Medical Waste: A Review of the Essentials for the Infection Preventionist

By Karin Lillis

From a disease-transmission perspective, medical waste is one important topic that should be within the purview of the infection preventionist. It is well understood that the unsafe disposal of medical waste such as contaminated syringes poses public health risks. Contaminated needles and syringes represent a particular threat, as the failure to dispose of them safely may lead to dangerous recycling and repackaging which lead to unsafe reuse. Contaminated injection equipment may be scavenged from waste areas and dumpsites and either be reused or sold to be used again. The World Health Organization (WHO) estimated that, in 2000, contaminated injections with contaminated syringes caused 21 million hepatitis B virus (HBV) infections (32 percent of all new infections); 2 million hepatitis C virus (HCV) infections (40 percent of all new infections); and at least 260 000 HIV infections (5 percent of all new infections). In 2002, the results of a WHO assessment conducted in 22 developing countries showed that the proportion of healthcare facilities that do not use proper waste disposal methods ranges from 18 percent to 64 percent.

“Responsibility begins with CMS requirements as well as accrediting agency standards such as the Joint Commission,” says Phenelle Segal, RN, CIC, a Florida-based infection prevention consultant. “Specifically CMS §482.42 Condition for participation states that, 'The hospital must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases.'”

In addition, she says, the Occupational Safety and Health Administration (OSHA) requires that every facility that handles blood and other potentially infectious materials (OPIM) abides by the Bloodborne Pathogens Standard, 29 CFR 1910.1030 (and California OSHA’s Safety Order 5193). Segal emphasizes that healthcare facilities must maintain an exposure control plan (ECP), and the disposal of biohazardous waste should be included in that ECP.

“Whether addressed within the ECP or as a separate policy, it is also very important that facilities develop and institute a “regulated medical waste” policy that must be adhered to at all times,” Segal says. “Federal OSHA, the responsible agency, spells out very specifically in their definitions, what is considered 'red bag waste' and regulated medical waste. In addition, certain states have their own regulations apart from federal OSHA for example CAL-OSHA in California and they follow the federal regulations but may have their own state requirements too.”

According to the CDC, the definition of heavily soiled items is subjective and open to interpretation, but if items are visibly bloody or saturated with blood or OPIM, discard items in Regulated Medical Waste (RMW). If not visibly bloody, discard in regular solid waste. Regulated Medical Waste Container(s) are used for disposal of heavily soiled items (blood and OPIM). Biohazard Laundry Bin or impervious linen bags are to be used only if linen is heavily soiled with blood or OPIM.

The following are considered to be RMW or biohazardous waste:
- Cultures and stocks of infectious agents including:
• Cultures from medical/pathological laboratories
• Cultures and stocks of infectious agents from research and industrial laboratories
• Wastes from the production of biological; discarded live and attenuated vaccines
• Culture dishes and devices used to transfer, inoculate, and mix cultures
- Human pathological wastes including:
• Tissues, organs, body parts and body fluids that are removed during surgery or other medical procedures
• Specimens of body fluids and their containers
- Human Blood and Blood Products
• Liquid waste human blood
• Products of human blood
• Items saturated and/or dripping with human blood
• Items caked with dried human blood, including serum, plasma, and other blood components
 - Containers, which were used or intended for use in either patient care, testing and laboratory analysis or the development of pharmaceuticals that are saturated or caked with dried human blood including serum and plasma/other blood components
- Intravenous bags (particularly those that contained blood products) are also included in this category in some states, so check with your State agencies if they regulate OSHA requirements versus Federal OSHA
- Sharps
Sharps that have been used in patient care or treatment or in medical, research, or industrial laboratories including:
Hypodermic needles
Syringes (with or without the attached needle)
Pasteur pipettes
Scalpel blades
Blood vials
Needles with attached tubing
Culture dishes (regardless of presence of infectious agents)
Broken or unbroken glassware that were in contact with infectious agents, such as used slides and cover slips
Note that unused discarded sharps (e.g., suture needles, syringes) shall also be handled as RMW
- Surgery
Wastes from surgery or autopsy that were in contact with infectious agents, including soiled dressings, sponges, drapes, lavage tubes, drainage sets, underpads, and surgical gloves
Regarding disposal, here's a review of the proper method for each category:
- Cultures and Stocks: All cytology and histology slides will be disposed of as RMW
 - Pathological Wastes: Pathological waste generated in Histology and Cytology labs including tissue, cells, and specimen containers will be disposed in the RMW flow stream
- Human Blood and Blood Products: All items saturated with blood or body fluids shall be collected in approved biohazardous red bags and transported to the designated RMW holding / preparation area. Body fluids (such as urine and stool that contains blood) may be discarded in the sanitary sewer by pouring into toilet and personnel performing this task must utilize personal protective equipment (e.g. fluid resistant gowns, gloves, goggles or face shield.)
- Sharps
Sharps are placed in designated sharps containers (puncture and leak proof, color coded containers) which are readily available in all areas where sharps are utilized in the facility. Sharps containers are exchanged when they reach the fill line and must not be overfilled. Used sharps containers are collected, properly marked, packaged and transported to the designated RMW secure holding area within the Facility until pick-up by the Facility’s RMW vendor.

The Infection Preventionist's Role
The infection preventionist is a key part of the team that helps to develop, monitor and maintain a healthcare facility's regulated medical waste disposal program, says Lela Luper, RN, BS, CIC, infection prevention coordinator at Mercy Hospital Ada in Oklahoma. She also is vice chair of the Association for Professionals of Infection Control and Epidemiology (APIC)'s education committee, part of APIC's annual conference committee and a faculty instructor for its EPI courses.

“Yes, we do have a role. We need to be a part of the team and at the table to help determine where waste is generated and what we can do to help reduce the waste in a facility,” she says. That team is looking at how much waste a facility generates and turns around, which impacts the healthcare facility and dollars at the time of disposal.

“(The team) effort that involves infection prevention, environmental services and plant operations,” Luper says. “Some of the red-bag waste may need to be refrigerated or stored for a period of time. It's definitely a team effort. Nursing is also involved because at the bedside, you need to know how to get rid of that waste.”

Typically, the infection preventionist needs to know and distinguish different types of waste in his or her individual practice setting, Luper notes, as well as “how it is disposed of and how it applies in their setting. If it goes into the wrong stream,” Luper says, “and the facility is being charged by the container or the pound, it can result in excess charges.”

“The infection preventionist is not responsible for the entire program, but – depending on the size of the facility – he or she may be asked to wear different types of hats,” Luper says. “I'm familiar with some infection preventionists who wear the hat of IP and environmental care coordinator.”

Infection preventionists – especially in smaller hospitals – are key regulatory people, adds Richard Best, technical director and corporate director of OSHA compliance at Stericycle. “They are involved in almost every facet of regulated medical waste and other regulated items.”

Moreover, Segal notes, the infection prevention department is usually responsible for providing OSHA-required in-services (upon hire and annually). “It's important to incorporate regulated medical waste disposal as part of the OSHA requirements,” she explains.

“The two biggest concerns for infection preventionists regarding red bag waste is that the appropriate blood and OPIM materials go into the red bags. If they do not dispose of 'potentially infectious' materials appropriately and OSHA finds this to be an issue, the facility could be heavily fined,” Segal says.

Ultimately, whether or not infection preventionists have a say – direct or indirect – in cost-saving measures to cut down the amount of red bag waste “depends on how well their expertise is and whether the C-suite considers their input as valuable,” Segal says. “Infection preventionists are constantly looking for ways to cut costs. Wherever possible, they will advise administration and the appropriate departments of ways to cut down on red bag waste.”

“One of the challenges infection preventionists have is getting compliance from the staff they work with,” Best says. “Never-ending education is a challenge everyone faces.”

As Segal explains, “Many hospital employees are confused about what should or should not go into 'red trash bags or containers.' The go to the opposite extreme – generating unnecessary biohazardous waste which creates an environmental issue as well as a costly one for the facility, as the disposal of such by the appropriate companies creates huge costs.”

Segal continues, “I typically see red bag waste being over-generated rather than deficient in practice.  While OSHA clearly defines what should be disposed of in red bags, there are “always gray areas.”

One of the most common challenges she sees is a healthcare worker who is unsure about “a little blood on a gauze pad or Band-aid," she says. “It remains confusing to front-line staff as to what is considered blood-soaked and what is not blood-soaked.” Segal says that staff should be encouraged to ask “rather than just dump items into red bags.” She also sees a lot of regular trash – like plastic utensils and disposable lunch containers – and office items dumped into red bags if they are “within easy reach and convenient. This is a real issue and needs to be addressed often,” Segal says.

“Education is key in terms of reminding staff to look at the OSHA Bloodborne Pathogen Exposure Control Plan. The facility's medical waste disposal policy as both should address this,” Segal says.

The infection preventionist is responsible for ensuring such policies are well-defined. He or she must also ensure that red-bag waste disposal is monitored frequently during rounding, and that staff undergo a “sound education,” Segal says.

Adds Luper, “Education is ongoing. When we're bringing a co-worker on board, he or she is inundated with a lot of information – dos and don'ts, patient safety, environment of care, waste and how to handle it,” Luper says. “All the education you provide on hire has to be repeated.”

Like many other facilities, Mercy Health provides an illustrated chart placed above waste containers that outlines what should be deposited in red bags and what should not.

“A picture paints a thousand words. If you see that sign by a soiled container or a waste container, it's a visual reminder of where the waste needs to be disposed of,” Luper notes.

When something does go wrong, Luper says, “We can drill down and determine what areas we can focus on to improve. Again, it's constant retraining.”
One of the ways to have the biggest impact, Segal notes, is during unit and departmental rounds. For example, if an infection preventionist or another staff member notices that there are red bags in trash cans in areas where they are not necessary – like the nursing station or in patient rooms – they can address those issues at the time. There are at times “extenuating circumstances” that make it necessary for (red bag waste disposal) in a patient's room, Segal notes.

Healthcare Sustainability
Another aspect of addressing medical waste is through sustainability efforts, specifically recycling of items that can be diverted from the waste stream. According to Practice Greenhealth, U.S. hospitals produce more than 5.9 million tons of waste annually, a figure based on the amount of waste produced per staffed bed per day (33 pounds) for Practice Greenhealth award-winning hospitals and extrapolated to the number of staffed hospital beds nationwide. Reprocessing and/or remanufacturing can be a viable way to address the numerous single-use medical devices (SUDs) used in hospitals, with an approach that treats these SUDs as assets, not trash. Most SUDs cannot be used again; they must be thrown away or recycled. However, many SUDs can, with the right clinical and technical expertise, be remanufactured to perform at their original level for one or more additional uses.

Stryker Sustainability Solutions says it helps reduce 3,400 tons of medical waste per year and saves hospitals $6.5 in supply costs every second. "Infection preventionists should remember that some medical devices, while marketed by original manufacturers as “single-use," can be reprocessed by a regulated, third-party reprocessor," says Caryn Humphrey, RN, BSN, MBA, product manager for Stryker Sustainability Solutions. "Reprocessing can extend the life of a device and reduce the amount of waste entering our nation's landfills. Taking the time to educate staff about which devices can be reprocessed and how to follow proper collection protocols is a crucial step in ensuring that biohazard waste is handled appropriately. Reprocessing also helps hospitals minimize waste and maximize savings. In 2013 alone, Stryker Sustainability Solutions’ customers eliminated approximately 8.9 million pounds of medical waste from landfills."

Practice Greenhealth recommends that healthcare facilities can take a giant step toward improving their sustainability by first understanding how much waste they generate by developing a basic, quantitative waste baseline. The organization suggests that the facility designate a lead individual or group to gather waste invoices, tracking documents, contracts and other documentation to capture the volume and costs associated with waste removal. To simplify data collection, Practice Greenhealth says the healthcare institution should establish a system to collect and record six months' worth of data for all waste streams, including solid waste, hazardous waste, and recycled waste. It should also record data on waste diverted through reuse and donation programs because these can represent significant savings through avoided disposal costs.

Practice Greenhealth outlines methodologies for the following categories for waste data tracking:
1. Solid Waste: Gather invoices or talk to the facility’s waste hauler to figure out how many tons of solid waste is generated per month.

2. Regulated Medical Waste (RMW): RMW is usually charged by the pound and less often by the container. Add up the number of pounds removed and the associated costs, separating out any reusable sharps collection system. Pathological waste and residual/trace cytotoxic drugs may be included in these numbers. If you are treating this waste onsite (i.e. autoclave before landfill) you still need to track this waste steam; decreasing RMW will decrease your labor and energy costs to treat your waste, and reduce your landfill costs.

3. Universal Waste: If your facility is managing a portion of its hazardous waste stream as universal waste, most likely the vendor has detailed reports on the amount of material removed and the associated costs. Some facilities are charged per unit. In this case, weigh a sampling of the materials and multi­ply by the number removed. Organizations may be able to negotiate a price per pound in the con­tract or a reporting structure with the vendor. Universal waste requires special management and tracking requirements-less stringent than those for RCRA waste, but more stringent than other waste streams. Regulators may ask about proper labeling, storage and storage times for these waste streams.

4. Recyclables: While there often is much recycling going on in healthcare facilities, often there is little to no data. It’s important to track, even if roughly, the amount of recyclables removed from the facility. So whether it’s paper or corru­gated cardboard bales, pallets, electronics or mixed plastics, organizations should track the materials as it leaves the facility. You can weigh a sampling of bins or items and then track the number removed each week or make a conversion from un-compacted cubic yards to pounds.

5. Other Waste: Ask around to make sure you capture all other waste items including composted food waste, oil from the kitchen, landscaping debris, surplus equipment, empty tanks, pallets and furniture donations or bulky waste from an open box.

When it comes to compiling data, Practice Greenhealth advises, "Now that all of the information is gath­ered, it should be compiled to better comprehend the opportunities and assist with goal setting.  Some organizations develop tracking tools ranging from simple Excel spreadsheet to complicated databases to contractor-based tools. Make sure to utilize a mechanism that will allow you to regularly access and update the data. The collected data should be used to continuously track waste programs and enable performance tracking to demonstrate outcomes of various waste reduction or diversion activities. The collected data will allow the organization to do a basic gap analysis and can help plot the next stops of the organization’s waste reduction journey."

Karin Lillis is a freelance journalist. 

References

World Health Organization (WHO).Healthcare waste needs sound management, including alternatives to incineration. Fact sheet N0. 281. October 2011.

Practice Greenhealth. Developing a Waste Baseline. www.practicegreenhealth.org