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Ethylene Oxide Leak/Spill Evacuation Procedure

SECTION 1:  POLICY
It is the policy of this hospital to have a written plan outlining the procedures to be followed in the event of an Ethylene Oxide leak or spill.

SECTION 2:  PURPOSE
This policy outlines the procedure(s) to follow in the event of an Ethylene Oxide leak/spill in the Central Service department.

SECTION 3:  PROCEDURE

A.        If ETO Alarm Sounds:

1) ALERT all employees.

2) Ensure appropriate doors are closed:

a) Both doors to the ETO sterilizer room

b) The double doors between the sterile storage area and the supply breakdown area.

c) All doors that lead out of the Central Service department.

3)      Go to Central Service Break Room.

4)      CLOSE the door leading from the break room into the sterile storage area.

5)      If anyone is hurt or shows symptoms of ETO overexposure, take that person to the Emergency Room (The E.R. has a copy of the ETO MSDS.)  Some signs of ETO
overexposure are:

d) Eye, nose, & throat irritation.

e) Coughing.

f) Nausea and vomiting.

6)   Put tape across the double doors across from the E.R. elevator.

7)   Tape the "DO NOT ENTER.  AREA CLOSED" sign to the double doors.

8)   Contact JMH Security.  Security will prepare to cordon off and monitor access to  the area in preparation for evacuation if needed.

9) Contact the C.S. Manager or Lead Technician, whomever can be reached first. Phone numbers are located at the switchboard with the operator.

10) Contact the JMH Maintenance department.  Maintenance will ensure that the exhaust system is operational.

11) Observe the ETO monitor through the window in the break room.  If the ETO level is dropping--wait until the monitor reads "0" before re-entering the department.

12)   If the ETO level continues to rise and approaches "200", the senior Central Service employee on duty will need to don the "Self Contained Breathing Apparatus",  (SCBA) and enter the department to shut off the main ETO supply tank valve.  If, while performing this task, it is determined that the leak/spill is of a type that cannot be stopped by closing the main tank valve:

IMMEDIATELY NOTIFY

1. AGA's EMERGENCY RESPONSE TEAM AT:  1-800-242-0105

2. NURSING SHIFT SUPERVISOR AT:

a) In house Extension 厖厖.. 1195

b) In house Pager 厖厖厖. 77-04

B. The Nursing Shift Supervisor will make the determination as to initiating the hospital's Emergency Response Plan.

C. The C.S. Manager or Lead Technician will make the determination to contact the ETO sterilizer service technician.

SECTION 4:  REFERENCES

1. OSHA Standard 29 CFR 1910.38

2. AAMI Standards and Recommended Practices

US Patent Numbers 7,720,998 B2, 7,836,207