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Conducting an accurate assessment and inventory of hazardous chemicals

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February 23, 2017

Clear records and an ongoing inventory is key to keeping ahead of regulations

Editor’s note: The following is an excerpt from the upcoming HCPro book, Hazardous Waste in Healthcare: A Guide to Regulatory Compliance, by author James Crouch, BSBM, MHA, MS/AJS. The book, due to publish in June, will assist safety officers in wading through confusing hazardous waste regulations in healthcare, many of which often contradict requirements from other accreditation bodies.

Whether you are new to the role of ensuring environmental compliance for your organization, or you’ve been in your job for a long time, you may have struggled with the question of where to begin. The best place to start is with a chemical inventory. The chemical inventory serves as your foundation for environmental management. This can be a daunting task, as you may have multiple locations and multiple departments to oversee. The Occupational Health and Safety Administration (OSHA), not to mention standards from other accreditors, requires that you perform an annual chemical inventory to assess the risk and identify the chemicals on hand.

I use a process that has been effective and identified as a best practice by accreditation inspectors. Many have taken this back to their hospitals and are having success with it. I know that if you are working for any organization that is of a substantial size that it is virtually impossible to get out and conduct these inventories on our own. So, I send out a spreadsheet to make things easier. In the example I’ll share with you, some of the items may look similar to your own, but there are also some additional items that you may not have on your current inventory sheet. I always include the following:

  • Chemical Name
  • Chemical Manufacturer
  • Chemical State (Liquid, Gas, Solid)
  • Container Size
  • Number of Containers On-Hand/Stored
  • Storage Location/Room Number

Many times a variation of the chemical inventory that I see does not include the size of the containers or the number of containers stored at the site, location or in that department. Adding this information to your inventory allows you to assess more of the risk associated with a hazardous material if one is located in that area. Also, should you trigger any additional EPA, or state required, reporting the amount on hand is critical.

Getting your staff on board

Many times, we the professionals tasked with maintaining this information feel that this is our responsibility to perform these inspections. The challenge is figuring out how to handle everything if you have multiple locations, multiple departments, and not enough staff to support you. The best way to manage this is to draft a memo which includes the accreditation and regulatory requirements for conducting these inspections and then send this memo out to your department leaders to help them understand the importance of managing hazardous waste in your facility, and to help them realize that hazardous materials are found everywhere in your facility.

Examples of where hazardous materials are commonly found include but are not limited to:

  • Laboratories
  • Diagnostic imaging locations
  • Urgent care centers
  • Soiled utility rooms
  • Custodial closets
  • Storage and stock rooms
  • Maintenance shops
  • Mechanical areas
  • Rehabilitation centers
  • Clinics, patient care units
  • Cylinder storage rooms and cabinets
  • Surgical suites
  • Sterilization departments
  • Endoscopy departments

Include in your memos to department heads a deadline for returning this information—I have found that it is best to give them a couple of months to complete the inventory. You could send meeting requests out as a placeholder on their respective calendars; I have found this works extremely well with deadlines.

Additionally, many of the variations of chemical inventory forms I have used included forms that require the departments to check if the Safety Data Sheet (SDS) is on file. Even if you don’t require your department heads to maintain records, it is not a bad practice for them to know where to locate them.

I have audited some facilities in which the departments maintain their own SDS binders and chemical inventories. There may be a centralized database system, but the departments maintain their own backup binders with hard copies of all paperwork. The issue with this type of system is that the SDS binders never seem to get updated, especially with revised SDSs. If you have this type of system, ensure that you audit the binder for the appropriate chemicals in use and perform a spot check by going online and pulling up the SDS and ensuring that the sheet in the binder is the most current version. I personally do not use a binder system, as the standards do not require a hard copy be maintained.

I ensure compliance by making sure we have a centralized location with an emergency phone. If the computer system is down, staff with the need to access an SDS can call this number to gain access to the information. We perform downloads of the database every 6 months and place this information on a computer that is on emergency power. This ensures redundancy and access to the information. I also place these files directly on my laptop in case of an emergency. It is up to you to decide the best application for your facility; in my experience, the department binders are usually not maintained and can cause compliance issues, not to mention when you do need the information in an emergency, they may not have access to the most current information. 

Updating inventory forms

The inventory form should not be sent blank to the department each year, but should be an ongoing document that can be updated periodically. There needs to be a way for staff to indicate to you any new chemicals being used, or chemicals that need to be removed from the inventory because they are either expired or no longer in use. If they only complete the form each year, now it is on you to compare the new inventory to the previous year to get that information.

In the inventory process that I use, the first year is the hardest as it is the only time that I send out a blank form. In subsequent years, I will send out to my department heads the form they sent me the previous year, with a section on each line for the department to indicate any new chemicals or if chemicals need to be removed. This significantly assists departments, especially if leadership roles may have changed or new processes were introduced or changed.

Now, can’t the department just send it right back to you with no changes? Of course, but any department that returns the exact same inventory as the year before triggers an audit by me, because I know better. This audit goes, in detail, through the department to ensure that there were, in fact, no changes. So, it is in the best interest of the department to maintain their inventory accurately. Now, these are not the only audits I perform. Many times throughout the year I get to many departments for a wide variety of reasons. If I find a chemical in use during my tours, I write it down, take that information back to my office and cross reference the inventories they’ve submitted to me. This spot check is a really good form of check and balance.

Department inventories

Another frequent question I receive is what is required to be included in the inventory. While I make it a habit to send along a list of examples of what should and should not be included on the inventory, I always tell the department heads that if they are not sure whether to include the chemical, they err on the side of caution and include it. In my review of the record, I will add or remove the ones that are not required.  I would much rather they include chemicals then to miss ones that needed to be included.

Some examples of required chemicals to be reported on a chemical inventory include, but are not limited to:

  • Laboratory chemicals: Acids, bases, solvents, mercury, metallic salts, halogenated compounds, toxic substances such as lead compounds, and mixtures of hazardous chemicals
  • Compressed gas: Pressurized gas cylinders or mixtures of gases
  • Liquids under pressure: liquid nitrogen, liquid oxygen, propane, aerosols, chlorofluorocarbon refrigerants (liquid/gas phases)
  • Paints and inks: Both water and oil-based paints, spray paints, inks, etc.
  • Solvents and spirits: Degreasers, kerosene, paint thinners
  • Lubricants: hydraulic oil, motor oil, pump oils, greases, gels
  • Finishes: varnishes, floor waxes, lacquers
  • Flammable or Combustible Liquids: Gasoline, Xylene, diesel fuel
  • Maintenance or structural materials: asphalt-containing roofing, adhesives, and bonding agents
  • Groundskeeping materials: fertilizers, plant food, soda ash, etc.
  • Pesticides: Insecticides, rodenticides, fungicides, herbicides
  • Custodial materials: cleaning agents, bleaches, floor strippers, soaps and detergents, corrosive products, ammonia, etc.

Identifying the hazardous waste

Now that all the chemical inventories are completed, the next step in conducting the assessment is to determine where your hazardous waste is generated. It sounds fairly easy, but this is the step that can easily be overlooked and can create compliance issues for your organization. In order to identify what waste you may be generating requires you to go through each and every inventory submitted. What you are looking for are the acids, bases, aerosol cans, chemical reagents (typically in labs), flammable chemicals/solvents, and degreasers/disinfectants/sterilizing solutions.

It is best to go through each inventory with a highlighter. Highlight the ones that fall, or may fall, into these categories. The reason that your assessment needs to go to this level of detail is that you are looking for potential areas of noncompliance. For all you know, there are people in the hospital disposing of chemicals by inappropriate means (i.e., pouring chemicals down the drain, throwing items in the garbage, placing the item in with regulated medical waste, etc.), and you need to catch this.

To give you an example, I was contacted by a department to dispose of a flammable chemical.  The container size was very small, and the contents had exceeded the expiration date on the bottle. I contacted our waste hauler, received a profile from the destruction facility, and sent the quote back to the department. It was going to cost more than $200 to dispose of this little bottle. So the department asked whether they could just place the material in some kitty litter and dispose of it with the regulated medical waste. Well, you can imagine my response to that request. I give this example to you as an example that staff throughout the hospital may not be aware of the appropriate means of disposal of certain chemicals and may in fact be disposing of chemicals inappropriately. However, it is our duty to identify these gaps and get the proper disposal procedures in place. The best way to ensure this compliance, I have found, is to conduct your assessment to this level of detail.

See a Hazardous Waste Determination Assessment Form that will provide assistance in identifying chemicals that fall into one or more of the reportable waste categories. This serves to help identify all the different waste streams in your facility; this will be crucial as you move forward to the EPA ID number registration and determining your generator status.

Conducting this assessment requires you to go through each and every chemical in your building, and I know that this is a tedious job. However, by getting used to doing this (especially if you’ve never done it before), you start to become familiar with names of chemicals, where they are stored, and, more importantly, if chemicals you have on hand will trigger additional regulatory requirements

Regulated medical waste and DOT regulations

Regulated medical waste (RMW), also known as biohazardous or infectious waste, does not usually pertain to your chemical waste, or even your chemical inventory. However, where this falls into your hazardous materials and waste management program is the fact that this waste may contain blood, bodily fluids or other potentially infectious materials. Most states have their own regulatory authority as it pertains to this waste stream, and it would benefit you to research and obtain a copy of those standards for your records.  There is also a specific OSHA standard, 29 CFR 1910.1030 related to bloodborne pathogens that outlines specific procedures in handling waste and to include specific training requirements.

The following are types of wastes commonly regulated under these standards:

  • Pathological waste—Tissues, organs, body parts, and body fluids removed during surgery and autopsy
  • Human blood and blood products—Waste blood, serum, plasma and blood products
  • Cultures and stocks of infectious agents (microbiological waste)—Specimens from medical and pathology laboratories. Includes culture dishes and devices used to transfer, inoculate, and mix. Also includes discarded live and attenuated vaccines
  • Contaminated sharps—Contaminated hypodermic needles, syringes, scalpel blades, Pasteur pipettes, and broken glass
  • Isolation waste—Generated by hospitalized patients isolated to protect others from communicable disease, such as biological waste and discarded materials contaminated (or those that have the potential to have been contaminated) with blood, excretion, exudates, or secretion from humans or animals who are isolated to protect others from highly communicable diseases (Lassa fever virus, Marburg virus, monkey pox virus, Ebola virus and others.
  • Contaminated animal carcasses, body parts and bedding—This is usually from animals intentionally exposed to pathogens in research, biologicals production, or in vivo pharmaceuticals testing.

The EPA, in 1980, was the main enforcer of the regulated medical waste standards. Also in 1980, used syringes and medical waste items started washing up on several East Coast beaches. In response, Congress enacted the Medical Waste Tracking Act (MWTA), which required the EPA to create a two-year medical waste demonstration program.  In response to this requirement the EPA established regulations which enacted the following:

The regulations identified which wastes would be regulated, and also:

  • Established a cradle-to-grave tracking system based on a generator-initiated tracking form (similar to RCRA manifests for hazardous waste)
  • It required management standards for segregation, packaging, labeling, and storage of the waste
  • It established recordkeeping requirements
  • It defined penalties that could be imposed for mismanagement

The MWTA, along with EPA’s initial regulations, served to focus attention on the medical waste issue from 1989 to 1991.  It also provided a model that was subsequently used by some states and by other federal agencies in developing their own medical waste programs.

Most states have their own environmental or waste management division and in most of these cases this division has the primary responsibility for the medical waste regulations. However, there are some states that choose to have these regulations managed by their department of health. In some states there are responsibilities shared by both agencies. In either case it is crucial to obtain a copy of these regulations.

In most instances states require healthcare facilities to register and/or obtain a permit to generate medical waste.  Make sure to check with your state for the permit requirements. In addition, if you have multiple clinics/hospitals spread throughout your coverage area you need to ensure that each one with a separate physical address has a separate permit/certificate. As indicated in the previous chapter with the Joint Commission standards, whomever accepts the responsibility of the Environmental Management System needs to ensure tracking of these permits and ensure they do not expire. State rules may also cover the development of contingency plans, on-site treatment, training, waste tracking, recordkeeping, and reporting, all of which shall also be maintained by the person responsible for the program.

Something else that requires effective management with medical waste is the manifests, or shipping papers.  Because medical waste is defined by the DOT as a hazardous material and as such, shippers (in this case the clinic or hospital) of hazardous materials must sign hazardous materials shipping papers before they offer their shipments for transport. Before signing, you should check the information entered on the manifest to ensure that it is accurate and complies with the applicable DOT regulations.  When you sign a hazardous waste manifest, you certify that the materials listed on the manifest are properly classified, described, packaged, marked and labeled, and are in proper condition for transportation according to the applicable regulations of the DOT. Therefore, because the person that signs the manifest is responsible for its accuracy, that person is classified as a hazardous material employee by the DOT.




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