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Safe Management of Healthcare Waste... One Year On The Department of Health published HTM-07-01 at the end of November 2006 to update guidance on how to segregate, contain and dispose of healthcare waste in order to fully comply with latest regulations and legislation. Nick Davis, Group Managing Director, Frontier Medical Despite the fact that HTM-07-01 was long awaited, it is fair to say that the implementation of the guidance across the NHS has been generally slow. One sharps container manufacturer carried out informal research amongst customers several months after the guidance was published with the following broad conclusions: ■ ■ ■ Awareness of the guidance was patchy – not all Trusts realised its significance; The person responsible for implementing the guidance varied across Trusts but with Waste Managers (or equivalent) being the most common; No set timescales for the implementation had been set within most organisations; It is now a year since the guidance was published – this article provides a brief overview of the main provisions, particularly in respect of the containment of waste, and how they have been interpreted and implemented throughout the National Health Service to date from the perspective of the container manufacturers. HTM 07-01: Safe Management of Healthcare Waste obliges NHS organisations to segregate healthcare waste into specific colour-coded waste streams, according to the nature of the waste. Whilst it is inappropriate to try to synthesise well over 100 pages of guidance in a short article, the key recommendations of HTM-07-01 include the adoption of: ■ ■ ■ A new methodology for identifying infectious and medicinal waste that complies with health and safety, transport and waste regulations (described as the Unified Approach); A best-practice waste segregation and packaging system involving colourcoded containers; An offensive/hygiene waste stream to describe waste that is non-infectious. The guidance incorporates definitions of infectious and medicinal waste: ■ ■ Infectious waste is essentially that which poses a known or potential risk of infection, regardless of the level of infection posed; Medicinal waste includes expired, unused, spilt and contaminated pharmaceutical products, drugs, vaccines and sera that are no longer required and need to be disposed of properly. HTM-07-01 divides medicines into three broad categories: Cytotoxic and cytostatic; pharmaceutically active but not cytotoxic or cytostatic; and not pharmaceutically active and possessing no hazardous properties (e.g., saline or glucose). In the broadest possible terms, the guidance suggests the following colour coding for sharps containers: ■ ■ ■ ■ Orange lids - for sharps not contaminated with medicinal products and/or fully discharged sharps; Yellow lids – for partially discharged sharps contaminated with medicinal products other than cytotoxic or cytostatic medicines; Purple lids - for sharps contaminated with cytotoxic and/or cytostatic medicinal products. Pharmaceutical products – HTM-07-01 suggests that these should also be included in yellow containers – however, a consensus has emerged that this would lead to confusion in identification during the disposal process so container manufacturers continue to supply either blue or green lidded containers for this purpose. It should be noted that the colour-codes are significant in terms of the permitted disposal route of the waste stream as well as the contents. Also, it is not necessarily the case that all organisations will need to use all of the different colour options. It is usually possible and preferable to simplify the segregation – manufacturers and others can assist in working through a process to arrive at an optimal solution balancing cost and ease of use whilst maintaining compliance with the guidance. ■ In the case of one of the main recommendations of the guidance – segregation of sharps into colour-coded containers – there was no clear consensus as to which combination of colours to adopt. More recent research from another of the manufacturers suggests that, on the whole, the situation remains broadly the same a year later, with relatively low levels of awareness and indeterminate implementation intentions From discussions throughout the NHS and the associated supply and waste management organisations, there would appear to be a number of diverse reasons for this slow take up of HTM-07-01: ■ ■ ■ ■ ■ The guidance is only that – guidance – and HTM-07-01 makes no reference to date by which it should be implemented. Whilst there is recognition that it is an issue that needs to be addressed, many other priorities within the NHS seem to be taking precedence. Whilst the authors of the guidance made every effort to synthesise a complex subject, the result was a large and, for the non-expert, largely impenetrable document. Many Trusts appeared to be waiting for interpretation of the guidance or for others to take the lead to demonstrate a workable implementation. Although the guidance was badged by the health services in England, Scotland and Wales, it was clear from the outset that different interpretations would be made in each country. In particular, Scotland is expected to publish differing guidance, which has yet to be finalised. It has taken manufacturers and wholesalers some time to make available the products required by the guidance (for example, colour-coded sharps containers) for use by the NHS. Possibly, the main reason for the slow interpretation is that the guidance appears to address a problem that was not recognised as such by the many hundreds of thousands of frontline healthcare workers. Having said why the uptake of the guidance has been slow, progress has certainly been made over the past year. All the clinical waste container manufacturers have changed their ranges to ensure that products are available to meet the guidance. Whilst this may appear to be a relatively simple exercise, the reality is far more complex, involving considerable effort and cost. Taking sharps containers as an example, the range of products has been increased at least threefold to take account of the different coloured lids for the containers. Issues which have needed to be addressed to facilitate this from a production perspective include: ■ ■ ■ ■ Sourcing appropriate masterbatch (plastic colourant); Changing the labelling / printing on the containers to reflect the segregated contents; Increasing moulding capacity – whilst the overall number of sharps containers may not rise, the injection moulding tools require cleaning at each colour change, reducing throughput; Increasing stockholding capacity – the increased number of products requires more stocks to be held to ensure that the typical same-week delivery timescales continue to be met. These product changes have added significantly to the manufacturing cost of the containers although companies have chosen to absorb these additional costs rather than pass them on to the customers through price rises. It is not only the manufacturers that have incurred additional costs resulting from the new colour-coded products. All organisations involved in the supply chain between the factory gates and hospital ward or clinic have needed to adapt to the changes. Wholesalers, including NHS Supply Chain, have increased their stocked ranges of sharps containers to accommodate the colour-coded products. Consequently, NHS organisations should have no difficulty in sourcing the requisite equipment through their normal supply channels.
Safe Management of Healthcare Waste ... One Year On SMDSA secures Agency concessions and derogations Martin Foulser – Secretary, SMDSA CONTINUED Waste management companies have also incurred costs in developing systems to ensure that the segregation of the waste is maintained throughout the various routes to its appropriate final disposal. All of the sharps container manufacturers within the SMDSA have produced detailed information on their ranges of products, which is available to assist producers in complying with these guidelines. As well as providing the equipment, the manufacturers will be happy to provide guidance, both in person and through media such as literature, flowcharts, “toolkits” and websites which will guide NHS entities all the way from deciding the best course of action to comply with the guidance through to the final implementation of the preferred option throughout their organisation. Many waste disposal companies are also in a position to assist in choosing an appropriate implementation strategy. In summary, the guidance has been in place for nearly a year and it is now time for NHS organisations to address the issue where they have not already done so. Appropriate colour-coded equipment is readily available from a variety of Veterinary waste and its safe management The 2005 regulations on Hazardous Waste, present veterinary practices with major changes to the way they segregate and classify wastes. As a leading service provider in this area, Vetspeed has produced two posters to help practices establish a suitable waste handling regime. These stem from guidance agreed between the Environment Agency and the British Veterinary Association. The situation is that clinical waste, anatomically and medicinally contaminated sharps and anatomical waste must now be considered as infectious and hazardous. These wastes have to be consigned under the Hazardous Waste Regulations. Further, most practices will need to register with the Environment Agency as a single bag of such waste per week is enough to exceed the 200kg exemption. Howard Jonas, Director, Vetspeed Ltd manufacturers at no additional cost through all of the widely-used NHS supply channels. Help and advice is freely available from container manufacturers and others to assist with the decision making necessary to change over to a HTM-07-01 compliant waste segregation system, and both NPAG (National Performance Advisory Group) and CIWM (Chartered Institution of Wastes Management) with assistance from SMDSA have held seminars across the country to assist those affected. Vetspeed’s posters distil a 120 page technical guide into an easily understandable format. The first poster explains which waste types should go into which colourcoded containers. The second is a decision tree to make it easier to segregate wastes correctly. Free copies are available by emailing support@cpccares.com or calling 01763 207750. Steady persistence in discussions with senior managers at the Environment Agency has finally paid off with the SMDSA recently securing a number of important concessions and derogations that will ease the burden on its member companies and the wider industry. Potentially high direct costs have been largely avoided which, together with the accompanying administrative costs could have seen an unjustifiable rise in the price paid by customers for some services. Disposal of Aerosol canisters from washroom servicing A Problem Aired … In late 2006, Albany Washroom Services (a long term SMDSA Member) was approached by a local Environment Agency officer during a routine inspection of their waste transfer station regarding the collection and disposal of spent aerosols from servicing. Albany Washroom Services, in common with other SMDSA members provide automatic air freshener services to commercial premises, which use an electronically controlled aerosol to provide measured bursts of fragrances into the working environment. The company replaces the aerosol and batteries at each scheduled service visit. Since the banning of CFCs, the propellant contained in many aerosols is butane, a flammable gas, and when the aerosol is changed, the partially empty canister may become a hazardous waste for disposal due to the flammable nature of the residue. As a hazardous waste the ‘nominally empty’ canister would need to be consigned from the customer to a licensed facility for disposal. The Albany transfer station was not licensed for hazardous waste and the Agency officer suggested that the company would need to apply for a modification to its licence (at a cost of £7500) and should be consigning these aerosols. In addition the company would also need to pay for the site manager to upgrade their Certificate of Technical Competence in order to cover hazardous waste and an increased subsistence cost. Faced with an initial bill of about £15,000 plus the cost of administering the consignments and with the expectation that they would have to charge the client an additional £10-15 per visit or up to £200 per year, Albany’s Sales Director, Barry Marsham, contacted the SMDSA for help. The Picture Unfolds … It soon became apparent that the implications for the industry were far reaching. The industry generally had returned spent aerosols from servicing to their service depots and then designated them as waste and consigned them onward for disposal. The situation is likely to affect many other service industries where waste is produced as a result of providing a service to a client away from the depot, such as mobile car or machinery servicing, builders, double glazing, pest control, and the vending industry. Many of these wastes are also hazardous – oil, asbestos lining, fluorescent tubes, pesticides and contaminated vermin, lead acid batteries, paints, adhesives and other aerosols are similarly returned to unlicensed depots for later disposal. Many hygiene and washrooms service companies also do not operate or require waste transfer stations, but Albany had been identified as part of a routine inspection of their licensed facility whereas many of the other operations above fall below the Agency’s ‘radar’. A survey of SMDSA members indicated an estimated 3 million aerosol canisters from servicing air fresheners each year with about 2 million separate consignments effected. If these were all consigned back to the depots the cost of consignment fees paid to the Environment Agency could be £20M – three times the Agency’s own previous estimate for the total revenue from hazardous waste consignment notes. Practical Solutions The SMDSA and Albany entered a process of discussion with management in the policy section of the Agency on the basis that: ■ ■ ■ ■ If the aerosol canisters were left with the client, the majority would be likely to be incorrectly dispersed into the commercial waste stream for landfill, whereas collecting them together by service providers created a sufficient quantity to enable economic recovery and recycling or controlled treatment and removes them from landfill. The cost of 2 million ‘internal’ consignment fees would serve as an impediment to recovery or recycling opportunities. The generation of over 2 million consignment notes where the contractor is simultaneously producer, carrier, and disposer served no useful purpose providing that the required information remained available for audit or inspection. The requirement for every washroom service provider to obtain a Waste Management License (or amend their existing license) was wholly disproportionate regulation to the risk and further impedes recovery or recycling. Following careful consideration of all the implications, the Agency have agreed: ■ ■ ■ That exemption 28 in Schedule 3 of the Waste Management Licensing Regulations may be used instead of applying for a license i.e. The storage of returned goods that are waste, and the secure storage of returned goods that are hazardous waste, pending recovery or disposal, for a period not exceeding one month, by their manufacturer, distributor or retailer. Companies may register this exemption by telephoning the Agency’s Helpdesk on 08708 506 506. To add this waste stream to the derogation from payment of consignment fees such that only a single consignee return fee shall be payable each quarter. - see 'Different rules for specific waste streams' at the following link: http://www.environmentagency.gov.uk/subjects/waste/1019330/1217981/1411674/?version=1&lang=_e That consignment notes do not have to follow the standard Agency format but may be in another format achieved by adapting existing paperwork or electronic system providing the same information can be provided to the Agency in an intelligible form.
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