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WASTE MANAGEMENT POLICY
Summary This document outlines the Trust’s waste management policy. It details the Trust’s arrangements to minimise waste production, improving waste segregation and increasing waste recycling by utilising the “Waste Hierarchy”. In the context of this policy, wastes include: domestic, recyclable materials (paper, glass, cardboard and metals), clinical, sharps, pharmaceutical (including cytotoxic and cytostatic medications), GM wastes, chemical, radioactive waste, electrical and electronic equipment (inclusive of fluorescent tubes) and other hazardous wastes e.g. mercury. The document also takes account of any clinical waste produced off site, e.g. Kingston Medical Day Unit. CONTENTS
- Authoring Department: Estates Version Number:
- Author Title: Waste Manager Published Date: 14/11/2018 09:51:
- Ratified By: Waste Management Committee, IGRM Review Date: 14/11/2019 09:51:
- 1 Waste Management Policy Statement Section Page
- 2 Introduction
- 3 Scope
- 4 Definitions
- 4.1 Non Hazardous Domestic Waste
- 4.2 Recyclable Waste
- 4.3 Clinical Waste
- 4.4 Pharmaceutical Waste
- 4.5 Pharmaceutical Waste
- 4.6 Non-Clinical Hazardous Waste
- 4.7 Waste Electrical and Electronic Equipment and Batteries
- 4.8 Radioactive Waste
- 4.9 Laboratory Waste
- 4.10 Discharge to Sewer
- 4.11 Gene Therapy Waste Plaster of Paris / Gypsum
- 4.12 Plaster of Paris / Gypsum
- 5 Roles and Responsibilities
- 5.1 ISS
- 5.2 Trust Staff
- 5.3 Waste Manager
- 5.4 Infection Prevention and Control
- 5.5 Pharmacy Department
- 5.6 Procurement Department
- 5.7 Estates Management Department
- 5.8 Computing Department
- 5.9 Radiology Department
- 5.10 Medical Equipment
- 5.11 Dangerous Goods Safety Advisor (DGSA)
- 5.12 Health and Safety Committee
- 6 Principal Legislation and Guidance
- 6.1 Principal Legislation
- 6.2 Guidance Documents
- 7 Training and Information
- 8 Audit and Review
- Appendix 1 Waste Management Quick Guide
- Appendix 2 A-Z of Waste Items
- Appendix 3 Relevant Trust Documents
Authoring Department: Estates Version Number: 13 Author Title: Waste Manager Published Date: 14/11/2018 09:51: Ratified By: Waste Management Committee, IGRM Review Date: 14/11/2019 09:51: Uncontrolled if printed
1. Waste Management Policy Statement
1.1 The Trust is committed to managing waste on all of its sites safely, cost-effectively and in line with current legislation. The Trust will confirm that it has fulfilled its duty to apply the Waste Hierarchy as required by Regulation 12 of “The Waste (England & Wales) Regulations 2011 when consigning its waste streams.
1.2 Correct waste segregation is necessary to keep the manual handling of clinical and other hazardous wastes to a minimum and to keep clinical waste disposal costs and other hazardous waste management costs to a minimum.
1.3 The Trust is committed to working together with contractors to continually improve waste services on all of its sites including: Implementing recommendations contained in the Department of Health’s ‘Safe Management of Healthcare Waste’ HTM 07-01 Guidance Version 2:0. Complying with the environmental and health and safety regulations and where possible best practice. Ensuring compliance with Care Quality Commission Care Standards. Reviewing waste management activities to identify any problems, undertaking waste audits, risk assessments and investigating untoward incidents when necessary and then prioritising any actions required to improve waste management procedures. Setting, measuring and reviewing waste management performance indicators to ensure good waste management practice. Raising awareness of waste management issues by offering waste management training to all staff. Minimising waste production, improving waste segregation and increasing waste recycling by utilising “The Waste Hierarchy”.
Waste Management Information is provided to all new Trust staff at induction, additional specific training programmes are delivered to employees and contractors involved in any waste activities.
Staff and contractors must follow local waste management procedures.
The Trust waste management policy and procedures will be reviewed annually or as required by changes in legislation and best practice.
Authoring Department: Estates Version Number: 13 Author Title: Waste Manager Published Date: 14/11/2018 09:51: Ratified By: Waste Management Committee, IGRM Review Date: 14/11/2019 09:51: Uncontrolled if printed
4.3 Clinical Waste The Hazardous Waste Regulations (2005) categorises all waste by assessing the hazardous properties of each waste type. Under the Regulations healthcare wastes are categorised as follows:
European Waste Catalogue Code Description of Waste
Wastes from natal care, diagnosis, treatment or prevention of disease in humans
Sharps except 18 01 03
Body parts and organs including blood bags and blood preserves (except 18 01 03)
Waste whose collection and disposal is subject to special requirements in order to prevent infection
Waste whose collection and disposal is not subject to special requirements in order to prevent infection, e.g. dressings, plaster casts, linen, disposable clothing, sanitary products
Chemicals consisting of dangerous substances
Chemicals and other than those listed in 18 01 06
Cytotoxic and Cytostatic medicines
Medicines other than those mentioned in 18 01 08
Amalgam waste from dental care
The Regulations define infectious as ‘Substances containing viable micro- organisms or their toxins which are known or reliably believed to cause disease in man or other living organisms’. As such all general clinical waste generated within the Trust is classified as Hazardous Waste (18 01 03) due to its infectious properties.
Clinical waste must be rendered safe prior to final disposal either by processing through a clinical waste incinerator or other approved alternative technology (i.e. autoclaving). The majority of the clinical waste generated by the Trust is suitable for disposal by autoclaving; however some clinical wastes including wastes contaminated with medicines, certain pathology wastes and human tissue must be disposed of by incineration. The Trust uses a tagging system to identify clinical wastes suitable for treatment by alternative technology and clinical wastes which must be disposed of by incineration. This tagging system also enables the Trust to track its waste from the point of collection from the site to its ultimate disposal.
Authoring Department: Estates Version Number: 13 Author Title: Waste Manager Published Date: 14/11/2018 09:51: Ratified By: Waste Management Committee, IGRM Review Date: 14/11/2019 09:51: Uncontrolled if printed
The Safe Management of Healthcare Waste Guidelines produced by the Department of Health recommends a colour coding system for the packaging of all healthcare wastes as follows -
Colour Description
Yellow Waste which require incineration in a suitably permitted or licensed facility. s disposal by incineration^ Treatment/disposal required is
Orange
Waste which may be “treated” Treatment / disposal required is to be “rendered safe” in a suitably permitted or licensed facility, usually alternative treatment plants (ATPs). However this waste may also be disposed of by incineration.
Purple Cytotoxic and Cytostatic waste suitably permitted or licensed facility.^ Treatment^ /^ disposal required is^ incineration^ in a
Tiger Stripe Offensive/hygiene waste* Indicative treatment/disposal required is landfill or municipal incineration/energy from waste at a suitably permitted or licensed facility.
Red Anatomical waste for incineration suitably permitted facility.^ Treatment/disposal required is^ incineration^ in a
Clear
Domestic (municipal) waste Incineration / energy from waste or other municipal waste treatment process at a suitably permitted or licensed facility. Recyclable components should be removed through segregation. Clear Bags may also be used for Recyclable waste.
Blue Medicinal waste for incineration suitably permitted facility.^ Treatment^ /^ disposal required is^ incineration^ in a
Blue Paper Towels only Domestic/clear bags^ -^ if you do not have a Paper Towel bin dispose of these in the
Clinical waste must be placed in yellow/orange bags which conform to U.N. 3291. Clinical waste bags are sealed and tagged using a cable tie with a unique identification number or colour, enabling the Trust to track waste produced by individual wards/departments.
Once sealed the clinical waste bags are placed in Yellow Clinical bins , marked and labelled on two opposite sides with class 6.2 danger label and UN3291 clinical waste, unspecified, n.o.s., the clinical bins are tagged indicating the type of waste contained in the bin and identifying the correct disposal route for the waste.
Authoring Department: Estates Version Number: 13 Author Title: Waste Manager Published Date: 14/11/2018 09:51: Ratified By: Waste Management Committee, IGRM Review Date: 14/11/2019 09:51: Uncontrolled if printed
4.8 Laboratory Waste Special arrangements are in place relating to the disposal of waste from the Trust’s diagnostic and research laboratories specifically referencing the treatment requirements of high-risk waste. The Trust’s Pathology Departments are responsible for ensuring that their procedures are regularly reviewed to ensure they reflect current legislation and satisfy the accreditation requirements for their facilities.
4.9 Discharge to Sewer The Environmental Permitting Regulations require that a permit or authorisation must be obtained prior to discharging anything other than clean, uncontaminated water to surface water or groundwater. The Trust currently has no permits in place and therefore all discharges to the sewage system are prohibited (this is particularly relevant for ward staff wishing to dispose of IV fluids contaminated with medicines. This waste must be placed into rigid containers - with absorbent material if required
- and removed from site for disposal by incineration).
4.10 Gene Therapy Waste All gene therapy waste will be disposed of in accordance with procedures agreed by the Trust’s Genetic Modification Safety Committee (GMSC). In order to comply with The Carriage of Dangerous Goods and Use of Transportable Pressure Equipment (Amend) Regulations 2011, the Trust will not be transporting waste across sites; obviously this has an impact on the current GM waste situation. GM waste that is created on either site will be collected in a separate collection by our waste contractor (SRCL) under special arrangement. Our licensed specialist clinical waste contractor (SRCL) will undertake the collection of GM Waste. CGM Waste will be transported from The Trust premises by road, utilising specialist vehicles equipped for the purpose. The GM waste will then be taken to a permitted incineration facility for destruction.
4.12 Plaster of Paris (gypsum) has to be collected separately and cannot go to landfill. This is because it degrades in landfill sites to produce hydrogen sulphide gas which goes up into the atmosphere and mixes with water and comes back down as acid rain (sulphuric acid). This includes gypsum used for plaster casts medicinally and for the disposal of plaster and plaster board from the Estates Department.
5. Roles and Responsibilities It is the overall responsibility of the Chief Executive to ensure that the Waste Management Policy is implemented within the Trust.
5.1 ISS ISS provide a total waste management service at the Trust and can be contacted via their Helpdesk on extension 5050. This includes all aspects of waste management, from collecting waste at ward level, ensuring waste streams are correctly segregated, stored, transported and tagged, to final waste consignment off site via licensed waste contractors. Further, ISS are responsible for ensuirng all clinical waste is correctly tagged and labelled in accordance with HTM 07-01 to ensure the Trust complies with its waste Duty of Care and traceability responsibilities. ISS will supply an up-to-date list of tags in use at each ward or department to the Waste Manager on request.
Authoring Department: Estates Version Number: 13 Author Title: Waste Manager Published Date: 14/11/2018 09:51: Ratified By: Waste Management Committee, IGRM Review Date: 14/11/2019 09:51: Uncontrolled if printed
5.2 Trust Staff All members of staff have a duty to ensure that waste is disposed of in accordance with this policy and local procedures and in a manner that will safeguard other people who may come into contact with it, this includes correct segregation of wastes at ward level, recycling wastes where appropriate and ensuring that confidential waste is disposed of in line with the Data Protection Act 1998.
5.3 Waste Manager
The Waste Manager ensures the following: That all waste is handled and disposed of in line with the Environmental Protection (Duty of Care) Regulations 1991 Section 34 That producer pre-acceptance healthcare waste audit information is made available to the Trust’s clinical waste contractor and the Environment Agency. That initiatives are introduced to improve waste management in line with current legislation and waste budgets. That waste is collected and transported and disposed of in accordance with current legislation. Dangerous Goods Safety Audits to be completed on clinical waste collections. That training and audit programmes are in place. That waste disposal records are maintained in accordance with relevant legislation, including hazardous waste registers. That appropriate contractors are appointed for the removal and disposal of all waste streams (including clinical waste, domestic waste, recycle waste, WEEE waste, confidential waste, batteries, chemical wastes, pharmaceutical waste). That appropriate exemption activities are registered with the Environment Agency under the Environmental Permitting Regulations 2010. That all Trust sites are registered as hazardous waste producers under the Hazardous Waste Regulations 2005. That Duty of Care Visits are undertaken at least annually to inspect the disposal facilities of the Trusts waste contractors.
5.4 Infection Prevention and Control Team The Infection Prevention and Control Team are responsible for developing procedures and guidelines, determining and auditing infection control standards and providing training to ensure good infection control practice Trust wide, which may include waste segregation and waste sharps management.
5.5 Pharmacy Department Pharmacy Department provides advice and guidance on handling and disposal of pharmaceutical waste with special reference to the Hazardous Waste Regulations. Local waste management protocols are in place for Pharmacy Department. Pharmacy Department is responsible to ensure that all controlled drugs are disposed of in line with current guidelines, including overseeing the rendering/denaturing of controlled drugs prior to disposal.
Authoring Department: Estates Version Number: 13 Author Title: Waste Manager Published Date: 14/11/2018 09:51: Ratified By: Waste Management Committee, IGRM Review Date: 14/11/2019 09:51: Uncontrolled if printed
5.10 Medical Equipment (Redundant) Each Department is responsible for controlling the disposal of any redundant medical equipment. Prior to disposal all medical devices must be decontaminated and decommissioned and removed from the Trust’s asset register. Redundant medical equipment will either be resold through auction or removed from site for treatment, recovery or recycling.
5.11 Dangerous Goods Safety Advisor (DGSA) As a “consigner” and “carrier” of items classed as dangerous goods under ADR 2011, the Trust has an appointed Dangerous Goods Safety Advisor (DGSA). The DGSA provides advice and carries out audits internally and on clinical waste collections. Registered Address: Independent Safety Services Ltd, Globe Works, Penistone Road, Sheffield. S6 3AE. Registered in England No: 3958917
5.12 Health, Safety and Security Committee The Health, Safety and Security Committee consist of staff and managers from across the Trust. The Committee reviews policies and procedures and delivers action plans to ensure the health and safety of Trust staff and site users.
6. Principal Legislation and Guidance
6.1 Principal Legislation Environmental Protection Act 1990 Environmental Protection (Duty of Care) Regulations 1991 Waste Management Licensing Regulations 1994 Hazardous Waste Regulations 2005 List of Wastes Regulations 2005 Controlled Waste Regulations 2012 International Carriage of Dangerous Goods by Road (ADR) 2011 Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2011 Control of Substances Hazardous to Health Regulations 2002 Pollution Prevention and Control Regulations 2000 The Waste Electrical and Electronic Equipment Regulations 2006 The Health and Safety at Work Act 1974 Management of Health and Safety at Work Regulations 1999 Manual Handling Operations Regulations 1992 Personal Protective Equipment at Work Regulations 1992 Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 Environmental Permitting Regulations 2010 Human Tissue Act 2004 Data Protection Act 1998 Environmental Permitting (England and Wales) Regulations 2007 (including Landfill Directive) Waste Batteries and Accumulators Regulations 2009 Human Tissue Act 2004 Control of Asbestos Regulations 2006 Waste Regs 2011
Authoring Department: Estates Version Number: 13 Author Title: Waste Manager Published Date: 14/11/2018 09:51: Ratified By: Waste Management Committee, IGRM Review Date: 14/11/2019 09:51: Uncontrolled if printed
6.2 Guidance Documents Department of Health HTM 07-01 Safe Management of Healthcare Waste version 2: Department of Health HTM 07-05 The Treatment, Recovery, Recycling and Safe Disposal of Waste Electrical and Electronic Equipment Waste Management – The Duty of Care – A Code of Practice Waste Management Licensing Regulations A Code of Practice EA Technical Guidance WM2 on Hazardous Waste Disposal EA Sector Guidance Note IPPC S5.06 – PPC for Clinical Wastes EA Guidance on Treatment of Non-Hazardous Wastes for Landfill NETREGS – A Simple Guide to Site Waste Management Plans Enforcement and E.A. Civil Sanctions Policies
7. Training and Information 7.1 The Trust has a duty to provide health and safety information to all staff, patients, visitors and contractors with regards waste and waste handling. 7.2 Ward sisters are responsible for ensuring all sharps bins labels are completed and the lids closed before sending for disposal. 7.3 When commencing their employment with the Trust, staff who are involved with handling Clinical Waste on a daily basis will be offered Hepatitis B and Tetanus Immunisation. 7.4 Training will be provided to ensure that staff are aware of the waste streams produced in their area.
7.5 Staff handling clinical waste and other hazardous wastes will be provided with the relevant waste management information. The legal requirements with regards to waste management Environmental Protection (Duty of Care) Regulations 1991 Section 34 The risks to their health and safety and why control measures are required (including immunizations and use of PPE) Any control measures necessary to complete their roles e.g. the use of protective equipment, personal hygiene, safe manual handling techniques etc. 7.6 Waste management training is provided by the Waste Manager and the Infection Prevention and Control Team.
8. Audit and Review 8.1 All Ward and Departmental Managers are responsible for the active day to day monitoring of their staff and areas with regards to health and safety issues including waste management activities. They must report any unsafe waste management activities or non-compliances to the Waste Manager. 8.2 The Waste Manager audits each ward and department on an annual basis. The purpose of the audits is to monitor waste management activities and compliance with the Trust waste management procedures and the regulations, and to satisfy the Clinical Waste Pre Acceptance (Producer) audit requirements of the Environment Agency. The Infection Prevention and Control Team will also include waste management auditing as part of their Infection Control Audit Programme. 8.3 The Waste Manager audits all waste management contractors who provide waste services in accordance with the waste management duty of care code of practice.
Authoring Department: Estates Version Number: 13 Author Title: Waste Manager Published Date: 14/11/2018 09:51: Ratified By: Waste Management Committee, IGRM Review Date: 14/11/2019 09:51: Uncontrolled if printed
APPENDIX 2
A-Z of Waste Items
Please note that all reference to the use of black and yellow striped ‘tiger’ bags assumes waste is non-infectious. If the waste is known to be infectious at point of use, the following waste streams should be used instead:
Orange – infectious only Yellow – infectious and contaminated with medicine Purple – infectious and contaminated with cytos
Waste Type Waste Packaging Aerosols (fully discharged) Contact Waste Manager. Amalgam Separate disposal arrangements in place Anatomical/identifiable human tissue
Red lidded container.
Aprons and gloves Yellow and black striped ‘tiger’ bag. incineration. Batteries Battery Disposal Drums Bed Pan Liners Yellow and black striped ‘tiger’ bag. incineration. Building Waste (Contractor)
Contractors are responsible for their own waste disposal Cans Green tinted bag Cardboard Flat Pack cardboard Catering Oil To be returned in original container for recycling Chest Drains Use original box packaging.
Crockery Ensure waste is protected prior to being placed in clear bag for compacting on site Computer Screens Contact IT. Department to arrange disposal Computer Equipment (excluding screens)
Contact IT. Department to arrange disposal
Confidential Waste Waste to be placed in shredding consoles or locked bins or cross-cut shredded at point of production Controlled Drugs Rendered irretrievable prior to disposal by incineration. Contact Pharmacy Department for details. Under no circumstances should this waste be discharged into the water system Cytotoxic/Cytostatic Drugs To be placed in Cytotoxic containers (Purple lid) Cytotoxic/Cytostatic Infectious Waste
To be placed in Cytotoxic rigid container or purple bag Domestic (household) waste
Clear bag
Electrical and Electronic Equipment
Contact ISS Helpdesk on 5050
Fluorescent Tubes Contact ISS Helpdesk on 5050. Food Waste Separate waste collection arrangements for food waste from kitchens/restaurants.
Authoring Department: Estates Version Number: 13 Author Title: Waste Manager Published Date: 14/11/2018 09:51: Ratified By: Waste Management Committee, IGRM Review Date: 14/11/2019 09:51: Uncontrolled if printed
Furniture Contact ISS Helpdesk on 5050 ISS Helpdesk on 5050. Giving Sets (not contaminated with medicinal products)
Yellow and black striped ‘tiger’ bags. incineration.
Giving Sets (contaminated with medicinal products)
Place in rigid containers with Yellow lid
Glass (contaminated with medicinal products)
Place in rigid containers or sharps containers with Yellow lid Glass - uncontaminated Contact ISS Helpdesk on 5050 Hand towels Blue tinted bag. Implanted Devices (including pacemakers)
Contact Waste Manager
Incontinence Waste Yellow and black striped ‘tiger’ bag IV Bags (used for saline or glucose only)
Yellow and black striped ‘tiger’ bag. incineration. IV Bags (contaminated with medicinal products)
Place in rigid containers with yellow lid. As there is likelihood that there will be large quantities of fluid it may be necessary to use an absorbent material to reduce the risk of spillage. Medical Devices Each Department responsible for disposal Medicines (in original packaging)
Place in rigid containers with Blue lid
Medicines (loose) Place in rigid containers with Yellow lid. Care should be taken to minimise the risk of combustion, explosion or noxious fumes as a result of intermixing. Mercury Contact Waste Manager Nappies Yellow and black striped ‘tiger’ bag. incineration. Paper and paper packaging
Green tinted bag.
Radioactive Refer to separate disposal procedure Refrigeration Equipment Contact ISS Helpdesk on 5050 Stoma Bags Yellow and black striped ‘tiger’ bag Surgical Dressings Yellow and black striped ‘tiger’ bag Syringes (contaminated with medicinal products)
Yellow bag (no sharps)
Syringes – Phlebotomy Yellow and striped ‘tiger’ bag Syringes (contaminated with Cytotoxic or Cytostatic drugs)
Purple bag (no sharps)
Toner Cartridges Call ISS Helpdesk on 5050 TVs Call ISS Helpdesk o n Toxic Chemicals Call ISS Helpdesk o n X Ray Film Separate disposal arrangements in place
