Infectious Medical
Waste Information and Guidance on Segregation and Reduction of Waste
Presentation
"There is no
epidemiological evidence to suggest that most hospital waste is any more
infective than residential waste. Moreover, there is no epidemiological
evidence that hospital waste has caused disease in the community as a result of
improper disposal. Therefore, identifying wastes for which special precautions
are indicated is largely a matter of judgment about the relative risks of
disease transmission. The most practical approach to the management of
infective waste is to identify those wastes with the potential for causing
infection during handling and disposal and for which some special precautions appear
prudent. Hospital wastes for which special precautions appear prudent include
microbiology, laboratory waste, pathology waste, and blood specimens or blood
products. While any item that has had contact with blood, exudates, or
secretions may be potentially infective, it is not usually considered practical
or necessary to treat all such wastes as infective." (Centers for Disease
Control, Morbidity and Mortality Weekly Report 36(2S); 12S,
Presentation Narrative
Welcome to this presentation
by the West Virginia Bureau for Public Health's Infectious Medical Waste
Program.
During this presentation we
will define Infectious Medical Waste,
discuss segregation of infectious medical waste from the
solid waste stream, and
look at ways to reduce the amount of Infectious Medical
Waste generated.
The West Virginia Infectious
Medical Waste Program has several goals we wish to achieve through regulation
of the Infectious Medical Waste stream:
To minimize the potential for
the spread of disease from a medical setting to the general public, and the
overall reduction of waste generated in West Virginia, which helps to protect
the environment and reduces the expenditures of healthcare facilities for waste
treatment.
We’re also trying to limit
the transmission of the following diseases from blood and fluid-borne
pathogens. Some of these diseases are
uncommon, but it is because of these and other blood and fluid-borne diseases
that we regulate Infectious Medical Waste.
It is very important to know what pathogens you may be exposed to while
working, especially in laboratory settings.
In order to further
understand why Infectious Medical Waste is regulated, we must understand what
Infectious Waste is.
According to the West
Virginia Infectious Medical Waste Rule, it is medical waste capable of
producing an infectious disease.
Waste items are Infectious
when they are contaminated by an organism that is pathogenic to healthy humans,
When the organism is not
routinely available in the environment, and
When the organism is present
in sufficient quantities, and with sufficient virulence to transmit disease.
Infectious medical waste
includes:
Blood and blood products in a free‑flowing or
unabsorbed state,
Contaminated sharps,
Unfixed pathological tissues, and
Animals used in research that are exposed to infectious
agents.
This suction canister
contains free flowing blood and must be disposed of in the biohazardous waste.
Blood plasma bags contain
remnants of blood products and must go into the biohazardous waste.
Laboratory wastes such as
cultures, etiological agents, specimens, stocks, and other contaminated wastes,
as well as all vaccine vials are Infectious Medical Waste.
Typical laboratory wastes,
such as these culture plates and trays, are infectious waste.
Pathological wastes like
these samples that have been fixed and are ready to be cut into slides are not
infectious medical waste.
Incineration is the preferred
method of disposal for pathological wastes that meet the definition of
Infectious Medical Waste. Therefore,
wastes containing pathological items must be properly labeled to ensure they
are incinerated.
Only isolation wastes from
patients having or suspected of having a disease caused by a viral agent listed
as Biosafety Level 4 by the CDC meet the definition of Infectious Medical Waste.
If the patient is isolated for any other reason and the waste does not
otherwise meet the definition of infectious medical waste, it must be disposed
as solid waste.
However, it is extremely
important to wear the appropriate level of personal protective equipment for every isolation.
Isolation wastes that are not
contaminated should be separated and disposed in the general waste stream,
(i.e., gowns, masks, and shoe covers that are not soiled).
Regardless of how isolation
wastes are disposed, all waste from an isolation room should be treated with
caution and the appropriate Personal Protective Equipment must always be worn.
What about OSHA?
OSHA’s goal is to ensure that all employees can safely
perform their normal duties without undue health risks.
The Bloodborne Pathogen
Standard was developed to protect all employees who have occupational exposure
to blood or other potentially infectious materials, from HIV and Hepatitis‑B
infection.
The standard requires
employers to evaluate engineering controls that would reduce or eliminate
exposure risks to employees (i.e., adoption of a needleless system).
The Bloodborne Pathogen
Standard also requires employers to:
Ensure that Universal
Precautions are observed.
Provide all necessary
personal protective equipment (PPE) and see that it is used.
Offer employees the Hepatitis‑B
vaccination series free of charge.
Provide Bloodborne pathogen
training at the time of hire, and annually thereafter.
Maintain records of all
training events.
Maintain a yearly updated
Exposure Control Plan, and
Record any
exposure incidents and follow‑up activities.
The Bloodborne Pathogen
Standard defines Regulated Wastes as:
Liquid or semi‑liquid blood, or other potentially infectious materials (OPIM);
Contaminated items that would
release blood or other potentially infectious materials in a liquid or semi‑liquid
state if compressed;
Items that are caked with
dried blood or other potentially infectious materials and are capable of releasing
these materials during handling;
Contaminated sharps; and
Pathological
and microbial wastes containing blood or other potentially infectious
materials.
OSHA requires that the
following fluids (OPIM) be regarded as infectious:
Any body fluid with visible blood
Amniotic fluid
Cerebrospinal fluid
Pericardial fluid
Peritoneal fluid
Pleural fluid
Saliva in dental procedures
Semen and vaginal secretions
Synovial fluid
Anywhere
body fluids are indistinguishable.
Essentially, all fluids except feces, urine, and vomit
without visible blood.
Urine with visible blood must
be disposed of as infectious waste.
The following items are specifically
not Infectious Medical Waste according to the WV IMW Rule:
Used personal hygiene
products such as tissues, diapers, and feminine products;
Gauze and dressings
containing small amounts of blood;
Fixed pathological tissues;
and
Medical
tubing and devices that are certified as not having been contaminated.
Note: All tubing with any visible blood, must be disposed of as infectious waste.
Uncontaminated IV bags are
commonly over‑classified, but are not infectious and belong in the
regular waste.
The paper towels in this
garbage bag are not saturated and therefore belong in the regular waste.
Human remains used for
medical purposes, under the control of a licensed doctor, or in preparation for
burial by a licensed mortician, are not infectious medical waste.
Hair, nails and extracted teeth are likewise, not
infectious medical waste.
Universal Precautions are the
single most effective measure to control the transmission of Bloodborne
Pathogens.
Under Universal Precautions,
employees are to treat all human blood and other potentially infectious
materials as if they are known to be infectious for Hepatitis B and HIV.
With the widespread adoption
of Universal Precautions and use of PPE, the incidences of exposure to medical
personnel have decreased, but continue to occur. The following are the three most common ways
medical personnel are exposed to infectious agents. When exposures such as these occur, it is
imperative that you follow your facility’s exposure control plan.
Accidental
puncture from contaminated needles, broken glass, or other sharps.
Contact between non‑intact
skin (cut, abraded, sunburned, or chapped) and infectious body fluids.
Contact between mucous
membranes and infectious body fluids, e.g., (splash in the eyes, nose, or
mouth).
When exposures do occur,
several factors affect possible disease transmission.
An Infected source ‑ The disease stage of the source individual affects the
probability of transmission. However, Universal Precautions require that you
treat every patient as if they are infected.
Means of entry ‑ the
severity and/or depth of: puncture wounds, broken skin (open sores, cuts, acne,
sunburn), or contact with a mucus membrane (eye, nose or mouth).
An
infective dose ‑ the amount and type of fluid, as well as the amount of
infectious agent in the fluid.
Blood is the fluid of greatest concern.
A susceptible host ‑
individuals who are immunocompromised, have underlying disease, or a history of
long‑term antibiotic treatment are at greater risk.
Prevention of exposure
incidents and disease transmission can be achieved by following these simple
guidelines, first and foremost
Observing
Universal Precautions.
Frequent
hand washing.
Standard barrier precautions ‑
gloves, gowns, face shields and masks.
Regular
cleaning and decontamination of work surfaces. For spill cleanup, the cleaning agent must be labeled
as being effective against Mycobacterium or TB.
Hepatitis‑B Vaccination
of all healthcare workers.
Proper
waste handling, both soiled linens and Infectious Medical Waste.
What should you do if you
have an exposure incident such as a needle stick or splash in the eyes, nose or
mouth?
Flush splashes to nose, mouth
or skin with water.
Irrigate eyes with water or
saline.
Report the exposure to your
supervisor and follow your facility’s response plan.
For your safety, report any
incident no matter how minimal it may seem.
Requirements
of the West Virginia Infectious Medical Waste Rule for managing IMW.
Infectious medical wastes
must be collected at the point of generation in properly color coded and
labeled bags.
Orange bags
for autoclaved waste. Red bags for
all other treatment methods.
Color coding helps landfill
personnel recognize which waste materials have been properly treated because
there is no change in appearance after waste is autoclaved.
Biohazard bags must be
labeled with the international biohazard symbol and appropriate wording.
Biohazard, Biomedical Waste, Infectious Medical Waste, or Regulated Medical
Waste
Sharps must be collected at
the point of generation in leak‑proof and puncture‑resistant
containers.
Containers must be labeled
with the biohazard symbol and appropriate wording.
They should never be
completely filled, and never filled above the full line indicated on the
container.
Liquid Infectious Wastes pose
a major problem in a hospital setting. Because of the large volume generated,
they can add a great deal of weight to the infectious waste stream. They can be disposed of several ways:
Placed
directly in the biohazard waste (spill potential).
They can be poured down a
sanitary sewer (splash hazards).
They can be solidified with a
disinfectant solidifier and put in the solid waste (hold time, chemicals).
Each of these methods has its
own drawbacks, and your facility should determine which method best suits your
needs.
When shipping medical waste
off site for treatment, it must be packaged in a labeled, lined, cardboard box
or reusable plastic container.
When the box or container is
full, the bag lining it must be sealed, and the box or container then sealed shut.
Sealed boxes must be labeled
with your facility’s name, address, phone number and with the date the
container was sealed.
Sealed and labeled boxes can
be stored on‑site for no more than 30 days.
Every load of medical waste
shipped off‑site for treatment is tracked using a manifest system.
The manifest is a multi‑copy
document that accompanies the waste to the treatment facility and lists the
number and type of containers shipped.
Every person who takes
possession of the waste must sign the manifest, including someone from your
facility who must sign before the boxed waste can be shipped off‑site.
Your facility is ultimately
responsible for your waste until you receive the proof of destruction (top
copy) of the manifest.
This manifest is blank and ready
for use. There are sections for the generator, the transporter, and treatment
facility.
The proof of destruction (top
copy) of the manifest must then be returned to your facility within 50 days of
the pick‑up date.
The West Virginia Infectious
Medical Waste Program should be notified of any waste that is unaccounted for
50 days after being picked up.
Manifests must be kept on
file at your facility for 3 years.
This manifest has been
completed and signed to certify destruction of the waste load.
Every medical facility is
required to maintain a spill kit on site to manage infectious waste spills.
The spill kit must contain
all of the items you see listed here.
It is very important that
each employee know where this spill kit is located, and to have the kit
accessible for use at all times.
Health care facilities that
are not permitted by the West Virginia Infectious Medical Waste Program are not
required to maintain as thorough a spill kit.
More information is available on the Program’s web site.
Over‑classification is
the term used when non‑infectious waste is disposed of as infectious, or
when wastes are not properly separated.
It is the most commonly cited
violation, nearly 98% of all facilities are cited
during inspection.
Over‑classification also
creates a financial burden, through higher infectious waste disposal costs for
health care facilities.
Paper, gloves, and wrappers
are all too commonly put in the biohazardous waste.
IV bags and tubing with no
visible blood are not infectious medical waste.
Foley catheters and
associated tubing with no visible blood should be disposed as solid waste.
Urine and feces, unless visibly contaminated with blood are not infectious
medical waste.
The West Virginia Infectious
Medical Waste Program places a great deal of emphasis on the proper
classification of wastes from medical facilities.
The main reasons are that
medical wastes typically contain large amounts of plastics, which when
incinerated produce carcinogenic compounds. Improper incinerator operation increases the
potential for atmospheric pollution.
The second reason is that
increased amounts of infectious waste generated due to over‑classification
require more vehicles to haul the waste. This increases the risk of accidents
and infectious waste spills during transportation.
Why should you bother to
segregate your wastes? Let’s look at the cost for waste disposal.
For routine solid wastes
being hauled to a landfill, it costs approximately $32 per ton, or $.01 per
pound.
Disposal costs for infectious
wastes range from $.28 cents, to well over $4.00 per pound.
This price will continue to
increase in the future as incinerator emission standards are strengthened, and
fuel costs continue to rise.
Let's
use a facility in southern WV as an example.
During
an 1996 inspection of this facility, it was noted that
the ER, ICU, Lab,
Management
said that their staff was too busy to segregate garbage.
Their
records indicated they generated 245,060 lbs. of infectious wastes in 1996,
with a treatment cost of $.29 per pound.
The cost of over‑classification! The inspection revealed
that 90‑95% of the materials in their infectious waste stream were
items that should have been disposed of in the solid waste stream.
The total cost for their off‑site
infectious waste disposal that year was $71,067.
This facility could have
saved up to $68,000 by properly segregating their wastes.
Everyone did their part, and
with teamwork, the records for this same facility in 1998 showed a reduction by
more than 50% to 114,000 lbs. With a cost savings of $38,007.
By 2001, this facility had
reduced their infectious waste weight to 58,838 pounds. A 76% reduction and a $54,004
savings from 5 years earlier.
Source separation is the key.
Everyone needs to consider
which waste stream an item goes in, every time wastes are disposed.
We understand that everyone
is busy, but it only takes a few seconds to separate waste into the proper
waste stream.
By properly segregating
medical wastes, the weight of Infectious waste can be drastically reduced in
every facility.
This is a source separation
problem. The sodium chloride IV bag is
not infectious waste.
However, the whole blood unit
and tubing are. By taking an extra
second, someone could have put each bag and tubing in the correct waste stream.
Medication bottles are not
infectious waste, but the tubing has blood in the end and is infectious waste.
The medication bottle should
go into the solid waste, or a special container for collection of non-infectious
glass. The tubing should go into the
biohazardous waste.
These are some solid waste
items commonly over‑classified as infectious, frequently found in
biohazard containers during inspections.
We recommend that every
facility review how items in this list are disposed of and ensure they are
segregated into their appropriate waste streams.
Diapers, both adult and
infant, are not infectious waste unless there is visible blood contamination.
Chucks and exam table papers
are frequently over‑classified as infectious waste.
A regular trash bag, or any
other items, left on top of biohazard containers results in a violation for
inaccessibility.
Biohazard containers must be
located and maintained free of obstructions at all times.
You can see medication vials
in this sharps container that have been disposed of as infectious. Remember,
the only glass items required to go into sharps containers are vaccine vials
and broken ampoules.
Other glass items can be
collected in a sealable container labeled as non‑infectious glass, for
example, a 5‑gallon plastic detergent bucket or sturdy cardboard box.
The West Virginia Infectious
Medical Waste Program does not assess fines for over classification of solid
waste.
Facilities are fining
themselves by paying more for the treatment of these materials.
Fines are assessed for
putting infectious waste into the regular garbage. The fines are based on the
severity of the incident as well as negligence and can be up to $25,000 per day.
Putting infectious medical
waste items into the regular garbage is a serious violation of the Infectious
Medical Waste Rule, and will result in your facility being fined.
If you misclassify a waste
item by placing it into the wrong waste stream, you are not permitted to
separate them. Once infectious and non‑infectious
items are co‑mingled, the entire contents are considered infectious.
A little history of where we
started. In 1996 WV saw its peak
infectious medical waste production, nearly 10 million pounds.
Since then, many facilities
have made great strides in reducing the amount of wastes they generate.
From 1996 to 1998 the total
amount of infectious medical waste generated in WV dropped roughly 3 million
pounds. That is a statewide decrease of 33%.
From 1998 to 2005 the annual
Infectious Medical Waste generated in
It is estimated that approximately
30% of this 6 million pounds could be eliminated if over‑classification
is reduced.
For more information on
infectious medical waste visit our website.
It contains many helpful
resources that we hope you are able to take advantage of.
If you have any suggestions
about changes or additions to the web site, please let us know.
If
you have questions or comments, please feel free to contact us, or visit our
online question and answer forum.