MEDICAL WASTE MANAGEMENT Christine Gallagher, Surveyor Accreditation Association for Ambulatory Health Care Executive Director – Salinas Surgery Center

MEDICAL WASTE – Regulated by CDPH BIOHAZARDOUS WASTE (aka Red bag waste) Waste, which at the point of transport from the generator’s site, at the point of disposal, or thereafter, contains recognizable fluid blood, fluid blood products or containers or equipment containing blood that is fluid. Blood tubing / hemovacs / soaked bloody dressings or sponges / suction liners with fluid blood / OPIM Lab waste / specimens / cultures SHARPS WASTE Needles / broken glass vials or ampoules / blades / scalpels / empty syringes with needles / trochars / introducers / guide wires / suture needles

MEDICAL WASTE Pharmaceutical Waste (aka Blue container waste that goes in the white box) MUST BE INCINERATED – NO INCINERATION FACILITIES IN CALIFORNIA Non Hazardous – all liquid medications (except controlled substances and RCRA hazardous) Per Ca MWMA, Section (e), Pharm waste meeting the state definition can be held for up to one year if less than 10 pounds is generated per year and up to 90 days if more than 10 pounds is generated 2 types of containers  $$$$-one that allows sharps - syringes and needles with residual / pourable medication in them – this is then Medical sharps waste and can be held only 30 days  $-the other is liquids only – no sharps / syringes and can be held longer

MEDICAL WASTE Pharmaceutical Waste Controlled Substances – DEA – states that they have no current requirements that mandate how small amounts of narcotic waste is disposed of, the are more concerned with it being non recoverable. Disposal companies or “Reverse Distributors” Sewer disposal of Pharmaceutical Waste ??down the drain?? POTW – Public Owned Treatment Works  Clean Water Act

RESOURCE CONSERVATION AND RECOVERY ACT (RCRA) HAZARDOUS PHARMACEUTICAL WASTE Ignitable / corrosive / reactive / toxic RCRA Hazardous (aka black container) about 8% of pharmaceutical waste Certain medications / chemicals P Listed = Acutely Hazardous  Epinephrine / Coumadin / Warfarin / Physostigmine salicylate /strichnine / nicotine inhalant UL Listed = BULK Chemotherapy Agents EPINEPHRINE –  Lidocaine and other local anesthetics containing epinephrine are NOT considered Hazardous Waste  Also some states allow epi pens to be non hazardous

MEDICAL WASTE – OTHER WASTE WHICH MUST BE IDENTIFIED, SEGREGATED AND INCINERATED Trace Chemotherapy Contaminated Waste IV Bags / vials / ampoules Yellow Containers Pathology Waste

NOT MEDICAL WASTE Urine / feces / saliva / sputum / nasal secretions / sweat / tears / vomitus unless it contains fluid blood. Waste such as paper towels and paper products containing non fluid blood IV bags and empty bottles are regular trash if they did not contain chemo agents or blood. Empty vials are not sharps or biohazard unless they contained vaccine Dressings / chux / gloves / foley bags and drainage bags / disposable patient items Paper with Patient information Compressed gas cylinders Radioactive Waste Fixatives and Preservatives

SMALL QUANTITY GENERATOR LARGE QUANTITY GENERATOR SMALL AND LARGE QUANTITY GENERATORS ARE REQUIRED TO REGISTER…LOCAL ENFORCEMENT AGENCY OR CDPH SMALL QUANTITY GENERATOR = Medical Waste generator, that generates less than 200 pounds per month of medical waste. Must have a Medical Waste management Plan Have inspection every 2 years Keep treatment and tracking records for 3 years LARGE QUANTITY GENERATOR = generates 200 or more pounds of medical waste per month Must have a Medical Waste Management Plan Have inspections every year

MEDICAL WASTE MANAGEMENT ACT - California 1991 Established procedures for the proper handling, storage, treatment and transportation of medical waste. DEFINITION: A waste product either biohazardous or sharps waste. Self assessment manual nts/MedicalWaste/SelfAssessmentManual.pdf nts/MedicalWaste/SelfAssessmentManual.pdf cuments/MedicalWaste/edicalWasteManageme ntAct.pdf

CONTAINMENT AND STORAGE Medical Waste shall be contained separately from other waste at the point of origin. Biohazardous waste shall be labeled with the words Biohazardous Waste or the international biohazard symbol and the word “BIOHAZARD”. Chemotherapeutic agents shall be confined and placed in a secondary container with the words “Chemotherapy Waste” or “CHEMO”. Biohazardous Waste – Human surgery specimens or tissues in fixatives shall be segregated and placed in a secondary container labeled with “Pathology Waste” or “PATH”. STORAGE – Leak resistant / have fitting covers 20 pounds or more per month - The generator shall not store biohazardous or sharps waste above 32 degrees Fahrenheit for no more than 7 days 20 pounds or less – The generator shall not store biohazardous or sharps waste above 32 degrees Fahrenheit for more than 30 days

EDUCATION AND TRAINING KNOW THE LAWS AND TRAIN THE STAFF Provide education and training Medical Waste Management Plan Types / Location of Containers Emergency Plan Signs and Labels Proper Disposal of Waste  Biohazardous Waste  Sharps  Pharmaceuticals – Non Hazardous / Controlled substances

VIOLATIONS AND COMMON COMPLIANCE ISSUES Overfilling containers Not using red biohazard bags to containerize and store medical waste The enclosure for the storage of medical waste is not secure. The enclosure for the storage of medical waste does not have required signage. There is an absence of adequate documentation for any leak or spill of medical waste. Failure to register and pay fees Sharps waste is not being placed into a sharps container or improperly containerized or labeled. Failure to maintain information and tracking documents

“CALIFORNIA ONLY” confusion There is confusion as to whether it is medical waste, hazardous waste or solid waste. A Pharmaceutical Waste Action Group was formed at the request of APIC for the purpose of understanding and complying with the MWMA as it relates to pharmaceuticals CDPH stated it was ok to put most in the sewer or the trash Then….DHS – Environmental Branch clarified by stating we need to abide by federal, local waste water laws and our POTW’s regulations. CA law prohibits the discharge of hazardous wastes to wastewater sewerage systems. POTW’s have additional local authority to further restrict. In general, specific written permission must be obtained from your POTW before any wastes, including pharmaceutical wastes, are sewered.

Although each POTW has the right to deny a request to sewer a waste based on local conditions, the following wastes are generally acceptable for sewering: Solutions in IV bags containing only saline solution, lactate, nutrients such as glucose (e.g., D5W), vitamins, and added salts such as potassium and/or other electrolytes. The following Wastes are not acceptable for sewering: Any hazardous wastes, both California-only hazardous wastes and federal hazardous wastes regulated under RCRA. The following wastes may not be acceptable for sewering if they contain materials known or suspected of being toxic to humans, animals, aquatic life, the environment, or to biological or other wastewater treatment processes. This will be of particular importance for POTWs engaged in water recycling or discharge to surface waters:

Liquid and solid pharmaceutical wastes, such as IV bags containing biologically active materials (e.g., antibiotics, painkillers, and antineoplastics) and controlled substances. In general, medical facilities are encouraged to reduce discharges of pharmaceuticals to the sewer to the extent feasible. If you have any questions about the discharge of a specific waste into the sewerage system, please contact your local POTW. To obtain contact information for your POTW, check your utility or property tax bills to see who provides your sewer service or call your city and ask who provides sewer services in your area. MEDICAL WASTE MANAGEMENT PROGRAM LOCAL ENFORCEMENT AGENCY CONTACTS /L%20E%20A.pdf /L%20E%20A.pdf