For the most up-to-date guidance please refer to NHSScotland Property and Environment Forum: Tel: 0141 548 3446
or e-mail: heeu@strath.ac.uk
7.1. INTRODUCTION
7. 1.1 The term "healthcare waste" is used to describe all waste resulting from healthcare activity. It includes waste which falls within the statutory definition of clinical waste and other non-clinical waste.
7.2. DEFINITION
7.2.1 Clinical Waste is defined in the Controlled Waste Regulations (see Appendix 2) as:
OR
7.3. SAFE MANAGEMENT OF CLINICAL WASTE
7.3.1 The Environmental Protection Act (see Appendix 2) imposes a duty of care on anyone who has a responsibility for clinical waste at any stage from its production to its disposal in order to ensure that it is legally and safely managed. The duty requires producers to take reasonable care to ensure that there is no unauthorised or harmful deposit, treatment or disposal of their waste whilst in their control or that of any other person and, on the transfer of the waste, to ensure that the transfer is only to an authorised person or to a person for authorised transport purposes (registered waste carrier). If some of this waste falls within the definition of Special Waste a written description of the waste must also be transferred (see 7.9.1 & 7.9.2 below). The Duty of Care has to be discharged by each person involved in the waste disposal chain and cannot be fully delegated to a waste contractor.
7.3.2 In NHS Trusts overall responsibility for the management of clinical waste rests with the CE. CEs and General Managers should ensure that their arrangements for the safe disposal of clinical waste comply with relevant legislation and good practice for the protection of patients, staff, the public and the environment. An exhaustive list of relevant legislation and guidance is to be found in the relevant Scottish Hospital Technical Note (SHTN) No 360. The primary guidance for the healthcare sector is contained in the HSAC document61. Specific instruction to Trusts in Scotland is to be found in NHS MEL (1994)88 62 . The publications of the London Waste Regulation Authority (address in Appendix 5) and the Department of Environment, Waste Management Papers also provide invaluable advice and guidance.
7.3.3 Trust CEs must ensure that a designated Clinical Waste Control Officer (CWCO) is appointed who will have overall responsibility for ensuring that the Trust fulfils its Duty of Care in respect of clinical waste. The CWCO will chair a Waste Committee which, it is recommended, should include the Infection Control Officer and ICN. In addition to providing infection control advice they will also be involved in carrying out audits and in designing appropriate training packages for all staff. The Waste Committee will produce a specific Clinical Waste Management Policy detailing aims and objectives, identifying individual responsibilities and outlining organisational and practical arrangements for the safe management of clinical waste. Where responsibilities are delegated there must be clear lines of management accountability and documented reporting procedures. It is recommended that regular revision and updating of this policy be undertaken by the Waste Committee.
7.3.4 Management should endeavour to minimise the production and the environmental impact of waste by reviewing materials used, the packaging of medical devices and medicinal products and the practices employed, such as the reuse and recycling of medical devices. When NHS Trusts contemplate the possibility of reusing and recycling devices they should be mindful of EC Directive 93/42/EEC63 and the Medical Devices Regulations64,65.
7.4. RISK ASSESSMENT
7.4.1 Regarding the management of clinical waste - its segregation, storage, collection, transport, treatment and disposal, there is a requirement under health and safety and environmental legislation for all patient care deliverers to perform a risk assessment focusing on the protection of staff and the environment. Guidance on the classification of clinical waste for the purposes of risk assessment is provided by the HSC61 and SHTN No 3 60.
7.5. SEGREGATION
7.5.1 Good management of clinical waste generated in hospital or in the community includes:
Waste for final treatment by INCINERATION only in YELLOW bags or containers.
Waste for HEAT DISINFECTION TREATMENT only in ORANGE bags or containers.
Where final disposal involves a heat disinfection process and incineration before landfill the appropriate stream colour code must be used at each stage (see Flow Charts 1 and Flow Chart 2).
7.5.2 Bags must be effectively sealed with tracking/locking ratchet seals or designated tape, colour and number coded or labelled to uniquely identify the source. Similarly, all used sharps containers must be labelled indicating the source and date and sealed before removal. Sharps containers, disposable or reusable, should conform to both BS66 and UN standards67.
7.5.3 Arrangements for the segregation of wastes in hospitals, nursing homes, medical and dental practices and similar premises should, as indicated above, be sufficiently robust to ensure that clinical waste does NOT enter the domestic (BLACK bag) waste stream.
7.5.4 All categories of healthcare waste arising in the community are subject to the same procedures for identification, handling and segregation. The healthcare professional responsible for patient care should carry out the risk assessment and identify the appropriate means of disposal consistent with the policy of his/her employer which will take into account agreements with the relevant waste collection and disposal authorities and SEPA (address in Appendix 5). Risk assessment will exclude from the domestic waste stream sharps, unused medicines and any substances which on the basis of risk assessment are deemed to constitute an infection hazard (see Flow Chart 1 for recommended disposal routes).
7.5.5 Where waste generated in the community is known to contain significant pathogens or is potentially dangerous because of its clinical content e.g. cytotoxic agents, this should be noted in the risk assessment and special appropriate arrangements made for handling, treatment and disposal after consultation between the attending healthcare professional, the local CPHM(CD/EH) and the waste collection authority.
7.5.6 Clinical waste in the community should be transported in UN type approved containers67 to a suitable designated storage area where there is a collection and disposal system. It is appropriate that arrangements for collection and disposal are made with the relevant Trust.
7.5.7 In accordance with HSAC guidance (currently under review)39, potentially infectious waste from pathology departments, clinical or research laboratories should be placed EITHER in YELLOW bags for incineration, where appropriate OR in transparent bags with LIGHT BLUE markings for autoclaving before leaving the laboratory. After autoclaving these bags should be placed in ORANGE bags for heat disinfection treatment - or YELLOW bags for incineration.
7.5.8 Mechanical compaction must NOT be used to reduce the bulk of any clinical waste in plastic bags or containers, unless previously autoclaved. Waste may only be compacted if it contains no sharps or free liquid and has been rendered non-hazardous.
7.5.9 Where clinical waste is to be transported by road, then the containers should be UN type approved . It should be noted that from 1 January 2002, all waste will have to be transported in UN type approved rigid containers.
7.6. STORAGE
7.6.1 Clinical waste, wherever it arises, should be disposed of as soon as it is practicable to do so. Arrangements for disposal and storage pending disposal will differ depending upon where the waste is generated - in the patient's home, hospital, or other healthcare facility, on the nature and quantity of the waste and perhaps on geographical constraints. The arrangements made for storage of clinical waste on whatever scale should accommodate not only the relevant requirements of legislation and good practice but also the reasonable operational needs of all those involved: those who produce the waste, those who deliver the waste to and remove it from the storage area and those who subsequently treat and dispose of the waste.
7.6.2 In all instances storage arrangements should:
7.6.3 Depending on the duration of storage a waste management licence under the Environmental Protection Act (see Appendix 2) may be required.
7.6.4 Storage in the domestic, community or homecare situation should be in a dedicated bag lined pedal bin or similar hard sided/lidded container kept in a cool dry place away from food, secure from pets and children. The British Medical Association (BMA) Code of Practice describes techniques and standards for cleaning and disinfecting healthcare waste handling equipment16 .
7.6.5 Where there is uncertainty about the best course of action, advice on storage of waste can be obtained from the local TICC, CPHM(CI)/EH), SEPA or the HSE as appropriate.
7.7.TREATMENT AND DISPOSAL
7.7.1 The means of treatment and disposal will differ with location in Scotland. In choosing means of treatment and disposal, management will have several objectives:
7.7.2 In that choice, technical and commercial judgement will play a major part as knowledge of what is consistent with legislation and good practice. Management will as a matter of course have standing liaison arrangements with local authority collection and disposal authorities or waste contractors. In all matters affecting clinical waste, Management should also have arrangements for discussion with SEPA. With advances in technology a range of alternative treatment processes designed to reduce the infection risk of clinical waste and render the waste non-hazardous are emerging. When such alternatives to incineration and/or heat disinfection treatment are being evaluated by Trusts it is recommended that advice is sought from HEEU, and SEPA (addresses in Appendix 5) regarding the appropriateness and applicability of the process concerned.
7.7.3 Treatment and Disposal to Sewerage System. The sewerage system is designed and operated to accept infectious material in the form of domestic sewage or macerated wastes from hospitals. The Infection Control Officer should be consulted for advice on the need for treatment to render material non-hazardous before discharge. The statutory responsibility for controlling discharges to sewers in Scotland rests with Water Authorities from whom advice and guidance can be sought.
7.7.4 Landrill Disposal is the means of disposal of incinerator residues and of the products of heat disinfection treatment. Managers responsible for the production of the waste should satisfy themselves that the incineration or heat disinfection treatment processes are technically adequate for their purpose and that the supervision of the processes is adequate to prevent inadequately incinerated or treated waste reaching landfill. Guidance in the Waste Management Papers published by the Department of the Environment is relevant - in particular, the series WMP2668 .
7.7.5 Heat Disinfection Treatment is designed to render the waste safe and unrecognisable as originating from healthcare. As such it is likely to be acceptable for disposal to landfill. It is appropriate for the following waste:
Hospital
Community
7.7.6 The temperature-time relationships employed in treatment plants are likely to differ from process to process depending on the technology used. The final operating parameters should be established for each plant and should include a safety margin. No service agreement should be agreed with a waste treatment contractor until the Trusts Microbiologists/Infection Control Officers, after discussion where appropriate with the HEEU and SEPA, are satisfied as to the efficiency and safety of the process.
7.7.7 Fundamental requirements for the design of a heat disinfection treatment plant are:
The adequacy of any disinfection process should be judged on the quality of the treated waste.
7.8. INCINERATION
7.8.1 Guidance on the suitability of any incineration facility, its compliance with statutes, emissions and good incineration practice in general is available from the HEEU or SEPA (addresses in Appendix 5).
7.8.2 Incineration can be used to treat ALL clinical waste but is essential for:
This will include products of conception from gynaecology, placentae not being submitted for pathological examination, and embryo or foetal tissue from pregnancies under 24 weeks duration NOT going for autopsy, cremation or burial.
NB: If patients prefer to make private funeral arrangements, their wishes must be respected. Guidance on all matters relating to the disposal of foetuses and foetal tissue following stillbirth or termination of pregnancy is contained in a Scottish Office Home and Health Department (SOHHD) letter69.
NOTE: Waste containing Hazard Group 4 pathogens is now classified as Special Waste and is subject to the requirements of the Special Waste Regulations71.
7.9. SPECIAL WASTE
7.9.1 Some clinical waste may fall within the definition of SPECIAL WASTE.
7.9.2 Special Wastes comprise, among others, substances or materials which are infectious, hazardous to life or flammable, and many pharmaceutical products. The regulations require that a consignment note system involving the proper description of proposed consignments, pre-notification of SEPA and the maintenance of records is in operation.
Detailed guidance is given in SOAEFD Circulars Nos. 13/9672 and 26/9673 the Special Waste Regulations71 and the "Carriage of Dangerous Goods (Classification, Packaging and Labelling) and the Use of Transportable Pressure Receptacles Regulations74.
7.10. RADIOACTIVE CLINICAL WASTE
7.10.1 The management of this waste is regulated by the Radioactive Substances Act (see Appendix 2) and related Exemption Orders. Enforcement of these Acts has been the responsibility of SEPA from 1 April 1996. The conditions for accumulation, storage and disposal will be specified in the Certificate of Authorisation issued to Hospital Trusts involved in medical diagnostic and therapeutic procedures using radionucleotides.
7.11. STAFF TRAINING, INSTRUCTION AND SUPERVISION
7.11.1 In recognition of their responsibilities under the Health and Safety at Work Act and the COSHH Regulations, Trusts must assess worker exposure to hazardous substances and provide employees with sufficient information, training, supervision, equipment and safe systems of work to carry out their duties.
7.11.2 The health and safety of everyone at work should be addressed in health and safety policies. The arrangements for carrying them into effect which should take account of HSAC guidance 61 should refer to means of ensuring that workers - including those who work for different employers - are adequately informed about hazards without patient confidentiality being prejudiced.
7.12. COLLECTION AND TRANSPORT
7.12.1 Arrangements for the collection, transport and labelling of clinical waste should comply with legislation and good practice, especially regarding the health and safety of patients, staff and others and protection of the environment60.
7.12.2 If Trusts have a service level agreement with a company to transport waste for disposal off site, they have a Duty of Care to ensure that the carrier is an "authorised person" registered by SEPA under the Environmental Protection Act (see Appendix 2).
7.13. HANDLING
7.13.1 Handling practices should comply with the Health and Safety at Work Act and, where appropriate, be agreed with the Health and Safety Officer, the Control of Infection
Officer and the TICC. Comprehensive guidance on the handling and transport of clinical waste, including the use of protective clothing is given in the HSAC guidance61. Staff should be given clear guidance on the requirements for protective clothing - face masks, heavy duty gloves, sturdy shoes or industrial boots, an industrial apron or leg protectors should be worn where appropriate. Healthcare staff including those in primary care who are exposed to blood or blood products waste or items contaminated with blood may be offered Hepatitis B vaccination, in accordance with the local immunisation protocol (see 8.5).
7.14. SPILLAGES
7.14.1 Managers must ensure that there is a written procedure for dealing with accidental spillages which will clearly state:
HEALTHCARE WASTE IN THE. COMMUNITY
Flow Chart
WASTE SEGREGATION AND DISPOSAL
FOR HOSPITAL AND HEALTHCARE PREMISES
(E.G. NURSING HOMES, GP & DENTIST PREMISES)
Flow Chart