Waste Management Policy - South Tyneside NHS Foundation Trust

Transcription

Waste Management Policy
Date
Approved
by Trust
Board
29/1/13
Version
Four
Issue
Date
Review
Date
Executive
Lead
Information
Asset
Owner
Author
January
2013
January
2015
Lead
Executive
Director for
Estates &
Facilities
Head of
Facilities
Brian Gaff
Health &
Safety
Advisor
Procedure/Policy RM0041.V4
Number
Procedure/Policy Risk Management Policy
type
Date Equality impact assessment completed: December 2012
RM0041.V4 Waste Management Policy
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DOCUMENT INFORMATION AND AMENDMENT RECORD
Document Number: RM0041.V4
Document Title:
Waste Management Policy
Executive Lead:
Executive Director for Estates & Facilities
Amendments page
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Date of
amendment
Index
Section
Title
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Introduction
Purpose and Aim of the Policy
Responsibilities
Legislation and Statutory Requirements
Environmental Protection Act 1990
Definition of Waste
Waste Management – Waste Hierarchy
Segregation and Containment of Waste
Waste generated in the Community
BIOTRACK
Collection of Waste from other Organisations
Waste Transfer and Waste Consignment Notes
Selection of Waste Contractors
Site Registration
Discharge to Drain
Recycling and Waste Minimisation
Waste Management Site Plans
Risk Assessment
Personal Protective Equipment
Staff Training Requirements
Chemical Storage
Accidents and Incidents
Waste Management Group
Waste Audit Arrangements
Review
References
Equality Impact Assessment
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Appendix 1
Appendix 2
Appendix 3
Appendix 4
Appendix 5
Appendix 6
Appendix 7
Appendix 8
Appendix 9
Mercury Spillage Procedure
Infectious Substances included in Category A
Collection of Household Infectious Waste Forms
Waste Container Colour Coding Guide
Biotrack Tagging Guide
Waste Disposal Procedures
Waste Flow Chart
Waste Audit Proforma
Example List of Cytotoxic and Cytostatic Medicines
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WASTE MANAGEMENT POLICY
1.
INTRODUCTION
1.1
Effective management of waste is essential to any organisation if
they are to avoid prosecution, avoid cross-contamination of waste streams
and prevent unnecessary financial burden upon the organisation. This policy
gives detailed guidance on the measures to take in order to manage waste
successfully and specifies everyone‟s responsibilities for the safe disposal of
waste. Waste disposal is a burden on the earth‟s natural resources. When
discarded all the materials, time, energy and money put into producing it in
the first place are lost.
1.2
Disposing of waste requires energy and material resources as well
as generating emissions. Consequently, as with any other activity, society
and industry both need to behave in a sustainable manner so as to safeguard
the availability of resources for future generations. In this context waste
needs to be considered as a potential resource wherever possible and
organisations have an important role to play in making this happen, and
ensuring that where waste cannot be reduced, reused or recycled it is
disposed of in the most sustainable manner.
2.
PURPOSE AND AIM OF THE POLICY
The purpose of this policy is to describe in detail the arrangements for the
correct segregation, storage, collection and disposal of all types of waste in
order to assist managers to establish and maintain safe and effective waste
management systems and procedures based on „Safe Management of
Healthcare Waste‟ best practice. To inform and assist staff to apply correct
and safe procedures at all times and comply with the law.
3.
RESPONSIBILITIES
3.1.
Chief Executive - Is ultimately responsible for the implementation of
this policy within the Trust however Heads of Service/Departmental
Managers have been delegated the responsibility for implementing the policy
within their area(s) of control.
3.2
Lead Executive Director for Estates & Facilities - Is the Board
Level Executive Director responsible for waste management and is
responsible to the Chief Executive for establishing systems to ensure that
waste is effectively managed within the Trust.
3.3
Head of Facilities - Will ensure that processes are in place to
monitor compliance with this policy and that any non-conformance is acted
upon and will also chair the Trust Waste Management Group.
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3.4
Clinical Business Managers/Heads of Service - Have been
delegated the responsibility for implementing this policy within their areas of
control by ensuring that:
Processes are in place to minimize risks from waste.
That all staff have been trained in how to correctly and safely dispose
of waste.
Risk assessments are carried out for waste management within their
areas of control, as appropriate.
Setting clear objectives for Ward/Department managers concerning
waste management.
Ensuring that Ward/Department managers receive appropriate
training in the safe management of waste in the workplace.
3.5
Managers - Will be responsible for the operational implementation of
safe management of healthcare waste and all supporting legislation within
their area(s) of responsibility and in particular will ensure that –
The waste hierarchy is applied to all materials before they are
considered as waste. (see Section 7)
Ensure Risk Assessments are carried out for the safe disposal of
waste.
Waste is correctly segregated into the appropriate containers and
that staff are made aware of the correct containers to use.
Will respond to any concern raised by staff through liaison with the
Waste Officer/Manager.
Will act upon the findings of waste audits and take any necessary
corrective action.
Ensure staff receive adequate training to allow them to safely
dispose of all healthcare waste.
3.6
Employees –
Dispose of waste safely and only in the correct container.
The waste hierarchy is applied to all materials before they are
considered as waste. (see Section 7)
Attend waste management training.
Keep all waste streams separate and correctly segregated.
Ensure as a minimum that all waste containers detail the hospital or
clinic, ward or department and date of disposal.
Report all incidents involving waste to their line manager or
supervisor.
Ensure that sharps boxes are correctly assembled, signed and dated
including the ward or department information.
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3.7
Waste Porters/Caretakers - In addition to the duties of employees
the Waste Porters/Caretakers will ensure that:
Waste is kept segregated throughout transport and disposal.
Waste is correctly consigned for disposal and that the waste is only
given to a waste contractor approved by the Trust to carry that type
of waste.
Complete and sign any necessary waste transfer notes or waste
consignment notes and return any customer copy to the correct
location for retention.
3.8
Waste Manager (SoTW owned premises)
Is responsible for providing advice, support, instruction and training
for the safe management of healthcare waste through the Service
Level Agreement (SLA) with the Trust for community sites and staff
based in the community.
Is a member of the Trust Waste Management Group.
Carrys out waste audits within all community premises and report on
the findings to the Trust.
Responsible for registering community healthcare sites with the
Environment Agency.
Complete a pre-acceptance audit, at the required frequencies, for
any waste carrier which requires us to produce one using the
ward/department waste audits as a basis. As a minimum for clinical
waste this is 10% + 1 of all wards/departments plus A & E,
Pharmacy, Laboratories and Theatres.
3.9
Health & Safety Advisor
Is responsible for updating and reviewing the Trust Waste
Management Policy, interpreting and advising the Trust on changes
in legislation and providing high level advice and guidance to both
the Head of Facilities and Trust Waste Officer.
3.10
Trust Waste Officer (Trust owned sites)
Is responsible for providing advice, support, instruction and training
for the safe management of healthcare waste with support from the
Health & Safety Advisor.
Carrying out waste audits within all Trust owned sites and report on
the findings. This includes any other Trusts whose waste we collect.
Complete a pre-acceptance audit, at the required frequencies, for
any waste carrier which requires us to produce one using the
ward/department waste audits as a basis. As a minimum for clinical
waste this is 10% + 1 of all wards/departments plus A & E,
Pharmacy, Laboratories and Theatres.
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3.11
Infection, Prevention and Control Team
Provide advice and guidance on the Infection Prevention and Control
issues concerned with the safe management of healthcare waste
within the Trust.
Is a member of the Trust Waste Management Group
3.12
Contractors Employed by Trust
The person introducing the contractor on site will ensure that before
a contractor is employed on site they are aware that they must not
use any of our facilities to disposal of their waste.
All waste is to be removed from site by the contractor which must be
overseen by the relevant Estates Department.
4.
LEGISLATION AND STATUTORY RESPONSIBILITIES
4.1.
Criminal Liability - The management and disposal of waste is
governed by both health & safety and environmental legislation.
Both sets of legislation assign strict duties to employers and to
individuals who create or handle waste. A breach of the legislation is
increasingly likely to result in a criminal prosecution of both the
employer and of any identifiable individual who committed the
offence.
4.2.
Health and Safety Legislation - the employer, through individual
managers, is responsible for providing –
The necessary resources for correct and effective waste
management.
Written assessments of any significant risk to health or safety
associated with waste generation, management and disposal.
Safe systems of work for staff generating, handling, storing or
transporting waste.
Appropriate information and training for all relevant staff.
Regular monitoring and periodic review of the system so that
deficiencies are corrected within a reasonable timescale and the
system continuously refined and improved in the light of experience.
4.3.
Individual employees - are required to:
Take reasonable care of themselves and others who may be affected
by their acts or omissions.
Co-operate in matters of health and safety.
Correctly use any personal protective equipment and any other work
equipment designated for the task.
Correctly apply the information and training, previously received.
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Report any perceived hazards in their working environment, or
deficiencies in the safe system of work, to their manager.
5.
ENVIRONMENTAL PROTECTION ACT 1990
Everyone concerned with waste has a 'Duty of Care' to:
Only receive waste if properly authorised to do so, and only from an
authorised person.
Keep waste securely contained, and prevent its escape or
unauthorised removal.
Ensure it is adequately contained and packed for safe transport.
Label the waste clearly to identify its contents and point of origin.
Transfer the waste only to a licensed contractor authorised to
transport that type of waste.
Describe the waste (on the appropriate forms) in sufficient detail that
subsequent carriers and disposers can deal with it safely.
Take reasonable steps to check that those providing or removing
waste are acting properly and within the law.
The employer must also comply with a range of waste management
regulations and guidance which govern the correct method of
disposal of waste and the keeping of adequate written records
regarding the disposal of the waste.
6.
DEFINITION OF WASTE
“Any substance or object the holder discards, intends to discard or is
required to discard" is WASTE under the Waste Framework Directive
(European Directive (WFD) 2006/12/EC),
Classes of Waste
6.1.
Controlled Waste – General waste comes under the category of
Controlled waste in the Controlled Waste Regulations 1992 SI 588
(Controlled Waste regs). Waste from this Trust would be classed as
commercial waste under the regulations. This waste stream consists of nonhazardous wastes including paper, some packaging materials, some metals
and some food waste. Typically it goes to landfill and in many companies the
waste is compacted to reduce the volume and increase the amount that can
be contained in a skip. The waste is carried by a licensed waste carrier who
will take it to either a transfer station or directly to a land-fill site.
6.2.
Hazardous Waste – Waste is classed as hazardous if it dangerous
to people, the environment or animals. Waste is also classified as hazardous
if it is covered under the Hazardous Waste Regulations 2005 SI 894
(Hazardous Waste Regs) and will be listed in the European Waste Catalogue
(EWC). Typical examples of hazardous waste include things such as lead
acid batteries, fluorescent tubes or clinical waste which has been designated
as infectious waste. Non-infectious clinical waste can be disposed of as
controlled waste. The hazardous nature of the waste will determine where its
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final destination will be. Some hazardous waste can go to land-fill following
treatment. Others may have to be incinerated with the level of incineration
being determined by the hazardous properties of the waste.
6.3.
Radioactive Waste – is covered under the Radioactive Substances
Act 1993 and excluded form this policy.
7.
WASTE MANAGEMENT
Waste is segregated into the classes as specified above. Each category will
then be disposed of via identified separate waste streams. The Waste
(England and Wales) Regulations 2011 place a specific requirement on all
organisations to utilise the waste hierarchy when dealing with waste. The
following steps should always be considered in descending order:
7.1.
Reduce the amount of waste produced by using less material in
design and manufacture. Keeping products for longer or using less
hazardous materials.
7.2.
Re-use waste items as and when appropriate, by checking, cleaning,
repairing, refurbishing, whole items or spare parts. THIS DOES NOT APPLY
TO SINGLE USE OR SINGLE PATIENT USE PRODUCTS.
7.3.
Recycle, turning waste into a new substance or product. Includes
composting if it meets quality protocols.
7.4.
Recovery which includes anaerobic digestion, incineration with
energy recovery, gasification and pyrolysis which produce energy (fuels, heat
and power) and materials from waste.
7.5.
8.
Disposal includes landfill and incineration without energy recovery.
SEGREGATION AND CONTAINMENT OF WASTE
Each waste stream requires a different method of disposal. Therefore it is of
paramount importance that each waste stream is segregated from the others
at source, and remains separate throughout the process of containment,
collection and disposal. Mixing wastes, even in small quantities is not
acceptable as this will mean the waste transfer or consignment note will have
the wrong information on it and will result in a range of non-compliances with
legislation. This section describes each type, and each sub-category of
waste and the means by which it is contained and kept separate from the
rest.
8.1.
Controlled Waste or municipal waste is defined in 6.1. This type of
waste is disposed of in black bags and typically goes to landfill. The parts of
this waste that cannot be recycled at present are segregated from the dry
mixed recycling. Typically this waste is food, dead flowers and anything else
which is biodegradable.
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8.2.
Dry Mixed Recycling is fractions of municipal waste which can be
recycled. This includes paper, cardboard, plastics and metal cans. This
waste is all collected in one clear bag which is taken away by the waste
contractor and recycled on our behalf. A compactor can be used to compact
the waste and maximise the space available in the skip. A paragraph 27
exemption from the Environment Agency needs to be in place to allow a
compactor to be used.
8.3.
Offensive waste, this describes healthcare and similar municipal
waste, apart from clinical and hazardous waste, which may cause offence to
people. Examples include nappies, feminine hygiene products, used but
uncontaminated PPE (has not been in contact with an infected patient), resin
casts and incontinence waste. This type of waste can be put through a
compactor which has low level compaction and is disposed of to a licensed
land-fill site for deep land-fill. Offensive waste goes into a yellow bag which
has black stripes on it (tiger stripe bags). Waste which has been autoclaved
is now classed as offensive waste. Blood bags are now classed as offensive
waste once any remaining blood has been discharged to drain. There is no
need to wash out blood bags.
Please note on sites that do not have the offensive waste stream
nappies will have to be disposed of in the municipal waste
which is a black bag.
8.4.
Offensive or Infectious? - When disposing of nappies, feminine
hygiene products, used but uncontaminated PPE and incontinence waste a
decision has to be made by health care workers whether this waste is
offensive or infectious. If it is known that the waste comes from a person
who has a known infection which would affect the waste then the waste is
clearly infectious. Infectious waste is classed as clinical waste and would be
disposed of in an orange bag. Conversely the absence of known infections
should ensure that the waste is disposed of as offensive waste and disposed
of in a tiger stripe bag. This decision should be considered every time this
type of waste is disposed of in case the results of tests indicate that the
patient‟s condition has changed.
8.5.
Clinical Waste – is defined as:any waste which consists wholly or partly of human or animal tissue,
blood or other body fluids, excretions, drugs or other pharmaceutical
products, swabs or dressings, or syringes, needles or other sharp
instruments, being waste which unless rendered safe may prove
hazardous to any person coming into contact with it; and
any other waste arising from medical, nursing, dental, veterinary,
pharmaceutical or similar practice, investigation, treatment, care,
teaching or research, or the collection of blood for transfusion, being
waste which may cause infection to any person coming into contact
with it.
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8.6.
Clinical waste is a major component of wastes from many NHS
Trusts. Clinical waste bags are coloured orange which denotes that they are
to be sent for treatment via alternative technology. Rather than burn the
waste it is pasteurised using hot oil and then when the biological hazard has
been reduced is sent for land fill.
8.7.
Yellow clinical waste bags are for incineration only and will not be
used at a hospital or clinic unless specified by Infection Control or the
Consultant Microbiologist. Supplies of yellow clinical waste bags are
available through the Caretakers (SoTW premises) or Waste Porters (STDH).
8.8.
Clinical waste carts and wheelie bins are all coloured yellow, and
clearly labelled and marked with a bio-hazard sign. Standard 'soft' waste is
placed in orange clinical waste plastic bags, whilst rigid yellow plastic boxes
are used for sharps and for large pieces of human tissue.
8.9.
Any substantial pieces of metal which are contaminated with blood or
body fluid are also classed as clinical waste. These must be labelled 'for
incineration only‟ due to the risk of damage to the shredder at the waste
disposal plant where most of the clinical waste is heat-treated prior to landfill.
Contaminated metal objects are placed in a suitable rigid plastic clinical
waste box, such as the Daniels long bin. If not a regular occurrence or an
unusual size or shape, contact the Infection Control Team for advice on
suitable containers.
8.10. Human Tissue – in any form must only be sent for incineration in red
lidded containers (with appropriately labelled body of the box) or incineration
only bags. For further information and guidance regarding the management
of Human tissue please refer to the appropriate Trust policies and
procedures on the Trust intranet.
8.11. Pacemakers – pacemaker generators removed from patients are
decontaminated in Theatres. The Cardiac Physiologist then completes
relevant paperwork and arranges return of the device to the company for
disposal.
8.12. Sharps - sharps boxes used within the Trust will have the following
colour coded lids:Orange coloured lids (with appropriately labelled body of the box) are
for sharps which do not contain prescription only medicines (POM).
This will include sharps that are used for blood or other bodily fluid
sampling.
Yellow coloured lids (with appropriately labelled body of the box) are
for sharps and other equipment used in conjunction with prescription
only medicines.
Purple coloured lids (with appropriately labelled body of the box) are
for cytotoxic or cytostatic drugs and equipment contaminated with
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these drugs. (A list of these drugs is available on the Pharmacy
intranet site)
8.13. Pharmaceutical Waste - within wards and departments is divided
into two separate waste streams.
Those medicine containers which contain more than a dose should
be returned to Pharmacy in the box provided for returns.
Medicine containers which contain less than a dose (residue) should
be disposed of at ward level into a blue lidded pharmacy box which
has a blue labelled body of the box.
Fluid bags and giving sets which have contained POMs must also be
disposed of in the blue lidded box.
Syringes which have not been fully discharged and contain POMs
should be put straight into a yellow lidded sharps box without
discharging the contents of the syringe.
Any establishment which carries out sorting or denaturing of
controlled drugs will need to register the site with the Environment
Agency for a T28 exemption. The only exception to this is where a
Pharmacy is operating within a building which already has an
exemption such as a hospital site.
8.14. Controlled Drugs – the disposal of these drugs are covered under
the Overarching Medicines Policy, under section 10 which can be found on
the Trust‟s Intranet site.
8.15. Amalgam Waste – is produced as a result of dentistry and contains
heavy metals which require specialist disposal. This waste is taken away by
a licensed contractor to recover the heavy metals.
8.16. Chemical Waste – is waste which is not infectious and contains
chemicals or chemical residue.
Examples within a clinical environment include alcohol gel containers
and aerosols.
Elsewhere chemical waste includes reagent containers, alcohols,
xylene, formaldehyde, formalin and waste chemicals.
If there are any chemical containers for disposal, establish does the
product go down the toilet, sluice or drain. If it does then wash out
the container with soap and water and put the container into the
municipal waste (black bag). If it does not then it will need to be
dealt with differently so contact the appropriate Waste
Officer/Manager for advice.
The soft alcohol gel bags which are fitted into the wall mounted
dispensers should also be cut open and washed out prior to disposal
as above.
Another type of container which will probably have at least one
hazard symbol is an aerosol. A fully discharged aerosol can be
placed in municipal waste but do not put accumulations of these
containers in the same bag.
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Any aerosols which have contained prescription only medicines
should be placed in a blue lidded pharmaceutical box.
8.17. Sealing Waste Containers - All waste bags and boxes must be
sealed before disposal. When sealing bags staff should be mindful of the
weight of the contents of the bag and to ensure that enough space is left to
gather the edges of the bag to seal it. Bags should never be filled more than
¾ full and should be tied with a cable tie. All bags and containers when full
and sealed must display the name of the hospital or clinic, ward/department
and the date. Boxes must be signed by the person sealing them.
8.17.1
It is essential that waste carts sited externally to
departments are kept locked at all times to prevent the unauthorised
removal or accidental loss of any waste bags or boxes.
8.18. Plaster of Paris (gypsum) has to be collected separately and
cannot go to landfill. This is because it degrades in landfill sites to produce
hydrogen sulphide gas which goes up into the atmosphere and mixes with
water and comes back down as acid rain (sulphuric acid). This includes
gypsum used for plaster casts medicinally and for the disposal of plaster and
plaster board from the Estates Department.
8.19. Glass is classed as controlled waste but for health and safety
reasons has to be collected separately from the rest of the controlled waste.
On some sites glass is collected for recycling and consigned separately in
either cardboard boxes or orange buckets, whichever is available. Where
recycling is not available the glass is put into orange buckets and then
disposed of with controlled waste at the point of disposal.
Glass which has contained pharmaceutical products cannot be
recycled and must be disposed of as pharmaceutical waste.
8.20. Batteries are collected at various points around the sites and sent to
a suitable recycling facility. There are plastic bins for collecting batteries for
recycling.
8.21. Waste Electrical and Electronic Equipment (WEEE) is collected
and then sent away for recycling.
8.22. Other Waste –any waste that is disposed of must not leave site
without the appropriate waste documentation being completed. In addition
the waste must only be handed to a registered waste contractor that has
been approved by the Trust (Trust owned sites) or SoTW Facilities
Department through the SLA for community premises.
8.23. Confidential Waste – This is waste containing staff or patient details
or potentially sensitive information about the Trust e.g. patient
records/information, financial records, non-paper items such as x-rays.
Confidential waste is shredded on site by a contractor who is also
responsible for the removal of this waste from site to send it for recycling.
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9.
WASTE GENERATED IN THE COMMUNITY
Waste generated in Community premises is disposed of through an SLA with
SoTW who are responsible for the waste removal contract arrangements,
registering community sites with the Environment Agency, correct waste
handling and consignment by Facilities staff employed by the SoTW. Despite
this agreement the waste produced by STFT staff remains our responsibility
in terms of correct segregation and handling.
9.1.
Healthcare carried out in the community by Trust staff will produce
waste and it is essential that this waste is disposed of correctly to ensure that
we meet our duty of care. Firstly an assessment should be made to establish
whether the waste is offensive or infectious.
9.2.
If it is infectious waste produced in patient‟s home:Place the waste in an orange bag at the household for collection by a
contractor.
Note: waste is still the responsibility of the
healthcare worker.
The Healthcare worker will arrange collection through the Trust‟s
referral system.
At present there are separate systems for
Gateshead, South Tyneside and Sunderland and each requires a
different form for each council. See Appendix 3 for the respective
referral system.
Ensure suitable storage away from vermin or contact by the public.
Ensure the waste company which is collecting the waste is provided
with enough information to allow safe handling and disposal, by
completing the relevant sections on the waste collection request
form.
SHARPS USED BY CLINICAL STAFF MUST NEVER BE LEFT IN
A PATIENT’S HOME.
9.3.
Non-infectious waste (Offensive waste) should be disposed of in the
domestic waste stream. Do not use orange or yellow NHS colour coded
bags as this could cause alarm at landfill sites should staff think it is
infectious waste. Use a carrier bag or black bag for disposing of this type of
waste in the domestic waste stream.
9.4.
Sharps must not be placed in household waste stream.
medicating patients should dispose of sharps through their GP.
Self-
9.5.
Home Births – Placenta must be placed in a red lidded placenta
bucket which has appropriately labelled body. Other infectious waste must
be placed into an orange bag. The waste is left at patient‟s home until
collected by a licensed waste contractor. Midwives should request a
collection using the referral system in Appendix 3.
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10.
BIOTRACK
This is the tagging system which is utilised by our waste contractor and
ensures that the yellow waste carts are dealt with in the most appropriate
manner for the class of hazardous waste they contain. The colour coded
tags are attached to the yellow waste carts before they are sent from site to
ensure that the waste goes to the correct place and receives the correct
treatment. See Appendix 7 for further details.
11.
COLLECTION OF WASTE FROM OTHER ORGANISATIONS
Waste that is collected from other organisations that utilise areas and
buildings on Trust owned sites is mixed in with our waste streams and
disposed of from our waste disposal facility. In order that this situation does
not compromise the Trust‟s legal position it is essential that the organisations
comply with the STFT‟s waste policy and compliance will be audited by the
Trust Waste Officer/Manager. Such organisations are responsible for
ensuring their staff are trained and comply with the STFT Waste Policy.
12.
WASTE TRANSFER AND WASTE CONSIGNMENT NOTES
12.1. Waste Transfer Note (Controlled Waste) – before any Controlled
waste leaves the Trust a waste transfer note must be produced ensuring all
the required information is put onto the form. The form must be signed by an
authorised Trust signatory and be given to the waste carrier when they come
to collect the waste. For regular collections an annual waste transfer note
can be set up in advance of the first collection. Waste transfer notes must be
retained for two years following the disposal of the waste.
No waste must leave the Trust without a waste transfer note or
waste consignment note.
12.2. Waste Consignment Note (Hazardous Waste) – before any
hazardous waste is removed from the Trust a waste consignment note must
be completed ensuring all relevant information is put onto the form. This
form cannot be completed annually but must be completed for each load.
Waste consignment notes must be retained for three years following the
disposal of the waste.
No waste must leave the Trust without a waste consignment
note or waste transfer note.
12.3. Producer Returns – is information that waste contractors send to
the Trust advising how much waste has been taken from site over a given
period (normally quarterly). It is important to maintain a database of these
returns for three years from the time the information is received so that waste
production levels can be monitored and there is an audit trail of where the
waste has been disposed of.
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12.4. Waste Transfer – transferring waste between sites within the Trust
is not permitted as the Trust does not have a waste transfer license. Waste
should only be consigned to a licensed waste contractor from the site it was
produced on. The Trust is not registered as a waste transfer station and
cannot accept waste brought onto any of the sites.
This prohibition includes vans bringing back waste or unused
pharmaceuticals from other sites, accepting sharps boxes or
pharmaceuticals from the public or staff bringing in waste from
home.
13.
SELECTION OF WASTE CONTRACTORS
All persons who remove waste from any Trust site must comply with the
following minimum requirements:Registered with the Environment Agency as a waste carrier.
Use the correct waste transfer or waste consignment notes for the
type of waste.
Give the Trust producer returns at agreed intervals to enable
monitoring of how much waste is being produced and how much is
being taken away for disposal.
In addition to the minimum requirements above there will be other contractual
obligations to be met which are arranged via the Supplies Department or
SoTW Facilities Department for Community premises.
14.
SITE REGISTRATION
The Hazardous Waste Regulations 2005 require that most sites which
produce hazardous waste are registered with the Environment Agency on an
annual basis by the respective Facilities Department. The exceptions are
those sites which produce less than 500kg per year. Each site is given a
unique registration number which must be quoted on every waste
consignment note.
15.
DISCHARGE TO DRAIN
Although not always thought of as waste the things that are put down the
drains, through toilets, sluices, sinks, etc, are as much waste as what goes
into a bin. Some things that are not allowed to be put down the drain are
chemicals such alcohols, xylene, etc. The company which takes away the
sewage from our Trust also dictates what is allowed to be put into the sewer
system. This information is contained within a document referred to as the
Consent to Discharge to Drain. If there is any doubt about what can or
cannot be put down a toilet, sluice or drain please ask the departmental
manager or the Waste Officer/Manager.
Page 16 of 62
16.
RECYCLING AND WASTE MINIMISATION
It is essential that the Trust seeks to minimise waste production as a means
of reducing costs. Every piece of waste costs the Trust to buy it in its original
form and if benefit is not derived from it then financial losses occur. Even
when benefit has occurred there are still opportunities for an organisation to
gain further income by separating out waste streams and sending waste for
recycling rather than final disposal. The Trust already carries out recycling of
many waste streams and further improvements are on-going as part of the
remit of the Waste Management Group.
17.
WASTE MANAGEMENT SITE PLANS
The Site Waste Management Plans Regulations 2008 requires the Trust to
produce a Site Waste Management Plan (SWMP) before the construction
phase begins on any construction project valued at over £300 000. The
purpose of the regulations is to promote the economic use of construction
materials and methods so that waste is minimised and any waste that is
produced can be reused, recycled or recovered. Additionally the regulations
seek to reduce fly tipping by restricting the opportunities available for the
illegal disposal of waste. This is the responsibility of the Trust Estates
Department (Trust owned sites) and the SoTW Estates Department for
schemes that are delivered in Community premises.
18.
RISK ASSESSMENT - THE STATUTORY REQUIREMENTS
18.1. The Management of Health and Safety at Work Regulations 1999
require that all 'significant' risks are assessed and the risks, together with
details of the persons at risk, and the control measures required to manage
those risks, are recorded in writing, and amended as necessary in response
to changes or new information.
18.2. The Control of Substances Hazardous to Health Regulations 2002
requires the same, in relation to chemical risks and infection risks and this
includes the risks posed by waste materials. Both also require the training of
staff and provision of information in relation to those risks.
18.3. The Use of Generic Risk Assessments should be adopted where
ever required but the generic assessments should be reviewed to ensure that
any ward/department specific risks are covered by the Risk Assessment.
19.
PERSONAL PROTECTIVE EQUIPMENT
19.1. Clinical staff will follow normal control of infection guidelines during
the generation and disposal of clinical waste on the ward or department,
which will include protective clothing suitable for the infection risk involved
and hand washing.
Page 17 of 62
20.
STAFF TRAINING REQUIREMENTS
20.1. Ward/Departmental Inductions for New Staff - it is essential that
waste disposal procedures are included as early as possible, in the ward or
department based induction process for new staff and new staff are given
access to this policy.
20.2. Clinical Staff - training sessions in the safe and correct disposal of
waste and an introduction to environmental issues are included in the annual
Trust training programme. Where more convenient for staff, specific
sessions can be arranged for individual wards or departments on request to
the respective Waste Officer/Manager.
20.3. Portering/Caretaking Staff – these staff have a very important role
to play in collecting, transporting, storage and disposal of waste. They will
require specific training to enable them to ensure correct segregation of
waste during collection, storage at the point of disposal along with ensuring
the paperwork is correct when the waste is handed over to the waste
contractor. A course specifically designed for waste porters will be delivered
for them and refresher training available when required.
21.
CHEMICAL STORAGE
21.1. All chemicals, regardless of the hazards they pose need to be stored
and handled in a manner which minimises the risk of spillage. Chemicals
should not be stored with other chemicals which they will react with e.g. acids
should not be stored with alkalis and oxidising agents should not be stored
with flammable chemicals.
21.2. Information on the hazards associated with chemicals can be found
on the material safety data sheet which is available free from the
manufacturer or supplier. All stored liquids should be stored inside a bund
(an outer wall or container designed to retain the contents of an inner tank in
the event of leakage or spillage) which is capable of holding 110% of the
liquid stored.
Spillage procedures should be established for stored
chemicals/substances and this should form part of the COSHH assessment.
As part of the assessment sufficient absorbing and clean up materials should
be available to cope with any spillages.
22.
ACCIDENTS AND INCIDENTS
22.1. General - whilst every effort should be made to avoid loss or spillage
of any kind, it is important that a clear procedure and a ready supply of the
necessary equipment is in place and is used whenever such an event occurs.
Information and training for staff must be provided prior to such an
eventuality.
Page 18 of 62
22.2.
Spillage Procedures - The aim of any spillage procedure is to:
Contain the spillage to limit the escape.
Protect staff, patients and visitors.
Protect the environment.
Restore the area to normal as quickly as possible.
Minimise the effect of the spillage on normal service provision.
22.3. Clinical Waste - The main risk is that of cross infection, and the
procedure consists of donning protective clothing consistent with the risk, in
most cases disposable gloves and apron if appropriate, and placing the
waste items into the appropriate orange bag, or into a sharps box, in the case
of needles, blades or other sharp items, taking special care not to receive a
sharps injury. Sharps must not be retrieved by hand. Please see
Decontamination policy on the Trust Intranet site.
22.4. Spilt blood or body fluids - Please see Decontamination policy on
the Trust Intranet site.
22.5. Mercury - a summary of the procedure is included at Appendix 1,
and the full procedure, together with a spillage kit, is issued on request by the
Pharmacy.
22.6. Other Chemicals - Similar principles apply to any other chemical
spillage. The essential steps are:
Find out how to deal with the individual chemical first; this information
should be on the COSHH assessment or the manufacturers‟ material
safety data sheet.
Only tackle the spillage if it is safe to do so and you have the
necessary equipment to hand.
Contain the spillage to prevent further spread.
Prevent exposure of other persons in the vicinity.
Absorb and dispose as quickly as possible.
Decontaminate the area and return it to normal use.
22.7. Before disposing of spillages or absorbent materials the COSHH
assessment should be consulted for the correct method of collection and
disposal.
22.8. Suitable contingency procedures to deal with foreseeable spillages of
harmful chemicals should be devised by the users, and included with the
COSHH assessment of health risks associated with that chemical or process.
22.9. If in doubt, contact the Waste Officer/Manager or the respective
Facilities Departments.
Page 19 of 62
22.10. Any injury which arises out of waste production, handling or disposal
must be reported to the relevant manager or supervisor in the normal way. If
there has been a sharps injury from an item contaminated with blood or body
fluid the Inoculation Injury Policy which is available on the Intranet site should
be followed, in full.
22.11. Any other untoward incident, whether it causes injury or not, should
be reported so that its implications can be considered and if appropriate,
further preventive measures taken.
22.12. Any injury or untoward incident which arises out of waste production,
handling or disposal must be recorded on the Trust accident/incident form in
the normal way and submitted via that person's manager or supervisor. If the
incident results in death or major injury of any person, or results in more than
five consecutive day‟s absence from work immediately after the incident to
a member of staff, it will also require reporting to the Health and Safety
Executive. Guidance on RIDDOR is available on the Trust‟s intranet site.
22.13. The waste porters on the main hospital site also complete Trust
accident/incident forms for incidents which they are involved with and these
will be discussed at the Waste Management Group along with any others
reported throughout the other premises.
23.
WASTE MANAGEMENT GROUP
This group meets every three months and is made up of Trust staff from;
Infection Control and Estates & Facilities, representatives from
Northumberland Tyne & Wear Mental Health NHS Foundation Trust and
SoTW Facilities Department. The group has its own Terms of Reference and
its purpose is to ensure compliance with the Trust Waste Management
Policy, oversee changes to the way the Trust manages waste and to look at
recycling and other environmental issues.
23.1. The Waste Management Group reports into the Infection Control
Committee via the Head of Facilities.
24.
WASTE AUDIT ARRANGEMENTS
An audit tool (see Appendix 8) based on Safe Management of Healthcare
Waste best practice has been established for waste audits to enable a true
picture to be established as to how each ward and department is managing
waste. These audits will be carried out by the Trust Waste Officer/Manager
(for Trust owned sites) and by the Waste Officer/Manager from SoTW
Facilities (community premises) inline with the frequencies recommended in
the Safe Management of Healthcare Waste and staff will be invited to
participate.
Page 20 of 62
25.
24.1.
The waste audits are carried out randomly and without prior
notification to establish a true picture of how well waste is being
managed.
24.2.
Each ward and department will be audited at least once annually but
follow up visits could be planned depending on the findings of the
original waste audit. Included in the schedule will be waste collection
services and record keeping.
24.3.
Following the audit visit a report will be compiled outlining the areas
of non-compliance and the remedial action required. The report will
be sent to the ward/department manager along with the Clinical
Business Manager for that area for information and action. Key
themes from the audits will be collated by the Waste Manager/Officer
for Acute and Community premises respectively for consideration at
the Waste Management Group.
24.4.
Periodically the carriers of our waste will request an audit of waste to
be carried out on site so that we can satisfy them that what we are
stipulating on our waste documentation is in fact what we put into our
waste bags. This will require liaison with other Trusts who share our
sites, and whose waste we collect, to ensure that they can give us
assurance about the contents of their waste containers.
24.5.
The Environment Agency views health care waste as a high risk
because if it is poorly managed it could have serious consequences
for the health of people or for the environment. The Environment
Agency carries out waste audits within NHS Trusts and can
recommend that changes be made to the manner in which waste is
managed and if necessary take enforcement action.
REVIEW
This policy will be reviewed every 2 years unless changes occur within waste
management which dictate that it must be reviewed earlier.
26.
REFERENCES
26.1. The following documents where used as sources of information when
compiling this policy:Environmental Protection Act 1990
Controlled Waste Regulations 1992
Hazardous waste Regulation 2005
Waste (England & Wales) Regulation 2011
Consolidate European Waste Catalogue
Safe Management of Healthcare Waste V.2
Biotrack Guide by SRCL
Page 21 of 62
27.
EQUALITY & DIVERSITY
In accordance with our equality duties an Equality impact Assessment has
been carried out on this policy. There is no evidence to suggest that the
policy would have an adverse impact in relation to race, disability, gender,
age, sexual orientation, religion and belief or infringe individual‟s human
rights.
Page 22 of 62
Appendix 1
Mercury Spillage Procedure
The Waste Officer/Manager in both the SoTW and Acute sectors both have a
Mercury spillage kit for dealing with spillages. Contact numbers are as follows:Ian Thurgood - 0191 2831089 and 07771562692
Gordon Smith – 0191 4041000 ext 2493
If large quantities of mercury are spilled or the area is hot or in a confined space this
could increase the amount of airborne mercury and a respirator may be required.
Consult the Health & Safety Team for further advice. This, however, would be a very
rare and exceptional circumstance.
Mercury spillage on a hard surface – vinyl, tiles, etc
In the event of spillage, try to confine the affected area to a minimum. Put on
protective GLOVES and MASK to reduce dust inhalation. Increase ventilation by
opening a window. Try to reduce the spread of the spill as much as possible. NEVER
USE A VACUUM CLEANER OR ASPIRATOR TO PICK UP MERCURY AND
NEVER DISPOSE OF MERCURY IN A SHARPS BIN. Using the SCOOP, move the
globules of mercury together to form one large pool. Pick up as much of this as
possible using the SYRINGE and place in the WASTE CONTAINER. Return the
syringe to the spillage kit.
Make a paste of equal amounts of SULPHUR and CALCIUM HYDROXIDE with a
little water and spread onto the spillage area. Keep mixing the paste on the spillage
area using the BRUSH and SCOOP for two or three minutes – it can be used wet
and does not need to dry out. Then BRUSH the paste into the SCOOP and transfer it
to the WASTE CONTAINER, wiping and residual paste from the BRUSH and
SCOOP on the lip of the WASTE CONTAINER, which is then capped tightly. Replace
in the spillage kit and store this in a well ventilated place away from sources of heat.
Mercury spillage on a fabric surface e.g. carpet or bedding (can also be used
on hard surfaces to avoid using paste)
Skin contact with mercury should be avoided – if bedding is affected, move the
patient away if possible. Put on protective GLOVES and increase ventilation.
Recover as much of the loose mercury as possible with the syringe and place in the
WASTE CONTAINER. Return the syringe to the spillage kit.
Break off a piece of ALLOY WOOL to form a sphere of 1” – 25mm diameter. Holding
the ALLOY WOOL between finger and thumb, press it firmly against a hard surface
e.g. work surface, to flatten one side. Place this flattened area GENTLY on top of
loose mercury and leave it for 20 seconds or so. The mercury will adhere to the
ALLOY WOOL and will be picked up. Then move the ALLOY WOOL pad to the next
area of mercury droplets. Place the contaminated ALLOY WOOL in the WASTE
CONTAINER. Repeat this until all visible mercury droplets have been removed, using
more „buds‟ of ALLOY WOOL if necessary.
Page 23 of 62
Decontamination procedure (hard floors only)
To a third of a bucket of warm water add a drop of washing up liquid and two heaped
teaspoons full each of SULPHUR and CALCIUM HYDROXIDE stirring to make a
suspension. Use a mop to apply this to hard floors doing this perhaps every month or
two months. After most of the suspension has been mopped off, clean the floor with a
proprietary cleaner.
WHEN THE WASTE CONTAINER IS FULL DISPOSE OF IT VIA THE WASTE
PORTERS AS TOXIC WASTE.
Page 24 of 62
Appendix 2
Indicative Examples of Infectious Substances
Included in Category 'A' in any Form Unless
Otherwise Indicated
Category A Infectious Substances
UN Number &
Proper Shipping
Name
UN 2814
Infectious
substances
affecting humans
Micro-organism
Bacillus anthracis (cultures only)
Brucella abortus (cultures only)
Brucella melitensis (cultures only)
Brucella suis (cultures only)
Burkholderia mallei - Pseudomonas mallei – Glanders
(cultures only)
Burkholderia pseudomallei – Pseudomonas
pseudomallei (cultures only)
Chlamydia psittaci - avian strains (cultures only)
Clostridium botulinum (cultures only)
Coccidioides immitis (cultures only)
Coxiella burnetii (cultures only)
Crimean-Congo hemorrhagic fever virus
Dengue virus (cultures only)
Eastern equine encephalitis virus (cultures only)
Escherichia coli, verotoxigenic (cultures only)
Ebola virus
Flexal virus
Francisella tularensis (cultures only)
Guanarito virus
Hantaan virus
Hantaviruses causing hemorrhagic 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 hemorrhagic fever virus
Page 25 of 62
Poliovirus (cultures only)
Rabies virus (cultures only) ‡
Rickettsia prowazekii (cultures only)
Rickettsia rickettsii (cultures only)
Rift Valley fever virus (cultures only) ‡
Russian spring-summer encephalitis virus (cultures only)
Sabia virus
Shigella dysenteriae type 1 (cultures only)
Tick-borne encephalitis virus (cultures only)
Variola virus
Venezuelan equine encephalitis virus
West Nile virus (cultures only)
Yellow fever virus (cultures only)
Yersinia pestis (cultures only)
UN 2900
Infectious
substances
affecting animals
only
African swine fever virus (cultures only)
Avian paramyxovirus Type 1 - Velogenic Newcastle disease
virus (cultures only) ‡
Classical swine fever virus (cultures only) ‡
Foot and mouth disease virus (cultures only) ‡
Lumpy skin disease virus (cultures only) ‡
Mycoplasma mycoides - Contagious bovine pleuropneumonia
(cultures only) ‡
Peste des petits ruminants virus (culture only) ‡
Rinderpest virus (cultures only) ‡
Sheep-pox virus (cultures only) ‡
Goatpox virus (cultures only) ‡
Swine vesicular disease virus (cultures only) ‡
Vesicular stomatitis virus (cultures only) ‡
Page 26 of 62
Appendix 3
Procedure for assessment and disposal of healthcare waste generated in
patients homes by community healthcare staff. (Gateshead Area).
INFORMATION
Community healthcare workers responsibilities
Producers of healthcare waste and specifically infectious waste are required to
comply with waste regulations including the Hazardous Waste Regulations and
therefore need to ensure that waste is segregated, described, classified and
disposed of appropriately.
Waste risk assessment - Infectious waste
Waste is classified as infectious waste where:
• it arises from a patient known or suspected to have an infection, whether or not the
causal agent is known, and where the waste may contain the pathogen; or
• where an infection is not known or suspected, but a potential risk of infection is
considered to exist.
Table: Risk assessment approach to waste segregation based on likelihood of
infection being present
Contaminant Proposed
general
classification
Urine,
Offensive (where
faeces,
risk assessment
vomit
and had
sputum
indicated that no
infection
is
present,
and no other risk
of
infection exist)
Blood,
pus Infectious unless
and
wound assessment
exudates
indicates
no
infection present.
If no infection, and
no other risk of
infection,
then
offensive
Examples
Exception to this rule
Urine bags,
incontinence
pads,
single-use
bowls,
nappies,
PPE
Gastrointestinal
and
other
infections
that
are
readily
transmissible in the community
setting
(e.g.
verocytotoxinproducing Escherichia coli (VTEC),
campylobacter,
salmonella,
chickenpox/shingles)¹ Hepatitis B
and C, HIV – only if blood is
present¹
Blood transfusion items
Dressings
contaminated
with
blood/wound exudates assessed
not to be infectious.
Maternity sanitary waste where
screening or knowledge has
confirmed that no infection is
present and no other risk of
infection exists
Dressings
from
wounds,
Wound
drains,
delivery
packs
Page 27 of 62
Notes: All Infectious waste A and B species, and therefore downstream waste items,
will be deemed infectious/hazardous under waste regulations irrespective of the
contaminant matrix.
1. Potential hazards from the use of cytotoxic and cytostatic medicines may also be
relevant in some instances and with some drugs. This would also prevent the waste
being considered offensive
2. Pleurex and Rocket drains need to be classed as infected clinical waste for
disposal.
Wound assessment
The following criteria are based on the Delphi process of identifying wound infection
in six different wound types (European Wound Management Association, 2005).
Signs and symptoms of infection
Probability of wound being
infected
Is there presence of erythema/cellulitis?
High
Is there presence of pus/abscess?
High
Is the wound not healing as it should, or has Medium
healing been delayed?
Is the wound inflamed and has it changed Medium
appearance?
Is the wound producing a pungent smell?
High
Is the wound producing an increased purulent Medium
exudate?
Has the wound increased in pain?
High
Has there been an increase in skin temperature? Medium/Low
Is the patient on antibiotics for an infection High
present in the wound?
Is the wound to be swabbed for infection?
Medium
Note: It should be recognised that this is not an exhaustive list of signs and
symptoms of wound infection and that different types of wound will present
differently. This tool is to assist in the basic assessment of all wounds in order to
correctly categorise whether the waste produced contains an infectious fraction and
therefore infectious waste. Further information and advice regarding assessment of
wound infections should be sought from the local tissue viability specialist nurse.
PROCEDURE
1.
The health worker needs to use their professional judgement and knowledge of
the patient, in conjunction with the above tables of information (from the
Department of Health Waste Manual) to assess whether contaminated
healthcare waste is infectious or offensive.
2.
If the waste is deemed to be Infectious, the waste should be bagged into an
Orange Clinical waste bag, the bag should be sealed.
3.
A suitable storage area needs to be confirmed with the householder.
Page 28 of 62
4.
Please contact Gateshead Council on 0191 433700 to request a new clinical
waste collection. Details of the waste to be collected, patient‟s name, address
and contact telephone number, frequency of collection and the health workers
contact details should be provided to the call centre.
5.
The Councils clinical waste contractor will be contacted to arrange a collection
and the patient notified of the collection arrangements
6.
For any queries or to discuss individual cases, please contact John Fenwick on
0191 433 7419, or via e-mail johnafenwick@gateshead.gov.uk.
7.
If the waste is deemed to be offensive, it needs to be wrapped or bagged and
placed into the householder‟s domestic waste bin. Do not use tiger stripe or
orange clinical waste bags in the domestic waste.
Page 29 of 62
Procedure for assessment and disposal of healthcare waste generated in
patients homes by community healthcare staff
(South Tyneside and Sunderland Areas)
INFORMATION
Community healthcare workers responsibilities
Producers of healthcare waste and specifically infectious waste are required to
comply with waste regulations including the Hazardous Waste Regulations and
therefore need to ensure that waste is segregated, described, classified and
disposed of appropriately.
Waste risk assessment - Infectious waste
Waste is classified as infectious waste where:
• it arises from a patient known or suspected to have an infection, whether or not the
causal agent is known, and where the waste may contain the pathogen; or
• where an infection is not known or suspected, but a potential risk of infection is
considered to exist.
Table: Risk assessment approach to waste segregation based on likelihood of
infection being present
Contaminant Proposed
general
classification
Urine,
Offensive (where
faeces,
risk assessment
vomit and
had
sputum
indicated that no
infection is
present,
and no other risk
of
infection exist)
Blood, pus
Infectious unless
and wound
assessment
exudates
indicates no
infection present.
If no infection, and
no other risk of
infection, then
offensive
Examples
Exception to this rule
Urine bags,
incontinence
pads,
single-use
bowls,
nappies,
PPE
Gastrointestinal and other
infections that are readily
transmissible in the community
setting (e.g. verocytotoxinproducing Escherichia coli (VTEC),
campylobacter, salmonella,
chickenpox/shingles)¹ Hepatitis B
and C, HIV – only if blood is
present¹
Blood transfusion items
Dressings contaminated with
blood/wound exudates assessed
not to be infectious.
Maternity sanitary waste where
screening or knowledge has
confirmed that no infection is
present and no other risk of
infection exists
Dressings
from
wounds,
Wound
drains,
delivery
packs
Page 30 of 62
Notes: All Infectious waste A and B species, and therefore downstream waste items,
will be deemed infectious/hazardous under waste regulations irrespective of the
contaminant matrix.
1. Potential hazards from the use of cytotoxic and cytostatic medicines may also be
relevant in some instances and with some drugs. This would also prevent the waste
being considered offensive
2. Pleurex and Rocket drains need to be classed as infected clinical waste for
disposal.
Wound assessment
The following criteria are based on the Delphi process of identifying wound infection
in six different wound types (European Wound Management Association, 2005).
Signs and symptoms of infection
Is there presence of erythema/cellulitis?
Is there presence of pus/abscess?
Is the wound not healing as it should, or has
healing been delayed?
Is the wound inflamed and has it changed
appearance?
Is the wound producing a pungent smell?
Is the wound producing an increased purulent
exudate?
Has the wound increased in pain?
Has there been an increase in skin temperature?
Is the patient on antibiotics for an infection
present in the wound?
Is the wound to be swabbed for infection?
Probability of wound being
infected
High
High
Medium
Medium
High
Medium
High
Medium/Low
High
Medium
Note: It should be recognised that this is not an exhaustive list of signs and
symptoms of wound infection and that different types of wound will present
differently. This tool is to assist in the basic assessment of all wounds in order to
correctly categorise whether the waste produced contains an infectious fraction and
therefore infectious waste. Further information and advice regarding assessment of
wound infections should be sought from the local tissue viability specialist nurse.
PROCEDURE
The health worker needs to use their professional judgement and knowledge of the
patient, in conjunction with the above tables of information (from the Department of
Health Waste Manual) to assess whether contaminated healthcare waste is
infectious or offensive.
1
If the waste is deemed to be Infectious, the waste should be bagged into an
Orange Clinical waste bag, the bag should be sealed.
2
A suitable storage area needs to be confirmed with the householder.
Page 31 of 62
3
A referral form needs to be sent to SRCL (clinical waste contractor) by fax, with
relevant details of the waste to be collected. A start/end date and frequency of
collection should be included. A copy to be kept for the purpose of keeping records.
TO RECEIVE THE APPROPRIATE FAX NUMBER, CONTACT SRCL VIA
TELEPHONE:
Number 08451242020
4
The patient should be notified of the collection arrangements.
5
If the waste is deemed to be offensive, it needs to be wrapped or bagged and
placed into the householder‟s domestic waste bin. Do not use tiger stripe or orange
clinical waste bags in the domestic waste.
Page 32 of 62
Community Health Services
SRCL Household Clinical Waste Collection Request Form
For collection of Infectious Clinical Waste from patients homes by SRCL please ring
the following number and SRCL will issue you with the correct fax number:
08451242020
Patient/Collection Details
Name:
Address:
Post Code:
Telephone Number:
Can SRCL contact the patient on this number to confirm collection detail Yes
No
Healthcare Professionals Contact Details
Name
Contact Tel
Description of Clinical Waste (i.e. Bagged Dressings from MRSA infected wound)
Frequency of Collection Required (please  where appropriate)
Weekly
Fortnightly
One Off (end of treatment)
Duration of Collection (please  where appropriate, collections in excess of 4 weeks
need to be re-referred for a further collection).
One Week
Two Weeks
Three Weeks
Maximum Four Weeks
Comment / Additional Information (please use this space to add any further
information you feel may be useful)
Page 33 of 62
Appendix 4
Colour coding key to segregation system
Colour
Description
Waste which requires disposal by incineration
Indicative treatment/disposal required is incineration in a suitably permitted or licensed
facility.
Yellow
Waste which may be “treated”
Indicative treatment/disposal required is to be “rendered safe” in a suitably permitted or
licensed facility, usually alternative treatment plants (ATPs). However this waste may also
be disposed of by incineration.
Orange
Cytotoxic and cytostatic waste
Indicative treatment/disposal required is incineration in a suitably permitted or licensed
facility.
Purple
Offensive/hygiene waste*
Indicative treatment/disposal required is landfill or municipal incineration/energy from waste
at a suitably permitted or licensed facility.
Yellow/black
Anatomical waste for incineration1
Indicative treatment/disposal required is incineration in a suitably permitted facility.
Red
Black
Domestic (municipal) waste
Minimum treatment/disposal required is landfill, municipal incineration/energy
from waste or other municipal waste treatment process at a suitably permitted or
licensed facility. Recyclable components should be removed through segregation.
Clear/opaque receptacles may also be used for domestic waste.
Medicinal waste for incineration1
Indicative treatment/disposal required is incineration in a suitably permitted facility.
Blue
Amalgam waste
For recovery
White
*The use of yellow/black for offensive/hygiene waste was chosen as these colours have historically been
universally used for the sanitary/offensive/hygiene waste stream.
1
The colours “red” and “blue” are new to the colour-coding system in this edition. Care should be taken when
ordering red containers to ensure that they can be clearly differentiated from orange. The colour-coding could
be agreed as part of a contract specification.
Page 34 of 62
Appendix 5
BIOTRACK TAGGING GUIDE
Tag each waste bin with the correct tag before the next waste collection
HT Infectious
Clinical Waste
Bags
HN Infectious
HA Infectious
Anatomical
Waste
HS Infectious
Sharps
HN Infectious Blood
Contaminated
Sharps
HY Cytotoxic
Medicines for
Incineration
HP NonHazardous
Medicines
HI Highly Infectious
Clinical Waste for
Incineration
HL Non Infectious
Clinical Waste
Page 35 of 62
Appendix 6
Waste Disposal Procedures
Waste
Anatomical
Type
Asbestos
Not covered
elsewhere
All
Batteries
All
Blood gas analyser waste
All
Builders waste
Except asbestos or
other hazardous
materials
All
Cardboard
Chemical Waste from
clinics, wards and
departments
Alcohol gel
containers, aerosols
not containing
POMs
Chemical waste from
Pharmacy, Labs, etc
All hazardous
chemicals other
than previous
Disposal Route
Container
Red lidded box with appropriately
labelled body
Only to be disposed of by a licensed
contractor
Place batteries in one of the battery
recycling boxes. Tape up pins of 9V
batteries to with Cellotape prevent
sparking
Must be disposed of for incineration
Red lidded box or yellow
incineration only bag
Sealed container/bags
Hazardous waste for
incineration only
Hazardous waste
Battery recycling boxes
Hazardous waste
Yellow lidded box with
appropriately labelled
body
Skip
Hazardous waste for
incineration only
None
Recycling
Black or clear bag
Recycling
Retain in original
container for disposal
Hazardous waste
Loaded into skip and then taken by
skip company
Boxes to be folded flat and then
collected and disposed of for
recycling.
Single aerosol which has not
contained medicines can be
disposed of in black bag. If the
product goes down the sluice or
drain then rinse out the container
and recycle. Plastic containers can
then be recycled
Dispose of via specialist contractor.
Page 36 of 62
Comments
Hazardous waste
Chest drains, urine bags
and wound drains
All
Clinical waste
All except group 3,
category A (see
Appendix 4)
Group 3, category A
(see Appendix 4)
Clinical waste
Empty contents down sluice or toilet
or gel the contents. No liquids to go
into waste bags
Collected in yellow waste carts by
waste porters and transported to
waste compound
Only use this method if instructed to
do so by Infection Control of
Consultant Microbiologist
Put into shredding bags and then
shredded on site
Rendered unrecoverable by
Pharmacy staff using chemical
destruction and then disposed of
with pharmaceutical waste
Waste oils are collected and stored
in catering until collected by a
licensed contractor
Collected by Estates staff
Offensive waste unless
infectious then place in
orange bag.
Orange bags
Disposal as appropriate
Yellow waste bags
(double bagged)
Hazardous waste for
incineration only.
Blue or paper bags
Paper recycled
Blue lidded bins with
body
Hazardous waste for
incineration only
Original containers
Recycling
Skip
Recycled
All including sharps
Purple lidded sharps box with
appropriately labelled body
Purple lidded sharps box
Hazardous waste for
incineration
Electrical equipment
Must be decontaminated and then
handed to waste porters for
transport to the waste compound.
For equipment which cannot be
decontaminated see below
Food waste, dead flowers or
anything else biodegradable. Carts
taken to waste compound – see also
dry mixed recycling
None
Taken by licensed
contractor for recycling
Black bags
Controlled waste for landfill
Confidential waste
All
Controlled drugs
All
Cooking oil
From Catering
Copper, brass and other
scrap metals
Cytotoxic or cytostatic
medicines or equipment
contaminated with these
medicines
Defective medical
equipment
All metals
Domestic waste ( also
known as municipal
waste)
All
Page 37 of 62
Hazardous waste for
alternative treatment
Dry mixed recycling
All recyclables
Electrical and Electronic
equipment
Electronic and Electrical
equipment
All including spare
parts (see below)
Contaminated with
bodily fluids or
faeces
Fluorescent light tubes,
sodium lights
Foetal Tissue
All lamps
Food waste
From Catering
Furniture
Furniture from Trust
premises
Furniture and electrical
equipment from Trust
owned houses
All
Furniture containing
electrical components
Beds, chairs, etc
All terminations
Plastics, paper, cardboard and metal
cans
Given to waste porters and then
transported to waste compound
Decontaminate if possible. Remove
any batteries if possible and dispose
of as above. Give equipment to
waste porters.
Collected by Estates staff and stored
until collected by contractor
Foetal tissue is sent down to
Histology where it is put into a coffin
and taken away for cremation or
burial
Food waste goes through a
macerator and then to drain
Furniture to be given to waste
porters and then transported to the
waste compound
If the item is owned by the tenant
then they should be encourage to
dispose of it them selves via the
local authority. Where ownership
cannot be established or the item
has been left following the end of a
tenancy then return to the Trust for
disposal
Furniture to be given to waste
porters and then transported to the
waste compound
Clear bars
Recycling
None
Taken by licensed
Hazardous waste for
incineration only
Double bag in heavy
duty incineration only
bags or put into yellow
lidded sharps box
Purpose made collection
unit.
Coffin
Recycling and disposal
Taken by undertaker for
burial or cremation.
None
Discharged to drain
None
Controlled waste for
landfill/recycling
None
or hazardous waste for
recycling
None
Taken by licensed
Page 38 of 62
Glass containers which
have contained POMs
Only residues
remaining in the
container
Glass containers which
have more than residues
of POMs
Glass and crockery
Anything more than
a residue
Human tissue
Not covered
elsewhere
All
Inkjet and toner
cartridges
IV fluid bags with or
without giving set
Laboratory waste
All except POMs
Except those that
have contained
cytotoxic or
cytostatic medicines
(list available on
wards)
Not required to be
autoclaved
Put into blue lidded pharmaceutical
boxes until the fill level is reached
and then sealed and given to waste
porters. For larger containers
dispose of with Pharmaceutical
waste
Return to Pharmacy
Blue lidded
pharmaceutical box with
body
Hazardous waste for
incineration only
Pharmacy box
Hazardous waste for
incineration only
Place into a stout cardboard box.
(Plastic orange bins are available for
this purpose) Seal cardboard box
with tape and write the following on
the box “HANDLE WITH CARE –
BROKEN GLASS/CROCKERY”.
Include NAME OF WARD OR
DEPARTMENT.
Hand to waste porters
Red lidded box with appropriately
labelled body
Collected centrally and taken away
by licensed contractor
Dispose of as pharmaceutical waste
Cardboard box or
orange plastic bin
Recycling
Red lidded box or yellow
incineration only bag
No special requirements
Hazardous waste for
incineration only
Recycling
Put into blue lidded
pharmaceutical waste
with appropriately
labelled body
Hazardous waste for
incineration
Collected in yellow waste carts by
waste porters and transported to
waste compound
Orange waste bag
Hazardous waste for
Page 39 of 62
Laboratory waste
Autoclaved
Laboratory waste
Group 3, category A
(see Appendix 4)
All
Mattresses which are
uncontaminated
Mattresses contaminated
with blood or bodily fluids
Mercury contained in
equipment
All
In equipment
Double bagged, collected as
offensive waste carts by waste
porters and transported to waste
compound
Double bagged and put into
incineration waste cart.
Inform waste porters that mattress is
to collect
Inform waste porters that a
contaminated mattress is to collect
Hand equipment to the waste
porters who will store it in the waste
compound
Follow spillage procedure and then
give the collected waste to the waste
porters.
Place waste in clinical waste stream
for incineration
Offensive waste bag
Non-hazardous waste for
deep landfill
Yellow bag
No special packaging
Hazardous waste for
incineration only
Controlled waste
Orange mattress bag
Hazardous waste
None
Recycling/recovery of heavy
metal
Spillage kit
Hazardous waste for
incineration
Red lidded boxes with
body or yellow
incineration only bags
Yellow bag with black
stripe. Where offensive
waste stream does not
exist use a black bag
Hazardous waste for
incineration only
Mercury spillage
Spillage
Mortuary and post
mortem waste
All
Offensive waste Nappies, incontinence
pads, sanitary waste,
plaster casts used but
uncontaminated PPE
Paints and empty paint
tins
Paint Tins
All which is classed
as offensive and not
infectious.
Place into tiger stripe bag
Empty or containing
small residues
Containing more
than residues
All types and all
departments
All except controlled
drugs
Place in building waste skip
Skip
Chemical waste, give to waste
porters
Decontaminate the unit
Original containers
Secure packing
Hazardous waste for
incineration
Return to manufacturer
Put into blue lidded disposal bins or
into yellow lidded sharps boxes as
Blue lidded bins or
sharps boxes
Hazardous waste for
incineration only
Pacemakers
Pharmaceutical waste
containing residues of
Page 40 of 62
Deep landfill
POMs (includes aerosols
containing POMs)
Pharmaceutical waste
containers which have
more than residues of
POMs
Placenta waste
appropriate
Anything more than
a residue
Return to Pharmacy
Pharmacy box
Hazardous waste for
incineration only
Acute site
Put into placenta bucket and seal
when fill line reached. waste porters
to freeze the contents until disposal
Place in placenta bucket and seal
bucket. Collected from the home by
licensed contractor.
Stored in Medical Physics until
collected by licensed waste
contractor
Put into sharps bin specifically for
this purpose
Red lidded placenta
bucket
Hazardous waste for
incineration only
Red lidded placenta
bucket
Hazardous waste for
incineration only
ADR packaging
Hazardous waste fro
incineration
Orange lidded sharps
bin with appropriately
labelled body
Hazardous waste for
Yellow lidded sharps box with
appropriately labelled body until the
fill level is reached and then sealed,
signed and given to waste porters
Purple lidded sharps box until the fill
level is reached and then sealed and
given to waste porters
Yellow lidded sharps
boxes with appropriately
labelled body
Hazardous waste for
incineration only
Purple lidded sharps box
with appropriately
labelled body or larger
purple lidded bin if
required
Offensive waste – tiger
stripe bag
Infectious waste –
orange bag
Hazardous waste for high
level incineration
Placenta waste
Community delivery
Radioactive waste
Medical Physics
Sharps not containing
POMs
Sharps used during
blood testing or
other diagnostics
not involving the use
of POMs
Excluding cytotoxic
or cytostatic drugs
(list available on
wards)
Include anything
contaminated with
the medicines
Sharps including those
used with prescription
only medicines.
Sharps use with cytotoxic
or cytostatic medicines
Stoma bags - reusable
All
Empty stoma bags down sluice or
toilet. When disposing of the bag is it
offensive or infectious?
Page 41 of 62
Hazardous waste for
alternative treatment or
landfill
Offensive waste – tiger
stripe bag
Infectious waste –
orange bag
Disposable units should be filled with Orange bag
gel and then put into clinical waste.
Re-usable containers should be
emptied out and then sent to HSDU
Put into Red lidded containers with
Yellow incineration only
appropriately labelled body and
bags or red lidded boxes
waste porters to freeze the contents with appropriately
until disposal
labelled body
Waste classed as infectious clinical. Orange bags
Stoma bags - disposable
All
Suction waste
All
Theatres
Anatomical waste,
limbs femoral heads
and prostheses
Theatres
Waste infected with
any of the following:Hepatitis B or C
HIV or AIDS, T.B.
E coli 157,Typhoid
Cholera,
Shigella Dysentery
All
Directly into the toilet, sluice or a
collection device.
All
Recovered
Urine and faeces
Waste oils from Estates
Is the waste offensive or infectious
Hazardous waste for
alternative treatment or
landfill
Hazardous waste for
Hazardous waste for
incineration
Hazardous waste for
Toilet
Discharge to drain
Original container
Recycling
Appendix 7
Page 42 of 62
Waste Flow Chart
No
No
Has the waste
contained a
chemical?
Is the waste
offensive waste?
Yes
No
Yes
No
Yes
Has the waste
contained cytotoxic or
cytostatic medicines?
Tiger Stripe bag Incontinence pads, nappies,
plaster casts, uncontaminated
PPE, etc
Yes
No
Municipal waste
Has the waste
contained POMs?
Is it a blade,
needle or syringe?
Has the waste
contained cytotoxic or
cytostatic medicines?
No
Yes
Yellow lidded
sharps box
No
Yes
Does it contain
a sharp?
Pharmaceutical
waste
(blue lidded bin)
No
Yes
Has the glass
contained
POMs?
No
Yes
Does it contain
human tissue?
Key:
Yes
Red lidded
anatomical bin
No
Can it be recycled?
Yes
Yes
No
Plaster of Paris casts
must be collected
separately
Orange lidded
sharps bin
Does the waste
contain glass?
Purple lidded
sharps box
No
Yes
If product goes down drain
then wash container out
and dispose of as municipal
waste. Put single aerosol
(fully discharged) into
municipal waste.
Is the waste
Pharmaceutical waste?
Yes
Chemical waste Alcohol gel containers,
aerosols, or container that
has contained a chemical
substance
Is the waste
infectious clinical
waste?
Orange glass bin
or stout
cardboard box
Orange Clinical
Waste bag
Dry mixed
recycling
POM’s - prescription
only medicines.
Cytotoxic drugs –
cancer treatment
Cytostatic drugs –
anti-virals, immunosuppressants,
hormonal, etc
Municipal waste –
what used to be called
domestic waste
Page 43 of 62
Appendix 8
Waste Management and Compliance Audit Proforma
Ward/Dept
Auditor
Date
Areas Excluded
Ward/Department Audit Check List
1
The Trusts current edition Clinical Waste posters are displayed in all relevant areas?
2
All waste bins are enclosed where necessary (i.e. solid bins not sack holders)?
3
4
All waste bins in the area are foot operated where necessary, lidded and in good working
order?
All waste bins are visibly clean?
5
Waste bags are not tied onto containers/trolleys?
6
Rolls of clean bags are not stored at the bottom of waste bins?
7
All bag colours in use are appropriate for the location and type of waste in them?
8
There is a clinical - offensive waste stream (Tiger Stripe Bags) and it is being used correctly?
9
There is a clinical - infectious waste stream (Orange Bags) and it is being used correctly?
10
There is a clinical - Anatomical waste stream and it is being used correctly?
Page 44 of 62
YES
NO
N/A
Comments
11
12
13
There is a Dry Mixed Recycling waste stream (DMR) (Clear Bags) and it is being used
correctly?
There is a Domestic waste stream (Black Bags) and it is being used correctly?
15
Waste sacks for disposal are no more than 2/3 full; correctly tied and labelled with the correct
information (Hospital, Ward/Dept and Date)?
Suction waste is disposed of in a manner which prevents spillage e.g. into a rigid leak proof
container or waste solidified with a gelling agent?
The sharps bins in use comply with national standards (UN 3291, BS 7320)?
16
All sharps bins have been assembled correctly and signed on assembly?
17
The correct coloured lids and labels are on all sharps boxes?
18
19
Sharps bins are stored safely out of reach of children on a flat work surface at waist height or in
a bracket (Not on the floor)?
All sharps bins are labelled and signed according to the Trusts Waste Policy?
20
Suitable sharps boxes are in use for the sharps waste produced?
21
Contents of sharps boxes are compliant (if safe viewing is possible)?
22
Needles and syringes are discarded into a sharps bin as one unit?
23
Sharps bins have not been filled above the fill line?
24
The temporary closure mechanism is used when sharps bins are not in use?
25
26
Sealed and locked sharps bins are stored in a locked room, cupboard or container, away from
public access?
All sharps boxes are collected by the waste porters separately from other waste?
27
All pharmaceutical glass containing more than residues is sent back to Pharmacy?
14
Page 45 of 62
28
29
All pharmaceutical glass containing residues is disposed of in sharps boxes or blue lidded
boxes?
No waste bags are stored on corridors or other areas in full view of patients and visitors?
30
All clinical waste bins in public areas are locked to prevent access
31
Internal storage areas are inaccessible to the public and locked?
32
There is a glass and crockery waste stream and it is being used correctly?
33
Broken glass and crockery is being correctly packaged and disposed of?
34
There is a chemical waste stream and is it being used correctly?
35
The storage of substances and chemicals is in line with legislation?
36
Batteries are segregated into battery recycling boxes and given to waste porters and are 9V
batteries pins taped over with Cellotape/similar to prevent sparking?
Any other issues regarding handling of waste?
37
Additional Comments:
I confirm that I have been briefed on the contents of this Waste Audit Report undertaken by the Trust “Waste Compliance Officer”. I understand my responsibility in
implementing the recommendations made in the WASTE AUDIT REPORT - SIGNIFICANT FINDINGS AND ACTION PLAN, and will continue to monitor and maintain
the recommendations made in order to provide a safe environment. I have communicated all findings and known risks to relevant staff & other relevant users of the
Ward/Department.
Page 46 of 62
Person to action the recommendations of this Waste Audit Report:
Name: ………………………………..…
Position: ……….………………………..
Date: ………….………
Signature: …………………………...……….
Position: Waste Compliance Officer
Date: ……….…………
Signature: …………………………………….
Review to be Undertaken by Ward/Department Manager:
Date: ……….…………
Signature: …………………………………….
Review to be Undertaken by Waste Compliance Officer:
Date: ……….…………
Signature: …………………………………….
Waste Compliance and Audit Assessor:
Name:
Advice concerning any aspect of this Waste Audit Report can be obtained from:
Gordon Smith (Waste Compliance Officer); Telephone extension: 2493 Bleep: 790 E-mail: gordon.smith@stft.nhs.uk
Or for high level advice contact: Brian Gaff (Health and Safety Advisor); Telephone extension: 2890 Bleep: 890 E-mail: brian.gaff@stft.nhs.uk
Page 47 of 62
Waste Container Contents
Ward/Dept:
Location
Waste Category
e.g. Cubicle 2
Size/Type
G HT Sh Cy An Ph R Gl Am Of
KEY:
G General
Ph Pharmaceutical
HT Clinical
R Recycling
Sh Sharps
Gl Glass
Cy Cytotoxic/static
Am Amalgam
Page 48 of 62
An Anatomical
Of Offensive
Waste Compliance - Staff Questionnaire
The following section contains a number of waste related questions for staff; its purpose is to help the
assessor determine that current waste segregation practices are correct and that the correct waste
stream containers are provided (Bins, Bags and Sharps).
Q: Do you use any Cytotoxic or Cytostatic drugs on
your Ward/Dept?
Q: If Yes into which container would you dispose of
the waste including syringe needles, syringe
bodies, containers, IV bags/tubing, cotton wool etc?
Q: Do you use needles and syringes for the
administration of drugs/medicines on your
Ward/Dept?
syringe needles and syringe bodies that have been
used to administer drugs/medicines?
Q: If you were giving a patient two paracetamol
tablets and one dropped onto the floor where would
you dispose of it?
Q: Do you use needles and syringes for the taking
of bloods or in the process of taking urine samples
from patients on your Ward/Dept?
syringe needles and syringe bodies that have been
used for the taking of bloods or in the process of
taking urine samples?
Q: Do you use any drugs/medicines on your
Ward/Dept?
drugs/medicine containers that contain less than
one dose?
Yes/No
A: Yellow sharps box with purple lid and purple label
Yes/No
A: Yellow sharps box with yellow lid and yellow label
A: Yellow sharps box with yellow lid and yellow label
Yes/No
A: Yellow sharps box with orange lid and orange label
Yes/No
A: Yellow sharps box with blue lid and blue label
Q: If Yes how would you dispose of drugs/medicine
containers that contain more than one dose?
A: Transport back to Pharmacy where they will action safe
disposal.
nominally empty drugs/medicine glass containers?
A: Yellow sharps box with blue lid and blue label
Q: Do you have separate Domestic and Recyclable
waste stream bins?
Q: If Yes into which bin would you dispose of Dead
flowers, banana skins or apple cores?
Yes/No
A: Black Bag – Domestic Waste
Q: If Yes into which bin would you dispose of
rinsed out drinks cans/bottles; newspapers and
magazines?
A: Clear Bag – Recyclable Waste
Q: If Yes into which bin would you dispose of tea
bags, microwave meal trays, fast food cartons or
general food waste?
A: Black Bag – Domestic Waste
Q: If Yes into which bin would you dispose of card
board and other packaging including sterile
packaging from medical items/equipment?
A: Clear Bag – Recyclable Waste
Q: If Yes into which bin would you dispose of
Page 49 of 62
unused syringe bodies that are out of date or have
been dropped on the floor?
Q: Where would you dispose of written records or
other written documentation containing identifiable
confidential information about patient or staff?
Q: Do you have Infectious and/or Offensive waste
stream bins on your ward/Dept?
Q: If Yes into which bag would you dispose of
Personal Protective Equipment e.g. gloves,
facemasks, gowns that are contaminated with
infectious body fluids?
Personal Protective Equipment e.g. gloves,
facemasks, gowns that are not contaminated with
infectious body fluids?
swabs, tissues or other soft items that are
contaminated with infectious body fluids?
swabs, tissues or other soft items that are not
nappies and feminine hygiene products that are
nappies and feminine hygiene products that are
not contaminated with infectious body fluids?
A: Yellow sharps box with orange lid and orange label or
Yellow sharps box with yellow lid and yellow label
A: Confidential waste bins
Yes/No
A: Orange Bag –Infectious Clinical Waste
A: Tiger Stripe Bag –Offensive Clinical Waste
Q: How and where would you dispose of your
nominally empty Alcohol Hand Gel containers?
A: Rinse out and then put in Recyclable Waste
Q: How and where would you dispose of your
empty glass jars and bottles e.g. Coffee, jam etc?
A: Rinse out and then put in a stout cardboard box
Page 50 of 62
WASTE AUDIT REPORT - SIGNIFICANT FINDINGS AND ACTION PLAN
Ward/Department:
Date:
Good practice:
Theme
Auditor:
Areas Excluded:
Issue
Action
Required
Waste Segregation
Waste containers
Storage
Handling
Regulation
Information &
Training
Page 51 of 62
Person
Responsible
Signed on
Completion
Date of
Completion
Photographic Record
Example:
Example:
Example:
Example:
Page 52 of 62
Example:
Example:
Page 53 of 62
Waste Management and Compliance Audit Proforma
Waste Compound
Auditor
Date
Areas Excluded
None
Audit Check List
1
Waste collection staff have received the current training programme?
2
Waste is collected and transported by dedicated staff?
3
Porters are transferring waste in line with Trust policy and procedures around the site and is
the correct PPE being worn?
4
Clinical waste is collected and transported separately?
5
Storage compound is totally enclosed and secure?
6
Storage compound is kept locked when not in use?
7
Waste compound access is restricted to authorised trust staff only to prevent unauthorised and
unsupervised access to clinical and other waste streams?
8
Storage compound is provided with separate storage for sharps receptacles and waste
medicines?
9
Clinical waste bins are locked to prevent unauthorised access?
10
The Bio-track system is in use and are waste carts correctly labelled?
11
Cytotoxic/Cytostatic waste, anatomical and pharmaceutical waste is consigned separately from
other waste streams?
12
Anatomical waste is stored securely in freezers prior to consignment?
Page 54 of 62
YES
NO
N/A
Comments
13
Storage of all Chemicals/Acids/Alkaline etc is in line with current H&S/COSHH legislation?
14
Storage area for Chemicals/Acids/Alkaline etc is provide the required segregation and is it
clearly marked with the appropriate hazard warning signage?
15
Storage compound is provided with clearly labelled areas for waste requiring different
treatment/disposal options?
16
Storage compound is clearly marked with warning signs?
17
The waste compactor is serviced and has a suitable planned maintenance schedule?
18
Storage compound is sited away from food preparation and general storage areas, and from
routes used by the public?
19
Storage compound is well-lit and ventilated?
20
Storage compound is appropriately drained?
21
Storage compound is secure from entry by animals and free from insect or rodent infestations?
22
Storage compound is provided with wash-down facilities?
23
Storage compound is provided with washing facilities for employees?
24
Are waste transfer notes available for all consignments of waste which leave the site?
25
Do waste transfer notes contain the enough information to describe and consign the waste
correctly?
Are waste transfer notes retained for three years?
26
27
28
Are items designated under WEEE kept separate from other waste streams and collected by a
waste contractor??
Are all waste contractors that take waste from the site registered as waste carriers with the
EA?
Page 55 of 62
29
Are waste registrations with the EA current for all sites?
30
Any other issues regarding handling of waste?
Additional Comments:
I confirm that I have been briefed on the contents of this Waste Audit Report undertaken by the Trust “Waste Compliance Officer”. I understand my responsibility in
implementing the recommendations made in the WASTE AUDIT REPORT - SIGNIFICANT FINDINGS AND ACTION PLAN, and will continue to monitor and
maintain the recommendations made in order to provide a safe environment. I have communicated all findings and known risks to relevant staff & other relevant
users of the Ward/Department.
Page 56 of 62
Person to action the recommendations of this Waste Audit Report:
Name: ………………………………..…
Position: ……….………………………..
Date: ………….………
Signature: …………………………...……….
Position: Waste Compliance Officer
Date: ……….…………
Signature: …………………………………….
Review to be Undertaken by Ward/Department Manager:
Date: ……….…………
Signature: …………………………………….
Review to be Undertaken by Waste Compliance Officer:
Date: ……….…………
Signature: …………………………………….
Waste Compliance and Audit Assessor:
Name:
Advice concerning any aspect of this Waste Audit Report can be obtained from:
Gordon Smith (Waste Compliance Officer); Telephone extension: 2493 Bleep: 790 E-mail: gordon.smith@stft.nhs.uk
Or for high level advice contact: Brian Gaff (Health and Safety Advisor); Telephone extension: 2890 Bleep: 890 E-mail: brian.gaff@stft.nhs.uk
Page 57 of 62
WASTE AUDIT REPORT - SIGNIFICANT FINDING AND ACTION PLAN
Waste Compound
Date:
Good practice:
Theme
Issue
Auditor:
Areas Excluded:
Action
Required
Waste Segregation
Waste containers
Storage
Handling
Regulation
Information &
Training
Page 58 of 62
NONE
Person
Responsible
Signed on
Completion
Date of
Completion
Photographic Record
Example:
Example:
Page 59 of 62
Example:
Example:
Example:
Example:
Page 60 of 62
Appendix 9
Example list of recognised cytotoxic and cytostatic medicines – March 2012 (based on Safe
Management of Healthcare Waste 2011*)
Key:- (a) Chemotherapy cytotoxic / cytotstatic drugs (BNF 63) (Neoplastics and monoclonal antibodies).
(b) other non chemotherapy cytotoxic / cytostatic drugs (e.g. Hormonal treatments and anti retrovirals).
A
Abacavir (b)
Cetrorelix (b)
Cetuximab (a)
Docetaxel (a)
Doxorubicin (a)
Fulvestrant (b)
G
Abiraterone (b)
Chlorambucil (a)
Dutasteride (b)
Ganciclovir (b)
Aldesleukin (a)
Chloramphenicol
(b)
Ciclosporin (b)
Efavirenz (b)
Gemeprost (b)
Cidofovir (b)
Emtricitabine (b)
Gemtuzumab (a)
Cisplatin (a)
Cladribine (a)
Enfuviritide (b)
Epirubicin (a)
Gonadotrophin (b)
H
Clofarabine (a)
Eribulin (a)
Histerelin (b)
Coar tar preps (b)
Erlotinib (a)
Colchicine (b)
Crisantaspase (a)
Estradiol (b)
Estramustine (a)
Hydroxycarbamide
(a)
I
Idarubicin (a)
Alemtuzumab
(a)
Amsacrine (a)
Anastrazole (b)
Antiretrovirals
(b)
Arsenic trioxide
(a)
Asparaginase
(a)
Atazanavir (b)
Azacitidine (a)
E
Gemcitabine (a)
Lomustine (a)
Lopinavir (b)
Paclitaxel (a)
Panitumumab
(a)
M
Pemetrexed
(a)
Maraviroc (b)
Pentamidine
(a)
Medroxyprogesteron Pentostatin (a)
e(b)
Megestrol (b)
Podophyllum
(b)
Melphalan (a)
Porfimer (a)
Menotropins (b)
Procarbazine
(a)
Mercaptopurine (a)
Progesterones
(b)
Methotrexate (a)
R
Tegafur Uracil (a)
Temoporfin (a)
Mifepristone (b)
Mitomycin (a)
Topotecan (a)
Toremifene (b)
Page 61 of 62
Raloxifene (b)
Raltegravir (b)
Temozolamide
(a)
Tenofovir (b)
Testosterone (b)
Thalidomide (a)
Thioguanine (a)
Thiotepa (b)
Tibolone (b)
Tipranavir (b)
Azathioprine
(b)
B
Cyclophosphamid
e (a)
Cyproterone (a)
BCG (b)
Bevacizumab
(a)
Bexarotene (a)
Bicalutamide
(b)
Bleomycin (a)
Bortezomib (a)
Buserelin (b)
Busulfan (a)
C
Capecitabine
(a)
Carboplatin (a)
Carmustine (a)
Estriol (b)
Ifosfamide (a)
Mitotane (a)
Raltitrexed (a)
Trabectedin (a)
Imatinib (a)
Mitoxantrone (a)
Ribavirin (b)
Trastuzumab (a)
Cytarabine (b)
D
Estrogen/progester
one
Combinations (b)
Estrone (b)
Ethinylestradiol (b)
Mycophenolate (b)
N
Ritonavir (b)
Rituximab (a)
Treosulphan (a)
Tretinoin (a)
Dacarbazine (a)
Dactinomycin (a)
Etoposide (a)
Etravirine (b)
Indinavir (b)
Interferon containing
(b)
Ipilimumab (a)
Irinotecan (a)
Nafarelin (b)
Nelarabine(a)
S
Saquinavir (b)
Triptorelin (b)
Trifluridine (b)
Danazol (b)
Darunavir (b)
Dasatinib (a)
Daunorubicin (a)
Exemestane (b)
F
Finasteride (b)
Fludarabine (a)
L
Lamivudine (b)
Nelfinavir (b)
Nevirapine (b)
Nilotinib (a)
O
U-Z
Valganciclovir (b)
Vinblastine (a)
Vincristine (a)
Dexrazoxane (a)
Diethylstilbestrol
(b)
Dithranol products
(b)
Dinoprostone (b)
Fluorouracil (a)
Flutamide (b)
Leflunomide (b)
Letrozole (b)
Oesrogens (b)
Oxaliplatin (a)
Sirolimus (b)
Sorafenib (a)
Stavudine (b)
Streptozocin
(b)
Sunitinib (a)
T
Fosamprenavir (b)
Leuporelin (b)
Oxytocin (b)
Tacrolimus (b)
Zidovudine (b)
Foscarnet (b)
Lopinavir (b)
P-Q
Tamoxifen (b)
J-K
Page 62 of 62
Vindesine (a)
Vinorelbine (a)

Waste Management Policy - South Tyneside NHS Foundation Trust

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