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