Policy for Monitoring Hazardous Gases & Vapors
Transcription
Policy for Monitoring Hazardous Gases & Vapors
Stony Brook University Hospital Environmental Health & Safety Policy & Procedure Manual Title: Occupational Exposure Monitoring for Hazardous Air Contaminants Number EH&S – 4-8 Revision: 4/6/15 Date 1/80 Pages 7 PURPOSE: To minimize occupational exposure of hazardous air contaminants by monitoring and completing any necessary corrective actions. SCOPE: Hospital wide. PROCEDURES: I. EHSD0142 (04/15) Monitoring Procedures in Patient Care, Laboratories and Service Areas A. Contaminants monitored include, but are not limited to: ethylene oxide, formaldehyde, hydrogen peroxide, lead/cadmium, methyl methacrylate, glutaraldehyde, xylene and waste anesthetic gases. B. Monitoring is completed as per the attached schedule in Appendix A and when a significant change in equipment, process, personnel or control measures indicates a retest is appropriate. Exposure monitoring frequency is based on a risk assessment that evaluates the hazard of the chemical and the potential for exposure. C. Air contaminants are measured by personal monitoring badges, or other equipment as appropriate, in work areas identified as using the potential hazardous chemicals. Badges are obtained from a commercial source (e.g., Assay Technology) for the specific contaminant to be measured. D. Monitoring is coordinated by Environmental Health & Safety (EH&S). When badges are used, EH&S provides the affected department’s Supervisor or designee the appropriate badges. Where other monitoring equipment is used, EH&S operates the equipment or facilitate the monitoring. E. Monitoring is conducted using protocols established by NIOSH, OSHA or other recognized sources. Personal monitoring badges are used as per the supplier’s instructions. Accurate documentation of the times opened and closed, and total time in use is necessary for accurate results. F. Laboratory analysis is conducted by an AIHA accredited industrial hygiene laboratory. G. Laboratory reports, received by EH&S, are initially forwarded to the affected supervisor to share with staff. Once all laboratory reports are received, EH&S completes a summary report with any corrective actions noted. The report is forwarded to the affected Supervisor, with a copy to Employee Health & Wellness for the employees’ files. page 1 / 7 www.stonybrook.edu/ehs TITLE: Monitoring for Hazardous Air Contaminants H. II. Where monitoring indicates an airborne concentration above a PESH regulatory exposure limit, immediate actions are recommended by EH&S, and implemented by the appropriate department. The results of the activity is reported to the EOC Committee, along with further monitoring to verify the effectiveness of the corrective actions. Corrective actions includes changes in work practices, installation of engineering controls such as local ventilation, and possible medical monitoring of exposed staff. Responsibilities: A. Environmental Health & Safety 1. 2. 3. B. Coordinate occupational exposure monitoring for the affected departments. Distribute Request for Exposure Monitoring form (Appendix B) to identified units for completion by the Supervisor or designee. Forward laboratory reports, within 15 business days of receipt, to the Supervisor of the affected department. Submit a formal report with exposure results, any corrective actions and recommendations to the Supervisor and to Employee Health & Wellness for the employee file(s). Department Supervisor 1. 2. 3. 4. EHSD0142 (04/15) POLICY: 4-8 When provided by EH&S, return the completed Request for Exposure Monitoring form to EH&S. Ensure that employees assigned to wear the exposure monitoring equipment conduct the monitoring in a timely fashion. Unused monitoring badges may require refrigeration and must be used by their expiration date. Comply with corrective actions and recommendations provided in the summary report. Provide a copy of laboratory reports and final report to the affected employees. C. Affected Employees Wear exposure monitoring equipment as instructed. Contact Supervisor or EH&S at 4-6783 with any questions regarding proper monitoring procedures. D. Employee Health & Wellness Review exposure monitoring reports for possible medical surveillance and maintain report in the affected employee’s medical file. page 2 / 7 www.stonybrook.edu/ehs TITLE: Monitoring for Hazardous Air Contaminants EHSD0142 (04/15) POLICY: 4-8 INQUIRIES/REQUESTS: Environmental Health and Safety L1-059 HSC Zip 8017 Main Office: 444-6783 Fax: 444-6845 RELATED FORMS: Occupational Chemical Exposure Monitoring Schedule (Appendix A) Request for Exposure Monitoring (Appendix B) RELATED DOCUMENTS: OSHA 29 CFR 1910 ACGIH Threshold Limits Values and Biological Indices (TLVs and BEIs) ACGIH Guide to Occupational Exposure Values page 3 / 7 www.stonybrook.edu/ehs Appendix A Occupational Exposure Monitoring Schedule HA 1-3 EA 1-3 Monitoring Frequency Location Formaldehyde Histology/Grossing Autopsy 3 3 3 3 annually annually UH-2-666/665 UH-2-735,739 Cytology Prep Lab Microbiology-Parasitology ACP Cancer Center Lab Special Hematology (Central Core) Cytogenetics/Tissue Culture Operating Room 3 3 3 2 2 2 every 2 yrs every 2 yrs every 2 yrs UH-2-714, 715 UH-3-722 ACP L2-067 3 3 3 2 2 2 every 2 yrs every 2 yrs every 2 yrs UH-3-651 UH-3-525 UH, L4-625 Soiled Utility Rm. Ambulatory Surgery Center (ASC) 3 2 every 2 yrs OR corridor BME 3 0 not required no formalin cube in dispensing station when changing filters Invasive Cardiology/Cath Lab 3 1 every 3 yrs UH-5-865 store rm Radiology Special Procedures 3 1 every 3 yrs UH, L4 Immunology - Flow Cytometry Endoscopy Carol Baldwin Breast Ctr. 2 3 3 1 1 1 every 3 yrs every 3 yrs every 3 yrs UH-3-705/725 UH, 14N ACP ACP Surgical Oncology 3 1 every 3 yrs ACP 2-110 Surgical Care Center 3 1 every 3 yrs 37 Research Way ENT 3 1 every 3 yrs 37 Research Way Dermatology 3 1 every 3 yrs 181 Belle Meade Urology 3 1 every 3 yrs 24 Research Way Ophthalmology ObGyn 3 3 1 1 every 3 yrs every 3 yrs 33 Research Way 6 Tech Drive Plastic Surgery 3 1 every 3 yrs 24 Research Way Family Medicine SB Life Care Center 3 3 1 1 every 3 yrs every 3 yrs 181 Belle Meade Hampton Bays 3 3 2 1 every 2 ys every 3 yrs UH, L3 CSS 3 1 every year (wipe)/3 yrs (air) UH, L2-629 Mold Rm. Microbiology-Parasitology 2 1 every 3 yrs UH-3-722 Surgical Pathology (Grossing) Histology/Tissue Processing/Frozen Section Cytology Prep Lab 2 1 every 3 yrs UH-2-665 2 2 1 1 every 3 yrs every 3 yrs UH-2-666 UH-2-667 3 1 every 3 yrs UH, L4 Ethylene Oxide Central Sterile Supply Physical Plant - HVAC Lead/Cadmium Radiation Oncology Xylene Methyl Methacrylate Operating Room EHSD0142 (04/15) page 4 / 7 www.stonybrook.edu/ehs TITLE: Monitoring for Hazardous Air Contaminants POLICY: 4-8 Nitrous Oxide/Waste Anesthetic Gases Ambulatory Surgery Ctr. OR Operating Room PACU Endoscopy Radiology: MRI, Diagostic Core, Special Procedures, CT, Nuclear Medicine BME Labor & Delivery Peds ED 2 2 2 2 2 2 2 2 every 3 yrs every 3 yrs every 3 yrs every 3 yrs ASC OR UH, L4 UH, L4 UH-14N-013 2 2 2 2 2 2 1 2 every 3 yrs every 3 yrs not required every 3 yrs UH, L4 HSC, L1 Level 5 Level 4, Closet by Nurses Station Glutaraldehyde (Microcide 28/TD5 disinfectant) Electron Microscopy (Histology) 2 2 every 3 yrs UH-2-666 Immunology - Flow Cytometry 2 2 every 3 yrs UH-3-705/725 Operating Room 2 2 every 3 yrs UH, L4, substerile 2 and Anesthesia Clean Up Room 4605 Non-Invasive Cardiology (Heart Center) 2 2 every 3 yrs UH, 5-740 Soiled Utility Room Biomedical Engineering 2 2 every 3 yrs HSC, L1 Urology 2 2 every 3 yrs 24 Research Way ortho-phthalaldehyde OPA Biomedical Engineering Endoscopy ObGyn (4) Labor & Delivery ACP Surgical Oncology (2) ACP Medical Oncology 2 2 2 2 2 2 1 1 1 1 1 1 not required not required not required not required not required not required HSC, L1 UH-14N-013 6 Tech Drive 5-213 Soiled Utility Room ACP, 2-110 ACP 2-083 Otolaryngology ENT Clinic Life Care Center 2 2 1 1 not required not required 37 Research Way Hampton Bays Hydrogen Peroxide and Acetic Acid Endoscopy 3 2 Radiology - Ultrasound & Acute ED (2) 2 1 ACP Imaging 2 1 ObGyn Clinic 2 1 Central Sterile Supply 2 1 every 2 yrs not required after initial sampling not required after initial sampling not required after initial sampling not required after initial sampling UH-14N-013 4-413 Work Room & Acute ED by Rm 12 ACP 1-110 6 Tech Drive L3 - Assembly area Legend: Hazard Assessment (HA): 1 = low chemical hazard, 2 = moderate chemical hazard (sensitizer), 3 = high chemical hazard (carcinogen) Exposure Assessment (EA): 1 = low potential for exposure (eg. specimen jars, used in fume hood, routine equipment maintenance, closed system) , 2 = moderate potential for exposure, 3 = high potential for exposure (eg., pouring, minimal controls) Monitoring Frequency (HA x EA): score of 9+ = annual, score of 6-8 = every two years, <6 = every 3 years NA: not applicable, no monitoring required at this time EHSD0142 (04/15) page 5 / 7 www.stonybrook.edu/ehs ENVIRONMENTAL HEALTH AND SAFETY Request for Exposure Monitoring Instructions: Complete this form and return to: EH&S, Healthcare Safety, UH Exposure Monitoring, z=8017 or Fax to (631) 444-6845, Attn: UH Exposure Monitoring. If you have any questions contact EH&S at (631) 444-6783 Date form completed: Chemical or Physical Hazard to be Monitored (use a separate form for each hazard): Ethylene Oxide Formaldehyde (product __________________) Glutaraldehyde (product used__________________) Hydrogen Peroxide Metals ____________________________________ Methyl methacrylate Nitrous Oxide o-phthalaldehyde (OPA) Peracetic acid Waste Anesthetic Gases (products used_______________e Xylene Other____________________________________________ Department and Address: Location(s) of Monitoring/Room #s: Contact Name/Title: Contact Phone: Contact Address/Zip: List all Work Shifts: Describe all procedures (tasks) involving the above hazard: Description of Each Task (attached additional sheet, if necessary) Name of Employee performing task Job Title & Employee ID Duration of Task Frequency of Task Has this area been monitored previously and, if so, when: EHSD0142 (04/15) page 6 / 7 www.stonybrook.edu/ehs TITLE: Monitoring for Hazardous Air Contaminants POLICY: 4-8 Check personal protective equipment (PPE) worn during procedures: gloves (type: ______________) apron/gown/lab coat (circle one) surgical mask/dust mask (circle one) respirator – N95, HF, FF (circle one) face shield goggles/safety glasses (circle one) head cover other: _______________________________________________ Check engineering controls used during procedures: chemical fume hood (type/manu/make/model: _________________________________________) grossing station (type/manu/make/model:_____________________________________________) biological safety cabinet (type/manu/make/model_______________________________________) Note: Only Type A2-Exhausted or Types B1 and B2 BSCs exhausting to the outside should be used when working with volatile, toxic chemical (chemical quantity used must be limited). other:_______________________________________ List other employees for whom this monitoring is representative (those that do the same procedures). Use additional sheet, if necessary: Employee ID # NAME JOB TITLE SHIFT For EH&S Use: Applicable Standard: OSHA/PESH PEL TWA: STEL: ACGIH TLV TWA STEL: NIOSH REL TWA: STEL: Other standard or guideline: Date and # of badges provided: Revised 3/24/15 EHSD0142 (04/15) page 7 / 7 www.stonybrook.edu/ehs