Department of Environmental Health and Safety Laboratory Decommission Policy

Transcription

1 Department of Environmental Health and Safety Laboratory Decommission Policy 1. Purpose and Applicability 1.1 It is the policy of New York Medical College (NYMC) that laboratory decommissioning takes place prior to the relocation of any laboratory space or upon vacating laboratory space or leaving the institution. In addition, safe and compliant moving practices must be adhered to at all times. 1.2 This policy is intended to minimize research laboratory downtime due to a laboratory move, and to protect contractors, laboratory personnel, and any other personnel involved in the process from potential laboratory hazards. 1.3 This policy applies to all NYMC employees and tenants occupying laboratory space within NYMC buildings. 1.4 Prior planning is key to a successful laboratory decommissioning and move. Your preparation and communication with the Department of Environmental Health and Safety (EHS) will be a major factor in minimizing delays, protecting your property against damage and loss, and most importantly, reducing the potential for personal injury. Contact EHS at , if you have any questions or need assistance. 2.0 Definitions 2.1 Abandoned Laboratory: A research laboratory that is left vacant by a Principal Investigator or Laboratory Supervisor and his/her laboratory staff that contains laboratory materials (biological, chemical, radioactive), equipment and/or waste that has not been removed properly. 2.2 Controlled Substance: A drug or other substance, or immediate precursor included in schedule definitions of the Drug Enforcement Administration. 2.3 Biological Materials: All human, plant and animal pathogens; all human blood, blood components and products, tissues and body fluids; all human and animal cultured cells; all infected animals and animal tissues; all culture/stocks of biological agents including recombinant DNA materials; and all biological toxins. Also includes biomedical waste and physically dangerous (sharps) waste.

2 2.4 Decommissioning: The process whereby a Principal Investigator or Laboratory Supervisor and his/her laboratory staff decontaminate existing laboratory space and make a research laboratory safe prior to vacating the space. The process also includes a confirmatory inspection by a representative of the Department of Environmental Health and Safety (EHS), and in some cases a third party vendor as needed. Finally, the process involves the completion of a Laboratory Decommissioning Certification (Appendix A) with appropriate signatures. 2.5 Decontamination: The process whereby the Principal Investigator or Laboratory Supervisor and his/her laboratory staff clean and disinfect laboratory surfaces and equipment so they are safe to handle. 2.6 Hazardous Chemical: A chemical that significant evidence indicates may cause acute or chronic health effects in exposed laboratory personnel. Chemicals that are classified as Ignitable, Toxic, Corrosive, and/or Reactive. This includes specific OSHA-regulated substances such as methylene chloride and formaldehyde. 2.7 Ionizing Radiation: Electromagnetic radiation (x-ray and gamma-ray photons) or particulate radiation (beta particles, electrons, positrons, neutrons, and alpha particles) capable of producing ions by direct or secondary processes. 2.8 Laser: A device which produces an intense, coherent, directional beam of light by stimulating electronic or molecular transitions to lower energy levels. An acronym for Light Amplification by Stimulated Emission of Radiation. 2.9 Radioactive Material: Any material that spontaneously emits ionizing radiation at levels above natural background levels. 3.0 Roles and Responsibilities 3.1 The Principal Investigator or responsible Department Administrator is responsible for: Appointing a Move Coordinator responsible for coordinating the laboratory decommissioning process Notifying EHS when chemical, biological or radioactive materials are to be relocated Notifying EHS when laboratory equipment is to be moved from a lab or discarded Notifying EHS when a laboratory is to be relocated or decommissioned The complete decommissioning of the laboratory space prior to vacating the laboratory. In cases where an abandoned laboratory is identified, the department that the Principal Investigator or

3 Laboratory Supervisor reported to will be responsible for the decommissioning and all costs associated with the process. 3.2 The Move Coordinator for the laboratory is appointed by the Principal Investigator and is responsible for coordinating the laboratory decommissioning and move. The Move Coordinator is the primary contact with the Department of Environmental Health and Safety. 3.3 The Department of Environmental Health and Safety (EHS) is responsible for: Providing advice on decontamination procedures as requested Providing radioactive materials and laboratory equipment surveys prior to certifying decontamination approval Removing biological, chemical, and radioactive waste for disposal Distribute this policy and attachment and advise Principal Investigators, Laboratory Supervisors and laboratory personnel on how to implement the various aspects of the policy Verifying that a laboratory has been appropriately decommissioned before a Principal Investigator or Laboratory Supervisor may leave or move his or her laboratory. 3.4 The Facilities Department, Moving Personnel, and Contractors should be aware of this policy and should not handle or dispose of laboratory materials, equipment or waste unless instructed to do so by their supervisor and/or EHS. 4.0 Procedures Waste Disposal 4.1 All biological waste, hazardous chemical waste, and radioactive waste must be disposed of according to current EHS policies and procedures. Boxes and trash must not be left in corridors. Prior arrangements for regular trash must be made with the Facililities Department. 4.2 Chemical Waste must be identified with hazardous waste labels regardless of whether they are identified by manufacture s labels. Hazardous waste labels must be properly filled-out prior to removal. 4.3 Radioactive waste must be disposed of in accordance with the Radiation Safety Manual. 4.4 Unwanted or outdated controlled substances must be sent to a Drug Enforcement Administration (DEA)-registered disposal firm for destruction.

4 4.5 Any unknown chemicals must be identified and labeled as hazardous waste. For chemical unknowns that cannot be identified by the Principal Investigator, Laboratory Supervisor, or laboratory personnel, the laboratory may be assessed a service fee for hazardous waste analysis prior to disposal. 4.6 Dark room tanks must be drained and the contents disposed of as hazardous waste. Empty compressed gas cylinders must be returned to the distributor prior to the move. Mercury thermometers must be disposed of as hazardous waste and vacuum pumps must be drained of oil and the oil disposed of as a hazardous waste. 4.7 Any unwanted laser or x-ray generating equipment must be drained and/or contamination-free of any oil, dyes and other chemicals. Such chemicals must be disposed as a hazardous waste. 4.8 Equipment classified as Universal Waste, must be removed by the Facilities Department. These materials include: monitors, electronics, computers, and assorted batteries. 5.0 Procedures Decontamination 5.1 All laboratory surfaces (e.g., bench tops, sinks, floor areas, etc.) must be decontaminated prior to vacating the laboratory. All laboratory equipment that is either remaining in the laboratory or being moved to a new laboratory must be decontaminated if potentially contaminated with biological, chemical, and/or radioactive materials. 5.2 Laboratory Equipment requiring decontamination includes but is not limited to, refrigerators, freezers, water baths, incubators, animal cages, centrifuges, fermenters, and fish tanks. 5.3 Fume Hoods must be decontaminated properly. Notify EHS at , if there are any current or past practices that might reveal potential problems. For example certain chemicals such as perchloric acid and mercury might remain on surfaces, equipment, and/or in building systems. 5.4 Biological safety cabinets and glove boxes that have been used with potentially infectious materials must be decontaminated. This must be done by a qualified contractor. Biological safety cabinets that are either to be moved to new laboratory areas or left behind must be reported to the EHS Biological Safety Officer at Decontamination methods must be discussed and approved well in advance. Biological safety cabinets that are moved must be re-certified after installation. Contact the Facilities Department to arrange for re-certification. 5.5 An appropriate disinfectant must be utilized in cases where biological materials were in use. A disinfectant is deemed appropriate if it targets the biological materials that were in use in the laboratory. In most cases, 70% ethanol, bleach solution (1:10 made fresh), or a phenolic disinfectant is

5 adequate for disinfecting laboratory furniture and equipment potentially contaminated with biological materials. If you have specific concerns, call the EHS Biological Safety Officer at The Principal Investigator or Laboratory Supervisor must complete the Laboratory Decommissioning Certification form (Appendix A) and submit the form to EHS when decontamination and decommissioning activities are completed. This will allow EHS personnel to review the decommissioning activities, visit the decommissioned laboratory, and alert the appropriate administrative personnel that the decommissioning had been performed. Upon receipt of the completed form, EHS will contact the Principal Investigator or Laboratory Supervisor to schedule a tour of the laboratory to confirm the decommissioning activities. 5.7 The NYMC Equipment Decontamination Record sticker will be affixed to all equipment that has been decontaminated. EHS is responsible for applying these stickers. This will allow moving personnel to safely move the equipment to the new laboratory space. Only equipment with this sticker will be moved. 5.8 For further information regarding proper decontamination or disinfecting procedures, contact EHS at Procedures Laboratories with Radioactive Materials 6.1 The Principal Investigator or Laboratory Supervisor is responsible for transferring and/or disposing of all radioactive materials from all laboratory areas. Contact the EHS Radiation Safety Officer (RSO) at to make appropriate arrangements. Written authorization from the RSO is required prior to any transfer outside the Principal Investigator or Laboratory Supervisor s lab areas. 6.2 A thorough area survey of laboratory areas and equipment is to be performed by the Principal Investigator or Laboratory Supervisor in accordance with the Radiation Safety Manual. 6.3 A final decommissioning survey is conducted by the RSO, or third party vendor as needed after the Principal Investigator or Laboratory Supervisor vacates the lab. The extent of the final survey depends on the future use of the space and will be determined by the RSO.

6 6.4 Prior to vacating a laboratory, all dosimetry devices (such as film badges and finger rings) must be returned to the RSO, if individuals will no longer be working with radioactive materials at NYMC. 7.0 Procedures Laboratories using Lasers or X-ray Generating Equipment 7.1 The RSO must be notified in writing prior to the move or transfer of any x- ray or laser-generating equipment to another laboratory or institution. 7.2 As the potential for electrocution may become present, the Principal Investigator or Laboratory Supervisor must report circuit breaker and/or laboratory electrical system rework to EHS. 7.3 Laboratory personnel using x-ray-generating equipment must return dosimetry devices (film badges and/or finger ring) to EHS prior to vacating the laboratory if individuals will no longer be working with radioactive materials at NYMC. 7.4 Laser or x-ray generating equipment that is moved on campus must be reinspected by the RSO after installation. 8.0 Procedures Laboratories using Controlled Substances 8.1 Prior to vacating a laboratory, arrangements must be made for the proper transfer and/or disposal of all controlled substances. Contact EHS at to make appropriate arrangements. 8.2 If controlled substances are being transferred to a new institution or state, federal registration must be obtained for the new address before transferring the controlled substance. Once the new registrations are obtained and controlled substances are transferred, the state and federal registrations at New York Medical College must then be terminated. 8.3 If controlled substances are no longer needed, after proper disposal arrangements are completed, the state and federal registrations are terminated. 8.4 For laboratories using Schedule 1 and/or 2 substances, the Principal Investigator or Laboratory Supervisor must mail all blank Order Forms (Forms 222) back to the federal Drug Enforcement Administration. 9.0 Procedures Designation of New Laboratory Space 9.1 The Principal Investigator or Laboratory Supervisor must inform EHS of any new laboratory space, so that the appropriate safety signage may be provided and safety equipment inspected.

7 9.2 The Principal Investigator or Laboratory Supervisor is responsible for notifying all applicable NYMC committees and outside agencies, as necessary, of the move to a new laboratory space. USDA Veterinary Service or Plant Service permits are laboratory specific, as are CDC Select Agent registration permits. Contact the Biological Safety Officer at if you need assistance Procedures Packing and Moving Materials 10.1 Laboratory personnel are responsible for gathering all packaging materials needed before the move date. Carts, polyethylene bags, towels, cushioning materials, absorbents, seal-able bags, boxes, and drums, labels, packaging tape, and spill clean-up kits should be readily accessible. Each container or piece of equipment must be labeled properly. Labels must identify the agent, hazard and necessary precautions. Materials that will be transported over public roads must be labeled and packaged according to Department of Transportation (DOT) regulations The Principal Investigator or Laboratory Supervisor is responsible for establishing safety and emergency procedures for all phases of the move. Potential emergencies include material spills, fires, slips, falls, and cuts. Protective clothing and spill absorbent materials must be available during packing, moving, and unpacking. Contact the RSO to arrange the moving or shipping of radioactive material or contaminated equipment. 11. Procedures Packing and Moving Laboratory Chemicals 11.1 In order to minimize the amount of biological, radioactive, and hazardous chemicals that need to be packed and moved, new materials should be ordered only as necessary and in small quantities. Laboratory personnel should plan in advance to minimize the inventory of chemical volume and weight of materials to be moved. In addition, reduction of active materials should be planned the week prior to the move. In accordance with DOT regulatory compliance, laboratory chemicals must be packed and transported by an outside contractor approved by EHS. Prior to the packing laboratory chemicals, laboratory personnel are responsible for labeling each chemical container with the proper written chemical name. Chemical container labels must include the Chemical Abstract Number (CAS#), purchase date and expiration date Compressed gas cylinders that are to be moved must have regulators removed and caps secured. If possible, cylinders should be collected and returned to the distributor and arrangements for future cylinder deliveries made to the new location.

8 11.3 Thermometers must be removed from refrigerators, water baths, and incubators prior to equipment moving Vacuum Pump Oil must be drained from pumps prior to equipment moving. The oil must be disposed of as hazardous waste. 12. Procedures Packing and Moving Biological Materials 12.1 Biological Materials must be appropriately packaged and labeled by the laboratory personnel Proper Packaging consists of a primary sealed container placed within a secondary sealed, unbreakable container, with enough absorbent material in between to contain and absorb any spill. Examples: petri dishes in a plastic sleeve within a plastic lined box using paper towel spacers, stabs in a sealed plastic container with paper towels to cushion vials, sealed tubes in a rack placed into plastic sealable container with absorbent material, tissue culture dishes placed into a plastic lined dishpan or a seal-able cardboard box with an absorbent. Freezers can be moved intact, provided all contents are in sealed, unbreakable containers, and the freezer remains closed. Enclose loose items in boxes, or engineer alternatives to avoid breakage and spills when the freezer is reopened. Other equipment, such as fermenters, refrigerators, incubators, and biosafety cabinets must be empty and decontaminated prior to the move Once packaged, all biological materials must be properly labeled. Labels must include: Biological agent name, Principal Investigator (PI), new location, biosafety level, contact telephone number, and a FRAGILE notice if applicable. The Universal Biohazard label must be used whenever packaging a biosafety level 2 (BL2) or higher agent. If you are not sure of the biosafety level of your biological materials, or need Biohazard labels, call the EHS Biological Safety Officer at If the biological material is to be transported over public roads, proper DOT regulations must be adhered which may require additional labeling or packaging Procedures Laboratory Furniture and Equipment 13.1 The Move Coordinator must make special arrangements for any furniture not discussed that may be fragile, valuable, or requires dismantling. Different moving companies may have different requirements that should be ascertained in advance of the move The Move Coordinator must be aware of any equipment under service contract and equipment not under contract, but requiring servicing and/or special handling (e.g., liquid scintillation counter containing a radioactive sealed source).

9 13.3 The Move Coordinator must arrange to have all equipment alarms properly disconnected before the day of the move Laboratory personnel must keep keys and combinations to equipment locks readily accessible during the moving process.

10 Department of Environmental Health and Safety Appendix A: Laboratory Decommissioning Certification 1. I certify that any biological materials, hazardous chemicals, and radioactive materials have been removed from the laboratory room(s) including main labs, equipment rooms, cold/warm rooms, tissue culture rooms, etc, under my supervision. These rooms include: Building Department Room # 2. I certify that the surfaces in these rooms and all equipment and utensils have been surveyed and completely decontaminated, if needed, with: (specify decontaminants and percentage, i.e. 70% Ethanol). Decontaminant Concentration 3. Hazardous Chemicals I certify that: Arrangements for pick-up and disposal of all excess chemicals have been made with the Department of Environmental Health and Safety All chemicals contained within equipment have been drained from the equipment and hazardous vapors have been released. Yes No N/A 4. Biological Materials I certify that: Arrangements for the pick-up and disposal of all biological materials have been made with the Department of Environmental Health and Safety. Biological Safety Cabinets and/or glove boxes used with potentially infectious materials have been decontaminated. Arrangements for the transfer and/or disposal of all select agents have been made with the Responsible Official or Biological Safety Officer. Yes No N/A

11 5. Radioactive Materials I certify that: Arrangements for the transfer and/or disposal of all radioactive materials have been made with the Radiation Safety Officer. All surfaces, equipment, and utensils used with or to store radiation have been checked for contamination and decontaminated to less than twice background radiation levels. Arrangements for the transfer and/or disposal of any liquid scintillation counter containing a radioactive sealed source have been made with the Radiation Safety Officer. Records of area surveys and decontamination have been provided to the Radiation Safety Officer. Film badges and/or finger rings have been returned to the RSO, if applicable. Yes No N/A 6. Controlled Substances I certify that: Arrangements for the transfer and/or disposal of all controlled substances have been made with EHS. For Schedule 1 and/or Schedule 2 Controlled Substances, all blank order forms (Form 222) have been mailed back to the Drug Enforcement Agency. Controlled substance registrations (State and Federal) have been terminated. Yes No N/A 7. Lasers I certify that: Arrangements for the transfer and/or disposal of any lasergenerating equipment have been made with EHS. All circuit breaker and/or laboratory electrical system rework has been reported to EHS. Yes No N/A 8. Equipment

12 I certify that: Centrifuges (table top or floor model) have been properly cleaned. Biosafety Cabinet has been emptied and cleaned. Refrigerators/Freezers have been emptied and cleaned. Incubators have been emptied and cleaned. Flammable Storage Cabinets have been emptied of all chemicals. Yes No N/A Model Serial # NYMC ID 9. Labels I certify that: Yes No N/A All biological materials, chemical, and/or radioactive wastes are properly labeled, and arrangements were made for transfer and/or disposal with EHS. All hazard-warning labels have been removed from equipment and/or utensils after decontamination surveys and cleansing is completed. Note: All warning signs posted outside of laboratories are to be removed by EHS after a confirmatory inspection has been performed. Signatures: Principal Investigator (Print) Signature Date Move Coordinator (Print) Signature Date Please return completed form to EHS, fax number EHS will schedule the confirmatory inspection upon receiving and review of this form. For EHS Use Only

13 EHS Survey: The Radiation Safety Officer has confirmed that the equipment is void of any radioactive materials/waste/residue. The Chemical Safety Officer has confirmed that the equipment is void of any chemical materials/waste/residue. The Biological Safety Officer has confirmed that the equipment is void of any biological materials/waste/residue. Yes No N/A Initials Laboratory Decommissioning Verification Environmental Safety Specialist Signature Date Biosafety Officer Signature Date Radiation Safety Officer Signature Date Director of EHS Signature Date