172 Hospital Hazards and Solutions: Glutaraldehyde

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Glutaraldehyde Hazards

Potential Exposure

xray
Glutaraldehyde is used as a hardening agent in the development of x-rays.
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In addition to its use as a disinfectant, glutaraldehyde is also used as a tissue fixative in histology and pathology labs and as a hardening agent in the development of x-rays.

Healthcare workers who might be exposed to glutaraldehyde include the following:

  • hospital staff who work in areas with a cold sterilizing procedure that uses glutaraldehyde (for example, gastroenterology and cardiology departments)
  • hospital staff who work in operating rooms, dialysis departments, endoscopy units, and intensive care units where glutaraldehyde formulations are used in infection control procedures
  • central service (supply) workers who use glutaraldehyde as a sterilant
  • research technicians, researchers, and pharmacy personnel who either prepare the alkaline solutions or fix tissues in histology and pathology labs
  • laboratory technicians who sterilize benchtops with glutaraldehyde solutions
  • workers who develop x-rays

Exposure Methods

Workers can be exposed to glutaraldehyde by breathing it or by skin contact during the following procedures:

  • cold sterilization of instruments in endoscopy and surgical units
    • when glutaraldehyde solution is poured into or out of the sterilizing pans
    • when sterilized equipment is removed from the sterilizing pans
  • disinfection of histology/pathology laboratory tabletops
  • mixing and activation of various glutaraldehyde solutions
  • tissue fixation in histology labs
  • development of x-rays

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1. How can healthcare workers be exposed to glutaraldehyde?

a. Only through breathing it in
b. Through breathing or skin contact
c. Only if it contacts the skin
d. Healthcare workers aren’t exposed to this chemical

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health effects
Exposure to glutaraldehyde can cause several health effects.

Health Effects

Short-term (acute) effects: Contact with glutaraldehyde liquid and vapor can severely irritate the eyes, and at higher concentrations burns the skin. Breathing glutaraldehyde can irritate the nose, throat, and respiratory tract, causing coughing and wheezing, nausea, headaches, drowsiness, nosebleeds, and dizziness.

Long-term (chronic) effects: Glutaraldehyde is a sensitizer. This means some workers will become very sensitive to glutaraldehyde and have strong reactions if they are exposed to even small amounts. Workers may get sudden asthma attacks with difficult breathing, wheezing, coughing, and tightness in the chest. Prolonged exposure can cause a skin allergy and chronic eczema, and afterwards, exposure to small amounts produces severe itching and skin rashes. Glutaraldehyde has been implicated as a possible cause of occupational asthma.

2. Which of the following is listed as a long-term effect of glutaraldehyde exposure?

a. Nosebleeds
b. Dizziness
c. Sudden asthma attacks
d. Headaches

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Possible Solutions

solutions
Workers can protect themselves from potential health risks of glutaraldehyde.

Workers can protect themselves from potential health risks of glutaraldehyde by using the following control methods and work practices:

  • Use local exhaust ventilation (capture velocity of at least 100 feet per minute) and at least 10 room air exchanges per hour.
  • Keep glutaraldehyde baths under a fume hood where possible.
  • Use only enough glutaraldehyde to perform the required disinfecting procedure.
  • Wash gloved hands after handling glutaraldehyde.
  • Wear goggles and face shields when handling glutaraldehyde.
  • Seal or cover all containers holding glutaraldehyde solutions.
  • Store glutaraldehyde in closed containers in well ventilated areas. Air-tight containers are available. Post signs to remind staff to replace lids after using product.
  • Attend training classes in safety awareness about use of and exposure to glutaraldehyde.

3. How can healthcare workers protect themselves from glutaraldehyde exposure?

a. PPE is not required
b. A fume hood is not necessary
c. Do not wear gloves
d. Wash gloved hands after exposure

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Hierarchy of Controls

hierarchy of controls
Workers can be protected from exposures to glutaraldehyde by using hierarchy of controls.

Workers can be protected from exposures to glutaraldehyde through engineering controls, administrative controls, and personal protective equipment.

  • Engineering Controls: Engineering controls include biological safety cabinets (BSC), compounding aseptic containment isolators, closed system transfer devices, and needleless systems. Engineering controls are the most effective way to control exposure to hazardous chemicals by preventing exposure from occurring.
  • Administrative Controls: Administrative controls include implementing work practices, management policies, and training programs to reduce worker risk. A medical monitoring program serves as a form of secondary prevention by identifying indicators of exposure or early disease.
  • Personal Protective Equipment: Employers are required to provide appropriate PPE, such as gloves, goggles, and splash aprons when employees are handling hazardous chemicals. [29 CFR 1910.132] PPE is the least effective control method because it relies on employee behaviors to prevent exposure.

Engineering Controls

The main goal of engineering controls is to keep glutaraldehyde vapor from entering the workroom and the employee’s breathing zone by containing and removing it at the source of release. The primary sources of employee exposure to glutaraldehyde during disinfection/sterilant activities include:

  • pouring glutaraldehyde solutions into container systems
  • opening soaking basins or reservoirs
  • handling instruments containing residual glutaraldehyde

Engineering controls tailored for these exposure sources include ventilation, both general exhaust ventilation and local exhaust systems (such as laboratory chemical hoods), process automation, and isolation (e.g., basins with tightfitting covers, dedicated centralized storage and use areas).

4. Which of the following is considered the most effective way to control exposure to hazardous chemicals by preventing exposure from occurring?

a. PPE
b. Engineering controls
c. Administrative controls
d. Removal of substance

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Personal Protective Equipment (PPE)

PPE
Employers must require employees to use appropriate hand protection when employees' hands are exposed to glutaraldehyde.
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Employers must select and require employees to use appropriate hand protection when employees' hands are exposed to potential skin absorption of substances such as glutaraldehyde (29 CFR 1910.138).

Use appropriate PPE covered under [29 CFR 1910.132(a)] including:

  • Use gloves and aprons made of nitrile or butyl rubber (latex gloves do not provide adequate protection).
  • Do not use latex surgical exam gloves for skin protection against glutaraldehyde, except in situations where only short-term, incidental contact is expected.
  • Wear lab coats, aprons, or gowns made of appropriate materials such as polypropylene to provide additional protection.
  • For shorter exposures, you can use gloves made of polyethylene. Do not use Neoprene and PVC gloves because they do not provide adequate protection against glutaraldehyde and may actually absorb it.
  • Wear splash-proof goggles and/or full-face shields when working with glutaraldehyde to protect eyes (29 CFR 1910.133).
    • Suitable emergency eyewash equipment must be immediately available for quick drenching or flushing of the eyes (for at least 15 minutes) in all glutaraldehyde usage locations. It is recommended that emergency eyewash units be accessible and located within a 10 second travel time of all affected areas.

5. Brent was disinfecting the x-ray machine with glutaraldehyde when the chemical splashed in his face. How long should he flush his eyes?

a. 5 minutes
b. 10 minutes
c. At least 15 minutes
d. Until his eyes don’t sting

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work practice controls
Use eye wash fountains and emergency showers if there is skin contact with glutaraldehyde.
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Administrative Work Practice Controls

Poor work practices can contribute significantly to an employee’s glutaraldehyde exposure. The health care facility should evaluate each glutaraldehyde-using operation and observe employees’ work practices to determine all potential sources of exposure. Developing procedures for safe work practices may be useful for training and communication purposes. These procedures should emphasize prevention of employee contact with glutaraldehyde solution or vapors. Only trained, designated personnel should be responsible for handling glutaraldehyde.

Here are some more work practice controls to help protect healthcare workers:

  • Provide eye wash fountains for immediate emergency use. [29 CFR 1910.151(c)]
    • Use eye wash fountains and emergency showers if there is skin contact with glutaraldehyde. Flush area with water for at least 15 minutes to remove chemical.
    • Change into clean clothes if clothing becomes contaminated.
  • Clean up spills immediately.
  • Do not eat, drink, or smoke in any area where glutaraldehyde is handled or stored.
  • Use a vacuum or wet method to reduce dust while cleaning up pure glutaraldehyde. Do not dry sweep.
  • Use less toxic products if feasible and available, or other processes for sterilization.
  • Automate the transfer of pure glutaraldehyde or pump liquid glutaraldehyde from drums or other storage containers to appropriate containers and operations, avoiding exposure to glutaraldehyde by keeping it in a contained process.

Case Report

Several nurses were working in an area where glutaraldehyde was stored in 1-liter baths on countertops and was used to disinfect bronchoscopes. They complained of hives, chest tightness, and watery eyes. Evaluation of the work area indicated that there was a separate (independent) recirculating ventilation system designed to provide 10% outside air. The nurses used no personal protective equipment (such as gloves). Measures were then taken to reduce exposures. These included changing glutaraldehyde containers to air-tight models, using appropriate gloves, and installing local ventilation hoods for glutaraldehyde stations. One month after the implementation of these measures, the nurses’ symptoms subsided [Charney 1991].

6. Who should be responsible for handling glutaraldehyde in the healthcare setting?

a. Trained and designated personnel
b. Management
c. Untrained employees
d. Competent person

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Local Exhaust Ventilation

ventilation
it is recommended that local exhaust ventilation be installed at the point of release of glutaraldehyde vapors.

ANSI/AAMI ST58 recommends that local exhaust ventilation also be installed at the point of release of glutaraldehyde vapors. The health care facility must ensure that the ventilation system is operating properly and is not obstructed or disturbed by drafts from sources such as fans, supply air diffusers, open windows and doors, and heavily traveled aisles. Local exhaust ventilation located at the level of vapor discharge is the preferred method of reducing glutaraldehyde vapor concentrations because it captures and removes vapor at the source before it can escape into the general work environment. Local exhaust ventilation systems for glutaraldehyde-based activities may include a local exhaust hood (such as a laboratory fume hood) and the associated ductwork and fan; or, a self-contained, freestanding, recirculating exhaust ventilation system (i.e., ductless fume hood).

Transfer Procedures

Reducing the release of glutaraldehyde vapor during transfer operations can be accomplished by the use of automated and enclosed equipment. For example, the transfer of glutaraldehyde from drums into process containers can be automated using pumps and closed transfer lines. Such automated equipment can help employees avoid glutaraldehyde exposure.

Automated Disinfection

The use of automated processing equipment to disinfect instruments can significantly reduce the glutaraldehyde exposures of employees performing disinfection procedures, as well as of other employees and non-employees in the vicinity. However, exposure is still possible, especially when poor work practices are used, or the equipment is poorly designed or improperly installed.

7. _______ can significantly reduce the glutaraldehyde exposures of employees performing disinfecting procedures.

a. Use of automated processing equipment
b. Decrease overall use
c. Decrease toxicity of glutaraldehyde
d. Poorly designed equipment

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Transportation and Storage of Glutaraldehyde

Storage
It is important to properly store and transport glutaraldehyde.
  • Transport glutaraldehyde solution only in closed containers with tight-fitting lids to minimize the potential for spills.
  • Designate centralized locations for using glutaraldehyde to reduce the potential for spills during transport.
  • Store unused glutaraldehyde solutions in tightly covered containers in a cool, secured, and properly labeled area.
  • Dispose of outdated solutions properly.

Use and Handling Procedures

  • When transferring glutaraldehyde to soaking basins and reservoirs, pour the liquid carefully and minimize splashing. Minimize splashing and agitation of glutaraldehyde solutions by careful placement and removal of instruments (NSW Health Department, 1993).
  • When transferring and pouring glutaraldehyde solutions, use safety nozzles designed with a flexible spout and shut-off valve, when available.
  • Keep covers on soaking basins closed as much as possible and use appropriately sized, tight-fitting lids for containers. Use appropriately sized soaking basins designed to minimize surface area (e.g., narrow, deep container) (ANSI/AAMI, 1996).
  • Keep automatic washer doors closed at all times except when necessary for loading or unloading of instruments to be disinfected.
  • Rinse soaked instruments under gently running water as close as possible to the soaking tray or washer to contain solution and minimize dripping on other surfaces (NSW Health Department, 1993).
  • Use adequate ventilation if using compressed air to dry instruments rinsed with ethyl or isopropyl alcohol rinses.
  • Use glutaraldehyde only in designated areas where traffic and ventilation can be controlled.
  • Ensure that the ventilation system is operating prior to handling glutaraldehyde solutions.
  • Close workroom doors to ensure the effectiveness of any available general dilution ventilation
  • Do not store food, eat, drink, smoke, or apply cosmetics in any area where glutaraldehyde is stored or used.
  • Clean up small glutaraldehyde spills and releases immediately. In the case of large spills or delayed response, employees should be encouraged to close doors, alert others and activate the HazMat spill response team.

8. How should unused glutaraldehyde be stored?

a. Tightly covered containers in cool area
b. Uncovered in an open space
c. Covered in a warm area
d. Uncovered in a warm area

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Employee Training

training
Employees should be trained on their facilities hazard communication program.
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All employers with glutaraldehyde solutions or other hazardous chemicals in their healthcare facility must develop and implement a written hazard communication program that meets the requirements of OSHA’s Hazard Communication standard, 29 CFR 1910.1200.

Such a program must include provisions for employee access to safety data sheets (SDSs), container labeling, and training for all potentially exposed individuals. Employees who use, handle, or may have potential exposure (e.g., accidental or possible) to glutaraldehyde solutions must be provided information and training prior to their initial work assignment.

Employees must be provided information regarding the requirements of the Hazard Communication standard; operations in their work area where glutaraldehyde solutions are present; and the location and availability of the written hazard communication program and safety data sheets (SDSs). Employee training must include, at a minimum, the following elements (29 CFR 1910.1200):

  • methods and observations that may be used to detect the presence or release of glutaraldehyde in the workplace
  • the physical and health hazards of glutaraldehyde
  • the measures employees can take to protect themselves, including specific procedures the employer has implemented to protect employees from exposure to glutaraldehyde, such as appropriate work practices, emergency procedures, and personal protective equipment
  • an explanation of the safety data sheet, the employer’s labeling system, and how employees can obtain and use the appropriate hazard information

9. What should be included in a written hazardous communication program?

a. List of employees who are allergic to the chemical
b. Fact sheets
c. SDSs, container labeling, and training
d. Names of employees

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