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MEDICAL WASTE CHARACTERIZATION

Prepared For C.C. Lee

Risk Reduction Engineering Laboratory

M. Greene Office of Solid Waste

U. S. Environmental Protection Agency

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Prepared By D. Hansell, B. Springsteen, H. Rooney, W. S. Lanier and R. G. Barton

Energy and Environmental Research Corporation

May 10, 1991

This Document is Printed on Recycled Paper.

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TABLE OF CONTENTS

1 EXECUTIVE SUMMARY ....................................................................................................................... 1 APPROACH .................................................................................................................................... 1

Selection of Representative Faalities ................................................................................ 1

Generation Analysis ........................................................................................................... 3

Waste Minimization Analysis .............................................................................................. 3 RECOMMENDATIOFS FOR FUTURE WORK ............................................................................... 5

Additional facility Types ..................................................................................................... 5 Population Data .................................................................................................................. 5 In-depth Treatability Studies ............................................................................................... 5

OBJECTIVES .................................................................................................................................. 7 SCOPE OF STUDY ......................................................................................................................... 7 TECHNICAL APPROACH ............................................................................................................... 8 DEFINITIONS ................................................................................................................................ 10

.O n.site Surveys of Waste Generation Practices ................................................................ 3

Treatability Analysis ........................................................................................................... 3

2 INTRODUCTION ................................................................................................................................... 7

.... 3 FACILITY DESCRIPTIONS ................................................................................................................. 13

Description ....................................................................................................................... 13 Waste Segregation Practices ........................................................................................... 13 Waste Handling and Disposal ............................................................................. : ............ 15 Generation Rates .............................................................................. yp. ......................... 17 Waste Minimization ................................................. ......................................& ................. 17

Description ....................................................................................................................... 18 Waste Segregation Practices ........................................................................................... 21 Waste Handling and Disposal .......................................................................................... 22 Generation ........................................................................................................................ 22 Waste Minimization .......................................................................................................... 28

LOCAL PRIVATE LABORATORY ................................................................................................. 28 Description ....................................................................................................................... 28 Waste Segregation Practices ........................................................................................... 29 Waste Handling and Disposal .......................................................................................... 30 Generation ........................................................................................................................ 30 Waste Minimization .......................................................................................................... 31

LOCAL PUBLIC LABORATORY ................................................................................................... 31 Description ....................................................................................................................... 31 Waste Segregation Practices ........................................................................................... 32 Waste Handling and Disposal .......................................................................................... 32 Generation ........................................................................................................................ 32 Waste Minimization .......................................................................................................... 32

Waste Segregation Practices ........................................................................................... 34

Generation Rates ............................................................................................................. 34 .

PRIVATE CLINIC .......................................................................................................................... 13

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PUBLIC CLINIC ............................................................................................................................ 18

NATIONAL SPECIALTY LABORATORY ...................................................................................... 33 Description ....................................................................................................................... 33

Waste Handling and Disposal .......................................................................................... 34

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Waste Minimization .......................................................................................................... 38 RESEARCWEACHING HOSPITAL A ......................................................................................... 41

Description ....................................................................................................................... 41 Waste Segregation Practices ........................................................................................... 41 Waste Handling and Disposal .......................................................................................... 42 Generation ........................................................................................................................ 42 Waste Minimization .......................................................................................................... 47

RESEARCWEACHING HOSPITAL B ......................................................................................... 47

.Waste Segregation Practices ........................................................................................... 49 Waste Handling and Disposal .......................................................................................... 52 Generation Rates ............................................................................................................. 52 Waste Minimization .......................................................................................................... 52

BLOOD BANK ............................................................................................................................... 53 Description ....................................................................................................................... 53 Waste Segregation Practices ........................................................................................... 53 Waste Handling and Disposal .......................................................................................... 57 Generation ........................................................................................................................ 57 Waste Minimization .......................................................................................................... 57

4 GENERATION ANALYSIS .................................................................................................................. 59 POPULATION DATA ..................................................................................................................... 59

Hospitals ........................................................................................................................... 60 Clinics ............................................................................................................................... 61 Medical Laboratories ........................................................................................................ 61 Blood Banks ................................................................................................. .. .. .............. 62

WASTE GENERATION RATES .................................................................... LA ....,. :: .................. 62 NATIONAL WASTE GENERATION ......................................................................... :: ................... 62

Hospitals ........................................................................................................................... 62 Clinics ............................................................................................................................... 70 Medical Laboratories ........................................................................................................ 70 Blood Banks ..................................................................................................................... 70

SUMMARY .................................................................................................................................... 70 5 WASTE MINIMIZATION ...................................................................................................................... 77

MINIMIZATION PROCEDURE ....................................................................................................... Step 1 . Define Regulations and Classification of Waste ................................................. 77 Step 2 . Analyze Waste Segregation Methods ................................................................. 79 Step 3 . Assess Minimization Options ................................................................. : ............ 80 Step 4 . Implement a Minimization Plan ........................................................................... 81

SUMMARY OF MINIMIZATION APPLICATIONS ......................................................................... 82 6 TREATABILIN ANALYSIS ................................................................................................................. 83

INCINERATION ............................................................................................................................ 83 Heating Value ................................................................................................................... 83 Toxic Metals ..................................................................................................................... 84 Chlorine ............................................................................................................................ 87

Description ....................................................................................................................... 47

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STEAM STERILIZATION (AUTOCLAVING) ................................................................................. 87 GRINDINGCHEMICAL DISINFECTION ...................................................................................... 87

7 CONCLUSIONS AND RECOMMENDATIONS ................................................................................... 89 ADDITIONAL FAClLlN TYPES ................................................................................................... 90 POPULATION DATA ..................................................................................................................... 90 IN-DEPTH TREATABILITY STUDIES ........................................................................................... 90

8 REFERENCES .................................................................................................................................... 91 APPENDIX A: FACILITY SPREADSHEETS .............................................................................................. 9 2 APPENDIX B: ANNOTATE0 BIBLIOGRAPHY .......................................................................................... 96

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LIST OF FIGURES

1 2 3 4 5 6 7

8 9

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13 Fraction of segregated medical waste from the local private laboratory which falls under

14 Work load for each department of the national specialty laboratory .................................................... 33 15 Waste generation rates at the national specialty laboratory ................................................................ 38

17 Fraction of the segregated medical waste from the national speaalty laboratory which falls

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Approach used to characterize medical waste ...................................................................................... 2

Patient load.for each department of the private clinic .......................................................................... 15 Segregated waste generation rates in each department of the private clinic ...................................... 18

regulatory class ............. L'............ ......................................................................................................... 20

Segregated waste generation rates at the public clinic ....................................................................... 25 10 Composition of segregated waste from the public clinic ..................................................................... 26

Fraction of the segregated waste from the public clinic which falls under each regulatory class ........ 27 12 Composition of segregated medical waste from the local private laboratory ....................................... 30

each regulatory class ........................................................................................................................... 31

16 Composition of segregated medical waste produced at the national specialty laboratory .................. 39

under each regulatory class ................................................................................................ ................ 40 18 Patient load for each department of . Hospital A ................................................................................... 41

Segregated medical waste generation rates at all facilities examined .................................................. 4 Procedure used to determine waste generation rates ........................................................................... 9

Composition of segregated medical waste from private clinic ............................................................. 19 Fraction of segregated medical waste from the private clinic which falls under each

Patient load at each department of the public clinic ............................................................................ 21

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19 Segregated waste generation rate from Hospital A ............................................................................. 47 20 Composition of waste from Hospital A ................................................................................................. 48 21 Patient load for each department of Hospital B ................................................................................... 49 22 Segregated waste generation rates at Hospital B ............................................................................... 53 23 Composition of segregated medical waste from Hospital B ................................................................ 54

25 Composition of segregated medical waste generated at the blood bank ............................................ 58 26 Fraction of segregated medical waste generated at the blood bank which falls under

each regulatory class ........................................................................................................................... 58 27 Estimated contribution of various facility types to the total medical waste .......................................... 60 28 Segregated waste generation rate at all faalities exanlned ................................................................ 63

30 Generation rates of Class 3 (blood) wastes for all facilities exapined ................................................ 65 31 Generation rates of Class 4 (sharps) wastes for all faalities examined .............................................. 66

33 Generation rates of unregulated waste which is segregated at each facility ....................................... 68 34 35

37 Heating value of key waste mponents ............................................................................................. 84 38 Metals content of waste components .................................................................................................. 86

24 Fraction of segregated medical waste from Hospital B which falls under each regulatory class ......... 55

29 Generation rates of Class 1 (cultures and stocks) wastes for all facilities examined .......................... 64

32 Generation rates of segregated waste containers for all facilities examined ....................................... 67

Distribution of national waste based on data from faalities with largest generation rates ................... 74 Distribution of national waste based on data from faalities with smallest generation rates ................ 74

36 Steps required to develop a waste minimization plan .......................................................................... 78

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LIST OF TABLES ..

1 2 3 4 5 Sharp and Red-Bag Waste Components Generated by Each Department at National Private

6 Sharp and Red-Bag Waste Components Generated by Each Department at Hospital A ................... 43 7 Sharp and Red-Bag Waste Components Generated by Each Department at Hospital B ................... 50 8 9 Characteristics of General Medical and Surgical Hospitals ................................................................. 61 10 Predicted National Generation Segregated Medical Waste ................................................................ 69 11 Predicted National Segregated Medical Waste Generation From Heatth Clinics ................................ 69

Characteristics of Faallties Studied ..................................................................................................... 14 Sharp and Red-Bag Waste Compnoents Generated by Each Department at the Private Clinic ......... 16 Sharp and Red-Bag Waste Components Generated by Each Department at the Public Clinic .......... 23 Sharp and Red-Bag Waste Components Generated by Local Private Laboratory .............................. 29

Laboratory ............................................................................................................................................ 35

Sharp and Red-Bag Waste Components Generated by Blood Donor Center ..................................... 56

12 Predicted National Segregated Waste Generation Rates for Clinical Laboratories ............................. 71 13 Predicted National Segregated Medical Waste Generation Rates for Blood Banks ............................ 72 14 Estimated National Waste Generation Based on Largest Rates Observed in this Program ............... 72

Estimated National Waste Generation Based on Smallest Rates Observed in this Program ............. 73 c- . 15 16 Regulated Waste Generation Rates .................................................................................................... 75 17 Materials Wth Low Heating Values ..................................................................................................... 85 18 Characteristics of Materials for Which Metals Content was Determined ............................................. 85 19 Materials Which May Present Problems for Steam Sterilization .......................... ......... 1. ................. 87

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SECTION 1

\ EXECUTIVE SUMMARY

The purpose of this study was to characterize medical waste generation. The focus was on the portion of medical waste which is segregated for special treatment. The impact of facility type and waste handling practices on the quantity and composition of medical waste produced were examined. The data were analyzed to provide information on the types, quantities, and treatability of materials which are being considered for regulations. In addition, the potential for minimizing the production of some types of medical waste was assessed.

APPROACH

The approach employed in this program is shown schematically in Figure 1. It involved the following activities:

Selection of representative facilities

Waste generation analysis

Treatability analysis

8 Waste minimization analysis

< L On-site surveys of waste generation practices ./* ,/. ,

SELECTION OF REPRESENTATIVE FACILITIES

Four major classes of facilities were chosen for evaluation: clinics, hospitals, laboratories and blood banks. These types of facilities account for 85% of the medical waste generated in medical institutions in states covered by the Medical Waste Tracking Act demonstration program (1). Two heatth clinics and a blood donor center were evaluated. The first health clinic was a large private clinic in Califomia serving 1,988 patients er day. It had allergy, family practice, obstetrics/gyneco@y, iatrics and dermatology depart-

child heatth, immunization, maternal health, special disease and pulmonary departments. he blood bank was also located in California and served 25 donordday.

The hos 'tals that were chosen were large faalities with as much diversity as possible. Both were

demonstration program. The other hospital was located in the state of North Carolina. The Connecticut hospital had 863 beds and 5,400 employees while the North Carolina facility had 1,000 beds and employed 12,000. Both hospitals had emergency room, radiology, surgery, labor and delivery, patient care, clinical labs, and pharmacy departments.

Three laboratories were evaluated, one medium size (1 000 samples per da and 28 employees) local

samples per day and 800 employees) national specialty laboratory. The local private laboratory conducted primaril blood and urine tests, and pap smears. The local public laboratory conducted virology, serolo y

specialty areas of the large private national specialty lab included chemistry, microbiology, sero ogy, R&D, hepatitis/HIV, biovet, paternity and toxicology.

7 ments. P he second health clinic was a public clinic in California serving !F 63 patients per da It had dental,

teaching hospita P s. One was located in Connecticut and was participating in the Medical Waste Tracking Act

private lab, one medium size (770 samples per day and 35 employees) local public r ab and one large (24,300 clinical L acteriology, special bacteriology, enterics, food poisoning and mycobacteriobgy anal ses. lk r

Major generator classes Many healthcarwr medical subunits

Evaluation of Waste Generation Practices

JI Treatability Analysis

Waste chemical composition Waste physical characteristics

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Amounts Materials Regulated categories

Source reduction Reuse Recycling

Figure 1. Approach used to characterize medical waste.

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&-SITE SURVEVS OF WASTE GENERATION PRACTICES

For each of the eight facilities, on-site surveys %re conducted to evaluate the waste generation practices and to uantify the enerationof selectedcomponents of medical waste. The componentsof interest

These classes are: - were those list ea by the EP B . The regulatory classes used were the 7 classes defined in 40 CFR Part 259. e Cultures and stocks

. Pathological wastes e Human blood and blood products

. Sharps # ' e Animal wastes

e Isolation wastes

e Unused sharps

GENERATKN ANALYSIS

A variety of procedures were utilized in an attempt to quantify the generation rates, including the use of purchasing records, direct observations, weighing samples, and waste disposal records. All waste components that were segregated by the institutions and given special treatment were examined. Usually both regulated and un-regulated materials were found in the segregated waste. The surveys were conducted on a department by department basis. Differences between the total waste generation rates calculated based upon purchase records and those determined based on disposal records were reconciled via reexamination of data. A spread sheet data base was then developed that enables analysis of waste generation rates by

Figure 2 illustrates the waste generation rates observed at each faali examined on a department generation rates were predicted. The predicted generation rate of medical waste which is segregated for special treatment in the U.S. is between 160,815 and 761,366 towyear.

TREATABIL~ ANALYSIS

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< - I material, regulated category, and department. s ./* /'

basis. Generation rates varied over four orders of magnitude. Based on the 3 ata obtained, national waste

tional techniques such as steam sterilization, incineration, and grindirgkhemical disinfection. L owever,

There is a need for direct testing of the treatability of these pro lem materia 8 s. Once these materials are

The medical waste characterized in this study consists generally of materials treatable b conven-

some problem materials were identified for steam sterilization including body parts and organs, animal carcasses, and wastes containing volatile chemicals. For incineration, the problem materials were not those that could not be treated but rather materials that had the potential for by-product formation in the incineration process. These materials included colored plastics containing metals and plastics with high chlorine contents. There is currently no index to determine which materials would be roblems for rindinglchemical disinfection.

identified they can be eliminated through use of product substitution and segregation practice.

WASTE MINIMIZATION ANALYSIS

For each of the faalities, practices which could be used to minimize the quantity of waste produced wereidentified. Based upon the types of strategies that could be implemented at each of these facilities, a general medical waste strategy was developed that could be applied to other similar institutions.

Some of the facilities investigated in this program were found to be using universal precautions to dictate waste management procedures. For this reason, these facilities were generating higher rates of medical waste than necessary.

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L Lsbor and Delive Waste Generation Rate, (IWpabient vldt)

Wasre Generation Rate. (IblpaUlent-Qy) waste Generation Rare, (Iblspedm) -. 4

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Patient Care

Pharmacy

Other

Emergency Room

Lsbor and Delivery

Radiology

m Patient Care

N W Y

3 Family Practice

0 -. tebicsKiynocdogy 6 , $.

Pedialrics

Dermatology

Child Health

Dental

The general steps for waste minimization were defined. These steps include:

Step 1. Define applicable regulations and classifications of waste

Step 2. Analyze current waste segregation methods and opportunities for minimization involving strict segregation of individual waste streams.

Step 3. Assess minimization options such as modification of operating practice, product substitution to reduce toxic materials or by-product formation, us8 of biodegradables, modification of analytical testing procedures to reduce waste, and encourage multiple use products which

. can be reused or recycled after disinfection.

Step 4. Implement\ation of Minimization Plan via education and employee training, labeling, imple- menting incentives, and improved inventory control to provide monitoring of success.

RECOMMENDATIONS FOR FUTURE WORK.

This program has gone far in providin a broad base of data on medical waste generation. However, additional work is needed. Three areas whic R require more work have been identified. These are:

Additional Facility Types

Population Data

In-depth Treatability Studies

ADDITIONAL FACILITY TYPES

The facilities examined in this study produce about 85 percent of the medical waste in the US. (1). The facilities responsible for the remaining 15 percent of the waste should be examined. ‘These facilities include: J- / I I ,

Funeral Homes

Nursing Homes and Hospices

Dentists

. Private Physicians Veterinarians

It is likely that the effort required to characterize these types of facilities will be equal to that required to characterize the facilities examined in this study.

POPULATICN DATA

The generation analysis is weakened by the lack of comprehensive data characterizing all of the medical facilities in the U.S. Data needed includes total patient loads for each department in each facility. Because waste generation varies significantly from department to department within a facility, total facility atient loads are not sufficient to accurately predict medical waste generation rates. This information could b obtained through the use of a questionnaire accompanied by strict follow-up.

IN-OEPTH TREATABILITY STUDIES Several items that may present problems to the most common treatment techniques were identified

in this study. The treatability of these materials should be examined in detail to quantify the precise impact of the treatment methods.

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SECTION 2

lNTRODUCllON \

There is much recent concern over the management of medical wastes. In response to this concem, the U. S. Congress enacted the Medical Waste Tracking Act of 1988. This act has many provisions including a requirement that the U. S. Environmental Protection Agency (EPA) prepare a series of reports evaluating medical waste generation and treatment. Much of the data needed to prepare these reports to Congress is not available.

One key area of data which is missing is a detailed characterization of medical waste and medical waste generation practices. These data are needed to support the many analyses which must be conducted to provide Congress with useful reports. This study assembled a unique data base on the characteristics of medical waste and on medical waste generation practices.

OBJECTIVES

/&dling practices on the quantity and composition of medical waste produced was also investigated. A- ,-.

SCOPE OF STUDY ,

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The objective of this study was to characterize medical waste generation. The focus was on the rtion of medical waste which is segregated for special treatment. The impact of generator type and waste

This study consisted of three tasks. These tasks were:

1.

2.

3. Analyze medical waste generation

The study was structured so that no waste was handled once it was contaminated. This constraint was instituted to ensure the health of project personnel. The number of facilities to be examined was limited. The following facility types were selected:

Identify and obtain cooperation from appropriate facilities

Quantify waste generation as a function of facility type

e A large medical center located in a state participating in the Medical Waste Tracking Act.

A large medical center located in a state not participating in the Medical Waste Tracking Act.

An off-site national specialty laboratory located in a state not covered by the Medical Waste

A local private laboratory located in a state not covered by the Medical Waste Tracking Act.

A local public laboratory located in a state not covered by the Medical Waste Tracking Act.

A multi-disciplinary private clinic located in a state not covered by the Medical Waste Tracking

A muttidisciplinary public clinic located in a state not covered by the Medical Waste Tracking

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Tracking Act.

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A blood bank located in a state not covered by the Medical Waste Tracking Act.

These facilit types produce most of the medical waste generated in the U.S. Previous studies have indicated

Thus, large facilities were selected so that many different types of subunits could be examined. that medica r waste characteristics may vary significantly from one subunit to another within a given facility.

To quantify the waste generated, the waste management practices were examined. The types of materials segregated for special treatment were identified and the quantity disposed of was determined. The dependence of waste generation rates and composition on facility and subunit type were observed.

The waste characteristics and waste generation practices were then analyzed. The potential for waste minimization was examined. In addition, the wastes were subjected to chemical analysis to determine the potential effectiveness of various waste treatment methods.

TECHNICAL APPROACH

Figure 1 illustrates the approach used in this study to characterize medical waste. The first task was to identify appropriate facilities and obtain permission to assess their waste generation processes. This approach may have influenced the resutts of the study. It is likely that only those facilities which were confident of their waste handling practices would rant permission for a comprehensive ana sis of theirwaste handling the amounts of wastes produced by the participating facilities. Three criteria were used to select facilities for analysis:

procedures. However, this bias shoul 8 not adversely influence this study since t x e results are estimates of Facility type

Faality size

Faality location ,.r

Four types of facilities were identified for analysis. These are hospitals, ou@ienf,clinics, blood banks, and clinical laboratories. These four facility classes produce approximately 85 percent of all medical waste (1 ).

Large facilities were selected for participation in this study. Previous studies have found that waste generationcharacteristics vary from subunit to subunit in a facility. Largefacilitieswould have a large number of subunits. Data from a large facility could be used to determine the waste characteristics of many different subunits. The subunit data could then be used to predict the characteristics of many smaller facilities.

The final criteria was facility location. The regulations which govem the handling of medical waste vary from location to location across the country. It was desired to examine facilities from different geographic regions so that a variety of waste handling procedures could be compared.

Each of the facilities which agreed to participate in the program were visited by a team observers. The observers noted waste handling procedures, determined quantities of waste produced, and obtained samples of key materials. Purchasing records from each facility were examined in detail. The purchasing records proved to be an accurate method for quantifying the amount of different waste components in the waste.

Figure 3 illustrates the method used to determine the item specific waste generation rates for each subunit of each facility. During the site visit, the waste segregation and handling procedures were determined. A list was compiled of the items segregated from the eneral trash. Samples of the prinapal items were obtained and weighed. Purchasing records for the faclity were analyzed to determine the number of each item disposed of. The data were then used to predict the total mass of each item disposed of and the total mass of waste. This value was reconciled with the waste disposal records maintained by the faality. The final waste generation rates obtained were normalized by the number of patients or specimens treated each day.

Waste generation rates from each type of facility were used to estimate the total amount of waste generated on a national level. Where possible, subunit-specificdatawere used. However, detailed population data for medical facilities is not available. Population data are needed to accurately determine the characteristics of medical waste generated in the entire nation.

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practice via on-site inspection

Normalize generation rates by number of patients or

specimens processed per day

I Define handling and disposal practice for each subunit

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Compile list of items disposed of in each

subunit

Use departmental supply records to determine

amounts of each item used

Determine mass of each waste component

Estimate total segregated waste generation using purchasing records and

component masses

1 Reconcile differences in

disposal records and predicted total waste

generation rate

Figure 3. Procedure used to determine waste generation rates.

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The waste handling procedures observed were analyzed to determine potential waste minimization options. The potential for source reduction, item reuse, and material recycling was examined. A detailed procedure for the minimization of medical waste was devebped based on the observations of waste handling procedures.

The impact of the waste's characteristics on the potential effectiveness of different treatment techniques was examined. Samples of highuseitems within the facilities were sent to an analytical laboratory for chemical characterization. These samples were tested for trace amounts of toxic metak and waste characteristics such as heating value and ultimate analysis which may play a role in waste treatability.

DEFINITIONS . The management of,medical waste is a complex issue. Many regulatory bodies have addressed

different aspects of the problem. As a result, many of the key issues related to medical waste management have no commonly accepted definitions. It is necessary to clearly identify the definitions that were used in this

The Medical Waste Tracking Act of 1988 is the current basis for development of federal regulations

"...any solid waste generated in the diagnosis, treatment or immunization of human beings or animals, in research pertaining thereto, or in the production or testing of biologicals. Such term does not apply to any hazardous waste identified or Gsted under subtitle C or any household waste as defined in regulations under subtitle C.'

study.

controlling medical waste disposal. This act defines medical waste as:

The act defines nine subcategories of medical waste which should be regulated but ives the EPA authority to modify or delete categories 6-10 and add additional categories as necessa 7 #,categories defined in the act will be referred to as the "statutory categories" and are defined as fo dws:

Cultures and stocks of infectious agents and associated biologicals, inckrdjng': cultures from medical and pathological laboratories; cultures and stocks of i-ousagents from research and industrial laboratories; wastes from the production of biologicalCdscafded live and attenuated vaccines; and culture dishes and devices used to transfer, inoculate, and mix cultures.

Pathologlcal wastes, including tissues, organs, and body parts that are removed during surgery or autopsy. Waste human blood and products of blood, including serum, plasma, andothercomponents.

Sharps that have been used in patient care or in medical, research, or industrial laboratories, including hypodermic needles, syringes, Pasteur pipettes, broken glass, and scalpel blades.

Contamlnated animal carcasses, body parts, and bedding of animals that were exposed to infectious agents during research, production of biologicals, or testing of pharmaceuticals.

Wastes from surgery or autopsy that were in contact with infectious agents, including soiled dressings, sponges, drapes, lavage tubes, drainage sets, underpads, and surgical gloves.

Laboratory wastes from medical, pathological, pharmaceutical, or other research, com- mercial, or industrial laboratories that were in contact with infectious agents, including slides and cover slips, disposable gloves, laboratory coats, and aprons.

Dialysis wastes that were in contact with the blood of patients undergoing hemodialysis, including contaminated disposable equipment and supplies such as tubing, filters, dispos- able sheets, towels, gloves, aprons, and laboratory coats.

Discarded medical equipment and parts that were in contact with infectious agents. Blolo~lcal waste and discarded materials contaminated with blood, excretion, exudates or secretron from human beingsoranimalswho are isolated to protect othersfromcommunicable diseases.

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7.

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9.

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11. Such other waste materlai that results from the administration of medical care to a patient by a health care provider and is found by the administrator to pose a threat to human health or the environment.

Thustwodefinitionsof medical waste exist. The Statutory deflnitlon for medlcal wastewhich consists of all the medical waste which falls into any of the subcategories defined above. Unregulated medical waste consists of all of the material which falls under the definition of waste produced by a medical facility but which is not included in any of the subcategories. Unregulated medical waste would included such items as food wastes from a hospital cafeteria and office supplies from a physicians office.

In Marcti of 1989, the €PA promulgated the regulations required by the Medical Waste Tracking Act under 40 CFR Part 259. In the regulations, the categories of medical waste which are to be regulated were modified. These categories will be referred to as the "regulatory classes" and are defined as follows:

Cultures and Stocks. Cultures and stocks of infectious agents and associated biologicals, including: cultures from medical and pathological laboratories; cultures and stocks of infectious agents from research and industrial laboratories; wastes from the production of biologicals; discarded live and attenuated vaccines; and culture dishes and devices used to transfer, inoculate, and mix cultures.

Pathological Wastes. Human pathological wastes, including tissues, organs, body parts, and body fluids that are removed during surgery or autopsy or other medical procedures, and specimens of body fluids and their containers.

Human Blood and Blood Products. 1. Liquid waste human blood; 2. products of blood; 3. items saturated andlor dripping with human blood; or 4. items that were saturated and/or dripping with human blood that are now caked with dried human blood; including Serum, plasma, and other blood components and their containers, which were used or intended for use in either patient care, testing or laboratory analysis or the development of pharmaw- ticals. Intravenous bags are also included in this category.

Sharps. Sharps that have been used in animal or human patient care ottreatment or in medical, research or industrial laboratories, including h dermic needles, sytinges (with or

with attached tubing, and culture dishes (regardless 04 presence of infectious agents). Also included are other types of broken or unbroken glassware that were in contact with infectious agents, such as used slides and cover slips.

Animal Wastes. Contaminated animal carcasses, body parts and bedding of animals that were known to have been exposed to infectious agents during research (including research in veterinary hospitals) , production of biologicals, or testing of pharmaceuticals.

Class 1.

Class 2.

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Class 3.

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Class 4.

without attached needle), Pasteur pipettes, scalpel bla ydp" es, blood vials, test tubes, needles

Class 5.

Class 6.' Isolation Wastes. Biological waste and discarded materials contaminated with blood, excretion, exudatesorsecretionsfrom humanswhoareisolatedtopmted othersfromcertain highly communicable diseases, or isolated animals known to be infeded with highly communicable diseases.

Unused Sharps. The following unused, discarded sharps: hypodermic needles, suture needles, syringes and scalpel blades.

Several of the regulatory classes are broader than the corresponding statutory categories or combine

Class 7.

two or more statutory categories. The definitions of medical waste and regulated medical waste also vary from state to state. Each

facility must inte ret the current regulations that apply and enact a waste segregation and handling poli

classes used to define regulated medical waste. For the purposes of this study, the waste placed in separate receptacles and given special treatment in a facility will be referred to as segregated waste.

A phrase that has rebntly come into common use is "unhrersal precautlons.' The phrase was

7 as needed. Often, 'R t e materials segregated by a medical facility for special treatment do not fall into any o the

coined to refer to a set of medical facility operating procedures designed to rotect the rights of patients with special diseases such as AIDS while at the same time protecting care workers from exposure.

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Universal precautions suggest that health care workers treat all patients as if they have an infectious disease. while these procedures were not intended to be used as a waste segregation tool, in practice no such distinctions occurs. If personnel at a facility treat any patients as if they have an infectious disease, all wastes generated by that person are treated like isolation wastes. Facilities who choose to utilize universal precaution procedures as a method for segregation of medical wastes will consequently have larger volumes of waste which will be disposed of as medical waste at higher waste disposal costs.

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SECTION 3

FACILITY DESCRIPTIONS

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Eight medii1 facilities of varying size and function were visited to obtain data on medical waste generation and handling. During each visit information on waste generation rates, waste composition and waste handling procedures was determined. After the visits, detailed purchasing records were obtained and analyzed. These records were used to supplement the data obtained from direct observation in the determination of waste generation rates and composition. Table 1 summarizes the facilities examined in this Study.

PRIVATE CLINIC

DESCRIPTION

The private clinic examined was a multidisciplinary, private outpatientclinic operated by a health maintenance organization in Califomia. The clinic consisted of five departments - allergy, family practice, obstetricdgynecology, pediatrics, and dermatology. These five departments treated an average of 1,988

/fl ;’,

The pediatrics department had three subsections-well-baby, after-hours, and chemotherapy. The subsedion admimstered

\ - * patients per week day. Figure 4 illustrates the patient bad for each department. b.

well-baby subsection performed routine examinations while the chemothera

injections. !his department also had an acutecare clinic which handled walk-in patients.

cytotoxic chemicals. The cytotoxic chemicals were disposed of separate from ot pt; er waste items. The family practice de artment provided general medical care such as physi C J examinations, watt removal, and

WASTE SEGREGATKX PRACTICES

Waste from each of the departments at the clinic was separated into three classes - sharps, red- bag waste, and regular waste. The sharps class consisted of any rtemwhii had the potential to cut a patient or an employee. It included glass tubes, syringes with needles, blades, scalpels, slides, antigen and drug vials, and needles.

In the allergy, family practice, dermatology, and obstetrics/gynecokgy departments, red-bag waste consisted of non-sharp i t e m which had contacted a patient with a communiCaMe disease. These departments only saw one or two patients with communicable diseases each month. The most significant source of red-bag waste came from the chemotherapy subsection of the pediatrics department. This subsection generated two or three red-bags per day, containing glass bottles which did not fit in the sharps containers, gbves, and paper.

Most of the waste a the faality was disposed of as regular waste. This waste included gbves, speculums, tongue depressors, swabs, gowns, and other disposable wastes which did not fall under the facility definitions of sharp and red-bag wastes.

Table 2 lists the items which were placed in the sharp and red-ba dasses for eachof the departments component of the segregated waste. The segregated waste at this facility was composed of the sharp and red-bag classes.

at the clinic. In addition, Table 2 lists the primary material, regulatory 3 ass and quantity ploduced for each

13 b

TABLE 1. CHARACTERISTICS OF FACILITIES STUDIED.

Faality'

Private Clinic

Public Clinic

Local Private Laboratory

Local Public Laboratory

ResearMeaching (Hospital A)

ResearcNTeaching (Hospital 6)

National Specialty Laboratory

Blood Bank

Description

Multidisiplinary private medical clinic

Multidisiplinary public health clinic

Clinical medical laboratory

Public health laboratory

Large medical center, research facilities and teaching hospital on-site

Large medical center, research facilities and teaching hospital on-site

Clinical medical laboratory, specialty analyses on national basis

Blood collection center

Location

Ca

Ca

Ca

Ca

CT

NC

NC

Ca

Partidpate in Tracking

Demonstration Program

No

Yes

No

No

No

14

1200

8 z E n

2 f

L s 'a 'E Q) L.

CI

6

d \ '. ,'; ,

Figure 4. Patient bad for each department of the private clinic.

WASTE HA"m AND DISPOSAL

Each of the d8partf" a! the clinic handled and disposed of their segregated wastes in the same -containers or beige, 6 by 12 inch

Any non-sharp waste mntaminated by a patient with a communicable disease of generated in the chemotherapy subsection of the pediatrics department was placed in a red ba . Most of the red-bag waste was generated in the chemothe subsection of the pediatrics department. h e red-bag waste Oenerated in the chemotherapy subsection "%y id not contain bulk amounts of cytotoxic material bul consisted instead of used glass bottles and rubber gbves which might have been contaminated. Red-bag waste from other departments and their subsections was almost nonexistent because of the low vobme of patients with communicable diseases treated at the facility.

The full red bags and sharps containers were picked up night by the housekeeping stafl and

st of the waste in the wastemanagement areawas contributed by the blooddonationcenter and the laboratory. 80th facilities will be discussed in this report: The waste management area was emptied eve other day. For the month

manner. Sharps were placed in either lOSquart, r i 'd, red, Winfield sha wall sharpscontainers. Needles and knives were lt ft uncapped and u g k e n .

"840 delivered to an encbsed waste mana ement area outside the building. x, e waste man ement area was also used by a Mood bank and a cfinica B laboratory occupying the same building as the clinic. of June 1990,1,801 bs of segregated waste were picked up at a cost of 299.1 r doflat's.

15

. TABLE 2. SHARP AND RED-BAG WASTE COMPONENTS GENERATED BY EACH

DEPARTMENT AT THE PRIVATE CLINIC.

Department

Allergy

Dermatology

Famity Practice

Obstetrics/ Gynecology

Pediatrics

Item \

Antigen Bottles Needles Sharps Containers Syringes

Blades Needles Scalpels Suture Kits Syringes Sharps Containers

Blades Drug Vials Needles scalpels Sharps Containers Suture Kits Syringes

Microscope Slides Sharps Containers

Blood Collection Sets Needles Sharps Containers suture Kits Syringes

Mate rial

Glass Metal Plastic Plastic

Metal Metal

Plastic' Silk

Plastic Plastic

Metal Glass Metal

Plastic' Plastic Sik

Plastic

Glass Plastic

Plastic Metal P W i

Silk Plastic

Regulatory Class

Class 1 (Cult.) Class 4 (Sharp)

Containers Chss 4 (Sharp)

Class 4 (Sharp) Class 4 (Sharp) Class 4 (Sharp) Class 4 (Sharp) Class 4 (Sharp)

Containers

Class 4 (Sharp)

Class 4 (Sharp) Class 4 (Sharp)

Containers Class 4 (Sharp) Class 4 (Sharp)

class 1 (Cuky- -

Class 4 (Sharp) Containers

Class 4 (Sharp) Class 4 (Sharp)

Containers Class 4 (Sharp) class 4 (Sharp)

2.13

12.14 16.43

0.93 2.60 0.93 0.1 1 6.75 8.02

8.49

L. -0.11 ''.* 0.45 ' 0.55

0.15 2.72 0.02 2.33

5.90 0.45

1.26 4.86 66.12 0.03 16.96

' - Scalpels consisted of a metal blade attached to a plastic handle. Containers - while the sharps containers are an integral part of the waste, they are not defined as a regulated

medical waste.

16

GENERATK~ RATES

To determine the generation rate of waste from the clinic asa whole andfromeach of the departments listed in Table 2, departmental supply records were analyzed. Five month's records from the dermatology and allergy departments and two month's records from the pediatrics, family practice, and obstetricslgynecobgy departments were analyzed.

The analysis had three steps. first, information from the site visit was used to generate a fist of materials generally placed in the segregated waste in each department. Second, each item on the list was weighed and its main material makeup and color were recorded. Third, the purchasi records and data from

with waste disposal recorda. thesitevisitswereusedtodeterminethequantityof eachitemdisposedof overtime. % isdatawasreconciled

Figure 5 illustrates the segregated waste generation rates for each department. The allefgy department, whose waste consisted mainly of syringes and needles, generated the most waste per patient. The family pradice group generated the least waste per patient. The facility waste generation rate was 0.004 IUpatient (1.81 gpatient).

Figures 6 illustrates the material breakdown for each of the departments at the clinic. This m r e shows that the predominate waste component in each of the departments except obstetrics/ m k q y was

microscope slides used for pap smears. Only 20 percent of the slides generated in obstetrics/gynecokgy department were examined in the department. The rest of the slides were sent to a clinical laborato . The slides sent to the laboratory were not included in the obstetricslgynemlogy department's SegregatJWastQ stream. A small percentage of the pediatrics, dermatology, and family practice waste was composed of silk from suture kits.

Figure 7 shows the fraction of the waste from each department which fan sinto each regulated medical waste class (as defined in 40 CFR 259). Table 2 contains a detailed breakdown of the matenals considered to fall into each class. Sharps comprised a large fraction of the segregated waste stream. 'A large fradon of the segregated waste consisted of sharps containers. These containers are d r e lated but form an and disposed of at the onsite laboratory and were not considered part of the clinic's waste stream.

WASTE MINIMIZATION

Potential source reduction options at the clinic are very limited. Most of the segregated wastes consisted of sharps and the containers used to hold them. Because sharps represent a significant risk to health care workers and potentially the public, it would probably not be safe to change the sharp segr ation

containers accounted for about 40 percent of the segregated waste generated. Use of lighter containers would reduce the facilities disposal costs, however lighter containers are easier to puncture, potentially endangering health care workers.

Recycling of certain materials appears to be the most attractive waste minimization procedure available to the facility. If a recycling

Often, plastic and metal (primarily steel) are intimately n ixed and cannot be safely separated. For example, lastic s y n i and steel needles were the most common items in the clinic's segregated waste. Experience

Ras shown that while separation of syringes and needles is possible, it may increase the potential for accidents.

If effective se ration is possible, recycling may prove to be an economically W e attemative. that is becoming economically feasible. However, the economics of recycling have not been clearly defined. An income resulting from plastics recycling must be compared with the increased cost and risks aSsoCiated

plastic. The main waste component in the obstetricslgynecobgy department was glass, w 7Y ich came from r.

integral part of the segregated wastes. The blood and culture samples generated at the r in& were analyZed

practices. The greatest potential for source reduction would be to moLMy the containers. The "R s arps

material type at the source or a recyc &"g ng method which separates the various materials ww% need2

Eighty-five percent oft Ra e waste stream at the clinic consisted of plastic. The recycling of plastic is a new idea wit z increased waste handling.

ram is implemented, the wastes would have to be regated

17

0.025

0.020

-- . . 0.005

0.000

Figure 5. Segregated waste generation rates in each department of the private dnk.

PUBLIC CLINIC

D E S C R I P l "

The pub& didc examined was a mufti-disciplinary, public outpatrentclinic rated by a California county. The clinic focused on preventive mediane and had six departments -de-%ld health, matemal health, immrnizatkn, special diseases, and pulmonary. These six departments treated an average of 563 patients per weekday. Figure 8 illustrates the patient load for each department.

The dental department treated HIV patients in additbn to well patients. The HIV mbectkm of the dental department performed complete dental care while the remainder Os dental department exclusively performed extractions. The maternal health department had three SubseCtkns-pregnancytestlnQ, prmtal care, and family planning. These subsections saw 273,492, and 640 patients per month, respebrvely. The special diseases department diagnosed and treated various sexually transmitted diseases.

i a

Silk (0.57)

G b (5.44)

Silk (0.32)

Family Practica

D.rmatology

figure 6. Composition of segregated medical waste frwn private dink.

19

C b 1 (Cia. 5.44)

C k a 1 (CJr 7.1 1)

Figure 7. Fractiorr of segregated medical waste from the private clinic which fak under each reguuw-.

I

300

250

P 2 200 8 u)

u) & .- .- ' 150 75-

3 E 3 100 n

m

Q

50

0

Figure 8. Patient bad at each department of the public clink.

WASTE SEGREOATION PRACTICES

Like the private clinic, the public clinic segre ated its W e e into Sharp, classes. The sharp wastes, including mictoscope s P des, dNg vials, which had the potential to cut an empbyee or a patient. Unbrdtenglass items

Each de rtment at the Mi clinic had its own criteria for determining which item would be its non-sharp waste in red bags. The non-HIV subsection of the dental department had a list of red- g items on the lid of each garbage can. This list included:

gab"d classified as red-& waste. The I? IV subsection of the dental department was very caubioLls and

a Cotton applicators,

a Cotton rolls,

a Gauze,

a Masks,

a Gloves,

21

cups,

Bracket tray covers

Paper from light handles, and

Ross.

In addition, any item which was heavily contaminated with body fluids was also disposed of in a red bag. No distinction was made between patients with infectious diseases and those without.

The child heatth and immunization departments generated only sharp items like syringes and dmg vials. Consequently, these twp departments generated little red-bag waste.

The matemal heatth department had a written policy for the segregation of its waste into the regular trash, red-ba , and sharp waste classes. The sharp policy was the same as that given at the beginning of this section. %e non-sharp policy stated that dro rs, test cups, urine cups, andglovesfromthe pregnancy subsections be disposed of in red ba s. In addition, rossly contaminated drapes and wipes were sposed

The pulmonary and spedal disease departments used universal precautions due to the nature of the diseases treated. These precautions required the segregation of all items which had contacted a patient's bbod or body fluids. The primary red-ba waste component in the pulmonary department was the aerosol setup which included a mask, tubing, an 8 filter. Urine tubes, speculums, and pregnancy test kits were the main waste components in the speaal disease department.

Table 3 lists the items which were placed in the sharp and red-bag dassesforeach of the departmenls at the clinic. In addltion, Table 3 lists the primary material, regulato class, and quantity produced for each

red-bag classes.

w m HANmffi AND DISPOSAL Sharps were placed in Pgalbn, red, rigid, winfield sharpcontainers and red-bag waste was placed

in either 30.5 x 41 or 15 x 23 inch, red, polyethylene bags. Full sharp containers and bags were taken to an enclosed storage location b the nurses at the end of each day. The storage location was enptied twice per

GENERATION

Todetermine thegeneration rateofwastefromthecfinicas awhole andfromeachofthedepartments listed in Table 3, facility su records and detailed departmental observations were a w e d . Since the su ly records were not b$P en down by department, the procedure used to quaMy waste generation had to modified. First, information from the site visit was used to generate a list of materials generalty placed in the segregated waste in each department. Second, each item on the list was weighed andrts main material and color were recorded. Third, the quantity of each item disposed in the segregated waste stream was obtained from interviews with ke personnel in each of the departments. Hgh use items were totaled over all departments and compared b the facility supply m r d s to check the accuracy of the departmental information.

Figure 9 illustrates the segregated waste generation rates for each departmen!. The per went waste generation rate at the public clinic was 0.094 Ib/patient (42.62 glpatient). This value is rmch higher than the per patient waste generation rate of 0.004 Ibgpatient at the private clinic. This difference was due to differences in waste segregation polldes and specialties at the two clinics. The b w e r ~ m e of potentially infectious patients treated at the mate clinic resulted in a less comprehensive waste segregatkm practice.

rdce testing section, and dip sticks, unne cups and bott pp" es, and gloves from the prenatal care and f m l y in red bags. Only about 2 percent o B the drapes a J wipes used were considered grossly contaminated.

_.- component of the segregated waste. The segregated waste at this 7 aciSty was composed of the sharp and

,

week. In May, 1990,1333 r bs of waste were picked up at a cost of 235 dollars.

22

TABLE 3. SHARP AND RED-BAG WASTE GOMPONENTS GENERATED BY EACH DEPARTMENT AT THE PUBLIC CLINIC.

Department

Child Health

Dental

Dental (HIV)

mmunization

';\, Item

Needles

Dmg vials Syringes

sharps containers

Gauze Needles SYfingeS Gbves Masks sharps containers Red bags

Cotton balls Needles Gauze Syringes Gbves Mad

TABLE 3. (CONTINUED)

H a t e d iealth

;pedal Diseases

Item

N W b S Gloves syringes F(pers Masks Tubing sharps Containers Red bags

Tongue depressors swabs Utine collection kit Needles urine aJps Microscope slides SYdnOeS urine bottles Pregnancy test kits Gloves specubm sharps Containers Red bags

Material

Metal Rubber P W i PhStiC pbstic mastic Plastic Phstic

Wood Wood Plastic Metal Plastic Glass Plastic Phstic Plastic Rubber PhStiC Phstic P W i

Wood Wood Phstic Metal PI* Glass Plastic PhStiC Rubber Phstic Phsbic Plastic

Regulatory Class

class 4 (Snarp) None

class 4 (Sharp) None None None

cofaainers containen

~~~

Amount Generated Wmonth 3.68 5.34 12.96 51.33 72.40 95.09 15.81 55.92

0.11 0.16 0.58 0.92 2.97 3.24 3.84 10.51 13.67

, 38.99 7.90 2.87

2.05 31.08 6.21 8.37 1.94 15.73 4.98 8.20 45.75 86.01 8.66 11.47

\'i .., 19.78

- These items am either saturated or dripping with human blood. Containers - while the

rwlated containers are an integral pad of the waste, they are not defined as a %z% waste.

24

0.4

0.35

0.3

3

5 0.25 i % 3 0.2

U

.-

U

3 (0

0.15

v)

0.1

0.05

0

Figure 9. Segregated waste generation rates at the public clinic. The dental HIV subsection of the dental department produced the most s regated waste r patient.

This did not affect the clinic's segregated waste eneration per patient SigninCantly L s e of the I Z v o l ~ m e of patients treated in the HIV dental subsection. B he pulmona department had the second largest genetation rate per patient and it also had a high fbw of patients per day. nsequently, this department had a significant affect on the clinic's per patlent waste generation rate. The aerosol setup, whose segregated waste components consisted of a mask, tubing, and filter, weighed 0.29 bs per patient and was pdmarily responsible for the pulmonary department's high per patient waste generation rate.

Figure 10 iUustrates the material breakdown for the pubk clinic. The predominate waste material was plastic. Waste generated at the of matedals than waste from the pn'vate clinic. The child hean R" and immunization departments generat 2r high percentages of glass and plastic because they performed injections. These injections generated plastic syringes and ghss vaccine bottles. The s regated waste stream from the matemal health, pulmonary, and special disease depart- ments consist 3 mainly of plastic item. Paper was an important component in both the dental and dental HIV departments.

Figure 11 shows the fraction of the waste from each of the departments which fall into each regulated medical waste class (40 CFR 259). Table 3 indicates the items in each waste class. The child health and immunization departments had the la est fraction of sharps in their segregated waste stream. Many of the departments segregated materials di 7 not fit in any of the regulated medical waste classes.

z o

biic clinic contained a much broader ra

25

Child With

ckch (1.12)

-tal - HN

Pulmonay

lmmunkation ck)l(2.11)

Cbth cotton Glass Metal

0 paper Plastic

Figure 10. Composition of segregated wale from the public dinic.

26

I .

Figure 11. Fraction of the segregated waste from the public Ccnic which fatis under each regulatory dass.

27

WASTE MINIMIZATION

There is a much greater potential for waste minimization at the public clinic than at the privm clinic. Several of the departments segregated more waste than would be required if the regulatory definitions in 40 CFR 259 were applied. Since each department had lls own criterion for detemning which items were segregated, e@ department will be discussed separately.

Dental - The HIV subsection of the dental department considered any item which contacted a patient as

segr atedwaste. Thiswasmoreconservative than requiredbycunentunderstandingof thecommunicability of HI? Data indicates that the Human Immunodeficiency Virus does not survive for extended periodsof Zme outside its human'host. However, because of the general outcome of the disease and the public's perception of HIV, the extreme waste dis sal precautions used ma have been needed. Despite the large waste

significantly to the overall clinic waste generation rate.

The non-HIV dental section had a list of items marked on the segregated waste container lid that were considered to be segr ated waste. Included on this list were items that might not have been contaminated with bodily fluids, inclu 2 n masks, cups, and cotton rolls. A waste minimization strategy might be to throw only items known to have?" contaminated with bodily fluids. Disposable items such as kbs and gowns might also be replaced with items which could be washed and reused.

generation rate per patient in t R" e HIV section of the denta r department, this department did not contribute

Child Health / Immunization

Most of the waste from these two departments was generated dud the administration of In Thus, the most promising potential minimization scheme would be to r& metal, lass and

segregated. Acompanywillingto recycle potentially infectiouswastewouldbe hardtoflndandwouldpmbably charge high rates for its services.

This is difficult and potentially dangerous, however, since the plastic. glass and metal R ems would have to be

Matemal Health \ 4 f- ,*',

The matemal health department had a written policy for the segregation of its waste into s h a g red- bag, and regularwaste classes. Items such as speculums, tongue depressors, gbves and swabs, whi were not considered segregated items by the private clinic unless the were contaminated with an infectious waste set forth in 40 CFR 259 could reduce the quantity of segregated waste produced by maternal health department by over 75 percent.

disease were deposited in the segregated waste stream at the pub r c clinic. Use of the definitions of medical Pulmonary / Special Disease

Each of these departments were very cautious due to the potentially intectroUs nature of the diseases which the treated. Consequently, they segr ated any waste that was contaminated b was probably necessary to reduce public concern over the waste. Some recycling may be possible, however the extensive segregabon required would probably be cost ineffective. discussdabove, this approach rmght not have % en needed to prevent the spreadof inf &? s seases fluids* but As

LOCAL PRIVATE LABORATORY

DESCRIPTION

. This laboratory was rated by a health maintenance organization and was located in Califomia. It ate clinic 'ned from

patients re erred by t e c6nic. About half of the specimens analyzed come from the clink, the remainder were obtained at specimen collection stations within the laboratory. Approximately 1,OOO Specimens were processed each day.

The laboratory employed 28 people and operated seven days per week, two shifts per day. About 1,000 Ibs of segregated waste were produced each month.

!lz performed a 19Med range o ope common procedures and it was in the same building as the Nearly all specimens processed were either submitted by the Conic of o

28

WASTE SEGREGATKN PRACTICES

Waste from the laboratory was segregated into four classes - sharps, r w , regular trash, and sewa e. The sha class consisted of any item which had the potential to art a patient or an employee,

vacutainertubes. Vaartainer tubes, ranging in size from 5 to 15 ml, were used to store bloqd specimens. Red- bag wastes consisted of non-sharp items which had cpntacted blood and other body fluids. Some of these items included gloves, urine containers, 3000 ml unne collection containers, t , and drain penroses.

separatefromtheotherwaste types. The final wastedisposalclass wassewage. The mainwastecomponent discharged in the sewer was urine, which was poured from 3000 ml collection bottles. Bbod was left in the vacutainers and disposed in the sharp waste stream.

Table 4 lists the items which were placed in the sharp and red-bag classes at the laboratory. In addition, Table 4 lists the primary material, regulatory class, and quantity produced for each co nent of the segregated waste. The segregated waste at this fadlity was composed of the sharp and red- g classes. Blood and the rubber stoppers in Table 4 were separated from the vacutalner tubes to determine the

inclu&g bkod co Y W i o n sets, syringes with needles, microscope slides, needles, capillary tubes, and Regular waste contained non-sharp, uncontaminated items like office supplies. % ese wastes were kept

T

TABLE 4. SHARP AND RED-BAG WASTE COMPONENTS GENERATED BY LOCAL PRIVATE LABORATORY

Item

Analyzer cups Blood Blood Collection Sets Capillary Tubes Gloves Gloves Hemoculture Slides Microscopic slides Needles Pipettes Sharps Containers Specw”e containers stoppers SY Tape Test tubes Test tubes (Vacutainers) Urine bottle Waxed container

Material

Plastic Liquid Plastic Glass

Rubber Plastic Paper Glass Metal Plastic Plastic Plastic Rubber Plastic Plastic Plastic Glass Plastic Paper

Regulatory Class

Class 3 (Blood)’ Class 3 (Blood) Class 4 (Sharp) Class 4 (Sharp)

NO@ None

chss 1 (cult.) class 4 (Sharp) Chss 4 (Sharp) Class 3 ( B W

Container None

Class 3 (Blood) Class 4 (Sharp)

None Class 3 (Blood)’ Class 4 (Sharp)

None None

w w ! ‘k Generat&:‘: Wmnth

1.76 255.95 40.42 0.33 19.18 22.49 15.07 97.80 39.68 0.83 5.70

129.80 76.98 0.49 6.53 0.61

248.47 9.55 46.85

- These i t e m are either made from flexible plastic or are too small to be broken, thus they are not Class 4.

29

generation rates of bkod and tubber. Needles were separated from the syringes to determine the generation rate of metal.

WASTE Hwm” DISPOSAL

were placed in either 2-gallon, rigid, red, Winfield sharp containers or 1 quart, yelbw, sharp containers. Shar eedles and knives were left uncapped and unbroken. Any non-sharp waste generated that came into contact with bkod and body fluids was placed in a red bag.

The full red bags and sharp containers were picked up nightly by the housekeeping staff anddelivered to an encbsed trash dump outside the building. The dump was emptied every other day. For the month of June 1990,1801 b s of segregated waste were picked up at a cost of 299.1 5 dollars. A large fraction, 1000 Ibs, of this total came from thq laboratory. The other fraction was from the blood donor center and the private clinic. These departments are discussed in this report.

GENERATKM To determine the generation rate of waste from the laboratory, two months of supply records were

analyzed.

The anal@ had three steps. First, information from the site visit was used to generate a list of materials placed in the s regated waste. Second, each item on the B s t was weighed and its main material the quantity of each item disposed of over time. These data were reconciled with waste disposal data.

The laboratory generated 0.036 Ibdspecimen (1 6.3 gspeamen) of segregated waste. To check the daily waste generation rate determined from purchasing records, the amount of waste generated at the laborato over a three day period was recorded. The avera e waste

and cobr were recorded. Y h ird, the purchasing records and data from the site vis& were used to determine

% was 37.3 7 Wday which agrees with the generation rate of 36. f Wday o ri ained using the purchasing reco considere 8” for each material class. G e moisture content of the waste was estimat e t By as+~ming all the

r -

neration rate over these three

Fi re 12 illustrates the com sition of the segregated waste. Table 4 fists th w ~ h O m p o n e n t s

Figure 12. Composition of segregated medical waste from the bcal private hbomry.

30

vacutainers disposed of were full of blood. This assumption was based on observations made during the site visit. Glass, moisture, and plastic were the most common components of the waste.

Figure 13showsthefractionofthewastefrom eachde artmentineach regulatedmedicalwastedass (as defined in 40 CFR 259). Table 4 contains a detailed bre aE down of the items in each class. Sharp items

Class 1 (Cult. 1.56)

Containers

m a I Class 1 (Cult.) Class 3 (Blood) Class 4 (Sharp) Containers None

,

Figure 13. Fraction of segr ated medical waste from the bcal private laboratory which falls under each regulatory 7 c ass.

made up the largest fraction of the segregated waste. Unlike most of the other facilities examined, sharps containers and red bags made up only a small portion of the waste generated by the hboratofy. WASTE M H ~ M ~ ~ T I O N

There is little potential for reduction in the quantity of segre ated waste produced at this facility. Most of the waste fell under one of the regulatory classes and most o 3 what did not was intimately mixed with regulated materials.

means of separating bbod and bkod products from containers were used. LOCAL PUBLIC LABORATORY

There is virtually no practical opportunity for product reuse. Recycling would be limited unless some

DESCRIPTION

The laboratory examined was a large multi-functional public laboratory W e d in California and was operated by a Califormacounty. The laboratory emplo ed 35 people who essed 770 specimens per day.

specimens from the clinic. The remaining s eamens and samples came from a variety of county distributed to the folbwing departments: virology, serology, clinical bacteriology, Special baderblogy,

It was located in a building next to the public clinic c! ixussed earlier. r e lab received 75 percent Of its organizations. Most of the specimens and samp P es were received in the central processing department and

31

entetics, food poisoning, and mymbcteriolagy. The lab atso had a department which tested water samples from the clinic and other sources for contamination.

The viroboy department performed tests to detect a variety of viral organisms including rabies. All animal remains were sent to an animal shelter for disposal after rabies testing. The dinical and special bacteriobgy departments examined urine, stool, throat cultures, nasal and genital secretion spedmens for various bade&. The mycobaderiology department performed tests on sputum samples to detect mycobacterium. These specimens came mainly from the pulmonary de artment at the clinic. The serology

fecal specimens for enteric pathogens. department tested bkod and serum for various diseases such as syphi P s. The enterics department tested WASTE SEGREGATION PRACTICES

Waste generated in the laboratory was separated into two classes - segregated waste and r tar trash. The segregated waste was placed in orange, autoclavable bags. Any waste which contacted& fluids or infectious agents was placed in an orange bag. Segregated wastes included-pipets, culturedishes, glass test tubes, throat culture swabs, paper towels, microscope slides, and gbves.

Drinking cups, office supplies and other items which had not contacted body fluids and infectious agents were placed in the regular trash.

WASTE HANmffi AND DISPOSAL - Segregated waste from the lab was placed in orange, autoclavable bags. The bag!3 were collected

regula* by the waste handling crew and placed in one of the laboratories three autoclaves. Before the bags were autoclaved, one half cup of water was poured into each bag. The bags were then exposed to steam at 121OC for30 minutes. Aftera20-mnutecool~wncycle,the ba sweretakenfromthe autoclavesand placed

a landfill.

GENERAT~ON

Supplies for the lab came from a central storehouse and individual contractors. The storehouse’s records contained supply orders for the lab, public dinic, and other small clinics in the re@on. Consequently, it was not possible to segregate the supplies delivered to the lab f” the su e8 delivered to the other

a total segmgated waste necessary to breakdown the labs segregated waste into material types. generation rate was obtained from the lab. The laboratory generated 270 bs o waste per day or 0.35 Ibs/ specimen (158.9 glspecimen).

The quantity of waste produced by the local public laboratory was a factor of ten greater than the amount produced by the local private laboratory. Since both fadtities had similarwaste segregation policies, the difference in waste generation rates was probably due to diff erences in the analyses performed at t h e m facilities.

r .

unopened in 55gaIbn plastic garba e drums. Four and a half 8 rum were generateddaily. The d”s were emptied into a large container outsi 1 e the facility once per day. The contents of the container were takento

8- I , * ,

facilities serviced by the storehouse. Thus, the purchasing “Is did not pro t? de the detailed informatbn T

WASTE MINIMIZATION

This fadlily treated its segregated waste on-site and did not produce any waste requiring Special handti (the state Oj Califordadoes not require special handling after treatment). A# the wastes were treated

at the facility. However, general waste minimization should be examined. Waste disposal costsfor the facility as regu Y ar waste with regard to final disposal. Thus, no regulated waste minimration proorams are needed

32

can be reduced if general waste minimization was instituted. Minimization techniques could incbde recycling of glass and plasbc items, and reuse of items whenever possible. NATIONAL SPECIALTY LABORATORY

DESCRIPTION

This private lab was a la e clinical testing facility located in North Carolina. It empbyed 800 workers and consisted of the following departments: microbiology, toxicology, radioimmunoassay, hepatitiSmlJ chemistry, serology, paternity, cell immunology, biovet, research and devebpment, and cytobgy. Figure 14

in three shifts and operated five 7 ays a week. The faciltty analyzed approximately 24,300 samples per da \

10,000

8,000

P 0

6,000 4 3 5

5

4,000

-3 (0 n

2,000

0

A

\ b.

J- ,", ,

Figure 14. Work bad for each department of the national specialty laboratory.

33

shows the work bad for each department. A majority of the samples processed at the lab were received from branch kcations situated throughout North Carolina, South Carolina, Jirginia, and Maryland.

WASTE StEGREOATm PRACTICES

Waste generated at the clinical testing facility was segregated into the following classes: sharps, red- bag, and regularwaste. The sharpsclass consisted mainlyof needleswhich were disposedof in plasticsharps containers. The microbiology department generated most of the sharps. The other testing areas did not require the use of needles for their testing. As a resutt, only a small quantity of needles were generated.

The red-bag wastes consisted of non-sharp items which contacted blood or bodily fluids. Some of these items included vacutainer tubes, urine containers, gloves, gauze, and pipettes. The regular waste generated at the facility consisted of non-sharp, uncontaminated items such as office supplies. These wastes were disposed of separately from the sharp and red-bag waste.

Sharps and red-ba wastes generated at the facil i i were classified as segregated wastes. Table 5

addition, Table 5 lists the primary material, regulatory class, and quantity of each segregated waste component.

WASTE HANmiffi AND DISPOSAL

Box containers for the storage of segregated wastes were located throughout each department of the facilii. Approximatev 100 boxes of segregated waste weighing no more than 35 pounds per box were collected from the faality daily. In addition to the non-sharp wastes mentioned previously, there were also small quantities of radioactive waste generated. All radioactive waste was held until it had decayed to safe levels. The waste was surveyed to ensure it had deca ed to within the regulated waste limit for radioactive

lists the items which were p P aced in the sharp and red-bag wastes for each department at the laboratory. In

r .

waste, and then it was disposed of as a non-sharp in t z e segregated waste stream. The sharps enerated at the faality consisted primarily of needles. The needles weredetached from

the plastic syriqes.8hese syringes were then disposed of as red-bag waste. The &les were contained in Pquart plastic sharps containers. These containers held approximatel 200 needles. The sharps

segregated waste. All segregated waste generated at the facility was eventually combined and collected by the waste disposal contractor.

GENERATION RATES

contamers were collected as needed and placed into double-tined red bags. ? hey were then disposed of as

The clinical testing facility generated approximately 3350 pounds of segregated waste per day, Waste rates for each department were

rts, a microbiolosy standing order The branch reports indicated the

approximately 0.14 Ibdsp 'men (64 gkpecimen). determined by analyzing purchasi records from the facility.

m e purchase order quantity of fluids enferi the testing facility from the branch locations. The microbio standing order report reports indicated the items that the department ordered from vendon. The warehouse reports indicated the stock items that were ordered by the departments. Principal co nents of the waste were identified and listed for each department. The information is summarized in T s 5. Figure 15 illustrates the segregated waste generation rates for each de