AREAS OF RESPONSIBILITY

Applies To: UNM Hospitals Responsible Department: Infection Prevention & Control Revised: 2/2017 Procedure Patient Age Group: (X ) N/A ( ) All Ages ( ) Newborns ( ) Pediatric ( ) Adult DESCRIPTION/OVERVIEW It is the practice to ensure that infectious waste disposal procedures are followed to reduce occupational exposure to bloodborne pathogens. These procedures are designed to prevent the spread of potentially infectious organisms among patients, heath care workers, and visitors. REFERENCES New Mexico Environment Department, Solid Waste Bureau regulations 20.9. Association for Professionals in Infection Control and Epidemiology (APIC). (2014). Chapter 113 Waste Management. APIC Text of Infection Control and Epidemiology Fourth Edition. Environmental Protection Agency (EPA), 49 CFR 173.197, Regulated Medical Waste AREAS OF RESPONSIBILITY All departments which generate infectious waste will ensure the actions in this procedure are followed. All infectious waste generators will be responsible for the following unless otherwise noted: o Transport and storage of hospital infectious waste (except for sharps) to a local, secure storage area. o Ensure the storage area is kept clean and orderly. o UH Environmental Services (UH only): Ensure all transport containers are kept clean and disinfected. The Director for Environmental Services at UNM Hospitals will be the primary contact, coordinator, and enforcement of bio-hazardous waste generated at all UNM Hospitals facilities. 1 All personnel will follow the policies on Standard and Transmission Based Precautions and wear the appropriate Personal Protective Equipment (PPE) in anticipation of any potential bloodborne pathogen exposures. 2 Stericycle, Inc. is UNM Hospitals contracted provider for the incineration and autoclaving of all bio-medical, pathological, and chemotherapeutic waste including sharps containers generated at the University of New Mexico Hospital, Carrie Tingley Hospital, Outpatient Surgical and Imaging Services, Behavioral Health Facilities, and University of New Mexico Clinics. Transporter location & Primary Treatment Facility: Stericycle, Inc. 1920 First Street NW Albuquerque, New Mexico 87102 (505)-247-9454 Page 1 of 8

Secondary Treatment Facility: Stericycle, Inc. 3140 North 7th Street Kansas City, KS 66115 (913)-321-1554 3 Personal Protective Equipment: Impermeable gloves (Nitrile, vinyl, or rubber) will be worn by all employees handling, transporting, and disposing of infectious material. Additional protective equipment such as masks, goggles, and protective aprons are available and required if there is a chance of spray, splatter, or soak through of infectious waste. 4 Storage and Containment: The following rules apply to all storage and containment of infectious waste: 4.1 All containers used for storage or disposal of infectious waste must be clearly labeled indicating the contents, potential health hazards, and safety hazards associated with the waste. 4.2 Containment of infectious waste must be in a manner and location which affords protection from animal intrusion, does not provide a breeding place or a food source for insects and rodents, and minimizes exposures to the public. 4.3 To provide the maximum amount of protection to patients and personnel all infectious waste will be contained at the point of generation and segregated from all other solid waste. Infectious waste will be placed into labeled biohazardous waste bags that are tied or sealed at the point of generation then placed into lined, labeled biohazardous designated rigid refuse containers. 4.4 Non-hazardous solid waste which has been mixed with infectious waste will be managed as infectious waste, except for sharps. Solid infectious waste must be contained in plastic bags inside rigid containers. 4.5 Infectious waste, once removed from the collection receptacle must be stored in the Soiled Utility room located on the unit. 4.6 Infectious waste stored in the Soiled Utility rooms must be in a properly labeled and lined rigid storage container. 4.7 Soiled Utility Rooms: 4.7.1 Soiled Utility rooms must be labeled with a prominent warning sign. 4.7.2 Soiled Utility rooms must remain locked at all times and only accessible to authorized personnel. 4.8 All infectious waste to be placed in a lined, red, rigid container must be sealed in infectious waste red plastic bags. 4.9 Rigid Containers: 4.9.1 Rigid containers must be labeled Biomedical Waste or otherwise conspicuously labeled as holding infectious waste. 4.9.2 Rigid containers must be lined and securely sealed at all times. 4.9.3 Rigid containers must not be over filled. 4.9.4 Disposable rigid containers must meet or exceed the standards for a classified strength of at least 200-pound Mullen test. 4.10 Fluid-filled containers (e.g. disposable suction containers and hemovacs) which cannot be opened should be placed in a red plastic biohazard bag and tied securely. A second bag should be used for added strength, if indicated. Red bags will be transported to a secure area(s) for proper storage and disposal. Page 2 of 8

4.11 All blood and microbiological culture-contaminated devices shall be disposed of in containers lined with red bags or designated sharps containers. Red bags and sharps containers shall be sealed and transported to a designated biohazard shed in the south courtyard next to hospital compactor for proper disposal. 4.12 Rigid infectious waste containers may be reused for infectious or non-infectious waste if they are thoroughly washed and decontaminated each time they are emptied. The surfaces of the containers must have been completely protected from contamination by disposable, un-punctured or undamaged liners, bags or other devices that are removed with the infectious waste. Surfaces of the containers must be free from damage or punctures. Soiled multi-use containers used to contain red bags must be cleaned with detergent followed by disinfection with a dilute bleach solution (1:10 dilution) or other germicidal disinfectant registered with the Environmental Protection Agency (EPA) to kill tuberculin, HIV, and Hepatitis B agents. 4.13 If non-infectious waste is placed in the same container as infectious waste, the waste must be packaged and labeled as infectious waste. 4.14 Storage and containment areas must protect infectious waste from weather elements, must be ventilated to the outdoors, must be only accessible to authorized personnel, and must be labeled with a prominent warning sign on or adjacent to the exterior door gates. Warning signs must be easily read during daylight from a distance of 25 feet and must possess the international biohazard symbol and major message as follows: BIOHAZARD 4.14.1 All containers of infectious waste when deemed full and placed in storage shall be clearly labeled or marked, indicating the name and address of the generator, contents, and date placed in storage. 4.15 Generators of infectious waste must place an absorbent material inside the liner of the rigid container equal to one (1) cup of absorbent material per each six (6) cubic feet of box area if the rigid container is to hold any disposable containers containing free liquids. Rigid containers holding disposable containers containing free liquids shall have enough absorbent material added inside the liner sufficient to absorb 15% of the total volume of free liquids. 4.16 Compactors, grinders, or similar devices shall not be used to reduce the volume of infectious waste before the waste has been rendered non-infectious unless prior approval has been obtained from the New Mexico Environment Department. 5 Anatomical Pathology and Laboratory Waste: 5.1 Labor and Delivery: Placental material must be sealed and labeled with biohazard symbol. Material should be contained and secured to prevent leakage during handling and transport. Bags must be placed inside transport containers located in the Labor and Delivery Department. Environmental Services will then transport containers located in Labor and Delivery to the north storage area located on the second floor where it will be regularly picked up for disposal by the contracted infectious waste disposal company. Page 3 of 8

5.2 Surgery Department: Pathology waste, tissue, and blood products will be taken to pathology for inspection. Items must be contained and secured to prevent leakage during handling and transport. Disposal is coordinated with the contracted infectious waste disposal company. 5.3 Pathology Laboratory: Pathology wastes or tissues must be kept in containers or a refrigerator. Items should be contained and secured to prevent leakage during handling and transport. Disposal of waste is coordinated with the contracted infectious waste disposal company. 5.4 Clinical Laboratory: 5.4.1 Bulk blood and blood products will be identified with a special generator label and manifested separately to ensure proper disposal of all product to meet FDA requirements. Bulk blood and blood products must be disposed of in containers lined with red bags or designated sharps containers. 5.4.2 All microbiological lab wastes defined as cultures of infectious agents, disposable culture dishes, and devices used to transfer, inoculate, and mix cultures must be disposed of in containers lined with red bags or designated sharps containers. 6 Articles contaminated by agents of highly communicable disease: The Environmental Protection Agency (EPA) definition of highly communicable disease refers to a limited class of diseases, such as Lassa Fever, which require special containment facilities. These diseases are extremely rare and have never been present in New Mexico. Note: Red bags shall be used for no other purpose than disposal of infectious waste only. Consult the Hazardous and Pharmaceutical Waste Management Procedure for information on infectious waste that contains a chemically regulated component. 7 Needles and other sharps: Needles and other sharps must be contained for storage, transportation, treatment, and disposal in leak-proof, rigid, puncture resistant containers manufactured for the purpose of sharps containment. Sharps containers must be taped closed or tightly lidded to preclude loss of contents. Containers should be conveniently located in all patient care areas. Sharps containers which are 2/3 full shall be sealed and transported by the individual departments to a secure area where they will be stored until collected for appropriate disposal. Any lab specimen in a disposable glass container and blood sample collection devices (e.g. vacutainer, pipette, etc.) shall be disposed of in a sharps container. 8 Containment bags: All bags used for containment purposes of infectious waste must be red or orange and clearly identified in the following manner. 8.1 They must contain the biological hazard symbol and a major message. 8.2 The major message must indicate the specific hazardous condition or the instruction to be communicated to the employee. 8.3 The biological hazard symbol must be readable at a minimum distance of five (5) feet or such greater distance as warranted by the hazard. 8.4 The biological hazard symbol and major message must be understandable to all employees who may be exposed to the identified hazard. 8.5 All employees must be informed as to the meaning of the biological hazard symbol and major message used throughout the workplace and what special precautions are necessary to ensure safety. Page 4 of 8

8.6 The biological hazard symbol and major message must be affixed as close as safely possible to the hazard by a positive means that prevents their loss or unintentional removal. 8.7 The biological symbol must be as indicated below. The major message must be presented in written text and at a minimum must contain the words: BIOHAZARDOUS or INFECTIOUS WASTE or BIOMEDICAL WASTE 9 Transport Carts: Impermeable, non-leaking, covered carts dedicated solely for infectious waste are recommended for in-house transport of red-bag material. Transport carts are to be identified by warning labels bearing the international biohazard symbol with the words infectious waste. Carts utilized to transport red-bag materials should not be overfilled and are to remain covered except when loading or unloading waste materials. 10 Treatment & Disposal: Infectious waste must be disposed of only at waste facilities authorized and permitted by the New Mexico Environment Department, Solid Waste Bureau for disposal of infectious waste. If infectious waste is to be incinerated, it must only be incinerated through an infectious waste incinerator authorized under applicable Air Quality and Solid Waste Regulations and permitted under these regulations. 10.1 The treatment and disposal of infectious waste must be accomplished by one of the following methods only: 10.1.1 Discharge to sewage treatment systems that provide secondary treatment of waste if (and only if) the infectious waste is liquid or semi-solid, provided it is not hazardous chemical waste, radioactive waste, or otherwise regulated waste. The sewage treatment systems for the cities of Albuquerque, Gallup, and Los Alamos meet these criteria. Discharge to a sewage treatment system is via the sanitary sewer system. 10.1.2 Containers of blood, urine, stool, sputum, wound drainage, etc. should be emptied into a toilet or other appropriate device which is piped to the sanitary sewer system. Gloves must be worn. Other barrier precautions such as gowns, masks, and eye shields should be used if splashing is anticipated. Fluid-filled containers (e.g. some suction containers, hemovacs) which cannot be opened should be placed in a red biohazard bag and tied securely. A second bag should be used for added strength if indicated. Biohazard bags will be transported to a secure area for proper storage and disposal. 10.2 Removal from site must be performed by the UNM Hospitals infectious waste management contractor. It is highly encouraged that all infectious waste within a single building be brought to a controlled, central storage area within the building for pickup. 10.3 Human Remains: Human fetal remains must be disposed of by incineration or interment. Human fetal remains are defined as such when measured to be 500 grams or greater as defined by the Office of Medical Investigation. Recognizable human anatomical remains must be disposed of by incineration or interment unless such remains have been contaminated with a regulated hazardous chemical or radioactive Page 5 of 8

substance. Such contaminated remains must be disposed of at a permitted hazardous or radioactive waste facility. 11 Spills: All personnel performing cleanup of infectious waste spills must have received bloodborne pathogens training within the last year and must wear appropriate Personal Protective Equipment. Spillage of potentially infectious materials must be cleaned with detergent followed by disinfection with a dilute bleach solution (1:10 dilution) or other germicidal disinfection registered with the Environmental Protection Agency (EPA) to kill tuberculin, HIV, and Hepatitis B agents. Consult the Bloodborne Pathogen Exposure Control Plan and Spills, Clean ups & Disposal Procedures for Blood and Body Fluids Procedure for additional information regarding spill cleanup. 12 General Hospital Waste: 12.1 Trash generated from patient care areas and the laboratory, not defined as infectious waste, can be disposed of in clear plastic trash bags. When bags are 2/3 full they are tied and transported to a designated area for final transportation to a sanitary landfill. 12.2 Mental Health Center: Environmental Services and the Mental Health Technicians (MHT) share this responsibility at the Mental Health Center. 12.2.1 Procedure: 12.2.1.1 Plastic bag liners are not allowed to be used in patient sleep rooms. 12.2.1.2 Individual trash cans in patients rooms are to be emptied in housekeeper s cart when 2/3 full. 12.2.1.3 Trash cans are to be wiped inside and outside with a hospital approved disinfectant after each emptying. 12.2.1.4 When there is no scheduled EVS staffing, the Behavioral Health staff are responsible for the above. 12.3 All soiled linen is stored in laundry bags. When the bags are 2/3 full they will be tied and transported to the dirty utility area. No special precautions beyond Standard Precautions Policy are necessary. 13 UNMH Environmental Services responsibilities: 13.1 Maintain records/manifests that document interaction with contracting agencies for the removal and processing of infectious waste generated at the facility. 13.2 Minimize infectious hazards potentially associated with the collection, transportation, and disposal of hospital wastes. 13.3 Ensure compliance with all federal, state, and local regulations in collecting and disposing of infectious waste. DEFINITIONS To Define Infectious Waste: The definition of infectious waste conforms to the current Centers for Disease Control (CDC) definition as well as state regulations: 1. Infectious Waste includes, but is not limited to, the following types of wastes when they pose a probable risk of transmitting disease to humans due to their inherent nature or due to the presence of infectious contamination: a. Contaminated Sharps; used sharp objects, including needles, syringes, scalpel blades, Pasteur pipettes, and broken glass. Page 6 of 8

b. Contaminated Animal Material; carcasses, body parts, bedding, and other contaminated material from animals that were exposed to pathogens in research, in the production of biologicals, or in the testing of pharmaceuticals. Blood, organs, or other tissue from experimental animals infected with Human Immunodeficiency Virus (HIV) / Hepatitis B Virus (HBV). c. Human Blood and Blood Product; Liquid, semi-solid, and solid human blood and body products, including whole blood, serum, plasma, platelets, and serosanguinous fluids. Also, those body fluids which have the potential to harbor pathogens such as the HIV and HBV and which include blood, semen, vaginal secretions, lymph fluids, cerebrospinal fluids, synovial fluids, pleural fluids, peritoneal fluids, pericardial fluids and amniotic fluids. All body fluids in situations where it is difficult or impossible to differentiate between body fluids. d. Microbiologic Laboratory Waste; cultures and stocks of infectious agents and associated biologicals from clinical research laboratories, discarded live and attenuated vaccines, and disposable culture dishes and devices used to transfer, inoculate, and mix cultures from any clinical research, medical diagnostic and teaching laboratory, or industrial laboratory. e. Other Potentially Infectious Materials; saliva from dental procedures, human dialysis waste materials. f. Pathological Waste; Human or animal tissues, organs, and body parts, removed during surgery, autopsy or biopsy. Any unfixed tissue or organ other than intact human skin. Recognizable anatomical remains including human remains measured to be 500 grams or greater, must be disposed of by incineration or interment unless such remains have been contaminated with a regulated hazardous chemical or radioactive substance. g. Special Pathogens; disposable equipment, instruments, utensils, and other materials or items which require special precautions because of contamination with infectious pathogens capable of causing illness through casual exposure (e.g. non- percutaneous exposures such as inhalation of aerosolized particles or droplets or contact with mucous membranes). This applies primarily to laboratory generated waste contaminated with agents classified as requiring special handling under Biosafety Levels 3 & 4 by the Biosafety in Microbiological & Biomedical Laboratories publication, HHS #938395 (CDC). However, for rare specific pathogens (e.g. Lassa Fever, Ebola, and Creutzfeldt Jakob) special handling may be indicated for clinical items, which could contain infectious materials. The New Mexico Department of Health should be consulted for advice in these rare situations. 2. Infectious waste is not: a. A bandage with only a spot of blood on it, with no soak through. b. An animal carcass including a mouse, unless it is reasonably certain that the animal was diseased or contaminated with an infectious agent. c. Body excretions such as feces, nasal discharges, saliva, sputum, sweat, tears, urine, and vomitus unless visibly contaminated with blood. d. Sharps Material that is very sharp in nature or can become very sharp when broken or bent, and that can easily puncture the skin unless visibly contaminated with blood. This includes needles, syringes, intravenous (IV) tubing with attached needles, scalpel blades, razor blades, laboratory slides, or hard plastic capable of breaking or shattering. This includes Pasteur pipettes, broken glass, and all other devices with Page 7 of 8

physical characteristics capable of puncturing, lacerating, or otherwise penetrating the skin. SUMMARY OF CHANGES 11/2014: Formatting changed 07/2016: Changed from a Guideline to a Procedure, Removal of outdated information and (3.4) addition of NMED requirements 2/20/17: Added 4.14.1 per NMED recommendation RESOURCES/TRAINING Resource/Dept Infection Prevention & Control 272-9722 Facilities Safety 220-5221 or 220-2288 Environmental Services 272-2102 Contact Information DOCUMENT APPROVAL & TRACKING Item Contact Date Approval Owner Manager, Infection Prevention and Control Department Committee(s) Clinical Operations PP&G Committee, Nursing PP&G Subcommittee Y Nursing Officer Sheena Ferguson, Chief Nursing Officer Y Medical Director Meghan Brett, MD, Hospital Epidemiologist Y Official Approver Michael Chicarelli, Administrator, Professional & Support Services Y Official Signature Date: 1/18/2017 Effective Date 1/18/2017 Origination Date 10/1997 Issue Date Clinical Operations Policy Coordinator 1/2017 ATTACHMENTS None Page 8 of 8