University of Kentucky Hospital

Hazardous Materials and Waste Management Plan

 

 

Objectives

 

This plan is designed to

·         Provide a safe environment and reduce the risk of injuries by providing guidelines and directions for the proper selection, handling, storage, transport, use, and disposal of hazardous materials and waste used or generated in the Hospital.

·         Help assure the health and safety of the patients, visitors, staff, and the community by mandating and monitoring the adherence to local, state, and federal regulations.

·         Reduce the volume of hazardous waste and the cost of disposal through proper identification, segregation, and disposal procedures.

·         Reduce the risk associated with hazardous materials by identifying and evaluating alternative products and processes for use within the Hospital.

·         Provide procedures for quick and efficient response to hazardous material emergencies by developing response procedures consistent with regulatory requirements and identified institutional need. 

 

Because it is designed as an overview, the plan may reference Hospital policies or other documents that provide more detailed information.

 

Scope

 

This plan is general in nature, an overview designed to provide direction and a framework for managing hazardous materials and waste and responding to hazardous materials incidents. More detailed information can be found in the materials referenced at the end of this plan.

 

In general, this plan covers:

 

·         All Hospital areas, including all healthcare, ambulatory, and business occupancies operated by the University of Kentucky Hospital.

·         Hazardous materials and waste, defined as materials that pose a physical, health, or environmental hazard. Hazardous materials may include: chemicals, gases, biological and infectious agents identified as “select agents,” medical waste, and radioactive or nuclear materials. See Appendix 1 for more information.

 

Program Coordination

 

University of Kentucky Hospital utilizes the services of departments and individuals throughout the University in order to provide a comprehensive hazardous materials and waste management program. In addition, each department or individual that uses or generates hazardous materials or waste is required to maintain a program to regulate and manage their use, in compliance with this plan.

 

·         The Hospital Safety Officer oversees the program, as outlined in this management plan; acts as a liaison, when necessary, between the areas and individuals who have functional responsibility for aspects of the program and their constituents; facilitates review of Hospital  policies and procedures; and facilitates the annual program evaluation. (See Hospital Policy 10-00, Hospital Safety Program.)

·         The Hazardous Materials Management Subcommittee of the Hospital Environment of Care (EOC) Committee reviews hazardous materials incident reports and reports all incidents to the EOC Committee for recommendation and follow up. The subcommittee evaluates the plan annually.  As the program review body, the subcommittee is responsible for establishing or adopting written criteria, consistent with applicable law and regulation, to identify, evaluate, and inventory hazardous materials and waste.

·         The Safety Surveillance Team monitors compliance with aspects of the program through semi-annual inspections and staff interviews. An inspection report, noting deficiencies, is submitted to the service director or designee for corrective action.

·         The Environmental Management Department of the University of Kentucky Environmental Health and Safety Division acts as the hazardous waste coordinator, a program consultant, and emergency responder.

·         The Special Assistant to the Director of Environmental Health and Safety  been designated as the Responsible Official for coordinating the approval and use of biological and infectious agents identified as Select Agents in the Patriot Act. The Director acts as the alternate.

·         Environmental Services and OR Housekeeping oversee collection of medical waste throughout inpatient areas of the Hospital. Medical Center Physical Plant Division (MCPPD) oversee  ontract services, managed by Medical Center Physical Plant Division, collect medical waste in outpatient occupancies.

·         MCPPD manages the medical waste sterilization, packaging, and disposal programs.  (See Hospital Policy 03-11, Disposal of Used Needles and Syringes, and Hospital Policy 03-23, Disposal of Medically-Regulated Waste.)

·         The Radiation Safety Officer acts as the designated radiation safety official for the Hospital. The Radiation Safety Officer is responsible for 1) investigating and reporting unsafe practices, 2) ordering, receiving, storing, and distributing radioactive materials, 3) maintaining possession limits, and 4) assuring proper radiation waste disposal.

·         The Radiation Safety Committee is responsible for implementing and maintaining the radiation safety program for the Hospital. 

·         Clinical Engineering and Occupational Health and Safety are responsible for monitoring hazardous gases and reporting results to the Hospital Safety Officer and users.

·         Occupational Health and Safety inspects chemical fume hoods for compliance.

·         Biological Safety inspect biological hoods for compliance.

·         Hospital Service Directors are responsible for maintaining compliance with the established program. Specifically, Hospital service directors are responsible for the procurement and safe storage, use, segregation, and disposal of hazardous materials, in compliance with established policies and procedures. Service directors, managers, and supervisors are responsible for ensuring that all employees who come in contact with hazardous materials are trained in their use and disposal and in emergency procedures. (See Hospital Policy 10-29, Management of Chemicals.)

·         All Hospital employees are responsible for attending orientation and continuing education sessions, following safe work practices, segregating waste, wearing appropriate personal protective equipment, and knowing and following emergency procedures.   

 

Program Review and Evaluation

 

The Hazardous Materials Management Subcommittee evaluates the Hazardous Materials Management Plan annually, using established criteria to ensure the appropriateness of scope, objectives, and effectiveness. Results of this annual evaluation are presented to the EOC Committee for review and recommendation.

 

Managing Hazardous Materials and Waste

(See also Hospital policies listed in the reference section at the end of this plan.)

 

Selecting and Ordering Hazardous Materials  

 

·         Materials Management is responsible for selecting and ordering chemicals used in a variety of locations throughout the Hospital. Materials Management audits the list of chemicals annually to identify products that may have a safer alternative. When a safer product is identified, it is evaluated for operational, safety, and cost considerations and presented to the Hospital products committee.

·         Hospital service areas that utilize specialized products are responsible for selecting and ordering these agents, in compliance with applicable regulations and established guidelines and procedures. Each department is required to evaluate its products and safer alternatives during the annual inventory process. (See Procedures for Use and Disposal of Hazardous Chemicals and Waste, this manual.)

·         The Radiation Safety Committee is responsible for approving all radioactive materials used in the Hospital. The Radiation Safety Officer is responsible for the ordering, receiving, storing, and distributing radioactive materials.

·         The Special Assistant to the Director of Environmental Health and Safety has been designated as the Responsible Official for approving biological and infectious agents identified as Select Agents in the Patriot Act. Before a select agent can be acquired or retained, the Principle Investigator or Service Director must comply with all pertinent University policies and regulatory requirements and the agent must be registered with the RO and the CDC.

 

Identifying, Handling, and Using Hazardous Materials

 

·         Environmental Health and Safety has developed a model chemical hygiene plan to guide personnel in managing the chemicals that they use. The Hospital has adopted the plan as a part of its Hazardous Materials Management program. (See UK Laboratory Safety Manual.)

·         The Hospital seeks to comply with all requirements of 29 CRF 1910.1200, The Hazard Communication Standard, and NFPA 704, Identification of the Fire Hazards of Materials.

·         Each department maintains a current inventory of chemicals and sends an inventory update to the Hospital Safety Officer at least annually.

·         The Hospital maintains a current MSDS for all chemicals listed on the inventory. MSDS are accessible to employees online or through compact disks located at various locations throughout the institution. Some user areas also maintain hard copies of MSDS. 

·         The Radiation Safety Committee is responsible for establishing record-keeping standards for all radioactive sources and waste. The Radiation Safety Officer is responsible for maintaining possession limits and ensuring the proper handling of radioactive materials.

·         All hazardous materials containers are marked with standard labels (i.e., NFPA chemical labels, international biohazard and radiation symbols) so that staff can identify the hazards quickly and easily. Staff is trained to recognize and read standard hazardous materials labels as a part of orientation and continuing education.

 

Disposing of Hazardous Waste

 

The Hospital complies with all federal, state, and local regulations when disposing of hazardous waste.

 

·         Environmental Management assumes primary responsibility for disposing of the Hospital’s chemical waste, including chemotherapy waste. Procedures are in place for the removal of hazardous waste by licensed hazardous waste transporters from the designated staging and handling area. 

·         Medical waste, including sharps, generated in the Hospital, is identified and segregated by the generator and stored in approved and appropriately labeled containers. Environmental Services or OR Housekeeping or an approved contractor, managed by MCPPD, collects and transports medical waste to the autoclave area. Medical waste, excluding sharps, is autoclaved to render it non-biohazardous and then disposed of as solid waste.  Sharps are packaged according to DOT standards and transported for disposal by an approved contractor.

·         The Radiation Safety Officer is responsible for disposing of radioactive materials. All solid waste, including medical waste, is monitored to ensure that it is free of radioactive waste before is it disposed.

·         The Hospital conducts a waste stream analysis periodically. A report is provided to the Hazardous Materials Management Subcommittee for review and evaluation. Results are reported to the EOC Committee for corrective action.

 

Hazardous Materials and Waste Storage

 

The Hospital has designated hazardous material and waste storage areas, maintained in compliance with Life Safety Code and other applicable regulations to ensure minimal risk to patients, staff, the public, and the environment.  Hospital Safety maintains a list of all storage areas and inspects them during routine surveillance activities.

 

Storage facilities are equipped with appropriate personal protective equipment, restraint and containment equipment or cabinets and fire suppression equipment. Chemicals and other hazardous materials are stored away from floor drains to prevent environmental contamination. The Radiation Safety Officer evaluates all areas that will be used for storage and disposal of radioactive materials.

 

MSDS are maintained in proximity to storage areas for immediate accessibility.

 

Capital Project Management, Hospital Safety, and/or agents of areas with functional responsibility for waste handling and storage review all plans for new construction and building renovation to ensure adequate space is provided for safe handling and storage of hazardous waste. The Safety Surveillance Team inspects these areas and the equipment in them to ensure proper maintenance.

 

Monitoring and Disposing of Hazardous Gases and Vapors

 

Clinical Engineering or Occupational Health and Safety monitors all areas in which the following are used:

 

·         Nitrous oxide

·         Formaldehyde

·         Methylene chloride

·         Gluteraldehyde

·         Xylene

 

The Hospital conducts periodic screening to determine point-in-time airborne concentrations of hazardous gases and vapor in order to identify whether the risk of overexposure exists. If a risk of overexposure is identified, the Hospital conducts personal sampling to determine specific concentration in the breathing zone of the employee.

 

Clinical Engineering conducts:

 

·         Quarterly testing/monitoring of equipment, laboratories, and operating rooms

·         Testing/monitoring after the repair of equipment

·         Testing/monitoring when work process or procedure that could affect airborne concentrations change

·         Testing/monitoring at the request of the Hospital Safety Officer.

 

Occupational Health and Safety conducts 8-hour monitoring for formaldehyde as required by the formaldehyde standard.

 

All tests are conducted while the equipment is in use. If an area tests above the allowable exposure limits:

 

·         Clinical Engineering or Occupational Health and Safety will notify the Hospital Safety Officer and departmental personnel.

·         The Safety Officer and other appropriate personnel will investigate to determine the cause of the excessive levels and to implement a correction.

 

All results are documented and posted.

 

The Hospital recognizes that a work area that is below acceptable exposure limits at the time of any test may be contaminated a short time later. Given this knowledge, the service trains employees who work in areas that use medical or other hazardous gases to observe for contamination and report it immediately.

 

Environmental Management is responsible for the proper disposal of all hazardous gases.

·         The vendor will pick up all empty reusable cylinders.

·         Environmental Management will pick up and dispose of all disposable cylinders.

 

Hazardous Materials Program Management Guides    

 

Hospital and service area policies and procedures have been established to guide the management and use of:

 

·         Chemical waste, including chemotherapy waste

·         Infectious (medically-regulated) waste, including sharps

·         Radioactive waste

·         Hazardous gases and vapors

·         Biological or infectious agents and agents identified as Select Agents

 

Reporting and Investigating Hazardous Materials Incidents

 

All employees are trained to report hazardous materials incidents for emergency response, if necessary, and for investigation. The Hospital provides employees with badge cards that provide emergency numbers and with reporting procedures.

 

University of Kentucky Hospital has established a Reportable Occurrence (RO) program that requires employees to report all accidents or incidents involving patient, visitors, and employees. Each accident/incident must be reported at the time that it is discovered to guarantee that the information is complete and accurate.

 

·         The Hospital Safety Officer reviews all ROs and follow-up on those that warrant further investigation.

·         Environmental Management responds to and investigates hazardous materials incidents involving chemicals or biological agents and those identified as select agents.

·         Radiation Safety responds to and investigates hazardous materials incidents involving radioactive materials.

·         Environmental Services responds to mercury spills to facilitate clean up. The Hospital Safety Officer and/or Occupational Health and Safety investigate mercury spill incidents, if warranted. 

·         The Hospital Safety Officer investigates medical waste incidents.

 

·         The Hospital Safety Officer and the Hazardous Materials Management Subcommittee review all incidents that involve hazardous materials.

·         The Hospital Environment of Care Committee receives regular reports of incidents that involve hazardous materials and of all accident and incident trends for evaluation and recommendation of additional corrective action.

 

 

Emergency Procedures

 

Each service area that manages or handles hazardous materials maintains Material Safety Data Sheets and emergency procedures which detail steps to be taken during a waste spill or exposure.

 

To ensure consistency in reporting and clean up, the Hospital Safety Officer and Environmental Management have established the following basic notification procedures to be used by all staff.

·         Small spill of known, standard materials--Follow established departmental procedures. Fill out Hazardous Waste Ticket for pick up and disposal for Environmental Management.  For the purposes of this procedure, “known, standard materials” are defined as those materials that the employee works with frequently.

 

·         Large spill of unknown or extremely dangerous materials, call 911 to notify Environmental Management. 

 

·         Any mercury spill, call Environmental Services, 3-5133.

 

Specific procedures have been developed for chemotherapy and gene therapy spills. Employees who work with chemotherapy or gene therapy are trained to follow these procedures and to notify Environmental Management immediately if additional assistance is needed.  (Note: Gene therapy response procedures are developed based on the particular gene therapy.)

 

Environmental Management has established emergency procedures which detail the specific precautions, procedures, and protective equipment used during hazardous material and wastes spills or exposures. (See Hazardous Materials Emergency Response Plan.)

 

The Hospital has established patient/personnel decontamination procedures as a part of its emergency preparedness plan.  (See Hospital Policy, 12-13, Decontamination Plan—Hazardous Materials/Radiation Incident.)

 

Staff Orientation and Education

 

There is the potential for all employees to come in contact with hazardous materials while working in the Hospital. For this reason, all employees participate in general hazard communication education as a part of Hospital orientation.

 

Employees who work routinely with chemicals and other hazardous materials must receive additional training, appropriate to their jobs and level of risk. These employees are evaluated annually to ensure that their knowledge and skills are consistent with their job responsibilities. These employees are retrained as new hazardous materials are added or if they do not demonstrate competency to perform their job responsibilities safely.

 

Course/Subject	Employee Training Requirement	Mechanism
Hazard Communication	All employees	New Employee Orientation Resident Orientation Departmental Orientation Continuing Education
Emergency Procedures	All employees who work with hazardous materials	Hospital Orientation Resident Orientation Departmental Orientation Continuing Education
Hazardous Waste Training	Laboratory and other employees who work regularly with hazardous materials	Environmental Management
Radiation Safety Hazards Recognition Course	Employees, such as Environmental Services, who may work in an area in which radioactive materials are used or stored	Radiation Safety
Radiation Safety Basic Course	Employees who work with radiation and have no previous experience	Radiation Safety
Radiation Safety Advanced Course	Employees who work with radiation	Radiation Safety
DOT and IATA Training	Employees who prepare “dangerous goods” for shipping and receive them.	Environmental Management
Asbestos Awareness Training	Housekeeping employees	Environmental Management
Hazmat/WMD Awareness Education	Employees who may be first to notice hazmat or WMD incident.	Hospital Safety
Hospital First Receivers Operations Level Course	ED or other employees who may be a part of the patient decontamination team	Hospital Safety

 

Performance Standards 2004

 

·         Employees in areas that use or store hazardous materials will be able to access MSDSOnline and find material safety data sheet for the chemicals that they use or come in contact with.

·         The Hospital will reduce the volume of medical waste by 75% through use of sterilization equipment.

·         Waste disposal chutes, chute rooms, and chute discharge areas will be maintained according to NFPA standards and established infection control guidelines. 

 

Performance standards are monitored through standard surveillance and survey activities of the Surveillance Team and through data collection conducted by Environmental Services.

 

University and Hospital References

 

This plan references or relies on more specific policies and plans, including but not limited to:

·         Hospital Policy 03-11, Disposal of Used Needles and Syringes

·         Hospital Policy 03-23, Disposal of Medically-Regulated Waste

·         Hospital Policy 03-27, Safe Handling of Gene Therapy Medications

·         Hospital Policy 10-11, Hazard Communication

·         Hospital Policy 10-26, Mercury Reduction

·         Hospital Policy 10-28, Safe Handling of Antineoplastic  Agents

·         Hospital Policy 10-29, Management of Chemicals

·         Hospital Policy 10-30, Decontamination of Patient Rooms

·         Hospital Policy 10-32, Safe Handling of Aerosolized Ribaviran

·         Hospital Policy 12-13, Hazardous Materials Incident—Decontamination Plan

·         Hospital Policy 12-17, CSEPP Program

·         University of Kentucky Model Chemical Hygiene Plan 2003

·         University of Kentucky Hazardous Waste Manual

·         University of Kentucky Radiation Safety Manual

·         University of Kentucky Hazardous Materials Emergency Response Plan

 

 

 

Regulatory References

 

·         Kentucky Administrative Radiation Regulations 902 KAR 100, specifically 902 KAR 100:019, Standards for Protection Against Radiation and 902 KAR 100:021, Disposal of Radioactive Material.

·         29 CFR, 1910. 

·         ASTM D-323-72

·         Patriot Act of 2001

·         Public Health Security and Bioterrorism Preparedness Act of 2002

 

 

 

Evaluated: 7/04

Revised: 9/04

Appendix 1

 

Hazardous Chemicals and Waste

 

·         Hazardous chemical - A chemical for which there is statistically significant evidence based on at least one study conducted in accordance with established scientific principles that acute or chronic health effects may occur in exposed employees. The term "health hazard" includes chemicals which are carcinogens, toxic or highly toxic agents, reproductive toxins, irritants, corrosives, sensitizers, hepatotoxins, nephrotoxins, neurotoxins, agents which act on the hematopoietic systems, and agents which damage the lungs, skin, eyes, or mucous membranes.

 

The University’s Model Chemical Hygiene Plan and Hazardous Waste Manual and Appendices A and B of the Hazard Communication Standard (29 CFR 1910.1200) provide further guidance in defining the scope of health hazards and determining whether or not a chemical is to be considered hazardous for purposes of this standard.

 

·         Hazardous Waste - A waste material that meets one or more of the characteristics identified in state and federal regulations and the University of Kentucky Hazardous Waste Manual.

 

·         Mixed Waste - Waste that is both hazardous and radioactive.

 

Listed Hazards

 

Federal and state regulations reference several categories of substances which have toxic, carcinogenic, mutagenic, or teratogenic effects in humans or adverse impact on the environment.  This list can be obtained from Environmental Management .  Many other chemicals do not appear on these lists but are still considered hazardous (e.g. ethidium bromide and malathion).  In general any chemical suspected of having toxic or hazardous properties should be considered hazardous. You should refer to Material Safety Data Sheets (MSDS) or other competent reference books such as the Merck Index to make determinations about toxicity.  For guidance about whether a waste is hazardous or not, contact the Environmental Management staff.

 

Characteristic Hazardous Materials and Wastes

 

Certain chemicals which are not specifically listed by name are regulated as hazardous because they exhibit one or more of the following characteristics: ignitability, reactivity, corrosivity, or toxicity.  If chemicals exhibit any of these characteristics they must be handled as hazardous and disposed of by Environmental Management.  Material Safety Data Sheets, the manufacturer's container labels, and reference books can be used to identify whether one or more of these characteristics are present.

 

Ignitable:  A material exhibits the ignitable characteristic if it is a liquid with a flash point of less than 140 degrees Fahrenheit (60 degrees Celsius).  This includes most non-halogenated solvents such as methanol, acetonitrile, ethanol, gasoline, and ethyl ether.  The University also treats as hazardous chemicals which are flammable solids, such as magnesium dust, solid naphthalene and nitrocellulose.

 

Corrosive:  A material exhibits the corrosive characteristic if it is a liquid with a pH of less than 5.5 or more than 10.5 and must be treated as hazardous. It cannot be disposed of in the sanitary sewer without first being neutralized (provided it has no other dangerous properties such as toxicity).  Examples include hydrochloric acid, photographic chemicals, sodium hydroxide, and corrosive cleaning agents.  Dilution of acids or bases with water is not an acceptable practice.  It is recommended that acids and bases be neutralized as part of the experimental procedure to reduce the amount of hazardous waste generated.

 

Reactive:  A material exhibits the reactive characteristic if it is unstable, explosive, water or air reactive, a strong oxidizer, an organic peroxide, or contains cyanide or sulfide bearing materials that release toxic gases in contact with acids.  Examples include picric acid, potassium metal, metallic picrates, trinitrotoluene, and old ethers.

 

Toxic:  A material exhibits the toxicity characteristic if it contains a defined concentration of one or more of 39 specific contaminants included in the Toxicity Characteristic Leaching Procedure (TCLP) table:

§            Arsenic

§            Barium

§            Benzene

§            Cadmium

§            Carbon Tetrachloride

§            Chlordane

§            Chloroform

§            O-Creosol

§            M-Creosol

§            2,4-D

§            1,4 Dichlorobenzene

§            1,2 Dichloroethane

§            1,1 Dichloroethylene

§            2,4 Dinitrotoluene

§            Endrin

§            Heptachlor

§            Hexachlorobenzene

§            Hexachlorobutadiene

§            Hexachloroethane

§            Lead

§            Lindane

§            Mercury

§            Methoxychlor

§            Methyl ethyl ketone

§            Nitrobenzene

§            Pentachlorophenol

§            Pyridine

§            Selenium

§            Silver

§            Tetrachloroethylene

§            Toxaphene

§            Trichloroethylene

§            2,4,5 Trichlorophenol

§            2,4,6 Trichlorophenol

§            2,4,5-TP (Silver)

§            Vinyl Chloride

 

In the absence of concerntration data, wastes containing these constituents should be considered hazardous. Many chemical wastes produced at the University are not specifically identified on the TCLP list but are still considered hazardous and cannot be disposed of in the sink or regular trash.

 

Non-Hazardous Chemicals and Wastes

 

As a rule persons who generate chemical wastes should not pour them down the sink or put them in the regular trash unless they are certain that the wastes are non-hazardous to humans or the environment.  University personnel should consult Material Safety Data Sheets, the manufacturer's container labels, reference manuals, or call Environmental Management  for guidance on how to dispose of these materials.  In general, only non-hazardous solids should be disposed of in the regular trash.  Non-hazardous free liquids that are water soluble may be disposed of down the sink.  Free liquids that are not water soluble should be referred to Environmental Management  for disposal.  Materials that have strong or unpleasant odors should be referred to the Environmental Management for disposal.  Chemicals in damaged containers should be placed into appropriate secure containers.  If not safe to do so, they should be referred to Environmental Management for disposal.

 

Unknown Chemicals and Wastes

 

All waste materials picked up by Environmental Management must be completely and accurately identified.  Materials that are not identified are referred to as "unknowns."  EPA permit regulations prohibit Environmental Management from picking up, transporting, or storing unknown waste materials.  When an unknown is discovered, an attempt must be made to identify its contents immediately.  Usually the contents can be identified by consulting persons who work in the area where the material was used.  If this fails to positively identify the material then some elementary analysis on the material must be performed.  Elements of this analysis may include:

 

     pH on liquids

     Flash point

     Reactivity with water (on a very small scale)

     Specific gravity

     Flammability (on a very small scale)

     Water solubility

 

If the persons with the unknown cannot or choose not to perform analysis of the unknown, then the University's hazardous waste contractor will perform the analysis for a fee.  Maintenance of labels, periodic inspections of chemical stocks, and good chemical hygiene practices will prevent the occurrence of unknowns.  The University's Chemical Hygiene Plan also has specific requirements for labeling chemical containers.  Persons should consult the Chemical Hygiene Plan or call the Occupational Health and Safety department for specific information on these labels.

Appendix 2

 

Gases

 

Compressed gas means:

 

·         A gas or mixture of gases having, in a container, an absolute pressure exceeding 40 psi at 70 degrees F (21.1 degrees C); or

·         A gas of mixture of gases having, in a container, an absolute pressure exceeding 104 psi at 130 degrees F (54.4 degrees C) regardless of the pressure at 70 degrees F; or

·         A liquid having a vapor pressure exceeding 40 psi at 100 degrees F (37.8 degrees C) as determined by ASTM D-323-72.

 

Flammable gas means:

 

·         A gas that, at ambient temperature and pressure, forms a flammable mixture with air at a concentration of 13 percent by volume or less; or

·         A gas that, at ambient temperature and pressure, forms a range of flammable mixtures with air wider than 12 percent by volume, regardless of the lower limit.

Appendix 3

 

University of Kentucky

 

Hazardous Materials Emergency Response Plan

 

The University of Kentucky is committed to providing a safe and healthy environment for all persons associated with the institution.  The University intends to be a role model for the commonwealth in its environmental stewardship, health protection and safety standards and its compliance with all laws and regulations relating to the environment, health and safety.  To help meet this commitment, Environmental Management has developed this Hazardous Materials Emergency Response Plan (HMERP) for UK campus.

 

TABLE OF CONTENTS

 

Section	Subject
1.	Purpose
2.	Responsibilities
3.	Pre-emergency Planning and Coordination with Outside Agencies
4.	Personnel Roles, Lines of Authority, and Communication
5.	Emergency Alerting, Evacuation Routes and Procedures
6.	Emergency Medical Treatment and First Aid
7.	Post-emergency Cleanup Operations
8.	Critique of Response and Follow-up
9.	Personal Protective Equipment and Emergency Equipment
10.	Training and Medical Surveillance
11.	Regulatory reporting
12.	Plan revision and maintenance
Appendix A	Hazardous Materials Emergency Response Contacts

 

Purpose

 

The purpose of this plan is to define what Environmental Management (EM) and other UK support units do in the event of emergency response operations covered under 29 CFR 1910.120.  As defined by OSHA, an Emergency Response means a response effort by employees from outside the immediate release area or by other designated responders to an occurrence which results or is likely to result in an uncontrolled release of a hazardous substance.  An Emergency Response includes the following situations:

 

a.       The release poses or has the potential to pose, conditions that are immediately dangerous to life and health (IDLH);

 

b.       The release may pose a serious threat of fire or explosion (exceeds or has the potential to exceed the lower explosive limit);

 

c.       The release may cause high levels of exposure to toxic substances;

 

d.       There is uncertainty that the employees in the work area can handle the severity of the hazard with the training, personal protective and other equipment that they are provided;

 

e.       The release is uncontrolled and if not contained, stopped, and removed, the release would pose a hazard to employees in the path of the release; or

f.         There is an imminent threat of release to the environment.

 

The following emergencies are not covered under this plan: fires, natural disasters, inclement weather, civil unrest, bomb threats, terrorist attacks, small spills not covered above, and other emergencies not covered under 29 CFR 1910.120.

 

Responsibilities

 

EM’s role is to provide technical expertise to the Lexington Fire Department (LFD) Incident Command system.  EM staff who are properly trained and certified will provide planning and operations support under the Lexington Fire Department Emergency Response Plan and may also participate in a Unified Command System as a combined resource.

 

Pre-emergency Planning and Coordination with Outside Agencies

 

UK submits SARA Title III reports and conducts annual site visits with LFD and Lexington-Fayette Urban County Government’s (LFUCG) Division of Environment and Emergency Management (DEEM) to major chemical storage and use areas.  EM and other units within EH&S work closely with LFD to discuss planning and coordination of hazardous material emergency response situations.

 

Appendix A is a list of telephone numbers of various agencies that may need to be contacted before, during or after a response covered by this plan.  The list will be kept current at all times.

 

Personnel Roles, Lines of Authority, and Communication

 

EM has employees that are properly trained and certified to function in several roles during Emergency Response operations.  Initial and refresher training for those personnel has been in accordance with applicable OSHA and EPA regulations.

 

UK Police Department (UKPD) employees are trained to function at the First Responder Awareness level.

 

Appropriate UK Physical Plant Division (PPD) workers and various outside contractors may be called upon to assist in an Emergency Response operation as skilled support personnel.

 

At the discretion of the LFD Incident Commander, EM will provide the entry team and LFD will provide properly trained and certified hazardous materials technicians to serve as backup personnel to provide assistance or rescue.  LFD also will provide and administer decon procedures during and after the emergency and provide advanced first aid support personnel with medical equipment and transportation capability.

 

The LFD incident commander will have overall authority of the Emergency Response.  The incident commander will have authority to delegate responsibility to those participating in an Emergency Response.  If the incident commander determines that the hazardous materials incident is beyond the capabilities of this plan, authority will be transferred to the agency with proper jurisdiction.

 

Emergency Alerting, Evacuation Routes, and Procedures

 

In the event that a UK building needs to be evacuated, established emergency action plans and fire evacuation routes will be utilized.  UKPD will assist with the evacuation when necessary.  When a fire alarm is pulled, electronic notification is received at the central monitoring station and UKPD.  UKPD is responsible for notifying the LFD.

 

When a hazardous materials incident occurs, EM will, to the extent possible, identify the character, source, amount, and areas actively or potentially involved in the incident and assess the possible hazards along with potential response actions.  If EM is notified before the UKPD is contacted, EM will immediately relay all pertinent information to UKPD as well as any specific instructions regarding the incident.  EM and LFD will make the determination as to whether or not other response agencies need to be notified and whether adjacent buildings or properties need to be evacuated.

 

The area immediately surrounding the emergency will be kept clear of all persons not actively involved in the response.  UKPD shall be responsible for maintaining site security and control, when appropriate.  EM will take necessary steps to prevent the recurrence or spread of uncontrolled releases during an Emergency Response.  This may include the stopping of processes and operations, collection and containment of released hazardous materials/wastes and/or isolating containers, and neutralizing or chemically inerting released materials.  Additional mitigation steps will be conducted by LFD in accordance with its emergency response plans and procedures.

 

Emergency Medical Treatment and First Aid

 

LFD emergency medical care units are relied upon to provide emergency medical treatment and first aid.  At least one unit on site will be on site at all times during an emergency response.  UKPD staff are trained and certified to render first aid if necessary.

 

Post- Emergency Cleanup Operations

 

When the Emergency Response has been brought under control and the threat to human health and the environment has been stabilized or eliminated, EM will initiate the following remedial actions in order to restore the incident area and department resources back to operational readiness.  If necessary, the University may contract with qualified remediation contractors for such activities.

 

a.                               Monitoring of cleanup operations

 

EM will continue to monitor the area during the remedial cleanup operations. The area of the incident will continue to be kept isolated and only activities related to monitoring and remediation will be allowed.  EM will ensure that remediation activities follow applicable local, state, and federal guidelines for safety and remediation.

 

If flammable liquids are involved, EM or other EH&S units will monitor concentrations of combustible gases and/or airborne chemical contaminants.  The University maintains a variety of air monitoring equipment and supplies for use in such cases.  If flammable materials are involved, all sources of ignition, including remediation equipment, will be removed.  Intrinsically safe equipment will still be used, if applicable. 

 

b.                               Storage, treatment, and disposal of released material

 

All recovered materials, contaminated absorbent materials, contaminated personal protective equipment, and materials that can’t be decontaminated will be containerized in appropriate DOT approved containers that are compatible with the waste materials.  EM will make arrangements for treatment and/or storage at the Environmental Quality Management Center (EQMC), the University’s permitted hazardous waste storage facility.

Critique of Response and Follow-up

 

Upon completion of any Emergency Response in which this plan has been implemented, a critique will be conducted with all parties that were involved in the incident.  This critique will address strategies and identify flaws or weaknesses in the plan.

 

Personal Protective Equipment and Emergency Equipment

 

EM employees who participate in responses will use and properly maintain personal protective equipment and emergency equipment.  This equipment is stored at the EQMC and on EM vehicles.  Upon activation of the emergency response plan, the Incident Commander will determine what level of PPE is necessary for the hazards present.  EM has PPE on hand to respond to level B, C, or D as described in 29CFR1910.120.  EM is also trained to respond to level A if LFD requests such assistnance and supplies appropriate equipment and clothing.

 

Training and Medical Surveillance

 

EM has employees that are properly trained and certified to function in several roles during Emergency Response operations.  Initial and refresher training for those personnel has been in accordance with applicable OSHA and EPA regulations.

 

The following medical surveillance and consultation program covers EM employees who are trained and certified to participate in an emergency response.  All medical examinations and procedures will be performed by a licensed physician with UK Preventive Medicine and will be provided without cost to the employee.  Examinations and consultations will be performed as follows:

 

a.                               Prior to assignment;

 

b.                               At least once every twelve months unless the attending physician believes a longer interval (not greater than biennially) is appropriate;

 

c.                               At termination of employment or reassignment to an area where the employee would not be covered if the employee has not had an examination within the last six months;

 

d.                               As soon as possible upon notification by an employee that they have developed signs or symptoms indicating possible over-exposure to hazardous materials during an emergency response;

 

e.                               At more frequent times, if the examining physician determines that an increase frequency of examinations or follow-up examinations is medically necessary.

 

Regulatory Reporting 

 

Telephone notifications will be made when the specified criteria are met:

 

·         For releases in excess of CERCLA hazardous substance amount, EM will notify the National Response Center (800-424-8802).

 

·         For releases in excess of SARA Title III thresholds, EM will notify the state Disaster and Emergency Services (DES, 502-564-7815) and LFUCG DEEM (258-3784; 911 after 5pm for emergencies, 254-1120 after 5pm for non-emergencies).

 

·         For releases in excess of any reportable quantities or limits set by applicable regulatory agencies, EM will notify the appropriate agency (see Appendix A for a list of phone numbers).

 

Written notification will be submitted to the Kentucky Environmental and Public Protection Cabinet and LFUCG DEEM within fifteen days of a release in excess of regulatory thresholds.  The report will contain the following information:

 

a.                               Name, address, and telephone number of the university unit involved;

b.                               Name, address, and telephone number of responding agencies;

c.                               Date, time, and description of the incident;

d.                               Name and quantity of material(s) involved;

e.                               Details of fatalities, injuries, or illnesses;

f.                                 An assessment or actual or potential hazards to human health or the environment, where applicable;

g.                                Estimated quantity and disposition of recovered material that resulted from the incident.

 

Incident Plan revision and Maintenance

 

A copy of this plan will be kept at the EM office and UKPD’s dispatch office.  This plan will be revised whenever necessary, including when a critique and follow-up of an Emergency Response indicates deficiencies. 

 

 

Emergency Response Contacts

 

 

Environmental Management

 

	Office	Mobile
Woody Bottom	257-3285	509-2238
Mike Blackard	257-7375	509-3238
Brian Butler	323-5005	509-1922
Lee Faulkner	257-7373	509-2840
On-call number	509-2659

 

(AFTER 5 P.M., WEEKENDS AND HOLIDAYS, CALL UKPD @ 911)

 

 

Other UK Departments

 

UK Police Department	257-1616
UK Hospital Emergency Room	323-5901
Lexington Campus Physical Plant Division	257-2830
Medical Center Physical Plant Division	323-6281
UK Public Relations	257-3303

 

Emergency Response Agencies

 

Lexington Fayette Urban County Government (LFUCG)
Police, Fire, and Emergency Medical Service	911
DEEM  (Division of Environmental & Emergency Management)        Environmental Concerns/Hazardous Materials          Disaster Preparedness/LEPC	258-3784 After 5 p.m. for     Emergencies, dial 911 After 5 p.m., for    Non-emergencies, dial    254-1120
Sanitary Sewer Administration	258-3460
KY State Government
Department of Natural Resources -      Division of Water – Emergency Response Line	(502) 564-2380 (800) 928-2380
State Fire Marshal’s Office	(502) 564-3626
Disaster and Emergency Services (DES)	(502) 564-7815
National Response Center (24 hour)	(800) 424-8802
CHEMTREC (Information source only)	(800) 424-9300

 

 

Emergency Response Contractors

 

Chase Environmental	1-502-267-1455
Environmental Enterprise Inc.	1-800-722-2818
Hinkle	1-859-263-7558
Spill Recovery of Indiana	1-317-291-3972