Version: 5.0. Effective From: 28/11/2014

Transcription

1 Policy No: IC09 Version: 5.0 Name of Policy: Waste Disposal and Re cycling Policy Effective From: 28/11/2014 Date Ratified 17/10/2014 Ratified Infection Prevention & Control Committee Review Date 01/10/2016 Sponsor Director of Midwifery & Nursing/DIPC Expiry Date 16/10/2017 Withdrawn Date This policy supersedes all previous issues. Waste Disposal and Re cycling Policy v5

2 Version Control Version Release Author / Reviewer Ratified By / Authorised By Date /02/2002 February /03/2005 Risk March 2005 Management and Standards Committee Changes /12/2008 Trust Central Team 16/12/ /08/2012 Mr J Simpson /11/2014 Mr J Simpson Infection Prevention and Control Committee Infection Prevention and Control Committee 27/07/2012 Policy put into new Trust format Waste posters to be recalled and replaced as: Red lids now required for anatomical waste drums ordered as not available in UK Blue lids for pharmacy waste An offensive waste stream to be introduced tiger stripe bagsi. When contractor disposal has been secured and ii. With IPCT approval for streams other than sanitary waste. Rigorous audits prior to waste transfer required from July 12 across the whole organisation 17/10/2014 Policy put into OP27 Version 6.1 format Update of audit section Removal of Mandatory training statement (2 slides will be added to IPC presentations) Introduction of the Sustainability Officer role Job Titles updated throughout Section for management of Foetal waste Waste Disposal and Re cycling Policy v5 2

3 Contents 1 Introduction Policy Scope Aim of the Policy Duties, Roles & Responsibilities Definition of Terms Domestic (Municipal) Waste Confidential Waste Clinical Waste Medicinal Waste Waste Which Poses a Risk of Infection Hazardous Waste Offensive/Hygiene Waste Radioactive Waste Waste Electrical & Electronic Equipment (W.E.E.E.) Waste Classification, Segregation & Containment Determinations i) Non Medicinal Sharps ii) Offensive Waste iii) Traceability of Cradle to Grave iv) Category A Pathogen List v) Anatomical Waste vi) Collection of Radioactive Waste vii) Collection of Clinical Waste from Private Households viii) Expertise Regarding Hazardous Clinical Waste Handling Procedures Non Clinical Waste Clinical Waste Drainage Bottles Sharps Anatomical Waste Medicines Storage (At Ward or Department Level) Handling of Spillages Areas of Activity Requiring Special Consideration Pharmacy Procedure for Theatres Disposal of Prosthesis Procedures for Obstetrics/Gynaecology Cases of Infectious Disease Health Surveillance, Immunisation & Personal Protective Equipment (PPE) Accidents & Incidents Spillages Waste Handling Bags (All Types) Sharps Boxes Collection Consignment Note & Controlled Waste Transfer Note System Consignment Note for Hazardous Waste Consignment Note for Radioactive Waste Waste Audits Waste Disposal and Re cycling Policy v5 3

4 6.44 Report of Compliance to the Health and Safety Committee Waste Register Review Waste Minimisation Hierarchy of Waste Minimisation Training Training Records Equality & Diversity Monitoring Compliance with the Policy Consultation & Review Implementation of Policy (Including Raising Awareness) References Associated Documentation APPENDIX 1 Clinical Verses Offensive Waste APPENDIX 2 Labelling of Clinical or Offensive Waste Bags APPENDIX 3 Clinical waste contingency plan APPENDIX 4 Mercury Spillage Procedure APPENDIX 5 Inactivation of spills related to body fluids APPENDIX 6 Glossary & Acronyms APPENDIX 7 Contacts and Emergency Numbers Waste Disposal and Re cycling Policy v5 4

5 1 Introduction It is the Trust s policy to limit the amount of waste arising through the Trust s activities, in so far as is reasonably and economically practicable. This is to be achieved by careful consideration from purchasing through to final disposal. Where waste arisings are unavoidable, it is the Trust s policy to ensure the safe segregation, handling and disposal of those arisings and that all persons handling any such waste, exercise care to avoid injury or risk of harm to themselves or others, including the general public and the environment. This is to be achieved by the production and implementation of appropriate Waste Management Procedures, which will ensure compliance with all relevant legislation, codes of practice and guidelines as far as is reasonably practicable. Large quantities of waste are produced every day from a broad range of work places. Unless the segregation, handling, transport and disposal are properly managed, such waste can present risks to the health and safety of people at work, members of the public, and the environment. The Environmental Protection Act 1990 which came into force in April 1992 imposes legal responsibility upon all industrial and other processes, including the NHS for taking all reasonable steps to ensure that all wastes are disposed of correctly. Duty of Care requirements demand the proper management of such waste from the time that they are generated and continues until they are ultimately made safe or disposed of (Cradle to Grave). The Duty of Care Regulations explain that a breach of care is a criminal offence, irrespective of whether there has been any other breach of law or any consequent harm or pollution. An unlimited fine may be imposed on conviction or indictment. Clinical waste falls within the scope of the Control of Substances Hazardous to Health (COSHH) 2002 Regulations, which specifically require risk assessments for all hazardous substances likely to be encountered as a result of a work activity. The categories of waste identified within this policy are intended to form the foundation for local risk assessment, although the actual level of risk will vary both within and between the groups. However, to ensure that waste does not present a risk to staff and others, suitable control measures must be adopted and adhered to as appropriate to each group. 2 Policy Scope This policy covers all waste arisings in the Trust in relation to patients, staff, visitors and members of the public in all Trust premises which are the responsibility of Gateshead Health NHS Foundation Trust. Waste Disposal and Re cycling Policy v5 5

6 This policy applies to all members of staff, including locums, agency staff and volunteers (where appropriate), working within the Trust. 3 Aim of the Policy The aim of the policy is to ensure: Trust wide systems are developed and maintained to ensure staff, patients and others are not unnecessarily exposed to contaminated waste. Staff are aware of their responsibilities when disposing of waste. The risks from disposing of waste are minimised. Staff receive training and guidance in complying with current disposal legislation. Best practice is regularly promoted and monitored through the waste disposal process. The policy incorporates a cradle to grave concept in which the management of all waste, including Controlled and Hazardous waste is covered from the point of generation until it is safely disposed of in accordance with current legislation. 4 Duties, Roles & Responsibilities The Trust Board The Trust Board of Directors, as the employer, are ultimately responsible for fulfilling all duties assigned to them in current UK Health and Safety Legislation. This includes having a robust system of Corporate Governance within the organisation and ensuring that there is a systematic process for the development, authorisation and management of policies. The Chief Executive The Chief Executive has overall responsibility for safe waste handling and will ensure that adequate Directors, Managers and staff are aware of, and carry out the roles and responsibilities identified in this policy. This policy is applicable within all premises owned and operated by the Trust, and waste will be appropriately disposed of in accordance with legal requirements and acknowledged good practice. Director of Estates & Facilities The Director of Estates and Facilities is responsible to the Chief Executive for the planning, organisation, control, monitoring and review of waste disposal and recycling within the Trust. He is also responsible for the appraisal of all new legislation and guidance, as well as new procedures and technology available to help reduce the risk associated with waste. The Director of Estates and Facilities is also responsible for developing and promoting increasing levels of re use and recycling of all waste when it is safe and economical to do so. Waste Disposal and Re cycling Policy v5 6

7 Directors of Infection, Prevention & Control (DIPC) The Directors of Infection, Prevention and Control will: Oversee the endorsement of the Disposal of Hazardous Waste component of this policy and its implementation Trust wide. Report directly to the Chief Executive and the Board regarding new initiatives. Have the authority to challenge inappropriate practice in relation to the Disposal of Hazardous Waste component of this policy. Act as a role model. Make recommendations for change in relation to the Disposal of Hazardous Waste with regard to any advice from Purchasing and Supplies Agency (PASA), the National Patient Safety Agency (NPSA) and evidence based practice. Consultant Microbiologist Endorses and supports adherence to the Disposal of Hazardous Waste. Advises the DIPC as necessary. Infection Prevention & Control Team It is the responsibility of the Infection Prevention and Control Team to: Stipulate the requirements for the Disposal of Hazardous Waste based on current guidance, evidence based practice and relevant research. Disseminate the Waste Management Policy following approval by the Board of Directors, to all ward/departments within the Trust. Provide advice to the Trust on the provision of adequate facilities and products to enable adherence to the Hazardous Waste component of the policy, including any requirements for new build and development. Act as advisers in all matters relating to the Disposal of Hazardous Waste in conjunction with the Waste Manager. Attend relevant committees and working groups to provide active membership and appropriate specialist input. Work in close collaboration with matrons to promote and maintain adherence to the Waste Management Policy throughout the Trust, particularly regarding Hazardous Waste. Provide information, written and verbal, and advice to patients, carers and staff according to the recognition of their individual needs relating to the Disposal of Hazardous Waste. Work in collaboration with the Patient Advisory Liaison Service and other disciplines to assist in the update and formulation of written information relating to the Disposal of Hazardous Waste for patients, volunteers and visitors. Represent the Trust externally to share best practice and report back to the organisation. The Infection Prevention and Control team will, via the link people for infection prevention and control, and in conjunction with the Waste Manager, maintain an audit of the Disposal of Hazardous Waste throughout Waste Disposal and Re cycling Policy v5 7

8 the Trust as part of the annual Infection Control audits, and this will form a major part of the review process. The Waste Manager The Waste Manager is responsible for: Ensuring that the Trust manages waste disposal in accordance with its Waste Management Policy. The revision of this procedure on a bi annual basis or more frequently if required. The provision of necessary training and regular updates throughout the Trust. The promotion of good waste reduction processes throughout the Trust. The carrying out of audits in conjunction with the Infection Prevention and Control team. Duty of Care inspections to companies employed by the Trust. The keeping of all waste control transfer notes and records. The premise notification required under the Hazardous Waste Regulations. Administration of the waste disposal contract. Contingency planning in the event of an emergency. The keeping of a waste register of all contractors used by the Trust. The Sustainability Officer Will ensure that any recycling opportunities are economical and complementary to the waste policy and current disposal methods. Support the waste manager in audit of this policy. Chief Pharmacist The Pharmaceutical Services Manager will ensure that cytotoxic and cytostatic waste is correctly recorded, packaged and securely stored in preparation for collection and disposal by the appointed waste disposal contractor. All waste consignment notes supplied and completed by the waste contractor are correct prior to the waste leaving site, and copies of the completed consignment notes are forwarded to the Waste Manager for audit purposes. Will ensure that the disposal of all pharmaceutical waste is in accordance with the Pharmacy Standard Operating Procedures. Radiology Assistant Divisional Manager The Radiology Directorate Manager will ensure that radioactive waste is disposed of in accordance with the Radioactive Substance Act 1993 that disposal limits are complied with in accordance with that specified on the authorisation certificate, and the Radiology Directorate policy for the handling and disposal of radioactive waste is complied with. All waste consignment notes supplied and completed by the waste contractor are correct prior to leaving site and copies of the completed consignment note are forwarded to the Waste Manager for audit purposes. Waste Disposal and Re cycling Policy v5 8

9 Pathology Manager The Pathology Manager will be responsible for the sterilisation and packaging of all discarded samples in accordance with the Laboratory Standard Operating Procedure, and for implementing any contingency arrangements in the event of equipment failure. Occupational Health Department The Occupational Health Department will advise, in the event of injuries due to sharps or other adverse health effects from handling waste. Any staff who have been exposed to waste that has resulted in harm or potential harm to the health of employees should contact the Occupational Health Department for advice. Sharps injuries should be managed in line with Trust Policy IC07. The Occupational Health Department will carry out annually a sharps waste audit. Portering Manager Responsible for managing all Porters involved in the waste handling process. Also responsible for identifying any skills/training gaps of any staff handling waste and filling these gaps in a timely fashion in collaboration with the Infection Prevention and Control department as well as the Waste Manager. The Portering Manager will ensure that the Bio track cart tagging labels are correctly attached to every waste cart prior to collection by the waste disposal contractor, and that all waste transfer notes are completed and signed. The Portering Manager will ensure that all faulty black and blue carts are call logged for repair, and yellow faulty carts are reported to the clinical waste carrier. Associate Directors, Service line Managers, Heads of Service & Ward Managers Associate directors, ward managers and heads of service will, in the areas under their control, ensure that policies, procedures, Codes of Practice, risk assessments, Safe Working Practices and National Guidelines are implemented and adhered to at all times. Failure to do so will constitute a breach of the Duty of Care and could incur a risk of prosecution. Managers shall ensure that: Staff are released to attend waste training sessions, and that records of people trained are kept. External and internal containers are purchased and replaced as necessary. COSHH risk assessments are undertaken and safe systems of work implemented. Incidents reported during the handling of waste are investigated and reviewed. The training requirements of staff by grade and discipline are identified and acted upon. Staff are made aware that unsafe practice will constitute misconduct under the Trust s Disciplinary Policy. Waste Disposal and Re cycling Policy v5 9

10 Appropriate and acceptable range of clinical waste containers and protective clothing are available as appropriate. Waste bags are stored away from the general public and patients, in storage or sluice rooms, i.e. not in corridors unless in lockable containers. Bags are never filled more than two thirds full, and must be capable of being lifted with an outstretched arm. All full bags are stored in the approved wheeled containers provided. Clinical bags are segregated from non clinical bags at ward level and thereafter. Ensure that porters collect approved wheeled containers from the designated points in accordance with local policies. Approved wheeled storage containers, when not in use, are to be kept locked at all times. Managers should note that bags which are split or that have not been correctly tied and marked will not be removed from the Ward or Department. Non compliance to the above procedure will be reported by the porters to local management. These will be communicated to the head of department, who must then take corrective action. Waste Producers In line with this procedure, to ensure that: Waste is segregated and placed into the correct container. The correct specification of bag is used (colour and source coded). Bags are sealed correctly when no more than two thirds full. Bags and sharps containers are transferred to the waste collection point and stored safely and securely. Waste/Compound Porter In line with this procedure, is to: Move securely tied and coded bags to the waste collection point. Move securely sealed sharps boxes and drums to the waste collection point. Bring to the attention of the producer any insecurely tied bags. Transport full and empty wheeled carts between waste collection points and storage areas. Report faulty carts to the portering manager. Colour code full carts before collection with Bio track labels. Comply with the requirements of the Northern Regional Waste Consortium. Complete and sign waste transfer notes on behalf of the Trust. Segregate waste into appropriate waste streams for recycling and process accordingly. Currently waste streams exist for: Clinical Waste Household Waste Waste Disposal and Re cycling Policy v5 10

11 Cardboard Paper for Recycling Metal Oil Ink Cartridges W.E.E.E. Chemicals Offensive waste Plaster casts Employees Employees have a responsibility under Health and Safety legislation: (i) To follow this policy and implement any instructions and training they receive and follow procedures that are issued under this policy. (ii) To wear any protective clothing provided to protect them and to prevent cross infection. The safe and correct disposal of waste is the responsibility of all staff in order to minimise accidents especially with sharps, and to prevent infection. Failure to comply with this policy may result in disciplinary action being taken. Items not covered in this policy should be drawn to the attention of the waste manager. It is the responsibility of all staff to ensure that they comply with this policy and attend training when required by management. The Carrier Ensure the waste is collected from the waste compound storage area and transported to the agreed facility as per agreed contract. The Disposer Ensure the waste is disposed of in accordance with the agreed contract and current UK legislation. Health & Safety Committee All matters relating to this policy and the result of audits undertaken will be reported to and considered by the Health and Safety Committee. 5 Definition of Terms It is very important that waste is properly identified in order that it can be effectively managed. This section sets out definitions for waste as used in this policy, and it is essential that staff have a proper understanding of the classifications. Waste Disposal and Re cycling Policy v5 11

12 5.1 Domestic (Municipal) Waste For the purposes of this document, domestic waste is the same as, or similar to, waste from accommodation used purely for living purposes which is suitable for disposal by landfill and which is not confidential or recyclable. 5.2 Confidential Waste This is regarded as any document, record or computer disk or tape, microfiche, audio or video tape or similar items for disposal, from which could be obtained the name and address of a patient, next of kin or employee of the Trust. 5.3 Clinical Waste Clinical waste is defined as: a) Any waste which consists wholly or partly of human or animal tissue, blood or other bodily fluids, excretions, drugs or other pharmaceutical products, swabs or dressings, syringes, needles or other sharp instruments, being waste which unless rendered safe may prove hazardous to any person coming into contact with it; and b) Any other 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. Broadly, therefore, clinical waste can be divided into two categories of materials: i) Medicinal waste ii) Waste which poses a risk of infection 5.4 Medicinal Waste Medicinal waste can be further divided into: a) Cytotoxic and cytostatic medicines which are classified as hazardous under the Hazardous Waste Regulations. b) Medicines other than those which are cytotoxic or cytostatic. 5.5 Waste Which Poses a Risk of Infection Infectious waste is defined as: a) Substances containing viable micro organisms or their toxins which are known or reliably believed to cause disease in man or other living organisms. b) Waste traditionally known as clinical waste falls within this category. Waste Disposal and Re cycling Policy v5 12

13 5.6 Hazardous Waste Hazardous waste is waste that contains hazardous properties that may render it harmful to human health or the environment. The 15 hazard groups identified in the Hazardous Waste Regulations are: H1 Explosive H2 Oxidising H3A Highly Flammable H3B Flammable H4 Irritant H5 Harmful H6 Toxic H7 Carcinogenic H8 Corrosive H9 Infectious H10 Toxic for reproduction H11 Mutagenic H12 Substances that release toxic gases H13 Sensitising H14 Ecotoxic H15 Waste capable by any means, after disposal, of yielding another substance, for example a leachate, which possesses any of the characteristics H1 to H14. The European Commission has issued Directives on the controlled management of such waste and hazardous waste is further defined on the basis of a list, the European Waste Catalogue (EWC). Producers are required to describe their waste using a written description of the waste and the use of the EWC codes contained within the catalogue: EWC Description of Waste Code Waste from healthcare, diagnosis, treatment or prevention of disease in humans Sharps except Body parts and organs, including blood bags and blood preserves (except ) Waste whose collection and disposal is subject to special requirements in order to prevent infection Waste whose collection and disposal is not subject to special requirements in order to prevent infection, e.g. dressings, plaster casts, linen, disposable clothing Chemicals consisting of dangerous substances Chemicals other than those listed in Waste Disposal and Re cycling Policy v5 13

14 EWC Description of Waste Code Cytotoxic and cytostatic medicines Medicines other than those mentioned in Amalgam waste from dental care Cytotoxic and cytostatic medicines returned by patients Medicines other than those mentioned in returned by patients Although this will cover most types of waste generated within the Trust, there will be exceptions which require codes allocated from one of the other chapters of the EWC catalogue (other than healthcare). 5.7 Offensive/Hygiene Waste The term offensive/hygiene waste describes waste which is non infectious and which does not require specialist treatment or disposal, but which may cause offence to those coming into contact with it. Offensive/hygiene waste includes waste previously described as human hygiene waste and risk assessed continence waste, and does not need to be classified for transportation. Examples of offensive/hygiene waste include: Incontinence and other waste produced from human hygiene. Sanitary waste. Nappies. Medical/veterinary items and equipment which do not pose a risk of infection, including gowns, personal protective equipment, etcetera. Animal faeces and soiled animal bedding. The bags used to dispose of this waste should be yellow with black stripes. 5.8 Radioactive Waste Relatively small amounts of radioactive clinical waste are generated at a limited number of locations at the Queen Elizabeth Hospital site. The creation, minimisation, handling and treatment of this waste is controlled under the Radioactive Substances Act 1993 with a specific Certificate of Authorisation. Any departure from the authorised procedures must be approved through the Radiation Protection Adviser. 5.9 Waste Electrical & Electronic Equipment (W.E.E.E.) The W.E.E.E. Regulations require that all electrical and electronic equipment is appropriately disposed of at the end of its life by being refurbished and reused or recycled. Many electrical/electronic items are also classified as Waste Disposal and Re cycling Policy v5 14

15 hazardous to the environment under the Hazardous Waste Regulations and cannot be disposed of to landfill. All equipment powered by electricity or batteries falls within the requirements of the W.E.E.E. Regulations such as batteries, computers, monitors, refrigerators, torches and the like. These items must be separately collected and disposed of in accordance with the Trust Waste Segregation Chart. 6. Waste Classification, Segregation & Containment The basis of all hospital waste disposal is segregation into defined waste streams which are colour coded for quick and easy visual reference. As producers of hazardous waste, we have a legal obligation to ensure that not only our hazardous waste is segregated from other waste, but different categories of hazardous waste are not mixed together. This is the most important single principle of waste disposal, understanding that hazardous waste must be segregated and cannot be mixed. Clear information, instruction and training in identifying specific categories of waste must be provided for staff working in areas where waste arises. In addition, notices detailing the identification system should be posted at appropriate locations to assist in the information, instruction and training process. It is essential that the national colour coding for waste segregation is observed to ensure easy and immediate recognition of the various types of waste. Waste will be segregated as follows: Waste Disposal and Re cycling Policy v5 15

16 COLOUR CODING FOR WASTE PACKAGING COLOUR DESCRIPTION CONTAINMENT Hazardous Waste which requires Yellow bag no more than two thirds disposal by incineration full, securely tied and source Indicative treatment/disposal labelled. The Infection Prevention required is incineration in a and Control Team will be aware of Yellow suitably permitted or licensed this patient. facility. Clinical Waste which may be treated Orange bag no more than two thirds full, securely tied and source labelled Indicative treatment/disposal Orange required is to be rendered safe in a suitably permitted or licensed facility, usually alternative treatment plants (ATPs). However this waste may also be disposed of by incineration. Purple Yellow Cytotoxic and cytostatic waste Indicative treatment/disposal required is incineration in a suitably permitted or licensed facility. Sharps not contaminated with cytotoxic/cytostatic waste Yellow bodied purple lidded sharps container, all details on the label must be completed and the lid securely latched. Yellow bodied sharps container Yellow/black Red Black Blue Offensive/hygiene waste Indicative treatment/disposal required is landfill, municipal incineration/energy from waste at a suitably permitted or licensed facility. Anatomical waste for incineration Indicative treatment/disposal required is incineration in a suitably permitted facility. Domestic (municipal) waste Minimum treatment/disposal required is landfill, municipal incineration/energy from waste or other municipal waste treatment process at a suitably permitted or licensed facility. Recyclable components should be removed through segregation. Clear/opaque receptacles may also be used for domestic waste. Medicinal waste for incineration Indicative treatment/disposal required is incineration in a suitably permitted facility. Yellow and black bag no more than two thirds full securely tied and source labelled. Place into a yellow drum and attach a red source label and securely fix a red lid. Place in a black bag no more than two thirds full and securely tied. Yellow rigid drum with blue latching lid appropriately source labelled (blue label). Waste Disposal and Re cycling Policy v5 16

17 COLOUR DESCRIPTION CONTAINMENT Amalgam waste For recovery White Green Batteries Waste paper for recycling Confidential waste paper W.E.E.E. waste (Electrical) Cardboard Printer cartridges Broken crockery and tins Chemicals Asbestos Plaster Casts White rigid drum with a green lid Clear bag no more than one third full, securely tied. Any confidential document which has been shredded can be disposed of into this waste stream. Woven polyester white bag marked confidential waste for shredding no more than one third full, securely tied. Collected from the ward or department and taken to the waste compound for consignment under the Regulations. Folded flat and taken to the waste compound for baling. Placed into original packaging and returned to the waste compound for recycling. Placed in white hard waste container in ward or department. Kept in original labelled containers, stored appropriately in accordance with manufacturer s recommendations. These items will be disposed of on an individual basis, as per departmental policies and risk assessments. Please Note: COSHH safety data sheets and assessments will be required. Handled and disposed of by licensed specialist contractor under the control of the Trust s authorised person. Dedicated cardboard container. Waste Disposal and Re cycling Policy v5 17

18 6.1 Determinations i) Non Medicinal Sharps Although it is permissible for sharps from non medicinal sources to be processed via the continuous feed heat treatment disinfection unit, adequate segregation of such sharps cannot be guaranteed and therefore the Trust chooses to dispose of all sharps via the more expensive incineration route in the interests of safety. ii) Offensive Waste It is permissible under legislation for nappies, incontinence pads, etcetera, to be disposed of using a tiger bag (yellow with black stripe) to landfill if the waste is not infected. Current microbiological advice suggests that an infectious risk could remain with such products and discretion must be used and approval given by the Infection and Prevention Control Team before this is introduced to a patient area. iii) Traceability of Cradle to Grave The whole process of exercising our Duty of Care from cradle to grave, relies upon good segregation of waste at source using the correct coloured bag/box. The traceability of all waste is also key to the review process. No sharps box or bag will be removed from the ward or department unless it is source coded with a pre printed label or the appropriate information filled in on the sharps box label. iv) Category A Pathogen List The use of the continuous feed heat treatment process for general clinical waste kills most but not all organisms and is therefore unsuitable for any infectious substances on the Category A Pathogen List. Such pathogens are rarely found in healthcare, and any patients suspected of having an infection on the list will be transferred to the dedicated Infectious Diseases Unit. See Appendix 5 of the IC06 Isolation Policy. The Infection Prevention and Control Department will be involved in the nursing of any patient in this pathogen group, and their advice must be followed. Any clinical waste arising in these circumstances will be incinerated and any actions in this regard will be initiated by the Infection Prevention and Control Department. Waste Disposal and Re cycling Policy v5 18

19 v) Anatomical Waste All anatomical waste, placentas, etcetera, will be kept separate from all other waste and held in a refrigerated store whilst awaiting collection. Please note that foetal tissue is not part of the waste stream and is managed via the pathology department and relevant local departmental protocol. vi) Collection of Radioactive Waste Collection of radioactive waste will be made directly from the Medical Physics Department. vii) Collection of Clinical Waste from Private Households Where waste is generated by a healthcare worker in the community, the healthcare worker is responsible for ensuring that the waste is managed correctly. Two options are available: a) Small quantities of waste may be transported back to base for disposal in rigid containers properly labelled. b) The waste may be left at the home in a secure place with the agreement of the householder, and arrangements made with Gateshead Council for collection. The Council telephone number to arrange this is viii) Expertise Regarding Hazardous Clinical Waste The Infection Prevention and Control Department have the expertise in the correct handling, storage and disposal of hazardous clinical waste and their stipulated requirements will prevail over any other advice and must be complied with at all times. 6.2 Handling Procedures 6.21 Non Clinical Waste General household refuse (including paper towels) suitable for bagging must be placed in a black bag. Waste Disposal and Re cycling Policy v5 19

20 Glass, crockery and other sharp materials shall be adequately protected by placing in a white plastic hard waste container provided in each area. Cardboard should be flattened and bundled up separately for collection. Packaging for medical/nursing supplies should be placed in a black bag. N.B. Any of the above waste which is contaminated with clinical or cytotoxic waste must be classified as clinical and placed in an orange/yellow bag (with horizontal purple stripe) respectively Clinical Waste Soiled surgical dressings, clinical swabs and other contaminated waste from treatment areas must be placed in an orange bag at the point of generation. Urinary catheter tubes and bags must always be emptied of fluid before being placed into an orange bag. The route of disposal for incontinence pads and stoma bags is general clinical waste or offensive waste. Items shall be placed in orange bags, if infection is suspected or confirmed, or yellow stripe bags, where there is no infection; after the major liquid content has been drained into the WC or sluice. If this is not possible, careful bagging and sealing must be carried out to prevent leakage. Personal protective equipment must be worn as per the IC02 Personal protective equipment in clinical practice Drainage Bottles a) Chest Cavity Drains on surgical wards will be sealed and gelled by ward staff, placed in an orange bag for disposal with general clinical waste. b) Glass Disposable Vacuum bottles in Orthopaedics will be sealed by ward staff and placed in an orange bag for general clinical disposal. c) Single use plastic Vacuum bottles in Theatres will be gelled by theatre staff and placed in an orange bag for disposal with general clinical waste Sharps Syringes, needles and sharp cartridges must be discarded into designated containers. No attempt must be made to re sheath needles. Ampoules should also be discarded into these containers: Waste Disposal and Re cycling Policy v5 20

21 Yellow bodied, yellow lidded for all sharps not contaminated with cytotoxic/cytostatic residue. Yellow bodied, purple lidded for all sharps contaminated with cytotoxic/cytostatic residue Anatomical Waste Human tissue must be placed in yellow bags, which, in turn, must then be placed in yellow 30L or 60L yellow drums with red lids and labelled with red labels, then held in a refrigerated store to await collection Medicines Unwanted medicines should be returned to Pharmacy for either recycling or disposal. Glass bottles which have contained liquid medicines should be returned to Pharmacy for disposal Storage (At Ward or Department Level) Waste bags not in holders and not awaiting immediate collection from the area of generation must be stored in a designated area, which is secure and affords easy access for collection. These areas should be locked at all times. Bags must not be placed in passageways, lift areas or areas to which the public have uncontrolled access. Wheeled bins in public areas should be kept locked at all times Handling of Spillages General Arrangements all spillages must be regarded as potentially hazardous and be cleaned immediately Staff have a Duty of Care when dealing with a spillage. The ward or department nurse is responsible for addressing a spillage in the clinical area. In non clinical areas a trained member of staff may be called upon to handle the spillage as can the domestic rapid response team. For spillages occurring during transit, cleaning will be carried out by the person in charge of the waste. Gloves and suitable protective clothing must be worn when handling clinical spillages and/or when using disinfectants. See IC02 Personal protective equipment in clinical practice. Waste Disposal and Re cycling Policy v5 21

22 Departmental Managers will be responsible for ensuring that adequate equipment and procedures are drawn up to cover all eventualities. 6.3 Areas of Activity Requiring Special Consideration 6.31 Pharmacy i) The Pharmacy shall be responsible for the segregation and disposal of all medicines within their department, and for all returns to the Pharmacy. ii) The completion and retention of all controlled waste transfer notes relating to medicine disposal. iii) The production and compliance with all Standard Operational Procedures (SOP s) relating to medicine disposal. iv) The segregation, packaging and disposal of all cytotoxic and cytostatic waste within the Pharmacy department Procedure for Theatres Anatomical waste must be placed in yellow clinical waste bags which will be used in the first instance as the primary containment, and then the wrapped item must be placed in a yellow 30L or 60L rigid drum with a red latching lid. The lid has an in built seal to prevent any leakage, which, when latched correctly in place, is airtight. The drums must be labelled with a self adhesive red label, and then placed in the theatre refrigeration to await removal to the waste compound. The drums will be collected by the waste porter and taken to a refrigerated store in the waste compound for collection by the waste disposal contractor. All anatomical waste is incinerated. Please Note: Do not overfill the containers which could cause a manual handling lifting hazard Disposal of Prosthesis Heavy metal hip joints and the like must never be disposed of into orange waste bags which are mechanically shredded then heat disinfected. These items will damage the shredding equipment. All metal prosthesis must be disposed of into yellow rigid drums for incineration. Waste Disposal and Re cycling Policy v5 22

23 6.34 Procedures for Obstetrics/Gynaecology Placenta must be placed in yellow clinical waste bags which will be used in the first instance as the primary containment, and then the wrapped item must be placed in a yellow 30L rigid drum with a red latching lid. The lid has an in built seal to prevent any leakage which when latched correctly in place is airtight. The drums must be labelled with a self adhesive red label then placed in the Maternity refrigeration to await collection. The drums will be collected by the waste porter and taken to a refrigerated store in the waste compound for collection by the waste disposal contractor. All anatomical waste is incinerated. Local protocol in theatre and maternity is available to guide staff in the correct management of foetal products. Please Note: Do not overfill the containers which could cause a manual handling hazard Laboratory Specimens All laboratory waste specimens will be autoclaved prior to disposal in accordance with laboratory standard operating procedures, and then be introduced into the waste stream for disposal. Rigid drums are under review for these items to provide an alternative Cases of Infectious Disease Under the COSHH Regulations, where the assessment indicates a risk of infection to staff, special procedures must be drawn up for such cases. In doing so, clinicians will refer to the operating procedures of the Control of Infection Committee and/or consult the Infection Control team Health Surveillance, Immunisation & Personal Protective Equipment (PPE) The COSHH assessment will identify the need for PPE when the hazard cannot be dealt with by any other means. Managers will therefore ensure that appropriate health surveillance, immunisation and PPE assessment is undertaken, items are provided, used and maintained, e.g: Hepatitis B and tetanus primary immunisation. Heavy duty gloves Sturdy shoes or industrial Wellington boots Waste Disposal and Re cycling Policy v5 23

24 Leg protectors Face visors Managers must also enable their staff to maintain their personal hygiene by providing appropriate hand hygiene facilities. See policies IC01, IC 02, IC03 and IC04 which must all be read in relation to this policy Accidents & Incidents The guidelines identified in the Blood Borne Virus Policy must be adhered to following needle stick/blood splash incidents. Certain incidents relating to needle stick injuries are reportable to the Health and Safety Executive (HSE) under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995, the manager of the area must, in addition, take the following actions: Provide immediate first aid and send to the Occupational Health and Safety Department, and to the Accident & Emergency Department out of office hours. Notify Occupational Health Department/arrange for the appropriate medical intervention. Adhere to the Blood Borne Virus Policy. Ensure the incident is recorded on the Datix incident reporting system. Investigate the circumstances of the incident and take appropriate corrective action. Ensure these details and whether it is Riddor reportable are entered onto Datix in a timely manner in accordance with the Trust s Incident Reporting and Investigation Policy (RM04). Retain the sharp, if appropriate, in its original receptacle for investigation Spillages All sharps container spillages must be reported to the Health and Safety Officer so that appropriate investigations can be made, prior to the disposal of the damaged container. COSHH Risk Assessments and Spillage Procedure will consider the following points: The system of work to be used when clearing up clinical waste, including decontamination of the affected areas. Protective clothing. Spillage kits to be used. Appropriate disinfectants. Waste Disposal and Re cycling Policy v5 24

25 NB: On no account should sharps be picked up by hand Waste Handling Bags (All Types) In order to carry out procedures safely, the appropriate materials for collecting waste and placing it in containers must be available. In the first instance, the spill must be contained and further spillage minimised. Access to the area should then be restricted so as to limit exposure. Under no circumstances should patients or members of the public be allowed to assist or be involved in any way with the cleaning of spillages. (Spilled waste from clinical waste must be re bagged together with the cleaning materials used and sent for disposal as required). All spillages of clinical waste whilst in transit must be reported to the Waste Manager and originator of the waste if appropriate. Where applicable, information regarding the cause of the spillage should be passed on to the appropriate departmental head and procedures modified accordingly. Advice on the handling of accidental spillages of clinical waste is given in the Cleaning and Disinfection Policy. Spillages should be reported via the Datix incident reporting system. Ensure that the bags are no more than two thirds full and enough material is left at the top to gather the plastic and tie a secure knot. Ensure that all orange clinical waste bags have a pre printed label attached and the date is written on the label. When moving the bags hold by the neck with the bag at arms length away from the legs. Do not mix different waste bags in the same storage container. Lock the storage container lid or store room door after depositing the bag. Sharps Boxes Sharps boxes must be handled in accordance with the procedures set out in the Trust s Control of Infection Manual see Standard Precautions for the Control of Infection Policy (Infection Control Policy No. 3). Waste Disposal and Re cycling Policy v5 25

26 Collection Before removal, all bags must be sealed and labelled which will be the department s responsibility, and no bags will be removed if it is apparent that they are unable to retain the contents. Clinical Waste must not be carried in the same wheeled bin or trolley as any other material 6.4 Consignment Note & Controlled Waste Transfer Note System To demonstrate compliance with the Duty of Care Regulations, a consignment note system for clinical and hazardous waste will be operated. The responsibility for the implementation of this system rests with the Waste Manager or appointed representative. This system will ensure: a) The suitability of the disposal facility and its location is known to the Trust. b) The carriers and disposers of the waste are aware of its place of origin. c) Special precautions will be prescribed on the consignment note where necessary. N.B: The identification of waste bags/boxes and the consignment note form the basis of the correct procedure. For the system to work effectively, designated staff at the hospital need to check the outward flow of waste. The Waste Manager or appointed representative must certify the quantity concerned in a legible manner, together with the carrier s acceptance signature Consignment Note for Hazardous Waste Hazardous Waste has particular consideration in its safe disposal. The Pharmacy shall be responsible for the completion of these notes in relation to medicine disposal Consignment Note for Radioactive Waste Radioactive waste is subject to detailed consignment note completion at departmental level. Methods of disposal of radioactive waste are subject to legal controls exercised by the Chief Inspector of Pollution through advance authorisation. This authorisation covers solid and liquid to drain disposal. All hospital departments using radioactivity Waste Disposal and Re cycling Policy v5 26

27 materials/processes operate approved procedures for disposal of radioactive waste and no deviation is permissible. If there is any doubt regarding methods of disposal it must be resolved by consultation with the Radiation Protection Supervisor of the relevant department, or with the hospitals Radiation Protection Adviser, before any waste is created. A consignment note completed by the Radiation Protection Supervisor of the relevant department will accompany each cart. It will state the number of the cart, the level of radioactivity and the surface dose rate. The consignment note will accompany the waste and be handed to the contractor on collection. The relevant copy of the consignment note will be returned to the Radiological Protection Supervisor, with details of disposal completed. The Radiological Protection Adviser will require sight of this documentation for inspection purposes Waste Audits Waste audits must be carried out to demonstrate that effective segregation is in place to comply with the regulations and the Duty of Care obligations. The audits must be thorough, and give assurance through documented evidence that all waste is being suitably segregated, stored, transported and disposed of at appropriate permitted waste facilities. The audit should also determine where improvement to working practices can lead to improved efficiency and recycling. Audits shall be carried out twice yearly or more often if required and shall cover: Clinical waste Hazardous waste Medical waste Domestic waste W.E.E.E. waste Items for recycling Offensive waste Plaster waste Audits shall be carried out using: Observation and recording of practice Detailed examination of waste Staff questionnaires Visiting of disposal premises to check Duty of Care compliance. The appropriate technique shall be used, depending upon the waste stream under consideration, and the risks posed to the person undertaking the audit. Waste Disposal and Re cycling Policy v5 27

28 6.44 Report of Compliance to the Health and Safety Committee An annual report on the current state of waste disposal compliance shall be submitted to the above committee for consideration Waste Register A waste disposal register shall be drawn up and maintained by the Estates Department covering all sites. 6.5 Review An on going review of the implementation of this policy will be carried out by the Health and Safety Committee using evidence from the on going Infection Prevention and Control audits as well as that from the Waste Manager s Risk Assessment of all waste handling processes. The policy will be updated within two years from its ratification date Waste Minimisation Although much of this policy is on managing waste once it has been produced, the best financial and environmental option is not to produce waste in the first place. This is because whether waste goes for recovery, recycling or disposal it is still a product that the organisation has usually bought, handled and is then having to pay for disposal of. Avoiding producing the waste at all reduces both buying costs and disposal costs Hierarchy of Waste Minimisation Reduce Re use Recycle Recover Dispose Waste at service by ordering the correct materials in the correct quantities for the work in hand. Re use items if at all possible, usually items which have been specifically designed for day and multiple use. Recycle any item which can be recycled cost effectively and for which the hospital has an established waste stream. Certain materials can be sent off site for specialist recovery such as x ray film where silver can be recovered through a chemical process. Fully if none of the above can be achieved we need to dispose of the item safely into the appropriate segregated waste stream. Waste Disposal and Re cycling Policy v5 28