Infection Control Manual

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Waste Management

Good clinical waste management is essential in every practice to reduce the risk to staff, patients and visitors and to protect the environment. It is the responsibility of the person generating waste to ensure that it is segregated according to the national guidelines. The dentist has a Duty of Care to provide a description of the waste that enables the waste contractor to dispose of the waste at a suitably authorised facility.

 

The Hazardous Waste Regulations 2005

Two new Regulations came into force on the 16 th July 2005 governing the management of hazardous waste. The Hazardous Waste Regulations 2005 (which replace the Special Waste Regulations 1996) and the List of Wastes Regulations 2005 that transposes into English law the list of hazardous wastes described in the European Waste Catalogue, the latter was implemented by the European Commission in 2002.

Hazardous waste is a waste with one or more properties (e.g. oxidizing, explosive, flammable, highly flammable, irritant, infectious, toxic, carcinogenic, mutagenic, harmful, release toxic gases and ecotoxins) that are hazardous to health or the environment . These regulations therefore apply to amalgam, infectious waste and other clinical wastes e.g. radiographic generated in the dental practice that are classified as having hazardous properties. Non-hazardous waste and hazardous are no longer permitted to be co-disposed at the same sites.

In summary:

• Definition of hazardous waste (which replaces the term "special waste")
• Requires producers (consignor) of hazardous waste to notify their premises to the Environment Agency. Dental premises are exempt if they produce less than 200kg of hazardous waste in any given 12 month period. Hazardous waste now also includes televisions, fridges, computer monitors and fluorescent tubes in addition to the infectious hazardous waste generated in the surgery.
• You will be committing a criminal offence if hazardous waste is transferred from the practice that is not either notified (registered) or exempt.
• Producers can notify their premises on-line via the Environment Agency website ( www.environment-agency.gov.uk ) or by post or phone. The cost of registration varies according to the method used register and is currently between £18 and £28 per site (dental practice). Owners of multiple practices are required to register each practice separately.
• Once a site is registered it is given a unique six digit "premises" code by the Environment Agency. Waste producers have a duty to provide their waste contractor with this unique reference number. This is required for each movement of hazardous waste.
• Ends the requirement to pre-notify wastes to the Agency as currently required under the Special Waste Regulations
• Ensures safe management of hazardous waste
• Provides cradle to grave documentation for the movement of hazardous waste
• Requires the consignees (waste disposal contractors) to keep thorough records of hazardous waste and provide the Agency with quarterly disposal and recovery information
• Dental practices are required to keep records of the hazardous waste they produce for a period of 3 years. These records will essentially consist of a copy of the consignment note from the carrier plus the return from consignee (waste disposal contractor) certifying receipt of the waste.
• Dental amalgam is classified as a hazardous waste and amalgam separators must be installed to ensure that amalgam waste is prevented from entering the drains and sewers and is collected and disposed of appropriately.

 

Notification to the Environment Agency of premises producing waste

One of the major changes is the introduction of a requirement to notify the Environment Agency of premises producing hazardous waste. From 16 th July 2005 the movement of hazardous waste from premises that are not either notified or exempt will be prohibited. Producers failing to notify the Environment agency will be committing an offence. However, dental surgeries are exempt from this requirement if the total amount of hazardous waste produced in any 12 month period is less than 200kg and the hazardous waste is removed from the premises by a registered carrier.

If the surgery produces more than 200kg of hazardous waste (which also included non clinical items such as TVs, fluorescent tubes, computer monitors, fridges) in a 12 month period they must notify the premises to the Environment Agency and they will be issued with a unique premises code which is valid for a year and is used on consignment notes and consignee quarterly returns. 200 kg is equivalent to 5 small domestic fridges or 10 TVs! So you will need to estimate the total amount and weight of the hazardous waste you produce over a year.

Although the duty to notify would normally fall to the owner or the occupier of the premises they can ask their waste management company to notify the Environment Agency on their behalf. Producers of waste will have to prove to waste management contractors that their premises have been notified to the Environment Agency. Where a practice owner has multiple practices each premise will need to be notified separately to the Agency. For immediate registration with the Environment Agency you can go on-line (cheapest option at £18) or register by phone using a credit card or by post; the latter takes up to 28 days. Please remember waste cannot be moved from a site unless you are registered or can prove exemption. You have a duty to provide your waste contractor with this unique reference number for each movement of hazardous waste. You do not need to register an exemption but you must allocate yourself a unique premises code in a format agreed by the agency see www. environnment-agency.gov.uk .

 

Examples of Waste Codes

The List of Wastes Regulations includes both hazardous and non-hazardous waste streams. Most hazardous clinical waste generated in the dental surgery as a result of treating patients will be categorised under chapter 18 01- Waste from natal care, diagnosis, treatment or prevention of diseases in humans . Other hazardous waste such as radiographic developers and fixers, computer monitors, electrical and electronic equipment, which contains hazardous waste are listed under separate chapters. (See Hazardous waste: Interpretation of the definitions and classifications of hazardous waste, June 2003 for the European Waste Catalogue list of codes available on http://www .environment-agency.gov.uk

In the List of Wastes Regulations a waste product is assigned a six digit code. Hazardous waste is marked with asterisk * after the code. Entries highlighted in red in the code and marked with the letter A refers to "Absolute entries" which are hazardous waste regardless of threshold concentration. Those highlighted in blue and marked with an M are "Mirror entries" which are hazardous waste only if the dangerous substance is present above threshold concentrations.

 

Examples of a code:

18 01 10* Amalgam waste from dental care

 

Classification of Clinical Waste and Infectious Hazardous Waste

The Environment Agency and DEFRA have issued interim guidance on the disposal hazardous waste in www.environment-agency.gov.uk/business/444217/590750/590821/502174/496498/?lang=_e . In conjunction with the Department of Health an approved code of practice was published for public consultation in November 2005 "The Safe Management of Healthcare Waste; a public consultation, Gateway No 5471. www.dh.gov.uk.

 

Definition of clinical waste

Clinical waste is defined in the Controlled Waste Regulations 1992 as any waste which consists wholly or partly of:

• human or animal tissue;
• blood or bodily fluids;
• excretions;
• drugs or other pharmaceutical products;
• swabs or dressings; or;
• syringes, needles or other sharp instruments;

Which unless rendered safe may prove hazardous to any person coming into contact with it. And any other waste arising from dentistry.. being waste which may cause infection to any person coming into contact with it.

This definition is likely to be retained in order comply with the waste producers Duty of Care towards safeguarding both the public and the environment.

 

Definition of infectious hazardous waste

However, not all clinical waste is classified as hazardous waste under the Hazardous Waste Regulations 2005 and the List of Wastes Regulations 2005. The infectious fraction of clinical waste is defined as wastes that contain substances containing viable micro-organisms or their toxins which are known or reliably believed to cause disease in man or other living organisms are hazardous wastes (H9 infectious). Infectious hazardous fractions must be segregated at source in the dental practice and consigned appropriately. Previous regulations on Special Waste relating to pathogen types have been removed and all infectious waste, irrespective of the level or type of infection, is considered hazardous waste .

The Standard Precautions approach outlined in Section one and used throughout the rest of these Guidelines are not applicable under the Hazardous Waste Regulations. The Department of Health are currently developing risk assessments to help waste producers segregate their infectious waste, which will be published later in 2006 (for further information see Summary of responses to the consultation on joint-agency guidance "Safe management of healthcare waste", Gateway 6537 May 2006 www.dh.gov.uk/Consultations/LiveConsultations/fs/en )

 

Classification of medicines waste

Under the Special waste Regulations 1996 medicines were designated as special wastes. Whereas, under the new regulations for hazardous waste only medicines that are classified as cytotoxic or cytostatic are hazardous waste. These are waste medicines possessing hazardous characteristics H6 toxic, H7 carcinogenic, H10 teratogenic or H11 mutagenic. Definitive guidance from the Department of Health and the Environment Agency is still awaited on exactly which medicines will be included on the cytotoxic hazardous waste list.

Current recommendations are based on the definitions found in the British National Formulary (www. bnf.org.uk), National Institute for Occupational Safety (NIOSH) and World Health Organisation (WHO). Using the latter definitions, Dentists are unlikely to use during the course of routine dentistry any medications, which fall into this category. Prescription only medicines (POMs) such as Lidocaine and other local anaesthetic (LA) agents are not classified as a cytotoxic or cystostatic hazardous waste. Solutions of saline or glucose are not defined as medicines waste. Further clarification on the feasibility of segregating different types of medicines waste is likely to become available by the end of 2006 and will be posted on the Department of Health website (www.dh.gov.uk).

However, regardless of their classification, the disposal route for prescription only medicines waste has not changed and they must be segregated from other types of clinical and hazardous waste and placed in a puncture proof container and disposed of by incineration by a suitably authorised facility. LA cartridges and LA syringe needles and medicines vials should be all be consigned as medicines waste for incineration, the waste bin should be labeled as containing both medicines and sharps waste H9.

 

Amalgam waste and installation of amalgam separators

Key point: Amalgam waste must be removed using an amalgam separator and disposed of as a hazardous waste

The main impact for the dental profession of these new regulations is the disposal of amalgam, which is now classified as a hazardous waste. In practical terms this means that the surgery must segregate amalgam waste from other categories of waste as well as from the drains (waste water system) or sewers. This is achieved by fitting an amalgam separator to ensure that waste amalgam is removed from the suction apparatus, and then the segregated waste amalgam is disposed of separately from other types of clinical waste. Amalgam separators (meeting the requirements of BS EN ISO 11143) can be retrofitted to existing suction equipment either in each individual surgery or fitted to central suction unit serving multiple surgeries. Alternatively, it can be installed on the ultimate outflow pipe from the premises but only if all waste routes carrying waste amalgam, discharge via the same waste water pipeline.

 

Segregation of waste

• Household and clinical waste must be segregated at all times.
• Household waste (e.g. paper, packaging, food, paper towels used for drying hands) is classified as a controlled waste. Dispose of in black (or clear) plastic waste bag for landfill or recycle. Local councils are responsible for disposal.
• Non-hazardous clinical waste should be segregated from infectious hazardous waste
• Hazardous infectious waste bags for (infectious H9) clinical waste disposal should be placed in a foot operated pedal bin during use. Each clinical area should have ready access to at least one yellow bag pedal bin. All hazardous infectious clinical waste (e.g. untreated infectious waste) must be transported in appropriately labeled UN type clinical waste sacks (except for sharps).
• All types of waste bags should be discarded when three-quarters full, be securely tied, labeled and dated with name of practice prior to disposal.
• Wastes should not be allowed to escape or leak and manual handling should be kept to a minimum. Do not transfer waste items between clinical waste sacks.
• Non infectious sharps must be disposed of in rigid, puncture proof containers that conform to UN3291 (British Standard 7320:1990. Dispose of containers and seal when ¾ full. Keep away from direct sources of heat. Label with the name and address of the dental practice (European waste code e.g. 18 01 01.
• Sharps bins are considered as hazardous waste if they contained sharps used on a patient with a known infection (European waste code 18 01 03).
• Medicines waste including vials, local anaesthetic cartridges and syringes and unused medicines must be segregated from other sharps waste or clinical waste and disposed of in puncture proof container bins and sent for incineration (European waste code 18 01 09)
• If a sharps container is damaged, place into larger container, lock and label prior to disposal.
• Certain categories of chemical clinical waste produced in the dental practice are designated as hazardous waste e.g. amalgam, radiographic processing chemicals and must be segregated from other types of waste and consigned for appropriate disposal.

 

Safe handling and storage of clinical and hazardous waste prior to disposal

• All staff who handle waste must be trained in its safe handling, segregation and disposal (this includes cleaning staff)
• All Staff must wear PPE when handling waste (e.g. heavy duty gloves, plastic apron, mask) and be immunised against Hepatitis B
• Sharps injuries should be managed as in section 2 ( add hyperlink to section ) and recorded on an accident report form
• Wastes should not be allowed to escape or leak but a spillage kit should be readily available (see section 4 add hyperlink to section ) should an accident occur
• Manual handling should be kept to a minimum. Do not transfer waste items between clinical waste sacks or sharps containers
• Waste should be stored in a dedicated area prior to collection. The area should be clean, secure and inaccessible to unauthorised persons or pests. Store waste on an impervious hard surface that can be washed down should there be a spillage. Clinical waste for collection should be stored in a rigid locked bin
• Waste should be collected at an appropriate frequency according to level of waste generation

 

Transport of clinical waste

Clinical waste must be transported by the carrier in UN type approved rigid containers in compliance with the requirements of the Carriage of Dangerous Goods Act and the UN's European Agreement on the International Carriage of Dangerous Goods by Road. Only an authorised waste carrier who holds a certificate of registration can collect clinical waste for disposal. Failure to dispose of waste in the correct manner leaves the dentist open to fines and prosecution by HSE, Environment Agency and the possibility of investigation before the General Dental Council.

 

Completing Consignment Notes for hazardous waste and keeping records

Every movement of hazardous waste (technically referred to as consigning) must be accompanied by a completed multi-part consignment note. This must be signed at each stage of the transfer of waste, from the surgery to the waste disposal site

The dentist (consignor) before collection and removal of the waste must complete the Annex of the consignment note (containing a written description of the waste with the appropriate European waste code) and both the carrier and dentist (consignor) must sign the note.

The new consignment note includes the following :

• The European Waste Catalogue code
• A written description of the waste
• Information about the hazardous nature of the waste and if applicable each hazardous substance
• The weight of the waste to be consigned
• Number of waste containers and their colour and size

The carrier must then give a copy to both the waste producer (dentist) and the waste disposal contractor (consignee).

The waste disposal contractor will send returns (evidence that their waste has been treated and disposed of correctly) to the dentist usually in the form of a copy consignment note. The waste contractor will also have a duty to notify the Environment Agency of the amount of hazardous waste collected, treated or disposed of and they will be charged by the Agency accordingly. They are likely to pass on this charge to the Producer (Dental Practice).

Practices are required to keep records on the hazardous waste they produce consisting of the consignment notes plus the return from the consignee certifying receipt of the waste. Records are to be kept for a period of 3 years from the date the waste was removed.

In order to save money you will need to carefully segregate hazardous from non-hazardous waste streams as well as wastes that require incineration e.g. identifiable human tissue (does not include extracted teeth) and medicines waste from waste that can be treated by alternative technology methods e.g. microwaving.

For further information on clinical waste management regulations contact your local Dental Infection Control Advisor or Community Infection Control Nurse or the helpline at DEFRA or the Environment Agency.

 

References 

Technical Guidance WM2. Hazardous waste-interpretation of the definition and classification of hazardous waste. Environment Agency.

Department of Health Estates & Facilities Directorate. The Safe Management and Disposal of Healthcare Waste 2005. Department of Health.