So what happens next …?

A review of the draft NHS Guidance document "SAFE MANAGEMENT OF HEALTHCARE WASTE"

- Brian Latham

Known to many as the ‘purple book, guidance on the safe management of healthcare waste was produced by the Health Services Advisory Committee in 1999 - the ‘Safe disposal of clinical waste’. However new legislation, in particular, that arising from EC directives on Landfill and Hazardous waste required major changes.

In November 2005 the Department of Health published the consultation document ‘Safe management of healthcare waste’. The document was produced through a Steering Group comprising Dept of Health, DEFRA, EA, SEPA Dept for Transport (DfT), Health and Safety Executive, Health Protection Agency and devolved administrations. The SMDSA and its members took part in many of the working groups formed to concentrate on the various issues. The aim of this document was to replace the ‘purple book’ and provide a framework of good practice for waste management to assist NHS organisations and others to deal properly with their waste and meet legislative requirements.

The document made the following key recommendation:

A new methodology (known as the ‘unified’ approach) for identifying and classifying infectious and medicinal wastes to comply with waste, health and safety and carriage regulations.

The use of European Waste Catalogue (EWC) codes to describe waste in place of the A to E classification.

An offensive waste stream to describe wastes which are not infectious e.g. human hygiene waste, nappies etc.

A revised colour coding system for packaging.

To assist the consultation process the document sought a response to a number of questions: Following the consultation process the Department of Health issued a summary of responses to the consultation. The following looks at the SMDSA response to the consultation questions and the summary of responses to the consultation.

 

Question 1 Do you agree the recommendation that clinical waste is defined as hazardous infectious waste?

 

The SMDSA and its member companies do not agree that clinical waste is redefined as hazardous infectious waste. SMDSA believes that there is a substantial percentage of non-hazardous clinical waste that needs to be treated or the producer requires the waste to be treated. There is no evidence that the proposed definition either has, or will increase segregation as it is evident that the NHS has adopted a precautionary approach to avoid potential prosecution. The redefinition gives no environmental benefit since it has not changed the route for disposal of these wastes to treatment and incineration. It will however increase the cost to the NHS and others through administrative costs of consignment notes for no tangible benefits. In its summary of consultation responses the Department of Health Steering Group stated that 54% of responses agreed the need to redefine clinical waste. The Steering Group will reconsider the definition.

 

Question 2 Do you agree with the methodology proposed for identifying and classifying infectious and medicinal waste?

 

SMDSA disagreed with the methodology of classifying infectious waste. A more sensible approach would be to incorporate the threshold for what constitutes hazardous waste, due to infection risk, with clinical practice in preventing the spread of infection. The Department of Health summary of responses also identified concern about the definition of infectious as it relates to the use of universal precautions in healthcare establishments. This is to be addressed by a working group.

The SMDSA disagreed with the methodology for medicinal waste. The imposition of the United States NIOSH list does not represent a practical option and introduces further confusion. The majority of the drugs listed in NIOSH are not applicable to the UK. The summary of consultation responses identified concerns from others and the need for greater clarity and understanding of cytotoxic and cytostatic medicines.

The SMDSA has established a working group to consider how the Hazardous Waste Directive applies a definition of hazardous medicines throughout the rest of Europe and to evaluate the technical options including the use of British National Formulary BNF 8.1.

 

Question 3 Do you agree with the benefits of introducing an "offensive waste" stream?

 

Offensive waste is not a new concept. It has been known as Group E, Sanpro or incontinence waste. The SMDSA is strongly opposed to the wholesale expansion of this waste stream to include anything that was previously treated as clinical waste but can be assessed to be non-hazardous. This approach is likely to promote the movement of these wastes through the black bag commercial waste stream and arriving at materials recycling facilities (MURFs) where manual sorting is undertaken, exposing employees to risk. It also appears contrary to government policy to reduce waste to landfill and the requirement to pre-treat waste for landfill by 2007, when waste is currently being treated. It also reduces the opportunity for recycling using new technologies which are able to utilise waste from treatment plants. In addition there is the issue of public acceptance of these waste going to landfill and whether landfill sites will accept this waste stream. The summary of responses to the document notes that there was a slight balance in favour of introducing an offensive waste stream, though there was much comment on the appropriateness of this course of action. The Steering Group agreed that this was a decision for individual NHS organisations and is not a mandatory or central requirement.

 

Question 4 Do you agree with the benefits of a nationally based system of colour-coded packaging?

 

The SMDSA agrees with the principle of a nationally based system of colour-coded packaging, but believes the existing proposal is confused between coding for hazard and coding for disposal route. SMDSA propose that the scheme code only by disposal route. This allows producers to move waste up the waste hierarchy and specify a higher level of treatment irrespective of hazard. SMDSA supports the use of purple to indicate presence of Cytotoxic and Cytostatic medicines and the continued use of Tiger bags for hygiene waste going to landfill.

The Department of Health summary of responses records that the nationally based system of colour coding was given unanimous support with many calls for the approach to be made mandatory to guarantee effectiveness. However the responses also commented that the approach was complex and greater clarity was needed.

The SMDSA propose a system of positive segregation for incineration colour coded by the use of red bags or red lids. Wastes suitable for treatment would remain in yellow bags or with yellow lids, however the scheme could simply accommodate the transitional phase over an extended period by allowing existing colours to be used for treatment. This approach requires the minimum amount of change, reduces the amount of staff retraining, removes commercial conflicts, and retains the benefit of easy visual segregation throughout the disposal chain. In addition it does not require separation of hazardous and non-hazardous wastes that are all routed to incineration.

 

Question 5 Views are sought on the practicality of segregating sharps waste contaminated with cytotoxic/cytostatic medicinal products and sharps boxes not contaminated with cyto-medications.

 

SMDSA does not agree with the use of NIOSH list to specify cytostatic waste. It proposes the continued use of British National Formulary BNF 8.1. which is widely known, available and understood. NIOSH is problematic as it includes medicines which, where they are widely used, do not justify being classed as hazardous e.g. birth control hormones.

SMDSA believes the position that fully discharged syringes, which have been used to administer hazardous medicines, are automatically hazardous requires further consideration. Simply being contaminated with a hazardous substance does not automatically turn an empty container into hazardous waste. There are many examples which allow for waste and waste containers not to be treated as hazardous themselves despite a residual contamination with hazardous substance e.g. contaminated drums.

A pragmatic approach is required, where segregation of medicines and sharps is of a sufficiently high standard, it would serve little purpose to extend the definition of cytostatic further than necessary.

 

The way forward

 

The proposed ‘Safe Management of Healthcare Waste’ is a key document for all those involved in healthcare waste management. It is vital that the document provides sound practical advice to producers of waste and the waste treatment industry. It is clear from the review process that the document needs to provide greater clarity, however a number of elements e.g colour coding have universal acceptance. The Department of Health Steering Group is currently revising the document in the light of the comments it has received and proposes to issue a revised document shortly for peer review prior to publication. The SMDSA looks forward to taking part in the peer review.