Reducing Regulated Medical Waste

1. Reducing Regulated Medical Waste Janet Howard Director, Member Engagement

2. Prioritize Worker Respect

3. the sustainability continuum

4. Learn from our waste

6. Low Hanging Fruit • Red Bag Reduction • Fluid Management • Reusable Sharps • Single Use Device Reprocessing • Material Recycling • Equipment Donation

7. Assessments • On-Site Walk-through or Audit: checking waste and work practices

8. Importance of Creating a Baseline • Can’t manage what you don’t measure • Where’s the starting line? • Take credit for current successes!

9. What’s Your Waste Profile?

10. What is EPP? Incremental • Selecting products & services whose environmental impacts have been considered and found to be preferable to comparable alternatives. • A way for purchasers to implement their values and goals as they relate to environment, health, and safety. • Performance, availability, and price Comparative Evolving *

11. Reusable Products Supply Chain: Include waste fees when comparing disposable versus reusable products.

12. Regulated Medical Waste Reduction

13. RMW: Why Do We Care?

14. …Design materials and systems that promotes and facilitates waste minimization and segregation… Understand waste issues

15. Waste Segregation – Implementation • Present Plan • Form a team • Define waste streams • Survey Facility • Develop Materials • Purchase equipment, supplies. • Issue Memo • Container placement • Properly Labeled, Signage • Proper placement • Training (never ends.) • Monitoring and reporting • Continue!

16. Policy & Training • Committee Work, Review and Policy Development • Standardized methodology (signage, cans) • Retrain current staff with agreed upon definition of RMW. • Make staff aware of facility’s RMW reduction goals. • Departmental role in their own RMW generation and associated disposal costs. • Develop incentives • Connect with safety • Tracking and Reporting

17. Waste Segregation – Best Practices • Implement an Infrastructure Conducive to Waste Minimization- • Colorcoded, strategically placed and well labeled containers for: • Solid Waste • Infectious Waste • Hazardous Waste • Recycling • Universal Wastes • Others

18. Container Placement • Red bags containers should be covered to reduce solid waste casually tossed in. • Remove red bags from under hand-washing sinks, non-critical care patient areas, hallways and other areas where people are likely to dispose of solid waste. • Where there ARE red bags, locate a solid waste container directly adjacent so staff make conscious disposal and segregation decisions.

19. Container Sizing • Where red bags must remain for safety reasons, use smallest feasible container. • 8-gallon or 12-gallon. • Place red bag dispenser inside cabinet in patient rooms.

20. Container Placement and Signage

21. What goes in a red bag anyway?* YES! RED BAG NO! Put in Clear Bag • IV Bags, tubing, foley bags • Non bloody gloves • Packaging, • Urine-soaked waste, feces, vomit • Blood-tainted waste • (Note distinction between blood-soaked and blood-tainted. A little bit of blood on an item can go in the regular waste stream.) • Blood, Products of Blood • Anything caked, soaked or dripping in blood • Tissues from surgery and autopsy • Cultures and stocks of infectious agents and discarded vaccines. • Suction canisters with any fluid. Hemovac and pleurovac drainage. • Operating room waste saturated with body fluids as defined by OSHA. • Waste from patients isolated with HIGHLY communicable diseases. (These are CDC Class IV definitions including Ebola, Lassa Fever, Marburg and Small Pox. NOT such conditions as AIDS< Hepatitis or TB.) • Sharps, including syringes and unused sharps. Questions? Call Waste Manager * Check your local regulations

22. Signage • Post signage above or on RMW containers outlining types of waste are to be disposed of as RMW • Use large font and bullet format, preferably in color • Consider MULTIPLE LANGUAGESto ensure optimal communication.

23. Training • Make staff aware of facility’s RMW reduction goals. • Retrain current staff with agreed upon definition of RMW. • Train new employees about waste segregation procedures as part of employee orientation. • Consider making “compliance with hospital waste management policies” part of every job description.

24. Respect

27. Celebrate and say thank you

29. Obstacles • Housekeeper collecting clear bags into red bag. • Use closest can • Change of Staff • No time • No can available • Confusion of Isolation rooms • Confusion over body fluids • Fear of Waste • Lack of training • Old habits • No clear can available • Overfilled clear lined can • Ran out of clear bags!

30. Problem Identification & Resolution Plan • You WILL encounter mistakes. • Conduct tours of trash areas monthly. Take a digital camera! • Develop a mechanism to report concerns or issues (e.g. photo w/ written report of issue and responsible floor/dept/unit.) • Re-educate promptly. Hold in-service with responsible unit to explain problem and proper segregation technique. • Engage a nurse leader to help communicate program.

31. Reusable Sharps Containers

32. Disposable vs. Reusable Sharps Containers Disposable Reusable • Vendor offered a full-service sharps management service. • One dedicated person for handling sharps. • Much fewer incidents of overfilled containers. • Nicer looking container • Reduces needle sticks associated with waste • Eliminates disposable containers as waste • Reduced liability • Positive feedback from staff. • Who is responsible for changing containers? • Are containers overfilled. • Are containers removed without being closed properly. • Multipe employees handling sharps containers. • Sheer volume of disposable containers headed to incinerators and autoclaves.

33. Reusable Products Supply Chain: Include waste fees when comparing disposable versus reusable products.

34. Single Use Device Reprocessing

35. What is Third Party Reprocessing? • Sterilize used, unused but open or expired materials for reuse in patient care settings • Strictly regulated by FDA • TPRs incur liability from faulty devices • No reported deaths from using reprocessed devices—per FDA database. • ‘Single-use’ is a labeling designation determined by original equipment manufacturers (OEMs) and not required by the FDA

36. www.amdr.org Some Commonly Reprocessed “Single-Use” Medical Devices • Arthroscopic shavers • Blood pressure cuffs • Soft tissue ablators • External fixation devices • Electrophysiology catheters • Scissors and staplers • Biopsy forceps • Laparoscopic scissors and forceps • Clamps and dissectors • Compression sleeves (DVT) • Phaco tips • Pneumatic tourniquet cuffs • Pulse oximeter sensors • Orthopedic drill bits and burrs • Tracers • Trocars • and many opened-but-unused items

37. AMDRwww.amdr.org

38. Resources on Fluid Management • ECRI Resource: • http://www.mcdmag.com/MedLiquid.pdf • 2. MnTAP Resource: • http://mntap.umn.edu/health/91-Canister.htm • 3. HPN Article: http://www.hpnonline.com/inside/2006-12/0612-CS-wastemgmt.html 40% of Operating Room waste suction canisters!

39. Fluid Management Systems • Stationary vs Mobile • Drain-Rinse-Disinfect • Reduce worker exposure risk • Reduce medical waste costs http://mntap.umn.edu/health/91-Canister.htm

40. 19-20% of the waste stream generated by surgical services is from sterilization wrap. Reusable Totes, Blue Wrap Recycling, and Composting: Environmental Best Practices for Health Care Facilities. The United States Environmental Protection Agency. http://www.ciwmb.ca.gov/wpie/HealthCare/EPATote.pdf. Accessed 5/15/09

41. Hospital Waste Stream…myths and facts • Myths: • Waste from surgery is soaking in blood and body fluids • Waste from any patient care items must be contaminated • Facts: • Waste from opening a surgical suite prior to patient arrival is clean • Items added to the sterile field after patient arrival are just as clean if separated at point of use

42. Hard Cases Instead of Blue Wrap at Metro • Rigid containers selected in FY 2007 for surgery and central sterile departments. • Reduced use of sterile blue wrap • Phasing in over time. As of Fall 2008, 50% are reusable. • So far, blue wrap reduction is estimated at 2.5 tons. • Metro’s estimated savings in purchase and disposal of blue wrap is $62K per year.

43. Operating Room Waste Reduction at Boulder • Blue wrap prevention at Boulder Community Hospital • Boulder Community Hospital worked with EPA on a zero waste program. • Conducted a waste audit and identified “blue wrap” as a significant portion of the waste stream. • Invested in durable, reusable containers for sterilization of instruments in the OR Setting.

44. Reusable Containers • Invested in hard cases - $120,000 one time cost. • Reduced disposable blue wrap purchase from $250,000 in 2003 to $60,000 in 2005 or $190K in savings. • This does not include reduction in waste costs. • Manufacturers of surgical equipment are now required to provide the durable container as part of the equipment purchase.

45. Blue wrap is universally used for sterilizing reusable instruments. • Blue Wrap ispolypropylene,which is a #5 plastic

46. Blue Wrap Recycling • Almost 80% of packaging waste from a single procedure is generated before the patient even enters the operating room. • 20% of surgical waste is blue wrap • Blue wrap is made of polypropylene

47. Blue Wrap Recycling • Work with haulers to accept blue wrap • Set up a pilot: start with Surgical Services • Set up schedule for collection • Find space for storage and/or baling • Work with hauler to adjust pick-up schedule

48. Track Progress, Report Successes and Reward Staff! • Make sure to track waste generation rates in a reliable spreadsheet. • Track cost-savings. • Let staff know how they’ve done… • Reward staff for their efforts- create incentives such as movie tickets, catered lunches, pizza parties • Apply for an award from Practice Greenhealth. • Use results as a Performance Improvement Initiative for JCAHO.

49. Jen Ogden RN, BSN, CNOR , Operating Room Educator, Shawnee Mission Medical Center

50. Medical Supply Donation • Cleveland Clinic supports MedWish International with its donations, which it then distributes to humanitarian missions • MedWish is housed in one of our warehouses, which makes deliveries easy! • MedWish donations contribute to charitable mission and recycling rate • They accept supplies and equipment, but no pharmaceuticals • Last year Cleveland Clinic Health System donated 80,000 lbs of material to MedWish. This year, thanks to our green teams, we’ve already given 134,000 lbs in just the first half of 2008! Office for a Healthy Environment l August 2008 l