Transcript Common Types of Hazardous Waste – Infection Control

Handling Hazardous Drugs
Pharmacy Benefits Management
Drug Accountability Conference
May 13, 2010, San Antonio, TX
George Knight, RPh
VISN 2 Network Pharmacy Executive/PBM Manager
In Collaboration with Kevin Hartman, CHMM
Environmental Engineer, Syracuse VAMC
Hazardous Waste Training for
Healthcare Workers – What’s Up?
 The EPA considers some chemicals, including
some drugs, to be hazardous waste when
discarded.
 Having Addressed the Manufacturing
Industry, the EPA is Now Focusing on the
Health Care System as the Next Largest
Contributing Factor to Environmental
Contamination.
Why the Focus on Pharmaceuticals?
 They are being found in the environment and
in our public water works.
 Regulatory emphasis by all levels of the EPA
(local, state and federal)
 Standards require compliance with
regulations; Joint Commission, CAP, CARF …
 VA Directive 2003-030 Management of
Hazardous Chemicals
CARTOON: “I’m going to prescribe a birth control pill
and an antibiotic and a tranquilizer! Or you can drink
two quarts of tap water and call me in the morning!”
Potential Problems
 Increased Occurrence of Cancer
 Unusual Physiological Processes
(Reproductive Impairment)
 Antibiotic-Resistant Bacteria
 Augmented Toxicity of Chemical Mixtures
Not just a fish story…
How is Pharmaceutical Waste
Generated?
 IV Preparation
 General compounding
 Spills/breakage
 Partially used vials/syringes
 Discontinued/unused
 Unused repacks (unit dose)
 Patient’s personal medications
 Outdated pharmaceuticals
Health Care Facilities Must Follow the
Hazardous Waste Regulations
 Proper Identification
 Segregation & Storage
 Manifesting and Transporting
 Proper Disposal, i.e. Incineration at a
Federally Permitted Incineration Site
Resource Conservation and Recovery
Act (RCRA)
 RCRA Regulates the Disposal of Solid Wastes
Enforced by the EPA and the States
 Defines Hazardous Waste and Procedures for
Handling and Disposal of Wastes
 Most States have a Hazardous Waste Program
approved by the EPA
EPA Universal Waste Rule
 Proposed Addition of Hazardous Pharmaceutical
Waste to the Universal Waste Rule
 Streamlined Management
 Encourage Disposal of Non-Hazardous
Pharmaceuticals as Universal Waste
 Facilitate Collection of Personal Medications
from the Public
 Michigan and Florida have done this at the State
Level
Categories of RCRA Hazardous Wastes:
P-Listed
 Acutely Hazardous
 Sole Active Ingredient - Unused
 Empty – Only if Triple Rinsed
 Rinse Solution is Hazardous, or ….
 Manage Un-rinsed Containers as Hazardous
(vials, IV tubing)
Examples of P-Listed Wastes
 Arsenic Trioxide (Chemotherapy)
 Epinephrine (Excluded if in used syringe;
may be discarded as regulated medical
waste) ** not EPI salts ** except MN
 Nicotine (patch backing but not wrappers)
 Warfarin > 0.3% (all Rx dosages)
 Nitroglycerine (Excluded federally and
some states if in final dosage form)
 Phentermine (1 of 2 Controlled Substances)
Categories of RCRA Hazardous Wastes:
U-Listed
 Toxic - not as disastrous as P
 Sole Active Ingredient - Unused
 Empty Containers
 All contents have been removed through
normal means and < 3% by weight remains =
not hazardous
 Residues removed from containers must be
managed as hazardous waste
Examples of U-Listed Wastes
 Chloral Hydrate (2nd CS)
 Chlorambucil
 Lindane
 Warfarin < 0.3% (all Rx dosages exceed
this percentage)
 Saccharin
Categories of RCRA Hazardous Wastes:
Characteristic (D-Listed)
 Pharmaceutical, chemical formulations not
on P-List or U-List, which exhibit one or
more of the following characteristics:
 Ignitability (nitroglycerin inj.)
 Toxicity (M-cresol or thimerosol as
preservative; fluvax; reserpine)
 Corrosivity
 Reactivity
Examples of D-Listed or Characteristic
Wastes
 Used or Unused, but only when present in
concentrations at or above the indicated RCRA
regulatory level:
 Chloroform – 6.0 mg/L
 Mercury – 0.2 mg/L; contains thimerosol
and fails this threshold
 Silver – 5.0 mg/L; silver nitrate applicators
 Selenium – 1.0 mg/L; Selsun Blue
When is an Outdated Drug a Waste?
 At the time and place the decision is made to
discard it
 If a Reverse Distributor is used and the
decision to discard is made there – we are still
the generator of the waste.
 We can ship creditable outdates to a reverse
distributor as product. All non-credit
materials must be handled as hazardous
waste on-site, once we know they are not
creditable. Keep a list.
Uncreditable Items
Manufacturer
Product
Form
IVAX PHARMACEUTICALS, INC.
ALBUTEROL
AERO
AMERICAN REGENT LABS, INC.
ALCOHOL DEHYDRATED
SOL
APLICARE, INC.
APLICARE IODOPHOR PVP PREP
PAD
BOEHRINGER INGELHEIM
ATROVENT
AERO
THE PURDUE FREDERICK
COMPANY
BETADINE
OINT
HUMCO
COLLODION FLEXIBLE
SOL
Pharmacy/Ward Procedures
 P-Listed: Use Black Container
 U-Listed: Use Black Container
 D-Listed: Use Black Container
 Unlisted: Use Red Container
 Regulated Medical Waste
 Un-creditable pharmacy returns
Labeling & Education
 Black Dot Labeling; U-Listed & Characteristic
(D-Listed)
 Caution Label; Special Disposal Required P-
Listed + containers
 Med Cart Containers
 Listing by Location
 Develop a Comprehensive Facility and
Departmental SOP
Formulary List
CYCLOPHOSPHAMIDE
INJECTION
Black Dot Toxic [U058]
U-list
CYCLOPHOSPHAMIDE
TABLETS
Black Dot Toxic [U058]
U-list
DAUNORUBICIN INJECTION
Black Dot Toxic [U059]
U-list
DEXAMETHASONE
Black Dot Flammable [D001]
Characteristic
DIETHYLSTILBESTROL TAB
Toxic [U089Black Dot
Diethylstilbestrol] U-list
WARFARIN SODIUM
Caution
Toxic [P001-Warfarin]
Conc. > 0.3%
P-list
Chemotherapy Waste (U-Listed)
 Two waste streams for this waste are
required
 Trace Waste (Yellow chemo containers in
Pharmacy)
 EMPTY vials, syringes, IV bags.
 Soft waste: gowns, gloves, goggles,
tubing and wipes UNLESS overtly
contaminated, container holding any
amount of free liquid, overtly
contaminated garments and spill
cleanup kits.
Chemotherapy Waste (U-Listed)
 Bulk Waste Containers


EMPTY vials, syringes, IV bags. A
container holding any amount of free
liquid, overtly contaminated garments
and spill cleanup kits.
Only style used on the Nursing units
Chemo Waste Containers
Trace Chemo Waste
Empty vials, syringes, IVs,
tubing, gowns, gloves,etc.
Bulk Chemo = Hazardous Waste
Unused/partially used vials, or IV’s; Vials
or IV’s with ANY amount of free liquid;
grossly contaminated items; and spill
clean up materials
Satellite Accumulation
 Good Idea to Label
as Satellite
Accumulation
 Must have the
words “hazardous
waste”
 Must have a clear
description of the
waste
 Date not required
Satellite Accumulation
Acetone & methanol
Labeling Requirements
(Storage Area)
 The words “Hazardous
Waste” must be on the
container.
 Clear description of the
waste type must be neatly
printed on the label.
 Accumulation start date
for 90 or 180 day areas.
Generator Status
 Large Quantity Generator
 > 2.2 lbs. “P”
 > 2200 lbs./mo. non-acute
 Small Quantity Generator
 < 2.2 lbs. “P”
 < 2200 lbs./mo. non-acute
Additional Points
 Incompatible wastes
must be properly
segregated.
 Weekly inspections
are required to be
documented for all
long term hazardous
waste storage areas (90
or 180 day areas).
Additional Points
 Must have spill response equipment &
containment equipment in the area
 Secondary containment is required to
prevent uncontrolled spills
 Training requirements for long term
storage areas
 Within 6 months
 Annual requirement
 "Cradle-to-grave" responsibility
Consequences of Non-Compliance
Recent Example
08/18/2009
Department of Veterans Affairs
Eastern Kansas Health Care
System Civil Penalty $51,501
Department of Veterans Affairs
Eastern Kansas Health Care
System VA must also spend at
least $482,069 on management
project.
 Compliance
inspections
 Fines/penalties
 License revoked
 Criminal
citations
 Civil actions
 Imprisonment
 Corrective orders
Managing Our Waste Streams
REGULAR TRASH
• Packaging
• Empty bottles
• Paper
SEWER SYSTEM
• Non-Haz IV’s (NaCl, D5W)
•User must evaluate if the liquid
is or is not a hazardous waste**.
• Plastic
Recycle whenever possible
Unused NonHaz Rx
HAZARDOUS
WASTE
• P-Listed + Their Containers
• U-Listed
• Characteristic waste
CHEMO WASTE
This stream is divided in two
1) Trace Chemo Waste
2) Bulk Chemo Waste
** Other items that our Sewer Use
Permit allows
SHARPS
Collected in pharmacy.
Empty non-chemo & non-P-listed
Ampoules
Returned for credit through
Reverse Distribution.
Empty non-chemo & non-P-listed
needle-syringes
Note Federal Exemption for used
Epinephrine syringes - treat as a sharp
This waste stream must be
properly segregated, labeled and
stored. Includes pharmaceutical
wastes
Turn into the Environmental
Engineer ext. 12345 for disposal at
a State or Federally Permitted
Hazardous Waste Facility
1) Trace is sent to a Medical
Incinerator
2) Bulk follows the requirements
of the Hazardous Waste Stream.
Know Where to Throw
Trash
Recycling
Sewer
Packaging
Paper, Glass,
Empty bottles*
Plastic,
Non-haz IV’s
(NaCl, D5W)
Paper
Metal,
Plastic
Toner
Cartridges,
Batteries,
**Other items
that our
Sewer Use
Permit
allows**
Hazardous
Waste
Know Where to Throw
Trace Chemo
Contact
Environmental
Engineer
Empty vials,
syringes, IVs,
tubing, gowns,
gloves, etc.
Newspaper,
Electronics,
Radiation
Bulk Chemo
Contact
Radiation
Safety Officer
Vials or IV’s
with ANY
amount of liquid;
Grossly
contaminated
items;
Spill clean up
materials.
Computers,
Furniture
Waste
Pharmaceuticals
ANY Unused or
partially used Med.
Spill cleanup
aerosol cans
Special attention to:
Epinephrine: including
empty IV bags, tubing,
ampoules, and vials.
Nicotine: including
wrappers Warfarin:
including empty
wrappers and
containers
Bio Hazard
Sharps
Bloody
Regulated Body
Fluids (e.g. joint
fluid)
Laboratory
Waste
Empty nonchemo & non-Plisted Ampoules
Empty nonchemo & non-Plisted syringes
**Note Federal
Exemption for
Empty
Epinephrine
syringes - treat
as a sharp
Pharmaceuticals may not be disposed of down the sink, sewer, or toilets without special permission from the Environmental Engineer and Pharmacy.
DEA Controlled Drugs: follow proper protocol for disposal of these items.
Questions, comments, concerns?
 Be sure to evaluate your area
 Do you have waste that has not
been evaluated (cleaning rags,
other chemicals, equipment
that automatically dumps into
the sewer system)?
 Do you have ample/proper spill
kits?
 Do you have proper postings?
 Emergency contacts, spill
plans, exit routes….