Spooner Health SystemSUBJECT: 696 Disposal of Waste – HM-26

Current Revision: Oct. 2013

POLICY: Personnel who handle and dispose of waste need to follow appropriate guidelines. When handling infectious waste extraordinary precaution to avoid splashing, spills or percutaneous injury and utilize the personal protective equipment that is supplied.

AFFECTED PARTIES: All Spooner Health System employees

WASTE CATEGORIES COVERED BY POLICY:

I. Regulated Medical WasteII. Pathological WasteIII. Trace Chemotherapy WasteIV. Mercury Containing MaterialsV. Solid WasteVI. Pharmaceutical Waste

DEFINITION AND CATEGORIES:

I. Regulated Medical Waste (Infectious) – Definition and Categories : Infectious waste under Section NR500.03(67) Wis. Adm. Code, means solid waste

which contains pathogens with sufficient virulence and quantity so that exposure to the waste by a susceptible host could result in an infectious disease. This is considered “regulated medical waste” Isolation room waste will not be considered infectious unless it meets the criteria listed below:A. Regulated Medical Waste (Infectious)

1. “Microbiology lab wastes,” cultures, and equipment that have come in contact with infectious agents.

2. Blood, blood products and body fluids.3. Sharps – examples include, but are not limited to: hypodermic needles,

syringes, Pasteur pipettes, scalpel blades, glass slides, and cover slips.4. “Regulated Medical waste” means waste or disposable equipment that is

contaminated with patients’ blood or body fluid or is saturated or “dripping” with the fluid or that is caked with dried blood or other potentially infectious material that are capable of releasing these materials during handling.

II. Trace Chemotherapy Waste/Pathological Waste: (is accepted but must be marked with yellow tag for incineration)

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Spooner Health SystemA. Trace-contaminated Chemotherapy Waste-empty drug vials, syringes and

needles, spill kits, IV tubing and bags, contaminated gloves and gowns. B. Pathological waste- Human tissue, body parts, organs, tissues and surgical

specimens.

III. Hazardous Waste/Mercury Containing Waste Chemicals: Formaldehyde, acids, alcohol, waste oil, solvents, reagents, fixer developer, etc.A. Hazardous Waste- Any container with a hazard warning symbol, batteries, heavy

metals, etcB. Fixatives or preservativesC. Radioactive WasteD. Complete Human RemainsE. Bulk Chemotherapy WasteF. Compressed Gas Cylinders, Canisters, Inhalers and aerosol cansG. Glass thermometers

IV. Solid Waste: All other waste not listed above. See attached table for examples ( table entitled Waste Segregation Guidelines)

V. Pharmaceutical Waste (see chart below entitled Pharmaceutical Waste Streams):

A. Non-hazardous pharmaceutical-vials, tablets, IV bag/tubing containing labeled medication, ampoules, oral medications

B. Incompatible pharmaceutical waste- inhalers, aerosolsC. Dual Waste- hazardous drug waste mixed with infectious wasteD. P-listed pharmaceutical waste-nicotine, warfarin (Coumadin), packaging of

nicotine and warfarin.E. Sharps pharmaceutical waste- epinephrine (syringes and EpiPens), syringes with

needles, vaccine syringes, empty controlled substance syringes.F. Bulk chemotherapy waste-chemo agents, containers with residue, chemo spill

cleanup, IV with residual.G. Trace chemotherapy waste-empty chemotherapy vials, syringes, IV’s; gowns,

gloves, goggles, empty tubing and wipes.H. Waste not accepted by Stericyle that needs to be disposed in the sewer system-

maintenance IV fluids, saline with bicarb, saline with KCl, lactated ringers, TPN, controlled substances.

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Spooner Health SystemPROCEDURE FOR HANDLING:

I. EQUIPMENT:A. Gloves – located on wall of every patient room and in accessible areas of all

hospital departments that have the potential to handle blood/body fluids.B. Gowns, aprons, face shields – located in clean utility rooms and appropriate

areas of other departments.C. Red bags-For disposal of Regulated Medical wasteD. Red-bags with yellow tags for “incineration only”-For disposal of

chemotherapy/pathologic wasteE. Small bags- For disposal of solid waste small trash binsF. Large bags-For disposal of solid waste large trash binsG. Rigid sharps containers (Red)-For disposal of sharpsH. Rigid black container-for disposal of Rx hazardous waste, incompatible

hazardous waste, dual hazardous waste, P-listed pharmaceutical waste and bulk chemo waste.

I. Rigid yellow container-for disposal of trace chemotherapy waste.

II. Regulated Medical Waste:A. Regulated waste fitting the criteria listed above will be placed in a red bag prior to

being discarded in the lined, reusable barrels found in the soiled utility rooms. Each bag will be securely tied so that it is leak proof. The barrel should only be filled 2/3 to ¾ full so the liner can be tied. Do not overfill the barrel.

B. Sharps shall be contained in a rigid, puncture resistant container labeled biohazard. These are located in every patient room and in designated areas where needles are used. Nursing staff checks the rigid containers located in the patient rooms on a daily basis. When the containers are 2/3 full, they shall be sealed and transported upright as to preclude the loss of the contents. Do Not recap, purposely bend, or clip needles by hand. Do Not remove the needle from the syringe by hand. The outside of the container must be labeled biohazard or have a visible biohazard emblem. These are then placed in the lined, reusable barrels found in the soiled utility rooms. On a daily basis Environmental Services will pick up the sealed containers and dispose of them in the locked outside storage facility until picked up by the licensed hauler.

C. The soiled utility rooms are marked by a biohazard symbol and the door will remain closed at all times.

D. Containers of blood or body fluids: Using gloves and a face shield or fixed protective shield, pour bulk blood, suctioned fluids, peritoneal dialysis fluid, excretions and secretions CAREFULLY down the sanitary sewer. Sanitary sewers may also be used for the disposal of other infectious wastes capable of being ground and flushed. Once emptied completely, containers from the above fluids may be disposed of in the regular trash. If such containers are unable to be emptied safely, discard as the other regulated waste with equal amounts of a solidifier or absorbent toweling.

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III. Chemotherapy/Pathological Waste: A. Must be placed in a red, leak-proof bag with sufficient strength to prevent tearing

or bursting under normal conditions. These containers are double-bagged and flagged with yellow tag marked “for incineration only”. If body fluids are present, equal amounts of a solidifier or absorbent toweling must be present.

B. Women’s Health/Surgery: Handling of placentas: Put a clean peri-pad in the red bag with the placenta to absorb any excess blood and then place it in a zip lock bag and seal, prior to refrigeration. The peri-pad may be substituted by wrapping the placenta in a blue pad prior to placing it in a red bag.

IV. Solid Waste: Dispose of in clear or gray plastic bags.

VI. Hazardous Waste/Mercury Containing Waste:A. Until the regulated medical waste is hauled away by a licensed hauler and

treated, it shall be segregated and contained in the outside storage area. Spill kits are available at bulk storage locations.

C. If an exposure occurs, follow the procedure in the Infection Control located on the Intranet. Policy search “needle stick”

D. Each department is responsible for packaging and securely sealing their infectious waste. It is then removed daily or more often if requested by department, by Environmental Services and stored in the outside storage area until off-site removal by a licensed hauler.

VII. Pharmaceutical Waste: All pharmaceutical waste is disposed of as outlined on the chart below (Pharmaceutical Waste Streams)A. Spooner Health System is by definition a small time user of pharmaceutical P-

Waste. This means that the amount of P-waste disposed of at one time cannot exceed 2.2 pounds each month. Pharmacy personnel will track and subsequently log P-waste on a monthly basis.

B. A medication-containing container is considered empty if it contains 3% or less by volume. Empty glass containers will be stored separately for disposal and labeled “glass”. Environmental Services will pickup when needed and dispose of the empty glass containers as solid waste.

C. Contact environmental services when pharmaceutical waste containers are in need of pickup and removal to a waste storage area.

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