Medical Waste Management Plan

Medical Waste Management Plan Sonoma State University 3/12

Table of Contents TABLE OF CONTENTS... 1 SECTION ONE... 1 BACKGROUND AND INTRODUCTION... 1 SECTION TWO... 2 PURPOSE AND SCOPE... 2 Purpose... 2 Scope... 2 SECTION THREE... 3 RESPONSIBILITIES... 3 University President... 3 Management, Deans, Directors, and Appropriate Administrators... 3 Faculty, Staff, Student employees, and Volunteers... 3 Environmental Health and Safety... 3 SECTION FOUR... 4 GENERAL INFORMATION AND PROCEDURES... 4 Generator Information... 4 Name and Address... 4 Type of Business... 4 Medical Waste Information... 4 Waste Hauler... 4 General Procedures... 4 Generation and Storage... 4 Treatment... 5 Area Decontamination Due to a Spill or Leak... 5 Container Decontamination... 6 Contingency Plan... 7 Disposal... 7 Recordkeeping... 7 SECTION FIVE... 8 DEFINITIONS... 8 ATTACHMENT ONE CALIFORNIA MEDICAL WASTE MANAGEMENT ACT (CMWMA) ATTACHMENT TWO DEPARTMENT SPECIFIC PROCEDURES,RESPONSIBLE DEPARTMENT PERSONNEL, AND MEDICAL WASTE TYPES & ESTIMATED MONTHLY QUANTITIES GENERATED MWMP Table of Contents / Page 1

Section One Background and Introduction California enacted a law in January of 1991 known as the California Medical Waste Management Act (CMWMA), presented as Attachment One. The CMWMA sets specific requirements regarding the handling, treatment, and disposal of medical waste. The new law is a culmination of extensive input by the legislature regulated medical, dental, veterinary professionals, treatment facilities, and the regulators, to achieve a safe and more comprehensive level of medical waste management. This law redefines infectious waste as medical waste, and establishes methods for handling, tracking, record keeping, hauling, and disposal by all generators of medical waste. In addition, the CMWMA requires that all medical waste generator facilities that provide onsite treatment of medical waste and/or generate over 200 pounds of medical waste per month are required to register with the enforcement agency, pay a fee, maintain tracking documents and develop a management plan to demonstrate compliance with this act. Sonoma State University is a multi-disciplinary school that generates medical waste through various activities and functions. The Departments that currently generate or have the potential to generate medical waste are Biology, Kinesiology, Nursing, and the Student Health Center. This program outlines the methods of complying with the CMWMA for all affected Departments at Sonoma State University. MWMP Background and Introduction / Page 1

Section Two Purpose and Scope Purpose The purpose of this Medical Waste Management Plan is to ensure that Sonoma State University complies with all requirements set forth in the California Medical Waste Management Act. This plan describes the processes necessary to safely manage University generated medical waste and defines the responsibilities for all aspects of the plan. Scope The scope of this plan includes the Sonoma State University campus located at 1801 East Cotati Avenue in Rohnert Park, California. MWMP Purpose and Scope / Page 2

Section Three Responsibilities All Sonoma State University (SSU) faculty and staff which work with or around medical must read, understand and implement this Medical Waste Management Plan. To ensure the successful implementation and maintenance of this plan the following roles and responsibilities have been identified. University President The President is responsible for ensuring that management, staff, and faculty support and comply with this program and its requirements. The President will also ensure that adequate resources are allocated to implement and maintain this program. Management, Deans, Directors, and Appropriate Administrators Will ensure that this plan is implemented and maintained and that the faculty, and staff affected by this plan are familiar with and understand the processes outlined in this plan to safely manage medical wastes generated within their departments. Notify Environmental Health and Safety (EH&S) and any changes which would require the updating of this plan. Identify individuals within each affected department to act as the liaison in the implementation of this plan (Attachment Two). Faculty, Staff, Student employees, and Volunteers Will perform periodic audits for compliance with this plan and notify an Appropriate Administrator and EH&S of any changes which would require updating this plan. Environmental Health and Safety Ensure that this plan is periodically reviewed for accuracy with SSU s processes and compliance with any revisions to the CMWMA. Maintain and distribute this plan and any updates. Pay use and generation fees to the local regulatory agency. Manage contract(s) with outside medical waste vendor and coordinate waste pickups. MWMP Responsibilities / Page 3

Section Four General Information and Procedures Generator Information Name and Address Sonoma State University 1801 East Cotati Avenue Rohnert Park, CA 94928-3609 Type of Business School of Higher Education Medical Waste Information See Attachment Three Waste Hauler PSC Environmental Services is the primary contractor to transport and dispose of selected medical wastes. Stericycle is our backup contractor. PSC Environmental Services Stericycle 11855 White rock Road 1551 Shelton Dr Rancho Cordova, CA 95742 Hollister, CA 950234 916-351-1707 866-783-7422 General Procedures The medical wastes generated at Sonoma State University shall be managed in accordance with the CMWMA and County of Sonoma Department of Health Services, Environmental Health Division. Generation and Storage All medical waste will be accumulated seperately from other wastes in compliant red containers clearly labeled BIOHAZARD and containing the inernational biohazard symbol. These containers will be labeled on the top and sides as required by Section Health & Safety Code 118280. Red plastic biohazard bags will be utilized for non-sharps waste accumulation. The waste bag must be tied to prevent leakage of contents prior to transferring to a rigid container for storage. Sharps will be collected in a rigid puncture resistant container. These sharps containers can be combined with non-sharps waste in plastic biohazard bags only if the waste will be transferred off-site by a licensed biohazardous waste vendor. Sonoma State University generates more than 20 pounds of medical waste per month, therefore all medical waste sharps (full containers) and non-sharps must be treated within MWMP General Information and Procedures / Page 4

7 days unless waste is stored below 32 F. If the waste is maintained below 32 F it may be stored for up to 90 days before treatment or off-site disposal by a licensed medicals waste hauler. Treatment for Sonoma State is autoclaving, which is described in detail later in this Section. Treatment Sharps and non-sharps medical waste will be treated by steam sterilization. Standard operating procedures will be available at each steam sterilization unit and must include the following: Sterilization time (minimum 30 minutes) Temperature (minimum 250 F) Pressure Type of waste Type of container Closure on container (preferably heat-sensitive tape) Pattern of loading Water content Maximum loading quantity The procedures will require that a log be maintained at each unit which will record, at a minimum the sterilization time, temperature and load size. Additionally the log must include the date and results of the following: Annual thermometer calibration Monthly Bacillus stearothermophilus indicator (must be placed in center of load) Liquid and semi-liquid wastes that are acceptable for sewage disposal shall be treated prior to discharge unless material is considered laboratory waste or microbiological specimen (see Definitions Section Five). Treatment must include the addition of bleach in a concentration that will destruct all pathogenic microorganisms. Area Decontamination Due to a Spill or Leak In the event of a spill or leak of biohazardous materials, the following procedure shall be followed: Universal precautions shall be utilized by trained personnel including the use of protective gloves, goggles and other PPE as necessary to prevent potential exposure; All biohazardous materials shall be removed from affected surfaces; Affected surfaces shall be decontaminated by immersing the surfaces in a chemical sanitizer for a minimum of three minutes. The sanitizer must contain one of the following ingredients at the concentration stipulated: Hyperchlorite solution (500 ppm available chlorine) (5% bleach or 1.5 cups of bleach per gallon of water): Phenolic solution (500 ppm active agent): MWMP General Information and Procedures / Page 5

Iodoform solution (100 ppm available iodine): Quaternary ammonium solution (400 ppm active agent); and All waste generated including PPE shall be disposed of in a compliant red biohazardous waste bag or compliant sharps containers as necessary. The bags or containers must be conspicuously labeled with the international biohazard label and marked as Biohazard or biohazardous waste. Container Decontamination All secondary containers are lined with biohazard bags and do not normally require disinffecting. If a biohazard container does become contaminated the following procedure shall be follwed: Universal precautions shall be utilized by trained personnel including the use of protective gloves, goggles and other PPE as necessary to prevent potential exposure; All biohazardous materials shall be removed from the affected container and properly bagged and labeled; Container shall be decontaminated by using one of the following procedures: Exposure to hot water at or above 180 F for a minimum of 15 seconds; Exposure to chemical sanitizer by rinsing with, or immersion in, one of the following for a minimum of three minutes: Hyperchlorite solution (500 ppm available chlorine) (5% bleach or 1.5 cups of bleach per gallon of water): Phenolic solution (500 ppm active agent): Iodoform solution (100 ppm available iodine): Quaternary ammonium solution (400 ppm active agent); and All waste generated including PPE shall be disposed of in a compliant red biohazardous waste bag conspicuously labeled with the international biohazard label and marked as Biohazard or biohazardous waste. MWMP General Information and Procedures / Page 6

Contingency Plan In the event that the autoclaves at the Student Health Center and the Biology Department become inoperable and the primary hauler is unavailable. Sonoma State University has identified an emergency backup hauler the following medical waste transporter to collect medical waste as needed: Stericycle 1551 Shelton Dr Hollister, CA 950234 866-783-7422 Disposal Once treatment has been completed non-sharps waste may be disposed in standard solid waste dumpsters. Sharps waste must be transferred to the accumulation drum located in the Student Health Center. After the waste has been treated there is no limit on storage as long as the waste will not putrefy. A licensed third party biohazardous waste vendor will collect the accumulation drum on a periodic basis. DO NOT COMBINE ANY SHARPS WASTE IN THE SOLID WASTE. The County landfill prohibits any type of sharps disposal, even if it has been treated. Recordkeeping All records associated with the treatment and disposal of medical waste will be maintained by the treating department and/or EH&S for a minimum of three years. All pink waste tracking forms must be maintained by EH&S. MWMP General Information and Procedures / Page 7

Section Five Definitions Biohazard Bag disposable red bag which is impervious to moisture and has a strength sufficient to preclude ripping, tearing, or bursting under normal conditions of usage and handling of the waste filled bag. A Biohazard Bag shall be constructed of material sufficient single thickness strength to pass the 165-gram dropped dart impact resistant test as prescribed by Standard D 1709-85 of the American Society of Testing and Materials and certified by the bag manufacturer. Biohazardous Waste (a) Laboratory waste, including but not limited to, all of the following: (1) Human or animal specimen cultures from medical and pathological laboratories. (2) Cultures and stocks of infectious agents from research and industrial laboratories. (3) Wastes from the production of bacteria, viruses, or the use of spores, discarded live and attenuated vaccines, and culture dishes and devices used to transfer inoculate and mix cultures. (b) Waste containing any microbiologic specimens sent to a laboratory for analysis. (c) Human surgery specimens or tissues removed at surgery or autopsy, which are suspected by the attending physician and surgeon or dentist of being contaminated with infectious agents known to be contagious to humans. (d) Animal parts, tissues, fluids or carcasses suspected by the attending veterinarian of being contaminated with infectious agents known to be contagious to humans. (e) Waste which at the point of transport from the generator s site, at the point of disposal, or thereafter, contains recognizable fluid blood, fluid blood products, containers, or equipment containing blood that is fluid or blood from animals known to be infected with diseases which are highly communicable to humans. (f) Waste containing discarded materials contaminated with excretion, exudate, or secretions from humans who are required to be isolated by infection control staff, the attending physician and surgeon, the attending veterinarian, or the local health officer, to protect others from highly communicable diseases or isolated animals known to be infected with diseases which are highly communicable to humans. Common Storage Facility - Any designated accumulation area maintained in accordance with this chapter, used by small generators otherwise operating independently, for the storage of medical waste for collection by a registered hazardous waste hauler. Container The bag or rigid container in which the medical waste is placed prior to transporting for purposes of storage or treatment. Enforcement Agency - The department or the agency administering this chapter. MWMP Definitions / Page 8

Enforcement Officer - The director, or agents or registered environmental health specialists appointed by the director, and all local health officers, directors of environmental health, and their duty authorized registered environmental health specialists and environmental health specialist trainees, or the designees of the director, local health officers, or the directors of environmental health. Hazardous Waste Hauler A person registered as a hazardous waste hauler pursuant to Article 6 (commencing with Section 25160) and Article 6.5 (commencing with Section 25167.1) of Chapter 6.5 of this division and Chapter 30 (commencing with Section 66001) of Division 4 of Title 22 of the California Code of Regulations. Highly Communicable Diseases - Diseases such as those caused by organisms classified by the federal Centers for Disease Control as Biosafety Level IV organisms, which, in the opinion of the infection control staff, the department, local health officer, attending physician and surgeon, or attending veterinarian merit special precautions to protect staff, patients, and other persons from infection. Highly Communicable Diseases does not include diseases such as the common cold, influenza, or other diseases not representing a significant danger to nonimmunocompromised persons. Household Waste - Any material, including garbage, trash, and sanitary wastes in septic tanks and medical waste, which is derived from households, farms or ranches. Infectious Agent A type of microorganisms, bacteria, mold, parasite, or virus which normally causes, or significantly contributes to the cause of, increased morbidity or mortality of human beings. Large Quantity Generator - A medical waste generator that generates more than 200 or more pounds per month of medical waste. Local Agency - The local health department, as defined in Section 1102, or the local comprehensive environmental agency established in accordance with Section 1155.5 of a county which has elected to adopt a local ordinance to administer and enforce this chapter, pursuant to Article 3 (commencing with Section 25030). Medical Waste is all of the following: (a) Biohazardous waste or sharp waste. (b) Waste which is generated or produced, as a result of the diagnosis, treatment, or immunization of human beings or animals, in research pertaining thereto, or in the production or testing of biologicals. Medical waste may contain infectious agents. Medical waste which has been treated in accordance with Article 9 (commencing with Section 25090) and which is not otherwise hazardous, shall thereafter be considered solid waste as defined in Section 40191 of the Public Resources Code and not medical waste. Medical waste does not include any of the following: MWMP Definitions / Page 9

(a) Waste containing microbiological cultures used in food processing and biotechnology and any containers or devices used in the preparation and handling of these cultures, that is not to be an infectious agent pursuant to Section 25022.5. (b) Waste which is not Biohazardous, such as paper towels, paper products, articles containing nonfluid blood, and other medical solid waste products commonly found in the facilities of medical waste generators. (c) Hazardous waste, radioactive waste, or household waste. (d) Waste generated from normal and legal veterinarian, agricultural and animal livestock management practices on a farm or ranch. Medical Waste Generator - Any person whose act or process produces medical waste and included, but is not limited to, a provider of health care as defined in subdivision (a) of Section 56.05 of the Civil Code. All of the following are examples of businesses which generate medical waste: (a) Medical and dental offices, clinics, hospitals, surgery centers, laboratories, research laboratories, other health facilities required to be licensed pursuant to Division 2 (commencing with Section 1200), and unlicensed facilities. (b) Veterinary offices, clinics and hospitals. (c) Pet shops. Medical Waste Management A document which is completed by generators of medical waste pursuant to Sections 25042 and 25052, on forms prepared by the enforcement agency. Medical Waste Permit - A permit issued by the enforcement agency to a medical waste treatment facility. Medical Waste Registration A registration issued by the enforcement agency to a medical waste generator. Medical Waste Treatment Facility All adjacent land and structures, and other appurtenances or improvements on the land, used for treating medical waste or for associated handling and storage of medical waste. Medical waste treatment facilities are those facilities treating waste pursuant to subdivision (a) or (c) of Section 25090. A medical waste treatment method approved pursuant to subdivision (d) of Section 25090 may be designated as a medical waste treatment facility by the department. Mixed Waste Mixtures of medical and non-medical waste. Mixed waste is medical waste, except for all of the following: (a) Medical waste and hazardous waste is hazardous waste and is subject to regulation as specified in the statutes and regulations applicable to hazardous waste. (b) Medical waste and radioactive waste is radioactive waste and is subject to regulation as specified in the statutes and regulations applicable to radioactive waste. (c) Medical waste, hazardous waste, and radioactive waste is radioactive waste and is subject to regulation as specified in the statutes and regulations applicable to radioactive waste and hazardous waste. Offsite - Any location which is not onsite. MWMP Definitions / Page 10

(a) Onsite A medical waste treatment facility on the same or adjacent property. (b) Adjacent - for purposes of subdivision (a), means real property within 400 yards from the property boundary of the existing medical waste treatment facility. Person - An individual, trust, firm, joint stock company, business concern, corporation, including, but not limited to, a government corporation, partnership, and association. Person also includes any city, county, district, commission, the State or any department, agency, or political subdivision thereof, the Regents of the University of California, any interstate body, and the federal government or any department or agency thereof to the extent permitted by law. Sharps Container - A rigid puncture-resistant container which, when sealed is leak resistant and cannot be reopened without great difficulty. Sharps Waste - Any device having acute rigid corners, edges, or protuberances capable of cutting or piercing, including but not limited to, all of the following: (a) Hypodermic needles, syringes, blades, and needles with attached tubing. (b) Broken glass items, such as Pasteur pipettes and blood vials contaminated with other medical waste. Small Quantity Generator - A medical waste generator that generates less than 200 pounds per month of medical waste. Storage - The holding of medical wastes at a designated accumulation area, as specified in Article 8 (commencing with Section 25080). Tracking Document - The medical waste tracking document specified in Section 25063. Transfer Station - Any offsite location where medical waste is loaded, unloaded or stored during the normal course of transportation of the medical waste. Treatment Any method, technique, or process designed to change the biological character or composition of any medical waste so as to eliminate its potential for causing disease, as specified in Article 9 (commencing with Section 25090). MWMP Definitions / Page 11

Attachment One California Medical Waste Management Act (CMWMA) MWMP California Medical Waste Management Act (CMWMA) / Page 12

Attachment Two Department Specific Procedures,Responsible Department Personnel, and Medical Waste Types & Estimated Monthly Quantities Generated MWMPDepartment Specific Procedures,Responsible Department Personnel, and Medical Waste Types & Estimated Monthly Quantities Genera

SSU MEDICAL WASTE MANAGEMENT PROCEDURE General Procedure Biohazardous waste must be collected in sealed rigid containers lined with nonautoclavable biohazardous waste bags (minimum 3mm thickness red bags). Biohazardous waste in the non-autoclavable biohazardous waste bags must be placed inside autoclavable biohazardous waste bags prior to autoclaving. Note that the nonautoclavable bag will shrink around the contents and the exterior autoclave bag will prevent the non-autoclave bags from melting to the autoclave walls. Biohazardous waste treated in this manner may be thrown directly into exterior dumpsters. Untreated sharps may be stored in sharps containers until the container is full. Full containers need to be treated within seven (7) days and transported in rigid containers to the Student Health Center sharps collection container. Biology Department - Stephanie Thibault, Instructional Support Technician (x4-2949) Sharps Waste (Approximately 8 Liters per semester) (1) Autoclave sharps waste within seven (7) days of sharps containers being full. (2) Place full containers of treated sharps into Student Health Center sharps collection tub within seven (7) days of treatment; see third party contract document for pickup schedules. Biohazardous Waste (Approximately 2 to 5 large bags per week) (1) Separate liquid waste from solid waste. Collect liquid waste as hazardous waste in EH&S provided containers. (2) Autoclave solid biohazardous waste within seven (7) days of generation. Verify proper operation and calibration of autoclave unit according to manufacturer specifications. Documentation of monthly Kilits test required. MWMPDepartment Specific Procedures,Responsible Department Personnel, and Medical Waste Types & Estimated Monthly Quantities Genera

(3) Dispose of autoclaved biohazardous waste bags directly into exterior dumpsters. Do not place treated biohazardous waste into building trash cans. Note: Biology staff will autoclave biohazardous waste generated in Kinesiology. Athletics Department Julie Miller, Athletics Trainer (x4-2937) Sharps Waste (None normally generated) (1) Within seven (7) days of sharps containers being full, deliver in a sealed rigid container to the Biology Media Kitchen with instructions to autoclave. Biohazardous Waste (Approximately 1 to 3 small bags per month) (1) Collect biohazardous waste in biohazard bags. (2) Mark bags with the date that waste was first put into the bag and deliver in a sealed rigid container to the Biology Media Kitchen within thirty (30) days that waste was first put into the bag. Nursing Program on Campus Eileen O Brien, Administrative Coordinator (x4-2862) Sharps Waste (Approximately 1 Liter per month) (1) Autoclave sharps waste within seven (7) days of sharps containers being full. (2) Place full containers of treated sharps into Student Health Center sharps collection tub within seven (7) days of treatment; see third party contract document for pickup schedules. Biohazardous Waste (Approximately 1 to 2 large bags per month) (1) Autoclave solid biohazardous waste within seven (7) days of generation. Verify proper operation and calibration of autoclave unit according to manufacturer specifications. Documentation of monthly Kilits test required. MWMPDepartment Specific Procedures,Responsible Department Personnel, and Medical Waste Types & Estimated Monthly Quantities Genera

(2) Dispose of autoclaved biohazardous waste bags into exterior dumpsters. Do not place treated biohazardous waste into building trash cans. Student Health Center Paula Coffaney (x4-2921) Sharps Waste (Approximately 2 to 4 gallons per month) (1) Autoclave sharps waste within seven (7) days of sharps containers being full. (2) Place full containers of treated sharps into Student Health Center sharps collection tub within seven (7) days of treatment; see third party contract document for pickup schedules. Note: The Student Health Center serves as the central receiving area for all treated sharps waste containers generated at Sonoma State University. Biohazardous Waste (Approximately 2 to 5 large bags per week) (1) Autoclave solid biohazardous waste within seven (7) days of generation. Verify proper operation and calibration of autoclave unit according to manufacturer specifications. Documentation of monthly Kilits test required. (3) Dispose of autoclaved biohazardous waste bags directly into exterior dumpsters. Do not place treated biohazardous waste into building trash cans. MWMP / Page 16