Exposure Control Plan 2010

1. Exposure Control Plan 2010

2. Emergency Notification Numbers Buck Turbeville Operations Manager 843-495-7329 Mark Self Director of Compliance, Training & Education 843 662-8887 Ext. 304 843 610-1042 Lowcountry RM Pee Dee RM 843- 495-6693 843-495-7222 Sean Halliburton Tony Scott Any Shift Supervisor or any of the people below….. The Supervisor must call the Regional Manager during a weekday between 8:00 am and 6:00 pm as soon as possible. If the Regional Manager is not available, then call the Director of Compliance. If neither is available then contact the Operations Manager.

3. Potentially Infectious Body Fluids • BLOOD • SEMEN • VAGINAL SECRETIONS • CEREBROSPINAL FLUID (CSF) • SYNOVIAL FLUID • PLEURAL FLUID • PERITONEAL FLUID • PERICARDIAL FLUID • AMNIOTIC FLUID • ANY OTHER BODY FLUIDS CONTAINING FRANK OR VISIBLE BLOOD • SIGNS AND SYMPTOMS OF LONG TERM RESPIRATORY ILLNESS Standard Precautions do not apply to feces, nasal secretions, sputum, sweat, tears, urine, or vomitus unless visible or suspected blood is present.

4. CLASSIFICATION OF STATUS • Class I Employees: High Potential for Exposure • This policy applies to all Carolina MedCare personnel who respond to calls as a primary function of his/her membership/employment. It applies to any member/employee whose regular response requires patient care. • Class II Employees: Moderate Potential for Exposure • Members/employees who provide direct supportive functions to field personnel. These employees do not provide direct patient care, but could be employed to handle supplies necessary to the company mission. • Class III: Low Potential for Exposure • These employees are strictly office/administrative type employees, who are not used for the purpose of call response, patient care or equipment manipulation. Board members and owners who do not respond to calls are included in this category. 

5. EMPLOYEE COMPLIANCE • These Exposure Control guidelines have been implemented to promote employee and patient safety, and full compliance is expected. Failure to comply will bring potential injury to patients and company personnel alike; and will create unnecessary liability for our service. Non-compliance will result in disciplinary action, which may include suspension or dismissal.

6. Some Communicable Diseases • Hepatitis A (HAV) • Route of Exposure: Food, Drink, Feces • Incubation Period: 15-50 days • Vaccine: Vaccine in a two shot series. • Safety Equipment: OSHA approved face Masks • Signs & Symptoms: Weakness, Anorexia, Nausea & Vomiting, RUQ Pain, Jaundice & Dark Urine

7. Some Communicable Diseases • Hepatitis B (HBV) • Route of Exposure: Blood, Saliva, Semen, Vaginal Secretions • Incubation Period: 45-100 days • Vaccine: Vaccine in a three shot series. • Treatment: Baraclude • Safety Equipment: BSI (Gloves, Eye Protection, Face Mask) • Signs & Symptoms: Weakness, Anorexia, Nausea & Vomiting, RUQ Pain, Jaundice & Dark Urine

8. Some Communicable Diseases • Hepatitis C (HCV) • Route of Exposure: Blood, Sex • Incubation Period: 14-180 days • Vaccine: No Vaccine • Treatment: Pegasys • Safety Equipment: BSI (Gloves, Eye Protection, Face Mask) • Signs & Symptoms: Weakness, Anorexia, Nausea & Vomiting, RUQ Pain, Jaundice & Dark Urine

9. Some Communicable Diseases • Hepatitis D • Route of Exposure: Blood, Sex – Susceptible to Hep-D only if currently infected with Hep-B • Incubation Period: 14-180 days • Vaccine: No Vaccine • Treatment: Unknown • Safety Equipment: BSI (Gloves, Eye Protection, Face Mask) • Signs & Symptoms: Weakness, Anorexia, Nausea & Vomiting, RUQ Pain, Jaundice & Dark Urine

10. Some Communicable Diseases • Tuberculosis • Route of Exposure: Air Born • Incubation Period: 28-84 days • Treatment: No Vaccine. Treated with antibiotics • Safety Equipment: OSHA approved face Masks • Signs & Symptoms: Fever, Night Sweats, Weight Loss & Fatigue, Productive Cough

11. Some Communicable Diseases • HIV & AIDS • Human Immunodeficiency virus (HIV) Acquired immune Deficiency Syndrome (AIDS) • Route of Exposure: Blood Borne, Sexually Transmitted • Incubation Period: Four Phases of Infection. Incubation period may last longer than seven years in some individuals. Some HIV infected patients may never develop AIDS. • Treatment: A large number of drugs are now on the market to help fight off the Infection. • Vaccines: There are none available. Clinical trials are underway for vaccines. • Safety Equipment: BSI (Gloves, Eye Protection, Face Mask) • Signs & Symptoms: The signs & symptoms are caused by any infection the body cannot fight off due to an impaired immune system.

12. Some Communicable Diseases • MRSA • Methicillin Resistant Staphylococcus aureus (Staph infection) • Route of Exposure: Mostly from contact with active skin infections. Healthy individuals commonly carry the bacteria on their skin and in the lining of their nose. Per the CDC, approx 25% to 30% of the population has colonized staph bacteria. • Incubation Period: Unknown Incubation Period. • Treatment: Antibacterial Agents. MRSA is resistant to the antibiotics related to Penicillin. • Safety Equipment: Gloves & Wash hands after patient contact. • Signs & Symptoms: Skin Rash, Ulcers, UTI, Bone infections, Pneumonia, Blood Infections, etc …… Almost any infection can lead to a Staph infection.

13. Some Communicable Diseases • Meningitis • Multiple serogroups of Neisseria meningitidis. • Route of Exposure: The bacteria are spread through the exchange of respiratory and throat secretions (i.e., coughing, kissing). Generally occurs through direct contact with respiratory secretions from a nasopharyngeal carrier. • Incubation Period: Unknown Incubation Period. • Treatment: There are vaccines against Hib and against some strains of N. meningitidis and many types of Streptococcus pneumoniae. The vaccines against Hib are very safe and highly effective. • Safety Equipment: Mask & Gloves; wash hands after patient contact. • Signs & Symptoms: High fever, headache, and stiff neck are common symptoms of meningitis in anyone over the age of 2 years. These symptoms can develop over several hours, or they may take 1 to 2 days. Other symptoms may include nausea, vomiting, discomfort looking into bright lights, confusion, and sleepiness.

14. Some Communicable Diseases • Syphilis • Treponema pallidum • Route of Exposure: Syphilis is passed from person to person through direct contact with a syphilis sore. • Incubation Period: 10 to 90 days (average 21 days) • Treatment: Syphilis is easy to cure in its early stages. A single intramuscular injection of penicillin, an antibiotic, will cure a person who has had syphilis for less than a year. Additional doses are needed to treat someone who has had syphilis for longer than a year. • Safety Equipment: Gloves & Wash hands after patient contact. • Signs & Symptoms: The primary stage of syphilis is usually marked by the appearance of a single sore (called a chancre), but there may be multiple sores. Skin rash and mucous membrane lesions characterize the secondary stage. The latent (hidden) stage of syphilis begins when secondary symptoms disappear.

15. Some Communicable Diseases • DiphtheriaCorynebacterium diphtheriae • Route of Exposure: Direct person- to-person transmission by intimate respiratory and physical contact. Cutaneous lesions are important in transmission. • Treatment: Diphtheria antitoxin is available only in the United States through CDC; this should improve the reporting of suspected diphtheria cases. • Safety Equipment: BSI (Gloves, Eye Protection, Face Mask) • Signs & Symptoms: Respiratory diphtheria presents as a sore throat with low-grade fever and an adherent membrane of the tonsils, pharynx, or nose. Neck swelling is usually present in severe disease. Cutaneous diphtheria presents as infected skin lesions which lack a characteristic appearance.

16. Some Communicable Diseases • Plague • Route of Exposure: Respiratory droplets from an infected person or from being bitten by a rodent flea that is carrying the plague bacterium or by handling an infected animal. • Treatment: Post-exposure antibiotics • Safety Equipment: BSI (Gloves, Eye Protection, Face Mask) • Signs & Symptoms: The typical sign of the most common form of human plague is a swollen and very tender lymph gland, accompanied by pain. The swollen gland is called a "bubo" (hence the term "bubonic plague"). Bubonic plague should be suspected when a person develops a swollen gland, fever, chills, headache, and extreme exhaustion, and has a history of possible exposure to infected rodents, rabbits, or fleas.

17. Some Communicable Diseases • Viral Hemorrhagic Fevers • Route of Exposure: Most body fluids of an infected human – even if deceased, or the bite of an infected animal. • Incubation Period: 14-180 days • Treatment: In general, no specific treatments or established cures have proven benefit for patients with VHF. • Safety Equipment: BSI (Gloves, Eye Protection, Face Mask) • Signs & Symptoms: Although some types cause relatively mild illnesses, many of these viruses can cause severe, life-threatening disease. Severe illness is characterized by vascular damage and increased permeability, multiorgan failure, and shock.

18. Some Communicable Diseases • Rabies • Route of Exposure: Transmitted through the bite of a rabid animal • Treatment: rabies postexposure prophylaxis (PEP) • Safety Equipment: BSI (Gloves, Eye Protection, Face Mask) • Signs & Symptoms: Rabies virus infects the central nervous system, causing encephalopathy and ultimately death. Early symptoms of rabies in humans are nonspecific, consisting of fever, headache, and general malaise. As the disease progresses, neurological symptoms appear and may include insomnia, anxiety, confusion, slight or partial paralysis, excitation, hallucinations, agitation, hypersalivation, difficulty swallowing, and hydrophobia (fear of water). Death usually occurs within days of the onset of symptoms.

19. Epidemiology Epidemiology is the study of the distribution and determinants of health-related states or events in specified populations. Carolina MedCare currently provides services with over 50 ambulances in most of eastern/southeastern South Carolina, including patients and contracts in 14 counties. With a sustained growth rate expected throughout the state, and given the fact that patients are often transported across county lines, epidemiology statistics are being utilized from a state-wide perspective. The following data is collected and maintained by SC Department of Health and Environmental Control, and is posted here as a direct reflection of the most recent data available:

20. GENERAL GUIDELINES • Wash hands and forearms often with soap and water. • Use disposable gloves during all potential patient contacts when contact with blood or other potentially infectious materials. Latex-free gloves are provided by Carolina MedCare. • Be careful to avoid all opportunities for cross contamination

21. GENERAL GUIDELINES • Wear protective eyewear and a mask when there is a possibility of splashing or spraying of contaminated material. Wear other personal protective equipment when its use is indicated. Full Body Substance Isolation consists of: Gloves, Eye Protection, Mask, and Gown. • Change any contaminated, or potentially contaminated clothing as soon as possible. • Always bag, seal, tag, and properly dispose of all contaminated disposable supplies or equipment and linen to include uniforms in the proper manner.

22. GENERAL GUIDELINES • Account for, and properly dispose of all sharps and/or needles while properly protecting yourself and others. • Only use needle-safe IV safety needles. • Carolina MedCare is only responsible for the disposal of contaminated sharps that are generated by the company.

23. GENERAL GUIDELINES • Carolina MedCare is only responsible for decontamination of company durable supplies, equipment, vehicles, uniforms, or any part of a scene where contamination was caused by company personnel. • Always use only approved BVM resuscitators, demand valves, or pocket masks to avoid mouth-to-mouth resuscitation. These devices should be latex-free. • Clean all contaminated/potentially contaminated equipment and surfaces with soap and water and an OSHA/EPA approved germicidal or a hypochlorite solution as soon as possible, but always prior to the next use of same. Company vehicles that are contaminated will be removed from service until proper cleaning and disinfecting can be completed.

24. GENERAL GUIDELINES • Report exposures (with or without injury) as soon as possible. • Company personnel will cover any open wounds or lesions, with a dressing sufficient to protect both the patient and Carolina MedCare personnel. • Employees are not permitted to wear artificial fingernails, and are not permitted to have fingernails that are longer than ¼ inch from the end of the finger. • All durable, porous items that have the tendency to “soak” liquids (such as wooden backboards) should be removed from service and replaced.

25. HANDWASHING POLICY Handwashing is the single most important means of preventing the spread of infection. Carolina MedCare personnel must wash their hands: • WHEN COMING ON DUTY • WHEN HANDS ARE OBVIOUSLY SOILED • AFTER REMOVING GLOVES • AFTER USING THE TOILET AND/OR PERSONAL HYGIENE • AFTER HANDLING ANY CONTAMINATED MATERIALS AND/OR EQUIPMENT • BEFORE EATING • BEFORE GOING OFF DUTY • AFTER EVERY EMERGENCY MEDICAL RESPONSE

26. PROTECTIVE EQUIPMENT • Protective equipment is to be provided for use by all personnel during their performance of patient care and ancillary duties such as equipment handling and cleaning. It is the responsibility of the company to provide this equipment free-of-charge (as required by law), • It is the responsibility of unit personnel to insure that the equipment is readily accessible during unit check-off and before each call. • All protective gear and other supplies should be latex-free. Non-latex-free items should be removed from service at once. • Gloves, masks, gowns and eyewear should be within reach of personnel before exiting the cab upon arrival at a scene. • Availability of extra gloves will be maintained within portable medical kits on each medic unit. • All items bought, stocked, and used by Carolina MedCare employees in the course of duty will be latex free. • All Nitrile items used in the workplace will be free of the chemical MBT (Mercaptobenzothiazole), an allergen common to latex items.

27. GLOVES • Non-sterile, non-latex disposable gloves must be worn for each patient contact in which body fluids may be contacted. • Gloves must be changed before moving between patients in multi-casualty situations. • Gloves must be worn when cleaning or handling contaminated materials • Gloves that are torn, punctured, cracked or are in any way damaged must be replaced. • Contaminated gloves must be removed and disposed of properly prior to driving any vehicle or handling company durable equipment (such as two-way radios, nextells, etc.).

28. GLOVES • Gloves must be changed when changing environments; i.e.: when getting out of the ambulance to enter the hospital with a patient even when not contaminated and other such circumstances.   • Heavy-duty, non-latex gloves (such as those used when washing dishes) should be worn when decontaminating the vehicles or other large items. • All items bought, stocked, and used by Carolina MedCare employees in the course of duty will be latex free. • All Nitrile items used in the workplace will be free of the chemical MBT (Mercaptobenzothiazole), an allergen common to latex items.

29. Masks • In situations where aerosolization or splash of contaminated fluid or material may contact the mucous membrane of the mouth and nose, a surgical mask must be worn. • A surgical mask shall be used during suctioning and childbirth. • Patients with a known or suspected communicable respiratory disease should have a mask placed on them, unless the patient's respiratory status is in any way unstable.

30. Masks • In an unstable patient requiring oxygenation, a mask type delivery system should be used unless contraindicated, and satisfies the requirements for airborne protection of the employee. • Surgical masks placed on the patient satisfy airborne protection requirements for patients with suspected or confirmed respiratory diseases. The reason for this is that surgical masks filter particulate from the wearer prior to aerosolization into the environment; N-95 masks filter environmental respiratory particulate after aerosolization into the environment, which requires fit-testing and NIOSH approved N-95 masks.

31. PROTECTIVE EYEWEAR • Safety glasses, goggles, or eye shield/mask combinations approved by the company must be worn when contamination of the eyes via aerosolization or splash is possible. • Protective eyewear shall be used during suctioning, childbirth, or when near invasive procedures. • Personnel who wear eyeglasses must wear approved eye protection over their glasses when exposed to these outlined hazards.

32. GOWNS • Disposable gowns should be worn anytime contamination of splashing of uniforms/clothing and/or unprotected skin is likely. • If splashing occurs and bodily fluids soak through gowns and/or onto uniform, the member must leave duty at once to remove contaminated clothing and shower.

33. RESUSCITATION EQUIPMENT • Carolina MedCare Units are equipped with DHEC approved bag-valve-mask resuscitators and/or pocket masks for patient use to avoid mouth-to-mouth resuscitation. While the case where mouth to mouth resuscitation occurs by company personnel is rare, should it occur, must be documented and followed up by the Director of Compliance.

34. HANDLING OF SYRINGES AND NEEDLES (SHARPS) • The term "sharps" includes bloody glass, IV needles, drug needles, blood lancets, broken ampules, vials, etc. Especially included in this category are items contaminated with blood, body fluids and/or tissues. Other items that must be considered in this category include contaminated metal on accident scenes, knives at crime scenes, or any other "sharp" instrument, part, edge, etc. • Treat all used needles, syringes, or other sharps as if they are contaminated and use EXTREME CARE to prevent needles and/or other sharps sticks to you and others.

35. HANDLING OF SYRINGES AND NEEDLES (SHARPS) • Needles and other “sharps” used in patient care should be handled by the unit/personnel that generates those sharps. • As a general rule, if an item is small enough to fit into a sharps box, then it should be disposed of as such. If an item is too large for a sharps box, then it should be decontaminated in place. • Carolina MedCare is only responsible for disposing of sharps generated by the company.

36. HANDLING OF SYRINGES AND NEEDLES (SHARPS) • Needles shall not be recapped, bent or broken, and are not to be removed from any syringe or otherwise manipulated by hand. All syringes removed from packaging, whether subsequently used or not, shall be disposed of as if used. • At no time, will fingers be inserted into a used sharps container. • Do not throw used needles, syringes or sharps into a trash can at any location. These materials must be disposed of only in approved sharps containers, even when they are safety-capable devices.

37. HANDLING OF SYRINGES AND NEEDLES (SHARPS) • Wash hands with soap and water immediately after handling used sharps. • Treat and report all injuries from sharps as outlined in "CONTACT EXPOSURE AND INJURY". A separate sharps injury form will be maintained by the Director of Compliance.

38. One-Handed Recap Procedure • Under normal circumstances, Paramedics should not recap used needles. However, if a Paramedic receives order to administer a controlled substance, there may be a need to recap the medication for later use. • If the decision is made to recap a needle, only use a One-Handed Recap Procedure, whereby the cap will remain on a surface and the needle inserted with one hand until the cap fully encapsulates the needle. • The cap may then be safely “snapped on”. This procedure will be demonstrated during annual safety training, new employee orientation, inservice, and as needed. • Never hold the cap while inserting a used needle.

39. Engineering Controls • All durable, porous items that have the tendency to “soak” liquids (such as wooden backboards) should be removed from service and replaced. • It also shall be the policy of Carolina MedCare to maintain a “needle-less” work environment. • Needle-less, or less needles, is accomplished by only purchasing and using devices that limit or eliminate the possibility of sharps injury for assigned/necessary tasks.

40. Engineering Controls • Safety I.V. catheters that are designed with a safety sheath that covers the needle immediately following use. Although these devices effectively cover the needle when used properly, they are still to be disposed of in a sharps container. • Needle-free transfer devices employ plastic ends that have the capability to puncture soft seals for the purpose of transfer of medications and other fluids. The range of use can include devices for transferring medication out of vials or ampules, IV injection, and transferring blood into blood testing devices (Glucometers, blood tubes, etc.). As a common practice, Carolina MedCare should NOT be using blood tubes for any reason.

41. Engineering Controls • Piggyback medications can be infused with the use of plastic devices used to puncture the seal of an I.V. administration set … these devices are usually used to puncture the set by direct penetration of screwing the device onto the port. • OB Kits with either umbilical scissors or lock-over-blade sheath limit sharps injury by providing a method for covering blades.

42. Engineering Controls • I.V. Catheters –Protect IV or Protect IV Plus will be the standard stock of IV catheters for Carolina MedCare.

43. Engineering Controls • Lancets – The spring-loaded and activated lancet is the standard for Carolina MedCare. Any lancets found that are not spring-loaded should be removed from truck stock or supply inventories. • Drug delivery – Pre-filled syringes should be the safety tip type, such as the LifeShield Brand made by Abbott Laboratories. Non-safety tip pre-filled syringes are prohibited. • OB Kits – OB Kits that contain non-safety scalpels will be replaced by OB Kits that contain either unbilical scissors or safety scalpels ONLY.

44. Engineering Controls • All access devices used for patient care shall be needle-free or needle-safe when such alternatives are commercially available. Employees are not to bring non-needle-safe patient care needles or latex items of any kind to the workplace. No needle-safe alternatives have yet been found to replace non-safety IM, Sub-Cutaneous, or Intra-Osseous needles. Research is ongoing for replacements. • All items bought, stocked, and used by Carolina MedCare employees in the course of duty will be latex free. All Nitrile items used in the workplace will be free of the chemical MBT, an allergen common to latex items.

45. Work Restrictions • Everyday life brings the possibility of contracting various forms of illnesses, including on-the-job illnesses. While an employee can call out for a shift due to illness as allowed by the Employee Handbook, some circumstances will warrant that an employee be removed from work status. Some of those conditions include, but are not limited to the following, as observed and judged by management: • Productive cough, particularly if frequent • Visible, weeping open sores • ACTIVE Signs and/or symptoms of conditions as outlined in the CDC/OSHA Work Restriction Guidelines Criteria • Diagnosis of one or more ACTIVE conditions as outlined in the CDC/OSHA Work Restriction Guidelines Criteria

46. Exposures at Work With No Associated Injury • Decontaminate self, equipment, and vehicle as applicable. • Call Supervisor or Dispatcher to be sent for screening • Supervisor, Dispatcher, and/or employee notify Director of compliance. • Fill out incident report • Notify Director of compliance of any problems

47. Exposures at Work With Associated Injury - Seek Medical attention – call an ambulance if necessary • Decontaminate self, equipment, and vehicle as applicable. • Call Supervisor or Dispatcher to be sent for screening • Supervisor, Dispatcher, and/or employee notify Director of Compliance • Fill out incident report • Notify Director of Compliance of any problems

48. Exposed Employee Work Status • Carolina MedCare will follow the direction of our contracted employee health facilities and the governing Health Department to determine when and if an employee may return/continue to work. • If an employee is infectious with a communicable disease that could be transmitted to others while at work, the governing health department is responsible for notifying Carolina MedCare. • Carolina MedCare intends to comply fully with all Health Service and Health Department mandates.

49. CLEANING PROCEDURES • All equipment or surfaces contaminated or suspected of contamination by body fluids must be cleaned with soap and water and must be disinfected with an OSHA/EPA-approved germicidal agent or a hypochlorite solution. • Use hypochlorite solutions in a well-ventilated area only. • Wastewater may be disposed of in a routine fashion. • Hypochlorite solutions should be assembled fresh daily using 1/4 cup of bleach to 1 gallon of water; this formula will produce a concentration of approximately 1:100 dilution.

50. CLEANING PROCEDURES • All personnel involved in the movement or cleaning of contaminated equipment must wear approved eye protection and disposable gloves. • If a water hose is used during cleaning procedures, with a resultant potential for splashes or sprays, wear a disposable gown or apron in addition to gloves and eye protection. • Heavy-duty gloves (such as those used in washing dishes) should be worn when cleaning equipment.