Operating room (OR) personnel are frequently overwhelmed by their numerous responsibilities of not only “fixing” the patient, but also preventing infection, maintaining a sterile field, utilizing only sterile instruments, and in general, ensuring the patient’s safety, as well as that of the OR staff. Proper fluid management is one of those crucial steps to preserving the wellbeing of both staff and patient.
The Basic Principles
Has your OR personnel been trained in the disposal of liquid waste? Are they aware of state and/or city regulations? Is their bloodborne pathogen training recent? Is annual competency testing required?
The Basic Principles
“Basically, in the OR, all body fluids are considered potentially infectious, and universal contact precautions are observed at all times to prevent contact with blood or other potentially infectious materials,” says Dov Kolker, MD, assistant professor in the department of orthopedic surgery at Mount Sinai Medical Center in New York City.
In the OR, the body fluids in an orthopedic procedure can include blood or any bloody fluid, synovial fluid, and arthroscopic fluid that is used during arthroscopic surgeries. “The other fluids that would appear in general surgical procedures would also consist of pericardial fluid, cerebrospinal fluid, and peritoneal fluid, for example. Everything in the OR, any of the body fluids, basically must be considered potentially infectious. Even if they’re not, they need to be considered and treated as potentially infectious,” Kolker comments.
“The disposal of potentially infectious fluids in the OR is obviously of significant importance, and entails a multidisciplinary team approach, involving a wide range of OR healthcare personnel,” he says. “Our work practice controls that are used to eliminate or minimize employee and patient exposure are done in compliance with the Occupational Safety and Health Administration (OSHA) bloodborne pathogens standard.
Routinely, during and at the completion of a surgical procedure, fluids consisting of blood or other potentially infectious materials are placed in a properly labeled, sealed container. These containers are not reusable, and a clean canister is available for backup. At the end of the surgical procedure, all containers with body fluids are placed on soiled case carts, which are then sent to the decontamination area, which is a subdivision of the sterile processing department.”
The sterile processing department, he points out, is a non-patient care area, and that limits the possibility of patient exposure, at least. “Here at Mount Sinai, we have recently updated our liquid waste disposal system. The sterile processing staff, who are at all times wearing personal protective equipment (PPE), efficiently dispose of these fluids using a state-of-the-art drainage system, and that safely disposes of the potentially infectious fluid into the municipal sewer system. So the risk of infectious exposure from splashing, spattering, spraying, or aerosolization is minimized, ultimately enhancing staff safety. It’s also cost-effective for the hospital, as it reduces red bag disposal and cost, and reduces overall hospital waste volume.”
Not only that, but, Kolker adds, “Our director of the sterile processing department, Jim Heller, has been involved with the design of an automatic enzymatic cleaner and flushing system, which automatically flushes degredative enzymes down the drain with each disposal and also every 45 minutes, 24 hours a day, which keeps the drains clean and prevents clogging in a harmless fashion.”
Minimizing the risk of exposure by healthcare workers and patients is the most crucial step. A solidifier and sanitizer in combination could be cost effective by providing the means of conversion from biohazardous waste to “regular” waste, also eliminating the potential exposure to harmful pathogens.
There are obvious benefits to solidifying liquid waste — it has the potential to reduce splashing and aerosolization of potentially infectious blood or body fluids. It is necessary to solidify in many cases, because certain Department of Transportation regulations require absorbent material such as a solidifier in the shipment of potentially infectious specimens, such as specimens from a hospital laboratory being shipped to another lab.
In the Association for Professionals in Infection Control and Epidemiology (APIC) “Guidelines for Environmental Infection Control in Healthcare Facilities,” the guidelines discuss regulated medical waste and the microbial load thereof. “No epidemiologic evidence suggests that traditional waste-disposal practices of healthcare facilities (whereby clinical and microbiological wastes were decontaminated on site before leaving the facility) have caused disease in either the healthcare setting or the general community,” the guidelines state.
However, that does not remove the need for care when handling medical waste. “Healthcare facility medical wastes targeted for handling and disposal precautions include microbiology laboratory waste (e.g., microbiologic cultures and stocks of microorganisms), pathology and anatomy waste, blood specimens from clinics and laboratories, blood products, and other body-fluid specimens,” they say. “Medical wastes require careful disposal and containment before collection and consolidation for treatment. OSHA has dictated initial measures for discarding regulated medical-waste items. These measures are designed to protect the workers who generate medical wastes and who manage the wastes from point of generation to disposal. Healthcare facilities are instructed to dispose medical wastes regularly to avoid accumulation. Medical wastes requiring storage should be kept in labeled, leak-proof, puncture-resistant containers under conditions that minimize or prevent foul odors. The storage area should be well ventilated and be inaccessible to pests. Any facility that generates regulated medical wastes should have a regulated medical waste management plan to ensure health and environmental safety as per federal, state, and local regulations.”
Also, they say, “Regulated medical wastes are treated or decontaminated to reduce the microbial load in or on the waste and to render the byproducts safe for further handling and disposal. From a microbiologic standpoint, waste need not be rendered ‘sterile’ because the treated waste will not be deposited in a sterile site.”
Specific to blood and fluids, and their disposal, the guidelines add, “The contents of all vessels that contain more than a few milliliters of blood remaining after laboratory procedures, suction fluids, or bulk blood can either be inactivated in accordance with state-approved treatment technologies or carefully poured down a utility sink drain or toilet. State regulations may dictate the maximum volume allowable for discharge of blood/body fluids to the sanitary sewer. No evidence indicates that bloodborne diseases have been transmitted from contact with raw or treated sewage. Many bloodborne pathogens, particularly bloodborne viruses, are not stable in the environment for long periods of time; therefore, the discharge of small quantities of blood and other body fluids to the sanitary sewer is considered a safe method of disposing of these waste materials. The following factors increase the likelihood that bloodborne pathogens will be inactivated in the disposal process: a) dilution of the discharged materials with water; b) inactivation of pathogens resulting from exposure to cleaning chemicals, disinfectants, and other chemicals in raw sewage; and c) effectiveness of sewage treatment in inactivating any residual bloodborne pathogens that reach the treatment facility.
“Small amounts of blood and other body fluids should not affect the functioning of a municipal sewer system. However, large quantities of these fluids, with their high protein content, might interfere with the biological oxygen demand (BOD) of the system. Local municipal sewage treatment restrictions may dictate that an alternative method of bulk fluid disposal be selected. State regulations may dictate what quantity constitutes a small amount of blood or body fluids. Although concerns have been raised about the discharge of blood and other body fluids to a septic tank system, no evidence suggests that septic tanks have transmitted bloodborne infections. A properly functioning septic system is adequate for inactivating bloodborne pathogens. System manufacturers’ instructions specify what materials may be discharged to the septic tank without jeopardizing its proper operation.”
Of special interest, APIC’s guidelines also point out the more recent anxiety related to Creutzfeldt-Jakob disease (CJD). “Concerns also have been raised about the need for special handling and treatment procedures for wastes generated during the care of patients with CJD or other transmissible spongiform encephalopathies (TSEs),” the guidelines observe. “Prions, the agents that cause TSEs, have significant resistance to inactivation by a variety of physical, chemical, or gaseous methods. No epidemiologic evidence, however, links acquisition of CJD with medical-waste disposal practices. Although handling neurologic tissue for pathologic examination and autopsy materials with care, using barrier precautions, and following specific procedures for the autopsy are prudent measures, employing extraordinary measures once the materials are discarded is unnecessary. Regulated medical wastes generated during the care of the CJD patient can be managed using the same strategies as wastes generated during the care of other patients. After decontamination, these wastes may then be disposed in a sanitary landfill or discharged to the sanitary sewer, as appropriate.”1