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SCOPE All UAMS employees, faculty, staff and students PROCEDURE: (RESPONSIBILITIES) 1. The Department of Occupational Health and Safety (OH&S) will be responsible for the following: Conducting introductory Hazard Communication training sessions (see Procedure 11). Determining whether chemicals used are “hazardous” within the meaning of the definition established by Occupational Safety and Health Administration (OSHA). Reviewing MSDS for compliance with OSHA guidelines. Maintaining the UAMS central file for MSDS. Ensuring review and compliance with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards that require hazardous chemicals be handled safely, and training be conducted. 2. Department Managers are responsible for the following: Assigning a Hazard Communication coordinator to serve as point of contact for information updates. Providing specific training and information on Material Safety Data Sheets (MSDS) to their employees and contractors as required by the standard. Maintaining and reviewing applicable MSDS. Ensuring proper labeling on containers. Establishing a written department hazard communication program. Documenting employee training conducted within the department. PROCEDURE: (REQUIREMENTS) 3. All containers must remain properly labeled, tagged, or marked at all times with the appropriate required information, including the identity of the hazardous chemical, appropriate hazard warnings and the name and address of the chemical manufacturer, importer, or other responsible party. 4. Containers received without appropriate forms of warning must be properly labeled. The receiving department should contact Occupational Health and Safety for assistance. 5. Portable containers do not have to be labeled if they are intended for immediate use (on that shift), by the employee who transferred it from a labeled container. 6. Material Safety Data Sheets (MSDS) must be available and easily accessible to employees, OSHA and designated employee representatives during any shift, at any time; and must meet the requirements of the OSHA Hazard Communication Standard on form OSHA174 or the equivalent. 7. MSDS’s must be developed for hazardous chemicals manufactured or produced. Before hazardous chemicals are used, an MSDS must be obtained. In the event a hazardous chemical has been received without the MSDS, the Department of Occupational Health and Safety can grant an exception to this requirement. Safety precautions will be established in writing. Affected employees will be notified of the exception. The supplier will be contacted by the department to obtain an MSDS. PROCEDURE: (EMPLOYEE INFORMATION AND TRAINING) 8. Introductory Hazard Communication Training is conducted during new employee orientation and open sessions. Additional sessions are available upon request. This training is conducted by Occupational Health and Safety. Training will also be conducted at the time of an employee’s initial assignment and whenever a new hazard is introduced into the work area. 9. Employees will receive training in the following areas: Methods to detect hazardous chemicals. Physical and health hazards of chemicals. Protective measures. Details of the Hazard Communication program. 10. Employees will be provided the following information: Requirements of the OSHA Hazard Communication standard. Operations with hazardous chemicals present. Location and availability of the written hazard communication program. Location and availability of MSDS. Chemical hazards present during non-routine tasks. Hazards of chemicals in unlabeled pipes. 11. Contractors will be informed of the hazards of chemicals in their work area and of measures to protect their employees. 12. The specific chemical hazards and protective measures applicable to each department are not covered in the introductory hazard communication training (each department will be responsible for providing this training). PROCEDURE: (DEPARTMENTAL HAZARD COMMUNICATION TRAINING) 13. Employees are to be trained at the time they are assigned to work with a hazardous chemical. Retraining is to be done when a new hazard (not just a new chemical) is introduced into the work area. For example, if a new solvent is brought into the work place and it has hazards similar to existing chemicals for which training has already been done, no new training is required. Of course, the MSDS’s must be available and the product must be properly labeled. However, if the solvent is a suspect carcinogen, and there has never been a carcinogenic hazard in the work place before, new training on the carcinogenic hazard must be provided to employees working in the areas where it may be exposed. 14. Employees should complete, with documentation, the introductory Hazard Communication training prior to departmental training. Department training should concentrate on the following areas: Operations in the work area where hazardous chemicals are present. The location and availability of the written departmental hazard communication program. The location and availability of material safety data sheets. Methods and observations that may be used to detect the presence or release of a hazardous chemical in the work area (such as monitoring conducted by the employer, continuous monitoring devices, visual appearance or order of hazardous chemicals when being released, etc.). The physical and health hazards of the chemicals in the work area. The measures which employees can take to protect themselves from these hazards, including specific procedures the department has implemented, such as appropriate work practices, personal protective equipment to be used, and emergency procedures. PROCEDURE: (RECORD KEEPING) Department Hazard Communication Programs will be updated annually or as new hazards enter the work place. 16. A copy of all Hazard Communication Programs (as updated) will be forwarded to the Department of Occupational Health and Safety. PROCEDURE: (CONTINGENCY PLANNING) The purpose of contingency planning is to address situations that may arise when handling potentially hazardous or toxic material. These plans cover spills, exposures, recommended medical surveillance, protective equipment and finally disposal. These plans will help to ensure the protection of employees, students, patients and visitors, as well as the surrounding UAMS community. 17. INFECTIOUS/BIOHAZARDOUS AGENT SPILL PLAN To provide direction in protecting students, employees, patients and visitors, and the environment from the potential hazards by managing spills involving infectious/ biohazardous agents. These types of agents can be categorized into the following groups: Isolation Wastes Cultures and stocks of infectious agents and associated biologicals, specimens from medical and pathology labs, cultures and stocks of infectious agents from clinical and research labs and disposable culture dishes, wastes from production of biological and discarded live and attenuated vaccines. Human blood and blood products - waste blood, serum, plasma, and blood products, or items contaminated with blood or blood products. Human body fluids - including cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid, semen and vaginal secretions and items contaminated with regulated body fluids. Pathological waste - tissues, organs, body parts, blood, and body fluids removed during surgery, autopsy, and biopsy. Contaminated sharps - contaminated hypodermic needles, syringes, scalpel blades, pasteur pipettes, broken glass and IV catheters. Contaminated animal carcasses, body parts and bedding - contaminated animal carcasses, body parts, and bedding of animals that were intentionally exposed to pathogens. 18. Cleanup of spills involving small volumes of infectious agents shall be performed by the individual who initiated or was primarily involved with the incident. 19. A wash bottle of disinfectant should be kept at hand to carry out decontamination of such spills. Phenolics are most useful in laboratories that do not culture for viruses, while a hypochlorite (bleach) is recommended when contamination by viruses is expected. 20. For larger spills, during normal working hours, the Department of Occupational Health and Safety, extension 686-5536, shall be contacted immediately and will respond to the area. After hours, notify the appropriate housekeeping department and Physical Plant Control Center (686-6424). 21. Major Spills Outside a Biological Safety Cabinet Any spill or accident involving all class III organisms such as; M. tuberculosis, C. immitis, F. tularensis, or Brucella, species should be considered a major hazard. Accidents with cultures of moderate - risk agents that have the potential for generating large quantities of aerosol, such as breakage in a centrifuge, should also be handled with precautions designed to minimize inhalation of airborne infectious agents and the following actions should be taken: In the event of a major aerosol producing spill, i.e., breakage in a centrifuge, the following should be initiated: Hold your breath, leave the room immediately, and close the door. For a smaller spill - immediately cover with an amphyl soaked paper towel. Warn others not to enter the contaminated area. Remove contaminated garments and place them in a container for autoclaving; thoroughly wash hands and face. Wait at least 30 minutes to allow reduction of aerosols created by the spill. Obtain a “spill kit” as provided by the Department of Occupational Health and Safety or the In-patient Pharmacy. Before reentering the room, don the protective clothing provided in the “spill kit.” Use disinfectants that are two to three times more concentrated than those routinely employed in the laboratory, because the volume of the spill may reduce their concentration. Pour the disinfectant around the spill and allow it to flow into the spill. Paper towels soaked with disinfectant may be used to cover the area. To minimize aerosolization, avoid pouring disinfectant directly on the spill. Allow 20 minutes contact time, leave area and shut the door. Use paper towels to wipe up disinfectant and spill, working toward the center of the spill. Discard towels into an autoclavable container as they are used. Using an autoclavable dustpan and squeegee, transfer broken glass and other debris to an autoclave pan. Wipe the outside of the discard container, especially the bottom, with disinfectant. Place protective clothing, dust pan, and squeegee in container and autoclave them. 22. Major Spills in a Biological Safety Cabinet If a spill is confined to the interior of the cabinet it should not be hazardous; however, the following disinfection procedures should be initiated at once while the cabinet continues to operate to prevent escape of contaminants: Wear gloves and gown for the cleanup. Spray or wipe walls, work surfaces, and equipment with a disinfectant. Use sufficient disinfectant to flood the top work surface tray and, if a class II cabinet, the drain pans and catch basins below the surface. Allow to stand 15 minutes. See your biological safety cabinet manual for procedures to disinfect drain pans and catch basins. Autoclave disinfectant, gloves, towels, and sponges before discarding. Documentation: In the event of a spill, the individual primarily involved in the spill will document the incident by completing a UAMS Injury & Incident Report. Upon completion, all documentation regarding the spill should be distributed to the following: Department of Occupational Health and Safety Student/Employee Health Department Head Medical Surveillance: Any individual involved in a spill cleanup of the above organisms should contact Student/Employee Health at the Department of Family and Community Medicine. The examining physician will use his or her discretion in performing the appropriate health examination and lab studies. 23. CHEMICAL SPILL PLAN A department experiencing a chemical spill can often perform clean up procedures with little or no outside help. If additional assistance is needed, the Department of Occupational Health and Safety will be contacted. Spill response will vary widely depending on circumstances. For purposes of preplanning, most spill scenarios can be characterized as to whether a known or unknown chemical is involved and if the spill is or is not confined to a laboratory hood. Known Chemical Spilled in Laboratory Hood. The first consideration is the safety of building occupants. If there appears to be immediate danger of fire, explosion or extensive vapor migration from the spill area, close the hood sash, initiate area evacuation and notify Occupational Health and Safety (686-5536), 7:30-4:30, Monday-Friday or Physical Plant Control Center (686-6424) after hours. If there is no immediate danger apparent, close the hood sash and locate a Material Safety Data Sheet (MSDS) for the chemical. The MSDS will include spill clean-up procedures. In many cases this will require a spill kit and protective equipment. Usually, the MSDS will not provide detailed guidance for disposal, other than “comply with existing laws.” The Department of Occupational Health and Safety can provide technical assistance or equipment, if needed during any step of the response. If employee injury/exposure is known or suspected, send the individuals to Student Employee Health Services (SEHS) or the Emergency Department. Notify OH&S that the spill occurred, even if their assistance was not required. This will insure notification to outside agencies, if necessary. Complete a UAMS Incident & Injury report form. Unknown Chemical Spilled in Laboratory Hood The first consideration is the safety of building occupants. If there appears to be immediate danger of fire, explosion, or extensive vapor migration from the spill area, close the hood sash, initiate area evacuation, and notify Occupational Health and Safety (686-5536), 7:30-4:30, Monday-Friday or Physical Plant Control Center (686-6424) after hours. If there is no immediate danger apparent, close the hood sash and contact other lab personnel who would possibly know the identity of the spilled substance. If the identity is established, follow the procedures for known chemical spill. If the identity cannot be established, contact the Department of Occupational Health and Safety for assistance in identification, neutralization and cleanup. If employee injury/exposure is known or suspected, send the individuals to Student Employee Health Services or the Emergency Department. Complete a UAMS Incident & Injury Report form. Known Chemical Spilled (Not in Lab Hood) The first consideration is the safety of individuals in the area. If there appears to be immediate danger of fire, explosion, or extensive vapor migration from the spill area, initiate evacuation and notify Occupational Health and Safety (686-5536), 7:30-4:30, Monday-Friday or Physical Plant Control Center (686-6424) after hours. If there is no immediate danger apparent, control the area and obtain an MSDS for the chemical. The MSDS will contain spill clean-up procedures. A spill kit and protective equipment will often be required. The MSDS will often provide non-specific guidance for disposal such as “comply with existing laws.” Consult OH&S if technical assistance or equipment is needed during any step of the response. If employee injury/exposure is known or suspected, send the individuals to Student Employee Health Services or the Emergency Department. Notify the Department of Occupational Health and Safety (686-5536) that the spill occurred, even if their assistance was not required. This will insure notification to outside agencies, if necessary. Complete a UAMS Incident & Injury Report form. Unknown Chemical Spilled (Not in Lab Hood) The first consideration is the safety of individuals in the area. If there appears to be immediate danger of fire, explosion, or extensive vapor migration from the spill area, initiate evacuation and notify Occupational Health and Safety (686-5536), 7:30-4:30, Monday-Friday or Physical Plant Control Center (686-6424) after hours. If there is no immediate danger apparent, control access to the area and contact others who work in the vicinity who could possibly know the identity of the spilled substance. If the identity is established, follow the procedures for known chemical spill. If the identity cannot be established, contact the Department of Occupational Health and Safety for assistance in identification and follow on actions. If employee injury/exposure is known or suspected, send the individuals to Student Employee Health Services or the Emergency Department. Complete a UAMS Incident & Injury Report form. CHEMOTHERAPY DRUG SPILLS IN CLINICAL AND RESEARCH APPLICATIONS To provide direction in protecting students, employees, patients, visitors and the environment from the potential hazards in managing chemotherapy drug spills. Equipment: Chemotherapy Drug Spill Kit There should be one spill kit available on each nursing unit that administers chemotherapy agents, research laboratories or other areas where chemotherapy agents are used. In addition, the in-patient pharmacy and the Department of Occupational Health and Safety will maintain an inventory of several kits for re-supplying these areas. Procedure : The immediate cleanup of any amount of chemotherapy agent spilled shall be performed by the individual who initiated or was primarily involved with the incident. If problems develop or questions arise during normal working hours, contact either the Pharmacy (686-6221) or the Department of Occupational Health and Safety (686-5536). After hours, contact the Pharmacy (686-6221), and Physical Plant Control Center (686-6424). Material Safety Data Sheet’s are available for chemotherapy agents in the MSDS Manual located in the Nursing Office and the In-Patient Pharmacy if needed. Actions for spills should be as follows: Direct contact with chemotherapy agents. The following action should be taken for overt contamination of gloves or gowns or direct skin or eye contact with chemotherapy agent: Immediately remove the involved gloves or gown. Immediately wash the affected skin area with soap and water. The affected area should be examined by a physician as soon as possible. For eye exposure, immediately flood the affected eye with water or eyewash designated for that purpose. Medical attention should be obtained immediately. Spills in hood. Spills involving chemotherapy material that occur inside a hood should be handled as follows: Leave blower on. Put on double gloves, gown, and eye protection. If liquid, clean up with absorbent gauze pads or an absorbent pillow provided in the spill kit. The absorbent should be gently placed on the spill so that liquid is not splashed about the hood. If solid, cover and wipe with wet (with water) absorbent gauze. Place the pad(s) with the absorbed chemotherapy material in a yellow bag. All contaminated surfaces should be thoroughly cleaned with detergent solution and wiped with clean water. Any broken glass fragments should be placed in a sharps container. If it is necessary to raise the hood’s sash to clean up the spill, a NIOSH-certified respirator (N-95 or equivalent) and splash goggles must be worn during the cleanup. If a chemotherapy agent is spilled into the intake perforations of the hood, remove the work surface according to the manufacturer’s directions and thoroughly clean the drain pan in the proper manner, discarding all cloths and other materials used in the cleaning process. If, for some reason, the HEPA filter of a hood is contaminated with chemotherapy agents, the unit must be turned off. A sign “Do Not Use-Contaminated” should be placed on the unit. The filter must be changed as soon as possible according to the manufacturer’s instructions by personnel wearing protective double gloves, goggles, NIOSH-certified respirator (N-95 or equivalent), and gown. Whoever is changing the filter must be informed that it is a chemotherapy contaminate. The filter must be placed in a yellow bag. Spills not in hood. Spills involving chemotherapy material on counter tops, floors, or other areas outside the hood should be handled as follows: Isolate the area of the spill so that it is not disturbed by other personnel. Put on double gloves, gown, and eye protection. A NIOSH-certified respirator (N-95 or equivalent) must be used when there is any danger of airborne powder or an aerosol being generated. If liquid, clean up with disposable absorbent toweling or absorbent pillow provided in the spill kit. The absorbent should be gently placed on the spill so that liquid is not splashed. If solid, cover and wipe with wet (with water) absorbent gauze. Place the pad(s) with the absorbed chemotherapy material in a yellow bag. All contaminated surfaces should be thoroughly cleaned with detergent solution and wiped with clean water. Any broken glass fragments should be placed in a sharps container. Non-cleanable items, including any other drugs or supplies that may have been contaminated, will be put in a yellow bag. Glassware or other contaminated items should be placed in a plastic bag so that they do not spread the spill, transferred to the sink, and then carefully washed with an appropriate detergent. Avoid splashing while washing. Upon completion of the cleanup, notify the Housekeeping Department to remove the bagged waste and to perform any final cleanup of the area. Documentation of Spills: In the event of a spill, the individual primarily involved in the spill will document the incident by the following means: Patient Involved - Complete the UAMS Patient Visitor Incident Report and the UAMS Chemotherapy Drug Spill Checklist. Employee Involved - Complete the UAMS Chemotherapy Drug Spill Checklist and Employee/Student Incident Report. (Incident forms may be filled out by ER or Student Employee Health.) Upon completion, all documentation regarding the spill will be distributed to the following: Clinical patient care - Department of Occupational Health and Safety, Nursing Administration, Hospital Administration and Student/Employee Health. Research - Laboratory department head, Department of Occupational Health and Safety and Student/Employee Health. Medical Surveillance: Any individual having direct contact with a chemotherapy agent as a result of a spill should contact Student/Employee Health at the Department of Family and Community Medicine/or ER on evenings, weekends, and holidays. The employee should take a copy of the “UAMS Chemotherapy Drug Spill Checklist.” If determined necessary by Student/Employee Health, the examining physician will be responsible for the following: Hemogram and a panel of four liver function tests. Complete health questionnaire if no previous records on the employee are available. Above lab study redrawn in two weeks. UNIVERSITY OF ARKANSAS FOR MEDICAL SCIENCES CHEMOTHERAPY DRUG SPILL CHECKLIST Patient Room or Lab # _____________________________ Date of Spill Patient Name (if applicable) _________________________Time of Spill Staff exposure Patient exposure (if applicable) Name of Chemotherapy Agent Amount of agent in amount of solution Estimated amount of solution lost Signature of employee preparing checklist Chemotherapy agent spill kits are available through the Department of Occupational Health and Safety and the In-Patient Pharmacy. _____1. Remove involved clothing immediately. _____2. Flush eye(s) involved. _____3. Wash skin involved with copious amounts of soap and water. _____4. Move patient to another bed if the bed is contaminated; transfer patient to another room if large areas of the carpet is involved. _____5. Isolate the area of the spill. _____6. The individual involved in the cleanup should notify the Department of Occupational Health and Safety (during normal work hours) or the in house pharmacy (weekends and holidays). _____7. An incident report and chemotherapy drug spill checklist should be completed with copies to Department heads and the Department of Occupational Health and Safety. Biohazardous/Infectious/Medical Waste (The terms are synonymous) The Arkansas Department of Health (ADH) regulates the management of potentially infectious waste from health care related facilities. ADH defines medical waste as a waste which if improperly treated, handled or disposed of may serve to transmit an infectious disease(s) and which includes the following: Pathological waste - all human unfixed tissues, organs and anatomical parts, other than intact skin, which emanate from surgeries, obstetrical procedures, dental procedures, autopsies and laboratories. Such waste shall be exclusive of bulk formaldehyde and other preservative agents. Liquid or semi-liquid blood - such as human blood, human blood components and/or products made from human blood (e.g., serum, plasma) and other potentially infectious materials, to include regulated human body fluids such as cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, semen, vaginal secretions, saliva in dental procedures, pericardial fluid, amniotic fluid, any body fluid that is visibly contaminated with blood and all body fluids where it is difficult or impossible to differentiate between body fluids, not to include urine or feces, which cannot be discharged into the collection system of a publicly owned treatment works (POTW) within the generating facility. Contaminated items - to include dressings, bandages, packing, gauze, sponges, wipes, personal protective equipment, cotton rolls and balls, etc., which cannot be laundered or disinfected and from which blood, blood components, or regulated body fluids drip freely, or which would release blood or regulated body fluids in a liquid or semi-liquid state if compressed or are caked with dried blood or regulated body fluids and are capable of releasing these materials during handling. Contaminated disposable, single-use gloves such as surgical or examination gloves shall not be washed or decontaminated for reuse and are to be handled as a contaminated item. Protective coverings such as plastic wrap and aluminum foil used to cover equipment and environmental surfaces when removed following their contamination are considered a contaminated item. All patient care items from hospital isolation rooms and end-stage renal dialysis units, or from patients with communicable diseases, which cannot be laundered and which are contaminated with regulated body fluids or blood or potential infectious material, must be considered a contaminated item. Microbiological waste - includes, but is not limited to, cells and tissue cultures, culture medium or other solutions and stocks of infectious agents, organ cultures, culture dishes, devices used to transfer, inoculate and mix cultures, paper and cloth which has come in contact with specimens or cultures and discarded live vaccines. Contaminated sharps - includes, but is not limited to, any contaminated object that can penetrate the skin, e.g., hypodermic needles, IV tubing with needles attached, syringes with attached needles, razor blades used in surgery, scalpel blades, pasteur pipettes, capillary tubes, and broken glass from laboratories, and dental wires. (Potential breakable containers of blood, regulated body fluid, microbiological waste, or infectious material must be treated as contaminated sharps when disposed of.) Animal waste - carcasses, body parts, bulk blood and blood products and bedding of animals exposed to pathogens known to cause human disease. Chemical Hazardous Waste Chemical wastes are either listed wastes or characteristic wastes as defined by EPA Resource Conservation and Recovery Act. Listed Waste - is waste that is considered hazardous because it appears on one of four lists of hazardous wastes, under EPA RCRA 40 CFR sec. 261.33. Characteristic Waste - Even if the waste doesn’t appear on one of the four lists, it may be hazardous if it meets one of the following characteristics: (40 CFR sec. 261.21, 22, 23, 25) Ignitable - < 140o flammability. Corrosive - pH < 2 or > 12.5 Reactive - unstable, water reactive, produce toxic gas. Toxic - toxic contamination due to presence of heavy metals, pesticides or specific organic. Radioactive Waste Radioactive waste is defined as an unwanted by product, special nuclear or source material. Low level radioactive waste - is defined as any waste not classified as high level radioactive waste. High level radioactive waste - is defined as irradiated reactor fuel or solid and liquid waste generated in a facility for reprocessing irradiated reactor fuel. The UAMS campus produces only low level radioactive waste. Chemotherapy/Cytotoxic Residual Waste Certain chemotherapy agents are “U” listed hazardous materials (40 CFR 261.33f). These materials in volumes greater than 3 percent will be handled as chemical hazardous waste. Other items containing less than 3 percent residual contamination with chemotherapy agents will be incinerated by the medical waste contractor. Examples CyclophosphamideMitomycinUracil MustardMelphalanStreptozocinChlornaphazinDaunomycinChlorambucilMelphalanWaste materials such as trace contaminated needles, syringes, IV tubing, vials, bottles, ampoules, gloves, mask, gowns, wipes, liners, pledgets and pharmacy preparation waste will be incinerated by the medical waste contractor. Special Wastes Wastes that require special types of handling. Examples: ExplosivesEPA ban materialsMultiple hazardsCertain heavy metalsShock hazards HANDLING HAZARDOUS WASTE The basic principle of an effective waste management program is to: (1) reduce volume of materials purchased thus reducing waste; (2) substitute, where possible, a non hazardous material for what is characteristically a hazardous material; (3) recycle, distill, fuel blend, etc., to reduce the volumes of material that goes into the campus waste stream thus the community waste stream. This portion of the UAMS Waste Management Program will focus on the following elements of waste handling on campus: Segregation Packaging Storage Transport and handling Treatment techniques Disposal Contingency planning Biohazardous/Infectious/Medical Waste Segregation/Packaging - All biohazardous waste should be separated from the general waste stream at the point of origin by the employee involved in its generation. Biohazardous waste should be discarded directly into either red sharps containers or red plastic bags labeled with the universal biohazard symbol. Some biohazardous waste is pretreated by autoclaving the material prior to transport. Autoclaved biohazardous materials are identified by orange biohazard bags. Once autoclaved this waste may be labeled with the campus name and address and the word “treated”, and included in the normal waste stream. Biohazardous agents are identified by the color of the container (red or orange). Should a different container have to be used be sure the container is clearly marked with the international biohazards symbol. Storage - of these wastes should be kept at a minimum. Temporary areas (a few hours) should be kept close to the site of generation, i.e.; trash rooms, freezers, biohazardous containers in laboratories and so forth. The storage containers should be dedicated only for biohazardous waste. These containers must be clearly marked with a biohazard sign and label. Biohazard storage areas will have restricted access by employees, patients and visitors. Longer term storage requires dedicated areas and must have restricted access. Freezers may be required to minimize microbial growth and odors. These areas are clearly marked or labeled with biohazardous symbols. Freezers should be locked if unauthorized access is possible. Long term storage areas are located in proximity of the treatment and disposal site such as incinerator area, animal facility, and OH&S. Transport – Biohazardous wastes generated by all departments that fall under Clinical Programs are picked up at the point of generation, transported and packaged for commercial disposal by the Biohazardous Waste Team under the direction of the Department of Occupational Health and Safety. Processing is done in a specially designed area on the “F” level of the parking deck. The carts used for transport are red, labeled with the universal biohazard symbol, have tight fitting lids, and are leak proof. The carts are cleaned and sanitized daily by the team. Regulated biohazardous waste from all other departments on the UAMS campus including research, is transported by the Campus Housekeeping Department in the same manner, and is delivered to the “F” level processing area, where it is processed by the Biohazardous Waste Team. Treatment/Disposal - All biohazardous waste is treated off campus by a commercial facility utilizing incineration/autoclaving/shredding. Red bag waste and sharps containers are picked up several times weekly. Some biological wastes are autoclaved at the point of generation before disposal by the commercial facility. These materials are mostly from research areas, such as microbiology. Some potential biohazardous agents, (bulk human blood and blood products, certain regulated body fluids as listed in Chapter I, section II) may be discharged to the sanitary sewer. These materials should be poured carefully into the drain to avoid splashing. Chemical Hazardous Waste Segregation/Packaging - Chemical waste treatment or disposal methods are determined by characteristics of the waste. Chemicals must be segregated from the normal trash to prevent inappropriate or illegal disposal. Once the department has collected the chemicals for disposal a list should be prepared and sent to the Department of Occupational Health and Safety to arrange for disposal. The list or inventory should include: Name of the chemical Volume Type of container (can, bottle, etc.) To ensure the safety of the area and personnel be sure all chemicals are separated by hazard class. Place all segregated chemicals in a safe place (hood, corner of the room, etc.) out of traffic and work areas to prevent accidental spills. Storage - Chemicals are not considered waste until they are declared so by the facility. As a permitted large quantity generator of hazardous wastes, the campus can retain chemical hazardous waste no longer than 90 days after the designated “accumulation start date”. Strict adherence to these guidelines is necessary because of regulatory ramifications of long term large quantity storage. Accumulation areas for chemical waste must be considered for safety, security and location. Personnel access must be limited. Currently there is very limited storage for chemical waste on campus. When storing chemicals in departments or laboratories the following should be given utmost consideration; (1) flammability, volatility, (2) liquid (spill containment) or (3) chemical incompatibilities. Once a department has declared the chemicals waste, an inventory of the waste chemicals should be sent to Occupational Health and Safety at Slot 617. This inventory should include the name of the chemical, and the volume of the container. All containers shall be labeled. Disposal of organic solvents can be arranged by calling the Department of Occupational Health and Safety. These chemicals are bulked and sent to a fuel blender for disposal. Transport - Chemical wastes are only transported by a limited number of persons. This is limited to employees of the Department of Occupational Health and Safety, licensed contact waste handlers and personnel approved by the Department of Occupational Health and Safety. Transport within the facility will normally be by lab carts, with materials carefully packaged, or drum hauler for bulk liquids. Transportation through the facility will be arranged to minimize potential exposure to employees in the event that there is a spill or accident. The flammable storage building is normally used as a staging area for off campus disposal activities. If circumstances permit, individual departments or labs may also be used as lab-pack staging areas. External transport involving any public roads will be arranged through Occupational Health and Safety because this is strictly regulated by DOT and EPA. Treatment/Disposal - Most chemical waste classified as hazardous requires off campus disposal. The treatment and disposal will be arranged and handled by the Department of Occupational Health and Safety. The materials will only be handled by an EPA approved licensed transporter in accordance with state and federal regulations. Most organic solvents can be bulked on site and each drum will list the component flammable materials. Disposal to the sanitary sewer must be limited to those chemicals pre-approved by the authority having jurisdiction (Little Rock Waste Water Utility). The Clean Water Act has limited dramatically the types and quantity of materials that can be released to the sanitary sewer. All disposal of regulated chemical hazardous waste material is specifically and solely managed by the Department of Occupational Health and Safety and its licensed contractor. Radioactive Wastes Segregation/Packaging - Radioactive waste will be segregated by the user department from the normal campus waste stream. All radioactive waste shall be placed in a designated waste container which is appropriately labeled with a Universal “Radioactive Material” label. All radioactive waste is segregated based on radioisotope half life, relative isotope activity, physical nature (liquid, dry solid, aqueous based or organic, biological) and disposal alternatives. The Department of Occupational Health and Safety handles the disposal of all radioactive materials. All materials for disposal should be placed in blue bags. All bags shall be tagged by the user with the appropriate tag (see radioactive materials policy) before the waste will be accepted by OH&S. Storage - Radioactive wastes are generated by many campus departments. The Department of Occupational Health and Safety processes and stores all radioactive waste. Once the radioactive material is declared waste, it is placed in a blue bag and delivered to the Department of Occupational Health and Safety Laboratory for processing. The Occupational Health and Safety department accepts waste by appointment only. Please call extension 686-5550 to schedule an appointment. Transport - The wastes classified as radioactive will be transported by the generating department to Occupational Health and Safety Laboratory. These materials will be transported on carts to minimize potential spills and accidents. Radioactive materials will be delivered by the researcher to OH&S (hospital) G-172 or to Biomedical Research room 167 by pre-arrangement only. All blue bags or bottles are to be tagged in order to be accepted. The radioactive materials are controlled and stored by OH&S in the sub basement. Treatment/Disposal - All radioactive material waste will be handled in strict accordance with state and federal guidelines. These materials will only be handled by Occupational Health and Safety and licensed contracted brokers. These materials require specific handling based on the isotope, activity level and the physical form. Radioactive wastes are segregated for disposal by on site decay, sanitary sewer disposal, off site incineration of deregulated materials, off site incineration or burial by a licensed contracted broker. Radioactive materials in flammable liquids will be bulk containerized by the Department of Occupational Health and Safety to reduce lab pack loads and contain costs. A large volume of the radioactive waste for disposal is held on site for decay. These materials are labeled, tagged in blue bags and placed in plastic tubs. Once the material is decayed (10 half lives or longer) and no longer in need of special handling, then the material is surveyed to confirm background levels and is placed in the biohazard waste and sent for incineration. The blue bags will have all labels and tags removed and are considered “non radioactive waste” by definition. The handling, treatment and disposal are coordinated and handled strictly by the Department of Occupational Health and Safety. Chemotherapy/Cytotoxic Waste Segregation/Packaging - Chemotherapy/Cytotoxic drug contaminated waste, must be separated and segregated from other facility waste. It is identified through the use of a yellow bag. Contaminated disposables should be placed in a yellow bag. Be cautious not to put any sharps in the yellow bag. All sharps (IV needles, syringes, etc.), go into red sharps containers. If the chemotherapy agent or cytotoxic drug to be disposed of is an EPA regulated material, as defined previously, in a volume > 3% it must be segregated into the chemical hazardous waste and treated as part of the chemical hazardous waste stream. Storage - Chemotherapy/Cytotoxic wastes are often classified as mixed waste, possessing chemical toxicity as well as being biohazardous. It is important that the generator make this determination before the waste is classified for storage. If the chemotherapy/cytotoxic waste is from a patient care area chances are the waste is residual contaminated disposables (bags, tubing, etc.). All chemotherapy/cytotoxic drug waste in less than 3% quantities should be placed in trash containers lined with yellow bags. The trash cans are stored in the trash rooms until housekeeping can transport the materials out of the cans. Needles and other sharps used for chemotherapy agents should be placed in yellow or red sharps containers and handled like other contaminated sharps materials. In situations where the chemotherapy agents are in original containers in residual amounts greater than 3%, the material must be handled similarly to the guidelines under chemical waste management. Please see the section of chemical waste management for handling. Containers with less than 3% should be placed into a yellow bag. Transport - See the section on infectious/biohazards. The housekeeping department will transport all residual chemotherapy/cytotoxic wastes (yellow bags) through the facility. The department of Occupational Health and Safety will handle all chemotherapy/cytotoxic wastes in volumes greater than 3% as outlined in chemical waste. Treatment/Disposal - There are three classifications of chemotherapy/cytotoxic wastes; (1) federal and state regulated liquid wastes, (2) unregulated liquid wastes and (3) residual or trace contaminated waste: Federal or state regulated liquid wastes are wastes that are regulated under EPA, RCRA regulations. These are considered toxic hazardous materials and require off-site disposal. These wastes require the generating department to contact Occupational Health and Safety for disposal. When more than 3% of the original volume remains in the original container, it is considered and handled under the provisions of the chemical hazardous waste section of this policy. Unregulated liquid wastes are those wastes that, while containing chemotherapy/cytotoxic agents, are not regulated because of the volume of chemotherapy agent (< 3%) or because the agent is an unregulated material. These materials because they are unregulated can be discharged to sanitary sewer (urine, blood etc.), disposed of in sanitary landfill or incinerated in yellow bags. Residual or trace contaminated solid waste, although unregulated, because it has < 3% of the agent, is incinerated in yellow bags by the commercial waste facility. This waste includes vials, bags, absorbent paper, etc. Special waste Segregation/Packaging - Please contact the Department of Occupational Health and Safety for any wastes not covered by this policy. Materials such as explosives require special handling different from the scope of regular institutional hazardous waste. Storage - Special wastes such as potentially explosive ethers, should not be moved until the Department of Occupational Health and Safety is contacted to evaluate the hazards. The OH&S department has limited storage space for special hazards. Transport - All other materials (excluding normal institutional waste) not covered by this policy will be coordinated by the Department of Occupational Health and Safety. Please call 686-5536 for instructions. 4. Treatment/Disposal - These wastes will be specifically dealt with by Occupational Health and Safety. If you have a material that is not covered by any of the prescribed methods, please contact Occupational Health and Safety at 686-5536. 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