Hospital eTool: HealthCare Wide Hazards Module - Tuberculosis

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Safety and Health Topics > Hospital eTool > TB Module > Sample Exposure Control Plan

Sample Exposure Control Plan

Sample Exposure Control Plan (ECP) [Non-Mandatory]

Policies and Program Administration

(company name) maintains, reviews and updates the Exposure Control Plan (ECP) at least annually, and whenever necessary to reflect new or modified tasks, procedures and engineering controls * that affect occupational exposure. The ECP is also updated to reflect new or revised employee positions with occupational exposure.

This facility has had ________ cases of confirmed TB in the last 12 months.

(b) This facility is located in __________ county which has reported cases of TB in the last twelve month reporting period.

Employee Exposure Determination

ALL employees in the following job classifications have or may have occupational exposure to TB:

JOB TITLE

TASKS/PROCEDURES

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Employee Notification of TB Hazard:

(organization's name ) uses the following procedures to assure that all employees with job tasks that offer potential for occupational exposure are informed of the hazard and take proper precautions against exposure to TB.

(procedures described)

______________________________________________________________________

(*) ________ (responsible person(s)/department) ________ maintains contact with all outside contractors who provide temporary or contract employees who may incur occupational exposure. This allows the contractor to institute precautions to protect his or her employees. Theses contractors are informed of the TB hazard and the facility's procedures for protecting themselves from exposure.

(*)The sign must include a signal word (e.g. "STOP", HALT", or "NO ADMITTANCE") or biological hazard symbol and a descriptive message (e.g., "Respiratory Isolation, No Admittance Without Wearing a Type N95 or More Protective Respirator", or "See nurses' station before entering this room") [1910.145(f)(4)] - Specifications for Accident Prevention Signs and Tags.

(*) Signs are posted at the entrance to:

(*) 1) Rooms or areas used to isolate an individual with suspected or confirmed infectious TB.

(*) 2) Areas where procedures or services are being performed on an individual with suspected/confirmed infectious TB, and

(*) 3) clinical land research laboratories where M. tuberculosis is present.

(*) ________ (organization's name) ________ ensures that warning labels are placed on AFB isolation room exhaust ducts and areas where occupational exposure to TB is expected.

(*) All systems carrying air that may be contain aerosolized M. Tuberculosis are labeled at all points where ducts are accessed prior to HEPA filter, at fans and at the discharge outlets of non-HEPA filtered direct discharge systems. The label says: "Contaminated Air–Respiratory Protection Required". [OSHA Directive CPL 2.106, L.4. (1996)].

(*) ____ (organization's name) ____ notifies employees entering the laboratory and the autopsy room of the occupational hazards by using signs at the entrance to both these locations. These signs indicate the name and telephone number of the director of the laboratory, infectious agent– M. tuberculosis, and the special requirements for entering the laboratory or autopsy room. The sign displays the Biohazard symbol.

Exposure Incident Reporting

All employees must report exposure incidents immediately to (responsible person(s)/department). ____ (Organization's name) is responsible for investigating, evaluating, and documenting the circumstances surrounding the exposure incident for instituting changes to prevent similar occurrences.

The following procedures are used to investigate/evaluate exposure incidents at (organization's name):

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Prompt Identification of Individuals With Suspected or Confirmed Infectious TB

(Organization's name) considers an individual to be suspected of having Infectious TB (unless the individual's condition has been medically determined to result from a cause other than TB) if either the company or any of its employees determine(s)/learn(s) that the individual:

(*) has a persistent cough lasting 3 or more weeks with 2 or more signs and symptoms of active infectious TB (e.g., bloody sputum, night sweats, weight loss, fever, anorexia).

(*) has a positive AFB smear.

Based on the criteria listed above, (Organization's name) utilizes the following procedures for early detection of individuals with suspected/confirmed infectious TB.

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Employers Who Transfer
Procedures for Transfer of Individuals With Suspected or Confirmed Infectious TB:

If/when an isolation room is not available at our facility, the individual is transferred within 5 hours of identifying the infectivity to a facility (name of facility) where isolation rooms are available. The following procedures for transfer of an individual with suspected/ confirmed infectious tuberculosis are utilized:

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

While awaiting transfer, the individual is masked or segregated to protect employees who are without respiratory protection. (organization's name) uses the following procedures/equipment when masking and segregating an individual with suspected/confirmed infectious TB:

______________________________________________________________________

______________________________________________________________________

If a situation arises and the individual is not able to be transferred within 5 hours of identifying the suspected or confirmed infectious TB, the following procedures, including AFB isolation, are instituted:

(list procedures used)

(detail responsibilities and steps)

______________________________________________________________________

______________________________________________________________________

(*) Employee exposure in AFB isolation rooms is minimized by combining tasks the amount of time an employee spends in an AFB isolation room is minimized by ______

(list procedures used)

_________________________________________________________________________________

(*) ____ (organization's name) ______ uses the following procedures, minimizing the number of workers entering AFB isolation rooms:

______________________________________________________________________

______________________________________________________________________

(*) ____ (organization's name) ______ utilizes the following procedures to delay transport or relocation within the facility until the individual is considered non-infectious:

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

(*) Services are provided in the patient's room whenever feasible such as portable x-ray and ______ (list other services provided in the patient's room to minimize exposure)

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

(*) This facility uses ________ (list the type of engineering controls in use–properly fitted masks or valveless respirators for the for the patient to be masked or portable containment devices)

______________________________________________________________________

on individuals with suspected or confirmed infectious TB when it is necessary to transport or relocate the individual.

(*) The following procedures assure that the individual is returned to the AFB isolation room as soon as practical after completion of the procedure ______

(list of procedures)

(list procedures)

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

(*) Engineering Controls Maintenance Schedules and Records

(*) The maintenance schedule for engineering controls is as follows:

(*) Daily–Negative pressure areas are qualitatively demonstrated by using smoke trails.

(*) Whenever HEPA filters are changed, the system is inspected and its performance monitored in accordance with current USPHS guidelines. HEPA filters are changed every ______ in this facility or whenever.

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

(*) Every six months–HEPA filters in contained air exhaust systems are inspected, maintained and performance monitored in accordance with current USPHS guidelines.

Clinical and/or Research Laboratories

The ________ (type of laboratory–clinical or research) ________ operates at biosafety level ________ as determined by ________ (name of laboratory director) ________ for ________ (organization's name) ________. This is in accordance with CDC/NIOSH Biosafety in Microbiological and Biomedical Laboratories).

The following controls are in operation in the laboratory at this facility ________ (list controlled access, anterooms, sealed windows and other controls required in the standard and determined necessary by the laboratory director):

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

The procedures in this Exposure Control Plan minimize the occupational exposure to TB. The procedures for isolating and managing care are used until the individual with suspected or confirmed infectious TB is determined to be non-infectious or until the diagnosis for TB is ruled out.

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