DEPARTMENT: Design and Construction
- Facility Management and Engineering
Services
PAGE: 1 of 4
EFFECTIVE DATE: November 1, 2005
POLICY DESCRIPTION: Environmental – Air
Pollution Emission and Control
REPLACES POLICY DATED: 1/12/1999,
7/21/1999
REFERENCE NUMBER: DC.004
SCOPE: All Company-affiliated facilities including, but not limited to, hospitals, ambulatory
surgery centers, outpatient imaging centers, home health agencies, physician practices, and all
Corporate Departments, Groups and Divisions and on-site subcontractors.
PURPOSE: To require each facility to comply with environmental permitting, operating, response
and reporting procedures with respect to air or gaseous emissions and air pollution controls in
accordance with Environmental Protection Agency (EPA), state, and/or local regulations.
POLICY:
1. Federal and state environmental regulations affect a facility’s compliance plan for air emissions.
The Facility Manager or Director must be familiar with all potential air pollutant emission sources at
the facility.
2. Facilities must report incidents of an unpermitted (usually associated with an accident) or
uncontrolled (exceeding the permitted level) air pollutant emission episode occurring at the facility
to the state air pollution control agency.
3. In the event of an unplanned release of an air pollutant, a facility must follow these basic priorities:
a. protect patients, visitors, and employees from injury;
b. prevent further release of air pollutants to the environment;
c. protect property from damage; and
d. report regulated air pollutant release to appropriate agencies.
4. If a facility is located in a non-containment area, facility personnel must follow the special
procedures/requirements approved by relevant local authorities.
This policy addresses federal regulatory requirements. State laws or regulations may impose
additional requirements. Each facility should consult with Corporate Engineering Services and the
facility’s Operations Counsel to identify and comply with any such additional requirements.
DEFINITION:
Responsible Manager – the individual in each facility charged with maintaining compliance with
federal, state, and local environmental statutes and regulations for the facility. The Responsible
Manager may be a designated Environmental Compliance Officer, ES&H manager, facility
manager, or plant operations manager depending on the local organizational structure and
management roles and responsibilities.
10/2005
DEPARTMENT: Design and Construction
- Facility Management and Engineering
Services
PAGE: 2 of 4
EFFECTIVE DATE: November 1, 2005
POLICY DESCRIPTION: Environmental – Air
Pollution Emission and Control
REPLACES POLICY DATED: 1/12/1999,
7/21/1999
REFERENCE NUMBER: DC.004
PROCEDURE:
1. The Responsible Manager shall review health care operations requiring compliance with air
emissions and air pollution control including:
a. on-site incineration of biomedical waste;
b. ethylene oxide sterilization;
c. toxic air emissions;
d. refrigeration chemical management;
e. boiler operation; and
f. emergency generator operation.
2. The Responsible Manger shall be familiar with air pollution emission incidents that may have
federal, state, or local reporting requirements including:
a. fire or explosion;
b. toxic gaseous chemical (e.g., ethylene oxide, chlorine) leak;
c. incinerator malfunction or improper operation of incinerator;
d. improper dust suppression or isolation during construction or renovation activities;
e. deficiency in chemical storage or chemical handling practice; and
f. malfunction of any air pollution control equipment (scrubber or catalytic converter).
3.
The Responsible Manager or Director must review the heat input (in terms of million BTU/hour) of
the gas- or oil-fired boiler against the state regulatory threshold levels to determine whether an air
pollution control permit is needed. Depending on the heat input capacity rating of boilers, a facility
may be subject to air emissions permitting requirements.
4.
The Responsible Manager must determine if a facility uses an incinerator for biomedical waste
treatment. The Responsible Manger must keep a medical waste incinerator permit, a permit
exemption, or proof of permit-by-rule. Reporting requirements and procedures for uncontrolled air
pollutant emissions from the incinerator are usually stated in the air permit.
5.
The Responsible Manager must ensure that asbestos fibers are not released. Asbestos fiber releases
that occur during a fire, flood, or asbestos abatement project must be reported to regulatory
authorities and should be handled jointly by an asbestos abatement contractor and facility personnel.
6.
The Responsible Manager must be aware that EPA has classified ethylene oxide as an “extremely
hazardous air pollutant.” OSHA has classified ethylene oxide as a “highly hazardous chemical.”
By definition, this chemical causes death, injury, serious adverse effects to human health and the
environment if it is accidentally released. All safety procedures recommended by the sterilizer
manufacturer must be followed. In some states, a catalytic converter is required to abate ethylene
10/2005
DEPARTMENT: Design and Construction
- Facility Management and Engineering
Services
PAGE: 3 of 4
EFFECTIVE DATE: November 1, 2005
POLICY DESCRIPTION: Environmental – Air
Pollution Emission and Control
REPLACES POLICY DATED: 1/12/1999,
7/21/1999
REFERENCE NUMBER: DC.004
oxide sterilizer exhaust. Never disengage any air pollution control device. Do not exhaust the
ethylene oxide sterilizer off-gas to sewer. Major elements requiring routine inspection and regular
maintenance include:
a. tank/cylinder storage room, and loading room;
b. ethylene oxide sterilizer;
c. detection instruments and alarm system;
d. emission control equipment;
e. duct work and exhaust piping; and
f. health and safety equipment and material supply.
7.
The Responsible Manager must review the list of 189 chemicals classified by the EPA as hazardous
air pollutants and ensure the facility is operating within the established limits and reporting
requirements. Each facility must review the list of chemicals used at the facility against the
regulatory reporting limits.
8.
The Responsible Manger or designee must make annual notification to federal and/or state
authorities for facilities manufacturing, emitting, or possessing hazardous air pollutants.
9.
The Responsible Manager must ensure compliance with SARA Title III (Section 304) which
requires a facility to provide a notification of any release of an Extremely Hazardous Substance
(EHS) or Comprehensive Environmental Response, Compensation and Liability Act (CERCLA)
hazardous substance in an amount equal to or greater than the reportable quantity (RQ) to the
appropriate authorities.
10. The Responsible Manager may be required by the EPA to file a Risk Management Plan if a facility
stores more than 18,000 gallons of propane. A Risk Management Plan must be updated and
certified every five years. Preparation of a Risk Management plan should be coordinated with the
HCA Facility Management and Engineering Services Department.
11. Refrigerants, including chlorofluorocarbons (CFCs) and hydrochlorofluorocarbons (HCFC), are
used in chillers, air conditioners, ice makers, and refrigerators. CFC is also used as a diluent in
ethylene oxide sterilizers. Clean Air Act Amendments (CAAA) prohibit the release of CFCs to the
atmosphere and require use of these substances be phased out. Each facility must use EPA-certified
technicians to service equipment containing CFC and HCFC refrigerants. A facility may store
CFCs in a secure outdoor location; or in a properly lighted, forced-air ventilated room, or a
continuously ventilated room provided that:
a. the location is locked at all times with controlled access and there is a proper sign at the
entrance;
b. a respirator is located outside the room at a visible place;
10/2005
DEPARTMENT: Design and Construction
- Facility Management and Engineering
Services
PAGE: 4 of 4
EFFECTIVE DATE: November 1, 2005
POLICY DESCRIPTION: Environmental – Air
Pollution Emission and Control
REPLACES POLICY DATED: 1/12/1999,
7/21/1999
REFERENCE NUMBER: DC.004
c. forced-air venting is provided before personnel enter the location (manual switch located
outside the entrance);
d. pure and spent refrigerants are separated and properly labeled;
e. inventory is maintained and the room is inspected bi-weekly; and
f. if refrigerants are co-stored with hazardous materials, the stricter health and safety
requirements are observed.
REFERENCES:
EPA regulation: SARA Title III Section 302
29 CFR 1910.109 and 119, OSHA Process Safety Management of Highly Hazardous Chemicals
Federal EPA Clean Air Act Amendments of 1990
HCA CFC Questions and Answers (available on Atlas at:
http://atlas2.medcity.net/content/ethics/policies/DC_Design_and_Constructions/DC_Design%25
20and%2520Construction%2520Attachments/DC004CFC_Questions_and_Answers.doc)
10/2005