PRE-FLOW PREP Keeping fluid off the floor is essential to staff and surgeon safety.

Orthopedic teams have a particular interest in keeping OR floors dry during notoriously messy arthroscopies. From basic disposal containers to high-end direct-to-drain systems, there are plenty of ways to keep staff and surgeons from slogging through irrigation overflow.

1. Manual discharge to sewer
This is the only way it was done for years, until surgical professionals raised legitimate concerns about exposure to infectious fluid. Under most regulations, liquid waste can be discharged into the sanitary sewer. Naturally, this is the simplest way and the one that involves the smallest number of steps. But make sure you have an industrial wastewater discharge permit, or something similar, before dumping waste into the sewer. If, for example, your facility is part of a medical office building, the landlord, who'll ultimately be held responsible, might not have a discharge permit.

The manual dumping of fluid waste increases staff exposure risk, so be sure all personnel charged with the task wear appropriate personal protective equipment: gloves, gowns and eyewear.

Try to dispose of as much fluid as you can via the sewer. It's as cost effective as you can get. Though the requirements are complex, some basic precautions and common-sense procedures can let you dispose of waste manually in a way that's in compliance with your local regulations, safe for staff and beneficial to your bottom line.

Pharmaceutical waste, whether generated in pre-op, OR, or recovery, is also an important consideration. When IV meds are only partially delivered, you need to dispose of the remainder. You might be permitted to dispose of some in the sanitary sewer, but you'll need to get approval from the local sewer district — which can be difficult. Most waste pharmaceuticals have to be either sent to reverse distributors for credit or for disposal by incineration. There are also patient confidentiality issues with partially used IVs, because they have patient identification on them. It pays to minimize the amount of liquid medications that end up being only partially delivered. In other words, when possible, always dose completely.

POSITION STATEMENT
AAOS Urges Care in Handling Fluid Waste

GIVE AND TAKE Solidifying fluid waste reduces concerns about splashing and spills, but the chemicals come with some concerns of their own.

Blood and bodily fluids that come in contact with your staff put them at risk for contracting hepatitis B, hepatitis C and HIV infections, warns the American Academy of Orthopaedic Surgeons. The AAOS advises you to treat all patients as if they were infected with bloodborne pathogens, and to take necessary steps to protect patients and staff from cross-contamination.

Many of your infection control efforts related to blood and body fluid exposures are likely geared at preventing needlestick injuries, but the AAOS says mentoring and competency training for surgeons, nurses and other staff members should also focus on the proper ways to "handle supplies or dispose of waste."

The AAOS also notes that orthopedic surgeons should be familiar with the exposure prevention protocols handed down by the CDC and OSHA. And during procedures, advises AAOS, staff and surgeons must wear appropriate footwear, such as boots or surgical shoe covers, to prevent skin exposure to blood or other body fluids that may spill outside of the surgical field.

— Daniel Cook

On the Web:

Check out the American Academy of Orthopaedic Surgeons' information statement "Preventing the Transmission of Bloodborne Pathogens" at tinyurl.com/k7sr6rt

2. Solidifying
Suction canisters may or may not come with a solidifying component. Manufacturers of some disposable containers like to advertise that they also treat the waste (which means you don't have to red bag it), but there are issues with the chemicals they use to treat it — either gluteraldehyde or sodium chloride. A lot of caregivers are concerned about exposure to the treating chemicals, which can cause lung irritation, asthma, headaches and nausea, among other ailments. If you use suction canisters that include a solidifier, don't consider that a treatment system. Simply use the canister as a collection vehicle and solidifier, and then place it in a red bag for disposal.

The other option is to use suction canisters with no treatment, but you can't just throw untreated waste in the trash. You'll have to red bag it, and it tends to be very heavy. Since disposal rates are typically by the pound, costs can add up quickly. On the positive side, solidifying fluid waste in suction canisters also mitigates the risk of spills. There's no risk of splashing because you're not pouring fluids into a sink or a hopper, and if a canister happens to break, you don't end up with fluid all over the place.

Facility leaders are sometimes surprised at how much container-based disposal methods can cost, so it's important to remember you're buying containers and paying more for red bag waste on a regular basis. Those are important and significant budget lines to consider.

FLUID FACTS
Inside the Numbers

25% to 40% Percentage of hospital regulated medical waste comprised of suction canisters

3L Fluid capacity of a single suction canister

8 lbs. Approximate weight of a filled suction canister

$0.28 Average cost per pound to dispose of regulated medical waste

$5 to $30 Average per cost of fluid waste solidifiers

$35,280 Approximate regulated waste disposal costs for a hospital that performs 7,000 surgeries a year

$105,000 The hospital's annual cost for solidifiers

$25,0000 Approximate initial capital investment for an automatic direct-to-drain fluid management system

$15 to $20 Per-case costs of disposable manifolds or lids used with direct-to-drain fluid management systems

SOURCE: Practice Greenhealth

3. Closed or direct-to-drain discharge
The cleanest — and safest — ways to manage fluid waste are with closed or direct-to-drain automatic disposal systems. They discharge waste directly to the sewer, with virtually no possibility of staff exposure. With closed systems, staff attach full containers to wall-mounted drainage units, which pump the waste directly into the sewer with no pouring needed. The top of the line is the direct-to-drain disposal system. These high-capacity roving units collect fluid directly from the surgical site, suction mats or floor wicking devices. Staff simply wheel filled rovers to a docking station, hook them up and stand back as the contents are automatically emptied into the sewer.

Direct-to-drain units minimize staff contact with infectious fluids, limit red bag waste and, therefore, reduce overall disposal costs. They also reduce room turnover times. You'll pay a premium price for all those benefits, but it's an investment that might be worth making for high-volume orthopedic facilities.

Last year's FDA recall of Stryker Neptune systems has complicated things. Current users can continue to use the devices until March 2014 as long as they post warnings on the units, undergo company-sponsored in-services, sign device-related competencies and complete checklists after each use. If you're shopping for a new system, you'll have to focus on the alternatives.