Volume 14, Issue 1 Spring 2012

Hazardous Drugs Rule is on the Street 1

Sewering Slide Stain Washes: When You Can and When You Can’t

2

Disposal of Bulk Beckman-Coulter Analyzer Reagents

3

Cutting Operating Costs by Reducing Waste

4

Inside this issue:

Hospital Waste

Our firm…

H ospital Waste Man-agement is committed

to assisting healthcare facilities in complying with hazardous material management and waste disposal regulations and better managing their wastes. Our clients are hospitals, clinics, and medical labs.

Our services include con-ducting dangerous, solid, radio-active, and regulated medical waste audits; risk assessment; hazmat audits; developing waste management plans for Joint Commission compliance; haz-mat emergency response train-ing; and annual dangerous waste and Pollution Prevention reporting.

Our e-mail address is: Al-anBJones@frontier.com. For past Hospital Waste issues, check our website at http://www.hospitalwastemgmt.com.

“Helping Hospitals Manage Waste”

L&I Hazardous Drugs Rule Is On the Street

Hospital Waste Management

W ashington Labor & Indus-tries’ (L&I) Hazardous Drug

Rule (WAC 296-62-500, Part R—Hazardous Drugs) is finally on the street. It promises to change the way hospitals and some retail pharmacies manage chem-otherapy, hormone-mimicking and other drugs labeled as hazardous by the Nation-al Institute of Occupational Safety & Health (NIOSH) at the Centers for Dis-ease Control.

You can download a .pdf copy of the new rule by simply typing “Part R Haz-ardous Drugs” into your browser.

The rule seeks to minimize exposure of healthcare employees to hazardous drugs. It requires each health care facility to de-velop and implement a written hazardous drugs control program. The program must include:

• A written inventory of hazardous drugs,

• A hazard assessment for which there is reasonably anticipated occupational exposure,

• Policies and procedures including: ◊ Engineering controls, ◊ PPE, ◊ Safe handling practices (receiving

and storage, labeling, preparing, adminis-tering and disposing of hazardous drugs),

◊ Cleaning, housekeeping and waste handling,

◊ Spill control, ◊ Personnel issues (e.g., pregnant

workers), and ◊ Training.

Positions potentially covered by the program include pharmacists, physicians, nurses, OR staff, home health workers,

veterinarians, environmental services and receiving/warehouse staff.

Each facility must conduct hazard as-sessments to determine appropriate pre-cautions to be taken. The assessments must include:

• PPE, • Engineering controls, • Physical layout of work areas, • Types of drugs handled, • Volume, frequency, packaging and

form of drugs, • Equipment maintenance, • Decontamination and cleaning, • Waste handling, • Potential hazardous drug exposures

during work operations, and • Spill response. Representatives from several large

healthcare systems in Washington worked with L&I last fall to amend some of the most onerous provisions of draft versions of the new rule, which is based upon NIOSH’s 2004 Hazardous Drug Alert. One of the elements that concerned most reviewers were engineering controls, par-ticularly ventilated cabinets. The final rule is much more flexible in safety cabinet design and ventilation requirements.

Ventilated cabinets must use outside exhaust, be equipped with a continuous airflow monitoring device, must have fil-tering (HEPA) media and—where feasi-ble—exhaust 100% of the filtered air to the outside. Cabinets that recirculate air inside the cabinet or exhaust into the room are not allowed.

Medical surveillance—an early provi-sion which threatened to cost facilities a

(Continued at bottom of page 2)

Hospital

Waste

“Helping Hospitals Manage Waste”

Publisher: Alan B. Jones, Ph.D.

Hospital Waste Management 17629 N.E. 138th Street

Redmond, WA 98052-1226

Hospital Waste is published quarterly for hospital, clinical, and medi-cal laboratory waste managers.

Hospital Waste Management is committed to serving the Healthcare Industry by assisting hospitals in manag-ing their waste. Hospital Waste aims to broadcast information about waste regulations and waste manage-ment initiatives and to provide helpful hints and general waste information to healthcare waste managers.

If this newsletter has reached you in error, please notify the Editor by phone, fax, or e-mail. If you wish to be placed on our quarterly mailing list, please con-tact the Editor. For past issues and an index of articles, check our website at http://www.hospitalwastemgmt.com.

This newsletter is copyrighted by Alan B. Jones. Reprints are en coura ged wi th acknowledgement to Alan B. Jones, Ph.D. Please send any letters or comments to:

Alan B. Jones, Editor Hospital Waste

17629 N.E. 138th Street Redmond, WA 98052-1226

Ph: (425) 883-0405 Fax: (425) 895-0067

E-mail: AlanBJones@frontier.com http://www.hospitalwastemgmt.com

Our Editorial Policy While every effort was made during the development of this newsletter to insure accuracy, we make no warranties or cer-tifications. We encourage you to contact the references listed in the articles or Alan B. Jones for further information about any topic mentioned in this news-letter.

PAGE 2 HOSPITAL WASTE VOLUME 14 , ISSUE 1

H ospital clinical labs stain slides of patient tissue to

better assess disease. When the stain has done its job the excess stain must be washed off. Frequently, slides are arranged on a metal slide rack and the rack positioned under a faucet above a sink to thoroughly rinse the excess stain. Because washing is a part of the process, dilution may legitimately reduce the hazard to a point below sewer pretreatment discharge thresh-olds.

Sometimes you can sewer this stain wash and sometimes you can’t.

One of the best sources of infor-mation on this subject is the King County Laboratory Waste Manage-ment Guide by Dave Waddell [www.labwasteguide.org] in Appen-dix C: Proper Disposal of Fixatives & Stains.

Generally, the guidance in Ap-pendix C of the Laboratory Waste Management Guide is applicable across Washington, but you should confirm your assessments with your local wastewater treatment officials if your facility is outside King County (enter your community name and the words “sewer agency”).

The first step is to designate your waste; i.e., determine what hazardous components are in your stain(s) and their pretreatment discharge thresh-olds. Discharge thresholds for vari-ous chemicals are listed in the Dan-gerous Waste Regulations (DWR),

WAC 173-303-90 and -100. You can find the DWR online at http://www. ecy.wa.gov/biblio/danghazwaste.html

If your stain’s only hazardous com-ponent is alcohol and designates as flammable (D001), it is possible to dis-charge the wash to the sewer provided the wash is collected in a tub placed in the sink below the slides. When full of slide wash, the tub can be tipped and emptied to the sewer (collecting the wash will reduce the alcohol concentra-tion to below the 24% threshold). The tub is required; you may not simply rinse the excess stain directly into the sink.

Slide stain washes that contain sodium azide or picric acid cannot be sewered because they form explosive salts by contact with metals. Chromi-um, silver and cadmium solutions can-not be diluted sufficiently to be sew-ered. Their washes must be captured, barreled, and managed as dangerous waste using a vendor to haul it offsite. Other waste parameters such as pH and solubility (e.g., grease), must be checked and, if necessary, adjusted be-fore discharge.

Sewer limits for pH, total organic carbon (TOC), total organic loading rate (TOLR) and some other wastewater parameters vary considerably from one jurisdiction to another. It is important that you contact your local wastewater treatment officials and learn any re-strictions that apply to your facility.

Sewering Slide Stain Washes: When You Can and When You Can’t

great deal of money—has been re-moved from the final rule.

Training for all employees with occupational exposure must be pro-vided at the initial job assignment and regularly afterwards.

Written control programs must be completed and implemented by Janu-

ary 1, 2014. Appropriate ventilated cabinets must be installed by January 1, 2015.

L&I will establish a hazardous drug advisory committee consisting of healthcare employer and employee rep-resentatives and agency staff to discuss issues related to the rule.

PAGE 3 HOSPITAL WASTE VOLUME 14 , ISSUE 1

Many clinical laboratories use one or more Beckman Coulter analyzers to test blood and urine. Some of this reagent remains in the plastic cassettes after they’re used. If you plan to recycle the cassettes, the left-over reagent is waste and must be managed as such. Some can be dis-posed of directly into the sewer, but much cannot. The following is a guide to the disposal of excess Beckman-Coulter reagents.

Reagent Hazardous Criteria Disposal ALBm Corrosive; Acet¡c acid; DW Vendor pH=5.3 TPm Corrosive; NaOH; DW Vendor pH=12.8-13.0 CREm Corrosive; NaOH; DW Vendor pH=12.8-13.3 BUNm None Sewer CO2 Acid Corrosive; H2SO4; DW Vendor pH=1.2-1.8 PHOSm Corrosive; H2SO4; pH=1.0 DW Vendor Wash Concentrate II Corrosive; KOH; DW Vendor pH=12.73 ISE Buffer None Sewer CO2 Alkaline Buffer None Sewer ISE Reference None Sewer LX No Foam None Sewer CCWA None Sewer Sodium Hypochlorite None Sewer DIL1 (Diluent 1) None Sewer MG (Magnesium) Corrosive; pH=3.5 DW Vendor TBIL (Total Bilirubin) None Sewer DBIL (Direct Bilirubin) Corrosive; HCl; DW Vendor pH=1.3-1.7 Iron/IBCT Calibrator Corrosive; HCl; DW Vendor pH=1-2 GLUCm (Glucose) None Sewer ACTM Sodium Azide (0.1%) DW Vendor ALP (Alkaline Phosphatase) None Sewer ALT Sodium Azide (0.1%) DW Vendor AMM (Ammonia) None Sewer AMPH Sodium Azide (0.1%) DW Vendor AMY7 (Amylase G7) Sodium Azide (0.1%) DW Vendor AST Sodium Azide (0.1%) DW Vendor BARB (Barbiturate) Sodium Azide (0.1%) DW Vendor BNZG Sodium Azide (0.1%) DW Vendor CAR Sodium Azide (0.1%) DW Vendor CHOL (Cholesterol) None Sewer CK (Creat¡ne Kinase) None Sewer

Disposal of Bulk Beckman Coulter Analyzer Reagents Reagent Hazardous Criteria Disposal COCM Sodium Azide (0.1%) DW Vendor CRP Sodium Azide (0.1%) DW Vendor Cyclosporine Plus UDR Sodium Azide (0.1%) DW Vendor Iron Toxic D; Hydroxylamine HCl (5%) DW Vendor GEN (Gentamicin) Sodium Azide (0.1%) DW Vendor GLU (Glucose) Sodium Azide (0.1%) DW Vendor GGT Sodium Azide (0.1%) DW Vendor HDLD (HDL Cholesterol) None Sewer LACT (Lactate) Sodium Azide (0.1%) DW Vendor LD Sodium Azide (0.2%) DW Vendor LDLD (LDL Cholesterol) None Sewer LIP Corrosive; HCl; DW Vendor pH=0.1-0.5 MA (Microalbumin) Sodium Azide (0.1%) DW Vendor METD (Methadone) Sodium Azide (0.1%) DW Vendor MTP Corrosive; pH=2.5 DW Vendor OP (Opiate) Sodium Azide (0.1%) DW Vendor PCP (Phencyclidine) Sodium Azide (0.1%) DW Vendor PHE (Phenobarbital) Sodium Azide (0.1%) DW Vendor Phenytoin Sodium Azide (0.1%) DW Vendor PAB (Prealbumin) Sodium Azide (0.1%) DW Vendor SALY (Salicylate) None Sewer THE (Theophylline) Sodium Azide (0.1%) DW Vendor THC5 Sodium Azide (0.1%) DW Vendor TG (Triglyceride) Sodium Azide (0.1%) DW Vendor TRFN (Transferrin) Sodium Azide (0.1%) DW Vendor UIBC None Sewer URIC (Uric Acid) None Sewer VANC (Vancomycin) Sodium Azide (0.1%) DW Vendor Valproic Acid Sodium Azide (0.1%) DW Vendor B HCG Total Sodium Azide (0.1%) DW Vendor Contrad Detergent Corrosive; KOH; pH=13 DW Vendor Digoxin Sodium Azide (0.1%) DW Vendor Dilant¡n Sodium Azide (0.1%) DW Vendor PSA Hybritech Sodium Azide (0.1%) DW Vendor Ferrit¡n Sodium Azide (0.1%) DW Vendor Folate Sodium Azide (0.1%) DW Vendor FSH Sodium Azide (0.1%) DW Vendor LH Sodium Azide (0.1%) DW Vendor PSA Free Sodium Azide (0.1%) DW Vendor CKMB reagent Sodium Azide (0.1%) DW Vendor

The notat¡on for “DW Vendor” is a recommendat¡on to have this waste hauled off-site for disposal. Reagents with common hazardous criteria should be eligible for co-mingling the waste, but check with your dangerous waste vendor before you combine wastes.

Alan B. Jones, Ph.D. Hospital Waste Management 17629 N.E. 138th Street Redmond, WA 98052-1226

Phone: 425-883-0405 Fax: 425-895-0067 E-mail: AlanBJones@frontier.com http://www.hospitalwastemgmt.com

“Helping Hospitals Manage Waste”

TO:

Hospital Waste

Hospitals operate on very thin financial margins

and have two choices in order to increase profit: in-crease revenue or cut costs. Federal reimbursements are not going back to what they once were.

Cutting costs by just a few hundred thousand dollars annually generates as much profit as bringing in tens of millions of dollars in new business. You have complete control over your costs and very little control over new business; which makes more sense to spend your time on?

Environmental Services and Facilities Engineering can be profit centers—rather than cost centers—for your hospital. Showing your supervisor cost savings for the past year is a lot more fun for both of you than ex-plaining cost overruns.

Where can you find cost savings? The internet is overflowing with hints, but here are some healthcare-specific ideas:

• Recycle—paper, plastic, metal, electronics and

food waste; • Replace disposables with reusables. Look at

what’s in your waste bins and explore using durable goods;

• Reusable sharps containers save tons in plastic waste;

• Track your waste streams month by month. You can’t achieve goals if you don’t measure. Consider in-vesting in Practice Greenhealth’s Greenhealth Tracker [http://practicegreenhealth.org/tools-resources/green health-tracker]. Hospitals using this tool have reported $40,000 to $600,000 in savings in the first year; and

• Look at Life Cycle Costing: to justify investment in waste and energy reduction you must have numbers showing the total cost of existing practices. Total cost accounting looks at costs and benefits associated with a piece of equipment or procedure over the entire time it is to be used.

You can save money in waste management—don’t just continue to toss in the dumpster what staff give you.

Cutting Operating Costs By Reducing Waste