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In these days of increased environmental awareness, more healthcare workers want to reduce waste. Infection control, however, poses a challenge because standards of what can be recycled become stringent and chances can't be taken. When medical waste must be disposed of, what happens to it and where does it go?
Every facility staff has its own answers. Practices differ, and state regulations do too. Even the definition of medical waste invites interpretation.
The Medical Waste Tracking Act of 1988 defines medical waste as "any solid waste that is generated in the diagnosis, treatment, or immunization of human beings or animals, in research pertaining thereto, or in the production or testing of biologicals."¹ This definition includes, but is not limited to:
culture dishes and other glassware
discarded surgical gloves
discarded surgical instruments
discarded needles used to give shots or draw blood
cultures, stocks or swabs used to inoculate cultures
Medical waste falls into one of four categories: infectious, hazardous, radioactive, and "other."¹ Infectious, hazardous, and radioactive materials represent only a small portion of all medical waste, but attract the most concern. The Environmental Protection Agency (EPA) estimates that infectious waste constitutes between 10 percent and 15 percent of the medical waste stream.¹ Most is packaging, food stuffs, etc. and is similar to that which is generated by any public facility such as schools.
The operating room (OR) presents great opportunity for reduced waste, as it is among the largest waste generators, says Janet Brown, partner program manager for the non-profit organization Practice Greenhealth! (formerly Hospitals for a Healthy Environment—H2e). Practice Greenhealth! provides resources to integrate green strategies in healthcare.
Regulated medical waste can be dramatically reduced through fluid management and improved segregation, Brown says. Otherwise, it typically ends up in a landfill, autoclave or incinerator. As for solid waste, it can be in the form packaging, medical devices, papers, food, plastics, and may or may not be recycled. Typical recycling processes are for it to be segregated, picked up by a contractor, repacked or relabeled, sent to a commodity broker and then turned into new things.
Recycling is even more optimal in certain regions, as some states have extremely limited landfill space. "In New York City, for example, there is no landfill for metro area waste and it is all trucked somewhere else," Brown says. "New York City hospital waste has gone, over the years, to Ohio, North Carolina, Pennsylvania, Virginia and New Jersey, to name a few."
At St. Luke’s Hospital in Chesterfield, Mo., the OR waste disposal process starts with readily-available red bags, says Joan Jenne, RN, BSN, CIC, infection control coordinator at the facility. Small and large bags are available in the OR and soiled-utility area. St. Luke’s authorities contract with a service that picks up red bag waste; the materials are then sterilized and shredded before final disposal.
To ensure bloodborne pathogen safety, bio-hazardous waste needs to be regulated. However, Jenne states, "Healthcare facilities as a whole need to be conscientious of the burden of waste when looking at and selecting products. There are so many factors to consider—patient safety, healthcare worker safety, and the end of the process, environmental safety."
At Moffitt Cancer Center and Research Institute in Tampa, Fla., biohazardous waste is collected at the point-of-use site, including the bedside, exam room, OR suite, etc., says Tom Cayce, manager of environmental services at Moffitt.
The containers are removed when they become full, or at set intervals during the day. The waste is taken to a soiled-utility room and placed into a larger movable container with a lid. These containers are removed from the soiled-utility rooms at predetermined times throughout the day and are taken to the containers of a regulated medical waste hauler. The Moffitt team recently audited its facility’s waste stream when it partnered with Waste Management, Inc.
"They took a look at our process to help us reduce bio-hazardous waste," Cayce says. "By reducing our bio-hazardous waste we have increased our general waste and in turn have found more opportunities to add to our recycling program initiatives."
Cayce’s biggest advocate in this process is a senior nurse and epidemiologist who helps him improve the system. At Moffitt, there is a great relationship between infection control and environmental services. This is an integral part of an effective waste removal program.
At St. Luke’s, the staff uses Stericycle for waste hauling and disposal and does not use boxes or tubs, says Jenne’s colleague Darrel Hicks, director of environmental services at the facility.
All the red bags are placed in 2-cubic-yard plastic carts on wheels, Hicks says. The carts have lids with a gasket to prevent leaks in case they are overturned. When the carts are filled with red bags they are taken from the hospital to a facility where they are mechanically emptied, dumped, washed and returned.
"The waste is fed into a steam autoclave where it is melted, unrecognizable and rendered innocuous," Hicks says. "It comes out of the steam autoclave as a liquid ooze that is landfilled."
The St. Luke’s crew uses Stericycle for sharps disposal. Every patient room in this 500-bed hospital includes a mounted reusable sharps container. A worker services the facility three times a week, checks wall-mounted containers and replaces those that are 50 percent or more full with an empty one.
"They, too, are taken to the same facility where the containers are emptied of their contents, washed, sanitized and returned to us," Hicks says. The syringes and needles are melted until they’re unrecognizable (except for the steel needle) and are rendered innocuous. Like red bag waste, the syringes leave the steam autoclave as a ‘liquid ooze’ that is sent to a landfill.
At Stanford University Medical Center (SUMC) in Palo Alto, Calif., there is an expansive surgical services program that completes more than 24,000 cases per year through Stanford Hospital & Clinics and Lucile Packard Children’s Hospital. SUMC leaders have been able to reduce the amount of waste they send to the landfill, while keeping high standards of infection control, says Krisanne Hanson, project manager for the general services division.
Within the shared main OR setting, sterile materials and waste are moved in two separate elevators, which reduces the chance that sterile supplies will be contaminated. The infection control managers at SUMC ensure that the facility is in compliance with all regulatory requirements for the handling of regulated medical waste.
After each surgery the case carts, soiled linen, solid waste and regulated medical waste (RMW) are sent down the dedicated soiled elevator and enter the dirty side of the sterile processing department. The bags of case-waste are segregated at this time. The solid waste in clear bags is placed in large bins that end up at the landfill. RMW, on the other hand, is placed in lidded, 96-gallon, red "Toter®" containers.
"These containers are on wheels and have been customized with metal rods on the front, which benefit housekeeping operations two-fold," Hanson says. "First, they can be connected together allowing one employee to pull several carts at a time from the biohazardous waste holding area to the dock for on-site autoclaving, or steam sterilization. Second, the customized Sanipak installation has a lifting device which grabs the metal rod and tips the container directly above one of three, lined and ‘tipped up,’ Sanipak treatment chambers."
This allows the individually tied-off red bags to fall inside a chamber-size autoclave bag. Once the chamber is full (three "Toters" of material with total weight of approximately 350 pounds), the chamber is lowered via the control panel to a level position, the autoclave liner is tied off and the chamber is closed and secured, Hanson says. Finally, the housekeeping specialist and trained operator enter codes that are required to begin each specific chamber’s autoclaving operation.
"The control panel monitors and records each chamber’s operation to verify California-state required temperature of 250 degrees F is reached and time at temperature of at least 30-minutes is held," Hanson says.
Once the treatment cycle is complete, the housekeeping operator allows the chamber to cool down. The chamber releases the treated bag of waste onto a conveyor system and deposits the material directly into a connected compactor. This compactor is taken to a local transfer station and ends up at the local landfill.
"The transfer station and landfill staff is knowledgeable on the look and shape bags of autoclave-treated medical waste take on," Hanson says. "For waste streams, which by state regulation cannot be autoclaved, Stanford University Medical Center contracts with an off-site treatment company." They also partnered with Daniels Sharpsmart in 2005 for reusable sharps container and pharmaceutical container services. More than 2,100 containers are checked and changed regularly.
A hazardous waste specialist through the department of environmental health and safety at SUMC oversees compliance with the medical center’s medical waste management plan.
Many facility staffs find suction canisters to be useful tools for reducing the amount of waste that goes to landfill. A single knee surgery, for example, has the potential to generate as many as 10 suction canisters, and this liquid can be sent right down the drain and into the sewage system (though standards do vary depending on location).
To simplify disposal of liquid regulated waste, St. Luke’s converted house-wide to a suction canister system that allows mechanical disposal of the waste and subsequent cleaning and disinfection of the canister. The Dornoch Medical System is efficient and reduces workers’ exposure to body fluids, Jenne says.
"We found it to be a win-win," she adds. "Canisters are collected in the department’s designated area where environmental services transports them to the processing area. Soiled canisters are replaced with (a) clean one and new lids. Lids and tubing are not recycled."
Hicks says the system mechanically empties used canisters, washes them with an enzymatic detergent and sanitizes them with a bleach solution. It takes about three minutes for a load of two canisters. St. Luke’s has two machines that handle a load of 130-plus canisters per day.
"It saves the hospital $30,000 to $45,000 per year by taking them out of the RMW stream, meets OSHA’s bloodborne pathogen standard (for engineering controls) and reduces the amount of waste on the highways," Hicks says.
SUMC installed a similar system, Neptune by Stryker, in their ambulatory surgery center in 2003 and have six machines in operation.
Many facilities use solidifying agents that turn liquid into jelly-like solid material so that it is contained better and is less dangerous during the transport process. Practice Greenhealth!, however, does not recommend this practice, as it requires purchase of solidifiers and does not reduce the volume of waste.
"We advocate for the fluid management systems that both eliminate multiple suction containers and take the fluid right to the sewer," Brown says. "This is safer and less expensive, but you do have to check with the local sewer authority. If you (solidify waste, it) has to be treated either through incineration or alternative methods."
Federal agencies that regulate medical waste include the EPA, the Occupational Safety and Health Administration, and the U.S. Department of Transportation. The Centers for Disease Control and Prevention provides guidance, but not regulation.³ State government agencies include the health department and environmental protection departments.³
The majority of medical waste generated in the United States is regulated at the state and local level, and state regulations usually cover potentially-infectious medical waste.¹ Some waste is subject to federal regulations, however, such as any that contains mercury or radioactive isotopes.
Standardization among states for consistency, simplicity and practicality would be helpful, Jenne says. "The key to standardization is input from the users, experts and stakeholders of waste management — infection control, safety, environmental services and OR leadership."
Brown believes that it would be great if there were a national definition of RMW.
"This would certainly make it easier for hospitals, especially those that transport their waste to another state for treatment and disposal," Brown says.
According to the authors of a paper, "Syringes in the sea: why federal regulation of medical waste is long overdue," a uniform federal system should specify minimum standards for handling, disposal, and treatment. It should also call for nationwide tracking, create a regulatory framework for individual sources of medical waste, and impose civil and criminal liability for individuals who violate medical waste regulations.4 "If we cannot muster the political will to tackle medical waste regulation today, thousands of Americans may pay for our failures with their lives," the authors write.
All medical waste should be subject to increased federal regulation which would ideally be aimed at simplifying processes, says Chryssa Deliganis, JD, an author of the paper and a partner at Calandrillo & Deliganis. "Fortunately, in recent years many states have increased their regulation of medical waste, but this has resulted in a patchwork of regulations which could encourage dumping and other abuses in less regulated states," Deliganis says.
She contends that uniform regulation would provide for tracking of medical waste across the country. "I think this is extremely important," Deliganis says. "Just as law enforcement officials have long sought a nationwide database for tracking violent offenders, our efforts to properly dispose of medical waste are seriously compromised by the fact that we can’t be sure of its final destination once it passes from one state to another (possibly un- or under-regulated) jurisdiction."
She suggests that uniform federal regulation could address the problem of individual generators of medical waste. "Although some jurisdictions do a great job of collecting used sharps and providing for their disposal, far more have never addressed the issue at all," she says.
Deliganis does not want all power in federal hands, however. She notes that states should have the freedom to create practical, custom-tailored solutions. "I think states should be encouraged to handle medical waste as they see fit as long as certain minimum standards are met and there is cooperation in terms of tracking, etc.," she says. "I view the states as ‘laboratories of change’ and welcome experimentation, which can only help us to determine which methods of regulation are most effective and efficient. In my view, federal regulation ideally would not replace state laws, but would streamline their implementation across state lines and otherwise coordinate the efforts of different jurisdictions."
History of Medical Waste Regulation
After medical waste washed up on several East Coast beaches, concern over the potential health hazards prompted members of Congress to enact the Medical Waste Tracking Act (MWTA) of 1988.² This act amended the Solid Waste Disposal Act, defined medical waste and established which medical wastes would be subject to program regulations. It also created a ‘cradle-to-grave’ tracking system that included tracking forms.² The act required management standards for segregating, packaging, labeling and storing medical waste, and established penalties for mismanagement.²
In 1990, MWTA authorities required EPA representatives to examine various treatment technologies and rate them on their ability to reduce disease-potential of medical waste. The EPA examined incinerators and autoclaves (onsite and offsite), microwave units, and various chemical and mechanical systems.²
The EPA concluded that the disease-causing potential of medical waste is greatest at the point of generation and naturally tapers off after that point. Therefore, the risk to healthcare workers and others who are occupationally exposed to the waste early on are at a much greater risk than the general public.²
Educating healthcare employees about how to sort and treat waste is extremely important. At St. Luke’s Hospital, all employees receive orientation about correct procedures, Jenne says.
"Compliance is usually connected to knowledge or orientation of the process," Jenne says. "Noncompliance may indicate that it’s time to look at the process or the education cycle. Is it a systems failure or is it time to creatively reinforce in some form of education that is both interactive and fun? Many times we include waste management in our selected ‘safety fair’ topics."
Proper training, staff education, material monitoring, ongoing ‘rounding’ and inspections are critical in all treatment options, whether onsite or offsite, according to Brown. Numerous healthcare facilities continue to red bag OR waste in excess or in entirety, and should address this issue by conducting a walk-through of ORs.
Facility leaders should review the facility and strive to understand the various waste streams. Working with infection control personnel, they can determine proper definitions, standardize containers, make labels, develop policies, identify vendors, try new systems, etc., Brown says.
Staffs should take a multi-pronged approach to RMW reduction. They can start by increasing their recycling initiatives, improving their segregation of RMW, transitioning to reusable sharps containers, and implementing suction canister fluid management systems and reusable sterilization containers.
"The cumulative effect of these various initiatives results in worker safety, cost savings and waste reduction," Brown says.
For information on state specific medical or biomedical waste requirements, visit the EPA’s state medical waste programs and regulations page at: www.epa.gov/epaoswer/other/medical/programs.htm
2. U.S. Environmental Protection Agency. H.R. 3515 Medical Waste Tracking Act of 1988.
3. Sehulster L. Division of Healthcare Quality Promotion. Medical Waste Management in the Bioterrorism Era. Centers for Disease Control and Prevention.
4. Deliganis CV and Calandrillo S. Syringes in the sea: why federal regulation of medical waste is long overdue. Georgia Law Review. Vol. 41, pp. 169-227. 2006.