Resources: Waste Management Concerns for Small Community Healthcare Facilities

For many small community healthcare facilities, waste management is one of those tasks which becomes an “additional” duty for a laboratory manager, environmental services manager, or facilities manager.  It will be “taken care of” by someone else, and is of “no concern” to facility and clinical administrators unless wastes are not removed in a timely manner from treatment areas.  Further, many managers assigned these duties remain unaware of the requirements associated with such responsibilities.  In fact, improper waste management can potentially close the doors of the facility and/or be the source of significant financial penalties.

One of the most fundamental issues, which has been addressed through many venues for years, is the segregation of general wastes and Regulated Medical Wastes (RMW).  This action facilitates the proper and cost-effective disposal of wastes, and is easily implemented.  However, with small volumes of wastes generated, many facilities still place a single waste container in each treatment room.  A red bag is generally placed in this container, to ensure that potential RMW is adequately handled.  General wastes placed in the container will be treated and disposed of sufficiently; albeit at a much greater cost.  Minimal staff training, and a change of mindset, can significantly reduce the costs of RMW management.

Another basic issue of concern involves the timely collection and disposal of RMW (e.g., bloody bandages and gauze, bodily fluids, sharps, etc.) and the cleaning/disinfection of surfaces in treatment areas between patients.  The Joint Commission has established specific standards addressing infection control, requiring certain procedures and guidelines to be instituted to minimize the potential for hospital acquired infections (HAI).  Failure to maintain these standards may cause the facility to fail an accreditation survey and/or come under review by local/state public health agencies.  Either event may adversely impact public confidence in the facility and affect its future viability.  Waste collection frequently occurs on a regularly scheduled basis during routine operations.  This system can become quickly stressed during any unscheduled/emergency event, though.  The introduction of additional patients, for example, would create a need for enhanced waste collection and clean-up/disinfection of surfaces.  Many small healthcare facilities possess a very limited environmental services staff, or contract it out altogether, creating significant problems during this type of event.  Such activities must be addressed within the facility’s Emergency Management Program (EMP).

Facility RMW is frequently stored in loading dock areas or in small external sheds/structures.  Pick-up of these wastes is generally contracted to a local/regional vendor, and occurs every two weeks, or so.  It is incumbent upon the individuals responsible for RMW management within the healthcare facility to ensure that such wastes are packaged, treated, and disposed of properly.  In other words, investigate the mode and location of final waste disposition prior to committing to a contract.

Similarly, a number of recurring issues have been observed at small healthcare facilities involving hazardous waste management.  Most facilities do not generate significant quantities of these wastes (which is sometimes part of the problem).  Most hazardous wastes are generated within the laboratories at such facilities, in the form of laboratory reagents for various clinical tests, machine calibration, etc.  In addition, fixer and developer solutions emanating from older X-ray machines (radiology departments) are quite corrosive, and must be handled as hazardous wastes.  Fortunately, many facilities have now converted to the newer, digitized machines, which do not require such solutions.  However, a number of small healthcare facilities have been observed maintaining containers of used fixer and developer solution, after a couple of years, claiming that they do not know how to manage them or are waiting until they accumulate larger volumes of similar wastes, to make it cost-effective to dispose of them.

Several potentially problematic issues have been observed at small healthcare facilities, involving simple administrative details.  All can be mitigated through simple familiarization training and minor procedural changes in facility operational protocols.  Among the issues frequently noted are an inability to adequately characterize the wastes and an absence of consistent hazard waste manifesting.

The hazardous wastes generated within these facilities are generally segregated from other wastes and materials and are secured, to limit unauthorized access.  However, these collection/storage areas frequently have no inventory or log sheet which allows the individual(s) introducing wastes to delineate the chemicals or types of wastes, relative volumes, or container(s) in which they are held.  The Resource Conservation and Recovery Act (RCRA) regulations normally covering such wastes are rather vague regarding the requisite measures for this type of operation.  However, Title 40, Code of Federal Regulations, Section 261 mandates that wastes be characterized prior to transport for disposal, to ensure that potentially incompatible wastes are not mixed together and that a suitable means for treatment and disposal is rendered.  Waste characterization can be accomplished via either generator knowledge or laboratory analysis.  The first method is far less costly and time-consuming, and should be easy to use, as long as the individuals using the chemicals identify what they are when placing the wastes into the storage area.  The placement of a waste log sheet, accompanied by brief familiarization training of all departments/individuals who might introduce hazardous wastes to the storage area, should facilitate compliance with this requirement.  The waste manager, responsible for controlling this area, maintains the keys for the site, and should be aware of all persons requesting access for the purpose of depositing wastes.  This is an easily implemented, and preferable, method to meeting this requirement.

Due the vagueness of the Federal regulations, hospital waste storage has often not been designated as “90-day storage” sites.  Unless otherwise specified by the local/state regulatory authorities, this eliminates the requirement that hazardous wastes not accumulate beyond 90 days after the first introduction of wastes prior to pick-up/transport for disposal.  However, good waste management practices dictate that wastes not be allowed to sit for too long (e.g., greater than 6 months) or accumulate to the point where full containers remain onsite prior to disposal.  In the former case, some organic and/or corrosive wastes may compromise the container integrity over time, and in the former instance, personnel safety and the ability to segregate incompatible wastes may be impacted.  Waste managers should remain cognizant of the status of wastes within the storage area and program for waste pick-up prior, if either situation occurs.

A hazardous waste manifest must accompany shipments of wastes to ensure and document “cradle to grave” management, and the proper treatment and disposition of wastes.  The manifest must be initiated by the generator of the wastes (i.e., the healthcare facility).  It “travels” with the wastes, and is signed by each individual assuming responsibility for the wastes throughout transport and intermediate storage (i.e., transfer locations).  (A copy of the signed manifest is kept by each individual/organization releasing control of the wastes.)  The owner/manager of the facility where the wastes are ultimately treated and/or disposed of must sign the manifest and mail a copy back to the original generator.  Title 40, Code of Federal Regulations, Section 262 mandates that the generators maintain a file of all manifests for a minimum period of three years as proof that hazardous wastes were handled and disposed of in an appropriate manner.  A number of small healthcare facilities visited have not routinely received the final copy of manifests, or cannot produce a file containing these documents over the past several years.  In some cases, the final manifests have been received by an administrative office, who did not forward to the facility waste manager or was unaware of the filing requires promulgated in the regulations.  Once again, familiarization training and a change in administrative procedures would remedy these common problems.

A final issue, noted recently at some small facilities, involves the disposition of chemical wastes from newer, automatic blood analyzers in the laboratories.  Some laboratory managers have heard that others have received permission to pour such wastes down the sink, into the respective wastewater collection systems, and have assumed the same practice as an accepted practice.  Different types and brands of equipment will use different chemicals.  Each facility must request approval from the local environmental authorities and the organization responsible for operation of the receiving wastewater treatment facility for such discharge of their particular chemicals.  The unauthorized introduction of certain chemicals may adversely impact the bacteria used to perform the treatment of wastewater, and upset facility operations.  If granted approval from the proper authorities, laboratory personnel will, likely, be provided associated disposal instructions which will include significant flushing of water while pouring the chemicals down the sink.  This dilution will minimize/preclude adverse impacts to the treatment facilities.  If such requests are denied, the healthcare facility laboratory personnel must physically collect and store the subject materials as hazardous wastes, and follow the pertinent procedures for storage, transport, and disposal.

This text identifies just a few, basic waste management issues recently observed at small community healthcare facilities.  Should the Joint Commission surveyors, or local/state/Federal environmental authorities, identify these circumstances, the potential consequences for the facility in question could prove devastating.  However, most issues can be readily overcome, or avoided, with minor training of facility personnel, and minimal changes to administrative procedures in the waste management program.  In almost all cases, facility personnel responsible for these areas want to do the right thing, and believe that they are doing so.  The phrase “that’s how it’s always been done here” is heard all too often.  This doesn’t mean that the way previous managers have done things was the correct way.  They, likely, were unaware of the requirements, as well.  Review your waste management procedures, and obtain some basic training in waste management and handling.  It will go a long way in keeping your facility in compliance with the Joint Commission (TJC) standards.

(c) JVR Health Readiness, Inc. 2008

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