This section has been reviewed and updated as needed: April 2012

Policy

It is the policy of UNC-CH Clinical Facilities and UNC Healthcare that all employees be protected from overexposure to glutaraldehyde in the course of performing their jobs. If glutaraldehyde exposure is documented by EHS above 0.2 ppm, engineering or administrative controls will be implemented to reduce exposure below the limit. Typical trade names for glutaraldehyde solutions used in UNC-CH Clinical and UNC Healthacre facilities are Cidex, Rapicide, and Wavicide.

Purpose

Glutaraldehyde’s effectiveness as a chemical sterilant was first recognized in the early 1960s when the healthcare industry searched for a safer substitute for formaldehyde, which has carcinogenic properties. However, glutaraldehyde is an irritant to the skin and mucous membranes and can cause allergic contact dermatitis. Exposure can occur through inhalation of glutaraldehyde vapor or through skin contact with the solution. The North Carolina Department of Labor – Occupational Safety and Health (OSH) Division set a permissible exposure limit (PEL) for glutaraldehyde of 0.2 ppp, as a ceiling limit. This is the regulatory limit for North Carolina and cannot be exceeded at any point throughout the work shift. Also, the American Conference of Governmental Industrial (ACGIH) recommends that personal exposure to glutaraldehyde in the workplace not exceed an airborne concentration of 0.05 ppm (ceiling limit) during the work shift.

Engineering

Those areas using glutaraldehyde are to be kept under negative pressure to avoid transmigration of the chemical vapor and its odor. Adequate dilution ventilation (ideally at least ten air exchanges per hour vented directly to the outside, where feasible) must be maintained to protect workers from glutaraldehyde exposure. Glutaraldehyde baths are to be covered and completely enclosed with a local exhaust system or kept in a fume hood. Engineering controls will be utilized in all areas to minimize exposure. UNC-CH Clinical and UNC Healthcare currently utilize three types of engineering controls in areas using glutaraldehyde: general room ventilation, fabricated local exhaust ventilation, and automated ductless fume hoods.

Personal Protection

All skin contact with glutaraldehyde must be avoided. Use gloves and aprons made of butyl or nitrile rubber where there is a potential for a major splash to the skin. Latex gloves do not provide adequate protection. This chemical will pass readily through latex to unprotected skin. Wash gloved hands after handling glutaraldehyde. Goggles and face shields shall be worn when handling glutaraldehyde to preclude exposure to the mucous membranes of the eyes, nose and mouth.

Industrial Hygiene

Air monitoring, using acceptable methodologies with the proper detection limits, shall be performed in areas using glutaraldehyde. The National Institute for Occupational Safety and Health (NIOSH) manual of analytical methods will be consulted for details. UNC-CH Environment, Health and Safety and UNC Healthcare’s Environmental Health and Safety Department will conduct air monitoring at the specified intervals.

Monitoring shall be conducted:

  1. Initially to determine glutaraldehyde exposure levels.
  2. After equipment changes or revised work practices.
  3. In response to worker complaints.
  4. Subsequent air monitoring will be conducted regularly every three years and on an as needed basis.
  5. Areas with exposures above the ACGIH TLV of 0.05 ppm will be viewed as “Priority Areas”, and will be montiroed more often (at least annually).
  6. All results of air monitoring shall be given to each department and kept on file in the Environment, Health and Safety Department.

Work Practices and Training

Safe work practices for minimizing glutaraldehyde exposure include:

  1. Reviewing work practices periodically in all areas where glutaraldehyde is used in order to prevent overexposure.
  2. Communicating between all areas of UNC-CH Clinical and UNC Healthcare that use glutaraldehyde to provide useful ideas for reducing exposure. Minimizing agitation of the chemical and keeping lids on the containers.
  3. In case of eye or skin contact, wash with water immediately for a period of 15 minutes. An emergency eyewash must be installed in areas that use glutaraldehyde.
  4. Wash gloved hands after handling glutaraldehyde solution.
  5. Clean up spills immediately using spill kit.
  6. The Departmental Safety Coordinators in each department with the assistance of the Environmental Health and Safety Department will train and educate new and current employees regarding safe work practices which are essential in reducing and/or eliminating chemical exposures. Training for new and current employees who are potentially exposed to glutaraldehyde will be implemented through the LMS system. All employees having potential exposure to glutaraldehyde will complete the online training on an annual basis. Training shall include the potential hazards associated with glutaraldehyde, proper use of protective clothing, safe work practices, personal hygiene concerns, signs and symptoms associated with overexposure to glutaraldehyde, and spill clean up procedures.

Implementation

It is the responsibility of the Departmental Safety Coordinators in each department and the UNC-CH Environmental Health and Safety Department to implement this policy.