NHS FORTH VALLEY. Waste Disposal Operational Policy

Transcription

1 NHS FORTH VALLEY Waste Disposal Operational Policy Date of First Issue 31/03/2005 Approved 24/04/2015 Current Issue Date 01/06/2015 Review Date 01/06/2017 Version 5.00 EQIA Yes Author/Contact Gerald Ferrie (Transport & Waste Manager) Group/Committee Health and Safety Committee Final Approval This document can, on request, be made available in alternative formats Version st June 2015 Page 1 of 45

2 Management of Policies Procedure control sheet (Non clinical documents only) Name of document to be loaded Area to be added to Waste Disposal Operational Policy General Type of document Priority Policy Guidance Protocol Other (specify) X Immediate 2 days 7 days 30 days X Questions Understanding Yes No X Options Where to be published External and Internal X Internal only Target audience NHSFV wide X Specific Area / service Version st June 2015 Page 2 of 45

3 Consultation and Change Record for ALL documents Contributing Authors: Consultation Process: Distribution: Infection Control Consultants and Advisors. Primary Care Contracts Manager. Control of Infection. Laboratories management Pharmacy management Theatres management Risk management Occupational Health Service NHSFV Intranet. Change Record Date Author Change Version 01/02/2010 G Ferrie Format revised to comply with NHS Forth Valley Policy on Developing Guidelines Two yearly review of Policy contents 04/06/2010 E Headridge Published NHSV Intranet /03/2012 G Ferrie 27/03/2015 G Ferrie Format revised to comply with NHS Forth Valley Policy on Developing Guidelines Two yearly review of Policy contents Format revised to comply with NHS Forth Valley Policy on Developing Guidelines Two yearly review of Policy contents Version st June 2015 Page 3 of 45

4 Contents 1 Introduction Responsibilities Training Requirements Types of Waste Waste Segregation Waste Disposal Clinical Wastes Orange Stream Clinical Waste Orange Stream Waste Bags Orange Stream Waste Sharps/Bin Containers Yellow Stream Clinical Waste Yellow Stream Waste Bags/Containers Yellow Stream Waste Contaminated Metal Parts (Artificial Joints/Pins/Surgical Tools Waste Containers Yellow Stream Placenta Waste Containers Yellow Stream Waste Laboratory and Other Highly Infectious Waste Containers Pharmaceuticals and Other Pharmacy Chemicals Cytotoxic Waste Radioactive Waste Mercury Clinical Waste Arising in Community Settings Transport and Storage Arrangements Storage of containers in clinical areas Basic Safety Rules Minimum Standards for Clinical Waste Stores Staff Protection Security Review Arrangements References Appendix 1: Household Waste Disposal Appendix 2: Clinical Waste Disposal Appendix 3: Community Waste Assessment and Clinical Waste Uplift Request Form Appendix 4: Mercury Spillage Flowchart Appendix 5: Community pharmaceutical waste Appendix 6: General Dental Practitioners clinical waste Appendix 7: Transport Version st June 2015 Page 4 of 45

5 1 Introduction NHS Forth Valley attaches the greatest importance to the management of Waste in a manner that is safe for its employees and all other persons likely to be affected by the production, storage, transportation and disposal of clinical and other waste arising from the activities of the organisation. With this in mind, this Waste Disposal Operational Policy has been prepared to provide a basis for doing all that is reasonably practicable to achieve a service provision that is safe and without risk to health. NHS Forth Valley is committed to the effective management of clinical and other waste arising through the development of realistic and acceptable procedures which meet the spirit and letter of the law. Such procedures must be effectively carried out and acknowledged in all of the Boards practices. NHS Forth Valley will, so far as is reasonably practicable, ensure that clinical and other waste arising is properly and efficiently segregated, stored, transported and disposed of, in keeping with the Boards Duty of Care as prescribed in the Environmental Protection (Duty of Care) Regulations 1991 and all other relevant waste management legislation and guidance. The main guidance is currently contained in Scottish Hospital Technical Note No 3 Version 5: NHSScotland Waste Management Guidance and Health Technical Memorandum Version 1.0: Safe management of healthcare waste. In recognition of its responsibilities under the Health and Safety at Work etc Act 1974, the organisation will provide employees with sufficient information, training, supervision, equipment and safe systems of work to carry out their duties with regard to implementing this policy. NHS Forth Valley recognises and accepts their responsibility to ensure the safe management of all waste arising from the provision of healthcare services. In order to achieve this, the highest attention will be accorded to the following aims and objectives, which are not listed in any order of priority: a. Safeguard against the uncontrolled release or spillage of waste material b. Minimise the production and environmental impact of waste by reviewing materials used and practices employed; c. Ensure that clinical waste is properly and efficiently segregated, stored, transported and disposed; d. Ensure procedures for waste management are established, adopted, understood and implemented; e. Provide information, instruction, training and supervision as necessary to ensure the implementation of waste management systems; f. Regularly review all activities to ensure compliance with environmental and Health and Safety legislation; g. Take cognisance of, and implement any actions necessary, to address relevant matters raised by Infection Control, Health and Safety and other Committee meetings. The assistance and co-operation of all employees is required in the pursuit of these aims and objectives. Version st June 2015 Page 5 of 45

6 The allocation of duties for waste management and practical arrangements for implementation are set out in this Policy. NHS Forth Valley will monitor, review and revise this Policy every two years or as circumstances demand. Jane Grant Chief Executive Version st June 2015 Page 6 of 45

7 2. Responsibilities It is the responsibility of all line managers to ensure that the Waste Disposal Operational Policy is efficiently implemented by staff at all levels. Responsibility for specific aspects of waste disposal is as follows: 2.1 The Chief Executive and Directors are responsible for: a. Ensuring that Policies and Procedures are in place for the management and disposal of controlled waste and that these procedures are discharged by the staff designated below. 2.2 The Departmental Head/Line Manager/Person in Charge is responsible for: a. Assessment of the risk arising from wastes in area of control. b. Ensuring compliance with this Waste Management Policy - correct segregation, marking etc. c. Transfer of the waste to a responsible person who is authorised for this purpose and who will carry out duties in accordance with the transfer certification under the Duty of Care. d. Identifying training needs and organising the training and instruction of staff through the Waste Manager and Infection Control Department and keeping accurate records of training provided. e. Ensuring that waste management is covered within local induction, for all new, temporary and locum staff. f. Reporting incidents through the Safeguard Incident Management System and reviewing these incidents with the aim of preventing reoccurrence. g. Community and Nursing staff are responsible for ensuring that a Waste Assessment is carried out on their clients waste, so correct segregation and disposal is achieved. They are responsible for identifying their training requirements. 2.3 The Designated Waste Manager is responsible for: a. Receipt of properly packaged waste and depositing this safely in the correct containers to an agreed time schedule. b. Ensuring each area where clinical waste is generated has the appropriate clinical waste containers in place. c. Ensuring that the waste received at the designated area is disposed of in accordance with the Environmental Protection Act authorisation. d. Reviewing procedures for the handling and disposal of clinical waste in line with current legislation and best practice. e. Representing the organisation in liaison with external authorities. f. Monitoring handling and disposal of clinical waste, ensuring any identified shortcomings are rectified as soon as possible. g. In conjunction with Department Heads, Identify training needs and organise the training and instruction of staff and maintenance of accurate records of training provided. Version st June 2015 Page 7 of 45

8 h. Oversee monitoring of all waste disposal arrangements and carrying out of regular audit of clinical waste procedures and practices in conjunction with the Infection Control Nurse Team (where applicable) and members of the waste management group, thus ensuring compliance with legislation. 2.4 Producers - Nursing / Medical and Domestic Staff are responsible for: a. Clinical/domestic waste is segregated and placed into correct colour coded waste bag. b. Clinical/domestic/recycling waste bags must be no more than two thirds full. When sealing clinical/domestic waste bags the following must be adhered to: 1) Clinical waste - the bag should be swan necked and sealed using a ratchet type tag. On use, these bags should also be marked with the date and name of generating ward/department, hospital, health centre/clinic using a marker pen. Sharps containers should be correctly sealed and identified. 2) Household waste - the bag should be sealed and preferably swan necked using a ratchet type tag. There is no need to date these bags. 3) Recycling - the bag should be sealed and preferably swan necked using a ratchet type tag. There is no need to date these bags. c. All waste must be segregated and placed into the appropriate containers to await uplift. These containers must not be overfilled. d. Community staff carry out a waste assessment on all waste designated as clinical waste and ensures that the correct collection procedures are in place and regularly reviewed. 2.5 Facilities staff are responsible for: a. The uplift and transport of all clinical/domestic waste from the designated collection points to the central storage areas. b. Staff must not uplift any clinical waste bags which are not identified and sealed using a ratchet type waste tag. If this situation occurs, the staff member will bring this to the attention of the person in charge and request that the bag be appropriately sealed. c. Ensuring correct use of personal protective clothing when collecting, handling waste. d. Ensure utmost discretion when collecting waste from community settings. e. Ensuring that waste carts received from the waste contractor are in a clean and usable condition (lockable) prior to being issued to wards and departments. f. Ensuring that Waste Transfer Notes are completed when waste is transferred to waste disposal contractor. g. Reporting any incidents relating to waste procedures to their line manager as per local protocol. Note The term Facilities staff used throughout this Policy can be applied to FM staff employed by Serco who perform these, or similar, waste duties. Version st June 2015 Page 8 of 45

9 3. Training Requirements Suitable training must be given at regular frequencies in order to ensure the safety of all staff involved in the waste disposal process. All staff who work in areas where waste arises must receive instruction in waste handling, segregation, storage, and disposal procedures, and the use of protective clothing as appropriate to their range of duties and other circumstances. All staff who may be required to move clinical waste by hand within a particular location must: a. Ensure that the date and origin of the waste is marked on the bag/container; b. Check the storage bags are securely sealed using the swan neck method; c. Handle bags by the neck only; d. Know the procedure in the case of accidental spillage; e. Check that the seal on waste storage bag is unbroken when movement is complete; f. Wear protective clothing and gloves at all times; g. Segregate BLACK, ORANGE, YELLOW, CLEAR bags, cardboard and rigid sharps containers and ensure that they are stored separately; h. Ensure that local ward/departmental wheeled bins are kept locked, and are used safely at all times; i. Follow hand washing techniques as per the National Infection Prevention and Control Manual, Chapter One, Standard Infection Control Precautions. Training will be provided at induction and on a local needs assessed basis, as identified by ward/departmental managers, to groups of staff involved in the processing, transportation and storage of clinical waste. Training records will be maintained by ward/departmental managers. Additional ad-hoc training will be provided when there have been changes to legislation, Policy, or operational needs. Online elearning via the learnpro learning management system is now available and includes a waste management module. Version st June 2015 Page 9 of 45

10 4. Types of Waste 4.1 Clinical Waste Clinical waste means any waste which consists wholly or partly of: Human or animal tissue; Blood or other body fluids; Excretions; Drugs or other pharmaceutical products; Swab or dressings; Syringes, needles or other sharp instruments; Which unless rendered safe may prove hazardous to any person coming into contact with it. Clinical waste means any waste arising from medical, nursing, dental, veterinary, pharmaceutical or similar practice, investigation, treatment, care, teaching or research, or the collection of blood for transfusion, being waste which may cause infection to any person coming into contact with it. (The Controlled Waste Regulations 1992) Since clinical waste in Scotland is classed as Special Waste, the Scottish Environmental Protection Agency (SEPA) require to be notified at least three working days before any clinical waste is moved and Consignment Notes require to be kept for three years. 4.2 Other Wastes Type of waste Disposal Route 1. Household waste (black bags) Internal collection by Facilities staff and disposal from a central storage area by a registered waste carrier or uplifted direct from locations by waste carrier and sent to landfill. Bags to be securely sealed, preferably swan necked and tied with ratchet tag. See Appendix 1 2. Confidential paper waste Depending on location, white or blue sacks available. Bags secured by staff and uplifted by Facilities staff. Items sent for disposal and recycling with certificate of destruction provided. 3. Cardboard All boxes to be flat packed by staff. Uplifted by Facilities staff and sent for recycling or uplifted direct by waste carrier for recycling. 4. Glass (uncontaminated glass e.g. coffee jars, drinks bottles etc.), crockery Glass can no longer be disposed of along with general household waste. Any glass bottles/jars brought onto NHS Premises should be taken home for disposal or disposed in the Council provided bins located outside certain hospitals. Where glass waste results from NHS business, separate containers shoud be used to store glass prior to uplift. Version st June 2015 Page 10 of 45

11 5. Drinks cans, plastic bottles, non-confidential papers Designated bins are located in certain areas. Contents uplifted and transported by waste carrier for re-cycling. 6. Food waste Any food waste from patient meals/staff restaurant is disposed via specific waste disposal equipment within catering departments and wards. Due to new legislation, this method of disposal will change by the end of 2015 with food waste being taken off site for disposal. 7. Printer/Toner Cartridges In certain areas Used cartridges are collected and uplifted by carrier for recycling. 8. I.T. Equipment (Computers, printers etc) The ICT Department will ascertain if any items identified as surplus can be re-used elsewhere in the organisation. If not, at certain times a specialist contractor is used to recycle, or dispose, all or part of the equipment. Managed by ICT Dept in accordance with WEEE Regulations. 9. Batteries Items generated by or received by Estates are sorted by type and held. Uplifted by a registered specialist contractor when the volume held merits. 10. Fluorescent Tubes Used lamp tubes are collected from properties and returned to Estates. Uplifted by a registered specialist contractor when the volume held merits. 11. Engineering/ Building scrap Securely stored in Estates compounds and removed by a specialist contractor when the volume held merits. 12. Electrical Equipment Uplifted and stored. Uplifted by registered waste carrier in accordance with WEEE Regulations. 13. Garden/Grounds Waste Where possible grounds waste is taken to a contractor and recycled via chipping or composting. Otherwise, waste is disposed of via the household waste stream and landfill. Managed by Estates Dept. 14. Asbestos All potential sources/sites have been surveyed and identified materials documented. Only specialist contractors handle, remove, store or transport asbestos waste. Managed by Estates Dept. 15. Refrigerators Uplifted and stored. Uplifted by a registered specialist contractor in accordance with WEEE Regulations. 16. Aerosol Waste Used or expired pharmaceutical aerosols must be returned to the pharmacy for disposal using the Pharmacy Box, or other local arrangement. Version st June 2015 Page 11 of 45

12 Non-pharmaceutical aerosols will be disposed with other recyclable materials (see section 5 above). 17. Medical Devices and Equipment Disposal of medical devices in accordance with Waste Electrical and Electronic Equipment Regulations, (WEEE Regulations) and the Board s management of Medical Equipment arrangements. This requires separate collection, storage, treatment and disposal of equipment and requires retailers to offer the facility to take back waste equipment when replacing on a like-for-like basis or ensure that the final user can return the equipment by another system that is no more difficult. Some of the equipment will be classed as Special waste due to the nature of the components they contain. Medical Physics and Estates departments are the managing departments for medical equipment disposal. Version st June 2015 Page 12 of 45

13 5. Waste Segregation Segregation is a key element of waste management and has a major influence on the options for the treatment and disposal of waste. Part II of the Environmental Protection Act imposes a duty of care on everyone, who produces, carries, keeps and disposes of waste, to take all reasonable measures to ensure that pollution to the environment and harm to human health are avoided. All duty of care legislation is subject to criminal law and civil law. It is therefore vitally important that all members of staff handle, package, store and transport waste in a safe and secure manner and that the various types of waste detailed in Section 4 of this Operational Policy are segregated at source. In addition to the environmental and legal aspects of incorrect segregation, all staff involved in waste production and disposal should be made aware that clinical waste disposal costs are significantly more than that of general household waste. Facilities staff who are responsible for removal of waste from wards and departments must ensure that household waste containers and clinical waste containers are collected and transported separately and remain segregated at all times. The term Facilities staff used throughout this Policy can be applied to FM staff employed by Serco who perform these, or similar, waste duties. Section 6 of this policy details the correct methods of disposing of clinical waste and how waste should be packaged. Waste which is not packaged in accordance with this policy will not be uplifted by Facilities staff. Details of the colour coding system of bags and containers are shown in Appendix 1 and 2. The arrangements for segregating wastes clearly apply in NHS hospitals, health centres, clinics, general medical and dental practices, mobile units or within schools and nursing homes registered by NHS Forth Valley. However similar arrangements require to be made by healthcare professionals when administering care in residential homes and sheltered housing registered by Local Authorities and patients homes to ensure that clinical waste does not enter the household waste stream. When healthcare professionals administer care outwith NHS premises they must carry out a waste assessment to ensure that the decision on waste disposal is consistent with this policy. Appendix 3 The arrangements consider locating clinical waste containers in clinical areas such as Wards, Treatment Rooms, Sluice Rooms or other dedicated areas where clinical waste is produced. Access to these waste streams by patients and public should be minimised to avoid domestic type waste/recyclable materials entering the clinical waste stream. Version st June 2015 Page 13 of 45

14 From the Waste (Scotland) Regulations 2012, there is a revised hierarchy of waste management principles that apply throughout Scotland. These principles are based on a simple and straightforward guide to waste production. Prevention Prevent waste at source. i.e. Suppliers to reduce packaging materials Prepare for reuse Put items back into use before they become waste. Internal envelopes being an example within this organisation. Recycle This involves the recycling of as much waste as possible from the disposal route. Most common items are paper, card, plastics, cans and glass. Recover Re-use of waste by-products, e.g. to generate energy. Disposal The last resort is disposal which may involve landfill, heat treatment or incineration. Version st June 2015 Page 14 of 45

15 6. Waste Disposal 6.1 Clinical Wastes All the waste as described in Section 6 is classed as Special Waste. Clinical waste shall be disposed of in one of the following ways: Heat treatment and shredding. This is also referred to as Heat Disinfection System (HDS); Incineration Maceration and discharge into sewer. See Appendix Orange Stream Clinical Waste Low risk clinical waste consists of any of the following. a. Soiled dressings, swabs, examination gloves, tubing, etc, and any other contaminated items which may have been in contact with or used in the treatment of patients placed in approved bag containers; b. Soiled incontinence pads, nappies and bed pan disposables - placed in approved bag containers; c. Used sharps and empty drugs glass vials - placed in approved sharps containers; Volumes of contaminated liquids, including suction waste - solidified to prevent leakage and placed in identified transit container; Unrecognisable tissue - placed in approved bin containers; Peritoneal dialysis and haemodialysis waste, or dialysis waste - placed in approved bin containers; Autoclaved microbiological culture and other pathogenic laboratory/pathology waste placed in transparent bags with light blue markings prior to autoclaving, thereafter in approved bag containers; Blood, including tubes - solidified to prevent leakage and placed in approved bin containers. note - These may contain Advisory Committee on Dangerous Pathogens Hazard Group 1 3 pathogens but will exclude Transmissible Spongiform Encephalopathy and the agents associated with Creutzfeldt-Jakob Disease (CJD) and the wastes arising from related research, as detailed in the Report of the Advisory Committee on Dangerous Pathogens. Version st June 2015 Page 15 of 45

16 6.1.2 Orange Stream Waste Bags Low risk clinical waste for bag containers must be placed in ORANGE BAGS (UN type approved) to suit care setting policy. The bags should be filled to no more than 2/3 full, closed using the swan neck method and securely sealed with a ratchet type clinical waste tag. Staples must not be used as they may cause injury to handlers and damage the bag. Bags should be marked when put in use with the date and name of generating ward/department, hospital, health centre/clinic. Papier Mache utensils for faeces, urine and vomit must be macerated for discharge into the sewer. If no macerator is available the contents must be flushed down the toilet and the empty container placed in an ORANGE BAG (UN type approved) and treated as low risk clinical waste. Urine bags and tubing, nappies and incontinence pads and stoma bags which cannot be macerated must also be placed in ORANGE BAGS (UN type approved) and treated as low risk clinical waste. Sanitary items such as nappies, sanitary towels, tampons, etc, should be placed in the designated disposal unit, where provided. Otherwise it should be disposed of as low risk clinical waste as detailed above Orange Stream Waste Sharps/Bin Containers Containers for Sharps For used sharps, which comprise syringes, needles, scalpels and similar metal parts, cartridges, glass ampoules and vials, broken glass and any other sharp instrument, must be discarded intact and placed in a UN type approved sharps container complying with British Standard Plastic syringes used for wound irrigation without a needle attached are not sharps waste and may be placed in an orange bag. Sharps containers supplied to clinical areas via Central Stores, purchased on National Contract, comply with the above standards. Containers should only be filled to the fill-to mark. Unused medicinal or pharmaceutical products must be returned to the Pharmacy. Containers for Liquid Waste Quantities of liquid blood, dialysis fluid and other contaminated liquids must be contained in a flexible container and placed in a rigid leak proof UN Type approved Bin container, of suitable size, complying with British Standard 7320, often referred to as SULO or WIVA bins. Containers for other Waste Other low risk clinical waste for bin containers must be placed in a rigid leak proof UN Type approved Bin container, of suitable size complying with British Standard All bin containers supplied to clinical areas via Central Stores, purchased on National Contract, comply with the above standards. Sharps and Bin containers must bear the name of the assembler and date assembled. The hospital, health centre/clinic, date and name of the ward/department generating the waste should be written clearly on the Sharps/Bin container as well as Version st June 2015 Page 16 of 45

17 the name of the person who seals the container after use. These Sharps/Bin containers must NOT be filled above the "fill-to" line. Sharps/Bin containers must NOT be placed inside bags. The temporary closure mechanism on Sharps/Bin containers should be used whilst the container is not in use. (See Management of Exposure to Blood Borne Virus Infection Policy) Sharps/Bin containers must be stored securely and shall be routinely uplifted by Facilities staff Yellow Stream Clinical Waste High risk clinical waste consists of any of the following: a. Human Tissue - Recognisable Body Parts placed in special bin containers; b. Contaminated Metal Parts Prosthesis and pins, etc placed in special bin containers; c. Highly Infectious Waste Hazard Group 4 (incl. Ebola) and CJD agents, etc which cannot be autoclaved placed in rigid yellow containers prior to uplift; d. Infected Blood Waste Hazard Group 4 (incl. Ebola) and CJD agents which cannot be autoclaved stabilised to prevent leakage and placed in bin containers; e. Placenta stored in clear bag, yellow bag and bin container in ward fridge prior to uplift. Care must be taken to ensure that aerosols and certain glass waste are not put into the YELLOW STREAM for incineration due to the explosion damage within incinerators and the resulting risk of injury to incinerator attendants Yellow Stream Waste Bags/Containers Waste shall be bagged in UN type approved YELLOW BAGS for incineration to suit care setting policy, The bags should be filled to no more than 2/3 full, closed using the swan neck method and securely sealed with a ratchet type waste tag. Staples must not be used as these may cause injury to handlers and damage the bag. Bags should be marked when put in use with the date and name of generating ward/department, hospital, health centre/clinic. Wards and departments should arrange uplifts of this waste by Facilities staff. Anatomical waste is double bagged and placed in UN type approved YELLOW bin containers for incineration. Containers should be locked and marked with details of, i.e. theatre, laboratory, theatre number, case number, date and time. After uplift of anatomical or pathological waste containers, Facilities staff shall transport this waste to dedicated, secure storage Yellow Stream Waste Contaminated Metal Parts (Artificial Joints/Pins/Surgical Tools Waste Containers All contaminated metal parts are to be incinerated. The metal for disposal is to be placed directly in the UN type approved YELLOW BOX with yellow lid for Version st June 2015 Page 17 of 45

18 incineration. This system will be used for all Disposable Metal Products. The date and name of the ward/ department generating the waste should be written clearly on the container along with the waste type printed INDELIBLY in BOLD e.g. CONTAMINATED METAL or PROSTHESIS. Departments should arrange special uplifts of this waste by Facilities staff. After special uplift of contaminated metal or prosthesis waste, Facilities staff shall transport the waste to dedicated, secure storage Yellow Stream Placenta Waste Containers Placenta not being submitted for pathological examination should be contained in a clear plastic bag, yellow bag and bin container and stored in a fridge prior to uplift. thereafter placed in a special UN type approved for incineration (placentapak) box container. Placentapak boxes have pre-printed labels attached to them which require to be completed to indicate the contents are for incineration. Departments should arrange special uplifts of this waste. After uplift of waste, Facilities staff shall transport the waste to dedicated, secure storage. The guidelines provided by the Scottish Government in July 2012 in Circular SGHD/CMO (2012)7 on the sensitive disposal of pregnancy losses shall be followed at all times. If patients prefer to make private funeral arrangements their wishes must be respected Yellow Stream Waste Laboratory and Other Highly Infectious Waste Containers Potentially hazardous microbiological culture and other pathogenic clinical waste from pathology departments and other clinical or research laboratories should be autoclaved or otherwise made safe near the site of production before final disposal. Wastes destined for autoclaving should be labelled and bagged in a 170 gauge transparent bag marked "Autoclavable Disposable Bag" in blue lettering. Treated material should then be rebagged in ORANGE BAGS (UN type approved). If autoclaving is not possible the waste shall be placed in UN type approved bin container for incineration. Certain Laboratory and Other Highly Infectious Waste which can only be disposed by incineration waste shall be placed in UN type approved bin container for incineration, e.g. a. all clinical waste from highly infectious cases i.e. patients in strict isolation with known or suspected infection with Hazard Group 4 pathogens (e.g. Lassa, Ebola and haemorrhagic fever viruses, etc); b. all clinical waste from the agent associated with Creutzfeldt-Jakob Disease (CJD) and any waste products arising from related research; c. all unautoclaved microbiological culture and other pathogenic clinical waste from clinical or research Laboratories, with known or suspected infection with Hazard Groups 2-4 pathogens; Version st June 2015 Page 18 of 45

19 d. infected blood with known or suspected infection with Hazard Group 4 pathogens. Departments should arrange special uplifts of this waste by Facilities staff. After special uplift of any contaminated waste, Facilities staff shall transport the waste to dedicated, secure storage Pharmaceuticals and Other Pharmacy Chemicals Pharmaceuticals and Other Pharmacy Chemicals is taken to mean: a. any medicinal product, as defined by section 130 of the Medicines Act 1968 (or a component used in the manufacture of such a product), which becomes unsuitable for use on the grounds of safety, quality or efficacy; or b. pharmaceutical residues arising from healthcare treatment. These wastes are designated as Special Wastes under the Special Waste Regulations: 1996 and require a pre-notification consignment note to facilitate handling and disposal. The required monitoring, handling, documentation and disposal of pharmaceutical waste is managed by the Pharmacy Department, Forth Valley Royal Hospital. In the context of the Waste Disposal Operational Policy, such pharmaceutical waste can arise from the supply, storage and use of pharmaceutical products within the organisation or indeed the return for disposal of unwanted medicines collected from patients whose treatment has been amended. a. Medicinal/pharmaceutical products considered unsuitable for use MUST be returned to the Pharmacy Department, for disposal. Each item being returned to Pharmacy, following agreed procedures, must be documented; i. products removed from ward/departmental storage. Unsuitable Items being returned must be recorded on a Returns Indent form. Items being returned for destruction must be recorded on a Returns Indent for the destruction of medicines form. It is thereafter the responsibility of the Pharmacy Department to determine the appropriate disposal of the returned item(s). ii. products removed from patients with their authority for disposal must be recorded on an Authorisation for use or destruction of Patients Medicines. iii. controlled drugs from wards. The Pharmacy must be notified by telephone of the intended return of any Controlled Drug. Pharmacy will arrange for their return. b. Pharmaceutical residues from healthcare treatment are processed: i. Used ampoules/vials/syringes which may contain residual pharmaceutical waste must be discarded intact and placed in a UN type approved bin Version st June 2015 Page 19 of 45

20 container complying with British Standard 7320 and disposed by the Low Risk Clinical Waste (ORANGE STREAM) as described in above. Bin containers supplied to clinical areas via Central Stores, purchased on National Contract, comply with the above standards. Containers should only be filled to the fill-to mark. ii. Unused or large volume residual pharmaceutical waste from hospital settings, including all unopened medicinal or pharmaceutical products must be retained in the original container and returned to pharmacy for disposal. Advice on the disposal of pharmaceutical waste is available from the Pharmacy Department. iii. Large volume residual pharmaceutical waste from community settings, including medicines, vaccines must be placed in a UN type approved bin container for incineration. The container for medicinal waste being a blue top container. This waste must be kept separate from Orange stream wastes. All Pharmaceuticals and Other Pharmacy Chemicals from Pharmacy Department are to be incinerated. Pre-notified wastes must be placed in a UN type approved BIN for incineration, of suitable size complying with British Standard The name of the pharmacy department generating the waste should be written clearly on the container along with the waste type printed INDELIBLY in BOLD e.g. PHARMACY WASTE. Pharmacy Department arranges uplift of this waste by the licensed waste contractor Cytotoxic Waste Cytotoxic wastes are designated as Special Wastes under the Special Waste Regulations: 1996 and require a pre-notification consignment note to facilitate handling and disposal. The required monitoring, handling, documentation and disposal of pharmaceutical waste is normally managed by the Pharmacy Department. Advice on the disposal of pharmaceutical waste is available from the Pharmacy Department. All cytotoxic wastes are to be incinerated. Pre-notified wastes must be placed in a UN type approved bin container for incineration, of suitable size complying with British Standard Bin containers supplied to clinical areas via Central Stores, purchased on National Contract, comply with the above standards. Containers should only be filled to the fill-to mark. The date and name of the hospital, ward/department generating the waste should be written clearly on the bin, along with the waste type being identified by means of a purple top container. Where purple top containers are not available, printed tape may be used to identify the waste. Bin containers must also bear the name of the assembler, as well as the date and name of the person who seals the container after use. These bin containers must NOT be filled above the "fill-to" line. Bin containers must NOT be placed inside bags. Bins must be stored separately from all other waste and shall be uplifted by the licensed special waste contractor at predetermined times. Version st June 2015 Page 20 of 45

21 Cytotoxic waste such as wipes, gloves, containers, etc that have been exposed to cytotoxic materials will be disposed of in UN type approved YELLOW bags Radioactive Waste The waste generated is a by-product of Medical Diagnostic and Therapeutic Procedures using Radionuclides. The accumulation, storage and disposal of this waste is regulated by the Radioactive Substances Act NHS Forth Valley has a Certificate of Authorisation for the accumulation, storage and disposal of Radioactive Waste. The Radioactive Wastes are listed under: a. Solid Radioactive Waste b. Liquid Radioactive Waste. The Certificate includes proposals for the accumulation of Radioactive Waste, before it is disposed of. The waste will be contained in approved metal containers as appropriate in the consent. Storage takes place in a locked storage room. Shielding will be used during storage where necessary. Appropriate protective clothing will be worn when handling these wastes. Disposal of Radioactive Waste will be in accordance with the conditions contained in the Certificate of Authorisation for the Disposal and Accumulation of Radioactive Waste. Disposal of Radioactive Waste is managed by NHS Forth Valley Radiation Protection Advisor Mercury Mercury, e.g. from sphygmomanometers is designated as Special Waste under the Special Waste Regulations: 1996 and require a pre-notification consignment note to facilitate handling and disposal. The Pharmacy Department normally manages the required monitoring, handling, documentation and disposal of this Special Waste. Advice on the disposal of such Special Waste is available from the Pharmacy Department or Waste Manager. This waste must be stored separately from all other waste. Wards or Departments should arrange special uplifts of this waste by Facilities staff for return to the Pharmacy Department. Within community hospitals, health centres and clinics mercury waste should be returned to the special waste storage area for storage prior to correct pre-notified disposal. Procedural advice on the disposal of such Special Waste is available from the Waste Manager. Mercury spillage kits are available at locations detailed in Appendix 4. A licensed special waste contractor is used to remove this at periodic intervals. Thermometers and sphygmomanometers may contain mercury and if so must be treated as special waste if they are broken or are no longer required. Version st June 2015 Page 21 of 45

22 The following gives information and advice in the event of a mercury spillage. Safety Requirements when dealing with mercury spillage See Appendix 4 Mercury vapour has a very high toxicity and it is essential that all spillages should be cleared up as quickly and as thoroughly as possible. IT MUST NOT BE VACUUMED, as this will merely disperse mercury vapour through the environment. Mercury is extremely toxic by ingestion, inhalation and skin contact. Toxic effects are cumulative. Personal Protective Equipment Staff must wear personal protective equipment when dealing with mercury spillages i.e. disposable gloves, safety goggles, plastic apron. Further advice on gloves will be contained within the Management of Latex Products Policy. Responsibilities when dealing with mercury spillage It is the responsibility of the medical/nursing staff using mercury-containing equipment at time of incident to deal with the spill unless the member of staff is, or suspects they may be, pregnant in which case they should immediately leave the area. All staff must report any spillage of mercury to the person in charge. The person in charge should follow the procedure for the management of mercury spillage as detailed in Appendix 4. Once the spillage has been dealt with the person in charge must ensure that the full details are recorded through the Safeguard Incident Management System. New kits, or replacements for out-of-date kits, should be ordered from the Central Supplies Department. Version st June 2015 Page 22 of 45

23 6.2 Clinical Waste Arising in Community Settings When healthcare professionals administer care outwith NHS premises they must carry out a waste assessment as shown in Appendix 3 to ensure that clinical waste does not enter the household waste stream. All used sharps and any wastes with a designated infection hazard will be returned to an operational NHS base using appropriate containers, or be subject to special collection arrangements, for disposal in the ORANGE STREAM. Placenta and any wastes with a designated high infection hazard will be returned to an operational NHS base using appropriate containers, or be subject to special collection arrangements, for disposal in the YELLOW STREAM. Unused pharmaceuticals and other unused pharmacy chemicals administered by the healthcare professional outwith NHS premises and any designated special wastes will be returned to an operational NHS base, or be subject to special collection arrangements, for disposal as High Risk Clinical Waste. Any of the patients own unused pharmaceuticals and other unused pharmacy chemicals, etc. should be returned by the patient via their community pharmacy. NHS Forth Valley has a responsibility for arranging the disposal of specific waste streams from community pharmacies and General Dental Practices. Examples of the information and guidance issued to community pharmacies and General Dental Practices on the disposal of healthcare wastes from their settings is contained within Appendices 5 and 6. Version st June 2015 Page 23 of 45

24 7. Transport and Storage Arrangements To agree the appropriate storage and transport arrangements, a decision should be made taking into consideration the risk assessment findings, the packaging involved and the offensive nature of the waste. Bags used for waste disposal should be filled to no more than 2/3 capacity. During filling the bags should be held in an appropriate floor standing holder. When the bag is ready for disposal, it should be removed from the holder, closed using the swan neck method and securely sealed with a ratchet type waste tag. Cardboard should not be bagged before collection. Facilities staff will remove waste from wards and departments and transport the waste to designated collection areas. Dedicated trolleys and bins must be used to transport waste to minimise the risk of cross contamination. It is a serious disciplinary offence not to follow this requirement. See Appendix Storage of containers in clinical areas Keep an adequate supply of clinical waste bags, sharpsbins and bin containers in a clean dry storage area to avoid contamination prior to use in the clinical area; a. Keep filled clinical waste bags, sharpsbins and bin containers in designated areas separate from other waste e.g. laundry prior to uplift; b. Never allow clinical waste to accumulate in corridors, wards, treatment areas or other such unsuitable places; c. Never place heavy or sharp objects on top of clinical waste bags, sharpsbins and bin containers; d. Never throw or drop clinical waste bags, sharpsbins and bin containers. 7.2 Basic Safety Rules a. Clinical waste must be handled and transported safely and carefully at all times. Damaged containers create a risk of infection and/or injury to staff and others; b. Incorrectly packaged, inadequately sealed or unlocked clinical waste containers will not be handled or transported. Always: a. Examine clinical waste containers carefully before handling or moving; b. Wear suitable protective clothing and gloves; c. Report all damage or incorrectly sealed containers to the person in charge of the designated collection point and supervisor; d. Carry clinical waste bags by the neck and away from the body; e. Carry sharpsbins, bin and box containers by the handle provided; f. Transport clinical waste separately from all other items; g. Ensure that a Spillage Kit is carried in the Collection Vehicle; Version st June 2015 Page 24 of 45

25 h. Ensure that the load is secure. i. Wash hands with soap and water after handling waste and before carrying out other duties. Never: a. Remove clinical waste containers unless they are properly sealed and labelled, showing type of the waste, origin and date sealed; b. Remove damaged clinical waste containers; c. Compact or crush clinical waste containers; d. Throw or drop clinical waste containers; e. Leave clinical waste unattended. 7.3 Minimum Standards for Clinical Waste Stores Clinical Waste Stores shall: a. Be secured (by lock) against unauthorised entry at all times; b. Be exclusive for clinical waste. If this is not possible, designated and delineated areas that pose no risk of infection or injury must be identified; c. Be so arranged to ensure YELLOW and ORANGE containers of suitable sizes are stored separately; d. Be clean, free from spillage and subject to cleaning at regular appropriate intervals; e. Have adequate access and egress whenever required; f. Have a copy of the organisation s Written Spillage Procedure on display; g. Be provided with a complete Clinical Waste Spillage Kit; h. Have access to washing facilities; i. Be free from pest infestation; j. Be adequately ventilated and illuminated. 7.4 Staff Protection As part of the control measures to reduce risks to staff, those handling clinical waste shall be offered appropriate immunisation, including Hepatitis B and Tetanus. Whilst these immunisations are recommendation for all staff who handle clinical waste, the Prevention of Exposure to Blood Borne Virus Infection Policy highlights the arrangements for dealing with staff who decline to accept the immunisations offered or those who do not produce any immunity following vaccination (sero-convert). As part of the safe system of work, the manager should ensure that all staff who handle waste are aware of: a. Information in relation to potential risks and how these are reduced and controlled. Version st June 2015 Page 25 of 45

26 How to obtain and use any Personal Protective Equipment required Information and support on how to access relevant immunisations Accidental Spillage and Contamination with Blood/Body Fluids Staff should access the relevant information from the National Infection Prevention and Control Manual, Chapter One, Standard Infection Control Precautions. This is available via the HAI information icon on the staff Intranet Accidental Exposure to Blood/Body Fluids and Sharps Injury Staff should access the relevant information from the Management of Exposure to Blood Borne Virus Infection Policy contained within the Infection Control Guidelines. This is available via the HAI information icon on the staff Intranet. Version st June 2015 Page 26 of 45

27 8. Security During local ward or department storage of waste, ORANGE bags, YELLOW bags and Sharps containers must be held in an appropriate colour coded clinical waste bin. The bins must be locked at all times, and should be held, where possible, in an area not normally accessible by patients or members of the public. Where colour coded bins are not available, then the waste should be stored securely, and separately from other waste streams (i.e. yellow, orange and black waste must be kept separate from each other at all times). During collection of waste, ORANGE bags, YELLOW bags, Sharps containers and designated containers must be transported in an appropriate separate colour coded collection run by Facilities staff. The collection trolleys must be secured before leaving the ward or department and remain secure at all points between ward/department, and the clinical waste storage areas/loading bays as described in Section 5. a. Anatomical waste from Theatres will be taken to the Clinical Waste Store and kept within locked storage until collected for incineration; b. Placenta from Women & Childrens Services will be kept in a locked refrigerator whilst awaiting collection. It will be taken to the Clinical Waste Store and kept within locked storage until collected for incineration; c. Pathological waste will be taken to the Clinical Waste Store and kept within locked storage until collected for incineration. Version st June 2015 Page 27 of 45

28 9. Review Arrangements This Waste Disposal Policy will be revised every two years. It will be kept under review and may also be amended in the light of service development or new legislation. Complaints, queries or suggestions concerning this policy should be forwarded to the Waste Manager who can be contacted on Version st June 2015 Page 28 of 45