Clearing the confusion on waste disposal.

What is hazardous waste? What is infectious waste? And whose disposal rules do you follow?

Confusion seems to be the watch-word for nursing homes when it comes to determining what constitutes infectious and hazardous waste. For infectious waste in particular, definitions and labeling and shipping requirements vary from state to state. The situation on the federal level is not much better.

One agency's published description of infectious waste is not necessarily that of another.

Without clear, universal definitions, the amount of waste a nursing home separates for special handling as either infectious or hazardous can become needlessly high. In an industrial plant, one or two persons functioning as safety managers are responsible for determining which items fit into the categories of hazardous, infectious, or regular solid waste. A nursing home may have scores of caregivers making that decision on a moment's notice at a patient's bedside. Erring in favor of caution almost always seems the more acceptable choice, but that error has its own high cost.

Many people in the medical community use the terms "infectious" and "hazardous" interchangeably when talking about waste. They are not the same thing. Compared to regular solid waste, it costs ten times as much to dispose of infectious waste and a hundred times more to get rid of hazardous waste. Disposal of regular solid waste, the kind that ends up in the dumpster, averages two to three cents per pound. Infectious waste, red-bag items, runs from the high teen to the low thirty-cent range. Hazardous waste removal can cost two to three dollars a pound.

Though hazardous waste may be the more costly to deal with, its definitions and regulations are far clearer. It falls under the jurisdiction of the Environmental Protection Agency (EPA) and is defined and regulated under the Resource Conservation and Recovery Act. States do have their own regulations, but these cannot be less stringent than the federal requirements, which take precedence. Basically, a solid waste is hazardous if it is a "listed" waste by the EPA or if it exhibits one or more of four hazardous characteristics: ignitability, corrosivity, reactivity, and toxicity. It is any solid waste which could, if mishandled, cause death, serious bodily injury, or pollute surface or ground waters, the land, or air.

When it comes to disposing of hazardous waste, the key is to determine whether a nursing home fits the definition of either a small- or a large-quantity generator. A small-quantity generator produces within a 30 day period more than 220 but less than 2,000 kilograms of hazardous waste exhibiting one or more of the four characteristics, or 2.2 kilograms of other listed hazardous waste. Anything above those guidelines is large-quantity generation. Small- and large-quantity generators need to make special arrangements for disposing of their hazardous waste. A producer of less than the minimum amount of hazardous waste, according to federal law, needs only dispose of the waste in a responsible manner.

State agencies and the EPA are very helpful in determining hazardous waste and how to handle it. The EPA has an "800 number" hotline. States also offer assistance over the phone. Requests for information are handled informally; callers are not required to identify themselves or their organization.

In the hierarchy of wastes, hazardous is rated as more dangerous than infectious. That means that when a waste contains both hazardous and infectious components, the rules for dealing with hazardous waste override those for handling infectious waste.

Infectious, regulated medical, biohazardous, and biomedical waste are all the same thing and are defined as any waste that has the capability of transmitting disease to an individual exposed to it. Also remember that certain factors must be in place before a disease can be transmitted, i.e., a susceptible host, a virulent pathogen, and a means of getting into the body, such as a skin cut or puncture.

The Centers for Disease Control and Prevention (CDC) lists four basic categories of infectious waste:

1. Blood and blood products (i.e. serum, plasma, waste blood)

2. Laboratory waste (i.e. cultures and stocks of infectious agents, vaccines)

3. Pathological waste (i.e. tissues, organs, body parts)

4. Sharps (i.e. needles/syringes/scalpels, razors, glass lab slides).

When scrutinized carefully, we see that the EPA definitions and most state agency definitions for infectious waste actually do fit into the CDC categories. For example dialysis waste is sometimes listed as a separate category because the tubing and filters are contaminated with blood and body fluids. An isolation waste category is sometimes made separate because of the body fluid carrying the infectious agent. Sudden onset of diarrhea stools in a resident might be considered suspicious until a diagnosis is made. Therefore diapers or chux might be included in the infectious waste red bag until culture results are returned. Clearly you would treat this material in the same way as blood and blood products deemed to be infectious.

Much is being written and discussed about the confusing infectious waste definitions and how differently each state or agency has defined this waste stream. Requirements for defining, labeling, shipping, and handling infectious waste are confusing. They vary from state to state and between federal agencies. JCAHO, state departments of health, OSHA, and the EPA all have good basic guidelines and standards to adhere to. However, I have yet to see a definition or category devised by a federal or state agency that does not fit into the CDC categories. That is, by using common sense and applying the CDC's four categories against the basic definition of infectious waste--any waste that has the capability of transmitting disease to an individual exposed to it--it is possible to determine what constitutes red-bag material in nearly all cases.

Just as important as understanding the basic definitions of infectious materials, and thereby the resultant potential infectious waste from these materials, is the development of a written waste plan. It must coordinate with the institution's written infection control plan and be easily understood by all employees, and it must be carried out in a manner satisfying any and all regulatory or accreditation agencies. This plan should include, above any other consideration, the naming of a responsible person or committee charged with assuring and overseeing its implementation. Areas that need to be addressed by a written waste plan include:

1. Identification/definitions

2. Handling/segregation/packaging

3. Labeling and signage

4. Transportation (in-house and external)

5. Disposal

6. Records maintenance/documentation

7. Training and education (requirements and documentation)

8. Contingency planning.

Because infectious and hazardous wastes have the potential to be created at every bedside in a nursing home, the training and education component of the plan is particularly important.

Connie Neal, RN, is a compliance analyst/customer consultant with BFI Medical Waste Systems, Inc., Houston, TX, and previously worked in hospital settings for 24 years.