Waste Management Procedure - WhatDoTheyKnow

Procedure: 265 Page 1 of 43 Version: 2

Waste Management Procedure

To whom this document applies: All staff employed by Colchester Hospital University NHS Foundation Trust (CHUFT), volunteers and to all visiting staff including tutors, students and agency/bank/locum/contracted staff Procedural Documents Approval Committee Issue Date: Interim Procedure October 2008 Document reference: 265 Date(s) reviewed: June 2009 Version 1 Approved by: Procedural Document Approval Committee

October 2011 Version 1a February 2015 Version 2

Date approved: February 2015 Next Review date: February 2017 Version No: 2 Responsibility for review: Head of Facilities Contributors: Please See Procedural Development, Consultation Proposal Form – page 2

Archiving information held by the secretary of the Procedural Documents Approval Committee


Procedural Development Consultation Proposal Form

Title: Waste Management Procedure – Interim

Policy • Procedure Guideline • Protocol • Standard •

Name of person presenting document: Fiona Sparrow – Head of Facilities

Reason for document development/review: A number of organisational changes have occurred since the previous procedure was reviewed. The previous document has a number of anomalies surrounding management structure, waste handling, storage and segregation, which have been amended on an interim basis pending a re-tendered waste contract, improved storage facilities.

Names of development team (including a representative from all relevant disciplines): Fiona Sparrow – Head of Facilities Ian Crockett – Associate Director, Planning and Development

Who has been consulted? Radiation Protection Adviser, Radioactive Substances Health and Safety Advisor Pathology Service Manager Chief Biomedical Scientist Biochemistry Department Manager Histopathology Department Manager Haematology Department Manager Head of Information Governance Senior Infection Control Nurse Mortuary and Bereavement Services Manager

Does this document require presentation and agreement from Health and Safety Committee or Staff Partnership Forum prior to PDAC approval? Yes No •

Specify groups of staff to whom the document relates: All staff employed by Colchester Hospital University NHS Foundation Trust (CHUFT), volunteers and to all visiting staff including tutors, students and agency/bank/locum/contracted staff.

Source of supporting evidence (references etc.): See Evidence Base.

Are there resource implications? Yes • No If yes please detail them:

Does the Procedure/Guideline meet latest NHSLA, Risk Management Standards, Essential Standards of Quality and Safety (CQC)? Yes No •

Does this Procedure/Guideline include children, if applicable? 1. Does this document apply to children? Yes No 2. Are there aspects of this document that differ with regard to the treatment of children? Yes • No

If yes, please state who has been consulted

A Trust review will occur every two years unless national guidance states otherwise.

Date: January 2014


Contents

Page No.

Review, Updating and Archiving of the Document 1

Document Development and Consultation Process 2

Contents 3

Introduction 5

Related Documents 5

1. Definition of Terms 6

2. Roles and Responsibilities 6

3. Process 9

Minimisation 9

Transportation of Waste 10

Handling of Clinical Waste 10

Handling of Healthcare Waste 12

Handling of Non-Clinical Waste, Domestic and Recyclable Waste 14

Handling of Hazardous Waste (including Cytotoxic, Prescription Drugs and Radioactive Waste)

15

Disposal of Radioactive Waste 16

Pharmacy Disposal of Waste 16

Pathology Disposal of Waste 17

Disposal and Prevention of Sharps Contamination Injuries 17

Recycling of Batteries 18

Disposal of Waste from Outpatients and Surrounding Hospital Facilities

18

Disposal of Confidential and Paper Waste 18

Asbestos Disposal 19

Funding and Financial Arrangement 19

Anatomical Waste 19

Sensitive Disposal of Fetal Remains, Limbs, Tissue and Organs 19

Spillage Procedure 20

Infectious Substances for Transport 20

4. Training and Staff Awareness 21

5. Evidence Base 21


6. Monitoring Compliance and Audit 22

7. Dissemination, Implementation and Access to the Document 22

Appendices Appendix A – Waste Disposal Data Sheets

23

001 Clinical Waste 23

002 Sharps – Non-Medical 24

003 Sharps – Medicinal (Including Cytotoxic and Cytostatic Materials) 25

004 Pharmaceutical Waste 26

005 Anatomical Waste 27

006 Laboratory Chemical Waste 28

007 Fluorescent Lamps 29

008 Batteries 30

009 Redundant Furniture, Mattresses and Electrical Equipment 31

010 IT equipment (Including Toner Cartridges) 32

011 Medical Equipment 33

012 Waste Oils 34

013 Domestic/Household 35

014 Recycling Paper 36

015 Recycling Cardboard 37

016 Recycling – Glass 38

017 Offensive/Hygienic Waste 39

018 Mercury Waste 40

019 Recycling – Packaging 41

020 Radioactive Waste 42

Appendix B

Hemorrhagic Fever (Category A Waste) 43


Introduction The production of waste is a significant indicator of activity within the hospital. The segregation of this waste, its handling and disposal require effective management if the Trust is to meet its obligations, both environmental and financial, as well as ensuring effective infection control and adherence to Health and Safety policies and guidelines. Waste disposal is the generic term given to the whole spectrum of activities associated with waste, namely generation, handling, storage and actual disposal, which continues right up until the final destruction of the waste. The Trust has a cradle to grave responsibility and must ensure arrangements are consistent with its responsibility. The Trust recognises the need for a comprehensive Waste Management Procedure, which meets the requirements as outlined in the:

Health and Safety at Work Act 1974

Control of Substances Hazardous to Health (COSHH)

The Environmental Protection Act 1990

The Hazardous Waste Regulations 2005

The Health & Technical Memorandum 07-01 (Safe Management of Healthcare Waste), related legislation, guidance for ensuring the health, safety, welfare of its employees, patients and any others on its premises and in the environment at large. Hospitals generate a significant amount of every classification and category of waste, each of which has its own disposal standards and routes. This makes for a very complicated system of controls, which need to be easily understood and implemented at shop floor level. Therefore particular effort has been made to simplify the guidance issued, which primarily involves the procedure itself, which is then supplemented by waste data disposal sheets (WDDS) (Appendix A).

Related Documents 210 – Infection Control Procedure 204 – Health and Safety Policy 067 – Policy for the Use of Medicines 118 – Risk Management Strategy and Policy 336 – Pharmacy Supplies to Colchester Hospital University NHS Foundation Trust (CHUFT) Wards and Departments – Supply Chain Procedure 239 – Data Protection Procedure 238 – Information Governance Procedure 291 – Information Security Policy 312 – Sending a Fax including a Safe Haven Fax Procedure 189 – Health Records Management Procedure 310 – Creation of Corporate Records Procedure 309 – Creation of Corporate Records Policy 266 – Environmental and Sustainability Policy 100 – Management of Sharps and Contamination Injuries Procedure 165 – Radiation Safety Policy 219 – Trust Decontamination Procedure 196 – Safe Administration and Handling of Cytotoxic Chemotherapy Guidelines Laboratory Waste Disposal – Document No: WU 0012 Pathology Health and Safety Code Disinfection Guidelines – Document No: SAF 0003 Microbiology Safety Code – Document No: SAF 0005 Cellular Pathology – Document No: SOP P0005 Specimen Storage and Control – Document No: SOP CT0018


1. Definition of Terms The definition of clinical waste used in this procedure is taken from the Controlled Wastes Regulations 1992. Part II of the Environment Protection Act 1990 defines waste as, “any substance which constitutes a scrap material or effluent or other unwanted surplus substance arising from the application of any process, and any substance or article which requires to be disposed of as being broken, worn out, contaminated or otherwise spoiled”. EVD – External Ventricular Drain (Brain Fluid) HTM – Health Technical Memorandum (Best practice guidance for healthcare) DGSA – Dangerous Goods Safety Advisor WDDS – Waste Data Disposal Sheets COSHH – Control of Substances Hazardous to Health EWC – European Waste Code ACDP – Advisory Committee on Dangerous Pathogens WEEE – Waste of Electrical and Electronic Equipment Regulations ADR – Automatic Driver Recognition CDG – Carriage of Dangerous Goods UN – United Nations EA – Environment Agency UKAS – United Kingdom Accreditation Service BS – British Standard

2. Roles and Responsibilities All Staff All staff have a responsibility to identify any material that they are using or have used, which is destined for the waste stream, are to be appropriately categorised (as defined in the Health & Technical Memorandum 07-01) to ensure it is disposed of in accordance with the requirements as specified on the waste disposal data sheet (WDDS), and in accordance with the appropriate Control of Substances Hazardous to Health (COSHH) assessment. Chief Executive The Chief Executive has overall responsibility on behalf of the Trust Board of Directors for its compliance with statute law, waste legislation and governance standards (imposed upon the NHS from such organisations as the Care Quality Commission. Trust Board The Board will ensure that the requirements specified within this procedure and Code of Practice are resourced, and implemented within the Trust. Special Projects Director The Director of Estates and Facilities will be responsible to the Chief Executive for the Trust‟s day-to-day compliance with the requirements of this procedure and for ensuring that any documentation issued in pursuance of the safe handling and disposal of waste reflect legal requirements, good working practice or accepted guidance. They will ensure that proactive arrangements exist for the monitoring and policing of this procedure and notifying the Chief Executive of any areas of concern. They will ensure joint monitoring with the Estates and Facilities Department and contracted services. Associate Director of Estates, Capital Projects and Development The Associate Director of Estates, Capital Projects and Development, under the guidance of the Special Projects Director shall be responsible for the provision of adequate waste storage and handling facilities on site.


Head of Facilities (HoF) The Head of Facilities (HoF) is responsible for overseeing the implementation of the policy and procedures in support of clinical service and ward/department managers, and for ensuring that staff are trained in all aspects of waste segregation and handling. This includes the managers of those organisations and/or companies‟ operating within the Trust, who dispose of waste through the Trust waste streams. Head of Facilities (HoF) (Disseminated to Support Staff and Supported by the Trust’s Waste Advisor) The Head of Facilities (HoF) will be responsible for the management of waste contracts and ensure compliance with Duty of Care Regulations and the Carriage of Dangerous Goods Regulations by contracted suppliers and staff. This will include an annual duty of care visit to waste contractors providing services to the Trust. The HoF will identify, in conjunction with Estates and Facilities, work streams to ensure that facilities are available or are purchased for the disposal of all waste generated within the Trust, which comply with relevant legislation and Standing Financial Instructions. The HoF must keep Hazardous Waste Consignment notes for a period of 3 years and make them available for inspection by the Environment Agency if required. All other waste transported off site must have a waste transfer note and be kept by the HoF for a period of 2 years. The HoF will undertake such initiatives as are necessary and practicable to reduce waste generation. THE Hof will also work on such recycling initiatives that are cost effective and do not place undue working practices on its personnel. The Hof must always be consulted regarding the generation of an unusual quantity and/or type of waste that falls outside of normal funding. The Hof will monitor compliance and administer the central returns for licences, certificates and other formal paperwork required by law (not for radio-actives). Legal paperwork received from waste contractors, Dangerous Goods Safety Advisor (DGSA), Automatic Driver Recognition (ADR) and the Environment Agency (EA) are used as monitoring tools The Hof must liaise with the Radioactive Waste Adviser as regards potential radioactive waste. Portering and Logistics Manager The Portering and Logistics Manager is responsible for ensuring that the day-to-day operational issues surrounding waste disposal within the Trust are conducted in line with the procedure and code of practice. The Portering and Logistics Manager must ensure that there is sufficient manpower available to carry out the required collections in line with the Service Level Agreements (SLAs). The Portering and Logistics Manager must ensure that the waste removed from the dedicated ward storage areas is removed to the bulk storage areas, segregated into the correct waste streams pending collection by the approved contractor. The Portering and Logistics Manager must also ensure that the correct frequency of collections by the approved contractor is set and maintained, so that the environmental impact of waste is kept to a minimum in line with legislation requirements.


The Portering and Logistics Manager must liaise with the Radioactive Waste Adviser regarding potential radioactive waste. Service Managers, Line Managers and Supervisory Staff It will be the line management responsibility to ensure the implementation and adherence to the Waste Management Procedure within their areas of responsibility. They will ensure that all staff under their direct control are aware of the details necessary to deal with the types of waste most frequently produced within their respective work area or activity and comply with these details. They must also be aware of what to do if other waste is encountered, even if that is some form of holding/emergency action. They will ensure that the necessary local resources, financial and other are available to ensure that all aspects of the procedure and WDDS (Appendix A) can be met. If there are problems in this respect then this should be drawn to the attention of management until the problem is resolved. Notification in writing should be made to the HoF of any problems or incidents relating to compliance. A Datix electronic incident reporting form must also be completed. They will ensure that staff working within their areas or responsibility are appropriately trained, are provided with specialist equipment and protective clothing as necessary and receive immunisation as advised by Health and Wellbeing. Housekeeping Housekeeping services are responsible for ensuring an adequate supply of all disposal bags and unique identifiable clinical waste tags are provided at ward/department level. Housekeeping staff must ensure that waste generated at ward/department level must be stored with a unique identifying tag, when being removed from the receptacle prior to transportation. Additionally under the direction of ward/department heads, all staff must ensure that waste collection is segregated within the dedicated waste holds. All staff must report to their immediate line manager any incidents/accidents to enable action to be taken as appropriate. Wardsmen The Wardsmen are responsible for the collection and removal of all waste generated by each ward/department from the designated ward/departmental waste storage zones. Wardsmen must ensure that when collecting the waste from the designated storage area, that waste is kept segregated at all times. Under no circumstances must waste be mixed. Each waste stream is to be removed and returned to the external waste storage areas, prior to collection and disposal by the contractor. When arriving at the dedicated waste holds, a visual inspection of all clear domestic waste bag should be undertaken and any identified as contaminated (Clinical Waste or Sharps) must be reported straight away to the Ward Sister or Nurse in charge and their Line Manager so that a Datix incident report can be raised. At the soonest opportunity, it should also be reported to the Risk Management Team. Any waste identified as contaminated, must be quarantined pending investigation. When arriving at the external waste storage zones, it is imperative that the waste collected is stored within the relevant containers/storage facilities, whilst ensuring that all waste remains segregated at all times.


If the waste requires to be assigned at this stage, then the relevant labels with the appropriate EWC codes must be applied pending collection/disposal. All Wardsmen must report to their immediate line manager any incidents/accidents to enable action to be taken as appropriate. Estates and Capital Projects Staff The Capital Projects and Estates Department staff are responsible for the management and removal of building waste and asbestos removal from the site in line with legislation requirements. Ward/Departmental Managers Ward/Departmental Managers will implement the procedures for the management of waste and segregation practices including infection control requirements. They are responsible for making sure all staff are up to date with infection control training and for ensuring their staff abide by safe practices around waste segregation and handling. Radioactive Waste Advisers and Radiation Protection The Trust Radioactive Waste Advisers are appointed by the Chief Executive to advise the Trust on all aspects of radioactive waste. They will ensure that all procedures concerning the handling and disposal of radioactive waste comply with legal requirements and good working practice. The Radiation Protection Section of the Medical Physics Department is responsible for maintaining the site Environment Agency permits, which allow the Trust to accumulate and dispose of radioactive waste. They also manage the central radiation store, organise between site and off site transfers of radioactive waste and maintain the central records of radioactive waste. Annual audits of departments using radioactive material are performed in accordance with the Trust Radiation Safety Policy, document number 165. Any concerns regarding radioactive waste will be brought to the attention of Line Managers, Service Managers and the Chief Executive as appropriate. A Datix electronic incident reporting form should also be completed. Head of Department/Ward (Contractors) It is the responsibility of the employing head of department/ward to ensure all contractors‟ staff are made aware of the contents of this procedure. Contractors All contractors employed by or working on behalf of the Trust, in, on or adjacent to Trust property will make the necessary arrangements to comply with this procedure. Any contractor who does not comply with this procedure maybe requested to cease work or to leave site until an undertaking is given to work within the remit of the Waste Management Procedure.

3. Process Minimisation of Waste Careful consideration will be given by the Trust to the elimination or minimisation of waste at source by use of the waste hierarchy. The ethos of the Waste Management Procedure is to develop sustainable practices based upon the waste hierarchy encompassing the principles (prevention – re-use – recycled – recovery – landfill) to reduce pollution and damage to the environment.


Every process undertaken by the Trust from procurement, new buildings, revised practices, new procedures and either revised or new techniques need to ensure that waste is based upon the waste hierarchy legislation. By using the waste hierarchy in every day practices, this will ensure that waste is kept to a minimum whilst evidencing best practice. Transportation of Waste A registered waste carrier must undertake all transportation of wastes off site and all movements of waste must be accompanied by the correct documentation. All queries regarding the movement and transportation of waste should be raised through the HoF, who has the overall responsibility for these contracts. All waste carriers must comply with the requirements of „The Carriage of Dangerous Goods Regulations‟ for the correct provision of equipment and suitable driver training. All matters pertaining to waste transfer should be made to either the Portering and Logistics Manager or HoF who are responsible for the movement of waste around the Trust sites. The Trust has appointed a Dangerous Goods Safety Advisor (DGSA) to ensure compliance and advice on matters relating to the carriage of dangerous goods. A Hazardous Waste Consignment Note must be completed for every movement of hazardous waste off site and copies of the documentation must be kept by the HoF for a period of 3 years and made available for inspection by the Environment Agency if required. Radioactive waste may only be transported off site by a named contractor, specified in the site Environment Agency permit issued under the Environmental Permitting Regulations 2010 [SI 675] revised 2011, to the incineration sites listed under the said permit. Copies of the permits are held in those departments using unsealed radioactive material (Nuclear Medicine, Pharmacy Support Unit and Medical Physics). The contractor must be furnished with the correct hazard warning signage and documentation in accordance with the ADR (Automatic Driver Recognition in Transport)/CDG (Carriage of Dangerous Goods) regulations. Handling of Clinical Waste Segregation Clinical waste will be segregated at source and placed in the UN (United Nations) approved orange clinical waste sacks (or yellow clinical waste bags in selected areas within the Trust) or rigid containers as appropriate to prevent contamination. As the clinical bags are filled, they must be tied and identified using the ID tags, then transported to a sub-storage area or to the bulk storage facility prior to transportation off site for final disposal. Bags and bins must not be overfilled. Full refers to 75% full or a maximum 5kg in weight. Bags must have their necks secured so as to render them leak-proof, before being collected and transferred to either sub/bulk storage areas. Rigid containers will be sealed before transfer to the storage area. Handling Prior to Disposal Waste comprising of human tissue, items containing liquid blood or body fluids (with the exception of urine and faeces waste) must be placed in the specified rigid plastic containers at the point of generation. Containers must be removed daily or when 75% full. Contents must not be decanted or transferred from one container to another. Urine and faeces waste may be placed in orange waste sacks, which are double bagged and leak-proof. Each container must be secured prior to removal from wards or departments, the relevant ID tag applied and identification tie attached.


Waste compromising of discarded syringes, needles and cartridges, broken contaminated glass and any other sharp item(s) must be placed in UN approved rigid plastic sharps bin containers. Syringes containing drug or drug ampoules or bottles in which there is no minimum threshold for residues must be segregated and disposed of as Special/Hazardous Waste, refer to section Handling and Segregating of Special/Hazardous Waste. These containers must be kept in secure areas in order that they cannot be accessed by unaccompanied patients gaining access to them. Each container must be sealed prior to removal and have the relevant identification details placed on the labels provided, which is a legislative requirement. No sharp items must ever be placed in the disposal sacks. This would be a direct breach of the Prevention of Sharps Injuries in the Healthcare Sector Regulations 2014. Waste comprising laboratory or post mortem waste may contain pathogens and must be rendered safe prior to disposal (autoclaved). This waste must be then placed in specific leak-proof containers, either sacks or rigid plastic containers as appropriate, sealed prior to removal and have the relevant identification tie attached. The handling of laboratory waste must be done so in accordance with the Laboratory Waste Disposal – Document No: WU 0012. Human tissue, limbs, placentas, any large quantities of body fluids shall be disposed of in appropriately sized rigid plastic containers. Under no circumstances must they be placed in yellow/orange sacks. Each container must be sealed prior to removal and have the relevant identification label attached completed (this is a legislative requirement). Transportation to the disposal area must be supervised. Waste comprised of a certain pharmaceutical and chemical waste must be returned to the Pharmacy. Advice on the final disposal must be sought from a technically competent person/manager. The disposal of cytotoxic drugs is contained in a separate, specific procedure, document number 196, and should be referred to for disposal methods. Waste, which includes incontinence pads, disposable urine containers, disposable bed pan liners and stoma bags, unless arising from high risk areas, should be discharged to sewer via purpose built units.. Items which cannot be discharged to the sewer by this means must be placed in orange clinical waste bags or, if bodily fluids are present, placed in rigid plastic leak-proof containers and sent for disposal by heat treatment/incineration. Storage Internal means of storage, such as wheelie bins, are provided. These storage containers are cleaned and disinfected by the contractor when the bin is sent for emptying/incineration. They must be located so as not to obstruct access routes or form potential fire hazards in lobbies. They must be secured to prevent access at all times, except when being loaded. Clinical waste bags and sharps bins must be placed in these containers and not accumulate in corridors, wards or unsuitable areas (public areas, offices and sluice rooms). Under no circumstances must clinical and non-clinical waste be mixed or come into contact with each other during transportation or storage either in temporary or bulk storage areas. Bulk clinical waste storage must be located away from food preparation areas, general storage areas and general public access routes. The storage area must be secured, and kept hygienic, clean and tidy at all times. Hand washing facilities for waste disposal staff must be available, suitable protective clothing provided and equipment supplied and maintained. The Emergency Spillage Procedure, document number 377, is available on the intranet for all ward/department managers and should be made available to all staff during times when waste collection services are in operation.


Clinical waste will neither be accepted at any licensed bulk disposal facility, nor dispatched from a CHUFT site without the correct consignment note completed to record all relevant information, identification and European Waste Codes. Handling of Healthcare Waste Healthcare waste is classified into the four following categories:

Clinical Waste (Hazardous/Infectious).

Non-Clinical Waste (Non-Hazardous).

Hazardous Waste (Domestic/Household).

Non-Hazardous Waste (Domestic/Household). The definition of clinical waste has historically been used to describe those wastes produced from healthcare and similar activities that pose a risk of infection or may prove hazardous. Clinical Waste must be segregated from the other wastes and treated/disposed of appropriately in suitably licensed facilities on the basis of the hazard it poses.

The current legal definition of clinical waste in the UK is taken from the Controlled Waste regulations 1992, issued under the Environment Protection Act 1990.

Clinical Waste is defined as: o Any waste which consists wholly or partly of human or animal tissue, blood or other

bodily fluids, excretions, drugs or other pharmaceutical products, swabs or dressings, syringes, needles or other sharp instruments, being waste which unless rendered safe may prove hazardous to any person coming into contact with it.

o Any other waste arising from medical, nursing, dental, veterinary, pharmaceutical or similar practice, investigation, treatment, care, teaching or research, or the collection of blood transfusion, being waste which may cause infection to any person coming into contact with it.

Non-Clinical Waste All non-clinical wastes, with the exception of hazardous waste, are classified under the provisions of the Environmental Protection Act 1990, Controlled Waste Regulations 1992, as controlled waste. Non-Clinical waste can be divided into a number of categories:

Non-Clinical domestic waste placed into black bags.

Recyclable materials such as packaging, cardboard, office paper, printer cartridges and batteries, which can all be placed within clear bags or original packaging and placed with the general domestic waste awaiting collection/removal to the central storage zone whereby the waste will be segregated into its individual waste stream.

Large items of broken furniture or other equivalent items.

Confidential paper waste, which is placed within the sited secure units, whereby the unit will be serviced by the approved contractor.

Hazardous Waste Hazardous Waste is defined by the Hazardous Waste Regulations 2005 as any which contains any of the 14 key hazardous elements i.e. H1 = Explosive, H2 = Oxidising. Clinical Waste is determined by H9 = Infectious, which is interpreted in to „Substances containing viable micro-organisms or their toxins which are known or reliably believed to cause disease in humans or other organisms‟. The term „Hazardous Waste‟ can be used to describe a number of different wastes generated within a healthcare environment such as waste chemicals, waste oils, batteries, fluorescent light bulbs, computer and/or TV monitors and fridge freezers etc. Segregation The disposal of all wastes must be facilitated by the identifying and segregating groups of waste. Specified recognisable sacks or containers, which meet required UN standards, are used for the disposal of clinical waste and the majority of non-clinical waste (known as black bag/recycled waste). Large items of domestic/household waste e.g. broken furniture and


hazardous wastes are disposed of by notification and arrangement via the Portering Department by contacting the Facilities Helpdesk on extension 7676. Clinical waste will be segregated at source and placed into specified Orange (or yellow where applicable, as mentioned previously) or leak-proof rigid containers to prevent contamination. As the containers are filled they must be securely sealed using approved methods and the identification label correctly completed (this is a legislative requirement). The waste shall then be transported to either the sub-storage area or the final collection/ storage point as appropriate. Black bag waste must not contain dressings, gloves, aprons, incontinence pads or any sharp items from any clinical area. To avoid errors in segregation, clinical wastes and domestic wastes must be stored separately and never be in contact with one another, including whilst in transport. Bags must never be overfilled and must have their necks secured before being collected and removed to the main storage area/zones. (Full refers to 75% full or weighing a maximum of 5kg). Clinical waste bags and containers must be marked as to their origin with the appropriate identification labels or ties firmly attached. Confidential waste must not contain any material such as:

batteries.

food waste.

hanging folders.

large metal objects.

any domestic waste. Only Confidential Waste (client files, financial reports, private correspondence, employee records or patient information) and/or paper waste is fit for recycling (Magazines/Newspapers). Storage Internal means of storage for waste such as containers will be provided, which can easily be cleaned and disinfected as appropriate. This type of storage must not obstruct access routes or form a potential fire hazard in lobbies. Storage facilities/containers must be secured to prevent access at all times apart from when the unit is being loaded or exchanged. Waste must not accumulate in corridors, wards or other unsuitable places (public areas, offices or sluice areas). All storage containers for clinical waste will be clearly identified to indicate they are for clinical waste only. Bulk waste storage will be sited away from food preparation areas, general storage areas and general public areas. These areas must be secured, enclosed and sited on an appropriate surface, well ventilated, signed and washed down regularly. Provision for a hose point is required. Care must be taken when washing down not to cross-infect adjacent surface waste drainage systems. The bulk storage areas must be secure at all times and access must be limited to authorised personnel only. Clinical and Non-Clinical waste must be segregated in all bulk storage areas. Washing facilities for staff must be available and suitable protective clothing and equipment supplied and maintained.


Transportation Trolleys and carts used for the movement of waste within premises must be designed and constructed so they are easy to manually handle. Assessment of manual handing operations must be undertaken as outlined in the Health and Safety Policy, document number 204. Trolleys and carts must be regularly cleaned and disinfected to prevent infestation. High pressure cleaning or disinfection as appropriate should be undertaken weekly or when required. Trolleys and carts must be disinfected when spillages occur. Where external contractors are required to remove waste, their vehicles must be fit for purpose, so that waste can be easily be loaded and unloaded minimising any manual handling risk. They must carry the required protective clothing, safety equipment and cleaning materials for dealing with spillages. Where external contractors are required to remove waste, the drivers and the assistants (where applicable) must be trained to handle waste as appropriate and to maintain required levels of hygiene. The employer must provide written instructions in accordance with this Trust procedure for the employees. All contractors removing waste from Trust premises must be registered with the Environment Agency as an approved waste carrier. Where external contractors are required to move waste, a waste transfer/consignment note system detailed in the Environmental Protection (Duty of care) Regulation 1991 will be established. At all times they must employ a safe system of work, provide details of their procedures to the Trust and follow emergency spillage procedures. Handling of Non-Clinical Domestic and Recyclable Waste Handling and Storage Internal means of storage for domestic bagged waste such as 360/750/1100 litre bins will be provided which can easily be cleaned and disinfected as appropriate. This type of storage must not obstruct access routes or form a potential fire hazard in lobbies. Storage facilities/containers must be secured to prevent access. Domestic waste bags must not accumulate in corridors, wards or other unsuitable places (public areas, offices, sluice). All storage containers for domestic bag waste must be clearly identified (waste bins are black in colour) to indicate they are for domestic bag waste only. Bags must not be overfilled. Bags must have their necks secured as to render them leak-proof before being collected and transferred to the storage area. Full refers to 75% full or maximum 5kg in weight. Large items of broken furniture or surplus equipment for disposal must be reported to the Portering Department via the Facilities Helpdesk on extension 7676, and they will make the necessary arrangements for collection.

Broken furniture.

IT equipment – ICT Department.

Medical equipment – Liaise with Electronics Biomedical Engineering (EBME) Department – (Please refer to the Trust Decontamination Procedure, document number 219).

Unless instructed, large items of broken or surplus equipment must not be placed in corridors. Subject to staffing and manual handling requirements these items will be collected and removed as speedily as possible. Waste for recycling such as printer cartridges must be placed within the replacement boxes and batteries placed within the dedicated storage units. The Trust will attempt to recycle, re-use and/or recover as many different materials as is practicable by working with the waste


contractor and local authorities to promote recycling, re-use and recovery before final disposal. Cardboard or paper must be separated from the general domestic waste streams. Cardboard boxes must be collapsed flat and bundled. This material must be placed neatly adjacent alongside the black domestic waste ready for collection. ALL confidential paper such as person identifiable and commercially sensitive as per IG guidance (patient files/details, financial statements/reports, private correspondence, employee records, Trust documents and business files) must be placed in the confidential waste units located around the hospital. The emptying of the units occurs fortnightly directly by the contractor. If the unit fills prior to the collection schedule, please contact the Facilities Helpdesk via extension 7676. Under no circumstances must food/drink or any other waste be placed within the confidential waste paper stream. General paper waste and/or paper-based material that is not confidential or not classed as case sensitive can be placed in cardboard based paper recycling stations. When full, the bags must be placed with the domestic waste ready for collection, segregation and recycling. Many electrical items which are currently classified as domestic waste are governed by the Waste Electrical, Electronic and Equipment Directive (WEEE Directive). This means that all electrical items must be recovered, recycled or re-used and not disposed of to landfill. Any department wishing to dispose of electrical items must also consider the costs for the disposal, as this will be recharged to the department. All departments disposing of any WEEE items must inform the Facilities Helpdesk on extension 7676 of any pending disposal along with details of the item(s) to be disposed of. Handling of Hazardous Waste (including Cytotoxic and Prescription Drugs) Arrangements for the Disposal of Special/Hazardous Waste A list of waste chemicals or other items for disposal, their nature, quantities and COSHH information must be submitted to the HoF responsible for waste disposal. Further information may be required before disposal can be arranged. Because of the costly nature of special/hazardous waste disposal, and the notification procedures necessary under the Hazardous Waste Regulations, there may be a delay before disposal can be arranged. Hazardous waste for disposal must be stored safely in the department of origin until final collection is arranged. Separate disposal arrangements already exist for the disposal of cytotoxic and prescription drug residues. Under no circumstances must Special/Hazardous waste, other than infectious clinical waste, cytotoxic or prescription drug residues, be stored in clinical waste bins or yellow waste sacks. Once arrangements are made for the disposal of hazardous items, they will be collected from their place of storage by an authorised member of staff. The Pharmacy department‟s officer responsible for safety must notify any handling hazards associated with these items to either the member of staff or contractor collecting. Storage and Disposal The authorised member of staff collecting the chemicals will transfer them to a secure storage area under the control of the Pharmacy Manager responsible for waste disposal, to await packaging and collection. The storage area must be kept locked at all times and display appropriate HAZCHEM signs. All Special/Hazardous wastes being disposed of must be identified and listed with the appropriate European Waste Code (EWC) and entered on the Hazardous waste


consignment note in accordance with the requirements of Hazardous Waste Regulations 2005 and Environmental Protection Act 1990. Cytotoxic and Prescription Drug Residues These items must be placed into the appropriate cytotoxic waste bins with a purple Lid, placed into a rigid plastic container and clearly identified by affixing a hazard warning sign and cytotoxic residue tape. These containers must not be placed in the clinical waste streams but notified to the Pharmacy Department via e-mail for the safe collection and storage away from any other waste stream, ready for controlled/supervised collection/disposal.

All sharps that may contain prescription drug residues in which there is no minimum threshold must be disposed of as a hazardous waste and sent for incineration only.

All sharps possibly containing non-cytotoxic drug residues must be disposed of into sharps bins with a Yellow Lid.

Disposal of Refrigerant Gases (Fgas) All refrigerant gas works must be carried out by an approved contractor in reference to the Defra (Managing fluorinated gases and ozone-depleting substancesguidelines).

It is the responsibility of the approved contractor carrying out any works to remove the redundant equipment and to provide the Trust with the relevant Hazardous Waste Consignment notes as is required under the The Duty of Care Regulations 1991-10. Legal paperwork must be provided prior to collection and at the end of the disposal process to ensure entire cradle to grave compliance.

Accumulation and Disposal of Radioactive Waste

The accumulation and disposal of all radioactive waste must be carried out in accordance with the Environment Permitting Regulations 2010 (as amended 2011). The Trust‟s Principal Physicist in the Radiation Protection Section of the Medical Physics Department maintains the permits issued by the Environment Agency and monitors compliance with the conditions and limits set within these permits. The Radiation Protection document „System of Management for radioactive materials registration, accumulation, disposal and security‟ details the systems in place to control production, accumulation and disposal of radioactive waste in the Trust. Local rules in each department using radioactive materials also detail procedures to be followed. Each department producing and accumulating radioactive waste must have written procedures for handling and disposing of radioactive waste which comply with the System of Management policy document. All radioactive waste must be stored in designated labelled bins and storage areas and disposed of through the correct disposal route. New procedures involving radioactive material must be approved by Radiation Protection prior to introduction. For further details and instructions on this matter, please contact the Trust Radiation Protection Advisers or Radioactive Waste Advisers. Pharmacy The Trust‟s Pharmacy Department operates via an internal Waste Disposal Policy (6006 – Version: 008). The policy concerns the disposal of waste from the Pharmacies. The policy and procedures aim to ensure the safe and prompt disposal of waste according to relevant legislation, minimising any risks to staff, external contractors, the general public and the environment. The policy and procedures aim to recycle waste whenever there are recycling arrangements within the Trust. Recycling is an essential component of the Trust‟s environmental objectives.


Ward and departments must return all pharmaceutical waste to the Pharmacy for disposal. It is the responsibility of nursing staff within the wards/departments to dispose of empty glass pharmaceutical containers using the sharps units that are already in situ. Patients must be counselled to return any unused medicines to a Pharmacy for correct disposal and not to dispose of medicines into household waste. The internal Pharmacy policy includes:

Procedures for Different Types of Waste.

Pharmacy Contacts.

Advice for Departments outside Pharmacy on the Disposal of Pharmaceutical Waste.

Trust Toxic Waste Consignment Notice. Pathology The Trust‟s Pathology Departments operate under a number of Government Legislation (Standards for the medical laboratory – Version 2.02 Nov 2010) and National Guidelines (Code of Practice 5 – Disposal of Human Tissue, The Retention & Storage of Pathological Records and Specimens) as well as a number of internal Standard Operating Procedures (SOPs) as follows for each department: Haematology HC009 – Version 1.2, HC0021 – Version 2.1, SOP CR0001 – Version 1.1, HC 0018 – Version 1.3, HC 022 – Version 2.0 Cellular Pathology SOP P0005 – Version 1.4, SOP CT0018 – Version 4.0, SOP CT0023 – Version 6.1 Laboratory Health & Safety Code 2.4, SAF 0003, SAF 0005, MI WU0012 Biochemistry Specimen Storage & Disposal – Document No: SOP OFF0017 – Version 1.4 The above operating procedures provide the relevant details for each operation in the correct disposal of all waste generated within the departments. Disposal of and/or Prevention of Sharps Contamination Injuries Sharps Injuries In reference to „Management of Sharps and Contamination Injuries Procedure‟, document number 100. All staff members that come into contact with sharps need to be aware of the responsibilities that both the employer and employee have to ensure the safety and wellbeing of not only themselves but other staff members, patients and visitors. If a splash incident has occurred, the affected area must be rinsed with tap water or saline. If it is a needlestick injury, the wound must be encouraged to bleed, washed with soap and water and covered with a waterproof dressing.

Safe Practices – Sharps

Needles must not be re-sheathed. Re-sheathing needles is a common cause of needlestick injury (Health and Safety (Sharp Instruments in Healthcare) regulations 2013). Under the new regulations needles must not be recapped after use unless the employer‟s risk assessment has identified that recapping is itself required to prevent a risk (e.g. to


reduce the risk of contamination of sterile preparations). In these limited cases, appropriate devices to control the risk of injury to employees must be provided. For example, needle-blocks can be used to remove and hold the needle cap and so allow safe one-handed recapping.

If a suitable safer sharp is not available to reduce the risk injury, the employer must ensure that procedures are relevant and that risk assessments and safe methods of working with the disposable sharps are in place.

Syringes/cartridges must be disposed of intact. Sharps must never be passed hand-to-hand, handling must be kept to a minimum (MDA SN 2001 (19), Safe use and disposal of sharps, Medical Devices Agency July 2001). All sharps must be disposed of carefully at the point of use. A suitable sharps container (conforming to British Standards BS 7320) must be portable enough to take to the site of a procedure.

Recycling of Waste Batteries It is the Trust‟s policy to recycle all waste batteries. Each ward/department must dispose of all waste batteries by placing them into battery collection containers ready for disposal at the central waste storage container located in the Maintenance Department (Main Building)

Under no circumstances must redundant batteries be placed within the domestic waste stream for disposal.

If a collection of batteries is required, please contact the Facilities Helpdesk via extension 7676 to arrange for a collection.

Disposal of Waste from Outpatients and surrounding Hospital Facilities (Essex County Hospital, Microbiology and Chestnut Villas) All of the external hospital facilities have either an ad hoc or a pre-organised collection covering the following:

Domestic Waste.

Hazardous Clinical Waste.

Cytotoxic/Cytostatic Waste.

Radioactive Waste.

Confidential and Paper Waste. Disposal of Confidential and Paper Waste The disposal of confidential paper waste must be carried out in relation to the Information Governance policies and procedures as listed below:

239 – Data Protection Procedure.

238 – Information Governance Procedure.

291 – Information Security Policy.

312 – Sending a Fax including a Safe Haven Fax Procedure.

189 – Health Records Management Procedure.

310 – Creation of Corporate Records Procedure.

309 – Creation of Corporate Records Policy. The Trust has a number of confidential waste paper stations located around the hospital site. With reference to the above policies and procedures, staff must ensure that all confidential paper waste is securely placed within the units provided. Under no circumstance must confidential paper waste be placed within any other waste stream operated by Colchester General Hospital, as this will be classed as a breach of Information Governance. Any breaches may be dealt with under the Trust‟s Disciplinary Policy.


If there is any doubt regarding the above policies, procedures and guidance, then the relevant line manager, Information Governance Team or the Facilities Helpdesk (extension 7676) must be contacted. Asbestos Disposal All asbestos positive material that needs to be removed from the Trust and disposed of must be done so by following the Asbestos Management Plan (Redhills – CHUFT/001). Only Environment Agency/UKAS (United Kingdom Accreditation Service) accredited contractors will be used to carry out such works. Funding and Financial Arrangements The cost of normal waste disposal requirements are funded centrally, although it is recognised that some departments/areas will, from time to time, generate an unusual quantity or type of waste that will fall outside of this normal funding. In these circumstances the HoF must be consulted. When requesting approval for funding for items over £5000, or when any replacement item may fall outside of the domestic waste categorisation code (e.g. WEEE), a disposal charge must be built into the cost for any replacement items. Anatomical Waste Anatomical waste, which includes recognisable body parts and placenta, requires disposal by incineration in a suitably licensed or permitted facility. The waste must be stored and transferred in yellow UN approved rigid containers with red lids and be clearly labelled. Defining Anatomical Waste

Sensitive Disposal of Fetal Remains, Limbs, Tissue and Organs The disposal of Fetal Remains, Limbs, Tissue and Organs are covered in the Sensitive Disposal of Fetal Remains, Limbs, Tissue and Organs Policy and Procedure, document number 094.

Description of Anatomical Waste Anatomical

YES/NO

Limbs (Whole or Part)

YES

Whole or Part Fingers, Toes, Ears, Eyes or other appendages (part = any single item – 5% of the total mass of the item whole)

YES

Whole or Part Bones (part = any single item – 5% of the total mass of the item whole)

YES

Whole or Part Organs (part = any single item – 5% of the total mass of the item whole)

YES

Skin/Muscle (when individual pieces are greater than approximately 4 cm2/cm3)

YES

Afterbirth/Placenta

YES

Foetal Remains

(seek further specialist advice)


The document concerns the dignified disposal of the remains from a pregnancy loss up to 14 weeks gestation and of tissue and organs from surgical procedures or histological investigations. This includes therapeutic terminations under 14 weeks‟ gestation. All such tissue and organs must be disposed of in a dignified and respectful manner. For the correct disposal of foetuses please refer to the following guidelines in conjunction with Stillbirth and Neonatal Death Society (SANDS) (1995) Pregnancy Loss and the death of a baby – guidelines for professionals and the institute of Cemetery and Crematorium Management (ICCM) (2004) Policy document for the disposal of fetal remains. Spillages The disposal of waste generated via a spillage is covered in the Emergency Spillage Procedure, document number 377. Infectious Substances for Transport Under the classification requirements of The Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2009 and The Carriage of Dangerous Goods and Use of Transportable Pressure Equipment (Amendment) Regulations 2011 and ADR (Automatic Driver Recognition in Transport) infectious substances are substances which are known or are reasonably expected to contain pathogens (micro-organisms, e.g. bacteria, viruses, rickettsiae, parasites, fungi, and other agents e.g. prions, which can cause disease in humans or animals). Under this classification infectious substances handled by the Trust are divided into two categories – Category A and Category B: Category A: An infectious substance which is transported in a form that, when exposure to it occurs, is capable of causing permanent disability, life threatening or fatal disease to humans or animals. NOTE: An exposure occurs when an infectious substance is released outside of the protective packaging, resulting in physical contact with humans or animals. An indicative list of infectious substances that meet these criteria is provided in Appendix 020. Infectious substances that do not meet the criteria for inclusion in Category A are Category B. Classification of Category A Clinical Waste Category A clinical waste from humans are those materials that are known or suspected of containing any of the particular micro-organisms on the list in Appendix 020. Assessment is based on the known medical history and symptoms of the source human, endemic local conditions or professional judgement concerning individual circumstances of the source human or confirmed cases from diagnostic testing. Materials meeting the criteria for Category A shall be assigned to: UN2814, INFECTIOUS SUBSTANCES, AFFECTING HUMANS Classification of Category B Clinical Waste Category B clinical waste from humans are those materials that are known or suspected of containing an micro-organism which can cause disease in humans, but does not meet the criteria for inclusion in Category A. Materials meeting the criteria for Category B shall be assigned to: UN3291, CLINICAL WASTE, UNSPECIFIED, N.O.S. Category A Clinical Waste Security Plan Category A contaminated clinical waste is considered a „high consequence dangerous goods‟ in accordance with the carriage regulation. High consequence dangerous goods are


those which have potential for misuse in a terrorist incident and which may, as a result, produce serious consequences such as mass casualties or mass destruction. Movement of any high consequence dangerous goods from the Trust sites must be controlled by a Category A-Plan. Category A Clinical Waste Handling Procedures Category A waste generated in the Trust laboratories is treated in the laboratory autoclaves on site to render it safe for transport. This process is controlled by local laboratory procedures. The Trust laboratories may also have cultures and specimens that meet the criteria for inclusion in Category A that are to be transported to reference laboratories. This process is controlled by the local laboratory procedures. The Trust does not deal with patients with infections meeting the criteria of Category A, but there is a very remote possibility that the Trust could have a patient that does have a known or suspected Category A infection. The Viral Haemorrhagic Fever Policy will be followed for patient care. Immediate Action Where a known or suspected Category A infection is identified the Trust Infection Control Team must be informed immediately either on extension 4268 or 2702. During “out of hours” staff should contact the on call Microbiologist via Switchboard.

4. Training and Staff Awareness All staff receives Infection Control training at induction and on a 2 yearly basis for mandatory updates. Both of which include training on basic waste management procedures. Staff also receive the relevant waste management information on induction to their ward or department. Facilities staff receive more specific waste management training dependent to what is pertinent to their job role. It is the duty of managers at all levels to ensure that their staff are trained in the correct methods for the disposal of waste produced in their areas. Any training, re-training or awareness training given to staff must be recorded on personal staff training records or on the Trust training management software

5. Evidence Base

HTM/07/01 Safe Management of Healthcare Waste

Safe Disposal of Healthcare Waste, Health Services Advisory Committee

Health Technical Memorandum 2065, Segregation of Waste Streams in Clinical Areas

The Health and Safety at Work Act 1974

The reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995

Management of Health and Safety at Work Act 1999

The Control of Substances Hazardous to Health Regulations (COSHH) 2002

The Environmental Protection Act 1990

The Duty of Care Regulations 199110. The Landfill (England and Wales) Regulations 2002 (2005/2009)

The Special Waste Regulations 1996

Control of Pollution Act 1974

Hazardous Waste Regulation 2005

List of Waste Regulations 2005

Transportation of Infectious Substances Regulations 2005

Waste Electrical, Electronic, Equipment Regulations (WEEE) 2007

2006 Batteries Directive

Information Security Management – NHS Code of Practice


The Caldicott Guardian

WRAP Legislation (WFD 2008)

Pre-Treatment Legislation 2007

EU Landfill Directive 1993

The waste management licensing act 1994

The Environmental Permitting Regulations 2010 (as amended 2011)

The Carriage of Dangerous Goods and Use of Transportable Pressure 27. Equipment Regulations 2009 (as amended 2011)

Standards for the medical laboratory (version 2:02 – Nov 2010) – Clinical Pathology Accreditation (UK) Ltd

Code of Practice 5: Disposal of Human tissue – Human Tissue Authority

The Retention and Storage of pathological Records and Specimens

094 – Sensitive Disposal of Fetal Remains, Limbs, Tissues and Organs Policy and Procedure

The Ionising Radiation Regulations 1999

6. Monitoring Compliance and Audit The Trust has a responsibility to ensure that all waste is managed in accordance with waste legislation and governance standards imposed upon the NHS by the Environment Agency and Care Quality Commission (CQC). In practical terms all managers have a monitoring and compliance role. They should draw to the HoF attention any local instances of non-compliance whether this is due to poor working practices or lack of resources. A Datix electronic incident reporting form should also be completed. All staff must note that non-compliance with regulations made under the Environmental Protections Act could, in certain circumstances, result in individual prosecution. Deliberate non-compliance with this procedure or code of practice may result in disciplinary action. Fines imposed by the waste contractors or Environment Agency will be cross-charged to directorates for any identifiable non-conformance incident or shared incidents where responsibility cannot be identified. Adhoc and planned waste compliance audits will be undertaken by external waste advisors throughout the year. The DGSA advisor will undertake a quarterly review whilst the Environment Agency pre-acceptance audits will be completed annually with any urgent follow up audits completed dependant upon any non-compliance identified. All audits carried out by the external waste advisor will be given to the HoF who will produce an action plan to rectify any remedial actions found. The results of these audits will be reported to the quarterly Trust Health and Safety Committee within the Estates and Facilities report. The Trust Health and Safety Advisor will include waste compliance in the annual departmental Health and Safety Audit. Individual wards and departments also receive an annual Infection Control Audit that includes a section specific to waste management. Exceptions from Infection Control audit reports are reported to the Hospital Infection Control Committee.

7. Dissemination, Implementation and Access to the Document This procedure is available on the Trust intranet. All staff are notified via email, of the procedure and other amendments.


Appendix A

Waste Disposal Data Sheet – 001 Clinical

Waste Category

Hazardous EWC 18 01 03

Examples

Human tissue, including blood (whether infected or not) from hospital or laboratories, and all related swabs and dressings. Waste materials, where assessment indicates a risk to staff handling them, for example from infectious disease cases. Soiled surgical dressings, swabs and other soiled waste from treatment areas such as soiled surgical dressings, swabs, sanitary pads, incontinence pads, disposable nappies, bedpan liners, urine containers, stoma bags, waste from ward toilets and sluice rooms. Pathological waste.

Appropriate Storage Containers

Clinical Waste Bag – Heavy Duty 55 Micron Griff/Weaver rigid container for liquids and unbroken glass. Extra large waste bags are available for the disposal of contaminated mattresses.

Allocated Colour Code

Orange.

Local Storage Arrangements

Enclosed pedal operated sack holders.

Safety Instructions

Bags should be removed from container when ¾ full or at the end of a clinic. Bags should be twisted at the neck (swan necked) and sealed with a tag issued to the area producing the waste.

Central Storage Arrangements

Bags must be transferred to nearest secure storage area and placed direct into locked wheeled transport containers.

Spillage Arrangements

Any package that is broken or leaking should not be transferred. Bags should be re-bagged, causing as little disruption as possible. Bags should be resealed using a seal from housekeeping service department stock. The spillage of biological fluids presents an infection risk to those who come into contact with them. Therefore any spillage of body fluids must be dealt with immediately. If possible do not leave the area where the spillage occurred until it has been correctly contained and hazard cones employed to warn others of the spillage. It is important that housekeeping staff do not clear up biological fluids. This is because they are not trained to handle biological fluids. However housekeeping staff may clean the area after the removal of biological fluids. Disinfectant Tablets The disinfectant tablet in current use to disinfect surfaces following biological spillages is chlorine releasing tablets Antichlor Plus.

Safety Instructions

Bags must only be handled by the neck and always carried safely as instructed in line with the Trust Manual Handling Procedure. Bags must never be thrown. Clinical waste must never be transported or mixed with domestic or other waste. All transport carts must be locked at all times, other than when being loaded. Assessments made under the Control of Substances Hazardous to Health Regulations should show any pre-treatment required prior to final disposal.


Waste Disposal Data Sheet – 002 Sharps – Non-Medicinal

Waste Category

Hazardous EWC 18 01 03/18 01 09

Examples

Discarded needles, syringes contaminated with blood


Sharps safe containers to BS 7320 standard


Yellow containers with Yellow Lids


Sharps containers must be placed in areas not accessible to children

Collection and Movements Arrangements

Containers should be closed when ¾ full and sealed


Containers must be transferred to secure storage area and placed within the large clinical waste containers provided.


Any package that is broken or leaking should not be transferred. The Portering and Housekeeping Manager should be called to the spillage. Sharps should be cleared using forceps or swept and transferred into another compliant sharps Unit. The forceps/brush should be disposed of as clinical waste.

Safety Instructions

All sharps bin lids should be permanently closed PRIOR to disposal to avoid spillage. The label should be completed in full to identify the originating department.


Waste Disposal Data Sheet – 003 Sharps – Medicinal (including Cytotoxic and

Cytostatic Medicines)

Waste Category


Examples

Discarded needles, syringes, cartridges, glass ampoules, scalpel blades and any other shared implement, including any sharp attached to giving sets, intravenous and perfusion system which has been in contact with medicines, including cytotoxic and cytostatic drugs.


Sharp safe containers to BS 7320 standard.


Yellow containers with purple lids.


Sharps containers must be placed in areas not accessible to children.

Collection and Movement Arrangements

Containers should be closed when ¾ full and sealed. Labels at the front of the bin must be completed PRIOR to disposal.


Containers must be transferred to secure storage area and stored loosely by clinical waste area. Sharps bins with purple lids MUST NOT be mixed with clinical waste bags.


Any package that is broken or leaking should not be transferred. Portering and domestic manager should be called to spillage. Contents should be swept up and transferred into another sharps box. The brush should be disposed of as clinical waste. Cytotoxic Spillages All wards/departments involved with the handling of cytotoxic agents have cytotoxic spill kits available to them on their stock list. Spill kits are readily available from Central Pharmacy and maybe ordered in the same way as other stock items. A cytotoxic spillage kit is available on all wards and in all clinics where chemotherapy is given. Any spillage should be dealt with immediately by the staff member who has administered the drug. Mopping up must not be delegated to domestic staff.

Safety Instructions

INTRAVENOUS GIVING SET PERFUSION SYSTEM. Attempts should NOT be made to cut sharps from lines and tubes. The whole device should be placed inside the sharps box.


Waste Disposal Data Sheet – 004 Pharmaceutical Waste

Waste Category


Examples

Drugs, medicinal products, cytotoxic and cytostatic medicines and controlled drugs (non-sharps). Cytotoxic and cytostatic waste must be kept separate to other pharmaceutical waste.


Approved containers (griff bin) The packages (Pharma-bins) must also bear the Class 6.1 UN Hazard Warning Diamond symbol for Toxic Substances and bear the following UN designations: o UN1851 Waste Medicine, Liquid, Toxic, n.o.s. o UN3248 Waste Medicine, Liquid, Flammable, Toxic, n.o.s. o UN3249 Waste Medicine, Solid, Toxic, n.o.s. The correct identification in line with the above designations must be made by the Pharmacist.


Yellow containers with purple lids for Cytotoxic and Cytostatic waste. Yellow containers with blue lids for all other pharmaceutical waste (or from Mid 2014 – Blue containers with blue Lids)


All out of date drugs and pharmaceutical products must be returned to local Pharmacy.


Such products will be bulked in the Pharmacy until transferred as Pharmaceutical waste by the porter. Cytotoxic waste should be double bagged and clearly labelled. Pharmacy waste, such as out of date prescription only medicines not classified as cytotoxic or cytostatic, must be placed into a yellow-lidded sharps bin and stored securely prior to disposal by the contracted waste company. All Pharmacy waste should be disposed of as Hazardous Waste. Pharmacy waste of this type must also be packaged according to ADR Packing Instruction P001 for Liquids and P002 for Solids when “packages” are used, typically these will be plastic drums with a removable head of a type known as “1H2”.


Stored on site within Pharmacy areas. Cytotoxic waste must be kept separate. Hazardous Chemical Waste Store managed by the Pharmacy Department.


In accordance with the requirements of relevant COSHH assessment. Cytotoxic Spillages

All wards/departments involved with the handling of cytotoxic agents have cytotoxic spill kits available to them on their stock list. Spill kits are readily available from Central Pharmacy and maybe ordered in the same way as other stock items. A cytotoxic spillage kit is available on all wards and in all clinics where chemotherapy is given. Any spillage should be dealt with immediately by the staff member who has administered the drug. Mopping up must not be delegated to housekeeping staff.

Safety Instructions

Drugs and chemical must not be disposed to the drainage system.


Waste Disposal Data Sheet – 005 Anatomical Waste

Waste Category


Examples

Identifiable human body parts.


Double bag using heavy gauge bag and placed within a Griff /Weaver rigid container.


Yellow Body with Red Lid or Anatomical Yellow Bags


Identified designated areas within departments, including designated refrigeration where appropriate.


Bags and Units should be removed when ¾ full or at the end of a clinic. Bags and Units should be either, twisted at the neck or lids secured and sealed with a tag issued to the area producing the waste and double bagged.


Bags and containers must be transferred to the Mortuary for refrigerated storage until collected by waste disposal contractor. Departments must complete appropriate documentation (Consignment Note for the Carriage and Disposal of Human Tissue) to be transferred with waste. Consignment Notes for the Carriage and Disposal of Human Tissue must be maintained by the Mortuary Department for 2 years.


Any package that is broken or leaking should not be transferred. Bags should be re-bagged causing as little disruption as possible. Bags should be resealed using a seal from Domestic service department stock. Blood spillages should be cleaned up using hypochlorite granules in accordance with the infection control procedures. Any further cleaning required should be undertaken as advised by the Infection Control service in consultation with the Waste Manager.

Safety Instructions

Bags must only be handled by the neck and always carried safely as instructed in line with the Trust Manual Handling Procedure. Bags must never be thrown. Clinical waste must never be transported or mixed with domestic or other waste. All transport carts must be locked at all times, other than when being loaded. Assessments made under the Control of Substances Hazardous to Health Regulations should show any pre-treatment required prior to final disposal.


Waste Disposal Data Sheet – 006 Laboratory Waste

Waste Category

Hazardous Various

Examples

Laboratory and Pharmaceutical acids, solvents, stains etc


Bottles, Drums and Cartons


As agreed with Energy and Sustainability Manager


Cartons or Special Crates


As agreed with Energy and Sustainability Manager


Hazardous Chemical Waste Store managed by the Pharmacy Department


In accordance with the requirements of the relevant COSHH assessment

Safety Instructions

All chemical waste disposals will be in accordance with the requirements for Hazardous Waste and storage and collection advice are available from the Waste Manager.


Waste Disposal Data Sheet – 007 Fluorescent Tubes

Waste Category


Examples

Light Bulbs


N/A


N/A


In a safe manner and secure location within the department/ward


Estates will remove and fluorescent tubes from departments and wards. They should not be left within waste disposal store rooms or abandoned in corridors


Designated Tubes Container


Estates staff should be called to any incident. Glass should be cleared using a dustpan and brush and placed within a strong bag for safe disposal


Waste Disposal Data Sheet – 008 Batteries

Waste Category

Hazardous EWC 16 06 02, EWC 16 06 03, EWC 16 6 04, EWC 20 01 33, EWC 20 01 34

Examples

Cadmium, mercuric oxide and lead acid batteries.


Dedicated Battery Storage Bins Lead-acid batteries should be packaged according to ADR Packing Instruction P8021.


N/A


All batteries should be returned to a central point. Batteries used in bleeps should be returned to Switchboard, General Office and Main Reception at CGH and General Office at ECH.


Container will be collected as required by an approved contractor.


Hazardous Chemical Waste Store managed by the Pharmacy Department.


The Pharmacy Store Manager should be called to any spillage.


Waste Disposal Data Sheet – 009 Redundant Furniture, Mattresses and Electrical

Equipment

Waste Category

Hazardous (EWC 16 02 10 - EWC 16 02 14) Non-Hazardous Various

Examples

All electrical and electronic items other than I.T equipment and medical equipment. Any electrical equipment.

Any items of unwanted furniture and mattresses.


N/A


N/A


In a safe manner and secure location within the department/ward.


Porters must be contacted to remove any items of furniture or equipment from departments and wards. They should not be left in waste disposal store rooms or abandoned in corridors. The Removal/Disposal Request Form (Appendix 19.4) should be completed and returned to Porters to arrange removal. Decontamination tags must be used for equipment coming from clinical areas.

Mattresses must be condemned by Infection Prevention Team PRIOR to collection, as per Trust Mattress Procedure.


Items will be stored either within the Clinical Waste Compound or Recycling Centre until waste contractors collect for disposal. Where feasible, metal will be taken from the items and disposed of as scrap metal.

Safety Instructions

Any permanent electrical disconnecting/disabling MUST be undertaken by the Estates Department. This can be arranged via the Helpdesk on 7676.


Waste Disposal Data Sheet – 010 IT Equipment (Including Toner Cartridges)

Waste Category

Hazardous EWC 16 02 13, EWC 16 02 14, EWC 16 02 16

Examples

PCs, Monitor, Printers and Servers. Also printer and copier cartridges.


N/A


N/A




IT Helpdesk must be contacted to request removal of any IT equipment from departments and wards. They should not be left in waste disposal store rooms or abandoned in corridors. The Removal/Disposal Request Form (Appendix 19.4) should be completed and returned to IT to arrange removal, quoting reference number provided by IT Helpdesk. Toner cartridges must be taken to Villa 5 where they are sent off for recycling.


Within IT Department until ready for removal from site via waste contractor. Cartridges are held within Villa 5.

Safety Instructions

Any permanent electrical disconnecting/disabling MUST be undertaken by the Estates Department. The can be arranged via the Estates Helpline.


Waste Disposal Data Sheet – 011 Medical Equipment

Waste Category

Hazardous (EWC 16 02 10 - EWC 16 2 14)

Examples

All items of medical equipment.


N/A


N/A




EBME must be contacted to remove any items of medical equipment from departments and wards. They should not be left in waste disposal store rooms or abandoned in corridors. The Removal/Disposal Request Form (Appendix 19.4) should be completed and returned to EBME to arrange removal.

All medical equipment must be returned to EBME prior to disposal. It must be cleaned free from any bodily fluids and have the yellow decontamination tag completed and attached in accordance with the Decontamination Procedure, document number 219. EBME must then be contacted for collection of medical items.


Items will be stored within the waste compound until waste contractors collect for disposal. Where feasible, metal will be taken from the items and disposed of as scrap metal.

Safety Instructions

Any permanent electrical disconnecting/disabling MUST be undertaken by the Estates Department. The can be arranged via the EBME.


Waste Disposal Data Sheet – 012 Waste Oils

Waste Category

Hazardous EWC 13 07 01 and EWC 06 13 05

Examples

Engineering lubricants, cutting fluids, waste oils from catering areas.


Cylinder drums.


N/A


Designated areas within individual departments.


Collections from Waste Disposal Contractor direct from department.


N/A


Any spillages of oils or cutting fluids should be covered with sand or similar material, once absorbed; the area should be swept clean and subsequently cleaned.

Safety Instructions

Drums must NOT be moved once used due to manual handling restrictions. Waste oils are stored in a secure tank and bunded, supplied by the contracted disposal company. Arrangements for waste oil disposal should be made with the Estates Department. Oils must not be disposed of via the drains.


Waste Disposal Data Sheet – 013 Domestic & Household Waste

Waste Category

Non-Hazardous Waste EWC 20 03 01

Examples

Hand towels and any un-recyclable material


Bags of 225 gauge low density.


Black


Enclosed pedal operated sack holders. Bags should be removed from holder when ¾ full and placed in nearest waste disposal room. All bags should be tied at the neck.


Bags must be transferred to a secure storage area or direct into domestic waste container. They must not be left in corridors or areas where public, patient and visitors have access. If clinical waste is discovered in a domestic sack, the entire content of the sack must be consigned as clinical waste, and treated accordingly.


All waste must be transferred to the on site compactor. Arrangements exist for domestic waste to be disposed of to a suitably licensed disposal facility. A compactor is located in the waste compound. Access to the compactor is available via portering staff only. The compactor should only be used for the disposal of non-recyclable domestic waste generated in non-clinical areas.


Any broken or damaged bags must be re-bagged prior to onward transit.

Safety Instructions

Bags must only be handled by the neck and always carried safely as instructed in line with the Trust Manual Handling Procedure. Bags must never be thrown. Clinical waste must never be transported or mixed with domestic or other waste. All transport carts must be locked at all times, other than when being loaded.


Waste Disposal Data Sheet – 014 Recycling – Paper

Waste Category

Non-Hazardous EWC 20 03 01

Examples

Non-confidential Paper, Newspaper, Magazines, Packaging, Milk Cartons and other recyclable materials


Clear plastic and designated cardboard boxes with clear plastic bags inside. Bags should only be ¾ full and sealed before leaving the department.


Clear/White Plastic Bags


Within the department or at designated locations.


Housekeeping/Porters/Transport collects as part of routine cleaning schedules.


Designated on site paper recycling storage.


Waste Disposal Data Sheet – 015 Cardboard – Recycling

Waste Category

Non Hazardous EWC 20 01 01

Examples

Packaging cardboard boxes.


N/A – cardboard should be loosely stored.


N/A


Flattened and placed inside designated waste disposal store.


Cardboard boxes MUST be flattened prior to disposal. Porters will collect from waste disposal store as part of routine collections.


All waste must be transferred to the on site cardboard compactor.


Waste Disposal Data Sheet – 016 Recycling Glass

Waste Category

Non Hazardous EWC 10 11 12 and EWC15 01 07

Examples

Bottles and jars (including broken glass).


Orange strong plastic style units for domestic glass only (i.e. coffee jars and not medicine bottles). Clinical associated broken glass must be placed in sharps bin.


Orange glass units (Daniels – Dani units FSL413).


Alongside Black Domestic bins. Bags should be removed from holder when ¾ full. All bags should be tied at the neck.


Bags must be transferred to designated waste disposal storage area.


Wardsmen will collect from waste disposal store as part of routine collections.


Caution must be taken when sweeping up any broken glass.

Safety Instructions

Any broken or damaged bags must be re-bagged prior to onward transit.


Waste Disposal Data Sheet – 017 Offensive/Hygienic Waste

Waste Category

Non-Hazardous EWC 189 01 04, EWC 20 01 99

Examples

Hygiene wear from staff toilets and nappies from Maternity.


225 gauge low density for general clinical waste.


Yellow and Black Striped bags (known as Tiger bags).


Enclosed pedal operated sack holders. Bags should be removed from holder when ¾ full and placed in designated waste disposal room. All bags should be tied at the neck.


Bags must be transferred to a secure storage area or direct into designated waste container. They must not be left in corridors or areas where public, patient and visitors have access.


Housekeeping staff collect as part of routine cleaning schedules.


Call housekeeping staff to spillage area via the helpdesk.

Safety Instructions

Bags must only be handled by the neck and always carried safely as instructed in line with the Trust Manual Handling Procedure. Bags must never be thrown. Clinical waste must never be transported or mixed with domestic or other waste. All transport carts must be locked at all times, other than when being loaded.


Waste Disposal Data Sheet – 018 Mercury Waste

Waste Category


Examples

Thermometers.


Griff/Weaver rigid container.


N/A.


All mercury waste must be returned to the Pharmacy Department for disposal.


Container will be collected as required by an approved contractor.


Hazardous Chemical Waste Store managed by Pharmacy Department.


Mercury spillage kits are available from Pharmacy. Any spillage must be cleared up immediately using the appropriate kit and following the written instructions provided with such.


Waste Disposal Data Sheet – 019 Recycling Packaging

Waste Category

Non Hazardous EWC 20 01 0

Examples

Non Confidential Paper, Newspaper, Magazines, Milk Cartons, Packaging and any other recyclable material

Appropriate Storage Containers-

Clear plastic and enclosed foot operated sack holders (Ward Based) or designated cardboard boxes with clear plastic bags inside. Bags should only be ¾ full and sealed before leaving the department.


Clear/White Plastic Bags.


Enclosed pedal operated sack holders.


Housekeeping/Porters/Transport collects as part of routine cleaning schedules.


Designated on waste recycling facility (bulk storage)


Waste Disposal Data Sheet – 020 Radioactive Waste

Waste Category

Hazardous

Examples

Solid radioactive waste, waste radiopharmaceuticals, radioactive aqueous waste, radioactively contaminated patient body fluids

Appropriate Storage Containers-

Strong bags labelled with radiation trefoil tape or sharps bins labelled with radiation trefoil tape. Double bagging recommended.


Yellow clinical waste bags. Yellow sharps bins for sharps waste.


Patient body fluids are disposed of via designated toilets and sluices. Solid radioactive waste is stored in designated locked labelled areas of the producing department for a period not exceeding that authorised by the Environment Agency permit for that radionuclide. Bags must not be more than ¾ full and securely sealed prior to onward transport.


Radioactive waste must only be moved and transported by trained staff and must not be left in non-designated locations. It is collected for off site incineration by contractors authorised by the Environment Agency on arrangement with the Medical Physics Department. The site EA permit must be complied with.


Waste will be stored on site in accordance with the site EA permits and records will be maintained. Solid radioactive waste from short lived radionuclides (Tc-99m) is dealt with at the point of origin within the Nuclear Medicine Department and Radio pharmacy and must have decayed to background levels before disposal. Any radioactive waste produced in Cardiology or Theatres or from Wards is transferred to Nuclear Medicine for storage and disposal. Longer-lived radionuclides will be stored within Nuclear Medicine and Radio pharmacy prior to transfer to the Central Radiation Waste Store until transportation off site for incineration. Aqueous waste cannot be stored.


Nuclear Medicine and Radiation Protection staff is available for advice and assistance. The contingency plans in the local rules must always be followed. Wear protective disposable gloves and aprons. Always contain the area of spillage. Minor spills e.g. splashed urine on skin, should be removed by washing under running water. Larger spills of radioactive urine etc. should be soaked up with paper towel. Repeat the process after wetting the same area at least twice. The contaminated material and any contaminated gloves must then be double bagged and given to Nuclear Medicine for storage and disposal. NOTE. never mop the floor as the head will then become radioactive.

Safety Instructions

Radioactive liquids can be disposed of into the drainage system via designated sinks and toilets Vials, needles and syringes containing radiopharmaceuticals must be placed in sharps bins which are then securely closed and disposed of as solid waste. Accurate records must be kept of all radioactive waste, on the day the waste is created. A monthly summary of the radioactive waste disposal from each department must be sent to Radiation Protection.


Indicative List of Category A Micro-organisms (ADR 2011)

Items contaminated with the specific micro-organisms identified in the list below, are to be classified as Category A infectious substances.

Micro-organisms Bacillus anthracis (cultures only) Brucellaabortus (cultures only) Brucellamelitensis (cultures only) Brucellasuis (cultures only) Burkholderia mallei - Pseudomonas mallei – Glanders (cultures only) Burkholderiapseudomallei– Pseudomonas pseudomallei (cultures only) Chlamydia psittaci- avian strains (cultures only) Clostridium botulinum (cultures only) Coccidioidesimmitis (cultures only) Coxiellaburnetii (cultures only) Crimean-Congo haemorrhagic fever virus Dengue virus (cultures only) Eastern equine encephalitis virus (cultures only) Escherichia coli, verotoxigenic (cultures only) Ebola virus Flexal virus Francisellatularensis (cultures only) Guanarito virus Hantaan virus Hantavirus causing haemorrhagic fever with renal syndrome Hendra virus Hepatitis B virus (cultures only) Herpes B virus (cultures only) Human immunodeficiency virus (cultures only) Highly pathogenic avian influenza virus (cultures only) Japanese Encephalitis virus (cultures only) Junin virus Kyasanur Forest disease virus Lassa virus Machupo virus Marburg virus Monkeypox virus Mycobacterium tuberculosis (cultures only) Nipah virus Omsk haemorrhagic fever virus Poliovirus (cultures only) Rabies virus (cultures only) Rickettsia prowazekii (cultures only) Rickettsia rickettsia (cultures only) Rift Valley fever virus (cultures only) Russian spring-summer encephalitis virus (cultures only) Sabia virus Shigelladysenteriae type 1 (cultures only) Tick-borne encephalitis virus (cultures only) Variola virus Venezuelan equine encephalitis virus (cultures only) West Nile virus (cultures only) Yellow fever virus (cultures only) Yersinia pestis (cultures only)

Nevertheless, when the cultures are intended for diagnostic or clinical purposes, they may be classified as infectious substances of Category B. NB this authorisation does not apply to waste material for disposal.

Appendix B