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Chemical Safety Program Policies

5.1 – Chemical Safety Program

In compliance with federal, state and local regulations, and recommendations of internationally and nationally recognized organizations, Temple University developed a program for the safe use of chemicals. This program has been developed to meet the requirements of the Occupational Safety and Health Administration (OSHA) Hazard Communication Standard (HAZCOM) and Occupational Exposure to Hazardous Chemicals in Laboratories (Lab Standard). The chemical safety program and policies are specified in the following sections of this handbook

  • Environmental Health and Safety Committee 1.6
  • Hazardous/Chemical Waste Removal 2.8
  • Hazardous Communication Training 3.2
  • Chemical Hygiene Training 3.3
  • Specific Training 3.8
  • Hazard Communication Program 5.2
  • Chemical Hygiene Plan 5.3
  • Chemical Hygiene Officer 5.4
  • Chemical Safety Audit Program 5.5
  • Chemical Inventory 5.6
  • Chemical Spill Management 5.7
  • Formaldehyde Safety 5.8
  • Mercury Safety 5.9
  • Ethylene Oxide Safety 5.10
  • Glutaraldehyde Safety 5.11
  • Cyanide Safety 5.12
  • Nitrous Oxide Safety 5.13
  • Lead Safety 5.14
  • Hydrofluoric Acid Safety 5.15
  • Emergency Response Program 7.1

5.2 – Hazard Communication Program

The Occupational Safety and Health Administration (OSHA), the Environmental Protection Agency (EPA) and The Pennsylvania Department of Environmental Protection (PaDEP) require that all employees are effectively trained and informed of the potential hazards associated with hazardous chemicals in the workplace.

Chemical Inventory

An inventory of hazardous chemicals must be maintained and submitted periodically to EHRS, in accordance to policy 5.6. The inventory must be updated periodically and available upon request. Chemical lists should be available to all employees who work with or who are at risk of exposure.

Material Safety Data Sheets

All employees must review Material Safety Data Sheets (MSDSs) prior to working with or exposure to chemicals. MSDSs contain pertinent safety information about the chemical or chemical products being used and must be provided by the manufacturer or supplier to the users. A copy of MSDSs for all chemicals must be available and accessible at all times in any location that chemicals are used and/or stored.

The MSDSs are available on line at www.temple.edu/EHRS/msdslink.html. A library of MSDSs are available at the Environmental Health and Radiation Safety Department (EHRS) located in the basement of the Pharmacy, Nursing and Allied Health Building at 3307 North Broad Street, Room B-49. A copy of the MSDS for each chemical must be forwarded to EHRS.

Labeling and Sign Requirements

The container of chemicals must accurately labeled with the chemical name and the associated hazards. This includes the secondary containers and working solutions in the laboratories. The full name of the chemical and/or list of chemicals must be clearly identified on the label. Abbreviations, chemical formula(s) or trade names are not acceptable.

Medical Support

Temple University provides medical support to all of its employees if necessary in accordance with (Policy No. 1.8). Occupational Health & Safety is located in the basement of the Temple University Hospital, (215) 707-4455.

Training Requirements

All employees who have potential for exposure to hazardous chemicals must receive appropriate training. It is Temple policy that all new employees receive Hazardous Communication training (Hazard Communication Training, Policy No. 3.2). This training is also provided as part of New Employee Orientation. It is the responsibility of the PI/supervisor to train employees on hazards associated within the workplace. Additional training is also required whenever there is a change in hazard conditions.

5.3 – Chemical Hygiene Plan

In compliance with federal, state, and local regulations, as well as Temple University policy, Environmental Health & Radiation Safety has developed a generic chemical hygiene plan. The chemical hygiene guide provides guidelines and acceptable procedures for laboratory related activities. The Supervisor, Principal Investigator (PI), Department Head or Managers are ultimately responsible for ensuring that safe practices consistent with the Chemical Hygiene Guide are followed.

The CHG is to be used and supplemented, as needed, by each Supervisor, Principal Investigator, Department Head, or Manager. It is the responsibility of these individuals to review the CHG and to use it in the development of a complete guide specific to their laboratories. Site Specific information and Standard Operating Procedures (SOP) need to be available for each laboratory. The CHG worksheet is intended to ensure that you are in compliance with this requirement. The CHG worksheet, cover page and supporting documentation (SOP, training records, Hazard assessments, etc...) must be readily available for review upon request.

The Chemical Hygiene Guide was developed to address specific concerns in the laboratory and existing federal and state regulations and guidelines from various sources (Occupational Health and Safety Administration, Environmental Protection Agency, National Research Council, Centers for Disease Control, International Agency for Research of Cancer, etc.). Although it is not meant to address every possible situation for every laboratory. The Supervisor, Principal Investigator, Department head, or supervisor is ultimately responsible for ensuring that safe practices consistent with the Chemical Hygiene Plan are followed.

The complete generic Chemical Hygiene Guide is available from EHRS at this website address: www.temple.edu/ehrs/safety/chemical-safety/ChemicalHygieneGuideIndex.asp

The following policies address other issues of concern identified in the OSHA Lab Standard:

Assurance on Hazardous Procedures 1.3

Principal Investigators and supervisors 1.4

Vacating Laboratory Spaces 1.5

Environmental Health Safety Committee 1.6

Prohibition of Certain Activities in Laboratories 1.7

Medical Assessment and Treatment 1.8

Hazardous/Chemical Waste Removal 2.8

Chemical Hygiene Training 3.3

Chemical Hygiene Officer 5.4

Chemical Laboratory Inspection Program 5.5

Chemical Inventory 5.6

Chemical Spill Management 5.7

Emergency Response Program 7.1

5.4 – Chemical Hygiene Officer

The Director of Environmental Health and Radiation Safety has appointed a Chemical Hygiene Officer (CHO) who is responsible for implementing the chemical hygiene program and ensuring that chemical operations are being performed in accordance with approved policies and regulatory requirements and procedures. The CHO is authorized to stop an operation if, in the CHO's judgment, that operation is in violation of Temple University policies and may require specific actions be taken to assure compliance with all applicable regulations and Temple policies.

The responsibilities of the CHO include:

  • General surveillance of all activities, including investigations of overexposures, accidents, spills, losses, thefts, uses, transfers, disposals, and other deviations from approved chemical hygiene practice and implementation of corrective actions as necessary
  • Evaluating equipment, physical facilities, operational techniques and procedures
  • Evaluating personnel monitoring equipment, establishing requirements for special monitoring procedures, and keeping records of personnel exposure
  • Assuring that personnel who work with chemicals receive appropriate training
  • Monitoring disposal of chemical waste and maintaining required disposal records
  • Providing advice and supervision for decontamination
  • Preparing any pertinent report(s) on chemicals in accordance with applicable regulations.
  • Actively participating in the Environmental Health and Safety Safety Committee
  • Ensuring compliance with all applicable regulations.

5.5 – Chemical Laboratories Inspection Program

A program of periodic audits of the use of hazardous materials and equipment by users is implemented by the Environmental Health and Radiation Safety Department (EHRS) to ensure that activities are being conducted in a safe manner and in accordance with regulatory requirements. Consistent with federal and Pennsylvania regulations a chemical laboratories inspection program is established. For the purpose of this policy, an area is defined to mean a labora­tory; a corridor, an office, a storage facility, a room, a shop, or any other facility. The chemical laboratories inspection program consists of a number of seg­ments.

The Chemical Laboratory Inspection program includes items on chemical hygiene, chemical compatibility; flammable materials, equipment safety, personnel protective equipment, compressed gases, good housekeeping, general hygiene, signage, fire safety including fire safety equipment, electrical safety and waste.

General Audit: The periodic, comprehensive audit is performed by EHRS. A written report of the audit is prepared and the PI/supervisor is notified of any deficiencies. The PI/supervisor is required to respond to the noted deficiencies. The results of the audit are presented to the appropriate safety committees (EHSSC, EOC committee, etc. The committees have the authority to limit or suspend PI’s use of hazardous materials if the noted deficiencies are not addressed adequately.

Special Audit: These are designated for the resolution of any complaints, allegations, incidents, or as a follow-up of previous non-compliance issues identified during routine auditing. These inspections will be conducted at the discretion of the director of EHRS or as requested by the safety committees. Other special audits may be conducted as needed to ensure compliance.

Frequency of Audit: The Environmental Health and Safety Safety Committee determines audit frequency. Health care facilities are audited annually and patient-care areas are audited semi-annually.

5.6 – Chemical Inventory

In compliance with federal, state, and city regulations, as well as Temple University policy, it is necessary to have an accurate ongoing inventory of hazardous chemicals. The principal investigators/supervisors are responsible for placing the inventory of all hazardous chemicals in their possession into the University Chemical Environment Management System (CEMS) software. CEMS is the only software acceptable by the University to track chemical inventories. The information allows the university to be in compliance with International Fire code and City of Philadelphia Building Occupancy Code. EHRS audits the inventory system for accuracy and compliance during its periodic audit program. Emergency response personnel can readily access to the list, quantity, type of hazards and MSDS of chemicals prior to entrance to the location.

In addition EHRS uses the information:

  • to determine appropriate PPE and precautions in response to an emergency.
  • to provide reports to the Chemical Anti-Terrorism Standards of the Department of Homeland Security.
  • to provide reports federal, state, and City emergency planning committees.

5.7 – Chemical Spill Management

Temple University policy on chemical hygiene relies upon prevention of uncontrolled release of chemicals. Temple University has a policy for responding to uncontrolled releases or accidental spills of chemicals

Principal Investigators/supervisors (PI) (EHRS Policy No. 1.4) are responsible for responding to a minor (incidental) spill. If necessary, PI’s can request and will receive the assis­tance of the Environmental Health and Radiation Safety Department (EHRS) personnel in responding to these situations.

Each PI/supervisor is required to have access to an appropriate spill control kit in or close to the work area to be used for the cleanup of chemical spills. Spill control kits must be readily available during all hours of operation. Individuals who are involved in minor spills should immediately attempt to remedy the spill. Unattended spills outside the work area have the potential of significant safety consequences for others.

Minor (Incidental) Chemical Spill

For a minor chemical spill the following must be followed:

1) Only trained individuals should respond to minor (incidental) spills.

2) Wear personnel protective equipment, including safety goggles, gloves and a long-sleeve lab coat.

3) Alert people in the immediate area of the spill.

4) In case of injury to any personnel, seek medical attention.

5) Confine spill to small area with absorbent materials.

6) Increase ventilation in area of the spill (e.g. open window, turn on fume hood).

7) Avoid breathing vapors from the spill.

8) Use appropriate kit to neutralize, absorb or contain spill. Collect residue, place in container, label the container, and the call the EHRS department at 215-707-2520 for proper disposal information.

9) Clean spill area for soap and water.

Major Chemical Spill Or Spill Of An Extremely Hazardous Chemicals

A large spill is defined as a spill greater than 1 liter or it involves extremely hazardous or unknown chemicals. Example of very hazardous substances includes bromine, hydrazine, cyanides, Class 1A flammable solvents, alkali metals, and white phosphorus. No individuals should attempt to clean the large spill.. They should rely on trained personnel.

For large spills the following must be followed:

  • Immediately call the EHRS at 215-707-2520, page operator 215-707-4545, or the University Security Department at 1-1234.
  • Alert people in the surrounding area and evacuate.
  • Do not re-enter area until it has been cleared by appropriate emergency response personnel. Follow their directions.
  • Attend to injured or contaminated persons and remove them from potential exposure, in case of personal contamination, remove affected clothing and flush the contaminated skin with water for at least fifteen minutes. Seek medical attention immediately.
  • Immediately activate the fire alarm system by pulling the fire alarm system under the following circumstances:

-The chemical released or large spill requires immediate attention because of imminent danger;

-The chemical released or large spill requires evacuation/control of employees beyond the immediate spill area(e.g. any toxic material spilled in a hallway or other public area);

- The chemical released or large spill a serious threat of fire or explosion;

- The chemical released or large spill may cause high level of exposure to toxic substances that are uncontained;

- The situation is unclear or important information is lacking.

If the release does not meet any of the criteria above, yet exceeds the scope of incidental release, call EHRS at 2-2520 for assistance.

  • If there is no potential health or safety risk, turn off ignition and heat sources, maintain fume hood ventilation, and open windows to increase ventilation.
  • Close doors to affected areas as you leave.
  • Have person with knowledge of incident to assist the emergency response personnel upon arrival. The PI/supervisor must be available to provide additional information to emergency response personnel.

5.8 – Formaldehyde Safety

Purpose

In accordance with applicable regulations and Temple University, this policy was developed to minimize exposure to formaldehyde.

Applicability

This policy is applicable to all Temple University employees, to all work conducted under the authority of Temple University, and to all equipment and property managed by Temple University. Non-Temple and contractor personnel must follow the provisions of this policy while at Temple University facilities.

This policy applies to facilities, branches, or divisions with any of the following situations:

  • An employee who may be exposed to formaldehyde at levels greater than or equal to 0.5, parts per million (ppm).
  • Employees who work with solutions that contain greater than 0.1 percent formaldehyde.
  • Employees who show symptoms of formaldehyde exposure.

Health Effects

Formaldehyde irritates the skin, eyes, throat, and respiratory system, is an acute toxin, and is a potential carcinogen. Formaldehyde can also cause allergic sensitization of the respiratory system and skin after an individual receives an initial high exposure. This means an individual who develops formaldehyde sensitization may experience an allergic respiratory or skin reaction. Because of this fact, a formaldehyde management system must be based primarily on exposure prevention.

Responsibilities for Formaldehyde Safety

Environmental Health and Radiation Safety Department (EHRS)

The EHRS has the following responsibilities related to formaldehyde activities:

  • Policy implementation.
  • Surveillance as requested by responsible supervisor.
  • Training as requested by responsible supervisor.
  • Exposure monitoring as requested by responsible supervisor.

Supervisors and Managers must:

  • Assess their site and operations to determine whether formaldehyde is present or used.
  • All persons designated as formaldehyde users shall be issued a copy of this section by their supervisor. The copy should be kept in the user's laboratory for reference. Additional copies are available through the EHRS.
  • Inform all individuals who work with formaldehyde regarding health risks and safety precautions. They must also be provided a copy of the formaldehyde policy.
  • Provide employee training regarding the safe use, storage, and disposal of formaldehyde.
  • Provide appropriate stock of required personal protective equipment (PPE).
  • Provide safety equipment such as eyewash stations, showers, and, if applicable, ventilation devices.
  • Request surveillance and exposure monitoring by EHRS
  • Ensure that any area that is required to be monitored by either EHRS or an approved outside monitoring service.
  • Inform EHRS of areas of formaldehyde use
  • Maintain relevant Material Safety Data Sheets (MSDSs) for formaldehyde products used.
  • Contact EHRS for transportation and disposal of formaldehyde-related waste.
  • Perform periodic visual inspections of areas where formaldehyde is used and stored.

Formaldehyde Users

Formaldehyde users are those workers who work with or handle formaldehyde-containing products in their job. These workers have the following responsibilities related to formaldehyde activities:

  • Attend required training classes.
  • Use and maintain safety devices and PPE.
  • Follow the instructions of the PI/supervisor and EHRS
  • Comply with the requirements as stated in this policy.

Exposure Monitoring

Exposure monitoring must be conducted to determine likely exposure for a work area or activity. The OSHA time-weighted average for formaldehyde is .75 parts per million (ppm) averaged over 8 hours.

The OSHA defined short-term exposure limit for formaldehyde is 2.0 ppm. The OSHA action-level for formaldehyde is .5 ppm, which is averaged over an eight hour period.

Additional monitoring must be conducted:

  • Whenever there is a change in procedure, work area, safety equipment, or the engineering of administrative control.
  • Whenever an employee shows any sign or symptom of formaldehyde exposure.
  • Whenever requested by appropriate safety committees or the Director of EHRS

Exposures above the Action Level

If the exposure monitoring indicates that an employee exposure is at or above the Action Level, the supervisor must implement the following:

  • Perform periodic personal exposure monitoring must be conducted at least every six months. This monitoring can be terminated if two consecutive monitoring results, at least seven days apart, indicate exposure less than the AL
  • A medical monitoring program for affected employees.

Exposures Above the Short Term Exposure Limit PEL

The OSHA-defined Short Term Exposure Limit (STEL) PEL for formaldehyde is 2.0-ppm over a 15 minute period. If exposure monitoring indicates that an employee exposure is at or above the STEL PEL, the supervisor must:

  • Periodic exposure monitoring must be conducted at least every year under the worst conditions. This periodic monitoring may be terminated if two consecutive monitoring results, at least seven days apart, indicate exposures less than the STEL.
  • Regulate areas by posting formaldehyde danger signs. The signs must be posted at all entrances and accessways and bear the following information: “Danger: Formaldehyde irritant and potential cancer hazard. Authorized Personnel Only!”
  • Establish a formaldehyde medical monitoring program for affected employees.
  • Implement engineering controls, improved work practice control, and, if necessary, increase PPE.

Exposures Above The Time-Weighted Average PEL

The OSHA-defined time-weighted average (TWA) PEL for formaldehyde is 0.75-ppm, which is the maximum allowable exposure concentration, calculated as an 8-hr TWA. If the exposure monitoring indicates that an employee exposure is at or above the TWA, the supervisor must ensure that the following activities are implemented:

  • Periodic exposure monitoring must be continued at least every six months under the worst conditions. Performance of this periodic monitoring may be terminated if two consecutive monitoring results, at least seven days apart, indicate exposures less than the AL.
  • Establish regulated areas by posting formaldehyde danger signs.
  • Train employees to recognize the danger of formaldehyde exposure.
  • Provide respiratory protection adequate to reduce the employees' exposure to less than the TWA PEL.
  • Implement engineering controls and improved work practices to reduce employee exposures to less than the TWA.

Controlling Formaldehyde Exposure

Engineering Controls - Ventilation Systems

Engineering controls should be implemented when there is a potential for exceeding action levels. Examples of engineering controls include ventilation systems, air pollution control devices, laboratory hoods, enclosures, shields, barriers, isolation chambers, automatic emergency shut off valves, and remote-control equipment.

The following considerations should be included in the design and installation process for such equipment:

  • The ventilation systems must be 100-percent exhausted to the outside of the building; thus, dilution ventilation is prohibited. Laboratory fume hoods must be evaluated for proper operation annually. If requested, EHRS can provide evaluation of the fume hood.
  • To minimize formaldehyde exposure and control the buildup of gases and vapors in the general work area, it is important that adequate room ventilation be provided. The recommended ventilation rate for laboratory areas is 4 to 12 air changes per hour. To prevent gas and vapor migration into adjacent areas, the formaldehyde work area should be maintained at a negative air pressure with respect to surrounding rooms. In addition, it is essential that air in the formaldehyde work area be 100-percent exhausted to the outdoors. The exhaust duct stack should be located away from any building air intakes to prevent re-introduction of contaminated air.

Personal Protective Equipment (PPE)

PPE provides additional protection even with proper engineering controls in place. While working with formaldehyde solutions of more than 1%, proper PPE must be used. It is required that employees wear chemical protective clothing and eye protection.

The following are examples of proper PPE:

Impermeable Gloves and Body Covering: Impermeable gloves and body covering, such as chemical-resistant aprons, will reduce exposure in cases of splash hazards or other skin contact. Butyl and nitrile rubber are appropriate choices for glove material. Consult EHRS for additional information.

Eye and Face Protection: Eye protection in the form of goggles will reduce exposure in cases of splash hazards.

Respiratory Protection

Respiratory protection, in the form of supplied air or air-purifying type, is not allowed as a substitute for engineering controls, but may be required in cases where engineering controls alone will not adequately reduce exposures. For air purifying respirators, specific formaldehyde cartridges are available. When employees are required to wear respirators to reduce exposure, they must be enrolled in a Respiratory Protection Program, as required by OSHA. The Temple University requires respirator use in the following situations:

  • During emergencies and entry into areas of unknown concentrations of formaldehyde
  • During the period to evaluate, purchase, and install engineering control equipment and/or modify work practices to achieve compliance with the PELs.
  • In work situations where engineering and work practice controls are not yet capable of reducing employee formaldehyde exposure to or below the PEL.
  • During cleaning, maintenance, repair, and other work where engineering and work practice controls are not feasible.

Work Practices

Each facility shall review each employee’s work practices with formaldehyde and implement alternative work practices that will minimize exposure. Please contact EHRS to evaluate the effictiveness of any change.

Leak and Spill Detection

Facilities with formaldehyde shall maintain a program to detect leaks and spills. The leak and spill detection program shall include:

  • Regular visual inspections for leaks and spills
  • Preventative maintenance of equipment
  • Program should include spill containment and clean-up, surface decontamination, and waste disposal in work areas where spillage may occur
  • Methods for surface decontamination and proper waste disposal

Emergency Showers and Eyewash Stations

Eyewash unit shall be located in the same area and must be accessible within ten seconds. Path to eyewash station shall be free of all obstructions.

Emergency showers may be required in some cases. Please contact EHRS for additional information.

Emergency Situations

For any emergencies, please follow instructions in EHRS policy 5.7. Laboratory workers can clean up a small spill that does not present an immediate health risk, such as a spill within a fume hood. Any resulting waste must then be packaged, and then disposed of as a hazardous waste. Consult with the EHRS for specific disposal requirements.

For larger spills, the EHRS provides cleanup assistance. If a worker is unsure of his/her ability to clean up a formaldehyde spill outside the control of a local exhaust ventilation device, he/she should call EHRS.

Any time respiratory irritation occurs, leave the area and get to fresh air. In case of skin/eye contact with liquid, immediately remove contaminated clothing and flush affected areas with water. Any exposure (inhalation, absorption, ingestion) to formaldehyde shall require a visit to the Employee Occupational Health Office for evaluation.

Spill control supplies (adsorbent, gloves, goggles, and disposal bags) shall be made accessible to chemical laboratories and storage sites.

Contact the EHRS for more information and details.

Formaldehyde-Contaminated Waste

Any formaldehyde waste must be characterized in accordance with EPA regulations. Waste determined to be hazardous will be affixed with a hazardous waste label, and handled on site for proper disposal by a hazardous waste contractor, as arranged by the EHRS Chemical Hygiene Officer. Items and materials contaminated with formaldehyde must be handled in accordance to EHRS policy. Personnel from the EHRS must sign all manifests for hazardous waste disposal.

Employee Training Requirements

Formaldehyde training shall be provided to all employees and their supervisors where formaldehyde is used in the workplace. Information regarding this training can be obtained from the EHRS. This training must be provided at the time of the initial job assignment, annually, and whenever there is a change in work practice. The topics covered in this class may include:

  • The contents of the OSHA formaldehyde standard (29 CFR 1910.1048), as well as the location and availability of these regulations.
  • The contents of MSDSs.
  • Health risks of formaldehyde: skin, respiratory tract, eye, and throat irritation; sensitizing effects of formaldehyde; acute and chronic toxic effects.
  • The medical surveillance program.
  • PPE use and limitations.
  • Instructions for the use of engineering controls in minimizing exposure.
  • Instructions for handling spills and emergency situations.
  • Access and location of training materials for the affected employees.

Record-keeping Requirements

The following records must be maintained in accordance to Temple University policy. The records shall consist of:

Exposure Monitoring Records shall include the following information:

  • Date of measurement.
  • Operation being monitored.
  • The methods of sampling and analysis used and evidence of their precision and accuracy.
  • The number, duration, time of day, and results of samples obtained.
  • The types of protective devices worn.
  • The names, job classifications, social security numbers, and exposure estimate of employees whose exposure is represented by actual monitoring results.
  • When it is felt that objective data will relieve exposure-monitoring requirements, records shall consist of the objective data and calculations that demonstrate that no employee is exposed to formaldehyde at or above the Action Level.
  • Exposure monitoring records shall be kept for at least 30 years.

2. Medical Evaluation Records shall consist of:

  • The name and social security number of the employee.
  • The physician's written opinion.
  • A list of employee health complaints that may be related to exposure to formaldehyde.
  • A copy of the employee's medical examination results, medical questionnaires, and results of medical tests that are required by the regulation or mandated by the examining physician.
  • Medical evaluation records shall be kept for the duration of the employee's employment plus at least 30 years.

3. Respirator Fit Test Records shall consist of:

  • A copy of protocol used to test the fit of negative-pressure respirators.
  • The-name and social security number of each employee assigned to wear a negative-pressure respirator.
  • The date of the employee's most recent respirator fit test and a copy of the test results.
  • A list of the brands, types, and sizes of respirators available at the facility from which respirator selection and assignment was made.
  • Respirator fit test records shall be kept until replaced by a more recent record.

Contractors are responsible for complying with these record-keeping requirements for their own employees.

5.9 – Mercury Safety

Purpose

This chapter provides guidelines for minimizing exposure to mercury and compliance with applicable mercury regulations.

Applicability

This chapter is applicable to all Temple University employees, to all work conducted under the authority of Temple University, and to all equipment and property managed by Temple University. Non-Temple and contractor personnel will follow the provisions of this chapter while at Temple University facilities.

This chapter may apply to facilities, branches, or divisions with any of the following:

  • An employee who may be exposed to mercury at levels greater than or equal to 0.05-mg/m3.
  • Employees who show symptoms of mercury exposure.
  • Facilities that generate mercury-containing hazardous waste.

Health Effects

Mercury is a poison by inhalation. It is corrosive to the skin, eyes and mucous membranes. Systemic effects by inhalation include wakefulness, muscle weakness, anorexia, headache, tinnitus, hypermotility, diarrhea, liver changes, dermatitis, and fever. There is evidence of possible reproductive effects.

Responsibilities for Mercury Safety

Environmental Health and Safety Department (EHRS)

The EHRS department has the following responsibilities related to mercury activities:

  • Policy implementation.
  • Surveillance as requested by responsible supervisor.
  • Training as requested by responsible supervisor.
  • Exposure monitoring.

Supervisors and Managers

Supervisors and Managers must follow these responsibilities related to mercury activities:

  • Assess their site and operations to determine whether mercury is present or used.
  • All persons designated as mercury users shall have access to a copy of this section. The copy should be kept in the user's laboratory for reference. Additional copies are available through the EHRS department.
  • Review and approve proposed uses of mercury containing products in areas within their jurisdiction. Such approval signifies that management will provide the resources necessary to control hazards and will establish, as organization policy, the procedures necessary to comply with OSHA, EPA, and other government regulations. Such compliance may include the following actions:
  • Provide employee training regarding the safe use, storage, and disposal of mercury.
  • Maintain an adequate stock of required personal protective equipment (PPE).
  • Provide equipment such as eyewash stations, showers, and ventilation devices when required.
  • Make requests to the EHRS department for required exposure monitoring and surveillance of work activities.
  • Maintain relevant Material Safety Data Sheets (MSDSs) for mercury products used.
  • Arrange for transportation and disposal of mercury-related waste.
  • Make regular visual inspections for leaks and spills for facilities with liquid mercury.

Mercury Users

Mercury users are those workers who work with or handle mercury-containing products in their job. These workers have the following responsibilities related to mercury activities:

  • Attend required training classes.
  • Properly use and maintenance of PPE.
  • Comply with Temple University, OSHA, and EPA and other government regulations as they pertain to mercury use.

Exposure Monitoring

For personal exposure monitoring, area air monitoring should also be performed to document levels within the work area. Area air monitoring data can be a worst-case exposure indicator for casually exposed workers. Exposure and area monitoring can be performed by EHRS, if required or needed. Please contact EHRS for more information.

Personal Protective Equipment (PPE)

Certain types of PPE are effective in controlling mercury exposure. In normal work situations, PPE should be used only as a supplement to engineering controls.

Any mercury-contaminated PPE or clothing must be disposed of as mercury-contaminated waste. Employees must not take mercury-contaminated materials, clothing, or equipment home.

Impermeable Gloves: N-Dex gloves are among the appropriate glove choices for protection against skin contact with mercury. Contact EHRS for additional information.

Body Covering: Contact EHRS for assistance and additional information.

Eye and Face Protection: Eye and face protection in the form of goggles will reduce exposure in cases of splash hazards.

Respiratory Protection:

Respiratory protection, in the form of supplied air or air purifying type, is not allowed as a substitute for engineering controls, but may be required in cases where engineering controls alone will not adequately reduce exposures. For air purifying respirators, specific mercury cartridges are available. When employees are required to wear respirators to reduce exposure, they must be enrolled in a Respiratory Protection Program, as required by OSHA. The Temple University requires respirator use in the following situations:

  • During emergencies, and entry into areas of unknown mercury concentration.
  • During the period to evaluate, purchase, and install engineering control equipment and/or modify work practices to achieve compliance with the PELs.
  • In work situations where engineering and work practice controls are not yet capable of reducing employee mercury exposure to or below the PEL.
  • During cleaning, maintenance, repair, and other work where engineering and work practice controls are not feasible.

Work Practices

Each facility shall review each employee’s work practices with mercury and implement alternative work practices that will minimize exposure. Please contact EHRS to evaluate the effictiveness of any change.

Leak and Spill Detection

Facilities with liquid mercury shall create and maintain a program to detect leaks and spills. The equipment leak and spill detection program shall include:

  • Regular visual inspections for leaks and spills;
  • Preventative maintenance of equipment, including surveys for leaks, at regular intervals;
  • Provisions for mercury spill containment, surface decontamination, and waste disposal in work areas where spillage may occur;
  • Prompt cleanup of spills and repair of leaks using persons who wear appropriate protective clothing and equipment and are trained in the proper methods for mercury cleanup and decontamination;
  • Placement of mercury-contaminated waste and debris resulting from leaks and spills into sealed containers that bear a mercury hazard-warning label. The EHRS personnel will bear this responsibility.

Emergency Showers and Eyewash Stations

Eyewash unit shall be located in the same area and must be accessible within ten seconds. Path to eyewash station shall be free of all obstructions.

Emergency showers may be required in some cases. Please contact EHRS for additional information.

Emergency Situations

For any emergencies, please follow instructions in EHRS policy 5.7. Laboratory workers can clean up a small spill that does not present an immediate health risk, such as a spill within a fume hood. Any resulting waste must then be packaged, and then disposed of as a hazardous waste. Consult with the EHRS for specific disposal requirements.

For larger spills, the EHRS provides cleanup assistance. If a worker is unsure of his/her ability to clean up a mercury spill outside the control of a local exhaust ventilation device, he/she should call EHRS.

Any time respiratory irritation occurs, leave the area and get to fresh air. In case of skin/eye contact with liquid, immediately remove contaminated clothing and flush affected areas with water. Any exposure (inhalation, absorption, ingestion) to mercury shall require a visit to the Employee Occupational Health Office for evaluation.

Spill control supplies (adsorbent, gloves, goggles, and disposal bags) shall be made accessible to chemical laboratories and storage sites.

Contact EHRS for more information and details.

Mercury-Contaminated Waste

Any mercury waste created must be characterized in accordance with EPA regulations. Waste determined to be hazardous will be affixed with a hazardous waste label, and handled on site for proper disposal by a hazardous waste contractor, as arranged by the EHRS Chemical Hygiene Officer. Personnel from the EHRS department must sign all manifests for hazardous waste disposal.

Medical Surveillance Program

The medical surveillance program is provided to monitor the health of mercury-exposed employees, and determine whether continued exposure will adversely affect their health.

  • The medical surveillance program is mandatory for employees who are exposed at or above the AL.
  • The medical surveillance program is optional for the following groups of employees; employees who show symptoms of mercury exposure, or employees who are exposed during an emergency.

Hazard Communication Program

Implementation of a written hazard communication program is required of each branch or division that uses mercury gas. The hazard communication program must address the following items:

  • Health risks of mercury:
  • Material Safety Data Sheets (MSDSs)
  • Container labeling of mercury
  • Medical surveillance program.
  • Instructions to immediately report signs of mercury exposure to the supervisor.
  • Uses and limitations of PPE.
  • Instructions for handling spills and emergency situations.
  • Proper work practices and the use of engineering controls.

Employee Training Requirements

Information regarding hazard communication training can be obtained from the EHRS department. Training must be provided at the time of the initial job assignment and whenever there is a change to the work process. At a minimum, the topics addressed in the hazard communication training shall include:

  • The contents of the OSHA mercury standard (29 CFR 1910.1048), as well as the location and availability of these regulations.
  • The contents of MSDSs.
  • Health risks
  • The medical surveillance program.
  • The mercury work activities that take place at the facility, and the appropriate work practices that will minimize exposure.
  • PPE use and limitations.
  • Instructions for the use of engineering controls in minimizing exposure.
  • Instructions for handling spills and emergency situations.
  • Access and location of training materials for the affected employees.
  • Container labeling

Record-keeping Requirements

EHRS will keep accurate and complete records for all mercury-related work areas.

When it is felt that objective data will relieve exposure-monitoring requirements, records shall consist of the objective data and calculations that demonstrate that no employee is exposed to mercury at or above the Action Level.

Exposure monitoring records shall be kept for at least 30 years.

Medical evaluation records shall be kept for the duration of the employee's employment plus at least 30 years.

Respirator fit test records shall be kept until replaced by a more recent record.

Contractors are responsible for complying with these record-keeping requirements for their own employees.

5.10 – Ethylene Oxide Safety

Purpose:

In accordance with applicable regulations and Temple University, this policy was developed to minimize exposure to Ethylene Oxide.

Applicability

This policy is applicable to all Temple University employees, to all work conducted under the authority of Temple University, and to all equipment and property managed by Temple University. Non-Temple and contractor personnel must follow the provisions of this policy while at Temple University facilities.

Definition Of Terms:

Ethylene Oxide: A colorless gas with a characteristic ether-like odor that is used by various facets of the health care industry for the sterilization of delicate instruments and heat or moisture sensitive devices.

Action Level (AL)l: A concentration of airborne Ethylene Oxide of 0.5-parts per million (ppm) calculated as an 8-hour time weighted average.

Permissible Exposure Limits (PEL): A concentration of airborne Ethylene Oxide of 1 parts per million (ppm) calculated as an 8-hour time weighted average.

Short Term Exposure Limit (STEL) or Excursion limit- A concentration of airborne Ethylene Oxide of 5 parts per million (ppm) averaged over a sampling period of 15 minutes.

Responsibilities

Environmental Health and Radiation Safety Department (EHRS)

The EHRS has the following responsibilities related to Ethylene Oxide activities:

  • Policy implementation.
  • Surveillance as requested by responsible supervisor.
  • Training as requested by responsible supervisor
  • Exposure monitoring when requested responsible supervisor.
  • Establish procedures for the use and operation of respiratory protective devices.

Supervisors and Managers

  • Assess their site and operations to determine whether ethylene oxide is present or used.
  • All persons designated as ethylene oxide users shall be issued a copy of this section by their supervisor. The copy should be kept in the user’s work place for reference. Additional copies are available through EHRS..
  • Ensure that all required (area and personal) monitoring is performed.
  • Maintain all required documentation ( exposure monitoring, hazards assessment, medical monitoring, etc)
  • Inform all individuals who work with ethylene oxide regarding health risks and safety precautions. They must also be provided a copy of the ethylene oxide policy.
  • If the supervisor or manager provides the training, this training must be documented. The supervisor may forward the training documentation to EHRS.
  • Review and approve proposed uses of ethylene oxide in the areas within their jurisdiction. Such approval signifies that management will provide the resources necessary to comply with OSHA, EPA, and other government regulations. Such compliance may include the following actions:
  • Provide employee training regarding the safe use, storage, and disposal of ethylene oxide.
  • Maintain an adequate stock of required personal protective equipment.
  • Provide equipment such as eyewash stations, showers, and ventilation devices when required.
  • Make requests to the EHRS department for required exposure monitoring and surveillance of work activities.
  • Maintain relevant Material Safety Data Sheets (MSDSs) for ethylene oxide.
  • Arrange for transportation and disposal of ethylene oxide waste gas.
  • Make regular visual inspections for leaks and spills.
  • Maintain ethylene oxide leak detection equipment.
  • Maintain an inspection log of leak detection equipment.

Ethylene Oxide Users

Ethylene oxide users are those workers who work with or handle ethylene oxide in their job. These workers have the following responsibilities related to ethylene oxide use:

  • Attend required training classes
  • Properly use and maintain PPE
  • Comply with Temple University, OSHA, and EPA and other government regulations as they pertain to ethylene oxide use.

Director of Maintenance

  • Ensure that his staff is trained in the safe handling of Ethylene Oxide.
  • Ensure the availability of safety equipment and clothing for his employees.
  • Notify the Director of Supply, Processing and Distribution, the Operating Room Head Nurse, the Manager of Central Supply, and the EHRS whenever a change to the ventilation system may effect the exhausting of the Ethylene Oxide from the work area(s).

Exposure Monitoring

Initial:

The level of ethylene oxide exposure for a particular work activity dictates the regulatory requirements for exposure monitoring, engineering controls, PPE, training, and medical surveillance. Initial exposure monitoring must be conducted to determine the likely exposure for a work activity. A representative sampling of employees exposures are permitted. When initial exposure monitoring results show that airborne ethylene oxide is below the OSHA levels specified below, the facility may discontinue monitoring. However, any time there is a change in the work activity, personnel, equipment, or control measures that may result in new or additional exposure to ethylene oxide, monitoring must be resumed. Furthermore, if an employee indicates signs or symptoms of ethylene oxide exposure, additional monitoring must be conducted. For certain exposure situations, the air monitoring requirements can be relieved if it can be proven with objective data that an employee is exposed below the Action Level. For example, if a chemist is exposed below the Action Level while performing continuous ethylene oxide activities, objective data might indicate that a second worker in the same area, who does not work with ethylene oxide, is also exposed below the Action Level.

As required by OSHA, within 15 days of the employer receiving the results of exposure monitoring, the employer shall notify the affected employees of the results in writing. If monitoring results reveal exposure levels above the OSHA defined Permissible Exposure Limit (PEL), the employer shall implement a written plan that describes what actions will be taken to reduce employee exposure to or below the PEL. This written plan shall be distributed to all affected employees.

In addition to personal exposure monitoring, area air monitoring should also be performed to document levels within the work area. Area air monitoring data can be a worst-case exposure indicator for casually exposed workers. The EHRS department should be contacted to conduct both personal and area air monitoring activities.

Periodic Exposure Monitoring

This section only applies when employee exposure monitoring results are at or above the

  1. Action level (AL) of 0.5 ppm ;
  2. Permissible Exposure Limit (PEL) of 1 ppm; or
  3. Short-term Exposure limit (STEL) or Excursion limit of 5 ppm

The frequency of employee exposure monitoring is specified in the following table:

Table 1.

Periodic Exposure Evaluation Frequencies

If employee exposure monitoring results:

Then

Are above the Action level (AL) of 0.5 ppm

and below Permissible Exposure Limit (PEL)of 1 ppm

Conduct additional exposure monitoring every 6 months

Are above the PEL of 1 ppm or STEL or Excursion limit of 5 ppm

Conduct additional exposure monitoring every 3 months.

Have been obtained at least every 3 months and have 2 consecutive monitoring results, taken at least 7 days apart, showing 8 hour employee exposure monitoring results that have dropped below the PEL but remain at or above the AL

You may decrease your frequency for PEL to every 6 months.

Have 2 consecutive evaluations, taken at least 7 days apart, showing 8-hour employee exposure monitoring results that have dropped below the AL and STEL.

You may stop periodic exposure evaluations.

Exposures above the Action Level

The Action Level (AL) for ethylene oxide is 0.5-ppm, as an eight-hour time weighted average (8-hr TWA). If the initial exposure monitoring indicates that an employee exposure is at or above the Action Level, the supervisor must ensure that the following activities are implemented:

  • Periodic personal exposure monitoring must be conducted according the specified frequencies in the above table 1 under the worst conditions.
  • Establish an ethylene oxide medical monitoring program for affected employees.

Exposures above the Time-Weighted Average PEL or STEL (Excursion limit)

The OSHA-defined time-weighted average (TWA) PEL for ethylene oxide is 1.0-ppm, which is the maximum allowable exposure concentration, calculated as an 8-hr TWA. The STEL or Excursion limit for Ethylene Oxide is 5 ppm averaged over a 15 minute sampling period.

If the initial exposure monitoring indicates that an employee exposure is at or above the TWA PEL, the supervisor must ensure that the following activities are implemented:

  • Establish and implement a written compliance program to reduce exposures below the PEL and STEL.
  • Periodic exposure monitoring must be must be conducted according the specified frequencies in the above table 1 under the worst conditions.
  • Establish regulated areas by posting ethylene oxide danger signs.
  • Train employees to recognize the danger of ethylene oxide exposure.
  • Provide respiratory protection adequate to reduce the employees' exposure too less than the TWA PEL.
  • Implement engineering controls and improved work practices to reduce employee exposures to less than the PEL or STEL.

Controlling Ethylene Oxide Exposure

Engineering Controls - Ventilation Systems

It is the policy of the Temple University that all ethylene oxide-related work activities with potential for exceeding the Action Level shall implement feasible engineering controls. Examples of engineering controls include ventilation systems, air pollution control devices, laboratory hoods, enclosures, shields, barriers, isolation chambers, automatic emergency shut off valves, and remote-control equipment.

The following considerations should be included in the design and installation process for such equipment:

  • On an annual basis, laboratory fume hoods must be evaluated for proper operation and airflow. The EHRS department provides these services upon request.
  • To minimize ethylene oxide exposure and control the buildup of gases and vapors in the general work area, it is important that adequate room ventilation be provided. The recommended ventilation rate for laboratory areas is 4 to 12 air changes per hour. To prevent gas and vapor migration into adjacent areas, the ethylene oxide work area should be maintained at a negative air pressure with respect to surrounding rooms. The exhaust duct stack must be located a sufficient distance from any building air intakes to prevent re-introduction of contaminated air.
  • If the facility ventilates containers of contaminated clothing and equipment, the facility shall establish an appropriately labeled storage area for this purpose, and locate and arrange it in a manner that minimizes ethylene oxide exposure. The facility shall allow only persons trained in recognizing the hazards of ethylene oxide to remove containers from the storage area.

Personal Protective Equipment (PPE)

Certain types of PPE are effective in controlling ethylene oxide exposure. In normal work situations, PPE should be used only as a supplement to engineering controls. Employees must not take ethylene oxide-contaminated materials, clothing, or equipment home.

Impermeable Gloves: Latex gloves are among the appropriate glove choices for protection against skin contact with ethylene oxide. Check with EHRS for other material options.

Eye and Face Protection: Eye and face protection in the form of goggles will reduce exposure in cases of splash hazards.

Respiratory Protection

Ethylene oxide, as it is used in the Temple University Hospital Sterile Processing area, displaces oxygen and creates an oxygen-deficient atmosphere. For this reason, a self-contained breathing apparatus (SCBA) is the minimum level of respiratory protection to be used. When employees are required to wear respirators to reduce exposure, they must be enrolled in a Respiratory Protection Program, as required by OSHA. The Temple University requires respirator use in the following situations:

  • During emergencies, and entry into areas of unknown ethylene oxide concentration.
  • During the period to evaluate, purchase, and install engineering control equipment and/or modify work practices to achieve compliance with the PELs.
  • In work situations where engineering and work practice controls are not yet capable of reducing employee ethylene oxide exposure to or below the PEL.
  • During cleaning, maintenance, repair, and other work where engineering and work practice controls are not feasible.

Work Practices

Each facility shall examine the work practices that employees use, and consider alternative work practices that will minimize exposure.

Leak and Spill Detection

Facilities with ethylene oxide shall create and maintain a program to detect leaks and spills. The equipment leak and spill detection program shall include:

  • Regular visual inspections for leaks and spills;
  • Preventative maintenance of equipment, including surveys for leaks, at regular intervals;
  • Regular testing of monitoring equipment to assure proper function;
  • Provisions for ethylene oxide spill containment, surface decontamination, and waste disposal in work areas where spillage may occur;
  • Prompt cleanup of spills and repair of leaks using persons who wear appropriate protective clothing and equipment and are trained in the proper methods for ethylene oxide cleanup and decontamination;

Container Labels

The label must list the name and address of the responsible person; and must state that physical and health hazard information is readily available from the employer and from MSDSs.

Emergency Showers, Eyewash Stations

If there is an eye splash possibility eyewash stations must be present in the immediate work area. Showers must be present in the immediate work area if there is a splash hazard. The locations of the stations must be close enough so that an injured worker can reach one within ten seconds.

Emergency Situations

Leak sensors are in place in Temple Hospitals Sterile Processing area, where ethylene oxide is used to sterilize equipment.

In case of a leak:

  • Personnel should immediately evacuate the effected area when the monitor alarm sounds, and assist injured personnel to safety,
  • Seek medical assistance for injured personnel,
  • Call the EHRS department (ext. 707-2520) or Page Operator (ext. 707-4545) immediately,
  • Never re-enter contaminated area without fully encapsulated clothing, SCBA, and back-up personnel.

Ethylene Oxide Waste

Any ethylene oxide waste must be characterized in accordance with EPA regulations. Waste determined to be hazardous will be affixed with a hazardous waste label, and handled on site for proper disposal by a hazardous waste contractor, as arranged by the EHRS Chemical Hygiene Officer. Personnel from the EHRS department must sign all manifests for hazardous waste disposal.

Intentional discharge of ethylene oxide or other hazardous material into the sewer system or storm drain is prohibited. Similarly, hazardous materials may not be disposed of by evaporation in a fume hood. If such an incident does occur, it may be reportable to local or Federal authorities, and shall be reported immediately to the EHRS department.

Where vapors may be exhausted as a by-product of work being done with ethylene oxide (not as a means of disposal), the fume hood will be equipped with filters to prevent atmospheric releases.

Medical Surveillance Program

The medical surveillance program is provided to monitor the health of ethylene oxide-exposed employees, and determine whether continued exposure will adversely affect their health.

  • The medical surveillance program is mandatory for employees who are exposed at or above the AL.
  • The medical surveillance program is required for the following groups of employees; employees who show symptoms of ethylene oxide exposure, or employees who are exposed during an emergency.

Hazard Communication Program

Implementation of a written hazard communication program is required of each branch or division that uses ethylene oxide gas. The hazard communication program must address the following items:

  • Health risks of ethylene oxide
  • Material Safety Data Sheets (MSDSs)
  • Container labeling of ethylene oxide
  • Medical surveillance program
  • Instructions to immediately report signs of ethylene oxide exposure to the supervisor.
  • Uses and limitations of PPE.
  • Instructions for handling spills and emergency situations.
  • Proper work practices and the use of engineering controls.

Employee Training Requirements

Information regarding hazard communication training can be obtained from the EHRS department. Training must be provided at the time of the initial job assignment and whenever there is a change to the work process. At a minimum, the topics addressed in the hazard communication training shall include:

  • The contents of the OSHA ethylene oxide standard (29 CFR 1910.1048), as well as the location and availability of these regulations.
  • The contents of MSDSs.
  • Health risks
  • The medical surveillance program.
  • The ethylene oxide work activities that take place at the facility, and the appropriate work practices that will minimize exposure.
  • PPE use and limitations.
  • Instructions for the use of engineering controls in minimizing exposure.
  • Instructions for handling spills and emergency situations.
  • Access and location of training materials for the affected employees.
  • Container labeling

Record-keeping Requirements

The EHRS department will keep accurate and complete records for all ethylene oxide-related work areas. The records shall consist of:

Exposure Monitoring Records

Exposure monitoring will include the following information:

  • The date the measurement was taken.
  • The operation that is being monitored.
  • The sampling and analytical methods used and evidence of their precision and accuracy.
  • The number, duration, time of day, and results of samples obtained.
  • The types of protective devices worn.
  • The names, job classifications, social security numbers, and exposure estimate of employees whose exposure is represented by actual monitoring results.

When it is felt that objective data will relieve exposure-monitoring requirements, records shall consist of the objective data and calculations that demonstrate that no employee is exposed to ethylene oxide at or above the Action Level.

Exposure monitoring records shall be kept for at least 30 years.

Medical Evaluation Records

Records shall consist of:

  • The name and social security number of the employee.
  • The physician's written opinion.
  • A list of employee health complaints that may be related to exposure to ethylene oxide.
  • A copy of the employee's medical examination results, medical questionnaires, and results of medical tests that are required by the regulation or mandated by the examining physician.

Medical evaluation records shall be kept for the duration of the employee's employment plus at least 30 years.

Respirator Fit Test Records

Respirator fit test records shall consist of:

  • A copy of protocol used to test the fit of negative-pressure respirators.
  • The name and social security number of each employee assigned to wear a negative-pressure respirator.
  • The date of the employee's most recent respirator fit test and a copy of the test results.
  • A list of the brands, types, and sizes of respirators available at the facility from which respirator selection and assignment was made.

Respirator fit test records shall be kept until replaced by a more recent record.

Contractors are responsible for complying with these record-keeping requirements for their own employees.

5.11 – Glutaraldehyde Safety

Purpose

In accordance with applicable regulations and Temple University, this policy was developed to minimize exposure to glutaraldehyde.

Applicability

This policy is applicable to all Temple University employees, to all work conducted under the authority of Temple University, and to all equipment and property managed by Temple University. Non-Temple and contractor personnel must follow the provisions of this policy while at Temple University facilities.

This policy applies to facilities, branches, or divisions with any of the following situations:

  • An employee who may be exposed to glutaraldehyde at levels greater than or equal to 0.1 parts per million (ppm).
  • Employees who work with solutions that contain greater than 0.1 percent glutaraldehyde.
  • Employees who show symptoms of glutaraldehyde exposure.

Regulations

Currently there are no federal regulations concerning the use, storage, or disposal of glutaraldehyde-containing chemicals and products. The National Institutes for Occupational Health and Safety (NIOSH) has established a recommended exposure limit of 0.2-ppm (parts per million) for 15-minutes of exposure. The American Conference of Governmental Industrial Hygienists has also established a threshold limit value (TLV) of 0.2-ppm.

Health Effects

NIOSH recognizes that glutaraldehyde irritates the skin, eyes, throat, and respiratory system, and is a potential mutagen and possible teratogen. Glutaraldehyde can also cause allergic sensitization of the respiratory system and skin after an individual receives an initial high exposure.

Responsibilities for Glutaraldehyde Safety

Environmental Health and Radiation Safety Department (EHRS)

The EHRS has the following responsibilities related to glutaraldehyde activities:

  • Policy development.
  • Surveillance as requested by responsible supervisor.
  • Training as requested by responsible supervisor.
  • Exposure monitoring.

Supervisors and Managers

Supervisors and Managers have the following responsibilities related to glutaraldehyde activities:

  • Assessment of their site and operations to determine whether glutaraldehyde is present or used.
  • All persons designated as glutaraldehyde users shall be issued a copy of this section by their supervisor. The copy should be kept in the user's work place for reference. Additional copies are available through the EHRS.
  • Review and approve proposed uses of glutaraldehyde-containing products in areas within their jurisdiction. Such approval signifies that management will provide the resources necessary to control hazards and will establish, as organization policy, the procedures necessary to comply with OSHA, EPA, and other government regulations. Such compliance may include the following actions:
  • Provide employee training regarding the safe use, storage, and disposal of glutaraldehyde.
  • Maintain an adequate stock of required personal protective equipment (PPE).
  • Provide equipment such as eyewash stations, showers, and ventilation devices when required.
  • Make requests to the EHRS for required exposure monitoring and surveillance of work activities.
  • Maintain relevant Material Safety Data Sheets (MSDSs) for glutaraldehyde products used.
  • Arrange for transportation and disposal of glutaraldehyde-related waste.
  • Make regular visual inspections for leaks and spills for facilities with glutaraldehyde.

Glutaraldehyde Users

Glutaraldehyde users are those workers who work with or handle glutaraldehyde-containing products in their job. These workers have the following responsibilities related to glutaraldehyde activities:

  • Attend required training classes.
  • Properly use and maintain PPE.
  • Comply with Temple University, OSHA, and EPA and other government regulations as they pertain to glutaraldehyde use.

Exposure Monitoring

There are no regulatory requirements for glutaraldehyde exposure levels or monitoring frequency, however Temple University had adopted the Recommended Exposure Limit of 0.2-ppm. Monitoring is performed when requested and to develop a base-line database of worker exposures. The Temple University defined action level (AL) for glutaraldehyde is 0.1-ppm, as an eight-hour time weighted average.

Controlling Glutaraldehyde Exposure

Engineering Controls - Ventilation Systems

It is the policy of the Temple University that all glutaraldehyde-related work activities with potential for exceeding the Action Level shall implement feasible engineering controls. Examples of engineering controls include ventilation systems, air pollution control devices, laboratory hoods, enclosures, shields, barriers, isolation chambers, automatic emergency shut off valves, and remote-control equipment.

The following considerations should be included in the design and installation process for such equipment:

  • On an annual basis, laboratory fume hoods must be evaluated for proper operation and airflow. The EHRS provides these services annually or upon request.
  • To minimize exposure and control the buildup of gases and vapors in the general work area, it is important that adequate room ventilation be provided. The recommended ventilation rate for laboratory areas is 4 to 12 air changes per hour.

Personal Protective Equipment (PPE)

Certain types of PPE are effective in controlling glutaraldehyde exposure. For activities using greater than 1-% glutaraldehyde solutions, it is required that employees wear chemical protective clothing. In normal work situations, PPE should be used only as a supplement to engineering controls.

Impermeable Gloves: Impermeable gloves will reduce exposure in cases of splash hazards or other skin contact. Rubber, nitrile, and neoprene are commonly used protective materials for glutaraldehyde. However, PPE manufacturers' data should be consulted for specific information about material types, breakthrough times, and permeation rates.

Eye and Face Protection: Eye and face protection in the form of goggles and face shields will reduce exposure in cases of splash hazards. When a face shield is worn, chemical goggles are also required if a potential for eye splash exists.

Respiratory Protection

Respiratory protection, in the form of supplied air or air purifying type, is not allowed as a substitute for engineering controls, but may be required in cases where engineering controls alone will not adequately reduce exposures. For air purifying respirators, specific glutaraldehyde cartridges are available. When employees are required to wear respirators to reduce exposure, they must be enrolled in a Respiratory Protection Program, as required by OSHA. The Temple University requires respirator use in the following situations:

  • During emergencies, and entry into areas of unknown glutaraldehyde.
  • During the period to evaluate, purchase, and install engineering control equipment and/or modify work practices to achieve compliance with the RELs.
  • In work situations where engineering and work practice controls are not yet capable of reducing employee glutaraldehyde exposure to or below the REL.
  • During cleaning, maintenance, repair, and other work where engineering and work practice controls are not feasible.


Work Practices

Each facility shall examine the work practices that employees use, and consider alternative work practices that will minimize exposure. An example of an acceptable work technique change might be to have workers store glutaraldehyde-releasing materials in sealed containers until immediately prior to use.

Leak and Spill Detection

Facilities with glutaraldehyde shall create and maintain a program to detect leaks and spills. The equipment leak and spill detection program shall include:

  • Regular visual inspections for leaks and spills;
  • Preventative maintenance of equipment, including surveys for leaks, at regular intervals;
  • Provisions for glutaraldehyde spill containment, surface decontamination, and waste disposal in work areas where spillage may occur;
  • Prompt cleanup of spills and repair of leaks using persons who wear appropriate protective clothing and equipment and are trained in the proper methods for glutaraldehyde cleanup and decontamination;
  • Placement of glutaraldehyde-contaminated waste and debris resulting from leaks and spills into sealed containers that bear a glutaraldehyde label.

Container Labels

Containers of glutaraldehyde must have labels indicating that they contain glutaraldehyde. The label must list the name and address of the responsible person; and must state that physical and health hazard information is readily available from the employer and from MSDSs.

Emergency Showers, Eyewash Stations

If there is an eye splash possibility eyewash stations must be present in the immediate work area. Showers must be present in the immediate work area if there is a splash hazard. The locations of the stations must be close enough so that an injured worker can reach one within ten seconds.

Emergency Situations

Laboratory workers can clean up a small spill that does not present an immediate health risk, such as a spill within a fume hood. The resulting waste must then be packaged, and then disposed of as a hazardous waste.

For larger spills, call EHRS (215-707-2520) to provide cleanup assistance. If a worker is unsure of his/her ability to clean up a glutaraldehyde spill outside the control of a local exhaust ventilation device, he/she should call EHRS.

Any time respiratory irritation occurs, leave the area and get to fresh air. In case of skin/eye contact with liquid, immediately remove contaminated clothing and flush affected areas with water. Any unusual exposure (inhalation, absorption, ingestion) to glutaraldehyde shall require a visit to the Employee Occupational Health Office for evaluation.

Spill control supplies (adsorbent, gloves, goggles, and disposal bags) shall be made accessible to chemical laboratories and storage sites.

Contact EHRS for more information and details.

Glutaraldehyde Waste

Glutaraldehyde-containing products may not be disposed of into the sewer system or storm drains, unless prior approval from EHRS is obtained. Where no approval is provided by EHRS, discharge of glutaraldehyde or other hazardous material into the sewer system or storm drain is prohibited. Similarly, hazardous materials may not be disposed of by evaporation in a fume hood. If such an incident does occur, it may be reportable to local or Federal authorities, and shall be reported immediately to the EHRS.

Where vapors may be exhausted as a by-product of work being done with glutaraldehyde (not as a means of disposal), the fume hood will be equipped with filters to prevent atmospheric releases.

Medical Surveillance Program

The medical surveillance program is provided to monitor the health of glutaraldehyde-exposed employees, and determine whether continued exposure will adversely affect their health.

  • The medical surveillance program is mandatory for the following groups of employees: Employees who are exposed at or above the AL.
  • The medical surveillance program is optional for the following groups of employees: Employees who show symptoms of glutaraldehyde exposure and employees who are exposed during an emergency.

Hazard Communication Program

The hazard communication program must address the following items:

  • Material Safety Data Sheets (MSDSs)
  • Container labeling of glutaraldehyde
  • Instructions to immediately report signs of glutaraldehyde exposure to the supervisor.
  • Uses and limitations of PPE.
  • Instructions for handling spills and emergency situations.
  • Proper work practices and the use of engineering controls.

Employee Training Requirements

Glutaraldehyde training is part of the workplace Hazard Communications Training that shall be provided to all employees. Information regarding this training can be obtained from the EHRS. This training must be provided at the time of the initial job assignment and whenever there is a change to the work process.. At a minimum, the topics addressed in the hazard communication training shall include:

  • The contents of the OSHA Hazard Communication Standard (29 CFR 1910.1200), as well as the location and availability of these regulations.
  • The contents of MSDSs.
  • Health risks of work place hazards
  • The medical surveillance program.
  • PPE use and limitations.
  • Instructions for the use of engineering controls in minimizing exposure.
  • Instructions for handling spills and emergency situations.
  • Access and location of training materials for the affected employees.
  • Container labeling requirements.

Record-keeping Requirements

The EHRS will keep accurate and complete records for all glutaraldehyde-related work areas. The records shall consist of:

Exposure Monitoring Records

  • The date the measurement was taken.
  • The operation that is being monitored.
  • The sampling and analytical methods used and evidence of their precision and accuracy.
  • The number, duration, time of day, and results of samples obtained.
  • The types of protective devices worn.
  • The names, job classifications, social security numbers, and exposure estimate of employees whose exposure is represented by actual monitoring results.

When it is felt that objective data will relieve exposure-monitoring requirements, records shall consist of the objective data and calculations that demonstrate that no employee is exposed to glutaraldehyde at or above the Action Level.

Exposure monitoring records shall be kept for at least 30 years.

Medical Evaluation Records

Records shall consist of:

  • The name and social security number of the employee.
  • The physician's written opinion.
  • A list of employee health complaints that may be related to exposure to glutaraldehyde.
  • A copy of the employee's medical examination results, medical questionnaires, and results of medical tests that are required by the regulation or mandated by the examining physician.

Medical evaluation records shall be kept for the duration of the employee's employment plus at least 30 years.

5.12 – Cyanide Safety

Purpose

This chapter provides guidelines for minimizing exposure to cyanide and compliance with applicable cyanide regulations.

Applicability

This chapter is applicable to all Temple University employees, to all work conducted under the authority of Temple University, and to all equipment and property managed by Temple University. Non-Temple and contractor personnel will follow the provisions of this chapter while at Temple University facilities.

This chapter may apply to facilities, branches, or divisions with any of the following:

  • An employee who may be exposed to mercury at levels greater than or equal to 2.3-ppm
  • Employees who show symptoms of cyanide exposure.
  • Facilities that store cyanide-containing compounds.
  • Facilities that generate cyanide-containing hazardous waste.

Regulations

Currently there are no federal regulations concerning the use, storage, or disposal of cyanide-containing chemicals and products. The National Institutes for Occupational Health and Safety (NIOSH) has established a recommended exposure limit of 0.2-ppm (parts per million) for 15-minutes of exposure. The American Conference of Governmental Industrial Hygienists has also established a threshold limit value (TLV) of 4.7-ppm.

Health Effects

Poisoning results mainly from breathing hydrogen cyanide gas or cyanide dust, but can also occur by absorption through the skin following contact with solutions of cyanide salts or even with hydrogen cyanide in the air. Cyanide dust can be absorbed through the skin if the dust is dissolved in sweat or other moisture.

Acute exposure to cyanide can result in symptoms including weakness, headache, confusion, vertigo, fatigue, anxiety, dyspnea (“air hunger”), and occasionally nausea and vomiting. Respiratory rate and depth are usually increased initially and at later stages become slow and gasping. Coma and convulsions occur in some cases. If cyanosis (bluish/grayish discoloration of the skin) is present, it usually indicates that respiration has either ceased or has been inadequate for a few minutes. If large amounts of cyanide have been absorbed, collapse is usually instantaneous. Unconsciousness, often with convulsions, is followed almost immediately by death.

Chronic exposure to cyanide can result in symptoms similar to those reported after acute exposure, e.g., weakness, nausea, headache, and vertigo. Dermatitis, itching, scarlet rash, papules, and severe nose irritation have also been reported. In addition, long-term exposures have produced thyroid changes, including goiter. Only occasionally has reference been made to eye irritation, conjunctivitis, or superficial keratitis developing after chronic exposure to hydrogen cyanide gas.

Responsibilities

Environmental Health and Radiation Safety Department (EHRS)

The EHRS has the following responsibilities related to cyanide activities:

  • Policy development.
  • Surveillance as requested by responsible supervisor.
  • Training as requested by responsible supervisor.
  • Exposure monitoring.

Supervisors and Managers

Supervisors and Managers have the following responsibilities related to cyanide activities:

  • Assessment of their site and operations to determine whether cyanide is present or used.
  • All persons designated as cyanide users shall be issued a copy of this section by their supervisor. The copy should be kept in the user's laboratory for reference. Additional copies are available through the EHRS.
  • Where possible, alter the process to eliminate the need for cyanide or substitute cyanide with a less toxic substance.
  • Ensure all safe practices involving cyanide are in accordance with statutory requirements, including appropriate codes of practice and standards. Consult EHRS for assistance.
  • Ensure all emergency first aid equipment is in place, maintained, and that trained staff is available.
  • Ensure ready access to emergency phone numbers.
  • Notify EHRS of the storage, handling and use of cyanide.
  • Review and approve proposed uses of cyanide containing products in areas within their jurisdiction. Such approval signifies that management will provide the resources necessary to control hazards and will establish, as organization policy, the procedures necessary to comply with OSHA, EPA, and other government regulations. Such compliance may include the following actions:
  • Provide employee training regarding the safe use, storage, and disposal of cyanide, or request this training from the EHRS department.
  • Document training. The documentation may be sent to the EHRS department.
  • Maintain an adequate stock of required personal protective equipment (PPE).
  • Provide equipment such as eyewash stations, showers, and ventilation devices when required.
  • Make requests to the EHRS department for required exposure monitoring and surveillance of work activities.
  • Maintain relevant Material Safety Data Sheets (MSDSs) for cyanide products used.
  • Arrange for transportation and disposal of cyanide-related waste.
  • Make regular visual inspections for leaks and spills for facilities with cyanide.

Cyanide Users

Cyanide users are those workers who work with or handle cyanide-containing products in their job. These workers have the following responsibilities related to cyanide activities:

  • Follow all safe practices involving cyanide use. Consult the EHRS for assistance.
  • Know emergency phone numbers.
  • Attend required training classes.
  • Properly use and maintain PPE.
  • Comply with Temple University, OSHA, and EPA and other government regulations as they pertain to cyanide use.

Exposure Monitoring

The level of cyanide exposure for a particular work activity dictates the regulatory requirements for exposure monitoring, engineering controls, PPE, training, and medical surveillance. Initial exposure monitoring must be conducted to determine the likely exposure for a work activity. When initial exposure monitoring results show that airborne cyanide is below the exposure levels specified below, the facility may discontinue monitoring. However, any time there is a change in the work activity, personnel, equipment, or control measures that may result in new or additional exposure to cyanide, monitoring must be resumed. Furthermore, if an employee indicates signs or symptoms of cyanide exposure, additional monitoring must be conducted. For certain exposure situations, the air monitoring requirements can be relieved if it can be proven with objective data that an employee is exposed below the Action Level. For example, if a chemist is exposed below the Action Level while performing continuous cyanide activities, objective data might indicate that a second worker in the same area, who does not work with cyanide, is also exposed below the Action Level.

As required by OSHA, within 15 days of the employer receiving the results of exposure monitoring, the employer shall notify the affected employees of the results in writing. If monitoring results reveal exposure levels above the NIOSH Recommended Exposure Limit (REL), the employer shall immediately cease activities and shall implement a written plan that describes what actions will be taken to reduce employee exposure to or below the PEL. This written plan shall be distributed to all affected employees.

In addition to personal exposure monitoring, area air monitoring should also be performed to document levels within the work area. Area air monitoring data can be a worst-case exposure indicator for casually exposed workers. The EHRS should be contacted to conduct both personal and area air monitoring activities.

Exposures above the Action Level

The adopted Action Level (AL) for cyanide is 2.3-ppm during any 15-minute work period. If the initial exposure monitoring indicates that an employee exposure is at or above the Action Level, the supervisor must ensure that the following activities are implemented:

  • Periodic personal exposure monitoring must be conducted at least every six months under the worst conditions. This periodic monitoring may be terminated if two consecutive monitoring results, at least seven days apart, indicate exposures less than the AL.
  • Establish a cyanide medical monitoring program for affected employees.

Exposures above the Ceiling Limit (CL)

The OSHA-defined ceiling limit PEL for cyanide is 10-ppm. The National Institutes for Occupational Safety and Health (NIOSH) has established a ceiling limit Recommended Exposure Limit (REL) of 4.7-ppm. Temple University has chosen to adopt the more stringent REL. If initial exposure monitoring indicates that an employee exposure is at or above the REL, the supervisor must immediately cease all activities and evacuate the area. Re-entry will not be allowed until the EHRS evaluates the area.

Controlling Cyanide Exposure

Engineering Controls - Ventilation Systems

It is the policy of the Temple University that all cyanide-related work activities with potential for exceeding the Action Level shall implement feasible engineering controls. Examples of engineering controls include ventilation systems, laboratory hoods, enclosures, shields, barriers, isolation chambers, automatic emergency shut off valves, and remote-control equipment.

The following considerations should be included in the design and installation process for such equipment:

  • The ventilation systems must be 100-percent exhausted to the outside of the building; thus, dilution ventilation is prohibited. On an annual basis, laboratory fume hoods must be evaluated for proper operation and airflow. The EHRS provides these services upon request.
  • To minimize cyanide exposure and control the buildup of gases and vapors in the general work area, it is important that adequate room ventilation be provided. The recommended ventilation rate for laboratory areas is 4 to 12 air changes per hour. To prevent gas and vapor migration into adjacent areas, the cyanide work area should be maintained at a negative air pressure with respect to surrounding rooms. In addition, it is essential that air in the cyanide work area be 100-percent exhausted to the outdoors. The exhaust duct stack must be located a sufficient distance from any building air intakes to prevent re-introduction of contaminated air.
  • If the facility ventilates containers of contaminated clothing and equipment, the facility shall establish an appropriately labeled storage area for this purpose, and locate and arrange it in a manner that minimizes cyanide exposure. The facility shall allow only persons trained in recognizing the hazards of cyanide to remove containers from the storage area.

Personal Protective Equipment (PPE)

Impermeable Gloves and Body Covering: Impermeable gloves and body covering, such as chemical-resistant aprons, will reduce exposure in cases of splash hazards or other skin contact. Consult the EHRS department for material options.

Eye and Face Protection: Eye protection in the form of goggles will reduce exposure in cases of splash hazards.

Respiratory Protection

Respiratory protection, in the form of supplied air or air-purifying type, is not allowed as a substitute for engineering controls, but may be required in cases where engineering controls alone will not adequately reduce exposures. For air purifying respirators, specific cyanide cartridges are available. When employees are required to wear respirators to reduce exposure, they must be enrolled in a Respiratory Protection Program, as required by OSHA. The Temple University requires respirator use in the following situations:

  • During emergencies, and entry into areas of unknown cyanide concentration.
  • During the period to evaluate, purchase, and install engineering control equipment and/or modify work practices to achieve compliance with the REL.
  • In work situations where engineering and work practice controls are not yet capable of reducing employee cyanide exposure to or below the REL.
  • During cleaning, maintenance, repair, and other work where engineering and work practice controls are not feasible.

Work Practices

Each facility shall examine the work practices that employees use, and consider alternative work practices that will minimize exposure.

Leak and Spill Detection

Facilities with cyanide shall create and maintain a program to detect leaks and spills. The equipment leak and spill detection program shall include:

  • Regular visual inspections for leaks and spills;
  • Preventative maintenance of equipment, including surveys for leaks, at regular intervals;

Emergency Showers, Eyewash Stations

If there is an eye splash possibility eyewash stations must be present in the immediate work area. Showers must be present in the immediate work area if there is a splash hazard. The locations of the stations must be close enough so that an injured worker can reach one within ten seconds.

Emergency Communications

A telephone or other communications device must be installed near the work area where cyanide or cyanide compounds are being used. This should not be in the immediate area, as it will be within the area of contamination if a cyanide spill or leak occurs. The communications device must be easily accessible.

Emergency Situations

The EHRS department will provide cleanup assistance. Do not attempt to clean up spills or leaks involving hydrogen cyanide.

Leave the area and get to fresh air. In case of skin/eye contact with liquid, immediately remove contaminated clothing and flush affected areas with water. Any exposure (inhalation, absorption, and ingestion) to cyanide shall require immediate transportation to the Temple University Hospital Emergency Department for evaluation.

Cyanide-Contaminated Waste

Any cyanide waste must be characterized in accordance with EPA regulations. Waste determined to be hazardous will be affixed with a hazardous waste label, and handled on site for proper disposal by a hazardous waste contractor, as arranged by the EHRS Chemical Hygiene Officer. Personnel from the EHRS department must sign all manifests for hazardous waste disposal.

Intentional discharge of cyanide or other hazardous material into the sewer system or storm drain is prohibited. Similarly, hazardous materials may not be disposed of by evaporation in a fume hood. If such an incident does occur, it may be reportable to local, state or federal authorities, and shall be reported immediately to the EHRS department.

Where vapors may be exhausted as a by-product of work being done with cyanide (not as a means of disposal), the fume hood will be equipped with filters to prevent atmospheric releases.

Medical Surveillance Program

The medical surveillance program is provided to monitor the health of cyanide-exposed employees, and determine whether continued exposure will adversely affect their health. The medical surveillance program is mandatory for the following groups of employees;

  • Employees who are exposed at or above the AL.
  • Employees who are exposed at or above the REL.
  • Employees who show symptoms of cyanide exposure.
  • Employees who are exposed during an emergency.

Hazard Communication Program

Implementation of a written cyanide hazard communication program is required of each branch or division that uses cyanide. A copy of the written program must be submitted to the EHRS department for review. The hazard communication program must address the following items:

  • Health risks of cyanide: skin, respiratory tract, eye, and throat irritation; acute and chronic toxic effects
  • Material Safety Data Sheets (MSDSs).
  • Medical surveillance program.
  • Instructions to immediately report signs of cyanide exposure to the supervisor.
  • Uses and limitations of PPE.
  • Instructions for handling spills and emergency situations.
  • Proper work practices and the use of engineering controls.

Employee Training Requirements

Cyanide training shall be provided to all employees and their supervisors where cyanide is used in the workplace. Information regarding this training can be obtained from the EHRS department. This training must be provided at the time of the initial job assignment and whenever the work processes change. At a minimum, the topics addressed in the hazard communication training shall include:

  • The contents of the OSHA Hazard Communication Standard as well as the location and availability of these regulations.
  • The contents of MSDSs.
  • Health risks of cyanide: skin, respiratory tract, eye, and throat irritation; acute and chronic toxic effects.
  • The medical surveillance program.
  • PPE use and limitations.
  • Instructions for the use of engineering controls in minimizing exposure.
  • Instructions for handling spills and emergency situations.
  • Access and location of training materials for the affected employees.

Record-keeping Requirements

The EHRS department will keep accurate and complete records for all cyanide-related work areas. The records shall consist of:

Exposure Monitoring Records, which will include;

  • The date the measurement was taken.
  • The operation that is being monitored.
  • The sampling and analytical methods used and evidence of their precision and accuracy.
  • The number, duration, time of day, and results of samples obtained.
  • The types of protective devices worn.
  • The names, job classifications, social security numbers, and exposure estimate of employees whose exposure is represented by actual monitoring results.
  • When it is felt that objective data will relieve exposure-monitoring requirements, records shall consist of the objective data and calculations that demonstrate that no employee is exposed to cyanide at or above the Action Level.
  • Exposure monitoring records shall be kept for the duration of the employee's employment plus at least 30 years.

Medical Evaluation Records, shall consist of:

  • The name and social security number of the employee.
  • The physician's written opinion.
  • A list of employee health complaints that may be related to exposure to cyanide.
  • A copy of the employee's medical examination results, medical questionnaires, and results of medical tests that are required by the regulation or mandated by the examining physician.
  • Medical evaluation records shall be kept for the duration of the employee's employment plus at least 30 years.

Respirator Fit Test Records shall consist of:

  • A copy of protocol used to test the fit of negative-pressure respirators.
  • The-name and social security number of each employee assigned to wear a negative-pressure respirator.
  • The date of the employee's most recent respirator fit test and a copy of the test results.
  • A list of the brands, types, and sizes of respirators available at the facility from which respirator selection and assignment was made.
  • Respirator fit test records shall be kept until replaced by a more recent record.
  • Contractors are responsible for complying with these record-keeping requirements for their own employees.

5.13 – Nitrous Oxide Safety

Introduction

Purpose

This chapter provides guidelines for minimizing exposure to nitrous oxide and compliance with applicable nitrous oxide regulations.

Applicability

This chapter is applicable to all Temple University employees, to all work conducted under the authority of Temple University, and to all equipment and property managed by Temple University. Non-Temple and contractor personnel will follow the provisions of this chapter while at Temple University facilities.

Regulations

Currently there are no OSHA regulations concerning the use of Nitrous Oxide. The National Institutes for Occupational Health and Safety (NIOSH) has established a recommended exposure limit of 25-ppm (parts per million) for the period of exposure.

Health Effects

NIOSH recognizes that Nitrous Oxide can freeze tissue. When present in high enough concentrations in the atmosphere, suffocation may result as it replaces oxygen. It may also cause drowsiness, euphoria or unconciousness. There is also evidence that it may cause adverse effects in unborn babies.

Responsibility

Environmental Health and Radiation Safety Department

The EHRS department has the following responsibilities related to Nitrous Oxide activities:

  • Policy development.
  • Surveillance as requested by responsible supervisor.
  • Training as requested by responsible supervisor.
  • Exposure monitoring.

Supervisors and Managers

Supervisors and Managers have the following responsibilities related to Nitrous Oxide activities:

  • Assessment of their site and operations to determine whether Nitrous Oxide is present or used.
  • A copy of this procedure should be made available to all users. Additional copies are available through the EHRS department.
  • Review and approve proposed uses of Nitrous Oxide containing products in areas within their jurisdiction. Such approval signifies that management will provide the resources necessary to control hazards and will establish, as organization policy, the procedures necessary to comply with OSHA, EPA, and other government regulations. Such compliance may include the following actions:
  • Provide employee training regarding the safe use, storage, and disposal of Nitrous Oxide.
  • Ensure the availability and proper function of safety equipment, i.e., nitrous oxide alarms, ventilation equipment, vacuum scavenging equipment (as appropriate), respirators and gloves.
  • Assure that anesthesia equipment related to the use of Nitrous Oxide is evaluated on a quarterly basis.
  • Maintain records of equipment evaluation.
  • Maintain an adequate stock of required personal protective equipment (PPE).
  • Provide equipment such as eyewash stations, showers, and ventilation devices when required.
  • Make requests to the EHRS department for required exposure monitoring and surveillance of work activities.
  • Maintain relevant Material Safety Data Sheets (MSDSs) for Nitrous Oxide products used.
  • Make regular visual inspections for leaks for facilities with Nitrous Oxide.
  • Do not expose pregnant women to Nitrous Oxide, as it may cause adverse reproductive effects.
  • Control waste Nitrous Oxide with a scavenging system that includes securely fitting masks, sufficient flow rates for the exhaust system, and properly vented vacuum pumps.

Nitrous Oxide Users

Nitrous Oxide users are those workers who work with or handle Nitrous Oxide-containing products in their job. These workers have the following responsibilities related to Nitrous Oxide activities:

  • Attend required training classes.
  • Properly use and maintain PPE.
  • Comply with Temple University and government regulations as they pertain to Nitrous Oxide use.
  • Inspect all anesthetic delivery systems and connections before starting anesthetic gas administration.
  • Eliminate or replace loose-fitting connections, loosely assembled or deformed slip joints and threaded connections, and defective or worn seals, gaskets, breathing bags and hoses.

Facilities Engineers

The Facilities Engineering Supervisor for an area where Nitrous Oxide is used shall;

  • Ensure that his staff is trained in the safe handling of Nitrous Oxide.
  • Ensure the availability of safety equipment for his employees.
  • Notify the EHRS department whenever a change to the ventilation system may effect the exhausting of the Nitrous Oxide from the work area(s).

Exposure Monitoring

There are no regulatory requirements for Nitrous Oxide exposure levels or monitoring frequency, however Temple University had adopted the Recommended Exposure Limit of 25-ppm. Monitoring is performed when requested and to develop a base-line database of worker exposures. The Temple University defined action level (AL) for Nitrous Oxide is 12.5-ppm, as an eight-hour time weighted average.

Controlling Nitrous Oxide Exposure

Engineering Controls - Ventilation Systems

It is the policy of the Temple University that all Nitrous Oxide-related work activities with potential for exceeding the Action Level shall implement feasible engineering controls. Examples of engineering controls include ventilation systems, air pollution control devices, laboratory hoods, enclosures, shields, barriers, isolation chambers, automatic emergency shut off valves, and remote-control equipment.

The following considerations should be included in the design and installation process for such equipment:

  • To minimize Nitrous Oxide exposure and control the buildup of gases and vapors in the general work area, it is important that adequate room ventilation be provided. The recommended ventilation rate for laboratory areas is 4 to 12 air changes per hour. To prevent gas and vapor migration into adjacent areas, the Nitrous Oxide work area should be maintained at a negative air pressure with respect to surrounding rooms. In addition, it is essential that air in the Nitrous Oxide work area be 100-percent exhausted to the outdoors. The exhaust duct stack must be located a sufficient distance from any building air intakes to prevent re-introduction of contaminated air.
  • If the facility ventilates containers of contaminated clothing and equipment, the facility shall establish an appropriately labeled storage area for this purpose, and locate and arrange it in a manner that minimizes Nitrous Oxide exposure. The facility shall allow only persons trained in recognizing the hazards of Nitrous Oxide to remove containers from the storage area.

Work Practices

Each facility shall examine the work practices that employees use, and consider alternative work practices that will minimize exposure.

Container Labels

Containers of Nitrous Oxide must have labels indicating that they contain Nitrous Oxide. The label must list the name and address of the responsible person; and must state that physical and health hazard information is readily available from the employer and from MSDSs.

Leak Detection

Facilities with Nitrous Oxide shall create and maintain a program to detect leaks. The equipment leak detection program shall include:

  • Regular visual inspections for leaks;
  • Preventative maintenance of equipment, including surveys for leaks, at regular intervals;
  • Prompt repair of leaks by persons wearing appropriate protective clothing and equipment and who are trained in the proper methods.

Emergency Situations

  • Immediately evacuate all persons in the area!
  • Close all the doors.
  • Notify in the following order:
  • Campus Police (1-1234) or Page Operator (2-4545).
  • EHRS (215-707-2520) or Page Operator (215 707-4545). Response is available 24-hrs/day, 7-days/week.
  • Do not re-enter until the EHRS representative has monitored the atmosphere and cleared the room(s) for re-entry.

Medical Surveillance Program

The medical surveillance program is provided to monitor the health of Nitrous Oxide-exposed employees, and determine whether continued exposure will adversely affect their health.

  • The medical surveillance program is mandatory for the following groups of employees: Employees who are exposed at or above the Action Level.
  • The medical surveillance program is optional for the following groups of employees: Employees who show symptoms of Nitrous Oxide exposure and employees who are exposed during an emergency.

Hazard Communication Program

The hazard communication program must address the following items:

  • Material Safety Data Sheets (MSDSs)
  • Container labeling of Nitrous Oxide
  • Instructions to immediately report signs of Nitrous Oxide exposure to the supervisor.
  • Uses and limitations of PPE.
  • Instructions for handling leaks and emergency situations.
  • Proper work practices and the use of engineering controls.

Employee Training Requirements

Nitrous Oxide training is part of the workplace Hazard Communications Training that shall be provided to all employees. Information regarding this training can be obtained from the EHRS department. This training must be provided at the time of the initial job assignment and whenever there is a change to the work process. At a minimum, the topics addressed in the hazard communication training shall include:

  • The contents of the OSHA Hazard Communication Standard (29 CFR 1910.1200), as well as the location and availability of these regulations.
  • The contents of MSDSs.
  • Health risks of work place hazards
  • The medical surveillance program.
  • PPE use and limitations.
  • Instructions for the use of engineering controls in minimizing exposure.
  • Instructions for handling leaks and emergency situations.
  • Access and location of training materials for the affected employees.
  • Container labeling requirements.

Record-keeping Requirements

The EHRS department will keep accurate and complete records for all Nitrous Oxide-related work areas. The records shall consist of:

Exposure Monitoring Records, which will include;

  • The date the measurement was taken.
  • The operation that is being monitored.
  • The sampling and analytical methods used and evidence of their precision and accuracy.
  • The number, duration, time of day, and results of samples obtained.
  • The types of protective devices worn.
  • The names, job classifications, social security numbers, and exposure estimate of employees whose exposure is represented by actual monitoring results.
  • When it is felt that objective data will relieve exposure-monitoring requirements, records shall consist of the objective data and calculations that demonstrate that no employee is exposed to cyanide at or above the Action Level.
  • Exposure monitoring records shall be kept for the duration of the employee's employment plus at least 30 years.

Medical Evaluation Records, shall consist of:

  • The name and social security number of the employee.
  • The physician's written opinion.
  • A list of employee health complaints that may be related to exposure to cyanide.
  • A copy of the employee's medical examination results, medical questionnaires, and results of medical tests that are required by the regulation or mandated by the examining physician.
  • Medical evaluation records shall be kept for the duration of the employee's employment plus at least 30 years.

Respirator Fit Test Records shall consist of:

  • A copy of protocol used to test the fit of negative-pressure respirators.
  • The-name and social security number of each employee assigned to wear a negative-pressure respirator.
  • The date of the employee's most recent respirator fit test and a copy of the test results.
  • A list of the brands, types, and sizes of respirators available at the facility from which respirator selection and assignment was made.
  • Respirator fit test records shall be kept until replaced by a more recent record.
  • Contractors are responsible for complying with these record-keeping requirements for their own employees.

5.14 – Lead Safety

Introduction

Purpose

This chapter has been developed to inform the University community of the University’s lead management program, and to outline work procedures for employees that disturb or contact potential lead containing materials during the course of their work.

Applicability

This chapter is applicable to all Temple University employees and contractors who may be occupationally exposed to lead.

Reference Regulations

The current regulations referenced concerning occupational exposure to lead are as follows:

“Lead”-Occupational Safety and Health Administration (OSHA) 29CFR 1910.1025 & 1926.62

“Residential Lead-Based Paint Hazard”-Environmental Protection Agency (EPA) 40 CFR 745

“Prohibition on use of lead pipes, solder, and flux”, (EPA) 40 CFR 141.43 & 141.86 & 141.80

“Lead Contamination”-U.S. Department of Housing and Urban Development (HUD) Control Act of 1988, 42 U.S.C. 201

“Preventing Lead Poisoning in Construction Workers”-National Institute for Occupational Safety and Health (NIOSH) Publication No.91-116a

Definitions

Action Level for Airborne Concentrations of Lead - employee exposure, without regard to the use of respirators, to an airborne concentration of lead of 30 micrograms per cubic meter of air (30 ug/m3) calculated as an 8-hour time weighted average (TWA).

Action Level for Lead in Drinking Water - action level is exceeded if the concentration of lead in more than 10 percent of tap water samples collected during any monitoring period conducted is greater than .015 mg/L.

Certified Inspector - an inspector who is certified as an inspector under a Federally accredited State certification program or under a Federal or State certification program.

Lead - includes all metallic lead, all inorganic lead compounds, and organic lead soaps.

Lead-Based Paint - defined by the EPA as paint or other surface coatings that contain lead equal to or in excess of 1.0 milligram per square centimeter (mg/cm2) or 0.5 percent by weight.

Lead-Based Paint Free - defined by the EPA as target housing that has been found not to contain paint or surface coatings with lead equal to or in excess of 1.0 mg/cm2 or 0.5 percent by weight. A certified inspector must make this determination.

Lead Containing Material (LCM) - building materials containing lead at any detectable concentration.

Lead Free – plumbing materials used in public water systems such as solders and flux which contain no more than 0.2 percent lead, and pipes and pipe fittings no more than 8.0 percent lead.

Permissible Exposure Limit (PEL) - occupational exposure to lead concentrations greater than 50 micrograms per cubic meter (50 ug/m3) calculated as an 8-hour time weighted average (TWA).

Target Housing - residential housing built before 1978 including private housing, public housing, and housing receiving federal assistance.

Target Housing does not include:

  • Housing built after 1978.
  • Zero bedroom units (such as efficiencies), lofts and dormitories, unless children under the age of 6 reside or are expected to reside there.
  • Housing leased for less than 100 days.
  • Housing reserved for the elderly, or handicapped, unless children under the age of 6 reside or are expected to reside there.
  • Rental housing inspected by a certified inspector and found to be lead-based paint free.

Health Effects

Short-term exposure may cause adverse effects on the gastrointestinal tract, blood, central nervous system and kidneys, resulting in colics, shocks, anemia, kidney damage and encephalopathy. Exposure may result in death. However, effects may be delayed.

Long-term exposure may cause adverse effects on the gastrointestinal tract, nervous system, blood, kidneys and the immune system resulting in severe lead colics, paralysis of muscle groups of the upper extremities (forearm, wrist and fingers), mood and personality changes, and anemia. Repeated exposure may also cause retarded mental development, and nephropathy, as well as retarded development of the newborn.

Responsibilities for Lead Safety

Environmental Health and Radiation Safety Department (EHRS)

The EHRS has the following responsibilities related to lead activities:

  • Policy development.
  • Surveillance as requested by responsible supervisor.
  • Training as requested by responsible supervisor.
  • Exposure Monitoring: Coordinate and/or contract consulting services to survey and monitor lead disturbance activities.
  • Monitoring Drinking Water: Coordinate with Facilities Maintenance and/or contract consulting services to survey and monitor any plumbing installed prior to June 19, 1986 which provides water for human consumption.

Supervisors and Managers

Assure that employees who may disturb lead containing material during construction and renovation activities receive training in accordance with this Guideline. In addition, assure that employees practice safe work procedures in accordance with their training, and use the proper equipment and controls.

Allocate resources to support the implementation of this Guideline. Contact EHRS to request technical assistance and to provide air monitoring when necessary.

Employees

Comply with this Guideline and any further safety recommendations initiated by your Supervisor or EHRS. Conduct assigned tasks in a safe manner, wear appropriate personal protective equipment, and use only equipment for which training has been provided. Contact the EHRS to evaluate health and safety conditions within your unit.

Facilities Planning, Design and Construction Management

Contact the EHRS during the design phase of projects that may involve the disturbance of suspect lead containing material when the scope of the project will include:

  • Scraping, hand-sanding, or otherwise removing lead containing material/paint from existing surfaces.
  • Cutting, drilling, abrading, demolishing, or otherwise disturbing building elements coated with lead containing material/paint.
  • Removal of lead sheet products such as, radiation shielding, soundproofing, flashing, and piping.
  • Coordinate with Facilities Maintenance and/or contract consulting services to survey and monitor for lead in any plumbing installed prior to June 19, 1986, which provides water for human consumption.

Engineering Controls and Personal Protective Equipment (PPE)

Depending upon the work performed involving lead, engineering controls and PPE will vary. Please contact the EHRS at 2-2520 for recommendations, and technical support.

Target Housing or Lease Disclosure

Before the sale or rental of pre-1978 target housing can take place, the University must provide the following information to the potential purchaser or lessee before being obligated under any contract to purchase or lease the property:

  • The EPA booklet "Protect Your Family from Lead in Your Home".
  • Any and all reports and records the University has that contains information on the presence, location or condition of any known lead-based paint and/or lead-based paint hazards in any portion of the target housing. The University is not obligated to perform any testing, but if testing reports exist, they must be disclosed.
  • A "Disclosure of Information" form attached to the contract, which contains a “Lead Warning Statement" as prescribed by 40 CFR Part 745 of the EPA Lead Disclosure regulation. A statement disclosing the presence of known lead-based paint or indicating no knowledge of lead-based paint.
  • A statement by the purchaser or lessee affirming receipt and review of the information provided, and signatures of the purchaser or lessee and a University representative.
  • Before the sale or rental of residential property, the University must give the purchaser or lessee a 10-day period to conduct a risk assessment or inspection for the presence of lead-based paint and/or lead-based paint hazards, unless the parties mutually agree in writing to a different period of time. The purchaser or lessee may waive the risk assessment or inspection opportunity by so indicating in writing.
  • The "Disclosure of Information" will be kept on file for three years with the University department holding the contract or closing documents. All building lead survey reports will be kept on file at the EHRS department.

The University is not obligated to perform residential building surveys before the sale or rental of residential property under this regulation. However, the University may choose to conduct a survey performed by a certified inspector and become exempt from the disclosure requirements if the building is found to be lead-based paint free.

Water Management

Federal and State regulations require that any plumbing in a residential or non-residential facility providing water for human consumption that is connected to a public water system is to be “lead free”. Any water system designed for drinking that was installed on Temple University property prior to June 19, 1986 must be randomly sampled for lead contamination. All documentation of sampling will be kept on file in the EHRS department.

Medical Surveillance Program

The medical surveillance program is provided to monitor the health of all employees who have the potential to be exposed to lead above the action level in their work environment.

Medical Evaluation of Records

Records shall consist of:

  • The name and social security number of the employee.
  • The physician's written opinion.
  • A list of employee health complaints that may be related to lead exposure.
  • A copy of the employee's medical examination results, medical questionnaires, and results of medical tests that are required by the regulation or mandated by the examining physician.

Medical evaluation records shall be kept for the duration of the employee's employment plus at least 30 years.

Record keeping Requirements

Environmental Health and Radiation Safety (EHRS) and Facilities Maintenance (FM) will keep accurate and complete records for all lead related work areas. The records shall consist of:

Exposure Monitoring Records

  • The date the measurement was taken.
  • The operation that is being monitored.
  • The sampling and analytical methods used and evidence of their precision and accuracy.
  • The number, duration, time of day, and results of samples obtained.
  • The types of protective devices worn.
  • The names, job classifications, social security numbers, and exposure estimate of employees whose exposure is represented by actual monitoring results.

When it is felt that objective data will relieve exposure-monitoring requirements, records shall consist of the objective data and calculations that demonstrate that no employee is exposed to lead at or above the Action Level.

Exposure monitoring records shall be kept for at least 30 years.

5.15 – Hydrofluoric Acid Safety

Introduction

Hydrofluoric acid (HF) differs from other acids because the fluoride ion readily penetrates the skin, causing destruction of deep tissue layers, including bone. Pain associated with exposure to solutions of HF (1-50%) may be delayed for 1-24 hours. If HF is not rapidly neutralized and the fluoride ion bound, tissue destruction may continue for days and result in limb loss or death. HF is similar to other acids in that the initial extent of a burn depends on the concentration, the temperature, and the duration of contact.

Purpose

This policy and procedure has been developed in order to promote the safe use and handling of Hydrofluoric Acid.

Applicability

This policy and procedure is applicable to all Temple Unversity employees, and to all work conducted under the authority of Temple University that deals with Hydrofluoric acid.

Physical Data

Chemical Name: Hydrofluoric Acid

Chemical Family: Inorganic Acid

Chemical Formula: HF

Synonyms: HF, Hydrofluoride, Fluoric Acid

Description: Colorless gas or fuming liquid (below 153°F) with a strong, irritating odor.

Boiling Point: 153° F (67° C)

Specific Gravity: 1.2 (H2O = 1)

Ionization Potential: 15.98 eV
Solubility in Water: Miscible

Vapor Density: 2.21 (Air = 1)

Odor Threshold: 0.5 – 3 ppm (caution: reported range is very broad)

Flammability: Nonflammable

Exposure Limits

American Conference of Governmental Industrial Hygienist (ACGIH) Threshold Limit Value (TLV):

  • 8-Hour Time Weighted Average (TWA): Not Listed
  • Ceiling: 3 ppm (2.3 mg/m3)
  • Skin Notation: Not Listed
  • Carcinogen: Not Listed

TLV Ceiling value based on irritation with possible burns and effects to bone, teeth, and fluorosis.

National Institute of Occupational Safety and Health (NIOSH) Recommended Exposure Limit (REL):

  • 8-Hour Time Weighted Average (TWA): 3 ppm (2.3 mg/m3) Ceiling: 6 ppm (5 mg/m3) (15-minute)
  • Skin Notation: Not Listed
  • Carcinogen: Not Listed
  • IDLH VALUE: (Immediately Dangerous To Life and Health): 30 ppm

NOTE: A TWA concentration is for an 8-hour workday (ACGIH-TLV, OSHA-PEL) and up to a 10-hour workday (NIOSH-REL) during a 40-hour workweek. A STEL value is a 15-minute TWA exposure that should not be exceeded at any time during a workday. A Ceiling value should never be exceeded for even an “instantaneous” exposure period.

Health Hazard Data: Dermal Exposure

DERMAL EXPOSURE - HF is an inorganic acid that is highly corrosive and readily penetrates the skin, causing deep tissue layer destruction. Severity and rapidity of onset of signs and symptoms depends on the concentration, duration of exposure, and penetrability of the exposed tissue. Pain may be delayed.

  • CONCENTRATIONS LESS THAN 20% - Erythema and pain may be delayed up to 24 hours, often not reported until tissue damage is extreme.
  • CONCENTRATIONS 20 TO 50% - Erythema and pain may be delayed from 1 to 8 hours, and is often not reported until tissue damage is extreme.
  • CONCENTRATIONS GREATER THAN 50% - Produces immediate burning, erythema, and tissue damage.

Work Practices

Hydrofluoric acid must be used in a properly ventilated area, and any procedure using HF must be performed inside a working fumehood. Never use HF alone in a laboratory. All lab personnel using HF must be informed of the dangers of this chemical and the emergency procedure necessary in case of any accident. All work must be performed near an emergency shower/eyewash station. All HF locations must be registered with EHRS.

Personal Protective Equipment

Personal Protective Equipment must be used when working with Hydrofluoric acid:

  • Face Shield/Goggles/safety glasses
  • Neoprene or Nitrile gloves

Incompatibles and Storage

NEVER STORE HF IN GLASS CONTAINERS!

Store HF in a cool and dry place away from incompatible materials. Hydrofluoric acid reacts with many materials therefore avoid contact with glass, concrete, metals, water, oxidizers, reducers, alkalis, combustilbles, organics and ceramics. HF must be stored in containers made of polyethylene or fluorocarbon plastic, lead, or platinum. HF must also be stored in polyethylene secondary containment.

Spills

All areas where HF is used must be equipped with proper spill equipment. Small spills can be neutralized by covering with acid neutralizer/sodium bicarbonate, and absorbed with spill control pads/absorbents. Once the spill is contained isolate the room and leave the area immediately. If it is a large spill immediately evacuate all persons in the area and close all doors. Any type of spill/accidental release of HF must be reported immediately to Environmental Health and Radiation Safety (EHRS), during working hours at (215) 707-2520 after hours call the page operator at (215) 707-4545 and ask for an Environmental Health and Safety/Radiation Safety representative.

Emergency Procedures

ALL HYDROFLUORIC ACID EXPOSURE SHOULD BE CONSIDERED A MEDICAL EMERGENCY! IMMEDIATELY CONTACT (215) 204-1234 or ON CAMPUS 1-1234 AND ARRANGE FOR IMMEDIATE MEDICAL TRANSPORT. A COPY OF THE MSDS MUST BE TAKEN TO THE HOSPITAL.

Hydrofluoric Acid Exposure Kit:

All labs or areas that store or work with Hydrofluoric acid are required to have a hydrofluoric acid first aid kit. The kit must be located in the area where the Hydrofluoric acid is used and/or stored. The kit must contain at a minimum:

  1. Calcium gluconate gel ( 2.5%).
  2. Proper Personal Protective Equipment (PPE)
    1. 2 pairs of Neoprene or Nitrile (minimum 22 mil) gloves
    2. Safety Glasses
    3. Disposable lab coat or jump suit
  3. Copy of Material Safety Data Sheet (MSDS) specific for Hydrofluoric acid used/stored in area.
  4. Copy of emergency medical treatment instructions

Skin Exposure:

  • Move victim immediately under an emergency shower or other water source and flush the affected area with large amounts of cool running water for at least 5 minutes (15 minutes if HF Exposure kit is not available until emergency personnel arrive on scene).
  • Don proper PPE
  • Remove all contaminated clothing while flushing with water. Clothing is able to absorb the toxic material and maintain it close to the skin.
  • Apply calcium gluconate gel to affected area

Eye Exposure:

  • Immediately flush eyes for at least 15 minutes with copius amounts of cool flowing water until emergency personnel arrive on scene.

Inhalation:

If a large volume of HF gas is inhaled:

  • Immediately remove victim to clean air until emergency personnel arrives on scene.

5.16 – Monitoring for Hazardous Chemicals

Introduction

Purpose

In accordance with applicable regulations and Temple University, this policy was developed to establish a policy for monitoring hazardous chemicals.

Applicability

This policy is applicable to all Temple University employees, to all work conducted under the authority of Temple University, and to all equipment and property managed by Temple University. Non-Temple and contractor personnel must follow the provisions of this policy while at Temple University facilities.

Responsibilities

Environmental Health and Radiation Safety Department (EHRS)

  • Policy implementation.
  • Coordinate exposure monitoring (including equipment and instructions) for the affected departments or areas as requested by responsible supervisor or administrator.
  • Provide technical assistance and support as requested by a responsible supervisor.
  • Provide a summary report with the results of exposure monitoring (if conducted by EHRS) and any recommendations to affected employees and responsible administer.
  • Audit the monitoring records if performed by an outside monitoring service.

Supervisors, Administrators and Managers must:

  • Assess their site and operations to determine whether hazardous chemicals are present or used.
  • Responsible to have proper monitoring performed in the areas where required (such as any area where those chemical listed in Appendix A are used.)
  • Ensure that any area that that is required to be monitored be monitored by either EHRS or an approved outside monitoring service.
  • Ensure that all employees assigned to wear the exposure monitoring equipment follow the instruction provided to them by EHRS or the outside monitoring service.
  • Ensure that all users follow the procedures listed in this document as well as department/hospital specific policies.
  • Comply with the recommendations provided in the summary report

Affected Employees

  • Wear the exposure monitoring equipment as instructed by EHRS or the outside monitoring service.
  • Contact EHRS at 215-707-2520 with any questions regarding proper monitoring procedures.

Definitions:

  • Occupational Exposure Monitoring: Monitoring conducted in the employee’s breathing zone. This type of sampling is most reflective of the employee’s actual exposure to hazardous material.
  • Area Monitoring: Monitoring conducted in the room or area where the hazardous chemical is used. This type of sampling can reflect the potential of exposure to anyone entering the room or area.

Procedures:

Areas to be monitored

Monitoring for hazardous chemicals will be conducted when:

  • Required by a specific safety and health standard
  • Requested by a Department Head or Administrator
  • A new process of procedure involving a hazardous chemical is introduced
  • Employee concerns

Monitoring Methods

Monitoring must be conducted using protocols established by NIOSH, OSHA or other nationally recognized organizations.

All samples requiring laboratory analysis must conducted by an outside independent approved or accredited laboratory.

Reports:

All reports must be given to the person making the request and the responsible department head and/or Administrator within 10 days from receiving the sample results.

Any problems noted must have corrective actions or recommendations associated with them, as well as any applicable codes or regulations involving the chemicals monitored.

Severity of Exposure

The Department of Environmental Health & Radiation Safety will take immediate action when exposures are deemed hazardous to employees, patients, students or visitors.

Appendix A

Regulations and Listing of Some Chemicals that require Exposure Monitoring

Contact EHRS at 215-707-2520 for information regarding the requirements of any chemical that may require exposure monitoring.

5.17 – Hazardous Drug Safety

Introduction

Purpose

In accordance with applicable regulations and the institutional policy, this procedure was developed to minimize exposure to hazardous Drugs (HD).

Applicability

This policy is applicable to all employee of Temple University (TU) and Temple University Health System (TUHS), to all work conducted under the authority of TU and TUHS, and to all equipment and property managed by these entities. Non-Temple and contractor personnel must follow the provisions of this policy while at working at these facilities.

Health Effects

Some studies have shown increased risks of miscarriage or of giving birth to malformed infants for persons occupationally exposed to certain HDs. The degree of risk for employees who are pregnant, or who are actively trying to conceive a child (female or male personnel) is uncertain at the present time.

Responsibilities HD Safety

Environmental Health and Radiation Safety Department (EHRS)

The EHRS has the following responsibilities related to HD activities:

  • Policy implementation.
  • Surveillance as requested by responsible supervisor.
  • Training as requested by responsible supervisor.
  • Exposure monitoring as requested.
  • Provide technical assistance and support as requested by a responsible supervisor.
  • Collect and dispose of any EPA listed hazardous waste

Supervisors and Managers must:

  • Assess their site and operations to determine whether hazardous drugs are present or used.
  • All persons designated as HD users shall be issued a copy of this section by their supervisor. The copy should be kept in the user's laboratory area for reference. Additional copies are available through the EHRS.
  • Ensure that all users follow the procedures listed in this document as well as department/hospital specific policies.
  • Inform all individuals who work with HD regarding health risks and safety precautions. They must also be provided a copy of the HD policy.
  • Provide employee training regarding the safe use, preparation, administration, storage, transportation and disposal of formaldehyde.
  • Provide appropriate stock of required personal protective equipment (PPE).
  • Provide safety equipment such as eyewash stations, showers, etc...
  • Ensure that all Class II, BS Biological Safety Cabinets (BSC) are working properly and are certified by a qualified technician on a semi-annual basis.
  • Maintain an inventory and relevant safety information for HD products that are used, stored and handled.
  • Ensure that anyone who will handle or work with HD is enrolled in a medical surveillance program prior to the start of working with HD.
  • Ensure that all containers of HD are properly stored, labeled and transported.
  • Contact EHRS for guidance for the transportation and disposal of EPA listed hazardous drug waste.
  • Perform periodic visual inspections of areas where HD are used, stored and handled.
  • Making the required report such as release, loss, intentional or unintentional injuries and security breaches
  • Providing additional information regarding safety, security, inventory and health risk of operations to his/her employees as a result of their duties.
  • Develop and maintain site specific Hazardous Drug Safety and Health Plan and Standard Operating Procedures..

Hazardous Drug Users

Hazardous Drug users are those workers who work with or handle HD-containing products in their job. These workers have the following responsibilities related to HD activities:

  • Attend required training classes.
  • Use and maintain safety devices and PPE.
  • Follow the instructions of the PI/supervisor and EHRS
  • Comply with the requirements as stated in this policy.

Knowing who to call in any incident involving HD and how to handle spills, release and personal contamination and exposure, and

Obtaining additional information regarding safety, security, inventory and risk of operations as is necessary to be fully informed regarding ones duties and to accurately assess health related risks.

Definitions:

Hazardous Drugs- Drugs are classified as hazardous when they possess any of the following characteristics

  • Genotoxicity- ability to cause change or mutation in genetic materials(mutagen)
  • Carcinogenicity- ability to cause cancer in animals, humans or both(carcinogen)
  • Teratogenicity-ability to cause defects in fetal development or fetal malformation (teratogen); and fertility impairment.

Antineoplasctic agents- Solutions of 1% (v/v) or greater, which either inhibit the maturation and proliferation of malignant cells or an agent having such properties

Antineoplastic waste- Waste that contains actual measurable volume of a chemotherapy drug or may continue traces.

  • Gross contaminated- Items containing greater than 3 % by volume ( 15 cc or ~ 3 teaspoons of fluid) of antineoplastic agents.
  • Trace Contaminated- Material which has come into contact with a prepared antineoplastic agent, such as gloves, gowns, linen or other material soiled by excreta of patients or animals being treated with antenoplastic agents (up to 72 hours after treatment), IV bags, vials, syringes tubing, or containers with less than 3% by volume (not exceeding 15 cc or ~ 3 teaspoons of fluid) remaining in them, or chux contaminated with small amounts of the drug.

Listed Hazardous Waste- The Environmental Protection Agency considers some hazardous drugs to be considered as RCRA hazardous waste. These listed wastes must be handled through the Hazardous Waste Management Program through EHRS. Contact EHRS for additional information at 215-707-2520. Some examples are:

  • Chlorambucil (Leukeran)
  • Cyclophoasamide (Cytoxan)
  • Daunorubicin (Daunomycin, Cerubidine)
  • Melphhalan ( Alkeran)
  • Mitomycin (Mitomycin C, Mutamycin)
  • Steptozocin 9Zanosar, Streptozocin)
  • Uracil Mustard (Uramustine)

Exposure Monitoring

Exposure monitoring may be necessary for particular hazardous drugs. Please consult the Material Safety Data Sheet (MSDS) for additional information or contact the EHRS office at 215-707-2520.

Controlling HD Exposure

Engineering Controls - Ventilation Systems

Engineering controls should be implemented when there is a potential for exposure. Examples of engineering controls include ventilation systems, air pollution control devices, laboratory hoods, enclosures, shields, barriers, isolation chambers, automatic emergency shut off valves, and remote-control equipment.

The following considerations should be included in the design and installation process for such equipment:

  • The use of a Class II-Type B Biological Safety cabinet is required for any area that is used in the preparation of a HD or where there is the potential for exposure. The BSC must be installed and maintained according the NSF-49 (most recent version). In addition, the BSC must be certified by a qualified technician on a semi-annual basis.
  • The ventilation systems must be 100-percent exhausted to the outside of the building; thus, dilution ventilation is prohibited. Laboratory fume hoods must be evaluated for proper operation annually. If requested, EHRS can provide evaluation of the fume hood.
  • To minimize HD exposure and control the buildup of gases and vapors in the general work area, it is important that adequate room ventilation be provided. The recommended ventilation rate for laboratory areas is 4 to 12 air changes per hour. To prevent gas and vapor migration into adjacent areas, the formaldehyde work area should be maintained at a negative air pressure with respect to surrounding rooms. In addition, it is essential that air in the HD work area be 100-percent exhausted to the outdoors. The exhaust duct stack should be located away from any building air intakes to prevent re-introduction of contaminated air.

Personal Protective Equipment (PPE)

PPE provides additional protection even with proper engineering controls in place. PPE must be worn during the preparation, handling, use, administration and disposal of all hazardous drugs It is required that employees wear chemical protective clothing and eye protection. Consult the Material Safety Data Sheet (MSDS) or contact EHRS for additional guidance.

Additional PPE may be necessary instances where there is an increased likelihood of the generation of splashes, sprays or the generation of aerosols. All PPE must be replaced if damaged or torn.

NOTE: Surgical masks offer little or no protection against inhalation of HD's. Do not rely on surgical masks for adequate personal protection.

The following are examples of proper PPE:

Impermeable Gloves and Body Covering: Impermeable gloves and body covering, such as chemical-resistant aprons, will reduce exposure in cases of splash hazards or other skin contact. Nitrile rubber is an appropriate choice for glove material. Consult EHRS for additional information.

Eye and Face Protection: Eye protection in the form of goggles will reduce exposure in cases of splash hazards.

Respiratory Protection

Respiratory protection, in the form of supplied air or air-purifying type, is not allowed as a substitute for engineering controls, but may be required in cases where engineering controls alone will not adequately reduce exposures. For air purifying respirators, specific cartridges are available. When employees are required to wear respirators to reduce exposure, they must be enrolled in a Respiratory Protection Program, as required by OSHA. The Temple University requires respirator use in the following situations:

  • During emergencies and entry into areas of unknown concentrations of HD
  • During the period to evaluate, purchase, and install engineering control equipment and/or modify work practices to achieve compliance and reduce an employee’s exposure level.
  • In work situations where engineering and work practice controls are not yet capable of reducing employee HD exposure to acceptable level.
  • During cleaning, maintenance, repair, and other work where engineering and work practice controls are not feasible.

Work Practices

Each facility shall review each employee’s work practices with HD and implement alternative work practices that will minimize exposure. Please contact EHRS to evaluate the effectiveness of any change.

General Precautions

  • Eating, drinking, smoking, chewing gum and storing food in any area where HDs are handled, stored or used is forbidden.
  • Avoid any techniques or procedures that may release hazardous drugs or generate aerosols (ex. Priming IV sets, expelling air from syringes)
  • Minimize the possible spread of contamination by placing HDs and associated supplies on an absorbent pad (Chux).
  • A spill kit must be available for use in any area where there is a potential for a release.

Preparation Area

  • All HDs must be prepared in a specifically designated area equipped with a certified Class II Biological Safety Cabinet (BSC); Type B. Preparations of HDs anywhere else shall not be permitted.
    • The BSC must be certified by a qualified technician to NSF-49 standards semi-annually and any time the cabinet is physically moved.
    • The inside of the cabinet must be cleaned and decontaminated after each use.
    • The BSC will be operated with the blowers on 24 hours per day, 7 days a week.
  • Warning signs designating areas as hazardous drug preparation areas must be clearly posted.
  • Emergency procedures must be posted in the immediate area.
  • Eyewash must be available in the area where the HD is prepared.
  • A spill kit for chemotherapeutic drugs must be available in the immediate area.
  • Safety syringes must be used for preparing and administering hazardous drug solutions. Care will be taken to ensure that all connections are secure. Syringes will be large enough so that they are not full when containing the total drug dose.
  • Commercially available drugs already in solution will be used when possible.
  • All waste items from hazardous drug preparation will be discarded in the designated waste trash receptacles.
  • All products will be labeled as "Chemotherapy" agents.
  • Consult department specific procedures and policies for additional guidance.

Drug Administration

  • Follow appropriate department or hospital procedures when administering HDs.
  • Follow the general precaution listed above.
  • Personnel administering HDs must wear proper PPE. Two pair offers significantly greater protection, and shall be worn if double gloving does not interfere with techniques. Other protective equipment such as gowns, chemical splash shields, goggles, or respirators may also be required depending on the drug characteristics and the conditions of drug administration. Consult the MSDS for additional information.
  • All unused Hazardous drugs must be handled according to your departmental/hospital policy

CAUTION: Lab coats, and the disposable isolation gowns presently used on nursing units, are easily permeated by these drugs. Do not rely on them to adequately protect you from skin absorption if they become contaminated.

  • Post signage in room alerting other personnel to special precautions.
  • Infusion sets and pumps shall be watched for signs of leakage during use. An absorbent pad must be used during tubing change or IV push administration to catch any leakage.
  • Disposal of appropriate items shall be handled according to the instructions found in the section on waste disposal.

Precautions Following Drug Administration

  • Universal Standard Precautions must be observed to prevent contact with blood or other potentially infectious materials. Under circumstances in which differentiation between body fluid types is difficult or impossible, all body fluids should be considered potentially infectious materials and must be managed appropriately.
  • Personnel dealing with excreta, primarily blood, urine, stool vomit from patients/animals who have received HDs in the last 72 hours should be provided with and wear appropriate PPE. All PPE items are to be discarded after each use or whenever contaminated, as detailed under Waste Disposal. The permeability of gloves increases with time, therefore gloves should be changed regularly (every 30 minutes) or immediately if they are torn or punctured. Eye protection should be worn if splashing is possible. Such excreta contaminated with blood, or other potentially infectious materials as well, should be managed according to department or hospital procedures. Hands shall be washed after removal of gloves or after contact with the above substances.
  • Linen contaminated with HDs or excreta from patients/animals who have received HDs in the past 72 hours is a potential source of exposure to employees. Linen soiled with blood or other potentially infectious materials as well as contaminated with excreta must also be managed according to department/hospital procedures. Linen that is grossly contaminated with HDs should be placed in a large chemotherapy waste container for disposal. Linens used by patients/animals who have received HDs, which are not grossly contaminated, shall be handled as other linen. Laundry personnel shall wear latex gloves and gowns while handling linens.
  • Any contaminated reusable items such as bedpans or commodes, shall be thoroughly washed in a sink with detergent two times, followed by a clean water rinse. PPE must be worn.

Receipt, Storage, and Transport of HDs

Receipt

  • HDs are delivered directly to appropriately secure area. Only properly trained personnel familiar with these guidelines shall handle HD packages.
  • When a damaged package is discovered, all contaminated packaging material will be handled with double gloves and a protective gown and placed into an appropriate labeled waste container.
  • If there is a possibility of exposure to airborne HDs, the damage material shall be packed in a waste disposal container within an approved BSC. Double gloves and any other appropriate protective equipment must be worn. Immediately contact EHRS.

Storage/Handling

  • Access to areas where hazardous drugs are stored is limited to authorized staff.
  • Orange "CHEMOTHERAPY" labels will be used to label shelves and bins where cytotoxic drugs are stored.
  • HDs products dispensed from the preparation area will bear a label identifying them as such.
  • HDs will be stored on shelves or in bins that will limit contamination in case of leakage.
  • Hazardous drugs requiring refrigeration will be stored separately from non-hazardous drugs and will be stored in bins designed to contain leakage.

Damaged Packages

The following procedure will be followed for handling damaged packages of hazardous drugs:

  • Damaged shipping cartons of hazardous drugs will be received and opened in an isolated area.
  • Protective apparel will be worn when handling damaged packages. This will include a chemo gown and disposable utility gloves over latex gloves. Eye protection and a mask will be worn.
  • Broken containers and contaminated packaging materials will be paced in designated chemo receptacles.

Transport.

  • Hazardous drugs will be transported by trained individuals in containers clearly labeled "Cytotoxic". Follow department/hospital specific policies for additional information.
  • They will not be transported in the pneumatic tube. The drugs will be in securely capped or sealed containers and packaged during transport to further reduce the chance of breakage and spillage in a public area.
  • Appropriate containers will be provided to patients for transporting discharge and home care medication that require special precautions.

Leak and Spill Detection

Facilities with HD shall maintain a program to detect leaks and spills. The leak and spill detection program shall include:

  • Regular visual inspections for leaks and spills
  • Preventative maintenance of equipment
  • Program should include spill containment and clean-up, surface decontamination, and waste disposal in work areas where spillage may occur
  • Methods for surface decontamination and proper waste disposal

Emergency Showers and Eyewash Stations

Eyewash unit shall be located in the all areas where HDs are prepared and must be accessible within ten seconds. Path to eyewash station shall be free of all obstructions.

Emergency showers may be required in some cases. Please contact EHRS for additional information.

Emergency Situations

For any emergencies, please follow instructions in EHRS policy 5.7. Laboratory workers can clean up a small spill that does not present an immediate health risk, such as a spill within a hood. Any resulting waste must then be packaged, and then disposed of as an appropriately. Consult with the EHRS for specific disposal requirements.

For larger spills, the EHRS provides cleanup assistance. If a worker is unsure of his/her ability to clean up a HD spill outside the control of a local exhaust ventilation device, he/she should call EHRS.

Any time respiratory irritation occurs, leave the area and get to fresh air. In case of skin/eye contact with liquid, immediately remove contaminated clothing and flush affected areas with water. Any exposure (inhalation, absorption, ingestion) to HD shall require a visit to the Employee Occupational Health Office for evaluation.

Spill kit and spill control supplies (adsorbent, gloves, goggles, and disposal bags) shall be made accessible to any area where HDs are used, prepared, or administered.

Contact the EHRS for more information and details.

Personnel Decontamination

Gross contamination of gloves, gown, or other clothing, or direct skin or eye contact with HDs must be treated as follows:

  • Immediately remove contaminated gloves, gown, or other clothing. If clothing is contaminated with large quantities of HDs, the individual shall proceed as rapidly as possible to the nearest safety shower (or ordinary shower). Contaminated clothing shall not be removed until the individual is standing under the flow of the water.
  • Any contaminated skin area must be washed with soap and water for not less than 15 minutes. After flushing the affected area, seek medical attention immediately.

Surface/Equipment Decontamination

  • After a spill clean up has been completed, all contaminated surfaces shall be thoroughly cleaned with a detergent solution three times, followed by a rinse with clean water. An area person familiar with these guidelines and the potential hazards of HDs shall do this. Double gloves shall be worn and all waste disposed of properly.
  • Any non-cleanable contaminated items shall be disposed of according to the contaminated waste guidelines.

Report for medical attention as follows:

Employees will report to the Employee Occupational Health Office during business hours (M-F, 8:00 a.m. to 4:30 p.m.) or to the Emergency Department after hours. Students will report to Student Health Services during business hours (M-F, 7:00 a.m. to 3:30 p.m.) or to the Emergency Department after hours

Medical Surveillance

All employees who handle or use hazardous drugs must be enrolled in a medical surveillance program. Medical evaluations must take place before job placement, periodically during employment, following acute exposure and at the termination of employment.

Medical information regarding any HD exposure will be maintained in the employee’s medical record in the Employee Occupational Health office or the student’s medical record in Student Health Services.

Employees working with HDs will complete a medical and occupational history at the time they are hired.

Personnel cleaning the BSC used to prepare Cytotoxic Drugs may be required to wear a respirator and will participate in the Respiratory Protection Program. The Employee Occupational Health Office will administer the medical surveillance portion of the program. The EHRS will administer fit testing and respirator training.

Hazardous Drug (HD) Waste

Hazardous drug waste includes drug substances, vials, ampoules, IV bags, tubing, syringes, gloves, masks, pads and other contaminated items used in the preparation, administration and handling of hazardous drugs. Please consult with the Hazardous Waste Manual at www.temple.edu/ehrs for additional information..

  • Proper PPE must be worn at all times when handling hazardous drugs.
  • Discarded gloves, gowns, and all other HD’s waste and any other disposable contaminated material must be placed in appropriately marked containers. Consult with your department/hospital specific policy for specific or additional information.
  • Any Hazardous drug that is listed by the EPA must be handled separately through EHRS. Please visit the EHRS webpage at www.temple.edu/ehrs. Some of the EPA listed waste are:
    • Chlorambucil (Leukeran)
    • Cyclophosamide (Cytoxan)
    • Daunorubicin (Daunomycin, Cerubidine)
    • Melphalan (Alkeran)
    • Mitomycin (Mitomycin C, Mutamycin)
    • Steptoxocin (Zanosar, Streptozocin)
    • Uracil Mustard (Uramustine, U-8344)
  • Needles, syringes, sharps and breakable items that were used in the preparation or administration of HD’s must be placed into an approved sharps container
  • Needles should not be clipped or capped nor syringes crushed (except as on a rare instance when a medical procedure requires recapping).
  • At least one such receptacle should be located in every area where the drugs are prepared or administered.
  • Waste must not be moved from one area to another and the lid should be kept on the container at all times.
  • Follow departmental/hospital specific procedures to arrange for the pickup and proper disposal of HD waste.

Employee Training Requirements

Hazardous Drug training shall be provided to all employees and their supervisors where HD is used in the workplace. Information regarding this training can be obtained from the EHRS. This training must be provided at the time of the initial job assignment and whenever there is a change in work practice. The topics covered in this class may include:

  • The contents and availability of this document.
  • The contents of MSDSs.
  • Health risks of HD: skin, respiratory tract, eye, and throat irritation; sensitizing effects of formaldehyde; acute and chronic toxic effects.
  • The medical surveillance program.
  • PPE use and limitations.
  • Instructions for the use of engineering controls in minimizing exposure.
  • Instructions for handling spills and emergency situations.
  • Access and location of training materials for the affected employees.

Record-keeping Requirements

The following records must be maintained in accordance to Temple University policy. The records shall consist of:

Exposure Monitoring Records shall include the following information:

  • Date of measurement.
  • Operation being monitored.
  • The methods of sampling and analysis used and evidence of their precision and accuracy.
  • The number, duration, time of day, and results of samples obtained.
  • The types of protective devices worn.
  • The names, job classifications, social security numbers, and exposure estimate of employees whose exposure is represented by actual monitoring results.
  • When it is felt that objective data will relieve exposure-monitoring requirements, records shall consist of the objective data and calculations that demonstrate that no employee is exposed to at or above the Action Level.
  • Exposure monitoring records shall be kept for at least 30 years.

2. Medical Evaluation Records shall consist of:

  • The name and social security number of the employee.
  • The physician's written opinion.
  • A list of employee health complaints that may be related to exposure to HD.
  • A copy of the employee's medical examination results, medical questionnaires, and results of medical tests that are required by the regulation or mandated by the examining physician.
  • Medical evaluation records shall be kept for the duration of the employee's employment plus at least 30 years.

3. Respirator Fit Test Records shall consist of:

  • A copy of protocol used to test the fit of negative-pressure respirators.
  • The-name and social security number of each employee assigned to wear a negative-pressure respirator.
  • The date of the employee's most recent respirator fit test and a copy of the test results.
  • A list of the brands, types, and sizes of respirators available at the facility from which respirator selection and assignment was made.
  • Respirator fit test records shall be kept until replaced by a more recent record.

Contractors are responsible for complying with these record-keeping requirements for their own employees.

5.18 – Cryogenic Liquids

Introduction:

Purpose

To establish policies, work practices and systematic procedures for ensuring the safe storage, use and handling of cryogenic liquids.

Applicability

Applies to all departments and personnel who work or handle cryogenic liquids at Temple University (TU) and Temple University Health System (TUHS), to all work conducted under the authority of TU and TUHS. Non-Temple and contractor personnel must follow the provision of this document while working at these facilities.

Responsibilities

Environmental Health & Radiation Safety (EHRS)

  • Policy development
  • Training as requested by responsible supervisor/manager
  • Provide technical assistance and support as requested by a responsible supervisor/manager
  • Conduct periodic audits

Supervisors, Principal Investigators (PI), Department Heads & Managers

  • Assess their site and operations areas to determine whether Employees may handle or use Cryogenic Liquids.
  • Develop and implement the procedures in accordance with this document.
  • Enusre that a site specific Standard Operating procedure is developed and implemented. The SOP must include any additional safety measure or Personal Protective Equipment (PPE) that is necessary to ensure that any cryogenic liquid is safely used , stored and handled
  • Ensure that adequate facilities, ventilation and equipment are provided for the safe storage, use and handling of cryogens.
  • Ensure that staff is aware of this document, instructed on the details of implementation, and provided with equipment, PPE and controls.
  • Maintain, review and update the SOP at least annually, and whenever necessary to include new or modified tasks and procedures.
  • Responsible to ensure that the appropriate PPE, engineering controls, labels and other supplies are available and properly used to the employee free of charge.
  • Ensure that all employees attend training (as listed in the training section) and follow the requirements listed in this document as well as department/hospital specific policies.
  • Ensure that all medical actions required by the standard are performed and that appropriate employee health and OSHA records are maintained.
  • Maintain all necessary documentation and training certificates.

Employees who work with Cryogenic Liquids

  • Attend required training classes
  • Use and maintain safety devices and PPE
  • Follow the instructions of the Supervisor, Principal Investigator, Department Head, Manager and EHRS.
  • Comply with the requirements listed in this document.
  • Conduct assigned tasks in a safe manner, wear appropriate PPE and only use equipment for which they have been formally trained.
  • Know who to call in any incident involving a cryogenic liquid and how to handle spills, releases
  • Know how to respond to personal contamination and exposure and,
  • Obtain additional information regarding safety, MSDS, security, inventory and risk of operations as is necessary to fully be informed regarding ones duties and to accurately assess any health related risk.

Key Definitions:

Chemical Hygiene Plan (CHP)

  • A written policy developed and implemented by a lab which sets forth procedures, equipment, personal protective equipment, and work practices that protect employees from the health hazards associated with the use and handling of hazardous chemicals. The Chemical Hygiene Plan is available for your review.

Cryogenic Liquid (Cryogen)

  • A liquid with a boiling point below minus 130º F

Dewar

  • Open mounted, unpressurized, vacuum-jacketed vessels used to hold cryogenic liquids (usually, argon, nitrogen, or oxygen).

Material Safety Data Sheet (MSDS)

  • Informational tool developed by chemical manufacturers containing the following information for a hazardous chemical: substance identification and synonyms, hazardous components(if a mixture), physical data, fire and explosion data, toxicity data, health effects and first aid, reactivity, storage and disposal procedures, spill and leak procedures and recommended protective equipment.

Personal Protective Equipment (PPE)

  • Protection worn by workers to guard against hazards in the environmental or work area. Examples include safety glasses, goggles, aprons (cryogen) , face shields, respirators, gloves (ex. cryogen gloves), etc.

Standard Operating Procedures (SOP)

  • A concise document that gives safety instructions specific to operation task, experiments and methods.

Compliance Methodology

The following measures are followed to ensure that Temple University and Temple University Health System (TUHS) have procedures in place to ensure the safe usage, handlings and storage of cryogenic liquids.

Standard Operating Procedures (SOP)

Anyone who works with cryogenic liquids is required to develop and implement a written site specific SOP. All individuals who are anticipated to use and handle must read the MSDS and any safety precaution outlined in the SOP.

Labs- read the MSDS and safety precautions for all cryogens used, and incorporate these precautions into the Chemical Hygiene Plan with written SOP.

Personnel should be aware of the hazards associated with the storage, handling and use of cryogens. If injured, individuals should seek immediate medical attention. An incident report must also be completed in the event of an employee injury or potential exposure.

Engineering Controls and Work Practices

  • It is the responsibility of the Supervisor, PI, Department Heads or Manager to ensure that the proper specific engineering controls and work practices are being implemented. EHRS can be contacted for assistance.
  • The Supervisor, PI, Department Head or Manager must periodically evaluate and document a review of existing procedures or products to determine if new or improved products or procedures can be implemented to reduce any potential exposure.
  • Labeling- a Cryogen warning sign incorporating shall be posted on the access door to any area. In additional, all vessels containing a cryogenic liquid must have the proper warning signs posted on them.
  • Limited access- Access to a lab or area is limited or restricted by the supervisor when work is in progress. When work with cryogens is being performed, non-personnel (Facilities, administrative personnel) and non Temple personnel should be discouraged from entering. If they must enter, the hazards of the work being conducted must be fully explained. Facilities personnel may be unfamiliar with the hazards present in the lab and must be fully instructed and carefully supervised by the supervisor when working in areas where cryogens are handled.

Personal Protective Equipment (PPE)

Personal Protective Equipment (PPE) – PPE will be provided at no cost to any individual who works or handles cryogens. All PPE must be inspected, cleaned, or replaced as needed at no cost to an individual. PPE will be chosen based on the cryogen used or handled.

      • Eye Protection.-Protective eye wear must be worn in any area when it is reasonably anticipated that cryogens may make contact with the eye. Face shields may be required if there is a potential for splashes, sprays or aerosols.
      • Gloves- Anyone who is engaged in work that may involve skin contact with cryogens must wear insulated cryogen gloves.
      • Lab coats and Uniforms- Lab coats, gowns, smocks, aprons, or uniforms must be worn in the lab. All protective clothing must be removed prior to leaving the area.
  • It is the responsibility of the Supervisor, PI, Department head or Manager to ensure that all their employees are provided with the proper PPE in their area. A Hazard Assessment Certification Form must be completed in Appendix B as outlined in the EHRS Handbook -10.4-Personal Protective Equipment (PPE) policy to determine the level of protection needed for the task. Typical PPE used to work with cryogens includes safety goggles, insulated gloves, lab coat or apron, and a face shield. Please consult with Section 10.4 in the EHRS handbook for the complete PPE program. In addition, EHRS can be contacted for assistance in determining proper PPE.
  • All personnel must wear gloves, lab coat and safety glasses whenever handling cryogens. Gloves must be replaced frequently and immediately if they become contaminated or damaged in any way. In addition to the above items, personnel must wear any additional PPE (apron, booties, face shield, etc.) that is needed to prevent cryogenic material from contaminating their street clothes, skin, mouth, or other parts of the body under normal conditions.
  • All staff required to wear PPE must receive training. PPE training can be provided through EHRS.
  • All PPE must be removed prior to leaving the work area and placed in designated area for disinfection or disposal. No PPE (including lab coats) are permitted to go home for laundering or cleaning.

Housekeeping

All contaminated work surfaces or equipment will be decontaminated after completion of procedures and immediately or as soon as feasible after any spill.

All bins, pails, and similar receptacles shall be inspected and decontaminated on at least a monthly basis. Any broken glassware that may have become contaminated will not be picked up directly with hands.

Shipping of Cryogenic Liquids

Cryogenic liquids that will be shipped to or from Temple University or TUHS must be clearly identified as such. The materials shall be placed in a closed container and a leak proof secondary container prior to shipment. Personnel involved in the shipping of cryogenic liquid pathogens must have documented Department of Transportation (DOT) training. Contact EHRS for training information and consult with Section 10.7 of the EHRS handbook for additional information.

Transporting on Campus

Transportation across roadways (i.e. streets) may fall under the jurisdiction of the Department of Transportation. The use of a motor vehicle to transport either within the campus or to a different campus is regulated by DOT. Contact EHRS for additional guidance at 215-707-2520.

Routine Tasks and Maintenance Procedures

  1. Use of Cryogenic Liquids

Cryogenic liquids have properties that make them more dangerous to use than other liquids: extremely cold temperatures, high liquid-to-vapor expansion ratios, and flammability for certain liquids.

Skin or eye contact with cryogenic liquids, cold equipment and materials that are used in conjunction with cryogens, or splashing liquid can cause severe tissue damage such as burns, frostbite, tearing of the flesh, and eye damage. Vapors from boiling liquids can also cause eye damage, frostbite to the skin, and oxygen deficient environment. To minimize exposure during use, implement the following procedures:

    • Long sleeve shirt and pants should be worn. Cuffless pants should be worn over the shoes. Shoes must be closed-toed leather or safety shoes. Never wear sandals or open toed shoes. Do not wear jewelry or other materials that could trap liquid to the skin if spilled.
    • Stay away from the vapor pathway.
    • Use fume hood when working with cryogen if possible.
    • Always use tongs when handling objects in liquids.
    • Cryotubes containing samples stored under certain cryogens (nitrogen) may explode without warning. Please take proper safety measures when handling and wear proper PPE if needed.
    • Only use approved materials with cryogens. Unapproved materials (such as plastic, rubber, wrought iron, hollow tubes, and carbon steel) will become brittle and shatter, or in the case of hollow tubes will become over pressurized.
    • Periodically inspect equipment and remove ice and frost blockages from openings to prevent over pressurization.
    • Do not tamper with pressure relief valves. Report any leaks or improperly set relief valves to the manufacturer.
    • Equipment should be kept clean without the use of corrosive cleaning materials that could damage the metal jacket.
  1. Dispensing and Transport of Cryogenic Liquids

Special precautions must be taken to prevent a spill while dispensing or transporting cryogens in addition to minimizing exposures from liquids and vapors. The high liquid to vapor expansion ratio could rapidly displace all oxygen in a room and result in asphyxiation. Implement the following procedures to minimize exposure.

    • Always wear proper PPE when dispensing or transferring cryogenic liquids.
    • When obtaining liquid from a large dispensing Dewar or cylinder, cool the secondary container by adding a little cryogenic liquid first. Dispense slowly to mitigate thermal stress, stay in constant attendance of the filling operation, do not overfill and do not allow the cryogenic liquid to fall through a distance to reach the receiving vessel.
    • When manually pouring liquid into a smaller Dewar, assure that the secondary container is secured, pour slowly to prevent excess splashing, and do not overfill.
    • Use no fewer that two personnel to transport cryogenic liquids and use handcarts equipped with brakes for large Dewars and cylinders.
    • Avoid traveling in an elevator with a dewar if possible. Spills or elevator failures may be dangerous in the restricted space by displacing oxygen if the cylinder failed or leaked. If this is not avoidable, make sure to use the buddy system and have another employee remain outside the elevator during transport.
    • Always use care when handling equipment. Damage to dewars could result in the loss of vacuum and increased evaporation.
  1. Storage of Cryogenic Liquids.

A cryogenic liquid storage unit left open to the atmosphere or a catastrophic failure of the unit could create an oxygen deficient atmosphere. Follow these procedures to reduce the likelihood of this occurrence:

  • Glass dewars must have an exterior coating/cover to minimize projectiles in the event of an explosion. Newer dewars may have a plastic mesh over the exterior for this purpose. Older dewars must be thoroughly taped or replaced.
  • Only store dewars in well ventilated rooms with a minimum of eight air changes per hour. Please contact Facilities Management to ensure that the storage location has the proper ventilation.
  • The installation of an oxygen detection sytem and alarms for cryogenic liquid storage areas may be needed depending on the storage location, ventilation, and the quantity of material stored. Please contact EHRS at 215-707-2520 for an evaluation.
  • Periodic equipment inspections, removal of ice blockages and replacement of damaged or old storage units will reduce the probability of the catastrophic failure of a storage unit. Ice blockages that prevent the container from venting properly can cause an explosion hazard
  • Do not store cryogenic liquids with corrosive or flammable chemicals.
  • Storage units must be placed so that vents and opening are oriented away from personnel and other equipment.
  • All storage areas must have proper signage and security controls in place.
  • Bulk cryogenic liquid dispensing areas within a building must be well, ventilated. All new installation must be designed with oxygen monitoring system and alarm.
  • Storage of cryogenic liquid dewars in hallways, unventilated closets or rooms, environmental (cold, hot or warm) rooms or boxes, and stairwells is prohibited.
  • No more than one full backup dewar is allowed per piece of equipment. Additional dewars must be stored in areas designed for such storage.
  1. Special Precautions for Flammable Liquids and Oxygen.

Flammable cryogenic liquids like methane, hydrogen and carbon monoxide introduce an additional hazard. Oxygen does not burn, but accelerates and supports combustion. High concentrations oxygen atmospheres substantially increase combustion rates of other materials and may form explosive mixtures with combustibles. It is important to implement the following procedures when using flammable cryogenics and oxygen.

  • Contact EHSR at 215-707-2520 to assess engineering and work practice controls if you plan to work with these materials.
  • All combustible materials must be kept away from flammable liquids. A “No Smoking” sign must be posted and all sources of ignition must be eliminated in his area.
  • Oxygen dewars and equipment must be kept clean. Surface contamination could become ignited if oxygen leaks from the dewar and provide a local oxygen enriched area.
  • Stationary equipment must be properly grounded and mobile equipment must be properly bonded when dispensing.
  • Valve operation must occur very slowly to prevent ignition of contaminants from the system.
  • Hydrogen venting must be independent from other ventilation systems and may require a nitrogen purge capability.
  1. Special Precautions for the use of Cold Traps

Cold traps are used when using instrumentation, a building vacuum system, water aspiration, or a vacuum pump. Cold traps prevent the introduction of liquids and vapors into and out of the system by providing a low temperature surface for molecules to condense. When using liquid nitrogen (LN2) in cold traps, the following procedures must be implemented to prevent over pressurization and explosion:

  • Do not open the system to the atmosphere until the trap is removed.
  • In the event that a system is opened with the trap still in place, there is a possibility that oxygen will condense out of the air and combine with the organic material inside the trap. There are two possible scenarios that could result: it could immediately create an explosive mixture and explode or the oxygen could stay condensed in the liquid. DO NOT RECLOSE THE SYSTEM. The condensed oxygen will vaporize after the trap is removed or the bath has evaporated resulting in an over pressurization and possible explosion.

Annual Review

The SOP must be reviewed and updated annually to reflect any changes.

Emergency Procedures

Spills or Releases

  • If the oxygen alarm sounds, or spill or release occurs, immediately exit the area. Contact EHRS immediately 215-707-2520 or 215-707-4545 after hours to monitor oxygen levels in the area and to determine when it is safe to reenter.
  • If experiencing symptoms such as light headiness, dizziness or confusion, immediately seek fresh air and receive medical attention.
  • Immediately contact Campus Police or dial 911 if an individual becomes unconscious in a cryogenic liquid storage area. Do not attempt to enter the area unless you are using a Self Contained Breathing Apparatus and are trained in its use and had respiratory fit test for it.

In the event that skin or eyes come into contact with a cryogenic gas or liquid.

  • Follow first aid procedures and immediacy seek medical attention
  • Immediately remove any clothing that has been contaminated.
  • Flush or soak the area with warm water.
  • Do not apply dry heat or rub the eyes
  • Report to Occupational Health for exposure evaluation and/or medical treatment.
  • Notify your supervisor immediately after the incident and provide detailed information about the incident. The Supervisor will submit the required forms to Workers Compensation.

See Temple University Hospital (TUH) policy 950.130, 950.130 (A) and 950.130 (B) or department specific policy on Post Exposure follow-up.

Administration of Post Exposure Evaluation and Follow –Up

It is the responsibility of the Principal Investigator/Manager or Supervisor to ensure that any post exposure evaluation is conducted and appropriate follow up measures are implemented.

Communication of Hazards to Employees

Training

All employees who work with Cryogenic liquids must receive an initial training and an annual retraining. The initial training must be conducted prior to their initial assignment where there is a potential for exposure. It is the Managers or Supervisors responsibility to ensure that anyone who works with cryogenic receives the appropriate training. Training can be scheduled by contacting EHRS at 215-707-2520.

Specific training on MSDS and the SOP must also be provided and documented by the Supervisor or Manager

Recordkeeping

All training records are maintained by EHRS. Function specific training is maintained by the Department. All medical records are maintained by Occupational Health.

All policies in the Environmental Health and Radiation Safety Handbook, including those related to Cryogenic Liquids, are periodically reviewed and revised, if necessary.