POLICY
It is the policy of UNC-CH Clinical Facilities and UNC Hospitals that all new employees be protected from unnecessary exposure to glutaraldehyde in the course of performing their jobs. It is recommended by the American Conference of Governmental Industrial Hygienists (ACGIH) that personal exposure to glutaraldehyde vapor in the workplace not exceed the concentration of 0.05 ppm (ceiling limit) during the work period.

PURPOSE
Glutaraldehyde’s effectiveness as a chemical sterilant was first recognized in the early 1960’s when the healthcare industry searched for a safer substitute for formaldehyde, which has carcinogenic properties. However, glutaraldehyde is an irritant to the skin and mucous membranes and can cause allergic contact dermatitis.

ENGINEERING
The areas using glutaraldehyde are to be kept under negative pressure to avoid transmigration of the chemical vapor and its odor. Adequate dilution ventilation (ideally at least six air changes per hour vented to the outside, where feasible) must be maintained to protect workers from glutaraldehyde exposure. Glutaraldehyde baths are to be covered.

PERSONAL PROTECTION
All skin contact with glutaraldehyde must be avoided. When using latex rubber gloves, the user is to double glove or change single gloves frequently (i.e., after 10 minutes of exposure). Alternatively, butyl rubber or nitrile rubber gloves may be worn when there is anticipated exposure or skin contact. This chemical will pass readily through unprotected skin. If splash or splatter is anticipated, additional personal protective equipment shall be worn to preclude exposure to the mucous membranes of the eyes, nose and mouth.

INDUSTRIAL HYGIENE
Air monitoring, using acceptable methodologies with the proper detection limits, shall be performed in areas using glutaraldehyde. The National Institute for Occupational Safety and Health (NIOSH) manual of analytical methods will be consulted for details. UNC-CH Environment, Health and Safety and the Hospitals' Environmental Health and Safety Department will conduct air monitoring at the specified intervals.
Monitoring shall be conducted:

1. Initially to determine glutaraldehyde exposure levels,
2. After equipment changes or revised work practices, and
3. In response to worker complaints.
4. All results of air monitoring shall be given to each department and kept on file in the UNC-CH Environment, Health and Safety Department.

WORK PRACTICES AND TRAINING
Safe work practices for glutaraldehyde include:

1. Reviewing work practices periodically in all areas where glutaraldehyde is used in order to prevent overexposure.
2. Communication between all areas of the hospital that use glutaraldehyde to provide useful ideas for reducing exposure. Meetings may be called at the discretion of the Departmental Safety Coordinators.
3. Minimizing agitation of the chemical and keeping lids on the containers.
4. The Departmental Safety Coordinators in each department with the assistance of the UNC-CH Environmental Health and Safety Department will train and educate new and current employees regarding safe work practices which are essential in reducing and/or eliminating chemical exposures. All new and current employees shall be instructed about the potential hazards associated with glutaraldehyde, proper use of protective clothing, safe work practices, avoidance of exposure in a confined space, and personal hygiene concerns. This shall include education regarding signs and symptoms associated with overexposure to glutaraldehyde.

IMPLEMENTATION
It is the responsibility of the Departmental Safety Coordinators in each department and the UNC-CH Environmental Health and Safety Department to implement this policy.