Friday, November 28, 2014

Sock Puppet Safety: Donning and Doffing PPE for Ebola Virus Disease (EVD) Infection Prevention

The Centers for Disease Control and Prevention (CDC) released improved procedures for donning (putting on) and doffing (taking off) personal protective equipment (PPE) for healthcare workers caring for a patient with suspected or confirmed Ebola Virus Disease (EVD). They have also released some pretty comprehensive video training to show the donning and doffing procedures.

These procedures are explained using two different types of respirators depending on the respirators the hospital may have available:
Image #1: PAPR, image courtesy of the CDC (
Image #2: N95 Respirator, image courtesy of the CDC (
  • Powered Air Purifying Respirator (PAPR): A PAPR with a full face shield, helmet, or headpiece. Any reusable helmet or headpiece must be covered with a single-use (disposable) hood that extends to the shoulders and fully covers the neck and is compatible with the selected PAPR. See Image #1. 
  • N95 Respirator: Single-use (disposable) N95 respirator in combination with single-use (disposable) surgical hood extending to shoulders and single-use (disposable) full face shield. See Image #2.

The CDC reminds hospitals that: "If a NIOSH-certified PAPR and a NIOSH-certified fit-tested disposable N95 respirator is used in facility protocols, [the hospital must] ensure compliance with all elements of the OSHA Respiratory Protection Standard, 29 CFR 1910.134, including fit testing, medical evaluation, and training of the healthcare worker." Since flu season is already upon us, and many hospitals have already started their annual fit testing requirement for use of N95 respirators, this should not be an increased burden on the hospital. 

I watched some of the CDC/Johns Hopkins Medicine videos for EVD PPE donning and doffing and quickly realized that many healthcare workers would start to "zone out" during this web-based video training. This lack of attention during training will be a challenge for hospital administrators, since most hospitals do not have the resources (time or personnel) available to do repeated hands-on training activities. The CDC used to have a poster of the steps for donning and doffing PPE, but it has not been re-released since the new, more comprehensive guidelines were published on October 20, 2014. 

So I decided to make my own PPE posters starring my team at Sock Puppet Safety (more info on that new project later). These posters were designed using the October 2014 CDC guidelines, with a handmade puppet with removable PPE. That's one of the other challenges that hospitals are facing - how to train healthcare workers in donning and doffing without using up all their supplies. Many manufacturers have the CDC required PPE on backorder and many hospitals only have enough to last a few days to care for one patient.

This Infectious Disease PPE Training Poster is brought to you by Sock Puppet Safety - starring Dr. Plurdistein (trained observer) and Peter (shown in proper PPE). 
(As a side note, Peter is named after Peter Piot, the "virus detective" who first unraveled the mystery of Ebola in 1976.)

Here's the front side of the DONNING poster.

Donning PPE (N95 Respirator option) for Ebola Virus Disease, front side. 

Here's the back side of the DONNING poster.
Donning PPE (N95 Respirator option) for Ebola Virus Disease, back side.

Here's the front side of the DOFFING poster.
Doffing PPE (N95 Respirator option) for Ebola Virus Disease, front side.

And, finally, here's the back side of the DOFFING poster.

Doffing PPE (N95 Respirator option) for Ebola Virus Disease, back side.

The donning and doffing protocols are particularly important to reduce the risk of infection of the healthcare worker providing care to the suspected or confirmed EVD patient. 

The waste associated with the EVD patient must be carefully controlled and the donning and doffing procedures are important to reduce the risk of transmission via direct contact with blood and bodily fluids.

The picture above shows EVD as the blue microbes in the mock DOT Category A waste container - these blue microbes are actually Penicillium (Giant Microbes) since they're all I had on hand at the time, but you get the idea. The Ebola Giant Microbe was sold out and won't ship until 12-10-2014.
When a healthcare worker leaves an EVD patient room, they are likely to be covered in Ebola virus from splashes of blood and bodily fluids.
If the donning and doffing procedures are carefully followed, the EVD potential exposure is significantly reduced.
If donning and doffing procedures are not carefully followed, unintentional exposure can happen. In the case of EVD, sharing is NOT caring. 

And yes, those are static-reducing laundry balls that have been broken in half by my overeager Alaskan Malamute. The laundry balls make great fake microbes.

If, for some weird reason, you like the posters and want to use them for training or entertainment purposes, send me an email and I'll be happy to share them. The posters are higher resolution than the images in this blog post.

Happy start to the holiday season from The Industrious Hygienist and her team at Sock Puppet Safety!
Meet the team at Sock Puppet Safety - you'll be seeing more of them in the next few months.

Saturday, November 15, 2014

DIY Safety Data Sheet Revision in Three Easy Steps

Manufacturers and importers of hazardous chemicals have until June 1, 2015 to update their labels and material safety data sheets to be in compliance with the Hazard Communication Standard (HCS) final rule promulgated by the Occupational Safety and Health Administration (OSHA). While you’re patiently waiting for manufacturers to conduct the revisions to labels and updating material safety data sheets to reflect the 16-section format required for Safety Data Sheets (SDS), you still have to train your employees in the new label elements and new SDS format.

OSHA has put together Quick Cards for sample labels and SDS, explaining the new requirements, but some employees and safety professionals may find it difficult to train employees without real, concrete examples. Many manufacturers and importers may also be moving slowly on their revisions due to the perceived difficulty of completing the revisions.

To assist safety professionals and industrial hygienists in their training, here’s some do-it-yourself (DIY) 3-step guidance on preparing your own labels and SDS.

Step 1: Review the requirements for SDS and labels.

First look at the OSHA sample label and list of the 16 required sections for an SDS. If you haven’t looked at your HCP lately, it’s also a good time to revise and update your program. OSHA provides guidance on establishing and maintaining your HCP in their “Small Entity Compliance Guide for Employers That Use Hazardous Chemicals.” 

Next, it might be helpful to review Annex 4 of the Globally Harmonized System for the Classification and Labelling of Chemicals (GHS), Third Revised Edition (2009). Annex 4 is entitled “Guidance on the Preparation of Safety Data Sheets (SDS)” and explains the purpose of each of the 16 sections in detail. 

Please note that OSHA cannot enforce the content of Sections 12 to 15 of the SDS, as these sections are enforced by other regulatory agencies like the U.S. Environmental Protection Agency (EPA) and U.S. Department of Transportation (DOT) that have not yet adopted GHS.

Step 2: Figure out the hazard classification and category of the substance or mixture.

This is the hardest part of SDS and label preparation – figuring out how to properly classify the substance or mixture. If you want to read through GHS Part 2: Physical Hazards and Part 3: Health Hazards to get an idea of the complexity of this task, you can, but you may find it overwhelming.

You’ll need some knowledge of toxicology and management of hazardous materials to complete this task. If you’re lucky, you’ll find a SDS already prepared by another manufacturer (usually with international capability who already has GHS-compliant SDS) that contains the hazard classification of the substance or mixture.

You have to assess if your chemical constitutes a physical hazard, a health hazard, or both. Some examples of physical and health hazards are included below.

Physical Hazard

Flammable Gases
Flammable Aerosols
Gases Under Pressure
Flammable Liquids
Self-Reactive Substances and Mixtures
Pyrophoric Solids
Oxidizing Liquids
Organic Peroxides
Corrosive to Metals

Health Hazard

Acute Toxicity
Skin Corrosion/Irritation
Serious Eye Damage/Eye Irritation
Respiratory or Skin Sensitization
Germ Cell Mutagenicity
Reproductive Toxicity
Specific Target Organ Toxicity – Single Exposure
Specific Target Organ Toxicity – Repeated Exposure
Aspiration Hazard

Physical Hazard: Here’s where the hazardous materials management knowledge will come in handy. You’ll want to find the upper and lower flammable limit/range of your chemical or mixture at standard pressure; understand whether you have a compressed gas, liquefied gas, refrigerated liquefied gas, or dissolved gas; know the flash point for your chemical or mixture; research the burning rate of your flammable solid; research the heat of decomposition; and know the corrosion rate or steel and/or aluminum.

Health Hazard: This is where knowledge of toxicology and ability to search various institutional databases will be useful.

Acute Toxicity: look up the various lethal doses for each anticipated exposure route (oral, inhalation, dermal, etc.). The LD50 indicates the lethal dose in 50% of test subjects (oral, dermal, and other routes) and the LC50 indicates the lethal concentration in 50% of test subjects (inhalation route).

Useful sources for health hazards:

  • National Institutes of Health ToxNet – Hazardous Substances Data Bank (HSDB): Look up the chemical(s) by Chemical Abstract Service (CAS) number or chemical name. This provides information on human health effects, emergency medical treatment, animal toxicity studies, environmental fate, chemical/physical properties, chemical safety and handling, and occupational exposure standards.
  • Centers for Disease Control and Prevention (CDC), National Institute for Occupational Safety and Health (NIOSH) Pocket Guide to Chemical Hazards: Look up the chemical(s) by CAS number of chemical name. This provides the synonyms and trade names, conversion rates, DOT Emergency Response Guide number, Immediately Dangerous to Life and Health (ILDH) concentration, recommended measurement methods, exposure limits, physical description, exposure routes, symptoms, incompatibilities and reactivities, personal protection, and first aid recommendations.
  • Registry of Toxic Effects of Chemical Substances (RTECS), linked from NIOSH Pocket Guide to Chemical Hazards: This provides skin and eye irritation data, mutation data, reproductive effects, and acute toxicity data. 
  • OSHA Occupational Chemical Database: This compiles information from the DOT Emergency Response Guidebook, NIOSH Pocket Guide to Chemical Hazards, and OSHA Chemical Sampling Information webpage.
  • Agency for Toxic Substances and Disease Registry (ATSDR) Toxic Substances Portal: Provides toxicological profiles, public health concerns, and health effects; search by CAS number of chemical name.
  • ATSDR Medical Management Guidelines: Use for basic chemical and exposure information, a summary of potential health effects (acute and chronic), routes of exposure, and incompatibilities.

Step 3: Start Writing the SDS.

Once you have the hazard classification for each chemical or mixture, the rest of the SDS is mostly data gathering.

Section 1 – Identification

Include the product identifier (as used on the label), other means of identification, recommended use, supplier’s details, and emergency phone number.

Section 2 – Hazard Identification

Using the hazard classification, go to Annex 3 for the “Codification of Hazard Statements, Codification and Use of Precautionary Statements and Examples of Precautionary Pictograms.” Look through the listed Hazard Statement codes for physical hazards in Table A3.1.1 and it will tell you what hazard statements and pictograms belong on the SDS and label based on the hazard class. There are also tables for the various Precautionary Statements (prevention, response, storage and disposal). Or, to make it simpler, on page 336 of Annex 3, there is a series of tables encompassing much of the rest of the Annex showing the required signal word, hazard statement, symbol, and precautionary statement(s) based on the hazard classification and associated hazard category. It makes Section 2 very simple to accomplish.

Pictograms can be downloaded as .JPG files from OSHA here.

Health Hazard Pictogram

Section 3 – Composition/Information on Ingredients

This should be present on the original material safety data sheet you are converting to SDS format.

Section 4 – First Aid Measures

This information can be obtained from the NIOSH Pocket Guide to Chemical Hazards, DOT Emergency Response Guidebook, ATSDR Medical Management Guidelines, or ToxNet HSDB. Provide first aid measures for each anticipated route of entry (eye contact, skin contact, inhalation or breathing, ingestion or swallowed).

For information about the most important symptoms (acute and delayed), and indication of immediate medical attention and special treatment needed, the sources listed above for researching health hazards will be useful.

Section 5 – Fire-Fighting Measures

Information from this section can be easily obtained from the NIOSH Pocket Guide to Chemical Hazards and DOT Emergency Response Guidebook, by finding the Guide number that matches the chemical(s) on your SDS and reviewing the emergency response fire information. Make sure to include the ILDH concentration from the NIOSH Pocket Guide to Chemical Hazards, as applicable.

Section 6 – Accidental Release Measures

Information from this section can be easily obtained from the DOT Emergency Response Guidebook, by finding the Guide number that matches the chemical(s) on your SDS and reviewing the emergency response spill or leak information.

Section 7 – Handling and Storage

The precautions for safe handling and conditions for safe storage, including any incompatibilities, is retrievable from the OSHA Occupational Chemical Database, ToxNet HSDB, and NIOSH Pocket Guide to Chemical Hazards. Make sure to include information on whether a safety eye wash and/or shower is required when using this chemical.

Section 8 – Exposure Controls/Personal Protection

Include relevant exposure limits here. It is best practice to include the following for each chemical, as applicable:

This section should also include information if the chemical(s) is a carcinogen, and include engineering controls and personal protective equipment (PPE) for the anticipated routes of entry (eye/face protection, skin protection, respiratory protection).

Useful resources for determining the proper PPE are included below:

Section 9 – Physical and Chemical Properties

This should be present on the original material safety data sheet you are converting to SDS format. Alternatively, the information on each chemical(s) may be able to be obtained from the ToxNet HSDB and the International Chemical Safety Cards by the CDC. The International Chemical Safety Cards can be searched by CAS number, chemical name, RTECS number, and UN number.

Section 10 – Stability and Reactivity

Your research using the ToxNet HSDB, OSHA Occupational Chemical Database, and NIOSH Pocket Guide to Chemical Hazards will have identified the stability and reactivity of the chemical(s) you are researching.

Section 11 – Toxicological Information

Your research using the ToxNet HSDB and ATSDR Toxic Substances Portal will have given you much of this information. Make sure to verify the carcinogenicity from ACGIH, International Agency for Research on Cancer (IARC), EPA Integrated Risk Information System, National Toxicology Program (NTP), and OSHA.

Section 12 – Ecological Information, Section 13 – Disposal Consideration, Section 14 – Transport Information, and Section 15 – Regulatory Information

These sections are not required by OSHA at this time; you can include the information or state “This section is not required according to 29 CFR 1910.1200(g)(2)” if your SDS is being developed for internal use only.

Section 16 – Other Information

This section can include the date of preparation of the last revision of the SDS, literature references and sources for data used to compile information for the SDS, a key for abbreviations, National Fire Protection Association (NFPA) and Hazardous Materials Information System (HMIS) ratings, and any internal “safety notices” or legalese you’re required to place at the end of every SDS by your corporate counsel.

Completion and Review

Request that a colleague review the SDS for typos and accuracy. Make sure the hazard statements and precautionary statements are correct for the hazard classification and associated category you have selected for the chemical(s) on the SDS. Double check CAS numbers and chemical concentrations.

Once the SDS revision is complete, if you have a need for facility-specific labels, this is a simple process. All the information you need for the label can be copy/pasted from the SDS to the label. The pictograms can be downloaded from OSHA’s Hazard Communication website for use in container labels. You’ll be surprised how much you’ll learn when completing the SDS revision.