IH Guidebook.pdf

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Table of Contents

PREFACE

Disclaimers ................................................................................................................ xii

Executive Summary ................................................................................................. xiii

Acknowledgements .................................................................................................. xiv

How to Use This Guidebook .................................................................................... xvi

Update Listing ......................................................................................................... xviii

Acronyms/Abbreviations ......................................................................................... xix

1 Confined Spaces

1.1. Introduction

1.2. Construction Versus Maintenance

1.3. Discussion

1.4. Definitions

1.5. Methods of Compliance

1.6. PRCS Requirements

1.6.1. Alternate Procedures and Reclassified PRCS

1.6.2. Air Monitoring

1.6.3. Contractors

1.6.4. Confined Space Rescue and Emergency Services

1.6.5. Training

1.7. Common Compliance Issues

1.8. References and Resources

2 Ergonomics

2.1. Introduction

2.1.1. Multi-disciplinary Approach

2.1.2. Psychosocial Stressors

2.2. References and Resources

3 Industrial Hygiene Issues in VA Fire Departments

3.1. Introduction

3.2. Discussion

3.3. Physical Hazards

3.3.1. Thermal Stress

3.3.2. Hazardous Noise Exposure/Hearing Conservation Program

ii

3.3.3. Ergonomic Hazards

3.4. Chemical Hazards

3.4.1.a. Fire Truck/Emergency Vehicle Exhaust

3.4.2. Chemical Hazards During and After Fire Incidents

3.5. Respiratory Protection

3.6. Medical Surveillance

3.7. Additional Considerations

3.8. References and Resources

4 Hearing Conservation

4.1. Introduction

4.2. Discussion

4.3. Noise Monitoring

4.3.1. Noise Source Survey

4.3.2. Employee Exposure Survey

4.3.3. Hearing Protection

4.4. Noise Exposure Limits - Job Performance

4.5. Audiometric Testing Program

4.6. Recording Criteria for Cases Involving Occupational Hearing Loss

4.7. Employee Exposure and Medical Records

4.8. Education and Training

4.9. Occupational Ototoxins

4.10. References and Resources

5 Thermal Extremes

5.1. Introduction

5.2. Heat/Cold Disorders

5.2.1. Heat Stroke

5.2.2. Heat Exhaustion

5.2.3. Heat Syncope

5.2.4. Heat Cramps

5.2.5. Heat Rash

5.2.6. Hypothermia

5.2.7. Frostbite

5.2.8. Trench Foot

5.2.9. Chilblains

5.3. Exposure Limits for Heat and Cold Stress

iii

5.4. Exposure Monitoring

5.5. Controls for Heat/Cold Stress

5.6. Medical Surveillance

5.7. Training

5.7.1. Training Resources

5.8. References and Resources

6 Chemical Safety in Clinical Laboratories

6.1. Introduction

6.2. Discussion

6.2.1. Occupational Exposure to Hazardous Chemicals in Laboratories

6.2.2. Application

6.2.3. Definitions

6.2.4. Elements of the Chemical Hygiene Plan

6.2.5. Employee Exposure Determination

6.2.6. Medical Consultation and Examinations

6.2.7. Information and Training

6.3. Chemicals of Special Interest

6.4. Other Applicable OSHA Standards

6.5. Chemical Storage

6.6. Chemical Spill Response

6.7. References and Resources

7 Biosafety in the Laboratory

7.1. Introduction

7.2. Discussion

7.2.1. Primary and Secondary Barriers

7.2.2. Laboratory Design

7.2.3. Personal Protective Equipment (PPE)

7.2.4. Special Precautions

7.2.4.a. Blood Collection Safety Devices

7.2.4.b. Specimen Collection, Handling, and Transportation

7.2.4.c. Storage

7.2.4.d. Aliquots and Transfer

7.2.4.e. Decontamination and Disinfection

7.2.5. Biohazards Associated with Select Laboratory Equipment and iv

Processes

7.2.5.a. Automated Analyzer

7.2.5.b. Blood Gas Analyzer

7.2.5.c. Flow Cytometry

7.2.5.d. Hematology

7.2.5.e. Cryostat

7.2.5.f. Centrifuge

7.2.5.g. Pneumatic Tube System

7.2.6. Exposure Control

7.2.7. Waste Management

7.2.8. Transporting Infectious Materials

7.3. Training

7.4. References and Resources

8 Non-Ionizing Radiation

8.1. Introduction

8.2. Discussion

8.3. Lasers

8.4. Electro-Magnetic Radiation

8.4.1. Electro-Magnetic Radiation Biological Effects

8.4.2. Electro-Magnetic Radiation Exposure Controls

8.4.2.a. Training

8.5. Ultraviolet Light and Health Effects

8.5.1. High-Intensity Discharge (HID) Lamps

8.5.2. Germicidal Lamps, Portable UV Devices, and UVGI

8.5.3. UV Safety Program

8.5.4. Electric Arc Welding

8.5.5. Exposure to the Sun and Introduction to the UV Index

8.5.6. Biological Effects

8.6. References and Resources

9 Respiratory Protection

9.1. Introduction

9.2. Discussion

9.3. Respirator Selection

9.3.1. NIOSH Respirator Filter Designations and Food and Drug v

Administration (FDA) Clearances

9.3.2. Respirator Cartridges

9.3.3. Atmosphere-supplying respirators (ASRs)

9.3.4. Respirators Maintained for Emergency Use

9.3.5. Specific Respiratory Protection Situations

9.3.5.a. Employee Voluntary Use of Respirators

9.3.5.b. Seasonal Influenza Respiratory Protection

9.3.5.c. Pandemic Preparedness

9.4. Medical Fitness Issues

9.5. Fit Testing

9.5.1. Pros and Cons of Fit-Test Types

9.5.2. Addressing Fit-Testing Challenges

9.6. Education and Training

9.7. Policies and Supporting Documentation

9.8. References and Resources

10 Hazard Communication Standard

10.1. Introduction

10.2. Discussion

10.2.1. Timeframe for 29 CFR 1910.1200 Implementation

10.3. Definitions

10.4. Methods of Compliance

10.4.1. OSHA Standard

10.4.2. Scope and Application

10.4.3. Components of the Written Hazard Communication Program (HCP) 122

10.4.4. Labels and Other Forms of Warning

10.4.5. Safety Data Sheets (SDSs)

10.5. Training

10.6. Trade Secrets

10.7. References and Resources

11 Hazardous Materials

11.1. Hazardous Drugs

11.1.1. Introduction

11.1.2. OSHA

11.1.3. U.S. Pharmacopeia (USP) 797

11.1.4. Discussion

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11.1.5. Hazardous Drug Program

11.1.6. Preparation/Compounding and Use

11.1.7. Primary Engineering Controls (PECs)

11.1.8. Surface Disinfection vs. Decontamination

11.1.9. Testing and Certification of USP 797 Facilities

11.1.10. Administration

11.1.11. Personal Protective Equipment

11.1.12. Spill Procedures

11.1.12.a. Air Sampling for Hazardous Drugs

11.1.12.b. Surface Residue Sampling

11.1.12.c. Surface Contamination Assessments vs. Dermal

Exposure Studies

11.1.12.d. One Hospital's Experience Evaluating Surface

Contamination

11.1.13. Hazardous Waste

11.1.14. Medical Surveillance

11.1.15. Training

11.1.16. Record Keeping

11.1.17. Industrial Hygiene Responsibilities

11.1.18. References and Resources

11.2. Asbestos

11.2.1. Introduction

11.2.2. Discussion

11.2.2.a. General

11.2.2.b. Regulatory Discussion

11.2.2.c. Personal, Area, and Bulk Sampling

11.2.2.d. Special Considerations

11.2.2.e. Methods of Compliance

11.2.2.f. Respirators

11.2.2.g. Regulated Areas

11.2.2.h. Communication of Hazards, Training, and Labels

11.2.2.i. Record Keeping

11.2.2.j. Protective Clothing

11.2.2.k. Hygiene Facilities and Practices

11.2.2.l. Medical Exams vii

11.2.2.m. Compliance Tips

11.2.3. References and Resources

11.3. Waste Anesthetic Gases

11.3.1. Introduction

11.3.2. Discussion

11.3.2.a. Exposure Limits

11.3.2.b. Health Effects from Exposure to WAG

11.3.2.c. Exposure Control Strategies and Methods

11.3.2.d. Evaluating Exposure and Air Monitoring

11.3.2.e. Medical Surveillance

11.3.3. Employee Education and Training

11.3.4. References and Resources

11.4. Ethylene Oxide

11.4.1. Introduction

11.4.2. Discussion

11.4.2.a. Health Effects

11.4.2.b. Regulations

11.4.3. Education and Training

11.4.4. References and Resources

11.5. Formaldehyde

11.5.1. Introduction

11.5.2. Discussion

11.5.3. Regulatory Discussion

11.5.4. Signs and Labels

11.5.5. Employee Information and Training

11.5.5.a. Record Keeping

11.5.5.b. Medical Records

11.5.5.c. EPA Information

11.5.5.d. Evaluation of Formaldehyde Hazard

11.5.6. Reference and Resource

11.6. Lead

11.6.1. Introduction

11.6.2. Discussion

11.6.2.a. OSHA

11.6.2.b. Other Federal Agencies viii

11.6.3. Lead Hazard Assessment

11.6.4. Clinical Issues

11.6.5. VA Police

11.6.6. Respiratory Protection

11.6.6.a. Medical Surveillance

11.6.6.b. Housekeeping

11.6.6.c. Education and Training

11.6.6.d. Compliance Tips

11.6.7. References and Resources

11.7. Pesticides

11.7.1. Discussion

11.7.2. Recommended Work Practices

11.7.3. Health Effects

11.7.4. Monitoring

11.7.5. Certification and Competence

11.7.6. Medical Surveillance

11.7.7. VHA Guidance

11.7.8. References and Resources

11.8. Latex

11.8.1. Discussion

11.8.2. Health Effects

11.8.3. Education and Training

11.8.4. References and Resources

11.9. Nanoparticles

11.9.1. Introduction

11.9.2. Discussion

11.9.3. Primary Health Hazards

11.9.4. Possible Uses of Nanoparticles within VA

11.9.5. Conclusion

11.10. Reproductive and Developmental Health

11.10.1. Introduction

11.10.2. Discussion

11.10.3. Recognized Hazards and Adverse Reproductive and

Developmental Effects ix

11.10.4. Evaluation and Management of Workplace Reproductive and

Developmental Hazards

11.10.5. Education

11.10.5.a. Risk Communication/Hazard Communication

11.10.6. References and Resources

12 Bloodborne Pathogens Disease Control

12.1. Introduction

12.2. Discussion

12.2.1. Exposure Control

12.2.2. Methods of Compliance

12.2.3. HIV and HBV Research Laboratories and Production Facilities

12.2.4. Hepatitis B Vaccination and Post-Exposure Evaluation and

Follow-Up

12.2.5. Communication of Hazards to Employees

12.3. Information and Training

12.4. Record Keeping

12.5. References and Resources

13 Tuberculosis Control

13.1. Introduction

13.2. Prevention and Controls

13.3. Key Differences between 1994 and 2005 CDC TB Control Guidance

13.4. Occupational Safety and Health Administration (OSHA)

13.5. Administrative Controls: The Facility TB Infection Control Program

13.6. Training

13.7. Hierarchy of Controls

13.8. Environmental Controls

13.8.1. Airborne Infection Isolation Rooms (AII Rooms)

13.8.2. Surgical Suites

13.8.3. Sputum Induction and Inhalation Therapy Rooms

13.8.4. Bronchoscopy Suites

13.8.5. Autopsy Suites

13.8.6. Maintenance of Environmental Controls

13.8.6.a. HVAC System Testing & Balancing

13.8.6.b. Smoke Trail Testing

13.8.6.c. Optimal Room Differential Pressure x

13.8.6.d. Room Differential Pressure Monitors

13.8.6.e. AII and Negative-Pressure Isolation Rooms Distinguished 260

13.8.6.f. Optimal Room ACH

13.8.6.g. Re-Entry Times

13.8.6.h. HEPA Filter Changeouts and In-Line HEPA Filter Testing 261

13.8.6.i. Maintenance Records

13.8.6.j. Portable HEPA-Filtered Air-Cleaning Units

13.8.7. Environmental Controls Summary

13.8.8. UVGI

13.9. Respiratory Protection

13.10. BSL-3 M. tuberculosis Laboratories

13.11. References and Resources

14 Hazardous Waste Operations and Emergency Response (HAZWOPER)

14.1. Introduction

14.2. Discussion

14.2.1. Releases that Are Clearly Incidental

14.2.2. Releases that May Be Incidental or Require an Emergency

Response, Depending on the Circumstances

14.2.3. Releases that Require an Emergency Response Regardless of the Circumstances

14.2.4. Response to Infectious Substances

14.2.5. Plans

14.2.5.a. Emergency Response Plan (ERP)

14.2.5.b. Emergency Action Plan (EAP)

14.3. Veterans Health Administration (VHA) First Receivers Decontamination

Program (FRDP)

14.4. References and Resources

15 Indoor Air Quality

15.1. Introduction

15.2. Discussion

15.3. Definitions

15.4. IAQ Sources and Strategies

15.5. Components of an IAQ Program

15.6. Protocol for Comprehensive IAQ Investigation

15.7. Recommended IAQ Guidelines

xi

15.8. IAQ During Construction

15.9. IAQ Technical Review

15.10. Mold

15.11. HVAC Duct Cleaning

15.12. References and Resources

16 Exposure Assessments

16.1. Introduction

16.2. Discussion

16.3. Definitions

16.4. Exposure Assessment

16.4.1. Exposure Assessment Strategies

16.4.1.a. Qualitative versus Quantitative Exposure Assessment

16.5. Air Sampling Methodology

16.5.1. Conducting air sampling

16.5.2. Calibrating the Equipment

16.6. Education and Training

16.7. References and Resources

17 Waterborne Pathogen Aerosol Risks

17.1. Introduction

17.2. Discussion

17.3. Training

17.4. Employee Protection

17.5. Reference

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Disclaimers Endorsement

Reference herein to any specific commercial product, process, or service by trade name, trademark, manufacturer, or otherwise, does not necessarily constitute or imply its endorsement, recommendation, or favoring by the U.S. Government.

The views and opinions of authors expressed herein do not necessarily state or reflect those of the U.S. Government and shall not be used for advertising or product endorsement purposes.

Hyperlinks

The appearance of external hyperlinks does not constitute endorsement by the

Department of Veterans Affairs (VA) of the linked Web sites or the information, products, or services contained therein. For other than authorized VA activities, the Department does not exercise any editorial control over the information you may find at these locations. All links are provided with the intent of meeting the mission of the Department and the VA Web site. Please let us know about existing external links that you believe are inappropriate and about specific additional external links that you believe should be included.

Liability

With respect to documents available from this server, neither the U.S.

Government nor any of its employees makes any warranty, expressed or implied, including the warranties of merchantability and fitness for a particular purpose, or assumes any legal liability or responsibility for the accuracy, completeness, or usefulness of any information, apparatus, product, or process disclosed, or represents that its use would not infringe privately-owned rights.

Reference from this Web site or from any of the information services sponsored by VA to any non-governmental entity, product, service, or information does not constitute an endorsement or recommendation by VA or any of its employees.

We are not responsible for the content of any "off-site" Web sites referenced from the Veterans Health Administration (VHA) Healthcare Environment and Facilities

Programs (HEFP) Web site, electronic media, or printed media.

Guidance

VHA guidebooks are “BEST PRACTICE” resources designed to assist health care facilities implement and enhance programs and more effectively comply with current VA/VHA policy and external regulatory standards. VHA guidebooks published by VHA HEFP are NOT OFFICIAL POLICY. In accordance with VA

Directive 6330, Directives Management System, official policy documents include:

(1) Directives, which carry the authority to mandate Department- or

Administration-wide policies, and (2) Handbooks, which carry the authority to mandate procedures or operational requirements implementing policies contained in directives.

http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1814 http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1814 xiii

Executive Summary This edition of the Industrial Hygiene Guidebook incorporates several significant changes:

1. Chapter 17, Waterborne Pathogen Aerosol Risks, has been added to the guidebook.

2. In line with Veterans Health Administration (VHA) environmental and financial goals, most chapters have been designed to facilitate the transition to electronic (only) publishing.

3. Safety Automated Facility Evaluation (SAFE) criteria statements (used to evaluate a facility’s compliance with Department of Veteran Affairs (VA)

Safety and Health Programs) were removed from each chapter to prevent inconsistencies while the SAFE audit program is updated.

4. The Guidebook Professional Advisory Group (PAG) incorporated a large number of Internet and VHA Healthcare Environment and Facilities

Programs (HEFP) hyperlinks into the chapter text; all of the associated attachments (online resources) are available via the HEFP Web site.

5. The individual chapters provide practical tips and solutions to aid VA facilities.

All policies, procedures, forms, and online resources for the guidebook are provided on the HEFP Web site. This enables each VA facility to easily retrieve and customize the documents for their own use. The documents are enhanced with desktop publishing quality formatting so facilities can easily produce their own documents with the same quality and appearance as professionally-printed guidebooks. To view this guidebook or other HEFP guidebooks online, visit the

HEFP Web site.

Please contact Mark St. Marie, Industrial Hygiene Product and Service Manager or Craig Brown, VHACO Occupational Safety and Health Program Manager, with any questions or recommendations regarding the content, use, and/or application of this guidebook.

/guidebooks xiv

Acknowledgements This guidebook was possible because of the devoted attention of the personnel and management of the Veterans Health Administration (VHA) Healthcare

Environment and Facilities Programs (HEFP), St. Louis, Missouri.

A special thank you is extended to the Industrial Hygiene Professional Advisory

Group (PAG) who developed this guidebook, and to management at their respective Veterans Integrated Service Networks (VISNs) and Department of

Veterans Affairs (VA)/VHA facilities for their support:

*Craig Brown, CIH, CSP, VHACO Occupational Safety and Health Program

Manager, VHACO, Washington, DC

**Daniel Erwin, Industrial Hygienist, VISN 1, Boston, MA

Laura Halterman, PhD, Occupational Health and Safety Product and Service

Manager, CEOSH, Reno, NV

*Michael Henrickson, MPH, CHMM, Safety Manager, VISN 7, Columbia, SC

Richard K. Hofman, CIH, CSP, CPEA, VHACO Senior Industrial Hygienist, VHACO, Washington, DC

Wendy Kady, CIH, CSP, GEMS Manager, VISN 6, Asheville, NC

Keith Kilpatrick, Industrial Hygienist, VISN 17, Arlington, TX

John Lechman, CIH, CHSP, CHMM, National Industrial Hygienist, CMOP

National Office, Lancaster, TX

Christian Lewis, Industrial Hygienist, VA Pittsburgh Healthcare System, Pittsburgh, PA

Brian Marcyjanik, CSP, CHMM, General Safety Program Manager, VHACO, Washington, DC

Rakeyta Scales, VISN 6 Industrial Hygienist Intern, Charles George VA, Asheville, NC

Mark Scogin, CIH, CHMM, CHSP, CHFM, VHA-CM, Safety Manager, VISN 9, Nashville, TN

Mark St. Marie, CIH, Industrial Hygiene Product and Service Manager, HEFP, Providence, RI

Lynn Treece, CHSP, Industrial Hygienist, VISN 6, Salisbury, NC

Laura Ulczynski, MS, Industrial Hygienist, Durham VAMC, Durham, NC

William Wooden, CIH, CSP, Safety Manager, Chillicothe VAMC, Chillicothe, OH

Lisa Woodings, Industrial Hygienist, VA Puget Sound Health Care System, Seattle, WA

*Denotes Chairperson(s)

**Denotes Senior Technical Editor xv

HEFP Publishing Staff:

Tina Beckner, Lead Technical Information Specialist, St. Louis, MO

Lesley Luscri, Technical Information Specialist, St. Louis, MO

Melody Watts, Technical Information Specialist, St. Louis, MO

Connie Young, Chief, Publishing Services, St. Louis, MO xvi

How to Use This Guidebook Veterans Health Administration (VHA), Healthcare Environment and Facilities

Programs (HEFP) guidebooks are “BEST PRACTICE” resources designed to assist health care facilities with the implementation and enhancement of programs, and to more effectively comply with current Department of Veterans

Affairs (VA)/VHA policy and external regulatory standards.

Each guidebook has three sections:

• Preface: Disclaimers, Executive Summary (summary of how this book supports each program), Acknowledgements, How to Use This

Guidebook, CD-ROM Instructions, Update Listing (list of any online updates made to the guidebook before a new publication−check the online version of the guidebook for this information), and Acronyms &

Abbreviations, (list of acronyms and abbreviations used in the guidebook).

• Chapter Contents: Each chapter contains a general discussion that provides VA-specific guidance on the topic.

• Additional Reference Materials: Enclosures and Appendices (many enclosures are provided in their original format to be edited for each facility’s use. Examples include templates, forms, samples, tools, and checklists).

Each guidebook is available in three formats:

Online Version: Can be accessed via the VHA HEFP Web site. The online version toolbar includes the following features:

• Previous and Back Buttons – These buttons allow you to page through the chapter contents.

• Contents – A hyperlinked table of contents that helps you navigate the guidebook quickly. Click this icon to return to the full table of contents from the Search or Favorites tools discussed below.

• Search – This feature allows you to type a specific word(s) to be found.

Once the search is complete, a hyperlinked list of locations of the word(s) will be displayed.

• Favorites – This icon with the star lists your saved favorite guidebook sections.

• Save Favorites – This icon with the star and the green plus sign allows you to customize the favorites list for your needs by saving favorite sections. When you are in a location you want to save as a favorite, click on the star with the green plus sign and that page will be saved in your favorites.

xvii

PDF Version (Printer-Friendly): Can be accessed via the VHA HEFP Web site.

This version is designed for you to print locally on a network printer at your workplace or save to a disk for printing at a reproduction facility. Each enclosure is a separate document and must be printed separately.

References and Web site links within each chapter and enclosure/attachment were current at the time of publication.

xviii

Update Listing The following listing identifies online updates since the initial publication of the

November 2014 edition of this guidebook. It is designed to assist the reader in verifying the most current information available.

Table 1: Update Listing

Update

Number Date Updated Remarks Chapter xix

Acronyms/Abbreviations Table 2: Acronyms/Abbreviations

Acronym/

Abbreviation Definition µ Micro µg Microgram µg/m3 Microgram per Cubic Meter µm Micrometer µW Microwatt

2PbCO3 Pb(OH)2 White Lead

AAPCO Association of American Pesticide Control Officials

AAPSE American Association of Pesticide Safety Educators

ABIH American Board of Industrial Hygiene

ACAAI American College of Allergy, Asthma & Immunology

ACBM Asbestos-Containing Building Material

ACGIH® American Conference of Governmental Industrial Hygienists

ACH Air Changes Per Hour

AChE Acetylcholinesterase

ACM Asbestos-Containing Material

ACS American Chemical Society

AFB Acid-Fast Bacillus

AFGE American Federation of Government Employees

AHERA Asbestos Hazard Emergency Response Act

AHR Alcohol-based Hand Rub

AHU Air-Handling Unit

AIA American Institute of Architects

AIDS Acquired Immunodeficiency Syndrome

AIHA American Industrial Hygiene Association

AII Airborne Infection Isolation

AIIR Airborne Infection Isolation Room xx

AL Action Level

ALA American Lung Association

AMA American Medical Association

ANSI American National Standards Institute

APF Assigned Protection Factor

APM Asbestos Program Manager

APR Air-Purifying Respirator

ASA Acoustical Society of America

AsH3 Arsine

ASHP American Society of Health-System Pharmacists

ASHRAE American Society of Heating, Refrigerating and Air Conditioning Engineers

ASR Atmosphere-Supplying Respirator

AST Above-Ground Storage Tank

ATS Ancillary Testing Site

AWE Annual Workplace Evaluation

BBP Bloodborne Pathogen

BC/MS Building Controls/Management Systems

BCG Bacillus Calmette-Guerin (Vaccine)

BCS Building Control System

BEI® Biological Exposure Indices

BHA Butylated Hydroxyanisole

BHT Butylated Hydroxytoluene

BLL Blood Lead Level

BMBL Biosafety in Microbiological and Biomedical Laboratories

BMS Building Management System

BSC Biological Safety Cabinet

BSL Biosafety Level

BUD Beyond-Use-Date

C Ceiling xxi

C or °C Celsius or Degrees Celsius

C-SCA Containment Segregated Compounding Area

CACI Compounding Aseptic Containment Isolator

CAI Compounding Aseptic Isolator

CAP College of American Pathologists

CAS Chemical Abstracts Service

CAV Constant Air Volume

CBC Complete Blood Count

CBOC Community-Based Outpatient Clinic

CBRN Chemical, Biological, Radiological, Nuclear

CBRNE Chemical, Biological, Radiological, Nuclear, and Explosive

CDC Centers for Disease Control and Prevention

CEOSH Center for Engineering & Occupational Safety and Health (VHA)

CERCLA Comprehensive Environmental Response Compensation and Liability Act

CETA Controlled Environment Testing Association cf Cubic Feet

CFD Computational Fluid Dynamics

CFM Office of Construction & Facilities Management cfm/p Cubic Feet Per Minute Per Person

CFR Code of Federal Regulations

CFU Colony-Forming Unit

Ch2 Methylene

(CH2)2O Di-carbon monoxide

CH3Br Methyl Bromide

CH3NH2 Methylamine

CHO Chemical Hygiene Officer

CHP Chemical Hygiene Plan

CIH Certified Industrial Hygienist

Cl Chlorine xxii

ClO2 Chlorine Dioxide cm2 Centimeters Squared

CMOP Consolidated Mail Outpatient Pharmacy

CNS Central Nervous System

CO Carbon Monoxide

CO2 Carbon Dioxide

COR Contracting Officer’s Representative

CPARD Certification Plan & Reporting Database

CPR Cardiopulmonary Resuscitation

CPSC Consumer Product Safety Commission

CSA Canadian Standards Association

CSHO Compliance Safety and Health Officer

CSP Compounded Sterile Preparations

CSS Consulting Support Service

CSTD Closed-System Transfer Device

CTAG Certification and Training Assessment Group

CXR Chest X-Ray

DASHO Designated Agency Safety and Health Official dB Decibel dB(A) A-Weighted Decibel dBc Decibels Relative to the Carrier dBP Decibels Peak

DDT Dichlorodiphenyltrichloroethane

DE Diesel Exhaust

DHHS Department of Health and Human Resources

DOT Department of Transportation

EAP Emergency Action Plan

ECP Exposure Control Plan

ED Emergency Department xxiii

EL Excursion Limit

EMS Environmental Management Service

ENL Effective A-Weighted Noise Level

EOHP Employee Occupational Health Provider

EPA Environmental Protection Agency

EPCRA Emergency Planning and Community Right-To-Know Act

EPS Environmental Program Service (VHA)

ERP Emergency Response Plan

ES Environmental Sampling

EtO Ethylene Oxide

F or °F Fahrenheit or Degrees Fahrenheit f/cc Fibers per Cubic Centimeter

FCC Federal Communications Commission

FDA Food and Drug Administration (U.S.)

FFPD Filtering Face Piece Device

FGI Facility Guidelines Institute

FID Flame Ionization Detector

FIFRA Federal Insecticide, Fungicide, and Rodenticide Act

FMS Facilities Management Service fpm Feet per Minute

FRDP First Receivers Decontamination Program

FSS Facilities Standards Service ft3 Cubic Foot

GEMS Green Environmental Management System

GFCI Ground Fault Circuit Interrupter

GHS Globally Harmonized System of Classification and Labeling of Chemicals

GSA General Services Administration

H2 Hydrogen

H2S Hydrogen Sulfide xxiv

HAZWOPER Hazardous Waste Operations and Emergency Response

HBV Hepatitis B Virus

HCHO Formaldehyde

HCI Hydrogen Chloride

HCN Hydrogen Cyanide

HCP Hazard Communication Program

HCP Hearing Conservation Program

HCP Health Care Professional

HCV Hepatitis C Virus

HCW Health Care Worker

HEPA High-Efficiency Particulate Air

Hf Hafnium

Hg Mercury

HHS Department of Health and Human Services (U.S.)

HID High Intensity Discharge

HIV Human Immunodeficiency Virus

HMIS® Hazardous Material Identification System

HNOC Hazard not Otherwise Classified

HPD Hearing Protection Device

HPLC High-Performance Liquid Chromatography

HRMS Human Resources Management Service

HUD Department of Housing and Urban Development (U.S.)

HVAC Heating, Ventilation, and Air Conditioning

Hz Hertz

IAQ Indoor Air Quality

IARC International Agency for Research on Cancer

IATA International Air Transport Association

ICB/TABB International Certification Board/Testing, Adjusting, and Balancing Bureau

ICRA Infection Control Risk Assessment xxv

ICU Intensive Care Unit

ID Infectious Disease

IDLH Immediately Dangerous to Life and Health

IEC International Electrotechnical Commission

IEQ Indoor Environmental Quality

IERA

Institute for Environment, Safety and Occupational Health Risk Analysis

(U.S. Air Force)

IFSAC International Fire Service Accreditation Congress

IgE Immunoglobulin-E

IGRA Interferon Gamma Release Assays

IH Industrial Hygiene/Industrial Hygienist

IL Information Letter

ILO International Labour Organization

IPCC Infection Prevention and Control Committee

IPCS International Programme on Chemical Safety

IPM Integrated Pest Management

IQ Intelligence Quotient

IRPA International Radiation Protection Association

ISO International Organization for Standardization

IT Information Technology

IUPAC International Union of Pure and Applied Chemistry

IV Intravenous

J/cm2 Joules Per Square Centimeter

Kg Kilogram

KOH Potassium Hydroxide

KTP Potassium Titanyl Phosphate

L Liter

L/min Liter per Minute

LAFW Laminar Airflow Workbench

LAI Laboratory Acquired Infection xxvi

LAM Laryngeal Airway Mask

LBP Lead-Based Paint

LC-MS/MS Liquid Chromatography-Tandem Mass Spectrometry

LCD Liquid Crystal Display

LD Legionnaires Disease

LEL Lower Exposure Limit

LEV Local Exhaust Ventilation lf Lineal Feet

LFL Lower Flammable Limit

LGAC Laser-Generated Airborne Contaminants

LIA Laser Institute of America

LO/TO Lockout/Tagout lpm Liters per Minute

LSO Laser Safety Officer

LSP Laser Safety Program

LTBI Latent TB Infection m Meter m3 Cubic Meter

MAP Model Accreditation Program

MCE Mixed Cellulose Ester

MCEF Mixed Cellulose Ester Filter

MCM Medical Center Memorandum

MDR Multi-Drug Resistant

MERV Minimum Efficiency Reporting Value mg Milligram

Mg/cm2 Milligram per Square Centimeter mil Milli-Inch mL Milliliter mm Millimeter xxvii

MMAD Mass Median Aerodynamic Diameter mmHg Mercury

MMS Materials Management Service

MMWR Morbidity and Mortality Weekly Report

MPE Maximum Permissible Exposure

MRI Magnetic Resonance Imaging

MSD Musculoskeletal Disorder

MUC Maximum Use Concentration mW Milliwatt

NASDA National Association of State Departments of Agriculture

Nd Neodymium-doped

NESHAP National Emission Standards for Hazardous Air Pollutants

NFPA® National Fire Protection Association

NH3 Ammonia

NHZ Nominal Hazard Zone

NIC Notice of Intended Changes

NIH National Institute of Health

NIOSH National Institute for Occupational Safety and Health

NIST National Institute of Standards and Technology nm Nanometer

NMAM NIOSH Manual of Analytical Methods

NO2 Nitrogen Dioxide

NOAA National Oceanic and Atmospheric Administration

NORA National Occupational Research Agenda (NIOSH)

NOx Mono-nitrogen Oxides

NPCA® National Paint & Coating Association

NPG NIOSH Pocket Guide

NPIR Negative Pressure Isolation Room

NRL Natural Rubber Latex xxviii

NRR Noise Reduction Rating

NRTL National Recognized Testing Laboratory

NSAID Nonsteroidal Anti-Inflammatory Drug

NTP National Toxicology Program

O2 Oxygen

OD Optical Density

OEL Occupational Exposure Limit

OEM Office of Emergency Management

OIG Office of Inspector General

ONS Oncology Nursing Society

OP Organophosphate (Pesticides)

OPIM Other Potentially Infectious Material

OR Operating Room

ORD Office of Research and Development (VHA)

ORM OSHA Reference Method

OSB Oriented Strand Board

OSH Occupational Safety and Health

OSHA Occupational Safety and Health Administration

P&LM Pathology and Laboratory Medicine

PACM Presumed Asbestos-Containing Material

PAG Professional Advisory Group

PAH Polycyclic Aromatic Hydrocarbon

PAPR Powered Air-Purifying Respirator

Pb Lead

PBM Pharmacy Benefits Management Service (VHA)

PCM Phase Contrast Microscopy

PCME Phase Contrast Microscopy Equivalent

PCR Polymerase Chain Reaction

PCS Personal Communications Services xxix

PE Protective Environment

PEC Primary Engineering Control

PEL Permissible Exposure Limit

PID Photo Ionization Detector

PII Personal Identifiable Information

POINTS Pesticide of Interest Tracking System

POV Privately-Owned Vehicle ppb Parts Per Billion

PPD Purified Protein Derivative

PPE Personal Protective Equipment ppm Parts Per Million

PRCS Permit-Required Confined Space

PVC Polyvinyl Chloride

RAST Radioallergosorbent Test

RCCP-SC Registered Cleanroom Certification Professional in Sterile Compounding

RCRA Resource Conservation and Recovery Act

REL Recommended Exposure Limit

RF Radio Frequency

RH Relative Humidity rpm Revolution Per Minute

RPP Respiratory Protection Program

RRP Renovation, Repair, and Painting (Lead)

SAFE Safety Automated Facility Evaluation

SAR Supplied-Air Respirator

SBS Sick Building Syndrome

SCBA Self-Contained Breathing Apparatus

SDS Safety Data Sheet

SEG Similar Exposure Group

SEM Scanning Electron Microscopy xxx sf Square Feet

SFO Solicitation for Offers

SG Serogroup

SMACNA Sheet Metal and Air Conditioning Contractors’ National Association

SO2 Sulfur Dioxide

SOP Standard Operating Procedure

SPCC Spill Prevention Control and Countermeasures

SPF Sun Protection Factor

SPHM Safe Patient Handling and Movement

SPL Sound Pressure Level

SPS Sterile Processing Service

STEL Short-Term Exposure Limit

STS Standard Threshold Shift

T&B Testing and Balancing

TB Tuberculosis

TBS Tight Building Syndrome

TDR Totally Drug-Resistant

TEM Transmission Electron Microscopy

TIL Technical Information Library

TLV® Threshold Limit Value

TMS Talent Management System

TSCA Toxic Substances Control Act

TSD Treatment, Storage, and Disposal

TSI Thermal System Insulation

TST Tuberculin Skin Testing

TWA Time-Weighted Average

UATW Unified Air Toxics Website

UCL Upper Confidence Limit

UHC University Health System Consortium xxxi

UL Underwriters Laboratory

ULD Upper Limit of Detection

ULPA Ultra-Low Penetration Air

UN United Nations

UN-GHS United Nation-Globally Harmonized System

USACHPPM U.S. Army Center for Health Promotion and Preventive Medicine

USP U.S. Pharmacopeia

UV Ultraviolet

UV-C Far-UV Range

UVGI Ultraviolet Germicidal Irradiation

UVR Ultraviolet Radiation

VA Department of Veterans Affairs

VAMC VA Medical Center

VAT Vinyl Asbestos Tile

VAV Variable Air Volume

VHA Veterans Health Administration

VHACO Veterans Health Administration Central Office

VISN Veterans Integrated Service Network

VOC Volatile Organic Compound

VPIH Veterans Affairs Professional Industrial Hygienist

V-SAT Very-Small Aperture Terminal w.g. Water Gauge

WAG Waste Anesthetic Gas

WBGT Wet Bulb Globe Temperature

W/cm2 Watts Per Square Centimeter

WHO World Health Organization

WOC Without Compensation

WPF Workplace Protection Factors

XDR Extensively Drug-Resistant xxxii

XRD X-ray Diffraction

XRF X-ray Fluorescence

YAG Yttrium Aluminum Garnet

ZPP Zinc Protoporphyrin (Level)

Chapter 1 Confined Spaces

1 Confined Spaces

1.1. Introduction

Veterans Health Administration (VHA) facilities must protect Department of

Veterans Affairs (VA) employees who enter permit-required confined spaces

(PRCSs) through a comprehensive program. VHA facilities also have a responsibility for communicating the hazards of PRCSs that contractors may encounter: their hazards, control measures, and procedures that will coordinate entries when both VHA employees and contractors will be entering simultaneously and/or coordinating confined space emergency response.

The Occupational Safety and Health Administration (OSHA) 29 Code of Federal

Regulations (CFR) 1910.146, Permit-Required Confined Spaces, is based on the understanding that a systematic approach to confined space hazard recognition, assessment, and control will protect employees from those hazards and prevent employee injury and death. Currently, OSHA regulates confined spaces in general industry under 29 CFR 1910.146. The construction standard found at 29

CFR 1926.21, Safety Training and Education, Section 1926.21(b)(6) includes provisions for training requirements for construction personnel required to enter enclosed or confined spaces.

29 CFR 1910.146 requires a written program; identification of PRCSs; entry procedures; a permit system to evaluate and document hazards; availability of equipment for atmospheric testing and for employee protection, rescue, and emergency services; and training.

1.2. Construction Versus Maintenance

Many PRCS program managers are confused as to whether or not to apply the construction or general industry standard. First, the program manager must determine if activities in the space fit the definition of construction. There are several considerations that the program manager needs to evaluate.

Construction Definition of Confined Spaces. The construction definition of a confined or an enclosed space is a limited means of egress, which is subject to accumulation of atmospheric hazards. Some examples of confined spaces in construction include:

• Open top spaces with more than 4 feet in depth (pits and vaults).

• Tanks and process vessels.

• Boilers.

• Ventilation or exhaust ducts.

• Sewers and underground vaults.

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Type of Activity Considerations. OSHA defines construction activities as construction, alteration, and/or repair, including painting and decorating. This is a very vague definition, so we need to determine what construction activities are.

Construction activities are the reconfiguration of spaces or installation of substantially new equipment. There are no specific definitions for maintenance activities, but OSHA does provide examples of what maintenance activities would include. Some examples of maintenance activities include:

• Partial patching of a surface material.

• Removal or replacement of an existing lining in a tank or refractory with the same type materials.

• Tuck pointing and individual brick replacement in manholes.

• Repainting as part of a scheduled program (preventative maintenance) to prevent deterioration.

Note: Replacing existing materials with different is considered construction activities.

Complexity of Work Considerations. Once maintenance activities are identified, the second consideration is the size and complexity of the project. The program manager will need to look at each activity on a case-by-case basis. For example, the removal and replacement of individual bricks is generally described as maintenance versus replacing a significant portion of the wall surface, which may be considered construction.

More Specific Standard Considerations. There is another confusing topic of construction versus general industry standards when it comes to trenching and shoring. A lot of practitioners consider trenching and excavations deeper than 4 feet a confined space as defined above. When a situation arises when there is a more specific standard for the work being performed, such as the case of trenching in 29 CFR 1926 Subpart P, Excavations, the more specific standard takes precedence in application.

Construction standards do not specify entry procedures or hazard determinations in detail in comparison with the general industry standard. However, the principles to control the physical and chemical hazards prior to entry of PRCSs are the same between the two standards. The general industry standard fills in the gaps where the construction standard is silent; therefore, a facility could use the general industry standard for PRCS entry during construction activities. For more information on construction confined spaces, please refer to the VHA

Construction Safety Guidebook.

1.3. Discussion

Confined space hazards have long been recognized as serious threats to the safety and health of both entrants and rescuers. Historically, many multiple-fatality incidents have resulted from improperly informed or equipped entrants being fatally stricken, followed by the deaths of inadequately-prepared rescuers.

Hazards associated with the work tasks performed by entrants are often increased by the nature of the restricted workspace, limited body movement, and lack of proper air circulation. Control of the hazards associated with permit spaces and the tasks performed by entrants, as well as having properly prepared entrants, attendants, supervisors, and rescue services, are critical to ensuring the safety of entrants.

All facilities are required to develop comprehensive plans for ensuring the safety and health of personnel required to work in PRCSs, including VHA employees, contractors, and rescue/emergency personnel. Only properly trained and equipped personnel are permitted to enter a PRCS once a valid PRCS entry permit is obtained.

If employees are expected to enter PRCSs, a written confined space entry program requires the following:

• Identify both confined spaces and permit-required confined spaces.

• Ensure employees who enter confined spaces are trained in accordance with OSHA requirements.

• Inform employees and contractors/vendors of the existence, location, and danger of the PRCS(s) they plan to enter by effectively communicating the hazards of these spaces.

• Implement a written permit system for each PRCS entry.

• Document completion of hazard control measures for entry into confined spaces by completing an entry permit before entry.

• Provide training to all affected employees so that they have the understanding, knowledge, and skills necessary for the safe performance of assigned duties.

• Assign standby personnel (attendant) for each entry into a PRCS. The standby person MUST be capable of either performing non-entry rescue for the entry or immediately obtaining rescue response.

• Establish rescue procedures before entry that are specific for each type of

PRCS (e.g., vertical versus horizontal rescue).

• Provide rescue service members with training to properly use personal protective and rescue equipment necessary for making rescues from permit spaces. If outside rescue services are being used, verify that they are capable of performing rescue for the PRCS being entered and that they can respond in a timely manner.

• Properly communicate relevant information, such as air monitoring results and information regarding additional hazards, to affected personnel.

• Provide the equipment necessary to monitor the atmosphere and to work safely in the PRCS.

1.4. Definitions

A Confined Space has all three of the following characteristics:

• It is large enough or so configured that an employee can physically enter and perform assigned work. It is important to note that “entry” into a confined space begins when any part of the employee’s body breaks the plane of the entry point. For example, “sticking one’s head,” or other body part, into a confined space constitutes entry, even if the employee does not completely enter the space; and

• It has limited or restricted means for entry or exit. Confined-space openings can be considered limited or restricted by size and/or location.

Openings may be small in size and difficult to navigate or move through, as is the case with many older boiler burner chamber openings. In some cases; however, openings may be very large, such as in open-topped vats, pits, excavations, and open tanks. Sometimes having to access the work area by a fixed ladder may constitute limited or restricted entry or exit. Both size and location of the entry point must be considered when evaluating this component and planning entry and rescue; and

• It is not designed for continuous human occupancy. Most confined spaces are not designed for employees to enter on a routine basis. They may be designed to store a product, enclose materials and processes, or transport products or substances. These spaces frequently will not have good ventilation or lighting; therefore, occasional employee entry for inspection, maintenance, repair, clean-up, or similar tasks can be difficult and dangerous.

Non-Permit Confined Space – A confined space that does not contain, nor has the potential to contain any recognized hazard capable of causing death or serious physical harm.

Permit-Required Confined Space (PRCS) – A confined space that is potentially hazardous. A PRCS has one or more of the following characteristics:

• It contains or has the potential to contain a hazardous atmosphere (e.g., oxygen deficient or enriched, explosive, toxic).

• It contains a material that has the potential for engulfing an entrant including liquids or solids.

• It has an internal configuration such that an entrant could be trapped or asphyxiated by inwardly converging walls or by a floor that slopes downward and tapers to a smaller cross-section.

• It contains any other recognized serious safety or health hazards.

Examples of serious safety or health hazards might include:

o Fall hazards.

o Slippery surfaces.

o Uncontained steam.

o Unguarded machinery.

o Extreme heat or cold (includes ambient and contact surface temperatures).

o Hazardous noise levels.

o Electrical (shock and arc flash) hazards.

o The presence of a substance or chemical over the allowable permissible exposure limits (PELs) (e.g., asbestos, nuisance dust, solvents, and welding fumes).

Hazardous Atmosphere – An atmosphere that may expose employees to the risk of death, incapacitation, impairment of ability to self-rescue (that is, escape unaided from a permit space), injury, or acute illness from one or more of the following causes:

• Flammable gas or vapors in excess of 10 percent of its lower flammable limit (LFL).

• Airborne combustible dust at a concentration that meets or exceeds its

LFL.

• Atmospheric oxygen concentration below 19.5 percent or above 23.5 percent at normal temperature and pressure.

• Atmospheric concentration of any substance for which a PEL published in the OSHA standards could result in employee exposure in excess of its

PEL. Other exposure resources can be viewed, such as the American

Conference of Governmental Industrial Hygienists (ACGIH®) Threshold

Limit Values (TLVs®) and Biological Exposure Indices (BEIs®) and the

National Institute for Occupational Safety and Health (NIOSH)

Recommended Exposure Limits (RELs).

• Any other atmospheric condition that is immediately dangerous to life or health.

Permit-Required Confined Space Program (Permit Space Program) - The employer's overall program for controlling and, where appropriate, protecting employees from permit space hazards and for regulating employee entry into permit spaces.

Permit System - The employer's written procedure for preparing and issuing permits for entry and for cancelling the permit following termination of entry.

1.5. Methods of Compliance

The employer must determine if any spaces are PRCS.

First, determine if a space is a confined space by meeting all three criteria in the definition (large enough to bodily enter to do assigned work, limited or restricted means for entry and/or exit, and not designed for continuous human occupancy).

It is important that the facility looks at all potential confined spaces on a case-by-case basis. For instance, is a laundry dryer considered a confined space? There are several types of laundry dryers used in the VHA. They can be standard household dryers, larger ones used in a laundromat, or industrial-sized dryers fed by large totes or a conveyor belt. The smaller dryers are designed for a person to be able to reach inside after machine shut down to retrieve clothing whereas the large industrial dryer is designed to be fed and cleared by mechanical means.

The difference between the two surrounds the definitions of being designed for continuous human occupancy or being large enough to bodily enter. In this case, the industrial dryer would satisfy all three definitions of being a confined space.

Other areas in VA facilities that would illustrate a case-by-case assessment would be steam tunnels, elevator pits, and clothing presses. All three definitions of a confined space need to be evaluated exhaustively.

If the space is not a confined space, this program does not apply.

If the space is a confined space, determine if the space is a PRCS by evaluating the hazards in the space.

Appendix A, Permit-Required Confined Space Decision Flow Chart, of 29 CFR

1910.146 can assist in determining if a space is a confined space or PRCS ().

Employees must be notified of PRCS hazards and locations through education and training and by posting a sign, marking, or other effective means. For example, a sign could state “DANGER -- PERMIT-REQUIRED CONFINED

SPACE, DO NOT ENTER” or similar language.

There is a hierarchy of PRCS entry procedures:

• Reclassified Entry Procedures - All hazards are eliminated prior to entry through the permit process (requires certification by entry supervisor or attendant on permit).

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• Alternate Entry Procedures - Only atmospheric hazard that can be controlled by continuous ventilation through the permit process (requires certification by entry supervisor or attendant on permit).

• PRCS procedures - hazards cannot be eliminated or controlled prior to entry.

Following the hierarchy above for PRCSs, it is apparent that the permit system can be utilized as a checklist to relax the requirements for entry if hazards can be controlled to the reclassified or alternate entry procedure.

Introduction of Hazards. If an employee would enter a non-permit required confined space, such as a large, empty vault or pit, under normal conditions, they are not required to follow the PRCS procedures. However, if the same vault is to be cleaned with a solvent or welding is to be performed, the confined space would then require PRCS procedures due to the introduction of the atmospheric hazards from the work being performed.

Entry supervisors, designated attendants, entrants, and rescue teams involved with confined space entries must remember that proper application of the confined space protection principles requires a thorough knowledge of the hazards/dangers that the space inherently has, as well as those created by the work performed within the space.

1.6. PRCS Requirements

Facilities with an identified PRCS must have a comprehensive written Confined

Space Entry Program that establishes specific roles and procedures for work in confined spaces.

The written Confined Space Entry Program contains elements necessary to ensure that:

• Unauthorized entry is prevented.

• Hazards are identified, evaluated, and controlled prior to entrance.

• Practices and procedures for safe entry are provided.

• All equipment necessary for safe entry is specified.

• Evaluation procedures are specified.

• Attendants are stationed or positioned outside the PRCS.

• Persons with active roles (authorized entrants, entry supervisor, staff trained to test atmosphere, etc.) are designated.

• Rescue procedures are developed.

• An entry permit system is designed.

• Review and revision of the process is conducted as needed.

• The permits must be reviewed annually, which is also a good time to review the Confined Space Entry Program.

Note that an inventory of not only the…