VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

[HAZARDOUS MATERIALS MANAGEMENT PLAN]{.underline}

1\. [PURPOSE]{.underline}: This policy describes a program designed to
accomplish the safe management of hazardous materials including chemical
wastes, radioactive wastes, and infectious wastes of the medical center.
This program, in conjunction with the safety and fire protection policy,
addresses the health and safety concerns of patients, personnel,
visitors, and the community.

2\. [POLICY]{.underline}: It will be the policy of the VA Ann Arbor
Healthcare System (VAAAHS) to maintain and enforce a program which will
monitor and control entry, use, storage, and disposal of all hazardous
materials. The policy will afford protection for all hospital patients,
personnel, and visitors as its first priority. The program will also
protect property and environment and will ensure compliance with all
pertinent federal, state, and local regulations. It will also be VAAAHS
policy to choose the least hazardous material possible in any procedure
that allows for a choice of chemical agents, and to minimize the volume
of hazardous materials used.

3\. [PROCEDURES]{.underline}: A copy of this directive will be
distributed to all department heads. In addition, a copy will be
maintained by each department in a prominent place, and will be made
available to all VAAAHS personnel.

4\. [RESPONSIBILITY]{.underline}: Responsibility for implementation of
this program lies with the Industrial Hygienist. Responsibilities for
individual aspects of the program are noted in appropriate sections.

5\. [REFERENCES]{.underline}:

40 CFR 240‑399

29 CFR 1910 & 1926

AHA Hospital Environmental Safety Education Program

Department of Transportation Regulations, 49 CFR 100‑199

Clean Water Act (1977)

Safety Management Program Policy Memorandum S-3, June 1, 2003

> Hazardous Drug Safety & Health Plan: Preparation, Administration and
> Disposal of Cytotoxic Agents, Policy Memorandum 119-6, July 6, 2000

\"Prudent Practices for Disposal of Chemicals from Laboratories\".

National Research Council, National Academy Press, Washington, D.C.,
1983

> JCAHO Comprehensive Accreditation Manual for Hospitals, Management of
> the Environment of Care
>
> \"Dangerous Properties of Industrial Materials\", 6th edition, N.
> Irving Sax, Von Nostrand Reinhold Company, New York, 1984
>
> \"Safe Storage of Laboratory Chemicals\", David E. Pipitone, Editor,
> John Wiley and Sons, New York, 1984
>
> \"Prudent Practices for Handling Hazardous Chemicals in
> Laboratories\", National Research Council, National Academy Press,
> 1981
>
> Ann Arbor Code of Ordinances, Chapter 28, Ordinances No. 23‑85, June
> 3, 1985
>
> Spill Prevention Control and Countermeasure Plan (*on file in the
> Industrial Hygienist's Office, Bldg 3, Room 107*)

2\.

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

6\. [RESCISSIONS]{.underline}: Policy Memorandum 00-3 dated August 1,
2000

7\. [EXPIRATION]{.underline}: September 2006

8\. [FOLLOW‑UP RESPONSIBILITIES]{.underline}: Industrial Hygienist
(50IH)

### James W. Roseborough

JAMES W. ROSEBOROUGH

Director

Attachments: A-P

Attachment N-5 (see index link)

Appendices (see index link)

Distribution: A

3\.

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

TABLE OF CONTENTS

HAZARDOUS MATERIALS MANAGEMENT PLAN ATTACHMENTS

Attachment A General Policies and Responsibilities

a-1 General

a-2 Scope and Applications

a-3 Objectives

a-4 Employee Rights and Responsibilities

a-5 Safety Office Responsibilities

a-6 Department Heads Responsibilities

a-7 Inspections

a-8 Review and Modification of the Policy

a-9 Hazardous Materials Definition

Attachment B Chemical Inventory and Annual Reports

b-1 Chemical Inventory2-1

b-2 Annual Reports

Attachment C Chemical Storage

c-1 General

c-2 Segregation of Chemical Storage areas

> c-3 Warning Signs

c-4 Labeling of Containers

c-5 Limitations on Storage

c-6 Annual Inventory and Inspection

c-7 Spill Kits

c-8 Waste Storage

c-9 Emergency Equipment

c-10 Additional References

Attachment D Carcinogen Policy

d-1 General

d-2 Restrictions on Carcinogen Use

d-3 Other Suspect Carcinogens

d-4 Safe Use and Handling of Carcinogens

d-5 Registration of Carcinogen Use

4\.

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

Attachment E Compressed Gas Policy

e-1 General

e-2 Labeling Requirements

e-3 Cylinder Storage

> e-4 Transport of Cylinders

e-5 Equipment Requirements

e-6 Safe Use of Compressed Gas

e-7 Ethylene Oxide and Nitrous Oxide

Attachment F Disposal of Hazardous Waste

f-1 General

f-2 Segregation of Wastes

f-3 Waste Pickup

> f-4 Labeling and Pickup

f-5 Packaging, Labeling, and Manifesting for Shipment

f-6 Drain Disposal of Chemicals

f-7 Policies Regarding Disposal of Specific Chemicals

Attachment G Hazard Communication Program

g-1 General

g-2 Procedure

g-3 Responsibilities

g-4 Additional References

Attachment H Ethylene Oxide Policies

h-1 General

h-2 Monitoring

h-3 Training

h-4 Labeling

h-5 Receiving and Storage

h-6 Personal Protective Equipment

h-7 Spill or Leak Response

h-8 Record Keeping

h-9 Medical Surveillance

Attachment I Anesthetic Gas Policies

i-1 General

i-2 Permissible Exposure Limits

i-3 Monitoring Programs

i-4 Maintenance and Leak Testing

5\.

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

i-5 Work Practices

i-6 Training

i-7 Medical Monitoring

> i-8 Labeling and Posting

i-9 Waste Disposal

Attachment J Special Policies

j-1 General

j-2 Mercury Policies

j-3 Picric Acid Policies

j-4 Formaldehyde Policies

j-5 Calcium Hypochlorite Policies

j-6 Cytotoxic Drug Policies

j-7 Radioactive Materials Policies

j-8 Disposal of Biohazardous Fluids

Attachment K Infectious Waste Policies

k-1 General

k-2 Responsibilities

k-3 Infectious Material Definition

k-4 Segregation of Waste

k-5 Disposal of Waste

Attachment L Spill Control Plan

l-1 General

l-2 Responsibilities

l-3 Policies for Pre‑Emergency Planning

l-4 General Policies for Spill Response

Attachment M Chemical Hygiene Plan

m-1 General

m-2 Procedure

m-3 Responsibilities

m-4 Additional References

m-5 Flowchart for Reporting Releases of Hazardous Substances Under

CERCLA & SARA

Attachment N Reporting of Environmental Incidents (Spills, Releases,
Discharges)

n-1 General

n-2 Procedure

n-3 Responsibilities

n-4 Additional References

n-5 Flowchart

6\.

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

Attachment O Peroxide Forming Compounds

o-1 General

o-2 Procedure

o-3 Responsibilities

Attachment P - Spill Prevention Control & Countermeasure Plan - on file
in bldg 3, rm 107

Appendix A -- HAZCOM Listing

Appendix B -- RCRA Listed Hazardous Wastes

Appendix C -- Request for Special Use of a Chemical Carcinogen

Attachment A

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

GENERAL RESPONSIBILITIES AND POLICIES

a-1 General:

Safe use of hazardous materials can only be achieved with the
cooperation of all involved personnel. It is the responsibility of all
employees to follow the procedures and recommendations described in this
policy. In addition, individual judgment may be called for in unusual or
unexpected circumstances. In these cases it will be medical center
policy to pursue the greatest reasonable level of caution. If an
employee suspects that a material may present a significant hazard, he
or she will being the situation to the attention of his or her
supervisor.

a-2 Scope and Application:

a\. The hazardous material policy applies to all hazardous or
potentially hazardous materials, as defined in Section a‑9. All these
materials have the potential to cause injury and environmental harm and
will be handled accordingly.

b\. This policy applies to all departments and to all VA personnel while
they are at the facility.

c\. This policy also applies to the Toledo VA Outpatient Clinic, which
is understood to be included in references to this facility where such
references are applicable.

a-3 Objectives:

a\. The primary objective of this policy is to protect VA employees,
personnel, patients, and visitors.

b\. The policy of this facility will also be to protect the community
and the environment from harm due to chemical exposure.

c\. The hazardous waste policy will be in compliance with all federal,
state, and local laws, as well as JCAHO regulations.

d\. To the extent possible, the hazardous waste policy will minimize the
generation of hazardous waste and the cost of waste disposal.

a-4 Employee Rights and Responsibilities:

a\. Employees have the responsibility to follow, the hazardous material
policy.

Attachment A-1

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

b\. Employees have the responsibility to report any unsafe condition or
use of hazardous materials to their supervisor.

c\. Employees have the responsibility to promptly report accidents and
spills that result in chemical exposure to VA patients or personnel.

d\. All 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.

e\. Employees who desire information regarding materials to which they
may be exposed, or who have suggestions for safer use of hazardous
materials, may direct questions and comments to the safety office.

f\. All employees who may be exposed to hazardous materials will receive
training in hazard recognition and in safe use of hazardous chemicals.
Training will follow the guidelines of the federal hazardous
communications act, 29 CFR 1910.1200.

a-5 Safety Office Responsibilities:

a\. The safety office has responsibility to identify the hazards which
may be associated with materials used in the medical center, and to
develop guidelines and recommendations for their safe use.

b\. The safety office has responsibility to investigate accidents and
make recommendations to avoid recurrences of similar incidents.

c\. The safety office has responsibility to train supervisors.

d\. The safety office has responsibility to respond promptly to requests
for assistance or information concerning hazardous materials.

e\. The Industrial Hygienist has been designated Hazardous Materials
Coordinator for the facility.

a-6 Department Head's Responsibilities:

a\. The head of each department has responsibility for training
employees of the department in safe handling, use, and disposal of
hazardous materials.

Attachment A-2

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

b\. The head of each department has responsibility to assist in
investigations of accidents involving hazardous material exposures.

c\. The head of each department has responsibility to report instances
or circumstances where he/she feels that the hazardous materials policy
requires modification to allow compliance or to achieve safe conditions.

d\. The head of each department has responsibility to conduct an annual
inventory of hazardous materials stored or used in his/her department
and report the results to the Industrial Hygienist.

e\. The head of each department has responsibility to designate a
Hazardous Materials Coordinator for that department.

a-7 Inspections:

The safety office will conduct annual inspections of all departments to
assess the effectiveness of the hazardous materials policy, and to
determine if each department is in compliance. These inspections will be
conducted with the assistance of department heads or designees.

a-8 Review and Modification of the Policy:

The use of hazardous materials at the medical center is expected to
vary, and will therefore require modification of the policy on a regular
basis. A formal review will be made by the Safety Committee each year,
and will include consideration of comments and suggestions made by
employees. Compliance records, accident records, and reasons for any
noncompliance will also be reviewed and considered.

a-9 Hazardous Materials Definition:

For the purposes of this document, hazardous materials will be defined
similarly to hazardous waste. Any material which, after use, will be
considered a hazardous waste will be considered a hazardous material. VA
Policy defines hazardous waste according to the Resource Conservation
and Recovery Act (RCRA). This act defines a waste as hazardous if it
meets any of the following three criteria.

a\. It has been listed as a hazardous waste in 40 CFR 261, subpart D.
(See Attachment B.)

b\. It contains a compound listed as hazardous in 40 CFR 261, subpart D.
(See Attachment B.)

Attachment A-3

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

c\. It is hazardous due to a dangerous property defined in 40 CFR 261,
subpart C. These dangerous properties include:

\(1\) Ignitability (Flash Pt. \<140oF)

\(2\) Corrosivity (pH \<2.0 or \>12.5)

\(3\) Reactivity (shock, light sensitive or reacts violently with

water)

\(4\) Toxicity Characteristic Leaching Procedure (i.e. heavy metals or

pesticides)

In addition, materials included on the OSHA Hazard Communication
Standard (HAZCOM) List will be defined as hazardous and handled
according to the hazardous materials policy. HAZCOM is considered the
definitive list of hazardous chemicals and is composed of all chemicals
for which American Conference of Governmental Industrial Hygienists
(ACGIH) has developed a threshold limit value, all chemicals on the
National Toxicology Program list of suspect carcinogens, and the
International Agency for Research on Cancer list of possible human
carcinogens.

Lists of hazardous materials, as defined in the Federal Hazard
Communication Act and the Resource Conservation and Recovery Act, are
included in the Appendices A and B..

Finally, it should be noted that exclusion of a chemical from the RCRA
and HAZCOM lists does not mean that the material is necessarily
non-hazardous. Many unlisted materials are capable of causing health or
environmental damage if handled or disposed of improperly and will be
used in compliance with this policy.

Attachment B

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

CHEMICAL INVENTORY

b-1 The Chemical Inventory:

The Industrial Hygienist will maintain an inventory of chemicals used or
stored at the medical center. The initial inventory list was complied in
1985 during a lab‑by‑lab survey of research and clinical labs and has
been expanded to include all departments. The inventory file will
include the following information:

a\. Trade Name and/or Chemical Name

b\. Synonyms (if applicable)

c\. Manufacturer

d\. Building Number

e\. Room Number

f\. Room Function

g\. Quantity on Hand

h\. Estimated Rate of Use Per Year

i\. Disposal End Point

j\. Material Safety Data Sheet Availability

b-2 Annual Reports:

Each department head will develop and implement a system for the annual
inventory of chemical substances. The annual report, due on September 1
of each year will include the above mentioned information. When
completed, the inventory form is to be returned to the safety office for
incorporation into the computerized data base.

Attachment C

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

CHEMICAL STORAGE

c-1 General:

Bulk storage of chemicals will be in compliance with NFPA codes and OSHA
standards. Research Service laboratories will store bulk chemicals in
G‑7. Laboratory Service will store bulk chemicals in B‑230d.

Individual labs will store no more than a single one gallon bottle of
each of their required acids, bases, and oxidizers. Individual labs may
store up to 10 gallons of flammable liquid per 5000 square feet outside
of storage cabinets. Up to 60 gallons may be stored in approved
flammable storage cabinets.

Laboratory supplies can be refilled from bulk stores as needed. Storage
of chemicals in individual labs is addressed in reactivity group safety
sheets. Volumes allowed to be kept in

chemical storage rooms will be regulated according to safety
considerations and limitation of space.

c-2 Segregation of Chemical Storage Areas:

Chemical storage rooms will be segregated into the six chemical
compatibility groups indicated below.

a\. Acids: Acids will be stored in designated acid storage areas which
are separated from bases and flammable storage areas. Acid storage areas
will be further subdivided into areas for oxidizing mineral acids,
non-oxidizing mineral acids, and organic acids. Organic and oxidizing
acids will be stored as far apart as feasible within the acid storage
area. Bottles will be stored on corrosion resistant shelves, in acid
cabinets, or on acid resistant mats. Bottles will be further segregated
such that the largest bottles are stored on the lowest shelves. Plastic
lined bottle carriers will be required for transporting acids to
laboratories from the store room.

b\. Bases: All bases will be stored in the designated base storage areas
on corrosion resistant shelves. As with acids, the largest bottles will
be stored on the lowest shelves. Inorganic hydroxides are to be stored
in polyethylene or polyethylene lined bottles. Bottle carriers will be
used to transport strong base solutions such as sodium and potassium
hydroxide.

c\. Oxidizers: Oxidizers will be stored in the designated area, well
away from flammables and combustible materials, and reducing agents.

d\. Flammables: Flammable liquids will be stored in enclosed storage
cabinets in the

Attachment C-1

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

designated area. Large metal cans should be grounded to minimize spark
hazards. Flammables are to be stored well away from oxidizers and acids.

e\. Water reactives: Water reactive materials will be stored in tightly
closed containers and in closed cabinets in their designated areas.
Signs warning that water is not to be sprayed on these compounds in
event of a fire must be prominently displayed.

f\. Toxics: Highly toxic materials will be stored in a cabinet in the
designated area. These materials will be clearly labeled and segregated
as acutely toxic, carcinogenic, teratogenic, or capable of releasing
acutely toxic fumes on heating or contact with incompatible materials.

c-3 Warning Signs:

Chemical storage rooms will be clearly marked as such. Segregated areas
within the storage rooms will be clearly marked indicating what can be
stored in that area.

c-4 Labeling of Containers:

Any container left in a chemical storage area will be labeled with the
following information:

a\. Name of the person responsible for the material

b\. Date of receipt

c\. Date of opening

d\. Expiration Date

(See c‑6 below)

c-5 Limitations of Storage:

Because many chemicals become unstable during storage, a time limit will
be placed on storage of chemicals in the store room. These time limits
will vary depending on the stability of the chemical under
consideration, but in general should not exceed four years. If a
chemical is used rarely, or in small volumes, it should be purchased in
small volumes. For chemicals such as solvents that are used frequently
and in large volumes, a first-in first-out rotation of stock should be
employed. Certain materials such as Picric Acid and Peroxide forming
chemicals present a special hazard of explosion and cannot be stored for
periods longer than outlined in Attachment O.

c-6 Annual Inventory and Inspection:

The facility Safety Manager and/or Industrial Hygienist will conduct an
annual inventory and inspection of chemical storage facilities during
hazardous surveillance rounds. At that time, any containers which are
improperly labeled, corroded, beyond their expiration date, or otherwise

> Attachment C-2

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

being stored in an unsafe manner will be disposed of. In addition, the
annual inventory will

include an inspection of shelving, cabinets, containers, and of the
storage facilities in general.

c-7 Spill Kits:

Acid neutralization, base neutralization, and flammable solvent spill
kits will be located in the immediate vicinity of the storage rooms for
use in case of bottle breakage or other accidental spills. Spill kits
will be sufficient to neutralize at least a one gallon spill. In the
event of a spill, the material should be absorbed using the supplied
spill kit and the appropriate person should be contacted. As noted in
the safety and fire protection regulations, each department is
responsible for spill cleanup within their department and should
designate a person to coordinate spill cleanup efforts. Spill kits will
be located in the immediate vicinity of the storage rooms.

c-8 Waste Storage:

Rooms designated for chemical storage are not to be used for storage of
waste materials. Hazardous material works generated by all VAMC, Ann
Arbor work stations will be stored in Building #1, RoomA‑24c until final
disposal is accomplished. Hazardous materials generated by the Toledo
Outpatient Clinic work stations will initially be stored on site at the
TOPC, in the Hazardous Waste Storage Room #3, located adjacent to the
receiving dock. On a weekly basis, this hazardous waste will be
transported (according to provisions in Attachment F-3) to the Ann Arbor
VAMC Hazardous Waste Storage Room A‑24c, to await final off‑site
disposal. Each work section/shop will designate a competent person to
coordinate the transfer of hazardous material wastes from points of
generation to the waste storage room. This transfer will be coordinated
with the Industrial Hygiene/Safety Office. Wastes will be handled
according to procedures in this manual.

c-9 Emergency Equipment:

The following safety devices will be located in, or just outside,
chemical storage rooms.

a\. Fire extinguishers rated for Class A, B, and C fires.

b\. Fire Blanket

c\. Emergency eye wash

c-10 Additional References:

The following sources may be consulted for more information

a\. NFPA‑99 ‑ Health Care Facilities

b\. NFPA‑45 ‑ Fire Protection for Laboratories Using Chemicals

> Attachment D

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

CARCINOGEN POLICY

d-1 General:

Safe practices for use and handling of hazardous chemicals should be
strictly followed for all carcinogens. Laboratory personnel must be
aware that while these chemicals are extremely hazardous, they usually
possess no warning properties. High exposures may therefore occur
without the knowledge of the exposed individual. The level of protection
necessary is somewhat dependent on the specific material in use and
conditions of use. Professional judgment may be called for in
determining levels of protection required.

d-2 Restrictions on Carcinogen Use:

As specified in the VA Safety Management Program, Policy S-3, the use of
certain carcinogens is prohibited except as approved by the VA Committee
on Safety and Health. Each researcher wishing to use a prohibited
compound must seek approval as described in the above referenced
memorandum. Prohibited materials include:

a\. Mixtures containing 1% or more by weight:

2‑Acetylaminofluorene

Acrylonitrile

3,3‑Dichlorobenzidine (and its salts)

Chromite Ore

4‑Dimethylaminoazobenzene

Alpha‑Naphthylamine

N‑Nitrosodimethylamine

Beta‑Propiolactone

4,4‑Methylene (bis) 2‑Chloroaniline

Ethyleneimine

Asbestos

b\. Mixtures containing 0.1% or more by weight:

Ethylene dibromide

4‑Aminodiphenyl

Benzidine (and its salts)

4‑Nitrobiphenyl

Beta‑Naphthalamine

Bis‑Chloromethyl Ether

Methyl Chloromethyl Ether

> Attachment D-1

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

d-3 Other Suspect Carcinogens:

A large number of other laboratory chemicals and drugs are known or
suspect carcinogens. Materials included on the HAZCOM list of
carcinogens will be considered as carcinogens in this policy. In
addition, if a chemical or drug is considered a suspect carcinogen by
the manufacturer, it will be treated as a known carcinogen.

d-4 Safe Use and Handling of Carcinogens:

Carcinogenic agents will be handled according to applicable federal
regulations (Federal Register Volume 39, No‑20, Part III, Tuesday,
January 20, 1974). In addition NIH guidelines, from publication No.
81.2385, 1981, will be followed. These guidelines are outlined below.

a\. Work Areas:

Work with carcinogens will be confined to clearly marked areas of the
laboratory. Access to carcinogen areas will be restricted to those
employees who must enter for work related activities, and to those who
have received training in carcinogen use. Areas of carcinogen use within
a lab will be clearly delineated and marked and warning signs will be
displayed on the door. Any equipment such as fume hoods, glove boxes, or
analytical instruments used with carcinogens, will be marked as possible
sources of exposure.

b\. Use of Personal Protective Equipment:

Personnel work with carcinogens will use the following protective
equipment.

\(1\) Laboratory coats or coveralls that completely protect street
clothing. Garments may be disposable or washable, but if washable must
be laundered separately from other clothing. Garments must be changed
each day and whenever contamination is known to have occurred.

\(2\) Disposable gloves are to be worn at all times. They are to be
replaced whenever contaminated or removed for any reason.

\(3\) Eye protection of splash proof design is to be worn at all times.

c\. Handling Procedures:

\(1\) Containment is required for work involving the use of volatile
carcinogens or

> Attachment D-2

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

for work that may generate aerosols or dust. Aerosol generating
procedures include grinding, blending, centrifugation, and vacuum
filtration. Containments may be achieved by working in a

fume hood, a biological safety cabinet, or glove box equipped with a
fan.

\(2\) Instruments used with volatile carcinogens, or those that may
generate an aerosol, must be equipped with local exhaust ventilation or
be used in a fume hood. Contaminated equipment is to be cleaned before
further use.

\(3\) Special equipment may be called for in the use of carcinogens.
Fume hoods and glove boxes used with carcinogens should be equipped with
activated charcoal and high efficiency particulate air (HEPA) filters.
Any vacuum lines used with carcinogens should be equipped with HEPA
filters. Vacuum pumps should be designated for carcinogenic use and
vented into a hood.

\(4\) Pipetting must never be done by mouth. All pipettes are to be
operated by mechanical devices.

\(5\) All work areas are to be covered with plastic backed absorbent lab
mat, which is changed each day.

d\. Housekeeping Procedures:

\(1\) Avoid dusting or use of dry mops since these activities tend to
stir up settled dusts. Clean work areas instead with wet mops and a damp
cloth.

\(2\) Workers are to wash their hands immediately after any skin contact
with a carcinogen and when they leave the work area.

\(3\) Contaminated materials are to be sealed in a plastic bag marked as
containing carcinogens. Bags are to be disposed of in a designated
receptacle.

\(4\) Liquid wastes containing carcinogens are to be stored in waste
disposal jars marked as containing carcinogens. The jars should also be
labeled with the name of the specific carcinogen.

\(5\) Glassware and equipment contaminated with carcinogens should be
segregated and washed separately from other equipment. Special care is
called for in order to prevent spread of the contamination.

\(6\) Carcinogens should be stored in designated areas of the laboratory
which will be clearly marked. An inventory of all carcinogens will be
maintained in each lab.

> Attachment D-3

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

\(7\) Carcinogens will be transported only in durable containers to
prevent spills and breakage.

\(8\) The safety office is to be notified immediately of spills of
carcinogenic materials. Clean-up will be conducted only with proper
protective equipment. In case of a spill

of a volatile carcinogen, the room should be evacuated and closed off.
Safety personnel will enter only with proper, NIOSH approved,
respirators.

\(9\) No eating, drinking, or smoking is allowed in areas of carcinogen
use. Storage of food or eating utensils is also prohibited.

e\. Training:

All personnel involved in use of carcinogens will be familiar with VA
safety policy. In addition each person will receive training in each of
the following areas:

\(1\) Sources of exposure

\(2\) Adverse health effects

\(3\) Laboratory practices and exposure controls

\(4\) Use and purpose of environmental and/or medical monitoring

\(5\) Their responsibilities for safe use of carcinogens.

f\. Monitoring:

The Safety Manager or Industrial Hygienist will have the responsibility
to conduct inspections of carcinogen work areas, and to conduct
industrial hygiene monitoring as deemed necessary by the Industrial
Hygienist.

g\. Use of Carcinogens in Animal Experimentation:

Animal experimentation involving carcinogens requires special
precautions. Careful planning must be included for animal care, dosage
preparation, exposure regimes, and waste management. Control of
contaminated feed, feces, urine, and bedding must be achieved and may
require special equipment and training. Health and safety precautions
for exposure of animals to carcinogens must be developed with the
cooperation of safety office personnel.

> Attachment D-4

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

d-5 Registration of Carcinogen Use:

Laboratories using or wishing to use carcinogens in research will fill
in a carcinogen use sheet and file it with the safety office. These
forms are available at the safety office and are of the type used at NIH
laboratories. A sample form is included in this policy as Appendix C.

> Attachment E

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

COMPRESSED GAS POLICY

e-1 General:

Cylinders of compressed gas present a dual chemical and physical hazard.
The extreme pressures contained in these cylinders creates the potential
for explosion if the cylinder is overheated or damaged. The large volume
of gas contained in a cylinder also creates a hazard, even if the
particular gas is normally considered non‑hazardous. Leaks or releases
of toxic or flammable gases, such as ammonia or acetylene, present an
obvious hazard. Less obvious, but equally dangerous, is the possibility
of asphyxiation due to displacement of oxygen in inert gases including
nitrogen, argon, or carbon dioxide. Increased oxygen levels create an
extreme fire hazard and must also be avoided.

e-2 Labeling Requirements:

Cylinder Labels:

The following information must be stenciled or stamped on the cylinder.

\(1\) Contents of the cylinder.

\(2\) Waning of toxic, corrosive, or flammable properties. Labels that
can be readily removed, color coding, and labeling of the cylinder cap
are not sufficient.

e-3 Cylinder Storage:

a\. Compressed gas cylinders are to be secured with a clamp and chain or
strap at all times. This requirement applies to empty cylinders as well
as full ones.

b\. In order to protect values, the cylinder cap is to be kept on all
cylinders when they are not in use.

c\. Cylinders are to be stored only in designated areas on the loading
dock. Due to the danger of slow leaks and gas accumulation, cylinders
must not be stored in confined spaces.

d\. The cylinder storage area is to be segregated into the following
four areas:

\(1\) Oxidizers

\(2\) Flammables

\(3\) Toxics

\(4\) Empty cylinders

> Attachment E-1

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

e-4 Transport of Cylinders:

a\. Cylinders, including empty ones, are to be moved only while strapped
onto a cylinder hand cart or dolly. Never roll or drag cylinders.

b\. Cylinder caps must be in place whenever cylinders are transported.

e-5 Equipment Requirements:

a\. Regulators: Regulators are equipped with fittings that match
cylinders for which they are approved. Under no circumstances are
fittings to be altered. Corrosion resistant regulators are required for
corrosive gases such as ammonia, chlorinem, and sulfur dioxide. Carbon
Dioxide approved regulators are required for Carbon Dioxide use. All
regulators should be equipped with a spring loaded pressure relief
valve. If toxic, corrosive, or flammable gas is in use, this pressure
relief must be vented to a hood or other exhaust system.

b\. Pressurized Lines: Pressurized lines must be constructed of an
approved, thick- walled, reinforced material. Tygon and similar plastic
tubing are inadequate for most uses. Lines must not be run across
floors, over heat sources, or near open flames.

c\. Connectors: Thread type and size on pressurized gas cylinders is
standardized to prevent mixing of incompatible gases. Only standard
approved valves and fittings are to be used.

e-6 Safe Use of Compressed Gas:

a\. Shatterproof safety glasses, goggles, or a face shield are required
whenever working with pressurized gas cylinders. This is especially
important when making connections or adjusting valves.

b\. Cylinders are to be placed so that the valves are readily accessible
at all times.

c\. The main cylinder valve is never to be opened without an approved
regulator in place.

d\. The cylinder valve is to be shut off when the gas is not in use. Do
not rely on the regulator valve to stop flow completely.

e\. Cylinders returned as empty should still contain some residual
pressure. This residual pressure should be no less than 25 psi. This
will insure humid air does not enter the

cylinder resulting in corrosion of the interior.

> Attachment E-2

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

f\. The main cylinder valve rarely, if ever, needs to be opened all the
way. The valve should be opened only as far as necessary.

g\. Pliers or other non‑approved tools are not to be used on valves or
fittings.

h\. Smoking is prohibited in areas where flammable gases or oxygen are
in use.

i\. Emergency response procedures must be developed by departments using
highly toxic gases such as ammonia or hydrogen sulfide.

e-7 Ethylene Oxide and Nitrous Oxide:

Ethylene oxide and nitrous oxide present special hazards and will be
handled and used according to specific procedures described in
Attachments H and I.

> Attachment F

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

DISPOSAL OF HAZARDOUS WASTES

f-1 General:

Disposal of chemical waste will be in accordance with federal, state,
and local regulations. Specifically, disposal practices will be in
compliance with RCRA and with local ordinances regarding disposal of
materials through the sewer system. VAAAHS is currently a small quantity
generator.

f-2 Segregation of Wastes:

Proper storage and disposal of laboratory wastes require segregation
into compatibility groups. Each laboratory will be required to segregate
their wastes into at least the following eight categories:

a\. Organic Acids

b\. Mineral Acids

c\. Bases

d\. Nonhalogenated Organics

e\. Halogenated Organics

f\. Mercury

g\. Waste oils (pump oil etc.)

h\. Radioactive Materials

Each laboratory will maintain clearly marked waste containers indicating
the category of waste they hold. Wastes will be stored in these
containers and will be transferred to the designated waste storage room,
A‑24c. One or two gallon jugs are considered suitable and will be
provided by the department generating the waste. Each jug should be
labeled with the date of first use.

f-3 Waste Pickup:

Hazardous waste materials generated at the Toledo VA Outpatient Clinic
will be disposed of through our hazardous waste contract and should be
left in the generating department. Waste chemical materials generated at
Ann Arbor VAMC work stations will be picked up and transported to Room
A‑24c at least weekly. It will be the responsibility of the head of each
department to designate a trained person to coordinate the transfer in a
manner that will minimize the possibility of spills or leakage. Whenever
possible, containers should be moved in carts. Glass bottles must be
carried in protective bottle carriers provided by the department
generating the waste.

> Attachment F-1

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

f-4 Labeling and Record Keeping:

At the time of waste pickup, each container must be labeled with the
following information:

a\. The words \"Hazardous Waste\"

b\. Room Number

c\. Principal investigators name

d\. Date

e\. Major constituents

f-5 Packaging, Labeling, and Manifesting for Shipment:

Packaging of waste into approved drums for shipment, labeling of the
drums, and manifesting for transportation will be done by the disposal
company, as called for in the disposal contract. It will be the
responsibility of the Safety Manager or Industrial Hygienist to confirm
that all procedures are conducted according to the specifications of the
contract, and in accordance with state, federal, and local regulations.
The Safety Manager or Industrial Hygienist is required to verify the
accuracy of the shipping manifest.

f-6 Drain Disposal of Chemicals:

Drain disposal of chemicals is limited by local ordinances and by the
potential danger of corrosion, fires, explosion, and generation of toxic
fumes. It is important that employees be aware that drains from the
different locations are interconnected, and that dangerous reactions can
occur when wastes from different lab mix.

The quantities of waste that can be disposed of at any one time will be
limited to a few grams or a few hundred milliliters of solution.
Disposal of material down the drain is to include flushing with at least
a 100 fold excess of water.

f-7 Policies Regarding Disposal of Specific Chemicals:

a\. Disposal of wastes will be done according to federal, state, and
local regulations. Disposal of wastes through the sewer system is
regulated according to city ordinances.

\(1\) Acids: Most acids may be neutralized and flushed down the drain
with a 100 fold excess of water. Neutralization should be to pH 7 to 8
with a sodium carbonate solution. Neutralization can be monitored with
pH paper, methyl red/thymol blue, or universal indicator. Note that
drain disposal of some acids, even after neutralization may be
inappropriate due to their

anion content. For example, dichromic acid should never be poured down
the drain.

> Attachment F-2

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

Care must be exercised in conducting the neutralization reaction since
heat is produced and an uncontrolled reaction may become violent.
Personnel conducting the neutralization must wear proper protective
equipment including a lab coat or apron, gloves, and eye protection.

\(2\) Bases: Bases may generally be neutralized and flushed down the
drain with a 100 fold excess of water. Neutralization should be to a pH
of 7 to 8, and can be accomplished with sodium bisulfite. Note that
drain disposal of some bases, even after neutralization may be
inappropriate due to their cation content. (See list at the end of the
attachment if there is any question. As with acid neutralization, care
must be used in neutralization of bases. See the previous section for
precautions.)

\(3\) Halogenated Organics: Halogenated organics such as chloroform and
carbon tetrachloride are not suitable for drain disposal. These
materials must be stored in waste disposal jugs for removal by the
contracted waste disposal company.

\(4\) Nonhalogenated Organics: Some nonhalogenated organics that are
highly soluble, nonreactive, of low toxicity, and low volatility may be
disposed as dilute solutions through the sewer system. Those that do not
meet these guidelines must be saved for disposal by the contractor.

Generally if 100 mg of the substance is soluble in 3 ml of water, then
drain disposal is permissible. This criteria excludes hydrocarbons,
nitro compounds, mercaptan, and oxygenated compounds with more then five
carbons.

b\. The National Academy of Sciences has developed the following list as
a guide to materials that can be disposed of through the sewer system.
If a material is not on the list, it should be saved for removal by the
contractor.

\(1\) Alcohols: Alkanediols with less than 8 carbons, t‑amyl alcohol,
glycerol, sugars and sugar alcohols, alkoxyalkanols with less than 7
carbons.

\(2\) Aldehydes: Aliphatic aldehydes with less than 5 carbons.

\(3\) Amides: RCONH2 and RCONHR with less than 5 carbons, RCONR2 with
less than 11 carbons.

\(4\) Amines: Aliphatic amines and diamines with less than 7 carbons,
benzylamine, pyridine.

\(5\) Carboxylic Acid: Alkanoic, alkanedioic, and hydroxyalkanoic acids
with

> Attachment F-3

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

less than 6 carbons. Aminoalkanoic acids with less than 7 carbon atoms,
ammonium, sodium, and potassium salts of the above classes with less
than 21 carbon atoms.

\(6\) Esters: Esters with less than 5 carbons, isopropyl acetate

\(7\) Ethers: Tetrahydrofuran, dioxane, dioxolane

\(8\) Ketones: Ketones with less than 6 carbons

\(9\) Nitriles: Acetonitrile, propionitrile

\(10\) Sulfonic Acids: Sodium or potassium salts

c\. Inorganics: Small amounts of lox toxicity inorganics may be flushed
down the drain as dilute solutions. If large amounts are to be disposed
of, or if solutions are of high concentration, the salts may be
precipitated out and separated from the fluid. The collected precipitate
must then be disposed of with the hazardous waste, while the fluid may
be flushed down the drain.

d\. Small amounts of the following anions and cations may be disposed of
down the drain after pH neutralization if needed.

[CATIONS]{.underline} [ANIONS]{.underline}

Aluminum Bisulfite

Calcium Borate

Copper Bromide

Iron Carbonate

Hydrogen Chloride

Potassium Hydroxide

Lithium Iodine

Magnesium Oxide

Sodium Phosphate

Strontium Sulfate

Tin Sulfite

Zinc Thiocyanate

Zirconium

e\. Mercury: Elemental Mercury is not to be disposed of down the drain.
If mercury is used on a regular basis, a battle for waste collection
should be maintained. For occasional mercury disposal problems contact
the safety office. Waste mercury will be disposed of by the contracted
waste disposal company.

> Attachment F-4

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

f\. Cyanides and Sulfides: Cyanide and sulfide waste must be handled
with special care due to the possibility of toxic gas production. Waste
cyanides must be stored in a bottle designated exclusively for these
materials. It is important to keep cyanide and sulfide wastes away from
acids. They should not be disposed of down the drain due to the danger
of toxic gas production in pipes. Save sulfide and cyanide waste in
tightly sealed containers for proper disposal.

> Attachment G

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

HAZARD COMMUNICATION PROGRAM

Part 1 ‑ General

g-1 General:

All employees have a \"right to know\" the chemicals they are working
with that constitute a health hazard when used without special
precautions and controls.

g-2 Procedure:

a\. Labels and Other Forms of Warning:

\(1\) The medical center will never accept any chemical which is not
labeled, tagged, or marked with the following information:

\(a\) Identify of chemical(s)

\(b\) Appropriate hazard warnings

\(c\) Name and address of the chemical manufacturer, importer, or other
responsible party.

\(2\) No one will ever remove or deface existing labels on incoming
containers of chemicals unless the container is immediately marked with
the required information.

\(3\) The labels and/or other forms of warning are to be legible in
English and prominently displaced on the container, or readily available
in the work area throughout each work shift.

\(4\) In‑house labels should contain information as outlined above in
paragraph (1).

b\. Material Safety Data Sheets (MSDS):

There will be a MSDS on every substance which, when used without special
precautions and controls, will constitute a health hazard to employees.

\(1\) The MSDS will be essentially similar to form OSHA‑174 which notes
who makes the product, its hazardous ingredients, physical/chemical
characteristics, fire/explosion hazard data, reactivity data, health
hazard data, precautions for safe handling, and use and control
measures.

> Attachment G-1

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

\(2\) Every time a substance is ordered that does not have a MSDS on
file, VA Form 2237 will indicate the approving official is requesting
two MSDS Forms be sent to the medical center on the substance when
delivered.

\(3\) The MSDS will be placed in a binder in the work area so they are
readily accessible during each work shift to all employees. The
Industrial Hygienist and Ambulatory Care Triage Area will maintain a
master set of all MSDS made available to them as well.

\(4\) MSDS must be reviewed every two years by the using department to
keep the list up to date.

\(5\) When a hazardous chemical arrives without a MSDS on site, the
Chief, Acquisition and Materiel Management, must notify the Industrial
Hygienist. The Industrial Hygienist will make the decision on whether
the chemical should be delivered to the using department. If an
exception is allowed, the user will consult with the Industrial
Hygienist on the safe use of the chemical. If an exception is not
granted, the chemical will be returned to the vendor. The decision to
allow an exception must not exceed the next workday.

\(6\) MSDS may also be accessed through the CEOSH website. All
supervisors will be trained in utilizing this system.

c\. Employee Information and Training:

Employees will be provided with information and training on hazardous
chemicals in their work area at the time of their initial assignment and
whenever a hew hazard is introduced into their work area.

\(1\) Employee information will include:

\(a\) The requirements of this chapter.

\(b\) Any operations in their work area where hazardous chemicals are
present.

\(c\) The location and availability of the written hazard communication
program, including the chemical inventory, and material safety data
sheets required by this attachment.

\(2\) Employee training will include:

\(a\) Methods and observations used to detect the presence or release of
a hazardous chemical into the work area.

> Attachment G-2

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

\(b\) The physical and health hazards of the chemicals in the work area.

\(c\) The controls employees must take to protect themselves from
chemical hazards, e.g., personal protective equipment, appropriate work
practices, emergency procedures, etc.

g-3 Responsibilities:

a\. Industrial Hygienist:

\(1\) Compiling a master set of MSDS for himself and the Triage Area.

\(2\) Employee information as outlined.

b\. Supervisory Personnel:

\(1\) Ensure all containers are labeled, tagged, or marked as outlined.

\(2\) See that MSDS are available to all their employees during each
work shift.

\(3\) Employee training as outlined.

\(4\) Retrieving MSDS via the CEOSH website.

c\. Acquisition and Materiel Management:

To ensure the MSDS is provided by the manufacturer when ordered by the
using department.

Part 2 ‑ List of Hazardous Chemicals which have a MSDS

See either of the master sets in Building 3, Room 107 or the triage
area.

Part 3 ‑ Informing the Employees of the Hazards Associated

with Non‑Routine Tasks

Non‑routine tasks are only done with and under the supervision of
supervisors knowledgeable in the health risks involved. They will have
informed and trained employees on the safe work practices associated
with this non‑routine task.

> Attachment G-3

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

Part 4 ‑ Informing Contractors of Hazardous Chemicals

To Which Their Employees May Be Exposed

Contractors will refer to the medical center\'s hazard communication
program.

Part 5 ‑ Informing Employees of Contractors Hazardous

Chemicals To Which They May Be Exposed

Employees can request MSDS for contractors' chemicals, through the
Industrial Hygienist.

7‑4 Additional References:

a\. OSHA: Material Safety Data Sheet, Cincinnati, Ohio, Government
Printing Office, 1977

b\. National Safety News. 131(1): 66‑67 (1983)

c\. DM&S Circular 00‑86‑21, dated June 16, 1986

d\. DM&S Circular 00‑86‑21 Supplement #1,dated August 6, 1987

e\. VHA Circular 10‑91‑108, dated September 20, 1991

> Attachment H

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

ETHYLENE OXIDE POLICIES

h-1 General:

Ethylene oxide, used in the sterilization of materials that cannot be
autoclaved, presents a number of hazards to both the user and to other
hospital personnel. The following hazards are to be considered in the
use of this material.

a\. Toxicity ‑ Studies of exposed workers have shown that ethylene oxide
can produce cancer, genetic damage, and neurological disease. In
addition it is both a reproductive hazard and causes allergic reactions
in some people. Despite its toxicity, ethylene oxide has poor warning
properties and individuals may be unaware of exposure.

b\. Fire Hazard ‑ Ethylene oxide gas is highly flammable and explosive.
It is easily ignited by sparks or flame, and must not be used in the
presence of an ignition source. Mixtures of ethylene oxide, such as that
used in the large sterilizer, are less hazardous but still must be
handled with care.

c\. Pressure Hazards ‑ Cylinders and canisters of ethylene oxide are
pressurized and must be handled according to safe practices for
pressurized gas cylinders. See Chapter 5 of the hazardous material
policy for safety information regarding compressed gas.

Use of ethylene oxide will be in accordance with accepted safety
practices and state, federal and local laws. OSHA regulations require an
extensive safety and health program if exposures above the action level
of 0.5 ppm are possible. Monitoring done by Industrial Hygiene
consultants for the VA indicate that current exposures are well below
that level. Despite the documented low levels of exposure, the following
program which includes training, monitoring, and an option for medical
supervision, will be followed.

h-2 Monitoring:

a\. Baseline surveys ‑ The eight hour TWA exposures have been found to
be below the VA Recommended Exposure Limit (VA REL) of 0.5 ppm and the
Excursion Limit (EL) of 5 ppm. Further baseline studies will be
conducted if the SPD monitoring program indicates an increase in
exposure levels, or if a change is made in the sterilization process.

b\. Monitoring ‑ SPD will conduct an on going program of monitoring
employees who work in the area of ethylene oxide use. An employee is to
be monitored, using a passive dosimeter, at least once a week. The day
of the week on which each employee is monitored should rotate so that
over several months each employee will have been monitored at least once
on each day of the week. Alternately, all monitoring may be conducted on
days of anticipated

> Attachment H-1

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

highest exposures. Records of weekly monitoring will be maintained in
SPD and with the Industrial Hygienist. Each monitored employee is
required to be notified of the results within 15 working days.

EL monitoring will be conducted annually. Monitoring for the EL will be
done when removing a load from the sterilizer.

c\. Leak Testing ‑ Leak tests of all lines and the doors are to be made
during normal operation on a semiannual basis. Connectors and valves are
to be tested by the General Repair Shop whenever maintenance is
performed. These tests can be made with a liquid leak detector (e.g.,
water/soap solution or other suitable leak detection fluid). Records of
all leak tests are to be maintained in SPD. Any leaks are to be reported
to Facilities Operations Section.

h-3 Training:

The Safety Manager and/or Industrial Hygienist will provide training and
educational materials to the Chief of SPD or a representative who will
be responsible for training of employees. Pre-assignment and annual
training will include instruction in the following areas:

a\. Requirements of the OSHA ethylene oxide standard.

b\. Operations utilizing ethylene oxide in their area.

c\. Location and availability of copies of the OSHA standard and policy.

d\. Availability of medical surveillance for employees who may have been
exposed at or above the VA REL of 0.5 ppm.

e\. Methods and observations that may be used to detect ethylene oxide
in the work area.

f\. The physical and health hazards of ethylene oxide including symptoms
of exposure.

g\. The measures employees can take to prevent or minimize their
exposure to ethylene oxide.

h\. Details of the VA hazard communication program, including the
labeling requirements and availability of information regarding ethylene
oxide hazards and use.

h-4 Labeling:

a\. Areas where ethylene oxide is used, and doorways leading to those
areas will be posted

> Attachment H-2

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

with signs bearing the following warning:

DANGER

ETHYLENE OXIDE

CANCER HAZARD AND REPRODUCTIVE HAZARD

AUTHORIZED PERSONNEL ONLY

RESPIRATORS AND PROTECTIVE

CLOTHING MAY BE REQUIRED

TO BE WORN IN THIS AREA

b\. Ethylene oxide tanks and storage cabinets will also be labeled with
the following warning:

CAUTION

ETHYLENE OXIDE

CANCER AND REPRODUCTIVE HAZARD

AVOID BREATHING FUMES

DO NOT EXPOSE TO FLAME

OR IGNITION SOURCES

Emergency response procedures are to be posted at the entrance to SPD as
described in section

h-7. No smoking signs should also be posted.

h-5 Receiving and Storage:

Ethylene oxide canisters are to be stored only in PD. They should be
brought directly to SPD.

h-6 Personal Protective Equipment(PPE):

SPD will provide workers with all necessary protective equipment to
ensure their safety. PPE will include, but may not be limited to, the
following:

a\. Respirators approved for ethylene oxide by NIOSH (TC‑14G‑134). Air
canisters should be discarded when the color indicator changes from
yellow (safe) to green‑blue (unsafe). Use of respiratory protection is
required when SPD personal monitoring results have been shown to exceed
the VA REL or EL. Respirators will also be used in the following
circumstances:

\(1\) In work operations, such as maintenance and repair activities, or
other activities for which engineering and work practice controls are
not feasible.

> Attachment H-3

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

\(2\) In emergencies.

b\. Protective, impermeable clothing. Protective clothing must
completely cover street clothing including shoes and is to be replaced
if it becomes contaminated.

c\. Gloves of an impermeable material are to be used whenever there is a
chance of exposure to liquid ethylene oxide or solutions containing
ethylene oxide.

d\. Splash proof goggles must be provided and worn whenever there is
chance of exposure to liquid ethylene oxide or ethylene oxide containing
solutions. Goggles must also be worn whenever pressurized lines or
fittings are being worked on.

All personal protective equipment will be selected and provided in
accordance with OSHA regulations, 29 CFR 1901.132 and 1910.133.
Respirator selection and use will be in compliance with 29 CFR 1910.134
and 30 CFR Part 11.

The Industrial Hygienist and/or Safety Specialist will be responsible to
ensure that PPE is used during the following events:

> \(1\) During spills or emergencies.
>
> \(2\) During maintenance and repair.
>
> \(3\) Whenever nonroutine exposures might be expected to occur.

h-7 Spill or Leak Response:

a\. In the event of an ethylene oxide spill or leak, the following steps
will be taken:

\(1\) All employees are to evacuate the area immediately.

\(2\) Notify Safety and Industrial Hygiene at extensions 5418 and 5417.

\(3\) Notify Police on weekends or evenings.

\(4\) Entry into the contaminated area will only be done with one person
(Industrial Hygienist) in and another (Safety Specialist) out.

\(5\) Re‑entry into the contaminated area is prohibited until clearance
is given by the Safety Specialist or Industrial Hygienist.

> Attachment H-4

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

\(6\) All overexposed personnel are to be seen by a physician.

\(7\) An accident report is to be filed with the Safety Specialist if
there is an overexposure.

\(8\) Clean up will be conducted by workers equipped with air supplied
respirators and other proper protective equipment.

b\. In the event that the exhaust alarm sounds, no EtO loads are to be
processed. If a load is in cycle, the following emergency steps will be
taken:

\(1\) All employees are to evacuate the area immediately.

\(2\) Notify the Electric/HVAC Shop (pager 525, phone 5428).

\(3\) Notify Safety and Industrial Hygiene, phone 5418 and 5417.

\(4\) Entry into the contaminated area will only be done with one person
(Industrial Hygienist) in and another (Safety Specialist) out.

\(5\) Notify Police on weekends or evenings.

\(6\) Re‑entry into the area is prohibited until clearance is given by
the Safety Specialist or Industrial Hygienist.

\(7\) All overexposed personnel are to be seen by a physician.

EMERGENCY RESPONSE PROCEDURES AND PHONE NUMBERS OF RESPONSE PERSONNEL
ARE TO BE POSTED AT THE DOOR OF SPD.

h-8 Record Keeping:

As required by OSHA regulations, the following records will be
maintained for 30 years. Records will be maintained by SPD and will be
available to the safety office.

a\. Records of baseline surveys of exposure to ethylene oxide.

b\. Monitoring records for all personal dosimeter monitoring conducted
by SPD. These will include:

> Attachment H-5

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

\(1\) The date of measurement.

\(2\) The operation involving exposure which is being monitored.

\(3\) Sampling and analytical methods used.

\(4\) Records of calibration or evidence of analytical accuracy.

\(5\) Number of samples taken, duration of sampling, and results of
analysis.

\(6\) Type of protective devices worn, if any.

\(7\) Name and exposure levels of monitored employees.

\(8\) Name of person responsible for conducting the analysis.

c\. Records of leaks or spills will be maintained by Facilities
Management and include at least the following information:

\(1\) Date of incident.

\(2\) Estimated amount of material spilled or leaked.

\(3\) Names of exposed personnel.

\(4\) Cause of the spill.

\(5\) Any medical consequences.

d\. Medical records will be maintained for any employee who participates
in the medical surveillance program.

h-9 Medical Surveillance:

In accordance with OSHA regulations, a medical surveillance program will
be made available to any employee exposed above the VA REL for 30 days
or more per year. Medical exams will meet OSHA requirements.

> Attachment I

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

ANESTHETIC GAS POLICIES

i-1 General

Waste anesthetic gases have been shown to present a number of health
hazards to exposed personnel. Primary among the adverse effects are an
increased frequency of spontaneous abortions and an increased incidence
of congenital malformations among children of exposed women and the
wives of exposed men. A number of other health problems including
cancer, liver, and kidney disease have also been associated with
exposure to waste anesthetic gases. Moderate exposure levels have also
been shown to cause decreased performance on tests involving audiovisual
tasks. Higher levels of exposure are both an acute health hazard and a
fire hazard.

i-2 Permissible Exposure Limits:

The federal government has not yet issued a legally enforceable limit on
exposure to waste anesthetic gases. The National Institute of
Occupational Safety and Health however, has recommended that Nitrous
Oxide levels be limited to an average of 25 ppm during the time of
anesthetic administration. In addition it has been recommended that the
use of halogenated anesthetics be controlled such that no worker is
exposed to levels over 2 ppm. Levels of halogenated anesthetics are
difficult to assess, however it can be assumed that they will be below 2
ppm if nitrous oxide levels are kept below 25 ppm.

It will be medical center policy to strive to attain the lowest level of
worker exposure to nitrous oxide possible. Average levels are not to
exceed 25 ppm during anesthetic administration.

i-3 Monitoring Programs:

Compliance with the 25 ppm exposure limit for nitrous oxide will be
insured through a regular monitoring program, which will include the
following components:

a\. A baseline survey documenting current exposure levels.

b\. Quarterly monitoring of exposed personnel to insure that exposure
levels have not changed significantly.

c\. In the event that future regulatory actions mandate the use of
audible alarms during anesthesia procedures, such alarms will be
installed. Alarms will be operational at all times of anesthetic use in
order to warn personnel of gas leaks or accidental releases. Such alarms
should be set to sound if nitrous oxide levels exceed 50 ppm.

> Attachment I-1

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

i-4 Maintenance and Leak Testing:

Proper maintenance and inspection of equipment used in the
administration of anesthesia is an important part of the health and
safety program. Inspections will include, but may not be limited to the
following:

a\. A visual inspection of all equipment for cracks, tears, or other
possible sources of leaks is to be made after each cleaning.

b\. Low pressure leak tests, as described in the NIOSH Publication
\"Criteria for a Recommended Standard for Exposure to Waste Anesthetic
Gases and Vapors\", are to be made before each use. Leaks must be less
than 100 ml/minute at 30 cm water pressure.

c\. High pressure leak tests as described in the NIOSH publication
referenced above are to be conducted on a quarterly basis.

Additional information on testing of equipment for leaks may be obtained
from the NIOSH publication \"Development and Evaluation of Methods for
the Elimination of Waste Anesthetic Gases and Vapors in Hospitals\" (GPO
Order No. 1733‑00061, Superintendent of Documents, U.S. Government
Printing Office, Washington D.C., 20402).

i-5 Work Practices:

Proper work practices are perhaps the most important part of any program
designed to minimize exposure to waste anesthetic gases. It has been
estimated that in some cases proper work practices can reduce exposures
by as much as 90%. Proper work practices will include, but are not
limited to, the following:

a\. Waste gas disposal systems will be connected and tested prior to
beginning administration of anesthetics.

b\. Vaporizers will be filled in a well ventilated area and in a manner
to minimize spillage.

c\. Vaporizers will be turned off when not in use.

d\. All leaks detected by leak tests or nitrous oxide detector systems,
will be repaired before the equipment is used again.

e\. Anesthetic flow will not be started before necessary for the
induction of anesthesia.

f\. When the breathing circuit is disconnected from the patient, the
flowmeters will be

> Attachment I-2

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

turned off, or the Y piece sealed.

g\. The breathing bag will be emptied into the scavenging system before
it is disconnected.

i-6 Training:

The chief of each department is then responsible for training of
employees. Training will be provided before assignment and on annual
basis thereafter. Training will include at least the following:

a\. A presentation of VA Policy on anesthetic gases.

b\. Information regarding the availability of NIOSH documents and other
relevant safety and health information.

c\. Information regarding the health hazards associated with
occupational exposure to nitrous oxide.

d\. Information regarding results of the monitoring program.

e\. A summary of methods that are being used to minimize exposures.

i-7 Medical Monitoring:

A medical monitoring program will be made available to all potentially
exposed employees. The program will include, but not be limited to, the
following:

a\. Comprehensive pre-placement occupational and medical histories with
special attention to outcomes of pregnancies of the employee or the
employee\'s spouse. Histories will be updated annually.

b\. Pre-placement and annual physical examinations of exposed employees.
Employees will be advised of the potential adverse effects of exposure
to waste anesthetic gases.

c\. Employees will be advised of the potential adverse effects of
exposure to waste anesthetic gases.

d\. Any adverse outcomes of pregnancies of the employee, or the
employee\'s spouse, will be documented as part of the employee\'s
medical record.

e\. Medical records will be maintained for 20 years following
termination of employment.

> Attachment I-3

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

i-8 Labeling and Posting:

Containers of volatile and gaseous anesthetic agents will be clearly
labeled with the warning shown below. Areas adjacent to rooms where
anesthesia is used will be similarly posted.

(NAME OF AGENT)

CAUTION: HARMFUL IF INHALED CONTINUOUSLY

USE ONLY WITH ADEQUATE

VENTILATION AND/OR SCAVENGING SYSTEM

KEEP AWAY FROM HEAT, SPARKS, OR OPEN FLAME

i-9 Waste Disposal:

Waste anesthesia is to be disposed of in accordance with policies
described in Attachment F. Nitrous oxide gas may be vented directly to
the outside air. Liquid waste will be collected in jars labeled with the
contents, date, and responsible department, and stored in Room A‑24c
until the day of waste pickup.

> Attachment J

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

SPECIAL POLICIES

j-1 General:

Some materials that are used regularly at this facility present unusual
or exceptional hazards. Use of these materials is regulated under both
the general hazardous materials policies and by special policies
developed during consideration of the particular hazards. The following
materials are regulated under special policies found in the following
sections:

a\. Mercury

b\. Picric Acid

c\. Formaldehyde

d\. Calcium Hypochlorite

e\. Cytotoxic Drugs

f\. Radioactive Materials

g\. Disposal of Biohazardous Fluids

j-2 Mercury Policies

a\. General:

Mercury, and compounds containing mercury, present a significant hazard
by inhalation or absorption through the skin. Chronic exposure to
relatively low levels of mercury vapor are associated with a number of
neurological problems. In addition mercury is a major environmental
pollutant and must be disposed of properly.

Permissible Exposure Limits:

\(1\) OSHA ceiling limit: 0.1 mg/m3

\(2\) NIOSH recommendation: 0.05 mg/m3

\(3\) ACGIH recommendation: 0.05 mg/m3

b\. Personal Protective Equipment:

Standard safe laboratory procedures should be followed when handling
mercury. Due to its

> Attachment J-1

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

ability to penetrate skin, plastic or rubber gloves should always be
worn. In addition, impervious protective clothing, such as an apron or
disposable chemical resistant lab coat is called for. Mercury
contaminated clothing is especially hazardous and should be removed as
soon as possible.

Work Practices:

\(1\) Use Mercury only in a well ventilated area, preferably in a hood.

\(2\) Wash hands immediately after each use.

\(3\) Smoking and eating in areas of mercury use are prohibited.

\(4\) Contact lens should not be worn while using mercury.

\(5\) Containers of mercury are to be kept tightly sealed to prevent
escape of vapors.

Spill Procedures:(See Policy Memorandum S-13, Mercury Spill
Decontamination.)

c\. Monitoring:

Mercury vapor monitoring will be conducted in all areas of mercury use
on an annual basis. In addition, monitoring will be conducted following
any spill. Mercury monitoring will be conducted under the supervision of
the facility industrial hygienist.

d\. First Aid:

\(1\) Skin: Wash with soap and water. If irritation persists, seek
medical attention.

\(2\) Eyes: Flush with water. Seek medical attention.

\(3\) Ingestion: If the victim is conscious, give large amounts of water
and induce vomiting. Seek medical attention.

e\. Disposal:

Elemental mercury is not to be poured down the drain. Save used mercury
in a waste disposal jar for removal in accordance with policies
described in Chapter 6.

j-3 Picric Acid Policies

a\. General:

Picric Acid, when it is dry, is a shock and heat sensitive explosive.
Bottles of solid material are shipped containing 10‑12% water and must
not be allowed to dry. The chemical is also safe while in solution.

> Attachment J-2

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

b\. Storage:

\(1\) A maximum of 2 bottles will be stored at this facility at any
given time. These bottles will be stored in the common equipment room in
research.

\(2\) Each bottle must be clearly labeled. The information that must be
included on the label will follow the format outlined below:

PICRIC ACID

Original date of Purchase

Dates of each inspection, and water addition

Expiration date

Name of Purchaser

The effective date of expiration occurs two years from date of purchase.

\(3\) Any picric acid purchased by an entity other than the VA should
not be utilized in this facility.

\(4\) Picric acid bottles will be checked for water content on a
semiannual basis. This check will be made by the designated hazardous
materials program coordinator of that department. Water will be added as
necessary. Before opening, the bottle should be inspected and if the
material appears to have dried out, or crystals have formed around the
lid, DO NOT OPEN IT. Call the Safety Officer or Industrial Hygienist.

\(5\) There will not be any situation in which any liquid containing
picric acid is to be disposed of via the laboratory drains. Mixture with
certain substances can cause explosions within the pipes as well as
toxic emissions.

\(6\) The compound is extremely sensitive to shock and heat, causing
explosions. DO NOT shake or heat bottles containing picric acid.

\(7\) Contact the Industrial Hygienist, extension 5417 for disposal.

\(8\) A new supply will not be purchased until it has been confirmed
that the current supply is nearly exhausted.

\(9\) Picric acid is not to be stored in any bottle other than the one
it is shipped in. Bottle caps containing metal may react with picric
acid to form highly explosive compounds.

c\. Handling and Personal Protection of Workers:

> Attachment J-3

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

\(1\) All general lab safety practices such as not eating, drinking, or
smoking are to be followed.

\(2\) Any worker using the substance will be required to use proper
protective clothing. This will include impervious apron or lab coat,
gloves, dust and splash proof goggles, and other appropriate clothing
required to prevent skin contact with solid picric acid or liquids
containing it.

\(3\) If the clothing of an employee becomes contaminated with picric
acid, the employee should change into uncontaminated clothing as soon as
possible.

\(4\) Clothing which may become contaminated should be placed in a
closed container(s) for storage until it can be discarded or until
provisions can be made to remove the substance from the clothing. If the
clothing is to be laundered or otherwise cleaned, the person performing
the operation should be informed of picric acid\'s hazardous properties.

\(5\) Non‑impervious clothing which becomes contaminated should be
removed immediately and not re-worn until the substance is removed from
the clothing.

d\. Sanitation Procedures:

Workers subject to skin contact with solid picric acid should wash any
areas of the body which may have contacted picric acid immediately
following contact, and at the end of each work day.

e\. Spill Procedures:

\(1\) In the case of an accidental spill, only persons wearing the
proper protective clothing will be allowed to enter the immediate area.

\(2\) In the case of a picric acid spill the following procedures should
be adhered to:

\(a\) Evacuate unnecessary personnel.

\(b\) Immediately notify the Safety Office at extensions 5417 or 5418.

\(c\) Remove all ignition sources from the area.

\(d\) Ventilate the area of the spill area.

\(e\) Attempt to reclaim spilled material; however, do not sweep or burn
unless this process is supervised by explosive experts.

f\. Disposal Procedures:

Proper disposal of dry picric acid can only be performed by explosive
experts. Solutions

> Attachment J-4

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

containing picric acid may also be hazardous if poured down the drain or
allowed to come in contact with metals.

\(1\) DO NOT pour any substance containing picric acid down the lab
drains. It has the potential of causing explosions within the pipes.

\(2\) All used picric acid should be collected and stored in a closed
container for proper disposal. Do not store waste in containers with
metal or metal containing caps.

\(3\) To arrange for disposal, contact the Safety Office, 5417 or 5418.

j-4 Formaldehyde Policies

a\. General:

Formaldehyde is a colorless pungent gas found most often as an aqueous
solution called formalin (37% or less formaldehyde) or as a solid called
paraformaldehyde. Formaldehyde is very irritating to the eyes, skin, and
respiratory system. It is very toxic by ingestion or inhalation. It also
induces allergic reactions which may progress to asthma.

Formaldehyde is a suspect carcinogen and exposure should be minimized
whenever possible. Formaldehyde is highly flammable. Gas released by
paraformaldehyde or formalin may ignite on contact with flame or sparks.

b\. Handling and Use:

Due to its carcinogenic potential, formaldehyde will be used in
accordance with carcinogen policies. The minimum requirements are
outlined below. See also, the carcinogen policy Attachment D.

\(1\) Protective Equipment:

\(a\) Laboratory coats or aprons are required to protect street clothes.
Once a lab coat has been exposed to formaldehyde it should be laundered
before it is used again. Disposable garments may be more useful than
washable ones.

\(b\) Gloves are to be worn at all times when working with formaldehyde.

\(c\) Splash-proof goggles are to be worn at all times.

\(d\) Formaldehyde is to be used only in a laboratory fume hood or with
other adequate ventilation.

> Attachment J-5

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

\(2\) Labeling and Training:

\(a\) All formaldehyde use and storage areas are to be marked as
described in the carcinogen policy.

\(b\) Containers of formaldehyde must be labeled as containing a
possible carcinogen.

\(c\) Personnel using formaldehyde will be trained in the hazards of its
use and will be familiar with the VA carcinogen policy.

\(3\) Inspection and Monitoring:

Any operation in which formaldehyde is used on a regular basis will be
reviewed by the Industrial Hygienist. If significant exposures are
possible, environmental monitoring will be conducted to assess whether
or not exposure is in excess of the Permissible Exposure Limit of 0.75
ppm or the Short Term Exposure Limit of 2 ppm.

j-5 Calcium Hypochlorite Policies:

a\. Synonyms:

Calcium Oxchloride (incorrect name)

Bleaching Powder

Chlorinated Lime

b\. General:

Calcium hypochlorite is a powerful oxidizing and bleaching agent. It is
toxic and presents a fire hazard on contact with combustible or organic
materials. It also reacts with water or alcohol to release highly toxic
fumes.

c\. Toxicity:

High via oral or inhalation routes. Powder is a severe irritant of skin,
eyes, and mucus membranes. Fumes released on contact with water or
alcohol or on heating are extremely toxic.

d\. Fire‑Explosion Hazard:

Moderate to high. May ignite acids or organic materials on contact.
Explosive if in contact with carbon tetrachloride (CCl~4~).

> Attachment J-6

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

e\. Handling Precautions:

Wear rubber gloves, use in a hood, wear eye protection, wear apron or
lab coat.

f\. Incompatibilities:

Water, alcohols, carbon tetrachloride, reducing agents, combustible
organics.

g\. Hazard Potential:

Great. If contact with carbon tetrachloride occurs, an explosion may
result. If heating or contact with water or alcohol occurs, evacuate the
area and contact the Safety Office, extension 5417 or 5418.

j-6 Cytotoxic Drug Policies

a\. General:

The use and disposal of cytotoxic drugs is regulated in a manner to
minimize the exposure of hospital employees to these materials. Proper
procedures for their use are described in Policy Memorandum 119‑6,
Hazardous Drug Safety & Health Plan: Preparation, Administration and
Disposal of Cytotoxic Agents.

b\. Disposal:

Disposal of cytotoxic drugs will be in accordance with JCAHO guidelines
and Federal and State regulations. All material contaminated with these
agents will be segregated and marked as cytotoxic. These materials must
be incinerated at a temperature of at least 1832 degrees Fahrenheit.
Incineration is conducted by a contracted disposal company.

j-7 Radioactive Materials Policy

a\. General:

Radioactive materials are considered a special class of hazardous
materials, and are to be handled in accordance with both the general
hazardous materials policy and special radiation policy referenced
below.

Attachment J-7

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

b\. Disposal:

The method of disposal of radioactive waste will be dependent on both
the particular isotope that is present, and on the level of radiation.
If the waste contains only Carbon‑14 and Tritium, and the total activity
is less than .05 microcuries per gram, then the material may be disposed
of as chemical waste. The decision about which materials will be
disposed of as chemical waste and which will be disposed of as radiation
waste will be made by the Radiation Safety Office.

c\. Radiation Safety Office Policy:

The following policy has been developed by the Radiation Safety Office:

Policy Memorandum S-1, Radiation Safety Committee and the ALARA Program

j-8 Disposal of Biohazardous Fluids

a\. Purpose:

The purpose of this memorandum is to define which biologic fluids are
infectious and thus hazardous and to outline their proper disposal.

b\. Policy:

According to the CDC in \"Morbidity & Mortality Weekly Report\" of
6/24/88, hazardous biologic fluids are the following: blood, body fluids
(CSF, pleural, peritoneal, synovial) and any other fluid which bathes
internal organs. Nonhazardous fluids are sweat, tears, saliva, nasal
secretions, sputum, vomitus, urine, and fecal material. Several
different containers are used to hold these fluids. Glass vacuum bottles
are used to extract and hold peritoneal fluid; large suction bags are
used in the operating room to hold fluids encountered during operative
procedures; smaller suction bags are used in the SICU/MICU areas to hold
both hazardous and nonhazardous fluids. Pleurovacs are used for pleural
fluid. Finally, hard plastic suction containers are used on the general
nursing units to hold gastric and pulmonary secretions. The handling of
these fluids should be aimed at minimizing the risk of exposure to those
handling them.

c\. Procedures:

In general the method of disposal of fluids is based on the hazard
involved in the fluid itself and the design of the container, which may
require special handling to prevent leakage.

\(1\) Peritoneal Fluid Bottles:

The fluid is hazardous because it is a fluid bathing internal organs.
The containers are glass, not

> Attachment J-8

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

designed for emptying without generating aerosols of hazardous fluid.
Best disposal method is incineration of the intact bottle.

\(a\) The bottles will be distributed to wards in original shipping
cartons by SPD.

\(b\) After the paracentesis is complete, Patient Care personnel place
each individual bottle in its own red bag. The bag will eventually be
boxed by Facilities Maintenance.

\(c\) The boxes will be removed by Facilities Maintenance personnel who
will place no more than two bottles per disposal box.

\(d\) The boxes will be placed on the infectious waste truck.

\(2\) Operating Room Suction Canisters:

The fluid is hazardous and contains both blood and body fluids. The
containers are heavy plastic but may leak if the container is handled
roughly. These units are not designed to be emptied. Because of the
fluids involved and the design of the container, the best disposal is
incineration of the intact container.

\(a\) Once filled, the tubing is removed and caps are used to seal the
unit.

\(b\) The filled units are then collected and placed in red bagged lined
boxes located at either end of the O.R. suites.

\(c\) The units are packaged and moved to the infectious waste truck by
Facilities Maintenance personnel, in a manner which will minimize
handling.

\(3\) MICU/SICU Suction Canisters:

The fluid is typically not hazardous, but on occasion can have blood in
the unit. The canisters differ from those in the operating room in that
they do not have a cap. A loop of tubing is used to seal the unit. Units
are not designed for emptying. The best disposal is incineration of the
intact container.

\(a\) Once filled, the tubing is secured, thus sealing the unit.

\(b\) The filled units are then collected in red bags in specific areas
of each unit for removal.

\(c\) The bags are boxed and moved to the infectious waste truck by
Facilities

> Attachment J-9

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

Maintenance personnel, in a manner which will minimize handling.

\(4\) Pleurovac Containers ‑ Fluid is hazardous because it bathes
internal organs. The container is not designed for emptying. The best
method of disposal is incineration of the intact container.

\(a\) Once treatment is completed the tubing is doubled‑knotted to seal
the unit.

\(b\) The container is placed in a red bag and the bag taped closed.

\(c\) The bag is boxed and taken to the dock by Facilities Maintenance
along with other red‑bagged trash.

\(5\) General Medical Units Suction Canisters ‑ Fluid is not hazardous
unless visibly contaminated with blood. The container is hard plastic
and designed to be emptied. Once filled, the contents are measured and
then disposed of in the dirty utility sink. The container is reusable.
After suction is discontinued, the container is emptied into the dirty
utility sink and then disposed of in the red bag trash.

> Attachment K

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

INFECTIOUS WASTE POLICIES

k-1 General:

Infectious waste materials may present a hazard to both employees and
patients. Hospital policy on the handling of infectious material will be
in accordance with JCAHO, Environmental Protection Agency, and Centers
for Disease Control and Prevention recommendations. For those areas in
which these agencies do not agree, the most conservative guidelines will
be followed.

k-2 Responsibilities:

a\. The Infection Control Committee will develop policies for the
handling and disposal of infectious material.

b\. All employees are responsible for following proper procedures for
handling infectious waste as described in this policy and as required by
the Infection Control Committee.

k-3 Infectious Waste Definition:

Any hospital waste that can reasonably be expected to be contaminated
with organisms that could cause infection is to be handled as infectious
waste. A certain amount of professional judgment is called for in
deciding whether a material is infectious; however, the following
materials should always be considered as infectious.

a\. Blood and Blood Products

b\. Sharps (syringes, blades, needles, etc.)

c\. Pathological Waste

d\. Non-autoclaved laboratory waste

e\. Other biological materials, such as animal carcasses and bedding

k-4 Segregation of Wastes:

Infectious wastes will be segregated from noninfectious waste at the
point of generation. All infectious waste is to be disposed of in red
bags. Objects capable of producing injury, such as syringe needles, will
be disposed of in sharps containers that can then be placed in red bags
for final disposal. Under no circumstance are red bags to be used for
disposal of noninfectious wastes.

> Attachment K-1

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

k-5 Disposal of Waste:

a\. All bags of infectious waste are to be disposed of by incineration
at a contracted facility. If microbiology laboratory infectious wastes
which have been autoclaved are to be mixed with general waste, it should
be placed inside another bag of the type used for noninfectious waste to
indicate that it is no longer infectious.

b\. All bags of infectious waste generated at the Toledo CBOC will be
transported to VAMC Ann Arbor for incineration at a contracted facility.

c\. All bags of infectious waste generated at the Flint & Jackson CBOCs
will be shipped directly for incineration at a contracted facility.

> Attachment L

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

SPILL CONTROL PLAN

l-1 General:

Unplanned releases of toxic or hazardous chemicals may threaten the
health and well being of hospital employees, patients, and visitors, as
well as the surrounding community. It is the responsibility of all
hospital personnel to recognize potential hazards and to be familiar
with the proper actions to be taken in response to a spill or other
accident.

l-2 Responsibilities:

a\. The Industrial Hygienist and the Safety Committee are responsible
for the development and implementation of a spill response program.

b\. The Industrial Hygienist is responsible for training the chief of
each department or the chief's representative in the proper responses to
a spill or other emergency.

c\. The chief of each department or the chief's representative is
responsible for training employees in their department.

d\. The Industrial Hygienist is responsible for coordinating the
in-house spill response team and for providing communication with local
police and/or fire (HazMat) officials.

e\. All hospital employees are responsible for notifying their
supervisors of potentially hazardous conditions.

l-3 Policies for Pre-Emergency Planning:

a\. An emergency response team will include, but may not be limited to:

1\) Industrial Hygienist

2\) Radiation Safety Officer

3\) Safety Specialist

b\. Spill kit training will be conducted for all employees on a
pre-assignment basis by their supervisors.

c\. The emergency response team will only be called if a spill occurs
which cannot be handled with an ordinary spill kit. The team will decide
whether or not a HazMat team will be called in.

> Attachment L-1

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

d\. The fire department is to be contacted and informed of potential
hazards in the facility.

l-4 General Procedures for Spill Response:

a\. Clear the area of unnecessary personnel.

b\. Determine whether the spill can be handled with an on-site spill
kit.

1\) If the spill can be cleaned up with a spill kit, initiate clean up.

2\) If the spill cannot be handled with a spill kit, call extension 3333
for assistance.

c\. The response team will then decide whether or not to contact HazMat
officials.

> Attachment M

VA Ann Arbor Healthcare System Policy Memorandum S-2

February 15, 2005

CHEMICAL HYGIENE PLAN

**m‑1 General:**

This plan is responsible for protecting employees from health hazards
associated with the use of hazardous chemicals in a laboratory setting.
That is primarily achieved by ensuring that employee exposures, to
chemical substances, are always kept below Permissible Exposure Limits
(PELS) as set by OSHA.

**m‑2 Procedure:**

a\. Standard Operating Procedures: (SOPs) must be adhered to at all
times. Those SOPs are basically Medical Center Policy Memorandum S-2 in
its entirety.

b\. Control Measures:

\(1\) Criteria for the implementation of controls will include (but will
not be limited to):

\(a\) Identity of chemical substance.

\(b\) Work task

\(c\) Duration of exposure.

\(2\) Priority of controls will be as follows:

\(a\) Engineering

\(b\) Substitution

\(c\) Isolation

\(d\) Administration

\(e\) Housekeeping

\(f\) Personal Protective Equipment

c\. Hoods: All fume hoods, biological safety cabinets & clean benches
will have their face velocities checked annually. This is to assure that
the average face velocity meets the manufacturer's specs. Chemo,
research, TB and iodination biological safety cabinets will be certified
semi‑annually. If any of the above mentioned hoods fail, they will be
taken out of service until they are repaired.

d\. Employee Information and Training: Shall be in accordance with the
OSHA Lab Standard (29 CFR 1910.1450(f)(3) & (4)).

e\. Activities which require prior approval:

> Attachment M

VA Ann Arbor Healthcare System Policy Memorandum S-2

February 15, 2005

\(1\) Flammable anesthetic gases ‑ require approval by the VISN
Industrial Hygienist.

\(2\) Work with chemicals of a high chronic toxicity shall be
accomplished according to Chapter D of this policy and pages 47-50 of
[Prudent Practices for Handling Hazardous Chemicals in
Laboratories]{.underline}. A copy of "Prudent Practices" is available
for review in the Industrial Hygiene Office.

f\. Medical Consultation and Examinations: Shall be handled as outlined
in Medical Center Policy Memorandum S-12, Medical Surveillance, and
Medical Center Policy Memorandum S-3, Appendix G, Safety Management
Program. Follow‑up exams will be provided under the following
circumstances:

\(1\) Whenever an employee develops signs or symptoms associated with a
hazardous substance which they were working with.

\(2\) Whenever an event (spill, leak, explosion etc.) takes place that
results in the likelihood of a hazardous exposure.

g\. Chemical Hygiene Officers:

\(1\) Pathology & Laboratory Medicine Service -- Assistant Chemistry
Supervisor

\(2\) Research Service -- Program Analyst

h\. Additional Employee Protection:

\(1\) No food or drink is allowed in any lab.

\(2\) Fume Hoods and other engineering controls should be used when
indicated on a MSDS.

\(3\) All chemical or infectious wastes shall be disposed of in a manner
consistent with Chapters F, J & K of this policy

\(4\) Decontamination shall occur as outlined on the MSDS.

**m‑3 Responsibilities:**

a\. Industrial Hygienist

\(1\) Instituting proper control measures.

> Attachment M

VA Ann Arbor Healthcare System Policy Memorandum S-2

February 15, 2005

\(2\) Assuring that all fume hoods have been certified.

b\. Supervisory Personnel

\(1\) Notifying affected employees to the location and availability of
the Chemical Hygiene Plan.

\(2\) Notifying affected employees of the availability of 29 CFR
191.1450 (Occupation Exposure to Hazardous Chemicals in Laboratories
Standard).

**m‑4 Additional References:**

a\. 29 CFR 1910.1450

b\. IL 142‑91‑002 dated January 28, 1991

c\. [Prudent Practices for Handling Hazardous Chemicals in
Laboratories]{.underline}, National Research Council, 1981.

d\. VHA Handbook 1200.8 dated June 7, 200

**CARCINOGENS (SUSPECT & CONFIRMED PER ACGIH) USED**

**BY RESEARCH PER CHEMICAL INVENTORY OF SEPTEMBER 2004**

[CONFIRMED HUMAN CARCINOGENS]{.underline} [SUSPECTED HUMAN
CARCINOGENS]{.underline}

ACRYLONITRILE

BENZENE

CARBON TETRACHLORIDE

FORMALDEHYDE

**CARCINOGENS (SUSPECT & CONFIRMED PER ACGIH)**

**USED BY PATHOLOGY & LABORATORY MEDICINE SERVICE**

**PER CHEMICAL INVENTORY OF SEPTEMBER 2004**

[CONFIRMED HUMAN CARCINOGENS]{.underline} [SUSPECTED HUMAN
CARCINOGENS]{.underline}

FORMALDEHYDE

> Attachment N

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

REPORTING OF ENVIRONMENTAL INCIDENTS

(SPILLS, RELEASES, DISCHARGES)

n-1 General:

These reporting procedures describe who and when an outside agency
(local, state or federal) should be contacted following an environmental
incident and by whom.

n-2 Procedure:

Depending on the type of release, the following procedures will be
followed:

a\. Underground Storage Tanks

\(1\) The Department of Natural Resources (DNR) will be contacted within
24 hours of a confirmed release at (517) 373‑7660.

\(2\) The Industrial Hygienist will make this notification.

b\. Air Use Permits (Incinerator & ETO)

\(1\) The DEQ will be contacted by 9:00 am the next working day at (517)
373‑7080 when a violation of the permit occurs.

\(2\) Within 10 days a written report on the incident will be sent to
the DEQ District Supervisor.

\(3\) The Industrial Hygienist will make these notifications.

c\. Spills into Navigable Waters

\(1\) From which oil or a hazardous substance is discharged greater than
a reportable quantity.

\(2\) Should be reported immediately to the U. S. Coast Guard at

\(313\) 568‑9580 ‑ 8:00 am to 4:30 pm

\(313\) 568‑9524 ‑ 4:30 pm to 8:00 am

\(3\) The Industrial Hygienist will make this notification

> Attachment N-1

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

d\. Requirements under CERCLA and SARA Title III

\(1\) See diagram page 60.

\(2\) The Industrial Hygienist will make this notification.

n-3 Responsibilities

a\. Industrial Hygienist: Is responsible for notifying as outlined in
this chapter.

b\. Supervisory Personnel: Are responsible for notifying the Industrial
Hygienist when the above mentioned type of incidents occur.

n-4 Additional References:

a\. Michigan Public Act 478 of 1988

b\. Michigan Public Act 348 of 1965

c\. 33 U.S.C. 1321 (b)(5)

d\. 40 CFR 355

e\. CERCLA of 1988

n-5 Flowchart for Reporting Releases of Hazardous Substances Under

CERCLA Section (Attached).

> Attachment O

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

PEROXIDE FORMING COMPOUNDS

o-1 General:

To establish policy and procedures for managing peroxide forming
compounds in the Ann Arbor VA Health Care Systems.

o-2 Procedure:

a\. General---Certain classes of compounds are capable of forming
peroxide during storage. Peroxides in general and organic peroxides in
particular are low intensity explosives that are extremely hazardous due
to their sensitivity to shock, friction, sparks, and other ignition
sources. Many also react violently with strong oxidizers and reducers.
In addition to their explosive properties, contamination of some
organics with peroxides can initiate violent polymerization reactions.

b\. Peroxide Forming Materials---The following materials are capable of
forming hazardous peroxides during storage. Peroxide formation is
accelerated by exposure to air and light; however, even unopened
containers may contain explosive levels of peroxides.

\(1\) CLASS A---High hazard in storage:

Isopropyl Ether

Divinyl Acetylene

Vinylidene Chloride

Potassium Metal

Sodium Amide

\(2\) CLASS B---Moderate hazard in storage, high hazard in
concentration:

Diethyl Ether

Tetrahydrofuran

Dioxane

Decahydronaphthalene

Ethylene Glycol

Dimethyl Ether

Vinyl Ethers

Acetal

Dicyclopentadiene

Diacetylene

Methyl Acetylene

Tetrahydronaphthalene\]

Cyclohexene

> Attachment O-1

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

\(3\) CLASS C---Moderate hazard, violent polymerization is possible:

Methyl Methacrylate

Styrene

Acrylic Acid

Acrylonitrile

Butadiene

Tetrafluorethylene

Chlorotrifluoroethylene

Vinyl Acetylene

Vinyl Acetate

Vinyl Chloride

Vinyl Pyridine

Chloroprene

c\. Storage

\(1\) Purchase and storage will be restricted to the minimum amounts
needed.

\(2\) Ethers will be purchased in the smallest volumes available in
order to minimize the amount exposed to air during storage.

\(3\) Friction, grinding, and impact must be minimized. Glass bottles
with screw cap lids or glass stoppers will not be used for storage.
Polyethylene bottles with screw cap lids are acceptable.

\(4\) Peroxides and peroxide forming materials are to be stored in cool
dark areas, but must not be allowed to freeze or precipitate because
these forms are extremely shock sensitive.

\(5\) Updated, open containers of ether are not to be used and will be
disposed of. In addition, any peroxide forming chemical containing solid
particles, or found to have undergone a change in any physical property,
must not be used.

\(6\) Class A compounds may be stored for three months after opening.
Class B

and C compounds may be stored for up to one year. Opened containers of
ethyl ether must not be stored more than one month.

d\. Labeling --Each container is to be labeled with the purchase date,
the opening date, dates of testing for peroxide content, and the
principal investigator's name. Laboratory tape can be used for labeling.

> Attachment O-2

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

e\. Use of Peroxide Forming Chemicals

\(1\) Do not return unused portion to the can.

\(2\) Do not distill or allow vaporizing if peroxides may be present.

\(3\) Do not use near open flame.

\(4\) Metal spatulas should be avoided with organics containing
peroxides because they may catalyze explosive decomposition; wood or
ceramic should be used instead.

f\. Testing for Peroxide Formation---Peroxide-forming chemicals will be
tested for peroxide content according to the following schedule:

\(1\) Tests are required when a new container is opened.

\(2\) Test before any use that involves heating, or procedures that
might cause vaporization of solvent. Peroxides are less volatile than
solvents and will become concentrated if solvent is allowed to vaporize.
It is especially important not to distill peroxide containing solvents.

\(3\) Open containers of chemicals in Class A above will be tested for
peroxide contamination on a monthly basis. Date of testing and the
result is to be noted on the container.

\(4\) Peroxide forming chemicals in Classes B and C above will be
testing every three months. Test date and result is to be noted on the
container.

g\. Peroxide Test Procedures

\(1\) The purchaser of the material is responsible for testing. Untested
or unlabeled material will be disposed of.

\(2\) Peroxide content of the chemicals listed above can be determined
by any of

three methods. The two wet methods as described below are more sensitive
and reliable than test strips, but the strips are inexpensive, easy to
use, and adequate in terms of performance. Test strips are available
from most chemical supply companies.

\(3\) Wet Test Methods

\(a\) Prepare a slightly acidic solution of KI, sulfuric acid, and
starch indicator. Add 1 ml of Iodine solution to 10 ml of the solvent
being tested and shake. A blue

color indicates the presence of peroxides.

> Attachment O-3

VA Ann Arbor Healthcare System Policy Memorandum S-2

September 20, 2003

\(b\) Prepare a 0.1% solution of sodium dichromate. Add 1 ml of
dichromate solution and one drop of dilute sulfuric acid (.01N) to 10 ml
of the solvent being tested and shake. A blue color indicates peroxides
are present.

o-3 Responsibilities:

a\. The Industrial Hygienist will be available for consultation
regarding policy and procedures, and will arrange for transportation and
disposal of used, unacceptable, untested or unlabeled materials,

b\. Service Chiefs will be responsible for proper use and storage of
peroxide forming compounds in their respective areas. They will also be
responsible for identifying these chemicals and reporting their presence
and quantities to the Industrial Hygienist annually through the Chemical
Inventory.