Waste Management Policy

Sharepoint Location Non-clinical Policies and Guidelines Sharepoint Index Directory 3.0 Corporate Sub Area 3.2 Trustwide Management Key words (for search purposes) Waste, Hazardous, Sharps, Household Central Index No 2335 Endorsing Body Policy Committee Health & Safety Committee Endorsement Date October 2010 Review Date September 2013 Lead author and designation Andrew Selby Soft Facilities Manager 1

KEY POINTS: This policy Applies to the whole Trust. Outlines the process that must be followed for good governance. Has implications for managers and staff in the relation to the production and handling of waste. 2

CONTENTS Background Page 3 Purpose and Scope Page 4 Accountability Page 4 Auditing, Monitoring, Effectiveness and Review Page 6 Appendix A Clinical Waste Page 9 Appendix B Domestic Waste including Catering, Page 11 Furniture, Glass and Recycling Appendix C Confidential Waste Page 14 Appendix D Hazardous Waste Page 17 Appendix E Amalgam Waste Page 22 Appendix F Radiological / Radioactive Waste Page 23 Appendix G Pharmaceutical Medicines and Page 24 Anaesthetic Gases Waste Appendix H Grounds and Gardens Waste Page 33 Appendix I Metal, Batteries, and Lamp Filaments Page 34 Appendix J Electrical or Electronic Equipment Page 35 Appendix K Medical Devices Waste Page 31 Appendix L Drains, Sewers and Emissions Waste Page 39 Appendix M IT Equipment Waste Page 40 Appendix N Waste Segregation Poster Page 41 Appendix O Equality Impact Assessment Page 42 Appendix P Audit, Monitoring and Effectiveness Page 44 3

WASTE MANAGEMENT POLICY 1. Background The management of waste changed with the introduction of new EU waste management regulations. This in turn led to NHS Estates issuing Health Technical Memorandum 07-01 A guide to Healthcare waste management. This policy will aim to improve the management of waste through a review and redesign of current processes and procedures to enable the Trust to become compliant with the new waste management regulations:- NHS Purchasing and Supply Agency WEEE Procurement Guidance Waste Electrical and Electronic Equipment (WEEE) Regulations (2006) Statutory Instruments 2006 No. 3289 Environmental Protection The Waste Electrical and Electronic Equipment Regulations 2006 Department of Health Environment and Sustainability Health Technical Memorandum 07-01: Safe Management of Healthcare Waste Satisfactory compliance with the Policy will help the Trust in meeting the requirements of: The Health & Safety at Work Act (1974) The Control of Substances Hazardous to Health Regulations (2002) Management of Health and Safety at Work Regulations (1999) Environmental Protection Act 1990 The Environmental Protection (Duty of Care) Regulations 1991 (SI 1991/2839) The Waste Management Licensing Regulations 1994 The Carriage of Dangerous Goods (Amendment) Regulations 1999 Controlled Waste Regulations 1991 The Producer Responsibility Obligations (Packaging Waste) Regulations 1997 as amended in SI 1361 & SI 3447 1999 Radioactive Substances Act 1993 The Transport of Dangerous Goods Regulations 1999 Hazardous Waste Incineration Directive 1994 The Hazardous Waste Regulations 2005 4

Control of Pollution Act 1974 Control of Pollution (Special Waste) Regulations 1980 Collection and Disposal of Waste Regulations 1988 Control of Pollution (Amendment) Act 19890 Controlled Waste (Registration of Carriers and Seizure of Vehicles) Regulations 1991 Controlled Waste Regulations 1992 Control of Substances Hazardous to Health Regulations 1994 The Radioactive Substances Act 1993 Special Waste Regulations 1996 2. Purpose and Scope This policy has been prepared with the purpose of: Ensuring compliance with relevant legislation; Providing all relevant persons with explicit guidance in the safe handling, segregation and disposal of all wastes in line with environmental health and safety and infection control requirements; Enabling all employees to recognise and comply with legal requirements; Identifying specific responsibilities; Identifying and promoting safe methods of segregation and disposal; Reducing the impact that the Trust s business has on the environment. Compliance with the Data Protection Act through shredding of confidential waste This policy will ensure that the Trust works towards a concept of total waste management, with waste prevention and reduction at its heart, to reduce pollution and potentially make cost savings. 3. Accountability The Chief Executive officer is the overall accountable officer for all Trust activities; Board level responsibility for waste management has been delegated to the Associate Director (Projects). This role includes ensuring the annual Duty of Care audit of the Trust s waste contractors is undertaken and reported to the Healthcare Governance Committee 5

Waste Streams and the nominated lead managers Due to the complexity of waste management, the following categories of waste streams have been operated by the named operational manager: Waste Stream Clinical Waste Domestic including Catering, Furniture and Recyclable Confidential Waste Hazardous Waste Amalgam Waste Radiological / Radioactive Waste Pharmaceutical Medicine & Anaesthetic Gases Waste Grounds & Gardens Waste Metal, Batteries, Lamp Filaments Waste Electrical or Electronic Equipment (Non IT / Medical Devices) Waste Medical Devices Waste Drains, Sewers & Emissions Waste IT equipment Lead Person Brookfield Services Brookfield Services Brookfield Services Brookfield Services Chief Dental Technician Radiology Manager Pharmacy Services Manager Brookfield Services Brookfield Services Brookfield Services EBME Manager Brookfield Services Head of IT Managers and staff at all levels of the organisation must take individual responsibility to ensure that waste management standards are applied within their relevant areas of responsibility. All employees have a responsibility to comply with: Legislation; This policy and the associated documents; All relevant guidance including; o HTM s o WEEE Regulations The agreed procedures for the segregation and handling of waste, to ensure compliance with current legislation and avoid possible prosecution of them as individuals, or the Trust as a whole. 6

4. Audit, Monitoring, Effectiveness and Review Process to be monitored Clinical Waste Domestic including Catering, Furniture and Recyclable Confidential Waste Hazardous Waste How will compliance with the outlined process be monitored? Duty of Care Inspection Consignment Notices Contractual Monitoring Ad-hoc Inspections Duty of Care Inspection Consignment Notices Contractual Monitoring Ad-hoc Inspections Duty of Care Inspection Consignment Notices Contractual Monitoring Ad-hoc Inspections Duty of Care Inspection Consignment Notices Ad-hoc Inspections Frequency By who? If compliance gaps have been identified, who is responsible for creating an action plan, and ensuring implementation of required changes? Annually Monthly Quarterly Ad-hoc Annually Monthly Quarterly Ad-hoc Annually Monthly Quarterly Ad-hoc Annually Monthly Ad-hoc Soft Facilities Manager Soft Facilities Manager Soft Facilities Manager Soft Facilities Manager Soft Facilities Manager Soft Facilities Manager Soft Facilities Manager Soft Facilities Manager 7

Amalgam Waste Duty of Care Inspection Consignment Notices Ad-hoc Inspections Annually Monthly Ad-hoc Oral Surgery Sister Oral Surgery Sister Radiological/Radioactive Waste Pharmaceutical Medicine & Anaesthetic Gases Waste Grounds & Gardens Waste Metal Batteries and Lamp Filaments Waste Electrical or Electronic Equipment ( Non IT / Medical Devices) Waste Medical Devices Waste Duty of Care Inspection Consignment Notices Ad-hoc Inspections Duty of Care Inspection Consignment Notices Ad-hoc Inspections Contractual Monitoring Ad-hoc Inspections Duty of Care Inspection Consignment Notices Contractual Monitoring Ad-hoc Inspections Duty of Care Inspection Consignment Notices Contractual Monitoring Ad-hoc Inspections Duty of Care Inspection Consignment Notices Ad-hoc Inspections Annually Monthly Ad-hoc Annually Monthly Ad-hoc Quarterly Ad-hoc Annually Monthly Quarterly Ad-hoc Annually Monthly Quarterly Ad-hoc Annually Monthly Ad-hoc Radiology Manager Pharmacy Services Manager Soft Facilities Manager Soft Facilities Manager Soft Facilities Manager EBME Manager Radiology Manager Pharmacy Services Manager Soft Facilities Manager Soft Facilities Manager Soft Facilities Manager EBME Manager Drains, Sewers and Contractual Monitoring Quarterly Soft Facilities Soft Facilities Manager 8

Emissions Waste Ad-hoc Inspections Ad-hoc Manager This policy will be reviewed by the Associate Project Director every three years or sooner if the legislation on waste management changes in the interim period. Frequent monitoring of the segregation, collection and disposal procedures must be introduced and any failure traced back to the source by the coded identification, so that corrective action can be taken. An ad hoc inspection of the Trust Waste Management Procedures shall be carried out on a regular basis. The schedule should be assigned accordingly to the inspection objectives and Trust sites. The objectives of the inspection are to: a. Determine whether proper procedures are in place in respect of generation, segregation, transport and disposal of waste and are being followed. b. Determine whether Trust staffs have sufficient knowledge and training of the correct procedures in respect of clinical waste generation, segregation, transport and disposal and of the procedures for dealing with spillage or other incidents. c. Checking that the transport and storage of waste is correctly carried out. d. Questioning of randomly selected members of staff who would come into contact with waste, regarding the correct procedures for the segregation, handling, transport and disposal of waste. e. A member of the audit team shall make an annual visit, to the waste contractor s facilities engaged by the Trust. The inspection team shall produce a brief written report of their findings, together with any recommendations for changes in policy, improvements in procedures, or further staff training needs, etc. The report shall be circulated to the Soft Facilities manager to be compiled in the Waste Evidence file. 9

Appendix A Clinical Waste Definition of Waste Any waste which consists wholly or partly of human or animal tissue, blood or other body fluids, excretions, drugs or other pharmaceutical products, swabs, dressings or syringes, needles or other sharp instruments, being waste which unless rendered safe may prove hazardous to any person coming into contact with it; and 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. Storage of Waste Clinical waste is split into three main groups, these being: o Waste requiring Incineration (Yellow Bags) o Waste which can be treated (Orange Bags) o Sharps (Yellow Sharp Bins). Clinical waste is stored on the wards and departments in suitable metal flip top bins with the appropriate coloured bag or in Sharps bins in agreed locations. Departmental Responsibility Yellow bags must only be used for Grossly Identifiable Human Tissue, Placentas, Products of Conception, Limbs or Organs, Diagnostic Specimens, Reagent / Test Vials (Labs only) Orange bags must only be used for soiled dressings, disposables, blood transfusion bags, plaster casts, human hygiene waste, incontinence pads, colostomy bags, urine bags, catheters, urine collection pots, contaminated paper towels, personnel protective equipment (contaminated with bodily fluids) Sharps bins must only be used for needles, syringes, scalpels, stitch cutters, razors, empty ampoules etc, Departmental staff must sign the sharps bin label prior to removal. Clinical Waste bags should not be filled above two thirds 10

Medirest Responsibility Domestic Services Domestic Services empty bags from the sack holders at regular intervals and deposit these to the relevant Wheelie Bins in local pre-designated locations. Before handling a bag at the point of collection, the neck of the waste bag should be securely fastened by adhesive tape to identify the ward the collection is made from. If sharp edges protrude from the bag, this should be reported to the ward / departmental manager Portering Services Wheelie Bins are collected twice daily by the porter and replaced with a clean empty bin. Portering staff, remove the wheelie bins to an agreed holding area as detailed below : o PCH Waste Compound to the rear of the building o Stamford Within garages to await collection by the Clinical Waste Contractor. Disposal of Waste from the Holding Areas Waste collections occur 6 days per week (Monday to Saturday) at PCH 2 times per week (Tuesday and Thursday) at Stamford Hospital. The waste is collected from the holding areas by the waste contractor and transported by road to their approved treatment / disposal centres. A consignment will be completed for all collections and stored on each site copies of which are held by the Facilities Department. 11

Domestic Waste including Catering, Furniture, Glass and Recyclable Waste Definitions Domestic Appendix B All waste not contaminated with blood or body fluids and classified as similar to household waste. In other words similar to waste produced at home, e.g. hand towels, clean packaging, flowers, drink packaging Catering Catering waste is divided into three types: o Dry waste e.g, tins, chicken bones, fish skins, o Wet waste e.g. food waste, raw food o Cooking oil Furniture Furniture (non metal) e.g. wooden desks, chairs, bathroom refits Glass - Glass, this can include broken glass i.e. vases, but also glass bottles and jars. Recyclable Co-mingled recycling waste is mixed recycling waste for sorting and treatment. Storage of Waste Domestic & Dry catering waste is stored on the wards and departments in suitable metal flip top bins with a black bags Wet catering waste is returned in the meal trolleys to the catering department for disposal Furniture no longer required is disposed of as part of the Dump the Junk Campaign or advertised in Factsheet for use by alternative departments. Glass waste should be stored locally in purpose designed boxes, until full and sealed Paper which is suitable for recycling should be placed in clear plastic bags 12

Departmental Responsibility Black bags must only be used for general waste, personal protective equipment not contaminated with bodily fluids, disposable cups, rinsed medicine tops, packaging from medication and uncontaminated dressings and bandages. Wet food waste will be disposed of through the catering department waste disposal units. Cooking oil waste is stored in plastic containers prior to disposal Furniture awaiting collection should be disposed of at the agreed locations see Dump the Junk campaign posters. Clear bags must only be used for co-mingled recycling where this facility exists. Glass collection should be undertaken using the supplied boxes which can be ordered from NHS supplies. Medirest Responsibility Domestic Services Domestic Services empty black bags from the sack holders and clear bags from waste receptacles at regular intervals and deposit these in local holding areas at pre-designated locations. Before handling a bag at the point of collection, the neck of the waste bag should be securely fastened. Portering Services Domestic, dry catering, glass & recyclable waste are collected twice daily by the porter to the compactors as detailed below : o PCH Waste compound to rear of the building o Stamford Adjacent to the garages to await collection by the Domestic Waste Contractor. Furniture for disposal is removed in accordance with the dump the Junk campaign to the skip brought to site on agreed dates. Bulk waste collection receptacles are cleaned on a daily basis Catering Services Cooking oil is removed by, stored in cages and is collected periodically by an authorised waste oil contractor for re-cycling. 13

Disposal of Waste from the Holding Areas Domestic Waste collections occur as follows: o PCH 3 times per week o Stamford once every 10 days. Furniture waste is collected by the Skip contractor as required Cooking oil waste is collected by authorised waste oil contractor 14

Confidential Waste Appendix C Definition of Waste Confidential waste relates to any document described in the Policy and Procedure for the Preservation, Retention and Destruction of Trust Records which is held on Share Point. Storage of Waste Waste deemed to be confidential that is destined for shredding must be segregated from all unclassified waste. Confidential waste must be placed in a shredding bag and the top secured, do not use bags that are used for other waste streams i.e. black, clear polythene bags or clinical waste bags. Departmental Responsibility Shredding bags are available by contacting the service desk or bleeping the Stamford porter. Once the bag is three quarters full seal the bag and contact the Service Desk or Stamford porter for collection. The full bag must be retained in the office environment where the waste was created until it is collected by the Porters, do not place it in public areas where it could be accessed by unauthorised individuals. Medirest Responsibility Portering services Portering staff collect the confidential waste on regular rounds and transport this to the following secure areas: o PCH Secure store to the rear of the site o Stamford Secure garage Disposal of Waste from the Holding Areas PCH Shredding is collected on a four weekly basis by a dedicated shredding contractor 15

Hazardous Waste Appendix D This procedure must be followed when disposing of any type of hazardous waste, waste that does not display on of the Hazardous Waste codes is not classed as hazardous and therefore should not be disposed of using this process, for any help of guidance in relation to waste please contact the Facilities department on 4882. Storage of Waste Materials must be disposed of in accordance with COSHH data sheets in the original containers and packaging. If not available the container must be clearly marked with the following information: name of manufacturer and material, whether it is flammable or non flammable, flash point (if appropriate), oxidant, corrosive or poisonous or any other relative information. Departmental Responsibilities Waste displaying any of the hazardous waste codes should be classed as Hazardous and stored securely in the department that created the waste until collection by the Portering Staff. Hazardous Waste Collections are arranged by contacting the Portering department on Ext 5656. On collecting the waste the Portering department will require a consignment of hazardous waste form, and a copy of the COSHH data sheet. Medirest Responsibility Portering Services Portering staff will collect the waste and take it to the secure store where the waste is stored for collection. The waste will be stored safely in the store in line with the segregation guidance displayed. Once the waste is placed in the store the Portering department will complete the Hazardous Waste index page. Disposal of Waste from holding area A specialist contractor is employed to classify and package all hazardous waste before transporting off site and to end disposal. 16

Definition of Waste PROPERTIES OF WASTES WHICH RENDER THEM HAZARDOUS H1 Explosive : substances and preparations which may explode under the effect of flame or which are more sensitive to shocks or friction than dinitrobenzene. H2 H3A H3B H4 H5 H6 H7 H8 H9 Oxidizing : substances and preparations which exhibit highly exothermic reactions when in contact with other substances, particularly flammable substances. A Highly flammable - liquid substances and preparations having a flash point below 21 C (including extremely flammable liquids), or - substances and preparations which may become hot and finally catch fire in contact with air at ambient temperature without any application of energy, or - solid substances and preparations which may readily catch fire after brief contact with a source of ignition and which continue to burn or to be consumed after removal of the source of ignition, or - gaseous substances and preparations which are flammable in air at normal pressure, or - substances and preparations which, in contact with water or damp air, evolve highly flammable gases in dangerous quantities. Flammable : liquid substances and preparations having a flash point equal to or greater than 21 C and less than or equal to 55 C. Irritant : non-corrosive substances and preparations which, through immediate, prolonged or repeated contact with the skin or mucous membrane, can cause inflammation. Harmful : substances and preparations which, if they are inhaled or ingested or if they penetrate the skin, may involve limited health risks. Toxic : substances and preparations (including very toxic substances and preparations) which, if they are inhaled or ingested or if they penetrate the skin, may involve serious, acute or chronic health risks and even death. Carcinogenic : substances and preparations which, if they are inhaled or ingested or if they penetrate the skin, may induce cancer or increase its incidence Corrosive : substances and preparations which may destroy living tissue on contacts. Infectious : substances containing viable micro-organisms or their toxins which are known or reliably believed to cause disease in man or other living organisms. 17

H10 H11 H12 H13 H14 Teratogenic 9: substances and preparations which, if they are inhaled or ingested or if they penetrate the skin, may induce non-hereditary congenital malformations or increase their incidence. Mutagenic : substances and preparations which, if they are inhaled or ingested or if they penetrate the skin, may induce hereditary genetic defects or increase their incidence. Substances and preparations which release toxic or very toxic gases in contact with water, air or an acid. Substances and preparations capable by any means, after disposal, of yielding another substance, e.g. a leachate, which possesses any of the characteristics listed above. Ecotoxic : substances and preparations which present or may present immediate or delayed risks for one or more sectors of the environment 18

CONSIGNMENT OF HAZARDOUS WASTE DATE OF REQUEST: REQUEST NAME: CONTACT NO: WARD / DEPARTMENT: (From where waste is to be collected from) HOSPITAL SITE: (From where waste is to be collected from) WASTE DESCRIPTION: PHYSICAL FORM OF WASTE: SIZE AND TYPE OF CONTAINER: QUANTITY OF WASTE: IS THERE A SAFETY DATA SHEET: Y / N SIGNATURE OF STAFF CONSIGNING WASTE: Please print name also : SIGNATURE OF PORTER THAT COLLECTED WASTE: Please print name also : 19

HAZARDOUS WASTE STORE INDEX DATE AREA TYPE OF WASTE Has Safety Data Sheet Been Supplied? SIGNATURE 20

Amalgam Waste Appendix E Definition of Waste Amalgam waste contains mercury & sliver as is a form of hazardous waste used in dental areas Storage of Waste Amalgam waste is produced in Oral Surgery & theatres. Any amalgam waste from Main Theatres is returned to Oral Surgery in the original carrier capsules. Departmental Responsibility Amalgam waste is stored in the Oral Surgery department in secure and suitable bulk containers until 90% full. Two bins are provided by PHS Waste Management, one for amalgam and one for the carrier capsules. Disposal of waste from holding area Once containers are 90% full arrangements are made with PHS to collect the containers and provide replacement containers for future use. 21

Appendix F Radiological / Radioactive Waste Definition of Waste Nuclear medicine waste - Covered under the environmental agency with annual inspections. X-Ray Film - All film including laser film is disposed of via specialist Disposal Company. The silver is extracted and remaining product disposed of. Silver waste from processors - Waste developer containing silver halide is pumped through a filter which removes he silver before it enters the drains. The filter is collected by a specialist waste contactor on a regular basis. Developer waste - Waste develop has the silver content removed before entering the drains were it is diluted with waste water. Fixer waste - Waste develop feeds directly in to the drains. It contains no silver. Storage/Disposal of Waste Nuclear medicine waste o Covered under the environmental agency with annual inspections. Film o All film including laser film is stored in cages in secure areas and then disposed of via specialist disposal company. The silver is extracted and remaining product disposed of Silver waste from processors. o Waste developer containing silver halide is pumped through a filter which removes he silver before it enters the drains. The filter is collected by a specialist waste contactor on a regular basis. Developer waste. o Waste develop has the silver content removed before entering the drains were it is diluted with waste water. Fixer waste. o Waste develop feeds directly in to the drains. It contains no silver. Departmental Responsibility The radiology department has a responsibility to ensure that all waste products produced as a result of its activities are disposed of in the correct manner in line with local trust rules and wider national legislation. 22

Pharmaceutical Medicine and Anaesthetic Gases Waste Appendix G 1. MEDICINAL WASTE 1.1 Scope All staff who are involved in the handling of medicinal waste from production to disposal. 1.2 Purpose To ensure that all staff who handle medicinal waste are aware of the regulations and their statutory duty of care in the waste management chain. Induction training must cover the relevant aspects for the particular job role and staff must be competent to handle the waste. 1.3 Introduction There are 3 pillars of regulation that apply to medicinal waste: 1. Health and Safety legislation 2. Environment and Waste legislation 3. Transport legislation This procedure covers these regulations and ensures medicinal waste is handled within the legislative requirements. 1.4. Clinical Waste This includes medicinal waste that is divided into 2 categories: 1. Cytotoxic/cytostatic (see Section 1 for definitions) 2. Medicines other than cytotoxic/cytostatic 1.5. Classification of Medicinal Waste 18 01 01: Sharps, except 18 01 03 =hazardous 18 01 08: Cytotoxic/cytostatic medicines = always hazardous 18 01 09: Medicines other than those in 18 01 08 = may require specialist treatment/disposal Cytotoxic/static waste must be segregated from other waste; otherwise the whole consignment has to be treated as hazardous. There are 14 hazardous properties. 1.6. Transport Classification for Waste There is a requirement to keep a written description adequately describing the type and quantity of waste produced. 23

Table 1: Medicinal Waste Dangerous in Transport Transport Category Medicinal Waste Amount of Waste 1 Cytotoxic drugs PG1 >20kg/L 2 Medicines PG 11 >333kg/L 3 Medicines PG111 >1000kg/L 1.7. Controlled Drugs (CDs) These are subject to additional controls, Schedule 2 stock CDs can only be destroyed in the presence of a person authorised under the Misuse of Drugs Regulations 1 by the Trust s Accountable Officer. Patients own drugs (PODs) are not subject to these destruction requirements, and are destroyed on the ward by a pharmacist and nurse. Refer to the Trust Safe and Secure Handling of Medicines Policy 2 and Pharmacy Standard Operating Procedure 3 (SOP) Section 6, No 004 for full information. In all cases controlled drugs in Schedule 1, 2, 3 and 4 Part I must be denatured 4 before final disposal of the container. In the case of tablets and capsules they must be de-blistered before placing in the kit. Commercially available DOOP kits are the preferred option; alternatively cat litter and water can be added to the waste container if large quantities are involved. This is because there are no provisions within the Misuse of Drugs Regulations for a waste carrier to possess Schedule 1, 2, 3 and 4 Part I CDs unless it has an appropriate licence. Any receptacles containing controlled drugs will be returned to pharmacy for final disposal. 1.8. Medicinal Waste This is defined as: Expired, unused, spilt, contaminated pharmaceutical products, drugs, vaccine and sera. Discarded items contaminated from use in the handling of pharmaceuticals e.g. bottles/boxes with residues, masks, gloves, connecting tubing, syringe bodies, drug vials The waste is further classified into 3 categories: Category 1 - Cytotoxic/cytostatic 5, which is always hazardous waste Category 2 - Pharmaceutically active, but not 1, this may be hazardous waste Category 3 - Not pharmaceutically active and no hazardous properties e.g. sodium chloride, glucose 6. This waste can be discharged to the foul sewer if it is in small quantities, is not infectious and has not had any further additions made to the bag. The empty bag can be disposed of into the offensive/hygiene waste. 24

To ascertain the status of a medicine the material safety data sheet (MSDS), (previously COSHH data sheet) should be consulted, or pharmacy staff asked to advise. Waste must be segregated at the point of production and placed in the correct container (see Figure 1) according to the national colour coded system. As far as possible waste medicines should be disposed of in their original packaging e.g. blister packs. Tablets and capsules should not be de-blistered before disposal, except controlled drugs before being denatured. Solid and liquid waste should not be mixed in the same container due to the risk of a chemical reaction. 1.9. Liquid Waste This should be placed in a rigid leak-proof receptacle for disposal; this may need to be solidified prior to removal Emptying partially used vials of liquids, or discharging of syringes into sharps bins is not in compliance with the regulations and is not permitted (see below). 1.10. Sharps Waste This is defined as items that could cause cuts or puncture wounds, including needles, syringes with needles that cannot be removed, broken glass ampoules and the sharps parts of infusion sets. Sharps waste does NOT include: Syringe bodies Medicinal waste in the form of bottles, vials, unbroken ampoules, tubes or tablets It is not acceptable practice to intentionally discharge syringes etc containing residual medicines in order to dispose of them in the fully discharged sharps receptacle. Partially discharged syringes contaminated with residual medicines should be disposed of either in the yellow-lidded receptacle, or if containing cytotoxic/cytostatic medicines in the purple-lidded sharps receptacle as shown in Figure 2. 1.11. Colour coding of sharps receptacles Orange-lidded sharps receptacles- fully discharged medicinally contaminated sharps that have not been used for cytotoxic or cytostatic medicines. The waste documentation must make it clear that fully discharged medicinally contaminated sharps are present. 25

Yellow-lidded sharps receptacles- for sharps containing a quantity of medicinal product. The container must be UN-approved for liquids, the waste documentation must accurately reflect the container contents and identify the presence of waste medicines. Yellow/purple-lidded sharps receptacles- for waste contaminated with cytotoxic or cytostatic medicinal products. These must be rigid containers, UN-approved for liquids and are treated as hazardous waste. 1.12 Other Waste Medicines Medicinal waste in original containers e.g. tablets in blisters, liquids, creams should be returned securely to pharmacy for disposal. In pharmacy this waste will be separated into liquid or solid waste, which may be disposed of in non-un-compliant packages subject to limited quantity exemptions. Any cytotoxic or cytostatic medicines in original packaging will be disposed of in a purple-lidded container. Medicinal waste removed from the original container, e.g. loose tablets must be segregated to minimise the risk of a chemical reaction and be returned securely and safely to pharmacy for disposal. This must be placed in a UN-compliant container, as it may not be possible to identify the properties of this waste. 1.13. Spillages of Waste Medicines These must be reported to the line manager or other suitable individual, and be investigated by them. In the case of a cytotoxic medicine spillage the advice in the Trust Cytotoxic Drug Policy 6 must be followed, using the correct spill kit and procedure. All staff that handle these drugs must undertake regular training, for further information contact the Pharmacy manufacturing Unit. 1.13. Waste Audits These are a legal requirement and should be undertaken at least annually, ideally by a competent waste manager. 1.14. Clinical Trials Waste This is usually removed by the sponsor unless agreed at the start of the trial due to safety concerns, e.g. cytotoxic medicines, in this circumstance a certificate of destruction is not supplied by the Trust and the sponsor is charged for the cost of disposal as part of the trial fees. 26

1.15. Waste from External Organisations The Pharmacy Department provides services to several external organisations under Service Level Agreements (SLAs), medicinal waste from these units, which are not part of this Trust (be they on site or not), cannot be returned as it breaches the waste handling regulations. These units need to make their own arrangements with a licensed waste contractor. Medirest Responsibility Portering Services Medicinal waste wheelie bins are collected twice daily by the porter and replaced with a clean empty bin. Portering staff, remove the wheelie bins to an agreed holding area as detailed below : o PCH Waste compound to rear of the building o Stamford Within garages to await collection by the Clinical Waste Contractor. Disposal of Waste from the Holding Areas Waste collections occur 6 days per week (Monday to Saturday) at PCH and 2 times per week (Tuesday & Thursday ) at Stamford Hospital. The waste is collected from the holding areas by the waste contractor and transported by road to their approved treatment / disposal centres. A consignment will be completed for all collections and stored on each site copies of which are held by the Facilities Department. 27

References - Pharmaceutical and Medicine 1. Misuse of Drugs Regulations 2001. SI 2001 No 3998 http://www.opsi.gov.uk/si/si2001/20013998.htm 2. PSHNHSFT Safe and Secure Handling of Medicines Policy 3. Pharmacy Department Standard Operating Procedure Section 6 No. 004 CD Returns and Destruction 4. Destruction of Controlled Drugs Royal Pharmaceutical Society of Great Britain http://www.rpsgb.org.uk/pdfs/restooldestrcd.pdf 5. Health Technical Memorandum 07-01:Safe Management of Healthcare Waste, DH, November 2006 6. Anglian Water Guidelines for the Disposal of Pharmaceutical Waste to Sewerage Systems, October 2007 7. The Hazardous Waste (England and Wales) Regulations 2005, Interim Guidance for the NHS Hospital Sector Royal Pharmaceutical Society of Great Britain July 2005 http://www.rpsgb.org/pdfshazwastehospphguide.pdf 8. Health Technical Memorandum 07-06: Disposal of pharmaceutical waste in community pharmacies http://www.nelm.nhs.uk/documents/htm%2007-06.pdf?id=588240 28

Cytotoxic and Cytostatic Drugs 6 List of hazardous medicines (Caution this is a list from an American paper, so the nomenclature used may not be familiar- UK list in Appendix 2) Note: Any other medicine which has the properties H6, H7, H10 or H11 is also hazardous Aldesleukin Alemtuzumab Alitretinoin Altretamine Amsacrine Anastrozole Arsenic trioxide Asparaginase Azacitidine Azathioprine Bacillus Calmette-Guerin Vaccine Bexarotene Bicalutamide Bleomycin Busulfan Capecitabine Carboplatin Carmustine Cetrorelix acetate Chlorambucil Chloramphenicol Choriogonadotropin alfa Cidofovir Cisplatin Cladribine Colchicine Cyclophosphamide Cytarabine Ciclosporin Dacarbazine Dactinomycin Daunorubicin HCl Denileukin Dienestrol Diethylstilbestrol Dinoprostone Docetaxel Doxorubicin Dutasteride Epirubicin Ergometrine/methylergometrine Estradiol Estramustine phosphate sodium Estrogen-progestin combinations Estrogens conjugated Estrogens, esterified Estrone Estropipate Etoposide Exemestane Finasteride Floxuridine Fludarabine Fluorouracil Fluoxymesterone Flutamide Fulvestrant Ganciclovir Ganirelix acetate Gemcitabine Gemtuzumab ozogamicin Choriogonadotropin alfa Goserelin Hydroxcarbamide Ibritumomab tiuxetan Idarubicin Ifosfamide Imatinib mesilate Interferon alfa-2a Interferon alfa-2b Interferon alfa-n1 Interferon alfa-n3 Irinotecan HCl Leflunomide Letrozole Leuprorelin acetate Lomustine Chlormethine hydrochloride Megestrol Melphalan Menotropins Mercaptopurine Methotrexate Methyltestosterone Mifepristone Mitomycin Mitotane Mitoxantrone HCl Mycophenolate mofetil Nafarelin Nilutamide Oxaliplatin Oxytocin Paclitaxel Pegaspargase Pentamidine isethionate Pentostatin Perphosphamide Pipobroman Piritrexim isethionate Plicamycin Podoflilox Podophyllum resin Prednimustine Procarbazine Progesterone Progestins Raloxifene Raltitrexed Ribavirin Streptozocin Tacrolimus Tamoxifen Temozolomide Teniposide Testolactone Testosterone Thalidomide Tioguanine Thiotepa Topotecan Toremifene citrate Tositumomab Tretinoin Trifluridine Trimetrexate glucuronate Triptorelin Uramustine Valganciclovir Valrubicin Vidarabine Vinblastine sulfate Vincristine sulfate Vindesine Vinorelbine tartrate Zidovudine 29

Cytotoxic and Cytostatic Drugs 8 List of hazardous medicines Note: Any other medicine which has the properties H6, H7, H10 or H11 is also hazardous 20 01 31* H3B, H4,H5, H6, H7,H8, H9,H10,H11, H14 See Note 18 01 08* Note 1 For obsolete dispensing stock, the pharmacy will know which hazardous medicines are being consigned and therefore will be able to particularise them including the weight, the medicine name, and the hazard code. For hazardous waste medicines consigned from the pharmacy, dispensing stock should be readily identifiable, and therefore the entry under EWC code 18 01 08* should be specific. Aldesleukin Alemtuzumab Alitretinoin Altretamine Amsacrine Anastrozole Arsenic trioxide Asparaginase Azacitidine Azathioprine Bacillus Calmette-Guerin Bexarotene Bicalutamide Bleomycin Busulfan Capecitabine Carboplatin Carmustine Cetrorelix acetate Chlorambucil Chloramphenicol Choriogonadotropin alfa Cidofovir Cisplatin Cladribine Colchicine Cyclophosphamide Cytarabine Cyclosporin Dacarbazine Dactinomycin Daunorubicin HCl Denileukin Dienestrol Diethylstilbestrol Dinoprostone Docetaxel Doxorubicin Dutasteride Epirubicin Ergonovine/methylergonovine Estradiol Estramustine phosphate sodium Estrogen/progestin combinations Estrogens Conjugated Estrogens Esterified Estrone Estropipate Etoposide Exemestane Finasteride Floxuridine Fludarabine Fluorouracil Fluoxymesterone Flutamide Fulvestrant Ganciclovir Ganirelix acetate Gemcitabine Gemtuzumab ozogamicin Gonadotropin chorionic Goserelin Hydroxyurea Ibritumomab tiuxetan Idarubicin Ifosfamide Imatinib mesilate Interferon alfa-2a Interferon alfa-2b Interferon alfa-n1 Interferon alfa-n3 Irinotecan HCl Leflunomide Letrozole Leuprolide acetate Lomustine Mechlorethamine Megestrol Melphalan Menotropins Mercaptopurine Methotrexate Methyltestosterone Mifepristone Mitomycin Mitotane Mitoxantrone HCl Mycophenolate mofetil Nafarelin Nilutamide Oxaliplatin Oxytocin Paclitaxel Pegaspargase Pentamidine isethionate Pentostatin Perphosphamide Pipobroman Piritrexim isethionate Plicamycin Podoflilox Podophyllum resin Prednimustine Procarbazine Progesterone Progestins Raloxifene Raltitrexed Ribavirin Streptozocin Tacrolimus Tamoxifen Temozolomide Teniposide Testolactone Testosterone Thalidomide Thioguanine Thiotepa Topotecan Toremifene citrate Tositumomab Tretinoin Trifluridine Trimetrexate glucuronate Triptorelin Uracil mustard Valganciclovir Valrubicin Vidarabine Vinblastine sulphate Vincristine sulfate Vindesine Vinorelbine tartrate Zidovudine 30

Waste Medicines Figure 4 Controlled Drugs schedule 1-4 (part 1) Contaminated with Cytotoxic/Cytostatic (see Appendix 1) yellow + purple lidded receptacle UN approved for liquids In Pharmacy PODS Destroy on ward (SOP No: 004/6/4) return DOOP bin in Pharmacy with Pharmacist for final disposal Stock Return to Pharmacy (SOP No. 004/6/2) In date/not left Trust return to Pharmacy stock Expired returned from outside the Trust destroy by Trust Authorised Witness Sharp (not contaminated with cytotoxic static) yellow + orange lid (= needle, syringe with non-removable needle, empty broken ampoules, sharps, parts of infusion sets. Denature Syringe Partially Discharged (not contaminated with cytotoxic/static) yellow + yellow lid UN approved Syringe Fully Discharged (not contaminated with cytotoxic/static) yellow + orange lid Waste carrier Liquid (not contaminated with cytotoxic/static) with pharmacologically active ingredients yellow rigid, leakproof container, UN approved for liquids Waste/ Excess Medicine Sodium Chloride/Glucose (no other additives) empty into sluice and place empty bag in domestic waste Tablets/capsules in original blister/liquids/creams in original containers (not cytotoxic/static) return Loose tables/capsules return seurity to Pharmacy in Pharmacy Liquid use leak proof yellow non- UN compliant container Solid waste yellow non-un complaint container Boxes used to contain medicines if not contaminated/labelled place in domestic waste - if have a label affixed this must be removed or box sent for shredding Medicinal items used outside Trust to be disposed of at the site of creation using licensed waste carrier e.g. HMP Whitemoor, Fitzwilliam Medicinal items used outside Trust to be disposed of at the site of creation using licensed waste carrier, e.g. HMP Whitemoore, Fitzwilliam 31

Appendix H Grounds and Gardens Waste Definition of Waste Litter, cigarette ends, waste in outside waste bins, animal faeces, pigeons, Grass cuttings, hedge trimmings, tree and shrub cuttings, Storage of Waste Ground & Gardens waste is collected in black bags Brookfield Responsibility Brookfield services collect the waste on a daily basis and transfer to the domestic waste compactors as detailed below : o PCH Waste compound at rear of the building o Stamford Adjacent to the garages to await collection by the Domestic Waste Contractor. Green Waste - At both sites grass cuttings are left to degrade naturally. Any pruning waste from hedges, trees and shrubs are taken away for disposal by the garden contractor. Disposal of Waste from the Holding Areas 32

Domestic Waste collections occur as follows: o PCH 3 times per week o Stamford once every 10 days. 33

Appendix I Metal, Batteries, Lamp Filaments Waste Definition of Waste Metal copper, aluminium, brass, iron, steel, titanium Batteries any cell that provides electrical energy Lamp filaments defined as any product that emits light Storage of Waste Scrap Metal PCH - Scrap metal from the sites are placed is the skip in the waste yard. Batteries Each battery type, lead acid, alkali etc is placed in a small plastic waste bin, each type having its own container Fluorescent Tubes Fluorescent tubes are stored for disposal in a special waste container at PCH waste yard. Departmental Responsibility Departments who need to dispose of this type of waste should contact Brookfield Services on ext 7774. Brookfield Responsibility 34

Brookfield services collect the waste on an ad-hoc basis and transfer to their waste storage facilities to await collection by an authorised contractor. Disposal of Waste from the Holding Areas Scrap metal is removed from the holding area by the contractor for recycling as required. Batteries are removed from the holding area by the contractor for disposal. Fluorescent tubes are collected as required from PCH estates by a recycling contractor. 35

Appendix J Electrical or Electronic Equipment (Non-IT / Medical Devices) Waste (WEEE Regulations) Definition of Waste Light fittings Kettles Microwaves Fans Cookers Fan ovens Extractor fans Any mains, battery or solar powered item Refrigerators Storage of Waste Designated stores are provided to the rear of the building. Departmental Responsibility Electrical items awaiting collection should be disposed of by contacting portering departments on Ext 7774. Completion of WEEE removal condemnation form by Brookfield Services, prior to approval by the Trust 36

Medirest Responsibility Portering Services Portering staff will collect the waste and take it to the secure store, where the waste is stored for collection. Brookfield Services PCH - Electrical items other than refrigerators are placed by estates staff in a designated store. PCH - Refrigerators are collected by the estates staff and are stored in a special waste store Disposal of Waste from the Holding Areas Electrical items are collected from the designated store for recycling by Peterborough City Council disposal Refrigerators are collected by a licensed contractor for de-gassing & recycling at a licensed disposal site. 37

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Appendix K Medical Devices Waste Definition of Waste A medical device that been identified for disposal will usually be either: o Beyond economical repair o Obsolete due to unavailability of spares, maintenance support or consumables o No longer required due to a change in practice or procedure o Superseded by newer technology o Found to pose a risk to patient safety This list is not exhaustive but acts as guidance only. Storage of Waste Designated storage is available in Ward 2, ECH. Departmental Responsibility No reusable device may be removed, destroyed or thrown away unless the following procedure is completed by the responsible person 1 and/or those authorised by that person. Departments arrange disposal via Estates Helpdesk, ext 4444. EBME responsibility 39

The device to be removed will be processed by an authorised person within Medical Electronics and disposed of in accordance with the recommendations of MDA DB9801 Supplement 2, particularly those that relate to specialist waste; batteries and packaging. A condemnation form will be completed and the original forwarded to the last owner of the device. The device to be condemned must be referred to the Medical Electronics Manager to be removed from the asset database. At that stage it will also be removed from any maintenance schedule or service contract. If the device has been identified to be traded-in then its removal from the operational area will be managed by the responsible person 1 and the Purchasing and Supply Department ensuring that the condemnation process is completed and all necessary checks undertaken. In certain circumstances devices may be disposed of to third parties, this will be controlled by the Purchasing and Supplies Manager under agreed guidelines. The responsible person 1 will forward details of condemnations to the Finance department to ensure that purchases from capital monies are removed from the capital asset database and to also inform the Medical Devices Coordinator to amend records both locally and centrally. Disposal of Waste from the Holding Areas Wherever possible, redundant items that are fit for purpose are to be recycled. The EBME department liaises with the purchasing department with regard to arrangements for items to be sent to auction. Single-use items will only be disposed of in a manner in which they cannot be reused. If an item is to be disposed of and contains hazardous substances or components including nickel, cadmium and mercurycontaining batteries, it must firstly be dismantled into it s component parts, labelled accordingly and disposed of by the correct route as follows: Electrical Items (WEE Regulations), Batteries, Waste Metal, General Waste. 40

Responsible Person ¹ = Medical Electronics Manager or appointed deputy. 41

Appendix L Drains, Sewers and Emissions Waste Definition of Waste Steam from CSSD chimney and pipes with in the Estates complex Flue gases from the boiler house chimney. Foul drainage from the Trust buildings Surface water from the roofs and roads within the site Storage of Waste Steam from the CSSD chimney and pipes within the estates complex go to atmosphere. Flue gases from the boiler house chimney go to atmosphere. The boilers are serviced quarterly which includes checking that the gas emissions are within the legal permitted parameters. Foul drainage from the Trust s buildings goes to a foul drainage system within the site and then to the main foul drainage system. The surface water from the roofs and roads within the site goes to a surface water system within the site and then into the main surface water drainage system 42

Food waste from the kitchens passes through waste disposal units before being discharged into the foul sewer systems. To prevent any grease getting into the foul water system the kitchen waste water is first passed through a grease interceptor. Brookfield Responsibility Records of flue gas readings Monitor the grease interceptor twice per annum as per Environmental guidelines 43

Appendix M IT Equipment Waste Definition of Waste Handheld computers (PDAs) Monitors Keyboards and Mice Barcode Scanners and Smartcard readers Windows Terminals Printer and Fax machines Scanners Cables Media UPS Network Equipment Telephones IT Equipment Waste Procedure See IT disposal policy on intranet http://intranet/itwebsite/files/policies/disposal%20policy.doc 44

Examples Waste Stream Colour Code Description and Method of Disposal Waste Segregation Containers Appendix N neral waste, including food waste. ersonal Protective Equipment not contaminated with body fluids. sed medicine tots, Uncontaminated dressings, bandages etc Household Waste Can go to Landfill Shredded Paper, Paper Towels, Disposable Cups, Newspapers, Packaging, Aerosols, Paper and board, Plastic Bottles, Glass Bottles, and Drink Cans, Cartons, Packaging from Medication Recycling Waste To go to Materials Recycling Facility commercially sensitive document not e public domain; any research not in ublic domain; any data that identifies individual and any of the following: al orientation, issues regarding their lth, their religion, date of birth, home ress, etc. This list is indicative not exhaustive. Confidential Waste Must be Shredded Hessian Style Bags 45

rossly Identifiable Human Tissue Placentas Products of Conception Limbs or Organs Diagnostic Specimens Reagent / Test Vials (Labs only) e Only Produced in: 6X, Theatres, DSU, tre 5, Delivery Suite, A&E iled Dressings, Soiled Disposables, od Transfusion Bags, Plaster Casts, man Hygiene Waste, Incontinence ads, Colostomy Bags, Urine Bags, Catheters, Urine Collection Pots, ntaminated Paper Towels, Personal ective Equipment (contaminated with Body Fluids) Anatomical Waste Must be Incinerated, to be placed in Yellow wheelie bins with Red Lids Treatable Waste Can go to alternative Treatments to be placed in Yellow wheelie bins with Orange Lids Sharps eedles, syringes, scalpels, stitch, tters, razors, empty ampoules etc. Sharps Waste Must go for Incineration To be placed in Yellow wheelie bins with yellow lids Sharps Sharps contaminated with cytotoxic and cytostatic medicinal products Cytotoxic Waste Must go for Incineration To be placed in Yellow wheelie bins with Purple Lids 46

Peterborough and Stamford Hospitals NHS Foundation Trust Appendix O STAGE ONE : Equality Impact Assessment (EqIA) Screening form Assessing Functions/Policies for Relevance Blue boxes are to be filled in Free text Yellow boxes - Click the box to select from the drop down list Select from drop down box Name of function/service/strategy/policy/project (activity) to be assessed: Name(s) of those completing this EqIA Screening form: Waste Policy Andrew Selby CBU/Department Corporate Support Date 15.6.10 Function/service/strategy/policy/project (activity) aim or purpose: To ensure the Trust operates legally in respect of all waste legislation/issues. Is this a new or existing activity? Existing What are the intended results of this activity? To ensure the Trust works towards a concept of total waste management How will you measure the outcome of the activity? Monthly monitoring of waste segretation, volumes and cost 47

Who is intended to benefit from the activity? Please identify any internal/external groups who have been consulted regarding this activity: All staff, patients and public using the hospital facilities Health & Safety Committee, Operational Management Committee, Waste & Recycling Management Group Use the table below to identify whether the activity could/does have a positive impact, a negative impact or no impact at all on either any or all of the equality groups specified. Age Disability Ethnicity/Race Gender Religion/Belief Sexual Orientation Eliminating unlawful or unjustifiable discrimination Promoting equality of opportunity Promoting positive attitudes and good community relations Eliminating harassment or victimization Encourage involvement and participation Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Eliminating health inequalities Neutral Neutral Neutral Neutral Neutral Neutral If there is either a Positive (Disability group exempted) or a Negative impact you must consider completing the Stage Two - Full Equality Impact Assessment form to address or remove any significant potential/actual impact. 48

Decision to proceed (please select): No, we have decided that it is not necessary to carryout a full EqIA If you have selected "Yes, a full EqIA is required", please identify when the Full EqIA will be completed. Date Reason for decision to proceed or not to full EqIA Policy has a neutral impact Executive Director/General Manager - I confirm that I have been briefed and agree with the results of this EqIA. Name Sarah Westwood Date 16.6.10 Job Title Facilities Performance Manager Please note the following: It is essential that this EqIA screening form is discussed by your management team and remains readily available for inspection. A copy should also be forwarded to the Communications team for publication on the Trust's internet site. 49