Managing clinical waste

The correct handling of healthcare waste is an issue that must not be overlooked within the NHS. Although the necessary procedures are not particularly complex or challenging, significant effort is required by management to ensure systems are set up properly and then monitored to ensure they continue to run effectively.

Environmental impact

The Environment Agency monitors all types of waste producers and their output with the aim of reducing the impact of that waste on the environment. In the case of clinical waste – almost all of which is classified as hazardous waste and where mishandling presents a very real risk to human health – the emphasis is on ensuring safe as well as efficient treatment or disposal.
The Environment Agency seeks to achieve this by working with healthcare establishments to promote and support best practice. Working in partnership with industry is the preferred option and has been found to be the most effective. However, as the environmental regulator, the Environment Agency also has enforcement powers to discourage infringements of the law, which can be used to impose fines on persistent offenders.
Best practice in managing healthcare waste would see employment of a full-time environment manager who oversees trained staff, ensuring complete waste segregation, keeping accurate records and employing a fully compliant waste contractor. There are several measures that are comparatively simple to implement that can help Trusts move towards this ideal.

Segregation is key
Segregation is the key to effective waste management as mixing hazardous wastes with non-hazardous wastes means it all has to be classified as hazardous. Trusts are reminded that this is not optional and that the law requires waste producers segregate materials through the Hazardous Waste (England and Wales) Regulations 2005. This prohibits the mixing of a hazardous waste with any other category of hazardous waste, non-hazardous waste or other substances (unless authorised to do so).
Guidance on this is available in the government’s Health Technical Memorandum, Safe Management of Healthcare Waste (HTM 07 01). This is available on the Department of Health’s website and explains how to segregate waste in order to meet legal requirements.
Implementing waste segregation is not difficult, particularly as most people sort their household waste already. Trusts that have implemented outstanding segregation procedures have done so by ensuring the following measures were in place:

  • The support of senior management
  • Trust-wide training and induction of all staff
  • Careful placement of properly labelled bins
  • Use of internal audits and ward champions to monitor performance
  • A co-ordinated programme of change.

The message behind this is that staff will segregate effectively if you provide the tools, training and support for them to do so. A few posters and e-mails will probably do little to bring about change.
Packaging and labelling is another vital aspect of segregation. The segregated waste must be kept in appropriate containers that are clearly labelled, identifying both the waste contents and the source department or unit. This is particularly important for pharmaceutical wastes, anatomical wastes (particularly from pathology laboratories), and chemically contaminated wastes.
Furthermore, the packaging must meet the requirements for the carriage of dangerous goods to ensure it can be transported by the waste carrier, or internally, without the risk of leakage. Advice on this should be sought from your dangerous goods safety adviser.

Audit yourself
Segregation is rarely going to be perfect. But what is important is that management systems are in place to prevent serious failures, to monitor performance and identify where improvements can be made.
An effective audit system would see each ward, unit or department having its own waste champion who supports local staff and audits performance each month. The trust could form a committee of these champions and the waste manager would then advise and co-ordinate a consistent approach.
Internal auditing is a major part of the Health Technical Memorandum and many disposal sites now demand this as a prerequisite for receiving waste from medical practices.

Waste documentation
Clinical waste from medical practices, with the exception of the small sub-waste stream of non-hazardous medicines, is always a hazardous waste. This means it must be accompanied by a consignment note when it is removed from a practice. If your waste contractor does not provide a hazardous waste consignment note you should seek advice from the Environment Agency immediately.
There are two problem areas surrounding consignment notes that are all too common. Firstly, the waste producer is often unaware that completion of key parts of the note remains solely its legal responsibility. This can lead to the second issue: producers tend to let the waste contractor complete it for them. Although this is acceptable in some circumstances, producers are reminded that the legal responsibility remains with them.
It is the legal responsibility of the waste producer to provide a detailed written description to the contractor of the composition of each clinical waste stream. Management should be aware that each time waste is collected a legal declaration is signed on behalf of the trust certifying that the description is correct.
Transport is another important issue. Waste producers have a duty to ensure waste is packaged properly for transport. The Carriage Of Dangerous Goods Manual, available on the Health and Safety Executive’s website, forms the basis of standards for this.
Primary Care Trusts should be particularly aware that the requirements for the carriage of loose bagged waste (‘in bulk’) can be fundamentally different to the carriage of waste in wheeled carts or other suitable rigid containers. If your contractor is collecting bagged waste ‘in bulk’ the Environment Agency would recommend checking this is packaged and loaded onto the vehicle in accordance with the relevant requirements.

Final destination
Historically, clinical waste has been sent to incinerators operating at hospitals. These incinerators were considered suitable for almost all clinical wastes and so poor segregation was not such an issue.
In recent years, however, the number of clinical waste incinerators has declined significantly, creating greater demand for the reduced incineration capacity.
In the last decade there has also been a rapid expansion in alternative treatments. Often these are based on the well established principles of the laboratory autoclave and the most modern of these devices use state of the art technologies that are very effective at killing bacteria and viruses. They represent a substantial, innovative and forward-looking investment by the clinical waste industry and now form a large and essential part of the treatment and disposal infrastructure.
Unfortunately, these alternative treatments have no recognised performance against chemicals and pharmaceuticals, are not used for anatomical waste for ethical reasons, and can be prone to mechanical problems if they are fed large metal implements. They are, therefore, not normally authorised to process certain clinical waste streams.
This point highlights further the increasing importance of segregation by the producer, to ensure that optimum use is made of the remaining incineration capacity, and that unsuitable wastes are not sent for alternative treatment.

Records and returns
As producers you are legally required to keep a register of hazardous waste records. This must include consignment notes (and related documents) and consignee returns provided by the destination waste management site to confirm the waste arrived and detail what was done with it.
If the destination waste site has not provided this confirmation, the Trust’s register is incomplete, something which should be addressed with some urgency.
Management should also be aware of how far their Duty of Care extends. Each producer has a Duty of Care that continues after waste has left the premises and been transferred to a waste contractor. To discharge this, Trusts should take reasonable measures, in addition to those mentioned here, to ensure that the company you transfer waste to is appropriately authorised to deal with it.
Waste management is not meant to be difficult, however, it does require some resources and management to ensure that there is no risk to the environment or human health. If things goes awry, the producer may have some liability that could result in a substantial fine. The Environment Agency hopes to avoid this through working in partnership with the healthcare industry to ensure waste is properly disposed of. This would benefit the healthcare industry and help improve the broader environment for all of us.

Clinical waste definition
Clinical waste means any waste which consists wholly or partly of:

  • human or animal tissue
  • blood or bodily fluids
  • excretions
  • drugs or other pharmaceutical products
  • swabs or dressings
  • syringes, needles or other sharp instruments which unless rendered safe may prove hazardous to any person coming into contact with them.

Top tips and tough questions
The handling of clinical waste is something that producers need to consider seriously. Here are four key steps that waste producers need to ensure they are implementing:

  • Segregate waste properly
  • Use suitable and clearly labelled packaging for wastes and ensure transport vehicles are suitable and correctly loaded
  • Check waste is sent for disposal at a suitably authorised site
  • Keep all records to demonstrate this

And four questions for waste managers to consider regarding the disposal of each clinical waste stream over the last year. Can you:

  • name all the sites where your waste was disposed of this year?
  • explain what form of disposal it underwent there?
  • explain where, if your waste went to a transfer station first, it was sent to next?
  • confirm whether the waste management site permit allows for this waste stream?