NETCARE LIMITED CLINICAL GOVERNANCE HEALTHCARE WASTE MANAGEMENT STANDARD OPERATING PROCEDURES W1-W11 INFECTION PREVENTION AND CONTROL AND

Transcription

1 NETCARE LIMITED CLINICAL GOVERNANCE HEALTHCARE WASTE MANAGEMENT STANDARD OPERATING PROCEDURES W1-W11 PREPARED BY INFECTION PREVENTION AND CONTROL AND NAVIGATOR RISK SOLUTIONS APPROVED BY CLINICAL GOVERNANCE PREPARATION DATE AUGUST 2012 ISSUE DATE OCTOBER 2012 REVISION DATE OCTOBER 2014 VERSION 6 (2012)

2 COPYRIGHT WARNING NOTICE This policy and procedures are the property of Netcare Limited. Copyright subsists in this work. Any unauthorised reproduction, publication or translation of the work are acts of copyright infringement and may lead to criminal prosecution. The compilation and input to the guide was obtained from experts in the field. Any changes and alterations can only be made with the approval of the authors and respective committees. Reference to one gender can be interpreted to imply belonging to either gender. Any deviations from this policy and its supporting standard operating procedures require the approval from the assigned approval committee. All deviations, comments and suggestions could be ed to

3 W1 ROLES AND RESPONSIBILITIES... 1 W1.1 HCRW TEAM CO-ORDINATORS... 2 W1.2 TECHNICAL SERVICE MANAGER/ SERVICES MANAGER... 3 W1.3 TECHNICAL SERVICE MANAGER/ SERVICES MANAGER / OTHER... 3 W1.4 UNIT MANAGER... 4 W1.5 HOUSEKEEPING... 4 W1.6 FINANCE DEPARTMENT... 4 W1.7 PHARMACY MANAGER... 5 W1.8 CATERING MANAGER... 6 W1.10 RADIATION OFFICER... 6 W1.11 INFECTION PREVENTION PRACTITIONER / OCCUPATIONAL HEALTH NURSE... 6 W2. SEGREGATION, RECYLCING AND PACKAGING OF HCRW... 8 W2.1 SEGREGATION AND RECYCLING... 8 W2.2 PACKAGING OF HCRW... 8 W3 INTERNAL HANDLING, WEIGHING AND TRANSPORTING OF HCRW W4. ON-SITE CENTRAL STORAGE AREA: MAJOR GENERATORS W5. HEALTH AND SAFETY W6 WEIGHING, RECORD KEEPING AND REPORTING W7. ANATOMICAL (HUMAN TISSUES) WASTE W7.1 PLACENTAS W7.2 FOETUSES W7.3 LIMBS W7.4 REMOVAL OF HUMAN TISSUE BY PATIENT, FAMILY OR RELIGIOUS LEADERS W7.5 FOREIGN OBJECTS REMOVED FROM PATIENTS IN OPERATING THEATRES W8. SHARPS DISPOSAL... 19

4 W8.1 OBJECTIVES W8.2 PROCEDURE W9 DISPOSAL OF RADIOACTIVE SUBSTANCES W10 DISPOSAL OF PHARMACEUTICAL AND GENOTOXIC / CYTOTOXIC CHEMICAL WASTE W11 DISPOSAL OF NON-CLINICAL HAZARDOUS WASTE... 23

5 Policy Reference W1 Page 1 of 27 Standard Operating Procedure W1 Roles and Responsibilities W1 ROLES AND RESPONSIBILITIES 1. The CEO (person responsible for overall management of the facility) shall retain overall responsibility for the management of healthcare waste in accordance with the relevant regulatory requirements. (SANS : 2009) 2. The Waste Management Team shall be assigned in accordance with SANS (a). 3. The person responsible for an area or department shall ensure that the healthcare risk waste is managed in that area. 4. The members of the Netcare Healthcare Risk Waste Team are detailed in the diagram below. Hospital Healthcare Waste Management Team General Manager TWO HOSPITAL EXCO TEAM CO-ORDINATORS SUGGESTED - Nurse Manager: Operations + Finance Manager: Administration Assistant Healthcare Waste Officers Technical Services Manager All Unit Managers Finance Clerk Pharmacy Manager Catering Manager Radiation HOD Infection Prevention Nurse Occupational Health Nurse Procurement Manager Other: Housekeeping Dental Labs Admin Service Provider when needed 5. The Health Care Risk Waste EXCO Management Team co-ordinates all activities and developments in a health care facility related to HCRW management. 6. One or more hospital EXCO members will co-ordinate the Team roles and responsibilities and report back to the Hospital General Manager regularly. All Assistant Healthcare Waste Officers will perform their roles and carry out their

6 Policy Reference W1 Page 2 of 27 Standard Operating Procedure W1 Roles and Responsibilities responsibilities separately and collaboratively and report to the Team Co-ordinators regularly. These roles and responsibilities need to be negotiated and allocated at hospital level. 7. The OH&S committee is responsible for reporting, recording and investigation of accidents and near-miss incidents. 8. All HCRW generators in all Netcare facilities should be registered with the National, Provincial and Local Government as HCRW generators as per relevant legislation. (All major generators should be registered with the Institute of Waste Management, SA, as per Waste Information Regulations, 2011.) Registration is done as per guidelines on the following website: 9. All facilities shall have a Healthcare Waste Management Plan as per Schedule 7 in terms of Regulation 16 (1) of Healthcare Waste Management Act. 10. A HCRW Plan must be completed per facility and submitted to the relevant authority. 11. An audit report must be completed upon re-application for registration as a HCRW Generator every 2 years 12. The HCWM Plan and HCRW Plan must be signed by the Facility General Manager. 13. The Best Practice Checklists, should be completed when the quarterly Waste audits are conducted. 14. All doctors on the premises should be made aware of their responsibilities as regards HCRW. All doctors on the premises should complete a registration form as a HCRW generator (see Form 3.4.8) (Netcare Internal Procedure and also required in some Provinces). W1.1 HCRW Team Co-ordinators 1. Nursing Manager - Monitor compliance with legislative requirements on a day to day basis on rounds 2. Financial Manager (or other appropriate EXCO member in Gauteng South West

7 Policy Reference W1 Page 3 of 27 Standard Operating Procedure W1 Roles and Responsibilities a. Monitor documentation regarding healthcare waste generation, collection and disposal b. Call meetings as frequently as necessary c. Template for meetings d. Regular slot at Hospital EXCO meetings W1.2 Technical Service Manager/ Services Manager 1. Technical service Manager / Services Manager responsible for storage room (incl. signage & security,) collection by authorized person and vehicle. 2. TSM / Services Manager (with Security / Contracted cleaning company) responsible for checking numbers of containers collected and deduction of weight of RUC s. 3. TSM/ Services Manager to send manifest information to responsible Finance Department clerk. W1.3 Technical Service Manager/ Services Manager / Other 1. Construct drop-in box at service area for HCRW documentation collection / delivery and mark clearly. Empty drop-in box weekly and forward documentation to designated Finance clerk 2. Liaise with service provider and appropriate internal staff member - late collections when waste storage area full - vehicle checks ( as per checklist) 3. Directly supervise the staff assigned to collect, transport and store the healthcare waste generated ( the bin pusher, as well as the cleaning staff involved in HCRW 4. Ensure a Netcare representative is designated to be present every day at weighing of waste and to keep duplicate records. Staff member to be literate and numerate. 5. Duplicate of weights or weighing book to be forwarded monthly to Finance clerk to reconcile with account sent by service provider 6. Spot checks: waste storage room cleanliness, signage, lock, scale functionality, calibration certificates, ensure scale use only for HCRW if not owned by Netcare. 7. Ensure all staff at service areas are trained in HBA Regulations by IPP / OHNP. Advise IPP / OHNP of new staff in the department needing training. 8. Liaise with HCRW Team members as required

8 Policy Reference W1 Page 4 of 27 Standard Operating Procedure W1 Roles and Responsibilities 9. Assist with development of waste management plan, together with team, in accordance with national, provincial and local guidelines and legislation. Develop contingency plans, egg. 8 days storage space in event of failures in service provider systems W1.4 Unit Manager 1. Micro-orientation for all new staff and para-medical staff and doctors regarding HCRW segregation, containerization, storage and internal transport as well as HBA Regulations, together with IPP / OHNP. 2. Ensure segregation of HCRW from HCGW ( correct bins + liners, posters, spot checks) 3. Check all red bags and sharps bins marked with hospital name, ward and date filled. 4. Ensure affidavits completed for any patient wishing to take their human tissue home for burial 5. Complete human tissue register and forward top copy to designated Finance clerk 6. Maternity & theatre: human tissue double-bagged, pt. sticker attached hospital, ward or theatre, date. Place in Specibin. Complete register. Accompany human tissue to temporary storage (fridge). Always two people to accompany human tissue on internal transfers. 7. Alert IPP regarding necessity for collection if regular collection not covered by internal SLA. W1.5 HOUSEKEEPING 1. Remove all waste from hospital to outside storage area ( bin pushers) 2. Supply and ensure use of protective attire (PPE) at all times 3. Ensure waste area locked if no one in attendance 4. Wash storage area down after each collection 5. Report irregularities e.g. no collection/delivery to TSM 6. Ensure all staff trained on HBA Regulations W1.6 FINANCE DEPARTMENT 1. Retrieve and store all documentation: a. Internal Human Tissue Control Register top copies from Maternity and Theatres service area drop-box contents (manifests) b. Duplicate weighing records, or weighing book from service area

9 Policy Reference W1 Page 5 of 27 Standard Operating Procedure W1 Roles and Responsibilities c. Original Human Tissue affidavits from Commissioner of Oaths d. Certificate of disposal for used oil from catering manager e. Certificate of disposal for contents of tube crusher drum from Technical Services Manager f. Radioactivity records decayed radioactive waste from medical physicist g. Pharmaceutical waste manifests and safe disposal certificates from Pharmacy Manager h. Any other relevant documents 2. Reconcile internal record of weights generated with service provider records of weights collected and weights billed. 3. Check service provider accounts for errors. 4. Reconcile weights generated with weights destroyed (safe disposal certificates from service providers; as well as incinerator treatment plants where human tissue and pharmaceutical waste is treated. 5. Store all documentation for 5 years. 6. Alert General Manager if no safe disposal certificates are received within 40 days from collection by the service provider. 7. Alert Pharmacy Manager if no safe disposal certificates received for pharmaceutical waste within 40 days of collection. 8. Compile a monthly volume report and provide feedback to General Manager and HCRW Task Team on year-on-year volumes of HCW generated. 9. Alert IPP if no safe disposal certificates received for HCRW, especially human tissue. W1.7 PHARMACY MANAGER 1. Micro-orientation of new staff HCRW related health & safety and legal issues 2. Ensure minimization of pharmaceutical waste 3. Monitor pharmaceutical waste: (expired drugs) collected into correctly coded bins (green); MSDS attached and list of drugs in container to accompany bin to waste area. 4. Pharmaceutical waste register completed and top copy sent to designated Finance clerk 5. Schedule 5&6 drug destruction protocol followed 6. No pharmaceutical waste to be stored for longer than 90 days 7. Advise team on HCRW issues regarding pharmaceutical waste

10 Policy Reference W1 Page 6 of 27 Standard Operating Procedure W1 Roles and Responsibilities W1.8 CATERING MANAGER 1. Food waste to be disposed of in general waste stream. Strictly no forwarding of food waste to farms (prohibited under Act 35 of 1984, the Animal Diseases Act ) 2. Volumes of used oil and Certificate of safe disposal of used oil to be forwarded to designated finance clerk W1.9 PROCUREMENT DEPARTMENT 1. Ensure sufficient stock ordered 2. Check stock delivered: size and thickness of bags, enough cable ties, bin lids are delivered, intact and fit bins, sharps bins are labelled and have appropriate lids that fit, sufficient trochar bins, pharmaceutical bins, and back-up stock of cardboard sacrificial boxes. 3. Assemble lids of sharps bins (correct way with opening and label aligned) before or on delivery to nursing units. Mark all sacrificial bins with name of hospital, waste registration number, ward, start date. 4. Mark each red liner bag with name of hospital, Waste registration number, ward, date. 5. Reconcile orders with deliveries and liaise with team on any anomalies. Warn appropriate person timeously of any short deliveries W1.10 RADIATION OFFICER 1. Minimize radioactive waste by storing half-life radioactive waste until decayed to a surface dose not exceeding 5 usv/h 2. Provide readings of decayed radioactivity before disposal to HCRW Team. ( Record readings and keep for 5 years) 3. Advise the team on the segregation and disposal of radioactive waste 4. Co-ordinate the monitoring of radioactive waste production, treatment and disposal, including Oncologists 5. Train staff involved in radioactive waste treatment and disposal W1.11 INFECTION PREVENTION PRACTITIONER / OCCUPATIONAL HEALTH NURSE 1. Education regarding infection prevention and occupational health aspects of HCRW management, including HBA Regulations, policies, procedures, PPE for every person that might handle HCRW. 2. Handling of staff exposures e.g. waste spills/splashes/needle sticks. 3. Hepatitis B vaccinations - staff handling HCRW.

11 Policy Reference W1 Page 7 of 27 Standard Operating Procedure W1 Roles and Responsibilities 4. Audits of compliance 5. Monitoring of microbiological swab results of containers (provided by service provider) 6. Liaison with HCRW Team and service provider

12 Policy Reference W1 Page 8 of 27 Standard Operating Procedure W2 Segregation and Packaging of HCRW W2. SEGREGATION, RECYLCING AND PACKAGING OF HCRW W2.1 Segregation and Recycling 1. HCRW shall be segregated from HCGW and disposed of appropriately. 2. All waste should be minimised and where possible recycled. Targets should be set for reducing waste. 3. Environmentally friendly procurement should be applied where possible to avoid adverse impact and harm on the environment. W2.2 Packaging of HCRW 1. All containers for HCRW shall be leak and puncture proof, have tight fitting lids, be clean and in good repair. 2. Colour coded plastic bags and re-usable containers (RUC s) or sacrificial cardboard boxes as supplied by the service provider will be used for the various categories of waste. 3. All containers shall be clearly marked with an international ISO Biohazard symbol. 4. All sacrificial containers shall be marked with the name and generator registration number of the generating facility, e.g. Hospital, Ward One, and date of fill. 5. All containers shall be bar-coded by the service provider for tracking purposes. 6. Manual handling of full HCRW containers must be minimised. 7. All HCRW should be safely containerised: Plastic bags used as liners in re-usable containers (RUC s), which form an integral part of the rigid container system, shall have a thickness of 60 microns or more. 8. Plastic bags used to line small HCRW bins in patient cubicles that are emptied into a lined RUC, shall have a thickness of 40 microns or more.

13 Policy Reference W1 Page 9 of 27 Standard Operating Procedure W2 Segregation and Packaging of HCRW 9. International colour coding is to be used: Waste Waste subcategory Colour coding and International hazard label International Label Hazard Infectious anatomical human Red Infectious hazard label Human or animal anatomical waste a Infectious anatomical animal ORANGE Infectious Non-infectious animal anatomical BLUE Infectious nonanatomical waste a RED Infectious hazard label YELLOW, the Sharps words DANGER CONTAMINATED Infectious hazard label SHARPS Chemical waste including pharmaceutical waste Chemical pharmaceutical Cytotoxic pharmaceutical or DARK GREEN DARK GREEN The appropriate International hazard label Cytoxic hazard label No colour coding Radioactive waste (Netcare rules: Red bag to be used with radiation sign Only the appropriate international radiation hazard label attached) General waste b Black, beige, white No hazard label b

14 Policy Reference W1 Page 10 of 27 Standard Operating Procedure W2 Segregation and Packaging of HCRW or transparent packaging can be used a Chemical or radioactive solutions containing human or animal anatomical, and infectious non-anatomical wastes, are considered as chemical or radioactive wastes respectively.

15 Policy Reference W1 Page 11 of 27 Standard Operating Procedure W3 Internal Handling, Weighing and Transportation of HCRW W3 Internal Handling, Weighing and Transporting of HCRW (The movement of HCRW from the point of generation i.e. the ward to the on-site central storage area) 1. Containers must be marked with ward, hospital and date details before being moved to the central waste storage area. 2. A hospital representative must verify the volumes before waste is removed from the premises by the medical waste contractor. 3. The transporter s vehicle must be inspected regularly (vehicle checklist-see Form vi to ensure it meets the requirements to transport the waste. 4. No harm shall come to any person by the transportation of HCRW. 5. The necessary equipment shall be provided to avoid manual handling of full HCRW containers. 6. An internal transportation plan shall be implemented. 7. No HCRW may be handled unless containerised. 8. No person may manually lift a container of HCRW which weighs in excess of 15kg including the container. 9. No person may transport a container for a distance exceeding 100m unless the container is mobile or on a mobile transport device suitable for this purpose. 10. Facilities must have a spill management plan (part of emergency/disaster planning) in place to ensure the safe handling of spills. 11. Radioactive waste must be handled as per Netcare Radiation policy/ procedure. A medical physicist must declare the waste is safe to join the hospital waste stream.

16 Policy Reference W1 Page 12 of 27 Standard Operating Procedure W4 On-site central storage area : Major Generation W4. ON-SITE CENTRAL STORAGE AREA: MAJOR GENERATORS 1. The on-site central temporary storage area must have sufficient capacity to store 8 days supply of HCRW generated at the facility (Gauteng) or must have sufficient capacity to handle emergency storage of HCW at the facility (other Provinces). 2. Storage area must be locked at all times. 3. The area must be secure from both human and animal scavengers and maintained to prevent the storage area from becoming breeding sites or food sources for insect vectors or rodents. 4. Waste storage areas should be sited away from food preparation and clinical areas. 5. Storage areas must be well lit and ventilated. 6. The storage area must be equipped with a spill kit as well as the necessary PPE for HCRW handlers. 7. The area must be clearly marked by a Biohazard warning sign. 8. The area must be kept clean by hosing down using detergent and water daily or after removal of HCRW containers by the HCRW contractor. Floor to have an impermeable slip-resistant, hard-wearing floor that is easy to clean and has good drainage to the sewerage system. 9. The HCRW Management Plan should detail times and routes for waste collection internally to the temporary central storage area. 10. Anatomical waste not collected for treatment within 24 hours of generation must be refrigerated at a temperature of -4 ºC. Exceptions may be made in the case of human tissue required for analysis, e.g. placentas of micro premature babies that may be needed for histology. 11. Time limits for the storage of healthcare risk waste (time from generation to safe disposal) are:

17 Policy Reference W1 Page 13 of 27 Standard Operating Procedure W4 On-site central storage area : Major Generation Type of HCR Waste Anatomical¹ Infectious¹ Sharps containers ( on sealing after use) Pharmaceutical ( on sealing after use) Time Limits 24 hours 72 hours 90 days 90 days ¹This waste may be stored at -4ºC for 90 days (time from generation to safe disposal by treatment facility) Source: SANS

18 Policy Reference W1 Page 14 of 27 Standard Operating Procedure W5 Health and Safety W5. HEALTH AND SAFETY 1. No HCRW is to be removed from the container. 2. If re-usable containers (RUC s) are in use, written plans for the frequency of cleaning and disinfection of these containers after use must be agreed between the generators i.e. the hospital and the medical waste contractor as per SLA. 3. Service provider shall supply generator with microbiological results from swabs taken from cleaned RUC s as per regulations and the SLA with the HCRW contractor. 4. All persons transporting and storing HCRW containers must wear protective clothing. 5. All staff handling HCRW are to be trained on correct segregation of waste, minimising waste, recycling and preventative measures relating to avoiding infection and injury. 6. All persons handling, transporting and storing HCRW containers must be trained on the HBA Regulations and regularly reviewed for the following:- Wearing the correct protective clothing Understanding the hazards of HCRW The correct use of equipment to transport containers The correct sealing of containers. 7. Training must be included in staff induction. 8. Records of training must be kept. 9. Cleaning contractors must provide proof of training if they are involved in the handling of HCRW.

19 Policy Reference W1 Page 15 of 27 Standard Operating Procedure W6 Weighing, record keeping and reporting W6 WEIGHING, RECORD KEEPING AND REPORTING 1. There will be a system in place to record the number and weight of all HCRW containers leaving the generator s premises. Records will be kept for 5 years. A responsible, numerate and literate person is to be allocated to oversee and check the weighing of HCRW leaving the premises, and to forward accurate records to the Finance Department. 2. The Finance Department will: i. Retrieve and store all documentation: ii. Internal Human Tissue Control Register top copies from Maternity and Theatres service area drop-box contents (manifests) iii. Duplicate weighing records, or weighing book from service area iv. Original Human Tissue affidavits from Commissioner of Oaths v. Certificate of disposal for used oil from catering manager vi. Certificate of disposal for contents of tube crusher drum from Technical Services Manager vii. Radioactivity records decayed radioactive waste from medical physicist viii. Pharmaceutical waste manifests and safe disposal certificates from Pharmacy Manager ix. Any other relevant documents 3. Reconcile internal record of weights generated with service provider records of weights collected and weights billed. 4. Check service provider accounts for errors. 5. Reconcile weights generated with weights destroyed (safe disposal certificates from service providers; as well as incinerator treatment plants where human tissue and pharmaceutical waste is treated. 6. Store all documentation for 5 years. 7. Alert General Manager if no safe disposal certificates are received within 40 days from collection by the service provider. 8. Alert Pharmacy Manager if no safe disposal certificates received for pharmaceutical waste within 40 days of collection. 9. Compile a monthly volume report and provide feedback to General Manager and HCRW Task Team on year-on-year volumes of HCW generated.

20 Policy Reference W1 Page 16 of 27 Standard Operating Procedure W7 Anatomical Waste W7. ANATOMICAL (HUMAN TISSUES) WASTE The Netcare Human Tissue Internal Control Register must be completed before anatomical waste is removed from the ward. See Form W7.1 Placentas 1. The placenta shall be weighed and weight recorded in Human Tissue Internal Register. 2. Each placenta is bagged separately in a red bag and cable-tied to prevent leakage. 3. Each individual bag must have the patient s sticker attached to the red bag. 4. The placenta shall be placed in a rigid walled plastic, leak- proof container 5. The placentas are refrigerated or frozen until the container (Specibin) is sealed for transport. 6. Designated staff will accompany anatomical waste to the storage area. 7. A 10L Specibin may be used for multiple placentas. Once a sealed Specibin leaves the premises, any contents are not retrievable staff are to ensure the placenta is not needed by the family before it is handed over to the service provider. Each placenta must be identified in the bin and on the internal and external tracking documents. Person sealing the Specibin/s remains accountable for contents matching records. W7.2 Foetuses 1. Non-viable foetuses (foetuses born dead under 24 weeks of gestation) may be disposed of as anatomical waste. 2. Parents requiring to bury a foetus must follow the procedures as per undertaker. 3. Appropriate documentation must be completed (Internal Human Tissue Control Register). 4. The foetus is placed in a 60 micron red bag in an appropriate sized, rigid walled, leak proof plastic container (plain coloured Specibin). Mother s sticker to be attached to the red bag inside the container and on the Netcare Internal Human Tissue Register. 5. The container is given to the patient or family, with documentation completed. Copies of documentation to be forwarded to the Finance Department for safekeeping.

21 Policy Reference W1 Page 17 of 27 Standard Operating Procedure W7 Anatomical Waste W7.3 Limbs 1. The surgeon must confirm that the limb is not required for histological examination. This statement must be recorded on the patient record. If histology specimens are required, the surgeon is to remove the required tissue before the limb is packaged for collection. Whole limbs are not sent for histology. 2. The patient record must also reflect that the patient gives consent for incineration of the limb. 3. The limb is placed in an 60 micron thick red bag marked with the patient s sticker and then in an appropriate sized, rigid walled, leak proof plastic container. If the limb cannot be contained in a leak-proof container, then it must be double-bagged securely to prevent leakage and be placed in a cardboard sacrificial container. 4. The container is taken to the storage area / receiving point in the presence of 5. The designated person after arrangements has been made for receiving it with the HCRW transporter. 6. All appropriate documentation is completed. 7. Any anatomical waste that cannot be disposed of at once must be stored in a refrigerator at a temperature of -4 ºC. This refrigerator must be cleaned and disinfected daily or after removal of waste as per hospital protocol. W7.4 Removal of Human Tissue by Patient, Family or Religious Leaders 1. The removal of human tissue by the patient, family or religious leaders must be controlled. 2. No human tissue (with the exception of teeth) will be given to any person unless required for the exclusive purpose of burial as per religious / cultural custom. 3. Anatomical tissue is regarded as a healthcare risk waste and is governed by Local, Provincial and National legislation. The removal of anatomical tissue or body parts by patients and families will be subject to the person removing the tissue agreeing to comply with legislative and Netcare Group requirements.

22 Policy Reference W1 Page 18 of 27 Standard Operating Procedure W7 Anatomical Waste 4. Patients requiring to remove any anatomical tissue, excluding teeth, from Netcare facilities will be required to: a. Obtain a letter from the treating physician, stating that the anatomical tissue he/she wishes to remove from the facility premises belongs to that person or his relative. b. Depose an affidavit attached as Form IPC HCW c. Have the affidavit commissioned outside the hospital at a bank, post office, SAPS or Attorney. d. Take cognizance of the additional information given him / her regarding safe disposal of anatomical tissue. e. Sign the Internal Tracking Document and Dangerous Goods Declaration manifest. f. Provide a copy of his / her ID document. g. Transport the tissue in a leak-proof container and dispose of it safely, as advised. 5. The facility will: a. Supply the necessary documentation and guide the person in completing it. b. Place the anatomical tissue in an appropriate size, rigid walled, leak proof plastic container, marked with the patient s sticker. c. Store it in the freezer until collected. d. If the waste is infectious, advice from the infection prevention practitioner as to burial or otherwise must be sought. e. A copy of the affidavit, ID document, doctor s letter and the manifest shall be kept for 5 years by the Finance Department, together with all other HCRW documentation. The copies are NOT to be placed in the patient s file. W7.5 Foreign objects removed from patients in operating theatres Foreign object removed from patients in operating theatres: e.g. metal titanium rods, screws, hip prostheses, pacemakers, etc. that has been removed from a patient. These metal foreign objects are to be decontaminated, and if they are autoclavable, they are to be autoclaved, packaged and returned to the patient. These items must be entered into the Human Tissue register. Bullets: As per SAPS protocol

23 Policy Reference W1 Page 19 of 27 Standard Operating Procedure W8 Sharps Disposal W8. SHARPS DISPOSAL W8.1 Objectives Sharp objects are to be managed and disposed of in such a manner as to prevent injuries and transmission of disease (via exposure to blood and body fluids) to patients, staff and other healthcare workers. Incorrect disposal of sharps can result in needle stick injuries and exposure to blood and body fluids. W8.2 Procedure 1. Sharps are to be disposed in designated sharp containers which are rigid walled plastic containers which are marked with biohazard sign, ¾ fill line, hospital, ward and date. 2. Sharps containers must be situated in a convenient place in all clinical working areas and should be located as close as is feasible to the immediate area where sharps are used. 3. Healthcare workers should be able to view the opening of the sharps disposal container while comfortably standing within arm s reach. 4. All sharps containers must be secured by proper hinges or brackets and should not be placed on the floor or be unsecured on work surfaces. 5. Sharps disposal container height at a standing workstation should be m above the floor. 6. Sharps containers are to be fully assembled before first use. The biohazard sign and fill line must face the user. 7. Do not carry sharps unless in an appropriate receptacle i.e. a receiver. 8. Do not disconnect, re-cap or bend needles. 9. Use a device (e.g. Novonordisk s Novonani device) to re-cap insulin pens. 10. Needles and syringe must be disposed of as one unit. 11. Place the syringe, needle first, into the container and let it drop. 12. Keep lid closed when not in use if not in a secured or monitored area. 13. Filled sharps containers are to be sealed securely under direct supervision of a responsible person and replaced with an empty one. Do not fill beyond the ¾ full line.

24 Policy Reference W1 Page 20 of 27 Standard Operating Procedure W8 Sharps Disposal 14. Do not shake container to create more space. 15. Do not empty one container into another one. 16. Do not attempt to remove anything from a sharps container. 17. Sharps are to be destroyed as per the HCRW contractor agreement. 18. Should an injury/exposure occur, follow the needle stick injury policy. 19. Any problems should be reported to Infection Prevention Practitioner. 20. Procurement Department to ensure there are sufficient containers in stock over weekends and after hours. 21. Sharps may not be stored for longer than 90 days from the date the container is sealed to the date of treatment.

25 Policy Reference W1 Page 21 of 27 Standard Operating Procedure W9 Disposal of Radioactive substances W9 DISPOSAL OF RADIOACTIVE SUBSTANCES 1. Radioactive substances must be disposed of in the correct manner to prevent contamination of persons and the environment. (This section to be read in conjunction with the Netcare Radiation policies). It will be the medical physicist s responsibility to: a. Minimize radioactive waste by storing half-life radioactive waste until decayed to a surface dose not exceeding 5 usv/h. b. Co-ordinate the monitoring of radioactive waste. c. Forward records of radioactivity readings of radioactivity decay to HCRW Team before disposal to the waste stream. d. Advise the team and handlers regarding management of radioactive waste. e. Train staff involved in radioactive waste handling and disposal.

26 Policy Reference W1 Page 22 of 27 Standard Operating Procedure W10 Disposal of Pharmaceutical Waste W10 DISPOSAL OF PHARMACEUTICAL AND GENOTOXIC / CYTOTOXIC CHEMICAL WASTE Vaccines, pharmaceutical products such as medicines, drugs, and chemicals must be disposed of under the control of the Pharmacy Department. (This section must be read in conjunction with the Netcare Pharmacy Policy) 1. Pharmaceutical waste is to be placed in a dark green container supplied by the contractor. 2. Schedule 5 and above drugs to be managed as per Medicines Control Council Guidelines, Pharmacy Policy and HCRW legislation. 3. Pharmaceutical waste may not be stored for longer than 90 days from the date the container is sealed to the date of treatment. 4. Pharmaceutical waste Schedules 1 4 are to be accompanied by a specific manifest detailing the contents of the green container. 5. Copies of pharmaceutical waste manifests and or register are to be forwarded to the Finance Department for reconciliation with the account.

27 Policy Reference W1 Page 23 of 27 Standard Operating Procedure W11 Disposal of non-clinical hazardous waste W11 DISPOSAL OF NON-CLINICAL HAZARDOUS WASTE A hazardous waste register should be kept by the facility and include waste such as: 1. Artificial limbs and electronic devices (for example, pacemakers) not required by the patient or family must be marked appropriately and put in a clearly marked container for collection by the HCRW contractor. 2. Chemical containers - Empty containers must be rinsed and punctured three times before being disposed of. 3. Confidential paper waste - Must be shredded and disposed with normal office waste 4. Fluorescent tubes and batteries -Must be recycled in line with the company s recycling policy. Batteries must be removed from all electronic devices if they are going to be disposed of by the HCRW contractor 5. Heavy metals - Such as mercury and lead must be disposed of in line with the appropriate policies. ( refer Technical Procedures) 6. Lead Aprons - To be checked annually, and disposed of by an appropriate contractor. 7. Oil (cooking) - Certificate of safe disposal required from the appropriate contractor. 8. X-ray department waste - Includes liquid, solid or gaseous materials that contain, or are contaminated with radionuclides at concentrations or activities greater than the clearance levels and for which no use is foreseen. 9. PPE (personal protection equipment) - Must be treated as HCRW, including the gloves of technical personnel working in theatres and isolation areas.