ENEH03-0805:
Fluid Waste Management: Control of Infections in Liquid Waste Management
Author:
Pat Tydell, RN, MSN, MPH and Jack Donaldson,
RN, CNOR, CSPDM
1.0 contact hours
OBJECTIVES
1. To identify the difference between safe work practices and engineering
controls related to handling and disposal of infectious liquid waste.
2. To recognize the regulatory problems of handling and disposing of infectious
liquid waste.
3. To list the advantages of one liquid waste solidification product.
One of
the most crucial issues facing hospitals and other medical facilities
today is protecting against disease transmission. Healthcare workers
are often exposed to hepatitis B virus (HBV), human immunodeficiency
virus (HIV), and other dangerous bloodborne pathogens on a daily basis.
Through the institution of safe work practices and engineering controls,
healthcare workers' exposure can be significantly reduced.
OSHA guidelines are clearly in support of standard precautions to treat
blood and other body fluids as if they were infectious for HBV, HIV,
and other bloodborne pathogens. The collection and disposal of biohazardous
liquid can pose a significant risk, bringing an untold occupational
challenge to hospital staff. From pathologic body sites, the microbial
content of suction load may be high and contain significant pathogens.1
Bacterial content of abscesses can include Clostridium, Bacteroides,
and Straphylococcus The respiratory tract can contain Streptococcus,
Pseudomonas, Klebsiella, Serratia, and a variety of gram negative
organisms. The female genito-urinary tract can contain polymicrobial
flora similar to that of the intestinal tract plus Herpes virus.<V>1<$>
When healthcare workers come in contact with these biohazardous fluids,
reducing their exposure by minimizing splashing, spraying, and splattering
is critical.
One source of biohazardous fluids that healthcare workers come in contact
with on a daily basis is from suction canisters. The use of reusable
and disposable suction canisters in the healthcare community and medical
industry is widespread. The use of surgical and medical suctioning occurs
in several areas throughout the hospital. These areas include the emergency
room, intensive care units, oral surgery and obstetric departments and,
most frequently, in the surgical department. The use of suction canisters
can include general patient care areas as well.
Standard precautions is an infection control system that assumes that
every direct contact with blood and body fluids is a potentially infectious
exposure. This system is based on the premise that not all patients
with bloodborne infections have been diagnosed, and therefore, precautions
must be applied.2
Handling of Suction Collection Canisters
There are additional basic principles that should be followed for safe
handling of suction canisters to minimize the risk to healthcare workers.
Disposable units should be discarded when full or when removed from
a patient. Although many hospitals (approximately 80%) have switched
to disposable suction collection units, glass and metal units are still
used. Some institutions have converted partially and have both systems
in use.1
As with
the suction canister itself, so too should the connectors and associated
tubing be disposable. Use of disposables reduces the handling of the
contaminated equipment by healthcare workers.
Care needs to be taken when removing the collection canister from the
patient care areas. Liquid contaminated waste needs to be carried out
in a sealed impervious container. Neither should the container be transported
unless sealed to prevent spillage or contamination of others en route
to its final disposal site. Once the protectively enclosed collector
unit has reached a disposal area, its contents should be disposed of
according to policy. The disposal should occur in a non-patient care
area to avoid the contaminated aerosols generated by the suctioning
process. The personnel doing this should be gowned, gloved and masked
to protect against aerosolized contaminants, spillage, and splattering.
If the canister is reusable, additional care needs to be taken in order
to place the equipment back in service. Also, a clean unit should always
be available for back-up.
An engineering control system that helps reduce exposure to body fluids
is liquid medical waste solidification products. Liquid medical waste
solidification products have been used in the healthcare and medical
industry for over 12 years. Healthcare workers have benefited from the
protection these products provide including the elimination of spilling,
splashing and aerosolization. However, until recently, none of the solidification
technologies demonstrated the level of efficacy required by most states
in order to convert the infectious waste to a non-infectious state and
ultimately be disposed of in the white bag waste stream.
Unfortunately, there were solidifiers that received approval in some
state agencies based on limited efficacy studies for landfill disposal.
However, they were later determined to be ineffective treatment technologies
and ultimately lost their approvals.
The disposal of medical waste is regulated on an individual state basis.
Accordingly, not all the states have the same efficacy requirements.
It is important to note, however, if a technology is approved by a certain
state as an Alternate Medical Waste Treatment Technology. It has to
be registered with the United States Environmental Protection Agency
before it can be marked and sold in that state.3
Conversely, just because a solidification product obtains an US EPA
registration, it does not mean it automatically becomes a countrywide-approved
Alternate Treatment Technology. The product must still demonstrate the
efficacy required within the state it plans to sell in.
If this process sounds confusing--you're right. However, in order to
assist manufacturers through this process several state agencies formed
a committee called State and Territorial Association on Alternate Treatment
Technologies (STATT)4.This committee developed
a guidance document for evaluating Alternate Technologies that have
been registered with the US EPA as a chemical treatment product. In
addition, Underwriters Laboratories Inc. (UL) has initiated the development
of a standard. UL, through the Accredited Organization Method of American
National Standards Institute (ANSI) is seeking recognition of this standard
as an American National Standard.
Scope
The scope of the standard is as follows. The standard is intended to
determine whether individual equipment or systems provide for microbial
inactivation and reduction of the risk of injury to persons and damage
to property related to their use.
These
requirements cover the construction, performance and maintenance of
technologies employed as an alternate to incineration for the disposal
of medical waste.
- Alternative
medical waste treatment technology--as covered by these requirements--consists
of various methods of microbial inactivation through the individual
or combined use of heat generated by assorted media, chemicals and
irradiation. It includes pre-and post-processing systems required
to be used with the treatment technology.
@bullet:These requirements do not cover incinerators or any other
equipment covered in whole or as part of a separate, individual requirement.
In addition, the requirements do not cover:
a. Hazardous waste identified or listed in 40 CFR Part 261.
b. Radioactive waste defined and regulated by the Nuclear Regulatory
Commission.
c. Domestic sewage materials identified in 40 CFR 261.4(a)(1).
- A product
that contains features, characteristics, components, materials or
systems new or different from those covered by the requirements in
this standard, and that involves a risk of fire, electric shock, or
injury to persons shall be evaluated using the appropriate additional
component and end-product requirements to determine that the level
of safety, as originally anticipated by the intent of this standard,
is maintained.
- A product
whose features, characteristics, components, materials, or systems
conflict with specific requirements or provisions of this standard.
Where considered appropriate, revisions of requirements shall be proposed
and adopted in conformance with the methods employed for development,
revision and implementation of this standard.
OBF Technologies' mission was to develop a product that would demonstrate
the required efficacy as set forth by STATT and meet the proposal
standards for Underwriters Laboratories, while keeping in balance
with the environment.
In 1997, OBF Technologies developed the first protocol for a Sanitation/
Solidification product to be approved by the US EPA and subsequently
received official registration from the US EPA March 7, 1997. EPA
registration number 59839-1.
A widely
used cold sterilant--known for demonstrating the high-level of efficacy
(sterilization) when challenged by the most virulent organism--is glutaraldehyde.
After several years of research and development, the company converted
liquid glutaraldehyde into a patented dry crystal. This process allows
the liquid glutaraldehyde to become encapsulated within a prilled silica
crystal and is only released when it comes into contact with the liquid
waste inside the suction canister. This technology allows the end user
to benefit from the high- level of efficacy demonstrated by the dry
glutaraldehyde crystal while minimizing the risk commonly associated
with liquid glutaraldehyde. By combining the dry glutaraldehyde crystal
with a fast and encapsulating group of acrylic polymers, the company
developed new technology called PremiCide.
PremiCide is a suction canister sanitation and solidification system
that allows for transport, storage, and disposal of sanitized medical
waste.
The efficacy demonstrated by PremiCide includes a 410 log reduction
of the Bacillus subtilis spore and 610 log Mycobacterium Phlei
in 100% whole blood serum. In addition, it inactivates non-sporulating
gram positive bacteria, fungi, non-sporulating gram positive bacteria,
and crystals.
It is manufactured in single-use (unidose) sizes to sanitize all suction
canister volumes. A patented closed delivery system called PremiGuard
brings added safety to the treatment, handling, and disposal of liquid
laboratory, human and animal waste.
The closed delivery system allows the treatment of infectious liquids
to occur within the sealed collection canister, eliminating unnecessary
chemical spills and potentially hazardous aerosolization and splashing
of the infectious collected waste fluids. The cap was designed to fit
most suction canister lids and can be used with or without suction.
To ensure the safety associated with the use of this solidification
and treatment product, the company conducted several environmental studies
and personal safety studies concluding that when used according to directions
of use, the product does not qualify as a hazardous waste and the occupational
exposure level to the dry glutaraldehyde is below recognized exposure
limits. In addition, a LD 50 Acute Dermal Toxicity Study demonstrated
an undetectable level of toxicity according to the procedure listed
in the TSCR guidelines, 40 CFR Part 798.
Pat Tydell,
RN, MSN, MPH, is the Risk Manager at North Chicago Veterans Administration
Medical Center (VAMC) in North Chicago, Ill.
Jack Donaldson is the Nurse Manager of Sterile Processing at Sutter
Medical Center in Sacramento, CA
References
1
Neblett, Thomas R. Ph.D. "Characteristics of Medical and Surgical
Suction Systems. The Microbiology and Nosocomial Hazards of Collection
Vessels". Published monograph of research conducted at Biosan Laboratories,
Inc. 10657 Galaxie Ave. Ferndale, Michigan 48220.
2 Goodman, Terri, RN, MA, Ph.D. "Control of Infections Related
to Bloodborne Pathogens". Infection Control Today. June,
2000.
3 Ng, Rebecca, BS, REHS. "Medical Waste Disposal Training
and Audits". Infection Control Today. November, 1999.
4 Underwriters Laboratories, Inc. "Standard for Safety for
Alternative Technologies for the Disposal of Medical Waste- UL2334".
www.UL.COM/epn/medwaste.htm.5 OBF Industries, Inc. www.enviro-safe.com
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