UAMS CLINICAL LABORATORY CHEMICAL HYGIENE PLAN


FOREWORD
The Occupational Safety and Health Administration (OSHA) promulgated a final rule on January 31, 1990 for occupational exposure to hazardous chemicals in laboratories (Lab Standard).  The basis for this standard is that laboratories typically differ from industrial operations in their use and handling of hazardous chemicals and that a different approach from the Hazard Communication Standard of 1987 is warranted.

The final standard applies to all laboratories which use hazardous chemicals in accordance with the definition of laboratory use and laboratory scale (see Glossary, Section II) provided in standard 29 CFR, Part 1910, of the Federal Register.

The information in this manual is compiled from sources and documents believed to be reliable and specifically concerning the Pathology Laboratories, University of Arkansas for Medical Sciences, Little Rock, Arkansas.

TABLE OF CONTENTS

I.         Formal Policy Statement                                           
II.        Glossary                                                                     
III.       Standard Operating Procedures
IV.       Chemical Inventory                                                   
V.        Material Safety Data Sheets (MSDS)                               
VI.       Chemical Storage                                                                 
VII.      Labeling                                                                               
VIII.     Engineering Controls
IX.       Personal Protective Equipment
X.        Contaminated Waste Removal / Disposal / Reduction
XI.       Mercury Reduction/Elimination
XII.      Administrative Controls                   
XIII.     Medical Consultations and Examinations
XIV.     Chemical Hygiene Officer / Committee
XV.      Training                                               
XVI.     Housekeeping
XVII.    Record Keeping                                                                         
XVIII.   References                                                                                
XIX.     Appendices  
                Appendix A--DOT Hazard Classification List                     
                Appendix B--EPA Hazard Classification List                                  
                Appendix C--Chemical Inventory Form                                        
                Appendix D--Sample MSDS Request Letter                                  
                Appendix E--MSDS Example                                                       
                Appendix F--Directory                                                                  
                Appendix G--Target organ Poster                                                 
                Appendix H—Waste Reduction Plan        

I.  FORMAL POLICY STATEMENT

The Department of Pathology and Laboratory Services (including clinical and anatomic laboratories) of the University of Arkansas for Medical Sciences is committed to providing a safe working environment and believes laboratory employees have a right to know about health hazards associated with their work.

This Chemical Hygiene Plan includes policies, procedures and responsibilities designed to develop in employees an awareness of potentially hazardous chemicals in the workplace and to train employees in appropriate, safe working conditions.  This Plan is intended to meet the requirements of occupational Safety and Health Administration (OSHA) Standard, Occupational Exposure to Hazardous Chemicals in Laboratories, 29 CFR 1910.1450.

All employees will have access to this policy, OSHA Standard 29 CFR 1910.1450 and pertinent safety information through their supervisory staff.

Because the standard clearly mandates training in the ''specific area'' in which the personnel are working, it is necessary that individual sections of the laboratory consider their procedures and develop a ''Chemical Hygiene Plan'' for that section.  Plans will be attached to the overall Laboratory Plan in Appendix Form.

 II.  GLOSSARY
The following terms are used as part of the Chemical Hygiene Program:
 

ACTION LEVEL A concentration of hazardous chemicals which triggers certain required activities such as exposure monitoring or medical surveillance.
ACUTE An adverse effect with symptoms of high severity coming quickly to a crisis.
CARCINOGEN A substance capable of causing cancer.
CHEMICAL AGENTS A wide variety of fluids that have a high potential for body entry by various means.  Some are more toxic than others and require special measures of control for safety and environmental reasons.
CHRONIC An adverse effect with symptoms that develop slowly over a long period of time or that frequently recur.
COMBUSTIBLE Able to catch on fire and burn
DOT Department of Transportation
EPA Environmental Protection Agency
FLAMMABLE Capable of being easily ignited and of burning with extreme rapidity. (Flashpoint below 140 degrees F.)
FLASHPOINT The temperature of a liquid at which it gives off vapors sufficient to form an ignitable mixture with the air near the surface of the liquid.
HAZARDOUS CHEMICAL A chemical for which there is significant evidence that acute or chronic health effects may occur in exposed employees.
INFECTIOUS AGENTS Sources that cause infections either by inhalation, ingestion, or direct contact with the host material.
LABORATORY SCALE Work with chemicals that can easily and safely be manipulated by one person excluding the commercial production of chemicals for sale.
LABORATORY USE A workplace where relatively small quantities of hazardous chemicals are used on a non-production basis.
LC 50 The concentration of a substance in air that causes death in 50% of the animals exposed by inhalation.  A measure of acute toxicity
LD 50 The dose that causes death in 50% of the animals exposed by swallowing a substance.  A measure of acute toxicity.
MSDS Material Safety Data Sheets
MUTAGEN Capable of changing cells in such a way that future cell generations are affected.  Mutagenic substances are usually considered suspect carcinogens.
OSHA Occupational Safety and Health Administration, the regulatory branch of the Department of Labor concerned with employee safety and health.
PEL Permissible Exposure Limits for the workplace, set by regulation and enforced by OSHA.
pH A measure of how acidic or caustic a substance is on a scale of 1 to 14.  A pH of 1 indicates that a substance is acidic; a pH of 14 indicates that a substance is basic.
PHYSICAL AGENTS Workplace sources recognized for their potential effects on the body.  Heat exposure or excessive noise levels are examples of this risk group.
SENSITIZERS Agents to repeated exposure over time creating an allergic reaction at some point in time.
STERILITY Changes made in male or female reproductive systems resulting in inability to reproduce
TERATOGENS A substance that causes a deformity in newborns if a significant exposure exists during pregnancy.
TLV Threshold Limit Value.  The time weighted average concentration for a normal 8-hour workday to which nearly all workers may be repeatedly exposed, day after day, without adverse affect.


  III.  STANDARD OPERATING PROCEDURES

Because few laboratory chemicals are without hazards, general precautions for handling all laboratory
chemicals should be adopted to include minimizing exposure and assuming that any mixture of hazardous
chemicals is more toxic than the most toxic component.

The following procedures are used when working with chemicals:

1.     Accidents and spills
       a.       Eye contact: promptly flush eyes with water for a prolonged period (15 minutes) and seek                  medical attention.

       b.       Ingestion: drink large amounts of water.

       c.       Skin contact: promptly flush the affected area with water and remove any contaminated                  clothing; use a safety shower when contact is extensive.  If symptoms persist after                  washing, seek medical attention.

       d.       Clean-up: promptly clean up spills, using appropriate protective apparel and equipment and                  proper disposal.
 

2.     Avoid unnecessary exposure to chemicals.
a.       Do not smell or taste chemicals.  Apparatus that can discharge toxic chemicals (vacuum          pumps, distillation columns, etc.) should be vented into local exhaust devices.

b.       Inspect gloves and test glove boxes before use.

c.       Do not allow release of toxic substances in cold rooms and warm rooms, since these have           contained recirculated atmospheres.

d.       Use only those chemicals for which the quality of the available ventilation system is            appropriate.

e.       Eating, drinking, smoking, gum chewing, or applying cosmetics or lip balm in areas             
          where laboratory chemicals are present is prohibited.  Wash hands before conducting
          these activities.
f.        Avoid storing, handling, or consuming food or beverages in storage areas, refrigerators,           glassware, or utensils that are also used for laboratory operation.

g.       Handle and store laboratory glassware with care to avoid damage; do not use damaged           glassware.  Use extra care with Dewar flasks and other evacuated glass apparatus; shield           or wrap them to contain chemicals and fragments should implosion occur.  Use equipment           only for its designed purpose.

h.      Wash areas of exposed skin thoroughly before leaving the laboratory.

i.       Avoid practical jokes or other behavior that might confuse, startle, or distract another          worker.

j.       Do not use mouth suction for pipetting or starting a siphon.

k.      Confine long hair and loose clothing.

1.      Wear shoes at all times in the laboratory, but do not wear sandals, perforated shoes,          sneakers, or any shoes made of canvas.

m.      Keep the work area clean and uncluttered, with chemicals and equipment properly labeled          and stored; clean up the work area on completion of an operation or at the end of each          day.

n.       Ensure that appropriate eye protection is worn by all persons, including visitors, in areas           where chemicals are stored or handled, where necessary.

o.       Wear appropriate gloves when the potential for contact with toxic materials exists;             inspect the gloves before each use, wash them before removal, and replace them            periodically.

p.       Use appropriate respiratory equipment when air contaminant concentrations are not            sufficiently restricted by engineering controls.  Inspect the respirator before each use.

q.       Use any other protective and emergency apparel and equipment as appropriate.

r.        Avoid use of contact lenses in the laboratory unless necessary; if they are used, inform           supervisor so special precautions can be taken.

s.        Remove and dispose laboratory coats in biohazard container immediately upon significant           contamination.

t.        Seek information and advice about hazards, plan appropriate protective procedures, and           plan positioning of equipment before beginning any new operation

u.        Leave lights on, place an appropriate sign on the door, and provide for containment of            toxic substances in the event of failure of a utility service (such as cooling water) in an            unattended operation.

v.        Use a hood for operations that might result in release of toxic chemical vapors or dust.
           As a rule of thumb, use a hood or other local ventilation device when working with any            appreciably volatile substance with a TLV of less than 50 ppm.

           Confirm adequate hood performance before use: keep hood closed at all times except            when adjustments within the hood are being made.  Keep materials stored in hoods to a            minimum, and do not allow materials to block vents or air flow.

           Leave the hood "on" when it is not in active use if toxic substances are stored in it or if            it is uncertain whether adequate general laboratory ventilation will be maintained when it            is ''off.''

w.        Be aware of unsafe conditions and see that they are corrected when detected.

 
 

IV.  CHEMICAL INVENTORY

A chemical inventory is performed annually, listing all the hazardous chemicals in the laboratory. 
Chemicals listed are those classified as hazardous by the Department of Transportation (DOT),
the Environmental Protection Agency (EPA), or displaying a 2 or greater number in any section
of the National Fire Protection Association (NFPA) diamond.  DOT and EPA classifications are in
Appendices A and B.

Chemicals are listed alphabetically by section according to the most commonly used name (e.g., bleach). 
A catalog number may be required by some manufacturers for MSDS.  The average quantity in storage
on a monthly basis, as well as the physical state (e.g., solid, liquid, gas), is included.  The NFPA hazard
classification, if known, is listed along with the manufacturer's name and complete address.  A comment
section is provided to further identify the chemical's location (e.g., under the sink, third shelf in the
safety cabinet, etc.). A chemical inventory form is provided in Appendix C.

A complete chemical inventory is located in the office of the Chemical Hygiene Officer, as well as in the
Department of Environmental Health and Safety.

V.   MATERIAL SAFETY DATA SHEETS
Upon completion of the chemical inventory, request letters are sent to manufacturers if MSDS are missing. 
A sample letter is in Appendix D.

MSDS must be available in each laboratory section in a 3-ring binder.  The MSDS are in alphabetical order
along with a chemical inventory of the section.  The laboratory relies on the chemical manufacturer's i
nformation to ascertain whether or not the chemical is hazardous.

The MSDS for each chemical is located in each section. An example of a MSDS is in Appendix E.

 VI.  CHEMICAL STORAGE
Chemical storage is kept as small as practical.  Storage on bench tops and in hoods may cause potential exposure to fire and spills.  Ventilated cabinets and specially monitored refrigerators are used for chemical storage only.  No food is permitted in these refrigerators.  Flammable liquids are stored in flammable storage cabinets with self-closing doors and proper ventilation according to NFPA standards.  Safety cans with a spring-loaded spout are used for transporting flammable liquids.

Acids are stored in a specially labeled ''acid cabinet'' located at floor level and contained on a polyethylene
acid-proof tray.

Bases are extremely hazardous because they are caustic and should be stored away from acids.

Toxic chemicals, including carcinogens, are stored in ventilated storage areas in unbreakable chemical
resistant secondary containers.  These containers are labeled "CAUTION: HIGH CHRONIC TOXICITY
OR CANCER-SUSPECT AGENT." The Chemical Hygiene Officer according to federal and state
regulations maintains a separate inventory list of carcinogens and suspected carcinogens.

Cylinders of compressed gases are strapped or chained to a wall or bench top and are capped when not in use.

VII.  LABELING
The 29 CFR 1910.1450 contains specific labeling requirements.  Labeling must be done on all hazardous
chemicals that are shipped and used in the workplace.  Labels must not be removed or defaced.

ON SHIPPED CHEMICALS

Chemical manufacturers, importers, and distributors make sure that each container of hazardous
chemicals leaving the workplace is labeled, tagged, or marked with the following information: 

          1.            Identity of the hazardous chemical

          2.            Appropriate hazard warnings

          3.            Name and address of the chemical company (i.e., manufacturer).

ON IN-PLANT CHEMICALS 

Each hazardous chemical transferred outside the laboratory that is not in its original container
must also be labeled.  These workplace labels must contain: 

          1.            Identity of the hazardous chemical

          2.            Route of entry (e.g., eyes, nose, mouth, skin)

          3.            Health hazard

          4.            Physical hazard

          5.            Target organ affected.

An example of a computer-generated label is shown below:

 

 

 

LABORATORY

ACETIC ACID

Route of Entry: Eyes, Skin, Nose

Health Hazard: Poison

Physical Hazard: Corrosive

Target Organ: Skin and Lungs

 VIII.  ENGINEERING CONTROLS

All biohazard and fume hoods are inspected annually and certified by (see each section for specific data). 
Any hood not passing inspection is taken out of service immediately and not used until the hood has
passed inspection.  It is the responsibility of the employer to purchase the parts and to replace the
unit in a timely fashion so as not to endanger the health and well-being of an employee or place the
facility at risk.

Eyewash fountains are inspected weekly, safety showers are inspected, tested, and flushed monthly,
and fire extinguishers are inspected monthly by the Physical Plant (telephone 686-6945).

All chemical stockrooms/storerooms are adequate and well ventilated.

Ventilated storage cabinets for chemicals are provided as needed and have a separate exhaust duct.

Cold rooms and warm rooms may be opened from either inside or outside manually to avoid entrapment.

Airflow through the laboratory should be relatively uniform and be exhausted to the exterior of the building. 
Quality and quantity of ventilation should be evaluated on initial installation, regularly monitored and
re-evaluated whenever a change in local ventilation devices is made.  System filters are checked and
changed as required, records are maintained by Physical Plant (telephone 686-6945).

All chemical hygiene-related equipment is monitored continuously and modified if inadequate.

IX.  PERSONAL PROTECTIVE EQUIPMENT

Employees are required to wear gloves when the employee has the potential for direct skin contact with
blood, hazardous chemicals, and infectious materials.

Lab coats are to be worn only in the laboratory area and are to be buttoned to protect the employee's
clothing.  Lab coats or disposable covers are provided by the Department of Pathology, UAMS.

In areas where chemical splashes are great (e.g., histology), an impervious apron appropriate for the task is
worn.

All personal protective equipment is removed immediately upon leaving the work area (or as soon as possible)
and placed in an appropriate laundry hamper located in each section and laundered on site or by an outside
contract service.

Masks and eye protection or chin-length face shields are worn to prevent splashes or sprays of blood,
infectious materials, or hazardous chemicals if there is a potential for eye, nose, or mouth contamination. 
This equipment is located in the Safety Equipment Cabinets or adjacent to area of use.

X.  CONTAMINATED WASTE REMOVAL/DISPOSAL/REDUCTION

To assure that minimal harm to people, other organisms, and the environment will result from the disposal of
waste laboratory chemicals, the waste disposal program, Departmental Safety Manual, pages 67-78, specifies
how waste is to be collected, segregated, stored, and transported and includes consideration of what materials
can be incinerated.  All disposal is done in accordance with the Department of Natural Resources in Arkansas,
PC&E and U.S. EPA Regulations.

The laboratory is considered a satellite generator and the UAMS Campus is a small quantity generator according
to the EPA and has an EPA generation number of ARD981158405.

Certain chemicals are permissible for drain disposal.  The local sanitary sewer district, City of Little Rock Waste
Water Utility, was contacted to determine what was and was not acceptable.- The drain system connects to
a sanitary sewer system that ultimately flows to the wastewater treatment facility.  At no time was a septic
tank system used. Only those chemicals reasonably soluble in water are suitable for drain disposal.  A compound
is considered water-soluble if it dissolves to the extent of at least 3% (ex. formaldehyde disposal).  These
compounds are flushed with at least 100 volumes of excess water.  Some exceptions should be noted:

1.       Those organics with boiling points less than 500C

2.       Those hydrocarbons, halogenated hydrocarbons, nitro compounds, mercaptans, and most oxygenated
  compounds that contain more than five carbon atoms (e.g., freon)

3.       Those organics that are explosives such as azides and peroxides

4.       Concentrated acids or bases

5.      Highly toxic malodorous or lachrymatory substances.

Incineration in an environmentally acceptable manner is the most practical disposal method for combustible
laboratory waste.  Indiscriminate disposal by pouring waste chemicals down the drain or adding them to mixed
refuse for landfill burial is unacceptable.  Hoods are not to be used as a means of disposal for volatile chemicals. 
 Disposal by recycling or chemical decontamination is used when possible.

Waste is removed from laboratories to a central waste storage area at least once per week and from the
central waste storage area at regular intervals.  The Department of Environmental Health and Safety are
responsible for the central waste storage area and subsequent disposal arrangements.

WASTE REDUCTION PLAN:

UAMS Department of Pathology and Laboratory Services personnel follow certain practice 
that are meant to reduce the amount of body fluids, reagents, and chemicals used in the different
sections testing.  The “less is better” concept is implemented through the 5 methods of
minimizing hazardous waste. The Department Waste Reduction Plan is provided in Appendix H.

XI.  MERCURY REDUCTION/ELIMINATION

To reduce or eliminate mercury in the laboratory sections of the Department of Pathology and
Laboratory Services have done the following:

XII.  ADMINISTRATIVE CONTROLS

The laboratory manager is responsible for the safe operation of the area. All activities and procedures require
approval by the medical director and the employer before implementation. Appendix F lists the important telephone
numbers for the laboratory.

Environmental Monitoring:

Regular instrumental monitoring of airborne concentrations is not usually justified or practical in laboratories
but may be appropriate when testing or redesigning hoods or other ventilation devices or when a highly toxic
substance is stored or used regularly.

EHS will measure the employee's exposure to any substance regulated by a standard which requires monitoring
if there is a reason to believe that exposure levels for that substance routinely exceed the action level or the PEL.

For laboratory uses of OSHA regulated substances, the University shall assure that laboratory employees' exposures
to such substances do not exceed the OSHA PEL.

If initial monitoring discloses employee exposure over the action level (or in the absence of an action level, the
PEL), the University shall immediately comply with the exposure monitoring provisions of the relevant standard.

Employee notification of monitoring results.  Within 15 working days after the receipt of any monitoring results,
the University shall notify the employee of these results in writing either individually or by posting results in an
appropriate location that is accessible to employees.

Environment monitoring is required in all laboratories for the following chemicals stored or used 3 times/week:

         29 CFR 1910 Subpart Z 

1910.1003                4-Nitrobiphenyl

1910.1004                alpha-Naphthylamine

1910.1005                (Reserved]

1910.1006                14ethyl chloromethyl ether

1910.1007                3,31-Dichlorobenzidine (and its salts)

1910.1008                bis-Chloromethyl ether

1910.1009                beta-Naphthylamine

1910.1010                Benzidine

1910.1011                4-Aminodiphenyl

1910.1012                Ethyleneimine

1910.1013                beta-Propiolactone

1910-1014               2-Acetyla-,,iinofluorene

1910.1015               4-Dimethylaminoazobenzene

1910.1016               N-Nitrosodimethylamine

 

1910.1017              Vinyl chloride
 

1910.1018              Inorganic arsenic
 

1910.1025              Lead
 

1910.1028              Benzene
 

1910.1029              Coke oven emissions
 

1910.1043              Cotton dust
 

1910.1044              1,2-dibromo-3-chloropropane
 

1910.1045              Acrylonitrile
 

1910.1047              Ethylene oxide
 

1910.1048              Formaldehyde
 

1910.1101              Asbestos

Chemical spills are contained using the Think C.L.E.A.N. Plan:
    *     Contain the spill.
    *     Leave the area.
    *     Emergency: eye wash, shower, medical care.
    *     Access MSDS.
    *     Notify a supervisor.

All spills are contained according to OSHA guidelines, and appropriate spill kits, located in each section of
the laboratory.

Assessment of significant risk of all operations is made by the Laboratory Manager or Chemical Hygiene 
Officer.  Chemical hygiene and safety policies will be established for each task performed and engineering controls
or personal protective equipment assigned.  An attached list identifies each workstation/task in the laboratory and
the required controls and equipment.

 CHEMICAL HYGIENE RISK ASSESSMENT

                       Department of Laboratories                                             Verified by:

                       Section:                                                                           Extension:

                       Task--routine operation                             Risk*             Protective Equipment

                       Coulter STKS                                            L                  Lab coat, gloves

                       Tissue Processor                                       H                  Lab coat, gloves,
                                                                                                         goggles, plastic apron

                           L = low risk
                           M = moderate risk
                           H = high risk

 XIII.  MEDICAL CONSULTATIONS AND EXAMINATIONS

All employees needing medical attention use the Student/Employee Health services at 521 South Elm Street
(telephone 686-6560) during its hours of operation or or in case of an emergency are referred to the
Emergency Room, University Hospital (telephone 686-5835).

All medical examinations and consultations are performed by or under the direct supervision of a licensed
physician without cost to the employee, without loss of pay, and at a reasonable time and place.  A
board-certified physician in occupational medicine is used whenever possible.

The employee is sent for medical evaluation: