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March 13, 2009

By Richard L. Best

In part one of this two-part series ("Protecting Your Most Important Asset &mdash Your People" from February 2009 Woman Dentist eJournal), an overview of the four basic safety plans needed by dental offices was provided:

1. Safety and Health Program (sometimes called Injury and Illness Prevention Program)
2. Hazard Communication Program
3. Emergency Preparedness Plan(s)
4. Bloodborne Pathogens Exposure Control Plan

For this month's article, we would like to discuss the Exposure Control Plan (ECP) in more detail. The goal is to point out what you need to do for your ECP to be in compliance with the requirements of the U.S. Department of Labor's Occupational Safety and Health Administration (OSHA). OSHA outlines its requirements in very formal documents known as Standards, and there are federal OSHA Standards for many of the risks encountered in various workplaces. In addition to federal OSHA, however, there are also individual state OSHA plans in about half of the nation. The rules in such state OSHA plans may vary in some details, but state OSHA Standards must always be at least as stringent as those of federal OSHA. It is important to remember that OSHA Standards, whether they are from federal or state OSHA plans, do carry the full force of law. An OSHA Standard is more than just a good idea — it's the law.

One of the primary occupational risks for health-care workers is the possibility for the transmission of disease to occur as the result of contact with human blood or other potentially infectious materials (OPIM). It was because of this specific risk that OSHA promulgated the Bloodborne Pathogens Standard in 1990 to 1991. The Bloodborne Pathogens (BBP) Standard prescribes certain precautions that must be followed whenever there is the reasonable expectation for a worker to be exposed to blood/OPIM. The single most important safety plan for dental employers is the plan mandated by the Bloodborne Pathogens Standard — the Exposure Control Plan.

Exposure Control Plan (ECP)

The ECP required by OSHA's Bloodborne Pathogens Standard is a key provision of the BBP Standard, because it requires the employer to identify the personal protective equipment (PPE), immunization practices, and training that are provided to the employees identified in the ECP. It is in the ECP that an employer identifies those tasks and procedures in which exposure might occur. The job titles or positions whose duties include those identified tasks and procedures are also identified. An ECP may be part of a larger document or manual, but it must be a cohesive entity by itself.

Guidance and assistance in creating your safety plans

One of the best ways to create and maintain your facility's ECP and other safety plans is to use the services of a company or consultant that provides such services and has expertise in the subject matter as it relates specifically to dental workplaces. Such a resource can provide you with a reliable guide through the maze of government regulations and can greatly simplify the time and involvement necessary for creating the various safety plans. One resource for use in creating your facility's ECP plan is available for download without charge from federal OSHA at http://osha.gov/Publications/osha3186.pdf. You may want to download this document and print out the model ECP it contains so that you can refer to it while you read the following comments that are keyed to that particular layout. Offices in California, however, should visit California OSHA's Web site at http://www.dir.ca.gov/dosh/dosh_publications/expplan2.pdf to download the particular guide that would apply for California, since there are some unique elements required for a California ECP.

Policy and program administration

It is in this opening portion of your ECP where you state your management commitment to providing a safe and healthful work environment for your staff and where you identify the specific person who is responsible for implementation of the ECP in your facility. Similarly, the specific person(s) charged with providing and maintaining personal protective equipment, medical actions required by the standard, and training will also be identified.

Exposure determination

The ECP is the document in which you identify those employees who have job classifications in which they have potential occupational exposure to blood/OPIM. Such job titles as dentist, dental assistant, dental hygienist, dental laboratory technician, etc., routinely have such potential by virtue of nearly everything they do. Such job titles would be listed in this portion of the ECP. Front desk personnel and others who should not have occupational exposure would not be listed.

There could, however, be occasions when a front desk or other employee might be assigned a specific task in which he or she might have potential exposure. A task such as changing sharps containers might be an example. Since that particular task for a front desk person would entail potential occupational exposure for an employee who would not normally have such potential, the task itself would need to be specifically identified in the ECP. Such a worker would also have to be offered all of the protections required for those personnel discussed in the preceding paragraph who have full-time potential for exposure.

Part-time, temporary, contract, or per diem employees are all covered by the Standard, and the ECP should describe how the Standard will be met for all such employees.

Methods of implementation and control

In this section of the ECP, you will list the specific safeguards employed in your practice. One fundamental safeguard is what OSHA calls universal precautions.

Universal precautions

When the BBP Standard was first implemented, it required a safety measure known as universal precautions. The overriding principle of universal precautions is to treat all blood and certain other potentially infectious materials as though they were capable of transmitting pathogens called bloodborne pathogens. Of primary interest to dental workers is the fact that one of the body fluids specifically listed by OSHA in the category of other potentially infectious materials is saliva in dental procedures. This inclusion means that dental workplaces are required by law to implement all of the precautions for saliva in dental procedures, just as they would for blood. Shortly after OSHA introduced the BBP Standard with the requirement for universal precautions, however, the Centers for Disease Control broadened the concept to include not just blood and the specific body fluids mentioned by OSHA, but basically any body fluids whatsoever. The term "standard precautions" was applied to this expanded concept, and most health-care facilities today utilize standard precautions instead of universal precautions. Both, however, are acceptable to OSHA. Universal precautions would be the bare minimum, but standard precautions are considered to be a "best practice."

ECP annual review and update

In an OSHA inspection, an OSHA compliance officer will review your facility's written ECP. He or she will determine whether your ECP contains all of the necessary information and whether it documents in writing that it has been reviewed annually and updated to reflect significant modification. OSHA does permit maintaining the ECP solely on a computer if your employees are trained to operate the computer, but a hard copy of the ECP must also be made available within 15 working days to any employee who requests one. If you have created your ECP electronically, therefore, it is a good idea to also print it out and make it available in a common work area where any employee who chooses may access and examine the ECP directly without having to ask a supervisor or manager first.

Work practices and engineering controls

The term "work practices" refers to things that workers either do or don't do in the workplace, such as following through on practicing hand hygiene, not eating in treatment areas, etc. The term "engineering controls" is basically safety profession jargon for things that a workplace provides for the safety of workers, such as scavengers for nitrous oxide machines, ventilation systems, eyewashes, handwashing stations, and what OSHA refers to as "safer medical devices."

Evaluation and implementation of safer medical devices

The ECP must document in writing the consideration and implementation of appropriate commercially available and effective engineering controls such as safer medical devices. Notice the words used by OSHA are "consideration and implementation." In other words, OSHA fully expects safer medical devices to not only be evaluated but also implemented. What OSHA is talking about here are such things as disposable safety syringes. Dental offices, of course, typically use reusable aspirating syringes, but keep in mind that there are disposable aspirating syringes available from dental vendors such as Septodont and Sultan. These devices should be evaluated for use in your practice, and they should be implemented depending on the findings of such evaluation. If your evaluation, however, develops a clear, sound, and demonstrable reason why a particular device would be contraindicated, then OSHA would likely consider that finding to be reasonable. One contraindication, however, for which OSHA would typically not agree, is the consideration of cost. The fact that a safer medical device might cost more is generally not a valid reason for not implementing it. Generally, if there is a safer device available, OSHA wants to see it being used.

Solicitation of nonmanagerial input

One of the key requirements for the evaluation of engineering controls as described above is for the employer to seek the collaboration of nonmanagerial workers directly affected by such a control. In other words, OSHA does not want management arbitrarily dictating what safer devices, other engineering controls, and work practices are implemented. Instead, OSHA wants such decisions to be a joint effort between management and labor. OSHA also expects such solicitation to be documented in writing. One way to satisfy this requirement is to use evaluation forms for evaluating products being considered, and to have the affected staff members (or, in cases of large numbers, a representative sampling from the group) fill out the forms to document their findings, evaluations, and opinions. These completed forms should be kept on file as evidence not only of evaluation and implementation of safer medical devices, but also to indicate that the input of nonmanagerial personnel was duly solicited. Such forms are available from commercial vendors or by searching on the Internet.

Personal Protective Equipment (PPE)

Anyone involved in dentistry today is so used to using PPE that it is typically done almost as a reflex action with a minimum of forethought. The use of facemasks, face shields, gloves, etc., have become standard practice in dentistry. OSHA, however, has specific rules about deciding just what PPE is to be used in a workplace and about how your workers are to be trained to use such PPE. This writer can report that OSHA is, indeed, serious about these requirements and that he has worked with practices that have been cited and fined by federal OSHA for not complying. So what requirements are we talking about here? There are three specific requirements concerning PPE:

1. Job hazard analysis
OSHA requires that a job hazard analysis be done to determine what hazards are present for particular jobs and what safeguards might be implemented to mitigate or eliminate those hazards. Keep in mind that PPE is always seen as a last resort, since the efficacy of PPE depends greatly on whether or not a worker properly utilizes it. Far better to eliminate a hazard entirely by substitution in cases where those safeguards would be applicable than to rely on PPE. Since the hazards of exposure to bloodborne pathogens, however, cannot be completely eliminated from the practice of dentistry, proper PPE must be selected and provided.

2. Training
OSHA requires that employees required to wear PPE be provided with training on the following topics:
a. When the PPE is necessary
b. What PPE is necessary
c. How to properly put on, take off, adjust, and wear the PPE
d. The limitations of the PPE
e. Proper care, maintenance, useful life, and disposal of the PPE

3. Certification of training
The employer is required not only to verify that each affected employee has received and understood the required PPE training, but also to prepare a written certification that contains the following:
a. Name of employee trained
b. Date(s) of the training
c. Identification of the subject of the training

Two federal OSHA Standards are at work on the subject of PPE. The above three items (job hazard analysis, training, certification of training) are required by federal OSHA for compliance with the PPE Standard 1910.132, and the Bloodborne Pathogens Standard 1910.1030 has the requirement for the ECP to discuss what types of PPE are provided, who is responsible for it, how it is to be handled, disposed of, etc.

Housekeeping

In this area of the ECP, OSHA wants to see an appropriate written schedule of cleaning and decontamination based upon:

a. Location within the facility (operatory vs. reception room, etc.)
b. Type of surface to be cleaned (e.g., hard surfaced flooring vs. carpeting)
c. Type of contamination present (gross contamination vs. minor splattering)
d. Tasks and procedures
e. Handling of regulated medical waste
f. Handling sharps containers
g. Identification of the job titles and tasks a particular job title will perform
h. Written schedule of when each housekeeping function will be done

Laundry

The precautions for handling contaminated laundry in your facility must be listed. Contaminated laundry must be labeled, color-coded, or otherwise identified as requiring universal precautions when handled. Laundry bags or containers must prevent soak-through or leakage of fluids. Employees having contact with contaminated laundry must wear utility gloves and not just exam gloves. The name of the person responsible for laundering and the time and/or location where laundering will occur should be listed in this portion of the ECP.

Labels

The ECP will list the methods used in your facility to identify equipment to be labeled. Employees must be provided with sufficient warning through labels, signs, and training to eliminate or minimize their exposure to bloodborne pathogens. Biohazard labels must be provided on containers of regulated medical waste, on refrigerators and freezers that are used to store blood/OPIM, and on containers used to store, transport, or ship blood/OPIM.

Hepatitis B immunization

This portion of the ECP deals with providing hepatitis B vaccinations to all employees who have the potential for exposure to bloodborne pathogens. An employee is free to decline the immunization, but in that case, he or she must sign a declination form, and such an employee also retains the right to come back at any time in the future to receive the vaccine.

Postexposure prophylaxis (PEP)

This portion of the ECP deals with the specifics of what you will do in the event that an employee suffers a needle stick or some other type of exposure to blood/OPIM. The specifics about just what will be done, where an employee will go for evaluation and treatment, blood testing of source patients and the injured employee, etc., should all be clearly laid out in advance. The immediate moments after a needle stick occurs should not be the first time a facility has begun to think about how it will handle such a matter, since the ideal time for postexposure prophylaxis in the case of HIV, for example, is within two hours. The media recently reported a dental office receiving a $75,000 fine from OSHA for not following protocol in the area of PEP.

Documentation of exposure incidents

The ECP must include the procedure for evaluation of the circumstances surrounding any exposure incidents that occur. OSHA reports that 75% of all exposure incidents occur with disposable syringes, but one consideration for that statistic is, of course, the fact that most syringes used are disposable syringes to begin with. Dental workers should not be lulled into complacency by such a statistic, because needles associated with reusable dental aspirating syringes also represent a potential hazard. This writer has worked with a dental office that was cited by federal OSHA for not utilizing an engineering control such as a heavy duty hemostat for removing needles from reusable syringes prior to autoclaving the syringe.

Employee training

What OSHA wants to see in the way of safety training is not just general information but rather what specific precautions are used in your particular practice. This requirement for specificity is one reason that generic training videos, DVDs, CD-ROMs, online training courses, etc., are not generally enough all by themselves to satisfy OSHA's training requirements. Such tools, however, can be important elements to satisfy certain required training topics. Altogether there are 14 specific points that must be covered in bloodborne pathogens training. The 14 points are listed for you in the sample ECP mentioned previously and available for download from the OSHA Web site. Keep in mind also that the PPE Standard also requires training. And although the BBP ECP deals only with the required training for bloodborne pathogens, other training such as PPE, hazard communication, etc., should also be provided and documented.

Recordkeeping

There are several different types of records that OSHA requires from employers:

a. Logs of workplace injuries and illnesses
OSHA requires records to be kept relating to specific work-related injuries and illnesses and to any lost workdays resulting from them. The rules surrounding this particular requirement, however, are so substantial that the OSHA handbook on the subject runs 200 pages. In most states, dental offices are exempt from having to keep a log of lost workdays. Space does not permit dealing with just which states require dental offices to keep these logs, so be sure to check for the rules in your particular state.

b. Training records
One particular type of recordkeeping, however, that is always applicable no matter what state your practice is located in, is the requirement to keep records concerning the annual BBP training that must be presented to your affected employees. Remember, too, that the PPE Standard also requires a certification of training. Some states require you to also offer your employees a regular system of communication on safety issues. Whether you provide such regular communication because your practice is located in a state that requires it, or whether you simply choose to adopt such communication as a best practice, a record of those communications and trainings should be maintained. There is at least one commercial vendor (Stericycle) that offers audio materials on health-care-related safety topics on a quarterly basis. Such a source provides you with a ready-made method for providing periodic communication on safety issues.

c. Medical records
Another type of recordkeeping that is always applicable is medical records. These confidential records must be kept for 30 years beyond the time that a worker ceases to work for your facility.

d. Sharps injury logs
A final type of recordkeeping is the sharps injury log in which you will record certain specifics concerning any sharps injuries. The rules concerning which types of health-care practices are required to keep sharps injury logs and which are exempt from this requirement vary depending on the state in which the practice is located. Once again, be sure to check your own state's requirements.

Your BBP exposure control plan should discuss all of these types of records as you can see in the template available for download from federal OSHA.

Closing

As we have discussed, the requirements for an exposure control plan are involved. Be assured that in the event of an OSHA inspection, your office's ECP is one of the first things a compliance safety and health officer will examine, typically within minutes of arrival. You can expect the examination to be thorough and complete. With the number of exceptions to particular rules, etc., depending on what state a practice happens to be located in, it is a bit much to expect any dental practice to be able to sort through all of the myriad twists and turns of OSHA's requirements on its own. For that reason, it is highly recommended that you seek professional assistance in completing this vital document and the other safety plans as well. One source to review is SteriSafe.com, the health-care industry's most complete Web-based solution for safety and compliance. This site has helped health-care professionals take the quick and easy path to total OSHA compliance, and you can hear their stories.

Far more important than just avoiding OSHA citations and penalties, however, is the fact that going through the exercise of creating and maintaining a well-constructed ECP will result in a safer, more healthful workplace for you and your staff. And safety, of course, is what it's really all about for OSHA, and for dedicated, busy, dental professionals as well.

Richard L. Best is corporate director of OSHA compliance for Stericycle, Inc., a leader in the field of medical waste management and regulatory compliance providing OSHA training in health-care facilities. Dick earned his bachelor's in communications and corporate training from Elizabethtown College and completed his OSHA training at Rochester Institute of Technology's OSHA Training Institute. He holds a certificate in industrial hygiene management from Columbia Southern University and is an OSHA authorized trainer. He served for many years in dental technology education and was previously technical director of fixed prosthodontics and manager of education for a major, multinational dental device manufacturer and, in that capacity, developed and presented technology and materials science-related educational seminars at health-care venues and universities throughout the world. He is responsible for developing the technical and educational content of OSHA Compliance Tools, including SteriSafe.com.

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