Guide to JCAHO Environment of Care Standard 3.10.5

© 2005 Joint Commission on Accreditation of Healthcare Organizations. Any use of any or all of the Joint Commission standards and elements of performance beyond this particular tool is strictly forbidden without the written permission of the Joint Commission. Citations from JCAHO standards are ©2005 Joint Commission on Accreditation of Healthcare Organizations. Any use of any or all of the Joint Commission standards and elements of performance beyond this particular tool is strictly forbidden without the written permission of the Joint Commission. These pages do not reflect any changes in the standards made after 2005.  

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Introduction        Table of Contents       Checklist for 3.10.5

Environment of Care Standard 3.10: The organization manages hazardous materials and waste risks

Element of Performance 5. Hazardous Gas and Vapor Management

The organization monitors and disposes of hazardous gases and vapors.

This page provides a set of criteria for evaluating a facility's system for tracking and disposing of hazardous gases and vapors

= Compliance
= Environmental Improvement
= Tools and Resources

Hazardous Materials Management

 Hazardous gases are inventoried throughout facility including:

   

Inventory:  EC 3.10.2

Hazard communication (OSHA): 29 CFR 1910.1200 (e)(1)(i)
  • waste anesthetic gases from surgery
  • ethylene oxide
  • materials with potential to emit hazardous vapors, including
    • formaldehyde
    • glutaraldehyde
    • xylene
    • other air contaminants
Use of hazardous gases and materials that emit hazardous vapors is eliminated to the extent possible.

Hazardous gas tanks are managed appropriately.

All waste anesthetic gases are scavenged using active scavenging methods such as a dedicated vacuum line.

Management and exposure control plans implemented for all hazardous gases and vapors in facility.

Documentation of monitoring program for employees exposed to hazardous gases and vapors is maintained.

Employees are trained and competency tested regarding hazardous gas and vapors use and disposal, if necessary.

   

Emergency: EC3.10.6

Hazard communication (OSHA): 29 CFR 1910.1200

 (Emergency: EC3.10.6, 29 CFR 1910.1200).

Materials of Concern

  Ethylene oxide

A management plan describes actions in the event of an accidental release of ethylene oxide.

Ethylene oxide sterilizer has valid operating permit if required.

Emission controls for ethylene oxide sterilizers are in place and well maintained.

Wherever employee exposure to ethylene oxide may exceed 1 ppm (8 hour time weighted average) or 5 ppm (15 minute average), exposure levels must be monitored periodically, or testing must indicate exposure is consistently below those levels.

   

 

Occupational exposure, ethylene oxide: 29 CFR 1910.1047 (d)
bullet Ethylene oxide is replaced with safer alternative sterile processing technology such as hydrogen peroxide plasma or ozone.
  Formaldehyde, glutaraldehyde

Employee exposure to formaldehyde is monitored in all appropriate areas, or statistically representative tests establish that employee exposure is consistently below 0.5 ppm, time weighted average.

   

 

Occupational exposure, formaldehyde: 29 CFR 1910.1048 (d)
bullet Formalin use is minimized to the extent possible.

Formalin is recycled.
bullet Glutaraldehyde is replaced with a less hazardous high-level disinfectant such as ortho-pthalaldehyde (e.g. Cidex OPA)
  Xylene and other solvents
bullet Xylene use is limited to the extent possible and/or terpene-based clearing agents are used.
bullet Solvents are recycled.
  Other air contaminants
bullet Use of aerosols, e.g. room deodorizers, cleaners, hand sanitizers is reduced or eliminated.  (Rationale:  aerosols add hazardous chemicals to breathing zone potentially diminishing patient safety.  Waste aerosols may be considered hazardous waste increasing management and disposal costs.)
  • A list of exposure limits for a wide range of toxic and hazardous substances can be found in 29 CFR 1910.1000.

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