Document number: HSWM-0003 Standard Operating Procedure Title: Segregation & Disposal of from Theatres Written by: Martin Long Change Control Version: Date Author(s): Summary of Changes: 0.1 26.11.10 Martin Long 1 st Draft 0.2 2 nd Draft 0.3 0.4 Contents Page: Contents: 2 Introduction 2 Purpose of guidance 2 Principles 3 Assumptions 3 Scope 4 Procedures for the Segregation & Disposal of Theatre Review Date and Person/Group to Review 01.04.2012 Trust Manager
Standard Operating Procedure Title: Procedures for the Segregation & Disposal of from Theatres Introduction The Heart of England Foundation Trust has a range of Theatres and Day Surgery Units on each of its main hospital sites. The Theatres and Day Surgery Units aim to ensure that the Trust complies with legislation concerned with all guide lines laid down by the Department of Health and other healthcare bodies in relation to all waste generated by the Department. In order to meet this commitment in relation to waste management, all Theatres and Day Surgery Units must maintain and segregate waste into eight waste streams; 1. Healthcare 2. Anatomical 3. Placenta 4. Sharps 5. Cytotoxic and Cytostatic 6. Chemical 7. Municipal 8. Medicinal 9. Tiger Gypsum The Theatres and Day Surgery Units must also follow the Trusts waste management systems in relation to all other waste streams, including but not only; 1. Batteries 2. Confidential 3. Paper and Cardboard 1. Purpose of guidance 1.1 Consistency of procedures across all of the Trust Theatre activities. 1.2 To ensure that the Trust maintains its waste segregation and consignment responsibilities. 1.3 To provide core information for staff training on waste management. 1.4 To ensure legislative compliance. 2. Target Group 2.1 All theatre staff 2.2 Portering staff 2.3 Site Operational Leads
3. Principles 3.1 The design of all new, and the reviewing of existing controls of each waste stream, is the responsibility of the Trusts manager. 3.2 Individual responsibility and accountability cannot be devolved to the centre and remains with everyone involved with waste generation, identification, security, segregation, movement, collection and ultimately disposal. 3.3 management systems must reflect the individual needs of each site, with the centrally maintained controls reflecting these needs. 3.4 The process and outcome will meet the needs of all relevant legislation and publish Environmental Agency guidelines. 4. Assumptions 4.1 All Hotel Services managers, designated waste leads and theatre staff involved in waste handling are fully trained and familiar with the Trust waste handling processes. 4.2 That all staff involved in the generation, temporary storage and handling of waste are fully aware of the Trusts requirements in relation to the correct identification, segregation and security of each waste stream. 5. Scope 5.1 The principles included in this Standard Operating Procedure will be applied fully and consistently on all of the Trusts Theatre and Day Surgery Units within each of the Trusts sites. 5.2 The duty for the Trust (regarding healthcare waste), is to: o Ensure management procedures are in place to facilitate compliance o Ensure equipment, facilities and systems are in place for staff to use, and o Ensure staff are adequately trained to deal appropriately with the waste types they encounter at work
Procedures for: The Segregation & Disposal of from Theatres Main Theatre Areas (Some or all of the following waste streams may be present in theatres) Healthcare Anatomical that is infectious and hazardous, but not contaminated with medicines or chemicals and does not contain recognisable anitomical waste. Examples include swabs, dressings and gloves. Recognisable anatomical waste; Limb Bins used for large sections of anatomical waste or whole/part limbs. Placenta Sharps To be used for the disposal of placenta waste from maternity units and may be used for the disposal of small items/amounts of anatomical waste. Sharps contaminated with medicines, but not cytotoxic/cytostatic. Examples include injection equipment and Giving Sets. Cytotoxic and Cytostatic Check the name of the product against the cytostatic and cytotoxic list and the patient details label if it does appear this must be disposed of in a purple lidded sharps container. Chemical WIVA bins are provided for the safe disposal of chemicals. Chemicals should be disposed of in the container (bottle, bag etc.) with the top secured and then placed into the designated WIVA bin.
Prep/Scrub Room Healthcare Municipal that is infectious and hazardous, but not contaminated with medicines or chemicals and does not contain recognisable anatomical waste. Examples include swabs, dressings and gloves. with no infectious or hazardous properties including packaging and hand towels. Sharpes Sharps contaminated with medicines, but not cytotoxic/cytostatic. Examples include injection equipment and Giving Sets. Recovery Rooms Healthcare Municipal that is infectious and hazardous, but not contaminated with medicines or chemicals and does not contain recognisable anitomical waste. Examples include swabs, dressings and gloves. with no infectious or hazardous properties including packaging and hand towels. Sharpes Sharps contaminated with medicines, but not cytotoxic/cytostatic. Examples include injection equipment and Giving Sets.
Specialist Streams Healthcare CELL SALVAGE COLLECTION (Incineration) AND PROCESS UNIT Catogorised as being infectious, hazardous and contaminated chemically and/or medicinally, cell salvage collection and process units must be disposed of in the dedicated yellow bag, specifically Healthcare (Incineration or authorised alternative treatment) identified for this purpose. CRD AND GUARDIAN SYSTEMS Catogorised as being infectious, hazardous and contaminated chemically and/or medicinally, CRD and Guardian Systems canisters must be disposed of in the dedicated boxes, specifically identified for this purpose. Healthcare (Incineration) 35 Litre yellow lidded theatre containers are provided specifically for the safe disposal of items that are infectious, hazardous and contaminated chemically and/or medicinally that are to large for disposal of in traditional sharps containers. segregation, storage and transportation Orange Bag Anitomical Placenta Orange Lid Red Lid Red Lid Having correctly identified, contained and secured all waste streams, it is imperative that segregation and security is maintained in storage and transit. The portering team will following the normal waste handling and segregation procedures including; Do not mix sharps waste with bagged waste. Maintain the security of all waste during transit (keep Sulo bins locked). Ensure correct consignment of all waste streams. Sharpes Cytotoxic and Cytostatic Chemical Contaminated Blue Lid Yellow body Purple Lid White Lid
Collection of Full Sulo Bins Sulo bins are collected by the waste disposal companies contracted to the Trust. Each collection must be accompanied with a Consignment Note for the Carriage and Disposal of Hazardous (one for each type of waste) and a Transfer Note for all Non Hazardous waste. Copies of all notes must be retained for a legally required period (three years). The note will indicate the type of waste being collected and the number of Sulo bins will be documented against the EWC code The consignment note requires that number and type of Sulo bins collected is documented accurately on the note, along with a description of each waste type and a signature is required by a member of the portering department that the details are correct. The Consignment note on each site must be completed by nominated individuals (where appropriate this should be a supervisor from the portering service) All consignment notes must be filed at each sites agreed location and be available for inspection at all times. For each collection there will also be a bin tracking sheet this records the individual numbers on the Sulo bins, it must be checked it is correct and the form signed as the customer.