For safety of patients, staff and public, it is essential that the hazardous materials in use in the hospital are identified and adequate measures are taken to prevent their toxic effects and safely manage any accidental exposure.
All staff must be fully aware of the areas with these hazards and the actions to be taken in case of accidental exposure. Some of the common hazardous items in use in hospitals are:
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Asbestos, Acryl amide solution, Diesel, Propylene LPG, Ethylene Oxide, Formaldehyde, Glutaraldehyde, Mercury, Phenol, Sodium Hypochlorite, Compressed gases, Cytotoxic agents, radioactive materials, insecticides, strong acids/alkalies.
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The staff in a particular area should be made aware of the hazardous materials in their work area and educated/trained in the correct procedures for handling the situations of accidental spillage of hazardous materials in a manner that neutralizes/eliminates the hazard at the earliest and in the safest possible manner. The area/department should have a documented procedure for handling the spillage.
Depending upon the hazard and the amount of spill (minor or major), the protocols for management of spillage is as follows:
1. Chemical Spill Protocol:
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a. Minor Chemical Spill:
A minor chemical spill is one which:
i. Involves spillage of only a small quantity of the chemical which is unlikely to cause any immediate toxicity to the staff exposed, and
ii. The staff has adequate knowledge about the chemical and the procedure to clean it up and can handle it themselves without outside assistance.
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Procedure:
i. Inform and alert all the people (patients/staff/public) in the immediate area of spill and cordon off the area.
ii. In case of spillage of chemical over the body part, immediately wash the chemical off thoroughly with plenty of water. In case of spillage over the clothes, remove the clothes immediately and rinse them thoroughly with water.
iii. In case of exposure of eyes with toxic fumes, wash the eyes thoroughly with water/ saline.
iv. Use all the appropriate protective equipment, including safety goggles, masks, gloves, and long-sleeve lab coat, gum boots, etc.
v. Avoid breathing the vapors from spilled chemical. Open the windows for ventilation, if the fumes are toxic.
vi. Use appropriate spill kit or absorb the spill with tissue paper.
vii. Do not directly touch the material. Instead use the forceps for picking the cleaning material (tissue paper, gauge) and dropping in the waste disposal bags/containers. The material of the bag should be compatible—such as would not react with the chemical.
viii.The chemical spilled (such as acid/alkali) may be diluted/neutralized before handling.
ix. The area should be thoroughly cleaned with water after collecting the spillage.
x. The incident should be recorded and reported including the details, such as the department/area of spillage, the chemical spilled, the quantity, the staff involved in cleaning and any hazardous effects on anybody.
b. Major Chemical Spill (all Other Spills):
Decontamination Procedures: In addition to the above:
i. Inform/alert all the people in the area evacuate the area completely and cordon it, immediately,
ii. Inform the HOD, the Hospital Safety officer and the security officer,
iii. If the spilled material is inflammable, turn off the gases supply and switch off/remove the heat sources, if any, in the area,
iv. Dilute/neutralize the spillage with water/appropriate chemical,
v. Remove the chemical by soaking/draining in the drain,
vi. Open the windows improve the ventilation in case there are toxic fumes,
vii. Ensure that all involved in handling the spillage are using all personal protective equipment,
viii.In case, there are any doubts, the safety officer may immediately call the outside experts, to limit/prevent the damage.
2. Management of Accidental Mercury Spill:
Since, mercury/mercury based instruments are still in use, it is very important that all the hospital staff is fully aware of its hazardous nature and its safe disposal.
It is also essential that the hospital staffs are fully aware of and trained in the safe management of any accidental mercury spills using the following standard procedure.
When an instrument breaks accidentally, spillage of mercury, especially if it is large, becomes a serious problem. In globules or tiny beads it spreads on the floor or other surfaces and becomes difficult to locate/collect and dispose safely.
A dime sized spill/spill from a thermometer would be called a small spill. However, a spill larger than that such as from a BP instrument should be treated as a large spill capable of producing toxic vapors large enough to cause serious poisoning and even death.
Hospitals using mercury based instruments /equipments /other items should have readily available Mercury Spill Kits containing the following (items may vary with the kit) items:
i. Zip lock-type bag (2-3)
ii. A plastic container with cap
iii. Nitrile/other Gloves and face mask
iv. Eyedropper and 10 cc syringe
v. Paper towels
vi. Cardboard stripes
vii. Mercury sponges
viii.Mercury absorbent powder (Zinc/Sulphur, etc. which amalgamates with and solidifies the liquid mercury and prevents release of mercury vapor also)
ix. Foot wear cover
x. Instructions for usage.
There are other kits available which contain a cleanup pan and brush, spray bottle or easy to use mercury adsorbent powder (activated carbon sorbent) or specially designed mercury vacuum cleaners.
Procedure for Safe Handling of Mercury Spill:
a. Switch off any source of heat that may be on, to reduce vaporization of mercury.
b. Remove the clothes if contaminated with mercury and remove any ornaments watch etc.
c. Put on the PPE-gloves and face mask to prevent any direct contact with the skin or inhalation of mercury vapor.
d. Clear the area around the mercury spill, of all items.
e. Collect the broken glass pieces with the help of a tong or paper towels, if too small, and put them in the zip lock bag. This should be labeled “Contaminated with mercury.”
f. Collect the mercury by using mercury brush/mercury sponge or piece of stiff paper/ thin card board to push it onto another piece of paper/cardboard.
g. If the kit contains mercury absorbent powder then sprinkle the powder over the mercury spilled. It amalgamates with mercury, solidifies it and prevents release of vapors.
h. Use a mercury sponge, an eye dropper or syringe to pick up smaller drops of mercury spilled in cracks. Even tape can be used for tiny particles.
i. Tiny particles can be seen with the help of the torch (after switching off the lights in the room and focusing the light along the surface).
j. Put all the mercury collected in the plastic container filled with water, close the container air tight, seal it and label it” Hazardous waste—Mercury”.
k. Clean the spillage area thoroughly.
l. Place the container and other items used for cleaning (including gloves) in the zip lock bag and label it “Contaminated with mercury”.
m. The zip lock bag is kept safely for disposal as per rules for disposal of hazardous (Mercury) waste.
n. The doors and windows of the room affected by the spillage should be kept open for a few hours to clear the mercury vapor.
o. Mercury poisoning case may present with chills, nausea, and general malaise, tightness in the chest, chest pain, dyspnoea, cough, stomatitis, gingivitis, salivation or diarrhea. In case of any signs/symptoms of exposure, immediate medical treatment should be provided.
3. Protocol for Spillage of Blood/Other Potentially Infected Materials (OPIM):
i. Blood or OPIM spills are to be immediately cleaned up by a staff member using the personal protective equipment and taking all the protective precautions.
ii. Any broken glass that may be contaminated should be removed using the tongs, forceps, or brush and dustpan and placed in the bag/container for sharps. Broken glass pieces/ sharps should never be picked up directly with hands even if wearing the gloves.
iii. The spilled blood/other material should be collected using absorbent material such as cotton wool/towels and the contaminated items used in the clean-up should be placed in an appropriately coded bag for disposal.
iv. The clean-up process should start at the periphery of the spillage, moving inwards.
v. Initial clean-up of blood or OPIM must be followed by the use of an approved hospital disinfectant chemical germicide.
vi. The equipment contaminated with spillage or during the clean-up process should be collected separately in a dirty utility room for wash up and decontamination with disinfectant such as sod hypochlorite (1%) as soon as possible.
vii. In case of spillage directly on the body parts, the body parts must be washed thoroughly with soap and disinfected using hand disinfectants, properly.
viii.In case of spillage over the clothes, the clothes should be removed, washed and disinfected at the earliest.
ix. The disposable gloves, masks, etc. should be disposed off in the biohazard labeled bag for safe disposal. The reusable equipment such as apron, boots should be washed and thoroughly disinfected before reuse.
4. Protocol for Spillage of Biological Agents in Microbiology Lab:
Accidental spillage of materials containing biological agents (such as due to accidental falls from the safety cabinets) in the laboratory can occur and can be very hazardous.
It can affect by direct spillage and contact with the body parts as well as by producing aerosol, which spreads the microorganisms in other parts of the laboratory also. The following precautions should be taken in such situations:
a. Immediately alerting and warning all the staff in the laboratory and informing the Lab. Safety Officer, if any, and the HOD laboratory.
b. To avoid the exposure through inhalation from the aerosol, the workers in the area should:
i. Immediately switch on the exhaust system at full speed
ii. Get out of the area/room of spillage and close the doors, immediately
iii. No staff should be allowed to enter the area for at least 30 to 40 minutes to allow the exhaust system to remove the aerosol from the area.
c. Clean-up and decontamination may be started after about 45 minutes by the staff trained in it, using all the personal protective equipment and precautions indicated for personal protection from infections.
d. The PPE should include a particulate mask, goggles, disposable gloves, a long sleeve apron/gown fastened at the back, shoe covers to effectively prevent direct contact of the eyes, mucous membranes and skin with the splattered material/aerosol.
e. Clean-up/Decontamination Procedure:
i. Carefully pour the disinfectant solution (1 % Sodium. Hypochlorite) without splashing, over the spilled material and leave it for about one hour for disinfection. After that place paper towels over the spillage, soak the material, pick the towels with the tongs/ forceps and drop them in the water proof red biohazard bag/container.
ii. Alternately, paper towels soaked in disinfectant solution may be placed over the spillage and soaked towels picked up with tongs and disposed off in the water proof waste container.
iii. Start the cleaning process at the periphery and move inwards, using a fresh towel each time.
iv. Continue the process until the entire spill has been removed. Then clean the entire area with fresh paper towels socked in disinfectant.
v. The PPE should be disinfected properly after the decontamination/clean-up is over.
vi. File an adverse event report for any hazardous material-related exposure or injury.
vii. In case, the spill has been directly on the exposed body parts, immediate wash with, the disinfectant soap and further disinfection with the hand disinfectants. The worker should, in such cases, report to the Occupational health clinic for post exposure treatment/ follow-up.
viii.In case of spillage over the clothes, immediate removal of the clothes, disinfection and wash, and wash and disinfection of the body part as well.
5. Protocol for Spillage of Cytotoxic Material:
a. Remove the patient, family members, visitors, and staff from immediate area where cytotoxic agent was spilled.
b. Minor Spills involving small quantities up to 5 ml of a cytotoxic drug:
i. Wipe liquids with absorbent gauze pads using double disposable gloves
ii. After removing the spillage, clean the area a number of times using a detergent solution followed by clean water
iii. Dispose of the used absorbent pads/other contaminated items in appropriate bags meant for chemotherapy waste.
c. Major Spills involving large quantities of a cytotoxic agent:
i. Implement the instructions given on the spill kit, if available
ii. Inform the Safety Officer who should come and supervise the cleanup process
iii. The clean-up process should start at the periphery of the spill, moving inwards
iv. The worker should wear PPE including a mask, double gloves, impermeable gown, goggles and boots so as to avoid any direct contact with the skin or mucous membranes
v. The worker should avoid any inhalation of the fumes
vi. In case of any direct spillage on the body parts, thorough cleaning using soap and water, followed by treatment/follow-up at the Occupational exposure clinic
vii. The body cloths, if soiled, should be removed immediately and washed with detergent soap
viii.Reporting of the incident as adverse/sentinel or near miss event as per the policy
ix. Investigation and analysis of the incident by the Safety Committee, implementation of all the measures for prevention of such incident in future and maintenance of records.
Note: Major spills can be cleaned-up more effectively by use of Spill Kits.
6. Protocol for Spillage of Radioactive Material:
Radiation from the spilled radioactive chemical spreads and affects the people in the surrounding area as well. The procedure is far more hazardous and requires far more precaution than a simple chemical spill.
Decontamination should, therefore, be done only by the radiation workers fully trained to handle it. The procedure for decontamination is described in brief below:
a. Alert and evacuate all people (patients, staff, public) from the area (including the surrounding area) and cordon off the area, restricting the entry of anyone except the staff fully trained, protected (using the safety goggles, lead apron and gloves, shoe covers) and wearing the TLD badges.
b. Any hospital/medical establishment authorized to have/use radioactive chemicals would be having a Radiation Safety Officer. He should be informed immediately to come and take control over the decontamination process.
c. In case of spillage over the unprotected body part, immediate thorough wash with water for complete decontamination of the individual at the decontamination chamber.
d. In case of spillage over the clothes, the contaminated clothes should be immediately removed and collected in the radioactive waste/containers/bags for safe disposal.
e. The spillage should be cleaned/decontaminated by:
i. Placing absorbent paper towels over liquid spills and towels dampened with water over solid material spills
ii. The process of decontamination should begin at the outer edges of the spill, working inward and avoiding spread of contamination
iii. The spills should never be touched directly. The worker should be wearing lead gloves, apron, boots and goggles and should use forceps for placing towels over the spillage and picking/dropping them in the radiation waste container
iv. The radiation level in the area of spillage should be measured and monitored with the help of a survey meter and the readings should be recorded
v. The cleaning/decontamination process should be continued until contamination in no longer detected
vi. After the area decontamination is completed, the PPE used (gloves/aprons, boots, goggles, etc.) by the radiation workers should be decontaminated by thorough wash with water at the decontamination chamber
vii. After completion of all activities, the radiation level in the spillage area and even over the bodies and the PPE used should be measured and recorded for verification of decontamination.
viii.The radioactive waste collected should be disposed off in the specially built tanks for disposal of radioactive waste
ix. The staff contaminated/potentially contaminated should be isolated in one area until they have been decontaminated, checked and confirmed to be radiation free
x. The incident should be investigated and analyzed by the safety committee and remedial measures for prevention in future, implemented
xi. In case of significant exposure of an individual, as confirmed from the level of radioactivity measured, the individual should be, after thorough decontamination, isolated and examined by the Occupational Health specialists for treatment/follow- up investigations, as indicated.