A program for reducing institutional risk when releasing potentially hazardous assets.

Introduction

Modern academic and research activities necessitate the use of a wide variety of hazardous substances and agents. The environmental health protection programs which exist within these institutions usually include monitoring for occupational exposures and environmental discharges to assist in maintaining a safe and healthy setting for students, faculty, staff, and the surrounding community. Discharges of potentially hazardous materials to the environment may include airborne releases through local exhaust ventilation, water discharges via laboratory or clinic sinks, vacuum and drain lines, and waste discharges in the form of designated radioactive, biological, or hazardous chemical waste materials. Another significant source of environmental discharge is represented by the release of potentially hazardous institutional assets through auctions, donations, or transfers [ILLUSTRATION FOR FIGURE 1 OMITTED]. Within this context, institutional assets are defined as any used or surplus equipment or supplies exhibiting a residual value, and include items such as laboratory apparatus and maintenance equipment. Institutional assets may possess overtly hazardous characteristics, such as sources of laser or x-ray radiation, or have hazardous characteristics enhanced or added by the institution, such as the removal of a safety switch or contamination with infectious agents. Such assets represent a source of personal harm and institutional liability when released as surplus through auction or donation (1). Examples of common potentially hazardous institutional assets are listed in Table 1.

Since institutional assets can be released in a variety of forms and configurations, environmental health protection programs may not have systems in place to effectively monitor and control this route of environmental discharge. To control the release of potentially hazardous assets, a program was developed and implemented at the University of Texas Houston Health Science Center which incorporates the comprehensive waste tracking principles established by the Resource Conservation Recovery Act (RCRA) for hazardous waste, and the due diligence investigation, mitigation, and disclosure principles applied in the environmental site assessment process for real estate transactions (2,3).

Facility and Program Description

The University of Texas Houston Health Science Center (UTHHSC) is a major research and academic institution located within the Texas Medical Center complex. Established in 1972, the UTHHSC consists of the Dental Branch, Graduate School of Biomedical Sciences, School of Public Health, Medical School, School of Nursing, and the School of Allied Health Sciences. To maintain a safe and healthy setting for all students, employees, faculty, staff and the surrounding community, the UTHHSC operates the Environmental Health and Safety Department, comprised of divisions for radiation safety, occupational hygiene & safety, and environmental protection. The primary function of the Environmental Protection Division is to ensure that all materials leaving the institution are in compliance with existing and anticipated environmental rules and regulations, and that such releases are performed in the most cost effective means possible. The scope of this charge includes the management and oversight of all designated hazardous waste materials, sanitary sewer releases, air effluents and, most recently, the release of potentially hazardous institutional assets. The Environmental Protection Division is responsible for the creation, implementation, and maintenance of the Comprehensive Asset Tracking, Evaluation, and Release program, subsequently assigned the acronym "CATER."

Prior to the creation of the CATER program, no systematic mechanism existed within the institution to address the release of potentially hazardous assets. Equipment overtly identifiable as potentially hazardous, such as biosafety cabinets and centrifuges, was previously subjected to review on an ad hoc basis. Equipment not readily identifiable as potentially hazardous was available for possible release without any prior formal review or disclosure to recipients.

With no comprehensive tracking and surveillance program in place, employees handling or transporting assets were possibly at risk of being exposed to potential hazards. The uncoordinated movement of assets resulted in the performance of remedial decontamination or abatement procedures. The potential for significant institutional liability also existed if assets containing or exhibiting hazards were released without disclosure to recipients. In recognition of these shortcomings, three primary objectives were established for the CATER Program: (1) protect the health and safety of persons handling assets, (2) provide a mechanism for the efficient mitigation of recognized hazards, and (3) disclose any remaining recognized potential hazards to receiving parties.

Classification of Assets

The CATER Program is based on a general classification scheme that encompasses all institutional assets. Assets are classified as either non-hazardous, inherently hazardous, or having a hazardous characteristic added. Assets bearing no overt hazardous characteristics, such as undamaged surplus desks, chairs and tables, are classified as "non-hazardous" and the processing of these items is not significantly impacted by the CATER program. Assets containing uncontrolled energy sources or potentially hazardous materials such as asbestos or polychlorinated biphenyls (PCB's) are classified as "inherently hazardous" and are identified for mitigation and documented disclosure. Items potentially contaminated with hazardous substances or altered in some potentially harmful manner while in the possession of the institution are classified as "hazardous characteristic added." Examples of such assets include laboratory exhaust hoods used to conduct experiments with hazardous chemicals and water baths used in conjunction with potentially infectious agents. Hazardous characteristic added assets are also identified for remediation and disclosure.

Asset Tracking and Processing

To initiate the tracking and systematic evaluation of assets to be released from the institution, the CATER program was designed to engage when a researcher or clinician placed a request for the removal or transfer of an asset. Assets identified for removal are listed on simple equipment transfer request forms which are submitted to the university's Capital Assets Management group. Upon receipt of the form, a representative screens the list for any suspected potentially hazardous assets and, if any are noted, forwards the list to the Environmental Protection Division. Ongoing in-service training sessions are provided to the Capital Assets Management staff regarding the recognition of potentially hazardous assets, along with a constantly updated list of examples, as shown in Table 1. Representatives are also encouraged to make conservative decisions regarding asset classification, so that the chance of missing a potentially hazardous asset (e.g., a false negative) is reduced.

After receiving the list of identified potentially hazardous assets, an Environmental Protection Division staff member inspects each item and once it is confirmed as potentially hazardous, ensures that Section I of a CATER program form is properly completed by the generator of the asset [ILLUSTRATION FOR FIGURE 2 OMITTED]. Then, by reviewing the information provided, the Environmental Protection Division staff member determines the most appropriate disposition for the asset. Personnel assigned the responsibility of moving institutional assets have been instructed not to move any item identified as potentially hazardous without the acknowledgment and approval of the Environmental Protection Division which is reflected in Section II of the form. Subsequent actions are dependent upon the classification assigned.

Assets Designated as Inherently Hazardous

Decisions regarding the possible mitigation of any inherently hazardous characteristics are based on the existing local, state, and national rules and regulations governing the disposal of hazardous substances, the relative worth of the equipment, and the potential liability present if the hazard is not mitigated. In consideration of these factors, the asset's hazardous characteristic is then either mitigated in some manner by the Environmental Protection Division staff or left unabated and acknowledged on the CATER form in Section II. Once Section II of the form is completed, the asset can be relocated. When a person eventually assumes the asset through an auction or donation, they are asked to sign Section III of the form, signifying their acknowledgment of the previous or persistent potentially hazardous characteristic that is inherent to the item. The sequential steps taken for the disposition of assets designated as inherently hazardous are outlined in Figure 3. Examples of the most common inherently hazardous characteristics mitigated to date include the collection of contaminated oils and coolants, and the removal of small radioactive counting standards.

Assets Designated as Hazardous Characteristic Added

Assets designated as hazardous characteristic added undergo a survey by an Environmental Protection Division staff member for possible physical hazards or possible chemical, radiological, or biological contamination. The type of survey performed is based on the disclosure information provided in Section I of the CATER form, which is obtained from the asset generator. A physical inspection of an asset typically includes verification that any safety stops or guards are in place and that any associated interlocks function properly. Most chemical surveys are limited to visual inspections and the application of specific indicator reagents when the presence of certain substances is suspected, such as perchloric acid. Radiological surveys usually consist of monitoring with appropriate portable survey instrumentation and wipe testing. Radiation-producing devices such as x-ray machines and electron microscopes, are usually subjected only to physical evaluations and additional tracking requirements for regulatory authorities. For devices possibly containing biological contaminants, such as biosafety cabinets, the principal investigator is asked to provide documentation of appropriate systemic disinfection, such as circulation of paraformaldehyde. For equipment and devices that could be potentially contaminated, such as storage racks and water baths, a visual survey for gross contaminants such as blood is normally performed, followed by general cleaning with disinfectants approved for identified agents, such as dilutions of sodium hypochlorite for the inactivation of the hepatitis B and human immunodeficiency virus (HIV) (4).

After each asset is satisfactorily surveyed, Section II of the CATER form is completed and the asset is available for relocation and eventual release. Equipment that cannot be decontaminated or adequately modified to mitigate recognized hazards are identified as a disclosure in Section II of the CATER form [ILLUSTRATION FOR FIGURE 2 OMITTED]. The sequential steps taken for the disposition of assets designated as hazardous characteristic added are outlined in Figure 4.

Results

Since the activity at academic and research institutions ebbs and flows with the academic calendar, the results of the CATER program were compared to similar calendar quarters. In the first three months of implementation, the CATER program resulted in 69 assets being evaluated for potentially hazardous characteristics (Table 2). This represented a 116% increase in the number of assets evaluated as compared to the same calendar period in the previous year. Using the same time periods for comparison, a 94% increase in the number of potentially hazardous assets were mitigated in some manner as a result of the program. An additional 17 assets were released with full recognized disclosures.

TABLE 2
Institutional Assets Evaluated in First Fiscal Year Calendar
Quarters of 1995 and 1996

Year      Number identified as        Number released
          potentially hazardous       with disclosure

1995               32                        4
1996               69                       17

Discussion

In just a short period, the CATER program resulted in a significant improvement in the surveillance and control of potentially hazardous asset releases. Additionally, the program helped reduce unnecessary exposures to potential hazards by individuals handling assets, and effectively disclosed remaining recognized hazards to recipients. However, several evolutionary difficulties were encountered, and the lessons learned were very useful in refining the program.

During the early implementation phase of the program, several essential needs were quickly recognized. The provision of continual training to the Capital Assets Management group was found to be necessary due to employee turnover and the vast array of assets encountered in the institutional environment. Feedback regarding potentially hazardous assets that may have been overlooked or not recognized was provided in a positive manner and found to be very useful by reducing recurrence. Allotting time to educate the institutional asset generators (e.g., researchers, clinicians, and their support personnel) was also found to be very beneficial. Within the initial three months of the program, a basic awareness and understanding of the program was instilled in most of the major asset generators through brief personal discussions, informational pamphlets, and short seminars.

Another unforeseen difficulty stemmed from the generation of multiple versions of the same form, as facilities were being relocated and hurriedly added other items to be moved. In some instances, up to five different versions of the same equipment removal request form were being mailed or transmitted by facsimile, leading to tremendous confusion. The problem was eventually addressed through education and the issuance and attachment of a single CATER form to each asset or group of assets to be moved. The incidence of multiple request forms has subsided, but has not been totally eliminated.

The initial estimate of workload for this endeavor was about 0.2 full time equivalents (FTE's) of an Environmental Protection Division staff member's time. Although this estimate is still considered to be relatively accurate, the difficulties experienced in the early stages of the program resulted in a disproportionate amount of time being expended on asset tracking. With the knowledge gained from experience, the amount of time required to perpetuate the program is expected to remain at 0.2 FTE.

With the CATER program fully instituted, emphasis is now being placed on continual program monitoring and preventive measures during asset procurement. The ability to review assets for potential hazards prior to purchase is expected to greatly enhance the program's overall effectiveness by eliminatingmany potential risks before becoming property of the institution. Efforts are also underway to merge the program into the institution's Capital Asset Management computer system which would greatly aid in locating and identifying potentially hazardous assets while in the possession of the institution. At present, only a simple commercially available spreadsheet program is being used by the Environmental Protection Division to account for items reviewed and released. An opportunity also exists to use the program to facilitate documented safety reviews of equipment prior to servicing. Presently, this responsibility rests with the principal investigators and the servicing company, and the need for more formalized oversight of these activities is expected to be easily accommodated by the CATER program.

TABLE 1

Examples of Assets Classified as Inherently Hazardous and Hazardous Characteristic Added

Inherently Hazardous Characteristic

Asbestos tiles, roofing, and insulation Hazardous chemicals Mechanical equipment Electrical equipment Light ballasts Smoke detectors Gas chromatographs Liquid scintillation counters Gamma counters Furnaces Medical instruments Compressed gas cylinders Refrigeration equipment

Hazardous Characteristic Added

Freezers Refrigerators Centrifuges Chemical fume hoods Biological safety cabinets Modified equipment Incubators Laboratory ovens Cell harvesters Vacuum systems Water baths Gel electrophoresis units Microplate readers Blenders/mixers Pumps Storage cabinets Autoclaves Titrators

FIGURE 3

Disposition of Assets Classified as Inherently Hazardous

1. Request for asset transfer submitted to Capital Assets Management (CAM)

2. Asset identified as possibly inherently hazardous by CAM

3. CAM informs Environmental Protection Division (EPD)

4. EPD reviews asset, confirms classification and initiates CATER form

5. EPD mitigates hazard if possible and practical and documents actions

6. EPD authorizes asset transfer and asset is moved

7. Asset is released from institution with CATER form

FIGURE 4

Disposition of Assets Classified as Hazardous Characteristic Added

1. Request for asset transfer submitted to Capital Assets Management (CAM)

2. Asset identified as possible hazardous characteristic added by CAM

3. CAM informs Environmental Protection Division (EPD)

4. EPD reviews asset, confirms classification and initiates CATER form

5. EPD mitigates hazard if possible and practical and documents actions

6. EPD authorizes asset transfer and asset is moved

7. Asset is released from institution with CATER form

Did you know...

Although 70 percent of the Earth's surface is water, 97 percent of that is in oceans and estuaries and not available for drinking or irrigation, and much of the remaining 3 percent is trapped in glacial ice.

(Source: Water Quality, March 1996, National Resources Conservation Service)

REFERENCES

1. Brauer, R.L. (1990), Safety and Health for Engineers, Van Nostrand Reinhold, NY.

2. U.S. Environmental Protection Agency (1992), Code of Federal Regulations, Title 40, Part 261, U.S. Government Printing Office, Washington, D.C.

3. American Society for Testing and Materials (1994), ASTM Standards on Environmental Site Assessments for Commercial Real Estate, ASTM, Philadelphia, Pa.

4. National Research Council (1989), Biosafety in the Laboratory, Prudent Practices for the Handling and Disposal of Infectious Materials, National Academy Press, Washington, D.C.

Corresponding author: Richard G. Costello, Environmental Health and Safety, University of Texas Houston Health Science Center, 1851 Crosspoint Drive, OCB 2.190, Houston, TX 77025.