The overlap of state and federal laws and recommendations from standard bearers such as the Joint Commission and AORN leave little wiggle room with regard to your waste disposal processes. Most of what you need to do to stay in compliance is dictated for you, making protocol-writing easy. If you follow these guidelines to the letter, you're sure to get the right trash in the right bags ' and yet, you may be missing many opportunities to prevent infections in your facility. Here we'll dig a little deeper into how you dispose of waste, particularly fluids, to understand how pathogens can potentially make the jump from waste to wound.

The ground rules
There is no shortage of guidelines for waste disposal that can serve as the basis for your facility's protocol. The CDC, AORN, APIC, AAMI and others each have a set of guidelines relevant to their organizations' foci that are based on government agencies' regulations, specifically, the EPA's definition of "medical waste," and OSHA's rules for how hazardous waste should be disposed of.

The Joint Commission asks healthcare facilities to identify any materials that, without special handling, could lead to problems in the care environment, says Louise Kuhny, RN, MPH, MBA, CIC, associate director of the Joint Commission's Standards Interpretation Group. In addition to other measures, the Joint Commission's standard IC.4.10 specifically calls for these components' inclusion in the waste disposal plan:

• appropriate storage, cleaning, disinfection, sterilization and/or disposal of supplies and equipment;
• reuse of equipment designated by the manufacturer as disposable in a manner that is consistent with regulatory and professional standards; and
• appropriate use of personal protective equipment.

These standards don't make a direct connection between waste control and the potential for surgical site infection, partly because there's no evidence that improperly disposing of waste will cause surgical site infections. But that doesn't mean it's illogical to think that infectious waste isn't potentially problematic, says Ms. Kuhny.

Fresh air and fluids
Used bandages, gloves and disposable instruments are relatively easy to throw out, but you can't just pick up liquid wastes. The air around you can also carry harmful pathogens that can lead to an infection later. You must take these factors into account when you're designing your infection control plan.

"In the OR, almost anything is potentially infectious because you have an open wound," says Nelson "Sig" Slavik, PhD, president of Environmental Health Management Systems in Niles, Miss. "You can have a relatively innocuous bacteria that you are exposed to every day or opportunistic pathogens."

The way you dispose of liquid wastes can affect the number of pathogens in the air. James Dunn, RN, says he hated having to dump fluids into a hopper or the toilet when he worked in a surgical center because he always felt the splashing contaminated the air ' not to mention the clothes of the nurse performing the disposal, which could compromise his health and, potentially, patients. He figured there had to be a better way, so he invented a canister disposal system called the Redaway, the forerunner of the current Transposal System, and co-founded Dornoch, where he is now vice president of product development and regulatory affairs.

When it comes to disposing of fluids, Mr. Dunn says there are three common practices:

• Pouring canister contents into a hopper or toilet. While usually condoned by the EPA and most local water departments, Mr. Dunn says the splash and splatter can lead to bacteria that linger in the air for hours and, if these pathogens come into contact with a nurse's scrubs, they could be carried back to the surgical site. The risks can be reduced through protective clothing including masks to reduce contamination, and engineering controls to stop splashing. This could be the most cost-effective technique, particularly if you use reusable canisters.
• Capping a filled canister and putting it in a bag. Although effective and environmentally sound, Mr. Dunn says a full canister can weigh close to 18 pounds, and that can be expensive if your waste disposal services charges by weight. "It could cost more to throw away the canister full of infectious fluids than it did to buy the canister itself," he says.
• Adding a gelling agent or fluid solidifier. This makes it easier to dispose of, but won't necessarily disinfect the fluids. "The manufacturers used to claim that the gelling agent would treat infectious fluids, but they couldn't really prove it," he says. Cost is a factor, he says, when you consider the price of the agent along with the canister.

The airflow through your ORs can also circulate pathogens from infectious waste, and Mr. Dunn says that this could become much worse if fluids come into contact with the air filters.

"It's our belief that if your HEPA filter gets wet, all the air you're pumping out could be infectious," he says. "You could cause a lot of pathogens to be pushed into the air during the procedure."

Dr. Slavik describes this as "capillary action" that causes germs to be pulled through one side and released in the other.

To help control how much air goes through your facility, Dr. Slavik recommends looking for equipment that draws air in without releasing any. "This is called negative air," he says.

Update and enforce
The right equipment for disposal can help, but your best bet is ensuring staffers are conscious of the regulations and the need for them. At Elkhart General Hospital in Elkhart, Ind., staff nurse Sherry "Twig" Hemenway, RN, BS, CNOR, says it's hard to keep some physicians and OR staffers compliant because they often feel they don't have time to put something into the correct bin during a procedure.

"Sometimes it's much easier to dispose of waste in the most convenient container, which may or may not be a hazardous materials container," she says. "But if you make it convenient for them, they will comply with the regulations."