University to all exposed faculty, staff and students.
Date Last Reviewed: March 2014 (July 2015)
Next Review: March 2017 (July 2018)
Date Passed: November 1993
Owner: Vice President for Student Life