BEST PRACTICES FOR DISINFECTION OF NON- CRITICAL SURFACES AND EQUIPMENT AND MEDICAL WASTE MANAGEMENT

BEST PRACTICES FOR DISINFECTION OF NON- CRITICAL SURFACES AND EQUIPMENT AND MEDICAL WASTE MANAGEMENT Wiiam A. Rutaa, Ph.D., M.P.H. Director, Statewide Program for Infection Contro and Epidemioogy and Research Professor of Medicine, University of North Caroina at Chape Hi, NC, USA Former Director, Hospita Epidemioogy, Occupationa Heath and Safety, UNC Heath Care, Chape Hi, NC

LECTURE OBJECTIVES Review the CDC Guideine for Disinfection and Steriization: Focus on roe of environmenta surfaces Review best practices for environmenta ceaning and disinfection Review the use of ow-eve disinfectants and the activity of disinfectants on key hospita pathogens Review medica waste management

BEST PRACTICES There is imited scientific evidence to inform us on ceaning/disinfecting practices and frequency There is itte scientific evidence that disinfecting schedues shoud emphasize certain high-risk or high-touch sites

ENVIRONMENTAL CONTAMINATION LEADS TO HAIs There is increasing evidence to support the contribution of the environment to disease transmission This supports comprehensive disinfecting regimens (goa is not steriization) to reduce the risk of acquiring a pathogen from the heathcare environment/equipment

DISINFECTION AND STERLIZATION EH Spauding beieved that how an object wi be disinfected depended on the object s intended use CRITICAL - objects which enter normay sterie tissue or the vascuar system or through which bood fows shoud be sterie SEMICRITICAL - objects that touch mucous membranes or skin that is not intact require a disinfection process (high-eve disinfection[hld]) that kis a microorganisms; however, sma numbers of bacteria spores are permissibe. NONCRITICAL -objects that touch ony intact skin require ow-eve disinfection

GUIDELINE FOR DISINFECTION AND STERILIZATION IN HEALTHCARE FACILITIES, 2008 Rutaa WA, Weber DJ., HICPAC Avaiabe on CDC web page-www.cdc.gov

CDC Guideine for Disinfection and Steriization Rutaa, Weber, HICPAC. November 2008. www.cdc.gov

Bood Pressure Cuff Non-Critica Patient Care Item

DISINFECTION OF NONCRITICAL PATIENT-CARE DEVICES Process noncritica patient-care devices using a disinfectant and concentration of germicide as recommended in the Guideine (IB) Disinfect noncritica medica devices (e.g., bood pressure cuff) with an EPA-registered hospita disinfectant using the abe s safety precautions and use directions. Most EPA-registered hospita disinfectants have a abe contact time of 10 minutes but mutipe scientific studies have demonstrated the efficacy of hospita disinfectants against pathogens with a contact time of at east 1 minute (IB) Ensure that, at a minimum noncritica patient-care devices are disinfected when visiby soied and on a reguar basis (e.g., once daiy or weeky) (II) If dedicated, disposabe devices are not avaiabe, disinfect noncritica patient-care equipment after using on a patient, who is on contact precautions before using this equipment on another patient (IB)

CLEANING AND DISINFECTION OF ENVIRONMENTAL SURFACES IN HEALTHCARE FACILITIES Cean housekeeping surfaces (e.g., foors, tabetops) on a reguar basis, when spis occur, and when these surfaces are visiby soied (II) Disinfect (or cean) environmenta surfaces on a reguar basis (e.g., daiy, 3x per week) and when surfaces are visiby soied (II) Foow manufacturers instructions for proper use of disinfecting (or detergent) products such as recommended use-diution, materia compatibiity, storage, shef-ife, and safe use and disposa (II) Cean was, binds, and window curtains in patient-care areas when these surfaces are visiby contaminated or soied (II) Prepare disinfecting (or detergent) soutions as needed and repace with fresh soution frequenty (e.g., repace foor mopping soution every 3 patient rooms, change no ess often than at 60-minute intervas) (IB)

REVIEW THE BEST PRACTICES FOR CLEANING AND DISINFECTING Ceaning and disinfecting is one-step with disinfectant-detergent. No pre-ceaning necessary uness spi or gross contamination. In many cases best practices not scientificay determined.

ALL TOUCHABLE (HAND CONTACT) SURFACES SHOULD BE WIPED WITH DISINFECTANT High touch objects ony recenty defined (no significant differences in microbia contamination of different surfaces) and high risk objects not epidemioogicay defined.

DAILY CLEANING/DISINFECTING PRACTICES Hota et a. J Hosp Infect 2009;71:123 Wash hands thoroughy and put on goves Pace wet foor sign at door Discard disposabe items and remove waste and soied inen Disinfect (damp wipe) a horizonta, vertica and contact surfaces with a cotton coth saturated (or microfiber) with a disinfectant-detergent soution.

DAILY CLEANING/DISINFECTING PRACTICES Hota et a. J Hosp Infect 2009;71:123 These surfaces (wipe a surfaces) incude, but are not imited to: Bed rais Overbed tabe Infusion pumps IV poes/hanging IV poes Nurse ca box Monitor cabes Teephone Countertops

DAILY CLEANING/DISINFECTING PRACTICES Hota et a. J Hosp Infect 2009;71:123 These surfaces incude, but not imited to: Soap dispenser Paper towe dispenser Cabinet fronts incuding handes Visitor chair Door handes inside and outside Sharps container TV remote, bed ca remote Bathroom-toiet seat, shower fixtures, fush hande

DAILY CLEANING/DISINFECTING PRACTICES Hota et a. J Hosp Infect 2009;71:123 Spot cean was (when visuay soied) with disinfectant-detergent and windows with gass ceaner Cean and disinfect sink and toiet Stock soap and paper towe dispensers Damp mop foor with disinfectant-detergent Inspect work Remove goves and wash hands

DAILY CLEANING/DISINFECTING PRACTICES Hota et a. J Hosp Infect 2009;71:123 Use EPA-registered disinfectant-detergent (if prepared on-site, document correct concentration) Ceaned surface shoud appear visiby wet and shoud be aowed to air dry at east one minute Change cotton mop water containing disinfectant every 3 rooms and after every isoation room Change cotton mop head after isoation room and after BBP spis (change microfiber after each room)

DAILY CLEANING/DISINFECTING PRACTICES Hota et a. J Hosp Infect 2009;71:123 Ceaning shoud be from the ceanest to dirtiest areas (the bathroom wi be ceaned ast foowed by the foor) Change ceaning coths after every room and use at east 3 coths per room; typicay 5-7 coths Do not pace ceaning coth back into the disinfectant soution after using it to wipe a surface Daiy ceaning of certain patient equipment is the responsibiity of other HCP (RC, nursing). Surfaces shoud be wiped with a cean coth soaked in disinfectant

TERMINAL CLEANING/DISINFECTING PRACTICES Hota et a. J Hosp Infect 2009;71:123 Termina or discharge ceaning of non-isoation rooms consists of the same procedure above pus disinfection of bed mattresses and inaccessibe items Trash can ceaned weeky and when visibe soied Do not wash was, strip and wax foors, or discard wrapped disposabe suppies eft in drawers

ISOLATION ROOM CLEANING ES staff use PPE required by the isoation card Same ceaning procedures as for non-isoation rooms (except C. difficie, norovirus) Do not use a dust mop or counter brush Leave the room ony when competed (uness requested to eave by nurse or doctor)

Perioperative Practice: Environmenta Ceaning AORN: 2014 Edition (p255-276) A mutidiscipinary team shoud deveop C/D procedures for managing contamination A cean environment shoud be reestabished after the patient Items used during surgica procedure shoud be C/D (OR beds, anesthesia carts/machines, positioning devices, Mayo stands) Foors/was C/D after each surgica procedure if contaminated Termina ceaning performed daiy when used C/D a exposed surfaces (anesthesia machine, OR beds, overhead ights, stoos, positioning devices, etc)

SHOULD WE CONCENTRATE ON HIGH TOUCH OR HIGH RISK OBJECTS No, not ony high risk (a surfaces). High touch objects ony recenty defined and high risk objects not scientificay defined.

Define the infection risks associated with medica waste Define medica waste terms, pubic heath impications Identify reguated medica wastes and treatment methods Review current management practices Identify treatment options Specify recycabe materia used in heathcare Discuss reguatory issues and hot topics

Hospita Privacy Curtains (sprayed grab area 3x from 6-8 with 1.4% IHP and aowed 2 minute contact; samped)

Decontamination of Curtains with Activated HP (1.4%) Rutaa, Gergen, Weber. Am J Infect Contro. 2014;42:426-428 CP for: Before Disinfection CFU/5 Rodacs (#Path) After Disinfection CFU/5 Rodacs (#Path) MRSA 330 (10 MRSA) 21*(0 MRSA) 93.6% MRSA 186 (24 VRE) 4* (0 VRE) 97.9% MRSA 108 (10 VRE) 2* (0 VRE) 98.2% VRE 75 (4 VRE) 0 (0 VRE) 100% VRE 68 (2 MRSA) 2* (0 MRSA) 97.1% VRE 98 (40 VRE) 1* (0 VRE) 99.0% MRSA 618 (341 MRSA) 1* (0 MRSA) 99.8% MRSA 55 (1 VRE) 0 (0 MRSA) 100% MRSA, VRE 320 (0 MRSA, 0 VRE) 1* (0 MRSA, 0 VRE) 99.7% MRSA 288 (0 MRSA) 1* (0 MRSA) 99.7% % Reduction Mean 2146/10=215 (432/10=44) 33*/10=3 (0) 98.5% * A isoates after disinfection were Bacius sp; now treat CP patient curtains at discharge

TERMINAL CLEANING PRACTICE Some hospitas change curtains after Contact Precaution patients At UNC Heath Care, privacy curtains are changed routiney every 3 months or when visibe soied In Contact Precaution rooms, frequenty touched surfaces of the curtains shoud be sprayed with approved disinfectant (e.g., improved HP) Viny shower curtains are ceaned when visiby soied or repaced as needed

Ceaning/Disinfection ES and nursing need to agree on who is responsibe for ceaning what (especiay equipment) ES needs to know Which disinfectant/detergent to use What concentration woud be used (and verified) What contact times are recommended (bactericida) How often to change ceaning coths/mop heads How important their job is to infection prevention

DISINFECTING NONCRITICAL PATIENT EQUIPMENT AND ENVIRONMENTAL SURFACES Cassification: Object: Leve germicida action: Exampes: Method: Noncritica objects wi not come in contact with mucous membranes or skin that is not intact. Can be expected to be contaminated with some microorganisms. Ki vegetative bacteria, fungi and ipid viruses. Bedpans; crutches; bed rais; EKG eads; bedside tabes; was, foors and furniture. Low-eve disinfection

LOW-LEVEL DISINFECTION FOR NONCRITICAL EQUIPMENT AND SURFACES Exposure time > 1 min Germicide Use Concentration Ethy or isopropy acoho 70-90% Chorine 100ppm (1:500 diution) Phenoic UD Iodophor UD Quaternary ammonium (QUAT) UD QUAT with acoho RTU Improved hydrogen peroxide (HP) 0.5%, 1.4% Peracetic acid with HP (C. difficie) UD UD=Manufacturer s recommended use diution; others in deveopment/testing-eectroyzed water; poymeric guanidine; cod-air atmospheric pressure pasma (Boyce Antimicrob Res IC 2016. 5:10)

Decreasing Order of Resistance of Microorganisms to Disinfectants/Steriants Most Resistant Prions Spores (C. difficie) Mycobacteria Non-Enveoped Viruses (norovirus) Fungi Bacteria (MRSA, VRE, Acinetobacter) Enveoped Viruses Most Susceptibe

MOST PREVALENT PATHOGENS CAUSING HAI Rutaa, Weber. Infect Contro Hosp Epidemio. 2014;35:855-865 Most prevent pathogens causing HAI (~75% easy to ki) S. aureus (15.6%) E. coi (11.5%) Coag neg Staph (11.4%) Kebsiea (8.0%) P. aeruginosa (8.0%) E. faecais (6.8%) C. abicans (5.3%) Enterobacter sp. (4.7%) Other Candida sp (4.2%) C. difficie in top 2-3 past 5 years Common causes of outbreaks and ward cosures (reativey hard to ki) C. difficie spores Norovirus Rotavirus Adenovirus

MOST PREVALENT PATHOGENS CAUSING HAI Most prevent pathogens causing HAI (easy to ki) S. aureus (15.6%) E. coi (11.5%) Coag neg Staph (11.4%) Kebsiea (8.0%) P. aeruginosa (8.0%) E. faecais (6.8%) C. abicans (5.3%) Enterobacter sp. (4.7%) Other Candida sp (4.2%) Common causes of outbreaks and ward cosures (reativey hard to ki) C. difficie spores Norovirus Rotavirus Adenovirus

PROPERTIES OF AN IDEAL DISINFECTANT Rutaa, Weber. Infect Contro Hosp Epidemio. 2014;35:855-865 Broad spectrum-wide antimicrobia spectrum Fast acting-shoud produce a rapid ki Remains Wet-meet isted ki/contact times with a singe appication Not affected by environmenta factors-active in the presence of organic matter Nontoxic-not irritating to user Surface compatibiity-shoud not corrode instruments and metaic surfaces Persistence-shoud have sustained antimicrobia activity Easy to use Acceptabe odor Economica-cost shoud not be prohibitivey high Soube (in water) and stabe (in concentrate and use diution) Ceaner (good ceaning properties) and nonfammabe

Key Considerations for Seecting the Idea Disinfectant for Your Faciity Rutaa, Weber. Infect Contro Hosp Epidemio. 2014;35:855-865 Consideration Question to Ask Score (1-10) Ki Caims Does the product ki the most prevaent heathcare pathogens Ki Times and Wet- Contact Times Safety Ease-of-Use Other factors How quicky does the product ki the prevaent heathcare pathogens. Ideay, contact time greater than or equa to the ki caim. Does the product have an acceptabe toxicity rating, fammabiity rating Odor acceptabe, shef-ife, in convenient forms (wipes, spray), water soube, works in organic matter, one-step (ceans/disinfects) Suppier offer comprehensive training/education, 24-7 customer support, overa cost acceptabe (product capabiities, cost per compiant use, hep standardize disinfectants in faciity) Note: Consider the 5 components shown, give each product a score (1 is worst and 10 is best) in each of the 5 categories, and seect the product with the highest score as the optima choice (maximum score is 50).

Quaternary ammonium compounds (e.g., didecy dimethy ammonium bromide, diocty dimethy ammonium bromide) Rutaa, Weber. Am J Infect Contro 2013;41:S36-S41 Advantages Disadvantages Bactericida, fungicida, virucida against enveoped viruses (e.g., HIV) Good ceaning agents Not sporicida In genera, not tubercuocida and virucida against non-enveoped viruses EPA registered Surface compatibe Persistent antimicrobia activity when undisturbed Inexpensive (in diutabe form) Not fammabe High water hardness and cotton/gauze can make ess microbicida A few reports documented asthma as resut of exposure to benzakonium choride Affected by organic matter Mutipe outbreaks ascribed to contaminated benzakonium choride

Acoho Rutaa, Weber. Am J Infect Contro 2013;41:S36-S41 Advantages Disadvantages Bactericida, tubercuocida, fungicida, virucida Not sporicida Affected by organic matter Fast acting Non-corrosive Non-staining Used to disinfect sma surfaces such as rubber stoppers on medication vias No toxic residue Sow acting against non-enveoped viruses (e.g., norovirus) No detergent or ceaning properties Not EPA registered Damage some instruments (e.g., harden rubber, deteriorate gue) Fammabe (arge amounts require specia storage) Evaporates rapidy making contact time compiance difficut Not recommended for use on arge surfaces Outbreaks ascribed to contaminated acoho

Quat/Acoho vs Quat Rutaa et a. Antimicrob Agents Chemother 2006. 50:1419-1424 Adenovirus is a hardy virus that is reativey resistant to disinfectants Quat about <0.5 og 10 reduction against adenovirus with 1m exposure time Acceerated hydrogen peroxide (0.5%) demonstrates ~0.7 og 10 reduction against adenovirus with 1m exposure time Quat/Acoho demonstrates a ~4 og 10 reduction against adenovirus with 1m exposure time Chorine (~5000ppm) demonstrates a ~5 og 10 reduction against adenovirus with 1m exposure time Quat/Acoho has improved virucida activity compared to Quat and acceerated hydrogen peroxide

Improved Hydrogen Peroxide Rutaa, Weber. Am J Infect Contro 2013;41:S36-S41 Advantages Bactericida, tubercuocida, fungicida, virucida Fast efficacy Easy compiance with wet-contact times Safe for workers (owest EPA toxicity category, IV) Benign for the environment Surface compatibe Non-staining EPA registered Not fammabe Disadvantages More expensive than most other disinfecting actives Not sporicida at ow concentrations

Sodium Hypochorite Rutaa, Weber. Am J Infect Contro 2013;41:S36-S41 Advantages Disadvantages Bactericida, tubercuocida, fungicida, virucida Reaction hazard with acids and ammonias Leaves sat residue Sporicida Fast acting Inexpensive (in diutabe form) Not fammabe Unaffected by water hardness Reduces biofims on surfaces Reativey stabe (e.g., 50% reduction in chorine concentration in 30 days) Used as the disinfectant in water treatment EPA registered Corrosive to metas (some ready-to-use products may be formuated with corrosion inhibitors) Unstabe active (some ready-to-use products may be formuated with stabiizers to achieve onger shef ife) Affected by organic matter Discoors/stains fabrics Potentia hazard is production of trihaomethane Odor (some ready-to-use products may be formuated with odor inhibitors). Irritating at high concentrations.

Phenoics Rutaa, Weber. Am J Infect Contro 2013;41:S36-S41 Advantages Bactericida, tubercuocida, fungicida, virucida Inexpensive (in diutabe form) Non-staining Not fammabe EPA registered Disadvantages Not sporicida Absorbed by porous materias and irritate tissue Depigmentation of skin caused by certain phenoics Hyperbiirubinemia in infants when phenoic not prepared as recommended

Effective Surface Decontamination Product and Practice = Perfection

MICROBIAL BURDEN ON ROOM SURFACES AS A FUNCTION OF FREQUENCY OF TOUCHING Husage K, Rutaa WA, Weber DJ. ICHE. 2013;34:211-212 Surface Prior to Ceaning Mean CFU/RODAC (95% CI) Post Ceaning (mean) Mean CFU/RODAC (95% CI) High 71.9 (46.5-97.3) 9.6 Medium 44.2 (28.1-60.2) 9.3 Low 56.7 (34.2-79.2) 5.7 The eve of microbia contamination of room surfaces is simiar regardess of how often they are touched both before and after ceaning Therefore, a surfaces that are touched must be ceaned and disinfected

Thoroughness of Environmenta Ceaning Caring P. AJIC 2013;41:S20-S25 >110,000 Objects Mean = 32%

Wipes Cotton, Disposabe, Microfiber, Ceuose-Based, Nonwoven Spunace

WIPES Rutaa, Weber. Infect Contro Hosp Epidemio. 2014;35:855-865 Wipes-cotton, disposabe, microfiber, nonwoven spunace Wipe shoud have sufficient wetness to achieve the disinfectant contact time. Discontinue use of the wipe if no onger eaves the surface visibe wet for > 1 minute. When the wipe is visiby soied, fip to a cean/unused side and continue unti a sides of the wipe have been used (or get another wipe) Dispose of the wipe/coth wipe appropriatey Do not re-dip a wipe into the cean container of pre-saturated wipes

DISPOSABLE WIPES Rutaa, Weber. Infect Contro Hosp Epidemio. 2014;35:855-865 Wetness-ideay, stays wet ong enough to meet EPAregistered contact times (e.g., bacteria-1 minute). Surface Coverage-premoistened wipe keeps surface area wet for 1-2 minutes (e.g., 12 x12 wipes keep 55.5 sq ft wet for 2m; 6 x5 equipment wipe keeps 6.7 sq ft wet for 2m). Wipe size based on use from sma surfaces to arge surfaces ike mattress covers Durabe substrate-wi not easiy tear or fa apart Top-keep cosed or wipes dry out

Surface Disinfection: Treatment Time (Wipes/Sprays) versus Contact Time (Liquids) Diutabe iquid disinfectant-contact time is wet time Wipes/Sprays-treatment time is undisturbed time ( wet time is not reevant)

Surface Disinfection: Treatment Time (Wipes/Sprays) versus Contact Time (Liquids) Rutaa, Weber. Submitted for pubication Registration test for iquid disinfectants is the AOAC Use-Diution Method (UDM). SS cyinders are inocuated with the test organism (S. aureus, S. choeraesuis, P. aeruginosa) and then dried. After drying, the cyinder is transferred to a disinfectant tube and immersed in the disinfectant for the contact time (e.g., 5 minutes). Thus, for iquid disinfectants tested by the UDM, the contact time shoud be the wet time (not undisturbed time).

Surface Disinfection: Treatment Time (Wipes/Sprays) versus Contact Time (Liquids) Rutaa, Weber. Submitted for pubication. Photos James Cayton. Registration test for wipe is EPA Disinfectant Toweette Test Treatment time is equa to combination of physica remova and inactivation caused by the disinfectant regardess of the surface appearance (i.e. wet or dry) Thus, if disinfectant wipe has a registration time of 1 minute, then the surface shoud be aowed to remain undisturbed for the registration time of 1 minute (i.e. wet time is not reevant)

Medica Waste Probem Perceived threat of AIDS via medica waste Beach wash-ups of medica waste Overy restrictive medica waste rues and increase in voume of reguated medica waste Options for medica waste treatment and disposa diminishing

Definitions Hospita waste (soid waste) refers to a waste (bioogica or nonbioogica) which are discarded and not intended for further use (e.g., administrative waste, dietary waste) Medica waste refers to materias generated as a resut of patient diagnosis, treatment, or immunization (e.g., soied dressing, intravenous tubing) Reguated medica waste ( infectious waste) refers to that portion of medica waste which coud transmit an infectious disease (e.g., microbioogica waste, sharps)

Tota Hospita Waste Generated per Patient by Bed Size Rutaa, Odette, Samsa. JAMA;262:1635-1640 Median Median Hospita Beds b/bed/day b/patient/day N Tota N Tota <100 90 5.72 69 11.30 100-299 108 10.36 84 15.79 300-499 40 12.51 32 18.47 >500 27 12.86 23 16.95 Combined 265 9.21 208 15.28

Reguated Medica Waste The CDC, EPA, and states define medica waste as reguated ( infectious ) When it is suspected to contain potentiay hazardous eves of microorganisms

Factors Necessary for Induction of Disease Dose Resistance of host Porta of entry Presence of a pathogen Viruence

Medica Waste Pausibe Transmission Routes Rutaa, Mayha. Infect Contro Hosp Epidemio 1992;13:38-48 Virtuay nonexistent - respiratory, urinary or gastrointestina tract or mucous membrane of the mouth, eyes, nose. Why? Waste must contain pathogens -> person must come in direct contact -> inject, ingest, or injury must foow the contact thereby creating porta of entry -> an infectious dose must enter susceptibe host via porta of entry -> agent causes infection. Rare - "Sharps" have an intrinsic capabiity to disrupt the skin's integrity and introduce infectious agents.

Pubic Heath Impications of Medica Waste Rutaa, Mayha. Infect Contro Hosp Epidemio 1992;13:38-48 Epidemioogic Evidence Ony medica waste associated with infectious disease transmission is contaminated sharps. A reports of transmission of infectious agents by sharps occurred in heath care setting. No evidence that a member of the pubic or a waste industry worker has ever acquired infection from medica waste (one exception). No infectious risks associated with any type of medica waste treatment method to incude sanitary andfi disposa.

Pubic Heath Impications of Medica Waste Rutaa, Mayha. Infect Contro Hosp Epidemio 1992;13:38-48 Microbioogic Quaity Househod waste contains on average 100x more microorganisms with pathogenic potentia for humans than medica waste. Common nosocomia pathogens (i.e. P. aeruginosa, Kebsiea spp, Enterobacter spp, Proteus spp) were detected more frequenty from househod waste than from hospita waste.

Reguated Medica Waste The CDC, EPA, and states define medica waste as reguated ( infectious ) When it is suspected to contain potentiay hazardous eves of microorganisms

Medica Waste Reguations State - designation, transportation, storage and treatment Federa (OSHA) - education, abeing, use of PPE

Types of Soid Waste Designated as Infectious and Recommended Disposa Methods Rutaa, Mayha. Infect Contro Hosp Epidemio 1992;13:38-48 Centers for Disease Contro Infectious Disposa Source/Type Waste Method Microbioogica Yes S,I Bood and bood products Yes S,I, Sew Pathoogica Yes Yes Sharps (especiay needes) Yes S,I Contaminated anima carcasses Yes S,I (carcasses) Isoation No --- Other (surgica waste, diaysis, contaminated ab waste) No --- Abbreviations: S-steam; I-incineration; Sew-sanitary sewer.

Compiance with CDC and EPA Recommendations for Treatment of Reguated Medica Waste Rutaa, Odette, Samsa. JAMA;262:1635-1640 Type of Medica Waste CDC USH% EPA USH% Microbioogica S,I 98.1 S,I,TI,C 98.1 Bood S,I,SEW 95.9 S,I,SEW,C 95.9 Pathoogy I 92.6 I,SW,CB 92.6 Sharps S,I 92.5 S,I 92.5 Isoation --- --- S,I 85.9 Cont. anima carcasses I 89.1 I,SW 89.1 Contaminated aboratory --- --- Optiona 87.0 Surgery --- --- Optiona 78.2 Autopsy --- --- Optiona 89.9 Diaysis --- --- Optiona 68.6 Contaminated equipment --- --- Optiona ND Overa 82.3 75.1

Contaminated sharps Reguated Waste: OSHA Pathoogica and microbioogica wastes containing bood or OPIM Liquid or semi-iquid bood or OPIM Contaminated items that woud reease bood or OPIM in a iquid or semi-iquid state if compressed Items caked with dried bood or OPIM that are capabe of reeasing these materias during handing

Reguated Waste: OSHA Can OSHA and states adopt uniform definitions of RMW? OSHA rues and state rues address two different concerns OSHA rue addresses waste management in the workpace to ensure worker safety State waste management rues ensure storage, shipping, and treatment/disposa practices that protect the environment and pubic heath

Segregation of Medica Waste by US Hospitas 95% segregate reguated medica waste from non-reguated medica waste 96% use abeed or coor-coded bags

Coection and Containment of US Hospita Waste Coection Housekeeping (82%), maintenance (4%) or both (7%) transfer wastes to on-site storage or processing site (at east daiy) 92% Container Leakproof wastebaskets 95% Pastic bags as wastebasket iners 99%

Transporting Waste Within US Hospitas Transfer Carts - used to transport 95% waste within the hospita Gravity Chutes - aows for vertica 13% transfer Pneumatic chutes - vacuum source 2% to prope wastes

Storage No singe requirement for storage of infectious waste in terms of time and temperature but most states do have reguations NC - if not shipped within seven days of generation, medica waste must be refrigerated.

Advantages Compaction Decreases the voume of waste 4-5 times Decreases size of storage faciities Decreases cost of transporting waste Disadvantage May interfere with the effectiveness of certain treatment processes

Medica Waste Management: Environmentay Responsibe Heathcare Treatment of reguated medica waste (RMW) Propery define RMW Rationa definition coud save miions in treatment costs Reduce waste now treated as RMW (e.g., incineration) Know what happens to faciity s wastes and how treated Locate red bags strategicay to capture RMW Encourage segregation of propery defined RMW

Treatment of Medica Waste by US Hospitas Rutaa, Odette, Samsa. JAMA;262:1635-1640 Infectious (%) Treatment/Disposa Methods (%) Waste Category Yes No I SL S Sew Other Microbioogica 99 1 70 11 38 2 1 Human bood 94 6 64 11 21 26 1 Pathoogica 96 4 93 3 6 2 1 Isoation 94 6 79 17 9 2 0 Sharps 99 1 82 15 13 0 1

Incineration Ash Residue: Air Emissions: Controed-air incinerators produce a sterie ash No difference between bacteria in stack emissions and ambient air. Chemicas (CO, metas, acid gases, dioxins, furans) emitted from hospita or municipa incinerators

EPA s Proposed Incineration Emission Limits New set of medica waste incineration reguations Reguates Hosp/Med/Inf Waste Incinerators Mandated by the Cean Air Act Amendments of 1990 Reguations wi substantiay reduce emissions (dioxins, CO, Pb, Hg) EPA estimates reguations woud cose 50-80% of existing medica waste incinerators.

North Caroina Medica Waste Rues Steam Steriization 250 o F for 45 min or other effective combination. Unit shoud have time-temperature recorder and pressure gauge. Bioogica monitoring at east weeky; og maintained and sha incude type of indicator used, date, time and resut of test.

Sanitary Landfi Untreated medica waste coud be discarded in sanitary andfis provided workers do not have contact Studies demonstrate Bacteria and viruses are reduced by therma inactivation, antimicrobia characteristics of eachate and absorption to organic materia Househod waste is more microbiay contaminated and it is discarded in sanitary andfis Unavaiabe, reaching capacity, or restricted to untreated medica waste

Neede Disposa Needes shoud not be recapped, purposey bent or broken by hand, removed from disposa syringes, or otherwise manipuated by hand. After they are used, disposabe syringes and needes, scape bades, and other sharp items shoud be paced in puncture-resistant containers for disposa; the puncture-resistant containers shoud be ocated as cose as practica to the use area. Centers for Disease Contro, MMWR August 21, 1987

Suctioned Fuids Disposa Treatment Sanitary sewer - suctioned fuids may be carefuy poured down a drain connected to a sanitary sewer (CDC, 1985) Incineration - suction canister may be tighty capped, bagged (coded) and incinerated. Sanitary andfi - suction canister fuid may be treated with iquid treatment system and sent to sanitary andfi (2/3 states) Sanitary andfi - suction canisters may be tighty capped, bagged and sent to a sanitary andfi (a few states).

Medica Waste Management: Treatment Goa of treatment is to reduce microbia oad Changes that impact treatment of RMW Incineration (new emission standards) Aternative treatment technoogies Some states aow aternatives, other states not Autocave

Medica Waste Management: Treatment Aternative technoogies Voume of medica waste reduced by equipment (grinders, shredders, hammermis) that puverize and shred waste Reduce voume by about 80% Disinfect in the process (e.g.chemicas, heat, steam, microwaves, eectrotherma radiation)

Aternative Medica Waste Treatment Technoogies Microwaving - therma decontamination Eectro-therma radiation - macrowaves Infrared heating Pyroysis - heating (1000 o F-6000 o F) in absence of oxygen Pasma burners - eectrica arcs used to create pasmas in range of 2500 o to 10000 o C

Aternative Medica Waste Treatment Technoogies (cont) Chemica processes Beach decontamination with shredding Shredding foowed by chorine dioxide treatment Shredding foowed by wet oxidation at 212 o F, ph 0. Poymers with disinfectants soidify and decontaminate Irradiation processes Gamma radiation such as cobat 60 Eectron beam radiation Adapted from ASHMM handout by Lawrence G. Doucet, P.E.

Medica Waste Reguations State - designation, transportation, storage and treatment Federa (OSHA) - education, abeing, use of PPE

North Caroina Medica Waste Rues Reguated Medica Waste Definitions Microbioogica - cutures and stocks of infectious agents Pathoogica - human tissues, organs and body parts; carcasses and body parts of animas exposed to pathogens Bood - iquid bood, serum, pasma, other bood products, emusified human tissue, spina fuids, and peura and peritonea fuids; in individua containers in voumes greater than 20 m (boody gauze, used goves, tubing and dressings are not reguated medica waste).

North Caroina Medica Waste Rues Definition - sharps means and incudes needes, syringes with attached needes, capiary tubes, sides, cover sips and scape bades. Requirement - sharps wi be paced in a container which is rigid, eakproof when in an upright position and puncture-resistant. Contained sharps sha not be compacted prior to off-site transportation. Treatment - none required. The package may be disposed with genera soid waste.

North Caroina Medica Waste Rues Reguated Medica Waste Treatment* Microbioogica - incineration, steam steriization or chemica treatment Pathoogica - incineration Bood and body fuids in individua containers in voumes greater than 20 m - incineration or sanitary sewage systems, provided the sewage treatment authority is notified. *Other methods of treatment sha require approva by the Division of Soid Waste Management

Medica Waste Minimization Recycing/Reuse/Reduction Corrugated boxes and paper products Auminum, gass, and pastic from defined areas Recovery/redistiation of aboratory sovents (e.g., acoho, xyene, touene) Source reduction-repace singe use items with reusabe items

Infectious Risks Associated with Recycing Hospita Waste No infectious risks associated with recycing hospita waste Presenty, recycing efforts have generay focused on nonpatient contact sources of waste such as gass, scrap meta, auminum cans, cardboard and packaging materia From an infectious disease perspective, ony a few items generated in the heath-care setting are not ikey candidates for recycing (e.g. sharps)

Waste Management: How to be Friendy to the Environment Recycing in heathcare Interna forces: empoyee requests, environment, pubic image, proactive posture Externa forces: state/nationa soid waste aws, oca government reguations, air quaity reguations Exampe: NC 1989-GS estabished recycing goa of 25% by 1993 1991-Amended to waste reduction and 40% by 2001 1995-Amended so County government seects own goa Orange county seected a reduction goa of 45%

BEST PRACTICES FOR SURFACE DISINFECTION AND MEDICAL WASTE The contaminated surface environment in hospita rooms is important in the transmission of heathcare-associated pathogens (MRSA, VRE, C. difficie, Acinetobacter). Disinfection of noncritica environmenta surfaces/equipment is an essentia component of Infection prevention Disinfection shoud render surfaces and equipment free of pathogens in sufficient numbers to cause human disease. Foow CDC D/S guideine. When determining the optima disinfecting product, consider the 5 components (ki caims/time, safety, ease of use, others) Compy with federa (OSHA) and state medica waste reguations

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