New Regulations Compound Challenges Posed by Fluid Waste
By Stanley R Shelver, RN, MHA
Along with the infection control challenges posed by infectious fluid wastes, new federal regulations for transporting hazardous biological wastes mean even greater cost pressures for healthcare managers charged with disposal of infectious fluids, motivating many to seek new alternatives to past disposal practices.
Incineration costs continue to increase, as do annual license fees demanded by the Environmental Protection Agency (EPA). Your facility may use a local landfill or you may have your contaminated waste hauled out of state at a premium cost. Does your facility provide cold storage for the waste before it is removed? Can you afford to microwave your contaminated waste before it is shredded and compacted?
Trash and contaminated waste are a major concern and budgetary issue for your operating room manager, infection control practitioner (ICP) and other healthcare administrators. This year may be the right time for you to consider some changes.
As an operating room director for the past 10 years, a portion of my time and budget has been to track and monitor trash and contaminated waste. As healthcare professionals, we have an obligation to remove the trash and waste from our facilities efficiently and as cost effectively as possible. Management objectives should include:
- Is adequate protection provided to the staff as the trash/waste is removed?
- What is the financial impact?
- What is the environment impact?
In the past, most hospitals and other healthcare facilities either capped suction canisters, added powders to congeal the canister contents or poured the suction canister contents down the drain. When there have been limited disposal options available, healthcare providers have had to make the best choice from limited options. Given today's environment, with HIV and hepatitis raising awareness of proper procedures for handling infectious fluids, pouring is clearly out of the question. The Occupational Safety and Health Administration (OSHA) essentially banned the practice when enacting the Bloodborne Pathogens Standard in 1991.1 This standard requires the implementation of engineering and work practice controls to eliminate or minimize occupational exposure to bloodborne pathogens, including those found in suction canister waste.
Some facilities have disposed of infectious fluid wastes by having staff cap suction canisters, placing them into red bags and having them hauled away. Some hospitals have even placed red bags in boxes for removal by a waste hauler. This approach obviously produces a large volume of red-bag waste that incurs high disposal costs and eliminates reuse of canisters.
In February 2003, new regulations from the U.S. Department of Transportation (DOT) went into effect, requiring even more bulky and expensive packing of infectious fluid waste containers. The changes are spelled out in the DOT's "Revision to Standards for Infectious Substances."2
The regulations effectively require packing suction liners in individual rigid packaging before being placed in red bags. Every suction canister must be wrapped with sufficient absorbent material to absorb the entire contents of the canister before placing the canister in a rigid, watertight non-bulk outer packaging.
Additionally, based on the regulation's weight limitations, no more than one full and wrapped 3,000cc suction canister can be placed in a single red bag. Wrapped suction canisters must be placed in rigid, watertight non-bulk outer packaging. Examples of non-bulk outer packaging include reusable plastic boxes or sealable cardboard boxes with heavy-duty liners.
Weight restrictions in the DOT regulations would not allow more than four full and wrapped 3,000cc suction canisters be placed in rigid, watertight non-bulk outer packaging.
These new regulations have even greater impact on facilities using bulk packaging for the off-site transport of regulated medical waste. Why? Because liquids must be packaged in rigid, watertight non-bulk outer packaging while solid regulated medical waste can simply be packaged in red bags before placement in bulk outer packaging (e.g., caster carts or roll-off bins).
Obviously, the newly mandated packaging material and the increased weight and bulk created by the packing will greatly increase the disposal costs for infectious fluid wastes.
The differing requirements for liquid and solid regulated medical waste effectively require facilities to segregate liquid and solid wastes. Segregation can be avoided if all regulated medical waste is placed in rigid, watertight non-bulk outer packaging; however, this adds significantly to the total cost of regulated medical waste disposal.
Based on where your facility is located, your choices may be dictated by state, county and municipal regulations. In the past decade there has been a decrease in the number of facilities that incinerate their trash. Even though some facilities may still incinerate, the regulatory controls will significantly limit those facilities. The limiting factors include increased air quality standards, increased licensure fees and additional hauling and landfill fees. There are less expensive methods for waste removal.
At many facilities, it is normal practice to pour the suction canister contents into hoppers. The canister liners are then generally discarded with the red bag/contaminated waste and are then sealed in rigid boxes. Some hospitals sort trash into non-contaminated (plastic), non-contaminated "other" and contaminated/red bag trash. Where you work makes a difference in what managers must do to avoid fines and litigation.
With each of these sorting processes, healthcare workers (HCWs) directly manage trash and are exposed to potential contamination. If a determination is made during the sorting process to collect non-contaminated items, one consideration that is especially appreciated by day care centers, kindergartens and pre-school programs is to donate the discarded prep kits (the clear plastic containers) for use as pencil boxes. This is just a small segment of tons of trash that must be eliminated from the waste stream; however, the donation is greatly appreciated by both the teachers and students.
In the past few years, states have imposed tariff and taxes on out-of-state trash. The tariffs are higher if contaminated waste is involved. For example, Oklahoma hospital trash that is hauled to Texas has higher tariffs than waste that is processed and hauled within the state.
Additional options for decreasing hauling costs are to microwave the trash either in a unit the size of an 18-wheel tractor trailer and then grind and compress the material so that it can be hauled at the lower, non-contaminated rate. The Texas-based firm that provides this service also provides a mobile microwave, trash compactor unit. This is an option for multi-hospital systems where landfill rate costs have escalated and managers have had to develop cost alternatives for a large-scale trash management program.
Even though there are two components of contaminated and non-contaminated waste products, let's turn our attention to the contaminated contents from suction canisters, which directly impacts nursing staff.
The weight and volume of the suction canister is the most significant item in the contaminated waste stream. HCWs cringe at the task of pouring liquid waste -- as it splashes, the odor is unpleasant and the contents are aerosolized when the liquids are dispensed into the hopper. Countless resources have been expended to deal with this single item, including commercial products devised to solidify the suction canister contents.
Solidification does not reduce the weight of the contaminated trash. A second concern is that infected whole blood that is solidified is not decontaminated or neutralized by solidifiers. As a result, the waste stream will still send contaminated waste into landfills. Directors must review and assess methods that will reduce the splash, odor and contamination problems associated with handling suction canister contents.
Is your facility charged by volume or weight, or both? Expect to pay two different rates for contaminated and non-contaminated waste. With the estimated cost of 40 cents per pound and an average weight of 8 pounds per canister, $3.20 does not seem to impact a multi-million dollar budget until the assessment is made. How many canisters are used daily? Do you use tandem set-ups? How much fluid do you use for ACLs and cysto cases? These considerations are compounded by the annual volume of the operating room. Arthroscopic procedures using high volumes of irrigants, which are common in outpatient surgery centers, produce much greater volumes of fluid wastes. Add to this the cost of red bags and boxes, and these expenses are significant.
Companies have developed various additives that congeal or solidify suction canister contents. This eliminates many of the hazards associated with the pouring of canister contents but it does not eliminate landfill contamination. Companies generally use plasma and not whole blood in their simulated operating room environments. The solidifiers have not generally been able to destroy viral and bacterial agents, thus keeping dangerous waste in a suspension. Contamination is then placed in a landfill.
The environmental impact of processing, hauling and disposing of medical waste has been a concern for many years. The EPA entered into a voluntary partnership four years ago with the American Hospital Association and its member hospitals to reduce overall hospital waste volume by 33 percent by 2005 and 50 percent by 2010.3
OSHA regulations, cost considerations and common sense have prompted more than two-thirds of all hospitals to use alternative methods for surgical fluids disposal.4 Many are using new technologies on the market to implement OSHA-mandated engineering controls for the safe disposal of fluid medical waste onsite. These systems use large reusable reservoirs or suction canisters to confine fluids prior to discharge into the sanitary sewer system. Unlike manual pouring, these systems do not expose HCWs to body fluids during disposal. In addition, infectious waste transportation and disposal costs are significantly lower with these systems.
Engineering controls that support onsite disposal of fluid waste present the least change for HCWs who pour fluids into hopper sinks. More importantly, these systems eliminate fluids close to the site of generation, thus protecting OR personnel, other employees and the public living downstream from the waste. These systems require an investment in capital equipment, ranging from a few thousand to several hundred thousand dollars depending on the system selected.
We are all part of the contaminated waste stream. It is rewarding to do your part in reducing waste while introducing new technology that improves infection control and staff safety and reducing costs.
Stanley R. Shelver, RN, MHA, is director of surgical services at Shawnee Mission Medical Center, in Shawnee Mission, Kan. Shelver was director of surgical services at Saint Luke's Hospital of Kansas City, Mo., from 1998 to September 2002.