VETERANS AFFAIRS MEDICAL CENTER\
Houston, Texas

MEDICAL CENTER POLICY February 8, 2001\
MEMORANDUM NO. 22S-003

Hazardous Material and\
Environmental Waste Management Program

I. [PURPOSE]{.underline}

The purpose of this policy is to establish a comprehensive Houston VA
Medical Center (HVAMC) policy based upon best available technology to
manage hazardous materials and waste from the point of requisition to
the point of disposal in a manner that will protect hospital patients,
personnel, visitors and the environment from any adverse affects, by
utilizing a trained waste management staff to ensure compliance with the
Federal, State, and local regulatory requirements for hazardous
materials and hazardous waste management

II\. [DEFINITION]{.underline}

A hazardous material is a substance (gas, liquid, or solid) capable of
creating harm to people, property, and the environment, as a result of
improper use, handling, storage, or disposal.

III\. [PROCEDURES]{.underline}

A. **Hazard Communication Procedures** establish a policy to assure the
safe use, handling and storage of hazardous materials (toxic substances
and harmful physical agents) through proper labeling, provision of
Material Safety Data Sheets (MSDS) and employee training throughout the
HVAMC per OSHA 1910. See Attachment A.

B. **Hazardous Material Spill Response Procedures** establish policy,
outline procedures and assign responsibility for chemical material spill
response at Small Quantity Generator facilities. This information
applies to all service and care lines and to all VA personnel, including
employees of the satellite facilities under the control of the HVAMC per
OSHA 1910. See Attachment B.

C. **Waste Minimization and Recycling Procedures** implement sound and
effective waste minimization practices for use and guidance in the
management, reduction, and recycling of hazardous and solid waste
produced by facility processes per EPA 40CFR. See Attachment C.

D. **Chemical Waste Management Procedures** describe chemical waste
management procedures necessary to enable proper and environmentally
sound treatment and disposal of chemical wastes generated at the HVAMC
in compliance with the Environmental Protection Agency (EPA) Resource
Conservation and Recovery Act (RCRA); Comprehensive Environmental
Response, Compensation, & Liability Act (CERLA); Clean Water Act (CWA);
Joint Commission on Accreditation of Healthcare Organizations (JCAHO);
state and under the authority of the Local Sanitary Sewer District.
Inherent to this comprehensive chemical waste management plan are
practices which identify, segregate, contain, store, transport, treat
and dispose of chemical wastes that will minimize health risks to
patients, staff, visitors, and the community environment per EPA 40CFR.
See Attachment D.

E. **Chemical Waste Management Procedures** establish safety procedures
and guidance for the labeling, handling, transport, and management of
microbiological, pathological and sharp waste generated by patient care
activities at the HVAMC to meet regulatory guidelines outlined the OSHA
1910.1030, TDH 25 TAC 1.131-1.137 and TNRCC Title 30 TAC 330. This
policy is applicable to all personnel handling, transporting, treating
or disposing of infectious material at the HVAMC. See Attachment E.

F. **Master file documentation.** The HVAMC MSDS master file and
facility hazardous chemical master inventory is maintained by and is
accessible from Facilities Management Service administrative offices in
Room 4B-330, Building 100, or by calling ext. 7395 or 7138. The VA
National Engineering Service Center **M**SDS **A**ccess by **P**hone
(MAP) system is available seven days a week by calling 314-425-4928 or
via the Internet at website
[http://vaww.nesc.med.va.gov](http://vaww.nesc.med.va.gov/) for
information needed on a chemical product.

G. **Radioactive Hazardous Material.** Radioactive material, waste and
releases or spills will be managed in accordance with procedures
outlined in Medical Center Policy Memorandum No. 22S-004, *Radiation
Safety Program*, and per NRC 10 CFR.

IV\. [RESPONSIBILITIES]{.underline}

A. The Medical Center Director (or designee) has overall responsibility
for ensuring proper management of hazardous waste and hazardous material
at time of entry into the HVAMC or from point of generation within the
HVAMC to the point of final disposal.

B. The FMS Safety Manager as the Chemical Hygiene Officer is responsible
for conducting annual walk-through surveys, obtaining documentation for
annual chemical inventories, assuring that a quarterly Hazardous
Material Management Status Report is provided to the Safety Committee
and for ensuring the State of Texas Water Commission Annual Hazardous
Waste Summary Report is completed annually. S/he will also provide a
24-hour monitored hazardous material spill cleanup assistance service
through the VA telephone operator.

C. Service and care line executives, particularly those with assigned
laboratory work sites, are responsible for developing safe work
procedures to include the following:

> 1\. Assuring that all employees who handle hazardous material or
> hazardous waste are properly trained annually by the Safety Manager
> and where necessary, by the Infection Control nurse on infectious
> materials.
>
> 2\. Assuring that the MSDS availability, chemical inventory, training,
> and labeling requirements of OSHA 1910.1200, Hazard Communication
> Standard, have been completed for all employees.
>
> 3\. Assuring that all employees are aware of proper hazardous chemical
> spill detection, containment, disposal and cleanup procedures and that
> affected employees participate in at least one hazardous material
> drill annually.
>
> 4\. Assuring that no chemical will be used in the absence of an
> appropriate MSDS.
>
> 5\. Assuring that contact lenses and open-toed shoes are not worn in
> any chemical work site.
>
> 6\. Assuring that appropriate personal protective equipment (PPE) is
> provided when necessary.
>
> 7\. Assuring that all carcinogenic chemical containers are properly
> labeled with a conspicuous universally recognized cancer hazard
> warning label.

D. The Environmental Management Section is specifically prohibited from
moving any hazardous chemical waste.

E. Chief, Acquisition & Materiel Management Section (A&MMS) will assure
that all on-site contract work bid specification submittals contain a
provision for providing \"right to know\" work site chemical hazard
identification information to prospective bidders and that all
contractors are required to provide the Safety Manager, in advance, with
an MSDS (OSHA Form 20) for each hazardous chemical brought onto HVAMC
property.

V. [REFERENCES]{.underline}

> VHA Directive 98-011, Management of Hazardous Chemicals, February 19,
> 1998.
>
> EPA 40 CFR Parts 60-799, Environmental Protection Regulations.
>
> 29 CFR Parts 1910.01-1910.1450, Occupational Safety and Health
> Standards.
>
> 49 CFR Part 172 ‑ Department of Transportation.
>
> 29 CFR Parts 1910.01-1910.1450, Occupational Safety and Health
> Standards.
>
> 49 CFR Part 172 ‑ Department of Transportation.
>
> *Comprehensive Accreditation Manual for Hospitals*, Joint Commission
> on Accreditation of Healthcare Organizations.
>
> Executive Order 12196 ‑ Occupational Health Program for Federal
> Employees.
>
> 29 CFR 1960 ‑ Federal Employee Occupational Safety and Health Program.
>
> Federal Acquisition Regulation (FAR) 48 CFR 52.223‑3.
>
> Federal Supply and Services Clause Manual Interim Change No.18,
> I‑FSS‑22, 5/85.
>
> Federal Standard 313.B.
>
> TNRCC Resource Exchange Network for Eliminating Waste, PD-002/97-1
> Clean Texas 2000.
>
> TNRCC Waste Reduction Policy Act of 1991, Title 30 Part IX, TAC
> 355.471 and 335.480, Subchapter Q. Pollution Prevention: Source
> Reduction and Waste Minimization, Adopted January 3, 1992.
>
> EPA Guide for Infectious Waste Management.
>
> BioSafety Chemotherapy Safety Reference.
>
> OSHA Instruction CPL 2-2.4, April 14, 1995, Controlling Occupational
> Exposure To Hazardous Drugs.
>
> TDH 25 TAC 1.131-1.137, Definition, Treatment & Disposition of Special
> Waste from Health-Care Related Facilities.
>
> TNRCC Title 30 TAC 330, Solid Waste Management Rules for Medical Waste
> management, Disposal, Transportation, Collection, Storage, and On Site
> Treatment on Mobile Vehicles.
>
> Medical Center Policy Memorandum No. 05-011, *Employee Health
> Services.*
>
> Medical Center Policy Memorandum No. 002N-002, *Emergency Medical
> Preparedness Plan.*

VI\. [RESCISSIONS]{.underline}

> Medical Center Policy Memorandum No. 154, *Silver Recovery* *Program*,
> dated March 10, 1998.
>
> Medical Center Policy Memorandum No. 234, *Refuse Disposal*, March 23,
> 1998.
>
> Medical Center Policy Memorandum No. 238, *Hazardous Material
> Management*, dated April 30, 1998.
>
> Medical Center Policy Memorandum No. 322, *Hazards Surveillance and
> Environmental Inspections*, dated March 9, 1998
>
> Professional Services Memorandum No. 8, *Management of Accidental
> Spills of Body Substances*, dated July 11, 1996.

\\es\\

THOMAS B. HORVATH, M.D., FRACP\
Acting Medical Center Director

Attachment A Hazard Communication Procedures

Attachment B Hazardous Material Spill Response Procedures

Attachment C Waste Minimization and Recycling Procedures

Attachment D Chemical Waste Management Procedures

Attachment E Chemical Waste Management Procedures

**Hazard Communication Procedures**

I. [Purpose]{.underline}

The purpose of this program is to ensure that the hazards of all
chemicals and that information concerning their hazards is transmitted
to employees to assure the safe use, handling and storage of hazardous
materials (toxic substances and harmful physical agents) through proper
labeling, provision of MSDS and employee training throughout the HVAMC
per OSHA 1910.1200, Hazard Communication Standard.

It is the policy of the HVAMC to pursue the greatest reasonable level of
caution when using hazardous materials. The Hazardous Chemical
Management and Medical Surveillance Programs apply to all VA personnel
who may be affected by hazardous or potentially hazardous materials, as
defined in Federal Hazard Communication Standard, 29 CFR 1910.1200.

II\. [Responsibilities]{.underline}

A. The Medical Center Director is responsible for ensuring that all
provisions of this policy are upheld throughout the HVAMC and that
effective hazard communication procedures are practiced.

B. The HVAMC Safety Manager (SM) is the designated Hazardous Material
Coordinator for the HVAMC. S/he is responsible for providing information
on the hazards of chemicals used in the workplace to the employee by
means of a comprehensive Hazard Communication Program. This shall be
accomplished by the following:

> 1\. Provide training to service and care line executives on the Hazard
> Communication Program and VA **M**SDS **A**ccess by **P**hone (MAP)
> system.
>
> 2\. Ensure review and compliance with the Joint Commission on
> Accreditation of Healthcare Organization\'s standards which require
> all hazardous material to be handled in a safe manner.
>
> 3\. Maintain a current inventory of hazardous chemicals used by the
> HVAMC including their purchase, storage, use, and disposal.
>
> 4\. Maintain and make readily available, MSDS for each hazardous
> chemical on-site.
>
> 5\. Granting exceptions for hazardous chemicals to be delivered by
> A&MMS to using service and care lines without an accompanying MSDS.
>
> 6\. Conducting contractor officer representative training (COTR) with
> all outside contractors who perform work at the HVAMC to ensure
> contractor compliance with hazard communication program procedures and
> other applicable OSHA, EPA or VA standards and directives.
>
> 7\. Shall make the written hazard communication program available,
> upon request, to employees and their designated representatives in
> accordance with OSHA 1910.1020.
>
> 8\. It is the responsibility of service and care line executives to
> designate in each service or care line, a Hazardous Material
> Management Coordinator (identify by name and extension), and to assure
> compliance to the Hazard Communication Program and the Medical
> Surveillance Program.
>
> 9\. Service and care line executives shall provide for the employee:
> Container labeling, other forms of warnings, training in the elements
> listed in Section III, paragraph E., below.

C. The following should also be included in the service or care line
Hazardous Materials Management Standard Operating Procedures (SOP):

> 1\. Preparing and maintaining a chemical inventory of MSDS and
> forwarding a copy to the Safety Office for chemicals ordered other
> than through a purchase request, VA Form 90-2237.
>
> 2\. Investigation of accidents in their areas involving hazardous
> chemical exposure.
>
> 3\. Reporting instances or circumstances where it is felt the
> Hazardous Chemical Management Program requires modification to allow
> compliance, or to achieve a safe condition.
>
> 4\. To conduct an annual inventory of hazardous chemicals stored or
> used in their service or care line and to provide an electronic copy
> of the inventory on a 3.5" diskette to the Safety Office, by January
> 31 of each year.
>
> 5\. To ensure the words \"**Hazardous: MSDS Required**\" are included
> in bold letters in the description block of the VA Form 90-2237 on all
> purchase requests for hazardous chemicals.
>
> 6\. To obtain, maintain, and review applicable MSDS and to ensure
> proper labeling on containers.
>
> 7\. To provide results of any industrial hygiene monitoring done in
> the employee\'s work area to the employee.

D. A&MMS.

> 1\. A&MMS is responsible for ensuring that the hazardous material
> requirements in the Federal Acquisition Regulation (FAR) 49 CFR
> 52.223‑3 and FSS Clause Manual I‑FSS‑22 are inserted into all
> solicitations and contracts.
>
> 2\. A&MMS will implement procedures to ensure hazardous chemicals
> ordered by credit cards or via other electronic methods contain the
> words \"Hazardous: MSDS Required\".
>
> 3\. A&MMS will require and ensure that all contractors provide MSDS
> for products used to the HVAMC Safety Manager.
>
> 4\. A&MMS will ensure that all contractors participate in a
> familiarization training with the HVAMC Safety Manager to inform the
> contractor of chemical hazards which may be encountered by their
> employees, the labeling system used by the HVAMC, and the methods
> contractors\' employees can use to protect themselves from the
> chemical hazards present.

E. Safety Section. The Safety Section is responsible for the following:

> 1\. To establish and verify safety precautions for each chemical for
> which an exception is granted.
>
> 2\. To investigate hazardous material-related accidents and make
> recommendations to avoid future recurrence.
>
> 3\. To train and assist supervisors in the development of the service
> or care line Hazardous Materials Management Standard Operating
> Procedure (SOP).
>
> 4\. To respond to service and care line executives' requests for
> assistance or information concerning hazardous materials.
>
> 5\. To inspect the various service and care lines for implementation
> and compliance of the Hazardous Material Management Program.
>
> 6\. To assist the service or care line Hazardous Material Management
> Coordinator with new Hazardous Material Programs and development.

F. Human Resources Management Section (HRMS) is also responsible for
giving support to the Employee Health physician to accomplish the
medical surveillance monitoring as described in Medical Center Policy
Memorandum No. 00C5-001, *Employee Health Services*, for the affected
employees. HRMS is responsible for notifying the Employee Health
physician of new and departing employees to ensure medical monitoring
requirements are met per OSHA standards, as applicable.

G. Employee Health.

> 1\. The establishment and conduct of the Occupational Medical
> Surveillance Program is the responsibility of Employee Health Section.
> The Safety Section will assist in identifying job categories or work
> processes with exposures that trigger surveillance requirements.
>
> 2\. Will establish an HVAMC-wide medical and biological monitoring
> program for employees who are exposed to hazardous chemicals or
> hazardous conditions (see Medical Center Policy Memorandum No.
> 00C5-001 *Employee Health Services*)

H. Employees have the responsibility to be familiar with and to follow
the guidelines of the Hazardous Material Management and Occupational
Medical Surveillance programs as follows:

> 1\. To report any unsafe condition or use of hazardous materials to
> the supervisor.
>
> 2\. Promptly reporting accidents and spills that result in chemical
> exposure to VA patients, visitors or personnel.
>
> 3\. To report to the Employee Health physician when instructed to do
> so by the supervisor or designated Safety Section personnel.
>
> 4\. Employees have the right to be informed about the potential
> hazards associated with materials to which they may be exposed. In
> addition, they will be informed of the results of any industrial
> hygiene monitoring done in their work area.
>
> 5\. All employees who may be exposed to hazardous material shall
> receive training in hazard recognition and in safe use of hazardous
> chemicals. Training shall follow the guidelines of the Federal Hazard
> Communication Standard, 29 CFR 1910.1200. Employees who desire
> information regarding materials they may be exposed to, or who have
> suggestions for safer use of hazardous materials, may direct questions
> and comments to the Safety Office.
>
> 6\. New employees will receive adequate information and training
> concerning the identity, hazards and safe handling of hazardous
> materials used in their workplace in accordance with 29 CFR
> 1910.1200(h).

III\. [Procedures]{.underline}

A. Hazard Determination.

> 1\. The Department of Veterans Affairs defines hazardous chemical or
> hazardous material as any chemical or chemical product or substance
> which is either a physical hazard or a health hazard.
>
> 2\. Health hazard means a chemical or chemical product for which there
> is statistically significant evidence, based on at least one study
> conducted in accordance with established scientific principles, that
> acute or chronic health effects may occur in exposed employees. The
> term health hazard includes chemicals which are carcinogens, toxic or
> highly toxic agents, reproductive toxins, irritants, corrosives,
> sensitizers, hepatotoxins, nephrotoxins, neurotoxins, agents having an
> effect on the hematopoietic system, and agents which damage the lungs,
> skin, eyes, or mucous membranes.
>
> 3\. Physical hazard means a chemical or chemical product or substance
> for which there is scientific valid evidence that it is a combustible
> liquid, a compressed gas, explosive, flammable, or organic peroxide,
> an oxidizer, pyrophoric liquid, unstable (reactive) or water reactive.

B. Hazardous Chemical Inventory (HCI).

> 1\. Service and care line executives shall conduct an initial HCI
> within their respective service and care line. A current master
> inventory shall be maintained in each service and care line and kept
> updated as each new chemical, product or substance is received or
> deleted. The inventory shall be subdivided to indicate the chemicals
> used in each section or work unit within a service or care line, and a
> copy placed in that work unit to be available to all employees on all
> shifts.
>
> 2\. The inventory for each hazardous material shall contain all of the
> requested information for each material. To obtain additional copies,
> photocopy the inventory format.
>
> 3\. The inventory must be completed no later than January 31 of each
> year. The inventory must be completed and accurate for the entire year
> by continuously updating it as changes occur.
>
> 4\. All materials used during the fiscal year must be included even
> though their use may have been sporadic or discontinued at the time of
> the inventory.

C. MSDS.

> 1\. Each service and care line executive shall obtain the most current
> copy of the specific MSDS for each chemical or hazardous material
> meeting the VA definition of hazardous material required to be listed
> in the service or care line\'s HCI.
>
> 2\. MSDS are available upon request from the vendor. It is sometimes
> necessary to contact either the distributor or manufacturer, but
> usually the salesperson, customer service department or the product
> managers are the appropriate contacts to request an MSDS.
>
> 3\. Service and care line executives shall obtain a copy of the most
> current MSDS from the vendor or via the VA MAP system, and assure that
> no hazardous material is requested by their service and care line
> without the purchase request indicating the material is hazardous.
>
> 4\. A&MMS warehouse and the receiving service or care line shall
> restrict the delivery and use of new hazardous materials delivered
> without the appropriate MSDS attached, unless an exception is granted
> by the Safety Manager or designee.

D. Labeling.

> 1\. Labels and other forms of warning information that accompany all
> hazardous chemical containers will not be removed or defaced.
>
> 2\. Where hazardous chemicals are transferred to a second container,
> the subsequent container must be labeled, tagged, or marked with the
> following information:
>
> a\. Identification of the hazardous chemical contained therein, as it
> appears on the MSDS; and,
>
> b\. Appropriate hazard warnings, indicating the target organ affected
> (i.e., eye irritant, respiratory hazard, etc.).

E. Training.

> 1\. Each employee who works with or is potentially exposed to
> hazardous chemicals shall receive initial training prior to the
> initial assignment, upon reassignment to a new work area, or whenever
> a new hazard is introduced into the work area. Refresher training
> shall be conducted annually.
>
> 2\. Hazard Communication Training shall include:
>
> a\. The requirements of OSHA Standard 29 CFR 1910.1200.
>
> b\. The elements of the HVAMC\'s Hazard Communication Program.
>
> c\. Hazardous chemical properties, including visual appearance, odor,
> and technical equipment that can be used to detect the presence or
> release of hazardous chemicals.
>
> d\. Physical and health hazards associated with potential exposure to
> chemicals used in the workplace.
>
> e\. Procedures and equipment to be used to protect against hazards,
> such as engineering controls, PPE, work practices, and emergency
> procedures.
>
> f\. Hazardous chemical spill and leak procedures for cleanup purposes.
>
> g\. The location of the service or care line\'s MSDS and inventory
> list and the location of the HVAMC\'s master MSDS file (Building 100,
> Room 4B-330).
>
> h\. Non-routine tasks performed by the service or care line and
> specific work practices to be used, chemical hazards resulting from
> the work, and PPE required. Retraining of affected employees on these
> elements will be conducted immediately prior to performance of
> non-routine tasks by the employees\' supervisor.

F. Outside Contractors.

> 1\. Outside contractors must be informed of the following elements:
>
> a\. Chemicals to which their employees may be exposed and how to
> obtain MSDS for those chemicals.
>
> b\. Methods which may be used to protect employees from hazardous
> exposure to those chemicals.
>
> c\. An explanation of the HVAMC\'s chemical container labeling system.
>
> 2\. If a contractor must bring chemicals onto the HVAMC, an MSDS for
> each chemical must be provided to the HVAMC Safety Manager prior to
> the use of any chemical.

G. Distribution of HCI and MSDS.

> 1\. The MSDS and hazardous chemical inventory shall be maintained
> together. A copy of both shall be placed in the service or care
> line\'s master file of hazardous materials. A copy shall be placed in
> each service or care line section or work place using the material.
> The copy must be accessible to employees during all shifts.
>
> 2\. All service and care lines that generate hazardous materials shall
> complete an electronic annual chemical inventory on a 3.5" diskette,
> and forward it to the Safety Office (22S/4C), no later than January 31
> of each year.

H. Processing of Purchase Requests.

> 1\. The words, \"Hazardous: MSDS Required,\" shall be placed in bold
> letters in the description section of all purchase orders by the
> contracting officer. If the manufacturer feels the product is not
> hazardous, written documentation should be requested with a statement
> to that effect and forwarded to the Safety Office upon receipt.
>
> 2\. All requests for hazardous materials which are not in the
> inventory and for which an MSDS is not on file should be routed
> through the Safety Manager. Any requests received by A&MMS Personal
> Property Management Section for mandatory source and classification
> which do not contain a certification, and which appear to request
> hazardous materials will be sent to the Safety Manager for
> verification (hazardous or nonhazardous) and MSDS status. The Safety
> Office shall ensure that purchase requests are acted upon (approved or
> rejected) following receipt. The approved purchase requests shall be
> returned to A&MMS for processing. If the items are not correctly
> categorized and the MSDS requirements are not met, the request shall
> be rejected.

I. Receipt and Delivery of Hazardous Materials.

> The Chief, A&MMS shall maintain a master collection of MSDS for
> hazardous materials stored by A&MMS warehouse personnel upon receipt
> of all shipments.
>
> a\. A&MMS shall identify the purchase order number and check for the
> words indicating \"Hazardous: MSDS Required.\" If MSDS are required,
> warehouse personnel shall check the shipment to determine the presence
> of an MSDS included by the vendor.
>
> b\. If the MSDS is present, the shipment will be delivered to the
> using service or care line. It will be the responsibility of the
> service or care line executive to determine whether the MSDS matches
> the shipment received by the service or care line.
>
> c\. If the shipment is received without the MSDS, warehouse personnel
> shall check the master inventory and MSDS collection already on file.
> If one is available from the file, a copy will be made and forwarded
> with the shipment.
>
> d\. If the receiving report indicates \"Hazardous: MSDS Required\" and
> no MSDS is received with the shipment, and an MSDS is not on file in
> the A&MMS master MSDS file, warehouse personnel must notify the Safety
> Manager of the receipt of hazardous material without an MSDS. The
> Safety Manager must either recommend an exception to accept the
> material without an MSDS, or recommend to the Hazardous Material
> Coordinator that the material be rejected and returned to the vendor.
>
> e\. No more than three exceptions on any hazardous material may be
> granted per fiscal year to move the material to the using service or
> care line without the availability of an MSDS. Prior to granting an
> exception, the Safety Manager must recommend to the using service or
> care line executive the specific safety precautions for each chemical
> for which an exception is granted and verify their implementation. In
> granting the exception, the Safety Manager shall request that HRMS
> notify both the union and the service or care line executive
> requesting the material. The service or care line executive shall
> notify the specific individuals using the material. Each exception for
> obtaining an MSDS is limited to a maximum period of 30 calendar days.
> The contracting officer is responsible for contacting the supplier
> within 72 hours after an exception is granted to obtain the MSDS. The
> decision to accept or reject shall not exceed the next working day. On
> a semi-annual basis, the Safety Manager shall prepare a list of
> exceptions that were granted, for forwarding to the Safety Management
> Committee.
>
> f\. If the Safety Manager recommends rejecting the material, s/he must
> contact and consult with the Chief, A&MMS, the service or care line
> executive who requested the material and the Facilities Management
> Service Line Executive, prior to making a final decision to reject the
> material and return it to the vendor. If material is rejected, the
> Safety Manager shall recommend safety precautions to be followed by
> warehouse personnel until the material is picked up.

**Hazardous Materials Spill Response**

I. [Purpose]{.underline}

It is the policy of the HVAMC to identify and respond to spills of
hazardous and infectious materials in a rapid and effective manner.
Potential exposure to patients, employees, volunteers, visitors, and the
community are to be minimized by proper cleanup and disposal of any
accidental spills of hazardous and infectious material. Spillage wastes
are to be disposed in accordance with applicable local, state, and
federal requirements.

II\. [Definitions]{.underline}

A. Hazardous Materials include cytotoxic (antineoplastic) drugs,
mercury, and other substances defined by federal standards as hazardous.
Other potentially infectious material (OPIM) includes, but is not
limited to: cultures, serums, and other lab specimens considered to be
infectious agents; articles contaminated with blood or specified body
fluids; blood and body fluids specified in OSHA 1910.1030 are considered
infectious.

B. Incidental Releases or Spills. This classification covers small
quantities of low hazard materials that do not represent a potential
safety or health hazard to nearby personnel. Most spills in the
healthcare setting should fall into this classification involving
uncontrolled releases of a hazardous substance. Responses to spills of
this type where the substance can be absorbed, neutralized, or otherwise
controlled at the time of release by employees in the immediate release
area are not considered to be emergency responses within the scope of
this procedure. Each service or care line handling chemicals routinely
shall be responsible for the cleanup of small spills of this type in its
area. After cleanup procedures and the situation is of no hazard,
Environmental Management Section will assist in the final cleanup.
Individual service or care line policies shall contain procedures
involving reporting releases or spills of potentially hazardous
substances.

C. Antineoplastic Drug Spills. It is the policy of the HVAMC to hold
each service and care line that comes in contact with antineoplastic
drugs, or waste containing these agents, responsible for the correct
handling, storage, and disposal. Spill cleanup procedures for
antineoplastic drugs shall be covered in applicable service or care
line's Spill Response Plan and should address the specific requirements
for regulated waste. In addition, any employee whose daily work duties
involve direct contact with these agents should be trained in spill
cleanup procedures and medical surveillance for exposure to
antineoplastic drugs.

D. Mercury Spills. The Safety Section is responsible for handling the
recovery and cleanup of spilled mercury. Supervisors are responsible for
ensuring that designated employees within the service or care line are
properly trained in the handling of devices that contain mercury. All
procedures will be accomplished in accordance with guidelines set forth
in the in-service training regarding recovery, disposal, and sanitation
of areas contaminated by mercury.

E. All Spills of Blood or OPIM. It is the policy of the HVAMC to hold
each service or care line that is involved with a blood or OPIM spill
responsible for the correct handling, storage, and disposal. Spill
cleanup procedures for blood or OPIM are covered in Medical Center
Policy Memorandum No. 111G1-002, *Exposure Control Plan for Prevention
of Occupational Exposures to Bloodborne Pathogens*. Cleanup and
disinfection shall be done using an EPA-approved germicide (currently
WEX-CIDE^^) or a fresh 1:10 dilution of sodium hypochlorite (bleach).
Personnel shall wear gloves, eye protection and other PPE as appropriate
at all times during the cleanup procedures. For large blood or OPIM
spills, contact Environmental Management Section for cleanup assistance.

F. First Responder Awareness Level. All HVAMC personnel shall be trained
to this level. First responders are those persons, who in the course of
their normal duties may be the first on the scene of hazardous materials
incident to respond in a safe manner when confronted with a hazardous
material incident. These personnel are not expected to take any actions
other than to recognize that a hazard exits, call for trained personnel
and secure the area.

G. Emergency Spill Response Situations. This classification covers those
spills that result in an uncontrolled release of a hazardous substance
which cannot be handled by personnel in the immediate spill area or
represents a hazard to nearby personnel, patients, visitors or the
environment (soil, water, air). **All releases or spills shall be
reported by dialing 911**.

III\. [Responsibilities]{.underline}

A. Service and care line executives who handle, store, or use hazardous
or infectious materials within their respective service and care lines
must develop local standard operating procedures for release and spill
response. The plan must cover all requirements as set forth in this
policy, including the following:

> 1\. Expected hazards of the materials.
>
> 2\. Location of MSDS.
>
> 3\. Type of PPE required and its location.
>
> 4\. Location of spill containment equipment or spill kits.
>
> 5\. Procedure for handling and disposal of spills or releases.
>
> 6\. Training requirements and frequency.
>
> 7\. Notification requirements. Service and care line executives will
> determine which chemical spills they cannot adequately remedy due to
> quantity, toxicity, or other special conditions. Service and care line
> executives will contact the Safety Office regarding these potentially
> unmanageable spills. The Safety Office or Environmental Health
> Technician will assist in preparation of a specific spill plan for
> those chemicals requiring special attention not otherwise covered in
> the policy.

B. Supplemental Responsibilities. The intent of this section is to
ensure that assistance is rendered in the event that service and care
lines have difficulties handling a spill or release. The following
service and care lines and sections will provide initial response, and
report any unmanageable hazardous or infectious material spill or
release:

> 1\. Police & Security Section will ensure that the affected area is
> secure from unauthorized entry. Without entering the immediate hazard
> area, isolate the area and assure the safety of people and the
> environment in the vicinity of the incident. Keep people away from the
> scene and the perimeter. Allow room enough to move and remove
> equipment that may be necessary to respond to the emergency.
>
> 2\. The Employee Health Clinic will provide technical and emergency
> medical assistance during normal business hours (8:00 a.m.-4:30 p.m.).
> However, during non-business hours (4:30 p.m.-8:00 a.m.), Urgent Care
> will provide technical and emergency medical assistance
>
> 3\. Pathology & Laboratory Medicine Section will provide technical
> assistance for spills or releases inside or outside the laboratory
> area.
>
> 4\. Pharmacy Section will provide technical assistance and spill kits
> for antineoplastic drug spills inside or outside the pharmacy area.
>
> 5\. Engineering Section will provide an air conditioning plant
> representative to the area involved in the spill or release. If the
> situation warrants, a shutdown or 100% exhaust of the affected area
> may be implemented to contain and control hazardous vapors.
>
> 6\. Environmental Management Section will provide technical
> assistance; and after the service or care line has completed the
> initial cleanup and the situation offers no hazard, they will assist
> in the final cleanup and decontamination.
>
> 7\. A Safety Office designee will be authorized as the emergency
> coordinator. The Safety Office will advise the Medical Center Director
> on the determination to call the Houston Fire Department's Emergency
> Hazardous Materials Response Team if on-site personnel cannot handle a
> spill or release. The Safety Office will provide technical assistance
> (if applicable). It is the responsibility of the emergency coordinator
> to determine if the spill or release is reportable to government
> authorities

IV\. [Procedures]{.underline}

All emergency notification of fire, chemical or radioactive release or
spill, and cardiac arrest on HVAMC property shall be reported by dialing
911. Additional notification requirements as outlined in Medical Center
Policy Memorandum No. 002N-002, *Emergency Medical Preparedness Plan,*
shall be followed.

V. [Training]{.underline}

During a spill or other transportation incident, personnel should not
attempt to clean up the material involved in the incident unless they
have proper training, equipment, and support personnel present. The
Occupational Safety and Health Administration has specific training and
experience requirements for individuals who respond to releases of
hazardous materials. It is important for personnel to understand that
they should not attempt to respond aggressively to the incident without
comprehensive training and on-site support. They should only respond in
a defensive fashion (keep themselves and others out of the area). The
service- or care line-specific training program shall address the
requirements of 29 CFR 1910.1200 and 40 CFR 262.

**Waste Minimization and Recycling Procedures**

I. [PURPOSE]{.underline}

This program is intended for use and guidance in the management,
reduction, and recycling of hazardous and solid waste produced by
facility processes. The HVAMC by virtue of its diverse medical
activities and operational support functions, requires the use of
materials which may pose a chemical or biological hazard to employees,
and a danger to the environment. Present use of these materials can
produce a waste stream, which still may be considered a safety or health
hazard unless properly managed.

II\. [RESPONSIBILITIES]{.underline}

A. Environmental Health Technician shall be responsible for managing the
hazardous and infectious and biological waste program for the HVAMC.

B. Environmental Management Section and A&MMS shall be responsible for
managing, collecting, storing and recycling non-hazardous solid waste
generated inside the HVAMC.

C. Engineering Section shall be responsible for managing, collecting,
storing and recycling industrial and municipal solid waste generated
outside the HVAMC to final disposition, regardless of the generator.

D. All HVAMC employees are responsible for the proper management of
materials from the beginning the materials enters the HVAMC from the
time they are generated as a waste, and continues until they are
ultimately treated or disposed of by applicable regulations.

III\. [Objectives]{.underline}

The HVAMC is committed to the establishment of a safe and effective
waste minimization and recycling program. To achieve this goal, this
program strives to meet the following objectives:

A. Protect the health and well being of the patients, staff, visitors
and the community environment.

B. Develop a system that addresses the identification of hazardous waste
and materials from the point of entry into the HVAMC to the point of
final disposal.

C. Provide safe handling, storage, treatment and disposal of hazardous
infectious and chemical wastes generated at the HVAMC where recycling or
reuse is not permitted by regulations.

D. Dispose of hazardous waste in an environmentally sound, responsible
and cost-effective manner that complies with federal, state and local
requirements.

E. Comply with federal, state and local regulatory standards, guidelines
and requirements for management of Industrial Solid Waste and Municipal
Hazardous Waste.

F. Enhance coordination and communication among service and care lines,
sections and various committees of the HVAMC to implement recycling
procedures or equipment where feasible.

IV\. [Procedures]{.underline}

Individual service and care lines are strongly encouraged to consider
ways of reducing the volume of solid and chemical waste generated
through the redesign of procedures, substitution, recycling of materials
and process upgrade (See the table below for summary of these
activities.). The Environmental Health Technician will administer a
waste exchange program. The program works on the theory that material is
not considered a non-product, until all avenues of reuse or benefit has
been exhausted. Recycling or reusing chemicals instead of disposal will
save the HVAMC both the cost of disposal and the cost of new raw
material. The waste exchange program contains the following elements.

A. A list of waste chemicals (non-product chemicals) in the hazardous
chemical waste storage area will be sent to all applicable service and
care lines two weeks before the next contracted quarterly hazardous
waste disposal.

B. Any service or care line or laboratory that can make use of the waste
chemical will be given that chemical provided they can demonstrate they
have adequate storage, engineering or proper personal protection to
ensure the safe use of the product requested. A current MSDS must also
be available for issue of a non-product chemical

C. Forming a liaison with state or regional waste exchange programs that
will identify potential users or recyclers of the HVAMC\'s hazardous
chemical waste will reduce the quantity of these wastes scheduled for
disposal by an EPA licensed hazardous waste contractor.

  ----------------------------------- -----------------------------------
  **Waste Minimization and Recycling  
  Activities In Place**               

  ***Method of Control***             ***Targeted Waste Minimization Item
                                      or Task***

  Acquisition                         Require purchases to be ordered in
                                      small quantities

  Process Evaluation                  Substitute non-hazardous chemicals
                                      for hazardous ones

  On Site Recycling Equipment         Xylene, methyl alcohol, fixer
                                      solution for silver, etc.

  Gas Recovery Scrubber System        Ethylene oxide, nitrous oxide, etc.

  Off Site Recycling                  Commercial recycling firms for
                                      batteries, metal scrap, cardboard
                                      boxes, paper, expired
                                      pharmaceuticals, oils, tires, etc.

  Waste Exchange or Final Disposition Identification of surplus or
                                      unwanted laboratory chemicals and
                                      relocating them to laboratories
                                      that can use them or identify for
                                      turn-in and hazardous waste
                                      disposal
  ----------------------------------- -----------------------------------

**Chemical Waste Management Plan**

I. [Purpose]{.underline}. To describe chemical waste management
procedures necessary to enable proper and environmentally sound
treatment and disposal of chemical wastes generated at the HVAMC in
compliance EPA RCRA, SARA, CERLA, CWA, JCAHO, State and under the
authority of the Local Sanitary Sewer District. Inherent to this
comprehensive chemical waste management plan are practices which
identify, segregate, contain, store, transport, treat and dispose of
chemical wastes that will minimize health risks to patients, staff,
visitors, and the community environment. The treatment and disposal of
chemical wastes from the HVAMC are regulated through federal and state
regulations. It is the policy of this VAMC not to discharge chemical
waste to the sanitary sewer, but to the maximum extent possible collect
even limited amount of hazardous chemical waste for proper disposal.

II\. [Hazardous Chemical Waste Identification]{.underline}. All
hazardous wastes will be identified using the criteria defined by the
Resource Conservation and Recovery Act of 1976 (RCRA), Subtitle C,
Hazardous Waste Regulations 40 CFR, Part 261. Wastes are either
\"Characteristic Waste\" or \"Listed Waste.\" The criteria for listing a
chemical as hazardous is briefly summarized as follows:

A. Characteristic Waste (40 CFR 261. 21-24).

> 1\. Ignitable (flammable)*.*
>
> o Liquids having a flash point below 140°F. (Aqueous solutions
> containing less than 24% by volume are excluded).
>
> Examples include: xylene, ethyl ether, acetone, methanol.
>
> 2\. Corrosive (strong acid or base).
>
> o Acids having a pH of 2 or less.
>
> o Base having a pH of 12.5 or more.
>
> Examples include: hydrochloric acid, sulfuric acid, sodium hydroxide.
>
> 3\. Reactive (violently unstable or reactive to air, water or
> pressure).
>
> o Waste materials violently unstable at normal temperatures or
> pressure or permitting the release of toxic fumes or vapors.
>
> Examples include: picric acid, hydrogen peroxide (\>30%), perchloric
> acid (\> 60%).
>
> 4\. EP toxin (toxic due to heavy metal or specific chlorinated
> pesticide content).
>
> o Wastes which contain certain toxic materials which could be leaked
> into ground water supplies.
>
> Examples include: arsenic, barium, mercury, silver.

B. Lists of Hazardous Waste (40 CFR, Part 260 et. seq.). This standard
includes lists of wastes that have been determined by EPA to be
hazardous. If a waste is found on this list, it is considered to be a
hazardous waste.

> 1\. Hazardous wastes from nonspecific sources (40 CFR 261.31) - These
> wastes are listed as \"F\" wastes.
>
> 2\. Hazardous wastes from specific sources (40 CFR 261.32) - These
> wastes, designated as \"K\" wastes, deal primarily with the byproducts
> formed as a result of chemical formulation. Most of these wastes will
> not be created by the operation of a VAMC.
>
> 3\. Discarded commercial chemical products, off-specification species,
> container residues, and spill residues (40 CFR 261.33). Materials
> covered by this section of EPA regulations are wastes when they are:
>
> q Discarded.
>
> q Mixed with waste or used oil and applied to the land.
>
> q Applied to the land in lieu of their original intended use.
>
> q Contained in products that are applied to the land in lieu of their
> intended use.
>
> q Mixed with fuel.
>
> a\. Acutely Hazardous Wastes (40 CFR 261.33(e)) - These wastes have
> been specifically listed because of their extreme toxicity. To be
> considered acutely hazardous the chemicals on this list must be of a
> commercially pure grade, technical grade or formulations in which the
> chemical is the sole active ingredient. VAMC's disposing of one
> kilogram or more of these chemicals would be considered a Large
> Quantity Generator of hazardous waste as opposed to 1000 kilograms for
> hazardous waste not considered acutely hazardous (40 CFR 261.5(e)(1)).
> These wastes are listed as \"P\" wastes.
>
> Examples may include: arsenic containing compounds, cyanides, sodium
> azide, osmium tetroxide, warfarin.
>
> b\. Commercial Chemical Products and Manufacturing Intermediates (40
> CFR 261.33 (f)) - These wastes are listed as \"U\" wastes.
>
> Examples may include: acetaldehyde, acetone, numerous benzene
> derivatives, carbon tetrachloride, chloroform, ethyl ether,
> formaldehyde, mercury, phenol, toluene, xylene.
>
> 4\. Toxic Wastes (40 CFR 261) - Wastes are considered toxic if they
> demonstrate the characteristic of toxicity through a Toxicity
> characteristic Leaching Potential (TCLP) analysis. TCLP analysis is
> done to evaluate if the heavy metal (e.g., lead, mercury selenium) and
> other specified contaminants content of a waste is sufficiently high
> to consider the waste toxic. The tables contained in 40 CFR 261.31 to
> 261.34 should be consulted to determine if listed hazardous waste is
> also considered a toxic waste. It should be noted that all toxic waste
> is hazardous, but not all hazardous waste is considered to be toxic
> waste.
>
> Examples include: cyclophosphamide, phenol, ethylene oxide, uracil
> mustard.
>
> 5\. Empty Containers - Containers that once held hazardous waste or
> materials are not themselves considered to be hazardous waste for the
> purposes of disposal if the container is \"empty.\" The regulatory
> definition for \"empty\" appears in 40 CFR 261.7.

III\. [General Procedures for Identifying Chemical Wastes]{.underline}

Chemical wastes can be generally classified as non-hazardous or
hazardous by EPA definition.

> 1\. All hazardous chemical wastes are subject to federal, state and
> local solid waste regulations and federal, state and local water
> pollution (CWA) requirements and local POTW requirements.
>
> 2\. Non-hazardous chemical wastes may be subject to disposal
> restrictions by local sanitary sewer district, landfill, or waste
> hauler. These non-hazardous chemicals subject to any of these
> restrictions should be identified.
>
> 3\. It is the responsibility of each service or care line executive
> and section chief to determine each service or care line and section
> process that produces a chemical waste stream meeting the EPA
> definition of a hazardous waste that require treatment and disposal by
> the HVAMC.
>
> 4\. Any chemical, original material or waste, must be stored in a
> container which properly identifies its contents.
>
> 5\. Each chemical or chemical product must have a corresponding MSDS.
> A hazardous chemical inventory along with MSDS shall be prepared for
> each service or care line and section per guidelines covered in
> Attachment A of this policy.
>
> 6\. Chemical wastes requiring temporary storage (within user service
> or care line) or extended storage (designated waste storage area) must
> be properly identified. A local VA Waste Disposal Form A or B shall be
> used to meet this requirement (available from the Safety Section).
>
> 7\. It is very important that chemical wastes be labeled. Failure to
> properly identify wastes presents a significant safety and health
> hazard. Unknown waste must be analyzed prior to transport and
> disposal. With diligent effort to labeling waste, this additional cost
> can be avoided.
>
> 8\. All chemical wastes collected and stored by the Environmental
> Health Technician for disposal will be electronically maintained on a
> chemical waste inventory log.
>
> 9\. All hazardous chemical wastes transported off-site will be
> manifested in accordance with EPA regulations (40 CFR Part 262.2).
> Yearly, all manifested wastes should be listed by name and quantity
> transported for record keeping purposes.
>
> 10\. No empty drums, jugs, jars, bottles, or any other containers that
> have held toxic, corrosive, or ignitable materials or chemicals will
> be recycled for any other use. Under no circumstances shall
> identifying labels and references to the HVAMC and its address be
> removed; refer to the MSDS for recommended container disposal or
> contact Environmental Health Technician for technical guidance.
>
> a\. The intent of this rule is to ensure that containers once
> containing hazardous waste cannot be reused in such a way that might
> cause injury. The classic example is cutting empty 55-gallon drums
> that once contained hazardous waste in half longitudinally and reusing
> the drum as a barbecue pit. The result can be disastrous. The disposal
> of 55 gallon drums that are deemed hazardous because they contain too
> much residual adds substantial mass to the hazardous waste being
> disposed of and moves the VAMC more quickly from a small quantity
> generator to a large quantity generator.
>
> b\. Labels should be removed from containers that are being used to
> accumulate different hazardous waste than the label on the container.

IV\. [General Procedures for Segregating Chemical Wastes]{.underline}

A. Non-hazardous chemical wastes should not be mixed with hazardous
chemical wastes. By definition the resulting mixture would be classified
as hazardous.

B. Halogenated solvents (those containing chemically bonded chloride,
bromide, or fluoride ions) should be kept separate from the
non-halogenated solvents. Separate organic solvents into three
categories:

> 1\. Flammable (e.g., toluene, hexane, etc.).
>
> 2\. Nonflammable (e.g., dimethylsulfoxide, formaldehyde).
>
> 3\. Halogenated Hydrocarbons (e.g., carbon tetrachloride, chloroform).

C. Oils are to be stored separately and never mixed with organic
solvents or other hazardous waste.

D. Any acutely hazardous waste chemicals are to be segregated, contained
within a plastic zipper-lock bag, and taped even if the container is in
good shape.

E. Acids and caustics are to be separated from each other as well as
from cyanides and organic chemicals.

F. Oxidizers (nitrates, perchlorates, permanganates, persulfates,
perchloric acid, hydrogen peroxide, and nitric acid greater than 40%)
are to be separated from any organics and reducers.

G. Any chemical which contains cyanide is to be segregated from the
acutely hazardous chemicals because of its extreme toxicity. Extra
precaution is necessary to prevent its exposure to acids and prevent the
production of hydrogen cyanide gas upon combination.

H. Pesticides are to be stored separately from other chemicals because
of the extra ventilation required.

I. Mercury should be kept separately for accumulation and recycling.

J. Silver from photographic and imaging processing should be recovered
in accordance with policy and procedures of the Office of Acquisition
and Materiel Management. Other used products that should be recycled
include waste xylene, methyl alcohol and formaldehyde.

K. Reactive chemicals, explosives, and sulfides are all potentially
explosive and are to be stored (if such storage is absolutely necessary)
outside the confines of the HVAMC. An outside building has been
designated as the HVAMC\'s waste storage area for this and other similar
chemical waste.

> 1\. Keep separate from other chemicals, alkali metals, alkyd metals,
> reducing agents, halides, picric acid and peroxidizable chemicals such
> as ethers, sodium, amide and vinylidene chloride.
>
> 2\. Reagents that react readily with oxygen or water are prone to
> deteriorate when stored for long periods of time after the original
> container has been opened. With hazardous peroxide-formers, the date
> of container opening, should be noted.

L. Gas cylinders (acute toxic, P-listed) should be separated by
manufacturer and by hazard class. They should be recycled, if possible,
back to the manufacturer. The small cylinders should be temporarily
stored in 55-gallon drums. Used gas cylinders containing compressed
hazardous gas should be emptied in accordance with EPA regulations to
render the cylinder itself nonhazardous.

M. Lead-acid and nickel-cadmium batteries should be stored separately
and recycled back to the manufacturer or a similar EPA-approved recycler
for reprocessing.

N. Chemical wastes destined for off-site shipment may have additional
contractor segregation provisions determined by the nature of the hazard
and risk that it represents to hospital personnel and function.

V. [General Procedures for Containing and Collecting Chemical
Wastes]{.underline}

A. All chemical waste must be properly contained in properly labeled
spill-proof, chemically compatible containers. No wastes are to be
placed in containers that cannot be adequately sealed. Only screw caps
or lids will be acceptable.

B. Collection of chemical wastes from individual service or care lines
and sections will be performed by trained staff personnel, primarily the
Environmental Health Technician or other trained Safety personnel on an
on-call basis by telephone call or receipt of the white copy of a
completed Waste Disposal Form A or B (available from the Safety
Section). Individual service and care lines should record on the form
the amount of waste to be picked up.

C. Chemical wastes are to be collected during the portion of the day or
night when population densities in the HVAMC are least.

D. Chemical wastes are to be collected using a plastic cart with shelves
and 2- inch high side panels. Each shelf should be liquid-tight and
covered with spill pads. The waste chemical transport cart is to include
spill material adequate to contain an accidental spill.

E. Attention should be given to chemical compatibility when transporting
chemicals. Bottles should be placed on the cart in such a manner to
avoid breaking. All chemical containers must be packed to remain upright
during transport.

F. The individual assigned to chemical waste collection inside the
building will be properly attired with chemical resistant gloves and a
chemical apron. Face shields and/or goggles will be available, but worn
anytime a potential splash hazard exist. A NIOSH approved half-face
respirator with organic vapor/formaldehyde cartridges, rubber/silver
shield apron and arm protection, and faceshield will be worn when
pouring and segregating bulk organic solvent waste collected from
clinical and research laboratories into the 55 or 30 gallon bulk waste
storage drum. Rubber foot covers shall be worn as needed to protect feet
and shoes from splashing chemicals. Individuals will practice safe
lifting procedures and be issued a back support belt to enhance safe
lifting posture.

G. Collected waste chemicals are to be taken directly to the designated
chemical waste storage area for inventory and segregation.

H. For those chemical wastes having an exceptional explosive or reactive
potential, do not attempt to remove. Contact the Environmental Health
Technician and do not remove from area where generated.

VI\. [General Procedures for Storage of Chemical Wastes.]{.underline}

A. The EPA has established regulations for storage of hazardous chemical
wastes based on the amount stored and the classification of the
generator as \"Conditionally Exempt Small Quantity,\" as a small
quantity generator, or as a large quantity generator. Regulations
pertaining to interim storage requirement are found in 40 CFR Part
262.34.

B. Generators of hazardous waste are permitted without an RCRA storage
permit to accumulate hazardous waste on-site for limited periods prior
to treatment or disposal. On-site satellite generators of hazardous
waste may accumulate up to 55 gallons of hazardous waste or one quart of
acutely hazardous waste at or near points of generation prior to being
transported to the HVAMC's hazardous waste storage area. Accumulation
times for off-site treatment and disposal are as follows:

> 1\. Up to 270 days are allowed if the distance hazardous waste must be
> transported to prior to final storage, treatment or disposal is 200
> miles or more.
>
> 2\. Allowable accumulation time for conditionally exempt small
> quantity generators does not start until 1000 kilograms have been
> accumulated on-site.
>
> 3\. If small quantity generators accumulate 6000 kilograms or more of
> hazardous waste on site at any time, an RCRA storage permit is
> required.
>
> 4\. Generator status is defined by EPA regulations 40 CFR 260 et.
> seq., as follows:

  ----------------------------------- -----------------------------------
  Category of Hazardous Waste         Generates
  Generators                          

  Conditionally Exempt Small Quantity No more than 100 kilograms
  Generator                           hazardous waste and no more than 1
                                      kilogram acutely hazardous waste in
                                      any month.

  Small Quantity Generator            More than 100 and less than 1000
                                      kilograms of hazardous waste or, no
                                      more than 1 kilogram acutely
                                      hazardous waste in any month.

  Large Quantity Generator            1000 kilograms or more of hazardous
                                      waste or, more than 1 kilogram
                                      acutely hazardous waste in any
                                      month.
  ----------------------------------- -----------------------------------

> C. Temporary Chemical Storage*.*
>
> 1\. Waste chemicals should not be allowed to accumulate to large
> volumes at the site of their generation.
>
> 2\. During waste chemical accumulation, waste chemical containers
> should be properly labeled and sealed.
>
> 3\. Temporary storage sites should be out of the path of traffic,
> preferably on a shelf and against the wall.
>
> 4\. If the chemical is volatile, or odiferous, it should be
> temporarily stored in an appropriate, properly operating fume hood
> with the slash down. Fume hood use for other chemical processes shall
> be limited and in some cases curtailed if incompatible, until removed
> for final storage and disposal. Placards should be posted to indicate
> the potential volatility of the chemical waste being stored. As an
> alternative, a flammable storage cabinet may also be used to
> temporarily store these materials if properly ventilated.
>
> 5\. For laboratory chemicals exhibiting a high toxic or carcinogenic
> potential, specific storage (cabinet) areas should be designated to
> reduce the potential from spillage and release.

VII\. [General Procedures for Treatment and Disposal of Chemical
Wastes]{.underline}

In general, hazardous chemical wastes should not be treated on-site at
VA medical centers. The RCRA permit required to treat hazardous waste is
extremely burdensome. Among other things RCRA permitted treatment
facilities must file extensive operational reports and comply with more
extensive and complex regulations. There may, however, be unusual
circumstances where a VAMC would want to treat hazardous waste. If such
circumstances should arise, the VAMC should very carefully evaluate the
pros and cons of this treatment. Under no circumstances should a
hazardous waste be disposed of at a VAMC. The "cradle to grave"
liability created by Superfund (CERLA and SARA) make the long-term risk
of hazardous waste disposal too great.

A. Xylene - For the sake of pollution prevention and waste minimization,
less toxic chemicals should be substituted for xylene when possible.
Xylene waste will be recycled to the maximum extent feasible. Waste
xylene disposed of off-site by a contractor will be disposed of in a
manner that complies with federal, state and local requirements.

B. Mercury - mercury will be collected in an airtight container or
well-sealed container for recycling.

C. Silver - silver is recovered on-site from spent fixers originating in
radiology.

D. Used Oil - used oils are to be recycled or used in fuel-blending
processes by an off-site contractor. Currently used oils are not
considered \"hazardous\" but may require manifesting.

E. Gas Cylinders - gas cylinders will be recycled to every extent
possible. Unless gas cylinders contain chemicals listed in 40 CFR Part
261.33e (acutely toxic), they may be emptied, visible marked as "EMPTY"
and placed in the general trash. It is important that the general waste
hauler be contacted on the suitability of these containers in the
general waste load.

F. Lead-acid and nickel-cadmium batteries will be recycled back to the
manufacturer or a similar EPA approved recycler to every extent
possible.

VIII\. [Off-Site Disposal of Hazardous Chemical
Waste]{.underline}***.***

A. Hazardous chemical wastes requiring off-site recycling, storage,
treatment or disposal shall be allowed only with vendors that are
Federal and State registered as contractor approved for transporting,
storing and treating hazardous materials for final disposal. The vendors
shall not be allowed to remove any waste from the HVAMC, until he has
approval from a TSD to accept the manifested waste contracted for
disposal.

B. Every effort should be made to have these wastes reclaimed,
inactivated, or incinerated (off-site) preferentially over the landfill
option.

C. The manifests are to be completed with the assistance of the off-site
contractor and signed by the HVAMC\'s designated waste management
coordinator. The manifest will contain the HVAMC\'s EPA generator ID
number.

D. All containers will meet state and U.S. Department of Transportation
(DOT) regulations and will be packed according to U.S. DOT regulations.
The transporter contracted shall provide proof to the HVAMC of training
in emergency and contingency response procedures should an accident
occur during transport of VAMC hazardous materials, per company policy.

IX\. [Emergency and Contingency Response]{.underline}.

A. Refer to Attachment B of this policy.

B. The Environmental Health Technician and Safety Manager are the
designated Hazardous Waste Emergency Coordinators for the HVAMC.

C. Each emergency response to a chemical spill or release will be
dependent on the chemical, physical, and toxicological properties of the
chemical(s) spilled. It is therefore imperative that the chemical is
properly identified before any inactivation or disposal procedure is
initiated. Emergency response planning is necessary to reduce the
magnitude of the spill, the environmental damage caused, and the number
of people exposed. Everyone working with known or potentially hazardous
chemicals must be familiar with the chemical, physical and toxicological
properties of those chemicals and be adequately trained to properly
respond to a chemical emergency situation. Further assistance can be
provided through the HVAMC Industrial Hygienist and Safety Manager.

X. [Documentation]{.underline}***.***

A. Although EPA regulations require that manifests for off site
shipments of hazardous wastes be maintained for three years, VAMC\'s
should keep manifests indefinitely. Manifests covering specific waste
shipments could be used in the future to demonstrate proper transport
and disposal should the specific waste covered by the manifest appear on
the listing of waste that EPA develops to determine responsible parties
for uncontrolled hazardous waste site cleanups.

B. Documentation should also be kept for chemical wastes not requiring
manifesting to demonstrate their disposal routes.

C. Documentation of preventive maintenance, and calibration according to
manufacturer\'s specifications are maintained by Engineering Section for
any on-site equipment used for recycling, distilling, or metal recovery.

XI\. [Contingency Planning and Emergency Response - Chemical Spill
Response]{.underline}.

A. Introduction: Each emergency response to a chemical spill or release
will be dependent on the chemical, physical, and toxicological
properties of the chemical(s) spilled. It is therefore imperative that
the chemical is properly identified before any inactivation or disposal
procedure is initiated. Emergency response planning is necessary to
reduce the magnitude of the spill, the environmental damage caused, and
the number of people exposed. Everyone working with known or potentially
hazardous chemicals must be familiar with the chemical, physical and
toxicological properties of those chemicals and be adequately trained to
properly respond to a chemical emergency situation. Further assistance
can be provided through the HVAMC Environmental Health Technician and
Safety Manager.

B. Response Duties:

> 1\. Police & Security section notified to secure area.
>
> 2\. Experts are called to the area to direct action whether chemical
> or radiation.
>
> 3\. Environmental Management, Engineering and other sections are
> called as necessary and by following the directions of the expert
> render the area safe for use.
>
> 4\. A list of emergency phone numbers and response team personnel
> shall be posted in each location using, storing, or disposing of
> hazardous chemicals.
>
> 5\. Decontamination and medical response procedures are outlined in
> the Medical Center Policy Memorandum No. 002N-002, *Emergency Medical
> Preparedness Plan*.
>
> 6\. Chemical Spill Kits will be available in each area that
> extensively stores or uses hazardous chemicals. Kits are constructed
> to meet the needs of the chemical response necessary for containment.
> Equipment in the kits include:
>
> o Absorbent -- Towel wipes, spill control pillows.
>
> o Goggles and Gloves (butyl rubber, neoprene, or latex).
>
> o Waste disposal bag and label.
>
> 7\. Spill control kits are located in:
>
> a\. Clinical -- Laboratories.
>
> b\. Research and Development - Laboratories.
>
> c\. Storage Locations - Hazardous Materials and Waste Storage.
>
> d\. Industrial shops where hazardous waste is handled and stored.
>
> 8\. Personnel potentially responding to an emergency release or spill
> using the Spill Kit shall be familiar with use and procedures on how
> to report the release or spill to emergency response personnel.

B. In the Event of a Spill or Uncontrolled Release*.*

> 1\. General Practices.
>
> a\. Contact the Emergency Hazardous Material Coordinator by dialing
> 911.
>
> b\. Personal Safety.
>
> 1\. Evacuate the area, if possible containment of spill to minimize
> the spread of the spill.
>
> 2\. Keep untrained personnel away from spill.
>
> 3\. If someone comes in contact with a chemical, immediately rinse the
> affected area with water. Use the nearest sink, emergency shower or
> eyewash station.
>
> 4\. Seek medical attention as soon as possible.
>
> c\. Response Personnel General Guidelines
>
> 1\. One person must assume responsibility for command.
>
> 2\. Conduct a hazard and risk assessment of the spill situation
> (Evaluate what is known, determine what additional data is needed to
> complete assessment)
>
> 3\. Once the hazards and risks are known determine whether the spill
> can be safely clean up by trained personnel on-site with proper PPE
> based upon your training, knowledge, and experience or seek further
> technical advice or determine, if HFD Hazardous Material should be
> notified.
>
> 4\. Determine further actions for effective management and control of
> spill site to render the site safe for reuse.
>
> 2\. General Response to Volatile Organic Liquid Spill.
>
> a\. Contact the Emergency Hazardous Material Coordinator by dialing
> 911.
>
> b\. Remove or shut off all ignition sources immediately.
>
> c\. Keep untrained personnel away from spill.
>
> d\. Isolate the area and warn others of the hazard.
>
> e\. Reenter the room only when informed by response personnel that it
> is safe to do so.
>
> 3\. General Response to Acid or Alkali Spill.
>
> a\. Contact the Emergency Hazardous Material Coordinator by dialing
> 911.
>
> b\. Evacuate the area, if possible containment of spill to minimize
> the spread of the spill.
>
> c\. Keep untrained personnel away from spill.
>
> d\. Isolate the area and warn others of the hazard.
>
> e\. Reenter the room only when informed by response personnel that it
> is safe to do so.
>
> 4\. General Response to Chemical Carcinogen Spill.

a.  Contact the Emergency Hazardous Material Coordinator by dialing 911.

b.  Evacuate the area, if possible containment of spill to minimize the
    spread of the spill.

> c\. Isolate the area and warn others of the hazard.
>
> d\. Keep untrained personnel away from spill.
>
> e\. Isolate the area and warn others of the hazard.
>
> f\. Reenter the room only when informed by response personnel that it
> is safe to do so.

**Medical Waste Management Program**

I. [Purpose]{.underline}.

To establish safety procedures and guidance for the labeling, handling,
transport, and management of Microbiological, Pathological and Sharp
waste generated by patient care activities at the HVAMC to meet
regulatory guidelines outlined the OSHA 1910.1030, TDH 25 TAC
1.131-1.137 and TNRCC Title 30 TAC 330. This policy is applicable to all
personnel handling, transporting, treating or disposing infectious
material at the HVAMC.

II\. [Definition]{.underline}

Infectious material is defined as any medical center waste that can
reasonably be expected to be contaminated with organisms that could
cause disease or infection. For waste to be infectious, it must contain
pathogens with sufficient virulence and quantity so that exposure to the
waste by an individual could result in an infectious disease. Infectious
material is defined as those waste and disposable materials generated in
association with:

> o Microbiology laboratory wastes.
>
> o Pathology waste.
>
> o Bulk human blood (100 ml or more), blood products, and body fluids.
>
> q Needles, syringes, scalpels and related sharps.
>
> o Animal laboratory wastes.
>
> o Research wastes included in any of the above categories.

III\. [Responsibilities]{.underline}

A. The Medical Center Director, or designee, has the overall
responsibility for ensuring proper management of infectious materials
and waste at the time of entry into the HVAMC and from a point of
generation to the point of final disposal per applicable federal, state,
and local directives.

B. The Chief of Engineering, as the designee, has the responsibility for
developing contingency plans to ensure proper management of infectious
materials and waste generated for final disposal.

C. The Safety Manager or Environmental Health Technician has the
responsibility for providing technical support, recommendations and
monitoring to ensure HVAMC compliance with applicable federal, state,
and local regulations involving management of solid and hazardous waste.

D. Service and care line executives and supervisors are responsible for
developing procedures and ensuring employee involved in handling and
transporting infectious material and waste are properly trained to
prevent exposure to the waste that could result in an infectious
disease.

E. Infection Control is responsible for providing guidance, monitoring
and recommendations via Medical Center Policy Memorandum No. 111G1-002,
*Exposure Control Plan for the Prevention of Occupational Exposures to
Bloodborne Pathogens,* in compliance with CDC, JCAHO, OSHA, Federal, and
state standards.

F. Employees are responsible for complying and using procedures, PPE,
reporting unsafe conditions, handling and disposing of infectious
materials and waste per medical center policies.

IV\. [Procedures]{.underline}.

A. All personnel responsible for handling, storing, transporting and
disposing of infectious materials and waste must identify and affix a
warning label to any container (bag, box, specimen, etc.) with an orange
and black sticker labeled \"BIOHAZARD".

B. Spills.

> 1\. Small spills of infectious materials and waste (less than a
> 24"x24" square) shall be cleaned up by Nursing personnel with the
> assistance of Environmental Management Section personnel (Call or page
> the EMS area supervisor) using universal precautions procedures and
> disinfectants outlined in Medical Center Policy Memorandum No.
> 111G1-002.
>
> 2\. Large spill of infectious materials and waste (greater than a
> 24"x24" square) shall be reported as an "Emergency Biological Spill"
> to the Police & Security dispatcher by dialing "911". Nursing and EMS
> personnel shall initiate and begin spill containment immediately and
> then began clean up of the spill area using universal precautions
> procedures and disinfectants outlined in Medical Center Policy
> Memorandum No. 111G1-002 to render the area free of contamination.
> Response personnel from the Safety Section will response to assist in
> the containment and monitor clean up of the spill area.
>
> 3\. Infectious materials and waste spills in other buildings will be
> handled through EMS by contract housekeeping and research personnel in
> accordance with the Facility's Exposure Control Plan, Medical Center
> Policy Memorandum 111G1-002.
>
> 4\. Infectious materials and waste spills outside the building and at
> the three temporary medical waste staging and holding areas shall be
> contained, cleaned up and disinfected per Medical Center Policy
> Memorandum No. 111G1-002.
>
> 5\. Disinfectants. Infection Control has approved two types of
> disinfectants that shall be used in the clean-up and disinfection of
> infectious materials and waste in the HVAMC. Wex-cide^^ (EPA Reg.
> #34810-8) shall be used for clean-up and disinfection of spill area.
> DISPATCH shall be used for clean-up and disinfection of spills in
> isolation rooms and on equipment contaminated by infectious materials.
> *([Precaution]{.underline}: Do not use both at the same time. Mixing
> products can produce toxic vapors).*

C. AIDS patients that die in the HVAMC should be placed in the
heavy-duty solid white morgue bags and marked with the infectious tag.

D. Use of Plastic Bags. The quality of a plastic bag and its suitability
for use to contain infectious wastes is determined by raw materials used
in its manufacture and the product specifications. Two different
criteria are used to judge the suitability of a plastic bag; its
thickness and its durability, as evaluated by the ASTM Standard Number D
1709-85 using a 165 gram dart test. The purchase of bags should be based
on one or both of these standards. The important consideration is the
selection of a tear-resistant plastic bag that maintains its integrity
(at least until waste is treated).

E. Precautions. The incidence of bag tearing can be reduced somewhat by
measures such as using impervious tear-resistant, distinctively colored
and marked bags for infectious waste; not placing sharps and sharp items
with weight in bags; not loading bags in excess of bag weight and volume
capacity; and exercising special care during handling in order to keep
the plastic bags from coming into contact with extremely sharp objects.
If strength of bag is 2 mil or more, single bagging is usually adequate.
Sharp container shall be used for sharp disposal only and removed for
disposal when full. All containers with infectious waste shall be
secured or closed to prevent leaks or spills of infectious waste before
transport for final disposal.

F. Containers. Any container used to dispose of infectious waste must
first be approved by the Infection Control Committee (ICC). The ICC will
be responsible for determining their adequacy. A&MMS will only purchase
those items approved by the ICC.

G. Segregation of Infectious Waste. All infectious waste shall be
segregated at the point of origin with special consideration for
management and treatment of multiple hazard material. All infectious
waste shall be disposed of in approved, impervious, rigid,
puncture-resistant containers or impervious, tear-resistant, color-coded
trash bags (red, red-orange, marked with universal accepted logo or
wording such as \"Biohazard or white as appropriate and marked with
universal accepted logo or wording such as "Chemotherapy Drug Toxic"),
etc.

H. Packaging of Infectious Waste. The selection of packaging material
shall be based on the type of waste; for example, plastic bags for solid
or semi-solid infectious waste; impervious, rigid, puncture-resistant
containers for sharps; tightly capped bottles or flasks for liquid. All
infectious waste shall be packaged in bags or containers that will
maintain its integrity during storage and transport. Some liquid
infectious and medical waste may be acceptable for disposal to the local
sewer. The Infection Control Section should be contacted to ascertain
which, if any, infectious and medical waste may be disposed of down the
drain.

I. Storage and Disposal of Infectious Waste. Infectious waste will be
treated by a mobile maceration/chemical disinfection processing unit,
and rendered harmless and unrecognizable for landfill disposal per
contract guidelines at the HVAMC, with the exception of morgue and
research pathological waste which is to be incinerated. Refrigerators
and freezers where morgue waste may be stored shall be marked with the
universal \"biohazard\" symbol. The area where infectious waste
transport carts are temporarily housed until pickup is accomplished each
day shall be maintained free of rodents and vermin. Infectious waste
storage shall be effectively separated from patient care, food
preparation and food serving areas. The carts shall be labeled with the
universal \"biohazard\" symbol. Carts shall be disinfected daily. A
contingency plan has been developed and approved in the current
contract, and contains storage and disposal procedures to be used when
the Mobile Processing unit is not operational.

J. Handling and Transport of Packaged Infectious Waste. Infectious waste
moved within the HVAMC shall be placed in a sealed plastic bag which is
subsequently placed in a closed container. Personal protective clothing
shall be worn by employees handling infectious waste to include gloves
as a minimum and aprons, eye protection, or N95 respirators as needed,
etc., depending on the level of hazard involved. Gloves are always worn
and eye protection is highly recommended. Practices for handling plastic
bags include loading by hand, transporting the loaded cart to minimize
handling and placing the plastic bags within rigid or semi-rigid
containers before handling and transportation.

K. Steam Autoclave. Effective steam sterilization requires that packaged
material allow steam penetration and evacuation of air. It is
recommended that low density plastics be used when autoclaving
infectious waste in order to enhance steam penetration and facilitate
air evacuation from the load. Low density plastic bags should be placed
within heat-resistant containers to ensure containment of the waste
during the steam sterilization process.

L. Transport of Infectious Waste on Medical Center Grounds. Infectious
waste should be transported to treatment area in closed, leak-proof
carts to prevent scattering, spillage and leakage during the treatment
process. Covered, leak-proof carts are suitable for moving packaged
infectious waste within the HVAMC. These carts shall be disinfected
daily. Carts should be labeled with the universal \"Biohazard\" symbol.

M. On-site Treatment of Pathological Waste Only (Incineration). All
infectious pathological and research animal waste that has been
generated and turned-in for pick-up and disposal shall be incinerated,
on an as needed basis. The morgue shall have pathological waste pick-up
and incinerated, when a minimum of 7-12 containers have been
accumulated. Engineering Section shall be contacted and arrangements
made to pick-up, transport, and incinerate pathological waste.

N. Contingency Plan for Handling Infectious Waste. Supervisors shall
provide a plan for their employees who handle infectious waste to be
used under the following circumstances:

> 1\. Spills of Liquid Infectious Waste. Cleanup procedures, protection
> of personnel and disposal of spill residue.
>
> 2\. Rupture of Plastic Bag (or other loss of containment). Cleanup
> procedures, protection of personnel and repackaging of waste.

V. [SERVICE- and care line-Specific Procedures]{.underline}

A. Environmental Management Section. Environmental Management Section
personnel will collect from the applicable areas, red or white marked
containers will be collected daily and in the orange carts for
collection of infectious waste. All full carts will be taken to the
temporary storage area located on the West dock in the basement. The
full cart will be left and a empty cart taken back to the applicable
area.

B. Engineering Section. Engineering personnel will pick-up and transport
infectious waste cart to the temporary medical waste holding area for
final treatment and disinfection by contract guidelines. The carts shall
be taken to the medical waste holding pad area (old incinerator pad)
without delay for disposal and treatment on a daily basis. The area will
be secured at the end of the work day, to prevent unauthorized entry.

VI\. [Training]{.underline}

Supervisors shall provide initial and annual training for employees
handling infectious waste per OSHA 1910.1030. Such training will include
an explanation of Standard Operating Procedures (SOP\'s); Personal
Protective Equipment (PPE) requirements; the contingency plan for
emergencies, assignment of roles, and responsibilities for
implementation of the plan. All employees who generate or handle
infectious waste regardless of the employee\'s role (i.e., supervisory
or non-supervisory) or type of work (i.e., Research, Laboratory,
Nursing, Environmental Management and Engineering) shall be trained in
the contingency plan for handling infectious waste by their supervisors.