By Stanley R Shelver, RN, MHA
Infectiousfluid waste disposal presents multiple challenges to healthcare managers --including control of infections and costs -- motivating many to seek newalternatives to past disposal practices.
Incineration costs continue to increase, as do annual license fees demandedby the Environmental Protection Agency (EPA). Your facility may use a locallandfill or you may have your contaminated waste hauled out of state at apremium cost. Does your facility provide cold storage for the waste before it isremoved? Can you afford to microwave your contamination before it is shreddedand compacted? Trash and contaminated waste are a major concern and budgetaryissue for operating room and infection control practitioner (ICP) and otherhealthcare administrators. This year may be the right time for you to considersome changes.
As an operating room director for a 640-bed, Level I trauma, tertiary-carereferral facility in Kansas City, my daily responsibilities include trash andcontaminated waste. There are three obligations in the management ofcontaminated waste: How is staff protected? What is the financial impact? Andwhat is the environment impact?
In the past, most hospitals and other healthcare facilities, including mine,poured all suction canister contents down the drain, but it was not anacceptable or enjoyable process. Given today's environment, with HIV andhepatitis raising awareness of proper procedures for handling infectious fluids,pouring is clearly out of the question. The Occupational Safety and HealthAdministration (OSHA) essentially banned the practice when enacting theBloodborne Pathogens Standard in 1991.1 This standard requires theimplementation of engineering and work practice controls to eliminate orminimize occupational exposure to bloodborne pathogens, including those found insuction canister waste.
Some facilities have disposed of infectious fluid wastes by having staff capsuction canisters, placing them into red bags and having them hauled away. Somehospitals have even placed red bags in boxes for removal by a waste hauler. Thisapproach obviously produces a large volume of red-bag waste that incurs highdisposal costs and eliminates reuse of canisters.
Based on where your facility is located, your choices may be dictated bystate, county and municipal regulations. In the past decade there has been adecrease in the number of facilities that incinerate their trash. Even thoughsome facilities may still incinerate, the regulatory controls will significantlylimit those facilities. The limiting factors include increased air qualitystandards, increased licensure fees and additional hauling and landfill fees.There are less expensive methods for waste removal. At many facilities, it isnormal practice to pour the suction canister contents into hoppers and use redbags and rigid boxes for the remainder of the trash. Some hospitals sort trashinto non-contaminated (plastic), non-contaminated "other" andcontaminated/red bag trash. Where you work makes a difference in what managersmust do to avoid fines and litigation.
With each of these sorting processes, healthcare workers (HCWs) directlymanage trash and are exposed to potential contamination. Some hospitals donatethe discarded prep kits to schools for use as pencil boxes, but that is only asmall segment of tons of trash that must be eliminated from the waste stream.
In the past few years, states have imposed tariff and taxes on out-of-statetrash. The tariffs is higher if contaminated waste is involved. For example,Oklahoma hospital trash that is hauled to Texas has higher tariffs than wastethat is processed and hauled within the state. Additional options for decreasinghauling costs are to microwave the trash either in a unit the size of an18-wheel tractor trailer and then grind and compress the material so that it canbe hauled at the lower, non-contaminated rate.
Even though there are two components of contaminated and non-contaminatedwaste products, let's turn our attention to the contaminated contents fromsuction canisters, which directly impacts nursing staff.
The weight and volume of the suction canister is the most significant item inthe contaminated waste stream. HCWs cringe at the task of pouring liquid waste-- as it splashes, the odor is unpleasant and the contents are aerosolized whenthe liquids are dispensed into the hopper. Countless resources have beenexpended to deal with this single item, including commercial products devised tosolidify the suction canister contents.
Solidification does not reduce the weight of the contaminated trash. A secondconcern is that infected whole blood that is solidified is not decontaminated orneutralized by solidifiers. As a result, the waste stream will still sendcontaminated waste into landfills. Directors must review and assess methods thatwill reduce the splash, odor and contamination problems associated with handlingsuction canister contents.
Isyour facility charged by volume or weight or both? Expect to pay two differentrates for contaminated and non-contaminated waste. With the estimated cost of 40cents per pound and an average weight of 8 pounds per canister, $3.20 does notseem to impact a multi-million dollar budget until the assessment is made. Howmany canisters are used daily? Do you use tandem set-ups? How much fluid do youuse for ACLs and cysto cases? These considerations are compounded by the annualvolume of the operating room. Add to this the cost of red bags and boxes, andthese expenses are significant.
Companies have developed various additives that congeal or solidify suctioncanister contents. This eliminates many of the hazards associated with thepouring of canister contents but it does not eliminate landfill contamination.Companies generally use plasma and not whole blood in their simulated operatingroom environments. The solidifiers have not generally been able to destroy viraland 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 medicalwaste has been a concern for many years. The EPA entered into a voluntarypartnership four years ago with the American Hospital Association and its memberhospitals to reduce overall hospital waste volume by 33 percent by 2005 and 50percent by 2010.2
OSHA regulations, cost considerations and common sense have prompted morethan two-thirds of all hospitals to use alternative methods for surgical fluidsdisposal.3 Many are using new technologies on the market to implementOSHA-mandated engineering controls for the safe disposal of fluid medical wasteonsite. These systems use large reusable reservoirs or suction canisters toconfine fluids prior to discharge into the sanitary sewer system. Unlike manualpouring, these systems do not expose HCWs to body fluids during disposal. Inaddition, infectious waste transportation and disposal costs are significantlylower with these systems.
Engineeringcontrols that support onsite disposal of fluid waste present the least changefor HCWs who pour fluids into hopper sinks. More importantly, these systemseliminate fluids close to the site of generation, thus protecting OR personnel,other employees and the public living downstream from the waste. These systemsrequire an investment in capital equipment, ranging from a few thousand toseveral hundred thousand dollars depending on the system selected.
My facility has adopted this advanced technology in which reuseable suctioncanisters are inserted into a machine. The HCW walks away and the machine doesthe rest. Three concerns are achieved: HCWs are protected, costs are comparable,if not less than what was paid to remove the volume and weight of the suctioncanisters, and the volume of waste going to the landfill is reduced. We havebeen doing our part to be stewards of our trust since 1999 by using a productmade by Dornoch Medical Company called the red-a-way system, and we are phasingin the company's newest technology, the Transposal system. We have found bothsystems to be employee focused, affordable and environmentally conscious.
We are all part of the contaminated waste stream. It is rewarding to do yourpart in reducing waste while introducing new technology that improves infectioncontrol and staff safety and reducing costs.
Stanley R Shelver, RN, MHA, is director of surgical services at SaintLuke's Hospital of Kansas City, Mo.