Version: 2 (Version 1 issued January 2004) Type: Operational (Tick Appropriate Corporate Services box) Risk Management/Health & Safety Personnel Mental Health Act
Author: Deputy Director of Nursing & Clinical Governance Ratifying Body: Approving Body: Strategy and Operational Performance Committee Approval Date: March 2008 Issue Date: June 2008 Review Date: May 2009
Distribution: All Policy Manual Holders MHA Manual Holders Operational Manual Holders
Lincolnshire Partnership NHS Partnership Trust Waste Management Standards
Waste Management Policy
1. Policy statement
This policy has been agreed between LtPCT, ULHT and LPFT and has involved other stakeholders such as Environment Office and local councils. Lincolnshire Partnership NHS Foundation Trust is committed to implementing the guidance provided in the Department of Health Environment and Sustainability Health Technical Memorandum 07-01: Safe management of healthcare waste (HTM 07-01)1. Implementation of this guidance will ensure the Trust complies with the regulatory requirements of relevant health and safety, environmental and transport legislation with respect to its management of wastes2,3,4,5. This Policy is intended as the main Policy Statement and outline of arrangements with respect to Waste Management.
2. Policy aims
The aim of this Policy, and its associated summary guidance and procedure notes, is to ensure Trust waste is appropriately managed from the time of production to its place of final recovery or disposal. This “cradle to grave” approach will require waste producers to assess wastes at the point of production and segregate them accordingly using the Policy’s assessment and segregation procedures in the Standard Operational Procedures (SOPs). These procedures are based on the “unified” segregation approach outlined in HTM 07-01 (see Appendix 1). The Trust has also to demonstrate compliance with the duties placed on all NHS organisations under the Health Act (2006) and the relevant Core Standard: C4e6. 3. Legal and statutory obligations
These obligations are accounted for in HTM 07-01, implementation of this guidance will fulfil these obligations. Future obligations will be highlighted by the waste management system incorporated into this policy.
4. Waste management arrangements
The Trusts assessment and segregation procedures and guidance will ensure healthcare wastes generated are appropriately segregated, described, packaged and securely stored whilst awaiting collection and disposal. Each waste will then be consigned to an appropriately licensed waste contractor for suitable disposal. Similar segregation protocols will be generated for non-healthcare municipal waste-streams requiring segregation and separate collection. 1 Department of Health (2006) Environment and Sustainability: Health Technical Memorandum 07-01: Safe Management of Healthcare Waste. 2 Great Britain (2005) The Hazardous Waste (England and Wales) Regulations, 2005. S12005 No 894. 3Environment Agency (2005) Technical Guidance WM2: Hazardous Waste: Interpretation of the definition and classification of hazardous waste (Second Edition. Version 2.1). 4 Great Britain (2004) The Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2004. 5 Great Britain (1990) The Environment Protection Act 1990 (c.43). The Stationary Office, London www.opsi.gov.uk 6 Department of Health (2006) The Health Act 2006; Code of Practice for the Prevention and Control of Health Care Associated Infections. 1st October 2006. Core Standard C4(e): The Stationary Office www.dh.gov.uk.
Waste audits will be undertaken by appropriately trained senior staff members within LSS to verify waste segregation protocols are being adopted by waste producers and that wastes are being appropriately packaged and stored prior to collection by waste contractors. Audits will also be undertaken to ensure wastes are being described, characterised and consigned to waste contractors according to relevant waste legislation.
5. Process for identifying improvement programmes and monitoring progress The person with responsibilities for waste management within the Trust (Support Services in LSS) will develop a waste management system to examine Trust premises waste audit records, and report back to the Trust. LSS will report to the Board, via the Infection Control Committee, recommending changes to waste policy and procedures. The LSS Lead will conduct; inspections at Trust premises, duty of care audits of waste contractors and cradle-to-grave audits of the waste-streams generated by the Trust. This person will also identify any relevant forthcoming legislation to the Trust so necessary changes can be made to the Trust’s Waste Policy and procedures (see Diagram 1 below). Diagram 1 The Waste Management Cycle
Assess Current & Future Legislation
Respond to Problems Identified
Review Policy Systems & Procedures
Write Waste Policy, Guidance & Procedures
Arrange Training & Instruction for Staff
Audit Procedures & Monitor Progress
Review Performance against Policy & Procedures
WASTE MANAGEMENT SYSTEM
6. Waste management responsibilities and lines of accountability
• It is the duty of those who produce waste to follow the assessment and segregation protocols, and deposit their waste into the appropriate colour coded waste receptacle. It is the unit manager’s responsibility to ensure the correct receptacles are in place. The external bins are the responsibility of the contracted disposal company, but it is the trust’s responsibility to ensure the correct labelling of bins requiring labelling. • It is the duty of all waste handlers to follow waste handling procedures and place colour coded waste receptacles into the appropriate bulk storage bins. • It is the duty of the premises/clinical/general manager to audit staff under their control to ensure they understand and follow assessment and segregation protocols. • It is the duty of premises/clinical/general managers to ensure wastes are described and characterised according to the guidelines. • It is the duty of the premises/clinical/general managers to ensure that waste assessment and segregation / duty of care audits are completed as Policy protocol. This may be allocated to other appropriate personal to undertake. • It is the LSS Lead’s duty to advise the Trust regarding current and forthcoming legislation and to audit premises for compliance with waste legislation. • It is LSS Lead’s duty to conduct duty of care audits of waste contractors and audits of the waste-streams generated by the Trust. • It is the duty of LSS to report progress to the Board via the Infection Control Committee. • The Trust’s Lead for Waste Management will develop a Summary of Guidance Notes which will clearly identify the legal obligations set out in waste, health and safety, and transport legislation in relation to healthcare waste.
7. Arrangements for implementation
Waste producers will be trained regarding segregation protocols. This will be via a cascade method that has been discussed at various meetings across the Trust and other stakeholder areas. All areas generating healthcare waste will be involved.
The Trust’s Lead for Waste will advise, oversee preparation of the training packages and assist in the training events. The packs will contain different training levels to meet the needs of different staff cohorts and agencies. The training will be cascaded to clinical areas by the Matrons for that service. The following list is an example: • Clinical staff guidance involves the segregation in treatment areas of infectious wastes, sharps and cytotoxic / cytostatic waste streams; • Domestic staff need specific training regarding the handling and storage of waste relevant to their area of work which may include keeping an accurate waste log • Some Managers will have need of instruction on the maintenance of the waste management system (verifying audit trails) • Particular emphasis will be placed on auditing waste segregation, handling, storage and waste transfer records for all senior staff/managers
It is intended that the training given to senior staff will include segregation protocol training, regulatory definitions and classifications of waste, consignment note procedures and audits at the premises / areas they are responsible for as a standard.
Packs will be given to these managers/senior staff and they will be encouraged to cascade the information to staff in their area of responsibility.
Other training events will be scheduled; these events will give all managers and senior staff the option to send other strategic personnel for training so that several cascade training sessions can be organised across the same vicinity. This takes account of the geographical area and the numbers of agencies requiring the information.
8. Tools and Guidance
This document is the over arching Policy underpinned by other documents that will be updated and developed to meet service need. These documents will be passed to the Infection Control Committee for ratification. This will ensure that all support documents and training tools remain up-to-date to guide staff in their responsibilities. The following is not an exhaustive list of the documents that support this Healthcare Waste Policy:
• Standard Operational Procedures • Range of training packages • Summary Guidance for completing hazardous waste consignment notes. • Summary Guidance for Duty of Care transfer notes. • Waste audit forms for: o waste assessment and segregation practice, o waste transfer notes and record keeping, o waste handling and storage. • Assessment and segregation procedure notes for all healthcare premises based on HTM 07-01 and what can be achieved within space constraints of treatment areas. • Audit Procedure for assessing healthcare premises compliance with waste legislation (based on Environment Agency inspection and audit protocols). • Audit Procedure for assessing waste contractors (based on Environment Agency inspection and audit protocols).
9. Waste Management process in LPFT
SOP has approved the proposal that all clinical waste should be classed as potentially infectious. There is some work to be done to ensure that staff only place true clinical waste (dressings, plasters, used wound packs etc) in clinical waste bags. This waste is to be placed in orange bags which means it can be treated and then disposed of at landfill.
There is a colour coding system for the 820 size bins which hold clinical waste ready for collection: a red label should be attached to the bins which will contain sharps waste, a yellow label should be attached to bins which only contain clinical waste. The labels are available through LSS from White Rose.
Clinical waste containers are lockable and should be placed in a secure area ready for collection, i.e. a locked bin compound.
For sharps containers in each unit LPFT staff should use yellow lidded yellow bins for sharps which have been fully or partially discharged of medication and for used phlebotomy sharps, and purple lidded bins for disposal of waste which has been in contact with cytotoxic/cytostatic substances. It is envisaged that there will be minimal need for the purple lidded bins but it is recommended that every unit has a small container in case a service user brings in a substance which need disposing of in this manner.
The trust’s Medicines Management policy covers disposal of pharmaceutical waste and staff are directed to that policy in relation to disposal of pharmaceutical waste, including disposal of refused medication, spilt medication and medication which has expired or is no longer required.
Used continence products such as incontinence pads and sanitary products should be classed as offensive waste and will be disposed of in tiger stripe bags (black with a yellow stripe). These bags can then be placed in a separate bin for pick up by White Rose. N.B. ULHT sites are not using tiger stripe bags yet e.g. Dept. of Psych, Rochford Unit, Manthorpe. These units will be notified at a later date when to implement tiger stripe bags.
Domestic/general waste for landfill will continue to be disposed of in black bags, and placed in the bin to be collected by Cleanaway.
Electrical/Electronic Waste (WEEE)
The disposal of electrical/electronic equipment is covered by the Waste Electrical Electronic Equipment (WEEE) Regulations to be enforced by July 2007.
The plan for LPFT is that containers will be kept at key sites – Peter Hodgkinson Centre, Carholme Court, Witham Court, Beaconfield and possibly Dept. of Psychiatry. The container will be locked and an identified person for each site will keep a logbook of all equipment placed in the container for disposal. When full the box will be picked up by an agreed contractor and taken for disposal a replacement container being provided at each pickup. There is currently a slight delay in implementing this to ensure there is a need for the containers at each site. This is being undertaken by LSS.
Low energy light bulbs are classed as WEEE and should be treated the same as fluorescent tubes; they should not be placed with other WEEE items because of risk of breakage. The bulbs should be stored safely until they can be picked up by Works Dept. (LSS).
Confidential waste is waste which, if disclosed, could: identify a service user, carer or member of staff; provide trust information to a third party which could result in litigation; provide statistical/financial information which could compromise the trust; include blank headed note paper which could be used by a third party for illegal purposes. Confidential waste which can be shredded should be shredded using a machine which cross shreds the paper. Any material which is confidential and cannot be shredded, either because of the amount or floppy disks, audio/video tapes should be put into the appropriately coloured bag provided by the contractor and disposed of using the agreed contractor via procurement. Computers/fax machines are disposed of via IT Department.
Disposed of in a brown paper bag and put in the bin for general waste. It is recommended that no more than 6 aerosols are placed in each bag.
Paper and cardboard which is not confidential can be placed in recycle bins at sites where this in place. It is planned that after the piloting of this process at some sites in LPFT this will be rolled out to all sites.
The required coloured bags will be available through procurement. All staff should be made aware of the correct segregation of waste to comply with these regulations.
This Waste Policy is based on the above (Chapter 3 Health Technical Memorandum 07-01 Safe management of healthcare waste – HTM 07-01) Further guidance is available from Support Services at Gervas House 01522 546546