Control of Infections in Liquid Waste Management

January 1, 2001

Control of Infections in Liquid Waste Management

By Pat Tydell, RN, MSN, MPH, and Jack Donaldson, RN, CNOR,
CSPDM


Disposal of fluids should always occur in a non-patient
area.

One of the most crucial issues facing hospitals and other medical facilities
today is protecting against disease transmission. Healthcare workers are often
exposed to hepatitis B virus (HBV), human immunodeficiency virus (HIV), and
other dangerous bloodborne pathogens on a daily basis. Through the institution
of safe work practices and engineering controls, healthcare workers' exposure
can be significantly reduced.

OSHA guidelines are clearly in support of standard precautions to treat blood
and other body fluids as if they were infectious for HBV, HIV, and other
bloodborne pathogens. The collection and disposal of biohazardous liquid can
pose a significant risk, bringing an untold occupational challenge to hospital
staff. From pathologic body sites, the microbial content of suction load may be
high and contain significant pathogens.1 Bacterial content of
abscesses can include Clostridium, Bacteroides, and Straphylococcus.
The respiratory tract can contain Streptococcus, Pseudomonas, Klebsiella,
Serratia,
and a variety of gram negative organisms. The female genito-urinary
tract can contain polymicrobial flora similar to that of the intestinal tract
plus Herpes virus.1 When healthcare workers come in contact with
these biohazardous fluids, reducing their exposure by minimizing splashing,
spraying, and splattering is critical.

One source of biohazardous fluids that healthcare workers come in contact
with on a daily basis is from suction canisters. The use of reusable and
disposable suction canisters in the healthcare community and medical industry is
widespread. The use of surgical and medical suctioning occurs in several areas
throughout the hospital. These areas include the emergency room, intensive care
units, oral surgery and obstetric departments and, most frequently, in the
surgical department. The use of suction canisters can include general patient
care areas as well.

Standard precautions is an infection control system that assumes that every
direct contact with blood and body fluids is a potentially infectious exposure.
This system is based on the premise that not all patients with bloodborne
infections have been diagnosed, and therefore, precautions must be applied.2

Handling of Suction Collection Canisters

Some products can inactivate a variety of bacteria and
fungi in suction canisters.

There are additional basic principles that should be followed for safe
handling of suction canisters to minimize the risk to healthcare workers.
Disposable units should be discarded when full or when removed from a patient.
Although many hospitals (approximately 80%) have switched to disposable suction
collection units, glass and metal units are still used. Some institutions have
converted partially and have both systems in use.1 As with the
suction canister itself, so too should the connectors and associated tubing be
disposable. Use of disposables reduces the handling of the contaminated
equipment by healthcare workers.

Care needs to be taken when removing the collection canister from the patient
care areas. Liquid contaminated waste needs to be carried out in a sealed
impervious container. Neither should the container be transported unless sealed
to prevent spillage or contamination of others en route to its final disposal
site. Once the protectively enclosed collector unit has reached a disposal area,
its contents should be disposed of according to policy. The disposal should
occur in a non-patient care area to avoid the contaminated aerosols generated by
the suctioning process. The personnel doing this should be gowned, gloved and
masked to protect against aerosolized contaminants, spillage, and splattering.

If the canister is reusable, additional care needs to be taken in order to
place the equipment back in service. Also, a clean unit should always be
available for back-up.

An engineering control system that helps reduce exposure to body fluids is
liquid medical waste solidification products. Liquid medical waste
solidification products have been used in the healthcare and medical industry
for over 12 years. Healthcare workers have benefited from the protection these
products provide including the elimination of spilling, splashing and
aerosolization. However, until recently, none of the solidification technologies
demonstrated the level of efficacy required by most states in order to convert
the infectious waste to a non-infectious state and ultimately be disposed of in
the white bag waste stream.

Unfortunately, there were solidifiers that received approval in some state
agencies based on limited efficacy studies for landfill disposal. However, they
were later determined to be ineffective treatment technologies and ultimately
lost their approvals.

The disposal of medical waste is regulated on an individual state basis.
Accordingly, not all the states have the same efficacy requirements. It is
important to note, however, if a technology is approved by a certain state as an
Alternate Medical Waste Treatment Technology. It has to be registered with the
United States Environmental Protection Agency before it can be marked and sold
in that state.3

Conversely, just because a solidification product obtains an US EPA
registration, it does not mean it automatically becomes a countrywide-approved
Alternate Treatment Technology. The product must still demonstrate the efficacy
required within the state it plans to sell in.

If this process sounds confusing--you're right. However, in order to assist
manufacturers through this process several state agencies formed a committee
called State and Territorial Association on Alternate Treatment Technologies
(STATT)4. This committee developed a guidance document for evaluating
Alternate Technologies that have been registered with the US EPA as a chemical
treatment product. In addition, Underwriters Laboratories Inc. (UL) has
initiated the development of a standard. UL, through the Accredited Organization
Method of American National Standards Institute (ANSI) is seeking recognition of
this standard as an American National Standard.

Scope

The scope of the standard is as follows. The standard is intended to
determine whether individual equipment or systems provide for microbial
inactivation and reduction of the risk of injury to persons and damage to
property related to their use.

  • These requirements cover the construction, performance and maintenance of
    technologies employed as an alternate to incineration for the disposal of
    medical waste.
  • Alternative medical waste treatment technology--as covered by these
    requirements--consists of various methods of microbial inactivation through
    the individual or combined use of heat generated by assorted media,
    chemicals and irradiation. It includes pre-and post-processing systems
    required to be used with the treatment technology.
  • These requirements do not cover incinerators or any other equipment
    covered in whole or as part of a separate, individual requirement. In
    addition, the requirements do not cover:

a. Hazardous waste identified or listed in 40 CFR Part 261.
b. Radioactive waste defined and regulated by the Nuclear Regulatory
Commission.
c. Domestic sewage materials identified in 40 CFR 261.4(a)(1).

A product that contains features, characteristics, components, materials or
systems new or different from those covered by the requirements in this
standard, and that involves a risk of fire, electric shock, or injury to persons
shall be evaluated using the appropriate additional component and end-product
requirements to determine that the level of safety, as originally anticipated by
the intent of this standard, is maintained.

A product whose features, characteristics, components, materials, or systems
conflict with specific requirements or provisions of this standard. Where
considered appropriate, revisions of requirements shall be proposed and adopted
in conformance with the methods employed for development, revision and
implementation of this standard.

OBF Technologies' mission was to develop a product that would demonstrate the
required efficacy as set forth by STATT and meet the proposal standards for
Underwriters Laboratories, while keeping in balance with the environment.

In 1997, OBF Technologies developed the first protocol for a Sanitation/
Solidification product to be approved by the US EPA and subsequently received
official registration from the US EPA March 7, 1997. EPA registration number
59839-1.

A widely used cold sterilant--known for demonstrating the high-level of
efficacy (sterilization) when challenged by the most virulent organism--is
glutaraldehyde. After several years of research and development, the company
converted liquid glutaraldehyde into a patented dry crystal. This process allows
the liquid glutaraldehyde to become encapsulated within a prilled silica crystal
and is only released when it comes into contact with the liquid waste inside the
suction canister. This technology allows the end user to benefit from the high-
level of efficacy demonstrated by the dry glutaraldehyde crystal while
minimizing the risk commonly associated with liquid glutaraldehyde. By combining
the dry glutaraldehyde crystal with a fast and encapsulating group of acrylic
polymers, the company developed new technology called PremiCide.

PremiCide is a suction canister sanitation and solidification system that
allows for transport, storage, and disposal of sanitized medical waste.

The efficacy demonstrated by PremiCide includes a 410 log reduction of the Bacillus
subtilis
spore and 610 log Mycobacterium Phlei in 100% whole blood
serum. In addition, it inactivates non-sporulating gram positive bacteria,
fungi, non-sporulating gram positive bacteria, and crystals.

It is manufactured in single-use (unidose) sizes to sanitize all suction
canister volumes. A patented closed delivery system called PremiGuard brings
added safety to the treatment, handling, and disposal of liquid laboratory,
human and animal waste.

The closed delivery system allows the treatment of infectious liquids to
occur within the sealed collection canister, eliminating unnecessary chemical
spills and potentially hazardous aerosolization and splashing of the infectious
collected waste fluids. The cap was designed to fit most suction canister lids
and can be used with or without suction.

To ensure the safety associated with the use of this solidification and
treatment product, the company conducted several environmental studies and
personal safety studies concluding that when used according to directions of
use, the product does not qualify as a hazardous waste and the occupational
exposure level to the dry glutaraldehyde is below recognized exposure limits. In
addition, a LD 50 Acute Dermal Toxicity Study demonstrated an undetectable level
of toxicity according to the procedure listed in the TSCR guidelines, 40 CFR
Part 798.

Pat Tydell, RN, MSN, MPH, is the Risk Manager at North Chicago Veterans
Administration Medical Center (VAMC) in North Chicago, Ill.

Jack Donaldson is the Nurse Manager of Sterile Processing at Sutter
Medical Center in Sacramento, Calif.

References

1 Neblett, Thomas R. Ph.D. "Characteristics of
Medical and Surgical Suction Systems. The Microbiology and Nosocomial
Hazards of Collection Vessels." Published monograph of research
conducted at Biosan Laboratories, Inc. 10657 Galaxie Ave. Ferndale, Mich.
48220.

2 Goodman, Terri, RN, MA, Ph.D. "Control of
Infections Related to Bloodborne Pathogens." Infection Control
Today.
June, 2000.

3 Ng, Rebecca, BS, REHS. "Medical Waste Disposal
Training and Audits." Infection Control Today. November, 1999.

4 Underwriters Laboratories, Inc. "Standard for
Safety for Alternative Technologies for the Disposal of Medical Waste-
UL2334." www.UL.COM/epn/medwaste.htm.

5 OBF Industries, Inc. www.enviro-safe.com


OBJECTIVES

  1. To identify the difference between safe work practices and
    engineering controls related to handling and disposal of infectious
    liquid waste.
  2. To recognize the regulatory problems of handling and disposing of
    infectious liquid waste.
  3. To list the advantages of one liquid waste solidification product.

TEST QUESTIONS

True or false:

  1. Body fluids are treated as potentially infectious biohazards.
  2. Exposure to potentially infectious body fluids can occur by
    splashing, spraying, splattering or aerosolized droplets.
  3. The use of suction canisters as a source of exposure to infectious
    body fluids is limited to mainly the surgical department.
  4. Standards precautions is a safe work practice.
  5. Safe work practices for handling and disposing of infectious liquid
    wastes includes gowning, gloving and masking.
  6. Reusable suction canisters decrease a healthcare worker's exposure
    to infectious liquid wastes.
  7. An engineering control system to reduce a healthcare worker's
    exposure to infectious liquid wastes includes a liquid medical waste
    solidification product.
  8. The principle behind this control is to convert infectious waste
    into a non-infectious solid waste.
  9. This technology is heavily regulated by local, state, and federal
    agencies.
  10. Underwriters Laboratories has developed a standard it hopes to have
    recognized as an American National Standard.
  11. Underwriters Laboratories standard scope is limited to incineration
    of liquid wastes.
  12. One product used to sterilize and solidify infectious liquid waste
    is called PremiCide.
  13. The chemical used in this product to sterilize the infectious liquid
    is cyanide.
  14. Use of this product allows the facility to dispose of its infectious
    liquid waste through the white bag disposable stream.
  15. The disposal of medical waste is regulated by each state.

1. T
2. T
3. F
4. T
5. T

6. F
7. T
8. T
9. T
10.T

11. F
12. T
13. F
14. T
15. T

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