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Infection Prevention
A Solid Waste Plan
Janet Brown
Publish Date: July 13, 2008   |  Tags:   Infection Prevention

If you generate it, you segregate it. That's the golden rule of waste management in the OR, where more trash is produced than in any other department in most healthcare facilities. Here are five ways to make sure your staff chooses wisely when standing in front of red and clear bag containers with a fistful of trash.

1. Define it. Work with your infection control manager to clearly define "regulated waste" in your facility's polices and procedures. This can be a complicated process. What constitutes regulated waste varies from state to state, and even from facility to facility, because local regulations are subject to interpretation by individual centers. It's not uncommon for a hospital to define regulated waste differently than, say, a neighboring surgery center.

When defining regulated waste in your facility, include insights from the environmental coordinator, front-line staff, staff educator and safety officer. Have them review each supply used in the ORs, either by touring rooms during surgery or by bringing supplies to committee meetings.

Assign each item to an appropriate waste category. Is it a sharp? Does it belong in a red bag? A clear bag? Detailing assignments in concert with your infection control specialist will ensure your staff follows local regulations and works with a consistent and clear definition of regulated waste.

Also consider including your waste hauler in the segregation discussion. While an unused needleless syringe, for example, might be cleared for clear-bag disposal, that syringe could be a prohibited clear-bag item for the company handling your waste.

2. Measure it. Establish a baseline for the amount of waste generated by your ORs. That amount will define your waste management problem and establish a starting point for a cost/benefit analysis. Work with your housekeeping or environmental services to determine the amount of waste generated by your facility each month.

Here's how. Review monthly invoices from your waste-hauling contractors for the pounds of waste removed and the per-pound charge. Push vendors for weights if those amounts are left off invoices; they should supply those figures.

If you're not able to obtain precise amounts from monthly hauling invoices, or if you work in a large hospital and the invoices don't itemize waste generated in ORs, weigh several red bags, clear bags and disposable sharps containers over a series of several weeks. Average those amounts for an individual bag's or container's typical weight.

Determining the approximate weight of a filled bag and counting the bags you fill each month will give you an idea of the amount of waste you generate. Apply that amount to the per-pound charge for hauling red bag trash from your facility for your monthly waste-hauling expense.

Collecting that data will empower you to make changes to your solid waste protocol. Present the solid waste costs to your administration, physician-owners and staff. Emphasize the obvious opportunity for cost-savings provided by reducing red-bag volume. When shown evidence of waste — both financial and environmental — management and front-line staff will be hard-pressed to ignore suggestions for improvement.

Ask, ???Where Does This Go?'

Each time a member of your surgical team picks up a supply to be discarded, she should think to herself, "Where does this go?" So says Julie Moyle, MSN, surgery manager at Boulder Community Hospital in Boulder Colo., and member of Practice Greenhealth. Here's Ms. Moyle's advice for training employees.

1. Give it the "squish" test. Regulated medical waste is disposable items that would release infectious fluid if compressed. Items at risk for being hazardous to trash haulers must go in red bag waste. Trash that isn't a risk to haulers can be placed in clear bag waste. Here's a quick and easy test: A soiled item belongs in red bag waste if it releases fluid when squished by staff. That's not to say that all trash placed in clear bags is not infectious; it's just not at risk of infecting those who handle the trash. For example, staff can carefully roll or fold an impervious gown containing a spot of blood before placing the gown in a clear bag to eliminate the chance of exposing waste haulers to that blood .

2. Place red bag waste containers out of the way. If bins aren't within easy reach of the front-line staff, the disposing of regulated waste becomes a deliberate act, not a matter of convenience.

3. Use closed fluid systems. Direct-to-drain delivery of fluid waste reduces staff's exposure to infectious waste. Closed systems also help reduce red bag disposal expenses by eliminating the discarding of full fluid canisters as regulated medical waste. Those canisters add significant weight, and therefore expense, to red bag hauling.

— Daniel Cook

3. Limit red bag bins. Too many red bags provide easy access for staff, who might be tempted to throw standard trash in regulated waste containers. A couple quick and easy changes: remove red bag bins from around scrub sinks and don't place them near the OR bed before the patient arrives for surgery. Trash generated at scrub sinks is properly disposed of in clear bags; the seemingly endless amount of supply packaging that piles up during room turnovers also belongs in clear bags.

Here are some other factors to consider when purchasing and placing waste bins:

  • Color-code the red and clear bag bins, and standardize those colors throughout your facility.
  • Consider the size of the red bag bins you use, as staff will be tempted to fill large bins with standard waste.
  • Put lids on regulated waste bins to limit the casual tossing of regular waste into those bins.
  • Place red bag and clear bag bins next to each other. That proximity will force front-line staff to choose between the two receptacles, hopefully giving them pause before they carelessly toss regular waste in the red-bag bin.

4. Keep it simple. An effective program for segregating solid waste at the front-line will endure if it's simple to follow. The placement of waste containers and the signage placed around them will aid staff in their disposal efforts. Post signs directly on the bins or on the wall next to the bins. Signage should include a list of supplies permissible for red-bag disposal. Make the signs straightforward and simple to read; use bullet points and a clear, large font.

Identify a phone number for staff to call when seeking answers to inevitable questions about the proper disposal of uncommon supplies. Red-bag labels or posters should include that phone number and a name for contact information. When staffers can't get quick answers, improper segregation is at risk, especially when they're unsure of how to dispose of IV bags or residual cytotoxic drugs. In larger facilities, that number might reach the infection control or environmental services officer. Smaller facilities might post the number of a roving cell phone that's passed between staff members trained in the center's waste-disposal policies. Regardless of who answers the hotline, staff should have easy access to a waste-management expert.

5. Monitor staff's progress. Educate your staff on your facility's solid waste-disposal policies, drive the message home with vigilant monitoring and keep them updated about their progress toward reaching targeted benchmarks. You may have heard that advice ad nauseam, but a clich?? is often a clich?? because it's true. Improving waste-management practices, more than most staff performance improvement initiatives, demands constant reminding. Annual in-services and monthly refreshers are simply not effective.

Crown a front-line champion responsible for answering disposal-related questions after each case and noting staff's performance in putting waste in the proper bin during room turnovers. At day's end, she should give staff a non-punitive update on their waste segregation efforts. Have her use benign phrases like "just a reminder" or "be aware of" when she reviews breaches in disposal protocols.

As the poundage of red-bag waste decreases and monthly hauling expenses drop, show staff the figures and praise their efforts. Post a congratulatory letter from yourself or the facility's administration. Putting the program's monthly goals in staff meeting minutes gives the program the attention it deserves. Your staff wants, and needs, recognition. When they receive direction for improvement, they should hear about the positive changes they helped spark.

Slow change
Add additional programs without increasing the chaos of an already busy work environment. Consider piloting some of the strategies we've discussed in a single OR before applying the program throughout your facility.

Set a realistic timeline for the complete overhaul of your solid waste-handling protocol. Many facility managers make the mistake of rushing change, in part because of the excitement generated by new initiatives. Conveying a "we're all in this together" attitude is paramount. Without insider support and the coordinated efforts of your OR leadership, environmental control experts, education leaders and infection control officers, your efforts toward a meaningful change to your trash segregation policies will be a waste of time.