Management of Community Clinical Waste
Management of Community Clinical Waste
Sian Fisher, Director, Catalyst Waste Solutions
Wendy Rayner, Enviros
With the provision of more and more healthcare in the community setting, either in patient’s own homes or at clinics and health centres, the amount of clinical waste arising in this sector is likely to increase. In addition there are numerous other producers located in the community environment, rather than the typical hospital setting including; GPs, dentists, vets, laboratories, funeral directors, tattooists, school nurses, nursing and care homes. There are also those organisations involved in the collection and disposal of this waste stream to consider, including private contractors and local authorities, the latter usually involved in the collection of clinical wastes produced by householders.
In the past guidance and assistance has been focused on the larger producers such as acute hospital trusts and the community clinical waste producers and collection authorities, have been neglected. Over the past twelve months there have been a number of significant changes in the management of clinical waste. These changes have appeared more complex than they actually are as the UK manages to get to grips with devolved waste regulation. In order to ‘break through’ the confusion this article attempts to identify the key parts of information and answer some common questions facing those who produce, manage and collect clinical waste in the community.
What is clinical waste?
Clinical waste is defined in the Controlled Waste Regulations and includes items which “may prove hazardous” and “may cause infection”. In practice the term ‘clinical waste’ is used to describe waste produced directly from healthcare which require specialist treatment and disposal such as: potentially infectious waste (swabs, dressings, sharps, etc) and pharmaceutical products. Many of these items are also classified as hazardous waste.
Which clinical wastes are hazardous ?
(a) Known or potentially infectious waste;
(b) Cytotoxic and cytostatic medicinal wastes; and
(c) Dental amalgam.
(a) Infectious and potentially infectious waste
Known or potentially infectious wastes includes all waste sent for specialist treatment and disposal because of its potentially infectious nature. Therefore all waste placed in clinical waste bags and sharps boxes and sent for treatment and disposal as clinical waste should be considered hazardous waste.
(b) Cytotoxic and cytostatic waste
Cytotoxic drugs, sometimes known as cancer or chemotherapy drugs are designed to kill damaged cells. Cytostatic drugs are those that inhibit or suppress cellular growth and multiplication. There isn’t a definitive list of cytotoxic or cytostatic medicinal products in the UK. WM2 provides definitions and interpretation in relation to waste management only, by reference to hazardous characteristics and products with the following characteristics should be classified as hazardous waste:
1 Toxic (H6)
2 Carcinogenic (H7),
3 Toxic for reproduction (H10),
4 Mutagenic (H11).
In order to establish the hazardous characteristics of a medicinal product reference needs to be made to the products Material Safety Data Sheets (MSDS) and assistance sought from a qualified Pharmacist.
Other non cytotoxic and cytostatic medicinal products may cause harm to the environment and although not considered hazardous waste should be segregated at source and sent for appropriate disposal which will normally be incineration or equivalent.
Do I need to segregate wastes?
The Hazardous Waste Regulations place a duty on producers to segregate hazardous and non-hazardous wastes. With respect to infectious (or potentially infectious) waste this means that producers should be encouraged to separate all the non-clinical (or non-hazardous) waste items from clinical waste bags such as packaging (wrappers, etc). In addition there is scope to segregate other, non-infectious, wastes such as hygiene wastes (nappies, etc) into the stream of “offensive” waste, with this stream being disposed of to landfill.
The segregation of medicinal waste is slightly more complicated and requires knowledge about the hazardous characteristics of each medicinal product. Guidance should be sought from a pharmacist. Mixing of medicinal waste is permitted if it occurs as part of the ‘use’ of the materials or as long as the mixing of the materials does not hinder the recovery of either material or cause a negative reaction e.g. result in the development of a toxic gas or an explosion . This means that as long as the mixing of hazardous and non-hazardous medical products does not effect the disposal and recovery options for the waste and is considered safe, mixing is permitted.
When reviewing opportunities to segregate cytotoxic and cytostatic medicinal waste the following should be considered:
1. Will the mixing of the waste effect the waste it is disposed of?
2. Can the hazardous characteristics of all medicinal products be ascertained?
3. Can effective segregation systems be put in place to separate the hazardous and non-hazardous medicinal wastes?
If the answer to any of the above questions is ‘no’ – it is advisable not to segregate hazardous (cyto) and non-hazardous medicinal products. In such circumstances all products should be classified as hazardous waste (cyto), although the accompanying consignment note should provide details regarding the percentage of and hazardous characteristics (if any) of the non-hazardous (non-cyto) component of the waste stream.
Consideration also needs to be given to the appropriate segregation of those sharps contaminated with either cyto or non-cyto medicinal products. As this may also be infectious as well as containing medicinal products, as a waste they will need to be accurately described on the consignment note to ensure the appropriate method of disposal.”
Hazardous Waste Regulation
In England, Wales and Northern Ireland, the Hazardous Waste and List of Waste Regulations set out a system of waste classification and hazardous waste management in line with the requirements of the Hazardous Waste Directive (94/31/EC). In Scotland, the requirements of the Directive have been incorporated into amended Special Waste Regulations.
Do I need to register (notify) as a hazardous waste producer?
In England and Wales all producers of hazardous waste are required to register (notify) with the Environment Agency each premises is allocated a unique code (premise code) which must be used on all consignment notes that accompany the movement of hazardous waste. In Scotland and Northern Ireland there is no need to register but producers are required to pre-notify the appropriate regulatory agency before waste is moved.
Certain sites, including healthcare centres, are exempt from registration if they produce less than 200kg of hazardous waste per annum. As the 200kg threshold applies to all hazardous wastes produced on site, (including monitors, fridges and fluorescent tubes) comprehensive waste management records will be required to ensure that the 200kg threshold is not exceeded. Exempt sites are responsible for assigning to themselves a unique premise code to be used on all consignment notes.
Waste contractors will require the appropriate reference number(s) before they can collect waste.
Households are not required to register and collections from these premises can be made without a premise code. Once taken to a waste storage or treatment facility, the organisation carrying out the collections is required to consign the waste from that point.
Who is responsible for waste generated in the community?
The producer of the waste has a duty of care to ensure that the waste is managed correctly. This means that the clinician must ensure that waste is packaged, stored, transported and treated appropriately.
Where the clinician is directly involved in the delivery of healthcare such as community nursing and midwifery they are responsible for ensuring that waste is packaged correctly and will often supply the appropriate packaging. Where patients are self caring or self medicating the clinician (such as a GP) must ensure that the patients have everything they need to manage the waste, for example self medicating diabetic patients should be supplied with a sharps box.
Clinical waste generated in the community can be collected in the following ways:
1. The clinician can remove the waste from the site immediately;
2. The clinician may leaves the waste on-site and arrange for the waste to be collected (this may be via a private contractor or the local authority);
3. Clinicians can provide a ‘take-back’ service, this is used predominately be GPs, Healthcare Centres and Pharmacists who are able to take back sharps boxes from self medicating patients.
If waste is left on site awaiting collection it must be ‘transferred’ to the householder. In order to transfer the waste the clinician must have permission from the householder and is responsible for the waste whilst it is being stored awaiting collection. This will involve an assessment of where the waste will be stored and how it will be packaged. For example it would not be appropriate to leave the waste unsupervised on the pavement awaiting collection.
Waste producers may use waste contractors to collect waste from community producers or in the case of waste produced from ‘household’ premises may request a collection by the Waste Collection Authority (usually the Local Authority). In line with the requirements of Regulation 45(1) of the Environmental Protection Act 1990, Waste Collection Authorities have a duty to collect household waste. The Collection Authority must be notified of the need to collect the waste by ‘the person who controls the waste’ (Regulation 45(3) of EPA 1990) and they may make a reasonable charge for the collection.
Which wastes can pharmacy premises accept?
Pharmacies can accept and store waste (medicines and sharps containers) returned by members of the public and individuals without the need for a waste management licence. The Essential Services within the pharmacy contract for England and Wales includes the disposal of unwanted medicines from these sources. Medicines from other sources can be accepted; however the pharmacy may require a waste management licence. The Royal Pharmaceutical Society of Great Britain (RPSGB) provides further guidance on waste management licence and exemptions.
All pharmacy sites regardless of size or location need a waste management licence to ‘treat’ medicinal wastes on-site. Treatment includes sorting and de-naturing or mixing of drugs (including Controlled Drugs). However, the Environment Agency has stated that these activities are considered to be ‘low risk’ (reference: LRW 023) and therefore they will not expect operators to obtain a waste management licence. In order to take advantage of this low risk exemption, pharmacies should endeavour to carry out all sorting and de-naturing activities in a way which minimises harm, the use of de-naturing kits is regarded as best practice.
How should waste be packaged ?
The Carriage of Dangerous Goods Regulations specify the packaging and labelling requirements for all dangerous goods (including waste materials). The Carriage Regulations implement the requirements of the ‘European agreement concerning the international carriage by road’ known as ‘ADR. Guidance on interpreting these Regulations should be provided by a qualified Dangerous Goods Safety Advisor (DGSA).
Clinical waste, including potentially infectious waste and medicinal waste are classified as dangerous goods and should be labelled and packaged as such. A DGSA can provide specific advice relating to the requirements of the Regulations and associated exemptions.
Transportation of clinical waste
Contractors employed to carry waste on behalf of the producers are required to be Registered Waste Carriers. Waste producers carrying their own waste, with the exception of building or demolition waste are exempt from the registration requirement. It is an offence to transfer waste to an un-registered waste carrier and those transferring the waste can be fined.
Drivers of vehicles carrying dangerous goods may require a vocational training certificate applicable to the class of goods that they are carrying. Previously the driver training requirement only applied to those driving vehicles over 3.5 tonnes (gross vehcile weight). However, as of the 1st January 2007 drivers of any vehicles carrying dangerous goods may require training.
The requirement for vocational training is dependent on the vehicle load; the Carriage Regulations specify ‘Load thesholds’ for goods, where vehicles carry goods above these threshold the driver requires training. Significant quantities of certain goods can be carried without the need for driver training for example; 333kg of clinical waste in rigid containers.
If clinical waste sacks are used on their own (i.e. without the use of wheeled container) this method of packaging is described as ‘bulk’. Bulk carriage of clinical waste is permitted under an exemption described as VV11 in the Carriage Regulations. If clinical waste is transported in bulk, the requirements of Carriage Regulation are onerous and include the displaying of placards on each of the four sides of the vehicle and the level of fire fighting equipment to be carried and driver training requirements.
The images below show the two types of placard required. The plate on the front of the vehicle should be orange and the plates of the two sides and rear of the vehicle should show the UN Number and classification of the material being carried.
Particular attention should be paid to the carriage of small quantities of clinical waste in vehicles, e.g. community nursing, etc. If a bag of waste is placed directly into any vehicle, including a car, the carriage of waste is considered to be in ‘bulk’. This would mean that the car and the driver would need to meet the requirements of carriage regulation including the use of orange plates on all four sides of the vehicle.
The above issues have already caused significant confusion amongst larger healthcare waste producers, such as acute Trusts, where generally there is a manager with responsibility for waste issues, with a degree of expertise available. However, the community setting and associated clinical waste producers are more diverse, with their circumstances presenting a different range of problems. In many cases there is an absence of up to date knowledge, which may result in waste being inappropriately segregated, packaged, handled and disposed. In addition, significant opportunities for the minimisation and diversion of certain streams, such as offensive waste, are being overlooked.
It is therefore essential that the producers, handlers, movers and disposers of this waste stream are fully aware of the changes and how they affect the community setting in order to ensure compliance and achieve long term sustainability.
References:
DEFRA - Clinical waste FAQ: http://www.defra.gov.uk/environment/waste/topics/clinical.htm
DEFRA – Hazardous waste FAQ: http://www.defra.gov.uk/environment/waste/special/pdf/hwr-faq.pdf
Royal Pharmaceutical Society of Great Britain – Hazardous Waste Regulations, Interim Guidance for Community Pharmacists: http://www.rpsgb.org.uk/pdfs/hazwastecommphguid.pdf
Joint Agency (EA, SEPA, EHS) - Hazardous Waste Classification Guidance: WM2: http://www.environment-agency.gov.uk/subjects/waste/1019330/1217981/1384307/
Department of Health – Safe Management of Healthcare Waste : http://www.dh.gov.uk/Consultations/ResponsesToConsultations/fs/en
National Diabetes Support Team – Disposal Fact Sheet: http://www.diabetes.nhs.uk/downloads/Factsheet_Sharps_Disposal.pdf
