Infection Control Today - 04/2003: Environmental Services

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 evengreater cost pressures for healthcare managers charged with disposal ofinfectious fluids, motivating many to seek new alternatives to past disposalpractices.

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 contaminated waste before it isshredded and compacted?

Trash and contaminated waste are a major concern and budgetary issue for youroperating room manager, 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 the past 10 years, a portion of my time andbudget has been to track and monitor trash and contaminated waste. As healthcareprofessionals, we have an obligation to remove the trash and waste from ourfacilities efficiently and as cost effectively as possible. Managementobjectives 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 cappedsuction canisters, added powders to congeal the canister contents or poured thesuction canister contents down the drain. When there have been limited disposaloptions available, healthcare providers have had to make the best choice fromlimited options. Given today's environment, with HIV and hepatitis raisingawareness of proper procedures for handling infectious fluids, pouring isclearly out of the question. The Occupational Safety and Health Administration (OSHA)essentially banned the practice when enacting the Bloodborne Pathogens Standardin 1991.¹ This standard requires the implementation of engineeringand work practice controls to eliminate or minimize occupational exposure tobloodborne pathogens, including those found in suction 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.

In February 2003, new regulations from the U.S. Department of Transportation(DOT) went into effect, requiring even more bulky and expensive packing ofinfectious 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 individualrigid packaging before being placed in red bags. Every suction canister must bewrapped with sufficient absorbent material to absorb the entire contents of thecanister before placing the canister in a rigid, watertight non-bulk outerpackaging.

Additionally, based on the regulation's weight limitations, no more than onefull 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 outerpackaging. Examples of non-bulk outer packaging include reusable plastic boxesor sealable cardboard boxes with heavy-duty liners.

Weight restrictions in the DOT regulations would not allow more than fourfull and wrapped 3,000cc suction canisters be placed in rigid, watertightnon-bulk outer packaging.

These new regulations have even greater impact on facilities using bulkpackaging for the off-site transport of regulated medical waste. Why? Becauseliquids must be packaged in rigid, watertight non-bulk outer packaging whilesolid regulated medical waste can simply be packaged in red bags beforeplacement in bulk outer packaging (e.g., caster carts or roll-off bins).

Obviously, the newly mandated packaging material and the increased weight andbulk created by the packing will greatly increase the disposal costs forinfectious fluid wastes.

The differing requirements for liquid and solid regulated medical wasteeffectively require facilities to segregate liquid and solid wastes. Segregationcan be avoided if all regulated medical waste is placed in rigid, watertightnon-bulk outer packaging; however, this adds significantly to the total cost ofregulated medical waste disposal.

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 is normal practice to pour the suction canistercontents into hoppers. The canister liners are then generally discarded with thered bag/contaminated waste and are then sealed in rigid boxes. Some hospitalssort trash into non-contaminated (plastic), non-contaminated "other"and contaminated/red bag trash. Where you work makes a difference in whatmanagers must do to avoid fines and litigation.

With each of these sorting processes, healthcare workers (HCWs) directlymanage trash and are exposed to potential contamination. If a determination ismade during the sorting process to collect non-contaminated items, oneconsideration that is especially appreciated by day care centers, kindergartensand pre-school programs is to donate the discarded prep kits (the clear plasticcontainers) for use as pencil boxes. This is just a small segment of tons oftrash that must be eliminated from the waste stream; however, the donation isgreatly appreciated by both the teachers and students.

In the past few years, states have imposed tariff and taxes on out-of-statetrash. The tariffs are 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 decreasing hauling costs are to microwave the trasheither in a unit the size of an 18-wheel tractor trailer and then grind andcompress the material so that it can be hauled at the lower, non-contaminatedrate. The Texas-based firm that provides this service also provides a mobilemicrowave, trash compactor unit. This is an option for multi-hospital systemswhere landfill rate costs have escalated and managers have had to develop costalternatives for a large-scale trash management program.

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.

Staff Protection

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.

Financial Impact

Is your facility charged by volume or weight, or both? Expect to pay twodifferent rates for contaminated and non-contaminated waste. With the estimatedcost of 40 cents per pound and an average weight of 8 pounds per canister, $3.20does not seem to impact a multi-million dollar budget until the assessment ismade. How many canisters are used daily? Do you use tandem set-ups? How muchfluid do you use for ACLs and cysto cases? These considerations are compoundedby the annual volume of the operating room. Arthroscopic procedures using highvolumes of irrigants, which are common in outpatient surgery centers, producemuch greater volumes of fluid wastes. Add to this the cost of red bags andboxes, and these expenses are significant.

Environmental Impact

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 2010.³

New Technology

OSHA regulations, cost considerations and common sense have prompted morethan two-thirds of all hospitals to use alternative methods for surgical fluidsdisposal.⁴ 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.

Engineering controls that support onsite disposal of fluid waste present theleast change for HCWs who pour fluids into hopper sinks. More importantly, thesesystems eliminate fluids close to the site of generation, thus protecting ORpersonnel, other employees and the public living downstream from the waste.These systems require an investment in capital equipment, ranging from a fewthousand to several hundred thousand dollars depending on the system selected.

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 ShawneeMission Medical Center, in Shawnee Mission, Kan. Shelver was director ofsurgical services at Saint Luke's Hospital of Kansas City, Mo., from 1998 toSeptember 2002.