WASTE HANDLING POLICY
Version / 5Name of responsible (ratifying) committee / Client Contractor Meeting
Date ratified / 19 February 2018
Document Manager (job title) / Facilities Monitoring Manager, Development Team
Date issued / 01 March 2018
Review date / 01 February 2021
Electronic location / Management Policies
Related Procedural Documents / Waste Disposal Procedures
Key Words (to aid with searching) / Waste management; Waste disposal; Disposal procedures; Clinical waste; Hazardous waste; Non hazardous waste; Infectious; Offensive; Cytotoxic/Cytostatic; Domestic; Confidential; Toxic substances; Radioactive waste disposal; Medicines; Sharps; Safe handling; Safe storage; Recycling; Health and Safety; WEEE
Version Tracking
Version / Date Ratified / Brief Summary of Changes / Author5 / 19/02/18 / Minor changes including updated quick reference guide and addition of Gypsum waste / N Hardman
4 / 11/11/14 / - / -
CONTENTS
QUICK REFERENCE GUIDE
1.Introduction
2.PURPOSE
3.SCOPE
4.DEFINITIONS
5.DUTIES AND RESPONSIBILITIES
6.PROCESS
7.TRAINING REQUIREMENTS
8.REFERENCES AND ASSOCIATED DOCUMENTATION
9.EQUALITY IMPACT STATEMENT
10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
EQUALITY IMPACT SCREENING TOOL
Waste Handling Policy
Version: 5
Issue Date: 01 March 2018
Review date:01 February 2021 (unless requirements change)Page 1 of 13
Waste Handling Policy
Version: 5
Issue Date: 01 March 2018
Review date:01 February 2021 (unless requirements change)Page 1 of 13
1.Introduction
As a waste producer, Portsmouth Hospitals NHS Trust (PHT) has a duty of care to ensure that all wastes produced on its sites are responsibly, effectivelyand safely managed, and that the storage, handling, transportation and disposal of waste materials comply with current legislation and take into account published best practice guidance.
This waste handling policy replaces all previous waste handling policies and is written in line with the Controlled Waste Regulations 2012, Hazardous Waste Regulations 2005 and the Department of Health Safe Management of Healthcare Waste version:2.0:England
The Controlled Waste Regulations 2012 replace and update the Controlled Waste Regulations 1992. They came into force on 6 April 2012.
Principle statutory requirements and guidance documents considered within this policy:
Legislation
The Hazardous Waste (England and Wales) Regulations 2005 (amended 2016)
The Waste Regulations (England and Wales) 2011
Controlled Waste Regulations (England and Wales) 2012
Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2011
Guidance
Health Technical Memorandum (HTM) 07-01
Safe Management of Healthcare Waste version: 2.0: England, Department of Health 2012
Technical Guidance WM2, Environment Agency, SEPA, NI Environment Agency
2.PURPOSE
The intention of this policy is to ensure that waste generated at Queen Alexandra Hospital is managed effectively and in accordance with the law. This policy sets out to: identify the legal and statutory obligations of the organisation; provide a framework for healthcare waste management, segregation and disposal; and identify an outline of responsibilities.
This policy should be read in conjunction with the associatedoperating procedures and guidelines for the storage and collection of hazardous/non hazardous, Radioactive and Domestic waste to be adopted by Portsmouth Hospitals NHS Trust.
3.SCOPE
This policy applies to all individuals involved in the production and collection of waste.
This policy applies to all staff (including voluntary workers, students, locums and agency) within the Trust, the DMGS (Portsmouth) and theFM Service Provider, whilst acknowledging for staff other than those of the Trust the appropriate line management or chain of command will be followed.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’
4.DEFINITIONS
The following definitions represent the main categories of waste generated at Portsmouth Hospitals NHS Trust, but are not exhaustive. Full details of the waste streams and disposal methods are clearly defined in the individual operational procedures documentswhich support this document
Clinical Waste
The definition of clinical waste is provided by the Controlled Waste Regulations(issued under the Environmental Protection Act) and in Northern Ireland by theWaste and Contaminated Land (Northern Ireland) Order.
Clinical waste is defined as:
1. “. . . any waste which consists wholly or partly of human or animaltissue, blood or other body fluids,excretions, drugs or otherpharmaceutical products, swabs or dressings, syringes, needles orother sharp instruments, being waste which unless rendered safe mayprove hazardous to any person coming into contact with it; and
2. any other waste arising from medical, nursing, dental, veterinary,pharmaceutical or similar practice, investigation, treatment, care,teaching or research, or the collection of blood for transfusion, beingwaste which may cause infection to any person coming into contactwith it.”
Offensive Waste (Non Hazardous)
Offensive waste, also known as human hygiene waste, consists of waste containing body fluids, secretions and excretions but is not clinical waste because it is not infectious. Such waste is liable to cause offense by virtue of odour or appearance. Examples would include items contaminated with non-infectious body fluids e.g. swabs, dressings, gloves, aprons, nappies, sanitary towels etc.
Infectious waste
Infectious waste consists of waste containing body fluids, secretions and excretions, which originate from a patient known or suspected to be infectious, and where barrier nursing procedures have been instigated. Examples would include items that have been in contact with the infected patient,or are contaminated with their body fluids, e.g. swabs, dressings, gloves, aprons, nappies, sanitary towels etc
Incinerate-only Hazardous Waste
Waste containing or contaminated by chemical or other substances which may generate hazardous properties, and which should be segregated and packed according to specified requirements
Medicinal Waste
Medicinal waste consists of medicinally/pharmaceutically contaminated products (other than those associated with cytotoxic/cytostatic medicines).
This includes, but is not limited to: syringe bodies (no sharps), medicines bottles, vials (unbroken), full/partially used blister packs, connecting tubing, intravenous drip bags infused with medicinal products
Cytotoxic/cytostaticwaste
Classification of medicinal waste used in the List of Wastes Regulations for medicinal products with one or more of the hazardous properties toxic, carcinogenic, toxic for reproduction or mutagenic.
Cytotoxic waste is to be known as hazardous waste
Anatomical Waste
Consists of body parts or other recognisable items, including all human and animal tissue and waste bones, which may be offensive to those who come into contact with such items. This excludes very small unidentifiable pieces of skin or flesh (known as “trimmings”) which may be treated as standard clinical waste
Sharps Waste
Sharps are items that could cause cuts or puncture wounds. They include, but are not limited to: needles; hypodermic needles; scalpels and other blades; knives;ampoules; broken medicine bottles/vials.
Gypsum Waste (Gypsona)
Gypsum waste is defined as waste arising from the following clinical sources:-
- Gypsum-based plaster casts, back-slabs etc. (from Plaster-of-Paris/Gypsona)
- Gypsum contents of the separator at plaster sinks
- Dental moulds
- Podiatry moulds
Domestic waste
Domestic waste means mixed municipal waste from healthcare and related sources that is the same as, or similar to, black-bag domestic waste from domestic households. Healthcare premises must not place any hazardous waste in this waste stream. The waste should therefore be non-hazardous and suitable for disposal by landfill (where pre-treatment requirements are met), municipal incineration with or without energy recovery, alternative municipal treatment processes, or via recycling streams.
Recycling
Recyclable waste includes: paper; cardboard; plastic bottles; cans; newspapers/magazines.
Healthcare organisations are prohibited from mixing domestic-type waste into the clinical waste stream and vice versa.
5.DUTIES AND RESPONSIBILITIES
Trust Board
The Trust Board has overall accountability for the activities of the organisation, which includes waste management.
The Trust Board will ensure that they receive appropriate assurance that the requirements of current waste management legislation are being met.
The Trust Board discharges the responsibility for waste management through the Chief Executive.
Chief Executive
The Chief Executive will, on behalf of the Board, be responsible for ensuring that current waste management legislation is complied with and where appropriate, DoH Safe Management of Healthcare Waste guidance is implemented.
The Chief Executive discharges the day to day operational responsibility for waste management through theHead of Estates and Facilities.
The Hospital Company (THC) General Manager
THC General Manager has overall responsibility for ensuring that theFM Service Provider provides waste services as detailed in the contract at the site of the Queen Alexandra Hospital.
Head of Estates and Facilities
The Head of Estates and Facilitiesis responsible for ensuring that waste management issues are highlighted at Board level.
This responsibility will extend to the proposal of waste elimination, minimisation, recycling and recovery as well as addressing the carbon impact related to waste through resource efficiency, transport impacts and disposal arrangements.
At an operational level theHead of Estates and Facilities will;
- Assist the Chief Executive with responsibilities for waste management matters.
- Ensure that the Trust has in place a clearly defined waste management policy and relevant supporting procedures.
- Ensure that the Trust, through the day to day management of waste, complies with current legislation and employs best practice guidelines as appropriate.
- Ensure through senior management and line management structures that staff participation in waste management training is maintained.
PHT Waste Representative and FM Services Environment Manager
The Trust Waste Representative (to be appointed by the Head of Estates and Facilities), and the FM Services Environment Manager (for Queen Alexandra Hospital site only) will be responsible for:
- Raising awareness of all waste management procedures and their purpose throughout the Trust.
- The operational aspects of waste management.
- Compliance with legislation in relation to waste management and the Carriage of Dangerous Goods Act.
- Reporting of non-compliance with legislation, policies and procedures to the Head of Estates and Facilities.
- The development, implementation and review of the organisation’s waste management policy and procedures.
- The reporting of waste management incidents in accordance with Trust policy and external requirements.
- Monitoring and reporting of incorrect waste disposal.
- Ensuring Duty of Care and pre-acceptance audits are carried out.
- Liaison with external enforcing authorities.
- Registering the hospital site with the appropriate authorities.
- Liaison with Trust Managers.
- Monitoring of external waste provider contracts.
- Obtaining expert technical advice on the application and interpretation of waste management guidance, including Safe Management of Healthcare Waste, Department of Health.
- Providing a link to the relevant Trust Committees.
- Ensuring an appropriate level of management is always available to all employees of the hospital premises.
Local Management
Matrons, Heads of Service and PHT and FM Service ProviderDepartmental Managers are responsible for:-
- Monitoring waste management within their respective workplaces and ensuring that contraventions of waste segregation and disposal do not take place.
- Ensuring that this document and relevant waste management procedures are brought to the attention of staff through local induction and ongoing staff briefings.
- Ensuring that all new and temporary staff, on their first day in the Ward/Department, are given basic familiarisation training within their workplace with regards to all relevant waste segregation and disposal procedures.
All Staff, Contract Staff and Volunteers
All staff, contractors and volunteers shall;
- Comply with the Portsmouth Hospitals NHS Trust waste management protocols and procedures.
- Participate in waste management training and awareness.
- Report waste management incidents, and breaches in accordance with Trust procedures.
- Ensure the promotion of waste management at all times to help reduce the volume of waste produced and the associated carbon impact
Contact details
Contact OfficerExtension number
FM ServicesEnvironment Manager 3461
PHT Waste Representative 023 9228 6603
Pharmacy Manager 6105
Occupational Health 0239228 3641
Accident & Emergency 6380 & 6062
Radiation Protection Advisor3299 or aircall via Switchboard
FM Helpdesk 6321
6.PROCESS
In England and Wales it is a legal requirement of the Hazardous Waste Regulations to segregate infectious waste (that is subject to special requirements in order to prevent infection) from other wastes. It is also a requirement not to mix other types of waste for disposal, for example, domestic waste and clinical waste.
The disposal processes for each of the following types of waste (as described in the Safe Management of Healthcare Waste Version 2) are clearly defined in the operational procedures- Waste Disposal Procedures:
- Infectious healthcare waste for incineration (anatomical)
- Infectious healthcare waste for incineration (clinical waste)
- Infectious healthcare sharps – incinerate (sharps / medicine)
- Infectious healthcare waste for alternative treatment (clinical waste)
- Hazardous healthcare medicine for incineration (cytotoxic / cytostatic)
- Non hazardous healthcare medicines for incineration
- Infectious healthcare waste contaminated with chemicals
- Non infectious healthcare waste (offensive waste)
The processes for disposal of the following specific types of waste are also included in the Waste Disposal Procedures:
- Highly Contaminated / Infectious waste –hazardous - category 4 pathogens.
- Toxic/chemical waste
- Radioactive waste
- Gypsum waste
- Aborted Foetuses - product of termination; product of miscarriage
- Domestic waste
- Confidential waste
- Recycling
- Other wastes (bulky, glass, aerosol, batteries, etc.)
- Waste Electrical and Electronic Equipment (WEEE)
- Waste from outside Queen Alexandra Hospital
Detailed in the Waste Disposal Procedures are the following requirements for the safe disposal of waste:
- Container labeling and handling
- Storage of waste
- Spillages
- Consignment
Incidents
Incidents such as spillage, damage to containers, inappropriate segregation or any incident involving sharps should be reported to Occupational Health Dept and the FMServices Environment Manager/PHT Waste Representative. Investigation will be undertaken to establish the cause of the incident and the remedial action to be taken. All accidents and injuries must be reported to the Occupational Health Department, who will initiate the appropriate action.
7.TRAINING REQUIREMENTS
Staff shall be made aware of appropriate processes for the segregation, storage, handling and transportation of waste.
Staff who are required to handle and move clinical waste shall be trained in procedures for dealing with spillages or other incidents for their area or work.
8.REFERENCES AND ASSOCIATED DOCUMENTATION
In addition to the Safe Management of Healthcare Waste version:2.0:England, Department of Health, setting out best practice for the segregation, handling and disposal of waste, this policy should be read in conjunction with the Trusts operational procedures of waste management as described in the ‘Waste Disposal Procedures’ which can be found on the Trust intranet.
9.EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
Our valuesare the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace.
Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do.
We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:
Respect and dignity
Quality of care
Working together
Efficiency
This policy should be read and implemented with the Trust Values in mind at all times.
Waste Handling Policy
Version: 5
Issue Date: 01 March 2018
Review date:01 February 2021 (unless requirements change)Page 1 of 13
10.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
This document will be monitored to ensure it is effective and to assure compliance.
Minimum requirement to be monitored / Lead / Tool / Frequency of Report of Compliance / Reporting arrangements / Lead(s) for acting on RecommendationsWaste Segregation within QAH / PHT Waste Representative
FM Services Environment Manager / Workplace Audits / Quarterly / Policy audit report to:
- Client Contractor Group
- Patient Partnership Environment Group
Waste Segregation Pre-Acceptance Audit / External Waste Consultant
PHT Waste Representative
FM Services Environment Manager / Structured Workplace Audit / Annually / Policy audit report to:
- Client Contractor forum
- Patient Partnership Environment Group
FM Services Environment Manager
CSC Leads, Heads of Nursing and Modern Matrons
Environment Agency Audit / Environment Agency Representative(s)
PHT Waste Representative
FM Services Environment Manager / Structured Workplace Audit / Upon Request of EA / Policy audit report to:
- Client Contractor forum
- Patient Partnership Environment Group
FM Services Environment Manager
CSC Leads, Heads of Nursing and Modern Matrons
Waste Handling Policy
Version: 5
Issue Date: 01 March 2018