HOSPITAL NAME INSTITUTIONAL POLICY AND PROCEDURE (IPP)
Department: Manual: Section:
TITLE/DESCRIPTION POLICY NUMBER
HAZARDOUS WASTE: HANDLING AND DISPOSAL
EFFECTIVE DATE REVIEW DUE REPLACES NUMBER NO. OF PAGES
APPROVED BY APPLIES TO
PURPOSE
To provide guidelines for the handling or disposal of hazardous waste, including infectious waste, radioactive
waste, chemical waste, and chemotherapy waste.
DEFINITION
infectious waste
“Solid or liquid wastes which contain pathogens with sufficient virulence and quantity such that exposure to the
waste by a suspectable host could result in an infectious disease.”
RESPONSIBILITY
CROSS REFERENCES
POLICY
Medical Center staff shall use the following procedures in the safe handling or disposal of hazardous waste. The guidelines of the Environmental Protection Agency (EPA), Centers for Disease Control and Prevention, and other agencies are used in the development of these procedures.
Specific Information: A. Infectious Waste
1. The Infection Control Committee/Office is responsible for the definition of infectious waste (See Attachment A) and is responsible for developing guidelines concerning the handling or disposal of infectious waste.
2. Waste items considered infectious include, but are not limited to, needles and sharps, items contaminated with Blood or body fluids, isolation room waste, all microbiological waste, anatomical pathology, and surgical waste (See Attachment A).
3. Handling, Storage, and Transport
a. All items defined as infectious waste are segregated from noninfectious waste at the point of generation and handled separately.
b. Red bagged waste are placed in secondary containers that will prevent leakage of contents.
c. The rooms where potentially infectious waste is stored are identified by signage with the biohazard symbol.
d. Infectious waste discarded in red bags is transported by Environmental Services or other designated housekeeping services to the autoclave in closed leak-proof containers with tight fitting covers . e. Sharps containers, pathological waste, and body fluid collection devices which cannot be emptied are
managed by incineration or autoclaving according to applicable state and federal regulations by a commercial medical waste vendor.
JCI CBAHI
f. For the offsite practices, infectious waste discarded in red bags, sharps containers, pathological waste, and Body collection devices which cannot be emptied are managed by incineration or autoclaving according to applicable state and federal regulations by a commercial medical waste vendor.
4. All needles and sharps are placed in color coded or labeled, puncture-resistant Sharps containers. Sharps containers must be checked and replaced as needed to prevent overfilling. They are then sealed when full. (NOTE: Sharps containers are not reusable.)
5. Blood and body fluids in easily emptied containers, such as suction canisters, may be carefully emptied into hoppers, utility sinks, or commodes in a manner that minimizes splashing and splattering. Personal protective equipment is used since there is a reasonable likelihood for exposure. The containers are then discarded in red infectious waste bags.
6. Closed systems containing blood, such as pleura-vacs and blood collection/administration systems, cannot be emptied. A solidifying agent (e.g., Isolyzer gel) is added to these blood and body fluid collection systems and single use suction containers, causing blood and body fluids to gel prior to being placed in the biohazardous waste container. These containers of blood or body fluids which have not been decanted into the Municipal sewer system are not placed in red bags, but are placed in Red bins for disposal and removal by Environmental Services or other designated housekeeping services.
7. Pathologic waste includes tissues, placentas, organs, body parts that are removed during the surgery and autopsy. Pathologic wastes must be incinerated by an offsite contracted biohazard waste disposal company. Pathologic Waste is not placed in any regular red bag disposal container. Pathologic waste bagged and placed in a designated yellow waste container.
8. Laboratory infectious waste is autoclaved prior to transport to the landfill. B. Radioactive and Chemical Waste
1. Environmental Health and Safety is responsible for developing guidelines concerning the handling or disposal of radioactive and chemical waste. Detailed procedures are available from the web site. For areas that do not have access to the internet, a hard copy of the procedures may be obtained by contacting the Environmental Health and Safety.
2. Faculty and staff in areas that generate chemical and radioactive waste follow the procedure below:
a. All waste is properly packaged for transport. All liquid waste must be in a chemically compatible Container (such as the container it came in), sealed with a screw-on cap, and free of any residue on the Outer surface of the container. Environmental Health and Safety will not accept any waste in water bottles, milk jugs, household detergent container, etc. All solid waste must be in an approved Environmental Health and Safety bag or box and sealed tape. The bag or box should not be leaking or have any residue on the surface.
(NOTE: If unsure of proper container for transport, contact Environmental Health and Safety).
JCI CBAHI
b. Items containing lead are packaged separately from all waste.
c. Chemical waste is stored by compatibility in secondary containment until collection. Waste containers are closed at all times except when adding waste.
d. Waste is tagged for disposal with the appropriate tag. These tags can be ordered free of charge through the Environmental Waste Collection Program. Available tag types are as follows:
i. Chemical waste
ii. Radioactive waste (solid) iii. Radioactive waste (liquid) iv. Radioactive waste (biowaste)
Note: Radioactive liquid waste requires both the “Radioactive waste (liquid)” tag and the “Chemical waste” tag.
e. Request a hazardous waste pick-up through the Environmental Health and Safety website. For areas that do not have internet access, complete the attached chemical waste or radioactive waste collection form and fax to Environmental Health and Safety.
C. Cytotoxic Waste
1. Trace contaminated cytotoxic drug waste includes: a. Items used to prepare drugs
b. Items used to clean areas and waste from patient rooms where drug is administered c. Empty bags, vials, IV tubing, etc.
These items are placed in a securely closed cytotoxic bucket or cytotoxic waste bag prior to transport. Cytotoxic waste is picked up by Environmental Services or other designated housekeeping service and transported to an offsite medical waste incinerator.
(Note: Sharps may be discarded in cytotoxic waste liners).
Bulk contaminated cytotoxic drug waste (unsused Ivs and vials of drugs) is returned to the pharmacy For disposal.
2. Faculty/staff who have regular contact with preparing, administering, removing, and destroying cytotoxic drugs are oriented to the hazards of handling cytotoxic drugs. Special instructions are given on the disposal of designated cytotoxic drug waste and cleaning of areas where these medications are in use.
3. Cytotoxic waste containers are available on units for disposal of waste from patients receiving cytotoxixc drugs. 4. Faculty/staff must wear appropriate personal protective equipment when handling cytotoxic drug waste containers.
PROCEDURE
FORMS EQUIPMENT REFERENCESJCI CBAHI
Standards
Page 3 of 8
Garner JS, Simmons. CDC Guidelines for Isolation Precautions in Hospitals. Atlanta, GA: US 1997
Web References:
Centers for Disease Control and Prevention website
http://www.cdc.gov
Clinical Policy Manual
• Cytotoxic Drugs (Chemotherapy) Administration and Management
• Blood Product Administration From
http://vumcpolicies.mc.vandebilt.educ/E-Manual/Hpolicy.nsf?OpenDatabase
Comprehensive Accreditation Manual for Hospitals. 2005. Management of the Environment of Care standard
from
http://www.mc.vanderbilt.edu/vumcdept/accreditation/camh.pdf
.
Rules of the Tennessee Department of Health and Tennessee Department of Environment and Conservation
http://www.state.tn.us/sos/rules/1200/1200-08/1200-08.htm
.
Safety Policy Manual
• Handling of Cytotoxic Drugs
http://vumcpolicies.mc.vanderbilt.edu/E-Manual/Hpolicy.nsf?OpenDatabase
.
Tennessee Department of Environment and Conservation website.
http://www.state.tn.us/environment
Tennessee Department of Transportation website.
http://www.tdot.state.tn.us
U.S. Environmental Protection Agency website.
http://www.epa.gov
.
Vanderbilt Environmental Health and Safety website.
http://www.safetyvanderbilt.edu
.
A
PPROVAL:
Name
Signature
Date
Prepared by Reviewed by Approved By Approved By
Latest Revision Approved By
