CAP always makes things "interesting." FYI, the entire text of the
formalin/xylene question is below. The question makes it sound as if
periodic monitoring must be done; otherwise, how do you prove that you have
"maintained" the level below the requirements? But the commentary only
refers to subsequent testing of formaldehyde and specifically says xylene
doesn't require "periodic" testing. It says nothing about testing for xylene
when conditions change. As is often the case, the "commentary" causes more
confusion than the question itself! Once again CAP has totally confused the
issue. This question should be re-written, and maybe broken up into two
parts - formaldehyde, and xylene, since CAP obviously treats each
differently. (and what would the xylene question be? "Have you EVER tested
for xylene vapors?" and would "Yes. 20 years ago" be OK?)

I have often felt that CAP just makes up these things to see what people
will do to solve the problems they purport to address, and then later modify
it to reflect those solutions (I've been through a dozen CAP inspections and
it never is easy to figure out what they want THIS year, and of course the
inspector always has their own nitpicks). Kind of backwards, but that's CAP
for you!


Tim Morken
Atlanta

ANP.24150             Phase II

"Are formaldehyde and xylene vapor concentrations maintained below the
following maxima, expressed as parts per million?"

NOTE:  Initial monitoring must be repeated any time there is a change in
production, equipment, process, personnel, or control measures which may
result in new or additional exposure to formaldehyde.  Periodic formaldehyde
monitoring is mandated only if the initial monitoring is at or exceeds 0.75
ppm (8 hr TWA) or 2.0 ppm (STEL).  The laboratory may discontinue periodic
formaldehyde monitoring if results from 2 consecutive sampling periods taken
at least 7 days apart show that employee exposure is below the action level
and the short term exposure limit, and no change in production, equipment,
process or personnel or control measures that may result in new or
additional exposure to formaldehyde, and no reports of conditions that may
be associated with formaldehyde exposure.  There is no requirement for
periodic monitoring of xylene.

COMMENTARY:

Air levels of formaldehyde or xylene vapors were above those permitted, or
no records were available that measurements have been taken.  Maximum
permissible levels under standard working conditions are as follows:


All laboratories using formaldehyde must monitor levels in accordance with
29CFR1910.1048.  Xylene levels should be monitored as well, and exposures to
xylene must be in accord with 29CFR1910, subpart z.  Initial monitoring must
be repeated any time there is a change in production, equipment, process,
personnel, or control measures which may result in new or additional
exposure to formaldehyde.  Periodic monitoring for formaldehyde is mandated
only if the initial monitoring is at or exceeds 0.75 ppm (8 hr TWA) or 2.0
ppm (STEL).  The laboratory may discontinue periodic formaldehyde monitoring
if results from 2 consecutive sampling periods taken at least 7 days apart
show that employee exposure is below the action level and the STEL, and no
change in production, equipment, process or personnel or control measures
that may result in new or additional exposure to formaldehyde, and no
reports of conditions that may be associated with formaldehyde exposure.
There is no requirement for periodic monitoring of xylene.

Tim Morken
Atlanta

-----Original Message-----
From: Charles.Embrey [mailto:Charles.Embrey@carle.com] 
Sent: Thursday, April 03, 2003 12:48 PM
To: 'LaFriniere, Mike'; Charles.Embrey; 'histonet@pathology.swmed.edu'
Subject: RE: Frequency of Xylene monitors


Michael, The original question was -"Does anyone know if there is a CAP
recommendation on how frequent you should monitor for Xylene."  Not state
law or personal opinion.  The last sentence on the CAP note for ANP.24150
reads "There is no requirement for periodic monitoring of xylene."  That
seems pretty straight forward.  It really burns me up when CAP inspectors
take it upon themselves to "interpret" something so plainly stated in black
and white to mean something else.  It's CAP inspectors like that make lab
managers afraid of the inspection process. Charles R. Embrey Jr. PA(AAPA),
HT(ASCP) Histology Manager Carle Clinic, Urbana Illinois  

-----Original Message-----
From: LaFriniere, Mike [mailto:Mike_LaFriniere@memorial.org]
Sent: Thursday, April 03, 2003 11:42 AM
To: 'Charles.Embrey'; 'histonet@pathology.swmed.edu'
Subject: RE: Frequency of Xylene monitors


CAP ANP.24150 states : ' ARE FORMALDEHYDE AND XYLENE VAPOR CONCENTRATIONS
MAINTAINED BELOW THE FOLLOWING MAXIMA EXPRESSED AS PARTS PER
MILLION....ETC...

In addition many states require monitoring that are more strict than CAP
requirements. As a inspector for CAP I would expect a laboratory to at least
monitor the xylene levels over a peroid of time, it may be anywhere in a
five year period, or when a major procedure change in the laboratory.
Mainily to include monitoring when a production or construction change has
taken place. The question Susan proposed was if every three months was
appropriate. Every three months is excessive, however, Susan needs to check
her State requirements. I have not known a State to require any more than
once a year.I would not give an opinion of less than yearly unless I knew
her individual state requirements.

It is the managers/Supervisors responsible to prove that the xlene vapor
concentrations are "maintained" below the maxima on CAP inspection. A one
time monitor in a five year time span would be unacceptable to me and on CAP
inspection I would recommend the laboratory have an additional monitor
performed.

Regards..

Michael LaFriniere PA,HT(ASCP)
Pathology Manager
Memorial Hospital
Chattanooga TN
423-495-6117 

-----Original Message-----
From: Charles.Embrey [mailto:Charles.Embrey@carle.com]
Sent: Thursday, April 03, 2003 11:40 AM
To: 'LaFriniere, Mike'; 'Walzer Susan'; 'Satterfield, Marirose';
'histonet@pathology.swmed.edu'
Subject: RE: Frequency of Xylene monitors


No where in CAP does it say that you have to repeat xylene monitoring after
a procedure change.  Only formaldehyde levels need to be rechecked after  a
"change in production, equipment, process, personnel or control measures
which may result in new or additional exposure...".  If we are talking
specifically about what CAP REQUIRES.  Once a year is not required and in my
opinion a waste of funds. Charles R. Embrey Jr. PA(AAPA), HT(ASCP) Histology
Manager Carle Clinic, Urbana Illinois  

-----Original Message-----
From: LaFriniere, Mike [mailto:Mike_LaFriniere@memorial.org]
Sent: Thursday, April 03, 2003 10:33 AM
To: 'Walzer Susan'; 'Satterfield, Marirose'; 'histonet@pathology.swmed.edu'
Subject: RE: Frequency of Xylene monitors


Susan,

Once a year is adequate for monitoring xylene and unless you change a
procedure or have a high reading, then you must monitor following the
procedure change, i.e., staining or processing in a new room with open
xylene, or continue monitoring if you have a high reading until you find the
reason for the high reading, FYI, if you have a high reading of xylene fumes
then you would have a major problem do to the fact the (US) OSHA acceptable
guidelines for xylene fumes are extremely high, ( I think currently they are
in the range of 50-100 ppm).

Regards...

Michael LaFriniere,PA,HT(ASCP)
Pathology Manager
Memorial Hospital
Chattanooga TN
423-495-6117

-----Original Message-----
From: Walzer Susan [mailto:Susan.Walzer@HCAHealthcare.com]
Sent: Thursday, April 03, 2003 10:54 AM
To: 'Satterfield, Marirose'; 'histonet@pathology.swmed.edu'
Subject: RE: Frequency of Xylene monitors


We do it once a year, have never had a high  reading.

-----Original Message-----
From: Satterfield, Marirose [mailto:marirose.satterfield@MercyMemorial.org]
Sent: Thursday, April 03, 2003 9:54 AM
To: 'histonet@pathology.swmed.edu'
Subject: Frequency of Xylene monitors


Does anyone know if there is a CAP recommendation on how frequent you should
monitor for Xylene. Currently we do it every 3 months and would like to do
it less if we could. Thanks Mari