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Safe management of healthcare waste Version 1.0 from spaceforhealth.nhs.uk © Crown copyright This document/publication is not covered by the HMSO Click-UseLicences for core or added-value material. If you wish to re-use this material, please send your application to: Copyright applications. The Copyright Unit Office of Public SectorInformation Information Policy Team Kew Richmond Surrey TW9 4DU e-mail:licensing@opsi. gov.uk Published: Fri, 25/03/2011 - 12:10pm Safe management of healthcare waste Version 1.0 Contents Summary Acknowledgements DepartmentofHealthInformationreaderbox(Gateway) 7660 page8 7663 8571 Introduction,scopeandapplicability Whoshouldusethismanual? Whatisprovidedinthemanual? UpdatetoHealthTechnicalMemorandum07-01(2006)andkeychanges Guidancestatusandimplementation Essentialstandardsofqualityandsafety 7666 page10 7689 7690 7691 7692 8583 Glossaryandacronyms 8550 page15 Legislationandhealthcarewaste 7672 page19 Overviewofregulatoryregimes 7675 Environmentandwastelegislation 7678 WasteFrameworkDirective 7684 Dutyofcareandcontrolledwaste 7685 Localauthorities’responsibilities 7686 Environmentalpermittingandwastemanagementlicensing 7687 Hazardouswaste(England,WalesandNorthernIreland)andspecialwaste(Scotland) 7688 Consignmentnotes 7694 EuropeanWasteCatalogue(EWC) 7696 Controlleddrugs 7700 Destruction/disposal 7698 Standardoperatingprocedures 7699 Producerresponsibility 7702 Healthandsafetylegislation 7706 Managementresponsibilities 7708 ControlofSubstancesHazardoustoHealth(COSHH) 7710 Healthandsafetyatwork 7712 Consultingemployees 7714 Transportlegislation 7717 CarriageRegulations 7719 Procurementregulations 8462 Europeanprocurementregulations 8463 Procurementguidance 8464 Healthcarewastedefinitionsandclassifications Typicalwastesproducedbyhealthcareactivities Clinicalandhazardouswaste Healthcarewasteclassificationandassessmentframework Step1 Step2 Step3 Step4 Step5 Step6 Specificwastetypes 1 7725 page38 7727 7731 7733 7744 7746 7742 7750 7752 7755 7757 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Amalgamwaste Medicaldevices Implants Radioactivewaste Domestic(municipal)waste Bloodtransfusionbags Gypsumandplastercasts 7759 7763 7765 7768 7770 7772 7774 Wasteminimisation,segregation,colour-codingandstorage Wasteminimisation Waste-derivedcarbonimpact Importanceofwastesegregation Colour-coding Containerlabelling Infectiouswaste:yellowstream Anatomicalwaste–red-liddedreceptacles Infectiouswaste:orangestream Infectiousliquidwaste:yellowororangereceptacles Medicinalproducts–blue-liddedreceptacle Cytotoxic/cytostaticwaste–yellowwithpurplestripeorpurplestream Sharpswaste–containerswithyellow,purpleandorangelids Fullydischargedsyringes Offensive/hygienewaste–yellow/blackbags Domesticwaste(usuallyblackbags) Specialistarrangementsforsegregation Chemicalwaste:fixeranddeveloper Amalgam–whitecontainers Radioactivewaste Largeequipmentandmattresses Implanteddevices Successfulwastesegregation Implementingwastesegregationsystems Wastereceptacles Storageandfrequencyofcollection Managingcompliance 2 7776 page76 7778 7781 7783 7785 7794 7796 7798 7800 7802 7804 7806 7808 7810 7815 7817 7819 7818 7821 7823 7825 7827 7830 7832 7834 7843 7845 page93 Healthcarewastepolicy 7847 Wasteaudit 7849 Auditscopeandprocedure 7851 Frequencyofaudits 7853 Audittechniques 7855 Observationandrecordingofpractice 7914 Observationofwastereceptacles 7916 Detailedexaminationofwaste 7918 Staffquestionnaire 7922 Wasteaudittrails 7926 Useofcontractors 7934 Training 7937 Trainingprocedures 7946 Trainingrecords 7948 Inductiontraining 7950 Job-specifictraining 7954 Deliveryoftraining 7957 Frameworkcontractforthedeliveryofwastemanagementtrainingwithinthehealthcare sector 7965 Specificationforpersonalprotectiveequipment(PPE) 7968 Immunisation 7970 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Wastecollectiondocumentation Transportdocumentation Wastetransfernote Dualtransfer/transportnotes Consignmentnotes Accidentsandincidents ReportingofInjuries,DiseasesandDangerousOccurrencesRegulations(RIDDOR) Spillages Disinfectants Mercury 7975 7978 7981 7989 7991 7993 7997 8000 8002 8005 Transportpackagingandoperations Transport:packaging,marking,labellinganddocumentation Transportofpackagedgoods Limitedquantities Specificpackagingissues Clinicalwaste(UN3291) CategoryAclinicalwaste Soiledsurgicalinstruments Usedlinen Wastemedicines(includingamalgamwaste) Sharpspackaging Batteriesincludingthoseusedforimplants/medicaldevices Radioactivematerial Otherchemicals Cleaningreceptacles Examplesoftypicalrigidpackagings Markingandlabellingofpackagings Bulktransport Transportontheroad Documentation Dangerousgoodssafetyadviser(DGSA) CarriageonshipsinUKwaters On-sitetransport 8008 page112 8016 8022 8036 8040 8044 8049 8054 8056 8058 8060 8063 8065 8067 8084 8083 8103 8155 8164 8167 8174 8177 8182 Wastemanagementlicensingandpermitting EnvironmentalPermittingRegulations(EnglandandWales) Exemptionsfromenvironmentalpermitting Healthcare-relatedexemptions Smallclinicalwastetreatmentplant(ontheproducer’spremises) Laboratoryautoclaves Wastemanagementlicences(NorthernIrelandandScotland) Pollutionpreventionandcontrol(PPC)permits(NorthernIrelandandScotland) 8189 page129 8191 8193 8196 8198 8200 8202 8204 Treatmentanddisposal 3 8206 page136 Renderedsafe 8208 CriterionA:reductioninpathogennumbers 8209 CriterionB:destructionofanatomicalwaste 8211 CriterionC:unusableandunrecognisable 8212 CriterionD:Therenderingsafeofpharmaceuticalsandchemicalswithinthewaste 8213 Treatmentanddisposalsystems 8215 Dischargetosewer 8217 Specifictreatment/disposalrequirements 8223 TSE-infectedwaste 8218 Cytotoxicandcytostaticwaste 8219 Wastecontaininggeneticallymodifiedmicroorganisms(GMMs) 8220 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Mercury Amalgam 8221 8222 SECTORGUIDES 8224 page141 Ambulanceservices 8226 page142 Scopeandtargetaudience Wasteriskassessment Examplewastestreams Limbsandbodyparts Wastereceptaclesandstorage Disposaloptions Option1–emergencyresponse Option2–wasteinthecommunity Option3–ambulancetransportservices Researchandlaboratoryfacilities Communityhealthcare Communitypharmacies 4 8228 8230 8232 8234 8237 8236 8238 8239 Briefdescriptionofthesectoractivities Wasteclassificationandsegregation Microbiologicalcultures Clinicalspecimens Environmentalsamples Autoclavedlaboratorywaste Wastepackagingandlabelling Packagingofinfectiouswastefortransport Markingandlabellingofinfectiouswaste Wastestorageandtransport On-sitetransport Off-sitetransport Wastetreatmentanddisposal Generalprovisions Transportsecurity 8241 page148 8243 8245 8247 8249 8251 8253 8256 8257 8258 8262 8260 8261 8264 8266 8268 Scopeandtargetaudience Wasteriskassessment Infectiouswaste ManagementofCategoryAinfectiouswasteinthecommunity ManagementofCategoryBinfectiouswasteinthecommunity Assessingwhetherwasteposesariskofinfection Offensive/hygienewastearisingfromhealthcare Examplewastestreams Self-medicatingpatientsandsharpsdisposal CaseStudy:PartnershipWorkingandBenefitsforall Single-useinstruments Stoma/catheterbags Maggots Wastepackagingandreceptacles Transportingoffensiveorinfectiouswastefrompatients’homes Option1–collectionfromthepremises/householder Option2–healthcareworkertransportswaste 8270 page158 8269 8272 8271 8274 8277 8276 8279 8283 8281 8282 8285 8286 8287 8289 8293 8291 8292 8295 page170 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Responsibilitiesofthepharmacy Wastesegregation,packaging,classificationandlabelling Classificationofwastemedicines Segregation,sortingandunpackingofmedicines Controlleddrugs Glass/plasticmedicinalcontainers Sharps Otherhealthcarewastes Offensivewastes Chemicals Domesticandtradewaste Incompatiblesubstances Storageofwaste Transportregulations Wastetransferanddocumentation Whocompletestheconsignmentnoteandwhen? Carrierroundcollections Wastetransfernotes Registrations,recordsandreturns Howtoregisterasahazardouswasteproducer Hazardouswaste–recordsandreturns Consigneereturnstothewasteproducerorholder Whereshouldtheregisterbekept? Howlongshouldtheregisterbekept? Non-hazardouswasterecords Thepharmacyasaconsignee Wasteauditanddutyofcareauditchecks Wastecarriers Wastedisposal Dischargetofoulsewer Exportofmedicinesanddonationstocharity 8297 8299 8301 8303 8305 8307 8309 8311 8313 8315 8317 8319 8321 8323 8325 8335 8336 8337 8334 8327 8328 8329 8330 8331 8332 8333 8339 8341 8343 8345 8347 Generalpracticesandhealthcentres Responsibilitiesofthegeneralpractice Wastesegregation,packaging,classificationandlabelling Cytotoxicandcytostaticmedicines Othermedicines Sharpsboxes Chemicals Orangeclinicalwastebags Yellowclinicalwastereceptacles/bags Offensive/hygienewaste Blackbags Humantissues Gypsum Otherwastes Wastelabelling Wastetransferanddocumentation Documentation Whocompletestheconsignmentnoteandwhen? Carrierroundcollections Wastetransfernotes Registrations,recordsandreturns Registrationasahazardouswasteproducer Howtoregisterasahazardouswasteproducer Hazardouswaste–recordsandreturns Consigneereturnstothewasteproducerorholder Whereshouldtheregisterbekept? 8349 page185 8351 8365 8353 8354 8355 8356 8357 8358 8359 8360 8361 8362 8363 8364 8367 8368 8369 8370 8371 8379 5 8373 8374 8375 8376 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Howlongshouldtheregisterbekept? 8377 Non-hazardouswasterecords 8378 Wasteauditanddutyofcareauditchecks 8381 Frameworkcontractforthedeliveryofwastemanagementtrainingwithinthehealthcaresector 8383 Wastestorage 8385 Wastecarriers 8387 Wastedisposal 8389 Dischargetofoulsewer 8391 Specificissues 8396 Staffworkinginthecommunity Movementofwastewithinapractice’spremises 8393 Movementofwastebetweenpractices 8394 Returnofmedicinestopharmaciesandcharities 8395 Dentalpractices Whataretheresponsibilitiesofthedentalpractice? Wastesegregation,packaging,classificationandlabelling Sharpscontainers Orangeclinicalwastebags Dentalamalgam Offensive/hygienewaste Teeth Dentalplastermadefromgypsum Domesticwaste Wastelabelling Wastetransferanddocumentation Whatisaconsignmentnote? Whocompletestheconsignmentnote,andwhen? Carrierroundcollections Wastetransfernotes Wastefromotherpracticesandhomevisits Registrations,recordsandreturns Whyregisterasahazardouswasteproducer? Howtoregisterasahazardouswasteproducer Wastestorage Hazardouswaste:recordsandreturns Consignmentnotes Consigneereturnstothewasteproducerorholder Rejectedloadsandcarrierschedules(whererelevant) Whereshouldtheregisterbekept? Howlongshouldtheregisterbekept? Non-hazardouswasterecords Wasteauditanddutyofcarechecks Wasteaudit Wastecarriers Wastedisposal Dischargetofoulsewer Clinicalwastetreatmentanddisposaloverview Hightemperatureprocesses Incineration Pyrolysis Plasmatechnology Gasification Non-burn/lowtemperaturealternativetechnologies Heat(thermal)disinfectionsystems 6 8400 page200 8402 8408 8409 8410 8411 8412 8413 8414 8415 8416 8423 8418 8419 8420 8421 8422 8426 8424 8425 8427 8428 8429 8430 8431 8432 8433 8434 8436 8435 8438 8440 8442 8443 page213 8448 8444 8445 8446 8447 8453 8449 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Chemicaldisinfectionsystems Otherchemicalsystems Landfill 8450 8451 8452 Carriageinformation:CategoryApathogenlist 8455 page216 Examplelistofcytotoxicandcytostaticdrugs 8457 page219 Examplesoftrainingsupportmaterials 8461 page222 7 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Summary 7660 Thisisthesecondeditionofthismanual.ItprovidesanupdatetoHealthTechnical Memorandum07-01firstpublishedin2006.Thekeyareasofchangeinclude: • updatestolegislation,specificallyforenvironmentalpermittingandtransport regulations; • afocusonthewastehierarchythroughprocurementpractices,andthe elimination,minimisation,recyclingandrecoveryofwaste; • adrivetoaddressthecarbonimpactrelatedtowastethroughresource efficiency,transportimpactsanddisposalarrangements; • theintegrationofnewsectorguidesonGPsanddentalpracticesaswellas incorporatingHealthTechnicalMemorandum07-06:‘Disposalof pharmaceuticalwasteincommunitypharmacies’asasectorguide; • afocusonpracticaladviceandexamplesforclassifyingwaste,inparticular theinfectiousandoffensivewastestreams,includingcasestudiestohighlight bestpractice; • areviewoftheterminologyusedforhealthcare,clinicalandnon-clinical wastes. Thiseditionsupersedesthe2006edition.Apartfromthedirectenvironmental benefitsachievedbythecompliantmanagementofhealthcarewaste,thisguidance presentsopportunitiesforintroducingcostsavings,saferworkingpracticesand reducingcarbonemissionsrelatedtomanagingwaste. HealthTechnicalMemorandum07-06:‘Disposalofpharmaceuticalwastein communitypharmacies’ Acknowledgements 7663 Thefollowingindividualsandorganisationshavecontributedtotheproductionofthis guidance: MickFanningWSPGroup LouiseWoodWSPGroup CatherineLynasWSPGroup PeterHoffmanHealthProtectionAgency JeffHartDepartmentforTransport ChrisLewisWelshHealthEstates BobMcIntyreEnvironmentAgency TonyRyanBuyingSolutions MartinCastleVehicleCertificationAgency GulRootDepartmentofHealth LorraineHolmeDepartmentofHealth SteveLutenerPharmaceuticalServicesNegotiatingCommittee JohnNewboldHealthandSafetyExecutive MarkHeggieScottishEnvironmentProtectionAgency AllisonTownleyEnvironmentandHeritageService,NorthernIreland TeenaPatelDepartmentforEnvironment,FoodandRuralAffairs AlisonGadsbyDepartmentforEnvironment,FoodandRuralAffairs DaveWiltshireThamesWater BrianLathamIHEEM HowardStevensAbertaweBroMorgannwgUniversityHealthBoard 8 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 DepartmentofHealthInformationreaderbox(Gateway)8571 DH INFORMATION READER BOX Policy HR / Workforce Management Planning / Clinical Estates Commissioning IM & T Finance Social Care / Partnership Working Document Purpose Best Practice Guidance Gateway Reference 15645 Title Health Technical Memorandum 07-01: Safe management for healthcare waste Author Department of Health Gateway Review, Estates & Facilities Division Publication Date March 2011 Target Audience PCT CEs, NHS Trust CEs, SHA CEs, Care Trust CEs, Foundation Trust CEs, Medical Directors, Directors of Nursing, NHS Trust Board Chairs, Special HA CEs, GPs Circulation List Description Cross Ref Superseded Docs Action Required Timing Contact Details This document provides a framework for good practice for the management of healthcare waste n/a HTM 07-01 2006 edition (Gateway reference 6874) n/a n/a Lorraine Holme NHS Finance, Performance & Operations Directorate Quarry House Leeds LS2 7UE 0113 254 6328 For Recipient's Use 9 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Introduction,scopeand applicability 7666 Themanagementofhealthcarewasteisanessentialpartofensuringthathealthcare activitiesdonotposeariskorpotentialriskofinfectionandaresecurelymanaged. ThisUK-wideguidanceprovidesaframeworkforbestpracticewastemanagementin ordertohelphealthcareorganisations,andotherhealthcarewasteproducers,meet legislativerequirementsaswellasidentifyopportunitiestoimprovewaste minimisationandreducetheassociatedenvironmentalandcarbonimpactsof managingwaste. Thismanualcoversarangeofwastestreamsproduceddirectlyfromhealthcare activitiesanddoesnotcoverindetailwastestreamsthataresimilartoothersectors (forexamplemunicipalwastemanagement).Thelistofthesewastestreamsisdetailed in‘Legislationandhealthcarewaste’.Anumberofsectorguidesareincludedfor specifichealthcareorganisationsinadditiontothemainguidancewithfurther information. Legislationandhealthcarewaste Whoshouldusethismanual? 7689 Thisguidanceprovidespracticaladviceforallthoseinvolvedinthemanagementof healthcarewaste,andisapplicabletoallwhocomeintocontactwithormanage healthcarewaste(wasteproducers,wastecontractorsandregulators),providingabasis ofcommonunderstandingforallpartiesincludingthepublic,allstaffandthird parties.Thisincludeshealthcarepracticesorthoseactivitiesproducingsimilarwaste,as listedbelow: NHStrustsandNHSfoundationtrusts(includingacutetrusts,mentalhealthtrusts, primarycaretrustsandambulancetrusts); • primarycaretrusts; • ambulancetrusts; • veterinarypractices; • mentalhealthtrusts; • dentalpractices; • opticians; • podiatrists; • generalpractices; • pharmacies; • residentialhomeswithandwithoutnursingcare; • researchfacilities; • privateandindependenthealthcareorganisations; • othernon-healthpracticesproducinghealthcarewaste(forexampletattooists, bodypiercers); • practicesofferingcomplementaryandalternativetreatments; • voluntaryorganisations. 10 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Someoftheabovehaveaccesstoparallelsector-specificwasteguidance(forexample theBritishVeterinaryAssociation’s).Thetablebelowprovidesanoverviewforexample rolesandthemostrelevantsections. Whoshouldusethismanual? Directors/seniormanagement Wastemanagers/transportmanager FMandestatemanagers Environmental/sustainabilitymanagers Procurements/purchasing Housekeepersandporters Cleaningstaff Nursingstaffanddoctorsandsupport teams Infectionpreventionandcontrolstaff Wastecontractorsandconsultants Whichsectionsaremostrelevant? ‘Legislationandhealthcarewaste’and ‘Managingcompliance’ Allsections Allsections Allsections ‘Legislationandhealthcarewaste’, ‘Healthcarewastedefinitionsand classifications’,‘Wasteminimisation, segregation,colour-codingandstorage’, possiblesectorguides ‘Healthcarewastedefinitionsand classifications’,‘Wasteminimisation, segregation,colour-codingandstorage’, ‘Managingcompliance’,‘Transport packagingandoperations’,possible sectorguides ‘Healthcarewastedefinitionsand classifications’,‘Wasteminimisation, segregation,colour-codingandstorage’, possiblesectorguides ‘Legislationandhealthcarewaste’, ‘Healthcarewastedefinitionsand classifications’,‘Wasteminimisation, segregation,colour-codingand storage’,‘Managingcompliance’,possible sectorguides ‘Legislationandhealthcarewaste’, ‘Healthcarewastedefinitionsand classifications’,‘Wasteminimisation, segregation,colour-codingand storage’,‘Managingcompliance’,possible sectorguides Allsections Legislationandhealthcarewaste Managingcompliance Healthcarewastedefinitionsandclassifications Wasteminimisation,segregation,colour-codingandstorage Transportpackagingandoperations SECTORGUIDES BritishVeterinaryAssociation 11 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Whatisprovidedinthemanual? 7690 Thediagrambelowprovidesasummaryofthekeysectionsoftheguidancewitha briefoverview. Legislation and healthcare waste Introduction Specific guidance for the ambulance, dental, community healthcare, community pharmacy, GP and research laboratory sectors Overview of the main regulatory regimes affecting waste management practices Provides a unified definition/classification approach and assessment framework to healthcare and similar wastes. including infectious, medicinal, offensive and sharps Definitions and classifications of healthcare wastes Sector guides Defines how infectious wastes are rendered safe, different options for treatment/disposal, specifies activities producing wastes discharged to foul sewer and associated requirements of the water regulators HTM 0701 Waste minimisation, segregation, colour coding and storage Guidance on policy content to include ownership, responsibility, audit and preacceptance requirements, staff training, transfer documentation, protective equipment and incident reporting Treatment and disposal Details the changes implemented by the Environmental Permitting Regulations and impacts on the management of healthcare wastes Waste management licensing and permitting Managing compliance Transport packaging and operations Details types of healthcare wastes, requirements for segregation, packaging and advice on colour coding. It also advises on treatment and disposal options, introduces carriage requirements and wastes with special requirements Details different classifications, packing, marking and labelling and documentation requirements for the compliant transport of healthcare wastes and advises on the use of Dangerous Goods Safety Advisors UpdatetoHealthTechnicalMemorandum07-01(2006)and 7691 keychanges Thissecondeditionofthismanualprovidesanupdatetotheguidancepublishedin 2006.Thekeyareasofchangeinclude: • updatestolegislation,specificallyforenvironmentalpermittingandtransport regulations; • afocusonthewastehierarchythroughprocurementpractices,andthe elimination,minimisation,recyclingandrecoveryofwaste; 12 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • adrivetoaddressthecarbonimpactrelatedtowastethroughresource efficiency,transportimpactsanddisposalarrangements; • theintegrationofnewsectorguidesonGPsanddentalpracticesaswellas incorporatingHealthTechnicalMemorandum07-06:‘Disposalof pharmaceuticalwasteincommunitypharmacies’asasectorguide; • afocusonpracticaladviceandexamplesforclassifyingwaste,inparticular theinfectiousandoffensivewastestreams,includingcasestudiestohighlight bestpractice; • areviewoftheuseofterminologyusedforhealthcare,clinicalandnonclinicalwastes. Theneedforrobustwastemanagementpoliciesandprocedurestosupportthesafe andcompliantprocessingofthevarietyofhealthcarewastesaddressedwithinthis guidanceisdrivenbyanumberofinterrelatedfactors. Apartfromthedirectenvironmentalbenefitsachievedbythecompliantmanagement ofhealthcarewaste,thismanualpresentsopportunitiesforintroducingcostsavings, saferworkingpracticesandreducingcarbonemissionsrelatedtomanagingwaste. Withregardtocarbonimpactreduction,in2009theNHSSustainableDevelopment Unitissued‘Savingcarbon,improvinghealth:carbonreductionstrategyfortheNHS inEngland’.ThisaddressesthekeymechanismsfortheNHStounderstandand manageitsactivitiestobeinlinewiththeClimateChangeAct. HealthTechnicalMemorandum07-06:‘Disposalofpharmaceuticalwastein communitypharmacies’ ‘Savingcarbon,improvinghealth:carbonreductionstrategyfortheNHSin England’ ClimateChangeAct Guidancestatusandimplementation 7692 TheguidanceprovidedinthismanualhasbeenproducedasUK-wideguidance. RegulatoryrequirementscanbesubjecttovariationacrosstheUK.Itistherefore essentialthattheapplicabilityofparticularlegislationbecheckedbeforedecisionsare finalised.Usersinthedevolvedregionsshouldrefertolocalregulatoryguidance. Inpreparingthisguidance,additionaladviceandinformationhasbeenprovidedbya broadcross-sectionofthehealthcarewasteprofessionincludinghealthcare practitioners,infectioncontrolteams,wasteproducers,wastemanagementandother contractorsandmanufacturersofequipmentandsupplies. Theadviceinthismanualandanyrecommendedcoursesofactionarenotin themselvesmandatory,buthealthcareorganisationsorotherschoosingnottofollow themareadvisedthatalternativestepsmustbetakentocomplywithallrelevant legislation.Regulatoryorganisationsseektosecurecompliancewiththelaw,and mayrefertothismanualasacombinationofillustratingbestpracticeandlegal requirements. Essentialstandardsofqualityandsafety 8583 TheCareQualityCommission(CQC)regulatesallprovidersofregulatedhealthand adultsocialcareactivitiesinEngland.CQC’sroleistoprovideassurancethatthecare peoplereceivemeetsessentialrequirementsofqualityandsafety. TheregistrationrequirementsaresetoutintheHealthandSocialCareAct2008 (RegulatedActivities)Regulations2010andincludearequirementrelatingtosafety andsuitabilityofpremises. 13 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 CQCisresponsiblefordevelopingandconsultingonitsmethodologyforassessing whetherprovidersaremeetingtheregistrationrequirementsandpublishedits ‘Guidanceaboutcompliance’inMarch2010.ThiscanbefoundontheCQCwebsite. Failuretocomplywiththerequirementsisanoffence,andunderthe2008Act,CQC hasawiderangeofenforcementpowersthatitcanuseiftheproviderisnot compliant.Theseincludetheissueofawarningnoticethatrequiresimprovement withinaspecifiedtime,prosecution,andthepowertocancelaprovider’sregistration, removingitsabilitytoprovideregulatedactivities. Outcome10ofCQC’s‘Guidanceaboutcompliance’focusesonthe“safetyand suitabilityofpremises”anddecreesthat“peoplereceivecarein,workinorvisitsafe surroundingsthatpromotetheirwellbeing”. ThisguidancehelpstoensurethatallhealthcareorganisationsinEnglandcomplywith therelevantpartsofOutcome10. • inWales,producersneedtocomplywithStandard19(d)oftheWelsh AssemblyGovernment’s‘HealthcarestandardsforWales’:“Healthcare organisationsshouldensurethat..(d)..theprevention,segregation,handling, transportanddisposalofwastearemanagedsoastominimisetheriskstothe healthandsafetyofstaff,patients,thepublicandthesafetyofthe environment”; • inNorthernIreland,producersneedtocomplywiththeControlsAssurance standardonwastemanagement; • inScotland,NHSScotlandBoardsarerequiredbytheScottishGovernment HealthDirectoratestomeettherequirementsspecifiedinthe‘Waste managementinNHSScotland:actionplans’publishedin2002and2007. Theymustalsocomplywithothermandatorywaste-relatedrequirements includingthosestemmingfromHealthDepartmentLetterHDL(2006)21. Accordingly,ScottishHospitalTechnicalNote3‘NHSScotlandwaste managementguidance’wasupdatedin2010toincorporaterelevantsections ofHealthTechnicalMemorandum07-01(2006)aswellasrelevantScottish legislationandregulatoryrequirements. Referenceswithinthisguidancerelatetotheminimumapprovedstandardor technologicalsolution.Furtherinformationontreatmentanddisposaloptionsshould besoughtfromwastemanagementcontractorsandtheappropriateregulatory authority. CQC’s‘Guidanceoncompliance’ WelshAssemblyGovernment’s‘HealthcarestandardsforWales’ NorthernIrelandControlsAssurancestandardonwastemanagement ScottishHospitalTechnicalNote3:‘Managementanddisposalofclinicalwaste’ HealthDepartmentLetterHDL(2006)21 14 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Glossaryandacronyms 8550 ACDP–AdvisoryCommitteeonDangerousPathogens.ACDPadvisestheHealth andSafetyCommission,theHealthandSafetyExecutive,healthandagriculture ministersandtheircounterpartsunderdevolutioninScotland,WalesandNorthern Ireland,asrequired,onallaspectsofhazardsandriskstoworkersandothersfrom exposuretopathogens. ACOP–ApprovedCodeofPractice.ApprovedbytheHealthandSafetyCommission, withtheconsentoftheSecretaryofState,anACOPgivespracticaladviceonhowto complywiththelaw.AnACOPhasaspeciallegalstatus.Ifsomeoneisprosecutedfor abreachofhealthandsafetylaw,anditisprovedthattheydidnotfollowtherelevant provisionsofanACOP,theywillneedtoshowthattheyhavecompliedwiththelaw insomeotherway,oracourtwillfindthematfault. ADR–Accordeuropéenrelatifautransportinternationaldesmarchandises dangereusesparroute(Europeanagreementconcerningtheinternationalcarriageof dangerousgoodsbyroad). Authorisation–Generictermusedtodenotethataregulatoryagencyhasgrantedan approval. BAT–BestAvailableTechniques. BOD–BiologicalOxygenDemand.Ameasureoftheamountoforganicpollution (thatcanbeoxidisedbiologically)inasampleofwater. CategoryA/CategoryB–Classificationofinfectioussubstancesinlinewiththe CarriageRegulations. CoTC–CertificateofTechnicalCompetence.Requiredbythedesignatedcompetent personatalicensedwastefacilityinNorthernIrelandandScotland. CJD–Creutzfeldt-Jakobdisease. CL–ContainmentLevel. Clinicalwaste–WastethatisclinicalwasteasdefinedbytheControlledWaste Regulations. COSHH–ControlofSubstancesHazardoustoHealthRegulations. CQC–CareQualityCommission.ThehealthandsocialcareregulatorforEngland. Culture–Cultures(laboratorystocks)aretheresultofaprocessbywhichpathogens areintentionallypropagated. Cytotoxicandcytostatic–ClassificationofmedicinalwasteusedintheListofWastes Regulationsformedicinalproductswithoneormoreofthehazardousproperties toxic,carcinogenic,toxicforreproductionormutagenic. DGSA–Dangerousgoodssafetyadviser. Defra–DepartmentforEnvironment,FoodandRuralAffairs. DfT–DepartmentforTransport. DutyofCare–Whenusedinrelationtowastemanagement,thistermreferstothe statutoryresponsibilitiesofindividualsandorganisations. EA–EnvironmentAgency.Regulatorresponsibleforenvironmentalregulation (includingwaste)inEnglandandWales. ECP–EmergencyCarePractitioner. EWC–EuropeanWasteCatalogue. FCP–ForwardCommitmentProgramme. GMO–Geneticallymodifiedorganism. 15 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 GMM–Geneticallymodifiedmicroorganism. GP–GeneralPractitioner. Hazardouswaste–WasteclassifiedashazardouswastebytheHazardousWaste RegulationsandtheListofWastesRegulations.(Theterm“specialwaste”isusedin Scotland.)Healthcarewaste–Wastefromnatalcare,diagnosis,treatmentor preventionofdiseaseinhumans/animals.Examplesofhealthcarewasteinclude: infectiouswaste;laboratorycultures;anatomicalwaste;sharpswaste;medicinal waste;offensive/hygienewastefromwardsorotherhealthcareareas. HG–HazardGroup. HIV–HumanImmunodeficiencyVirus. HMPS–HerMajesty’sPrisonService. HSAC–HealthServicesAdvisoryCommittee. HSE–HealthandSafetyExecutive.Regulatorresponsibleforhealthandsafetyinthe workplaceinGreatBritain. HSENI–HealthandSafetyExecutiveforNorthernIreland.Regulatorresponsiblefor healthandsafetyintheworkplaceinNorthernIreland. HTI–HumanTissueAuthority. IMDG–InternationalMaritimeDangerousGoodscode. Infectiouswaste–Wastethatpossessesthehazardousproperty“H9:Infectious”– thatis,substancescontainingviablemicroorganismsortheirtoxins,whichareknown, orreliablybelieved,tocausediseaseinmanorlivingorganisms. IPPC–IntegratedPollutionPreventionControl. ISO–StandardsproducedbytheInternationalOrganizationforStandardization. IT–InformationTechnology. IV–Intravenous. Licence–(WasteManagementLicence)ApprovalorconsentissuedbytheScottish EnvironmentProtectionAgencyorNorthernIrelandEnvironmentAgencyfora specifiedwastemanagementactivity. LoW–ListofWastesRegulations. MCN–MultipleConsignmentNote. MDS–MonitoredDosingSystem. MHRA–MedicinesandHealthcareproductsRegulatoryAgency. Medicinalwaste–Medicinalwasteincludesexpired,unused,spilt,andcontaminated pharmaceuticalproducts,drugs,vaccines,andserathatarenolongerrequiredand needtobedisposedofappropriately.Thecategoryalsoincludesdiscardeditemsused inthehandlingofpharmaceuticals,suchaspackagingcontaminatedwithresidues, gloves,masks,connectingtubing,syringebodiesanddrugvials.Thereareanumberof licensedmedicinalproductsthatarenotpharmaceuticallyactiveandpossessno hazardousproperties(examplesincludesalineandglucose).Thesewastesarenonhazardousnon-clinicalwastes.(Theaboveisnotadefinitivelistbutwillincludeother items.) Metabolite–Anysubstancethattakespartinachemicalreactioninthebody. MRSA–Methicillin-resistantStaphylococcusaureus. NetRegs–OnlytheprimaryActsandmainRegulationsarecitedinthismanual. MostoftheseActsandRegulationshavebeensubjectedtoamendmentsubsequentto thedateoffirstbecominglaw.Forupdatesonamendments,currentandnew environmentallegislation,visitNetregs. 16 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 NIEA–NorthernIrelandEnvironmentAgency.Regulatorresponsiblefor environmentalregulation(includingwaste)inNorthernIreland. N.O.S–Nototherwisespecified. Offensive/hygienewaste–Offensive/hygienewasteiswastethat:maycauseoffence duetothepresenceofrecognisablehealthcarewasteitemsorbodyfluids;doesnot meetthedefinitionofaninfectiouswaste;doesnotpossessanyhazardousproperties;is notidentifiedbytheproducer,orholder,asneedingdisinfection,oranyother treatment,toreducethenumberofmicroorganismspresent.(Offensive/hygienewaste mayalsoincludeautoclavedlaboratorywaste.) OJEU–OfficialJournaloftheEuropeanUnion. PAM–PremisesAssuranceModel. PCT–PrimaryCareTrust. Permit–(EnvironmentalPermit)ApprovalorconsentissuedbytheEnvironment Agency(EnglandandWales)foraspecifiedwasteprocessingactivity. Pharmaceuticallyactive–Pharmaceuticallyactivemedicinesmaybenon-hazardous orhazardousdependinguponpropertiesandinclude,butarenotlimitedto,cytotoxic andcytostaticmedicinalwastes(hazardouswaste).Examplesofnon-active pharmaceuticalproductsincludesalineandglucose. PPC–PollutionPreventionandControl.Thisisaregimeforcontrollingpollution fromcertainindustrialactivitiesinNorthernIrelandandScotland. PPE–PersonalProtectiveEquipment. RID–Règlementconcernantletransportinternationalferroviairedesmarchandises dangereuses(Regulationsconcerningtheinternationalcarriageofdangerousgoodsby rail). RIDDOR–ReportingofInjuries,DiseasesandDangerousOccurrencesRegulations. RPA–RadiationProtectionAdvisor.PersonappointedinlinewiththeIonising RadiationsRegulationstoadviseontheuseandmanagementofradioactive substances. SACGM–ScientificAdvisoryCommitteeforGeneticModification. SDS–Safetydatasheet(s).SEPA–ScottishEnvironmentProtectionAgency. Regulatorresponsibleforenvironmentalregulation(includingwaste)inScotland. Sharps–Sharpsareitemsthatcouldcausecutsorpuncturewounds.Theyinclude needles,hypodermicneedles,scalpelsandotherblades,knives,infusionsets,saws, brokenglass,andnails.Therearetwoprimarysources:thoseusedinanimalorhuman patientcare/treatment;andthosearisingfromnon-healthcarecommunitysources,for examplebodypiercinganddecoration,andsubstanceabuse. SHTN3–ScottishHospitalTechnicalNote3. SOP–StandardOperatingProcedure. SRM–SpecifiedRiskMaterial. STAATT–StateandTerritorialAssociationonAlternativeTreatmentTechnologies. TRANSEC–DepartmentforTransportSecurityandContingenciesteam. TSE–TransmissibleSpongiformEncephalopathies. VOSA–VehicleOperatorServicesAgency. VTEC–Verocytotoxin-producingEscherichiacoli. WEEE–WasteElectricalandElectronicEquipment(inrelationtoECDirective 2002/96/ECandthesubsequentWEEEregulations). WFD–WasteFrameworkDirective. 17 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 WM2–TechnicaldocumentproducedbytheEnvironmentAgency,theScottish EnvironmentProtectionAgencyandtheNorthernIrelandEnvironmentAgencyto provideguidanceontheassessmentandclassificationofhazardouswastebasedonthe HazardousWasteDirectivedefinitionofhazardouswaste. CarriageRegulations CarriageRegulations(NorthernIreland) ControlledWasteRegulations ControlledWasteRegulations(NorthernIreland) ControlofSubstancesHazardoustoHealthRegulations(COSHH) ControlofSubstancesHazardoustoHealthRegulations(NorthernIreland) CareQualityCommission ListofWastesRegulations(LoW) ListofWastesRegulations(NorthernIreland) ListofWastes(Wales)Regulations DepartmentforEnvironment,FoodandRuralAffairs DepartmentforTransport EnvironmentAgency(EnglandandWales) DepartmentoftheEnvironment(NI) NorthernIrelandEnvironmentAgency(NIEA) HazardousWaste(EnglandandWales)Regulations SpecialWasteAmendment(Scotland)Regulations2004 HazardousWasteRegulations(NorthernIreland)2005 HealthandSafetyExecutive(HSE) HealthandSafetyExecutive(NI)(HSENI) HumanTissueAuthority MedicinesandHealthcareproductsRegulatoryAgency NetRegs ReportingofInjuries,DiseasesandDangerousOccurrencesRegulations (RIDDOR) ReportingofInjuries,DiseasesandDangerousOccurrencesRegulations (NorthernIreland) ScottishEnvironmentProtectionAgency(SEPA) ScottishHospitalTechnicalNote3(SHTN3) WasteElectricalandElectronicEquipmentRegulations(WEEE) 18 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Legislationandhealthcarewaste7672 Thissectionprovidesanoverviewofthemainregulatoryregimesaffectingwaste managementpracticeswithinhealthcareorganisations.Thiscovershealthandsafety, environmental,infectioncontrolandtransportrequirements. EnglandandWales,ScotlandandNorthernIrelandhavetheirownsetsoflawsand regulationswhichdifferfromeachother.Thenameoftheregulatoryinstrumentis oftenthesame(orsimilar),althoughthedatewhenitcameintoforcemayvary.Itis forthisreasonthatwhereveraregulatoryinstrumentiscitedinthismanual,thedate hasbeenomitted. Theterm“hazardouswaste”isusedinEngland,WalesandNorthernIrelandto describewastewithhazardouscharacteristicsinlinewiththeListofWastes(LoW) Regulations,whichtransposetheEuropeanWasteCatalogue(EWC)intodomestic legislationandprovidecodesforallhazardousandnon-hazardouswastes.Readersof thisguidanceinScotlandshouldusetheterm“specialwaste”inlinewiththeSpecial WasteAmendment(Scotland)Regulations,whichimplementtherequirementsofthe HazardousWasteDirectiveinScotland. Theterm“dangerousgoods”signifiessubstanceswithintrinsichazardsposinga potentialrisktopersonsortheenvironmentwhileinthetransportchain.Such substancesareclassifiedonthesamebasisforanymodeoftransportusingUnited Nationscriteria.TransportbyroadorrailinGreatBritainisaddressedintheCarriage ofDangerousGoodsRegulations(hereaftercitedastheCarriageRegulations).Similar roadtransportlegislationappliesinNorthernIreland. ListofWastes(England)Regulations ListofWastesRegulations(NorthernIreland) ListofWastes(Wales)Regulations SpecialWasteAmendment(Scotland)Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) Overviewofregulatoryregimes 7675 Toeffectivelymanagewastegeneratedasaresultofhealthcareactivities,those responsibleforthemanagementofthewasteshouldunderstandandmustcomply withtherequirementsofthevariousregulatoryregimes,whichinclude: • environmentandwaste; • controlleddrugs; • infectioncontrol; • healthandsafety;and • transport. Foreachoftheseregimes,thereareanumberofassessmentsrequired.Thissection providesanoverviewofeachoftheseregimeswithclearstepsandinformationonhow toclassifyhealthcarewasteinlinewithlegislation. Forwastemanagementpracticestocomplywiththeserequirements,appropriately authorisedorpermittedwastemanagementservicesneedtobeprocured.Figure1 showstherelationshipbetweenregulatoryrequirements,procurementpracticeand effectivewastemanagement.Theindividualpillarsofregulationdictatethe 19 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 requirements,whileeffectiveprocurementstaketheseintoaccountandsupportwaste managementpractices.Furtherinformationregardingprocurementandwaste contractsisprovidedin‘Procurementregulations’. Figure1Keyregulatoryregimesforhealthcarewaste Healthcare waste management Effective procurement of goods and services Procurementregulations Environmentandwastelegislation 7678 EnvironmentandwasteregulationacrosstheUKspecifiestherolesandresponsibilities ofthoseinvolvedinthemanagementofwaste. 7684 WasteFrameworkDirective TherevisedWasteFrameworkDirective(WFD)cameintoforceon12December 2008.Memberstateswererequiredtotranspose/implementtheWFDby 12December2010. Note TheDepartmentforEnvironment,FoodandRuralAffairs(Defra)andtheWelsh AssemblyGovernmentconsultedonthesecondstageconsultationonthe transpositionoftherevisedDirectivebetween8July2010and16September2010. DefrawillissuegeneralguidanceontherequirementsoftheDirectiveindue course.Atpresent,theDirectiveisstillunderreview.Thissectionandthenext, ‘Dutyofcareandcontrolledwaste’,provideanoverviewoftheexistingDirective andkeychangesthatmayaffecthealthcarewaste. InEngland,WalesandNorthernIreland,thereareproposedchangestothecodesused torepresenthazardousgroupsusedintheHazardousWasteRegulationsandthe SpecialWasteRegulationsinScotland,asfollows: a. Theadditionofanewhazardousproperty“H13Sensitising”,definedas “substancesandpreparationswhich,iftheyareinhaledoriftheypenetrate theskin,arecapableofelicitingareactionofhypersensitisationsuchthaton furtherexposuretothesubstanceorpreparation,characteristicadverseeffects areproduced”. Note CategoryH13isonlyapplicable“asfarastestingmethodsareavailable”. b. TheexistingH13hazardouspropertywillberenumberedH15;thatis,waste capablebyanymeans,afterdisposal,ofyieldinganothersubstance(for examplealeachate)whichpossessesanyofthecharacteristicsH1toH14(see 20 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 under‘Consignmentnotes’forasummaryofthefulllist).Thisrenumbering meansthatthehazardousproperty“ecotoxic”(nowH14)hastobetaken intoaccountintheassessmentofwhetherawastedisplaysthehazardous propertyH15. c. Article18(2)oftheWFD,whichallowsmixingofhazardouswasteundera permit,requiresthemixingoperationtoconformtobestavailable techniques. d. TheconsultationontheWFDincludedpossiblechangestothemultiple collectionsystem.GeneralguidanceonthesechangeswillbeissuedbyDefra ortheEnvironmentAgencywhenfinaldecisionshavebeentakenpostconsultation. Note InEnglandandWales,attimeofpublication,thereareproposedchangestothe currentsystemfortrackingmultipleconsignmentmovements,asthesystemof associatedpaperworkprovidedforintheHazardousWasteRegulations2005does notprovideafullyeffectivecradle-to-gravetrackingsystemformat. TheWasteRegulations2011requiretheuseofanamendedstandard(single) consignmentnoteforeachcollectioninacarrierround,whichincludesaround numberasamultiplenote(butonlywhentheroundnumberfieldiscompletedand thatnoteformspartofamultiplecollectionasspecifiedintheregulations). Dutyofcareandcontrolledwaste Consignmentnotes WasteFrameworkDirective HazardousWaste(EnglandandWales)Regulations HazardousWasteRegulations(NorthernIreland) SpecialWasteAmendment(Scotland)Regulations Waste(EnglandandWales)Regulations Waste(Scotland)Regulations Dutyofcareandcontrolledwaste 7685 Thestatutoryrequirementscoveringdutyofcareinwastemanagementarecontained in:Section34oftheEnvironmentalProtectionAct; • Section5oftheWasteandContaminatedLand(NorthernIreland)Order; • theEnvironmentalProtection(DutyofCare)Regulations(England, ScotlandandWales);and • theControlledWaste(DutyofCare)Regulations(NorthernIreland). Everyonewhoproduces,imports,carries,keeps,treatsordisposesofcontrolledwaste isrequiredtofullycomplywiththe“dutyofcare”. Note ‘Wastemanagement:thedutyofcare–acodeofpractice’(statutory)isavailableon Defra’swebsite. Thereisalsoasummaryguidanceleaflet. SeealsotheNorthernIrelandEnvironmentAgency’swebsiteforthestatutorycode ofpractice. Thestatutorydutyofcareappliestoeveryoneinthewastemanagementchain.It requiresproducersandotherswhoareinvolvedinthemanagementofthewasteto 21 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 preventitsescape,andtotakeallreasonablemeasurestoensurethatthewasteisdealt withappropriatelyfromthepointofproductiontothepointoffinaldisposal.Thisis enforcedthroughthe“polluterpays”principle,makingproducersofwasteresponsible foritsmanagementanddisposal. Akeyelementtothedutyofcareistherequirementforproducers(otherthan householders)toensurethatawrittendescription,adequatelydescribingthetypeand quantityofwaste,accompaniesanytransferofthewasteasitismovedfrompointof productiontopointoffinaldisposal.Whereanannualwastetransfernoteisused,as longastheinitialnotecontainsthedetailsspecifiedinDefra’s‘Wastemanagement:the dutyofcare–acodeofpractice’,thewrittendescriptionwillonlyberequiredforthe initialtransfer. Anyonewishingtocarrycontrolledwastemustberegisteredasacarrierofcontrolled wastes,asrequiredbytheControlledWaste(RegistrationofCarriersandSeizureof Vehicles)Regulations.Waste-carrierregistrationcanalsobecheckedonlineatthe EnvironmentAgencywebsite. Wastecanonlybehandedtosuchauthorisedpersonsasregisteredcarriers,permit/ licenceholdersorsomeonewhoisexemptfromeitherbeingaregisteredcarrieror operatingunderapermit/licence(see‘Managingcompliance’forexamplesofsuch exemptions). Note Thecredentialsofanyorganisationcollectingwasteshouldbecheckedandacopy oftheircarrierregistrationdocument(specifyingtheirregistrationnumber)should berequested. Mainresponsibilitiesofthewasteproducerunderthedutyofcare: Describethewastefullyandaccurately(whichwouldtypicallybedefinedby regularinternalauditsofwaste). Storewastesecurelyandsafelyon-site. Packwastesecurely(whereappropriate)inlinewiththeCarriageRegulations. Registerasawastecarrier(ifrequired)andmakeallreasonablechecksonwaste carriers,whichincludescheckingallregistrationswiththeappropriateregulator (seelinksbelow). Selectanappropriaterecovery,treatmentordisposalmethod. EnsurethatthetypesofwastespecifiedbyEuropeanWasteCataloguecodes (andquantityifrelevant)fallwithinthetermsofthewastecontractor’s environmentalpermitorexemption(furtherdetailsareprovidedin‘Waste managementlicensingandpermitting’). Completeawastetransfernote(orconsignmentnoteforhazardouswaste)prior towastebeingtransferredtoanotherparty,signingasrequired. Note Atthetimeofwritingthisguidance,Defraisreviewingthepolicyand implementationofthedutyofcarerequirementsforEnglandandWales,including certainaspectsofrequirementsforcarriers,brokersanddealersofwaste. Managingcompliance Wastemanagementlicensingandpermitting EnvironmentalProtectionAct WasteandContaminatedLand(NorthernIreland)Order EnvironmentalProtection(DutyofCare)Regulations ControlledWaste(DutyofCare)Regulations(NorthernIreland) 22 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 ‘Wastemanagement:thedutyofcare–acodeofpractice’ Defrasummaryguidanceleaflet NorthernIrelandEnvironmentAgency’sstatutorycodeofpractice ControlledWaste(RegistrationofCarriersandSeizureofVehicles)Regulations ControlledWaste(RegistrationofCarriersandSeizureofVehicles)Regulations (NorthernIreland) EnvironmentAgencywebsite–waste-carrierregistration RegisterasawastecarrierforEnglandandWales RegisterasawastecarrierforNorthernIreland RegisterasawastecarrierforScotland CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) Localauthorities’responsibilities 7686 Localauthoritieshavespecificdutiesinrelationtohealthcarewaste.Section45ofthe EnvironmentalProtectionAct(inNorthernIreland,Article20oftheWasteand ContaminatedLandOrder)statesthatitisthedutyofeachwastecollectionauthority toarrangeforthecollectionofhouseholdwasteinitsarea. Schedule2oftheControlledWasteRegulationsidentifieswhereachargecanbemade forthecollectionofhouseholdwaste.Thisincludesclinicalwastefromadomestic property(seethe‘Communityhealthcare’sectorguide).Theseregulationsmustbe readasawhole.Schedule3,forexample,identifieswhereclinicalwasteis“industrial” (nothousehold)waste. Note Atthetimeofwriting,DefraisreviewingSchedule2oftheControlledWaste Regulations.Theaimistobringitintolinewithmodernwastelegislation,to furtherthewidersustainabilityaspirationsofDefraandtheWelshAssembly Governmentandtoimprovethetransparencyandaccountabilityofpublic funding.TheControlledWasteRegulationsdefineclinicalwaste,henceits continuedusewithinthisdocumentalongsideinfectiouswaste.Thedefinitionswill bekeptunderconsiderationasthereviewprogresses. Communityhealthcare EnvironmentalProtectionAct WasteandContaminatedLand(NorthernIreland)Order ControlledWasteRegulations ControlledWasteRegulations(NorthernIreland) 23 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Environmentalpermittingandwastemanagementlicensing 7687 Thestatutoryrequirementsforenvironmentalpermittingandwastemanagement licensingcanberepresentedasfollows: The Environmental Protection Act Northern Ireland The Waste Management Licensing Regulations (Northern Ireland) Scotland The Waste Management Licensing Regulations (Scotland) The Pollution Prevention and Control Regulations (Northern Ireland) The Pollution Prevention and Control Regulations (Scotland) England and Wales The Environmental Permitting (England and Wales) Regulations Environmental Protection Act Permitsandlicencesarerequiredforthestorage,transfer,treatmentanddisposalof manydifferenttypesofwaste.Generally,apermit/licenceisnotrequiredforthe storageofwasteonthesitewhereitwasproduced,asthismaybecoveredbyan exemptiontotheregulations(furtherguidanceisprovidedin‘Wastemanagement licensingandpermitting’). Pre-acceptanceauditsarearequirementforproducersofhealthcarewastesinEngland andWalesinordertocomplywiththepermitrequirementsofthewastecontractorat thepermittedsitereceivingthewaste.Guidanceonauditingisprovidedin‘Managing compliance’. Environmentalpermitsandwastemanagementlicences(andrelatedexemptions)are regulatedby: • theEnvironmentAgency(EA)inEnglandandWales; • theScottishEnvironmentProtectionAgency(SEPA)inScotland;and • theNorthernIrelandEnvironmentAgency(NIEA)inNorthernIreland. Note Anoverviewofresponsibilitiesandrequirementsfortheenvironmentalpermitting andwastemanagementlicensingregulationsareprovidedin‘Wastemanagement licensingandpermitting’. Wastemanagementlicensingandpermitting Managingcompliance EnvironmentalProtectionAct WasteManagementLicensingAmendment(Scotland)Regulations WasteManagementLicensingRegulations(NorthernIreland) PollutionPreventionandControl(Scotland)Regulations PollutionPreventionandControlRegulations(NorthernIreland) EnvironmentalPermitting(EnglandandWales)Regulations EnvironmentAgency(EA) ScottishEnvironmentalProtectionAgency(SEPA) NorthernIrelandEnvironmentAgency(NIEA) 24 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Hazardouswaste(England,WalesandNorthernIreland)andspecialwaste (Scotland) 7688 TheHazardousWasteRegulationsandtheListofWastesRegulationsdefineand regulatethesegregationandmovementofhazardouswastefromthepointof productiontothefinalpointofdisposalorrecovery(similarregulationsapplyin NorthernIreland). InEnglandandWales,theHazardousWasteRegulationsrequirethatmostpremises producinghazardouswastebenotifiedtotheEA(viaregistration).Premises registration/notificationdoesnotapplyinScotlandorNorthernIreland.Premisesare exemptfromtherequirementtonotifyiftheyproducelessthan500kgofhazardous wasteinanyperiodof12months.GuidanceonnotificationcanbefoundontheEA website. Note Thisexemptiononlycoverspremisesnotification.Allotherlegislativerequirements, includingconsignmentnotesforeachcollectionofhazardouswaste,continueto applytowastecomingfromthesepremises. Wherepremisesareshared,eachoccupantretainstheirownresponsibilityforwaste underdutyofcare.However,practicalarrangementsforthehandlingand managementofwasteareillustratedbythefollowingexample: Hospitalcomplexesareoftenoccupiedbyanumberofdifferentorganisationsthat producehazardouswaste.Thesemightforexampleincludeacute,primarycare, mentalhealthandambulancetrusts,privatepractices,shopsandlaboratories. Wheretheseorganisationshavetheirowndiscreteunitsorareas,theyareconsidered tobeseparateindividualpremisesforthepurposesofproducernotificationunder theHazardousWasteRegulations.Thosethatproduce500kgormoreofhazardous wasteperyearwillneedtoregistereachoftheirpremises.Thosethatproduceless willremainexemptfromregistration.Anacutehospitaltrustwouldnotnormally needtoregistermorethanonceasitsbuilding,unitsanddepartmentsarelikelyto fallwithinasinglecontinuouspremisesboundary.Otherorganisationswithtwoor moreseparatedareas(forexampletwoshops)mayfindthatmorethanone registrationisrequiredunlesstheyareadjacentoradjoining. Eachproducercanstoreitsownwasteonsite,orwastecanbestoredinashared storagearea.Aslongasitmeetstheconditions,thisstoragecanbenefitfroman exemptionfromanenvironmentalpermitfortemporarystorageatthepremisesof production.Wasteinsharedstorageareasmaybesegregatedbytyperatherthan producer;however,itisimportantthatclinicalwastereceptaclesarelabelledto identifytheindividualproducer.Ifaproducerstoresandmanagesitsown hazardouswaste,itmustcompleteitsownconsignmentnotesforeachcollection.If aproducertransfersitswastetooneon-siteorganisation(forexampletheacute hospitaltrustthatmanagesthewastestorageandcollection),asingleconsignment notecanbecompletedforacollectionofwaste.Theotherproducerswouldneedto beidentifiedonpartA5oftheconsignmentnote.Eachproducerwouldneedto ensurethatitcomplieswithitsdutyofcaretoprovidetheacutehospitaltrustwith theinformationtheyneedtocompletetheconsignmentnoteandmanagethe subsequenttransportanddisposalofthewaste.Thisisbestsupportedbya memorandumofunderstandingorpartnershippapersagreedbetweenallthe collaboratingorganisations. HazardousWaste(EnglandandWales)Regulations HazardousWasteRegulations(NorthernIreland) SpecialWasteAmendment(Scotland)Regulations ListofWastes(England)Regulations ListofWastesRegulations(NorthernIreland) 25 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 ListofWastes(Wales)Regulations EAwebsite Consignmentnotes 7694 Consignmentnotesarerequiredwhentransportinghazardouswaste.Theyare availablefromtherespectiveenvironmentalregulators(EA,SEPAorNIEA).They mayalsobesuppliedbythewastecontractor. Theproducerislegallyresponsibleforensuringtheaccuracyofaconsignmentnote andinsomeinstancesitmaybeappropriatetoseekadvicefromthewastecontractor (theformofaconsignmentnoteisillustratedintheHazardousWasteRegulationsfor England,WalesandNorthernIreland,andtheSpecialWasteRegulationsfor Scotland). InNorthernIrelandandScotland,producers(orconsignors)ofhazardouswasteare notrequiredtoregisterwiththeregulatoryauthority(NIEAandSEPA,respectively). Instead,theyarerequiredtoprovide72hours’priornotificationtotherelevant regulatoroftheirintentiontomovehazardous/specialwaste.Noteverymovementhas tobenotified(thisisusuallyforthefirstmovementinasuccession,a“carrier’sround” oraone-offmovement).SpecificguidanceisavailablefromNIEAandSEPAonthe relevantproceduresforNorthernIrelandandScotland.Carrier’sroundsarediscussed furtherat‘Consignmentnotes’under‘Wastecollectiondocumentation’. Note Owingtothedifferencesinthedevolvedadministrations,wasteproducedineach countryisrequiredtobemanagedinlinewiththelocalregulations,regardlessofits destination.Furtherguidanceisavailablefromtherelevantregulator.Cross-border consignmentsofwaste(fromonedevolvedregiontoanother)shouldbemadeby theproducerofthewasteusingboththeir“home”regulator’sguidelinesandthe “destination”guidelines(forexample,producersofwasteinScotlandshouldfollow theconsignmentprocedurelaiddownbySEPAforallwasteincludingwasteleaving Scotlandfortreatmentanddisposal). Thisdoesnotapplyto“cross-border”movementsbetweenWalesandEnglandor viceversa. TheRegulationsdonotprovidecomprehensiveguidanceontheclassificationofwaste. TheEA,SEPAandNIEAproducedajointguidancedocumentontheinterpretation, definitionandclassificationofhazardouswasteentitled‘WM2’.Thisdocumentis basedonsupportingEuropeanDirectivesandtestmethods. IntheUK,WM2usesacolour-codedEuropeanWasteCatalogue(EWC)toaid identificationofhazardouswastes.Absolutehazardousentriesareshowninredwith anasterix.Somewasteshavethepotentialtobeeitherhazardousornon-hazardous dependingonwhethertheycontaindangeroussubstancesat,orabove,certain thresholds.Thesearecoveredbymirrorentries,consistingoftwoormorerelated entriesincludingahazardousentry(entries)showninbluewithanasterix.Theyare subjecttoassessmentinrelationtothe14hazardgroupsidentifiedintheHazardous WasteRegulations.Non-hazardousentriesareshowninblack.Onlynon-hazardous entriesthatarenotpartofmirrorentriesdonotrequireassessment.The14hazard groupsoriginatefromtheHazardousWasteDirectiveandareshownbelow: • H1:Explosive • H2:Oxidising • H3A:HighlyFlammable • H3B:Flammable • H4:Irritant 26 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • H5:Harmful • H6:Toxic • H7:Carcinogenic • H8:Corrosive • H9:Infectious • H10:Toxicforreproduction • H11:Mutagenic • H12:Substancesthatreleasetoxicgases Pre-WFDimplementation H13:Substancescapableofyielding substanceslistedabove H14:Ecotoxic Post-WFDimplementation H13:Sensitising H14:Ecotoxic H15:Wastecapablebyanymeans,after disposal,ofyieldinganothersubstance e.g.aleachate,whichpossessesanyofthe characteristicsH1toH14.Including H14forthefirsttime. Note See‘WasteFrameworkDirective’under‘Environmentandwastelegislation’ regardingfuturepotentialchangestothehazardgroupsbasedonthe implementationoftherevisedWFDandsubsequentregulations.TheWM2 guidancewillbechangedinparttoreflectchangestothehazardgroups.Attimeof writing,thisandotherelementsoftheongoingimplementationprocessareunder reviewataEuropeanandnationallevel. AppendixCoftheWM2guidanceprovidescomprehensiveguidanceonthe classificationofwasteineachofthehazardgroups.Thewasteassessmentframework providesfurtherdetailsontheWM2guidancewithrespecttoinfectious,medicinal andamalgamhealthcarewaste. Consignmentnotes Wastecollectiondocumentation Environmentandwastelegislation WM2 EAwebsite SEPAwebsite NIEAwebsite HazardousWaste(EnglandandWales)Regulations HazardousWasteRegulations(NorthernIreland) SpecialWasteAmendment(Scotland)Regulations EuropeanWasteCatalogue(EWC) 7696 TheEnvironmentalPermitting(EnglandandWales)Regulations,theLandfill Regulations(inScotlandandNorthernIreland),theHazardousWasteRegulationsand theListofWastesRegulations(inEnglandandWalesandNorthernIreland)require producerstoadequatelydescribetheirwasteusingbothawrittendescriptionandthe useoftheappropriateEWCcode(s)onbothwastetransferandconsignmentnotes. 27 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 TheEWCisproducedbytheEuropeanCommissiontoprovidecommonterminology fordescribingwastethroughoutEurope.TheEWClistisreviewedperiodicallyand incorporatestheEuropeanHazardousWasteListpursuanttotheHazardousWaste Directive91/689/EEC. TheListofWastesRegulations2005transposedtheEWCintodomesticlegislation forEngland,WalesandNorthernIreland.InScotland,theSpecialWasteAmendment (Scotland)Regulations2004transposedtheEWCintoScottishlegislation. TheEWCcategoriseswasteinto20chapters.Eachchapterisdefinedbyeitherthe sourceofthewasteorwastetype.Withineachchapter,eachtypeofwasteisdescribed usingasix-digitnumericalcode: • thefirsttwodigitsofthecoderelatetotheEWCchapter; • thesecondtwodigitsrelatetoanysub-groupingwithinthechapter;and • thefinaltwodigitsareuniquetothewaste. TheEWCishierarchicalandsomechaptersandentrieshaveprecedenceoverothers. ThelistshouldbeusedinaccordancewiththerulessetoutinappendixAofWM2. Chapter18oftheEWCprovidesalistofcodesspecificallyforthehealthcaresector. Note 1.Healthcarewasteproducersarelikelytoproduceabroadrangeofwastematerials, manyofwhichshouldbeclassifiedusingEWCcodesotherthanthosestatedin chapter18oftheEWC.Forexample,X-rayfixeranddevelopermaybebest describedusingtheEWCcodesinchapter9oftheEWC,whichincludes“waste fromthephotographicindustry”.FurtherguidanceontheEWCisprovidedonthe EnvironmentAgency’swebsite. 2.InEngland,WalesandNorthernIreland,multipleEWCcodesmaybeappliedto aparticularwastestream(forexampleinfectiouswastethatispharmaceutically contaminated).InScotland,SEPArequiresproducerstoallocateonlyoneEWC code.Thisisthemostonerouscodeintermsofthedisposalprocess;thatis,waste containingcytotoxicmedicinesandsharpsshouldbeclassifiedas180108*andthe presenceofsharpsisestablishedthroughthewrittendescription. EnvironmentalPermitting(EnglandandWales)Regulations Landfill(Scotland)Regulations LandfillRegulations(NorthernIreland) HazardousWaste(EnglandandWales)Regulations HazardousWasteRegulations(NorthernIreland) ListofWastes(England)Regulations ListofWastesRegulations(NorthernIreland) ListofWastes(Wales)Regulations SpecialWasteAmendment(Scotland)Regulations WM2 EnvironmentAgencyguidanceontheEWC Controlleddrugs 7700 Controlleddrugsaresubjecttospeciallegislativecontrolsastheyarepotentially harmful.TheMisuseofDrugsRegulationsliststhemedicinesthatareclassifiedas controlleddrugs.Therearefiveschedulesthatdictatethelevelofcontrolappliedto eachmedicine–Schedule1havingthemostcontrolsandSchedule5thefewest. 28 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Theregulationssetouttheregimeofcontrolthatgovernsthevariouslegitimate clinicalactivitiesassociatedwithcontrolleddrugs,forexample: • whichprofessionalsareallowedtoprescribe,order,supplyoradministerthe drugs; • destructionand/ordisposalprocedures; • associatedrecord-keepingrequirements. TheMisuseofDrugs(SafeCustody)Regulationslistadditionalrequirementsinterms ofsafestorage(forexamplelockablecupboardsofsufficientstrength). MisuseofDrugsRegulations MisuseofDrugsRegulations(NorthernIreland) Destruction/disposal 7698 UndertheMisuseofDrugsRegulations,allSchedule1and2stock-controlleddrugs canonlybedestroyedinthepresenceofapersonauthorisedunderthoseregulationsto witnessdestruction.Whenastock-controlleddrugisdestroyed,detailsofthedrug mustbeenteredintothecontrolleddrugsregister.Thisshouldinclude: • thenameofthedrug; • itsform; • itsstrengthandquantity; • thedateitwasdestroyed;and • thesignatureoftheauthorisedpersonwhowitnessedthedestruction,andthe personwitnessingit(thatis,twosignatures). Onceissued/dispensedtoapatient,therequirementsforwitnesseddestructiondonot apply,althoughthereisageneraldutyofcaretoensuretheappropriatedisposalof wastemedicinesthatarereturnedbypatientstotheirlocalGPs. Healthcareorganisationsshouldbeawareofwhowithintheirorganisationis authorisedtowitnessdestruction.Furtherguidanceanddetailsofthecategoriesof peoplecurrentlyauthorisedareavailableontheDepartmentofHealth’swebsite(see ‘Standardoperatingprocedures’below). Note InSeptember2008,theNHSpublishedadocumentdetailingitscarbonemissions inacarbonfootprintingreport.Thecarbonassociatedwithprocurement specificallyofpharmaceuticalsaccountedfor21%ofthetotalcarbon.This highlightstheneedtoensurestocksofdrugsaretightlycontrolledtoensurewastage iskepttoaminimumforeconomicaswellascarbonmanagementreasons. MisuseofDrugsRegulations MisuseofDrugsRegulations(NorthernIreland) Standardoperatingprocedures 7699 TheHealthActrequireshealthcareorganisationstohavewrittenstandardoperating procedures(SOPs)ontheuseandmanagementofcontrolleddrugswithintheir organisation.Theseshouldcover: • orderingandreceiptofcontrolleddrugs; • assigningresponsibilities; • wherethecontrolleddrugsarestored; 29 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • whohasaccesstothecontrolleddrugs; • record-keeping;and • whoshouldbealertedifcomplicationsarise. Linkstoassociatedlegislationandguidancecanbefoundonthecontrolleddrugs sectionoftheDepartmentofHealth’swebsite. HealthAct2009 ControlleddrugssectionoftheDepartmentofHealth’swebsite Producerresponsibility 7702 ThegeneralrequirementsoftherevisedWFDfurtherdeveloptheprincipleof “extendedproducerresponsibility”,wherebyproducers,usuallybrandownersor suppliers,arerequiredtotakeresponsibilityfortheenvironmentalimpactoftheir products,especiallywhentheybecomewaste.Thisincludesregulationsgoverning: • wasteelectricalandelectronicequipment(WEEE); • wastebatteries; • wastepackaging;and • end-of-lifevehicles. Thebroadaimistoaddresstheenvironmentalimpactsoftheitemsandtoencourage separatecollectionandsubsequenttreatment,reuse,recovery,recyclingand environmentally-sounddisposal. Forredundantelectronicitems,healthcarewasteproducerswilllikelyfallwithinthe “business-to-business”elementandwillneedtotakeresponsibilityfortheirelectronic andelectricalequipmentwasteeitherbyreturningthewastetotheproducerfrom whomitwaspurchased(ortheircompliancescheme)orbydisposingofitdirectly(see HealthTechnicalMemorandum07-05:‘Thetreatment,recovery,recyclingandsafe disposalofwasteelectricalandelectronicequipment’.Seealso‘Batteriesincluding thoseusedforimplants/medicaldevices’). FurtherinformationandrequirementsforthemanagementofWEEEareprovidedin Chapters8and9oftheDepartmentforBusinessInnovationandSkills’(BIS) guidanceontheWEEERegulations. Batteriesincludingthoseusedforimplants/medicaldevices HealthTechnicalMemorandum07-05:‘Thetreatment,recovery,recyclingand safedisposalofwasteelectricalandelectronicequipment’ BISguidanceontheWEEERegulations WasteElectricalandElectronicEquipmentRegulations Infectioncontrol 7704 HealthcarewasteinEnglandisaddressedinthe‘HealthandSocialCareAct2008: CodeofPracticeforhealthandadultsocialcareonthepreventionandcontrolof infectionsandrelatedguidance’(referredtoinSection21oftheHealthandSocial CareAct). TheCodeofPracticemustbetakenintoaccountbytheCareQualityCommission (CQC)whenitmakesdecisionsaboutregistrationofallregulatedhealthandadult socialcareservicesandbyanycourtduringlegalproceedingsabouttheregistration. TheregulationsalsosaythatprovidersmusthaveregardtotheCodeofPracticewhen decidinghowtheywillcomplywithCQCregistrationrequirements. 30 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 ByfollowingtheCodeofPractice,healthandadultsocialcareregisteredproviderswill beabletoshowthattheymeettheregulationoncleanlinessandinfectioncontrol. (However,theydonotbylawhavetocomplywiththeCode.Aregisteredprovider maybeabletodemonstratethatitmeetstheregistrationrequirementregulationon cleanlinessandinfectioncontrolinadifferentway,equivalentorbetter,fromthat describedinthismanual.) TheCodeofPracticedoesnotreplacetherequirementtocomplywithanyother legislationthatappliestohealthandsocialcareservices,forexampletheHealthand SafetyatWorketcActandtheControlofSubstancesHazardoustoHealth Regulations(COSHH).TheCodeofPracticesetsouttencriteriaagainstwhichthe CQCwillensurecomplianceforregisteredprovidersofhealthandsocialcareservices. Withintheseisarequirementforcleanlinessandinfectioncontrol,whichincludes criteriaforthesafehandlinganddisposalofwaste. TheHealthandSocialCareActCodeofPractice–keypoints: a. Therisksfromwastedisposalshouldbeproperlycontrolled.Inpractice,in relationtowaste,thisinvolves: • assessingrisk; • developingappropriatepolicies; • puttingarrangementsinplacetomanagerisks; • monitoringthewayinwhicharrangementswork;and • beingawareoflegislativechange. b. Precautionsinconnectionwithhandlingwasteshouldinclude: • trainingandinformation; • personalhygiene; • segregationofwaste; • theuseofappropriatepersonalprotectiveequipment(PPE); • immunisation; • appropriateproceduresforhandlingsuchwaste; • appropriatepackagingandlabelling; • suitabletransporton-siteandoff-site; • clearproceduresfordealingwithaccidents,incidentsandspillages;and • appropriatetreatmentanddisposalofsuchwaste. c. Systemsshouldbeinplacetoensurethattheriskstoservice-usersfrom exposuretoinfectionscausedbywastepresentintheenvironmentare properlymanaged,andthatdutiesunderenvironmentallawaredischarged. Themostimportantoftheseare: • dutyofcareinthemanagementofwaste; • dutytocontrolpollutingemissionstotheair; • dutytocontroldischargestosewers;and • obligationsofwastemanagers. ‘HealthandSocialCareAct2008:CodeofPracticeforhealthandadultsocial careonthepreventionandcontrolofinfectionsandrelatedguidance’ HealthandSafetyatWorketcAct HealthandSafetyatWork(NorthernIreland)Order ControlofSubstancesHazardoustoHealthRegulations(COSHH) ControlofSubstancesHazardoustoHealthRegulations(NorthernIreland) 31 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Healthandsafetylegislation 7706 Note TheHealthandSafetyExecutive(HSE)istheregulatorybodywithresponsibility forenforcinghealthandsafetyintheworkplacelegislationinGreatBritain.The HealthandSafetyExecutiveforNorthernIreland(HSENI)istheleadbody responsibleforthepromotionandenforcementofhealthandsafetyatwork standardsinNorthernIreland. Healthandsafetylegislationisbasedontheassessmentofrisk.COSHHandthe ManagementofHealthandSafetyatWorkRegulations,inlinewithhealthandsafety atworklegislation,specificallyrequirethosedealingwithpotentiallyinfectious substances(includingwaste)toassesstherisktothepublicandstaffthatmaycome intocontactwithit.Inpractice,thisinvolvesthedevelopmentofriskassessment policiesandproceduresandputtinginplacearrangementstomanagetherisks effectively. Arrangementsformanaginghealthcarewasteneedtobepartofanemployer’soverall healthandsafetymanagementsystem.Anumberofguidancedocumentsareavailable inrelationtothemanagementofinfectiouswaste,including: • ‘Biologicalagents:managingtherisksinlaboratoriesandhealthcarepremises’ producedbytheAdvisoryCommitteeonDangerousPathogensand publishedonHSE’swebsite; • ‘Infectionsatwork:controllingtherisks’producedbytheAdvisory CommitteeonDangerousPathogensandpublishedonHSE’swebsite. (Thisguidanceisaimedatthosewhomaybeinadvertentlyexposedtomicroorganisms ratherthanthosedeliberatelyworkingwiththem.) HealthandSafetyExecutive(HSE) HealthandSafetyExecutive(NI) ‘Biologicalagents:managingtherisksinlaboratoriesandhealthcarepremises’ ‘Infectionsatwork:controllingtherisks’ ControlofSubstancesHazardoustoHealthRegulations(COSHH) ControlofSubstancesHazardoustoHealthRegulations(NorthernIreland) ManagementofHealthandSafetyatWorkRegulations ManagementofHealthandSafetyatWorkRegulations(NorthernIreland) Managementresponsibilities 7708 Employersareresponsibleforcomplyingwithhealthandsafetylegislation.Evenif staffareself-employedfortaxornationalinsurancepurposes,theyaretreatedas employeesforhealthandsafetypurposes.Ifanydoubtexistsaboutwhoisresponsible forthehealthandsafetyofaworker,thisshouldbeclarifiedandincludedintheterms ofacontract.However,legaldutieswithrespecttohealthandsafetyatworklegislation cannotbepassedonbymeansofacontract. ControlofSubstancesHazardoustoHealth(COSHH) 7710 COSHHsetsoutthedutyofemployerstomanagetheriskofexposuretohazardous substances,includinghealthcarewaste. 32 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 COSHH–keypoints: Employersmust,amongotherthings: • assesstheriskstoemployeesandothersfromhazardoussubstances, includinghealthcarewaste; • makearrangementsforreviewingtheassessmentasandwhennecessary, butatnolessthantwo-yearlyintervals–andsoonerifthereisanyreason tosuggesttheriskassessmentisnolongervalid; • aimtoeliminateorpreventtheserisks,andifthisisnotpossibleto adequatelycontroltherisks; • providesuitableandsufficientinformation,instructionandtrainingfor employeesabouttherisks; • providehealthsurveillanceandimmunisation,whereappropriate. ControlofSubstancesHazardoustoHealthRegulations(COSHH) ControlofSubstancesHazardoustoHealthRegulations(NorthernIreland) Healthandsafetyatwork 7712 TheManagementofHealthandSafetyatWorkRegulationsanditsassociated ApprovedCodeofPractice(ACOP)provideaframeworkformanagingrisksatwork, includingrisksfromhealthcarewaste,notcoveredbymorespecificrequirementssuch asCOSHH. TheManagementofHealthandSafetyatWorkRegulations–keypoints: Employersmustamongotherthings: • makeasuitableandsufficientassessmentoftheriskstoemployeesand others.Iftheyhavefiveormoreemployees,theymustrecordthe significantfindingsoftheassessment; • takeparticularaccountintheirassessmentofriskstonewandexpectant mothersandtheirunbornandbreast-feedingchildren; • takeparticularaccountintheirassessmentofriskstoyoungpeople; • makearrangementsfortheeffectiveplanning,organisation,andcontrolof risks; • monitorandreviewanyprecautions; • providehealthsurveillancewhereappropriate; • haveaccesstocompetenthealthandsafetyadvice; • provideinformationforemployees; • cooperatewithotheremployerswhomaysharetheworkplace. ManagementofHealthandSafetyatWorkRegulations ManagementofHealthandSafetyatWorkRegulations(NorthernIreland) Consultingemployees 7714 TheHealthandSafety(ConsultationwithEmployees)RegulationsandtheSafety RepresentativesandSafetyCommitteesRegulationsdealwithconsultationof employeesdirectlyandviarecognisedtradeunions. Employersmustconsultemployeesandtheirrepresentativesaboutaspectsoftheir healthandsafetyatwork,including: 33 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • anychangewhichmaysubstantiallyaffecttheirhealthandsafety; • theemployer’sarrangementsforgettingcompetenthealthandsafetyadvice; • theinformationprovidedonreducinganddealingwithrisks; • theplanningofhealthandsafetytraining; • thehealthandsafetyconsequencesofintroducingnewtechnology. Byincorporatinghealthandsafetyrequirementsinhealthcarewastepolicy,employers areabletoprovidestaffwithinformationrelevanttotheirjoborrole(furtherdetails onwastepoliciesareprovidedin‘Managingcompliance’).Thepolicycanthenbeused asabasisfortraininganddiscussions,andthiscaninturnsupportasaferworking environmentthroughcontinuingengagementwithallemployees. Managingcompliance HealthandSafety(ConsultationwithEmployees)Regulations HealthandSafety(ConsultationwithEmployees)Regulations(NorthernIreland) Transportlegislation 7717 Transportlegislationisbasedontheprinciplesofhazardandriskassessment,and substances(includingwaste)areclassifiedaccordingtotheirprimaryhazard.Theseare classifiedasdangerousgoodsandareassignedtodifferentclassesdependingonthe predominanthazard.Dangerousgoodsareliquidorsolidsubstancesandarticles containingthem,whichhavebeentestedandassessedagainstinternationally-agreed criteria.Furtherinformationontransportrequirementsisdetailedin‘Transport packagingandoperations’. Transportpackagingandoperations CarriageRegulations 7719 ThecarriageofdangerousgoodsissubjecttoregulatorycontrolundertheCarriageof DangerousGoodsandUseofTransportablePressureEquipmentRegulations(known astheCarriageRegulations),andtheseapplythroughouttheUK.TheCarriage Regulationsareintendedtoreduce,toreasonablelevels,theriskofharmordamageto people,propertyandtheenvironmentposedbythecarriageofdangerousgoods. IntheUK,theseregulationsimplementtherequirementsofthe‘Europeanagreement concerningtheinternationalcarriageofdangerousgoodsbyroad’(commonlyknown asADR)andthe‘Regulationsconcerningtheinternationalcarriageofdangerous goodsbyrail’(commonlyknownasRID).TheCarriageRegulationsmakedirect referencetoADRandRID.Bothdocumentsarerevisedeverytwoyears,andthe updatedversionsareincorporatedintotheUKbytheCarriageRegulations. OtherEuropeanandinternationalregulationsapplytothemovementofdangerous goodsbyair,sea,andinlandwaterway.Producersshouldseekspecialistadviceif healthcarewasteistobetransportedbymeansotherthanroadtransport.IntheUK, thevastmajorityofdangerousgoodsarecarriedbyroad. TheCarriageRegulationsdonotspecificallyregulatewastematerials.Theyapplytoall dangerousgoodsregardlessofwhetherasubstanceiswasteornot.Goodsareassessed ontheirhazardouscharacteristicsand,ifapplicable,areclassifiedintooneofnine classesofdangerousgoods.Thenineclassesareshown,alongwithexamplesof healthcarewasteineach,in‘Transportpackagingandoperations’. Oncegoodshavebeenclassifiedintotheirappropriateclass,thisinformationisusedto identifyappropriatepackaging,labellingandtransportrequirements.Thepackaging andlabellinginrelationtotheCarriageRegulationsisdiscussedingreaterdetailin ‘Transportpackagingandoperations’. 34 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 CarriageRegulations–keypoints: Theregulationscover(byreferencetoADR)amongotherthings: • trainingofpersonnelinvolvedinthechainofdistribution; • substanceclassificationandidentification; • packaging; • marking,labellinganddocumentation; • safetyequipmentandemergencyprocedures; • safeloading; • vehiclespecificationandoperation. Furtherinformationontransportrequirementsisprovidedin‘Transportpackaging andoperations’. Dutiesareimposedonpartiesatallstagesofthesupplychain,including manufacturers,consignors,carriersandreceivers.TheCarriageRegulationsmay requirehealthcareorganisationstoappointorcontractadangerousgoodssafety adviser(DGSA).TherequirementregardingDGSAsisadutyontheemployerandis inlargepartdependentonthequantityofdangerousgoodstransported(see ‘Transportpackagingandoperations’forfurtherdetails). TheHSEistheregulatorybodyresponsibleforenforcingtransportlegislationinGreat Britain(theHSENIinNorthernIreland).PoliceofficersandtheVehicleandOperator ServicesAgency(VOSA)(inEngland,WalesandScotlandonly)carryout“onthe road”enforcementunderanagencyagreementwiththeHSE. FurtherinformationontheCarriageRegulationscanbefoundontheDepartmentfor Transport’swebsiteandonHSE’swebsite. Transportpackagingandoperations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) Europeanagreementconcerningtheinternationalcarriageofdangerousgoodsby road(ADR) Regulationsconcerningtheinternationalcarriageofdangerousgoodsbyrail (RID) FurtherinformationontheCarriageRegulations(DfT) FurtherinformationontheCarriageRegulations(HSE) Procurementregulations 8462 Europeanprocurementregulations 8463 Allpublicly-fundedorganisationsmustensurethatallcontractsestablishedtocollect andtreatwasteconformtothePublicContractsRegulations. InformationaboutpublicprocurementregulationsandOJEU(OfficialJournalofthe EuropeanUnion)thresholdscanbeobtainedfromtheOfficeofGovernment Commerce. PublicContractsRegulations PublicContracts(Scotland)Regulations OJEU(OfficialJournaloftheEuropeanUnion) 35 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 OfficeofGovernmentCommerce Procurementguidance 8464 FurtherinformationontheECpublicprocurementregulationsandhowtodevelop andcompetitivelytenderwastecollectionanddisposalcontractsisavailablefromthe followingorganisations: • inEngland–followingthedisbandingofNHSPurchasingandSupply Agency,theownershipofthisguidancewillbetransferredtotheDepartment ofHealth.Detailsofhowtoaccessthisinformationwillbeprovidedindue [email protected]; • inNorthernIreland–theRegionalSuppliesService; • inScotland–NationalProcurement; • inWales–WelshHealthSupplies. ClinicalWasteConsortium–acasestudyfromNHSWales WelshHealthSuppliesestablishedtheAllWalesClinicalWasteConsortiuminthe early1990stomanagethecollectionanddisposalserviceforclinicalwastefrom NHStrustsinWales.TheConsortiumapproachwasadoptedinordertoensure thatallhospitalswereabletotakeadvantageofaprofessionallyprocuredand managedcontractwithasingleserviceproviderandthatasinglenationwidepricing structurewasagreed,ensuringconsistencyofpricingirrespectiveofgeographical locationandsizeoffacility. Benefitsoftheconsortiumapproachtoclinicalwastecontractmanagementhave includedimprovedcommercialtermsthroughtheincreaseineconomiesofscale whennegotiatingasaconsortiumratherthanasindividualentities.Thishas resultedinanotableincreaseinvalueformoneybeingachievedforNHSWales. Theconsortium’sinclusiveapproachhasalsoprovidedapowerfulforumfor discussingcontractualissuesandsharingbestpracticebetweenparticipatingNHS organisationsandengagingwiththecontractortodriveservicelevelimprovements throughapartnershipapproachincludingpositivesupportandcollaborationwith environmentalregulators. TheConsortiummodelhasprovidedNHSWaleswithsignificantbenefitsover manyyears,andtheapproachstillstandsscrutinywiththeincreasingcollaborative policyacrosstheWelshAssemblyGovernmentandwiderWelshpublicsector. 36 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Importantinformationforvets Animalby-productsfromhealthcare(forexampleresearchfacilities)havespecific legislativerequirementsfordisposalandtreatment.Theyaredefinedas“entire bodiesorpartsofanimalsorproductsofanimaloriginnotintendedforhuman consumption,includingova,embryosandsemen”.TheAnimalBy-Products Regulationsaredesignedtopreventanimalby-productsfrompresentingariskto animalorpublichealththroughthetransmissionofdisease.Thisaimisachievedby rulesfor: • thecollection,transport,storage,handling,processinganduseordisposal ofanimalby-products;and • theplacingonthemarket,exportandtransitofanimalby-productsand certainproductsderivedfromthem. Theregulationsdivideanimalby-productsintothreecategories: • Category1isthehighestriskcategoryandmustbedisposedof.It includescarcassesandmaterialsinfectedorsuspectedofbeinginfectedby atransmissiblespongiformencephalopathy(TSE),thecarcassesofzooand petanimals. • Category2isalsohigh-riskmaterial,andincludes,forexample,diseased animals,animalsthatdieonfarmsandwhichdonotcontain“specified riskmaterials”(SRM)atthepointofdisposal,andanimalswhicharenot slaughteredforhumanconsumption. • Category3isessentiallymaterialwhichisfit(butnotintended)for humanconsumption.Itincludespartsofslaughteredanimals,blood,raw milk,fishcaughtintheopensea,andshells. Thepermitteddisposalmethodsvaryforeachcategory.Furtherdetailsarefoundin Defra’sguidancenotesandalsoontheirwebsite. NorthernIrelandRegionalSuppliesService Scotland–NationalProcurement WelshHealthSupplies AnimalBy-ProductsRegulations AnimalBy-Products(Scotland)Regulations AnimalBy-ProductsRegulations(NorthernIreland) Permitteddisposalmethods 37 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Healthcarewastedefinitionsand 7725 classifications Thissectionprovidesthedefinitionsandassessmentframeworkfortypicalhealthcare wasteinlinewiththeregulatoryregimesoutlinedintheprevioussection.Theunified assessmentframeworkprovidesclearstepsonhowtoclassifywastewithpractical examples.Itemphasisestheneedtoundertakeanassessmenttoclassifyawasteas infectious.Thissectiondoesnotaddressallpackagingissuesrelatedtotransport(see ‘Transportpackagingandoperations’). Transportpackagingandoperations Typicalwastesproducedbyhealthcareactivities 7727 Figure2providesexamplesofsomeofthewastestreamsandtheirclassificationsthat areapplicabletothehealthcaresector. Figure3providesequivalentexamplesforwastessimilartobothhealthcarewasteand householdwastewhichmaybeproducedbynon-healthcareactivities. Thissectiondoesnotconsiderthefullrangeofnon-healthcare-relatedwasteitemsand streamsthatshouldnotenterhealthcarewastestreams,whichinclude: • fluorescenttubes; • batteries; • cleaningchemicals; • oils(hazardousandedible); • groundswaste; • domesticwastestreams; • paper,glass,cans,food; • foodwaste; • furniture; • constructionanddemolitionwaste; • asbestos; • paints; • wasteelectricalandelectronicequipment(WEEE). TheEWCcontainscodesthatapplytowasteproducedfromhealthcareandsimilar wastesfrommunicipalsources.Thecodesappliedtowastestreamsaredefinedbythe individualitemsplacedinareceptacle–theyareneverdeterminedbythetypeof receptacleused.Table1includessomeofthecodesthatmayapplyindividuallyorin groupstohealthcarewastestreams. Table1 EWCcode 09 0901 090101* 090102* 090103* 38 Descriptionofcode Wastesfromthephotographicindustry Wastesfromthephotographicindustry Water-baseddeveloperandactivatorsolutions Water-basedoffsetplatedevelopersolutions Solvent-baseddevelopersolutions for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 090104* 090105* 090106* 090107 090108 18 1801 180101 180102 180103* 180104 180106* 180107 180108* 180109 180110* Fixersolutions Bleachsolutionsandbleachfixersolutions Wastescontainingsilverfromon-sitetreatmentofphotographic waste Photographicfilmandpapercontainingsilverorsilver compounds Photographicfilmandpaperfreeofsilverorsilvercompounds Wastesfromhumanandanimalhealthcareand/orrelated research(exceptkitchenandrestaurantwastesnotarising fromimmediatehealthcare) Wastefromnatalcare,diagnosis,treatmentorpreventionof diseaseinhumans Sharpsexcept180103* Bodypartsandorgansincludingbloodbagsandbloodpreserves (except180103*) Wastewhosecollectionanddisposalissubjecttospecial requirementsinordertopreventinfection Wastewhosecollectionanddisposalisnotsubjecttospecial requirementsinordertopreventinfection,e.g.dressings,plaster casts,linen,disposableclothing Chemicalsconsistingoforcontainingdangeroussubstances Chemicalsotherthanthoselistedin180106* Cytotoxicandcytostaticmedicines Medicinesotherthanthosementionedin180108* Amalgamwastefromdentalcare 1802 Wastefromresearch,diagnosis,treatmentorpreventionof diseaseinvolvinganimals 180201 Sharpsexcept180202* 180202* Wastewhosecollectionanddisposalissubjecttospecial requirementsinordertopreventinfection 180203 Wastewhosecollectionanddisposalisnotsubjecttospecial requirementsinordertopreventinfection 180205* Chemicalsconsistingoforcontainingdangeroussubstances 180206 Chemicalsotherthanthoselistedin180205* 180207* Cytotoxicandcytostaticmedicines 180208 Medicinesotherthanthosementionedin180207* 20 Municipalwastes(householdwasteandsimilarcommercial, industrialandinstitutionalwastes)includingseparately collectedfractions 2001 Separatelycollectedfractions(except1501) 200131* Cytotoxicandcytostaticmedicines 200132 Medicinesotherthanthosementionedin200131* 200199 Otherfractionsnototherwisespecified(usedforoffensivewaste) *Hazardouswastescanbe: • absolutehazardousentries(inwhichcasetheyarealwayshazardous– highlightedredintheTable)or • mirrorentries(whichcanbeeitherhazardousornon-hazardousdepending ontheirproperties–highlightedblueintheTable). 39 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 HAZARDOUS WASTE NONHAZARDOUS WASTE Clinical waste Clinical waste Medicines other than those that are cytotoxic and cytostatic 18 01 09, 18 02 08, 20 01 32 Nonclinical waste Noninfectious anatomical waste, no chemicals present 18 01 02, 18 02 03 Noninfectious anatomical waste, chemicals present 18 01 02 and 18 01 06 18 02 03 and 18 02 05 Cytotoxic and cytostatic medicines 18 01 08, 18 02 07, 20 01 31 Clinical waste: infectious waste for carriage (Category A – UN 2814/UN 2900; Category B – UN 3291) Infectious anatomical waste no chemicals present 18 01 03, 18 02 03 Cytotoxic and cytostatic sharps 18 01 03 and 18 01 08 18 02 02 and 18 02 07 Sharps not contaminated with body fluids or medicines 18 01 01, 18 02 01 Infectious anatomical waste, chemicals present 18 01 03 and 18 01 06 18 02 02 and 18 02 05 Other medicinally contaminated sharps 18 01 03 and 18 01 09 18 02 02 and 18 02 08 Noninfectious gypsum (plaster) wastes 18 01 04 Other clinical infectious waste containing chemicals 18 01 03 and 18 01 06 18 02 02 and 18 02 05 Nonmedicinallycontaminated sharps 18 01 03, 18 02 02 Infectious gypsum (plaster) 18 01 03* Other clinical infectious waste arising from healthcare activities 18 01 03, 18 02 02 Offensive/hygiene waste 18 01 04, 18 02 03 Infectious waste containing dental amalgam 18 01 03* and 18 01 10 Mixed municipal waste 20 03 01 Recyclables (various) Healthcare chemicals without hazardous properties 18 01 07, 18 02 06 Healthcare chemicals without hazardous properties 18 01 06, 18 02 05 Nonclinical waste Dental amalgam 18 01 10 Xray fixer and developer 09 01 01, 09 01 02, 09 01 03, 09 01 04, 09 01 05 Figure2Healthcarewaste:examplesandbreakdownofclinicaland hazardousinlinewithregulatorydefinitions 40 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 NONHAZARDOUS WASTE HAZARDOUS WASTE Clinical waste Clinical waste Medicines other than those that are cytotoxic and cytostatic 20 01 32 Cytotoxic and cytostatic medicines 20 01 31 Infectious for carriage (Category A – UN 2814/UN 2900; Category B – UN 3291) Nonmedicinallycontaminated sharps 20 01 99 Other clinical infectious waste arising from healthcare activities 20 01 99 Note: This Figure assumes that any activities that generate anatomical waste, chemicallycontaminated waste or other medicinallycontaminated wastes are captured as healthcare waste Nonclinical waste Offensive/hygiene waste 20 01 99 Mixed municipal waste 20 03 01 Recyclables (various) Sharps not contaminated with body fluids or medicines 20 01 99 Figure3Municipalwastesimilartobothhouseholdwasteandhealthcare waste:examplesandbreakdownofclinicalandhazardousinline withregulatorydefinitions Clinicalandhazardouswaste 7731 ThedefinitionofclinicalwasteisprovidedbytheControlledWasteRegulations (issuedundertheEnvironmentalProtectionAct)andinNorthernIrelandbythe WasteandContaminatedLand(NorthernIreland)Order. Clinicalwasteisdefinedas: 1. “...anywastewhichconsistswhollyorpartlyofhumanoranimaltissue, bloodorotherbodyfluids,excretions,drugsorotherpharmaceutical products,swabsordressings,syringes,needlesorothersharpinstruments, beingwastewhichunlessrenderedsafemayprovehazardoustoanyperson comingintocontactwithit;and 2. anyotherwastearisingfrommedical,nursing,dental,veterinary, pharmaceuticalorsimilarpractice,investigation,treatment,care,teachingor research,orthecollectionofbloodfortransfusion,beingwastewhichmay causeinfectiontoanypersoncomingintocontactwithit.” Clinicalwastecanbedividedintothreebroadgroupsofmaterials: 1. anyhealthcarewastewhichposesariskofinfection(andthereforeby definitionpossessesthehazardouspropertyH9Infectious); 2. certainhealthcarewasteswhichposeachemicalhazard(forexampleoneof H1toH8,H10toH15); 3. medicinesandmedicinally-contaminatedwastecontaininga pharmaceutically-activeagent. Therelationshipbetweenthedefinitionofclinicalwasteandhazardouswaste definitionsissummarisedinFigures2and3(see‘Typicalwastesproducedby healthcareactivities’).Thekeyprincipleisthatclinicalwaste=hazardouswastewith onlytwopossibleexceptions: 41 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • segregatednon-cytotoxicandnon-cytostaticmedicines(thatis,fromhuman (180109)oranimalhealthcare(180208)andmanufacturing,orseparate fractionsofout-patient-returnedmedicines(200132)); • clinicalwastefrommunicipalsourcesthatarenotinanywaydirectlyor indirectlyassociatedwithhealthcare(forexampleneedlesandswabsfrom cosmeticbodyartorpiercinganddruglitter)andthataresimilarto householdwaste.Theseareclassifiedasnon-hazardoussolelybecausethe onlyavailableEWC(200199)isanabsolutenon-hazardousentryinthe EWC. Anyclinicalwaste,otherthanthesetwoexceptions,beingmovedasanon-hazardous wastewouldindicatethatthewastehasbeenincorrectlyclassifiedbytheproducer, holderorwastecontractor. Manyinfectiousornon-infectioushealthcarewastescontaminatedwithhazardous chemicalswillbeclassifiedasaclinicalwaste.Inisolation,abottleofwastechemical wouldnotfallunderthedefinitionofclinicalwaste,althoughitmaystillbe hazardous. Typicalwastesproducedbyhealthcareactivities ControlledWasteRegulations ControlledWasteRegulations(NorthernIreland) EnvironmentalProtectionAct WasteandContaminatedLand(NorthernIreland)Order Healthcarewasteclassificationandassessmentframework 7733 Thegeneralprinciplesbehindaunifiedapproachforclassificationofhealthcarewaste areprovidedinawasteassessmentframeworkasdetailedinFigure4.Compliancewith theunifiedapproachwillensurethatproducerscomplywiththeregulatory requirements. Theassessmentframeworkconsiders: • thedefinitionofaninfectiouswaste; • thedefinitionofahazardouswaste; • thestructureoftheEWCandtheclassificationofthewaste; • thegeneralprinciplesoftheCarriageRegulations. Todeterminetheirclassification,allhealthcarewasteitemsmustbeclinicallyand specificallyassessedbytheproducer,atthetimeofproduction,for: • medicinalproperties(seestep2andFigure5); • chemicalproperties(seestep3andFigure6);and • infectiousproperties(seestep4andFigure7). Wherethehealthcarewastehasnoneoftheseproperties,anassessmentmethodologyis providedtodeterminewhetheritisoffensive/hygienewaste(seestep6andFigure8). TheoverallassessmentframeworkispresentedinFigure4.Detailedassessment proceduresforidentifyingmedicinal,chemical,infectious,andoffensivepropertiesof healthcarewasteareprovidedtogiveguidanceonanappropriateclassificationof individualwasteitemswhenusedaspartoftheframework.Eachassessmentconsiders theelement,ortypeofwaste,presentinanywastereceptacle(bag,box,bin)separately. Eachmaythereforebeclassifieddifferently.Otherhealthcarewastestreamsand classificationsoutsidethisframeworkincludeamalgamwaste,implanteddevicesand radioactivewaste. 42 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Staffsegregatingwasteshouldbeprovidedwithclearinstructionsonthesegregation processandshouldbeprovidedwithappropriatetraining(furtherdetailsaregivenin ‘Managingcompliance’).Colour-codedwastereceptaclesshouldbesuppliedforeach wastestream.Classificationisessentialforcolourcoding(furtherdetailsonthecolour codesforhealthcarewasteareprovidedin‘Wasteminimisation,segregation,colourcodingandstorage’). Step 1a: Is the waste a healthcare waste? (See paragraphs 3.18 3.21) Step 2: Assess for the medicinal w a waste properties of a waste (Se (S e (See paragraphs 3.24–3.45) YES NO Ste Step 3: Assess for the chemical Ste s for the for the w a waste properties of a waste (Se (S e (See paragraphs 3.46–3.62) NO Step 1b: Is the waste a waste arising from m municipal sources which is ssimilar to healthcare waste? (See paragraphs 3.22–3.23) Ste Step 4: Assess for the infectious Ste s for the w a waste properties of a waste (Se (S e (See paragraphs 3.63–3.104) YES SStep 6: Assess for offensive tep te p s for or o offe p ro properties (See (Se e (See paragraphs 3.110–3.139) Where the waste is not a e waste is not a healthcare waste or similar municipal waste, it is not encompassed by this assessment framework NO IIs this element of the waste an th te? offensive waste? YES YES Step 5: Review the assessment Ste w the as the asss o fe nt of th thee of each element of the waste ffor medicinal, chemical and or or infe in fe infectious properties (See (S (See paragraphs 3.105–3.109) A re Are there any elements of the was wa s waste that are neither infectious norr hazardous, and that have no not no t not been classified in steps 2–4 or s or s or subsequently in step 6? NO Assessment complete Note: This flowchart contains a logic trap between steps 5 and 6 to prevent misclassification of the waste. If stuck in this trap, then there are two likely causes: a. the item that is being classified should not be in the waste stream in question (e.g. items of municipal waste like flowers, newspapers etc) and is not catered for by the assessment due to the prohibition on mixing; or b. the classification in the previous steps has been misapplied. Figure4Assessmentframeworkforhealthcare,andsimilarmunicipal wastes Managingcompliance Wasteminimisation,segregation,colour-codingandstorage CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) Step1 7744 Step1a:Isthewasteahealthcarewaste(orsimilartype)? Thisstepdistinguishesbetweenhealthcareandnon-healthcarewaste,astheseare (dependingontypeofwaste)assesseddifferentlyduetothestructureoftheEWC. Healthcarewasteislistedinchapter18oftheEWCandrelatestowastethatisboth: • producedbyhealthcareactivities;and 43 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • ofatypespecificallyassociatedwithsuchactivities. Healthcarewastedoesnotincludenon-specificwastesthatarealsocommonly producedbyothernon-healthcareactivities(forexamplephotochemicals,paper,food, electricalequipment,vehicularwastesetc).Healthcarewastemayincludesomesimilar wastesproducedbyotheractivitieswherethosewastesarenotconsideredtobe municipal. Figures2and3(see‘Typicalwastesproducedbyhealthcareactivities’)showthe differenttypesofhealthcarewasteclassifiedaccordingtowhethertheyarehazardous ornon-hazardous.Theseareforillustrativepurposesonlyandarenotintendedtobe usedaspartoftheassessmentframework. Step1b:Isthewasteawastearisingfrommunicipalsources,whichissimilarto healthcarewaste? Thereareafewmunicipalnon-healthcarewastestreamsthataresimilarinnatureto healthcarewasteandareconsideredwithintheassessmentframework. Municipalwaste:chapter20oftheEWC Thischapterisrestrictedtotheuseof • wastesfromhouseholds;and • similarwastesfromothersources wheresuitablecodesareprovided. Asageneralrule,therefore,thefollowingwastesshouldnotbeclassifiedunder Chapter20: • wasteproducedastheresultofaprocedurethatrequiresamedically qualifiedpersontoconductit(forexamplesomecosmeticprocedures)or • awasteitemsubstantiallydifferentintypeorquantity/sizetothatwhich wouldtypicallybeproducedbyadomestichouseholdintheabsenceof healthcareinvolvement,forexamplelargedressingsandbandages,and X-raywastes. Specificallyincludedarethefollowing: • humanhygienewastes(sanitaryproducts,nappies,incontinencewasteetc); • animalhygienewastes(animalbedding,dogfaecesetc); • wastesfromnon-healthcareactivities,forexamplesharpsandrelatedwastes frombody-piercingorapplicationoftattoos,andwastesarisingfrom substanceabuse(druglitter). Note Wasteproducedbyself-medicatingpatients(forexamplepeoplewithdiabetes)and unusedwastemedicinesareclassifiedashealthcarewaste. Typicalwastesproducedbyhealthcareactivities Step2 7746 Step2:Assessmentofmedicinalproperties Thisstepassesseseachelement(componentsandcontaminants)ofthewastefor medicinalproperties.TheassessmentissupportedbyFigure5.Eachelementis classifiedonthebasisofitsmedicinalpropertiesaloneas: • eitheraclinicalornon-clinicalwaste;and • eitherhazardousornon-hazardouswaste. 44 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 AnappropriateEWCcodeisthenassigned. Thechemical,infectiousandoffensivepropertiesofthewastemustalsobeassessed. Clinicalornon-clinicalwaste Thewastewillbeclassifiedasaclinicalwaste(withreferencetothedefinitioninthe ControlledWasteRegulations)ifitcontainsoriscontaminatedwithamedicine containingeither: • apharmaceutically-activesubstance(asubstanceabletoaffectbiological systems);or • adangeroussubstance(forexampleachemical)atsufficientconcentrationto generateahazardousproperty. Hazardousornon-hazardouswaste Thewastewillbeclassifiedashazardous(withreferencetothedefinitioninthe HazardousWasteRegulations)ifitcontainsoriscontaminatedwithacytotoxicor cytostaticmedicine.Othermedicinesarenothazardouswaste. EWCcodesareassigneddependingonthesourceofthewasteandthepresenceof cytotoxicandcytostaticorothermedicinesasillustratedbelow: • Humanmedicinesareclassifiedas180108*(cytotoxicandcytostatic)or18 0109(other). • Animalmedicinesareclassifiedas180207*(cytotoxicandcytostatic)or18 0208(other). • Domesticandout-patientreturnstopharmacyareclassifiedas2001 31*(cytotoxicandcytostatic)or200132(other). • Wastemedicinesfromthemanufacturingorsupplychainareclassifiedin Chapter18ashumanoranimalmedicines. Note Controlleddrugsaresubjecttospeciallegislativecontrols,astheyarepotentially harmful.TheMisuseofDrugsRegulationslistthemedicinesthatareclassifiedas controlleddrugs.Therearecurrentlyfiveschedulesthatdictatethelevelofcontrol appliedtoeachmedicine–Schedule1havingthemostcontrolsandSchedule5the fewest. 45 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Start (i) Does the waste contain medicinal waste? YES (ii) Does the waste contain cytotoxic and cytostatic medicinal waste? If yes, as a result of an assessment of its medicinal properties, this element of the waste should be assigned the EWC codes 18 01 08*, 18 02 07*, or 20 01 31* NO (iii) Does the waste contain other pharmaceutically active medicinal waste? If yes, as a result of an assessment of its medicinal properties, this element of the waste should be assigned the EWC codes 18 01 09, 18 02 08, or 20 01 32 (iv) Does the waste contain other non-pharmaceutically active medicinal waste? If yes, as a result of an assessment of its medicinal properties, this element of the waste should be assigned the EWC codes 18 01 09, 18 02 08, or 20 01 32 (vi) Go to Step 3 of the assessment framework (v) Classify the waste for transport. The elements above may be: • Medicine, Liquid, Toxic, UN 1851 • Medicine, Liquid, Flammable, Toxic, UN 3248 • Medicine, Solid, Toxic, UN 3249 • Other UN numbers may be applicable Figure5Assessmentandclassificationofmedicinalwaste Step2(i):Doesthewastecontainamedicinalwaste? Medicinalwasteincludes: 1. expired,unused,spilt,andcontaminatedmedicinalproducts,drugs,vaccines andserathatarenolongerrequiredandneedtobedisposedofappropriately; 2. discardeditemscontaminatedwithmedicinals,suchasbottlesorboxeswith residues,gloves,masks,connectingtubing,syringebodiesanddrugvials. Whereanyofthesematerialsarepresentinawaste,itcontainsmedicinalwaste. Therearethreespecificcaseswherefurtherguidanceisprovided(seethe‘Noteon specificcasesrequiringadditionalconsideration’below).Theseare: 1. secretions,excretionsorotherbodyfluidscontainingresidualmedicines; 2. anatomicalwasteandcarcassescontainingresidualmedicines;and 3. medicinalglassware,aerosolsandothercontainers. Step2(ii):Doesthewastecontainacytotoxicandcytostaticmedicinalwaste? Acytotoxicorcytostaticmedicineisdefinedasanymedicinalproductthatpossesses anyone,ormore,ofthefollowinghazardousproperties: • H6:Toxic; • H7:Carcinogenic; • H10:Toxicforreproduction; • H11:Mutagenic. 46 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Note Thedefinitionofcytotoxicandcytostaticusedinwasteclassificationismuch broaderthantheterm“cytotoxic”asusedintheBritishNationalFormulary(BNF). TheBNFshouldnotbeusedforwasteclassification.Anexamplelistofcytotoxic andcytostaticmedicinesforahospitalisprovidedin‘Clinicalwastetreatmentand disposaloverview’.Thisisprovidedtoassistpharmacists,butisnotpresented,or intendedtobeused,asacomprehensivelist,sincethisishighlydependentonwhat medicinesareusedinaparticularhealthcaresetting. Classificationisdeterminedbyassessmentofthemedicinalproductsintheform suppliedbythemanufacturerordistributoranddoesnotconsidertheeffectsofany subsequentdilutionthatmayoccurduringroutineuse.Furtherguidanceonthe assessmentofthesehazardouspropertiesmaybeobtainedfromWM2. Ifwastecontainsoriscontaminatedwithacytotoxicandcytostaticmedicine,that elementis: • ahazardouswaste;and • aclinicalwaste. ThatelementshouldbeassignedtheEWCcode(asappropriate): • 180108*(humanhealthcare); • 180207*(animalhealthcare);or • 200131*(municipalwaste:separatelycollectedfractionsfrompatient returns). Thepackagingcolourforcytotoxicandcytostaticmedicinesisyellowandpurple(see ‘Wasteminimisation,segregation,colour-codingandstorage’). Ifthepropertiesofamedicinecannotbedetermined,ratherthanhavenotbeen determined,thatelementshouldbeclassifiedascytotoxicandcytostatic. Step2(iii):Doesthewastecontainotherpharmaceutically-activemedicinal waste? Medicinesthatareneithercytotoxicnorcytostaticaremostlikelytocontaina pharmaceutically-activesubstanceand/oraconcentrationofdangeroussubstancesthat providesahazardouspropertyotherthanthoseassociatedwithcytotoxicandcytostatic medicines.Wherethewastecontainsamedicineofthistype,itisa: • non-hazardouswaste;and • aclinicalwaste. ThatelementshouldbeassignedtheEWCcode(asappropriate): • 180109(humanhealthcare); • 180208(animalhealthcare),or • 200132(municipalwaste:separatelycollectedfractionsfrompatient returns). Step2(iv):Doesthewastecontainothernon-pharmaceutically-activemedicines? Thisdocumentrecognisesthatthereareanumberoflicensedmedicinalproductsthat arenon-pharmaceuticallyactiveandpossessnohazardousproperties.Examples includesterilewater,salineandsugarsolutions.Thismedicinalelementofthewasteis: • non-clinicalwaste;and • non-hazardouswaste. Thisisasaresultoftheassessmentofitsmedicinalpropertiesonly.Thiselement shouldbeassignedtheEWCcode(asappropriate): • 180109(humanhealthcare); 47 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • 180208(animalhealthcare);or • 200132(municipalwaste:separatelycollectedfractions). Thepackagingcolourformedicinesissetoutin‘Wasteminimisation,segregation, colour-codingandstorage’. Wherenon-pharmaceutically-activeintravenousfluidsoccurinsmallquantitiesand presentnootherhazard(forexampleinfectiousduetocontaminationwithbodyfluids ortheadditionofpharmaceutically-activesubstances),thesecan: • eitherbeplacedinthemedicinalwastestream;or • bedischargedtofoulsewerandtheemptycontainersplacedintheoffensive/ hygienewastestream.Recyclingoptionsmaybeexplored,buttheymustnot beplacedinthemixedmunicipalwastestream. ThelandfillofliquidsisprohibitedundertheEnvironmentalPermitting(Englandand Wales)RegulationsandLandfillRegulationsinScotlandandNorthernIreland. Therefore,non-pharmaceutically-activeliquids(forexampleintravenoussalinebags) shouldnotbeplacedintheoffensivewastestreamiftheystillcontainfree-flowing liquid. Noteonmixedwastemedicines,segregationandhazardousproperties InEnglandandWales,themixingofcytotoxicandcytostaticmedicineswithother medicinesisprohibitedexceptinthecaseofdomestichouseholders.Inanyevent,if apackageofmedicinescontainsamixtureofcytotoxicandcytostaticmedicines,all non-domesticholders(thatis,healthcareorganisationsorpharmacies)havealegal dutytoseparatethematerial.Theconsignmentnotefortheremovalofmixed medicinesmustclearlyidentifythepresence(EWCcodes,descriptionsand hazardousproperties)ofbothwastesandlistthecomponents. InScotlandandNorthernIreland,themixingofcytotoxicandcytostaticmedicines withothermedicinesispermittedaslongasthedescriptionontheconsignment notereads“cytotoxicandmedicines’’andthewasteclassificationanddescription includeboththe180108*code(cytotoxic/cytostatic)and180109code(other medicines). However,inallcountries,amedicinemustnotbemixedwithanyothermedicine (cytotoxicandcytostaticorotherwise),chemicalormaterialthatischemically incompatible. Step2(v):Classifythewastefortransport Medicinalwasteshouldbeclassifiedfortransportonthebasisofitsphysicalformand properties(moredetailedinformationonthisisprovidedin‘Transportpackagingand operations’). 48 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Noteonspecificcasesrequiringadditionalconsideration Contaminated material arising after administration of a medicine a. Secretions,excretionsorotherbodyfluidscontainingcytotoxicand cytostaticmedicines. b. Anatomicalwasteandcarcassescontainingresidualmedicines. Thedefinitionofmedicinalwastedoesnotnormallyincludeanatomicalwaste, carcasses,secretions,excretionsorotherbodyfluidscontainingresidualquantitiesof medicineasaresultoftherapeuticadministrationtothepatient.However,insome circumstancesthepresenceofsuchsubstancesmayprovehazardoustothosecoming intocontactwiththewasteormayaffectdisposaloptions. Wherecytotoxicandcytostaticdrugsareinvolvedandthepharmacokineticsofa specificdrugarelikelytoresultinthepresenceofpotentiallydangerousquantities ofanunmetaboliseddruginthewaste: • thewastedescriptionshouldspecificallyidentifythepresenceofsuch substances; • theEWCcodeforcytotoxicandcytostaticdrugs(180108*or180207*) shouldbeassignedtothewaste; • thewasteisclinicalwasteandhazardouswaste. Anydisposaltofoulsewershouldbeinaccordancewithtradeeffluentconsent. Medicinal glassware, aerosols and other containers Containers(bottles,ampoules,vialsetc)usedforliquidmedicinesandpowdersare normallycontaminatedwithresidualquantitiesofthosemedicines.Innerpackaging usedfortabletsmayormaynotbecontaminated.Ifcontaminated,containers shouldbeclassifiedanddisposedofaswastemedicines.Onlyifrinsedout,in accordancewithatradeeffluentconsent,maytheybedisposedofaspackaging(for exampleglasswareforrecycling).Uncontaminatedouterpackagingmayalsobe recycled. Medicinesinaerosolformulationarenotpossibletocleanoutandshouldbe classifiedaswastemedicines(notaerosols). Clinicalwastetreatmentanddisposaloverview Wasteminimisation,segregation,colour-codingandstorage Transportpackagingandoperations ControlledWasteRegulations ControlledWasteRegulations(NorthernIreland) HazardousWaste(EnglandandWales)Regulations HazardousWasteRegulations(NorthernIreland) MisuseofDrugsRegulations MisuseofDrugsRegulations(NorthernIreland) EnvironmentalPermitting(EnglandandWales)Regulations Landfill(EnglandandWales)Regulations Landfill(Scotland)Regulations LandfillRegulations(NorthernIreland) SpecialWasteAmendment(Scotland)Regulations 49 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Step3 7742 Step3:Assessmentofchemicalproperties Note Thissectionisnotprovidedforuseinassessinglaboratorychemicalsandreagents. Itisprovidedasanoverviewtosupporttheassessmentofhealthcarewastestreams thatmaycontainwastechemicals.Thefollowingadviceappliesforwastechemicals: • Theyshouldnotbeplacedinclinical,offensiveormunicipalwastestreams (inEnglandandWalessuchmixingisprohibited). • Theyshouldbesegregatedandpackagedaccordingtotransport classificationsandchemicalcompatibilities. • Theyshouldnormallybeclassifiedas180106*or180107unlessthey arephotochemicals(theseareclassifiedundersub-chapter0901). • Hazardouspropertiesshouldbeassessedandclassificationcodesassigned usingtheproceduressetoutinWM2. Chemicalcontainers,unlesscompletelyempty(thatis,rinsedout),wouldnormally becontaminatedandclassifiedasthechemicaltheycontain(ignoringtheweightof thecontainer). Usedabsorbentsandspill-kitsforchemicalspillsshouldbeclassifiedunderchapter 15oftheEWC. Thisstepassesseseachelement(componentsandcontaminants)ofthewastefor chemicalproperties.TheassessmentissupportedbyFigure6.Eachelementis classifiedonthebasisofitschemicalpropertiesaloneas: • eitheraclinicalornon-clinicalwaste;and • eitherhazardousornon-hazardouswaste. AnappropriateEWCcodeisthenassigned. Themedicinal,infectiousandoffensivepropertiesofthewastemustalsobeassessed. Clinicalornon-clinicalwaste Awastechemicalwouldnotnormallybeaclinicalwaste.However,anotherhealthcare wastewillbeaclinicalwaste(withreferencetothedefinitionintheControlledWaste Regulations)ifitcontainsoriscontaminatedwithadangeroussubstanceatsufficient concentration(intheitem)togenerateahazardousproperty. Ifthechemicalisnotadangeroussubstanceorisnotpresentinthewasteorwaste iteminsufficientconcentrationtogenerateahazardousproperty,itwillnotresultin thewastebeingclassifiedasclinicalwaste. Hazardousornon-hazardouswaste Thewastewillbeclassifiedasahazardous(withreferencetothedefinitioninthe HazardousWasteRegulations)ifitcontainsoriscontaminatedwithadangerous substanceatsufficientconcentrationtogenerateahazardousproperty. EWCcodes Theseareassigneddependentonthesourceandhazardousstatusofthewasteitemas indicatedbelow: • Humanhealthcarechemicals(exceptphotochemicals)areclassifiedas 180106*(hazardous)or180107(non-hazardous). • Animalhealthcarechemicals(exceptphotochemicals)areclassifiedas 180205*(hazardous)or180206(non-hazardous). • Photochemicals(includingX-ray)areclassifiedinchapter09oftheEWC. 50 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Start (i) Does the waste contain waste chemicals? YES (ii) Does the waste contain waste chemicals that are dangerous substances? Assess the waste chemicals for hazardous properties H1–H9 and H10–H14. If yes, the EWC codes 18 01 06* or 18 02 05* should be assigned to the waste. NO (iii) Does the waste contain other chemicals? This element of the waste should be assigned the EWC codes 18 01 07 or 18 02 06. (v) Go to Step 4 of the assessment framework. (iv) Classify the waste for transport. Figure6Assessmentandclassificationofchemicalwaste Step3(i):Arechemicalspresentinthewaste? Wastechemicalsshouldneverbeplacedinanyclinical,offensiveormixedmunicipal wastestream.Examplesoftheseincludelaboratoryreagents,auto-analysercartridges fromlaboratoriesandwards,photochemicals,handgels,disinfectants,cleaning chemicals,andtherapeuticchemicalsandtheircontaminatedpackagings. Note Alcoholhandgelsthatdonotcontainsiloxanes(whichcausesignificantdamageto plantandequipmentusedinthesewagetreatmentprocess)andwhosesafetydata sheet(SDS)doesnotprohibitdischargetothesewermayberinsedoutandthe packagingrecycledorplacedintothemunicipalwastestream. Wherethesechemicalsarepresentinthewaste,changestosegregationshouldbe implementedtopreventthisoccurringinfuture.Thewastecontainingthemmust,in additiontoanyotherclassification,beclassifiedwiththechemicalcode(s),and appropriatemeasuresmustbetakentodescribe,package,transportanddisposeofthe wasteatasuitablyauthorisedfacility.Thesearenotconsideredfurtherinthis assessment. Insomeinstances,clinicalwasteitemsmaybeproducedthatcontainorare contaminatedwithchemicals.Examplesmightinclude: • anatomicalorpathologyspecimensorsamplespreservedinchemicals(for exampleformaldehydeoralcohol); • samplevialsordiagnostickitscontainingchemicals; • sharpsorotherclinicalwasteitemscontaminatedwiththerapeuticor laboratorychemicals; • materialsusedtocleanupbiologicalspillsthatarecontaminatedwith chemicaldisinfectants. Theseitemsareconsideredfurtherinthisassessment. 51 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Wheresuchitemsarepresent,thechemicals(evenifonlypresentinsmallquantities) shouldbeidentifiedinthewastedescriptionandcomposition(arequirementofthe consignmentnote),andthechemicalhazardouspropertiesoftheitemassessedusing WM2,asinstep3(ii). Step3(ii):Arechemicalscontainingdangeroussubstancespresentinthewaste? Thefirststepistoidentifythechemicalspresentandwhethertheyaredangerous substances(forexample,havetheybeenassignedachemicalriskphraseonanSDS?). Ifthechemical(s)presentincludeoneormoredangeroussubstances,theproperties andconcentrationshavetobeconsideredfortherelevanthazardouspropertiesusing theassessmentproceduressetoutinappendixCofWM2.Wherethewasteitemisa container(forexampleasamplevialorspecimenpot),theweightofthecontaineris normallyexcludedfromtheassessment. Iftheitempossessesachemicalhazardousproperty,thewasteisaclinicaland hazardouswasteandshouldbeassignedthe180106*EWCcode(or180205*for animalhealthcare)asaresultofthispartoftheassessment.Thechemicalsand hazardouspropertiesmustbeidentifiedinpartBoftheconsignmentnote. Iftheitemdoesnotpossessachemicalhazardousproperty,thewasteisnotaclinical wastenorahazardouswasteandshouldbeassignedthe180107EWCcode(or1802 06foranimalhealthcare)asaresultofthispartoftheassessment.Ifthewasteisa hazardouswasteduetoothercomponents,thechemicalsmuststillbeidentifiedin partBoftheconsignmentnote. Step3(iii):Areotherchemicalspresentinthewaste? Wherethechemicalspresentinthewastedonotpossesshazardousproperties,this elementofthewasteis: • notclinicalwaste;and • notahazardouswaste asaresultoftheassessmentofitschemicalpropertiesonly.Assessmentofother properties,orelementsofthewaste,canalterthisstatus.Thepresenceofthechemical mustbedescribedontheaccompanyingpaperwork.TheEWCcodes180107 (humanhealthcare)or180206(animalhealthcare)shouldbeused. Step3(iv):Classificationfortransport Theclassificationofchemicalsfortransportisbeyondthescopeofthisguidance. ‘Transportpackagingandoperations’containsgeneraladviceontransportmatters. Transportpackagingandoperations WM2 ControlledWasteRegulations ControlledWasteRegulations(NorthernIreland) HazardousWaste(EnglandandWales)Regulations HazardousWasteRegulations(NorthernIreland) SpecialWasteAmendment(Scotland)Regulations Step4 7750 Step4:Assessmentofinfectiousproperties Thisstepprovidestheassessmentforeachelement(componentsandcontaminants)of thewasteforinfectiousproperties.Theassessmentissupportedbyaflowchart(see Figure7).Eachelementisclassifiedonthebasisofitsinfectiouspropertiesalone: • asclinicalandhazardousanddangerousforcarriage(typicallyUN3291);or 52 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • asnon-clinicalandnon-hazardousandnotdangerousforcarriage;and • theappropriateEWCcode(s)is/arealsoindicated. Thisassessmentconsiders: • thelegaldefinitionofclinicalwaste(theControlledWasteRegulations); • appendixC9ofWM2onthehazardousproperty“infectious”(H9); • thedefinitionofinfectioussubstancesgiveninADR. Clinicalornon-clinicalwaste Thewastewillbeclassifiedasaclinicalwaste(withreferencetothedefinitioninthe ControlledWasteRegulations)ifitmaycauseinfectiontoanypersonoranimal comingintocontactwithit(thatis,ifitpresentsanyriskofinfection). Hazardousornon-hazardouswaste Healthcarewastewillalwaysbeclassifiedashazardous(withreferencetothe definitionintheHazardousWasteRegulations)ifitis: • aclinicalwasteasindicatedelsewhereinstep4(see‘Keypoints’below); • dangerousforcarriageunderUN3291orotherinfectiousUNcode. Keypoints: Aclinicalwastethatisconsideredinfectiousforcarriagepurposes(forexample UN3291)mustpossessthehazardouspropertyH9:Infectious; Theonlyhealthcarewastesthatcanbebothclinicalandnon-hazardouswaste arenon-cytotoxicandnon-cytostaticmedicines. EWCcodes Theseareassignedtoinfectiouswastedependentonthesourceofthewaste,as illustratedbelow: • Infectiouswastefromhumanhealthcareisclassifiedas180103*. • Infectiouswastefromanimalhealthcareisclassifiedas180202*. • Non-healthcare-relatedinfectiouswastefrommunicipalsourcesisclassified as200199. 53 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Note:Segregationofinfectiousandnon-infectiouswaste 1.InScotlandandNorthernIreland,segregationofinfectiousandnon-infectious wasteisbestpractice. InEnglandandWales,mixingisprohibited.Therefore,producersmust segregateinfectiouswastefromotherwastes,andthesub-typesofinfectious wasteindicatedinthisdocumentmustbesegregatedfromeachother.Where offensivewastesegregationisnotimplementedintreatmentareas(ratherthan sanitaryfacilities),theresultantwastestreamwillcontainmixedoffensiveand infectiouswaste.Thiswastemustbeclassifiedanddescribedassuch.Producers areremindedoftheirstatutorydutytouseasuitablyauthoriseddisposalfacility andareadvisedthatalternativetreatmentplantsarenotnormallypermittedfor thismixedwaste.Producerswhohavenotimplementedoffensivewaste segregationintreatmentareas(ratherthansanitaryfacilities),andwhoareusing non-incinerationtechnologiesfordisposal,areadvisedtoreviewboththeir segregationproceduresandthedisposalsite’sauthorisation. Thecostimplicationsandcarbonimpactofmanagingthemixedwasteshould alsobeconsidered.Ifnon-infectiouswasteismixedwithinfectiouswasteand treatedassuch,itisbeingtreatedunnecessarily,requiringenergyduringthis process.Energyefficiencyisnormallytakenintoaccountwhenwastedisposal permitsareissued. 2.TheclassificationsystemusedintheAdvisoryCommitteeonDangerous Pathogens’(ACDP)‘Approvedlistofbiologicalagents’(thatis,ofbiological agentsintohazardgroupsHG1–HG4)isnotusedforwasteclassificationand transport,andthereforeisnotapplicabletothismanual. 54 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Start (i) Is the waste a culture or enrichment of a microorganism or toxin known or reliably believed to cause disease in man or other living organisms? OR Is the waste a sample from an animal or human known or clinically assessed to have a disease caused by a microorganism or its toxin? Clinical waste only YES (v) This element of the waste possesses the hazardous property “H9: Infectious” and should be assigned the EWC codes 18 01 03* or 18 02 02* or 20 01 99. NO (ii) Does the waste arise from a patient who is YES known or suspected to have a disease caused by a microorganism or its toxin? (vi) Does the waste contain infectious anatomical waste? NO (iii) Might the waste cause infection to any person or other living organism coming into contact with it? a (vii) Is the waste an infectious sharp? YES Note: a. This question incorporates part of the legal definition of a clinical waste. NO (iv) Has the individual waste item and source patient been clinically assessed for H9 Infectious? b YES (vi) Does the waste contain noninfectious anatomical waste? (viii) Classify for transport NO Note: b. For clarification, step (iv) represents a precautionary step to confirm the appropriate assessment has been conducted in accordance with steps (ii) to (iii) in determining that a waste is non-infectious. (vii) Is the waste a non-infectious sharp? (ix) Go to Step 5 of the assessment framework Non-clinical waste only Figure7Assessmentandclassificationofinfectiouswaste 55 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Step4(i):Isthewasteacultureorenrichment,orpathogenoritstoxin? Allcultures,enrichmentsordiagnosticsamples(discarded)knownorsuspectedto containviablemicrobialpathogensortheirtoxinsrenderthewaste“H9:Infectious”. Thiselementofthewasteis: • clinicalwaste;and • hazardouswaste. TheEWCcodes180103*or180202*shouldbeassigned. Whereatoxinispresent,theassessmentshouldalsoconsiderboththeconcentration andthechemicalpropertiesofthetoxintodeterminewhetherthewastealsopossesses hazardouschemicalproperties(forexample“H5:Harmful”or“H6:Toxic”).Seethe ‘Researchandlaboratoryfacilities’sectorguideforfurtherinformation. ThefollowingisanexcerptfromWM2,whichmayassistinundertakingthe assessmentspecifiedinsteps(ii)–(iv)ofFigure7andSteps4(ii)–4(iv). “Special requirements” (andH9infectious)applytohealthcarewasteswhereanyof thefollowingapply. (i)thesourcepersonoranimalisknownorsuspectedtohaveadisease/ infectioncausedbyamicroorganismoritstoxinandthewasteislikely tocontaintheviableinfectiousagentortoxin. (ii)thewasteis,oriscontaminatedwith,acultureoranenrichmentofa microorganismoritstoxinthatmaycausediseaseinmanorother livinganimals. (iii)Thehealthcarewaste“may cause infection to any person (or other living organism) coming into contact with it”.(Notethisstepreferstothe definitionofaclinicalwaste.) Thisshouldbedeterminedbyclinicalassessmentofeachitemandsourcepatient, asfollows: Clinicalassessmentshouldbecarriedoutbyahealthcareprofessionalwhois familiarwiththetypeofwastegenerated,thecurrentmedicalconditionand, wherefeasible,thepastmedicalhistoryofthepatient. Itisunlikelythatitwillalwaysbepracticalorpossibletoidentifyspecific pathogensortoxinswithinthewastewhenapatientfirstpresentssymptoms,as definitivelaboratoryidentificationrequirestimetoundertake.Theprocedurefor determiningwhetherawasteisconsideredhazardousbyH9musttherefore, wherethisisthecase,assumethatthediseasecausingagenthasnotbeen confirmed,andshouldbebasedonclinicalassessmentofwhetheran unidentifiedinfectionofanytypeissuspectedorknown.Laboratory identificationisnotrequiredtoassessthewasteforH9. Allpathogensandmicrobialtoxinsshouldbeincludedintheassessment.H9 doesnotconsidertheseverityofthedisease. Notethatanyunderlyingorsecondaryinfections,previouslydiagnosedbya healthcareworker,mayalsogeneratewastethatissubjecttoassessmentfor specialrequirements. Step4(ii):Doesthewastearisefromapatientwhoisknownorsuspectedtohave adisease/infectioncausedbyamicroorganismoritstoxin? Theterm“knownorsuspected”relatestodiagnosisandtreatmentratherthan laboratoryidentification.Therefore,whereapatientpresentswithsymptomsthatmay haveseveralcauses,oneofwhichisaninfectiousagent,aninfectionis“suspected”. Onceadiagnosishasbeenmade,oralaboratoryresultobtained,thismaybecome “known”.Bothareconsideredtorepresent“H9:Infectious”underthisassessment. Theassessmentofthewastedoesnotrequiretheidentificationofapathogen;thefact thatthesymptomsmaybecausedbyapathogenofanytypeissufficient. 56 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Theassessmentdoesnotconsidertheseverityofdiseaseortransmissionpotentialof thepathogenatthisstage.Allpathogensofmanorotherlivingorganismsare included.Wherethewaste(atthetimeofproduction)containstheviablepathogen associatedwiththediseaseinanyquantity,thewastepossessesthehazardousproperty “H9:Infectious”. Note Theprevioustwoparagraphsrefertotheassessmentforahazardouswastebasedon thepresenceorsuspectedpresenceofinfectionbasedonappendixC9ofWM2on hazardousproperty“H9:Infectious”. Where(i)healthcarepremiseshavepatient-specificassessmentproceduresinplaceand itispossibletoassesstheindividualpatient,and(ii)itcanbeconfirmedthatthereis noriskofinfection,certainwastefromthatpatientmaybeconsideredtobe potentiallyoffensive/hygienewaste(thesubsequentstepsintheassessmentframework mustbefollowedbeforethatcanbeconsidered).Table2isprovidedtoillustratesome examplesrelevanttothisstep. Table2Examplesoftheapplicationofstep(ii)ofFigure7(infectious) (ii)Doesthewastearisefromapatientwhoisknownorsuspectedtohaveadiseasecausedbyamicroorganism oritstoxin? Yes No Examplesofwherewastefromaspecificpatientwitha Theindividualpatientisnotsufferingfromanailmentor specificdiseasecausedbyamicroorganismoritstoxinis displayinganysymptomsthatmightbecausedbya likelytogenerateinfectiouswaste.Forexample: microorganismoritstoxin. • wastefrominfectiousdiseasecases; • wastefromwoundinfections; • hygieneproductsfrompatientswithurinary tractinfections; • wastefrompatientswithdiarrhoeaorvomiting causedbyinfectiousagentsortoxins(for examplenorovirusesandClostridiumdifficile); • blood-contaminateddressingsfromapatient withHIV,hepatitisBorotherinfectionthat maybepresentintheblood; Thewasteisnotcontaminatedwithanymaterialfroma patient. Thewasteisfrompatientsknowntobecolonisedwith microorganisms(includingmulti-resistantorganisms)but noinfectionispresent. Note:Usersneedtoproceedtosteps(iii)and(iv)for furtherconsiderationbeforeconcluding“noninfectious”. • respiratorymaterialsfrompatientswithopen pulmonarytuberculosis,influenzaorother respiratoryinfections; • wastecontaminatedwithbodyfluidsfrom patientswithknownorsuspectedmicrobial diseases,likelytobecontainedinthebody fluids. Notes: AnywasteclassifiedasCategoryAorBwastesfortransportwillbedeemedinfectious. Wastefromsingleroomsusedforisolationofinfectionmaybeclassifiedasinfectiouswhereriskassessmentindicates thatthisisappropriate. Step4(iii):Maythewastecauseinfectiontoanyperson,orotherlivingorganism, comingintocontactwithit? Essentially,isthereanyotherreasonwhythewastemaycauseaninfectionand thereforebeconsideredaclinicalwaste?Thewasteproducer,throughpatientand item-specificriskassessment,mayidentifyreasonsotherthanthoseoutlinedabove 57 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 whythewasteisinfectious(forexample,wastefromemergencytreatmentwherethere isinsufficientknowledgeofthesourcepatient’sconditiontoconcludethematerialis non-infectious).Inthesecircumstances,theproducerhasidentifiedthatthewaste possessesapropertythatrendersitclinicalwasteandthatareductioninthenumberof microbesisrequired. Inreachingthatconclusion,theproducerhasassessedthewasteinamannerthat wouldalsoresultinthisassessmentframeworkassigningthehazardousproperty“H9: Infectious”tothewaste(thedefinitionofclinicalwasteisusedintheassessmentof “H9:Infectious”byWM2). Thisstepprovidesthehealthcareworkerwiththeabilitytoapplyaprecautionary approachtocontaminateditems;thatis,iftheyareuncertain,theymayclassifyitas infectious.Thiswouldnot,however,extendtouncontaminateditems. Wherethepatientisnotknownorsuspectedtohaveadiseasecausedbya microorganism(understep(ii)above),clinicaljudgementcanbeusedinthe assessment.Thehealthcareprofessionalshouldapplytheirprofessionaljudgementto theknowledgeofthesourcepatientinquestionandtheitemofwasteproduced.If theybelievethattheiteminquestionfromthatpatientpresentsnoriskofinfection, thenitisnotclinicalwaste(asaresultofariskofinfection).Thesamedecisioncan reasonablybeappliedelsewhereifcircumstancesrepeat,givinglimitedscopeto applyingthespecificdecisionmorewidelytosimilargroupsofpatients/items.So,for example,itmaybedecidedthatincontinencewastescontaminatedwithurineand faecesfromapatientinanelderlycarewardarenotinfectiousbecausethepatientis notknownorsuspectedtohaveaninfectionthatwouldresultinthepathogenbeing presentinthoseexcretions.Thisapproachcouldthenreasonablybeappliedtoother patientsinsameunit.Table3isprovidedtoillustratesomeexamplesrelevanttothis step. 58 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Table3Examplesoftheapplicationofstep(iii)ofFigure7(infectious) (iii)Mightthewastecauseinfectiontoanypersonorotherlivingorganismcomingintocontactwithit?(Note: thisquestionincorporatespartofthelegaldefinitionofaclinicalwaste) Yes No Anyhealthcarewastecontaminatedwithblood,pus, Thiswillincludeurine-,sputum-,vomit-andfaecallywoundexudatesandsimilarsubstancesisregardedas contaminatedmaterials(includingurinebags, presentingariskofinfection. incontinencepads,single-usebowls,nappies,PPE)where theanswertoquestion(ii)was“no”afterappropriate Thiswouldnotapplyifbothofthefollowingweretrue: item-andpatient-specificassessment. • itwasknownthattheindividualsourcepatient Sufficientinformation(egfrompathologytestsorclinical doesnot(egasaresultofpathologytestsor assessment)isknownaboutaspecificitemcontaminated clinicalassessment)haveaninfectionthat withbloodfromaparticularpatienttoclassifyan mightresultinpathogenscontaminatingthe individualitemasnon-infectious.Examplesofthismight waste;and include: • nootherriskofinfectionwasidentified(such • bloodtransfusionitems; thatthematerialisnotconsideredaclinical waste). • maternity,sanitaryandplacentalwastewhere pathologytestshaveconfirmedorclinical assessmenthasassessedthatnoinfectionis presentandnootherriskofinfectionexists; • dressingscontaminatedwithbloodwherethere issufficientknowledgeofthepatientforthe assessmenttoconclude‘notinfectious’(egitis knownthatnoblood-bornevirusesorother infectiousagentsarepresent); • faecally-contaminatedpads,nappiesorsimilar itemswherepathologytestsorclinical assessmentindicatenogastro-intestinal infection. Note:Iftheanswertothisquestionis“no”,the materialisbeingdeclaredas: • notaclinicalwaste;and • notinfectiousforcarriage(egUN3291); and • suitableforlandfillwithoutfurther treatment. Usersneedtoproceedtostep(iv)forfurther considerationbeforeconcluding“non-infectious”. 59 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Furtheradviceoninfectioushealthcarewasteclassification Theresultsthatdeterminewhetherawasteisclassifiedasinfectiousornoninfectiouswouldbeexpectedtobethesameregardlessofthehealthcaresetting (whetherintheacutehospitalorinacommunityenvironment). Ifanitemiscontaminated,forexamplewithabodyfluid,itmaybeclassifiedas eitherinfectiousornon-infectiousbasedonstep4oftheassessmentframework.If itisuncontaminated,itshouldnotbeclassedasinfectious.Examplesof contaminateditemsareswabs,bandages,incontinencepads,protectiveclothing (soiledgloves,aprons).Uncontaminateditemsmayincludeprotectiveclothing (uncontaminatedgloves,aprons,forexample,usedwhenservingfood)andouter dressingsnotcontaminatedwithbodyfluids. Iftheassessmenthasbeenimplementedcorrectly,themajorityofboth uncontaminatedmaterialsandmaterialssoiledwithlower-riskcontaminants(such asurine,faeces,vomitandsputum)wouldbeclassifiedasnon-infectiousand thereforenon-clinicalwaste.Theassessmentwould,however,alsobeexpectedto classifyaminorityofthiscontaminatedmaterialasinfectiousandthereforeclinical waste.Ahealthcareorganisationclassifyingalloftheirwastematerialsunderonly oneofthesecategoriesisalmostcertainlyassessingthewasteincorrectly. Conversely,theassessmentwouldbeexpectedtoclassthemajorityofhigher-risk contaminants(forexampleblood,pus,woundexudatesetc)aspresentingariskof infectionandthereforeasinfectiousandclinicalwaste.Insomecircumstances,the practitionermayhavesufficientknowledgetoclassifywastefromanindividual patientasnon-infectiousasaresultofitem-andpatient-specificassessment.Itis expectedthatapracticemayhavesufficientknowledgetoclassifyaminorityofsuch materialasnon-infectious.Ahealthcareorganisationclassifyingthemajorityofthe materialsasnon-infectiousisalmostcertainlyassessingthewasteincorrectly. Step4(iv):Hastheindividualwasteitemandsourcepatientbeenclinically assessedfor“H9:Infectious”? Municipalproducersorholdersarenotexpectedtohavetheexpertiseorpatient knowledgetoundertakethisassessment.Inthesecircumstances,allwaste contaminatedwithblood,pus,woundexudatesandsimilarsubstancesshouldbe regardedasinfectious.Thisdoesnotextendtouncontaminateditemsorthose containingorcontaminatedwithfaeces,urine,vomitorsputum,asthesecanbe consideredundertheoffensiveassessment. Healthcareproducersareexpectedtoundertakesuchassessments.Genericassessment ofawastestreamdoesnotmeettheassessmentrequirementssetoutinWM2.Ifsuch assessmenthasnotbeenconducted,thewasteisclassifiedasmixedinfectiousandnoninfectiouswaste.BothEWCcodes180103*and180104,or180203and1802 02*,shouldbeassigned,andthewasteconsignedashazardouswaste. Note Thisisnotsuggestingthatsuchmixingisallowed;itsimplyidentifieshowthelaw requiressuchmaterialtobemanagedoncemixinghasoccurred. Incertaincircumstances,assessmentofthepatientanditemwillnotbepracticalfor thehealthcareworker:forexampleambulancestaffinemergency environments;dentists,dentaltherapistsordentalhygienistswithoutaccesstothe patient’sfullmedicalhistory.Inthesecircumstances,allwastecontaminatedwith blood,pus,woundexudatesandsimilarsubstancesshouldberegardedasinfectious.In adentalsetting,forexample,salivamaybeconsideredpotentiallyinfectiousduetothe presenceoftracesofblood.Thisdoesnotextendtouncontaminateditems.These activitieswouldstillbeexpectedtogenerateahealthcareoffensivewastestream.Table 4isprovidedtoillustratesomeexamplesrelevanttothisstep. 60 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Table4Examplesoftheapplicationofstep(iv)ofFigure7(infectious) (iv)Hastheindividualwasteitemandsourcepatientbeenclinicallyassessedfor“H9:Infectious”?: Yes No Healthcare Healthcare Bloodtransfusionbags. Wasteproducedbyambulancestaffengagedin emergencyactivities. Placentalandsanitarywastefromamaternityunitwhere Domesticdiabeticsharpsreceivedbycommunity patientsarescreenedforinfections. pharmacies. Itemsnotcontaminatedwithsecretions,excretionsetc. Municipal Municipal Notapplicable. Sharpsfromsubstanceabusecollectedbylocal authorities. Sharpsfrombodyart. Step4(v):Thiselementofthewastepossessesthehazardousproperty“H9: Infectious”andshouldbeassignedtheEWCcodes180103*or180202*or 200199 Atthisstage,ithasbeendecidedthatanelementofthewasteisinfectious.Itis assignedanEWCcodedependentonsourceactivity: • humanhealthcareis180103*; • animalhealthcareis180202*. Thesearebothclinicalandhazardouswaste. Wherethewastearisesfrommunicipalactivitiesthathavenorelationtoprovisionor receiptofhealthcare,the200199codecanbeused.Thisisaclinicalbutnonhazardouswaste.Thisappliestowastessuchassharpsfrombodyartandsubstance abuse,butnottodiabeticsharpsfromdomesticpremises(whicharehealthcare). Step4(vi):Doesthewastecontainaninfectiousornon-infectiousanatomical waste? Forthepurposeofthismanual,thedefinitionofanatomicalwasteincludesbodyparts orotherrecognisableanatomicalitemsthatmaybeoffensivetothosewhocomeinto contactwithsuchitems.Theseinclude: • allhumanandanimaltissue,asthisisconsideredanatomicalwaste(being partofabodyororgan),withtheexceptionofverysmallunidentifiable piecesofskinorfleshincidentallyremovedfromtreatmentofwoundsor duringveryminorsurgery(forexamplemoleremoval,nailclippingsetc); • piecesofwastebone/tissuefrommaxillofacialsurgery. FurtherguidanceisprovidedbytheHumanTissueAuthority’s‘CodeofPractice5: disposalofhumantissue’. Thetwoprimarycriteriaforclassificationofanatomicalwasteare: • Isitinfectiouswaste? • Isit,orhasit,beenpreservedinchemicals(forexampleformaldehydeor alcohol)? Wheretheanatomicalwastehasbeen,oris,preservedinchemicals,thiswillneedto beincludedinthewasteclassificationanddescription.TheassignmentofEWCcodes relatingtothisisdealtwithinstep3oftheassessmentframework. Infectiousandmixedanatomicalwaste Healthcarewasteproducerswhoproduceanatomicalwastearelikelytoproducesome thatisinfectiousandsomethatisnot.Asthisdoesnotnormallyaffectdisposal 61 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 requirements,thisguidancedoesnotrecommendtheitem-specificassessmentand segregationofanatomicalwasteintoinfectiousandnon-infectious.Anatomicalwaste producedasaresultoftheproposedsegregationwillincludesomethatpossessesthe hazardousproperty“H9:Infectious”andbothclinicalandhazardouswaste.The appropriateEWCcodes(seeTable5)wouldthereforebe: • both180103*and180102(humanhealthcare);or • both180202*and180203(animalhealthcare). Non-infectiousanatomicalwaste Wasteproducerscanimplementitem-specificassessmentandsegregationtodivide theiranatomicalwasteintoinfectiousandnon-infectious.UN3291-labelled containersshouldnotbeused.Incertaincircumstances,humanoranimaltissuewaste willarisewherethereissufficientknowledgetoclassifyitasnon-infectious.An examplemightbeplacentasfrommaternityunits,wherescreeningofmothersallows thesmallnumberofpotentiallyinfectiousplacentastobesegregatedandclassified separately. Thenon-infectiouselementofthewasteisnon-clinicalandnon-hazardouswasteafter assessmentofinfectivity.TheEWCcodeisdependentonthesourceofthewaste: • 180102ifitarisesfromhumanhealthcare; • 180203ifitarisesfromanimalhealthcare. Segregation,packagingandlabelling Anatomicalwastemustbesegregatedfromotherinfectiouswastestreamsandplaced inveryclearlylabelled(as“anatomical”)rigidreceptaclescapableofcontainingbone, bloodandothertissuefluids(see‘Wasteminimisation,segregation,colour-codingand storage’).Wastedocumentationshouldspecificallyhighlightthepresenceofthiswaste. Anatomicalwasteshouldnotbedisposedofinclinicalwastebagsduetothe significantriskofitbeingconfusedwithotherwastetypes. Wherethetissueisnotinfectious,packagingmaybedefinedbyanychemical preservativespresent.Inanyevent,UN3291receptaclesshouldnotbeusedfornoninfectiouswaste. Furtherinformationondisposalarrangementsandclassificationisprovidedin‘Waste minimisation,segregation,colour-codingandstorage’. Table5EWCcodingforanatomicalwaste EWCCode 1801XX 180102 180103* 180202* 180203 62 Descriptionofwaste Wastefromnatalcare,diagnosis,treatmentorpreventionofdiseaseinhumans Bodypartsandorgansincludingbloodbagsandbloodpreserves(except180103*) Wastewhosecollectionanddisposalissubjecttospecialrequirementsinordertoprevent infection Wastewhosecollectionanddisposalissubjecttospecialrequirementsinordertoprevent infection Wastewhosecollectionanddisposalisnotsubjecttospecialrequirementsinorderto preventinfection for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Step4(vii):Isthewasteaninfectiousornon-infectioussharp Whatisasharp? Sharpsareitems(orpartsofitems)ofhealthcarewastethatcouldcausecutsor puncturewounds,includingneedles,theneedlepartofasyringe,scalpelandother blades,brokenglassampoulesandthepatientendofaninfusionset. Sharpswastedoesnotinclude: • syringebodies(otherthantheneedle)andtheresidualmedicinethey contain; • medicinalwasteintheformofbottles,vials,ampoules,openedampoules; • tubesortabletsetc,swabsorothersoftinfectiouswasteoranatomical waste; • brokencrockery/glasswarefromnon-healthcareitems(forexamplea coffeejar). Infectioussharps Sharpswasteproducedasaresultoftheproposedsegregationwillpossessthe hazardousproperty“H9:Infectious”.Insomecircumstancescertainsharpsthatarenot contaminatedwithbodyfluidsmaynotbeinfectious.Themaindisposaland segregationconsiderationforsharpswasteismedicinalcontamination.Thereforethis guidancedoesnotrecommendtheitem-specificassessmentandsegregationofthe smallproportionofsharpswastethatisdemonstrablynon-infectious(see‘Noninfectioussharps’below). Thiselementofthewasteisthereforeclinicalwasteandpossessesthehazardous property“H9:Infectious”.TheEWCcodeisdependentonthesourceofthewaste: • 180103*ifitarisesfromhumanhealthcare; • 180202*ifitarisesfromanimalhealthcare;and • 200199ifitarisesfromnon-healthcareactivities(forexampledruglitter, bodypiercingandtattooists). Theclassificationofthemedicinalelementofmedicinally-contaminatedsyringesis addressedinstep2andtheappropriatemedicinalEWCcodeswillhavebeenassigned. Producersshouldimplementthesegregationof: • cytotoxicandcytotoxiccontaminatedsharps(forexampleboth180103* and180108*or180202*and180207*)from • othermedicinallycontaminatedsharps(forexampleboth180103*and 180109or180202*and180208)from • non-medicinallycontaminatedsharps(forexample180103*or180202*). Non-infectioussharps Producersmayimplementitem-specificassessmentandsegregationofthesmall proportionof(non-infectious)sharpsthatarenotcontaminatedwitheithermedicines orbodyfluids,wherethisaffectsdisposaloptions.Thesewouldbetheonly circumstanceswheretheuseofthesingle180101and180201codeswouldbe appropriate(see‘Wasteminimisation,segregation,colour-codingandstorage’on disposaloptionsforsharpswaste). Inusingthesecodes,aproducerislegallycertifyingthatthewasteisnotaclinical waste,asitposesnoriskofinfection.Asaresultoftheassessmentoftheirinfectious properties: • theyarenotclinicalwaste; • theyarenothazardouswaste; • theyarenotdangerousforcarriage(forexampleUN3291); 63 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • theEWCcodes180101(humanhealthcare),180201(animalhealthcare) or200199(municipal)areassignedasappropriate. Sharpscontaminatedwithbodyfluids(forexampleblood)shouldbeclassifiedas infectious.Toconsiderclassifyinganysuchitemsasnon-infectious,sufficient informationabouttheindividualsourcepatientshouldbeknowntoconcludethat thereisnoriskofinfectionandthatthewasteisnotclinicalwaste.Forexample,if policyorpractice(includingthoseofwastecontractors)includesanyprophylaxisasa resultofneedle-stickinjurieswiththeseitems,ariskofinfectionhasclearlybeen identifiedandconsequentlythismaterialmustbeclassifiedasinfectious.Ifanyofthis materialisclassifiedasnon-infectious,theassessmentshouldbesupportedbyrobust writtenproceduresandrecords,asitcouldbechallengedbytheregulator. Sharpsfromnon-healthcaremunicipalsources(forexampleapplicationoftattoosor substanceabuse)possessthehazardousproperty“H9:Infectious”andareclinicalwaste becausetherewillbeinsufficientknowledgetoassessthewasteforinfectivity(seestep iv).Theycannotbeconsideredunderthisstep. Thiswastemustbepackagedandlabelledinreceptaclesthatclearlyidentifythe presenceofsharps(see‘Wasteminimisation,segregation,colour-codingandstorage’). ThewastemustnotbepackagedorlabelledinUN3291receptacles. Note Guidanceonsharpsusedbyself-medicatingpatientscanbefoundinthe ‘Communityhealthcare’sectorguide. Step4(viii):Classificationfortransport Wasteassignedthehazardousproperty“H9:Infectious”isclassifiedintotwosubcategories–CategoryAandCategoryB–forthepurposesoftransport: • CategoryA:aninfectioussubstancethatistransportedinaformthat,when exposuretoitoccurs,iscapableofcausingpermanentdisability,lifethreateningorfataldiseasetohumansoranimals. • CategoryB:aninfectioussubstancethatdoesnotmeetthecriteriafor inclusioninCategoryA. Wastethatisknownorsuspectedtobecontaminatedwithpathogenspresentingthe mostsevereriskofinfectionisclassifiedasaCategoryAwaste(examplesofCategory Apathogenscanbefoundin‘Carriageinformation:CategoryApathogenlist’). Withtheexceptionofcertainlaboratorywastes,verylittleCategoryAwastewillbe producedfromhealthcarepremiseswithintheUK.Thevastmajorityofinfectious wasteproducedfromthehealthcaresectorwillbeclassifiedasCategoryB(see ‘Transportpackagingandoperations’fortheclassificationsusedforinfectiouswastein theCarriageRegulations). Wherethewasteisnotassignedthehazardousproperty“H9:Infectious”,itmustnot bedescribedorlabelledasclinicalwasteorinfectious(forexampleUN3291)for carriage.Ifthewasteisclinicalwasteforotherreasons(specificallythepresenceof medicinesorchemicals),theseshouldbeconsideredtodeterminetheappropriate transportrequirementsthatapply. Note Whereanelementofthewasteisidentifiedasaninfectiousand/orhazardouswaste duetooneormoreoftheseproperties,thisclassificationapplies. Whereawastecontainsmultipleelementswithdifferentclassifications,thewasteis mixedandeachelementmustbedescribedandclassifiedseparately. 64 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Researchandlaboratoryfacilities Wasteminimisation,segregation,colour-codingandstorage Communityhealthcare Carriageinformation:CategoryApathogenlist Transportpackagingandoperations ControlledWasteRegulations ControlledWasteRegulations(NorthernIreland) Europeanagreementconcerningtheinternationalcarriageofdangerousgoodsby road(ADR) HazardousWaste(EnglandandWales)Regulations HazardousWasteRegulations(NorthernIreland) SpecialWasteAmendment(Scotland)Regulations Theapprovedlistofbiologicalagents(ACDP) ‘CodeofPractice5:disposalofhumantissue’ CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) Step5 7752 Step5:Reviewtheassessmentofeachelementofthewasteformedicinal, chemical,andinfectiousproperties Steps2–4provideanassessmentofeachelementofthewasteforthethreeproperties thatdefinehazardousandclinicalwastestatus.Step5reviewstheseresults. Whereanelementofthewasteisidentifiedasaclinicaland/orhazardouswastedueto anyoneormoreoftheseproperties,thisclassificationapplies. Whereawasteariseswithmultipleelementsofdifferentclassifications,thewasteis deemedmixed,andeachelementmustbedescribedandclassifiedseparately. Ifthewastecontainsanyelementsthatsteps2–4haveindicated,it: • isnotclinicalwaste; • isnothazardouswaste; • hasnotbeenassignedEWCcodesbysteps2–4. Theseelementscanbeassessedforoffensiveproperties.Iffoundtobeoffensive,these elementsmustalsobeclassifiedanddescribedaccurately. 65 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Step6 7755 Step6:Assessmentofoffensive/hygieneproperties Note Figure8andstep6explainhownappies,incontinencepadsandsimilaritemsare notalwaysclinical/infectiouswasteandcanoftenbeclassedasoffensive. Incontinencepadsarenotgenerallyregardedasinfectiouswasteunlesspatientshave aurinarytractinfection.Classifyingpadsandnappiescorrectlyandseparatingthem outisprobablythebiggestsavingthatcanbemadeinwastemanagement.Thisis possiblyoneofthebiggestopportunitiestoreducewastedenergyusedin unnecessarytreatmentofnon-infectiouswastesandpotentiallyintroducesignificant costsavings. Thisstepprovidesasuitableassessmentforoffensive/hygienewaste.Thefollowing assessmentissupportedbyaflowchart(seeFigure8).Offensive/hygienewasteis healthcarewasteorsimilarwastefrommunicipalsources,whichmeetsthefollowing criteria: • itisnotclinicalwaste; • itisnotdangerousforcarriage; • theproducerhasidentified,aftersegregationatsource,thatitissuitablefor disposalatanon-hazardouslandfillsitewithoutfurthertreatment; • itmaycauseoffencetothosecomingintocontactwithit. Offensive/hygienewasteincludeswastepreviouslydescribedashumanhygienewaste andsanprowaste.Potentiallyoffensive/hygienewastemayinclude(seealsoTables3 and4): • incontinenceandotherwasteproducedfromhumanhygiene; • sanitarywaste; • disposablemedical/veterinaryitemsandequipmentthatdonotposeariskof infection,includingPPE(thatis,itemsthatarenotclinicalwaste); • animalfaecesandsoiledanimalbedding. Offensive/hygienewasteisassessedverydifferentlydependingonsource: • Wasteitemsfromhealthcareactivitiesmustbeassessedforsteps2 (medicinal),3(chemical)and4(infectious)toconfirmthattheyarenot clinicalwastebeforeoffensivepropertiescanbeconsidered. • Incontrast,wasteitemsfrommunicipalsourcesareassessedforoffensive properties,withsteps2–4beingconsideredonlywheredirectedbythis assessment. Attheendofthisassessment,wasteitemsclassifiedasoffensive/hygienewasteare classifiedasnon-hazardous,andnon-clinicalwasteunderthefollowingEWCcodes: • 180104(humanhealthcare); • 180203(animalhealthcare);or • 200199(municipal). Offensive/hygienewasteisnotinfectious;therefore,fortransportpurposes,itisnot classifiedasdangerousgoods. Step6(i):Doesthewastecontainanyitemsthatareexcludedfromthis assessment? Theoffensive/hygienewastestreamshouldnotincludeanyofthefollowing: • sharps; • human/animalbodyparts,organsorbloodproducts; 66 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • petcarcasses; • wastechemicals; • medicinalwastethatconsistsofpharmaceutically-activesubstances; • anywasteitemalreadyclassifiedinsteps2–4. Ifanyoftheaboveitemsarepresent,thatelementofthewastecannotbeoffensive/ hygienewaste.Forassessmentofsuchitems(unlessalreadyclassifiedbythosesteps), steps2–5oftheassessmentframeworkneedtobefollowed. Anyitemsofnon-hazardousdomestic-typewastefoundinanywastestreamshouldbe coded200301.Theseincludenewspapers,flowers,foodanddrinketc,butexclude batteries,whichshouldbecodedseparately(asshouldotherhazardouswastes). Thefollowingitemsarealsoexcludedfromtheassessmentanddealtwithunder ‘Specificwastetypes’.Step4oftheassessmentframeworkmayapplyinsomecases: • dentalamalgam; • gypsum(plaster). Start (i) Does the waste contain any items that are excluded from this assessment? (see paragraphs 3.115–3.118) YES Not offensive waste. Go to Step 2 of the assessment framework to determine the classification NO (ii-a) Is the waste a healthcare waste classified under chapter 18 of the EWC? YES (iii-a) Has the waste item been specifically assessed as indicated in the assessment framework (Steps 1–4) and determined to be a non-infectious and non-hazardous waste? NO YES NO (ii-b) Is the waste a municipal waste that is similar to a healthcare waste? YES (iii-b) Has any risk of infection been identified by risk assessment? NO YES NO The waste is not offensive. Assign the EWC codes 18 01 03* and 18 01 04 or 18 02 02* and 18 02 03 and the hazardous property H9. Without assessment, it is assumed to be mixed waste. Offensive/hygiene waste. Assign EWC codes 18 01 04 or 18 02 03 Offensive/hygiene waste. Assign EWC code 20 01 99 The waste is not offensive waste. Assign the EWC code 20 01 99 and the hazardous property H9 Not offensive waste. The assessment is complete Figure8Assessmentandclassificationofoffensivewaste Step6(ii)a:Isthewasteahealthcarewasteclassifiedunderchapter18ofthe EWC? Thepurposeofthisstep(a)istodifferentiatetheassessmentrequirementsfor healthcarewastefromthoseofsimilarwastesarisingfrommunicipalsources. Healthcarewastesareclassifiedunderchapter18oftheEWCandarerequiredtobe subjectedtorigorousassessmentthroughsteps2–4oftheassessmentframeworkto determinewhethertheyare: 67 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • clinicalwaste; • hazardouswaste;or • dangerousforcarriage. Wastearisingfromhealthcareprovisioninthecommunity,evenifself-administeredby thepatient,isahealthcarewasteandnotamunicipalwaste.Healthcarewastewillalso includeanywasteproducedbyactivitiesthatrequireamedically-qualifiedpractitioner (forexamplesomecosmeticprocedures). Step6(ii)b:Isthewasteamunicipalwastethatissimilartoahealthcarewaste? Wastesimilartothatfromanimalorhumanhealthcare,butarisingfrommunicipal activities,isnotsubjecttothesamedegreeofassessment,asdomestichouseholders andnon-healthcareworkersarelikelytohavealimitedknowledgeofthisarea. Domesticpremisesproducearangeofminorfirst-aidandself-careitemsthatdonot involverecoursetoahealthcarepractitioner.Theseareassumedtobenon-infectious unlessahealthcarepractitionerindicatesotherwise.Therefore,soiledwastesuchas nappies,sanitaryproducts,smalldressingsandplastersarenotconsideredtobe infectiousunlessahealthcarepractitionergivesthedomestichouseholderadvicetothe contrary. Similarwastefromindustrialandcommercialpremisesisassumedtobenon-infectious providingthatariskassessmenthasbeenconducted.Therefore,soiledwastesuchas sanitaryproducts,minordressingsandplastersarenotconsideredtobeinfectious unlessaspecificriskisidentifiedorahealthcarepractitionergivesspecificadvicetothe contrary. Wastefromfirst-aidandothernon-healthcaresourcescoversawiderangeofactivities. Forclassificationasmunicipalwaste,theitemmusteitherbeproducedbyadomestic householderorbesimilartothatfromadomestichousehold.Therefore,thefollowing wastesshouldnotbeclassifiedunderchapter20oftheEWC: • wasteitemsproducedastheresultofaprocedurethatrequiresamedicallyqualifiedpersontoconductit(forexamplesomecosmeticprocedures);or • wasteitemssubstantiallydifferentintypeorquantity/sizetothatwhich wouldtypicallybeproducedbyadomestichouseholdwithouthealthcare involvement(forexamplelargedressings,bandagesandX-raywastes). Wastecontaminatedwithnon-infectiousbodyfluidsiscapableofcausingoffenceand thereforerequiresappropriatepackagingtoalertthoseinthewastemanagementchain ofthecontents.Thisisoffensive/hygienewaste. Step6(iii)aandb:Assessmentforoffensivepropertiesandriskofinfection Theassessmentisdividedintotwopartstodifferentiatehealthcarewastes(including thoseproducedinthedomesticpremises)fromsimilarmunicipalwastes. Forhealthcarewaste Step6(iii)a:Hasthewasteitembeenspecificallyassessedasindicatedinthe assessmentframework(steps1–4)anddeterminedtobeanon-infectiousand non-hazardouswaste? Wastesarisingfromanimalorhumanhealthcare(includingthoseproducedin domestichouseholdsandothercommunitysources)mustfirstbeassessedusingsteps 2–4ofthisassessmentframeworktodeterminewhethertheycanbeconsideredfor offensiveproperties. Onlyifthewasteitemandpatienthavebeenspecificallyassessedandthewaste identifiedaspotentiallyoffensivecanitbeconsideredhere.Nofurtherassessmentis requiredforthisstep,andthewastecanbeclassifiedasoffensive/hygienewaste. Ifclassifiedasoffensive/hygienewaste,thisfractionmustbesegregatedfrominfectious waste.Staffsegregatingwastemustbeprovidedwithclearinstructionsonthe 68 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 segregationprocessandshouldbeprovidedwithappropriatetraining.TheEWCcodes 180104or180203shouldbeassigned. Ifthehealthcareorganisationhasnotimplementedsegregationofoffensivehygiene waste,orifassessmenthasnotbeenconducted,thewastehasnotbeensegregated appropriatelyandisthereforeclassifiedasmixedinfectiousandnon-infectiouswaste. TheEWCcodes180103*and180104,or180203and180202*,shouldbe assignedandthewasteshouldbeconsignedashazardouswaste. Note Thisisnotrecommendingthatthewastesbemixed;itidentifieshowthelaw requiresproducerstomanagesuchwasteafterithasbeenmixed. Thedisposalofoffensivehealthcarewaste(180104/180203)byahealthcare professionalinthemixedmunicipalwaste(200301)bagmayconstitutean offenceunderdutyofcare. Onlywherethehealthcareworkerisworkingawayfromthepractice,inthe community,islimitedprovisionmadeforplacementofoffensivewasteitemsinmixed municipalwaste.See‘Part2:non-infectiousdressings’under‘Assessingwhetherwaste posesariskofinfection’inthe‘Communityhealthcare’sectorguideforclarification onsmallquantitiespotentiallyacceptableforinclusion. Forwastesotherthanhealthcarewaste Step6(iii)b:Hasanyriskofinfectionbeenidentifiedbyriskassessment? Domestic premises Waste(otherthanthoseidentifiedabove)fromdomesticpremisesisassumedto presentnoriskofinfectionunlessanindicationtothecontraryisprovidedbya healthcareprofessional. Wherethereisariskofinfection,thewasteisclinicalwasteandpossessesthe hazardousproperty“H9:Infectious”.TheEWCcode200199shouldbeassignedand thewastedisposedofinorangereceptacles.The‘Communityhealthcare’sectorguide providesfurtherinformation. Municipal premises other than domestic Thissectionconsiderspotentiallyoffensive/hygienewastefromnon-healthcare activitiesandpremises(forexampleoffices,shops,schools,childcarefacilities,animal boardingkennels,dogfaecescollectionbins,bodypiercingfacilities). Thesewastescannormallybeassumedunderthisstepoftheassessmenttopresentno riskofinfectionunlessanindicationtothecontraryisprovidedbyahealthcare professional.However,thosewhohaveadutyofcareforsuchwasteshouldundertake appropriateassessmentandsegregationwhereanyriskfactorsindicatethatanelement ofthewastemaybeinfectious. Wherethereisariskofinfection,thewasteisclinicalwasteandpossessesthe hazardousproperty“H9:Infectious”.TheEWCcode200199shouldbeassignedand thewastedisposedofinorangereceptacles. Wastecontaminatedwithnon-infectiousbodyfluidsiscapableofcausingoffenceand thereforerequiresappropriatepackagingtoalertthoseinthewastemanagementchain ofthecontents.Suchtypesofwasteshouldbeclassifiedasoffensive/hygienewaste. Thiswasteshouldbesegregatedwhereitisgeneratedinquantity–onebag(7kgor more)inanycollectioninterval.Onlyquantitieslessthan7kgmaybeplacedinthe black-bagwastestream. Note Carehomesthatprovidenursingormedicalcareandanimalquarantinefacilities areconsideredtoproducehealthcarewasteandareassessedassuchunderstep6(i). 69 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 EWCclassification,wastedescriptionandpackaging TheEWCcodeassignedtotheoffensive/hygienewastedependsonthesourceactivity (seeTable6).Thewrittendescriptionofthewasteshouldreflectitsnature,originand disposalrequirements.Forexample,thefollowingmightbeconsidered:“180104, offensive/hygienewastefromhumanhealthcaresuitablefornon-hazardouslandfillor municipalincineration”. Table6EWCcodingforoffensive/hygienewaste Source Humanhealthcare EWCcode 180104 Animalhealthcare 180203 Municipalwaste 200199 Codedescription Wastewhosecollectionanddisposalisnotsubjectto specialrequirementsinordertopreventinfection, e.g.dressings,linen,faecally-contaminateditems whereassessedtobenon-infectious,singleuse clothing(seeTable2) Wastewhosecollectionanddisposalisnotsubjectto specialrequirementsinordertopreventinfection. Otherfractionsnototherwisespecified. Offensive/hygienewaste(seeTable2) Packagingcolour Yellow/black Yellow/black Yellow/black or Forsmallquantities only–blackbag Summaryofadvicefornon-healthcarewasteproducers Sharps Syringesandneedlesaresharpsarisingfrom: • substanceabuse; • cosmeticpiercings;and • otherbodyart. ThiswasteisnotconsideredtoarisefromhealthcareandsoisclassifiedintheEWC asaseparately-collectedmunicipalfraction(200199).Itemsofsubstanceabuseare typicallytreatedasclinicalwasteduetotheriskofinfection,andpossessthe hazardouspropertyH9.Forduty-of-carepurposes,anypotentiallyinfectious clinicalwastenaturemustbedescribed,andthewastedisposedofbyincineration oralternativetreatment.Thewastemustbepackagedinasharpsreceptacleforboth transportandhealthandsafetypurposes. Soft waste Softwasteincludesswabs,smalldressingsandcottonwoolcontaminatedwithbody fluidsarisingfrom: • cosmeticpiercing;and • otherbodyart. Italsoincludeshygienewastefromboardingkennels,dogfaecescollectionbinsand catteries. Thiswasteshouldbesegregated,forduty-of-carepurposes,asoffensive/hygiene wastewhereitisgeneratedinanyquantity.Thisenablessubsequentholdersofthe wastetoidentifythenatureofthematerialandadapthandlinganddisposal proceduresaccordingly.Onlywhereitisgeneratedinsmallquantitiesshoulditbe disposedonintheblack-bagstreamwithotherwaste. Offices,childcarefacilities,publicconveniences,schoolsandshopswouldnot normallybeconsideredtobeclinicalwasteproducers.Appropriateriskassessments andproceduresshouldbeinplacetoidentifythosecircumstances(forexamplean outbreakofgastroenteritis)wherethismaynotbethecase. Communityhealthcare 70 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Specificwastetypes 7757 Amalgamwaste 7759 Seethe‘Dentalpractices’sectorguideandDefra’sguidanceondentalamalgam. Dentalpractices Defraguidanceondentalamalgam Medicaldevices 7763 AmedicaldeviceisdefinedintheMedicalDevicesRegulationsas: “Aninstrument,apparatus,appliance,materialorotherarticle,whetherusedaloneor incombination,togetherwithanysoftwarenecessaryforitsproperapplication,which: (a)isintendedbythemanufacturertobeusedforhumanbeingsforthepurpose of: (i)diagnosis,prevention,monitoring,treatmentoralleviationofdisease, (ii)diagnosis,monitoring,treatment,alleviationoforcompensationforan injuryorhandicap, (iii)investigation,replacementormodificationoftheanatomyorofa physiologicalprocess,or (iv)controlofconception;and (b)doesnotachieveitsprincipalintendedactioninoronthehumanbodyby pharmacological,immunologicalormetabolicmeans,evenifitisassistedin itsfunctionbysuchmeans,andincludesdevicesintendedtoadministera medicinalproductorwhichincorporateasanintegralpartasubstance which,ifusedseparately,wouldbeamedicinalproductandwhichisliableto actonthebodywithactionancillarytothatofthedevice.” MedicalDevicesRegulations Infected/used medical devices 7761 Whereimplantedmedicaldeviceshavebeenincontactwithbodyfluidsandhavebeen assessedtobeinfectious,theyshouldbeclassifiedandtreatedasinfectiouswaste. Ifthedevicecontainshazardoussubstancesorcomponentsincludingnickelcadmium andmercury-containingbatteries,thedescriptionofthewasteontheconsignment notemustfullydescribethewasteandallitshazards.Forexample,animplanted devicewithanickel-cadmiumbatteryshouldbeclassifiedas180103*infectious wastecontainingnickel-cadmiumbatteries(hazards–H9:InfectiousandH8: Corrosive). Thewastedescriptionshouldaccuratelydescribethewaste. Disinfected/unused medical devices 7762 Whereitisfeasibletodisinfectmedicaldevices,thesedisinfectedmedicaldevices shouldbeclassifiedasnon-infectioushealthcarewaste.Thedescriptiongiventothe wastemustadequatelydescribethewasteandanyhazardouscharacteristics(evenifthe wasteisnotclassedashazardouswaste).SeealsoHealthTechnicalMemorandum 01-01:‘Decontaminationofreusablemedicaldevicesinacutecare’orthelocal infectioncontrolteam. 71 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Note Furtherguidanceonalternativetreatmentsisprovidedin‘Treatmentanddisposal’. Somelargeimplantsmaynotbesuitablefortreatmentatcertainalternative treatmentfacilitiesduetotheirsize(forexample,hipimplantsmaynotbesuitable andmaydamagethefacility).Itmaybepossiblethatthesedevicesaredisinfected onsiteand,therefore,possibleoptionsfordecontaminationmaybeprovided. Batteriesmayalsobedisinfectedandsentforrecycling.Itmaybepossibletotrial thisinunitsthatdealwithalargenumberofimplants,suchasradiological interventionsuite/theatres. Adisinfecteddevicecontaininganickel-cadmiumbatteryshouldbeclassifiedas: “160213discardedequipmentcontaininghazardouscomponentsotherthanthose mentionedin160209to160212(H8:Corrosive)”.Thewastedescriptionshould accuratelydescribethewaste.Otherclassificationswithinsub-chapter1602may applytodisinfectedelectricaldevices.Adevicemayalsohavesharpcut-offleadsfrom extractionandthereforeshouldbeclassifiedasasharpanddisposedofappropriately. Treatmentanddisposal HealthTechnicalMemorandum01-01:‘Decontaminationofreusablemedical devicesinacutecare’ Implants 7765 Specialcareshouldbetakenwhenremovinganimplant,particularlyifithaselectronic componentssuchasanimplantablecardioverterdefibrillatororotherimplanted cardiacaid.Forexample: • theremaybeariskofelectricshocktoapersonremovingandsubsequently handlingthem; • cremationordisposalbyincinerationmightcausebatteriestoexplode, leakingtoxicgas. Suchimplantsshouldbedeactivated,removedwithconsent,decontaminated,and disposedofinasafemannerinthehazardouswastestream. Note Removeditemsarewasteproducedbythehealthcareorganisation.Wherethe patienthasaskedtoretaintheitem,itisnotconsideredwaste,sinceithasnotbeen discarded. Protocolsfortheremovalofimplantsshouldbedeterminedlocally.Localcardiac units,manufacturers/suppliersandfuneraldirectorsshouldbeconsulted.Helpful guidancehasbeenpublishedbytheAssociationofBritishHealthcareIndustries,the NationalAssociationofFuneralDirectors,theInstituteofCemeteryand CrematoriumManagement,andtheMedicinesandHealthcareproductsRegulatory Agency(MHRA)initscircularMDASN2002(35). Disposalmayincludereturntothemanufacturerorcardiacunittoaccessstoreddata (seealso‘Wasteminimisation,segregation,colour-codingandstorage’).Thereceiving authorityneedstobeawareofduty-of-careimplications.Referenceto decontaminationproceduresandappropriateprotocolsforreturningequipment shouldbeprovidedbythereceivingauthority. Wasteminimisation,segregation,colour-codingandstorage 72 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Radioactivewaste 7768 Thisguidancecoversthemanagementoflow-levelradioactiveinfectiouswaste producedfromhealthcareactivity.Itdoesnotcoverthemanagementanddisposalof sealedradioactivesources. Radioactivewastegeneratedfromhealthcareincludesradionuclidesusedintherapeutic anddiagnosticmedicine.Thiswasteisconsideredtobelow-levelradioactivewasteand issubdividedintothreecategories: • longhalf-life:3H,14C; • radioiodines:123I,125I,131I(anymixedwastecontainingradioiodinewillbein thiscategory); • otherBeta/Gammaemitters:89Sr,35S,32P,51Cr,201TI,111In,67Ga,99mTc, 57 Co,75Se,65Zn,59Fe,22Na,24Na,45Ca. TheEA,SEPAandNIEAregulatethestorageanduseofradioactivematerialin hospitals.RadioactivewasteisregulatedinaccordancewiththeEnvironmental PermittingRegulationsinEnglandandWalesandtheRadioactiveSubstancesActin ScotlandandNorthernIreland. IfradioactivewasteisexemptfromtherequirementsoftheEnvironmentalPermitting RegulationsortheRadioactiveSubstancesActbecauseitisbelowthethreshold,but hasoneormorehazardousproperties,thiswastewillbeahazardouswastewhere classifiedassuchintheEWC(thatis,theradioactivityisnotthehazardidentified). Note ForinformationontheEWCdescriptionrequirementsforradioactivewastein Scotland,thelocalSEPAofficeshouldbecontacted. Radioactivewasteshouldbelabelledwiththeappropriateclassaccordingtoitshazard characteristicsinaccordancewiththeCarriageRegulations.Radioactivewasteis classifiedasClass7substances.Thehazardwarningdiamondusedmayvarybasedon theisotopeandlevelofhazardposed.Anexampleofthehazardwarningdiamondis shownbelow: RADIOACTIVE Contents Activity Transport index 7 8 TheIonisingRadiationsRegulationsspecifythataradiationprotectionadviser(RPA) needstobeconsultedandshouldbeappointedtoadviseontheuseandmanagement ofradioactivematerials.TheRPAshouldworkwithhealthcarestaffandaDGSAto ensurethesafemanagementandtransferofradioactivewaste(see‘Transport packagingandoperations’). Transportpackagingandoperations EAwebsite SEPAwebsite NIEAwebsite RadioactiveSubstancesAct 73 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) IonisingRadiationsRegulations IonisingRadiationsRegulations(NorthernIreland) EnvironmentalPermittingRegulations Domestic(municipal)waste 7770 Forthepurposesofthisdocument,domesticwastemeansmixedmunicipalwastefrom healthcareandrelatedsourcesthatisthesameas,orsimilarto,black-bagdomestic wastefromdomestichouseholds.Healthcarepremisesmustnotplaceanyhazardous wasteinthiswastestream.Thewasteshouldthereforebenon-hazardousandsuitable fordisposalbylandfill(wherepre-treatmentrequirementsaremet),municipal incinerationwithorwithoutenergyrecovery,alternativemunicipaltreatment processes,orviarecyclingstreams. Thiswasteisclassifiedasmunicipalwasteinlinewithchapter20oftheEWC.For example: • 200301mixedmunicipal; • 200125edibleoilandfat. Healthcareorganisationsarealsoprohibitedfrommixingdomestic-typewasteinthe clinicalwastestream.Theplacementofclinicalwastebagsshouldbedesignedto remove(oratleastminimise)patientandvisitoraccesstothem.Whereadomestictypewastedoesentertheclinicalwastestream,producersareremindedoftheirdutyof care.Themixedwasteshouldbeclassifiedanddescribedusingthe200301EWC codeand“mixedmunicipalwaste”descriptioninadditiontotheappropriate descriptionfortheclinicalwastespresent.Thismixedwasteshouldbedisposedofata suitablyauthorisedfacility. Bloodtransfusionbags 7772 Bloodtransfusionbagswouldnormallyberegardedasanon-infectiouswaste.They areclassifiedundertheEWCas180102waste;however,asthisissharedwith anatomicalwaste,thewastedescriptionshouldmakeitveryclearthatthismaterialis bloodbags. Asanon-infectiouswaste,bloodbagsmustnotbeplacedintheclinicalwastestream, asmixingisprohibited.Asaliquidwaste,theyareprohibitedfromlandfillandmust notbeplacedintheoffensivewastestreamifthatislandfilled.Forsmallquantities, thecontentsofthetransfusionbagshouldbedischargedtofoulsewerbeforethe emptybagisdisposedofintheoffensivewastestream.The“empty”bagcanbecoded as180104(humanhealthcare)or180203(animalhealthcare). Gypsumandplastercasts 7774 Gypsum-richwastesarelikelytobeproducedas: • plastercastsandrelatedmaterialsinaccidentandemergencydepartments, fractureclinics,andperhapsveterinarysurgeries; • plastermodelsindentalpracticesandsimilarunitsinhospitals.Theymay alsobeproducedbychiropodists/podiatrists. Gypsum(calciumsulphate)willgeneratehydrogensulphidegasfrommicrobialaction ifitentersanormalmixedlandfill.Thetwomaindisposaloptionsforsuchwastesare: 74 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 1. gypsumrecycling;or 2. landfillinaseparatecellofalandfillthathasbeensetasideforsuchwaste. Thevastmajorityofplastercastsandmodelsarenotinfectiousandmustnotbeplaced intheclinicalwastestream.Gypsumplastercastsshouldnotbeplacedintheoffensive wastestreameither.Theseshouldbesegregatedasaspecific180104gypsumwaste stream. Whereaproducercandemonstratethattheyhavesegregatedandseparatelydisposed ofmostofthegypsuminthismanner,thepresenceofasmallnumberofgenuinely infectiousplasteritemsmayalsoneedtobesegregatedforseparatedisposal.Inany event,itshouldbeensuredthatthismaterialdoesnotendupdirectlyorindirectlyin landfill. 75 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Wasteminimisation,segregation, 7776 colour-codingandstorage Thissectionprovidesinformationonthesegregation,colourcodingandstorageof differentwastestreams.Italsoprovidesadviceonavoidingproducingwasteinthefirst place. Thelegalrequirementsfortransportingandpackagingthewastewhenremovedfrom site,inparticularwhereaDGSAisrequired(thisappliestomosthospitals),iscovered in‘Transportpackagingandoperations’. Transportpackagingandoperations Wasteminimisation 7778 Althoughmuchofthisguideisonmanagingwasteonceithasbeenproduced,thebest financialandenvironmentaloptionisnottoproducewasteinthefirstplace.Thisis becausewhetherwastegoesforrecovery,recyclingordisposal,itisstillaproductthat theorganisationhasusuallybought,handledandisthenhavingtopayfordisposalof. Avoidingproducingthewasteatallreducesbothbuyingcostsanddisposalcosts. Wastepoliciesshouldincludeaprogrammetocriticallyreviewthevolumeandtypes ofwastethatareproduced,andtoidentifyandimplementpracticalstepstoreduce wastevolumes. Identifyingwherewastesareproducedacrossasiteisafirstpriority.Thiscantakea systematicapproach,forexamplemappingwastearisings,clearlyaskingwhyeach wastestreamisproducedandidentifyingtheunderlyingreasonsforeach.Areasof focusshouldcoverwastearisingsfromhospitalactivitiesandwastegeneratedby patients.Itshouldalsocoverwastesgeneratedduringnormaloperationandalsononroutinecircumstances. Identifyingtherootcausesforthegenerationofwastewillrequireclearappraisaland openquestioning.Rootcausesmayalsolieindecisionsmadeelsewhereinthe organisation,oftenattheprocurementstage.Forexample,out-of-dateproductsgoing towastemaybebecauseofpoorstockcontrolinadepartment,orfromtheatresets whereoftenonlyoneitemisneededandthenthewholetrayhastobediscarded becauseitisnolongersterile.Itmayalsobebecausetheprocurementteamboughttoo muchofaproduct.This,inturn,maybebecauseanotherdepartmentaskedthe procurementteamtobuythatvolumeinthefirstplace. Whenchoicesaremadebetweenproductsattheprocurementstage,theenvironmental consequencesneedtobeconsidered.Itmaybecheapertobuyaparticularproduct, butsavingscouldbelostsimplybecausemorewasteisproducedoritisharderto recycle/disposeof. Finally,wastepoliciesshouldhaveaclearandtime-boundaimtoreducetotalwaste arisings–regardlessofwherethesewastesareeventuallydisposedof.Thisaimshould besupportedbypracticaldeliveryprogrammesandshouldaddresstherootcauses identifiedatreviewstage. Waste-derivedcarbonimpact 7781 Acarbonindicatorwasdevelopedtoassisttrustsincontinuingtoidentifytheirwider carbonfootprint.Itwasbasedupontheformatthatisnowcommonlyrecognisedfor indicatingtheenergyefficiencyofbuildingsandequipmentsuchaswhitegoods. Figure9isanexampleproducedbytheDepartmentofHealth,issuedinDecember 2009,andderivedfromERICdata.Itcanbeusedandupdatedlocallybytrusts. 76 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Figure9NHScarbonusecertificate Importanceofwastesegregation 7783 Segregationofwasteatthepointofproductionintosuitablecolour-codedpackagingis vitaltogoodwastemanagement.Healthandsafety,carriageandwasteregulations requirethatwasteishandled,transportedanddisposedofinasafeandeffective manner.Thecolour-codedwastesegregationguides(seeFigures10and11)represent bestpracticeinScotlandandNorthernIrelandandensurecompliancewithcurrent regulations.InEnglandandWales,theprohibitiononmixingmeansthatthe segregationofthedifferentcategoriesofwastepresentedinFigure11isrequiredto meetlegalrequirements(althoughthecolourcoderemainsbestpractice). Thesegregationofthedifferentwastestreamspresentedisnecessaryforthefollowing reasons: • InEnglandandWales,mixingisprohibitedbylaw–thedifferentcategories ofwastepresentedinFigure11mustbesegregated.Itrepresentsbestpractice inScotlandandNorthernIrelandandensurescompliancewithcurrent regulations. • Healthandsafety:reducingtheriskofexposureandinjury(forexample needle-stick)forallstaffhandlingthesewastestreams. 77 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • Environmental:potentialforwasteminimisation,recycling,anddecreasein wastepreviouslyincorrectlyclassifiedasinfectious. • Financial:potentialreductionofhazardouswastethroughcorrect classificationofoffensivewastestreams. • Carbon:unnecessarilytreatingnon-hazardouswasteashazardouscanwaste energyandassociatedcarbon. • Dutyofcare:theproducerislegallyrequiredtoclassifyanddescribetheir waste.Thisismuchsimplertocomplywithifthewasteisnotamixtureof severaltypes.Failingtodescribethemixedwastecorrectlyoftenleadstoits unauthoriseddisposal. Differentwasteshavedifferentdisposaloptions;segregatingthewasteallowsbetter managementofthematerial(thelegalrequirementtosegregatewastecannotbe avoided–choosingtoincinerateeverythingisnotanoption).Todisposeofmixed wastelegallycanbeveryexpensiveandproblematical. Insomecircumstances,additionalsegregationofthewasteintofurthercategoriesmay alsoberequired(forexamplechemically-incompatiblechemicalsormedicines). Note Inaddition,segregationisimportanttoensurethatpatient-identifiabledatais correctlydisposedof(thatis,madeunreadable).See‘Wastemanagementlicensing andpermitting’. CaseStudy:QueenMargaretHospital,Dunfermline AcasestudyatQueenMargaretHospitalinDunfermlineonhowtoreduce,reuse andrecycleinrenalunitsfoundjustover£18,000incostsavings.Improved segregationatsourcemeantthatmorematerialwentintothedomesticwastestream forrecyclingratherthanintotheclinicalwastestream. Furthermore,thenumberofsalinebagsusedwasreduced,andexpensivewash bowlsthatweredisposedofafteroneusearenowbeingwashedoutforreuse. Plasticcanistersholdingfluidforthedialysisprocessarenowbeingrecycled, diverting20,000canistersfromlandfilleachyear. Theuseofsalineandgivingsetswasreducedbystoppingtheunnecessarypractice ofhangingabagforemergenciesinfavourofusingthedialysismachinetoproduce thefluidneededforemergenciesandreinfusion.Thissavednotonlythecarbon embodiedintheirmanufacture,butalsotheemissionsassociatedwiththeir disposal.Abagofnormalsalinewascostingthedialysisunit£0.52p,whileasingle givingsetwascosting£0.35p.Duringthecourseofthe10,764treatmentsprovided peryear,theuseofonlinesubstitutionfluidsaves£9364(minusthesmallbutless quantifiablecostofproducingtheexactfluidvolumesonline)inprocurementcosts alone. Overtheannual10,764treatmentsprovidedbytheunitusingFresenius5008 machines,thiswouldresultinareductioninclinicalwasteof21,528kg–or21.5 tonnes.Asarelativelylargeproducerofclinicalwaste,theQueenMargaretHospital waschargedat£323pertonneofclinicalwaste,leadingtoanannualsavingof £69,445. Wastemanagementlicensingandpermitting Colour-coding 7785 Thecolour-codedsegregationsystemoutlinedinthissectionidentifiesandsegregates wasteonthebasisofwasteclassificationandsuitabilityoftreatment/disposaloptions inlinewithclassificationsin‘Healthcarewastedefinitionsandclassifications’. 78 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Theuseofthiscolour-codingsystemisnotmandatoryandisnotspecifiedin regulations.However,inEnglandandWalessegregationofthewastecategoriessetout inFigure11isaminimumrequirementarisingfromthelegalprohibitionofmixing, withadditionalsegregationnecessaryinspecificcircumstances. Producersshouldadoptthiscolour-codedsystemtoaidtheidentificationand segregationoftheirwaste.Byadoptingthebestpracticesystem,standardisationcanbe achievedacrosstheUK.Thisaidsstafftraining(recognisingthemovementofstaff betweentrusts),andhelpswastecontractorsandthepackagingindustry. Thisnationalcolour-codedsystemshouldbeadoptedwithimmediateeffectbynew facilitiesororganisationsthatproducehealthcarewaste.Existingfacilitiesand organisationsshouldseektoreorderthenewcolour-codedsupplyofwastereceptacles astheyreplacedepletedstocksinagreementwiththeirsuppliers/manufactiurers. Trainingtoimplementthenewsystemandcommunicatetheclassificationandstorage isfundamentaltosuccessfulimplementationoftherevisedcolourcodingsystem. Furtherinformationontrainingisprovidedin‘Managingcompliance’. Althoughtheuseofthecolour-codesystemisnotalegalrequirement,anyalternative thatisusedshouldnotconflictwiththosegivenhere.Specifically,acolourprovided hereshouldnotbeusedfordifferenthealthcarewastes,asthiscanresultinconfusion andmismanagementofthewaste. Referenceismadetotheminimumrequiredstandardofwastetreatment/disposal. However,wastemaybesenttoalternativetreatment/disposalmethodsthatoperateto anequivalentorhigherstandard.Anydisposalfacilityshouldholdtheappropriate permitsuitableforthewastetobetreatedandwithsufficientcapacity(see‘Treatment anddisposal’). Thefollowinghealthcarewastetypesareincludedinthissegregationguide: • infectiouswaste; • anatomicalwaste; • medicinalwaste; • cytotoxicandcytostaticwaste; • sharpscontaminatedwithcytotoxic/cytostaticproducts; • sharpscontaminatedwithothermedicinalwasteproducts; • sharpswhicharepotentiallyinfectious; • offensive/hygienewaste; • domesticwaste; • amalgamwaste; • chemicalwaste(includinglaboratory,X-rayandphotochemicals); • radioactivewaste; • largeequipmentandmattresses; • implanted/infectiousmedicaldevices. Propersegregationofdifferenttypesofwasteiscriticaltosafemanagementof healthcarewasteandhelpscontrolmanagementcosts.Theuseofcolour-coded receptaclesiskeytogoodsegregationpractice. Healthcarewastedefinitionsandclassifications Managingcompliance Treatmentanddisposal 79 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Containerlabelling 7794 Eachcontainermustbelabelledinaccordancewiththedetailsofthelegal requirementsfortransportingandpackagingthewaste(coveredin‘Transport packagingandoperations’). Thecontainerlabelsshouldclearlyidentifythewastetype(s)presentwithin.The purposeofthisistoensurethatwastessuchasanatomicalwastesandmedicinesare notmovedinanonymousyellowbinsthatmayleadtotheirsubsequent mismanagement. Inaddition,thecontainershouldbetaggedorlabelledinamannerthatidentifiesthe individualproducer.Thisislikelytoberequiredbydisposalsites.Inthecaseoflarger producers,bestpracticewouldbetoincludedepartmentalidentifiers. Itisnotsufficienttolabelbulkcontainers,aswasteisoftenremovedfromthesecarts duringsubsequentwastemanagementinthewastechain,andbadpracticecanresult indifferentwastetypesbeingplacedinthesamecarts. Colour Yellow Orange Purple Yellow/black Description Waste which requires disposal by incineration Indicative treatment/disposal required is incineration in a suitably permitted or licensed facility. Waste which may be “treated” Indicative treatment/disposal required is to be “rendered safe” in a suitably permitted or licensed facility, usually alternative treatment plants (ATPs). However this waste may also be disposed of by incineration. Cytotoxic and cytostatic waste Indicative treatment/disposal required is incineration in a suitably permitted or licensed facility. Offensive/hygiene waste* Indicative treatment/disposal required is landfill or municipal incineration/energy from waste at a suitably permitted or licensed facility. Anatomical waste for incineration1 Indicative treatment/disposal required is incineration in a suitably permitted facility. Red Black Domestic (municipal) waste Minimum treatment/disposal required is landfill, municipal incineration/energy from waste or other municipal waste treatment process at a suitably permitted or licensed facility. Recyclable components should be removed through segregation. Clear/opaque receptacles may also be used for domestic waste. Medicinal waste for incineration1 Indicative treatment/disposal required is incineration in a suitably permitted facility. Blue white Amalgam waste For recovery * The use of yellow/black for offensive/hygiene waste was chosen as these colours have historically been universally used for the sanitary/offensive/hygiene waste stream. 1. The colours “red” and “blue” are new to the colourcoding system in this edition. Care should be taken when ordering red containers to ensure that they can be clearly differentiated from orange. The colour coding could be agreed as part of a contract specification. Figure10Colourcodingkeytosegregationsystem 80 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Figure11(seeattachedfile)identifiesthedifferentwastestreams,EWCcodes, classification,packagingandpackagingcolourrequiredforeachwastestream.It assumesthatthepackagingmeetstherequirementsoftheCarriageRegulations(UNapproved)whereappropriate.(‘Transportpackagingandoperations’providesguidance oncompliantpackaging.) Figure11Wastesegregationchart.pdf Transportpackagingandoperations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) Infectiouswaste:yellowstream 7796 Theyellowinfectiouswastestreamisusedforwastethatisinfectiousbutwhichhasan additionalcharacteristicthatmeansthatitmustbeincineratedinasuitablylicensedor permittedfacility.Theknownexamplesare: • anatomicalwaste; • chemicallycontaminatedsamplesanddiagnostickits; • medicinally-contaminatedinfectiouswaste;and • CategoryApathogens.Anatomicalwasteisexplainedunder‘Anatomical waste–red-liddedreceptacles’. Laboratoriesandotherareasofmedicalpracticesmayproducesamplesordiagnostic wastesthatareinfectiousandalsocontaminatedwithchemicals.Similarly,infectious itemscontaminatedwithnon-cytotoxicandnon-cytostaticmedicinalwastemayarise insometreatmentareas. Note Wastechemicalsandmedicinesshouldnotbemixedintheclinicalwastestream. Incinerationisrequiredtodestroythesechemicalsandpharmaceuticals. Infectiouswasteknownorsuspectedtobecontaminatedwithpathogensclassifiedin CategoryAintheCarriageRegulationsshouldbetreatedon-sitepriortoremovaltoa disposalfacility;on-sitetreatmentmayincludeautoclavinginpurpose-builtautoclave facilities(examplesofCategoryApathogenscanbefoundinthe‘CategoryAclinical waste’sectionand‘Carriageinformation:CategoryApathogenlist’). Inexceptionalcircumstances(forexampleanautoclavemalfunction),wastethatis normallyautoclaved(thatis,microbiologicalculturesandotherinfectiouswaste classifiedasCategoryAinfectioussubstancesinADR)shouldbepackagedforcarriage andtransferredtoanincineratorassoonaspossible.Insuchinstances,thewaste shouldbeplacedinappropriateUN-approvedpackagesforthistypeofwaste(these maydifferfromotheryellowcontainersused).Itmustnotbeallowedtoaccumulate formorethan24hours.Healthcareorganisationsshouldseektheadviceoftheperson responsibleforsecurityattheorganisationtodevelopasecurityplantoensurethese wastesaresubjecttostrictprocedures. Wherethewasteisstoredforanyperiod,itshouldbestoredsecurelyandaccessshould berestrictedtoauthorisedandtrainedpersonnel(seethe‘Researchandlaboratory facilities’sectorguide).Wheredisposalortreatmenton-siteisnotpossible,an authorisationtomovethewastewillneedtobeobtainedfromtheVehicle CertificationAgency(seethe‘CategoryAclinicalwaste’section). 81 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Whereverpossible,CategoryAinfectioussubstances(includingwaste)shouldbe treatedon-site(usinganautoclaveorequivalent)beforebeingtransportedfordisposal asoffensive/hygienewaste(thatis,non-hazardouswaste). Anatomicalwaste–red-liddedreceptacles CategoryAclinicalwaste Carriageinformation:CategoryApathogenlist Researchandlaboratoryfacilities Managingcompliance CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) Anatomicalwaste–red-liddedreceptacles 7798 Anatomicalwaste,whichincludesrecognisablebodypartsandplacenta,requires disposalbyincinerationinasuitablylicensedorpermittedfacility.Thewasteshould betransferredinyellowUN-approvedrigidcontainerswithredlidsandclearly labelled.Forfurtherinformationontheclassificationofanatomicalwaste,see ‘Healthcarewastedefinitionsandclassifications’. Note Careshouldbetakenwhenorderingredlidstoensuretheycanbeclearly differentiatedfromorange;moreover,thenecessaryclearlabellingwillensurewastes aresegregatedinacompliantmanner.Thecolourcodingofthelidscouldbeagreed aspartofacontractspecificationwithmanufacturers. Teeth Asthedisposalofteethfromdentalpremisesisunlikelytocauseoffence,dental practitionersmaytreatthisasnon-anatomicalinfectiouswaste.Itiscommonpractice fornon-amalgamteethandspiculestobeplacedintheyellow-liddedsharps container.Dentalpractitionersmustensurethatallwasteistreatedappropriately,and teethcontainingamalgam(see‘Amalgam–whitecontainers’)shouldbesegregatedand sentforappropriaterecovery/disposal(seetheDefrawebsiteandthe‘Dentalpractices’ sectorguide). Foetalremains Disposaloffoetalremainsshouldbeinaccordancewithavailableguidance: • TheRoyalCollegeofNursinghaspublished‘Sensitivedisposalofallfoetal remains,guidancefornursesandmidwives’. • TheHumanTissueAuthorityprovidesinformationondisposalfollowing pregnancyloss. • TheHumanTissueAuthorityalsohasaCodeofPracticeonremoval,storage anddisposalofhumanorgansandtissues. Thekeyissueisaboutopenandsensitivecommunicationwiththemother(orparents) andforbereavementmanagers(orotherrelevantstaff )tobeawareoftheissuesand makearrangementsthatmeetthewishesoftheparentsinthemostsensitivemanner possible.Differentoptionssuchasburial,cremationorincinerationareprovided.This willinvolvecloseliaisonwiththefamiliesinvolved. 82 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Note Guidanceonthedisposalofwastegeneratedfromfuneralservicescanbefoundin HSE’s‘Controllingtherisksofinfectionatworkfromhumanremains’. Healthcarewastedefinitionsandclassifications Amalgam–whitecontainers Dentalpractices Defrawebsite ‘Sensitivedisposalofallfoetalremains,guidancefornursesandmidwives’ HumanTissueAuthority HumanTissueAuthorityCodeofPractice ‘Controllingtherisksofinfectionatworkfromhumanremains’ Infectiouswaste:orangestream 7800 Orange-streaminfectiouswastemaybetreatedtorenderitsafepriortofinaldisposal. Treatmentmayonlytakeplaceinasuitablylicensedorpermittedfacility(see‘Waste managementlicensingandpermitting’).Thiswastestreammustnotcontain chemicals,amalgam,medicinesoranatomicalwastes.Theorangeclinicalwastestream shouldnotcontainwastethatisnon-infectious(forexampledomestic,offensive, medicinal)orthathasadditionalcharacteristicsthatrequireincineration(medicinal, chemical,anatomical). Orange-streaminfectiouswasteiswasteknownorsuspectedtocontainpathogens classifiedinCategoryBasspecifiedintheCarriageRegulations.Forfurtherguidance ofthedefinitionofthisstream,see‘Healthcarewastedefinitionsandclassifications’ andthewasteassessment.Orange-streaminfectiouswasteishazardouswasteandis subjecttothecontrolsoftheHazardous/SpecialWasteRegulations(unlessusedfor EWC200199municipalwaste). Wastemanagementlicensingandpermitting Healthcarewastedefinitionsandclassifications CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) HazardousWaste(EnglandandWales)Regulations HazardousWasteRegulations(NorthernIreland) SpecialWasteAmendment(Scotland)Regulations Infectiousliquidwaste:yellowororangereceptacles 7802 Infectiousliquidwaste(forexamplebloodfromtheatres)shouldbeplacedinarigid leak-proofreceptaclefordisposal.Manyinfectious-wastetreatmentfacilitiesrequire thewastetobesolidifiedpriortoremoval;producersshouldseekguidancefromtheir wastemanagementcontractorregardingthis. Liquidwastemaybetreatedtorenderitsafeinsuitablylicensedorpermittedfacilities. However,notalltreatmentfacilitiesarelicensedtoacceptsuchwaste.Producers shouldseekguidancefromtheirwastecontractorregardingthemostappropriate disposalrouteforthiswasteandshoulduseappropriatecolour-codedreceptacles.See 83 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 ‘Transportpackagingandoperations’forguidanceonpackagingandreceptaclesfor transportingwaste. Note UndertheEnvironmentalPermitting(EnglandandWales)RegulationsandLandfill RegulationsinScotlandandNorthernIreland,itisprohibitedtosendinfectious wastedirecttolandfillfordisposal. Transportpackagingandoperations EnvironmentalPermitting(EnglandandWales) Landfill(Scotland)Regulations LandfillRegulations(NorthernIreland) Medicinalproducts–blue-liddedreceptacle 7804 Thepackagingforwastemedicinesissetoutin‘Transportpackagingandoperations’. Transportpackagingandoperations Cytotoxic/cytostaticwaste–yellowwithpurplestripeor 7806 purplestream Purple-streamwasteiswasteconsistingof,orcontaminatedwith,cytotoxicand/or cytostaticproducts;itrequiresincinerationinsuitablylicensedorpermittedfacilities. Healthcarefacilitiesthatproducecytotoxicand/orcytostaticwasteneedtoensurethat suitablepurple/yellowreceptaclesareavailableforthiswastestream,includingrigid receptaclesformedicinalwasteand/orinfectiouswaste,bagsforinfectiouswaste,and colour-codedsharpsreceptacles.Purplestreamwasteishazardouswasteandissubject tothecontrolsoftheHazardous/SpecialWasteRegulations. Notes 1. Residualmedicinalwasteiswastepharmaceuticalsnolongerintheir originalpackaging.Asitisnotpossibletoidentifythepropertiesofthis waste,itshouldbeplacedinUN-approvedpackagesfordisposalby incineration.Ifcytotoxic/cytostaticmedicinalresiduesarepresent,the receptacleshouldbelabelledassuch. 2. UndertheEnvironmentalPermitting(EnglandandWales)Regulations andLandfillRegulationsinScotlandandNorthernIreland,liquidwaste cannotbesentfordisposaltoalandfillsite. HazardousWaste(EnglandandWales)Regulations HazardousWasteRegulations(NorthernIreland) SpecialWasteAmendment(Scotland)Regulations EnvironmentalPermitting(EnglandandWales)Regulations Landfill(Scotland)Regulations LandfillRegulations(NorthernIreland) Sharpswaste–containerswithyellow,purpleandorange 7808 lids Sharpsaresegregatedanddisposedofonthebasisoftheirmedicinalcontamination. Thelidcolourofthecontainerorwholecontainerisbasedonthiscontaminationand 84 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 howthewasteshouldbetreatedanddisposedof(seeTable7under‘Fullydischarged syringes’): • Purplelid:sharpsthatarecontaminatedwithcytotoxicandcytostatic medicinesshouldbesegregatedanddisposedofatasuitablyauthorised incinerator.Purple-liddedsharpsreceptaclesshouldbeusedforthiswaste stream. • Yellowlid:sharpsthatarecontaminatedwith(thatis,usedinthe administrationof )non-cytotoxicandnon-cytostaticmedicinesshouldbe segregatedanddisposedofatasuitablyauthorisedincinerator.Yellow-lidded sharpsreceptaclesshouldbeusedforthiswastestream(see‘Fullydischarged syringes’). • Orangelid:sharpsthatarenotcontaminatedwithmedicinesshouldbe segregatedandcaneitherbesentforincinerationordisinfectedbyalternative treatmentatasuitablyauthorisedfacility.Orange-liddedsharpsreceptacles shouldbeusedforthiswastestream. Fullydischargedsyringes Fullydischargedsyringes 7810 ProducerslocatedinScotlandandNorthernIreland,wherethedisposalsite authorisationinthatcountrypermits,mayalsousetheorange-liddedsharpsreceptacle forfullydischargedmedicinally-contaminated(otherthancytotoxicandcytostatic) sharps.Thewastedocumentationmustmakeitclearthatfullydischargedmedicinallycontaminatedsharpsarepresent.Thisreducesthelikelihoodofthewastebeing disposedofatanunauthorisedfacility.Theproducermustdemonstratethattheyhave robustsegregationproceduresinplacetoseparatethosesharpsthatrequire incinerationfromthosesuitableforalternativetreatment. ForproducersordisposalsiteslocatedinEnglandandWales,fullydischarged medicinally-contaminated(otherthancytotoxicandcytostatic)sharpsshouldbe placedinayellow-liddedsharpsreceptacleandincineratedasmedicinallycontaminatedsharps. Itisnotacceptablepracticetotakeanyactiontointentionallydischargesyringesor itemscontainingresidualmedicinesinordertodisposeofthemintheorange-lidded sharpsreceptacle(as“fullydischarged”inScotlandorNorthernIreland).Ifthesyringe ispartiallydischargedandcontaminatedwithresidualmedicines,itshouldbedisposed ofintheyellow-liddedsharpsreceptacle. Forsharpstobeconsideredforalternativetreatments,theproducermustdemonstrate thattheyhaverobustsegregationproceduresinplacetoseparatethosesharpsthat requireincinerationfromthosesuitableforalternativetreatment.Whererobust segregationofsharpscontaminatedwithcytotoxicorcytostaticproductscannotbe guaranteed,allsharpswasteshouldbeincinerated. Table7Disposaloptionsforsharpswaste Sharpsbox colour 85 Disposaloption Contents for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Yellowwitha purplelid Sharpsincludingthosecontaminatedwithcytotoxicandcytostaticmedicines Incineration Partiallydischargedsharpsincludingthosecontaminatedwithmedicinesotherthan thosethatarecytotoxicandcytostatic SHARPS Incineration Yellowwitha yellowlid SHARPS Yellowwithan Incinerationor orangelid alternative treatment ForEnglandandWales:sharpsnotcontaminatedwithmedicinalproducts;for ScotlandandNorthernIreland:eitherfullydischargedorthosenotusedfor administeringmedicines SHARPS Note PartiallydischargedsyringesetcshouldbedisposedofinaUN-approvedsharps receptacle.Inparticular,medicationshouldbereturnedtothepharmacyand/or depositedinasuitable,approved,labelledreceptaclefordisposal.Thewaste documentationshouldaccuratelyreflectthereceptaclecontentsandidentifythe presenceofwastemedicines,wherepresent. Offensive/hygienewaste–yellow/blackbags 7815 Offensive/hygienewastemaybelandfilledinsuitablypermitted/licensedfacilitiesor sentforincinerationatmunicipalincineratorsfornon-hazardouswaste(including energyfromwaste).Owingtolandfillrestrictions,thiswastestreamshouldnotbe usedforgypsumwastes.Ifliquidwastesareplacedinthiswastestream,itisalso prohibitedfromlandfill. Note Beforebeingsentfordisposaltoalandfillsite,robustsourcesegregationis necessary.Verificationviaaproducer’spre-acceptanceauditisalsorequiredinorder toavoidinfectiouswastebeingmixedinwiththeoffensive/hygienewaste,whichis incontraventionofwastelegislation.Acceptanceofthiswastefordisposal ultimatelydependsonmeetingtheconditionsofthelandfilllicence/permit. Domesticwaste(usuallyblackbags) 7817 Domesticwasteiswastesimilarinnatureandcompositiontowastegeneratedinthe home.Domesticwasteshouldnotcontainanyinfectiousmaterials,sharpsor medicinalproducts.Wasteshouldalsomeetpre-treatmentrequirementsforthesitein linewiththeEnvironmentalPermitting(EnglandandWales)RegulationsandLandfill RegulationsinScotlandandNorthernIreland. 86 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Domesticwasteisusuallyplacedinablackbagfordisposalorfurthertreatment (throughamaterialrecyclingfacilityforextractionofmaterialsforreuseorrecycling). Useofclearbagsfordomesticwastehasbeenadvantageousforsometrustssincestaff canvisuallyinspectcontents.Domesticwasteseparatelycollectedatsourcefor recyclingshouldbereadilydistinguishedfromtheabovedomesticwastefordisposalor furthertreatment.Onceagain,thiscouldbeagreedwithinacontractspecification. Unlikedomestichouseholders,healthcareorganisationsareprohibitedfromplacing anyhazardouswastes(includingsomedeodorants,batteriesetc)intheblack-bagwaste stream. EnvironmentalPermitting(EnglandandWales)Regulations Landfill(Scotland)Regulations LandfillRegulations(NorthernIreland) Specialistarrangementsforsegregation 7819 Chemicalwaste:fixeranddeveloper 7818 Fixeranddevelopermaybeclassifiedashazardouswastedependingonthetypeof materialsused.Referenceshouldbemadetomanufacturers’safetydatasheetsfor productinformation. Ifappropriate,fixeranddevelopershouldbesenttoasuitablylicensedorpermitted wastefacilityformaterialrecovery.Ifrecoveryisnotappropriate,fixeranddeveloper shouldbetreatedorincineratedatsuitablylicensedorpermittedfacilities. Ifthematerialisrecycledorprocessedonthesiteofproduction,thepremisesmaybe subjecttoenvironmentalpermittingcontrolsandmayrequireatradeeffluentconsent. Note Theseitems/substancesmaybedeemeddangerousgoodsforcarriageonpublic roadsandhighways. Amalgam–whitecontainers 7821 Amalgamwasteconsistsofamalgaminanyformandincludesallothermaterials contaminatedwithamalgam.Amalgamwasteshouldbeplacedinrigidwhite receptacleswithamercurysuppressant.Amalgamwasteshouldbesenttosuitably licensedorpermittedwastemanagementfacilitieswherethewasteundergoesa mercuryrecoveryprocesspriortofinaldisposal(seealsoDefra’s‘Guidancefordentists onwastedentalamalgam’). ‘Guidancefordentistsonwastedentalamalgam’ Radioactivewaste 7823 Radioactivehealthcarewasteiswastecontaminatedwithlow-levelradioisotopes.This wasterequiresdisposalinsuitablylicensedfacilities,normallybyincineration. Appropriatepackagingisrequiredforradioactivewasteinlinewithtransport requirements. Largeequipmentandmattresses 7825 Wherepracticable,equipmentshouldbedecontaminatedpriortodisposal.Once decontaminated,infectiouspropertiesmayberemoved;however,theequipmentmay stillcontainhazardousproperties,whichwillbesubjecttostatutorywaste managementcontrols. 87 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Ifnohazardouspropertiesremain(forexamplecontaminatedmattresseswiththe perviouscoverintact),oncetheitemhasbeendisinfectedunderspecialist arrangements,theitemmaybedisposedofasdomesticwaste.Thedisposalofheavily soiledorinfectiousmattressesshouldbemadethroughthewastecontractor. Wheredisinfectionisnotpracticable,producersshouldcontacttheirwaste managementcontractortoestablishthebest-practicepackagingandtreatment/disposal options.Disposalofelectronicequipmentwillneedtobeinaccordancewiththe WasteElectricalandElectronicEquipmentRegulationsand,ifhazardous,the Hazardous/SpecialWasteRegulations. WasteElectricalandElectronicEquipmentRegulations HazardousWaste(EnglandandWales)Regulations HazardousWasteRegulations(NorthernIreland) SpecialWasteAmendment(Scotland)Regulations Implanteddevices 7827 Implanteddevicesaredefinedin‘Legislationandhealthcarewaste’.Producersshould contacttheirwastecontractortoestablishthebest-practicedisposalroutefor implanteddevices.Theproducershouldalsocontactthemanufacturerofthedeviceto establishwhetherthedevicemaybedisinfectedandwhethera“take-back”scheme existsforthiswaste. Note Soiledsurgicalinstrumentsmaybesentforcleaningandsterilizationpriortoreuse awayfromthehospital/clinicandarenotclassifiedaswaste.However,theywillbe subjecttotheCarriageRegulations(forfurtherguidancesee‘Soiledsurgical instruments’). Legislationandhealthcarewaste Soiledsurgicalinstruments CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) Successfulwastesegregation 7830 Forsegregationsystemstoworkeffectively,itisimportantthatstaffbeprovidedwith thenecessarytraining,supportandequipment,includingappropriatecolour-coded andlabelledwastereceptacles.Thelocationandpositioningofwastereceptaclesis criticaltosuccessinmeetingtherequirementsofworkpractice. Implementingwastesegregationsystems 7832 Staffarelikelytoadapttonewsegregationsystemsifthedesignofthesystemmeans thatstaffactionsareintuitive.Iftheactionsrequiredaretime-consumingorlaborious, staffmaystruggletocomplywiththesystem,resultingintheinappropriate segregationofwaste. Thefollowingissuesshouldbeconsideredinthedesignandsupplyofreceptaclesfor wastesegregation: • wasteshouldbeplacedinwastereceptacles,orotherappropriatereceptacles, asclosetothepointofproductionaspossible; 88 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • clinicalwastereceptaclesshouldnotbeplacedbywash-handbasinsinpatient baysorinothervisitor-accessibleareas; • receptacles/bagsshouldbereplacedwhenthree-quartersfull; • receptaclesshouldbesecurelysealed.Plastictieclosuresshouldbeusedfor healthcarewastebags; • labellingofbagstoindicatetheirorigin(forexamplebycodingonthebag itself,bysuitablepermanentmarkerbeforeuse,byalabelshowingclearlythe nameofthehospitalandthedepartment,pre-codedplastictiesorbypreprintedself-adhesivelabelsortape); • collectionsshouldbeatanappropriatefrequency(see‘Storageandfrequency ofcollection’). Backgroundinformation,trainingandregularcommunicationshouldbeprovidedto staffforthemtofullyunderstandwhywastesegregationisrequired.Thesystemsand proceduresusedforsegregatingwasteneedtobemonitoredandevaluatedonaregular basis(see‘Managingcompliance’). Storageandfrequencyofcollection Managingcompliance Wastereceptacles 7834 Thehealthcareorganisationisresponsibleforprovidingappropriatewastereceptacles thatarelegallycompliantandforprovidingadequatespacefortheamountofwaste produced. Atthepointofproduction,receptaclessuchaspedalbinsforbaggedwasteandsharps containersarerequired.Specificationforpackagingandsharpscontainersisprovided in‘Managingcompliance’. Specificationforbinsregardingfireretardancyareprovidedin‘FirecodeOperational provisionsmanualPartF’(specificallyunder“Management’). Managingcompliance PartF:ArsonpreventioninNHSpremises Storageandfrequencyofcollection 7843 Wherewasteaccumulatesinsmallquantitiesdaily,theintervalbetweencollections shouldbeasshortasreasonablypracticable.Withregardtoinfectiousandoffensive/ hygienewaste,excludingsharps,thecollectionperiodshouldensurethatodoursfrom thewastedonotcausenuisance.Thisshouldbeinlinewithstatutorynuisance requirementsandanywastemanagementlicence/permitrequirements. Healthcarewastereceptaclesmayneedtobestoredbeforebeingtransportedto treatment/disposalsites.Theyshouldnotbeallowedtoaccumulateincorridors,wards orotherplacesaccessibletounauthorisedpersonnelormembersofthepublic. Arrangementsshouldbemadetoroutinelytransportwastefromwardlevel,treatment roomordepartmenttoastorageareapendingcollectionbyawastecontractor(see ‘Transportpackagingandoperations’foron-sitetransport). Ifwasteispermittedtoaccumulate,producersshouldseekguidancefromthe appropriateenvironmentalregulatorregardingtheneedforanenvironmentalpermit orexemption(see‘Wastemanagementlicensingandpermitting’). Healthcarewasteshouldbestoredsecurelysoastopreventtheescapeofwaste,harm totheenvironmentandharmtohumanhealth.Failuretodosoisabreachofthe statutorydutyofcare.Thisappliestostorageatthepointofproductionandbulk storageareas. 89 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Note Careisrequiredwhenstoringwasteandarrangingthecollectionofwastetoensure itissecureandthatduty-of-carerequirementsarefulfilled. Incertaincases,localauthoritiesandbusinesseshavesimilarcoloursforwaste receptaclesforotherwastestreams(forexampleorangeforrecycling);thereforeitis essentialthewasteissecureandtransferredtotheappropriatepartyforcollection andtreatment. Laundrythatposesaninfectioushazardistransportedinredbags.Thesecanlook similartoorangebagsusedforhealthcarewaste.Thereforeclearlabelling, instructionandsecureseparatestoragearerequired. Transportpackagingandoperations Wastemanagementlicensingandpermitting Storage at the point of production 7836 Storageareasatthepointofproduction(thatis,patients’rooms)shouldbesecureand locatedawayfrompublicareas.Storageareasshouldbesufficientinsizetoallow packagedwastetobesegregatedandsoastoavoidwasteofdifferentclassifications beingstoredtogetherinthesamearea.Differentwastestreamsinthesamestore shouldbeclearlyseparated,suchthataleakfromonewastecategorycannot contaminatethecontentsorpackagingofanother. Note Differentwastestreams(forexampleinfectiousbagswithoffensivebags)shouldnot bemixedwheninstorage.Ifthewasteisthesame,suchasyellow-liddedsharps receptacleswithayellowbag,thismaybestoredtogether–thatis,sametypeof wasteandsameEWCcode(cautionshouldbeobservedifthesearestoredtogether toensurethatrigidcontainersdonotdamageorsplitbags).Itmaybepossibleto compartmentaliseanareaaslongtherearediscreteareaslabelledclearlyforeach typeofwaste.Ifcoloursofbagsaresimilar(forexampleorangeinfectiouswasteand redlaundrybags),extracareisrequiredforsegregation. Bulk storage 7837 Bulkstorageareasmaybesituatedwithinhealthcarepremisesoratalicensedor permittedtransferortreatment/disposalfacility.Regardlessoflocation,bulkstorage areasshouldbe: • reservedforhealthcarewasteonly; • well-litandventilated; • closetoanyon-siteincinerationorotherdisposalfacility; • sitedawayfromfoodpreparationandgeneralstorageareas,andfromroutes usedbythepublic; • totallyenclosedandsecure; • providedwithseparatestorageforsharpsreceptacles,anatomicalandwaste medicines,whichmayneedahigherdegreeofsecuritytoprevent unauthorisedaccess; • sitedonawell-drained,impervioushard-standing; • readilyaccessiblebutonlytoauthorisedpeople; • keptlockedwhennotinuse; 90 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • securefromentrybyanimalsandfreefrominsectorrodentinfestations; • providedwithwash-downfacilities; • providedwithwashingfacilitiesforemployees; • clearlymarkedwithwarningsigns; • providedwithseparate,clearly-labelledareasforwastethatrequires,rather thanisdestinedfor,differenttreatment/disposaloptions; • providedwithaccesstofirst-aidfacilities; • appropriatelydrainedtoasewer(withdischargeconsent). 7838 Size of bulk storage areas Allbulkstoresshouldhavestoragecapacitytomatchtheproposedfrequencyof collection.Bank(orother)holidaysneedtobetakenintoaccountandamargin providedforanyinterruptioninthedisposalsystem. Refrigerated storage 7839 Storingwastemustnotcreateodoursufficienttoposeastatutorynuisance. Refrigeratedstoragemayberequiredinhotweather(fittedwithadeviceforopening frominsideasaprecautionagainstpeoplebeingtrapped). Licences and permits 7840 Anenvironmentalpermit,wastemanagementlicenceorexemptionmayberequired forthebulkstorageofwaste,evenatthesiteofproduction(see‘Wastemanagement licensingandpermitting’forfurtherinformationonpermitting,licencesand exemptions).Wastebroughtintohealthcarepremisesfromotherhealthcaresources (forexampleotherpremiseswithinatrust)mayalsorequireasuitableauthorisation. Wastemanagementlicensingandpermitting Waste contracts and contingency planning 7841 Contingencyplanningiskeyforsuccessfulwastemanagementatalltimes.Problems withwastedisposalcontractsorwastedisposalarrangementscananddo happen.Wasteisrequiredtoberemovedfromsiteonaregularbasisanditisessential plansareimplementedformanagingwastefollowingunforeseencircumstances.This mayrangefromscenarioswherebythewastedisposalcontractorisnotabletoprovide theservice,extremeweathereventssuchasflooding,episodesofpandemicfluoracts ofterrorism.FurtherguidanceisprovidedontheDepartmentofHealth’swebsite. Contingencyplanningisrequiredtoensurethesecurityofwasteandmanagementfor non-typicalwastesuchasCategoryAwastestreams.Policiesandproceduresare requiredformanaging,packaging,handlingandtransportationofthiswaste. 91 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Procurementandmanagementofwastecontracts Therapidchangesinthewaywastestreamsareviewedandtheincreasingdrivefor evermoresustainablewastemanagementwillmeannotonlynewformsofcontract andprocurementspecifications,butnewandinnovativesolutionsfromthesupply chain. DHisworkingwithBIStopromotetheadoptionofForwardCommitment Procurement(FCP)asawayofdeliveringstep-changeimprovementstotheNHS. TheFCPprocedureisapracticalprocurementtoolthatcanhelptodelivercosteffectivesolutionstomeetaparticularrequirementorsocietalneed.Keyfeaturesof FCParetheidentificationofunmetneedsandrequirementsinoutcometerms, earlysupplierengagementandpro-innovationprocurementapproaches,suchasthe useofoutcome-basedspecifications,whole-lifecyclecosting,procurementofa whole-lifeand/orfully-managedserviceanduseofthe“competitivedialogue” procedure. DepartmentofHealthcontingencyplanningguidance ForwardCommitmentProcurement Case study: FCP project� 7842 Her Majesty’s Prison Service – Zero Waste Mattress Theproblem:HMPSwasbuyingaround60,000foammattressesandpillowsand disposingofaround60,000annually.Themajorityweresenttolandfillwiththe remainderclassedasclinicalorhazardouswaste,incurringhighdisposalcosts.In short,thesituationwascostlyandenvironmentallyunsustainableandoutofstepwith HMPSsustainabledevelopmentpolicies. “It was estimated that the volume of HMPS mattresses and pillows annually disposed of to landfill equated to 35 double-decker buses” – HMPS Procurement Team Thesolution:Thesituationrequiredaradicalrethink.Workingcloselywiththe Government’senvironmentalinnovationadvisorygroupFCPTeam,HMPSidentified arequirementforazero-wasteprisonmattresssystemandusedFCPtofindasolution. Thisledtoconsultationwithmattresssuppliersandaradicalshiftintheprocurement approach. InMarch2009,HMPSsignedasuppliercontractforazero-wastemattressandpillow solution.Innovativenewcoversextendedthelifeofthemattressesandmeanthatthere willbelittleneedforclinicalwastedisposal;instead,theywillberecycledintouseful products. Theoutcomes:Estimatedcostsavingsof£5million;zerowastetolandfill; minimisationofclinicalwaste;improvedenvironmentalandalsocommunitybenefits. “Theresponseofthesupplychainhasbeenexcellentandhasconfirmedthevalueof theFCPapproach.Theoutcomeshaveexceededallexpectationsfrombotha sustainabilityandfinancialsavingsperspective”–HeadofProcurementCompliance, MinistryofJustice Learning Whywasazero-wastesolutionnotavailablebefore?Aboveall,becauseHMPShad failedtoaskforit.TheFCPapproachledHMPStolookatthewholelife-cycleofthe mattress,establishwhattheyreallyneeded,consultwiththesupplychainandcreatea competitiveenvironment.Insteadofbeginningtheirprocurementsixmonthsbefore theendofacontract,itbegantwoyearsahead,givingpotentialsupplierstimeto respondinnovatively. 92 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Managingcompliance 7845 Thissectionisconcernedwithmanagementresponsibilityforensuringcompliance andhowtoestablishcontrolsystemstoachievethisobjective.Thesectionisstructured asfollows: • wastepolicy–theimportanceofhavingapolicytospecifyresponsibilities, objectivesanddetailedprocedurestogovernthesafemanagementof healthcarewaste; • auditing–oncethepolicyandproceduresareinplace,thissectionstresses theimportanceofregularstructuredcompliancecheckstoensurethe specifiedsystemsandproceduresarebeingfullyobserved; • training–ifthepolicyistobetrulyeffective,thecommunicationofitskey driversandobjectiveswillrequirefocusedtraininginitiativestoeducateand empowerstafftocomplywithitsrequirements; • documentationcontrol–theimportanceoffullycomprehendingwaste transferdocumentationandmanagingitsassociatedrecord-keeping requirements;and • incidentmanagement–thepolicyshouldspecifymeasuresfordealingwith incidentssuchasaccidentsorspillagesandthereafterreportingboth internallyandexternally,wherethisisastatutoryrequirement. Healthcarewastepolicy 7847 Climatechangeandwaste TheClimateChangeAct2008introducedlegallybindingtargetstocutemissions ofgreenhousegasesbyatleast80%by2050froma1990baseyear.TheActalso introducedpowerstoaskpublic-sectororganisationstoreportontheworktheyare doingtoadapttoclimatechange.Wasteisnowahighpriorityasithasasignificant carbonfootprint.Itincludestheemissionsduringproductionoftheproductsthat thengotowaste;transportoftheproductsandalsotransportrelatedtowaste disposal;andthetreatmentanddisposalarrangementssuchasalternativenon-burn technologies,incinerationandmethanefromlandfill.Thisdemonstratesthe importanceofreusing,recoveringandrecyclingproductsasmuchaspossibleand thisshouldbereflectedinthepolicyobjectives. Toeffectivelymanagehealthcarewaste,allthoseinvolvedinthemanagementofthe wastestreamshouldhaveaccesstoanappropriatehealthcarewastepolicythat identifieswhoisresponsibleforthewasteandprovidesclearlywritteninstructionson howitshouldbemanaged. Thepolicyshouldclearlyidentifythelegalobligationssetoutinwaste,healthand safety,andtransportlegislation.Thispolicyshouldsettheframeworkforoperational procedures,wastemanagementandresponsibilitiesinordertoachievethepolicy objectives. Asaminimum,ahealthcarewastepolicyshouldcontain: • aclearstatement,outliningtheaimsandrationaleofthepolicy,signedoffat boardleveltodemonstratehigh-levelcommitment; • legalandstatutoryobligationsincludingtransport; • currentwastemanagementcontractandarrangements,referringto contingencyintheeventofservicefailure; • anoutlineofwhohaswastemanagementresponsibilitiesandthelinesof accountability,withparticularattentiontothecommunityhealthcaresector duetothevarietyofactivitiesandsettingswherewasteisproduced; 93 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • theprovisionofinformation,instructionandtrainingonsafetransportation, specificationforuseofcorrectcontainersandbags,managingspillages, cleaningcontainersanddisposalprocedures; • arrangementsforimplementingthepolicy; • processesforidentifyingimprovementprogrammesandmonitoringprogress (thisshouldbeinlinewiththetrust’stargetsagainstbaselinefigures–thatis, numberofwaste/disposalroutes,wastecontractorlegalrequirements); • detailsaboutstafftraining,inductiontraining,updatesappropriatetospecific staffgroups–allthiswillincludebankandstudentnursesandhowtheir trainingneedswillbemet;and • sourcesoffurtherinformationandguidance(forexampleahealthcare organisation’swasteguidance).Someproducersprovidecontactdetailsfor helpdeskfacilities. Thepolicyshouldtakeintoconsiderationallaspectsofwastemanagementandshould identifytherolesandresponsibilitiesofthoseinvolvedinthewastemanagementchain from“cradletograve”(thatis,transport,finaltreatment/disposal,notnecessarilythe firstpointoftransfer,whichcouldbeawastetransferfacility).Thisshouldtakeinto considerationprocurementandwaste-contractorrequirements,andtakeintoaccount thewastehierarchyregardingwasteeliminationandminimisation,asdiscussedin ‘Wasteminimisation,segregation,colour-codingandstorage’. Thepolicyshouldclearlystatehowallpartiesinvolvedinwastemanagementshould communicatewitheachother,ensuringcompliancethroughoutthewaste managementchain.Thepolicyshouldspecifywhoisresponsibleforeachactivityto includecomplianceaswellasoperationalaspects.Theresponsibilitiesofdepartmental managersandothersneedtobeclear,andthewastemanagementarrangementsneed tobeproperlymonitoredandregularlyaudited. Theexistenceofapolicyshouldnotbeassumedtobeanindicationofpractice. Practicecanonlybedeterminedandmonitoredbyrobustauditprocedures. Theorganisationshouldhaveaccesstoadesignatedcompetentwastemanagerto coordinateandmanageallhealthcarewasteandotherwastemanagementactivities. Thiscouldbeasharedpost(forexamplethroughawasteconsortiumarrangement). ClimateChangeAct Wasteaudit 7849 Wasteauditsareanessentialtoolinassessingthecompositionofawastestreamforthe purposesofdutyofcare,foradherencetoproducerpre-acceptanceauditsforclinical wasteinEnglandandWales,andformonitoringwastesegregationandminimisation schemes.Itisimportanttonotethefollowing:theapproachandactualauditwill needtobeappropriatefororganisationandfunction,suchasahospitalordental surgery. ClinicalwastetreatmentpermitsinEnglandandWalesrequireproduceraudit informationforthepre-acceptanceproceduresspecifiedintheEA’sguidanceonthe managementofclinicalwaste(‘Howtocomplywithyourenvironmentalpermit: additionalguidanceforclinicalwaste(EPR5.07)’).ForScotlandandNorthern Ireland,thisisconsideredbestpractice. Auditsprovideusefulinformationonthecompositionandquantityofwaste produced.Thisinformationcanbeusedtodevelopandinfluencewastemanagement policiesandprocedures,andidentifyappropriatereuseorrecyclingoptionsor opportunitiestominimisewastebyamendingpurchasingpolicies. Auditsplayavitalroleindemonstratingcompliancewithregulatorystandards.Waste producersarerequired,inlinewiththedutyofcareandpre-acceptanceauditsfor 94 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 EnglandandWales,toensurethatwasteiseffectivelysegregatedtoensurethatitis treatedanddisposedofappropriately.Awastemanagementcontractormaybreach theirpermitrequirementsandbeforcedtodiscontinueserviceifthepre-acceptance auditsarenotcomplete.TheEAmayalsobeconcernedinrelationtofullcompliance ifsourcesegregationofwastesofdifferentclassificationsisnotevidentandsupported byauditdocumentation. Documentedevidencefromwasteauditsshowingeffectivesegregationdemonstrates thattheproduceriscomplyingwithregulations.Italsoreassuresthewastecontractor thatthewastereceivedissuitablefordisposalattheappropriatepermittedwaste facility.Anynon-conformancesfoundduringtheauditshouldbedetailedintheaudit report,andremedialactionshouldberecommendedtopreventreoccurrenceby focusingontheroot-causeissues. EPR5.07 Auditscopeandprocedure 7851 Wasteauditsneedtobecarriedoutbyanominatedpersonwhoisresponsiblefor wastemanagement,althoughthiscanbeconductedwithanexperiencedwasteaudit contractororconsultant.Inthiscase,thedesignatedwastemanagershouldbein attendancetounderstandtheissuesandrecommendationsfromtheaudit.Ateam approachisadvocatedtocoverallrelevantaspects(forexamplecontrolofinfection). Auditsshouldonlybeundertakenbythosemembersofstaffwhoaretrainedinthe auditprocedureandwhoarefullyawareoftheriskandhazardsposedbytheaudit protocol.Theauditprotocolshouldbereferencedinthewastemanagementpolicy.A detailedmethodstatementshouldbeproducedforeachaudittoolclearlystatingthe following: • whoshouldundertaketheaudit; • whatisincludedwithintheaudit; • howtheauditshouldbeundertaken; • themethodofrecordingandreportingthefindingsoftheaudit; • themanagementresponsibilityandmechanismtoactonthefindings; • anyinherentrisksandthecontrolmeasuresrequired(forexamplePPE required). Inpractice,internaldepartmentalauditscarriedoutregularlybytrainedwaste championswithinadepartment,supportedandcoordinatedbyacompetentwaste manager,areoftenthebestapproach. Thefirsttimeawasteauditisproduced,andforpurposesofthepermitting requirements,theauditshouldbethoroughandintensiveinitsapproach,includinga diagramordescriptionidentifying/listingmainwastestoragelocations.Itwillbe necessarytoundertakeperiodicwasteauditchecks(seethetwoparagraphsbelow)to ensurecontinuedcomplianceandalsotoensurethatthewasteauditremainsup-todateandpertinenttocurrentoperationalpractices,whichcanchangeovertime. Althoughtherearewasteaudittoolsavailable,eachwasteproducershouldproduce theirownwasteauditbasedonindividualneedsandcircumstances. Auditsshouldaddress(asaminimum)theeffectivesegregation,packagingand labellingofthefollowingwastetypes: • anatomicalwaste,otheranimalorhumantissues,andbloodproducts (includingchemicalpreservatives); • medicinesandmedicinally-contaminatedwaste(including,forexample, cytotoxicandcytostaticmedicines,andmedicatedandnon-medicated intravenousbags); 95 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • chemicalsandchemically-contaminatedwaste(including,forexample,hand gels,autoanalysercartridgesanddiagnostickits); • microbiologicalculturesandrelatedlaboratorywastestowhichadditional controlsmayapply; • mercuryandamalgam; • sharps(medicinally-contaminated,non-medicinally-contaminated,and cytotoxic-andcytostatic-contaminated); • clinicalwaste; • healthcareoffensivewastesinpatients’accommodationandtreatmentareas; • municipaloffensivewastesinpublicandpatients’toilets,andbaby-changing areas; • domesticwastes(ensuringnohazardouswastesarepresent). Differentissuesassociatedwithcomplianceinclude:classification; • segregation; • packaging; • wastedescription; • paperworkcompletionandretention; • storage; • movement/transport; • healthandsafety;and • finaldisposal. Frequencyofaudits 7853 Inlinewiththerequirementforpre-acceptanceauditsinEnglandandWales(whichis bestpracticeforScotlandandNorthernIreland),auditsarerequiredbytheproducer priortothedeliveryofthefirstbatchofwastetoapermittedfacilityandthenatthe followingminimumfrequencies: • every12monthsforeachmedicalpracticethatproducesfivetonnesormore ofclinicalwasteinanycalendaryear; • everytwoyearsforeachveterinarypractice,dentalpracticeandlaboratory thatproduceslessthanfivetonnesofclinicalwasteinanycalendaryear; • everyfiveyearsforotherhealthcareproducersofclinicalwaste. Asaminimum,auditsshouldbecarriedoutbeforedevelopingorupdatingwaste managementproceduresandatroutineintervalstomonitorcompliancewithwaste segregationschemes. Annualauditsprovideasnapshotofwastemanagementpractices,whilemorefrequent auditsallowproducerstomonitortheeffectivenessofwastesegregationand minimisationinitiatives,andtotakeactiontoremedynon-compliancesassoonas practicallypossible. Audittechniques 7855 Thereareanumberofmethodsthatcanbeusedtoauditawastestream.Thetypeand effectivenessoftheauditundertakendependsonthenatureofthewastestreamand thepurposeoftheaudit.Toaudittheentirewastestream,morethanoneaudit methodmayberequired.Anauditprotocolcontainingfouraudittoolsisprovidedin Table8.Theauditshouldberepresentativeof: 96 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • thefullrangeofwastereceptaclesinuse; • thefullrangeofdepartmentswherewasteisproduced;and • allstaffwhomayproducewaste(evenwhenwasteisproducedoff-site,for exampleinthecommunitysetting). Table8Examplewasteauditprotocol Typeofaudit Application Sharpsboxes Infectiouswaste Cytotoxic/ cytostatic substances Wastemedicines Offensive/ hygienewaste Auditobservation andrecordingof practice Y Y Y Y Y Observationof wastereceptacles Y Y Y Y Y Staffquestionnaire Y Y Y Y Y Detailed examinationof waste N (Y) N Y (Y) (Y)=Whereitcanbepracticablyachievablewithanappropriateriskassessment Observationandrecordingofpractice 7914 Auditsshouldinvolveareviewofstaffwastemanagementpracticesand,inparticular, theeffectivenessofsegregationprocedures.Theauditentailstheobservation,recording andclassificationofeachwasteitemasitisplacedintoareceptacle.Athorough examinationofthemedicines,equipment,reagentsetcintheunits,cupboardsand storesisaveryusefulwaytodeterminewhattheywillbediscarding,althoughwhich containertheywillbediscardedinwillthenneedtobedeterminedbyquestioningof staff. Thefinalstepintheauditistoconfirmthatthepaperwork(consignmentortransfer note)accompanyingthewastewhenitleavesthepremisesreflectstheauditfindings. Thisappliestoallwastetypes,includinghazardouswaste,andshouldbecarriedout onceperannumasaminimum. Observationofwastereceptacles 7916 Observationofthewastereceptaclesservestwopurposes.First,itprovidesa mechanismofspot-checksintendedtounderpintheobservationandrecordingof practice.In-usereceptaclesarevisuallyinspectedwithoutremovingthewaste.For example,thecontentsofasharpsboxcanbeviewedfromtheapertureoropeningof thebox.Second,itenablestheauditortopointitemsouttostaffandeitherask questionsorseekclarificationfromthosewhohaveproducedit.Thisappliestoall wastetypes,includinghazardouswaste,andshouldbecarriedout,atminimum,once perquarter. Detailedexaminationofwaste 7918 Detailedwasteanalysisisusedtodeterminethenatureandcompositionofwaste materials.Itinvolvesthemanualsortingofwastetodeterminetheeffectivenessof segregationprocedures. Auditproceduresshouldtakeintoaccountthespecificrisksposedandriskassessments undertakentoreduce,sofarasisreasonablypracticable,exposuretothewaste. ExposuretotheidentifiedrisksshouldbepreventedandtheuseofPPEshouldbe 97 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 consideredasadditionaltoothercontrolmeasures,whennecessary,toadequately controlexposure. Staffquestionnaire 7922 Staffunderstandingandpracticecanbeauditedbytheuseofquestionnaires.These canbeusedtotargetspecificareasormaybeusedrandomly.Questionnairesmaybe usedtoreviewstaffpracticeforallwastetypesincludinghazardouswaste.Theycanbe writtenorverbal.Themainuseofthistoolistoidentifyissuesfor,andtoestablish, staffawareness(forexampletodeterminehowanitemisclassifiedandhowitis disposedofonthatunit). Notes 1.Withregardtotheeffectivenessofsegregationpracticeorwastecomposition, questionnairesalonedonotprovidesufficientinformationforuseincompleting wastedocumentationorindemonstratingcompliance. 2.Anexampleproducerauditinlinewithpre-acceptanceauditisprovidedinthe EA’s‘Howtocomplywithyourenvironmentalpermit:additionalguidancefor clinicalwaste(EPR5.07)’. Approachtowaste-produceraudit 1.Produceadetailedreport,signedanddated,clearlyidentifyingresultsand realisticrecommendations/actionplansagainstasettimescale. 2.Signanddateperiodicauditreportsandlistlocationsofrepresentativesamples aswellasanyactionplansresulting,including: • legislativecompliance; • evidenceofpaperworkproperlyandfullycompleted; • sitevisits; • staffinterviews; • binaudits; • packaging; • siteinfrastructure; • organisationalstructure; • wastetypes–allwastestreams; • includeproductchemicals,laboratorysmallsandmedicinalwaste–can includeproductdatasheetsor•extrapolationofthisinformation; • wasteanalysis(visualacrossacross-sectionofareas–noteany inappropriatecontent); • wastequantities; • handling; • storage(cleanliness,security,capacity,segregation); • securityandlimitedaccesstoauthorisedpersonnel; • accidents/incidents; • healthandsafetyissues; • recycling,reuse,recovery; • prevention/minimisation; • trainingneedsanalysis; 98 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • procurementissues; • keydepartmentvisits; • movementandtransport; • monitoring,auditandreview; • communicateandpublicisewasteauditreportsaspartofwidertraining andawarenessrequirements. Dutyofcare • BasedonSection34EnvironmentalProtectionAct(Section5ofthe WasteandContaminatedLand(NorthernIreland)Order). • BestpracticeundertheEnvironmentalProtection(DutyofCare) Regulations. • Basedondisposalarrangementsforallwastestreams. • Auditsshouldbeundertakenonanannualbasisunlesscircumstances dictateamoreregularfrequency. • Peaceofmindforwasteproducer. • Followsprocessfrom“cradletograve”orsiteofwasteproductionthrough transporttoactualandfinaldisposalsite. • Confirmswasteisgoingwhereitshouldbegoing. • Includessitevisitsbothofwasteproducerandofwastedisposalcontractor. • Inspectionofregistration,permitsandexemptions. • Confirmationwiththeregulatorybodies. • Checkingtransferandconsignmentnotes. EnvironmentalProtectionAct WasteandContaminatedLand(NorthernIreland)Order EnvironmentalProtection(DutyofCare)Regulations EPR5.07 Wasteaudittrails 7926 Underenvironmentallegislation,wasteproducershaveacradle-to-graveresponsibility forthecontrol,management,transportanddisposaloftheirwaste.Wasteproducers shouldundertakeawasteaudittrail,atleasteveryyear.Thistoensurethatwasteis beingtransportedinaccordancewiththeCarriageRegulationsanddisposedofat appropriatelypermittedfacilitiesinaccordancewithduty-of-carerequirementsand localwastemanagementprocedures. Thiswillentailcheckingtherouteofthewastefrombeingcollectedandleavingthe sitethroughtofinaldisposal(forexamplewhereinfectiouswasteisrenderedsafe).For residualwastearisingfromthistreatment(forexampleashfromincineration),an auditofrelatedpaperworkandpermitdetailsissufficienttofulfildutyofcare obligations.Audittrailsmaybeundertakenmorefrequentlyifcircumstancesrequire. CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) 99 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Useofcontractors 7934 Commercialcontractorsandconsultantsmaybeusedtoundertakewasteaudits. Producersareadvisedtoconsiderthefollowing: • theproducerisresponsibleforthehealthandsafetyofcontractorsworking ontheirsite(see‘Legislationandhealthcarewaste’); • wasteremovedfromthesiteforthepurposeofanauditshouldcomplywith relevantwasteandtransportlegislation; • theorganisationconductingtheauditshouldnotbeaffectedbytheoutcome. Conflictsofinterestshouldbeavoided. Wasteaudits–thebenefits • demonstratescompliance; • looksatthebiggerpicture; • implementationofrecommendationswillresultinimprovements; • identifiesno-cost/low-costopportunitiestoimprove; • canrecovercoststhroughimprovedpracticesandmoreeffective segregation; • communicatingwasteauditreportsimprovesstaffawarenessand encouragesinvolvementandownership; • obtainevidence–takephotographsforimpactwhethergoodorbad; • actionlistswithtimescalesstimulatescompliance. Note Inadditiontothesewasteaudits,thePremisesAssuranceModel(PAM)foracute serviceshasbeenreleasedtosupportthehealthcaresectorinimprovingthequality andsafetyofthehealthcarepremiseswhileimprovingefficiencyandeffectiveness. MoredetailsareavailableontheDHwebsite. Legislationandhealthcarewaste DHwebsite–PAM Training 7937 Apolicyforthesafemanagementofhealthcarewastecannotbeeffectiveunlessitis appliedcarefully,consistentlyanduniversally.Thisrequiresthatallhealthcarestaff shouldbeawareofthepolicy/proceduresandthatthepolicyisimplementedby trainedandcompetentpeople. Trainingassistswithperformanceimprovementandmayfocusonanyareasofconcern fromtheauditsandanyspecificknowledgegaps.Itisimportanttoraiseawareness withstaffassoonaspossibleandthisensuresthatauditresultsarefollowedupwith relevantworkareas. Trainingneedsvarydependingontheresponsibilitiesandjobfunction.Ideally, separatetrainingprogrammesshouldbedesignedfor,andtargetedon,thefollowing groups: • infectioncontrolstaff,healthcaremanagersandadministrativestaff responsibleforimplementingregulationsonhealthcarewastemanagement; • medicaldoctors; • pharmacies; 100 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • allnursingstaff;and • cleaners,porters,auxiliarystaffandwastehandlers. Thosedeliveringtrainingshouldhaveexperienceinteachingandtrainingandbe familiarwiththerisksandpracticesofhealthcarewastemanagement.Smaller establishmentsgeneratinghealthcarewastemaynothavethisrangeofexpertise availabletothem,butshouldstillhaveaccesstocompetentadviceonhazardouswaste issues. Trainingprocedures 7946 Trainingproceduresandinformationneedto: • bewritteninawaywhichcanbeunderstoodbythosewhoneedtofollow them,includingthosewhomaynothaveagoodcommandoftheEnglish language; • usepicturesorphotoswhichwillassistwithanylanguagebarriers; • takeaccountofdifferentlevelsoftraining,knowledgeandexperience; • beuptodate; • beavailabletoallstaffincludingpart-time,shift,temporary,agencyand contractstaff; • beavailableinallareas. Examplesoftrainingpostersandinformationforasampleofhealthcareorganisations areprovidedin‘Examplesoftrainingsupportmaterials’. Managersneedtoensurethatproceduresarefollowedbyallstaff.Staffatalllevelswho generatethewasteneedtorecognisethattheyarepersonallyresponsibleforcomplying withagreedlocalprocedures. TheriskassessmentsrequiredbytheManagementofHealthandSafetyatWork RegulationsandCOSHHshouldidentifywhichstaffareinvolvedinthehandlingof healthcarewaste. UndertheHealthandSafetyatWorketcAct,theManagementofHealthandSafety atWorkRegulationsandCOSHH,theymustreceiveinformationon: theriskstotheirhealthandsafety,thatis,thedetailsofthesubstanceshazardousto healthtowhichtheyarelikelytobeexposed; • thesignificantfindingsoftheriskassessment; • anyprecautionsnecessary; • theresultsofanymonitoringcarriedout;and • thecollectiveresultsofanyrelevanthealthsurveillance. Examplesoftrainingsupportmaterials ManagementofHealthandSafetyatWorkRegulations ManagementofHealthandSafetyatWorkRegulations(NorthernIreland) ControlofSubstancesHazardoustoHealthRegulations(COSHH) ControlofSubstancesHazardoustoHealthRegulations(NorthernIreland) Trainingrecords 7948 Atrainingrecordwillreadilyenablelinemanagerstoidentifymembersofstaffwho arenotreceivingtheappropriateleveloftraining,andwheresuchtrainingshouldbe focused. 101 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Inductiontraining 7950 Trainingneedsvarydependingonthejobandontheindividual.Allstaffinvolvedin handlinghealthcarewasteneedtraining,informationandinstructionin: • therisksassociatedwithhealthcarewaste,itssegregation,handling,storage andcollection; • personalhygiene; • anyprocedureswhichapplytotheirparticulartypeofwork; • proceduresfordealingwithspillagesandaccidents; • emergencyprocedures;and • appropriateuseofprotectiveclothing. Trainingforstaffwhocollect,transfer,transportorhandlehealthcarewasteneedsto cover: • checkingthatstoragecontainersaresealedeffectivelybeforehandling; • ensuringthattheoriginofthewasteismarkedonthereceptacle; • handlingbags/receptaclescorrectly; • usinghandlestomoverigidreceptacles; • checkingthatthesealonanyusedwastestoragereceptacleisunbrokenwhen movementiscomplete; • specialproblemsrelatingtosharpsdisposal; • proceduresincaseofaccidentalspillageandhowtoreportanincident; • understandingofmarksandlabels;and • safeandappropriatecleaninganddisinfectionprocedures. Job-specifictraining 7954 Somestaffrequiremorespecifictraining.Theseincludepeoplewhouseprotective equipment,disposalfacilityoperators,drivers,andcommunityandlaboratorystaff. Operatorsofwastemanagementfacilitiesmustdemonstratethenecessarytechnical competencefortherelevantpermittedactivities.InEnglandandWales,thishas recentlychangedandisnowassessedonthebasisofeitheranemployee’sindividual competenceoranemployee’sindividualcompetencecoupledwithcorporate competence. Furtherinformationandthedetailsoftheapprovedschemescanbefoundonthe EnvironmentAgencywebsite. InScotlandandNorthernIreland,thesystemforcertificatesoftechnicalcompetence (COTC)remainsunchangedattimeofpublication. Driversofvehiclesusedtotransporthealthcarewastebyroadmayneedadditional trainingundertheCarriageRegulations,andthoseresponsibleforthemovementof thewasteshouldhaveaccessto,orbe,atrainedDGSA. Inaddition,transportregulationsrequirethatallthoseinthetransportchaininvolved inthetransportofdangerousgoodsreceiveappropriatetrainingcommensuratewith theirresponsibilities.Thiswouldincludeloadersandpackers.Informationongeneral trainingrequirementsandDGSAscanbefoundontheDepartmentforTransport’s website. Approvedwastemanagementschemes CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations 102 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) DepartmentforTransportwebsite Deliveryoftraining 7957 Trainingcanbedeliveredinavarietyofwaysdependingontheaudience.Thismay includeworkshopsandformalseminarsforseniorstaffandhands-ontraininginthe workplaceforsmallergroups.Thetrainingcanservetoeducatestaffandshould includeforeachgroup: • informationon,andjustificationfor,allaspectsofhealthcarewastepolicy; • informationontheroleandresponsibilitiesofeachhealthcarestaffmember inimplementingthepolicy;and • technicalinstructions,relevantforthetargetgroup,ontheapplicationof wastemanagementpractices. Frameworkcontractforthedeliveryofwastemanagementtrainingwithin thehealthcaresector 7965 BuyingSolutions(formerlyNHSPASA)hasdevelopedaframeworkagreementforthe deliveryofwastemanagementtrainingwithintheUK.Theaimistoensurethata comprehensivepackageoftrainingisavailableforaccessbytheNHS.Thetraining itselfaddressestherecommendationsoutlinedintheirguidancedocument. BuyingSolutionsguidancedocument Case study – Implementation of the offensive waste stream at Gloucestershire Hospitals NHS Foundation Trust 7966 GloucestershireHospitalsNHSFoundationTrustformedawastemanagementgroup inlightofthethenforthcomingHealthTechnicalMemorandum07-01inSeptember 2006tomanagethewaste.“Thegroupwastodecidethewastepolicy,atimescalefor implementation,thecommunicationsstrategyandtrainingmethods.Members includedtheboarddirectorresponsibleforfacilities,stafffrominfectioncontrol, procurement,supportservices(coveringdomesticsandporters),risk,communications, andleadnurses.”[JenGoode,EnvironmentManager.] Theimplementationoftheoffensive/hygienewastestreamwasakeypartofthenew wastemanagementsegregationscheme.Thiswasawell-publicisedandcarefully coordinatedproject,whichsawthewholetrustchangetothenewschemeforwaste segregationon“SORTITOUT”dayinFebruary2007. Paper towels tiger bin 103 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Everywardanddepartmenthasawastemanagementcoordinatorwhoattendeda trainingsessionandwasthentaskedtocascadethetrainingdowntotheirstaff,and advisehowmanybinsandofwhatsizeandcolourwererequired.Eachcompleteda scheduleoftheirrequirementsthatdetailedthepreciselocationofeachbin. Success–“We’reoftenrecommendedas‘theplacetovisit’bytheEnvironmentAgency sohopefullyweareanexampleofgoodpractice.”[JenGoode]“Therehavebeenafew staffwhohavehadissuesoveruseof‘tiger’[yellow/black]bags;however,tigershave beenfullyacceptedbymaternityandpaediatrics–maternityhaveoneorangebinin theirdirtyutilityandanotherinthesideroom(forbarriernursingifneeded); everywhereelseistiger.” Specificationforpersonalprotectiveequipment(PPE) 7968 COSHHrequiresthatriskstohealthbeeliminated,preventedor,wherethisisnot reasonablypracticable,reduced.AlthoughtheuseofPPEshouldbeconsideredas additionaltoothercontrolmeasures,itislikelythatevenafterallreasonably practicableprecautionshavebeentakentoreducetheexposureofstaffwhohandle, transfer,transport,treatordisposeofhealthcarewaste,somePPEwillstillberequired. Insuchcases,employersmustensurethattheseitemsareprovided,usedand maintained.Theymustalsomakeappropriatearrangementsforstorageandcleaning, whilstemployeesmustcooperatewithemployerstoensurethattheirlegaldutiesare met. RiskassessmentsmightidentifytheneedforPPE,suchas: • suitableheavy-dutygloveswhenhandlinghealthcarewastereceptacles; • safetyshoesorindustrialwellingtonbootstoprotectthefeetagainsttherisk ofreceptaclesbeingaccidentallydropped.Thesolesofsuchshoesorboots mayalsoneedtoprovideadditionalprotectionagainstslipperyfloorsand sharps; • anindustrialapronorlegprotectorsifreceptaclehandlingcreatesariskof bodilycontact; • protectivefacevisors,helmetsandstrongindustrialgloveswhereincinerators orothermachinesarechargedmanually. Emergencysituations,suchasspillages,shouldalsobeaddressedinanyrisk assessments.Thismightincludetheneedforprotectiveequipmenttopreventexposure viaroutessuchasskincontact(forexamplesingle-useapronsandgloves)orinhalation (forexamplerespiratoryprotectionand/orfacevisors). Basicpersonalhygieneisimportantinreducingtheriskfromhandlinghealthcare waste.Employersneedtoensurethatwashingfacilitiesareconvenientlylocatedfor peoplehandlinghealthcarewaste;thisisparticularlyimportantatstorageand incinerationfacilities. ControlofSubstancesHazardoustoHealthRegulations(COSHH) ControlofSubstancesHazardoustoHealthRegulations(NorthernIreland) Immunisation 7970 Staffhandlinghealthcarewasteshouldbeofferedappropriateimmunisation,including hepatitisA,Bandtetanus.Staffmustbeinformedofthebenefits(forexample protectionagainstseriousillnessandagainstspreadingillness)anddrawbacks(for examplereactionstothevaccine)ofvaccination. Wherevaccinationhasbeenidentifiedasacontrolmeasurerequiredwhenworking withhealthcarewaste,theemployermustofferthisfreeofcharge.Employersneedto establisharrangementsfordealingwithstaffwhodeclinetoaccepttheimmunisation 104 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 servicesthatareofferedandthosewhodonotseroconvert(thatis,donotproduce/ developantibodiesasaresultofimmunisation). Wastecollectiondocumentation 7975 Registeredwastecarriers Awastecarrierissomeonewhosebusinessorpartoftheirbusinessinvolvesthe transportingofcontrolledwastebyroad,rail,air,seaorinlandwaterways.Waste carriersarerequiredtoregisterwiththerelevantenvironmentalregulatorand complywiththedutyofcare.Allregistrationslastforthreeyearsfromthedateof issueorrenewal.Registeredcarriersshouldbeabletoprovideacertificateof registrationonrequest.Detailsoncarrierregistrationcanbefoundthroughthe followinglinkstoeachUKenvironmentalregulator: http://www.environment-agency.gov.uk/business/sectors/wastecarriers.aspx(for EnglandandWales) http://www.ni-environment.gov.uk/waste-home/authorisation/regulations_carrier. htm(forNorthernIreland);and http://www.sepa.org.uk/waste/waste_regulation/waste_carriers_and_brokers.aspx (forScotland). Exemptions ThefollowingcarriersareexemptfromregistrationundertheControlledWaste (RegistrationofCarriersandSeizureofVehicles)Regulations: • householderswhocarryonlyhouseholdwaste,generatedbythem,intheir ownvehicle; • wasteproducerscarryingtheirownwaste,exceptbuildingordemolition waste(forexamplepeoplesuchascommunitynursesandothersworking inhomehealthcare); • apersonwhotransportsonlywastewhichcomprisesanimalby-products collectedandtransportedinaccordancewithArticle7(1)or7(2)ofthe CarriageRegulations. Note Attimeofwriting,Defrahasconsultedonchangestothedutyofcareandwaste registrationregimetoensurethatpolicyobjectivesofensuringwasteissafelyand legallytransferredaremet.FollowingaEuropeanCourtofJusticejudgement requiringregistrationofallthosethatnormallyandregularlytransportwaste,the Defraconsultationproposedatwo-tiersystemwithexistingregisteredwastecarriers movingintoanuppertier,requiringperiodicreregistration,andmostother businesses(includingthosecarryingtheirownwaste)beingbroughtintoalower tierrequiringone-offregistration.ThedutyofcareCodeofPracticeandguidance relatingtoregistrationwillbeupdatedtoreflectanychangesmade. Environmentandwastelegislation ControlledWaste(RegistrationofCarriersandSeizureofVehicles)Regulations ControlledWaste(RegistrationofCarriersandSeizureofVehicles)Regulations (NorthernIreland) CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) 105 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Transportdocumentation 7978 Whereatransportdocumentisrequired,theminimumcontentsarespecifiedinADR asfollows: 1. theUNnumberofthegoodsbeingcarriedprecededbytheletters“UN”; 2. thepropershippingname,supplementedwhereapplicablewiththetechnical name; 3. theclassnumber(s); 4. thepackinggroup,whereassigned; 5. thenumberanddescriptionofthepackages; 6. thetotalquantityofeachitem; 7. thenameandaddressoftheconsignor; 8. thenameandaddressoftheconsignees; 9. thetunnelrestrictioncodeforthesubstance(s)beingcarried. Aproperlycompletedwasteconsignmentnotewillcontainthisinformation(see ‘Consignmentnotes’)andisacceptablefortransportpurposes). Note Transportdocumentsarenotrequiredfordangerousgoodsinlimitedquantities, andcertainloadsdonotrequiretransportdocumentsinGreatBritain.Thereareno limitedquantitiesforclinicalwaste;therefore,atransportdocumentwillbeneeded evenifacommunitynurseiscarryingclinicalwasteproducedfromdomestic premises. Thetransportdocumentistheresponsibilityoftheconsignor.Thecarriermayhaveto supplythedriverwithotherdocumentation. Consignmentnotes Europeanagreementconcerningtheinternationalcarriageofdangerousgoodsby road(ADR) Wastetransfernote 7981 Akeyelementofthedutyofcareiskeepingtrackofthewaste.Theholderofthewaste isresponsiblefor: • takingadequatestepstoensurethatthewasteismanagedsafelyandkept secure;and • transferringitonlytoanauthorisedorexemptperson. Whenwasteistransferredfromonepartytoanother,thepersonhandingiton(the “transferor”)mustcompleteatransfernote.Thetransferorandtherecipient(the “transferee”)signthenote;bothofthemtakeandkeepacopyofit.Anannualtransfer notemaybeusedtocoverallthemovementsofregulartransferofthesamenonhazardouswastebetweenthesameparties. Atransfernotemuststate: 1. thequantityofwastetransferred,byweightwherepossible; 2. howitispacked; 3. thetypeofreceptacle; 4. adescriptionofthewaste. Thedescriptionofthewasteshouldinclude: 1. theEWCcode(s),asindicatedelsewhereinthisguidance; 106 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 2. thetypeofpremisesorbusinessfromwhichthewastecomes; 3. thenameofthesubstanceorsubstances; 4. theprocessthatproducedthewaste; 5. achemicalandphysicalanalysis; 6. specialproblems,asidentifiedinthesecondparagraphbelow. Thedescriptionmustprovideenoughinformationtoidentifythespecificsub-typeof clinicalwaste(asaminimumtothecategoriessetoutinFigure11–seeunder ‘Containerlabelling’)toenablesubsequentholderstoavoidmismanagingthewaste. Drumsandreceptaclesshouldbelabelledwiththedescriptionofthewasteinaddition toanylabelsrequiredforthecarriageofdangerousgoods. Thedescriptionshouldalwayscontainanyinformationthatmightaffectthehandling ofthewaste(specialproblems).Thisshouldinclude: 1. anyspecialcontainmentrequirements; 2. typeofreceptaclerequiredandthematerialthereceptacleismadeof; 3. whetheritcanbesafelymixedwithotherwastesorwhethertherearetypesof wastewithwhichitshouldnotbemixed; 4. whetheritcanbesafelycrushedandtransferredfromonevehicletoanother; 5. whetheritcanbesafelyincineratedorwhetheritrequiresspecificminimum temperaturesorcombustiontimes; 6. whetheritcanbedisposedofsafelytolandfillwithotherwaste; 7. whetheritislikelytochangephysicalstateduringstorageortransport; 8. anyinformation,adviceorinstructionsaboutthehandling,recoveryor disposalofthewastebythewasteregulatorsorsuppliersetc; 9. detailsofproblemspreviouslyencounteredwiththewaste; 10.changestothedescriptionsincethepreviousload; 11.anythingunusualaboutthewastethatmayposeaproblem. Thereisnocompulsoryformatforthetransfernote,butanexampleform,ifrequired, isprovidedinAnnexCofDefra’s‘Wastemanagementdutyofcarecodeofpractice’. Copiesoftransfernotesshouldberetainedbyallpartiesforaminimumoftwoyears. Containerlabelling AnnexCofDefra’s‘Wastemanagementdutyofcarecodeofpractice’ Dualtransfer/transportnotes 7989 Theinformationcontainedonawastetransfernoteisverysimilartotheinformation requiredforthetransportdocument.Itiscommonpracticetocombinethesenotes; thiscanbedonebyprovidinganadequatedescriptionofthewasteandanyhazardous characteristicsusingbothwasteandcarriageterminology. Consignmentnotes 7991 Consignmentnotesarearequiredprocesswhentransportinghazardouswaste.They areavailablefromtherespectiveUKenvironmentalregulator. Thecompletionandaccuracyofthewasteclassification,descriptionandcomposition ofthewasteontheconsignmentnoteisthesolelegalresponsibilityofthewaste producer.Althoughthecompletionofconsignmentnotesshouldbediscussedwith wastedisposalcontractors,theyareunlikelytoknowwhatwastehasbeendisposedof inthewastereceptacles(theformofaconsignmentnoteisillustratedinthe 107 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 HazardousWasteRegulationsforEngland,WalesandNorthernIreland,andthe SpecialWasteRegulationsforScotland). Carrierscanchoosetorunmultiplecollectionrounds.Thesearecollectionsofsmall amountsofhazardouswastefrommorethanonefacility,whicharecollectedonthe samevehicleanddeliveredtothesameconsignee.Thefollowingpointsmustbe observedwhenrunningamultiplecollectionroundinEnglandandWales: • Eachcollectionfromeverysitemusthaveadifferentconsignmentnotewith auniquecodeandacommonroundnumberindicatingthisispartofa multiplenote. • Thecarriermustcollectwastefromatleasttwodifferentpremises. • WastemustnotbecollectedfromoutsideEnglandandWales. • Thewastemustbedeliveredtothesameconsignee. • Wasteshouldbedeliveredtotheconsigneeasquicklyaspossible,without anyunnecessarydelays. • Ifdifferenttypesofwastearecollectedonthesamevehicle,theymustnotbe mixed,exceptinlinewithmixingrules(seetheDefrawebsite). • Thetypesofwastecollectedshouldnotbeallowedtoreactwithoneanother. Materialsthatcouldpotentiallyreactwitheachothershouldeithernotbe collectedtogetherorbekeptapartfromoneanotheronthevehicle. • Wastecannotbetransferredtoanothercarrierbeforeitisdeliveredtothe consignee. ForScotlandandNorthernIreland,therearetwoclassificationsofcarrier’sroundsfor special/hazardouswastes: • 24-hourcarrier’sround;and • extendedcarrier’sround. Althoughcross-bordermovementisallowedundercarrier’sroundsandextended carrier’sroundsinasmuchastheroundcanbecompletedoutsideofScotlandor NorthernIreland,cross-bordercollectionisstrictlyprohibited. Forfurtherdetails: • inScotlandvisithttp://www.sepa.org.uk/waste/waste_regulation/special_ waste.aspxand • inNorthernIrelandvisithttp://www.ni-environment.gov.uk/guide_to_ consigning_hazardous_waste.pdf Wasteproducersmustkeepcompletedhazardous/specialwasteconsignmentnotesfor aminimumof3yearsfromthedateofwastecollection.Examplesofsample consignmentnotesareprovidedinthesectorguideswithinthisdocument. Defra–mixingrules HazardousWaste(EnglandandWales)Regulations HazardousWasteRegulations(NorthernIreland) SpecialWasteAmendment(Scotland)Regulations Accidentsandincidents 7993 Employersatallpointsinthewastechainneedwrittenproceduresfordealingwith accidentsorincidentsincludingspillages.Theseproceduresshouldformpartofthe wastemanagementpolicyandshouldinclude: • immediatefirst-aidmeasures.Inthecaseofsharpsinjuries,proceduresneed alsotocoverarrangementsforsuitablemedicaladviceandcounselling; 108 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • immediatereportingtoaresponsibledesignatedperson; • recordingoftheaccident/incident; • investigationoftheincidentandimplementationofremedialaction.Initial investigationshouldpreferablytakeplacebeforeanydamagedreceptacleis removed; • retention,ifpossible,oftheitemandinformationaboutitssourcetohelp identifypossibleinfectionrisks; • attendanceofanyinjuredpersonatanaccidentandemergencydepartment oroccupationalhealthdepartmentassoonaspossible; • involvementoftheriskmanager; • involvementofthewastemanager; • involvementoftheinfectioncontrolteam. Allincidentsinvolvingspillages,damagedpackaging,inappropriatesegregationorany incidentinvolvingsharpsneedtobereportedtothelinemanagerorothersuitable individual,andbeinvestigatedbythem.Theinvestigationoftheseaccidentsand incidentsneedstoestablishthecauseandwhatactionneedsbetakentopreventa recurrence. Theanalysisandinvestigationofincidentsinvolvinghealthcarewaste,whether reportableornot(seeabove),helpsidentifycauses,trends,thelevelofcompliance withcurrentlegislation,theeffectivenessoftheprecautionsinplace,andproblem areasforwhichsatisfactoryprecautionshaveyettobeprovided.Informationrelating toboththefinancialcostandthestaffingrequiredtodealwithincidentsisalso relevant,asitallowsmanagerstoassessthetotalcostofincidentsandaccidents. Thedepthofeachinvestigationwillvarydependingonthenatureoftheincident.To beworthwhile,however,anyinvestigationneedstoconsidercarefullytheunderlying causes.Actionafteranaccidentwillnotbeeffectiveifitaddressesonlythesuperficial andobviouscauses,andmissesmoresignificantissues. Theactiveandreactivemonitoringofhealthcarewasteproceduresismosteffectiveas partofanoverallsystemofhealthandsafetymonitoring,withinformationpassingup thelinemanagementchaintoseniormanagement. Note AnyaccidentduringthetransportofaClass6.2CategoryAsubstanceand CategoryBsubstance(undercertaincircumstances–seeADR1.8.5)mustbe reportedtothedangerousgoodsdivisionoftheDepartmentforTransport. Europeanagreementconcerningtheinternationalcarriageofdangerousgoodsby road(ADR) ReportingofInjuries,DiseasesandDangerousOccurrencesRegulations (RIDDOR) 7997 TheReportingofInjuries,DiseasesandDangerousOccurrencesRegulations (RIDDOR)requirecertainaccidents,work-relatedill-healthanddangerous occurrences(suchasanincidentthatresultsin,orcouldhaveresultedin,thereleaseof abiologicalagentthatcouldcauseseverehumandisease)tobereportedtothe appropriateenforcingauthority.Formosthealthcarepremises,thisistheHSE.The lossofdangerousgoodsduringtransportisincluded. SeverehumandiseaseincludediseasescausedbyhazardgroupHG3andHG4agents aswellassomeHG2agents(forexampleNeisseria meningitidis). TheSocialSecurity(ClaimsandPayments)Regulationsrequireanaccidentbookor similartobekeptandaccessibletostaff.Effectivehealthandsafetymanagement 109 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 systemsensuretheinternalreporting,recordingandinvestigationofawiderrangeof accidentsandincidentsthanthosewhicharelegallyreportable. HSE ReportingofInjuries,DiseasesandDangerousOccurrencesRegulations ReportingofInjuries,DiseasesandDangerousOccurrencesRegulations (NorthernIreland) SocialSecurity(ClaimsandPayments)Regulations Spillages 8000 Employersneedclearwrittenproceduresfordealingwithspillages,which: • specifythereportingandinvestigationprocedures; • specifytheuseofasafesystemofworkforclearingupthehealthcarewaste; • setoutappropriaterequirementsfordecontamination; • specifytheprotectiveclothingtobeworn. Thereadyavailabilityofappropriatespillagekitshelpstoensurethecorrectactionin theeventofaspillage.Suchkitsareparticularlyusefulatstorage,wastetreatmentand wastedisposalsites,andshouldbecarriedonallvehiclescarryinghealthcarewaste. Spillagekitsmaycontain,forexample: • single-usegloves; • single-useaprons; • anappropriateinfectiouswastereceptacle/medicinalwastereceptacle; • papertowels; • absorbentmaterials; • single-usecloths; • disinfectantrecommended,forexample,bythelocalcontrolofinfection policy; • ameansofcollectingsharps. Employersneedtoprovideappropriateequipmentforcollectingspilledwasteand placingitinnewreceptacles.Sharpsmustnotbepickedupbyhand.Spilledwasteand anyabsorbentmaterialsneedtobeplacedinaninfectiouswastereceptaclefordisposal whererelevant. Disinfectants 8002 Theuseofsuitabledisinfectantsshouldbedetailedinthehealthcarewastepolicy, whichshouldbemanagedandmonitoredbytheinfectioncontrolteam.Thepolicy shouldclearlyidentifywhichproductsaretobeused,wheretheyaretobeusedand forwhatpurpose.Thepolicyshouldalsoprovideguidanceontherelevantlevelof dilutionrequiredandthecontacttimerequiredforthedisinfectanttobesafeand effective. Suitableinertabsorbentmaterialsmaybeusedtodealwithliquidspillagesafter disinfectantmaterialhasbeenapplied.Guidanceontheuseofdisinfectantsshouldbe soughtfromsuitablyqualifiedpersonnel,forexampletheinfectioncontrolteam.They shouldbeconsultedafteraspillagecontainingorsuspectedtocontainunusual infectiveagents,forexamplevariantCreutzfeldt-Jakobdisease(vCJD). Theuseofdisinfectantsthemselvesmaypresentahealthrisk,particularlyinconfined spaces,andconsiderationshouldbegiventothegeneralprovisionsofCOSHH. 110 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Accordingly,onlystaffthathavethenecessarytrainingandexperienceshouldcarryout theapplicationofdisinfectants. ControlofSubstancesHazardoustoHealthRegulations ControlofSubstancesHazardoustoHealthRegulations(NorthernIreland) Mercury 8005 Employerswhousemercuryshouldcarryoutariskassessmentfordealingwith mercuryspillagesandproducewrittenprocedures.Aspillagekitincludingsingle-use plasticgloves,papertowels,abulbaspiratorforthecollectionoflargedropsof mercury,avapourmask,asuitablereceptaclefittedwithasealandmercury-absorbent paste(equalpartsofcalciumhydroxide,flowersofsulphur,andwater)needstobe available.Avacuumcleaneroraspirationunitshouldnotbeused,asthiswillvent mercuryvapourintotheatmosphere. 111 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Transportpackagingand operations 8008 Hospitals,clinics,surgeries,pharmaciesetcareresponsibleforrequiringdangerous goodstobetransportedoff-site.Thesebodiesaretheconsignoranditistheirdutyto complywiththetransportregulationslistedin‘Legislationandhealthcarewaste’. Legislationandhealthcarewaste Transport:packaging,marking,labellinganddocumentation 8016 TheCarriageRegulationsspecifytherequirementsfor: • classificationandidentification; • packaging; • marking; • labelling; • documentation. Thedutyforallthesefunctionsrestsinthefirstinstancewiththeconsignor. Note Theterm“CarriageRegulations“isusedtorefertotheCarriageofDangerous GoodsandUseofTransportablePressureEquipmentRegulations2009;however,in someofthereferencescitedinthissection,thesameregulationsarereferredtoas “CDGRegulations”. Inaddition,allpersonnelinvolvedinthetransportofdangerousgoodsmusthave appropriatetraining.Forcertainquantitiesofdangerousgoods,suchtrainingand approvalismandatory.Forotherpersonnel,trainingcanbejob-relatedanddeveloped onsite.Inrelationtotheaboverequirements,theconsignormustensurethattraining isundertaken. TheCarriageRegulationsusecriteriathataredifferentfromotherlegislativesystems. Classificationforhealthcarewastemanagementisaddressedin‘Healthcarewaste definitionsandclassifications’and‘Wasteminimisation,segregation,colour-coding andstorage’. TheRegulationsrequirethatalldangerousgoodsbeidentifiedusingafour-digit number(UNnumber)andadescription(propershippingname),andareassignedtoa “class”ofdangerousgoods.Table9givesexamplesofhealthcarewasteandother dangerousgoodslikelytobeencounteredinthewastestream. Dangerousgoodscanbetransportedinthreeways: • packaging(boxes,drumsetc); • bulkloosematerialinskips,containersandvehicles; • tanks. Thischapterconsidersonlypackagingandbulktransportwithregardstohealthcare waste,primarilyclinicalwasteandwastemedicine.Healthcareorganisationswilloften useotherdangerousgoods(forexamplegases,cleaningmaterials)andarenotdealt withinthisguide(see‘Otherchemicals’). 112 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Note Furtherguidanceonthetransportofdangerousgoodscanbefoundatthefollowing websites: 1. TheHSE’s‘Carriageofdangerousgoodsmanual’providesguidanceonall aspectsofroadtransport(http://www.hse.gov.uk/cdg/manual/index.htm). 2. TheVehicleCertificationAgency’s(VCA)websiteprovidesguidanceona rangeofpackagingissues(http://www.vca.gov.uk/dangerousgoods/ dangerous-goods-offi.asp). 3. TheDepartmentforTransport’swebsiteprovidesguidanceandcopiesof authorisations(http://www.dft.gov.uk/pgr/freight/dgt1). Healthcarewastedefinitionsandclassifications Wasteminimisation,segregation,colour-codingandstorage Otherchemicals CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) Transportofpackagedgoods 8022 OncetheUNnumberofasubstanceisknown,ADRprovidesinformationonthe packinggroup,packinginstructionandanyspecialpackingprovisionsthatapply. Table9showsthemostcommonpackingprovisionsforhealthcarewaste. Table9Packingprovisionsforhealthcarewaste Dangerousgoods(UN number) CategoryA •UN2814 •UN2900 CategoryB(UN3291)a Medicinalwaste •UN1851 •UN3248 •UN3249 Dentalamalgam (UN2025) Aerosols(UN1950) Notes: Propershippingname Packinginstruction Packagingexamples Infectioussubstance,affectinghumans Infectioussubstance,affectinganimals P620 Clinicalwaste,unspecifiedN.O.S(not otherwisespecified) P621(seeTable10) LP621 IBC620 Three-partpackaging Rigidpackagingsor wheeledbins b Medicine,liquid,toxicN.O.S Medicine,liquid,flammable,toxicN.O.S Medicine,solid,toxicN.O.S P001 Boxes,drums Mercurycompound,solid,N.O.S Limitedquantity Boxes,drums Aerosols Limitedquantity Box a.UN3373“BiologicalSubstance,CategoryB”shouldneverbeusedforwasteconsignments. b.Thethreeentriesaregenericandwillnotbeappropriateforallmedicines(e.g.cytotoxicsandcytostatic).Somewaste medicineswillhavetobeclassifiedinaccordancewiththeprovisionsofADR.Inmostcases,asafetydatasheet(SDS) forthemedicineshouldshowtheappropriatetransportclassification.Ifthisisnotavailable,advicefromaDGSAmay besought. 113 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Table10Packinginstruction621 P621 PACKINGINSTRUCTION P621 ThisinstructionappliestoUN3291 Thefollowingpackagingsareauthorisedprovidedthegeneralprovisionsof4.1.1except4.1.1.15and4.1.3aremet: (1)Rigid,leak-proofpackagingsmeetingtherequirementsofChapter6.1forsolids,atthepackinggroupIIperformance level,providedthereissufficientabsorbentmaterialtoabsorbtheentireamountofliquidpresentandthepackaging iscapableofretainingliquids; (2)Forpackagescontaininglargerquantitiesofliquid,rigidpackagingsmeetingtherequirementsofChapter6.1atthe packinggroupIIperformancelevelforliquids. Additionalrequirement: Packagingsintendedtocontainsharpobjectssuchasbrokenglassandneedlesshallberesistanttopunctureandretain liquidsundertheperformancetestconditionsinChapter6.1. Note:ParagraphandchapterreferencesinthistablearetosectionsinADR Source:ADR(2011) AllpackagingincludingUN-approvedpackagingorpackagingforlimitedquantities usedfordangerousgoodsmustbefitforpurposeandcapableofsafelycontainingthe goods(thatis,leak-proof )whenusedintransport,whethertheyarecarryingliquidsor solids. WhereapackinginstructionisindicatedinTable9,onlypackagingthathasbeenUNtestedandapproved(unlessotherwisespecified)mustbeused.Suchpackagingcanbe identifiedbytheUNmarkappliedtothepackage.Anexampleofamarkisshown below. U n 1st digit identifies type of container: 1 = drum 2 = barrel 3 = jerrican 4 = box 5 = sack 1H2/Y1/S/02/GB/4532 ‘H’ indicates Y= packing S = solids Year of construction group or inner manufacture material: 1 = 1 kg packagings A = steel (that may H = plastic contain liquid) GB = Great Identification Britain of type (Authorising approval State) Iftheletter“S”appearsintheUNmark,asshownabove,thepackagingmayonlybe usedforsolidsorinnerpackagings(forexamplebottlesthatmaycontainliquids)and notfreeliquids.Mostsharpsboxesaretype-approvedforsolidsonlyandmustnotbe usedforthedisposalofliquids.However,itisrecognisedinthetestingofthese packagingsthattheremaybesmallamountsofliquidresiduefromsyringes,vialsetc andthatthepackagingmustretainthesequantities,usuallybysomeabsorbent material(see‘Wastemedicines(includingamalgamwaste)’).Anexampleofanorange labelledbagisprovidedbelow. 114 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Wastemedicines(includingamalgamwaste) Europeanagreementconcerningtheinternationalcarriageofdangerousgoodsby road(ADR) Limitedquantities 8036 ADRspecifiesthatsomedangerousgoodsinsmallquantitiesneednotbepackagedin UN-type-approvedpackaging.Thisisreferredtoaslimitedquantityexemptions.Such dangerousgoodswillbepackagedinasmallreceptacle(nevermorethan5Lfor liquids/5kgforsolids),severalofwhichmaybeplacedinanouterpackagingthatmay notexceedagrossmassof30kgintotal.Thisisawidelymisunderstoodconcept; adviceshouldthereforebesoughtfromaDGSAifusingtheseprovisions(see ‘Documentation’and‘Dangerousgoodssafetyadviser(DGSA)’).Thereisnolimited quantityprovisionforclinicalwaste(UN3291). Documentation Dangerousgoodssafetyadviser(DGSA) Specificpackagingissues 8040 Healthcarewastedefinedasdangerousgoodsissubjecttopackingrequirementsin accordancewiththeCarriageRegulations.Thefollowingsubsectionsaddressmostof thecommonproblems. CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) Clinicalwaste(UN3291) 8044 MostclinicalwastewillbetransportedasUN3291anditissubjecttothepacking requirementsofP621(seeTable10)orLP621ofADR.Theformeraddressesboxes anddrumswhilstthelatterisforlargepackagingssuchaswheeliebins. Whilstintransport,clinicalwastemustbecarriedinarigidouterpackagingunless transportedinbulk(see‘Bulktransport’).Thereforecommunitynursescollecting smallamountsofclinicalwasteintheirvehiclesshouldensuretheyusearigid,secure andleak-proofreceptacle,inwhichbagscanbeplaced. Bulktransport Europeanagreementconcerningtheinternationalcarriageofdangerousgoodsby road(ADR) CategoryAclinicalwaste 8049 OccasionallyapatientproduceswastewhichmeetsCategoryAcriteria(forexamplean infectioussubstancewhichiscarriedinaformthat,whenexposuretoitoccurs,is capableofcausingpermanentdisability,life-threateningorfataldiseaseinotherwise healthyhumansoranimals).Indicativeexamplesofsubstancesthatmeetthesecriteria aregivenin‘Carriageinformation:CategoryApathogenlist’. Whereverpossible,thewasteshouldbetreatedonsitetorenderitsafefortransportas non-dangerousgoods.Wherethisactionisnotpossible,thehospital/clinicwillhaveto makeanapplicationforanauthorisation(seethenextparagraph).Generally,the shipmentwillhavetobeclassifiedasUN2814orUN2900andpackagedin accordancewithP620. 115 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 However,assuitablepackagingforCategoryAwasteisgenerallynotavailable,the wasteproducershoulddouble-wrapthewasteandthenplaceitinsideametalor plasticdrumandseekanauthorisation.Inthefirstinstance,theapplicationshouldbe madetotheVCA’sdangerousgoodsoffice.Theapplicationshoulddescribethe packagingtobeusedandmethodoftransport,withplanneddatesfordisposal. ContacttheVCAviaemail:[email protected] CategoryAclinicalwasteisdefinedforsecuritypurposesas“highconsequence dangerousgoods”.Thismeansthataspectsofsecurityhavetobetakenintoaccount. ShoulditbenecessarytomoveCategoryAwaste,thereisaneedtoappointaDGSA whointhefirstinstanceshouldadvise. Carriageinformation:CategoryApathogenlist Soiledsurgicalinstruments 8054 Wherehealthcareorganisationsareobligedtocarryusedmedicaldevicesorequipment byroadtoacentralisedsterileservicesfacility,arecent“multilateralagreement”now exemptsthesefromthetermsofADR,providingthefollowingconditionsaremet: 1. Theyarepackedinpackagingsdesignedandconstructedinsuchawaythat, undernormalconditionsofcarriage,theycannotbreak,bepuncturedorleak theircontents,andthepackagingsaredesignedtomeettheconstruction requirementslistedin6.1.4or6.6.4ofADR. 2. Thepackagingsmeetthegeneralpackagingprovisionsof4.1.1.1and4.1.1.2 ofADRandarecapableofretainingthemedicaldeviceswhendroppedfrom aheightof1.2metres. 3. Thepackagingsaremarked“USEDMEDICALDEVICE”or“USED MEDICALEQUIPMENT”.Whenusingoverpacks,ifthemarkisnot visible,theyneedtobemarked. Thisagreementdoesnotapplyto: 1. clinicalwaste(UN3291); 2. medicaldevicesorequipmentcontaminatedwith,orcontaining,infectious substancesinCategoryA(UN2814orUN2900);and 3. medicaldevicesorequipmentcontaminatedwithorcontainingother dangerousgoodsthatmeetthedefinitionofanotherhazardclass. Itisextremelyunlikelythatsurgicalinstrumentscontaminatedwithpathogensof CategoryAwillneedtobetransportedoff-site.Ifthisisnecessary,aspecial authorisationwillberequiredfromtheVCA(seethethirdparagraphinthe‘Category Aclinicalwaste’section). Note In2011,thisprovisionwillbeamendedandsimplified. CategoryAclinicalwaste ADR HazardousWaste(EnglandandWales)Regulations HazardousWasteRegulations(NorthernIreland) SpecialWasteAmendment(Scotland)Regulations Usedlinen 8056 Mostusedlinenbeingtransportedtooff-sitelaundrieswillnotnormallybeassessedas dangerousfortransport. 116 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Therewillbesomeoccasionalcircumstanceswheresoiledlaundrywillneedtobe classifiedasdangerousfortransport,suchaswhenaconsignmentisthoughttocontain pathogenswhichposeasignificantriskofspreadingdiseaseandtheloadisheavily soiledtotheextentthatthepotentialforexposureandinfectionishigh.Insuch instances,theloadshouldthenbeclassifiedandpackagedasUN3291(see‘Transport ofpackagedgoods’).Specialbagsareavailableforcontaminatedmattresses. Transportofpackagedgoods Wastemedicines(includingamalgamwaste) 8058 Forthepurposeoftransportregulations,medicinalwastewillcomeintwotypes– solids(pillsandpowders)andliquids(ampoulecontentsetc).Medicinesunopenedin originalretailpackaging(forexampledate-expiredmedicines)areexemptfromthe CarriageRegulations. PracticeinthepasthasbeentoplaceUN-packagedmedicinalliquidsandsolidsinto thesamedrums/sharpscontainer,therebymixingsubstances.Thereisgreatdanger thatachemicalreactioncouldtakeplace,causingheating,fireorevenexplosion.ADR states: “Dangerousgoodsshallnotbepackedtogetherinthesameouterpackagingorinlarge packagings,withdangerousorothergoodsiftheyreactdangerouslywitheachother andcause: (a)combustionorevolutionofconsiderableheat; (b)evolutionofflammable,asphyxiant,oxidisingortoxicgases; (c)theformationofcorrosivesubstances;or (d)theformationofunstablesubstances.” Therefore,wastemedicinesshould,asfaraspossible,bedisposedofintheiroriginal packagings(receptacles). Ifsolidsarestillintheiroriginalblisterpacksorarebagged/bottled,theyshouldbe collectedandplacedinsuitableouterpackagingfortransport(suchasfibreboardor plasticboxes).ThiswillrequirelabellinginaccordancewithADR–inthemain,such packagesarelikelytofallunderlimitedquantityprovisions(see‘Transportofpackaged goods’). Asimilarprocedurecanbeadoptedforliquids,providedmeasuresaretakento minimisethelikelihoodofbreakageoftheprimarypackaging(suchascushioning/ absorbentmaterial). Wherethepillsarelooseortheliquidscontainerhaslostitsclosure(stopper/cap),a suitablereceptaclethatiscompatiblewiththeproductshouldbeused.Onceasuitable receptacleisfound,theproceduresabovecanbefollowed. Amalgamwastemaybepackedinthesamewayaswastemedicinesabovebutthe packageshouldbemarkedwithUN2025(see‘Healthcarewastedefinitionsand classifications’). Transportofpackagedgoods Healthcarewastedefinitionsandclassifications CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) Europeanagreementconcerningtheinternationalcarriageofdangerousgoodsby road(ADR) 117 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Sharpspackaging 8060 Sharpscontainersaretestedforsolids.Theyarenotapprovedforthecarriageof liquids.However,mostsharpswillbecontaminatedwithliquids/fluids.Afew millilitresofliquidareunlikelytopresentariskofadversechemicalreaction,andsuch quantitiesinasharpsboxareacceptablefortransport. However,thepouringofliquidfrompartially-usedvialsofliquidorthedischargingof syringesintosharpsboxesisnotincompliancewiththeregulationsandisnot permitted. Batteriesincludingthoseusedforimplants/medicaldevices 8063 Batteriescancontainchemicalssuchaslead,mercuryorcadmium.Iftheyaredisposed oftolandfill,thechemicalstheycontainmayleakintotheground.Thiscanpollute thesoilandwaterandpotentiallyharmhumanhealth.Recyclingdivertsbatteriesfrom landfill,helpingrecoverthousandsoftonnesofmetals,includingvaluablemetalssuch asnickel,cobaltandsilver,andsavingonCO2emissionsbyreducingtheneedtomine newmaterials. Whilehospitalsarenotrequiredbylawtocollectandrecyclealltheirwasteportable batteries,thisisconsideredbestpractice.Wherehospitalschoosetoproviderecycling binsforbatteries,theywillberequiredtocomplywiththerequirementsofthe HazardousWasteRegulationsandtheCarriageRegulations,whichestablishspecial rulesforpackaging. Whenarrangingthecollectionofwastebatteries,hospitalscan: 1. liaisewithabatterycompliancescheme,whichmaybeinterestedin collectingthebatteries(althoughtheyareundernoobligationtodoso); 2. contacttheirlocalcounciltoseewhetherthereisanamenitysiteorfacility nearbythattheycanuse; 3. talktoawastemanagementcompanylicensedtocollectbatteries;or 4. contacttheirsupplierofbatteriestodiscusscollection. Forfurtherinformationonrecyclingbatteries,includingthebatterycompliance schemesandhowtocomplywiththeHazardousWasteRegulationsandtheCarriage Regulations,visitDefra’swebsite. Batteryrecycling–Defra HazardousWaste(EnglandandWales)Regulations HazardousWasteRegulations(NorthernIreland) SpecialWasteAmendment(Scotland)Regulations Radioactivematerial 8065 Forexceptedradioactivematerial,packagingsmustberigidandleak-proofand: • becompatiblewiththecontents; • haveabsorbentmaterialtosoakanyleakageinsidethepackage; • havenohollowsurfacesontheoutsidewhichcouldcollectwater;and • belargeenoughtocontainalllabelsandmarkings. Ifpackagingispurchased“offtheshelf ”,allinstructionsforusemustbefollowed. Conventionalbagsusedforclinicalwastearenotsuitableifthewasteiscontaminated withradioactivematerial. 118 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Otherchemicals 8067 Hospitalsandotherhealthcareorganisationsusealargerangeofchemicals(handgels, aerosols,industrialgases,cleaningmaterialsetc)thatmaybesubjecttothetransport regulations.Thisguidancedoesnotaddresstheseindetail.Itaddresseswastethat comesfromthedirecttreatmentofpatients.Managerswillhavetoconsiderthese otherchemicalsincomplyingwiththeirdutiesundertheregulations. Cleaningreceptacles 8084 Transportregulationsrequirethatnodangerousgoodsresidueshalladheretothe outsideofpackagings.Ifanydangeroussubstancesadheretotheinsideofareceptacle, thereceptacle,eventhoughnominallyempty,mustcontinuetobetreatedas dangerousgoods. Itisimportantthatlocalwastepoliciesincludeacart-cleaningprocedureclearly specifyingfrequencyandmonitoringofthecleaningprocesstoavoidthepotentialfor cross-contaminationbetweensites. Thecleaningprocedureshouldensurethatdrainagebungsareproperlyreplacedafter cleaningandthatmissingbungsarereplacedtopreventleakageofwasteliquids.This shouldbeagreedbetweenthehealthcareorganisationandthewastedisposalcontractor inthecontractprovisions. Examplesoftypicalrigidpackagings 8083 Examplesofsharpsboxes: TypicalUNcodemarkingstartswith:1H2/Y/S/(ifplastic“drum’)or4H2/Y/S/(if plastic“box”) 119 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Exampleofotherboxeswithfirmlyclosinglids–typicalUNmarkingbegins4H2/Y Largepackaging(“wheeliebins”)shouldbeusedwiththewastecontainedinaUNcertifiedplasticbagwhichinturnisplacedinthebin.TypicalUNmarkingwillstart: • forplastic,50H/Y/mmyy • forsteel,50A/Y/mmyy (mmyy=monthandyearofmanufacture). Markingandlabellingofpackagings 8103 MarkingistheapplicationoftheUNnumberandwherenecessarytheproper shippingnameontothepackage. Labellingistheapplicationofthelabel(commonlyreferredtoasthehazardwarning diamond)appropriatetotheclassofdangerousgoods.Thelabelsmustbe100mm× 100mmexceptwhenthesizeofthepackagesorequires;thedimensionsmaybe reducedprovidedthattheyremainclearlyvisible. Table11showsthenineclassesofdangerousgoods.Someadditionalexamplesbelow aregivenofdangerousgoodsineachclass,whichmaybegeneratedfromhealthcare, withtheappropriatehazardwarningdiamondfortheprimaryhazard.Afulllistofthe hazardwarningdiamondscanbefoundinADR. 120 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Table11Classesofdangerousgoods UNclassification Class1 Examplesofmaterialfromhalthcarepremises Hazardwarningdiamonds 1.4 Explosives *1 Class2 Class3 Gases Flammableliquids Oxygen(UN1072) CO2(UN1013) LPG(UN1978) Nitrousoxide(UN1070) Aerosols(UN1950) 2 Fuel(UN1202,UN1203) Alcohol Adhesives,paints 3 Class4.1 Flammablesolids 4 Class4.2 Spontaneously combustible Thisclassprovidesrawmaterialsforsomedrugsand medicines 4 Class4.3 Dangerouswhen wet 4 121 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 UNclassification Class5.1 Examplesofmaterialfromhalthcarepremises Hazardwarningdiamonds Oxidiser 5.1 Disinfectantsandlaundrychemicals Class5.2 Organicperoxide 5.2 Class6.1 Toxic Poisons,somedisinfectantsanddrugs 6 Class6.2 Infectious substances including pathogens UN3291infectiouswaste UN2814,UN2900CategoryAsubstances UN3373CategoryBsubstances 6 Class7 Radioactive Radiotherapyisotopes RADIOACTIVE Contents Activity Transport index 7 8 Class8 Corrosives Bleaches,cleaningmaterials 8 Class9 Miscellaneous Laundryadditivesandsomedrugs 9 Note:ThisisnotacomprehensivelistofUNnumbersorClasshazardwarningdiamonds 122 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Fordangerousgoodsinlimitedquantities,theonlymarkrequiredistheUN number(s)(ofthesubstance(s)containedinthepackage)placedinsideadiamond shape. UN 1851 From2011fordangerousgoodsinlimitedquantities,theonlymarkrequiredisas follows: OR Y Notethefigureontheleftshouldbeusedforlandtransport.Somepackagesmayhave thelabelontherightindicatingthattheyarepermissibleinlandtransportbutalso meetadditionalairtransportrequirements,althoughthemarkalonedoesnotindicate thatairshipmentswillbepermitted. Whenthenewlimitedquantitieslabelisused,thereisnorequirementfortheUN numbertoappearonthepackage. Note Thereisatransitionalperiodupto2015,andthereforeanyofthemarksabovemay beseenonpackagesduringthisperiod. Europeanagreementconcerningtheinternationalcarriageofdangerousgoodsby road(ADR) Bulktransport 8155 BulktransportofUN3291ispermittedforhealthcarewaste.Theloadthresholds(see ‘Transportontheroad’)onlyapplytowasteinpackages,inaccordancewiththe packaginginstructions.Therefore,ifwasteiscarriedinbulk(forexamplethecarriage ofhazardousinfectiouswasteinbags),thefullprovisionsapplyimmediatelyregardless ofloadorvehiclesize.However,bulktransportshouldnotbeundertaken. Note FurtherguidanceonthecarriageofbulkcanbefoundattheHSEwebsite. InADR,carriageinbulkispermitted: 1. inaccordancewiththeconditionsofspecialprovisionVV11;or 2. inanapproved“BK2”container.“Container”includestheload compartmentofavanorlorry. 123 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 ADRVV11states: “Carriageinbulkispermittedinspeciallyequippedvehiclesandcontainersina mannerwhichavoidsriskstohumans,animalsandtheenvironment,e.g.byloading thewastesinbagsorbyairtightconnections.” VV11bulkconditionsarelikelytobethemostcommonformofbulktransportof clinicalwastewithintheUKatthepresenttime.TheHSEhasissuedadditional guidanceonthemeaningandapplicationofthistext,inparticularthephrase “speciallyequippedvehicles”.Accordingly,HSEguidanceisthatVV11issatisfiedif theconditionssetoutbelowforBK2containersaremet(exceptforparagraph(c), althoughitisstronglyrecommendedthatbagstothisstandardareused). TheconditionsforaBK2containerareasfollows(extractfromADR): WastesofClass6.2(UN3291) (a) (Reserved); (b) Closed bulk containers and their openings shall be leak-proof by design. These bulk containers shall have non porous interior surfaces and shall be free from cracks or other features which could damage packagings inside, impede disinfection or permit inadvertent release; (c) Wastes of UN No. 3291 shall be contained within the closed bulk container in UN type tested and approved sealed leak-proof plastics bags tested for solids of packing group II and marked in accordance with 6.1.3.1. Such plastics bags shall be capable of passing the tests for tear and impact resistance according to ISO 7765-1:1988 “Plastics film and sheeting – Determination of impact resistance by the free-falling dart method – Part 1: Staircase methods” and ISO 6383-2:1983 “Plastics – Film and sheeting – Determination of tear resistance. Part 2: Elmendorf method”. Each bag shall have an impact resistance of at least 165 g and a tear resistance of at least 480 g in both parallel and perpendicular planes with respect to the length of the bag. The maximum net mass of each plastics bag shall be 30 kg; (d) Single articles exceeding 30 kg such as soiled mattresses may be carried without the need for a plastics bag when authorized by the competent authority; (e) Wastes of UN No. 3291 which contain liquids shall only be carried in plastics bags containing sufficient absorbent material to absorb the entire amount of liquid without it spilling in the bulk container; (f ) Wastes of UN No. 3291 containing sharp objects shall only be carried in UN type tested and approved rigid packagings meeting the provisions of packing instructions P621, IBC620 or LP621; (g) Rigid packagings specified in packing instructions P621, IBC620 or LP621 may also be used. They shall be properly secured to prevent damage during normal conditions of carriage. Wastes carried in rigid packagings and plastics bags together in the same closed bulk container shall be adequately segregated from each other, e.g. by suitable rigid barriers or dividers, mesh nets or otherwise securing, such that they prevent damage to the packagings during normal conditions of carriage; (h) Wastes of UN No. 3291 in plastics bags shall not be compressed in a closed bulk container in such a way that bags may be rendered no longer leak-proof; (i) The closed bulk container shall be inspected for leakage or spillage after each journey. If any wastes of UN No. 3291 have leaked or been spilled in the closed bulk container, it shall not be re-used until after it has been thoroughly cleaned and, if necessary, disinfected or decontaminated with an appropriate agent. No other goods shall be carried together with UN No. 3291 other than medical or veterinary wastes. Any such other wastes carried in the same closed bulk container shall be inspected for possible contamination. 124 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Transportontheroad HSEwebsite Europeanagreementconcerningtheinternationalcarriageofdangerousgoodsby road(ADR) Transportontheroad 8164 TransportofhealthcarewasteclassifiedasdangerousinaccordancewiththeCarriage Regulationsmustbeinfullcompliancewiththeregulations.Thescopeofthe regulationsisdependentonthequantitiesofdangerousgoodstobecarried. Dangerousgoodscarriedinlimitedquantities(see‘Transportofpackagedgoods’)are exemptfromotherprovisionsoftheCarriageRegulations. ADRspecifiestransportcategoriestodeterminetheloadthresholdsoverwhichthefull provisionsofADRapply.Forhealthcarewaste,thesethresholdsareindicatedbelow: Transportcategory 0 Substance CategoryAsubstances(UN2814/290) Quantity 0 2 Clinicalwaste 333kg/L 1 Medicines/chemicalwastesPGI(cytotoxicdrugs) 20kg/L 2 Medicines/chemicalwastesPGII(UN1851/3248/3249) 333kg/L Medicines/chemicalwastesPGIII(UN1851/3248/3249) 3 (ConsultADRforfulldetails) 1000kg/L Belowthesethresholdsthefollowingapply: • one2kgfireextinguishermustbecarriedonthevehicle; • generalawarenesstrainingtoallinvolvedinthetransportoperationmustbe provided. Seethelastparagraphinthissectionandthe“Communityhealthcare”sectorguide forwastearisinginthecommunitysetting. Dangerousgoodsinlimitedquantitiesasdescribedabovearenotsubjecttoanyofthe provisions. Abovethethreshold,thefollowingapply: • additionalvehicleequipment,fireextinguishersandPPEmustbeprovided; • vehiclesmustbemarkedwithorangeplatesifthegoodsarepackaged,andif inbulktheymustbefittedwithplatesdescribedinSchedule1tothe CarriageRegulations; • formalADR-approveddrivertrainingmustbeprovided; • additionaloperationalprovisionsasspecifiedinADRmustbeincorporated; • aDGSAmustbeappointed(see‘Dangerousgoodssafetyadviser(DGSA)’). Wheresmallquantitiesofclinicalwaste(UN3291)arecarriedinM1vehicles(thatis, privatecarsandcar-derivedvans),ashappensincommunitynursingforexample, thereisnoneedtocarrya2kgfireextinguisher.Bagsofwastemustnotbeplaced directlyintoanyvehicle,includingacar.Theymustbeplacedinarigid,secureand leak-proofouterpackagingdulyapprovedforthepurpose. Transportofpackagedgoods Communityhealthcare Dangerousgoodssafetyadviser(DGSA) 125 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) Europeanagreementconcerningtheinternationalcarriageofdangerousgoodsby road(ADR) Documentation 8167 Fordangerousgoodsconsignedinlimitedquantities,transportdocumentationisnot required.Inothercases,althoughwastecontractorsmaybewillingtoassistwith compilationoftheappropriatedocumentation,thelegaldutyremainswiththe consignor(see‘Managingcompliance’).Documentationislikelytobeneededto complywiththeHazardous/SpecialWasteRegulations. Managingcompliance HazardousWaste(EnglandandWales)Regulations HazardousWasteRegulations(NorthernIreland) SpecialWasteAmendment(Scotland)Regulations Dangerousgoodssafetyadviser(DGSA) 8174 Undercertaincircumstances,theCarriageRegulationsrequirehealthcaremanagersto appointaDGSA.Therequirementtoappointsuchapersonisadutyontheemployer andisinlargepartdependentonthequantityofdangerousgoodstransported. DGSAswillberequiredwhenthequantityofhealthcarewasteclassifiedasdangerous intransportexceedscertainthresholdsinADR(assummarisedinthetableunder ‘Transportontheroad’).AnyradioactivematerialsubjecttotheIonisingRadiations RegulationsrequiresaDGSA. Largerhealthcareorganisations(forexamplehospitals)mayneedtoappointaDGSA, whilesmallclinicsandsurgerieswillprobablynot.Organisationswhosemainor secondaryactivitiesarenotthecarriageorloading/unloadingofdangerousgoods–but whichmovesuchgoodsonlyoccasionally–neednotappointaDGSA. DGSAsdonotneedtobeemployeesofthehealthcareorganisation.Third-party consultantsmaybeappointed.ThenumberofDGSAstobeappointedisnot prescribedotherthanthereshouldbeenoughtoensurethattheirfunctionsandduties canbecarriedouteffectively. TheDGSAmonitorsandadvisesondangerousgoodscarriagecomplianceandensures thatrelevantincidents/accidentsareproperlyinvestigatedandreported.Theymust alsopreparefortheduty-holderanannualreportondangerousgoodstransport activities. Itisimportantthatallthoseinvolvedinthemovementofhealthcarewasteareaware ofthepersonprovidingDGSAsupport.Thenameandcontactnumber(s)ofthe DGSA(s)shouldbelistedinthesite’swastemanagementpolicy(see‘Managing compliance’). ThosehealthcaresitesthatdonotneedtoappointaDGSAmaystillfinditusefulto approachDGSAconsultantsforgeneraladviceonanad-hocbasistoensurethatthey, asconsignorsofdangerousgoods,arecomplyingwiththerequirementsconcerning classification,packaging,marking,labellinganddocumentation.Asallwaste contractorswillhavetoappointDGSAs,someofthemmaybeable/preparedtoassist withadvicetotheirowncustomers. Table12providesgeneralguidanceontheneedtoappointaDGSA. 126 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Table12AppointmentofDGSAsforthetransportofclinicalwaste1 Methodofcarriage Medicalpremises (hospitals,clinicsetc) Yes Wastecarrier Inbulk(seepicturesundertypicalpackageproblems) Yes Inpackages <333kgperload No No >333kgperload Yes Yes 1.ThisTableonlyrelatestoclinicalwaste(UN3291).Manymedicalsitesmoveotherdangerousgoods(e.g.radioactive materials,industrialgasesetc).Thesedangerousgoodsmustbetakenintoaccountinanyfinaldecisionregardingthe needforaDGSA. 2.Thecarriermustaggregatealltheloadshe/shecollects. Note MostwastemedicineswilleitherbeexemptfromtheCarriageRegulationsorthey willbeshippedasdangerousgoodsinlimitedquantities. FunctionsoftheDGSA ThefunctionsoftheDGSAareasfollows: • monitoringcompliancewiththerulesgoverningthetransportof dangerousgoods; • advisingtheemployeronthetransportofdangerousgoods; • ensuringthatanannualreporttotheemployerispreparedonthe activitiesoftheemployerconcerningthetransportofdangerousgoods; • monitoringpracticesandproceduresrelatingtotheactivitiesofthe employer. Transportontheroad Managingcompliance Europeanagreementconcerningtheinternationalcarriageofdangerousgoodsby road(ADR) CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) CarriageonshipsinUKwaters 8177 Whentransportingdangerousgoodsincludingwastematerialsbysea,the InternationalMaritimeDangerousGoods(IMDG)codemustbefollowed.Thiscode wasdevelopedasauniforminternationalcodeforthetransportofdangerousgoodsby seacoveringsuchmattersaspacking,containertrafficandstowage,withparticular referencetothesegregationofincompatiblesubstances. Dangerousgoodsforaseapassagemustbedeclaredonadangerousgoodsnotetothe shippingline.Thedocumentsdescribedin‘Managingcompliance’ondocumentation meettherequirementsoftheIMDGcode,providedthetransportinformationis included.ThiswillapplytoshipmentsfromNorthernIreland. Managingcompliance 127 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 On-sitetransport 8182 Onroadstowhichthepublicdonothaveaccess,dedicatedtrucks,trolleys,tugsor wheeledcontainersareneededtotransportwastereceptaclestostorageareas.To preventcontamination,theyshouldnotbeusedforanyotherpurpose.Theyneedto bedesignedandconstructedsothatthey: • areeasytocleananddrain; • containanyleakagefromdamagedreceptaclesorcontainers; • areeasytoloadandunload; • donotofferharbourageforinsectsorvermin;and • donotallowparticlesofwastetobecometrappedonedgesorcrevices. Containersforon-sitetransportneedtobesteam-cleanedordisinfectedfollowing leakagesorspills,andatregularintervals.Ifcontainersareheavilyused,cleaningis likelytoberequiredatleastweekly.Thehealthcarewasteproceduresneedtospecify themethodandfrequencyofsteamcleaningordisinfection. Internalvehiclesshouldnotbeusedtotransportwastematerialsonroadstowhichthe publichaveaccessunlesstheymeetthefullprovisionsoftheCarriageRegulationsas appropriate. Forfurtherinformationontypicalpackageproblemsandregulatoryrequirements, visittheHSE’swebsite. HSEwebsite CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) 128 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Wastemanagementlicensingand 8189 permitting Thissectionprovidesinformationforwasteproducersonwastepermitting/licensing exemptionsrelevanttotheiractivities.Italsoprovidesabriefoverviewofthe regulationsgoverningpermitting/licensing,principallytoinformandsupportwaste managersinthiselementoftheirduty-of-careaudits. EUpolicyonwastemanagementrequiresmemberstatestopromote: • wastereductionandprevention; • theuseofcleanertechnologies; • reusable/recyclableproducts; • energyrecovery; • reductionofdisposalofwastetolandfills;and • anintegratednetworkofwastemanagementfacilities. Thisshouldbeachievedwithoutdangertohumanhealthortheenvironment.Asa consequence,mostwastemanagementactivities–rangingfromasmalltransferstation throughtorecyclingfacilities,compostingandlandfill,toincineration–requiresome formofauthorisationunderlegislationwhichaimstopreventenvironmentalpollution orharmtohumanhealth,forexample: • theEnvironmentalPermittingRegulationsinEnglandandWales;or • theWasteManagementLicensingRegulations,orthePollution,Prevention andControl(PPC)RegulationsinNorthernIrelandandScotland. Otherlegislationmayalsobeapplicable,anddifferentaspectsofaproposedoperation mayberegulatedbydifferentregulatoryinstruments.Regulatorycontrolsoftenrunin parallelwith,andoverlap,theplanningprocess.Applicationforapermittooperatea wasteprocessingfacilityandanapplicationforplanningpermissionshouldnotbe consideredinisolation. EnvironmentalPermitting(EnglandandWales)Regulations WasteManagementLicensingAmendment(Scotland)Regulations WasteManagementLicensingRegulations(NorthernIreland) PollutionPreventionandControl(Scotland)Regulations PollutionPreventionandControlRegulations(NorthernIreland) EnvironmentalPermittingRegulations(EnglandandWales) 8191 TheEnvironmentalPermittingRegulationswereintroducedtoprovideastreamlined systemofauthorisationwiththeobjectiveofensuringthatforthemanagementof waste,itsstorage,treatmentordisposaldoesnotcausepollutionoftheenvironment, harmtohumanhealthorseriousdetrimenttolocalamenities.Forwaste-managementrelatedactivityinEnglandandWales,thiscombinesthepreviouswastemanagement licensingandpollutionpreventioncontrolregimes. Awasteoperationcarriedoutataninstallationoramobileplantundertakingawaste operationwillrequireanenvironmentalpermitunlessitisanexemptactivity(see ‘Exemptionsfromenvironmentalpermitting’and‘Healthcare-relatedexemptions’). 129 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Note TheEAforEnglandandWaleshasproducedasectorguidancenoteforoperatorsof wastetreatmentfacilitiesspecifyingrequirementstoensurecompliancewith environmentalpermits(‘Howtocomplywithyourenvironmentalpermit: additionalguidanceforclinicalwaste(EPR5.07)’).Theguidanceappliesto facilitiesthatarespecificallypermittedtoacceptclinicalwaste.Italsocoversthe integratedpollutionpreventionandcontrol(IPPC)Directive,bestavailable techniques(BAT)andoperationalaspectsofcompliance,includingtheneedfor wasteproducerstoundertakepre-acceptanceauditstodemonstratecompliant classificationandsegregationofwaste.BATalsoincludesconsiderationforenergy efficiency(forexample,thetreatmentofnon-infectiouswastemaynotcomplywith thepermitandmayunnecessarilyincreaseenergyconsumption). Exemptionsfromenvironmentalpermitting Healthcare-relatedexemptions EnvironmentalPermitting(EnglandandWales)Regulations EPR5.07 Exemptionsfromenvironmentalpermitting 8193 TheWFDrequiresestablishmentsandundertakingscarryingoutthedisposalor recoveryofwastetoobtainapermitfromthecompetentauthority.Itprovidesdetails ofcertainwastedisposalorrecoveryoperationsthatmaybeexemptfromtheneedto holdapermit,buttheseonlyrelatetothedisposalofwasteattheplaceofits productionortherecoveryofwaste.Italsospecifiesthatalthoughrecoveryand disposalincludesstoragependingarecoveryordisposaloperation,itexcludes temporarystoragependingcollectiononthesitewhereitisproduced(thatis,some activitiesmaynotrequireapermitoranexemption).Theseactivitiesarecoveredby exemptionsreferredtoasnon-WFDexemptionsanddonotrequireregistrationwith theEA.However,theregulationsdospecifycertainconditionsforthesetoapply;for example,see‘Healthcare-relatedexemptions’forthereceiptandstorageofunwanted pharmaceuticalspriortocollectionfordisposal. TheEnvironmentalPermittingRegulationsprovidedetailsoncertainactivitieswhere apermitisnotrequired,andtheseexemptionsarelistedandspecifiedonthebasisof whethertheactivityisbasedonuse,treatment,disposalorstorageofwaste.Each exemptwasteoperationisthendefinedinastandardformatwithaheadingwhich generallydescribesthenatureoftheoperation,asfollows: • adescriptionoftheoperationcoveredbytheexemption; • theEWCcodesandadescriptionofthewastetypespermittedunderthe exemption,withthequantitiesofdifferentwastesallowed;and • thespecificconditionsrelatingtothatexemptwasteoperationincluding quantitylimitsandstoragerequirements. Allexemptwasteoperations(exceptnon-WFDexemptions)mustberegisteredwith therelevantexemptionregistrationauthority,usuallytheEA.Anelectronic notificationformcanbefoundontheEA’swebsite. Theregistrationforeachexemptionmustberenewedeverythreeyears.Ifan establishmentorundertakingregistersmorethanoneexemptionforalocation,the subsequentregistration(s)is/areonlyvaliduntilthedateofrenewalforthefirst registration. Furtherdetailedguidanceonexemptionsfromenvironmentalpermitscanbefound ontheEAwebsite. Healthcare-relatedexemptions 130 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Directive2008/98/ECoftheEuropeanParliamentandoftheCouncilof19 November2008onwasteandrepealingcertainDirectivesTextwithEEArelevance (WFD) EnvironmentalPermitting(EnglandandWales)Regulations EA–electronicnotificationform EA–exemptionsfromenvironmentalpermits Healthcare-relatedexemptions 8196 Examplesofspecifichealthcare-waste-relatedexemptionsfrompermittinginEngland andWalesareasfollows: • Temporarystorageattheplaceofproduction(forexampleahospitalstoring itsownwasteatthehospitalwhereitwasproduced)isnowconsideredanonWFDexemption.Itmustbestored: –inasecureplace;and –fornolongerthan12months. • Temporarystorageofwasteataplacecontrolledbytheproducer(thatis,not necessarilytheplaceofproduction).Thisoperationmustnotbeundertaken inthecourseofprovidingawastemanagementservicetoanotherperson: –itmustbestoredinasecureplace; –itmustbestoredfornolongerthanthreemonths; –itmustnotbemixedwithothertypesofwastes; –fornon-liquids,thetotalstoragevolumemustnotexceed50m³; –forliquidwastes,thetotalvolumemustnotexceed1000Landbestored inacontainerwithsecondarycontainment. –Examplesinclude: –midwivesreturningclinicalwastefromhomebirthstothematernity unit,andothersimilarcareinthehome; –estates,facilitiesorITstaffwhoundertakemaintenanceorrepair activitiesatanumberoftrustpremisesreturningwastetoacentral point(forexampletheirbase)forcollection(seenotebelow); –anacutehospitalpharmacysupplyingmedicinesto,andcollection wastemedicinesfrom,othermedicalpracticesinthesametrust(see notebelow). • Temporarystorageofwasteatacollectionpointinasecurecontainer,where: –wastesofdifferenttypesmustnotbemixed; –forWEEE,thetotalquantityofwastestoredatanyonetimemustnot exceed30m³; –fornon-hazardouswastes(notWEEEinthiscase)toberecovered elsewhere,thestoragelimitis50m³;and –foranyotherwastes,thestoragelimitis5m³. –Examplesinclude: 131 –acommunityoracutepharmacyreceivingreturnedmedicinesorsharps fromdomesticpremises; –acommunityoracutepharmacyreceivingwastemedicinesorsharps fromothermedicalpracticesornursinghomesthatarenotpartofthe for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 sameorganisation,forexamplewheretheysupplymedicinalproducts andalsocollectthewastemedicines(seenotebelow); –ahospitalreceivingwastefromambulances. Theseareknownasnon-WFDexemptionsanddonotrequireregistrationwiththe environmentalregulator.Forfurtherinformation,seetheEnvironmentAgency website.Detailsofexemptionsfordenaturingcontrolleddrugsareprovidedinthe “Communitypharmacies”sectorguide. Note Thehazardouswasteregulationsapplyinfulltomovementsofhazardouswaste betweennon-domesticpremises.Themovementofhazardouswastefromone pharmacyormedicalpracticetoanotherpharmacyormedicalpracticeactingasthe temporarystoragepointmustbeaccompaniedbyahazardouswasteconsignment note.Inaddition,thepharmacyormedicalpracticefromwhosepremisesthewaste istobemovedisahazardouswasteconsigneewithdutiestosendreturnstoboth theenvironmentalregulatorandtheproducer,inadditiontospecificrecordand inventoryrequirements. Theserequirementsapplyequallytomovementsofhazardouswastewithinan organisationandbetweenorganisations. Theseexemptionsnowincludeancillarytreatments,meaningthatsometreatment operationscanbecarriedouttomakethewasteeasiertostoreandcollectforits recoveryordisposalelsewhere.Anyancillarytreatmentcarriedoutmustnotresultina changeinthecharacteristicsofthewaste.Thetreatmentcarriedoutmustbepurelyto helpwiththetransportorcollectionofdifferentwastes.Thefollowingareexamplesof someofthetreatmentsthatcanbeconsideredancillarytothecollectionofwaste: • compactionofpaperandcardboardinordertoincreasetheamountofwaste thatcanbestoredwithinacontainer; • shreddingconfidentialpapersforsecuritypurposes; • crushingorcompactinglargeitemstoalloweasierloading; • separatingrecyclablessuchaspaper,card,plasticandglassfrommixedwastes intoseparatestoragecontainers. Notes 1.Ifanon-sitecompactorisusedtoprocessthegeneralwastestream,anexemption frompermitting/licensingisnolongerneeded. 2.SeeDefra’swebsiteforlatestupdatesonexemptionsinEnglandandWales. Communitypharmacies Directive2008/98/ECoftheEuropeanParliamentandoftheCouncilof19 November2008onwasteandrepealingcertainDirectivesTextwithEEArelevance (WFD) WasteElectricalandElectronicEquipmentRegulations Non-WFDexemptions Defrawebsite 132 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 8596 Case study on the compaction of offensive healthcare waste Whileitisstandardpracticetocompactnon-hazardouswastematerialsfromthe municipal,commercialandindustrialsectors,thecompactionofoffensivehealthcare wastehastraditionallybeenavoided.Thisisduetothepotentialexposuretofoul odoursorbodyfluidsarisingfromtherupturingofthecompressedbags,aswellas non-statutoryguidancerelatingtothestorageofoffensivewastes. Collecting,storingandtransportingoffensivewastesinwheeledbinsisnotverycosteffective.Substantialspaceisrequiredtostorethelightweightoffensive-wastebags. Thisthenlimitsthenumberofbagsthatcanbetransportedanddisposedofper consignmentfromthesiteofproduction,meaningthatoverallprocessingcostscanbe similarorsometimeshigherthanthoseformanaginghazardousinfectioushealthcare wastes. OneUKhospitaldecidedtoinvestigatethepossibilityofsafeandcompliant compactionofsuchwastesusingabespokemobilecompactionunit.Following extensiveresearch,thehospitalidentifiedasupplierwhocouldprovideamobile compactionunitthatusesanadaptedcompactorramandaleakproofchargebox, ideallysuitedtowastesthatrequireadditionalcontainment.Itworksatlowhydraulic pressuresothattheoffensivewastebagsarelesspronetoruptureandliquidsarenot mobilisedduringcompaction. Mobile compaction unit TheTrust’sactualcostsavingoveryearonewas£88,000owingtowastereclassification andassociatedtransportationanddisposalefficiencies. Theaveragenetweightperconsignmentisintheregionof3.5tonnesandtheunitis exchangedtwiceperweek–significantlylessthantheoriginalwheeled-bincollection regime. Regularcleaningofthechargeboxisnotnecessarybecauseofthewaytheramsystem isdesigned.Inaddition,thecontainerthatthewasteiscompactedintoisfullysealed toensurethattheunitremainsleakandodour-proof.(Itshouldbenotedthereisa requirementforaproactivemaintenanceregimetobeimplementedtomaintainthe integrityoftheseals.) Theuseofthemobilewastecompactorhasresultedinthefollowingprocessand financialsavings: 133 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 1. Significantcostsavingsassociatedwiththereducedhaulagefrequencyof offensivewastes. 2. Reducedtransportationfromsiteresultingincarbonsavings. 3. Asignificantreductioninthespacerequiredtostoreoffensivewasteon-site. 4. Fullcontainmentofoffensivewasteswithinsealedcontainers. 5. Boththewastecontractorandlandfilloperatoraresupportiveoftheprocess asitspeedsupcollectionanddisposalandeliminateshealthandsafetyrisks associatedwithmanuallymovingwheeledbinsandhand-ballingthe offensivewastebags. Smallclinicalwastetreatmentplant(ontheproducer’s premises) 8198 ThereisnoallowanceintheWFDformemberstatestoprovideanexemptionforthe operationofasmall-scaleclinicalwastetreatmentplantatahealthcarefacility.Any plant,irrespectiveofsize,thattreatsinfectiouscategoriesofwasteissubjectto stringentcontrolsandrequiresapermittooperate.InEnglandandWales,thisplantis notallowedtooperatewithoutapermitunderalowriskormodernregulation position. Laboratoryautoclaves 8200 ForEnglandandWales,theon-sitetreatmentbylaboratoryautoclaveofcontainment levels1–3microbiologicallaboratorywasteispresentlyidentifiedasalow-riskactivity forwhichitisnotinthepublicinteresttoexpectoperatorstoobtainanenvironmental permit. Forfurtherinformation,visittheEA’swebsite. Seealsothe‘Wastetreatmentanddisposal’sectionofthe“Researchandlaboratory facilities”sectorguide,whichincludesguidanceontheeffectiveoperationand validationofautoclavesusedforthispurpose. Thosefacilitieshandlingcontainmentlevel4shouldseekadvicefromtheirlocalEA office(forEnglandandWales). Wastetreatmentanddisposal EAwebsite Wastemanagementlicences(NorthernIrelandand Scotland) 8202 ActivitiessubjecttocontrolbytheWasteManagementLicensingRegulationsfor NorthernIrelandandScotlandinclude: • storageofwaste(otherthanthatgeneratedbythewasteproducer); • reuse,recyclingortreatmentofwasteeitheratafixedpremisesorviaa mobileprocessingfacility; • operatingalandfillsite;or • operatingotherdisposalsites. Therearesomeexemptionsfromtheneedtoholdawastemanagementlicence, dependingonthefollowingcriteria: • typesofwasteprocessed; 134 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • typeofactivitiesundertakentoprocesswaste;and • lengthoftimewasteisbeingstored. Theseexemptionscanbeeithersimpleorcomplexandusuallyrequirenotificationto theenvironmentalregulator.Evenifawaste-processingactivityiscarriedoutunder oneoftheseexemptions,itisstillsubjecttostatutorycontrolstoprevent environmentalpollutionandharmtohumanhealth. Forthemanagementofhealthcarewastes,themostcommonexamplesofactivities subjecttoexemptionsfromtheneedtoobtainawastemanagementlicencecanbe foundinparagraphs28and39oftheWasteManagementLicensing(Scotland) Regulations. InNorthernIreland,paragraph39allowsthesecurestorageatapharmacy(pending theirdisposalthereorelsewhere)ofwastemedicineswhichhavebeenreturnedtothe pharmacyfromhouseholdsorindividuals.Italsoallowsthesecurestorageatthe premisesofamedical,nursingorveterinarypracticeofwasteproducedincarryingout thatpractice.Thetotalquantityofreturnedwastemedicinesatthepharmacymust notexceed5m³atanyonetime,andthetotalquantityofwastestoredatthepremises ofamedical,nursing,orveterinarypracticemustnotatanytimeexceed5m³(seethe WasteManagementLicensingRegulations(NorthernIreland)2003). Therearespecificlimitationsplacedonactivitiesusingtheseexemptions. Formoredetailedinformationonwastemanagementlicensingorrelated exemptions,visittheregulatorwebsitesforNorthernIrelandorScotland. Paragraph28oftheWasteManagementLicensing(Scotland)Regulations Paragraph39oftheWasteManagementLicensing(Scotland)Regulations WasteManagementLicensingRegulations(NorthernIreland)2003 RegulatorwebsiteforNorthernIreland RegulatorwebsiteforScotland Pollutionpreventionandcontrol(PPC)permits(Northern 8204 IrelandandScotland) ActivitiessubjecttocontrolbypermitunderthePPCRegulationsarelistedin Chapter5ofSchedule1totheRegulationsandinclude: • disposalofwastebyincineration; • disposalofwastebylandfill; • disposalofwasteotherthanbyincinerationorlandfill; • recoveryofwaste; • theproductionoffuelfromwaste. APPCpermitisrequiredtooperatefacilitiesthathavethecapacitytostoremorethan 10tonnesofhazardouswasteand/orhavethecapacitytotreatmorethan10tonnesof hazardouswasteperday. InformationandguidanceonapplyingforaPPCpermitisavailablefromtheNIEA andSEPAwebsites. PollutionPreventionandControl(Scotland)Regulations PollutionPreventionandControlRegulations(NorthernIreland) NIEAwebsite SEPAwebsite 135 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Treatmentanddisposal 8206 Thissectionfocusesontherenderingsafeofhealthcarewasteandspecifiesthe establishedtechniquestoachievethis. Alltreatmentanddisposalfacilities,regardlessofsizeortypeoftechnologyused,are requiredto“rendersafe”thewaste.Therequirementsofrenderingsafedependonthe typeofwastetreatedandonthenatureofthecontaminantspresentinthewaste.They willalsobesubjecttodetailedcontrolbytherelevantenvironmentalregulator. Renderedsafe 8208 “Renderedsafe”isanacceptedmethodorprocessthathasbeenappliedwhich: 1. demonstratestheabilitytoreducethenumberofinfectiousorganisms presentinthewastetoalevelatwhichnoadditionalprecautionsareneeded toprotectworkersorthepublicagainstinfectionfromthewaste; 2. destroysanatomicalwastesuchthatitisnolongergenerallyrecognisable; 3. rendersallclinicalwaste(includinganyequipmentandsharps)unusableand unrecognisableasclinicalwaste; 4. destroysthecomponentchemicalsofchemicalormedicinalandmedicinallycontaminatedwaste. (Forlaboratoryautoclaves,seethe“Researchandlaboratoryfacilities”sectorguide.) Alternativetreatmentplants(treatingwasteotherthananatomicalwaste,medicines andchemicals)shoulddemonstratethetwocriteria(1)and(3)detailedaboveinorder todemonstratethatthewasteisrenderedsafe.Thesecriteriaapplyto: • allnon-incinerationtechnologiesthatareusedtotreatclinical/healthcare waste; • eachindividualdeviceregardlessofloadcapacityandpermittingstatus; • existingoperationaldevices,aswellasdevicesbeingnewlyinstalled. Theadditionalcriteria(2)and(4)willapplyifsuchwastesaretreated. Wherethesehavenotbeenmet,thewasteisnotconsideredtohavebeenrendered safe.Thisisapplicableforthepurposesoflandfill,andfurthertreatmentwouldbe required. Researchandlaboratoryfacilities CriterionA:reductioninpathogennumbers 8209 Microbialinactivationisacriticalelementofthe“renderingsafe”ofcertaintypesof healthcarewaste.Therearethreecriticalaspects: 1. forinfectiouswaste,thetreatmentmustdemonstrate,asaminimum,the LevelIIIcriteriaprovidedbytheStateandTerritorialAssociationon AlternativeTreatmentTechnologies(STAATT)orequivalent; 2. forculturesofpathogenicmicroorganisms,theLevelIVcriteriamustbe achieved(pre-macerationorshreddingisnotappropriateforsuchwastes); 3. theabilitytoachievethesecriteriamustbedemonstratedfortheworst-case challengeload,andinamannerthatmeetstherequirementsofany applicableguidanceissuedbythewasteregulatoryagencies. STAATTLevelIII:inactivationofvegetativebacteria,fungi,lipophilic/hydrophilic viruses,parasitesandmycobacteriaata6log10reductionorgreater;andinactivationof 136 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Geobacillus stearothermophilus orBacillusatrophaeussporesata4log10inactivationor greater. CriterionB:destructionofanatomicalwaste 8211 Treatmentofanatomicalwasterequiresthatthewasteberenderedunrecognisablein suitablepermittedfacilities,whichatthistimemeansincineration. CriterionC:unusableandunrecognisable 8212 Thiscriterionappliestobothnon-incinerationandincinerationtechnologies.The treatmentorincinerationmustensurethatthereisnorecognisableclinicalwaste remaining.Thisreducesthelikelihoodofthewastecausingoffenceandremovesdata confidentialityconcernsfromanydisplaylabels/identificationofpatientdetailson itemssuchasspecimencontainers.Howthisisachievedmaydependonthe technology;however,alternativetreatmentplantsnormallymaceratethewasteprior to,duringorafterthedisinfectionprocess. Note Microbiologicalculturesshouldnotbemaceratedpriortotreatment,asmaceration maysignificantlyincreasetheriskofaerosolemission. CriterionD:Therenderingsafeofpharmaceuticalsandchemicalswithinthe waste 8213 Allpharmaceuticallyactivesubstances,bothhazardousandnon-hazardous,presentin themedicinally-contaminatedwasteandanywastechemicalsshouldbedestroyed duringdisposalatasuitablyauthorisedfacility.Forfurtherinformationon managementofcontrolleddrugs,seetheDepartmentofHealth’swebsiteandthe “Communitypharmacies”sectorguide. Communitypharmacies DepartmentofHealthwebsite Treatmentanddisposalsystems 8215 Treatmentanddisposalsystemsforhealthcarewastecanbesegregatedintotwobroad types: • hightemperature(incineration/combustionprocesses); • non-burn/lowtemperaturealternativetechnologies. Whilstnotstrictlyconsideredtreatment,landfilldisposalforoffensiveEWC180104 wastesremainsadisposaloptionforsomehealthcarewastesspecifiedin‘Waste minimisation,segregation,colour-codingandstorage’. Whiletherearealargenumberofsystemsavailabletotreathealthcarewaste,theyall useheat,chemicals,irradiationorcombinationsofthesemethods.Theselectionofthe mostappropriatesystemisdependenton: • thetypeofwastetobetreated(see‘Wasteminimisation,segregation,colourcodingandstorage’); • thevolumeofthewastetobetreated; • supportcapabilitiesofthesupplier; • staffingrequirements;and 137 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • initialandcontinuingoperatingcosts. Treatmentanddisposalmethodsneedtobereliableandcapableofconsistently achievingtherequiredstandardoftreatment.Theirperformanceneedstobe measurableandtheprocessneedstobecontrolledtoreproducethetargetstandards. Managersofwastetreatmentanddisposalfacilitiesneedtoworktoauditedprocedures whichtakeintoaccounttheriskstooperatorsaswellastootherpeopleonthesite,as wellastheneedtomaintainstandardsofwastetreatment. Alltreatmentanddisposalfacilitiesthatacceptwasteon-sitefortreatmentordisposal requireanenvironmentalorPPCpermitoravalidexemptionfromthepermittingor licensingregime(discussedinmoredetailin‘Wastemanagementlicensingand permitting’).Foranoverviewofspecifichightemperatureandnon-burn/low temperaturealternativetechnologies,see‘Clinicalwastetreatmentanddisposal overview’. Wasteminimisation,segregation,colour-codingandstorage Wastemanagementlicensingandpermitting Clinicalwastetreatmentanddisposaloverview Dischargetosewer 8217 Anydischargetosewer,otherthandomesticsewage,musthavetheprioragreementof thestatutoryresponsiblebodies.Anybodyintendingtodisposeanywastetosewerthat maypresentasubstantiallygreaterriskofdamagetothesewerageundertakers’assets thandomesticsewage(suchassingle-useitemsthataremaceratedincertainscenarios ofrestrictedinfrastructure)shouldfirstseekadvicefromthesewerageundertaker. Someexamplesoftypicaldischargesare: • bodyfluids–bloodandsimilarpotentiallyinfectioussubstances(forexample fromsuctioncanistersorwounddrains)–theapprovalofthesewerage undertakershouldbesought; • photochemicals(X-ray)–thesearesuitableforrecycling.Itispoorpractice, evenifpermittedbyadischargeconsent,todischargethismaterialtofoul sewer–theapprovalofthesewerageundertakershouldbesought; • pulpbedpansandurinebottles–macerationanddischargeofshredded materialtofoulsewerisknown,insomeinstances,tocauseobstructionof theseweragenetwork.Itisessentialthatthesewerageundertakerisawareof thepresenceofthismaterialandthatitsdisposalispermittedbythe producer’stradeeffluentconsent. Radioactivewastefromdiagnosisandintensiveradiotherapyhaslowradioactivityand ashorthalf-life.Ifthewasteisawater-misciblefluid,andthedischargeauthorisation permits,itmaybedisposedoftosewer. Atthetimeofpublication,WaterUKonbehalfofitsmemberwatercompaniesis preparingaguidancedocumentforthetreatmentofwastewaterarisingfrom healthcareactivities,aimedprimarilyatacutehospitaltrusts.Theguidancewill presentthefindingsofanin-depthresearchintothetypesandquantitiesofwaste waterproducedinahospitalenvironmentbasedondiscreteareasofactivityand makerecommendationstoassisthealthcaretrustsinensuringtheyimplement robustmanagementsystemstoprotectthefoulseweranddownstreamsewage treatmentworks.Thiswillincludeguidanceonfluiddisposalsystems. Althoughnotanall-inclusivelist,thefollowingrepresentsanoverviewoftypicalareas ofactivityinhealthcarefacilitieswheredischargetoseweroccurs: 138 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • in-patientaccommodationwithinhospitals–typicalarisingsincludeurine/ faeces/vomit,maceratedsingle-useitems,disinfectantchemicalsfrom cleaningandspillageresponse; • kitchenandcateringfacilities–mainarisingsarefoodwasteviasink macerators,usuallycontributingsignificantoil/greasecontenttotheeffluent. Thismayalsocontaindisinfectantcleaningchemicals; • laboratoriesincludingpathology–potentialforavarietyofchemical residues,eitherfromdirectflushing/rinsingofglasswareorwasheffluent fromindustrialwasher/dryermachines; • radiologydepartments–potentialforavarietyofphotochemical contaminantsineffluent; • centralisedsterileservicesdepartments–contributessignificantquantitiesof detergentsandsterilizationchemicalresidues. Wasteproducersshouldfirstseekadvicefromtheirsewerageundertakerbefore disposingofmedicinestothefoulsewer,particularlywastearisingfromtheuseof cytotoxicorcytostaticmedicines. Specifictreatment/disposalrequirements 8223 TSE-infectedwaste 8218 WasteknownorsuspectedtobecontaminatedwithTSEagents,includingCJD,must bedisposedofbyhigh-temperatureincinerationinsuitableauthorisedfacilities. AdditionalguidanceonthemanagementofTSE-contaminatedwasteisgiveninthe DepartmentofHealth’s‘Transmissiblespongiformencephalopathy:Safeworkingand thepreventionofinfection’. ‘Transmissiblespongiformencephalopathy:Safeworkingandthepreventionof infection’ Cytotoxicandcytostaticwaste 8219 Wastecontaminatedwithcytotoxicand/orcytostaticsubstancesshouldbedisposedof insuitableauthorisedfacilities,normallyincinerationfacilities. Sharpscontainerscontainingsharpscontaminatedwithcytotoxicand/orcytostatic productsshouldbedisposedofinsuitableauthorisedfacilitiesthatacceptcytotoxic andcytostaticwaste. Wastecontaininggeneticallymodifiedmicroorganisms(GMMs) 8220 Wastecontaminatedwithgeneticallymodifiedmicroorganisms(GMMs)mustbe inactivatedbyavalidatedmeans. “Inactivation”isdefinedasthe “complete or partial destruction of GMMs so as to ensure that any contact between the GMMs and humans or the environment is limited to an extent commensurate with the risks identified in the risk assessment and to provide a high level of protection for humans and the environment”. Thisimpliesthatthedegreeofinactivationrequiredwillvarydependingonthenature oftheGMMsbeingused. Thereareanumberofcommercialtreatments/disposalfacilitiescurrentlyusedfor infectiouswastethatareabletoeffectivelyinactivategeneticallymodifiedorganisms (GMO)orGMMwaste.However,inactivationofcontaminatedwastebythese facilitiesdoesnotobviatetherequirementtohaveanautoclaveon-site,inthebuilding 139 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 orinthelaboratorysuite(dependingontheriskclassificationofthewasteinvolved). Thereisacleardistinctionastowheretheinactivationneedstotakeplace,depending ontheriskclassofthewaste: • class1–wastetobeinactivatedbyvalidatedmeans; • class2–wastetobeinactivatedbyvalidatedmeans(recommendedbest practice–wastetobeautoclavedwithinthebuildingpriortooff-site treatment/disposal); • class3–wastetobeinactivatedwithinthelaboratorysuitepriortooff-site treatment/disposal; • class4–wastetobeinactivatedwithinthelaboratorypriortooff-site treatment/disposal. WastecontainingGMMswhichiscollectedfortreatment/disposalbycontractors beforeithasbeeninactivatedissubjecttotherequirementsoftheGenetically ModifiedOrganisms(ContainedUse)Regulations.Forexample,contractorsmay collectwasteinsealedreceptacles,whichtheythenincinerateorotherwisetreatto ensureinactivation.Thecontractorinthiscaseisundertakingacontained-useactivity, namelydestructionoftheGMOs,andmustregisterasaGMcentrewiththe competentauthority.Guidanceontheactivitynotification(registration)isavailable fromtheHSE. Wherethewastehasbeeninactivated,thecontractorisnotundertakingacontaineduseactivity.Thewastemaybecollectedandtreatedordisposedofwithouttheneedto considertheGeneticallyModifiedOrganisms(ContainedUse)Regulations.Further guidanceontheinactivationanddisposalofGMOandGMMwastecanbeobtained fromtheHSE. GeneticallyModifiedOrganisms(ContainedUse)Regulations GeneticallyModifiedOrganisms(ContainedUse)Regulations(NorthernIreland) HSE–inactivationanddisposalofGMOandGMMwaste Mercury 8221 Elementalliquidmercurycanbepresentinredundant-measuringdevices(forexample sphygmomanometers).Thesewillbeclassifiedashazardouswasteandtheirdisposal subjecttospecificcontrol;thatis,itshouldbeensuredthatthewastecontractor transfersthewastetoanauthorisedpermittedtreatmentfacilitytorecoverthemercury andpreventreleasetotheenvironment(mercuryisapersistentpollutantanddoesnot breakdownintheenvironment).Forthisreason,careshouldalsobetakentoensure themercuryiscontainedpriortoandduringbothcollectionandtransportation. Amalgam 8222 TheHazardousWasteRegulationsrequirethatdentalamalgamwasteiskeptseparate fromotherwasteandconsignedtoanappropriatewastemanagementfacility.In addition,dentistsneedtofitamalgamseparatorsandconsigntheamalgamtoan appropriatefacilityfordisposalorrecovery.SeeDefra’sguidanceondentalamalgam. HazardousWaste(EnglandandWales)Regulations HazardousWasteRegulations(NorthernIreland) SpecialWasteAmendment(Scotland)Regulations Defraguidanceondentalamalgam 140 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 SECTORGUIDES 141 8224 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Ambulanceservices 8226 Scopeandtargetaudience Theroleoftheambulanceserviceandemergencycarehasexpandedtoincorporate newanddiversewaysofapproachingcareinthecommunity(forexamplethe introductionofemergencycarepractitioners(ECPs)andrapidresponseteams). Theambulanceservice,asaproducerofhealthcarewasteandspecificallyinfectious waste,isrequiredtocomplywithwasteregulationsincludingtheHazardousWaste Regulations(SpecialWasteRegulationsinScotland)andthereforeneedstoensurethat wasteissegregated,described,classifiedanddisposedofappropriately. Thissectorguideisaimedatambulancetrustsincludingparamedics,ECPs,first respondersandambulancetransportservices. InadditiontheremaybecircumstanceswherebytheECPs,firstresponders,rapid responsevehiclesorparamedicsshouldfollowthe‘Communityhealthcare’sector guideinrelationtothecategorisinganddisposingofwaste. Communityhealthcare HazardousWaste(EnglandandWales)Regulations HazardousWasteRegulations(NorthernIreland) SpecialWasteAmendment(Scotland)Regulations Wasteriskassessment 8228 Classificationofwasteproducedbyemergencycareandtreatmentrequiresaclearrisk assessment.Usersofthissectorguideshouldthereforerefertothewasteassessment frameworkin‘Healthcarewastedefinitionsandclassifications’toensurethecorrect classificationisapplied.Thiswilltheninfluencesubsequentdecisionsonsegregation, storageandtreatmentthereafter. Owingtothelackofpriorknowledgeofpatients’medicalhistory(frompatient recordsandscreening),theabilitytoclassifyhealthcarewasteasnon-infectiousfor emergencycareservicesismorechallengingthaninsomeothersettings,wherethis informationismorereadilyavailable.However,theassessmentandsubsequent processingofthewastemustthereaftercomplywithlegalrequirementstosegregate hazardousfromnon-hazardouswaste(EnglandandWales),whilstensuringtheEWC numberassignedtothewastereflectsthosepermittedforreceiptbythewaste treatmentcontractor.Forexample,uncontaminatedpackagingmaybeplacedinthe municipalwastestream,oruncontaminatedPPEintheoffensivewastestream. Intheunlikelyeventthattheambulanceisusedfortransportingpersonswitha CategoryAinfection,specificadviceshouldbesoughtfromtheDepartmentfor TransportandtheHealthProtectionAgency(see‘CategoryAclinicalwaste’,‘Soiled surgicalinstruments’and‘Usedlinen’). Duringmajorincidents,poolingofbloodmayoccurontheroadside.Althoughthis canbesluicedwithwaterandallowedtorunofftosewer,itisnottheresponsibilityof theambulancecrewandshouldbemanagedbytheHighwaysAgencyorlocalhighway authorityasappropriate. IfthereisanincidentinvolvingthepoolingofbloodorbodyfluidfromaCategoryA patient,itshouldbecontained,treatedanddisposedofasappropriate.Thiswill involvedecontaminatingthepooled-bloodareabeforeitisreleased;however,once againthisisnottheresponsibilityoftheambulancecrew. Healthcarewastedefinitionsandclassifications 142 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 CategoryAclinicalwaste Soiledsurgicalinstruments Usedlinen Examplewastestreams 8230 Table13providesexamplesoftypicalwastearisingfromactivitiesintheambulance sector.Ambulancetrustscanandshouldimplementthefollowing: • yellow-liddedsharpscontainers; • orangewastereceptaclesforinfectiouswaste; • black/clearwastereceptaclesfordomesticwaste; • yellow/blackwastereceptaclesforoffensivewaste. Note Owingtolimitationsofspaceandthevarioustypesofambulancetransportation, thespecificsizeofthebinsorbagsandthetypewillvary(see‘Wastereceptaclesand storage’). 143 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Table13Examplesoftypicalwastearisingintheambulancesector Activity/cause Injections Classification Yellow-liddedsharps containers EWC:both180109 and180103* Treatingpatients(this Medicinesand Yellow-lidded mayincludearangeof medicatedintravenous container,clearly activities) bags(non-cyto) labelled¹ EWC:180109 Items/equipment/ Contaminated Infectiouswastein instrumentsfor packaging/gloves/ orangewaste treatingpatients aprons/otherPPE/ receptacles dressings/airways/ EWC:180103* suctionlinersetc/ plasticandmetal laryngoscopeblades² Items/equipment/ instrumentsfor treatingpatients/ passengertransport services Packagingasaresult oftreatingapatient or othermunicipal wastes Wastetype Contaminatedsharps/ syringebodieswith medicinalresidues Uncontaminated aprons/otherPPEetc/ non-medicated intravenousbags/noninfectiousurine/ faeces/vomitandtheir containers4 Contaminated packaging–plastic andcardboard or ifuncontaminated– packagingand municipalwastes Offensive/hygiene disposedofinyellow/ blackbags EWC:180104 Infectiousafteruse, disposedofinan orangebag EWC:180103* or ifnon-infectious EWC:200301 Justification Potentially contaminatedwith medicinal(non-cyto) products Medicinalproducts requiresegregation Riskassessment required;however,as theyareincontact withpatientsandare contaminatedwith bodyfluids,itis unlikelythattheywill beclassifiedasnoninfectiousi.e.no patientsrecordsor screening Riskassessmentto determinenopossible contaminationand non-infectious Usedpackaging, whilstcarryingout patienttreatmentsin thevehicle,willin mostcircumstances notbeinfectious/ clinicalwaste. Disposalroute Incineration Incineration Alternativetreatment orincineration³ Non-hazardous municipal incineration/energy fromwasteorlandfill –onlyifthereareno liquidsforthislast option5 Alternativetreatment orincinerationif contaminated infectious or non-hazardous municipal incineration/energy fromwaste,materials recyclingfacilitiesor landfill. Notes: 1.Liquidsmaybeplacedonlyincontainerswhichareleak-proofanddesignedforliquids 2.Ifmetal,specificarrangementsfordisposalmayberequired 3.Thewasteproducerneedstoliaisewiththewastecontractor/appropriatepartyfordisposal–see‘Disposaloptions’ 4.Boneinjectiongunswouldnotnormallybecontaminatedorinfectiousfollowingcorrectuse 5.Liquids(e.g.intravenousbagswithfluids)arebannedfromlandfill,andonlylimitedquantitiesfordisposalat municipalincinerationorenergyfromwastemaybepermitted.Thebanalsoappliestoliquidssuchasbodyfluids (e.g.urine,vomit).Smallquantitiesmaybeabsorbedontopapertowelstoclearaspillageandtheseitemsthen subjectedtoinfectious/offensiveassessment Staffwhoseuniformsarecontaminatedwithinfectiousmaterialsorinfectiouswaste shouldrefertoinfectioncontrolandlaundryprocedures.Unlessdiscarded,the uniformsarenotnormallydesignatedaswaste. Wastereceptaclesandstorage 144 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Limbsandbodyparts 8232 Limbs,bodypartsandtissueretrievedfromanaccidentsiteshouldaccompanythe patienttohospital.Ifthebodypartcanbereattached,itisnotclassifiedaswaste; therefore,thisguidancedoesnotapply.Thelimbsandtissueshouldbemanagedin linewithclinicalassessmentforpreservation: • containedinabagorcontainer; • sealed;and • thepatient’sidentificationmarkedonthereceptacle. Limbs,bodypartsandtissuesthatareclinicallyassessedtobebeyondreattachmentor useareclassifiedaswasteandshouldbecontainedinanappropriatecontainer (suitableforcontaininganyprotrudingbone)markedforincinerationonly,andbe sealedwithaplastictie/tagthatidentifiestheambulancesectorandarea(see‘Waste minimisation,segregation,colour-codingandstorage’). Wasteminimisation,segregation,colour-codingandstorage Wastereceptaclesandstorage 8234 Whereanyinfectiouswasteisbeingtransportedinvehiclespriortodisposal,thewaste shouldbeappropriatelypackagedinsafeandsecureconditions.Allwastereceptacles includingbagsandcontainersshouldbeinaccordancewiththespecificationsdetailed in‘Wasteminimisation,segregation,colour-codingandstorage’.Forpackagingused forbodypartsorlimbs,thepackagingneedstobestrongenoughtoresistthe protrusionofbones. Wastestreamsshouldbeclearlyidentifiableandlabelledinaccordancewiththewaste classificationandanyspecificrequirements,dependingonthedisposalroute.For example,wastedroppedoffatahospitalshouldbelabelledbythespecificambulance trust. Sharpscontainersusedduringthecourseofambulance/patienttransportservices shouldbecorrectlyassembled,labelled,datedandsignedasappropriate. Thesharpscontainershouldbedisposedofwhenitisfilledtothefilllineindicatedon thecontainerandshouldneverexceedthepermissiblemarkedmass. Allsharpscontainersshouldbetransferredincompliancewiththedutyofcare regulationsandfinallydisposedofatsuitablyauthorisedwastedisposalfacilitieseither bythehospitalwhereitisdroppedofforbytheambulancetrust. Note Agreementonthestandardformatofwastereceptaclesrequiredinambulanceshas yettobeagreed(attimeofwriting).However,minimumrequirementsinclude: • orangebagforsoftinfectiousitems; • yellow/blackbagfornon-infectious/offensiveitems(forexample uncontaminatedPPE); • blackorclearbagfornon-hazardousmunicipalitems(forexample packagingandgeneraldetritus);and • yellow-liddedsharpscontainer. Wasteminimisation,segregation,colour-codingandstorage 145 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Disposaloptions 8237 Theambulanceservice,duetoitsvaryingpatient-careactivities,hasanumberof optionsavailablewhendisposingofwaste. Option1–emergencyresponse 8236 Emergencyambulances,includingairambulances,cantransfertheirwastetothe hospitalwheretheyaretransportingthepatientforcareandtreatment,butonlyifthe hospitalhasagreedtoprovidethatservice. Note Thehospitalisnotrequiredtoprovidethisservice;itis,however,consideredbest practice. Firstrespondersgeneratingwasteon-siteshouldensuretheyhandthewastetothe attendingemergencyambulancefordisposal. Othertypesofambulanceservicethatmaygeneratesmallquantitiesofwasteshould eitherdisposeofthewasteattheattendinghospitalortakeitbacktobasefor collectionanddisposal. Wheretheambulancetrustdropsitswasteoffatahospital,thisisclassedaswaste transfer.Therefore,dutyofcareappliesandthetrustshould: • ensurethattheappropriateagreementsareinplacetoenableittotransferits wastetothehospital; • complywiththerequirementsofdutyofcare,andinparticularensurethat itswasteistransferredwithadetailedwastedescriptionandclassificationto enablethehospitaltodisposeofitappropriately; • ensurethatthewasteiscorrectlypackagedandlabelledinamannerthat identifiestheambulancetrustastheproducer; • useadesignatedwastecontainer(s)(forexampleawheeledcart)forthe storageofthiswasteatthehospital; • liaisewithhospitalstoconfirmarrangementsfordisposal(forexampleit shouldensurethatthedestinationdisposalfacilitiesaresuitablyauthorised andthewastedescriptionsandclassificationsonthepaperworkleavingthe hospitalareaccurate). Note Ahazardouswasteconsignmentnoteisnotrequiredforthetransferofthe hazardouswastefromtheambulancetotheambulancestationorhospital.Aduty ofcaretransfernoteis,however,required,althoughtherearemechanismstoenable thistobedoneonanannualbasis. Thehospitalcanacceptthewastefromtheambulancetrustunderanon-registerable exemptionfromanenvironmentalpermitfortemporarystorageatacollectionpoint, onlywhereaseriesofspecificconditionsaremet.Theseinclude: • Theambulancetrustmustnotpaythehospital. • Thewasteshouldnotincludeflammablesubstanceswithaflash-pointofless than21ºC. • Differentwastetypesmustnotbemixed.Thewastemustbestoredina securecontainer(s). • Thewastecanonlybestoredtemporarily(forexampleforlessthanthree months). 146 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • Thetotalquantityofwastestoredunderthisexemptioncannotexceed5m³ ofhazardouswaste(thehospitalwilltypicallyhaveanumberofothersources ofimportedwastethatcontributetothistotalinadditiontotheambulance trust). Note Ifthehospitalreceivespaymentforthisservice,thestorageisnotexemptandan environmentalpermitisrequired. Forwastethatisdisposedofthroughtheambulancestation,theambulanceservice shouldhaveawastedisposalcontractwitharegisteredandlicensedwastecontractorto safelycollect,transportanddisposeofitswasteappropriately. Option2–wasteinthecommunity 8238 ECPs,firstresponders,andrapid-responsevehiclesetcshouldfollowthedisposal optionsandguidanceprovidedinthe“Communityhealthcare”sectorguide,in particularforinfectiousandoffensivewastestreams. Forclinicalwasteproducedinthecommunitysetting,ambulancetrustsshouldliaise withtheappropriateauthority(thatis,thePCTorlocalauthority)toobtain informationondisposalarrangements. Communityhealthcare Option3–ambulancetransportservices 8239 Forservicessuchaspatienttransportservices,itislesslikelythatanyinfectiouswaste willbeproduced.Wheredomestic-typewasteisgeneratedandhasbeenrisk-assessed, thiscansafelybedisposedofintheblack-bagwasteorrecyclingstreamsanddeposited fordisposalatthenearesthospitalorreturnedtobase,dependingonarrangements. Ifinfectiouswasteisgenerated,itshouldbedisposedofintheorange-bagwaste streamandeitherdisposedofatthehospitalwiththeirpriorknowledgeandagreement ortakenbacktobase. 147 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Researchandlaboratoryfacilities 8241 InconjunctionwiththeHazardousWasteRegulationsandtheCarriageRegulations, thissectorguideemphasisesdutiesunderCOSHHandtheGeneticallyModified Organisms(ContainedUse)Regulationsastheyrelatetobiologicalagents. AnumberofadditionalHSEpublicationsproviderelevantguidanceonmanagement ofhealthandsafetywithinresearchandlaboratoryfacilities,andexpandonthepoints mentionedinthissection;hencetheyshouldbereadinconjunctionwiththissector guide.Theyare: • ‘Safeworkingandthepreventionofinfectioninclinicallaboratoriesand similarfacilities’(HealthServicesAdvisoryCommittee(HSAC)); • ‘Biologicalagents:managingtherisksinlaboratoriesandhealthcarepremises’ (theAdvisoryCommitteeonDangerousPathogens(ACDP)); • ‘Themanagement,designandoperationofmicrobiologicalcontainment laboratories’(ACDP); • ‘ScientificAdvisoryCommitteeforGeneticModificationcompendiumof guidance’(SACGM). Therulesforthetransportofwastespecimensthatareclassifiedasdangerousfor transportfromlaboratoriesaresetoutintheCarriageRegulations,whichrequirethe applicationofADR(see‘Legislationandhealthcarewaste’). Legislationandhealthcarewaste HazardousWaste(EnglandandWales)Regulations HazardousWasteRegulations(NorthernIreland) SpecialWasteAmendment(Scotland)Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) ControlofSubstancesHazardoustoHealthRegulations(COSHH) ControlofSubstancesHazardoustoHealthRegulations(NorthernIreland) GeneticallyModifiedOrganisms(ContainedUse)Regulations GeneticallyModifiedOrganisms(ContainedUse)Regulations(NorthernIreland) Safeworkingandthepreventionofinfectioninclinicallaboratoriesandsimilar facilities Biologicalagents:managingtherisksinlaboratoriesandhealthcarepremises Themanagement,designandoperationofmicrobiologicalcontainment laboratories ScientificAdvisoryCommitteeforGeneticModification:Compendiumof guidance Briefdescriptionofthesectoractivities 8243 Thissectorguidecoversresearchandlaboratoryfacilitiesthatundertakeworkwith infectioussubstances(thatis,thoseknownorreasonablyexpectedtocontain pathogensorGMMs). 148 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Whilethisguidancefocusesonwastegeneratedinhealthcarepremises,itisalso pertinentandapplicabletohealthcarewastefromotheroccupationalsettings. Forthemostpart,theresearchandlaboratoryfacilitiesmostlikelytogenerate infectiouswasteinclude: • researchlaboratories(forexampleuniversities); • teachinglaboratories(forexamplemedicalschools); • clinicallaboratories(forexampleclinicalmicrobiologydepartments); • forensiclaboratories(forexamplepathologyandpost-mortem); • veterinarylaboratories(forexamplediagnosticorresearchinstitutes);and • environmentallaboratories(forexamplefoodandwatertesting). Workinthesefacilitiesfallsintotwomaintypes: 1. wheretheworkinvolvestheintentionalpropagationorconcentrationof pathogensorGMMs(forexampleworkwithinfectedcellcultures,infected animals,orlarge-scalepropagationofpathogens); 2. wheretheworkinvolvesmaterials(forexampleclinicalspecimens)thatmay containpathogens(forexamplediagnosticworksuchaspathology, microbiology,haematologyorserology)andmayinvolvelimitedculturestage (forexamplepreliminaryisolationofbacteria). Toensurethatexposureoflaboratoryworkers(inaccordancewithdutiesunder COSHH)orlaboratoryworkersandtheenvironmenttopathogens(inaccordance withdutiesundertheGeneticallyModifiedOrganisms(ContainedUse)Regulations), GMMsorspecimensispreventedorelseadequatelycontrolled,suchworkis undertakenatanappropriatecontainmentlevel(CL). Riskassessmentispivotalinmatchingthelaboratorycontainmentandcontrol measuresrequiredforaparticulartypeofactivity.Toinformtheriskassessment, pathogenshavebeencategorisedintohazardgroups(HG)bytheAdvisoryCommittee onDangerousPathogens(ACDP)asdetailedinthe‘Approvedlistofbiologicalagents’. ClassificationofGMMsisbasedontheoutcomeoftheriskassessmentforthegenetic modificationactivitytheyarepartof. Note Theprinciplesofpreventionandcontrolofexposureandthespecificcontainment measuresforCL2,CL3andCL4canbefoundinRegulation7andSchedule3 (PartII)ofCOSHH,andareexpandedoninACDP’s: • ‘Themanagement,designandoperationofcontainmentlaboratories’; • ‘Biologicalagents:theprinciples,designandoperationofcontainment level4facilities’;and • ‘Biologicalagents:managingtherisksinlaboratoriesandhealthcare premises’. ForGMMs,theregulatoryrequirementsareexplainedinHSE’s‘Aguidetothe GeneticallyModifiedOrganisms(ContainedUse)Regulations’. FurtherguidanceonGMactivityclassification,containmentlevels(CL1toCL4) andcontrolmeasurescanbefoundinScientificAdvisoryCommitteeforGenetic Modification(SACGM)newsletters,guidancenotes(onamendmentstothese regulations)andthe‘SACGMcompendiumofguidance’. ControlofSubstancesHazardoustoHealthRegulations(COSHH) ControlofSubstancesHazardoustoHealthRegulations(NorthernIreland) GeneticallyModifiedOrganisms(ContainedUse)Regulations GeneticallyModifiedOrganisms(ContainedUse)Regulations(NorthernIreland) 149 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Theapprovedlistofbiologicalagents Themanagement,designandoperationofmicrobiologicalcontainment laboratories Biologicalagents:theprinciples,designandoperationofcontainmentlevel4 facilities Biologicalagents:managingtherisksinlaboratoriesandhealthcarepremises AguidetotheGeneticallyModifiedOrganisms(ContainedUse)Regulations 2000L29(thirdedition) SACGMcompendiumofguidance Wasteclassificationandsegregation 8245 Note ‘Healthcarewastedefinitionsandclassifications’explainsthebasisforclassificationof differenttypesofhealthcarewasteusingthesix-digitnumbersinlinewiththeEWC. Table14(attheendofthissectorguideunder‘Transportsecurity’)summarisesthe classification,packaginganddisposalforsomeofthemostcommonhazardouswaste emanatingfromlaboratories.Thetableshowsthewasteclassificationalongsidethe transportclassification.Fortransport,infectioussubstancesmustbeclassifiedas CategoryAorCategoryB: • CategoryA–aninfectioussubstancewhichistransportedinaformthat, whenexposuretoitoccurs,iscapableofcausingpermanentdisability,lifethreateningorfataldiseaseinhumansoranimals; • CategoryB–aninfectioussubstancewhichdoesnotmeetthecriteriafor inclusioninCategoryA. Thisclassificationmeansthattheinfectiouscomponentoflaboratorywasteis consideredaseitherCategoryAorCategoryB,whichdeterminestherequirementsfor colour-codedsegregation,packaging,transport,treatmentanddisposal. Healthcarewastedefinitionsandclassifications Transportsecurity Microbiologicalcultures 8247 ThedefinitionofculturesinADR,fortransport,isthefollowing: “Cultures(laboratorystocks)aretheresultofaprocessbywhichpathogens areintentionallypropagated.Thisdefinitiondoesnotincludehumanor animalpatientspecimensasdefinedinthisparagraph.” CultureswillincludeHG2,HG3orHG4pathogensaswellasClass1,Class2,Class 3orClass4GMMs,whetherinliquid(forexamplebroth)orsolidform(forexample agarplate),orwhetherinitiatedfromalaboratorystockorpatientspecimens. Culturesareassociatedwithhighconcentrationsofmicroorganismsandaconsequent increasedriskofinfection.Thisisparticularlypertinentwhentheculturesaretreated aswaste,since–unlikeculturesamples,whichwillbeusedforfurtherinvestigative purposesinanappropriatelaboratoryenvironment–wasteculturesareintendedfor disposalanddiscard. FororganismsontheCategoryAindicativelistfoundin‘Carriageinformation: CategoryApathogenlist’(suchasHG4pathogens,manyHG3pathogensandsome HG2pathogens–forexampleClostridium botulinum,poliovirus),theculturesmust beclassifiedasCategoryAwaste.However,theindicativelistprovidesexamplesandis 150 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 notexhaustive;hence,theremaybeothermicroorganismsnotontheindicativelist thatshouldbeclassifiedasCategoryA.Thekeyconsiderationiswhethertheyare: “inaformthat,whenexposuretoitoccurs,iscapableofcausingpermanent disability,life-threateningorfataldiseaseinhumansoranimals”. Ifthiswerethecase,thewastewouldnotbeconsideredsuitableforclassificationinto transportCategoryB,butwouldbetransportedandinactivatedasperanyCategoryA substance. WhilethemajorityofHG2organismsarenotonthisindicativelist,itisimportantto considertheCategoryAcriteriagivenabove(thatis,formofthecultures–for exampletheirconcentration,routesoftransmissionoftheorganism,hostrange, survivabilityintheenvironment,thequantityofculturesinanyoneconsignment) beforeclassifyingHG2organismsasCategoryBwaste. WhetherclassifiedasCategoryAorB,allculturesofpathogens(thatis,HG2toHG4 pathogensorClass2toClass4GMMs)shouldbeinactivatedon-sitepriortofinal disposalbecauseoftheincreasedriskofexposureassociatedwiththehigher concentrationofbiologicalagentstherein. TheGeneticallyModifiedOrganisms(ContainedUse)Regulationsspecifywhere wastecontainingGMMsshouldbeinactivatedforClass3(withinthelaboratory suite)andClass4(withinthelaboratory)activities.WhereCL1andCL2GMwasteis beingsentoff-sitefortreatment,aderogationisrequiredbytheHSE,whichisthe competentauthority. WhilethereisnospecificrequirementinCOSHHtoinactivateHG3orHG4cultures on-site,thereisarequirementtoachievecompletecompliancewiththegeneral provisions.Inparticular,Regulations7(3)and7(4)placeadutyonemployerstoapply controlmeasures(includingsafehandling,storageandtransportofbiologicalagents, andsuchwaste,attheworkplace)consistentwiththeriskassessment,whichreduceto aminimumthenumberofemployees(andothers)whomaybeexposedandthelevel/ durationofexposure.Basedonthisrequirement,wheretheriskassessmentidentifiesa significantriskofexposure(tothecommunity)duringtransportanddisposalofwaste (thatis,ofexposuretosomeHG2,andmostHG3andHG4pathogens),on-site inactivationbeforefinaldisposalwouldberequiredinordertocomplywithCOSHH. Carriageinformation:CategoryApathogenlist Europeanagreementconcerningtheinternationalcarriageofdangerousgoodsby road(ADR) GeneticallyModifiedOrganisms(ContainedUse)Regulations GeneticallyModifiedOrganisms(ContainedUse)Regulations(NorthernIreland) ControlofSubstancesHazardoustoHealthRegulations(COSHH) ControlofSubstancesHazardoustoHealthRegulations(NorthernIreland) Clinicalspecimens 8249 ClinicalspecimensshouldhavebeensenttothelaboratoryasCategoryAorCategory Bandthereforeshouldbedisposedofaswasteinthesamemannerunlesstheyhave beenneutralisedtomakethemnon-dangerous. Clinicalspecimensaredefinedfortransportthus: 151 “Patientspecimensarehumanoranimalmaterials,collecteddirectlyfrom humansoranimals,includingbutnotlimitedto,excreta,secreta,bloodand itscomponents,tissueandtissuefluid,swabs,andbodilyparts,beingcarried forpurposessuchasresearch,diagnosis,investigationalactivities,disease treatmentandprevention.” for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 ClinicalspecimensshouldhavebeensenttothelaboratoryasCategoryAorCategory Bandthereforeshouldbedisposedofaswasteinthesamemannerunlesstheyhave beenneutralisedtomakethemnon-dangerous. Itisthereforestronglyrecommendedthatunlessitisknown,orreasonablybelieved,to containinfectioussubstancesofCategoryA,allhumanoranimalmaterialshouldbe regardedasUN3373. Whenclinicalspecimensarediscarded,theywillformpartofthelaboratorywaste streamandneedtobemanagedappropriately.Theinfectivityassociatedwiththis wastetypeishighlyvariableandneedstobeconsideredaspartofariskassessment(as indicatedinFigure4under‘Healthcarewasteclassificationandassessment framework’).Inthelaboratorysector,thismeansthatthebulkofspecimensresulting fromdiagnosticinvestigationswithinclinicallaboratories(forexamplehaematology, cytogenetics,serology)willhavealowprobabilityofcontainingpathogens. However,clinicalspecimensusedformicrobiologicaltestingaremorelikelytocontain pathogens,andsegregationintothetwocategorieswillneedtobeconsideredaspartof theriskassessmentasindicatedabove. Toinformtheriskassessment,positivespecimensfromCL3andCL4shouldbe classifiedasCategoryAwasteandthosefromCL2beclassifiedasCategoryBwaste. Healthcarewasteclassificationandassessmentframework Environmentalsamples 8251 Asimilarriskassessmentneedstobemadeforenvironmentalsamples(non-human/ animal-derived). Wherethereisminimalorlowprobabilityofinfectioussubstancesbeingpresent(for examplefoodscreeningsamples,water,soiletc),wastespecimensshouldbetreatedas non-infectiouswasteandinsomecasesCategoryBwaste.However,wherethe environmentalsamplesarefromanoutbreakscenario(forexampleEbolavirus),the samplesshouldbetreatedaswastepotentiallycontainingCategoryAsubstancesuntil thesample’stestresultisnegative. Autoclavedlaboratorywaste 8253 Wastefromlaboratories(particularlyclinicalmicrobiology)thathasbeenautoclaved on-siteisnolongerconsideredtobeinfectiousorhazardous.However,suchwastehas traditionallybeensubjecttofurthertreatment,ratherthanbeingsentdirectlyto landfill,becauseofthepublicsensitivityassociatedwithclinicallaboratorywaste.For example,autoclavedinfectiouswastewillusuallyfollowthewastestreamformaterials potentiallycontainingCategoryBsubstances. Forthepurposesofclassification,wasteinactivatedon-siteshouldbeconsideredas offensiveratherthaninfectiouswaste,thereforeensuringthatthewastewillbesubject todeeplandfill. Wastepackagingandlabelling 8256 ‘Transportpackagingandoperations’providesdetailedinformationfortransport packagingandoperationsincludingtherequirementsforCategoryAwastes. Transportpackagingandoperations 152 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Packagingofinfectiouswastefortransport 8257 Wheretheinfectiouswasteistobetransportedoff-site,itneedstobepackagedina mannerthatmeetstherequirementsoftheADRpackagingspecificationforthat particularcategoryofwaste.WherethesubstancesareCategoryB,theymaybe disposedofinthesamewayasclinicalwaste(see‘Clinicalwaste(UN3291)’). ForCategoryAsubstances,theproceduressetoutin‘CategoryAclinicalwaste’should befollowed,ortheymustbepackagedinaccordancewithP620. Clinicalwaste(UN3291) CategoryAclinicalwaste Europeanagreementconcerningtheinternationalcarriageofdangerousgoodsby road(ADR) Markingandlabellingofinfectiouswaste 8258 CategoryBinfectiouswastesshouldbemarkedandlabelledinaccordancewiththe CarriageRegulations.Forfurtherdetails,see‘Otherchemicals’,‘Cleaningreceptacles’ and‘Markingandlabellingofpackagings’. Otherchemicals Cleaningreceptacles Markingandlabellingofpackagings CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations2004 CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) Wastestorageandtransport 8262 Wherethereisaneedtoinactivatethewasteon-site(forexamplepathogencultures, CategoryAwaste),thewasteshouldbestoredwithinthecontainmentlaboratory(to whichaccessisrestrictedtoauthorisedusers)andonlytransportedtotheautoclave whentheautoclaveisavailableforimmediateuse. Thiswasteshouldnotbestoredincommunalareasforanyextendedperiodunless appropriatesecurityandsafetycontrolsareinplace. Inthelaboratorysector,transportofthewastemayinclude: • internalmovementfromthelaboratorytotheautoclavefacilityora collectionpoint/dedicatedstoragearea;or • externaltransportusinganauthorisedcontractorfromthepremisestothe wastetreatment/disposalfacility. On-sitetransport 8260 CategoryAwasteemanatingfromCL4laboratoriesshouldbeinactivatedwithinthe laboratory. CategoryAwasteemanatingfromCL3laboratoriesshouldbeinactivatedwithinthe laboratorysuite(thatis,withoutleavingthecontainmentareaandpassingthrough communalareas). Wheresuchwasteneedstobetransportedtoaremoteautoclave,itmustbedelivered assafelyaspossible. 153 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Wheretransportofinfectiouswastetoaremoteautoclaveinvolvesmovementvia communalcorridors,thewasteshouldbecontainedwithintwolayersofcontainment –thesecondarycontainmentbeingrobustandleak-proofwithalidthatcanbe securedwhileintransitandtransported,whereappropriate,usingatrolleysystem. Theexteriorofthereceptacleshouldbesurface-decontaminatedpriortoleavingthe containmentlaboratory. Arrangementsneedtobemadetocoordinatethetransportofthewastefromthe containmentlaboratorytoensurethatwasteisautoclavedimmediatelyandisnot storedintheautoclaveroom. Off-sitetransport 8261 Wherethewasteneedstobetransportedoff-siteforinactivationbyincinerationorfor renderingsafebyalternativemethods,alicensedandreputablecontractorshouldbe used. Thecontractorneedstobeprovidedwithsufficientinformationtoallowthemtodeal withanyspillagesofmaterialfrombagsorreceptaclesofwastesafelyandeffectively. Wastetreatmentanddisposal 8264 ForCategoryAwaste(yellow),on-siteautoclavingorincinerationarethemost appropriatemeansofwasteinactivationduetothesignificantriskstothecommunity intermsofhumanandanimalhealth.ForClass3and4GMMs,thereisaspecific requirementintheGeneticallyModifiedOrganisms(ContainedUse)Regulationsto inactivatethewastewithinthelaboratorysuite(Class3)andwithinthelaboratory (Class4). Withregardtopathogensthatpresentasignificantrisktothecommunity,for employerstolegallycomplywiththerequirementsofCOSHH(seethefinal paragraphunder‘Microbiologicalcultures’),theyshouldinactivatethewasteon-site. WhileCategoryBwaste(orange)canberenderedsafebyalternativemeans,manyof thealternativemethodsrequireapre-treatmentstepinvolvingmacerationofthewaste, priortoinactivation,toensurethattheinactivationstageachievestherequireddegree ofkilltorenderthewastesafe. Themacerationstepmaynotonlygeneratesignificantaerosolsbutalsorequirestaff accesstodealwithanyblockages.Thismaysignificantlyincreasetheriskofexposure ofstaff.Withthisinmind–andbasedontherequirementsofCOSHHtopreventor elseadequatelycontrolexposuretobiologicalagents–wherethefollowingconditions aremetandappliedinanappropriatemanner,wasteproducers(thatis,laboratories) willbeimplementingadequatemeasurestocontroltheriskofinfection: • thetransportrequirementsforCategoryBwastearemet; • themethodofinactivationachievestheperformancenecessarytorenderthe wastesafe; • theproceduresandprotocolsoperatedbywastecontractorsdonotincrease thelikelihoodofexposuretobiologicalagents; • adequatecontrolsareinplacetopreventexposuretoinfectiouswasteduring pre-treatmentprocessessuchasmaceration(forexampleenclosedprocess, meansofsterilizingcontentsin-situ,inwardairflow). TocomplywithCOSHHandtheGeneticallyModifiedOrganisms(ContainedUse) Regulations,on-siteinactivationofwastepriortofinaldisposalcanbesummarisedas follows: 154 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • wastecontainingClass3andClass4GMMcultures(forexampleagarplates, liquidcultures,slopes)orcontaminatedmaterial(CategoryA)–requiredto achievecompliance; • wastecontainingmostHG3andHG4pathogencultures(forexampleagar plates,liquidcultures,slopes)orpositivespecimensthatareassessedas presentingasignificantrisktothecommunity(CategoryA)–requiredto achievecompliance; • wasteconsistingofClass2GMMsormanyHG2pathogencultures(for exampleagarplates,liquidcultures,slopes)orpositivespecimens(Category B)–recommendedmeansofachievingeffectivecontrol. Theautoclavecycleusedforinactivationofwasteon-siteshouldbeappropriately validatedtoensurethatitreachestheappropriatecore(ratherthanchamber) temperatureandpressurefortheappropriatelengthoftime,fortheworst-case challengeload(thatis,consideringlargestvolumes,leastconductivematerials,typesof receptacleetc).STAATTLevelIVcriteria(thatis,Bacillus stearothermophilus sporesat a6Log10reductionorgreater)shouldbeachievedforsuchloads. Autoclaveperformanceshouldbecheckedannuallyusingindependentthermocouple testsandtheperformanceshouldbemonitoredusingbiological,chemicalorthermal indicatorsonaregularbasis. Appropriaterecordsofvalidation,calibrationandmonitoringshouldbekept. Note Furtherguidanceonthestandardstowhichautoclavesforsterilizationshould conformcanbefoundin: • BS2646:1990–1993; • BSEN12347:1998;andHealthTechnicalMemorandum2010(parts 1–6)–‘Sterilization’(soontobereplacedandsupersededbyHTM01-01 –‘Decontaminationofreusablemedicaldevices’andHTM01-02– ‘Pathologylaboratories’). InScotland,seetheScottishHospitalTechnicalNote:‘Managementanddisposalof clinicalwaste’. Whereon-siteautoclavingisnotpossible(forexamplewheretheautoclavehasbroken down),inexceptionalcircumstances,thewastemaybetransportedoff-sitefordisposal byincinerationorothereffectiveheattreatment.Thisrequiresanauthorisationfor CategoryAwasteandrequiresadequatesecurityplanstobeinplace(see‘Transport packagingandoperations’).Thedutyformovementlieswiththeconsignor(waste producer)butwillinvolvearrangementswiththewastecontractorforitssafe collection,transportanddisposal. Wheresecondaryreceptacles(forexamplewheeledbins)arereturnedtotheconsignor, orsentelsewhere,theyshouldbethoroughlydisinfectedorsterilized;anylabelor markingindicatingthatithadcontainedaninfectioussubstanceshouldberemovedor obliterated. Subjecttoappropriateprocesscontrols,somewasteresiduescanbemanagedastrade waste.Manymightbeconsideredforrecycling.Thesewastesmightnotrequireformal shreddingifthetreatmentprocessrendersthemeffectivelyunrecognisableandunlikely tocauseoffence. Microbiologicalcultures Transportpackagingandoperations GeneticallyModifiedOrganisms(ContainedUse)Regulations GeneticallyModifiedOrganisms(ContainedUse)Regulations(NorthernIreland) ControlofSubstancesHazardoustoHealthRegulations(COSHH) 155 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 ControlofSubstancesHazardoustoHealthRegulations(NorthernIreland) HealthTechnicalMemorandum2010 ScottishHospitalTechnicalNote:‘Managementanddisposalofclinicalwaste’ Generalprovisions 8266 Regardlessofthelaboratorysetting,theproducersofwastehaveadutyofcareto ensurethattheytakeallreasonablemeasurestoensurewasteisdealtwith appropriately,fromsourceofproductiontothepointofdisposal. Inlinewithexistingguidance,eachlaboratoryshouldhaveastrictlyadministered policythatincludeswastemanagementandwhichissupportedbylocalSOPs specifyingthearrangementsforthehandlinganddisposaloflaboratorywaste. Staffshouldreceiveappropriateinstructionandtrainingonallrelevantaspectsof healthandsafetywithinthelaboratoryincluding: • wastemanagementarrangementssuchasappropriateclassificationand segregationofthewaste;and • theSOPsforitssafestorage,carriage,treatmentanddisposal. Trainingshouldalsobeprovidedonthestepstotakewhenthingsgowrong(for exampleleakageorspillageofhazardouswaste),andthesearrangementsshouldbe testedperiodically. Thewastemanagementprocedureswithinthelaboratoryorfacilityshouldbechecked aspartofanactivemonitoringprogramme(forexampleinspections,horizontalaudits) toevaluatetheireffectivenessandreliability.Anyactionsidentifiedshouldbe completedinatimelyfashionandreviewedbylaboratorymanagement. Staffworkinginlaboratoriesneedtoensurethatcontaminatedwasteisdiscarded appropriatelyinsuitablereceptacles(forexampledisposabletipsintodisinfectantpots ordrydiscardjars).Thesereceptaclesshould: • notbeoverfilled(thatis,nogreaterthantwo-thirdsfull); • belabelledappropriately; • beremovedfromthelaboratoryexpediently. Ifthelaboratoryissharedbymorethanoneorganisation,allpartiesshouldbeaware ofthearrangementsforwastemanagementandshouldensurethatthesearrangements areabidedby. Transportsecurity 8268 WherealaboratoryisinvolvedintestingandtransportinginfectiousCategoryA substances,thelaboratorymustmeetthesecurityrequirementsofChapter1.10of ADR.TheDepartmentforTransportsecurityandcontingenciesteam(TRANSEC) hasprovidedguidanceonthis.Detailscanbeobtainedfromtheirwebsite. 156 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Table14Classification,packaginganddisposalforexamplesoflaboratoryderivedhazardouswaste Waste type Examples EWC code Microbiological cultures (indicative list, Class 3 and Class 4 GMMs, most HG3 and HG4 pathogens) Liquid and solid cultures (including agar plates), biological agent stocks 18 01 03* Liquid and solid cultures (including agar plates); biological agent stocks 18 01 03* Limbs, organs, biopsies, tissue samples 18 01 03* Sharps not contaminated with cytomedicinal products Needles; scalpel blades; contaminated broken glass 18 01 03* Laboratory equipment HEPA filters from CL3 and CL4 laboratories, safety cabinets – assuming they are fumigated prior to being removed 18 01 03* Discarded clinical specimens; consumables (for example gloves, pipette tips) 18 01 03* Hazardous UN number Packaging waste Class 6.2, UN 2814/ UN 2900 Yellow1 Y Class 6.2, UN 3291 Orange1 Y Class 6.2, UN 2814/ UN 2900 Yellow Class 6.2, UN 3291 Yellow or orange Y Class 6.2, UN 3291 Orange Y Class 6.2, UN 3291 Orange N N/A Offensive/hygiene waste – yellow/black Deep landfill Y 18 02 02* (Category A) Microbiological cultures (not on indicative list or criteria for Category A (for example Class 2 GMMs, many HG2 pathogens) 18 02 02* (Category B) Anatomical waste may be infectious (Category A) (Category B) Potentially infectious waste (Category B waste) Minimum treatment/ disposal 18 02 02* Y 18 02 02* 18 02 02* P620 (threepart packaging) Treatment on site (contingency arrangements – incineration) Recommended onsite treatment: render safe P621 (yellow bags and at licensed/permitted wheelie bins) treatment facility P620 (threepart packaging) P621 (sharps bin) Hazardous waste incineration Render safe at licensed/permitted treatment facility Render safe at licensed/permitted P621 (yellow bags and treatment facility wheelie bins) Render safe at licensed/permitted P621 (yellow bags and treatment facility wheelie bins) Treated laboratory waste2 (noninfectious) Onsite autoclaved material (for example cultures and discarded positive clinical specimens) Environmental samples (not associated with outbreak) Discarded food and water samples; consumables etc 18 01 04 N N/A Offensive/hygiene waste – yellow/black Deep landfill Offensive/hygiene waste Human hygiene waste, animal bedding, excreta 18 01 04 N N/A Offensive/hygiene waste – yellow/black Deep landfill Domestic waste General refuse 20 03 01 N N/A Black Landfill 18 01 04 18 02 03 20 01 99 Notes: 1. The hazardous waste classification, UN number and packaging refers to noninactivated waste. Following onsite treatment, the waste is considered to be nonhazardous and should be treated as “offensive/hygiene waste” and packaged/disposed of appropriately. 2. Once autoclaved, the waste is considered to be noninfectious; however, due to public sensitivity around such waste, it may be subject to further treatment rather than going directly to surface landfill. DepartmentforTransportsecurityandcontingenciesteam(TRANSEC) Europeanagreementconcerningtheinternationalcarriageofdangerousgoodsby road(ADR) 157 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Communityhealthcare 8270 Scopeandtargetaudience 8269 Communityhealthcarecantakemanyformsandoccursinvariousenvironments.It includesactivitiesundertakenbyallhealthcareworkerswhoprovideservicesoutsideof thehospitalto: • patientsintheirownhomes; • residentsofcarehomes(withoutnursingcare); • householderswhoareself-medicatingandself-caring. Note “Patientsintheirownhomes”includesthoselivinginassistedlivingpremiseswhere thereison-sitemonitoringofresidents’activitiestohelptoensuretheirhealth, safetyandwell-being.WherethereisprovisionofhealthcareservicesbyNHSand non-NHShealthcareproviders(forexamplegrouphomes),thissectorguideapplies. Communityhealthcareworkers,asproducersofhealthcarewasteandspecifically infectiouswaste,arerequiredtocomplywithwasteregulationsincludingthe HazardousWasteRegulations(SpecialWasteRegulationsinScotland)andtherefore needtoensurethatwasteissegregated,described,classifiedanddisposedof appropriately. Arationalapproachtoassessmentofinfectiouswasteisappliedusingarisk-assessment approach.Bothinfectiousandoffensivewastestreamsrequiremanagementin communitysettings.Usingthisrationalapproachwillreduceunnecessarycostsand introducepotentialcarbonsavingsassociatedwiththeunnecessarytreatmentofnoninfectiouswaste. Note Othercommunityhealthcareworkersnotlistedaboveshouldrefertothemain guidanceandsectorguideswhereapplicable.Thissectiondoesnotapplyto: • generalpractices; • healthcare/medicalcentres; • carehomeswithnursingcare; • dentists;or • anyotherformofhealthcarepractice. HazardousWaste(EnglandandWales)Regulations HazardousWasteRegulations(NorthernIreland) SpecialWasteAmendment(Scotland)Regulations Wasteriskassessment 8272 Infectiouswaste 8271 Wasteisclassifiedasinfectiouswastewhere: • itarisesfromapatientknownorsuspectedtohaveaninfection,whetheror notthecausalagentisknown,andwherethewastemaycontainthe pathogen;or • whereaninfectionisnotknownorsuspected,butapotentialriskof infectionisconsideredtoexist. 158 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Thisassessmentmustbedoneonapatient-specificbasis.Thisshouldbeclassifiedas hazardousinfectiouswasteandshouldbepackagedappropriatelyandsentforsuitable treatmentanddisposal(seeTable15under‘ManagementofCategoryBinfectious wasteinthecommunity’). TheCarriageRegulations(see‘Healthcarewastedefinitionsandclassifications’) differentiatebetweentwotypesofinfectionrisk: • CategoryAinfectioussubstances(UN2814):theUnitedNationsproduces alistofinfectioussubstancesclassifiedwithCategoryAandincludesviral haemorrhagicfevers; • CategoryBinfectioussubstances(UN3373):thisclassificationincludesall otherwasteclassifiedasinfectiouswasteandthesearethemostcommon typesofinfectiouswaste.CategoryBinfectiouswastesubstancesconsigned aswastewillbetoUN3291. ManagementofCategoryBinfectiouswasteinthecommunity Healthcarewastedefinitionsandclassifications CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) ManagementofCategoryAinfectiouswasteinthe community 8274 Inpractice,itisunlikelythatCategoryAinfectiouswastewillbeencounteredinthe communitysetting.CategoryAsubstancesarelikelytocauselife-threateningdisease and,ingeneral,areabletospreadeasilyandthereforeposearisktothelocal communityandhealthcareworkers.IfitissuspectedthataCategoryAinfectious substancehasbeenencountered,theHealthProtectionAgencyandtheDepartment forTransportshouldbeinformedforadditionaladviceandauthorisationsregarding themovementofthewaste. TheCarriageRegulationsspecifythatCategoryAsubstancesshouldonlybepackaged inspecialistpackagesandboxes–forfurtherdetailssee‘Transportpackagingand operations’fortransportrequirements. Transportpackagingandoperations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) ManagementofCategoryBinfectiouswasteinthe community 8277 See‘Transportingoffensiveorinfectiouswastefrompatients’homes’forcollection arrangementoptions. Transportingoffensiveorinfectiouswastefrompatients’homes 159 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Assessingwhetherwasteposesariskofinfection 8276 Healthcareworkersworkinginthecommunityandinthehouseholdenvironment needtoassessthewastetheyareproducingforthehazardouspropertiesitmay contain,mostnotably,“infectious”. Toaccuratelyassesswhetherthewastegeneratedisinfectious,ariskassessmentshould beperformed.Thisshouldbebasedontheprofessionalassessment,clinicalsigns andsymptoms,andanypriorknowledgeofthepatient.Thefollowinginitial genericriskassessmentistobeusedinconjunctionwiththewasteassessmentprovided in‘Healthcarewastedefinitionsandclassifications’. Theusualcontaminantsassociatedwithtypicalitemsofhealthcarewasteareblood andbodyfluidsincorporatingurine,vomit,sputum,faeces,pusandwoundexudates. Thesegeneralcategoriesshouldbeusedtosubcategorisethewasteaseither: • infectious–wastefromanyknownorsuspectedinfection,andfromany othercaseswhereariskofinfectionhasbeenidentified;or • contaminatedwithbodyfluidsmoresuitedtotheoffensiveclassification (thatis,lowerriskwastes). Thewaste,theriskposedbythewasteandthewasteclassificationwillalwaysbe classifiedthesameregardlessofthehealthcaresetting(forexamplewhetherinthe acutehospitalorthecommunityenvironment). Examplesofcontaminateditemsareswabs/wipes,bandages,bedpads,equipment, protectiveclothing(gloves,aprons),single-useitems.Table15providesamatrixfor classifyingoffensiveandinfectiouswasteinthecommunity.Thisshouldbereferredto inlinewith‘Healthcarewastedefinitionsandclassifications’. Table15Riskassessmentapproachtowastesegregationbasedon likelihoodofinfectionbeingpresent Contaminant Urine,faeces, vomitandsputum Blood,pusand woundexudates Proposedgeneral classification Offensive(whererisk assessmenthad indicatedthatno infectionispresent, andnootherriskof infectionexist) Examples Exceptiontothisrule Urinebags,incontinence Gastrointestinalandotherinfectionsthatare pads,single-usebowls, readilytransmissibleinthecommunitysetting nappies,PPE (e.g.verocytotoxin-producingEscherichiacoli (VTEC),campylobacter,salmonella, chickenpox/shingles)¹ Infectiousunless Dressingsfromwounds, assessmentindicatesno wounddrains,delivery infectionpresent.Ifno packs infection,andnoother riskofinfection,then offensive HepatitisBandC,HIV–onlyifbloodis present¹ Bloodtransfusionitems Dressingscontaminatedwithblood/wound exudatesassessednottobeinfectious. Maternitysanitarywastewherescreeningor knowledgehasconfirmedthatnoinfectionis presentandnootherriskofinfectionexists Notes: AllCategoryAandBspecies,andthereforedownstreamwasteitems,willbedeemedinfectious/hazardousunderwaste regulationsirrespectiveofthecontaminantmatrix. 1.Potentialhazardsfromtheuseofcytotoxicandcytostaticmedicinesmayalsoberelevantinsomeinstancesandwith somedrugs.Thiswouldalsopreventthewastebeingconsideredoffensive 160 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Noteonpatientscolonisedwithmicroorganismsthatstafftraditionallymanage withprotectiveequipmentsuchasglovesandaprons(forexampleMRSA, glycopeptide-resistantenterococci(GRE)orcolonisationwithothermultiresistantbacteria) Whereapatientinthecommunityhasbeenfoundtobecarryingamulti-resistant organismandisbeingcaredforbyahealthcareworker,thehealthcarewaste generatedisnotnecessarilyinfectious. Inassessingtheriskofinfectionfromwasteproducedbysuchapatient,the followingshouldbeconsidered: Is the patient colonised but not receiving specific treatment for infection with this microorganism (for example MRSA)? Iftheansweris“yes”,thestatusofthepatientdoesnotaffectthe assessmentofthewaste.Thehealthcareworkershouldrefertothewound anddressingassessmentgiveninpart1andpart2inthissectorguide (below). Is the patient colonised and receiving treatment for an infection (for example, MRSA)? Iftheansweris“yes”,anassessmentofwasteisrequired. Is the patient infected with MRSA and receiving treatment, and is the microorganism present in the waste generated? Iftheansweris“yes”,thewasteproducedshouldbeclassifiedasinfectious waste. Followingthegenericassessment,therearetwofurtherpartstotheriskassessment. Part1:woundassessment ThefollowingcriteriaarebasedontheDelphiprocessofidentifyingwoundinfection insixdifferentwoundtypes(EuropeanWoundManagementAssociation,2005). Signsandsymptomsofinfection Istherepresenceoferythema/cellulitis? Istherepresenceofpus/abscess? Isthewoundnothealingasitshould,orhashealingbeendelayed? Isthewoundinflamedandhasitchangedappearance? Isthewoundproducingapungentsmell? Isthewoundproducinganincreasedpurulentexudate? Hasthewoundincreasedinpain? Hastherebeenanincreaseinskintemperature? Isthepatientonantibioticsforaninfectionpresentinthewound? Isthewoundtobeswabbedforinfection? Note: Probabilityofwoundbeinginfected High High Medium Medium High Medium High Medium/Low High Medium Itshouldberecognisedthatthisisnotanexhaustivelistofsignsandsymptomsofwoundinfectionandthatdifferent typesofwoundwillpresentdifferently.Thistoolistoassistinthebasicassessmentofallwoundsinordertocorrectly categorisewhetherthewasteproducedcontainsaninfectiousfractionandthereforeinfectiouswaste.Furtherinformation andadviceregardingassessmentofwoundinfectionsshouldbesoughtfromthelocaltissueviabilityspecialistnurse. Ifthewoundassessmentindicatesthatthewoundisinfected,allassociated contaminateddressingsetcshouldbeclassifiedasinfectiouswastetocomplywiththe definitionsofinfectiouswastegiveninAppendixC9ofWM2. Ifthereareanyotherreasonswhythewastemaypresentariskofinfection,itshould beclassifiedasinfectiouswasteanddisposedofappropriately.Ifthewasteisinfectious, thiswillneedtobepackagedforappropriatetreatmentanddisposal.Thiswillusually beinanorangebag. 161 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Part2:non-infectiousdressings Whereeitherassessmentabovehasidentifiedthatthedressingisnotinfectious,the followingshouldbeconsidered(notingthatthetypeofdressingsthatareproducedin thecommunitybyahealthcareworkercanvarygreatly): 1. Contaminateddressingsfromawoundassessedbythehealthcareworkeras non-infectiouscanbetreatedasnon-hazardousandshouldbecontainedand disposedofintheoffensive/hygienestream. 2. Anyrecognisableitemofnon-infectioushealthcarewastecannotlegallybe disposedofintheblack-bagwastestreamandshouldthereforebedisposedof intheoffensive/hygienewastestream. 3. Mixeddomesticwastedoescontainsmallnumbersofplasters,smalldressings andincontinenceproducts.Wherethehealthcareworkerproducesthesame orsimilaritems,these–withthefollowingconsiderations–canbedoublebaggedandplacedinthedomesticwaste(withthehouseholder’spermission). Thefollowingshouldbeconsidered: • typeofhealthcarewaste–ifitlookslikeahealthcarewaste,andisnot obviouslyanormalconstituentofdomesticwaste,thenitshouldnotgoin theblackbag; • thequantityproduced–whereanumberofsmalldressingsareproduced regularlyoveraperiodoftime,itmaybeappropriatetodisposeoftheseas offensive/hygienewaste.If,however,theamountproducedisrelativelysmall andconsistentwiththatlikelytobefoundinthehouseholdwastestream (forexamplethatboughtfromalocalpharmacyorsupermarketbythe householder),itmaybediscardedinthedomesticwaste; • packaging–wheresuchwasteisplacedinthedomesticrefuse,thewaste shouldbewrappedinaplasticbag.Thewrappingshouldnotbeyellowor orange,asthewasteisnotdeemedtobeinfectious–thinopaqueplasticbags suchassandwichbagsandbinlinersareappropriate. Healthcarewastedefinitionsandclassifications EuropeanWoundManagementAssociation.Positionpaper.Identifyingcriteria forwoundinfection AppendixC9ofWM2 Offensive/hygienewastearisingfromhealthcare 8279 Manyitemsclassifiedashealthcarewasteproducedinthecommunitybyahealthcare workerareunlikelytobeclassifiedasinfectiouswasteandshouldbesegregatedand managedasoffensive/hygienewaste.Thisrequiresitem-andpatient-specific assessment.ExamplesareprovidedinTable15under‘ManagementofCategoryB infectiouswasteinthecommunity’. Thiswasteshouldbesegregatedatsourceandpackagedandtreatedasoffensive/ hygienewaste.Inprinciple,thisshouldnotbeplacedinthedomesticwaste;however, exceptionstothishavebeennotedabovein‘ManagementofCategoryBinfectious wasteinthecommunity’(Part2)andbelowat‘Stoma/catheterbags’under‘Example wastestreams’. 162 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Notes 1.Anyoffensivewastearisingfromapatientbeingtreatedwithcytostaticor cytotoxicdrugsshouldbesentforincinerationinyellowbagswithpurplestripes (yellowbagsarealsoacceptable),astracesofthesemedicinesmayappearin contaminateditems.Theincinerationofsuchwasteswillensurecomplete destruction.Alternativearrangementsmaybemadefollowingexpertadviceon thebehaviouroftheparticularpharmaceuticalwhichindicatesthatthemedicine ordangerousbreakdownproductswillnotbepresentinthewasteitemin question. 2.Anyliquidwasteclassifiedasoffensivefollowingariskassessmentwillmostlikely bedisposedofatthepremisesviathefoulsewer.Liquidwastesarebannedfrom landfill;therefore,non-infectiousbodyfluids(forexampleurine/vomit), althoughclassifiedasoffensive,shouldnotbedisposedofintheoffensiveyellow/ blackwastestreamifthisisbeingsenttolandfill.Theycan,however,beabsorbed ontoacloth(forexamplekitchentowel)orsolidifiedwithabsorbentorgelling granules,forexample,andplacedintheoffensivebagwhilstensuringthereisno free-flowingliquidpresent. ManagementofCategoryBinfectiouswasteinthecommunity Examplewastestreams Examplewastestreams 8283 ExamplesareprovidedinTable16fortypicalwastearisingfromactivitiesinthe communitysector.Healthcareworkerswillproducethefollowingwastetypesand requirethefollowingcolourforsegregation: • yellow-orpurple-liddedsharpscontainer; • orangebagsforinfectiouswaste; • black/clearbagsfordomesticwaste; • yellow/blackbagsforoffensivewaste; • red-liddedcontainerforanatomicalwaste(forexampleplacentas). Thecolourofthewastereceptaclewilldependonhowthewasteshouldbetreatedand disposedofasdetailedinTable16(furtherdetailsonclassificationareprovidedinthis sectorguide). Table16Typicalwastestreams(seealso‘Transportingoffensiveor infectiouswastefrompatients’homes’) Activity/cause Classificationand colourcoding Healthcarevisitsof, Vastmajorityofsoft Wastefroman forexample,postinfectiouswastesuch infectionoris operativewoundsthat asdressings,bandages infectiousisdisposed areinfected andsomeplastic ofinorangebags single-useinstruments EWC:180103 canbetreated 163 Wastetype Justification Disposalroute Thevastmajorityof Alternativetreatment “bagged”infectious torenderitsafe wasteproducedinthe communitywillbe placedintheorange wastestream. Therefore,theuseof orangebagsinthe communityis recommended for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Activity/cause Wastetype Healthcarevisitsof, forexample,postoperativewoundsthat arenotinfected Non-infectious dressings,single-use instruments,stoma bags,catheterbags, incontinencepads¹ Classificationand colourcoding Wasteclassifiedas offensive/hygiene wastedisposedofin yellow/blackbags EWC:180104 Justification Disposalroute Usedforrecognisable Municipal healthcarewastethat incineration/energy isneitherinfectious fromwaste/landfill wastenorhazardous wasteandisclassified asnon-hazardous offensivewaste. Midwiferyand Anatomicalwastesuch Placedinan Arelativelysmall Disposalby delivery(e.g. asplacentas appropriatered-lidded amountofwaste incinerationonly anatomicalwastesuch container producedinthe asplacentas)² EWC:180103 community Medicinalinjections Associatedsharpsand Placedinan Sharpscontaminated Disposalby –forthe liquidresiduesofthe appropriatepurplewithcytotoxic/ incinerationonly administrationof medicinalproducts liddedleak-proof cytostaticmedicinal chemotherapy, thatarecytotoxic/ sharpscontainer products antiviraland/or cytostatic EWC:180103 hormonaldrugs 180108 Medicinalinjections Associatedsharpsand Yellow-liddedsharps Likelytobe Incineration withnon-cytodrugs medicinalproducts container.Ifthe medicinallythataredeterminedto syringecontains contaminatedsharps benon-cyto residualliquid inthecommunity medicines,this containerneedstobe leak-proof EWC:180103 Packagingasaresult Uncontaminated Ifnotcontaminated Usedpackaging, Non-hazardous oftreatingapatient mixedwastee.g. andnon-infectious whilstcarryingout municipal Orothermunicipal cardboard,plastic³ EWC:200301 patienttreatmentsin incineration/energy wastesi.e.mixed Domesticdisposedof thehomewillinmost fromwasteorlandfill/ domesticwaste inblack/clearbags circumstancesnotbe materialrecycling infectious/clinical facilities/reuse waste Notes: 1.Thereareexemptionstothis(see‘ManagementofCategoryBinfectiouswasteinthecommunity’(Part2)). 2.Whereanatomical,placentaorotherwastethatrequiresincinerationisbeinggenerated,itwillbeappropriatefor healthcareworkerstocarryyellowpackaging.Asmost“incinerationonly”wasteiseitheranatomicalorsharpsand/or containsfreeliquid,theuseofsmallrigidleak-proofyellowcontainersisrecommended. 3.Notapplicabletorecognisablehealthcarewaste(e.g.plasticequipment);however,thereareexemptionstothis(see ‘ManagementofCategoryBinfectiouswasteinthecommunity’(Part2)) Communitynursesshouldusethesharpscontainerappropriatetothewastetheygenerate,e.g.ayellowleak-proofsharps containerwithapurplelidforcytotoxicorcytostaticwaste.Orange-liddedsharpscontainersaregenerallynot advisableforuseinthecommunityinEnglandandWales,unlessthecommunitynursecanensuretheyarenot usedformedicinallycontaminatedsharps.InScotlandandNorthernIreland,orange-liddedsharpscontainers maybeusedforbothmedicinallyuncontaminatedorfullydischargedsyringes. Forallwastestreamsincludinghealthcarewaste,checksmustbeundertakentoensurethesitewherethewasteistakenis permittedorlicensedtoacceptthewastestream. 164 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Notes 1.SharpscontainersmustbeUN-type-testedandapproved,testedandcertifiedto BS7320(see‘Transportpackagingandoperations’). 2.Sharpscontainersshouldbecollectedwhenfilledtothefilllineandshouldnever exceedthepermissiblemarkedmass.Ifthesharpscontainerisseldomused,it shouldbecollectedafteramaximumofthreemonths,regardlessofthefilled capacity. Transportingoffensiveorinfectiouswastefrompatients’homes ManagementofCategoryBinfectiouswasteinthecommunity Transportpackagingandoperations Self-medicatingpatientsandsharpsdisposal 8281 Wherethehouseholderisaself-medicatingpatientwhousesinjectables(forexamplea personwithdiabetes)withnohealthcareworkerinvolvedintheadministration,the GPorhealthcareworkershouldprescribethehouseholderasharpscontainerrelevant tothemedicationbeingadministeredandadvisethemoflocaldisposaloptions. Thehouseholdershouldbetrainedinhowtousethesharpsreceptaclebeforeithas beenprescribed,toensurethattheyunderstanditsuseandensureitiscorrectlysealed andlabelled. Oncethesharpscontainerisfilledtothe“fillline”,itshouldbesealedbythe householderandtakenbackeithertotheGPsurgeryortothelocalpharmacyfor disposal,orarrangementsforcollectionsshouldbemadewiththePCTorlocal authority.Forself-medicatinghouseboundpatients,theGPorhealthcareworker responsibleforprescribingtreatmentshouldadviseoncollectionarrangements. Localauthoritieshavespecificdutiesinrelationtohealthcarewasteasdetailedin ‘Localauthorities’responsibilities’.Authoritieshaveadutytocollecthouseholdwaste includinghealthcarewastefromdomesticproperties.UndertheControlledWaste Regulations,theauthoritymaychargeforthecollectionofspecificwastestreams, whichincludesclinicalwaste(thatis,healthcarewastefromahouseholder’ssharps receptacle). Note Itisnolongeracceptabletoadviseself-medicatingpatientstodisposeoftheirsharps andlancetsintothehouseholdblack-bagwastestream. Localauthorities’responsibilities ControlledWasteRegulations ControlledWasteRegulations(NorthernIreland) CaseStudy:PartnershipWorkingandBenefitsforall 8282 Contaminatedneedlesandsharpsproducedinthecommunitycancauseproblemsfor LocalAuthoritiesandPCTsunlessarobuststorageandcollectionsystemisinplace. Diabeticsandothersharpsusershaveinsomeinstancesinthepastbeenadvisedto placesharpsinaplasticbottlefordisposal;however,thispresentsapotentialriskto councilstaffduringcollection.Inadditiontothis,itwasfelttherewasagenerallack ofawarenessofhowtodisposeofclinicalwastebyresidentsandholidaymakers, especiallyneedlesandsharps. CornwallNHSTrustbrokeredajointagreementwithCornwallCountyCouncil, NHStrusts,infectioncontrolandtheEnvironmentAgencytoimplementanew initiativetoprovidesharpsreceptaclesthroughGPstodiabeticandrenalpatients.To 165 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 supporttheinitiative,theyproducedapamphletonthesafedisposalofclinicalwaste tocaterforallusersofthescheme. Keybenefitsare: • raisedawarenessacrossCornwallofsafemanagementofsharps • improvedsafetysystemsforwasteoperativescollectingmunicipalsolidwaste (MSW)andclinicalwaste • synchronisedresponsetorequestcollection • financialcontrolacross“CornwallPlc”bysharingcost. Note Atthetimeofwriting,DefraisreviewingSchedule2oftheControlledWaste Regulations,withaviewtoestablishingasimplerandmoreequitablesystem. ControlledWasteRegulations Single-useinstruments 8285 Single-useinstrumentsarenowcommonlybeingusedinthecommunitybyanumber ofhealthcareprofessionals(forexamplechiropodists).Single-useinstrumentscantake theformofplastic,woodormetalinstruments. Contaminatedsingle-useplasticorwoodinstruments–wherethereisnoriskofsharps andtheyaredeemedtobeinfectious–canbesafelydisposedofasinfectiouswastein theorange-bagwastestream. Single-usemetalinstruments–wherethereisnoriskofsharpsandtheyaredeemedto beinfectious–shouldbeputintoarigidyellowcontainerclearlymarkedeitherfor decontaminationorforincineration.Thiswillvarydependingonthearrangement withthewastecontractorandfacilitiesavailable.Largemetalinstruments,ifplacedin thealternativetreatmentprocess,maydamagetheequipmentatthefacility. 166 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Wheretheinstrumentsaredeemedtobenon-infectious,theyshouldbesentfor disposalasoffensive/hygienewaste.Inthecaseofmetalinstruments,theyshouldbe sentformetalreclamationandrecoverywhereavailable. Note Single-useinstrumentscannotlegallybedisposedofintheblack-bagwastestream. Stoma/catheterbags 8286 Ifahealthcareworkerisinvolvedinthecareofastomasite,thewastefromastoma patientcanbedisposedofintheblack-bagwastestream(see‘Managementof CategoryBinfectiouswasteinthecommunity’(Part2)). Ifusedinbulk(thatis,largequantitiesofwasteasaresultofthehealthcareworkeror bytheindividual),thisbecomesoffensive/hygienewastefordisposalinyellow/black bagsforlandfillormunicipalincineration. However,ifthepersondevelopsanytypeofgastrointestinalinfectionorthesite becomesinfected,thebagneedstobedisposedofasinfectiouswasteintotheorangebagwastestream(seeTable16above)). Ifthehouseholderisself-medicatingwithnohealthcareworkerinvolved,theyareable todisposeoftheirownwasteintotheblack-bagwastestream. Note Wastearisingasaresultoftreatmentundertakenbythehealthcareworkerdoesnot constitutemixedmunicipalwaste.Itshouldthereforenotbedepositedinthe householdblack-bagstreamforcollectionasEWC200301mixedmunicipal waste.Byplacingsuchwasteinthehouseholder’sblackbag,theclassificationofthis wastewillneedtochangetoincorporatethepresenceofhealthcarewaste.Alsothe dutyofcarearrangementsandpermitrequirementsofthereceivingwaste managementfacilitywillchange–thismaynowincludewasteclassifiedasoffensive EWC180104.Forexemptionstothis,pleasesee‘ManagementofCategoryB infectiouswasteinthecommunity’(Part2). Therearecertainhealthcarewastestreams,evenwhenproducedbythehouseholder, thatshouldnotbeplacedintheblack-bagdomesticwastestream.Forexample, woundvacuumdrainsshouldbetreatedasinfectiouswasteanddisposedofinthe orange-bagwastestream.Thehouseholdershouldhavetherelevantprocedures explainedandtraininggivenatthetimeofprescription. ManagementofCategoryBinfectiouswasteinthecommunity Maggots 8287 Allmaggotsusedforwoundmanagementshouldbesecuredinarigidyellowcontainer ordouble-baggedinyellowbagsandmarkedasUN3291. Wastepackagingandreceptacles 8289 Thetypeofpackagingusedwillvaryonthetypeofwasteproduced–seeTable16in ‘Examplewastestreams’forfurtherdetails: • Ifthewasteisliquidorcontainsfreeliquids(forexampleapartiallydischargedsyringe),itshouldonlybeplacedinapackagedesignedtotake liquids,suchasarigidleak-proofplasticdrum,oronewithabsorbinggels/ materials. • Ifthewasteisasharp,itshouldonlybeplacedinasharpscontainer. 167 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • Allotherwastemaybepackagedinflexiblebags(infectiousoroffensive wastebags). Itisnotalwayspracticalforhealthcareworkerstocarrymanydifferenttypesof packagingwiththem.Therefore,healthcareworkersshouldbesuppliedwiththemost appropriatepackagestomeettheirneeds.Wherepossible,thetypeofpackaging requiredshouldbedeterminedpriortoin-situtreatmentbasedonthepre-visit assessmentandpatients’records. Examplewastestreams Transportingoffensiveorinfectiouswastefrompatients’ 8293 homes Wherewasteisgeneratedbyahealthcareworkerforpeopleintheirownhomes,the healthcareworkerisresponsibleforensuringthatthewasteismanagedcorrectly;this ispartoftheirduty-of-care(see‘Dutyofcareandcontrolledwaste’under ‘Environmentandwastelegislation’). Managersneedtoensurethatarrangementsareinplacetoensurethatthewasteis packagedandlabelledcorrectlyandtransportedforappropriatetreatmentand disposal.Localoptionsmayvary,butingeneralthecommunityhealthcare organisationhastwooptions. Environmentandwastelegislation Option1–collectionfromthepremises/householder 8291 Onlyifthehouseholderconsentstothestorageofthewastecanthehealthcareworker producingthewasteleaveitinthehomeforlatercollectionbyanappropriate organisation(forexampleawastecontractoractingonbehalfofthelocalauthorityor healthcareprovider).Ifthehouseholderdeclinestogiveconsent,thehealthcareworker cannotlegallyleavethewaste.Thisproblemshouldbediscussedwiththehouseholder andthemanagerofthehealthcareworkerinordertoexplorealloptionsofconvenient andsaferesolution. Healthcareorganisationsandtheiremployeeshaveresponsibilityforthewastewhileit isbeingstoredawaitingcollectionandforarrangingthatcollection.Whileawaiting collectionfromthehouseholder’shome,thewasteshouldbestoredinasuitable placetowhichchildren,pets,pestsetcdonothaveaccess.Itisnotappropriateto leavethewasteunsupervisedonthepavementawaitingcollection. Wasteshouldbepackagedandlabelledappropriately,andadequateinstructionshould begiveninrelationtosafepre-collectionstorage.Thehouseholdershouldbeprovided withthecorrectcontainers/packagingtoensurecorrectdisposal. Thepartycollectingthewasteshouldbeprovidedwiththeinformationrequired underduty-of-carerequirements(see‘Legislationandhealthcarewaste’ondutyofcare responsibilitiesand‘Wastemanagementlicensingandpermitting’fornon-WFD exemptions). Aconsignmentnoteisnotrequiredforthemovementofhazardouswastefrom domesticpremises.However,aconsignmentnoteshouldbecompletedand accompanythemovementofthewasteifnotfromdomesticpremises,asinfectious wasteisclassifiedashazardouswaste. 168 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Note Thecollectionofhealthcarewasterequiresgoodcommunicationbetweenallparties includingthepatient,healthcareworker,healthcareorganisation,localauthority andothernon-healthcarepartiesinvolvedinthecollection(forexamplewaste contractors).Thecollectiontimesandarrangementsneedtobecleartoallpartiesto ensurethesafedisposalofhealthcarewaste. Incertainregions,theremaybeissueswithsimilarcoloursusedforotherwaste streams.Forexample,orangebagsareusedforrecyclingbysomelocalauthorities. Inthesesituationsitisevenmoreimportantforgoodcommunication,consultation withhealthcareworkersandtheirsafetyrepresentatives,andcollaborativeworking betweenallpartiestotakeplace. Legislationandhealthcarewaste Wastemanagementlicensingandpermitting Option2–healthcareworkertransportswaste 8292 Thehealthcareworkerproducingthewastecantransporttheinfectiousoroffensive wastefromthehomeenvironmentbacktobasewherewastecollectionanddisposal arrangementsareinplace.Wherehealthcareworkersaretransportingwasteintheir ownvehicles,theyshouldensurethattheyaretransportingthewasteinsuitableUNapprovedrigidpackaging,forexamplecontainersordrums(see‘Transportpackaging andoperations’). Thecommunityhealthcareorganisationhasresponsibilityforprovidingsuitable equipment.Ininstanceswherethehealthcareworkerisexpectedtotransportthewaste andisnottravellingbycar(suchasbybicycleorpublictransport),thehealthcare organisationshouldmakeappropriatearrangementsforsuitablecontainersforthe collectionofwasteinthesecircumstances.Localproceduresshouldbeinplacefor managementofthewastefromcradletograveforcommunityhealthcarewaste (includingtransportandcompliancewiththeCarriageRegulations).Thisshouldbe detailedintheorganisation’swastepolicy.Thehealthcareworkershouldalsohave receivedappropriatetraining,eitherin-houseorcontracted-out,whichaddressesthe safetransportationofwaste.Thisistheresponsibilityoftheorganisationandshould bereviewedaspartoftheauditingprogramme.Forwastetraining,policy,and auditingsee‘Managingcompliance’. Normally,thecarriageofanyquantityofclinicalwasterequiresthecarrier(healthcare worker)tofita2kgfireextinguisherirrespectiveofthequantityofwaste.The DepartmentforTransporthasissuedanauthorisationtoexemptcommunitynurses fromthisrequirement(seethelastparagraphin‘Transportontheroad’). Transportpackagingandoperations Managingcompliance Transportontheroad 169 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Communitypharmacies 8295 Thisguideisintendedtoprovidecommunitypharmacieswithasummaryguideto thekeyrequirementsforwastemanagement.Thissectiondoesnotaddressthegreater complexityoflargerpharmacies,forexamplethosefoundinanacutehospital,to whichtheguidancepublishedbytheNHSPharmaceuticalQualityAssurance Committeeisapplicable. Guidanceisprovidedon: • theresponsibilitiesofthepharmacy; • wastesegregation,labellingandclassification; • wastetransferanddocumentation; • wasterecordsandreturns; • wasteauditsanddutyofcare. Responsibilitiesofthepharmacy 8297 Thepharmacyhasastatutorydutyofcare.Thisappliestoeveryoneinthewaste managementchainfromproducertodisposer.Itrequiresthatthewastebemanaged andthatallreasonablemeasuresaretakentoensurethatthewasteisdealtwith appropriatelyfromthepointofproductiontothepointoffinaldisposal. Note Pharmacies’responsibilitiesdonotendwhentheyhandtheirwastetotheirwaste collector. Thepharmacyissolelyresponsibleforensuringthatwasteis: • correctlysegregated; • appropriatelylabelled; • packagedappropriatelyfortransport; • storedsafelyandinasecureplaceawayfromareasofpublicaccesswithinthe premises; • describedaccuratelyandfullyontheaccompanyingdocumentationwhen removed; • transferredtoanauthorisedpersonfortransporttoanauthorisedwastesite. Inaddition,thepharmacyshouldensurethat: • eachofitspremisesisregisteredasahazardouswasteproducer(unless exemptfromregistration–see‘Managingcompliance’);and • itkeepsaregisterofthenecessaryrecordsandreturnsintheappropriate location(normallyonthepharmacy’spremises). Thepharmacymanagershouldalsoensurethatstaffaretrainedandawareofthewaste procedures.Thewastemanagementcontractorshouldbewillingtoadviseonfulfilling therequirementsfortheaboveresponsibilities.However: • itremainsthelegalresponsibilityofthepharmacy,notthewaste contractor,toensurefullcompliance;and • thewastecontractorwillhavelessknowledgethanthepharmacyaboutwhat isinthewaste. Managingcompliance 170 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Wastesegregation,packaging,classificationandlabelling 8299 Wastesegregationisdrivenbyanumberoffactorsincluding: • thetechnicalcapabilitiesandpermitsofthewastedisposalfacilities; • packagingrequirementsforsafelytransportingcertainmaterials; • healthandsafety; • theHazardousWasteRegulations(SpecialWasteRegulationsinScotland), whichprohibitthemixingofwastecategories. Thesegregationsystembelowisdesignedtoimplementtheserequirements:cytotoxic andcytostaticwaste; • othermedicines; • medicinallycontaminatedsharps; • non-medicinallycontaminatedsharps; • clinicalwaste(orangebag); • offensivewaste(yellow/blackbag); • domestic/tradewaste(blackorotherappropriatebag); • wastechemicals. Pharmaciesproducearangeofhazardousandnon-hazardouswastes.Figure11(see ‘Containerlabelling’)outlinessomekeywastestreams,includinganexplanationof eachstream,whatwastecontainersshouldbeused,whatcanbeplacedinthese containers,howwasteshouldbeclassifiedanddescribedonwastedocumentation. Specificadviceisprovidedbelowoncertainwastes. Containerlabelling HazardousWaste(EnglandandWales)Regulations HazardousWasteRegulations(NorthernIreland) SpecialWasteAmendment(Scotland)Regulations Classificationofwastemedicines 8301 Wastemedicinesareclassifiedboth: • bychemicalproperties; • andbysource. TheBNFisnotusedforwasteclassification.Classificationbychemicalproperties dividesmedicinesinto: • cytotoxicandcytostatic(hazardousclinicalwaste);and • other(non-hazardousclinicalwaste). Cytotoxicandcytostaticmedicinesareclinicalhazardouswasteandincludeany medicinethathasoneormoreofthehazardouspropertiestoxic(H6),carcinogenic (H7),mutagenic(H11)andtoxicforreproduction(H10).Thisisawidedefinition capturingmanyhormone-basedpreparations,antimicrobialsubstancessuchas chloramphenicol,aswellascancer-treatingagents. Allcommunitypharmaciesarelikelytoroutinelyproducewastemedicinesofthis type.Themedicinesinuseinthepharmacyshouldbereviewedtoidentifytheir propertiesandwhethertheyarecytotoxicandcytostatic(anindicativelistisprovided inthe‘Examplelistofcytotoxicandcytostaticdrugs’). 171 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Otherwastemedicinesthatarenotcytotoxicandcytostaticarenormallyclinicalwaste, butarenothazardouswaste.However,theymaypossessarangeofhazardous propertiesthatneedtobeprovidedtothewastecontractorfordutyofcarepurposes andmayrequiresegregationtokeepchemically-incompatiblesubstancesapart.Known examplesfromacommunitypharmacyincludemedicinesthatareflammable, harmful,irritant,oxidisingorecotoxic. Thesewastesneedtobeproperlyidentifiednotonlysothatthewastecontractor knowswhathe/sheishandling,butalsosothatthosewastesthatmightinteractif mixedcanbekeptseparateuntilcollectedbythewastecontractor.Medicinesarealso classifiedbysourceactivity,forexample: • humanhealthcare; • animalhealthcare; • municipalfractions. Medicinesproducedbypharmaciesandreturnedtopharmaciesfromnon-domestic producers(forexamplegeneralpractices,dentists,carehomesprovidingnursingcare etc)willnormallybeclassifiedasfromhumanhealthcare.However,manycommunity pharmaciessupplyveterinarymedicinesforpets.Thesewillbeclassifiedasfrom animalhealthcare.Wastemedicinesreturnedfromhouseholds,includingresidential carehomes,areclassifiedasseparately-collecteddomesticfractions.Thisisillustrated inTable17. Table17Classificationofwastemedicinesfromcommunitypharmacies Source Humanmedicines(includingnon-domesticreturns) Animalmedicines Domesticreturns Cytotoxicandcytostatic 180108* 180207* 200131* Othermedicines 180109 180208 200132 Examplelistofcytotoxicandcytostaticdrugs Segregation,sortingandunpackingofmedicines 8303 TheHazardousWasteRegulationsandSpecialWasteRegulations: 1. requirethatpharmaciesdonotmixahazardouswastewithothercategories ofhazardouswasteorwithanon-hazardouswaste;and 2. placeadutyonapharmacythatreceivedmixedwastetoseparateit,provided itissafeandpracticaltodoso. Categoriesaredefinedbyanumberofcriteriaincludingtypeofwaste,disposal requirements,incompatiblereagentsandtheabilitytorecycleorrecoverthewasteor elementsofit. Pharmaciesmustthereforesegregatetheirwastemedicinesinto: • cytotoxicandcytostaticmedicines;and • othermedicines. Theymustalsoensurethat: • chemically-incompatibleagentsarenotplacedinthesamecontainer;and • thewasteisappropriatelypackagedandlabelledfortransport(see ‘Incompatiblesubstances’). Forreportinganddocumentarycontrols,pharmacieswillalsoneedtobeableto accuratelyquantifyeachofthefollowingsubgroups,evenifthesearenotfully segregated: • cytotoxicandcytostatic–fromhumanhealthcare; 172 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • cytotoxicandcytostatic–fromanimalhealthcare; • cytotoxicandcytostatic–domestichouseholdpatientreturns; • othermedicine–fromhumanhealthcare; • othermedicine–fromanimalhealthcare; • othermedicines–domestichouseholdpatientreturns. Formedicinesinaerosolform: • adviceshouldbesoughtfromthewastecontractor;and • ifnotsegregated,theirpresenceshouldbespecificallyidentifiedonthe accompanyingwastedocumentation. Medicinesshouldnotberemovedfromthefinalinnerlayerofpackaging,forexample blisterstrips.Thissignificantlyreducesthepotentialforreactions. Single-usemonitoreddosingsystems(MDS)shouldbedisposedofintactwithout removingthemedicinesunlesstheycontaincontrolleddrugs.Wastemedicinescanbe removedfromreusableMDSwheretheMDSissuitableforreuseandprecautionsare takentoavoidcontaminationofthenewmedicinessupplied. Note Domestichouseholdsarenotsubjecttotheprohibitiononmixing.Therefore,they mayonoccasionreturnmixedwastemedicinestothepharmacy.Allreasonable stepsshouldbetakentosegregatethemedicines;however,inexceptionalinstances, therecanbehealthandsafetyimplicationsassociatedwithstaffputtingtheirhands intoacontainerofreturnedmedicines.Wherepossible,thecontentsofthebag shouldbeeitherexaminedthroughtheopeningoremptiedtemporarilyontoatray (whichwillcontainthewasteandavoidspillageontoothersurfaces).Thismaybe necessarytoidentifyifcontrolleddrugsarepresent.Identifyingindividualloose tabletsisoftenimpracticableandisnotrequired. PharmaciesshouldensurethattheyhavearobustSOP(standardoperatingprocedure) inplacetodealwiththereceiptofunwantedmedicinesfromhouseholds, demonstratingallreasonablestepsaretakentoensurewasteissegregatedandstored wherepracticableandappropriate. Becauseallpharmacieswillexpecttoreceivehazardousaswellasnon-hazardouswaste, thepharmacymusthaveseparatewastecontainersforhazardouswasteandfornonhazardouswaste(althoughtheymaybeofdifferentsizesandcollectedatdifferent frequenciesofcollection).Whereitisnotpracticaltoidentifythecontentsofa returnedbagofunwantedmedicinesasentirelynon-hazardous,thenundertheabove principle,thebagofwastemustallbeconsignedunderhazardouswastecontrolsas mixedhazardousandnon-hazardouswastemedicines,tocomplywiththehazardous wasteanddutyofcareregulations.Thedescriptionontheconsignmentnotewouldbe “mixedhazardousandnon-hazardouswastemedicines”andincludetherelevantEWC codesforeach. Thepreliminarysortingandstorageofwasteforthepurposesoftransporttowaste treatmentfacilityisanactivityconsideredtobeanon-WasteFrameworkDirective exemption;thatis,nopermitorregisteredexemptionisrequired(seethe‘Healthcare relatedexemptions’section).However,thisexemptionthatallowsthepharmacyto storereturnedmedicineswithoutanenvironmentalpermitorregisteredexemption doesnotallowthestorageofmixedwasteasdescribedabove. Incompatiblesubstances Healthcare-relatedexemptions HazardousWaste(EnglandandWales)Regulations HazardousWasteRegulations(NorthernIreland) SpecialWasteAmendment(Scotland)Regulations 173 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Controlleddrugs 8305 Pharmaciesshouldensurethattheycomplywiththefollowinglegislationapplicableto controlleddrugs: • theMisuseofDrugsRegulations • theMisuseofDrugs(SafeCustody)Regulations • theControlledDrugs(SupervisionofManagementandUse)Regulations. Thesesetoutrequirementsforthestorageofcontrolleddrugs(forexamplean authorisedwitnessisrequiredfordenaturing)andtheroleofaccountableofficersfor certainNHStrustsandindependenthealthcarebodies. Pharmacieswillproducecontrolled-drugswasteandmayreceivecontrolleddrugs returnedfromotherproducers: • Controlleddrugsreturnedfrompatientsshouldbedenaturedassoonas possibletoavoidthedangeroftheirbeingmixedwithpharmacystockandto reducetheriskofholdingunnecessaryquantitiesofcontrolleddrugs. • Controlleddrugsreturnedfromdomesticpremisesmustbestoredin compliancewiththeMisuseofDrugs(SafeCustody)Regulationsandneed tobestoredinacontrolleddrugscabinetuntiltheyaredenatured(seealso ‘Storageofwaste’). Controlleddrugsproducedonthepharmacy’spremisesmaybedenaturedunderan exemptionfromanenvironmentalpermitorlicence(T28).Thisexemptionmustbe registeredwiththeenvironmentalregulator. Controlleddrugsreturnedtothepharmacymaybedenaturedwithoutan environmentalpermit.TheEAhasissuedaregulatorypositionstatementindicating thattheywillnotnormallyrequireone. Denaturingshouldbeundertakenusingamethodconsistentwiththeguidancefrom theRoyalPharmaceuticalSocietyofGreatBritain(RPSGB). Denaturedcontrolleddrugsshouldbedisposedofaswastemedicinesofthe appropriatetype.Forfurtherguidanceonthemanagementofcontrolleddrugs,seethe RPSGBwebsite. Storageofwaste MisuseofDrugsRegulations MisuseofDrugsRegulations(NorthernIreland) ControlledDrugs(SupervisionofManagementandUse)Regulations EAregulatorypositionstatement RoyalPharmaceuticalSocietyofGreatBritain(RPSGB)guidance RPSGBguidanceonthemanagementofcontrolleddrugs Glass/plasticmedicinalcontainers 8307 Wastemedicinesshouldnotbedischargedtofoulsewer,socontaminatedcontainers ortheircontentsshouldnotberinsedout.Contaminatedbottles,vialsandampoules shouldbedisposedofaswastemedicines. Non-pharmaceutically-activemedicinesaretheexception.Liquids(includingsugar andsaltsolutions),sterilewater,andnutritionalsupplementscanbedisposedofto foulsewer;ifthereisanydoubt,advicefromthesewerageundertakershouldbe sought.Thecontainerscanberinsedandrecycled. 174 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Sharps 8309 Sharpsareitemsthatcouldcausecutsorpuncturewounds,includingneedles,broken glassmedicinecontainers,brokenampoules,scalpelandotherblades,andthesharp partofinfusionsets.Sharpsdonotincludemedicinecontainers(bottles,vials, ampoulesetc)orthemedicinally-contaminatedsyringebarrel(asopposedtothe needle). Pharmaciesmayproduceorreceivesharpsincluding: • returnsfromdomestichouseholderswithdiabetesandfromotherselfadministeringpatients; • needleexchange; • diagnosticprocedures. Sharpsaresegregatedonthebasisofmedicinalcontamination(asthisaffectsdisposal requirements)into: • contaminatedcytotoxicandcytostaticsharps; • othermedicinally-contaminatedsharps;and • non-medicinally-contaminated. Sharpscontainersfromself-medicatingpersonswithdiabetes(andotherpatients injectingmedicationunderprescription)wouldnormallycontainsharpscontaminated withinsulinandperhapstheinsulincontainers.Thesearemedicinallycontaminated andshouldbeinayellow-liddedsharpscontainer.Thesearetypicallyclassifiedas18 0103*and180109,andlabelledas“clinicalwaste,mixedmedicinallycontaminated sharpsandpharmaceuticalwaste(notcytotoxicandcytostatic)forincinerationonly”. Sharpsfrombloodtests,eitherfromnon-medicatingpersonswithdiabetesor diagnostictestsinthepharmacy,arenotnormallycontaminatedwithmedicines. Thesecanbeplacedinanorange-liddedsharpscontainer.Thesearetypicallyclassified as180103*andlabelledas“clinicalwaste,non-medicinallycontaminatedsharps suitableforalternativetreatment”. Sharpsfromneedle-exchangeprogrammesarelikelytobeproducedbynon-healthcare activities.Theyarelikelytobecontaminatedwithchemicalsormedicinesandshould beplacedinayellow-liddedsharpscontainer.Thesearetypicallyclassifiedas200199 andlabelledas“clinicalwaste,medicinallycontaminatedsharpsfromneedleexchange forincinerationonly”.Ifthesharpsarisefromaneedle-exchangeprogrammewhere anti-addictivemedicinesareprescribed,theseareclassedashealthcarewasteand shouldbeclassifiedas180103. Whereapre-filledsyringesetisreturnedtoapharmacywithaneedle,itshouldbe treatedasasharpandshouldbeclassifiedas180101and180109ifthemedicineis non-hazardous. Note Forhealthandsafetyreasons: needlesshouldnotnormallyberemovedfromsyringes;and asecondactionshouldnotbetakentodischargesyringes. Otherhealthcarewastes 8311 Pharmaciesmayproducesmallamountsofotherhealthcarewastes,forexample contaminatedPPE,swabs,plasters,andtissuesfromdiagnostictests.Ifthematerialis notcontaminatedwithpharmaceuticalsorchemicals,itcanbediscardedinanorange wastereceptacleandtypicallyclassifiedas180103*,describedas“healthcarewaste, infectious,suitableforalternativetreatment”. 175 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 PPEandotheritemsusedinthehandlingofpharmaceuticalsthathavebecome contaminatedshouldnotbeclassifiedasinfectiouswaste.Aclinicalwastereceptacle (approvedandlabelledforinfectiouswaste)isnotanappropriatecontainer.These materialsshouldbeplacedinthepharmaceuticalwastestream. Offensivewastes 8313 Communitypharmaciesmayproduceoffensivewastestreamsincluding: • femininehygienewastesfromstafforpublictoilets;and • somewastefromdiagnostictests. Femininehygienewastesfromtoiletsshouldbeplacedinayellow/blackreceptacleand classifiedas200199. Body-fluid-contaminatedwastefromdiagnostictestsshouldbeclassifiedasinfectious healthcarewasteunlessthepharmacycandemonstratethatitcanconducteffective screeningassessmentstoidentifytheproportionthatisnon-infectiousoffensivewaste. Ifitcan,itwillhaveaproportionthatisinfectiouswasteandaproportionthatis offensivewaste.Apharmacywouldnormallygeneratebothinfectiousandoffensive waste. Chemicals 8315 Pharmaciesmayemployarangeofchemicalsincludingdisinfectants,handgelsand oxidisingagents.Theymayalsostockarangeofchemicalsubstancesandpreparations intheirretailareas. Guidanceonthedisposalofwastechemicalsfromretailandpharmacyisnotprovided hereotherthantonotethatthepharmacyisprohibitedfrommixingbytheHazardous WasteRegulations(see‘Incompatiblesubstances’).Nohazardouswasteitemsmaybe placedinthedomesticortradewastestreams. Alcoholhandgelsthatdonotcontainsiloxanes(whichcausesignificantdamageto plantandequipmentusedinthesewagetreatmentprocess)andwhoseSDSdoesnot prohibitdischargetothesewermayberinsedoutandthepackagingrecycledorplaced intothedomesticwastestream(see‘Healthcarewastedefinitionsandclassifications’, ‘Wasteminimisation,segregation,colour-codingandstorage’and‘Transport packagingandoperations’). Incompatiblesubstances Healthcarewastedefinitionsandclassifications Wasteminimisation,segregation,colour-codingandstorage Transportpackagingandoperations HazardousWaste(EnglandandWales)Regulations HazardousWasteRegulations(NorthernIreland) SpecialWasteAmendment(Scotland)Regulations Domesticandtradewaste 8317 Blackbagsorothersuitablecontainersshouldbeusedfornon-hazardouswastesother thanmedicines. Pharmaciesshouldseektorecycle: • cardboard; 176 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • glasswarethathasnotbeenusedinmedicinecontainers;and • othersuitableitems. Electricalwastes,includingbatteriesandfluorescenttubes,shouldnotbeplacedin thesecontainers. Aspharmaciesareprohibitedfrommixingwaste,nohazardouswastescanbeplacedin thedomesticortradewastestreams.Inadditiontothewastesalreadymentioned, manyoftheproductsintheretailareasofpharmacieswouldbehazardouswasteif discarded.Typicalexamplesincludesomedisinfectants,handgels,aerosols,cosmetic products(forexamplealcohol-basedperfumes),batteriesandmanyothers.A proportionofwasteretailstockwillthereforebehazardouswaste. Pharmaciesthatprovidephotographicservicesshouldalsonotethatphotographic chemicals(fixersanddevelopers)arealsohazardouswaste. Incompatiblesubstances 8319 Somewastemedicinesandchemicals,undercertainconditions,mayreacttoproduce fireandflammableortoxicgases.Forthisreason,medicinesshouldnotberemoved frombottles/blisterpacksinordertoprovidesomeformofbarriertosuchreactions. Inaddition,specificincompatiblematerialsshouldbesegregatedinseparatewaste containersorstoredsecurelyforthewastecontractorwithidentificationofthetypeof producttoreducetheriskfurther,rememberingthatbottlescanleakandglasscan breakduringtransit.Thisisaknownproblemwithpharmacywasteswherethereare concernsoverflammableoroxidisingsubstances(forexamplepermanganatesand peroxides). Pharmaciesshouldensurethattheyareawareofthehazardouspropertiesofthe chemicalsandmedicinesthattheystockandthattheyhaveidentifiedthepotential incompatibilities. Thepharmacyisrequiredtoidentifythesehazardouspropertiesonthewaste consignmentandtransfernotes. Storageofwaste 8321 Therearethreespecificstorageissuestoconsider: • thepharmacy’sownwaste; • returnsfromdomestichouseholders; • eturnsfrommedicalpracticesandothernon-domesticsources. Theseareexemptfromtherequirementforanenvironmentalpermitanddonotneed toberegistered. Thepharmacymaystoretheirownwasteunderanexemptionfromanenvironmental permitfortemporarystorageofwasteatthepremisesofproductionwherethe followingconditionsaremet: • storageisinasecureplace; • storageisatthepremisesofproduction; • storageisfornolongerthan12months. Thepharmacymayalsostorewaste,includingmedicinesandsharps,returneddirectly fromdomestichouseholdsbythehouseholderorhealthcareworkerunderan exemptionforatemporarycollectionpointwherethefollowingconditionsaremet: • Thestorageis: –inasecurecontainer; 177 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 –atacollectionpoint; –doesnotincludewastescontainingasbestosorwithaflashpointofless than21°C. • Mixedwastesarenotstored. • Wastesarenotstoredforlongerthanthreemonths. • Wastequantitiesdonotexceed5m³ofhazardouswasteor50m³ofnonhazardouswaste. Thisexemptionfromanenvironmentalpermitalsopermitsstorageofwastereturned frommedicalpracticesandothernon-domesticsources(includinggeneralpractices, dentists,veterinarians,carehomesprovidingnursingcare,schools,prisonsetc). However,wherethisisthecase,thefollowingstillapply: • Hazardouswastemedicinesandmixedmedicinesofunknowncomposition mustbeconsignedfromthesepremisestothepharmacyusingahazardous wasteconsignmentnote. • Thepharmacyreceivinghazardouswasteisaconsigneeandmustkeepa registerandasiteinventory,andmustsendconsigneereturnstotheproducer andconsigneereturnstotheenvironmentalregulator.Eachconsignment receivedissubjecttoacharge. • Hazardouswastecontrolsapplytoallmovementsofhazardouswastebetween non-domesticpremises,eveniftheyarepartofthesamecompanyor organisation. • Non-hazardousmedicinesmustbetransferredtothepharmacyunderdutyof carecontrols,includingawastetransfernote. Note Theauthoritytoacceptthesewastesdoesnotinitselfplaceadutyonthepharmacy todoso.Ifitdoesdecidetodoso,thesewastescannotbereceivedthroughthe PCT-fundedservice,andthepharmacywouldhavetomakeitsownarrangements fordisposal. Transportregulations 8323 ThepharmacywillusuallybeconsideredtheconsignorundertheCarriageRegulations andmustensurethattherequirementsoftheCarriageRegulationsaremet. Forwastemedicines,thefollowingguidelinesmaybeused: • Medicinesunopenedinoriginalretailpackaging(forexampledate-expired medicines)areexemptfromtheCarriageRegulations. • Partially-openedpackagings,miscellaneousblisterpacksetcshouldbe packagedinaccordancewith‘Wastemedicines(includingamalgamwaste)’. Thesewillnormallybelimitedquantitiesandmaybemarkedaccordingly (seeunderTable11in‘Markingandlabellingofpackagings’),havingbeen identifiedinaccordancewiththefirstparagraphofthe‘Controlleddrugs’ sectionunder‘Environmentandwastelegislation’. • Sharpscontainersshouldcomplywiththeguidancegivenin‘Sharps packaging’(limitedquantityprovisionsdonotapplytosharps). • WasteaerosolsaresubjecttotheCarriageRegulations. • Otherwastechemicalsmustbeclassifiedaccordingtotheirhazard.Itislikely thatmostcanbemovedunderthelimitedquantityprovisionsexcept radioactivematerial. 178 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Whereatransportdocumentisrequired,primarilyforsharps,thestandardwastenote maybeused,providedthetransportinformationisincluded(fortransport,limited quantitiesdonotrequireatransportdocument). Wastemedicines(includingamalgamwaste) Markingandlabellingofpackagings Controlleddrugs Sharpspackaging CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) Wastetransferanddocumentation 8325 Astheproducerofthewaste,thepharmacybearsthelegalresponsibilityofensuring thatwastedocumentationiscompleteandaccurate.Therearetwodifferenttypesof documentationrequiredforwastetransfers: • consignmentnotesthatareusedforhazardouswastes; • wastetransfernotesthatareusedfornon-hazardouswastes. Aconsignmentnoteisusedtotrackthemovementsandensurethesafedisposalof hazardouswastes.Italsoensuresthattheinformationaccompanyingthewasteis sufficienttoenableitssafedisposal.Anewconsignmentnotemustbecompletedfor eachindividualcollectionofhazardouswaste.Eachnotewillconsistofproducer, carrierandconsigneecopies. Whocompletestheconsignmentnoteandwhen? 8335 Beforethewasteisremovedfromthepharmacy: • partAcontainsdetailsofthepharmacyandthedestinationofthewaste.The pharmacyisresponsibleforcompletionofthissection; • partBcontainsdetailsaboutthewaste,itspropertiesanditspackaging.The pharmacyisresponsibleforcompletionofthissection; • allthreecopiesshouldbethenprovidedtothewastecarrier; • partCcontainsdetailsofthewastecarrier,thedriver,thevehicleanda declarationthatthecarrierhasverifiedkeyinformationinpartsAandB. Thismustbecompletedbythecarrier; • thepaperworkisthenpassedbacktotheproducer.OnlyaftersectionCis completedcanthepharmacycompletepartDtoverifysectionsAtoC(as thisincludesarecordofthenumberplateofthevehicleontowhichthewaste wasloaded); • oncepartsAtoDarecomplete,thecarriermayremovethewaste. Onarrivalatthedestination(consignee)site,theconsigneecompletespartEtoverify whattheyhavereceived. 179 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Keypoints ThelawplacesthesoleresponsibilityforcompletionofpartsA,BandDof thenoteonthepharmacy. Theconsignmentnotesystemrequiresthepharmacytocertifythecarrier andvehicledetailsduringcollection.Unsupervisedout-of-hours collectionisnotallowed. Alistofcytotoxicandcytostaticmedicinesusedbythepharmacyandtheir hazardouspropertiesmustbeattachedasacontinuationsheettothe consignmentnoteandaccompanythewaste. Furtherguidanceonthisisprovidedby: theEA(forEnglandandWales); SEPA(forScotland); theNIEA(forNorthernIreland). EAguidance SEPAguidance NIEAguidance Carrierroundcollections 8336 Wastecarriersmaycollecthazardouswastefromanumberofsmallproducersinthe samejourney,referredtoasacarrierround. Eachcollectionwithinaroundwillneeditsownstandardconsignmentnotewith uniqueconsignmentnotenumber.Thecarrierroundwillhaveauniquenumberthat iscommontoallthecollectionsinthatround. Wastetransfernotes 8337 Wastetransfernotescanonlybeusedforthecollectionofnon-hazardouswastesfrom thepharmacy.Thesecannotbeusedforclinicalwastesotherthansegregatednonhazardousmedicinesandsharpsfromneedleexchange. Thepharmacycompletesawastetransfernote.Thelegalresponsibilityfordescribing thewasterestswiththepharmacy. Ifacontractorcollectsthesamewasteatregularintervalsoveraperiodnolongerthan 12months,aseasonticketcanbeused.Therefore,anewnotewouldnotberequired oneachoccasion. Registrations,recordsandreturns 8334 Allpharmaciesthatproduce500kgormoreofhazardouswasteinany12-month periodneedtoregistertheirpremisesannuallyasahazardouswasteproducer.Ifthe pharmacyproduceslessthan500kginany12-monthperiod,itisexempt.This informationisusedtotrackhazardouswastesandensurethattheyaresafelymanaged. The500kgincludesallofthepharmacy’shazardouswastesincludingelectricalwaste andthosefromretailpartsofthepharmacy. Note Wherearegisteredcommunitypharmacyoperateswithinahealthcentreofa hospital,thisisclassedasseparatepremisesinitsownrightandmayneeditsown registration. 180 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Howtoregisterasahazardouswasteproducer 8327 Therearethreewaystoregisterasahazardouswasteproducer: • onlineviatheenvironmentalregulator’swebsite; • byphoneattheenvironmentalregulator’scustomercontactcentre; • bypost. Whenthepremisesareregistered,thepharmacywillbegivenahazardouswaste producerregistrationnumbercalledapremisescode.Thiscodemustbeusedonall consignmentnoteswherehazardouswasteisremovedfromthosepremises. Registrationisonlyvalidfor12months,somustberenewedannually. Hazardouswaste–recordsandreturns 8328 Pharmaciesarerequiredtokeeparegisterthatcontainstheirhazardouswasterecords. Thisrequirementisusuallymetbykeepingcopiesofboth: • standardormultipleconsignmentnotes(includingbothmainnotesand annexes);and • consigneereturnstotheproducerorholder. Whererelevant,theregistershouldalsocontainrecordsofanyrejectedloadsorcarrier schedules.Guidanceonconsignmentnotesandtheircompletionisprovidedinaseries ofguidestotheHazardousWasteRegulations. GuidestotheHazardousWasteRegulations Consigneereturnstothewasteproducerorholder 8329 Eachconsignee(thedestinationsitewherethecarriertakesthewaste)isrequiredto sendtothepharmacyareturneachquarter.Thisreturnisarecordofwhathas happenedtothewasteandmustbeplacedinthewasteproducer’sregister.These returnsmustbepresenttoensuretheregisterislegallycomplete;therefore,ifthe returnisnotreceivedwithinareasonableperiodoftime,thepharmacyshouldcontact theconsigneeandrequestthatacopyissentbyreturn. Wherethewasteistakentoatransferstationbeforebeingsentelsewherefordisposal, thepharmacyshouldalsorequestcopiesoftheassociatedcompletedpaperworkfor thatonwardmovement,whichconfirmsthatitwasreceivedatthefinaldestination.If itisunclearastowhetheratransferstationistheinitialdestinationforthewaste,the wastecontractorshouldbeconsulted. Whereshouldtheregisterbekept? 8330 Wheretheregisteriskeptdependsonthenumberofpharmacybranchesandwhether theseareeachregisteredashazardouswasteproducersornot. • Registeredpremises–ifapharmacyisregistered,theregisterforany hazardouswastethatisremovedfromthatpharmacymustalwaysbekepton thatpharmacy’spremises. • Exemptpremises–ifapharmacybranchisexemptfromregistrationasa hazardouswasteproducer,theregisterforanyhazardouswastethatis removedfromthatpharmacyshouldbekeptatthepharmacyorprincipal placeofbusiness.Thismaybeanotherpharmacyifthepharmacyisoneof severalinacompany.Ifapharmacywishestokeeptheregisteranywhereelse, thismustbeagreedinwritingwiththeenvironmentalregulator. 181 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Howlongshouldtheregisterbekept? 8331 Theregistermustbekeptforatleastthreeyears,commencingfromthedatethewaste wasremovedfromthepharmacy’spremisesbyawastecarrier. Non-hazardouswasterecords 8332 Wastetransfernotesshouldbekeptforaminimumoftwoyears.Whereseasontickets areused,arecordshouldalsobekeptofthetimeswheneachoftheregularcollections ismadeusingthenote. Thepharmacyasaconsignee 8333 Wherethepharmacyreceiveswastemedicinesreturnedfromnon-domesticpremises, theyarelikelytobeahazardouswasteconsigneewithresponsibilitiesforkeepingasite inventory,andformakingconsigneereturnstotheproducerandquarterlyreturnsto theenvironmentalregulator.Furtheradviceonthiscanbefoundonthe environmentalregulator’swebsite. Wasteauditanddutyofcareauditchecks 8339 Wastesegregationandproceduresshouldbeauditedperiodicallyforthreereasons: 1. Itenablesthepharmacytoaccuratelydescribeandclassifyitswasteto completeitswastedocumentationanddischargeitsdutyofcare. 2. Thewastedisposermayberequiredbytheirpermittoobtainanauditfrom thepharmacybeforetheycanacceptthewaste(apre-acceptanceaudit). 3. Thisenablesthepharmacytomonitoritswastepractices,identifyany problemsandasaresultenablesittofixthem. Examplesofspecificissuestoidentifyinanauditofeachareaofthepracticearethe presenceofthefollowinginanywastestream: • cytotoxicandcytostaticmedicines; • medicines(forexampletablets,creams,vials,ampoules,intravenousbagsetc) andmedicinally-contaminatedwastes(forexamplesyringebarrels,tubing, etc); • sharps(includingwhethertheyaremedicinallycontaminatedornot); • chemicals(disinfectants,reagents,diagnostickits,resinsetc); • chemically-incompatiblesubstances; • body-fluid-contaminatedmaterialthatisinfectious(swabs,PPEetc); • healthcareitemsthatarenotcontaminatedwithbodyfluidsorother potentiallyinfectiousmaterials(forexamplePPE)(offensivewastes); • femininehygienewastes/nappybinsfromtoilets; • municipal-typewastes(newspapers,magazines,foodanddrinkcontainers, sterileequipmentandotherpackagingetc). Thefollowingshouldalsobeconsidered: • whatwastecontainersareusedforthesewastes; • howtheyarelabelled; • whetherthecontentsareaccuratelydescribedandclassifiedonwaste documentation. 182 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Undertakingsuchauditswillenablethepharmacytodemonstratethatithas dischargeditsdutyofcareindescribingandpackagingitswaste. Pre-acceptanceaudit Wastecarriers 8341 Thewastecontractorwhocollectsthewastemustbearegisteredwastecarrier.This shouldbecheckedby,forexample,comparingthecarrierregistrationnumberonpart Coftheconsignmentnotetotheinformationheldontheenvironmentalregulator’s electronicpublicregister.Thepharmacymustsupervisecollectionsofhazardouswaste toenableittocertifythecarrierandvehicledetailsinpartDofthenote. Note Ifthepharmacyprovidesawastecollectionservicefromdomestichouseholdsor otherpremises,forexamplewhendeliveringnewmedication,theywillneedtobe registeredwastecarriers. Environmentalregulator’selectronicpublicregister Wastedisposal 8343 Wastefromsmallpremisesisfrequentlytakentoawastetransferstationwhereitis combinedwithotherwastesandsentforfinaldisposal.Ifthewasteisbeingtakentoa wastetransferstation,copiesofthedocumentationusedforonwardmovementofthe wastetoitsfinaldestinationshouldberequested. Therearetwomaindisposaloptionsforclinicalwaste: alternativetreatments–whichdisinfectthewasteandarenormallyauthorisedonlyfor infectiouswastes(forexamplebaggedclinicalwastes); clinicalwasteincinerators–whichensurecompletedestructionofmedicinesand chemicalsaswellasinactivationofmicroorganisms. Dischargetofoulsewer 8345 Dischargestofoulsewershouldbeinaccordancewithatradeeffluentconsentfrom thesewerageundertaker. Wastemedicinesshouldnotbedischargedtofoulsewer.Non-pharmaceutically-active liquidsincludingsugarandsaltsolutions,sterilewaterandnutritionalsupplements canbedisposedoftofoulsewer. GuidanceonthisisduetobeprovidedbyWaterUKonbehalfofthesewerage undertakersin2011. Exportofmedicinesanddonationstocharity 8347 Wherewastemedicinesfromapharmacyarecollectedorsenttoacharityforreuse overseas: • theguidancefromtheRoyalPharmaceuticalSocietyofGreatBritain (RPSGB)onsuchdonations,whichfollowstheWorldHealthOrganisation line,shouldbefollowed; 183 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • cytotoxicandcytostaticwastemedicinesmustbeconsignedfromthepractice tothecharity,whichmustsendthepharmacy(andtheregulator)consignee returns; • otherwastemedicinesmustbetransferredusingaduty-of-carewastetransfer note; • thecharitymustholdanenvironmentalpermitforsortingofwaste medicines;and • aregisteredwastecarrierisnormallyrequiredtotransportthematerial. RPSGB 184 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Generalpracticesandhealth centres 8349 Thisguideisintendedtoprovidegeneralpracticeswithasummaryguidetothekey requirementsforwastemanagement.Althoughalsoapplicabletohealthcentres,care mustbetakenasthesemayprovideawiderrangeofservicesandproducemore complexwastes.Healthcentresthatprovidedentalservicesshouldalsoreadthe “Dentalpractices”sectorguide. Guidanceisprovidedon: • theresponsibilitiesofthegeneralpractice; • wastesegregation,labellingandclassification; • wastetransferanddocumentation; • wasterecordsandreturns; • wasteauditsanddutyofcare. Furtherinformationcanbefoundwithinthemainbodyofthisguidance. Dentalpractices Responsibilitiesofthegeneralpractice 8351 Generalmedicalpracticeshaveastatutorydutyofcare.Thisappliestoeveryoneinthe wastemanagementchainfromproducertodisposer.Itrequiresthepracticetomanage thewasteandtotakeallreasonablemeasurestoensurethatthewasteisdealtwith appropriatelyfromthepointofproductiontothepointoffinaldisposal. Keypoint: Thegeneralpractice’sresponsibilitiesdonotendwhenithandsitswastetoawaste collector. Thepracticeissolelyresponsibleforensuringthatwasteis: • correctlysegregated; • appropriatelylabelled; • packagedappropriatelyfortransport; • storedsafelyandinasecureplaceawayfromareasofpublicaccesswithinthe premises; • describedaccuratelyandfullyontheaccompanyingdocumentationwhen removed; • transferredtoanauthorisedpersonfortransporttoanauthorisedwastesite. Inadditionthegeneralpracticeshouldensurethat: • eachofitspremisesisregisteredasahazardouswasteproducer(unless exemptfromregistration–see‘Managingcompliance’);and • itkeepsaregisterofthenecessaryrecordsandreturnsintheappropriate location(normallythepractice’spremises). Thepracticemanagershouldalsoensurethatstaffaretrainedandawareofthewaste procedures. Thewastemanagementcontractorshouldbewillingtoadviseonfulfillingthe requirementsfortheaboveresponsibilities.However: 185 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • itremainsthelegalresponsibilityofthepractice,notthewastecontractor, toensurefullcompliance;and • thewastecontractorwillhavelessknowledgethanthepracticeaboutwhatis inthewaste. Managingcompliance Wastesegregation,packaging,classificationandlabelling 8365 Wastesegregationisdrivenbyanumberoffactorsincluding: • thetechnicalcapabilitiesandpermitsofthewastedisposalfacilities; • packagingrequirementsforsafelytransportingcertainmaterials; • healthandsafety; • theHazardousWasteRegulations(SpecialWasteRegulationsinScotland), whichprohibitthemixingofwastecategories. Thesegregationsystembelowisdesignedtoimplementtheserequirements.Ifnotall ofthestreamsindicatedareimplemented,itisunlikelythatthesegregationsystem meetsthelegalrequirements.Specifically,thefollowingwastesegregationshouldbe implemented: • cytotoxicandcytostaticwaste(unlessithasbeenconfirmedthatnoneof theseareusedinthepractice); • othermedicines; • medicinally-contaminatedsharps; • non-medicinally-contaminatedsharps; • clinicalwaste(orangebag); • clinicalwaste(yellowbag); • offensivewaste(yellow/blackbag); • domesticwaste(blackorotherappropriatebag); • wastechemicals; • humantissue; • gypsum; • otherwastes. HazardousWaste(EnglandandWales)Regulations HazardousWasteRegulations(NorthernIreland) SpecialWasteAmendment(Scotland)Regulations Cytotoxicandcytostaticmedicines 8353 Generalpracticesoftenuseasmallnumberofcytotoxicandcytostaticmedicinessuch ashormone-(forexamplecontraceptive)oroxytocin-basedagents.Healthcentresare likelytousemore.Theseareawiderangeofmedicinesincommonusageandinclude anymedicinethatistoxic,mutagenic,carcinogenicortoxicforreproductionregardless ofhowitisused.Thepracticeshould: • reviewthemedicinesinuseinthepracticetoidentifythosethatarecytotoxic andcytostatic(anindicativelistisprovidedin‘Examplelistofcytotoxicand cytostaticdrugs’);and 186 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • placewastesarisingfromthisinpurple-liddedcytotoxicandcytostaticwaste containers. Alistofcytotoxicandcytostaticmedicinesusedbythepracticeandtheirproperties shouldbeattachedasacontinuationsheettotheconsignmentnoteandaccompany thewaste. Examplelistofcytotoxicandcytostaticdrugs Othermedicines 8354 Healthcentresandgeneralpracticeswillemployarangeofothermedicinesincluding painkillers,eyedropsandvaccines: • Medicinesshouldbeplacedinaclearly-labelledwastemedicinescontainer. • Vialsorampoulesthathavebeenusedtochargesyringesshouldbedisposed ofintheyellow-liddedsharpsboxalongwiththesyringe.Itmust,however, beensuredthatthewastedescriptionandclassificationidentifiestheir presence. • Controlleddrugsmustbedenaturedandplacedwithotherwastemedicines. • Medicated(forexampleantibiotic)intravenousbagsshouldbedisposedofas wastemedicines. • Non-medicated(forexamplesaline)intravenousbagsshouldbedischarged tofoulsewerandtheemptybagsplacedintheoffensive/hygienewaste receptacle. • Formedicinesinaerosolform(betadineiodine,cryogesicsprays,asthma medicationetc),theymustbesegregatedfromothermedicinesor,wherethis isnotdone,theirpresencemustbeidentifiedontheaccompanyingwaste documentation. Sharpsboxes 8355 Themedicinalcontaminationofsharpsdeterminestheirdisposaloption.Cytotoxic andcytostaticcontaminatedsharpsaredealtwithabove. • Othermedicinally-contaminatedsharps(forexamplefromthe administrationofvaccines)shouldbeplacedinayellow-liddedsharpsbox. Thewastedescriptionandclassificationshouldidentifythepresenceofwaste medicines. • Non-medicinally-contaminatedsharps(forexamplepodiatryinstruments, sharpsfromtakingbloodsamples,andacupuncture)shouldbeplacedinan orange-liddedsharpsbox.Thewastedescriptionshouldidentifytheabsence ofwastemedicines. Chemicals 8356 Thepracticemayusearangeofchemicalsincludingdisinfectants,handgels,iodine, air-fresheners,diagnostickits,eyestains,possiblephotochemicalsetc.Adetailed explanationoftherequirementsfordisposalofchemicalwasteisbeyondthescopeof thissectorguide.Thereare,however,anumberofkeypointstonote: • Hazardouschemicals(includingphotochemicals)shouldnotbedisposedof tofoulsewerorsurfacedrains. • Emptychemicalcontainersarelikelytocontainsufficientresiduetoremain hazardouschemicalwasteunlessrinsed.Rinsingmayonlybeundertaken afterconsiderationofthehazardspresentandagreementwiththelocalwater authority.Alcoholhandgelsthatdonotcontainsiloxanes(whichcause 187 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 significantdamagetoplantandequipmentusedinthesewagetreatment process)andwhosesafetydatasheet(SDS)doesnotprohibitdischargetothe sewermayberinsedoutandthepackagingrecycledorplacedintothe domesticwastestream. • Chemicalsshouldnotbedisposedofintheclinicalwastestream.Thismay causechemicalreleasesandworkerexposureissuesduringsubsequent handlinganddisposal.Suchmixingisprohibited. • Placementofhazardouschemicalsinthedomesticwastestreamisalso prohibited. • Somechemicalsmayreacttoproducefireortoxicgases.Theseincompatible chemicalsshouldbedisposedofandstoredseparately.Flammable,corrosive andoxidisingchemicalsareofparticularconcerninhealthcare. • Aerosolsmayalsoneedtobesegregatedforspecialistdisposalorrecovery. FurtherguidanceonthestorageofchemicalsisavailablefromtheHealth&Safety Executive. Health&SafetyExecutive Orangeclinicalwastebags 8357 Orangebagsshouldbeusedforsoftclinicalwastes.Theyareusedtoindicatethatthe wasteissuitablefordisinfectionprocessessuchasautoclaves,ratherthanrequiring incineration. Thefollowingmustnotbeplacedintheorangebag: • medicinally-orchemically-contaminatedwastes; • domestic-typewastes,includinghandtowels; • offensivewastes. Examplesofwastethatcanbeplacedinthiswastestreaminclude: • contaminatedPPE(gloves,apronsetc); • contaminateddressings; • verysmallpiecesoftissue; • syringebodiescontaminatedwithbodyfluids,butnotmedicines. Dressingscancontainarangeofadditivesincludingmetalsalts(zinc,silveretc), organicmaterials(suchasalginate,paraffinorhoney),ormedicines(forexample ibruprofen).Somemetalsmaybechemicallyhazardous(forexamplezincoxideisan ecotoxicchemical).Asageneralprinciple: • anycontaminateddressingthatdoesnotcontainanactivepharmaceutical agentcanbediscardedintheorangebag; • however,anycontaminateddressingthatcontainsanactivepharmaceutical (forexampleibruprofen)shouldbediscardedinayellowclinicalwastebagor container. Yellowclinicalwastereceptacles/bags 8358 Yellowwastereceptacles/bagsshouldonlybeusedforwasteitemsthat(a)are infectiousclinicalwasteand(b)haveanadditionalsecondcharacteristic(forexample, chemicalorpharmaceutical)thatmakesincinerationthesoledisposaloption.For example: • anatomicalwastesandtissuesamplespreservedinhazardouschemicals; • medicines,medicinally-contaminatedsyringes,medicateddressingsetc; 188 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • diagnostickitscontaminatedwithpotentiallyinfectiousbodyfluidsand chemicalreagents(thisdoesnotincludesticksfromdiptests). Thewasteclassificationanddescriptionwouldneedtoclearlyidentifythesecond propertyandthatthewasterequiresincineration. Asfororangeclinicalwastebags,domesticandoffensivetypewastesmustnotbe placedinthiswastestream. Offensive/hygienewaste 8359 Generalpracticeswillgeneratetwodifferentoffensivehygienewastestreams.They shouldsegregate: • domestic-typeoffensivehygienewastes–femininehygienewastesfrom toilets,nappiesfromotherwisehealthychildrenetc–intoyellow/blackbags asa200199waste(unlessthetotalquantityislessthan7kginacollection intervalwhereitcanbeplacedinthemunicipalblackbag); • healthcare-typeoffensivehygienewastes–usedPPEthatisnotinfectious, uncontaminateddressings,emptynon-medicatedintravenousbags, cardboardvomit/urinebowls(unlessinfectionsuspected)etc–intoyellow/ blackbagsas180104waste. Liquids(urine,liquidfaeces,vomit)shouldnotbeplacedinthiswastestreamandmay needtobediscardedtofoulsewerbeforecontainersarediscarded. Note Withregardtooffensivewaste,thepracticehastwolegalobligations: mixingisprohibited,sooffensivewastemustbeseparatedfromtheclinical wastestream;and producersarerequiredtoaccuratelyclassifyanddescribetheirwaste; therefore,untilthepracticehasseparatedthismaterialfromitsbagged clinicalwaste,itmustensurethatitisclassifiedanddescribedasmixed clinicalandoffensivewaste,andthe180104codemustbeassigned alongside180103*onwastedocumentation. Blackbags 8360 Municipalwastecontainersshouldbeusedforanynon-hazardouspaper,magazines, newspapers,foodanddrinkcontainers,papertowelsfromhandwashing, uncontaminatedpaperrollsfromcouchcoversetc.Recyclingoptionsshouldbe consideredwhereavailable.Packagingfrominstrumentsanditemsshouldalsobe placedinthiswastestream. Humantissues 8361 Generalpracticesandhealthcentresmayproduceasmallamountofhumantissue: • Verysmallpiecesofunrecognisabletissuefromminorprocedures(for examplewartorverrucaremoval,orwoundcleansing)canbedisposedofin theclinicalwastebagsstream. • Largerorrecognisablepiecesoftissue,forexampleplacentas,mustbe segregatedasanatomicalwasteintoappropriatelylabelledcontainers. • Ifanywastespecimensarestoredinchemicalpreservatives(forexample formaldehydeormethanol),theyshouldbesegregatedfromotherwastes. Thechemicalmustbeincludedinthewasteclassificationanddescription. 189 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Gypsum 8362 Plastercastscanbeproducedbyarangeofhealthcareproceduresincludingdentistry, podiatryandfractureclinics.Inmostcases,thesecastsandrelatedmaterialarenot infectious.Thesematerials,iftheyenteranormallandfillwithotherwasteincluding residuesfromclinicalwastedisposal,mayproducehydrogensulphidegas.Forthis reasonitisprohibitedfromlandfill.Ifanygypsumwasteisproduced: • thepracticeshouldputinplaceprocedurestoidentifyandsegregatethe smallproportionthatisgenuinelycontaminatedandposesariskofinfection –thismaythenbedisposedofintheorangebag; • themajorpartofthematerialmustbesegregatedintoanappropriate containerandsenteitherforgypsumrecyclingorforlandfillinaspecifically designedlandfill–advicefromaspecialistcontractorshouldbesought. Otherwastes 8363 Generalpracticeswillproducemanyotherwastes.Manyofthesearebeyondthescope ofthisguidanceandshouldnotthereforebeplacedinthecontainersindicatedabove. Examplestoconsiderinclude: • wasteelectricalequipment(seeHealthTechnicalMemorandum07-06); • batteries(includingthosefromhearingaids,lead-acidbatteriesanddomestictypebatteries); • lightbulbsandfluorescenttubes(includingthosefrommedicalequipment). HealthTechnicalMemorandum07-06–‘Disposalofpharmaceuticalwastein communitypharmacies’ Wastelabelling 8364 Allhazardouswasteandmedicinalwastecontainersshouldbeindividuallyandclearly labelledtoidentify: • thenatureofthewastepresent(includingclassificationcodeswhere possible);and • thedetailsofthemedicalpractice. Forclinicalwastebags,itwouldtypicallybenecessarytofastenarobustidentification tagtotheneckofthebag. Wastetransferanddocumentation 8367 Transportregulations ThepracticewillusuallybeconsideredtheconsignorundertheCarriageRegulations, anditmustensurethattherequirementsoftheCarriageRegulationsaremet. Forwastemedicines,thefollowingguidelinesmaybeused: • Medicinesunopenedinoriginalretailpackaging(forexampledate-expired medicines)areexemptfromtheCarriageRegulations. • Partially-openedpackagings,miscellaneousblisterpacksetcshouldbe packagedinaccordancewiththeadviceat‘Wastemedicines(including amalgamwaste)’.Thesewillnormallybelimitedquantitiesandmaybe markedaccordingly,havingbeenidentifiedinaccordancewith‘Controlled drugs’. • Sharpscontainersshouldcomplywiththeguidancegivenin‘Sharps packaging’(limitedquantityprovisionsdonotapplytosharps). 190 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • Amalgamwasteisadangeroussubstance(UN2025)(see‘Amalgamwaste’), butcanbetransportedasalimitedquantity. • DiscardedaerosolsaresubjecttotheCarriageRegulations. • Otherwastechemicalsmustbeclassifiedaccordingtotheirhazard.Mostcan bemovedunderthelimitedquantityprovisions(exceptradioactivematerial). Whereatransportdocumentisrequired,primarilyforthesharps,thestandardwaste notemaybeusedprovidedthetransportinformationisincluded(fortransport, limitedquantitiesdonotrequireatransportdocument). Wastemedicines(includingamalgamwaste) Controlleddrugs Sharpspackaging Amalgamwaste CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) Documentation 8368 Astheproducerofthewaste,themedicalpracticebearsthelegalresponsibilityof ensuringthatwastedocumentationiscompleteandaccurate.Therearetwodifferent typesofdocumentationrequiredforwastetransfers: • consignmentnotesthatareusedforhazardouswastes; • wastetransfernotesthatareusedfornon-hazardouswastes. Aconsignmentnoteisusedtotrackthemovementsandensurethesafedisposalof hazardouswastes.Italsoensuresthattheinformationaccompanyingthewasteis sufficienttoenableitssafedisposal.Anewconsignmentnotemustbecompletedfor eachindividualcollectionofhazardouswaste.Eachnotewillconsistofproducer, carrierandconsigneecopies(seeFigure12). 191 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Figure12Examplehazardouswasteconsignmentnote PART A Notification Details 1. Consignment note code: ABC123/AB001 3. Premises code: ABC123 2. The waste described belo w is to be removed from (name, address, postcode, telephone, email & fax): The General P ractice, High Street, New Town, The S hire, XX12 3YY Tel 0123 456789, [email protected] 4. The waste will be taken to (address and postcode): The Transfer Station, Low Street, Old Town, The S hire YY12 4XX 5. The waste producer was (if different from 1) (name, address, postcode, telephone, email & fax) PART B Description of waste 1. The process giving rise to the waste(s) was: Dental healthcare. 2. SIC for the process giving rise to the waste: 85 3. WASTE DETAILS (where more than one waste type is collected all of the information given below must be completed for each EWC identified). Description of waste EWC code Qty (kg) Cytotoxic and 18 01 08* Cytostatic clinical 18 01 08 waste: Mixed sharps and pharmaceutical waste for incineration only The chemical/biological components of the waste, their concentrations Physical Hazard form code(s) Container type, number & size Sharps, syringe barrels, medicine vials and ampoules (cytotoxic and cytostatic); see attached list mixed H3, H6, 2 × 14litre H7, H9, purplelidded H10, H11 sharps box Clinical waste: 18 01 03* Mixed sharps and 18 01 09 pharmaceutical waste for incineration only 10 kg Sharps, syringe barrels, medicine vials and ampoules (not cytotoxic and cytostatic) mixed H3, H4, H5, H9, H14 7 × 14litre yellowlidded sharps box Clinical waste: non 18 01 03* medicinally contaminated sharps for incineration only 10 kg Sharps contaminated with body fluids, podiatr y instruments mixed H9 1 × 14litre orangelidded sharps box Clinical waste: infectious, 18 01 03* suitable for alternative treatment 20 kg Dressings, PPE and swabs, not contaminated with chemicals or medicines. Contains ZnO dressings mixed H9, H14 27 orange bags Clinical waste: infectious, 18 01 03* containing chemicals and 18 01 09 pharmaceuticals 18 01 06* 20 kg Medicated dressings, Formaldehyde preserved specimens mixed H9, H7 1 yellow bag Placenta mixed H9 1 × 14litre greenlidded bin EWC code Description for Carriage Special handling requirements 18 01 03* UN 3291 Clinical waste, unspecified, n.o.s, 6.2, II No persons in handling chain to have direct contact. Waste to be disposed of at authorised site etc etc etc Clinical waste: anatomical for incineration only 18 01 03* ADR information for each EWC identified above: 192 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 PART C Carrier s certificate PART D Consignor s/holder s certificate (If more than one carrier is used, please attach a schedule for I certify that the information in A, B and C above is correct, subsequent carriers. If a schedule of carriers is attached tick that the carrier is registered or exempt and was advised of the here) appropriate precautionary measures. All of the waste is packaged and labelled correctly and the carrier has been advised of any special handling requirements. I certify that I today collected the consignment and that the details in A2, A4 and B3 are correct and have been 1. Consignor/Holder name (please PRINT) advised of any specific handling requirements: Mr Sydney Note 1. Carrier driver name (please PRINT) Tony Driver 2. On behalf of on behalf of (name, address, postcode, telephone, email & fax) (name, address, postcode, telephone, email and fax) The Transfer Station, Low Street, Old Town, The S hire, The General P ractice, High Street, New Town, The S hire, XX12 YY12 4XX 3YY Tel: 0987 654321; email: [email protected] Tel 0123 456789, [email protected] 3. Carrier’s registration no/exemption reason: ABC/012345 Signature 4. Vehicle registration no: AB07 FIL Time: 18.00 Date: 29/02/2010 Signature Time: 18.00 Date: 29/02/2010 PART E Consignee s Certificate (where more than one waste type is collected, all of the information given below must be completed for each EWC) Individual EWC code(s) Quantity of each EWC code received received (kg) EWC code accepted/ rejected Waste Management operation (R or D code) I received this waste at the address given in A4 on Name: (please PRINT) Vehicle registration no (or mode of transport if not by road): On behalf of (name, address, postcode, tel, email & fax): Where waste is rejected please provide details: Signature: I certify that the waste management licence/permit/authorised exemption no(s). Date: Time: authorises the management of the waste described in B at the address given at A4 Whocompletestheconsignmentnoteandwhen? 8369 Beforethewasteisremovedfromthemedicalpractice: • partAcontainsdetailsofthedentalpracticeandthedestinationofthewaste. Thepracticeisresponsibleforcompletionofthissection; • partBcontainsdetailsaboutthewaste,itspropertiesanditspackaging.The practiceisresponsibleforcompletionofthissection; • allthreecopiesshouldbethenprovidedtothewastecarrier; • partCcontainsdetailsofthewastecarrier,thedriver,thevehicleanda declarationthatthecarrierhasverifiedkeyinformationinpartsAandB. Thismustbecompletedbythecarrier; • thepaperworkisthenpassedbacktotheproducer.OnlyafterpartCis completedcanthepracticecompletepartDtoverifypartsAtoC(asthis 193 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 includesarecordofthenumberplateofthevehicleontowhichthewastewas loaded); • oncepartsAtoDarecomplete,thecarriermayremovethewaste. Onarrivalatthedestination(consignee)site,theconsigneecompletespartEtoverify whattheyhavereceived. Keypoints: ThelawplacesthesoleresponsibilityforcompletionofpartsA,BandDof thenoteonthemedicalpractice. Theconsignmentnotesystemrequiresthegeneralpracticetocertifythe carrierandvehicledetailsduringcollection.Unsupervisedout-of-hours collectionisnotallowed. Furtherguidanceonthisisprovidedby: theEA(forEnglandandWales); SEPA(forScotland); theNIEA(forNorthernIreland). EAguidance SEPAguidance NIEAguidance Carrierroundcollections 8370 Wastecarriersmaycollecthazardouswastefromanumberofsmallproducersinthe samejourney,referredtoasacarrierround. Eachcollectionwithinaroundwillneeditsownstandardconsignmentnotewith uniqueconsignmentnotenumber.Thecarrierroundwillhaveauniquenumberthat iscommontoallthecollectionsinthatround. Wastetransfernotes 8371 Wastetransfernotescanonlybeusedforthecollectionofnon-hazardouswastesfrom themedicalpractice.Thesecannotbeusedforclinicalwastes,otherthansegregated non-hazardousmedicines. Thepracticecompletesawastetransfernote.Thelegalresponsibilityfordescribingthe wasterestswiththepractice. Ifacontractorcollectsthesamewasteatregularintervalsoveraperiodnolongerthan 12months,aseasonticketcanbeused;therefore,anewnotewouldnotberequired oneachoccasion. Registrations,recordsandreturns 8379 Registrationasahazardouswasteproducer Allgeneralpracticesthatproduce500kgormoreofhazardouswasteinany12-month periodneedtoregistertheirpremisesannuallyasahazardouswasteproducer.Ifthe practiceproduceslessthan500kginany12-monthperiod,itisexempt.This informationisusedtotrackhazardouswastesandensurethattheyaresafelymanaged. The500kgincludesallofthepractice’shazardouswastes,notjustthehealthcare wastes.Althoughsmallerpracticesmaybeexempt,manygeneralpracticesandmost healthcentreswillneedtoregister. 194 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Ahealthcentrethatincludesmorethanonepractice,eachwithitsowndesignated area,shouldconsidereachareaseparately.Ahealthcentreoccupiedbyadental practice,ageneralpracticeandaPCTpracticemayneedthreeseparateregistrations. Conversely,eachmaybenefitindividuallyfromthe500kgthresholdforregistration. Howtoregisterasahazardouswasteproducer 8373 Therearefourwaystoregisterasahazardouswasteproducer: • onlineviatheenvironmentalregulator’swebsite; • byphoneattheenvironmentalregulator’scustomercontactcentre; • bypost; • bywastecontractoronthepractice’sbehalf. Whenthepremisesareregistered,thepracticewillbegivenahazardouswaste producerregistrationnumber(calleda“premisescode”).Thiscodemustbeusedonall consignmentnoteswherehazardouswasteisremovedfromthosepremises. Registrationisonlyvalidfor12monthsandthereforemustberenewedannually. Hazardouswaste–recordsandreturns 8374 Generalpracticesarerequiredtokeeparegisterthatcontainstheirhazardouswaste records.Thisrequirementisusuallymetbykeepingcopiesofboth: • standardormultipleconsignmentnotes(includingbothmainnotesand annexes);and • consigneereturnstotheproducerorholder. Whererelevant,theregistershouldalsocontainrecordsofanyrejectedloadsorcarrier schedules.Guidanceonconsignmentnotesandtheircompletionisprovidedinaseries ofguidestotheHazardousWasteRegulations. GuidestotheHazardousWasteRegulations Consigneereturnstothewasteproducerorholder 8375 Eachconsignee(thedestinationsitewherethecarriertakesthewaste)isrequiredto sendtothegeneralpracticeareturneachquarter.Thisreturnisarecordofwhathas happenedtothewaste,anditmustbeplacedinthewasteproducer’sregister.These returnsmustbepresenttoensuretheregisterislegallycomplete. Wherethewasteistakentoatransferstationbeforebeingsentelsewherefordisposal, thegeneralpracticeshouldalsorequestcopiesoftheassociatedcompletedpaperwork forthatonwardmovement,whichconfirmsthatitwasreceivedatthefinal destination. Whereshouldtheregisterbekept? 8376 Wheretheregisteriskeptdependsonthenumberofpracticebranchesandwhetheror nottheseareeachregisteredashazardouswasteproducers. • Registeredpremises–ifapracticeisregistered,theregisterforanyhazardous wastethatisremovedfromthatpracticemustalwaysbekeptatthat premises,oracopyoftheregisteriftheregistrationisundertakencentrally. • Exemptpremises–ifapracticebranchisexemptfromregistrationasa hazardouswasteproducer,theregisterforanyhazardouswastethatis removedfromthatpracticeshouldbekeptattheprincipalplaceofbusiness. Thismaybeanotherpracticeifthepracticeisoneofseveralinacompany.If 195 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 apracticewishestokeeptheregisteranywhereelse,thismustbeagreedin writingwiththeenvironmentalregulator. Howlongshouldtheregisterbekept? 8377 Theregistermustbekeptforatleastthreeyears,commencingfromthedatethewaste wasremovedfromthepractice’spremisesbyawastecarrier. Non-hazardouswasterecords 8378 Wastetransfernotesshouldbekeptforaminimumoftwoyears.Whereseasontickets areused,arecordshouldalsobekeptofthetimeswheneachoftheregularcollections weremadeusingthenote. Wasteauditanddutyofcareauditchecks 8381 Wastesegregationandproceduresshouldbeauditedperiodicallyforthreereasons: • thisenablesthepracticetoaccuratelydescribeandclassifyitswasteto completeitswastedocumentationanddischargeitsdutyofcare; • thewastedisposermayberequiredbytheirpermittoobtainanauditfrom thepracticebeforetheycanacceptthewaste(apre-acceptanceaudit); • thisenablesthepracticetomonitoritswastepractices,identifyanyproblems andasaresultenablesittofixthem. Examplesofspecificissuestoidentify,inanauditofeachareaofthepractice,arethe presenceof: • cytotoxicandcytostaticmedicines; • medicines(forexampletablets,creams,vials,ampoules,intravenousbagsetc) andmedicinally-contaminatedwastes(forexamplesyringebarrels,tubing etc); • sharps(includingwhethertheyaremedicinally-contaminated); • chemicals(disinfectants,reagents,diagnostickits,resinsetc); • dentalamalgam(capsules,excessamalgam,separatorcontents,teethwith fillingsetc); • body-fluid-contaminatedmaterialthatisinfectious(swabs,PPEetc); • healthcareitemsthatarenotcontaminatedwithbodyfluidsorother potentiallyinfectiousmaterials(forexamplePPE); • femininehygienewastes/nappybinsfromtoilets; • municipal-typewastes(newspapers,magazines,foodanddrinkcontainers, sterileequipmentandotherpackagingetc). Thefollowingshouldalsobeconsidered: • whatwastecontainersareusedforthesewastes; • howtheyarelabelled; • whetherthecontentsareaccuratelydescribedandclassifiedonwaste documentation. Undertakingsuchauditswillenablethepracticetodemonstratethatithasdischarged itsdutyofcareindescribingandpackagingitswaste. Pre-acceptanceaudit 196 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Frameworkcontractforthedeliveryofwastemanagement 8383 trainingwithinthehealthcaresector BuyingSolutions(formerlyNHSPASA)hasdevelopedaframeworkagreementforthe deliveryofwastemanagementtrainingwithintheUK.Theaimistoensurethata comprehensivepackageoftrainingisavailableforaccessbytheNHS.Thetraining itselfaddressestherecommendationsoutlinedinthisguidance. Wastestorage 8385 Themedicalpracticemaystoreitsownwasteonthepremiseswhereitwasproduced withoutrequiringanenvironmentalpermitwherespecificconditionsaremet: • thewastemustbestoredinasecureplace;and • thewastemustbestoredforaperiodlessthan12months. Wastetypesshouldbekeptseparate;forexample,sharpsboxesandclinicalwastebags shouldnotbeplacedtogetherinalargercontainer(forexampleawheeledcart). Wastecarriers 8387 Thewastecontractorwhocollectsthewastemustbearegisteredwastecarrier.This shouldbecheckedby,forexample,comparingthecarrierregistrationnumberonpart Coftheconsignmentnotetotheinformationheldontheenvironmentalregulator’s electronicpublicregister.Thepracticemustsupervisecollectionsofhazardouswasteto enableittocertifythecarrierandvehicledetailsinpartDofthenote. Wastedisposal 8389 Wastefromsmallpracticesisfrequentlytakentoawastetransferstationwhereitis combinedwithotherwastesandsentforfinaldisposal. Thepracticeshouldcheckwhetheritswasteisbeingtakentoawastetransferstation. Ifthisisthecase,itshouldaskforcopiesofthedocumentationusedfortheonward movementofitswastetoitsfinaldestination. Therearetwomaindisposaloptionsforclinicalwaste: • alternativetreatments–whichdisinfectthewasteandarenormally authorisedonlyforinfectiouswastes(forexamplebaggedclinicalwastes); • clinicalwasteincinerators–whichensurecompletedestructionofmedicines andchemicalsaswellasinactivationofmicroorganisms. Dischargetofoulsewer 8391 Dischargestofoulsewershouldbeinaccordancewithatradeeffluentconsentfrom thesewerageundertaker. GuidanceonthisisduetobeprovidedbyWaterUKonbehalfofthesewerage undertakersin2011. Specificissues 8396 Staffworkinginthecommunity Practicestaffworkinginthecommunitymaystore: 197 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • wasteproducedinthecommunitybytheirstaffandreturnedtothepractice; and • wasteproducedbypatientsindomestichouseholdsandreturnedtothe practicebythehouseholderorpracticestaff. Thisdoesnotrequireanenvironmentalpermitaslongastheconditionssetoutinthe relevantexemptionsaremet: • theexemptionallowingthetemporarystorageofwasteattheplacecontrolled bythewasteproducer; • theexemptionallowingthetemporarystorageofwasteatacollectionpoint. Theseexemptionsdonotneedtoberegistered. Temporarystorageofwasteattheplacecontrolledbythewasteproducer Temporarystorageofwasteatacollectionpoint Movementofwastewithinapractice’spremises 8393 Wherethehealthcentreorpractice’spremisescontainmorethanonepractice,itis commonforoneorganisationtomanagethewastefortheothers.Forexample,aPCT maymanageallthewastefromahealthcentrecontainingaPCT’spractice,ageneral practiceandadentalpractice.Inthiscase,theotherpracticesaretransferringtheir wastetothePCT’spractice.Dutyofcarecontrolsapplytothis“withinpremises” transfer.ThesepracticesarerequiredtoprovidethePCTwithinformationontheir wastecompositionandwastepropertiestoenablethePCTtocompletethewaste documentationandtransferthewastetothewastecontractor. Movementofwastebetweenpractices 8394 Theremovalofhazardouswastefromamedicalpracticeissubjecttothefull requirementsoftheHazardousWasteRegulations.Noexceptionismadefor movementsbetweenpractices,eveniftheybelongtothesameorganisation.These requirementsinclude: • premisesnotification; • consignmentnotes; • records; • consigneereturns(receivingpremises); • producerreturns(receivingpremises). Followingonfromtheadvicegivenimmediatelyabove,eachpracticeshouldensure thatitswasteisclearlylabelled/taggedtoidentifythemastheproducer.Therefore,the PCTexemplifiedabovewouldneedtoidentifyeachpracticeontheconsignmentnote (forexample,partA5).Ifthereceivingpracticeisnotpartofthesameorganisation,it mayrequireanenvironmentalpermitorrelevantexemptiontostorethewaste. HazardousWaste(EnglandandWales)Regulations HazardousWasteRegulations(NorthernIreland) SpecialWasteAmendment(Scotland)Regulations Returnofmedicinestopharmaciesandcharities 8395 Wheremedicinesfromageneralpractice(orhealthcentre)aretakentoacommunity, PCTorhospitalpharmacy(forexamplewherethepharmacysuppliesmedicinesand collectsunwantedmaterial): 198 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • cytotoxicandcytostaticmedicinesmustbeconsignedfromthepracticeto thepharmacy,whichmustsendthepractice(andtheregulator)consignee returns; • othermedicinesmustbetransferredusingadutyofcarewastetransfernote; • aregisteredwastecarrierisnormallyrequiredtotransportthematerial; • ifthepracticeischargedforcollectionordisposalofthewastemedicinesby thepharmacy(oritsparentorganisation),thepharmacymustholdan environmentalpermit. Wheremedicinesfromageneralpractice(orhealthcentre)arecollectedorsenttoa charityforreuseoverseas: • aregisteredwastecarrierisnormallyrequiredtotransportthematerial; • theguidancefromtheRoyalPharmaceuticalSocietyofGreatBritain (RPSGB)onsuchdonations,whichfollowstheWorldHealthOrganisation line,shouldbefollowed; • cytotoxicandcytostaticwastemedicinesmustbeconsignedfromthepractice tothecharity,whichmustsendthepractice(andtheregulator)consignee returns; • otherwastemedicinesmustbetransferredusingaduty-of-carewastetransfer note; • thecharitymustholdanenvironmentalpermitforsortingofwaste medicines;and • aregisteredwastecarrierisnormallyrequiredtotransportthematerial. RPSGB 199 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Dentalpractices 8400 Thisbriefguideprovidespracticaladviceonwastemanagementtodentalpractices.It isintendedtobeusedasadditionalguidancetothatspecifiedin‘Decontaminationin primarycaredentalfacilities’. Followingthisadviceshouldassistdentalpracticesinmeetingthekeyrequirementsof environmentallegislation.Thedentalpracticemayneedtoseekfurtheradviceon specificaspects. Decontaminationinprimarycaredentalfacilities Whataretheresponsibilitiesofthedentalpractice? 8402 Thedentalpracticehasastatutorydutyofcare.Thisappliestoeveryoneinthewaste managementchainfromproducertodisposer.Itrequiresthedentalpracticetoprevent theescapeofthewasteandtotakeallreasonablemeasurestoensurethatthewasteis dealtwithappropriatelyfromthepointofproductiontothepointoffinaldisposal. Keypoint: Thedentalpractice’sresponsibilitiesdonotendwhenithandsitswastetoawaste collector. Thedentalpracticeissolelyresponsibleforensuringthatwasteis: • correctlysegregated; • storedsafelyandsecurelyonpremises; • packagedappropriatelyfortransport; • describedaccuratelyandfullyontheaccompanyingdocumentationwhen removed; • transferredtoanauthorisedpersonfortransporttoanauthorisedwastesite; • appropriatelyregisteredforhazardouswaste(seethe‘Whyregisterasa hazardouswasteproducer?’inthe‘Registration,recordsandreturns’section), withnecessaryrecordsandreturnsatpremises. Thepracticemanager,whetherinanindependentpracticeorfordentalcorporate bodies,shouldalsoensurethatstaffaretrainedandawareofthewasteprocedures. Registrations,recordsandreturns Wastesegregation,packaging,classificationandlabelling 8408 Wastesegregationisdrivenbyanumberoffactorsincluding: • thetechnicalcapabilitiesandpermitsofthewastedisposalfacilities; • packagingrequirementsforsafelytransportingcertainmaterials; • healthandsafety;and • theHazardousWasteRegulations(SpecialWasteRegulationsinScotland), whichlegallyprohibitthemixingofwastecategories. Dentalpracticeswillproduceawiderangeofbothhazardousandnon-hazardous wastes.Hazardouswasteswilltypicallyinclude: • baggedclinicalwastes; 200 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • sharps; • amalgamwastes; • X-raywaste–photochemicals; • refrigerators,freezers,computers,monitors,fluorescenttubesandsome batteries; • chemicaldisinfectantsandreagents; • cytotoxicandcytostaticmedicinesinsomecircumstances. Non-hazardouswasteswillofteninclude: • offensivewastes(forexamplePPEnotcontaminatedwithbodyfluids); • detergentwipesusedforcleaningsurgeriesifuncontaminatedwithbody fluids; • medicines(non-cytotoxicandnon-cytostatic); • otherelectricalequipmentandcertaintypesofbattery; • officewastes–paper,cardboard,inkcartridges,cleanglasswareandplastics; • X-rayfilmandleadfoils; • hygienewastesfromsanitaryfacilities; • dentalplastercasts; • domestic-type(blackbag)waste. Figure13outlinessomekeydentalwastestreams,includinganexplanationofeach stream,whatwastecontainersshouldbeused,whatcanbeplacedinthesecontainers, howwasteshouldbeclassifiedanddescribed,andadviceonwastedisposal. Note Cytotoxicandcytostaticmedicinesarerarelyusedindentalpractices.Iftheyare used,seeStep2(ii)forguidance. Thedentalpracticewilluseothermedicinesincludingforexampleanaesthetics, antibioticsandpainkillers. • Itiscommonpracticeforthemedicinalcontainersusedtochargesyringesto bedisposedofinthesharpscontaineralongwiththesyringe.Thedental practicemust,however,ensurethatthewastedescriptionandclassification identifiesthis. • Ifthedentalpracticereturnsmedicinestoalocalpharmacy,thesamelegal requirementsapplyastransferringthemtoawastecontractor.Thedental practicemustdischargeitsdutyofcareandinparticularmustusewaste documentationandkeepappropriaterecords.Ifthedentalpractice(orthe pharmacy)isinspectedbyaregulator,itshouldexpecttobeaskedtoproduce therequireddocumentsandrecords. 201 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Figure13Wastesegregationandclassificationtable(dental) Waste segregation and classification table (see supporting text) Container type Sharps box (yellow lid)1 Example waste description Contents Classification and EWC Disposal codes Clinical waste: mixed sharps and pharmaceutical waste – Hypodermic needles, syringes and syringe barrels including those contaminated with medicines (not cytotoxic and cytostatic) 18 01 03* & 18 01 09 Hazardous SHARPS Soft clinical wastes (orange bag) Incineration only – Used medicine vials – Other sharp instruments or items including teeth without amalgam fillings Clinical waste: infectious Bloodcontaminated dressings, disposable 18 01 03* gowns, clinical gloves, PPE (contaminated Hazardous disposable gowns and clinical gloves) and swabs, and other waste that may present a risk of infection (including salivacontaminated items from known infectious patients or where medical history is not available) Alternative treatment or incineration NO medicinally, chemically or amalgam contaminated wastes Medicines (rigid leakproof container)2 Clinical waste: noncytotoxic and cytostatic medicines Noncytotoxic and cytostatic medicines including used and outofdate stock 18 01 09 Non hazardous Incineration only Gowns, gloves, tissues and other items from dental care which are not contaminated with blood, medicines, chemicals or amalgam Non hazardous 18 01 04 Landfill or municipal incineration/ energy from waste Municipal offensive/ hygiene Hygiene waste from toilets only Non hazardous 20 01 99 Dental amalgam: infectious, clinical waste Teeth with amalgam fillings Hazardous 18 01 10* Metal recovery Gypsum or calcium sulphate study or working models 18 01 04 Gypsum recovery or landfill in a separate dedicated cell for gypsum Waste photographic fixer from Xray (must be kept separate from developer) Hazardous 09 01 04* Recovery (various) Offensive or hygiene Offensive/hygiene wastes waste from dental care, for example salivacontaminated items where no known infection risk is present WHITE CONTAINER WITH Hg Amalgam waste Plaster cast waste GYPSUM Plaster cast waste Dental amalgam and Dental amalgam and mercury including mercury: noninfectious spent and outofdate capsules, excess mixed amalgam, and contents of amalgam separators Xray fixer (container Photographic fixer type not specified) Xray developer (container type not specified) Photographic developer Waste photographic developer from Xray (must be kept separate from fixer) Hazardous 09 01 01* Xray film Xray film Waste photographic film from Xray 09 01 07* Silver recovery Lead foils from Xray film packaging Non hazardous 15 01 04 Recovery (various) Domestic type refuse: food packaging paper/magazines that cannot be recycled paper towels (no hazardous wastes) Non hazardous 20 03 01 Landfill or municipal incineration/ energy from waste Lead foils (container Xray lead foils from type not specified) dentistry Municipal waste Mixed municipal waste Note: 1. Use orangelidded sharps bins: for sharps not contaminated with medicinal products (in England and Wales); either for fully discharged sharps or those not used for administering medicines (in Scotland and Northern Ireland). 2. The bluelidded yellow container represents the new recommended national colour code for the segregation of nonhazardous waste medicines. This was previously a yellowlidded container as specified in Health Technical Memorandum 0105, and whilst adoption is recommended, it is not compulsory. 202 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Step2 HazardousWaste(EnglandandWales)Regulations HazardousWasteRegulations(NorthernIreland) SpecialWasteAmendment(Scotland)Regulations Sharpscontainers 8409 Themedicinalcontaminationofsharpsdeterminesthedisposaloption.Practicesare unlikelytohavecytotoxicandcytostaticmedicines.Thisguidanceassumestheirsharps arelikelytobecontaminatedpredominantlywithlocalanaesthetics.Therefore,yellowliddedsharpsreceptaclesshouldbeused.Othercolouredlidsshouldnotbeused; contractorswhoadvisetheuseoforange-liddedboxesshouldbeviewedwithcaution asthiscolourisspecificallyassociatedwithdisposaloptionsthatarenotappropriate forthiswaste. Orangeclinicalwastebags 8410 Orangebagsshouldbeusedforsoftclinical(infectious)wastesandareusedtoindicate thatthewasteissuitableforalternativetreatmentprocessessuchasautoclaves,rather thanrequiringincineration.Medicinally-,chemically-oramalgam-contaminated wastesmustnotbeplacedintheorangebag. Dentalamalgam 8411 Alldentalpracticesshouldhave(an)amalgamseparator(s)installed.Theseshouldbe ofanappropriateISOstandardandfittedinsuchawaythattheycaptureany amalgamcontainedinwastewaters. Offensive/hygienewaste 8412 Thenon-hazardousoffensivewastestreamshouldonlybeusedforsoftwastesfrom dentistrywhicharenotcontaminatedwithbodilyfluids(forexample,uncontaminated PPEandhygienewastesfromtoilets). Inthedentalsurgery,thefullmedicalhistoryofpatientsisnotalwaysknown.Inthese circumstances,allwastecontaminatedwithbodyfluidscanberegardedaspotentially infectious,includingsalivawhichmaycontaintracesofblood.Thisdoesnotextendto uncontaminateditems. Thedentalpracticeislikelytousearangeofchemicalsandphotochemicalsincluding disinfectants,handgels,resins,reagentsanddiagnostickits.Thepractice’swaste managementcontractorcanadviseonthesafedisposalrequirementsforsuch materials. Adetailedexplanationoftherequirementsfordisposalofchemicalwasteisbeyondthe scopeofthissectorguide.Thereis,however,anumberofkeypointstonote: • Emptycontainersarelikelytocontainsufficientresiduetoremainhazardous chemicalwastesunlessrinsed.Ifthesearetoberinsedandthewateris dischargedtothefoulsewerviathesink,atradeeffluentconsentmaybe required.Thedentalpracticeshouldcontactitslocalwatercompany.Alcohol handgelsthatdonotcontainsiloxanes(whichcausesignificantdamageto plantandequipmentusedinthesewagetreatmentprocess)andwhosesafety datasheet(SDS)doesnotprohibitdischargetothesewer,mayberinsedout andthepackagingrecycledorplacedintothedomesticwastestream.Ifnot rinsed,theyshouldbetreatedasthoughtheycontainedtheproductand 203 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 treatedaccordingly.Again,thedentalpractice’swastemanagementcontractor willadviseonthesafedisposalrequirementsforsuchmaterials. • Chemicalsshouldnotbedisposedofintheclinicalwastestream.Thismay causechemicalreleasesandworkerexposureissuesduringsubsequent handlinganddisposal. • Hazardouschemicals(includingphotochemicals)shouldnotbedisposedof tofoulsewerorsurfacedrains. • Somechemicalsmayreacttoproducefireortoxicgases.Theseincompatible chemicalsshouldbedisposedofandstoredseparately.Flammable,corrosive andoxidisingchemicalsareofparticularconcerninhealthcare. FurtherguidanceonthestorageofchemicalsisavailablefromtheHealth&Safety Executive. Health&SafetyExecutive Teeth 8413 Asthedisposalofteethfromdentalpremisesisunlikelytocauseoffence,dental practitionersmaytreatthisasnon-anatomicalinfectiouswaste.Itiscommonpractice fornon-amalgamteethandspiculestobeplacedintheyellow-liddedsharps container.Dentalpractitionersmustensurethatallwasteistreatedappropriately,and teethcontainingamalgam(see‘Amalgam–whitecontainers’)shouldbesegregatedand sentforappropriaterecovery/disposal(seetheDefrawebsite). Amalgam–whitecontainers Defrawebsite Dentalplastermadefromgypsum 8414 Plastercastscanbeproducedbyarangeofhealthcareactivitiesincludingdentistry.In mostcases,theseareusedtomakecasts(oftenreferredtoasstudyorworkingmodels). Theseandrelatedmaterialsarenotinfectious.Ifthismaterialisdisposedofata normallandfill,itmayproducehydrogensulphidegas.Forthisreason,itisprohibited fromlandfill. Ifanysuchwasteisproduced: • Proceduresshouldbeputinplacetoidentifyandsegregatethesmall proportionthatisgenuinelycontaminatedandposesariskofinfection.This shouldthenbedisposedofintheorangebag. • Themajorpartofthematerialmustbesegregatedintoanappropriate containerandsenteitherforrecyclingasgypsumorfordisposalina specifically-designedlandfill.Ifindoubt,adviceshouldbesoughtfroma specialistcontractor. See‘Gypsumandplastercasts’. Gypsumandplastercasts Domesticwaste 8415 Anumberofdomesticwastestreamswillbeproduced.Thiswillincludehandtowels usedforwashinghands. 204 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Wastelabelling 8416 Allhazardouswasteandmedicinalwastecontainersmustbeindividuallyandclearly labelledtoidentifyboth: • thenatureofthewastepresent(includingclassificationcodeswhere possible);and • thedetailsofthedentalpractice. Note Moredetailsonlabellingrequirementscanbefoundin‘Transportpackagingand operations’. Fororangebags,itwouldtypicallybenecessarytofastenarobustidentificationtagto theneckofthebag. Transportpackagingandoperations Wastetransferanddocumentation 8423 Astheproducerofthewaste,thedentalpracticebearsthelegalresponsibilityfor ensuringthewastedocumentationiscompleteandaccurate.Relyingonthewaste contractortodothiscouldleavethepracticelegallyliableshouldanyofthe documentationbeincorrect. Therearetwodifferenttypesofdocumentationrequiredforwastetransfers: • consignmentnotes,whichareusedforhazardouswastes(specialwastesin Scotland);and • wastetransfernotes,whichareusedfornon-hazardouswastes. Whatisaconsignmentnote? 8418 Aconsignmentnoteisusedtotrackthemovements,andensurethesafedisposal,of hazardouswastes.Itisalsodesignedtoensurethattheinformationaccompanyingthe wasteissufficienttoenableitssafedisposal.Anewconsignmentnotemustbe completedforeachindividualcollectionofhazardouswaste.Eachnotewillconsistof producer,carrierandconsigneecopies. Figure14providesacompletedexampleofastandardconsignmentnoteforanumber ofdentalwastestreams.Ifthesegregationadviceinthisguidanceisfollowed,Figure 14maybeusedasatemplate.Itshouldalsobeusedtocompareandcontrastwithany documentsprovidedbythewastecontractor. 205 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Figure14Examplehazardouswasteconsignmentnote(dental) PART A Notification Details 1. Consignment note code: ABC123/AB001 3. Premises code: ABC123 2. The waste described below is to be removed from (name, address, postcode, telephone, email & fax): The Dental Practice, High Street, New Town, The Shire, XX12 3YY Tel 0123 456789, [email protected] 4. The waste will be taken to (address and postcode): The Transfer Station, Low Street, Old Town, The Shire YY12 4XX 5. The waste producer was (if different from 1) (name, address, postcode, telephone, email & fax) PART B Description of waste 1. The process giving rise to the waste(s) was: Dental healthcare. 2. SIC for the process giving rise to the waste: 85. 3. WASTE DETAILS (where more than one waste type is collected all of the information given below must be completed for each EWC identified). Description of waste EWC code Qty (kg) The chemical/biological components of the waste, their concentrations Physical Hazard form code(s) Container type, number & size Clinical waste: 18 01 03* 18 01 09 mixed sharps and pharmaceutical waste for incineration only 10 kg Sharps, syringe barrels, medicine vials and ampoules (not cytotoxic and cytostatic) mixed H3, H4, H5, H9, H14 2 × 14litre yellowlidded sharps box Clinical waste: infectious, 18 01 03* suitable for alternative treatment 20 kg Dressings, PPE and swabs, not contaminated with chemicals or medicines mixed H9 4 orange bags Dental amalgam: 18 01 10* infectious, clinical waste, for recovery 0.5 kg Teeth with amalgam fillings (mercury) solid H6, H9, H14 1 amalgam pot 500 ml Dental amalgam and 18 01 10* mercury: noninfectious, for recovery 0.5 kg Dental amalgam and mercury – mixed spent and outofdate capsules, excess mixed amalgam, and contents of amalgam separators H6, H14 1 amalgam pot 1 litre Xray fixer solution 09 01 01* 10 kg Acetic acid 1–5% Silver 1–2% liquid H4 1 × 15litre drum Xray developer solution 09 01 04* 10 kg Hydroquinone 5–10% Diethylene Glycol 1–5% Sodium Carbonate 1–5% liquid H4, H7, H11 1 × 15litre drum ADR information for each EWC identified above: EWC code Description for carriage Special handling requirements 18 01 03* UN 3291 Clinical waste, unspecified, n.o.s 6.2 II No persons in handling chain to have direct contact. Waste to be disposed of at authorised site etc etc etc 206 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 PART C Carrier s certificate PART D Consignor s/holder s certificate (If more than one carrier is used, please attach a schedule for I certify that the information in A, B and C above is correct, subsequent carriers. If a schedule of carriers is attached tick that the carrier is registered or exempt and was advised of the here) appropriate precautionary measures. All of the waste is packaged and labelled correctly and the carrier has been advised of any special handling requirements. I certify that I today collected the consignment and that the details in A2, A4 and B3 are correct & have been 1. Consignor/Holder name (please PRINT) advised of any specific handling requirements: Mr David Bridge 1. Carrier driver name (please PRINT) Tony Driver 2. On behalf of on behalf of (name, address, postcode, telephone, email & fax) (name, address, postcode, telephone, email and fax) The Transfer Station, Low Street, Old Town, The Shire, The Dental Practice, High Street, New Town, The Shire, XX12 YY12 4XX 3YY Tel: 0987 654321; email: [email protected] Tel 0123 456789, [email protected] 3. Carrier’s registration no/exemption reason: ABC/012345 Signature D. Bridge 4. Vehicle registration no: AB07 FIL Time: 18.00 Date: 29/02/2010 Signature T. Driver Time: 18.00 Date: 29/02/2010 PART E Consignee s Certificate (where more than one waste type is collected, all of the information given below must be completed for each EWC) Individual EWC code(s) Quantity of each EWC code received received (kg) EWC code accepted/ rejected Waste Management operation (R or D code) I received this waste at the address given in A4 on Name: (please PRINT) Vehicle registration no (or mode of transport if not by road): On behalf of (name, address, postcode, tel, email & fax): Where waste is rejected please provide details: I certify that the waste management licence/permit/authorised exemption no(s). Signature: Date: authorises the management of the waste described in B at the address given at A4 Whocompletestheconsignmentnote,andwhen? Time: 8419 Beforethewasteisremovedfromthedentalpractice: • partAcontainsdetailsofthedentalpracticeandthedestinationofthewaste. Thismustbecompletedbythepractice; • partBcontainsdetailsaboutthewaste,itspropertiesanditspackaging.This mustbecompletedbythepractice; • allthreecopiesshouldbethenprovidedtothewastecarrier; • partCcontainsdetailsofthewastecarrier,thedriver,thevehicle,anda declarationthatthecarrierhasverifiedkeyinformationinpartsAandB. Thismustbecompletedbythecarrier; • thepaperworkisthenpassedbacktotheproducer.OnlyafterpartCis completedcanthedentalpracticecompletepartDtoverifypartsAtoC(as 207 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 thisincludesarecordofthenumberplateofthevehicleontowhichthewaste wasloaded); • oncepartsAtoDarecomplete,thecarriermayremovethewaste. Onarrivalatthedestination(consignee)site,theconsigneecompletespartEtoverify whattheyhavereceived. Furtherguidanceonthisisprovidedby: • theEA(forEnglandandWales); • SEPA(forScotland); • theNIEA(forNorthernIreland). EAguidance SEPAguidance NIEAguidance Carrierroundcollections 8420 Wastecarriersmaycollecthazardouswastefromanumberofsmallproducersinthe samejourney,referredtoasacarrierround. Eachcollectionwithinaroundwillneeditsownstandardconsignmentnotewith uniqueconsignmentnotenumber.Thecarrierroundwillhaveauniquenumberthat iscommontoallthecollectionsinthatround. Wastetransfernotes 8421 Wastetransfernotesareusedforthecollectionofnon-hazardouswastes. Thedentalpracticecompletesawastetransfernote.Thelegalresponsibilityfor describingthewasterestswiththedentalpractice. Ifacontractorcollectsthesamewasteatregularintervalsoveraperiodnolongerthan 12months,aseasonticketcanbeusedandthereforeanewnotewouldnotbe requiredoneachoccasion. Wastefromotherpracticesandhomevisits 8422 Dentistsmaybringbacktotheirpracticepremiseswastetheyhaveproducedin domestichouseholdsduringhomevisits.Nowastedocumentationisrequiredand thereisanexemptionfromtherequirementforanenvironmentalpermitfor temporarystoragebytheproducer. Dentistsmayalsomovewastebetweentheirpracticesunderthesameexemptionfrom apermit.However,ifhazardouswaste(thatis,clinicalwaste)ismoved,thepractice mustuseconsignmentnotes,andthereceivingpracticewillbeahazardouswaste consigneewithconsiderablelegalobligations. Registrations,recordsandreturns 8426 Whyregisterasahazardouswasteproducer? 8424 AlldentalpracticesinEnglandandWalesthatproduce500kgormoreofhazardous wasteinany12-monthperiodneedtoregistertheirpremisesannuallyasrequiredby theHazardousWasteRegulations.Ifthepracticeproduceslessthan500kginany 12-monthperiod,itisexempt.Thisdoesnotexemptthepracticefromthe 208 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 consignmentnoteprocedure.Thisinformationisusedtotrackhazardouswastesand ensurethattheyaresafelymanaged. The500kgincludesallofthepractice’shazardouswastes,notjustthehealthcare wastes.Therefore,althoughsmallerpracticesmaybeexempt,manyotherdental practicesmayneedtoregister. HazardousWaste(EnglandandWales)Regulations HazardousWasteRegulations(NorthernIreland) SpecialWasteAmendment(Scotland)Regulations Howtoregisterasahazardouswasteproducer 8425 Dentalpracticescanapplyforregistrationfromtheenvironmentalregulator: • onlineviatheenvironmentalregulator’swebsite; • byphoneattheenvironmentalregulator’scustomercontactcentre; • bypost. Whenthepremisesareregistered,ahazardouswasteproducerregistrationnumber (calleda“premisescode”)willbegiven.Thiscodemustbeusedonallconsignment noteswherehazardouswasteisremovedfromthosepremises.Registrationisonlyvalid for12monthsandthereforemustberenewedannually. Wastestorage 8427 Thedentalpracticemaystoreitsownwasteatthepracticepremiseswhereitwas producedwithoutrequiringanenvironmentalpermitwherespecificconditionsare met: • thewastemustbestoredinasecureplace;and • thewastemustbestoredforaperiodlessthan12months. Hazardouswaste:recordsandreturns 8428 Dentalpracticesarerequiredtokeeparegisterthatcontainstheirhazardouswaste records.Thisrequirementisusuallymetbykeepingcopiesofboth: • standardormultipleconsignmentnotes(includingannexes);and • consigneereturnstotheproducerorholder. Whererelevant,theregistershouldalsocontainrecordsofanyrejectedloadsorcarrier schedules. Consignmentnotes 8429 Standardmovement Wasteproducersmustretaintheircopyofeachconsignmentnotebeforethewasteis removedfromtheirpremises.Thiscopyshouldbeplacedintheregister. Multipleconsignments Thecarrierisrequiredtopassacopyofthemultipleconsignmentnote,includingthe relevantannex,towasteproducersbeforetheyremovehazardouswaste.Theserecords shouldbeplacedintheregister. Theregistermustcontaininformationonthequantity,nature,origin,destination, frequencyofcollection,modeoftransportofthewasteremovedanddetailsofthe wastecarrier.Ifproperlycompleted,consignmentnoteswillmeettheserequirements. 209 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Guidanceonconsignmentnotesandtheircompletionisprovidedbytheconsignment notesseriesofguidestotheHazardousWasteRegulations. HazardousWasteRegulations–consignmentnotesseriesofguides Consigneereturnstothewasteproducerorholder 8430 Eachconsignee(destinationsite)isrequiredtosendtothedentalpracticeareturn eachquarter.Thisreturnisarecordofwhathashappenedtothewasteandmustbe placedinthewasteproducer’sregister.Thesereturnsmustbepresenttoensurethe registerislegallycomplete. Whereawastecontractordoesnotprovidereturns: • theproducershouldformallyrequestoneinwriting; • ifthisisunsuccessful,thewasteproducershouldconsidermakingalternative arrangementsfortheirwastedisposaluntilthecontractorcomplieswiththe law,andshouldalsopasstheirdetailstotheenvironmentalregulator. Thereturnmaybeprovidedintwoways: • aformofthetypeprovidedintheRegulationswhichliststheindividual wastemovements,theirnature,andwhathashappenedtothem; • acopyoftheconsignee’scopyofeachconsignmentnote,togetherwitha description(orconfirmation)ofthemethodofdisposalorrecoveryapplied tothewaste.Thelatterisrequiredbecausethedisposalorrecoverypartofa consignmentnoteiscompletedonarrivalatthedestinationsite–thatis, beforedisposalorrecoveryactuallyoccurs. Thesereturnscontaintheinformationonthequantity,nature,origin,destination, frequencyofcollection,modeoftransport,wastecarrierandthedisposalorrecovery operationappliedtothewastereceived,whicharerequiredbytheRegulations. Wherethewasteistakentoatransferstationbeforebeingsentelsewhere,copiesofthe associatedcompletedpaperworkforthatonwardmovementshouldberequested, whichwillconfirmthatitwasreceivedatthefinaldestination. Rejectedloadsandcarrierschedules(whererelevant) 8431 Rejectedloads Consigneessometimesrejectconsignmentsofhazardouswaste.Whenthishappens, theymustsendanexplanation.Anewconsignmentnotewillbecompletedtomove thewasteelsewhere.Acopyofthisconsignmentnoteshouldbeprovidedtothewaste producer.Acopyofanynewconsignmentnoteandtheconsignee’sexplanationmust bekeptintheregister. Carriers’schedules Thisdocumentisneededwheremorethanonecarrierisinvolvedinthetransportof thewaste.Acopyofthescheduleofcarriersmustbeprovidedtowasteproducers beforethewasteisremovedfromtheirpremises.Thismustbekeptintheregister. Whereshouldtheregisterbekept? 8432 Wheretheregisteriskeptdependsonthenumberofpracticebranchesandwhether theseareeachregisteredashazardouswasteproducersornot. • Registeredpremises–ifapracticeisregistered,theregisterforhazardous wastethatisremovedfromthatpracticemustalwaysbekeptonthat practice’spremises. 210 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 • Exemptpremises–ifapracticebranchisexemptfromregistrationasa hazardouswasteproducer,theregisterforhazardouswastethatisremoved fromthatpracticeshouldbekeptattheprincipalplaceofbusiness.Thismay beanotherpracticeifthepracticeisoneofseveralinacompany.Ifapractice wishestokeeptheregisteranywhereelse,thismustbeagreedinwritingwith theenvironmentalregulator. Howlongshouldtheregisterbekept? 8433 Theregistermustbekeptforatleastthreeyears,commencingfromdatethewastewas removedfromthepractice’spremisesbyawastecarrier. Non-hazardouswasterecords 8434 Wastetransfernotesshouldbekeptforaminimumoftwoyears. Whereseasonticketsareused,arecordshouldbekeptofthetimeswheneachofthe regularcollectionsismadeusingthenote. Wasteauditanddutyofcarechecks 8436 Wasteaudit 8435 Wastesegregationandproceduresshouldbeauditedperiodicallyforthreereasons: 1. Thisenablesthedentalpracticetoaccuratelydescribeandclassifyitswasteto completeitswastedocumentationanddischargeitsdutyofcare. 2. Thewastedisposermayberequiredbytheirpermittoobtainanauditfrom thedentalpracticebeforetheycanacceptthewaste(apre-acceptanceaudit). 3. Thisenablesthedentalpracticetomonitoritswastepractices,identifyany problemsandasaresultenablesittofixthem. Examplesofspecificissuestoidentifyinanauditofeachareaofthepracticearethe presenceofthefollowinginanywastestream: • medicines(forexampletablets,creams,vials,ampoules,intravenousbagsetc) andmedicinally-contaminatedwastes(forexamplesyringebarrels,tubing, etc); • sharps(includingwhethertheyaremedicinallycontaminatedornot); • chemicals(disinfectants,reagents,diagnostickits,resinsetc); • dentalamalgam(capsules,excessamalgam,separatorcontents,teethwith fillingsetc); • body-fluid-contaminatedmaterialthatisinfectious(swabs,PPEetc); • healthcareitemsthatarenotcontaminatedwithbodyfluidsorother potentiallyinfectiousmaterials(forexamplePPE)(offensivewastes); • femininehygienewastes/nappybinsfromtoilets; • municipal-typewastes(newspapers,magazines,foodanddrinkcontainers, sterileequipmentandotherpackagingetc). Thefollowingshouldalsobeconsidered: • whatwastecontainersareusedforthesewastes; • howtheyarelabelled; • whetherthecontentsareaccuratelydescribedandclassifiedonwaste documentation. 211 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 TheEAisintroducingrequirementsfortheenddisposalsitestoholdadetailedand recentwastecompositionauditoftheproducerpracticebeforetheycanacceptthe waste. Thepracticewillexpecttobeaskedtoprovidedetailedinformationonitswaste segregationprocedures,theireffectivenessandthereforethecontentofeachwaste streamdeterminedbyanumberofmeansincludingstaffquestionnairesanddirect observationofin-usewastecontainercontents. Undertakingsuchauditswillenablethepracticetodemonstratethatithasdischarged itsdutyofcareindescribingandpackagingitswaste.TheBritishDentalAssociation hasrecentlyissuedguidanceonthesepre-acceptanceaudits. Pre-acceptanceaudit BritishDentalAssociationguidanceonpre-acceptanceaudits Wastecarriers 8438 Thewastecontractorwhocollectsthewastemustbearegisteredwastecarrier.This shouldbecheckedby,forexample,comparingthecarrierregistrationnumberonpart Coftheconsignmentnotetotheinformationheldontheenvironmentalregulator’s electronicpublicregister.Thedentalpracticemustsupervisecollectionsofhazardous wastetoenableittocertifythecarrierandvehicledetailsinpartDofthenote. Environmentalregulator’selectronicpublicregister Wastedisposal 8440 Wastefromsmallpracticesisfrequentlytakentoawastetransferstationwhereitis combinedwithotherwastesandsentforfinaldisposal. Thepracticeshouldcheckwhetheritswasteisbeingtakentoawastetransferstation. Ifthisisthecase,itshouldaskforcopiesofthedocumentationusedforonward movementofthewastetoitsfinaldestination. Figure13(see‘Wastesegregation,packaging,classificationandlabelling’)identities thatcertainclinicalwastesneedincineration,whilstothersaresuitableforalternative treatment.Diversionofwastecanoccur.Therefore,thefollowingstepsshouldbe taken: • Makesurethewastedescriptionsspecifyincinerationwhereindicatedin Figure13,especiallyifthewastecontractoradvisesotherwise. • Askforconfirmationofwhetherthefinaldisposalsitewasanincineratoror alternativetreatmentplant,andwhichfacilitythewastewastakento. • Askforacopyofthelastenvironmentalregulator’ssiteinspectionformfor boththetransferstationandthefinaldestinationsite(s). Wastesegregation,packaging,classificationandlabelling Dischargetofoulsewer 8442 Alldentalpracticesshouldhaveanamalgamseparatorinstalled.Theseshouldbeofan appropriateISOstandardandfittedinsuchawaythattheycaptureanyamalgam containedinwastewaters(seeDefra’sguidanceondentalamalgam).Spittoonwaste canthenbedischargedtodrain/foulsewerwithouttheneedforatradeeffluent consent. Defra’sguidanceondentalamalgam 212 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Clinicalwastetreatmentand disposaloverview 8443 Hightemperatureprocesses 8448 Incineration 8444 Healthcarewasteincineratorsarerequiredtomeettemperatureandemissionlimitsas setbytheWasteIncinerationDirective.Generallytheyhaveaprimarycombustion chamberoperatingat800–1000°Candasecondarychamberthatoperatesata minimumtemperatureof1100°C,witharetentiontimeforthecombustiongasesof twoseconds.Theincineratorplantalsoincludesgas-cleaningequipmenttoreduce emissionstoair.Thisequipmentdealswithcompoundssuchashydrogenchlorideand sulphurdioxide,whichformasaresultofchlorineandsulphurcompoundspresentin theoriginalwastematerial. Pyrolysis 8445 Pyrolysisinvolvesthehightemperature(545–1000°C)heatingofwasteintheabsence ofoxygentoproduceasynthesisgas.Thesynthesisgasproducedbyapyrolysissystem ismixedwithairandcombustedinasecondarychamber.Forgeneralwastes,the synthesisgasproducedbypyrolysiscanbecleanedandcombustedinanengine,but thisisavoidedwithclinicalwastewheresecurityofdestructionisparamount.Aswith incineration,thesecondarycombustioncomponentmustmeetatemperatureof1100 degreesandretaintheexhaustgasesfortwoseconds.Byheatingthewasteattheinitial temperatures,thesesystemstreat,destroypathogensandreducethevolumeofclinical waste. Plasmatechnology 8446 Inaplasmasystem,anelectriccurrentisdischargedthroughaninertgas(forexample argon)toproduceaplasmawithatemperatureashighas6000°C.Clinicalwasteisfed tothechamberwheretheplasmaispresentandisheatedtotemperaturesbetween 1300and1700°C,destroyingallpathogenicmicrobesandconvertingthewasteintoa glassyrockorslag,ferrousmetal(ifpresent)andasynthesisgas.Asinthepyrolysis process,thesynthesisgasproducedisoftencombustedinasecondarychamber, althoughtheveryhightemperaturesintheplasmachambermeanthegascanbefedto anenginegeneratorasanalternative.Theuseofanenginegeneratorcanresultin plasmasystemsexportingpowertoahospital(ifco-located)ortotheelectricgrid. Gasification 8447 Thegasificationprocessissimilartothepyrolysisprocess,exceptforthefactthatsmall amountsofairareintroducedtotheprimarytreatmentchamber.Theairaddeddoes notsupportfullcombustion,butenoughtoreleasemoreenergyfromthewasteinthe primarychamber.Itthereforeraisesthetemperatureintheprimarychambertoa higherlevel(900–1100°C)andproducesashratherthanchar. Non-burn/lowtemperaturealternativetechnologies 8453 Heat(thermal)disinfectionsystems 8449 Thesesystemsrelyonheatingthewastetoafixedtemperatureforaspecifiedtimeto deactivatetheinfectiouselementsinthewaste.Thecontinuousmonitoringand 213 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 recordingofwastetemperatureandtimearecriticaltoensuringtherequired temperaturelevelisachievedfortheentirebodyofthewaste. Autoclaves Inautoclaving,saturatedsteam(steamholdingwaterasavapour)isintroducedintoa vesselaboveatmosphericpressure.Someautoclavesaredesignedtoshredwasteduring thetreatmentcycle;othersystemsrelyontheuseofapre-treatmentprocessto maceratethewastebeforethewasteisheated.Theuseofinternalpaddles/arms/ridges designedtomixthewasteinsidetheautoclavechambermaynotmeetthe requirementsformaceration. Steamauger Thisindustrialthermaldisinfectionprocessoperatesatatmosphericpressureusinga combinationofresidencetimeandtemperaturetotreatthewasteandrenderitsafe. Wasteisshreddedpriortoitsentryintoasteamauger,whereitisturnedandtreated withsteamtoachievetherequiredinactivationofpathogens. Dryheat Somewastetreatmentsystemsavailableforbothlarge(forexamplehospitals)and small-quantitygenerators(forexampleGP/dentalpractices)thermallyinactivate potentiallypathogenicmicroorganismsthroughtheuseofelectrically-generatedheated air,oilormoltenplastic.AnumberofcommercialfacilitiesintheUKuseahot-oil process. Microwaves Microwavesareelectromagneticwaveswithafrequencybetweenradiowavesand infraredwavesontheelectromagneticspectrum.Whenappliedtothetreatmentof waste,themechanismofmicrobialinactivationisthermal.Itisimportantforthe wastetobewet,eitherasaresultofmoisturenaturallyoccurringinthewastestream orbytheadditionofmoistureintheformofsteam.Thecombinationofthetwo– microwavesandmoisture–createsthethermalprocess.Sometreatmentprocesses utilisemicrowavestoheatwatertoformsteam,whichisthenappliedtotheinfectious wastestream.“Dry”microwavesystemsarealsoavailable.Theseusedirectmicrowave energyinanitrogenatmospheretotreatthewasteandproducehighertreatment temperaturesthanthoseusedby“wet”microwavetechnologies. Macrowaves Thesesystemsapplylow-frequencyradiowavestoinactivatemicrobescontained withinthewaste.Themacrowavesheatthewastefromtheinsideofthematerialsto theirexternalsurfaces. Chemicaldisinfectionsystems 8450 Chemicalshaveanextensiveandwell-documentedhistoryintheclinicalsettingin disinfectingenvironmentalsurfacesandmedicaldevices.Chemicalscommonlyused aresodiumhypochlorite,chlorinedioxide,peraceticacid,glutaraldehydeand quaternaryammoniumcompounds.Thewastemustfirstbeshreddedinorderto bringallsurfacesofthewasteintodirectcontactwiththechemicals.Somesystems combineheatwiththechemicalstoreducethetreatmentcycle.Thekeyrequirements arethat: • thedisinfectanthastheabilitytoactonallthekeypathogengroups; • thedisinfectantismaintainedinthewasteatsufficientconcentrationoris givenenoughtimetoachievetherequiredleveloftreatmentforeachofthe keypathogengroups;and • thetreatedwaste(whichmaybehighlyabsorbent)shouldnotberendered chemicallyhazardousduetothepresenceofresidualdisinfectant. 214 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Otherchemicalsystems 8451 Otherchemicalprocesseshaveapotentiallywiderapplicationthandisinfection. Alkalinehydrolysisexposesthewastetohotalkaliforaperiodofseveralhoursand can,forexample,reducecarcassesorcadaverstoboneshadows.Noneofthesesystems areoperationalintheUKatpresent.Theorganicrichoutflowfromtheseunitsis likelytohaveaveryhighbiologicaloxygendemand(BOD),andshouldbesubjected toadditionaltreatmenttoensurethateffluentisdewatered,withonlythewaterbeing dischargedtofoulsewer. Landfill 8452 Infectiouswasteisbannedfromlandfill,althoughitcanbepre-treated(forexampleby alternativetreatment)sothatitisnon-infectiousandsuitableforlandfill.Sometypes ofhealthcarewastemaybedisposedofdirectlytolandfill(forexamplenon-infectious offensive/hygienewaste).Landfillsitesareclassifiedintooneofthreecategories: hazardous,non-hazardousandinert.Theyallmustcomplywiththestricttechnical andoperationalrequirementsoftheLandfillDirective.Importantly,wastethatissent tolandfillmustbepre-treated.Guidanceonthepre-treatmentrequirementsin EnglandandWales,NorthernIreland,andScotlandisavailablefromtherespective regulatoryauthorities(EA,NIEAandSEPA). 215 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Carriageinformation:CategoryA 8455 pathogenlist ThetablebelowshowstheCarriageRegulations’CategoryApathogenlist.The CarriageRegulationsdefineCategoryAas: “Aninfectioussubstancewhichiscarriedinaformthat,whenexposuretoit occurs,iscapableofcausingpermanentdisability,lifethreateningorfatal diseasetohumansoranimals.”(SeedetailsofCategoryAsubstancesinthe ADRregulations.) 216 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 IndicativeexamplesofinfectioussubstancesincludedinCategoryAinany formunlessotherwiseindicated(2.2.62.1.4.1) UNNumberandname Microorganism Bacillus anthracis (culturesonly) Brucella abortus (culturesonly) Brucella melitensis (culturesonly) Brucella suis (culturesonly) Burkholderia mallei – Pseudomonas mallei –Glanders(culturesonly) Burkholderia pseudomallei – Pseudomonas pseudomallei (culturesonly) Chlamydia psittaci –avianstrains(culturesonly) Clostridium botulinum (culturesonly) Coccidioides immitis (culturesonly) Coxiella burnetii (culturesonly) Crimean-Congohaemorrhagicfevervirus Denguevirus(culturesonly) Easternequineencephalitisvirus(culturesonly) Escherichia coli,verotoxigenic(culturesonly)ª Ebolavirus Flexalvirus Francisella tularensis (culturesonly) Guanaritovirus Hantaanvirus Hantaviruscausinghaemorrhagicfeverwithrenalsyndrome Hendravirus HepatitisBvirus(culturesonly) HerpesBvirus(culturesonly) Humanimmunodeficiencyvirus(culturesonly) UN2814 Highlypathogenicavianinfluenzavirus(culturesonly) Infectioussubstancesaffectinghumans JapaneseEncephalitisvirus(culturesonly) Juninvirus KyasanurForestdiseasevirus Lassavirus Machupovirus Marburgvirus Monkeypoxvirus Mycobacterium tuberculosis (culturesonly)ª Nipahvirus Omskhaemorrhagicfevervirus Poliovirus(culturesonly) Rabiesvirus(culturesonly) Rickettsia prowazekii (culturesonly) Rickettsia rickettsii (culturesonly) RiftValleyfevervirus(culturesonly) Russianspring-summerencephalitisvirus(culturesonly) Sabiavirus Shigella dysenteriae type1(culturesonly)ª Tick-borneencephalitisvirus(culturesonly) Variolavirus Venezuelanequineencephalitisvirus(culturesonly) WestNilevirus(culturesonly) Yellowfevervirus(culturesonly) Yersinia pestis (culturesonly) 217 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 UNNumberandname Microorganism Africanswinefevervirus(culturesonly) AvianparamyxovirusType1–VelogenicNewcastlediseasevirus(culturesonly) Classicalswinefevervirus(culturesonly) Footandmouthdiseasevirus(culturesonly) Lumpyskindiseasevirus(culturesonly) UN2900 Mycoplasmamycoides–Contagiousbovinepleuropneumonia(culturesonly) Infectioussubstancesaffectinganimals Pestedespetitsruminantsvirus(culturesonly) only Rinderpestvirus(culturesonly) Sheep-poxvirus(culturesonly) Goatpoxvirus(culturesonly) Swinevesiculardiseasevirus(culturesonly) Vesicularstomatitisvirus(culturesonly) ªNevertheless, when the cultures are intended for diagnostic or clinical purposes, they may be classified as infectious substances of Category B. CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations CarriageofDangerousGoodsandUseofTransportablePressureEquipment Regulations(NorthernIreland) DetailsofCategoryAsubstancesintheADRregulations 218 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Examplelistofcytotoxicand cytostaticdrugs 8457 ThisisanexamplelistfromanNHShospitalthathasassessedthepropertiesof medicinesinitspharmacy.Thelistforeachpracticewilldependonthemedicines theyuseandmayincludemedicinesnotlistedhere. Someofthesearedangerousgoodsandmayneedfurtherrestrictionsfor transportation. Allformulationsofcytotoxicandcytostaticdrugsmustbedisposedofinthe designatedcytotoxic/cytostaticwastereceptacle(purplelids)orappropriatereceptacles inlinewithtransportregulations.Thewastecontractorshouldbeconsulted. Thedrugsbelowaresplitintoanewlistofadditionaldrugsthatfallintothe cytotoxic/cytostaticcategoryandalistofcancerchemotherapydrugs,whichhave alwaysbeendisposedofinthismanner. Thislistisnotexhaustiveandmaynotincludeallverynew,unlicensedortrial medicines. 219 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Newlistofnon-chemotherapycytotoxic/cytostaticdrugs Productapprovedname Anastrozole Azathioprine Bcg Bicalutamide Chloramphenicol Ciclosporin Cidofovir Coaltarcontainingproducts Colchicine Danazol Diethylstilbestrol Dinoprostone Dithranolcontainingproducts Dutasteride Estradiol Exemestane Finasteride Flutamide Ganciclovir Gonadotrophin,chorionic Goserelin Interferoncontainingproducts(includingpeginterferon) Leflunomide Letrozole Leuprorelinacetate Medroxyprogesterone Megestrol Menotropins Mifepristone Mycophenolatemofetil Nafarelin Oestrogencontainingproducts Oxytocin(includingsyntocinonandsyntometrine) Podophyllyn Progesteronecontainingproducts Raloxifene Ribavarin Sirolimus Streptozocin Tacrolimus Tamoxifen Testosterone Thalidomide Toremifene Trifluridine Triptorelin Valganciclovir Zidovudine 220 for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Cancerchemotherapydrugs Productapprovedname Aldesleukin Alemtuzumab Amsacrine Arsenictrioxide Asparaginase Bleomycin Bortezomib Busulphan Capecitabine Carboplatin Carmustine Cetuximab Chlorambucil Cisplatin Cladribine Cyclophosphamide Cytarabine Dacarbazine Dactinomycin Daunorubicin Dasatinib Docetaxel Doxorubicin Epirubicin Estramustine Etoposide Fludarabine Fluorouracil 221 Productapprovedname Gemcitabine Gemtuzumab Hydroxycarbamide Idarubicin Ifosfamide Imatinibmesylate Irinotecan Lomustine Melphalan Mercaptopurine Methotrexate Mitomycin Mitotane Mitoxantrone Oxaliplatin Paclitaxel Pentamidine Pentostatin Procarbazine Raltitrexed Rituximab Temozolomide Thiotepa Topotecan Trastuzumab Vidaradine Vinblastine Vincristine for use in England, Scotland, Wales and Northern Ireland Safe management of healthcare waste Version 1.0 Examplesoftrainingsupport materials GREEN BAG Recyclable Waste Office paper (documents that do not need shredding), newspaper, empty drinks cans, plastic bottles and plastic packaging, small cardboard items (such as toothpaste boxes) Author: Estates and Facilities April 09 222 8461 BLACK BAG / CLEAR BAG Domestic Waste Flowers, nonrecyclable packaging (polystyrene cups, crisp & sweet wrappers, food contaminated packaging) Author: Estates and Facilities April 09 for use in England, Scotland, Wales and Northern Ireland
