Standard Operating Prcedure Bilgical Safety Cabinet SOP Number: SOP-BSC-01 Categry: Lab Equipment Supersedes: N/A Effective Date: December 1, 2017 Pages 7 Subject: Bilgical Safety Cabinet Prepared By: Lisa McAvy 16/Nv/17 dd/mmm/yy Apprved By: Vernica Harris-McAllister 17/Nv/17 dd/mmm/yy 1.0 POLICY Bilgical safety cabinets (BSCs) are the primary means f cntainment fr wrking with bihazardus materials. BSCs are designed t reduce the risk f infectin by islating the activities in the BSC frm the labratry envirnment. BSC als can be used t prtect the bihazardus materials during manipulatin. A Class II Type A2 BSC is lcated in the Research Centrifuge Rm within the W.J. Hendersn Centre fr Patient-Oriented Research (WJHCPOR). The Kingstn General Health Research Institute (KGHRI) will ensure that the BSC is inspected and certified annually. 2.0 PURPOSE T ensure that all users f the WJHCPOR can safely perate the BSC t manipulate ptentially infectius bispecimens and reduce the risk f infectin. 3.0 DEFINITIONS Class II Type A2 Bilgical Safety Cabinet (BSC): is the primary barrier prtectin fr individuals wrking with lw t mderate risk bihazardus materials designed t discharge HEPA-filtered exhaust air directly int the labratry r int an exhaust system ducted ut f the building with a thimble cnnectin. When ducted ut f the building, this BSC may be used fr applicatins invlving minute quantities f vlatile txic chemicals. During peratin, rm air is drawn int the inlet grill f the BSC. The air in the plenum beneath the wrk surface f the BSC is a mixture f unfiltered rm air and air that has just passed thrugh the wrk area f the BSC. This cntaminated air is drawn by the blwer thrugh the back plenum f the BSC, where apprximately 70% f the air is recirculated thrugh the supply HEPA filter and back ver the wrk area. The balance f the cntaminated air is discharged t the envirnment after passing thrugh the exhaust HEPA filter. Versin 1 (December 1, 2017) - 1 SOP-BSC-01
HEPA Filter: HEPA stands fr High-Efficiency Particulate Air. HEPA filters are defined as air-cleaning devices that have a prven minimum remval efficiency f 99.97% f particles in the air, equal t 0.3 μ (micrns) in diameter, with higher efficiency fr bth larger and smaller particle sizes. 4.0 PROCEDURES Users are respnsible fr: Ensuring they receive rientatin and training n the BSC by the designated KGHRI staff member befre using the BSC n their wn. Fllwing the prper prcedures fr BSC use, including cleaning/disinfecting after each use f the BSC. Reprting immediately any damage r malfunctin f the BSC t the designated KGHRI staff member. If after hurs, users are required t cmplete a BSC Damage Frm (fund in the binder n the shelf abve the centrifuges) and attach the FORM t the BSC. The FORM describes the prblem, the date/time the prblem ccurred and includes the user's cntact infrmatin (name, number, and email). The BSC MUST nt be used until fixed. Reprting incidents (i.e. spills, accidents, expsure) immediately. See Accidental Occupatinal Expsure and Reprting Wrkplace Incidents SOP Be familiar with the material safety data sheet (MSDS) fr the particular disinfectants, chemicals and bihazardus materials used in the BSC. The MDSC are lcated in the binder n the shelf abve the centrifuges. KGHRI is respnsible fr: Prviding all users f the WJHCPOR with rientatin and training n the prper use f the BSC in the Research Centrifuge Rm within the WJHCPOR. Ensuring all users receive BSC safety training regarding labratry wrk practices and BSC user guidelines prir t cmmencing wrk with the BSC. Ensuring that the BSC is tested and certified (NSF/ANSI 49 standard) after installatin, after relcatin, and at least annually by a qualified individual wh will prvide dcumentatin indicating the date f certificatin. Queen s University and KGHRI currently use CON-TEST fr BSC certificatin. BSC certificatin reprts are filed by the designated KGHRI staff member in the binder n the shelf abve the centrifuges and a cpy f the certificatin reprt is attached directly t the BSC. Versin 1 (December 1, 2017) - 2 SOP-BSC-01
Rutinely mnitr the Filter Gauge value f the BSC using a lg (fund in the binder n the shelf abve the centrifuges. As the Filter Gauge appraches 20% remaining capacity, the cabinet filter shuld be replaced. The designated KGHRI staff member will call CON-TEST t arrange a service visit and place a d nt use sign t ntify users that n wrk is perfrmed in a malfunctining BSC. Cnducting rutine (weekly, mnthly and annual) cleaning (full wipe-dwn) and maintenance as described in the Bisafety Cabinet User Manual. Crdinating maintenance, repair and new BSC equipment needs. General Rules when using BSCs Persnal Prtective Equipment (PPE) When wrking in a BSC, the user shuld wear: clsed-frnt ver garment (e.g. lng sleeve fully buttned lab cat). glves (latex r vinyl glves) Nte: Glves shuld verlap the cuffs t ensure that aersls d nt cntaminate the hands, arms and surfaces. lng pants r skirt and full cvering shes (cvering tp f ft, tes and heel). prtective eyewear (gggles) and prtective facemask (if apprpriate). Lighting There are tw types f lighting inside the BSC: flurescent and ultra-vilet (UV). The flurescent light shuld nrmally be ON while wrk is being dne within the cabinet. Direct expsure t UV light (apprximately 260 nm wavelength) can reduce the number f pathgenic micrrganisms n expsed surfaces and in air. Hwever, it is imprtant t nte that: (I) UV light has pr penetrating pwer; (2) the accumulatin f dust, dirt, grease r clumps f micrrganisms reduce its germicidal effects; (3) UV light is nt effective against all rganisms; and (4) expsure t UV light is hazardus (it may result in severe eye damage and bums t the skin). Rutine use f UV lamps t decntaminate a BSC is nt recmmended. They are useful in certain situatins, if prperly maintained, such as when using spre-frming bacteria since bacterial spres are resistant t chemical disinfectin. UV lamps must be turned ff whenever the labratry is ccupied unless the sash can be lwered s that it is cmpletely clsed. Versin 1 (December 1, 2017) - 3 SOP-BSC-01
BSC Start-Up Turn OFF the UV lamp (if it is n). Slwly raise the sash until the bttm f the sash aligns with the sash indicatr decal lcated n the left side f the wrk area. Raising the sash will autmatically turn n the flurescent light and blwer. Ensure that nthing is blcking the frnt grilles. Nte the filter gauge reading. If it is 20% r less cntact designated the KGHRI staff immediately and DO NOT USE the BSC. Allw the BSC t perate unbstructed fr 5 minutes. Ensure that the alarm has NOT been turned OFF, and that airflw is sufficient. Wash hands thrughly and dn PPE (lab cat, mask (if applicable), gggles and glves). Wipe-Dwn Slwly raise the sash until the bttm f the sash aligns with the sash indicatr decal lcated n the left side f the wrk area. Mute the alarm by depressing the Alarm Silence switch. Wipe dwn the interir surfaces f the cabinet with Oxivir, and allw time t dry. Clse the sash back t its perating psitin which will reset and unmute the alarm. Lading Materials Materials r equipment placed inside the BSC may cause disruptin t the airflw, resulting in turbulence, pssible crss-cntaminatin, and/r breach f cntainment. Only lad the materials required fr the prcedure. D nt verlad the BSC. D nt bstruct the frnt, side, r rear return air grilles. Large bjects shuld nt be placed clse tgether. Slwly clse the sash until it is in the crrect perating psitin. After lading the BSC wait 5 minutes t purge airbrne cntaminants frm the wrk area. Wrk Techniques Mvement f arms in and ut f the BSC can disrupt airflw, adversely affecting BSC perfrmance. Whenever pssible, place all materials needed fr a prcedure inside the BSC befre starting. Mve arms slwly and mve straight ut f the BSC. D nt sweep arms acrss the frnt f the BSC. D nt walk quickly in frnt f a cabinet when smene else is wrking in the BSC. Versin 1 (December 1, 2017) - 4 SOP-BSC-01
Ensure that the BSC can prvide prper prduct, persnnel and envirnment prtectin. It is imprtant that the frnt grilles are nt blcked. Raise arms slightly t ensure that arms are nt resting n the grille. Ensure ther items are nt blcking the grille (i.e. pipettes, etc.). Wrk twards the middle f the BSC, away frm the sash. All peratins shuld be perfrmed at least fur "4" inches frm the frnt grille n the wrk surface. Segregate all clean and cntaminated materials in the wrk area. Place cntaminated material at the rear f the wrk area. Active wrk shuld flw frm the clean t cntaminated area acrss the wrk surface. Discard cntaminated waste including cntaminated glves INSIDE the cabinet. The surfaces f all materials and cntainers placed int the BSC MUST be wiped with Oxivir t reduce the intrductin f cntaminants t the BSC envirnment. Clean up spills as sn as they ccur. If there is a spill r splatter during use, all bjects in the cabinet shuld be surface decntaminated with Oxivir befre remval. Thrughly disinfect the wrking area f the BSC WHILE IT IS STILL IN OPERATION, t prevent the release f cntaminants frm the BSC. Spills Remve glves and discard within the BSC. If tw pairs are wrn, discard the utermst layer. If sleeves are ptentially cntaminated, the labratry cat r gwn shuld als be remved and placed in the laundry bin behind the research centrifuge rm dr. Fresh glves shuld be dnned and if necessary, als a fresh labratry cat r gwn. Leave the BSC blwer n and the sash at the apprpriate level. Remve any debris using frceps, tweezers r tngs and place in the yellw Sharps waste bin/cntainer inside BSC. Surface disinfect all bjects within the BSC (e.g. pipettes, tube hlders, etc.) using Oxivir wipes befre remving them frm the BSC. If material has spilled thrugh the grill/catch tray f the BSC, pur sme disinfectant (Oxivir slutin) thrugh the grill/catch tray t fld the catch tray underneath. Wipe all inside surfaces f BSC with disinfectant (Oxivir wipes). Raise the wrk surface, clean the catch tray (yu may need t sak up the Oxivir slutin in the catch tray with paper twels), and then replace the wrk surface. All used paper twels saked in Oxivir and/r Oxivir wipes and cntaminated glves are t be discarded in the yellw bihazard waste bin/cntainer. Allw BSC t run fr at least 10 minutes befre resuming wrk r shutting dwn. Versin 1 (December 1, 2017) - 5 SOP-BSC-01
Cmpletin f wrk Clse r cver pen cntainers and leave the blwer n fr at least 5 minutes with n activity t purge the BSC. Surface disinfect bjects with Oxivir wipes befre remval frm the BSC. Remember that aersls generated during peratins in the BSC such as pipetting might have cntaminated bjects in the BSC, s there des nt have t be a spill fr this step t be necessary. Disinfect BSC surfaces with Oxivir wipes. Peridically remve the wrk surface and disinfect the area beneath it (including grill/catch tray) and wipe the surface f the UV light with disinfectant. All used paper twels saked in Oxivir and/r Oxivir wipes and cntaminated glves are t be discarded in the yellw bihazard waste bin/cntainer. Allw BSC t run fr at least 10 minutes befre shutting dwn. Dff PPE (glves, gggles, lab cat, mask (if applicable)) and wash hands thrughly. If lab cat siled, place in laundry bin behind dr. 5.0 CONTACTS Research Administratin Facilitatr (Designated KGHRI Staff Member): Lisa McAvy Kingstn General Health Research Institute W.J. Hendersn Centre fr Patient Oriented Research Cnnell 4, Kingstn Health Science Centre (KGH Campus) Kingstn, Ontari K7L 2V7 613-549-6666 ext. 3344 mcavye1@kgh.kari.net Directr, Health Sciences Research: Vernica Harris-McAllister Kingstn General Health Research Institute W.J. Hendersn Centre fr Patient Oriented Research Cnnell 4, Kingstn Health Science Centre (KGH Campus) Kingstn, Ontari K7L 2V7 613-549-6666 ext. 3653 harrismv@kgh.kari.net Versin 1 (December 1, 2017) - 6 SOP-BSC-01
6.0 SOP HISTORY SOP Number Date Issued Summary f Revisins SOP-BSC-01 01-DEC2017 Original versin. Versin 1 (December 1, 2017) - 7 SOP-BSC-01