Alan A. Ayers, MBA, MAcc is Practice Management Editor of The Journal of Urgent Care Medicine and is Chief Executive Officer of Velocity Urgent Care.

Urgent message: While any urgent care’s preferred “toilet bluing” method for urine specimen drug screen collects would seem a mundane matter, a careless or haphazard approach can result in unintended and potentially serious consequences.

Urgent care centers that provide occupational medicine and drug testing services are required to follow specific procedures when collecting urine specimens from a patient donor. The procedure that has become a hot-button issue and topic of discussion as of late is “toilet bluing” in the restroom or stall where the urine specimen is collected.

Toilet Bluing

Toilet bluing is the act of placing a blue dye in a toilet bowl to color the water, and is mandatory per most employer and government drug collection standards. This is done to ensure the integrity of the specimen; if the donor has attempted to dilute, adulterate, or tamper with their specimen by scooping water from the toilet bowl, it will be evident to the collector. They would then know that the sample has been adulterated, prompting them to discard it and proceed to direct observation of the specimen collection.

In the absence of some extenuating circumstance that compels the urgent care center to proceed otherwise, the easiest, most straightforward solution is to simply drop a single dye tablet into the toilet bowl for each patient. Dye pills typically cost $15 for 100—about 15 cents per tablet—which is a relatively low overhead for a urine drug collect and send-out for which an urgent care can charge an employer $35 or more. The problem arises when some urgent care centers attempt to realize further cost savings by dissolving the pills into a separate container, and then pouring or spraying the diluted solution into a toilet bowl for each specimen collection. This creation of a separate bluing solution may result in getting more “mileage” out of each tablet, but in attempting to save a few bucks, the operator introduces a whole new set of problems and issues.

Toilet Bluing Dilution Issues

The first concern is with the container the toilet bluing solution is held in. It would seem that if an urgent care staff were going to use a separate vessel to create a bluing solution, they would at least purchase an empty, never-before used container for the task. But you’d be surprised to learn some of things centers do to cut corners. Check out the following image:

 

 

This image is from an actual urgent care center—and obviously illustrates a huge OSHA risk. What substance is in this container? Is it toilet blue, (nontoxic) or bleach (toxic), or some other toilet cleaner (very toxic)? The hastily labelled container does not make clear which is the case. If someone were to be exposed to the contents of this container, what course of action would they take?

Second, what substance was in that container originally, and was it thoroughly cleaned before the bluing tablet was dissolved in it? Regardless of what was originally in it, it’s a bad idea to recycle any container that held a toxic cleaning substance, as you have no idea how any of the residual substance will react chemically with the bluing solution. When you consider how noxious the fumes are when, say, ammonia and bleach are mixed, combining unknown substances in this way could inadvertently create a potentially dangerous cocktail that will be exposed to urgent care employees and patients.

Additionally, when administering the solution into the toilet bowl, there’s always the possibility that over splash or over spray will stain the floors or the walls. This is the potential headache and hassle an urgent care staff signs up for when they decide to take this route.

Anecdotal Examples of Careless Toilet Bluing Procedures

Although toilet blue itself is nontoxic and hence doesn’t require a Safety Data Sheet (SDS), risky and sometimes humorous instances of careless toilet bluing use occur more often than you’d think.

At one urgent care center in North Carolina, the bluing agent was diluted into a Gatorade bottle in which the Gatorade label hadn’t been removed. That is a huge safety risk since there is a “Gatorade Ice” flavor that is very similar in appearance to toilet blue. The safety risk being, of course, that someone is choking and in desperation looks for a drink, grabs what appears to be Gatorade, and then chugs down toilet blue or a potentially toxic alternative.

 

We’ve also seen toilet blue dissolved in old water bottles, milk jugs, and unbelievably, a child’s sippy cup—none with labels. One other example that doesn’t involve bluing solution, but the careless placement of the bluing tablets, occurred at an urgent care center in Maryland. When asked to “tidy up” the drug screening bay, the manager of that center went so far as to get a nice little crystal dish to put the blue dye pills in. A patient then came out of the restroom after producing his specimen, saw that the center was so hospitable to provide “free mints” with their drug screens, and then proceeded to eat a toilet blue pill out of the crystal dish! Again, toilet blue is not toxic, but it probably tastes horrible and will likely stain your mouth and teeth badly for quite a long time.

Toilet Blue Handling Best Practices

We recommend, given the minimal cost expense, to simply drop a bluing pill into the toilet water each time a specimen is collected. This way there are no container issues, no labeling issues, and no staining issues resulting from overspray or over splash. There are urgent care centers, however, that do opt to create toilet bluing solutions to stretch the utilization of the pills further. In these cases, they’ll have to address the container, labeling, and application issues, and follow the best practices for each:

  • Bluing solution container – The urgent care center will need to procure a standard, previously unused bottle or container to hold the solution, such as a generic plant water bottle. This helps avoid any unexpected chemical reactions between the toilet blue solution and any residual substances from a previously used container.
  • Labeling – Per OSHA requirements, any secondary container used to store a manufacturer’s original product must have an OSHA-compliant label. OSHA provides descriptors and pictograms for that very purpose, which communicates any workplace hazards from the original product to anyone handling the secondary container.
  • Spray or pour – Should the specimen collector store the bluing solution in a spray bottle, or a container for pouring in the solution? Our observation has been that’s it simpler and cleaner to use a spray bottle and use one or two sprays at close range to blue the water. Pouring in the solution increases the chances of over splash.

Some urgent cares have opted to get out in front of the issue and adopt “No Diluting” policies for their bluing tablets. In this case the tablets are kept in their original form and packaging prior to use, and no labels are to be removed or defaced.

Conclusion

While urgent care toilet bluing approaches seem a trivial matter on the surface, it’s an issue that when mishandled can cause inconveniences and headaches at best, and serious OSHA violations at worst. Adopting a careful and prudent approach to this issue can therefore prevent a mishap that has everyone involved feeling “blue,” and keep the “blue” where it belongs—in the toilet.

 

 

 

Much Ado About Toilet Bluing (and Other Drug Testing Requirements)

Alan A. Ayers, MBA, MAcc

Chief Executive Officer of Velocity Urgent Care, LLC and is Practice Management Editor of The Journal of Urgent Care Medicine
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