Peracetic Acid Spills in Hospitals - an Administrators nightmare

Every hospital administrator's nightmare is to see hazmat crews dressed in white overalls breathing through respirators running into their facility in front of the TV cameras while staff are evacuating patients in response to a chemical spill. High level disinfectant (HLD) chemicals such as peracetic acid are an essential part of modern healthcare, being used to disinfect those items that cannot be heat treated. These HLDs are used safely everyday across the world; but if something goes wrong, these chemicals pose a risk to anyone exposed to them and the administrators start having those dreams again.

Recently a few adminstrators had to face this very problem.On November 8th, over 100 staff and outpatients were evacuated from Harrogate Hospital, in the UK after a spill from a drum of peracetic acid in the endoscopy department. Closer to home, on November 15th a hazmat crew responded to report of a leaking peracetic acid container at a dialysis unit of Cape Coral Hospital in Florida.

In February last year Llandudno Hospital, Wales evacuated their outpatient department due to a peracetic acid spill and in June a peracetic acid spill at the Northbay Surgical Regional Center in Novato, CA resulted in one employee being treated for throat discomfort from the acid fumes. and evacuation of the first-floor patients who were able to walk, while three surgery patients who were semi-sedated were sheltered in a sealed room with their attendants. In 2010 another spill had Addenbrook's hospital near Cambridge, UK in 2010 evacuate staff and patients.

Peracetic acid is widely used as a high level disinfectant because of its superior antimicrobial properties but like all high level disinfectants, it poses a risk to anyone exposed to it. These hazards are well recognized and the ACGIH has proposed a TLV of 0.4 ppm 15 minute STEL.

Peracetic acid spills and leaks can occur form many reasons including container failure, equipment malfunction, wear and tear and of course human error. Leaks may be as vapor or liquid, though with the latter, there will always be vapor associated with liquid. Therefore when using peracetic acid it is important to employ good engineering controls, continuous gas monitoring, person protective equipment and good training etc.

Some problems appear suddenly and if the problem results in the release of peracetic acid vapors a continuous gas monitor will sound an alarm if the concentration approaches hazardous levels. However, many, perhaps most problems develop gradually over time. For these problems, a continuous gas monitor may provide an alert of the problem before it becomes a major issue. For more information about continuous gas monitors for peracetic acid or other gases and vapors contact ChemDAQ by e-mail at info@chemdaq.com or by telephone at 412-787-0202.

Government News: OSHA proposes new rules to increase reporting of workplace injuries

OSHA has announced proposed rules to increase reporting of workplace injuries and illnesses. Employers are currently required to keep records of workplace injuries and illnesses but under the new rules instead of just recording injury data, OSHA would require companies with more than 250 employees and some smaller high-risk organizations to report quarterly on-line. The proposed rules are available on-line in the Federal Register and the public has until Feb. 6, 2014 to submit written comments.

For comparison, the current reporting/recording regulations are summarized below.

Reporting
If an employee is killed in a work place related accident or three or more employees are hospitalized then Under the current regulations (29 CFR 1904) the employer must orally report the death to OSHA within eight (8) hours.

Recording
Employers are also required to keep records of serious occupational injuries and illnesses, using the OSHA 300 Log (with certain exceptions for very small and/or very safe workplaces)

OSHA Lists the recordable events as follows:

• Covered employers must record all work-related fatalities.
• Covered employers must record all work-related injuries and illnesses that result in days away from work, restricted work or transfer to another job, loss of consciousness or medical treatment beyond first aid.
• In addition, employers must record significant work-related injuries or illnesses diagnoses by a physician or other licensed health care professional, even if it does not result in death, days away from work, restricted work or job transfer, medical treatment beyond first aid, or loss of consciousness.
• Injuries include cases such as, but not limited to, a cut, fracture, sprain, or amputation.
• Illnesses include both acute and chronic illnesses, such as, but not limited to, a skin disease (i.e. contact dermatitis), respiratory disorder (i.e. occupational asthma, pneumoconiosis), or poisoning (i.e. lead poisoning, solvent intoxication).
• OSHA's definition of work-related injuries, illnesses and fatalities are those in which an event or exposure in the work environment either caused or contributed to the condition. In addition, if an event or exposure in the work environment significantly aggravated a pre-existing injury or illness, this is also considered work-related.

Annually, the summary of all incidents must be posted in a public area where employees can see it.

Further information about the current requirements is available at https://www.osha.gov/recordkeeping/.

The New AAMI Chemical Sterilization and High Level Disinfection Standard

As mentioned earlier in this blog, AAMI recently released a revised version of ST58, "Chemical sterilization and high-level disinfection in health care facilities" and copies are available from the AAMI website. Most people in healthcare know of AAMI and the AAMI standards which provide best practices for a range of healthcare operations. AAMI has several standards associated with sterilization and high level disinfection/disinfectant (HLD) and these standards have become the go-to documents for current best practices. Sterilization and HLD is a subject currently undergoing rapid developments with new equipment, new chemicals and new practices introduced in recent years and this topic is likely to continue to rapidly evolve.

The completely revised ST58 standard covers both gas sterilization (hydrogen peroxide and ozone) as well as HLDs (glutaraldehyde, o-phthalaldehdye (OPA), peracetic acid (PAA) and sodium hypochlorite (NaOCl)) and provides practical advice to enable users to employ the best practices. Ethylene oxide (EtO) is not included in ST58 since it has its own standard ST41
Ethylene oxide sterilization in health care facilities: Safety and effectiveness.

Compared to the prior version, this new version has greater emphasis on workplace safety, a subject about which ChemDAQ cares passionately about, well beyond gas detection. ChemDAQ's own David Hilliker and Richard Warburton served on the AAMI Chemical Sterilants Hospital Practice Working Group that revised the standard.

About half of the standard is comprised of annexes and each of the FDA approved chemical sterilants and HLDs has its own annex that provides succinct information including the following topics:

• Sterilant/ HLD chemical's properties and how it is used
• Health effects (short and long term)
• Exposure limits
• Suitable personal protective equipment for eyes, skin, respiratory system
• Guidance on how to use the chemical safety (ventilation, transportation, storing, use, rinsing (for HLDs))
• What to do in the event of a leaks or spill
• Disposal and 
• Vapor monitoring. 

Hydrogen peroxide is listed twice, once in Annex C as an HLD and again in Annex H as a sterilant gas (Steris' VHP & ASP's plasma sterilizers) since the applications are very different.

The vapor monitoring section in each annex has been updated to indicate the need for continuous gas monitoring and whether they are commercially available. For example, in light of the hazards of inhaling hydrogen peroxide vapor, the vapor monitoring section of annex H now reads:

H.7 Vapor monitoring
Vapor monitoring is recommended if there is the potential for the hydrogen peroxide vapor concentration to exceed the OSHA recommended permissible exposure limits. Emissions from properly operated and maintained chemical vapor sterilizers should be well below the OSHA PEL (see H.4.1.3), but sterilizers and exhaust systems, as with any other complex equipment, can and sometimes do fail. If monitoring is deemed necessary, continuous personal and area monitors for hydrogen peroxide are commercially available.

Gas and vapor emissions can occur from even the best made equipment and odor is an unreliable indicator of the presence and concentration of hydrogen peroxide gas below hazardous concentrations. Continuous gas monitoring systems are available to help employers satisfy the requirement to provide a safe work environment by providing alerts in case of potentially hazardous concentrations, informing workers when it is safe to return after a release and provide record keeping. Review the SDS and consult the suppliers of the hydrogen peroxide solutions and the manufacturers of the sterilizer and the gas monitoring equipment for more information.

In addition to the chemical annexes, there is also a new section (Annex N) that provides users some background on gas monitoring, the pros and cons of the technologies available and the difference between personal monitoring and area monitoring and the advantages of each. This annex should prove very valuable to anyone who uses chemical sterilization and who knows they need gas monitoring but is not sure where to start. 

Of course, readers of this blog know that the best place to start for any gas/vapor monitoring question is www.chemdaq.com. ChemDAQ offers continuous gas monitors for ethylene oxide, hydrogen peroxide, peracetic acid and ozone among others.


While the annexes are chemical specific, there is a lot of valuable general information in the body of the annexes, especially regarding:

• The safe use of chemical sterilants and HLDs 
• Location of a sterilizer or automatic reprocessor
• Storage of chemicals
• Qualifications and training of personnel
• Personal protective equipment
• Selection of appropriate sterilization technologies including health and safety considerations, 
• Decontamination
• Device storage
• Quality control and Quality improvement.

 The new ST58 standard should prove to be a valuable resource to those healthcare facilities that use chemical sterilization and high level disinfection.