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Waste Management Procedures

Reference Number: NCAE031(19) Version Number: 1 Issue Date: 29/07/2019 of 58

It is your responsibility to check on the intranet that this printed copy is the latest version


Lead Author: Paul Corr, Portering & Waste Manager (Oldham CO)

Additional author(s) Paul Huxley, Portering & Waste Manager (Salford CO)

Division/ Department: Facilities Division

Applies to: Northern Care Alliance Group

Date approved: 16/07/2019

Expiry date: 15/07/2022

Contents

Contents

Section Page 1 What is the procedure about? 3

2 Where will this document be used? 3

3 Why is this document important? 3

4 What is new in this version? 4

5 What is the Procedure? 4

5.1 General Waste Handling and Storage Procedures 4

5.2 Domestic Waste (Clear or Black Bags) 5

5.3 Offensive/non-infectious waste / Tiger Stripe Bags 6

5.4 Clinical Waste / infectious Waste (Orange Bags) 6

5.5 Category A infected clinical waste (Yellow Bags) 7

5.6 Suction Containers 7

5.7 Yellow Sharp Bins 7

5.8 Pharmaceutical Waste 8

5.9 Pharmaceutically Contaminated Waste 8

5.10 Non-pharmaceutically Active IV fluid Waste 9

5.11 Anatomical & Blood Contaminated Waste 9

5.12 Cytotoxic/Cytostatic Waste 10

5.13 Confidential Waste 11

5.14 Waste Paper (non-confidential) 11

5.15 Cardboard 11

5.16 Printer inkjet cartridges 12

5.17 Large, bulky waste items, medical equipment and electrical/electronic equipment

12

5.18 Waste Chemicals 12

5.19 Fluorescent Tubes 13

5.20 Batteries 13

5.21 Radioactive Waste 14

Departmental Procedures

5.22 Infectious Diseases – Category ‘A’ Pathogens 14

5.23 Theatres 15

Group arrangements:

Salford Royal NHS Foundation Trust (SRFT)

Pennine Acute Hospitals NHS Trust (PAT)




5.24 Obstetrics and Gynaecology 16

5.25 Pharmacy 17

5.26 Pathology Department 18

5.27 Autoclaves 19

5.28 Human tissue/anatomical waste – Histology 19

5.29 Human tissue/anatomical waste – Mortuary 19

5.30 Chemically Contaminated Waste 20

5.31 Unused Kits and Reagents 20

5.32 Sharps 21

5.33 Medicinally Contaminated Waste 21

5.34 Maxillo-facial Unit 21

5.35 Radiology 21

5.36 A & E / Fracture Clinic 22

5.37 Community Services - Treatment in Patients’ Homes 22

5.38 Waste Generated in Health Centres / Clinics 23

5.39 EBME / MEMS Department 23

5.40 Estates Department 24

5.41 Catering Department 25

5.42 IM&T Department 28

5.43 Waste from Third Parties 28

6 Roles and responsibilities 29 - 35

7 Monitoring document effectiveness 35

8 Abbreviations and definitions 36

9 References and Supporting Documents 36

10 Document Control Information 38

11 Equality Impact Assessment (EqIA) screening tool 39

12 Appendices

Appendix 1 Monitoring and Review Arrangements 41

Appendix 2 Waste Description, Packaging and Disposal Methods 43

Appendix 3 Colour Coding of Waste 51

Appendix 4 Recognised list of Cytostatic Medicines (November 2015) 56

Appendix 5 Recognised list of Cytotoxic medicines (November 2015) 58




1. What is this procedure about? 1.1 These procedures should be read in conjunction with the Waste Management Policy

NCAE030(19)

Both documents provide the reader with their responsibilities in relation to the management

of our healthcare waste; this includes collection, segregation, removal, transport and

disposal of all waste which is generated on our premises through our daily activities

1.2 If you have any concerns about the content of this document please contact the author or

advise the Document Control Administrator.

2. Where will this document be used?

2.1 This document contains summarised instructions for the identification, segregation, collection, storage and transportation of healthcare waste produced by The Northern Care Alliance.

2.2 These procedures apply to all premises owned or leased by the Alliance and to all staff

(including contractors employed by the NCA and those working in the patient home environment).

2.3 If the healthcare premises is shared with other NHS Organisations and the NCA is not the

landlord, the waste management policy and procedures should be followed as directed by the Landlord i.e. NHS Properties

3. Why is this document important?

3.1 All members of staff have a Duty of Care to ensure that all waste generated within each Care Organisation, is dealt with appropriately, safely and in accordance with the Waste Management Policy NCAE030(19) and these Waste Management Procedures NCAE031(19)

4. What is new in this version?

4.1 This document is a New Document for use throughout the whole of the Northern Care Alliance. It replaces EDE023 Policy for Waste Management at Pennine Acute Hospitals

5. What is the Procedure?

Strategy to Reduce Waste To ensure a data collection system is in place for all waste streams at all Care Organisations in order to monitor waste and the success or otherwise of this waste prevention/reduction strategy.

Identify resources required to ensure correct and appropriate equipment, bins and bags are

in place.

Ensure a robust staff training and awareness programme is in place.




Provide contingency arrangements for waste disposal.

Wherever possible to identify space, equipment and facilities to allow proper segregation to

take place as a basis for making progress.

Identify no cost / low cost opportunities for preventing waste / recycling waste or waste

recovery.

Identify “quick hits” to prevent waste arising in the first place, to reduce waste and the cost

of waste disposal for the NCA.

Identify performance indicators for waste prevention, re-use, recycling, and recovery

targets across Care Organisations.

5.1 General Waste Handling and Storage Procedures

All staff must observe the following general procedures and precautions when handling waste:

Handle all waste bags and containers with care to avoid injury or risk of infection to yourself

or others.

Handle waste bags by the neck only. Do not clasp bags to the body when

moving/handling.

Use yellow numbered cable ties to identify the source of the clinical waste bags. If for

whatever reason ties are not available then you must write on the bag, using permanent

marker, to identify the hospital and ward or department

Only fill waste bags to ¾ capacity to allow tying or sealing to take place safely.

Check to ensure waste bags/containers are not split or leaking – if they are, re-package the

waste correctly.

Assemble sharps containers properly, ensuring that the lid is securely in place before

using. Indicate on label the person assembling the container, the ward / dept. and date of

assembly.

Fill sharps containers only to the indicated fill line and then seal by pulling the permanent

closure across; indicate on the label the name of the person closing the container and the

date before placing in the designated wheeled container or storage area.

Under no circumstances should sharps containers be placed in yellow wheeled containers

containing other clinical waste.

Place each separate stream of clinical waste in its dedicated yellow wheeled container

which should be tagged to identify the waste contained.

Remember under no circumstances should waste in different coloured bags or containers

be mixed together during storage or transportation as it is an offence to mix waste.

Keep all yellow wheeled containers locked at all times.




The Portering Waste Teams will ensure that the correct label is placed on the yellow

wheeled container to identify the waste contained inside it. As a failsafe the operatives

placing the wheeled containers in the main compound MUST physically lift the lid on the

wheeled containers to ensure the label attached reflects the contents, failure to do so could

lead to financial penalties.

Keep waste storage areas/containers locked and secure at all times and accessible only to

authorised persons. Each ward/department has their own bin key as have Domestics and

Porters.

Domestic waste (i.e. clear or black bags) should be stored in black / Grey, Green wheeled

containers. Any waste which cannot be stored in wheeled bins should be stored safely and

securely either in locked rooms or cupboards.

Under no circumstances should clinical waste be placed in these containers.

No waste should be stored on main corridors, along fire escape routes or blocking fire exits.

5.2 Domestic Waste (Clear or Black Bags)

The following procedures and precautions shall be followed when handling domestic waste:

Clear or black bags should be placed in the appropriate wheeled container or storage area.

Waste contaminated with patient bodily fluids must not be placed in a domestic waste bag.

Under no circumstances should domestic waste bags be mixed with any other wastes

(such as orange bags, yellow lidded sharps bins, medicinal containers or purple lidded

cytotoxic /cytostatic waste containers)

Glass must not be placed in the domestic waste bags

All domestic glass waste such as drinks bottles, coffee jars etc should be placed in an

empty cardboard box lined with a domestic waste bag.

It is recommended that these boxes be stored above waist height and not on the floor

to ensure compliance with moving and handling guidelines.

When full (taking account of the weight) the box should be sealed and marked with the

content description “glass for disposal as domestic waste”. The boxes should then be

placed with the clear/black domestic waste bags for disposal or put directly in to a

domestic

Waste wheeled container. Cardboard boxes should not be left outside as they deteriorate

quickly in adverse weather conditions.

5.3 Offensive/non infectious waste / Tiger Stripe Bags (Black & Yellow Stripe)

The following procedures and precautions will be followed when handling offensive/non-infectious waste (black & yellow stripe bags also known as tiger stripe bags):

All tiger stripe bags must have a orange numbered cable tie (identification tag) attached

before placing in the appropriate yellow wheeled bin, or designated storage area.




If numbered cable ties are not available the ward and hospital name should be written on

the bag with a permanent marker

Under no circumstances should tiger stripe bags be mixed with any other wastes (such as

clear/black bags, orange bags, yellow lidded sharps containers, blue medicinal containers

(BioBins) or purple lidded cytotoxic/cytostatic waste containers).

The wheeled bins / storage areas will be exchanged / cleared on a regular basis by the

Portering Department. However, if the wheeled bin /storage area is full and a collection is

not due, wards/departments should contact the Portering Department.

All tiger stripe bags can be disposed of via deep landfill and must not contain any clinical,

pharmaceutical, anatomical or chemical wastes, as these wastes must be disposed of by

other means

5.4 Clinical Waste / infectious Waste (Orange Bags)

The following procedures and precautions will be followed when handling clinical / infectious waste (orange bags):

All orange bags must have a orange numbered cable tie (identification tag) attached before

placing in the appropriate yellow wheeled bin, or designated storage area.



Under no circumstances should orange bags be mixed with any other wastes (such as

clear bags, yellow lidded sharps containers, blue medicinal containers (BioBins) or purple

lidded cytotoxic/cytostatic waste containers).




All orange bags (clinical/infectious waste) can be disposed of via alternative treatment and

must not contain any pharmaceutical, anatomical or chemical wastes, as these wastes

must be disposed of by incineration.

5.5 Category A infected clinical waste (Yellow Bags)

The following procedures and precautions will be followed when handling category A infected clinical waste (yellow bags):

All yellow bags must have a numbered cable tie (identification tag) attached before placing

in the appropriate yellow wheeled bin, or designated storage area.



Under no circumstances should yellow bags be mixed with any other wastes (such as clear

bags, orange bags, yellow lidded sharps containers, blue medicinal containers (BioBins) or

purple lidded cytotoxic/cytostatic waste containers).







All yellow bags Cat A infected waste (yellow) must be disposed of via incineration

5.6 Suction Containers

The following procedures and precautions must be followed when handling suction containers:

It is recommended that suction containers with solidifying gel are used.

A maximum of 2 suction containers (contents solidified) should be placed in each orange

bag.

5.7 Yellow Sharp Bins

The following procedures and precautions must be followed when handling sharps containers:

Only items that are considered to have a ‘sharp’ should be placed in these bins, NO

packaging, swabs, gauze etc.

All sealed, yellow lidded sharps bins should have the label completed before placing in the

appropriate yellow wheeled bins, or designated storage area.

Under no circumstances should yellow lidded sharps bins be mixed with any other wastes

(such as clear/black bags, orange bags, yellow bags, blue medicinal containers or purple

lidded cytotoxic/cytostatic waste containers).




5.8 Pharmaceutical Waste (Blue)

The following procedures and precautions must be followed when handling pharmaceutical waste:

Pharmaceutical waste includes both liquid and solid dose medicines, such as loose tablets,

blister packs and bottles of medicine. It also includes unused, part used and out of date

pharmaceuticals and medicinal patches.

Where appropriate, medicines that may be suitable for recycling should be returned to the

Pharmacy Department, via the secure Pharmacy bags/boxes. A list of items that can be

recycled will be provided by the Pharmacy Department; items that cannot be recycled

should be disposed of at ward level in the blue BioBins.

Pharmaceutical waste in points a. – c. (below)should be disposed of at ward level in blue

lidded rigid containers or medicinal BioBins and not returned to pharmacy

a. Any opened, part used or empty vials or ampoules that are considered to have a

‘sharp’ edge must be disposed of in yellow lid sharps bins.




b. Any opened, part used or empty vials or ampoules that are not considered to have a

‘sharp’ edge and dropped tablets may be disposed of in the medicinal blue lidded

rigid containers or medicinal BioBins.

c. Any denaturing kits used for the disposal of controlled drugs at ward level must be

placed in the medicinal BioBin or blue lidded rigid container.

All sealed, medicinal BioBins or blue lidded rigid containers should have the label

completed before placing in the appropriate yellow wheeled bins, or designated storage

area.

Under no circumstances should medicinal BioBins / blue lidded rigid containers be mixed

with any other wastes (such as clear/black bags, orange bags, yellow bags, sharps bins or

purple lidded cytotoxic/cytostatic waste containers).




5.9 Pharmaceutically Contaminated Waste

The following procedures and precautions must be followed when handling pharmaceutically contaminated waste e.g. part used infusions/injections, broken ampoules, empty medicine bottles and IV bags, tubing, etc contaminated with pharmaceuticals).

This waste shall be disposed of at ward level and not returned to Pharmacy:

Pharmaceutically contaminated waste includes items such as: IV bags and tubing – this

waste must NOT be placed in orange bags destined for alternative treatment it should be

placed in the blue BioBins

Any pharmaceutically contaminated waste that has a ‘sharp’ must be disposed of in yellow

lid sharps bins.

De-sharping of any kind is not permitted

Any pharmaceutically contaminated waste that does NOT have a ‘sharp’ must be disposed

of in a medicinal BioBin / blue lidded rigid container.

All sealed, medicinal BioBins or blue lidded rigid containers should have the label

completed before placing in the appropriate yellow wheeled bins, or designated storage

area.




5.10 Non-pharmaceutically Active IV fluid Waste

The following procedures and precautions must be followed when handling non-pharmaceutically active intravenous (IV) fluids:




Non-pharmaceutically active IV fluids include saline and glucose (without any

pharmaceuticals added).

The liquid content from non-pharmaceutically active IV fluid bags may be discharged to foul

sewer and the empty packaging containing a sharp should be placed in the yellow lidded

sharps bin, with large aperture.

All sealed, yellow lidded sharps bins should have the label completed before placing in the





Quantities of non-pharmaceutically active IV fluids should not be placed into the domestic

waste stream as the disposal of liquids to landfill is not permitted.

Care should be taken to ensure that no leakages occur during disposal.

5.11 Anatomical & Blood Contaminated Waste (Red)

The following procedures and precautions must be followed when handling anatomical or blood contaminated waste:

Anatomical waste must be disposed of in red lidded rigid containers.

Any blood bags, containing blood as a liquid, that contain a sharp must be disposed of in a

yellow lidded sharps bin, with large aperture.

Any blood bags, containing blood as a liquid, without a sharp must be disposed of in red

(anatomical) lidded rigid containers.

Any empty blood bags, including those that may have trace elements of blood, if containing

a sharp, should be disposed of in a yellow lidded sharps bin, with large aperture.

Any empty blood bags, including those that may have trace elements of blood, without a

sharp, should be placed orange clinical waste bags.

De-sharping of any kind is not permitted

All sealed, red lidded rigid containers should have the label completed before placing in the


Under no circumstances should red lidded containers be mixed with any other wastes

(such as clear/black bags, orange bags, yellow bags, sharps bins, blue medicinal

containers or purple lidded cytotoxic/cytostatic waste containers).







5.12 Cytotoxic/Cytostatic Waste (Purple)

The following procedures and precautions must be followed when handling cytotoxic/static waste:

Check the cytotoxic/cytostatic waste information poster provided by Pharmacy to determine

which medicines are classed as ‘cyto’ (see Appendix 2).If your ward/department does not

have a cytotoxic/cytostatic waste poster, contact the Pharmacy Department

All sharp or medicinal items contaminated with cytotoxic/cytostatic pharmaceuticals should

be placed in purple lidded cytotoxic/cytostatic waste containers and the label on the

container completed in full.

All ‘soft’ items contaminated with cytotoxic/cytostatic pharmaceuticals should be placed in a

yellow bag which has a purple stripe or purple writing on it.

All ‘cyto’ waste bags should be sealed using a numbered yellow cable tie

All cytotoxic/cytostatic waste bags/containers must be stored separately to other wastes in

the ward/department.The Portering Department should be contacted to arrange a separate

collection of this waste.

‘Cyto’ bags and/ or purple lidded containers must not be mixed with any other wastes (such

as clear/black bags, orange bags, yellow lidded sharps bins or blue medicinal containers).

Cytotoxic and Cytostatic medicines appearing on the Cytotoxic/Cytostatic medicines list

that are not suitable for reuse should be disposed of at ward level

5.13 Confidential Waste

The following procedures and precautions must be followed when handling confidential waste:

All confidential paper waste should either be shredded by a cross cut shredder or disposed

of in red confidential waste bins.

If confidential paper waste is cross-cut shredded, it should be placed in the waste paper

recycling stream.

In the main, locked red bins should be used, however, where large or bulky volumes are

generated an open red bin can be provided

The confidential waste red bins must be kept secure at all times. Bins must not be left in

any areas accessible to the general public

Everybody using the confidential waste red bin is responsible for its security

Contact the Portering Department when the red bins require emptying / exchanging

It is important that the confidential waste bins are located in an area where the bin and its

contents do not present a fire hazard e.g. blocking emergency exits (for further advice

contact the Fire Officer on your site).




For non-paper confidential waste disposal (i.e. x-rays, videos, CDs, DVDs etc) the

Portering & Waste Manager should be contacted.

If any items placed in the red bins require retrieval please contact the Portering & Waste

Manager

Return all computer hard drives, floppy discs and other computer storage items to IM&T to

be wiped clean and destroyed

5.14 Waste Paper (non-confidential)

The following procedures and precautions must be followed when handling waste paper:

All non-confidential waste paper (including cross cut shredded confidential waste) should

be disposed of in green 240L wheelie bins.

Contact the Portering Department when the green bins require collecting / exchanging

Green bins must not be left in any areas accessible to the general public. It is important that

the green waste paper bins are located in an area where they do not present a fire hazard

e.g. blocking emergency exits (for further advice contact the Fire Safety Advisor at your

Care Organisation).

5.15 Cardboard

The following procedures and precautions must be followed when handling cardboard waste:

Empty cardboard boxes must, wherever possible, be flat packed by the person disposing of

the box

Any boxes held together by large industrial staples should not be flat packed due to the risk

of injury

Flat packed cardboard waste should either be placed in designated storage areas, returned

to the ‘stores’ cage or placed in designated ‘cardboard waste’ wheeled containers where

available.

It is important that the cardboard does not present a fire hazard e.g. is accessible by the

general public or blocking emergency exits (for further advice contact the Fire Safety

Advisor).

5.16 Printer inkjet cartridges

The following procedures and precautions must be followed when handling printer inkjet cartridges:

Used printer cartridges, with all external packaging removed, should be taken to the

identified storage point(s) on site or to the Portering Department.

5.17 Large, bulky waste items, medical equipment and electrical/electronic equipment

The following procedures and precautions must be followed when handling large bulky items, medical equipment or electrical / electronic waste:




Wards and departments should contact the Portering Department if they require the

removal of large, bulky waste items (e.g. furniture and non-medical equipment) for disposal.

Any items awaiting collection by the Portering Department for disposal must be stored

within the ward/department. They should not be left on corridors, where they may restrict

general access, fire escape routes and fire exits.

For items of medical equipment, EBME/MEMS should be contacted for advice.

Any items of equipment being sent to EBME/MEMS for disposal must first be

decontaminated by the ward/department. A completed Decontamination Certificate must

accompany the item.

5.18 Waste Chemicals

The following procedures and precautions must be followed when handling waste chemicals:

All chemicals used should be disposed of safely and properly, with advice sought from the

Portering & Waste Manager when required.

COSHH data sheets should be consulted and risk assessments undertaken to determine

the hazardous properties of each chemical substance used and disposal

recommendations.

Under no circumstances should any chemicals or associated containers be disposed of in

the clinical or domestic waste streams, guidance should be sought from Portering & Waste

Manager

Users of chemicals should be aware that all chemical containers, unless completely empty

(i.e. rinsed out) are generally contaminated and classified as the chemical they contain,

unless determined otherwise by risk assessment

Any waste chemicals, paints and solvents awaiting collection must be stored in a secure

area (preferably in a designated, chemical store). Care should be taken to ensure that no

incompatible products are stored together.

5.19 Fluorescent Tubes

The following procedures and precautions must be followed when handling waste fluorescent tubes:

Fluorescent tubes are removed from wards/departments by Estates staff for recovery by a

specialist contractor.

All fluorescent tubes for disposal must be stored in the specially designed containers in the

Estates Department compound – under no circumstances must tubes be placed on the

ground (where they could smash and leach hazardous substances)

The fluorescent tube containers must be kept secure at all times.

Arrangements will be made by the Estates Department for a collection or onsite disposal of

fluorescent tubes, when the containers are nearly full.




A hazardous waste consignment note must be completed by Estates staff and the disposal

contractor for every movement of waste and records maintained for at least 3 years. A copy

of the hazardous waste consignment notes should forwarded to the Portering Manager for

inclusion in the hazardous waste consignment note site register.

5.20 Batteries

The following procedures and precautions must be followed when handling battery waste:

All batteries are deemed to be hazardous and must be segregated from other waste

streams and arrangements made to take them to the Estates Department who will arrange

for an authorised contractor to collect them for disposal. They must not be disposed of as

domestic or clinical waste.

All batteries should be removed from redundant medical equipment, prior to disposal.

Any batteries contaminated with body fluids, will require decontamination prior to disposal.

All spent, portable batteries used by EBME/MEMS must be taken to the Estates

Department for disposal via their battery recycling arrangements

All spent, portable batteries used by the Estates Department must be placed in the battery

recycling container.

When the battery container is nearly full, Estates will contact an approved contractor to

arrange a collection.


contractor for each collection and records maintained for at least 3 years. A copy of the

hazardous waste consignment notes should forwarded to the Portering Manager for


All spent, portable batteries used by the IM&T Department must be taken to the recycling

point in the Estates Department

5.21 Radioactive Waste

Wards / Departments disposing of patient derived waste generated by in-patients that have

been injected with radioactive material should ensure that the waste is segregated and

retained for 72 hours to allow it to dissipate, before placing it in the orange bag clinical

waste stream.

Information and advice relating to this waste stream is available by contacting the Nuclear

Medicine Department

Any spillages of this waste stream should be dealt with according to the departmental

procedures.

In the event of a suspected or known leakage of radioactive waste (including patient

derived), Nuclear Medicine and the Portering & Waste Manager must be informed and will

notify the Environment Agency when necessary.




5.22 Infectious Diseases – Category ‘A’ Pathogens

Handling of Waste in the Isolation Unit

A heavy duty yellow clinical waste bag will be used from the onset. When ¾ full, the yellow

bag is tied off and placed inside another yellow waste bag containing absorbent granules,

this bag is then tied off. Cable ties should be used to secure both waste bags. Care must

be taken when tying off the waste bags to ensure that they will fit easily inside a 60L

container.

Utilizing the buddy system, the sealed bag is placed carefully by the nurse within the room

(wearing appropriate PPE) into the 60 litre container. The container does not enter the

contaminated room but stays within the ‘clean’ area directly outside the patients’ room

The 60 litre container, when full, must be locked by the ‘buddy’ nurse in the ‘clean’ area,

and then wiped with either Chlor-Clean 1,000ppm or Virusolve Plus.

If the containers require collection while results are awaited the Portering Department will

provide a 770L yellow wheeled bin, the sealed yellow containers should be placed in the

bin which should then be locked. The Porter will then remove the 770L bin to an agreed

secure location.

If VHF positive the Category ‘A’ waste special collection procedure must be triggered by

contacting the Waste Management Co-ordinator

Collection of Waste from the Isolation Unit

If results are VHF negative the sealed yellow containers or bags should be collected by the

Portering Department in a 770L yellow wheeled bin and identified as infectious waste using

the appropriate label and taken to the main compound to be included in scheduled

collections.

If results are VHF positive the Portering Department will provide a 770L yellow wheeled bin,

the sealed yellow containers should be placed in the bin which should be locked. The

Porter will then remove the 770L bin to a secure location for special collection.

Security

Security must be contacted to oversee all movements of Category ‘A’ 770L bins from the

isolation area to the secure storage container and also for all collections by the approved

contractor from the secure storage container.

Siting of Secure Waste Storage Containers

The storage containers must only be sited in an agreed area as close as possible to

Isolation Unit to limit the distance it will have to be transported. The storage container must

be secured with a high security level padlock and be covered by CCTV.

Collection for Disposal




The Portering & Waste Manager will complete the required documentation in liaison with

the contractor to allow safe collection, transportation and disposal of the waste.

5.23 Theatres

Set up waste

Set up waste is clean packaging, etc produced during the “set up” of theatres, prior to the

patient entering the clinical area. This waste must be disposed of in a recycling container

for paper or in domestic waste bags.

Suction Containers

It is recommended that suction containers with solidifying gel are used. A maximum of two

(solidified) suction containers should be placed in each orange bag for disposal.

Human tissue, limbs, organs and teeth

Where limbs or organs require disposal, they should be carefully packaged in appropriate

sized red lidded sealed containers and labelled “anatomical waste”.

Placentas for disposal should be placed into small, yellow, plastic bags and then into the

red lidded placenta bins.

The sealed units/placenta bins must be labelled identifying the origin of the waste and date.

The sealed containers / placenta bins should be placed into dedicated anatomical waste

yellow wheeled bins.

The yellow wheeled containers containing anatomical waste should be moved to the main

collection compound as soon as possible to avoid unpleasant odours.

Under no circumstances should sealed units/placenta bins be placed in the yellow wheeled

bins used for clinical infectious (orange) waste bags or any other waste.

Anatomical waste will be collected by the waste contractor on a regular basis from the main

waste compound.

Teeth not containing amalgam may be disposed of as non-anatomical waste, in the general

infectious waste stream (orange bags), providing they are not sharp. Any teeth that are

sharp should be placed in a sharps container for disposal.

Any teeth containing amalgam should be disposed of with other amalgam waste and sent

for recovery via a specialist contractor. The Waste Management Co-ordinator should be

contacted for advice

Radioactive/Radio-isotope Waste

Any radioactive waste must be securely segregated and retained for 72 hours to allow it to

dissipate, before placing it in the orange bag clinical waste stream.




5.24 Obstetrics and Gynaecology

Placentas

Placentas for disposal should be placed into small, yellow, plastic bags and then into the

red lidded placenta bins.

When the placenta bins are full they should be sealed, labelled with the ward/department

details and date and placed in dedicated anatomical waste yellow wheeled bins.

Under no circumstances should red lidded placenta bins be placed in the yellow wheeled

bins used for clinical infectious (orange) waste bags / containers or any other waste.

The yellow wheeled containers containing anatomical waste should be moved to the main

collection compound as soon as possible to avoid unpleasant odours.

Anatomical waste will be collected by the waste contractor on a regular basis from the main

waste compound

Foetal tissue and remains

Disposal of foetal tissue and remains will be managed in accordance with the NCA

“Guideline for the Sensitive Disposal of Foetal Tissue up to 24 Completed Weeks

Gestation” (CPWC010) available on the Alliance Intranet.

Waste produced from home births

Placentas for disposal should be placed into small yellow plastic bags and then into the red

lidded “placenta bins”.

All associated clinical infectious waste produced from the home birth should be placed into

an orange rigid container, sealed and labelled with the patient’s NHS number.

The orange rigid container and red lidded placenta bin should then be removed by the

midwife for disposal at his/her base.

The orange container must be placed in a designated infectious waste yellow wheeled bin

The red lidded placenta bin must be placed in a designated anatomical waste yellow

wheeled bin.

Any sharps used during the birth should be placed in the midwife’s sharps container, which

will be removed by the midwife. Once the sharps container is full, it should be sealed,

labelled with the midwife’s name and taken by the midwife for disposal at his/her base in a

designated sharps waste yellow wheeled bin.

It is important to note that all clinical/infectious waste being transported in community staff

vehicles, must be contained within UN approved rigid containers (this includes sharps

containers, placenta bins and orange rigid containers). Loose waste bags (orange or

yellow) are not appropriate.




5.25 Pharmacy

General medicines

The outer packaging (i.e. cardboard boxes) should be removed from all waste

pharmaceuticals and be placed in the confidential waste stream if containing patient details

or recycled as waste paper/card if not.

Solid dose medicines must not be “de-blistered” prior to disposal, as this constitutes waste

treatment which is a licensable activity. The tablets, including the foil blister packs must be

disposed of together and placed in the blue pharmi bins / medicinal BioBins.

Any liquid pharmaceuticals must be disposed of in their bottles/containers which should be

placed in the blue pharmi bins / medicinal BioBins.

The Pharmacy Department must ensure that all medicinal containers (blue lidded pharmi

bins / medicinal BioBins) are placed in the appropriate yellow wheeled container in the

pharmacy disposal room / waste compound.

Cytotoxic / Cytostatic waste

A list of the cytotoxic/static pharmaceuticals should be displayed in the Pharmacy

Department.

Any additions / deletions to the list should be circulated to all wards and relevant

departments.

A copy of any updated lists should be provided to the Waste Management Co-ordinator

who will provide a copy for the clinical waste contractor.

Pharmacy must ensure that all cytotoxic/cytostatic waste containers from the department

are placed in the appropriate yellow wheeled container in the pharmacy disposal room /

waste compound.

Feeds/Nutritional Supplements

The liquid content from waste feeds/nutritional supplements may be discharged to foul

sewer and the empty packaging placed in the domestic waste stream.

Quantities of liquid feed/nutritional supplements should not be placed into the domestic

waste stream as the disposal of liquids to landfill is not permitted.

Care should be taken to ensure that no leakages occur during disposal.

Disposal to sewer

Checks should be made of the Alliance’s Discharge Consent (issued by the local Water

Company) prior to any pharmaceutical waste being disposed of to sewer/sink, etc.

Saline and glucose solutions are considered inert and may be disposed of to sewer.

Disposal of empty containers




Any empty containers/primary packaging which have contained cytotoxic/static

pharmaceuticals should be disposed of into the cytotoxic waste stream

Any empty containers/primary packaging which has contained pharmaceuticals which are

non- cytotoxic/cytostatic, should be disposed of into the medicinal waste stream.

Controlled Drugs

All waste controlled drugs must be rendered irretrievable (i.e. by denaturing) prior to

disposal.

Denatured controlled drugs should be disposed of in the medicinal waste stream.

Under no circumstances must controlled drugs be flushed to sewer

Controlled and Recorded Drugs that are suitable for re-use should be returned to pharmacy

by a registered pharmacist or pharmacy technician. Controlled and Recorded Drugs that

are not suitable for re-use should be disposed of in accordance with the EDC025 Policy for

the ordering, storage and administration of Recorded Drugs

5.26 Pathology Department

General

All offices, kitchens, toilets and non-laboratory areas within the Pathology Department

should have domestic waste bins only. Sanitary bins should be provided in female toilets as

required.

Domestic waste bins should be provided adjacent to all hand wash sinks, for the disposal of

wet, non-infectious paper hand towels.

Uncontaminated glass e.g. coffee jars, should be placed in a cardboard box lined with a

clear bag

to prevent seepage, marked ‘glass for disposal’ and placed in the domestic waste stream

Orange bags should be used for any infectious or potentially infectious waste that is not

contaminated with anatomical items, chemicals or pharmaceuticals

Yellow bags should be used for chemically contaminated waste, however, contaminated

glass items should be placed in yellow lidded rigid containers.

Sharps bins should be used for any sharp items including contaminated broken glass

Medicinal BioBins or blue containers should be used for medicinally contaminated waste

Further information is provided in the Department of Pathology’s ‘Treatment and Disposal

of Laboratory Waste’ (P-HS-2).

5.27 Autoclaves

All autoclaved waste should be placed into orange bags for disposal. In the event of the

autoclave breaking down, all of the waste which would normally be autoclaved (i.e.




microbiological cultures, specimen containers, etc) must be placed in heavy duty, yellow

plastic bags for disposal via incineration only.

Separate 770 litre bins should be identified and used for the containment of the waste, the

orange bag waste bin should be tagged for alternative treatment and the yellow bag waste

bin tagged to identify disposal by incineration only.

5.28 Human tissue/anatomical waste – Histology

All samples, specimens, biopsies of human tissue/anatomical waste must be kept

segregated from all other types of waste.

These items should be placed in red lidded rigid plastic containers for disposal. The label

on the container must be completed in full

The full containers must be placed in a yellow ‘anatomical’ waste wheeled bin.

5.29 Human tissue/anatomical waste – Mortuary

All items of human tissue/anatomical waste must be segregated from all other types of

waste.

These items should be placed in red lidded rigid plastic containers for disposal.

The label on the container must be completed in full

The full containers must be placed in a yellow ‘anatomical’ waste wheeled bin.

5.30 Chemically Contaminated Waste

This waste should be segregated from all other types of waste

Non-glass chemically contaminated waste should be placed in yellow bags for disposal,

secured with a yellow numbered cable tie

Glass chemically contaminated waste should be placed in yellow lidded rigid containers

with the label completed in full / if no label a yellow numbered cable tie should be used to

identify the origin of the waste

Users of chemicals should be aware that all chemical containers, unless completely empty

(i.e. totally rinsed out) are generally contaminated and classified as the chemical they

contain, unless determined otherwise by risk assessment.

Both yellow bags and yellow containers must be placed in a yellow ‘chemical’ waste

wheeled bin

5.31 Unused Kits and Reagents

Under no circumstances must any chemicals be disposed of to sewer, unless supported by

a relevant Discharge Consent (issued by the local Water Company). An up to date copy of

the Discharge Consent should be available within the Pathology Department.




An audit and risk assessment of all liquids discharged to sewer should be undertaken by all

laboratories. For those machines discharging dilute substances to sewer, checks should be

made of the above Discharge Consent.

COSHH Data Sheets should be consulted and risk assessments undertaken to determine

the hazardous properties of each chemical substance used and disposed

recommendations

All chemicals used should be disposed of safely and properly, with advice sought from the

Health & Safety Adviser or Waste Management Co-ordinator, as and when required.

Any waste chemicals awaiting collection must be stored in a secure area (preferably in a

designated chemical store). Care should be taken to ensure that no incompatible products

are stored together.

When hazardous chemical waste needs to be collected a full list, detailing the product,

packaging and any approximate volume remaining, should be sent to the Waste

Management Co-ordinator who will arrange a collection by an appropriately licensed

contractor.

A waste consignment note must be completed by Pathology staff and the disposal

contractor for every movement of waste and records maintained for at least 3 years – the

chemical waste contractor will supply this paperwork and assist staff with its completion. A

copy of the consignment note should be sent to the Portering manager for inclusion in the

site register.

5.32 Sharps

All sharps must be disposed of in a sharps bin

The label on the bin must be completed on assembly and again when closed for collection.

The sharps bins should be placed in a designated holding area for collection by Portering

staff who will then place them in a yellow ‘sharps’ waste wheeled bin

Note: There is a full managed service of reusable sharps across the wards and dept’s at Salford Royal

5.33 Medicinally Contaminated Waste

All medicinally contaminated waste must be placed in a medicinal BioBin (blue) or a blue

rigid container

The label on the BioBin or container must be completed in full when closed for collection.

Care should be taken to ensure that the medicinally BioBin is not too heavy to be collected.

The medicinal BioBin / blue containers should be placed in a designated holding area for

collection by Portering staff who will then place them in a yellow ‘medicinal’ waste wheeled

bin




5.34 Maxillo-facial Unit

Orthodontic wires

Orthodontic wires should be disposed of as sharps waste, into the yellow lid sharps

containers.

Teeth

Teeth not containing amalgam may be disposed of as non-anatomical waste, in the

infectious waste stream (orange bags), providing they are not sharp. Any teeth that are

sharp should be placed in a sharps container for disposal.

Any teeth containing amalgam should be disposed of with other amalgam waste and sent

for recovery via a specialist contractor.

5.35 Radiology

Film recovery

Old x-ray film being sent for silver recovery should be packaged securely and safely

according to the contractor’s requirements.

Waste transfer note must be completed by Radiology staff and the disposal contractor for

every movement of waste and records maintained for at least 2 years.

Barium enemas

Under no circumstances should barium enemas be disposed of into sinks/WCs

Bags should be clipped and placed in rigid yellow sealed units for disposal.

Radioactive/radio-isotope waste

Wards / Departments disposing of patient derived waste generated by in-patients that have

been injected with radioactive material should ensure that the waste is segregated and

retained for 72 hours to allow it to dissipate, before placing it in the orange bag clinical

waste stream.

Information and advice relating to this waste stream is available by the contacting Nuclear

Medicine Department

Any spillages of this waste stream should be dealt with according to the departmental

procedures.

In the event of a suspected or known leakage of radioactive waste (including patient

derived), Nuclear Medicine and the Waste Management Co-ordinator must be informed.

The Portering & Waste Manager will notify the Environment Agency when necessary.

5.36 A & E / Fracture Clinic

Gypsum




Gypsum waste must be segregated and disposed of separately to other waste streams.

The bag / box should be labelled “Gypsum Waste” and The Portering Department

contacted to arrange a special collection, they will take it to the designated ‘gypsum’ yellow

wheeled container

5.37 Community Services - Treatment in Patients’ Homes

Infectious Waste

This is clinical waste arising from a patient known or suspected to have an infection or

where an infection is not known or suspected, but a potential risk of infection is considered

to exist.

Infectious waste must be placed into rigid orange containers

Any infectious bodily fluids (not solidified) should be placed into rigid yellow containers

Rigid containers must be sealed and left with the patient for collection

DNs must follow the procedure for registering collections from a patient’s home

Sharps Waste

sharps used must be placed in a sharps bin for disposal and be returned to the DNs base

for disposal

Medicinal Waste

Patients or their carers / relatives should return waste/medicines no longer required to their

local community pharmacist.

Any medicinal waste generated by the District Nurse should be placed in a blue rigid

container and returned to the DNs base for disposal.

DOOP kits used to denature Controlled Drugs should be placed in a blue rigid container

and returned to the DNs base for disposal.

Cytotoxic / Cytostatic Waste

Patients or their carers / relatives should return waste/medicines no longer required to

Christies or their local community pharmacist.

Any ‘cyto’ waste generated by the District Nurse should be placed in a purple rigid

container and be returned to the DNs base for disposal

Non-Infectious Waste

Any waste generated by the DN should be bagged and given to the patient for them to

place in their domestic waste bin.

Disposal of Collected Waste from Patients Homes




The collection driver will maintain the segregation of the waste and return to their base. The

waste will then be placed into the appropriate designated containers sited in the main

waste compound at North Manchester General Hospital. When full they will be collected

with the other clinical waste containers from the hospital.

5.38 Waste Generated in Health Centres / Clinics

The Alliance has a service level agreement with NHS Property Services covering HCs and

clinics in the North Manchester area. The North Manchester CO pays them for the waste

services provided and all NCA staff working in these areas should comply with the

requirements of the NHS Property Services’ Waste Policy.

5.39 EBME / MEMS Department

General Medical Equipment

Wards/departments discarding medical equipment of any kind should ensure that the

equipment has been cleaned and/or decontaminated prior to removal and a

decontamination status certificate must be completed prior to devices being removed from

the area of use.

EBME/MEMS may be able to refurbish or redeploy the equipment. If the equipment is

obsolete or condemned EBME/MEMS will dispose of it via a reputable and assessed

contractor. All medical equipment disposal / recycling will be in accordance with Waste

Electronic and Electrical Equipment (WEEE) regulations.

Any items of equipment considered beyond repair will be removed from the NCA Asset

Register prior to disposal.

All removable hazardous components, i.e. batteries, should be removed from the

equipment prior to disposal/recovery

Items of WEEE should be placed in the WEEE storage area. Non WEEE items should

either be placed in the general waste open skip or scrap metal skip.

Disposal of equipment via the manufacturer will require appropriate documentation (i.e.

waste transfer/consignment notes).

Any items of usable, but redundant medical equipment will be sold by EBME/MEMS via an

appropriate third party. Such items of equipment must have all removable hazardous

components, i.e. batteries, removed from the equipment prior to being resold.

Equipment Containing / Contaminated With Mercury

EBME/MEMS should be advised of any redundant and/or broken equipment containing /

contaminated with mercury, who will arrange for it to be collected.

EBME/MEMS will liaise with Pharmacy for the disposal of mercury




Where possible EBME/MEMS will remove the mercury containing part or any leaking

mercury and store it in an appropriate container in the department’s fume cupboard. If

necessary a mercury spillage kit will be used.

The Waste Management Co-ordinator should be contacted to arrange a collection of

mercury waste, as and when required.

A hazardous waste consignment note must be completed by EBME/MEMS staff and the

disposal contractor for every movement of waste and records maintained for at least 3

years.

Copies of any hazardous waste consignment notes should be sent to the Portering

Manager for inclusion in the hazardous waste consignment note site register.

Batteries

All batteries should be removed from redundant medical equipment, prior to disposal.

Any batteries contaminated with body fluids, will require decontamination prior to disposal.

All spent, portable batteries used by EBME/MEMS must be taken to the Estates

Department for disposal via their battery recycling arrangements.

5.40 Estates Department

General Waste Skip

The general waste open skips should only be used for waste which cannot be compacted,

such as broken furniture and other large, bulky items, as well as non-hazardous Estates

Department wastes such as air filters.

The open skips should be kept secure at all times to prevent unauthorised use and fly-

tipping.

Arrangements will be made by the Estates Department or Porters for a collection/exchange

of the skip when it is full or nearly full.

The waste contractor provides a collection note each time a collection of the skip/container

occurs. The collection note must be signed by a member of the Estates / Portering

Department and a copy kept as a record.

An annual waste transfer note is provided by the contractor for this waste stream. These

records must be maintained for at least 2 years.

Batteries

All spent, portable batteries used by the Estates Department must be placed in the battery

recycling container.

When the battery container is nearly full, Estates will contact an approved contractor to

arrange a collection.


contractor for each collection and records maintained for at least 3 years. A copy of the






Fluorescent tubes

All fluorescent tubes for disposal must be stored in the specially designed containers in the

Estates Department compound – under no circumstances must tubes be placed on the

ground (where they could smash and leach hazardous substances).

The fluorescent tube containers must be kept secure at all times.

Arrangements will be made by the Estates Department for a collection or onsite disposal of

fluorescent tubes, when the containers are nearly full.





Waste electrical and electronic equipment (WEEE)

It is the responsibility of various wards/departments to ensure that all WEEE items are

removed from the NCA Asset Register (where relevant) and are suitably decontaminated

(where relevant).

Storage containers/areas are available on each site for WEEE items. Segregation of

hazardous WEEE for example fridges, and non-hazardous WEEE must be maintained at all

times.

Any removable hazardous components, e.g. batteries, should be removed prior to storage.

Arrangements will be made by the Estates Department for a collection of WEEE, when

there is a sufficient amount for removal.

It should be noted that the contractor used will arrange for the recovery/recycling of items

and their components where possible.

A hazardous waste consignment note or waste transfer note must be completed by Estates

staff and the disposal contractor for every movement of waste and records maintained for

at least 3 years (hazardous) or 2 years (Non-hazardous). A copy of the hazardous waste

consignment notes should forwarded to the Portering Manager for inclusion in the

hazardous waste consignment note site register.

Chemicals, Paints and Solvents

All chemicals, paints and solvents used should be disposed of safely and properly, with

advice sought from a suitably qualified person as and when required.

COSHH Data Sheets should be consulted and risk assessments undertaken to determine

the hazardous properties of each chemical substance used and disposal recommendations




Under no circumstances should any chemicals, paints or solvents or associated containers

be disposed of into the clinical or domestic waste streams, without risk assessments being

undertaken or guidance sought from a suitably qualified person.

Users of chemicals, paints and solvents should be aware that all associated containers,

unless completely empty (i.e. rinsed out) are generally contaminated and classified as the

substance they contain, unless determined otherwise by risk assessment.

Any waste chemicals, paints and solvents awaiting collection must be stored in a secure

area (preferably in a designated, chemical/flammable store). Care should be taken to

ensure that no incompatible products are stored together.

The Estates Department will contact a appropriately licensed contractor to collect and

dispose of waste chemicals, paints and solvents

A waste consignment note must be completed by Estates staff and the disposal contractor

for every movement of waste and records maintained for at least 3 years. A copy of the



Scrap metal

All scrap metal items must be placed in the appropriate scrap metal skip.

All scrap metal in the skip/storage area must be stored securely.

Collections will be made by arrangement with a licensed scrap metal dealer

A waste transfer note must be completed by staff and the disposal contractor for every

movement of waste and records maintained for at least 2 years.

Contractors waste

Arrangements should be made in all contractual documents agreed with third parties

carrying out works on the Care Organisation site for the disposal of waste.

Where feasible, contractors should be made responsible for the disposal of their own

waste.

It is essential that all contractors use reputable, fully licensed/permitted disposal companies

and that the appropriate legal paperwork (such as waste transfer/consignment notes) is

provided.

It is recommended that the NCA (Estates Department) receives a copy of any such legal

paperwork.

All contractors must agree a suitable, safe and secure location for any waste containers

(e.g. skips, FELs etc) with the Estates and Facilities Departments.




It remains the contractor’s responsibility to ensure the security of the waste containers

whilst they are located on NCA property and it is therefore suggested that all waste

containers are lockable or can be made secure in some way.

Under no circumstances must contractors be allowed to dispose of waste items in the Care

Organisation’s clinical or domestic waste bins.

Asbestos waste

Asbestos waste must be dealt with by a specialist waste contractor. This service is

arranged by the Estates Department.





5.41 Catering Department

Food Waste

Where possible, food waste should be disposed of via waste disposal units located in the

kitchen areas.

Where a waste disposal unit is not available, food waste should either be returned to the

main kitchen for disposal or double bagged and collected with general waste for disposal

Cooking Oil

Under no circumstances must use cooking oil be disposed of via the sink/sewer or into

clear domestic waste bags.

Waste cooking oil must be poured back in to the original container and placed in the

external secure waste store, ready for collection by the waste oil contractor.

In the event of a spillage of cooking oil, the spillage must be dealt with immediately using

the appropriate spillage kit.

A waste transfer note must be completed by Catering staff and the disposal contractor for


5.42 IM&T Department

IM&T Equipment

For any unwanted or faulty IT equipment contact the IM&T Department who will arrange

collection and provide a receipt. This will only be done on request.

The hard drives of all computers are destroyed by the IM&T Department.




The IM&T Department will arrange for the secure storage of all IT equipment awaiting

disposal and will arrange collection and disposal by an appropriately licensed contractor.

A waste transfer note must be completed by IM&T staff and the disposal contractor for


Batteries

All spent, portable batteries used by the IM&T Department must be taken to the recycling

point in the Estates Department

5.43 Waste from Third Parties

Other NHS Trusts on NCA premises

Where other NHS Trusts are based on Northern Care Alliance premises and have their

waste collected and disposed of via the Care Organisation no legal paperwork is required

to transfer the waste between the 2 parties. However the other NHS Organisation must

supply a description of the wastes concerned. It is recommended that this information is

provided on an annual basis.

Other Trusts must register as Hazardous Waste Producers with the Environment Agency, if

they produce 500 kg or more hazardous waste over a 12 month period, regardless of

whether the Trust manages their waste or they make their own arrangements. Information

relating to Hazardous Waste Producer registration should be supplied to the Northern Care

Alliance

Information must be supplied to the waste contractor to indicate that waste from other

Trusts is included within the NCA waste being sent to them.

Wastes from North West Ambulance NHS Trust

The North West Ambulance Service retain their own waste and dispose of it at their base site.

Waste from the general public

Waste brought to our Care Organisations by the general public, must not be accepted by

wards and departments unless the item originated here e.g. sharps bins provided to

patients.

Members of the general public should be instructed to take their sharps waste to either their

own GP or local community Pharmacy. Pharmaceutical waste should be taken to their

local community Pharmacy.

Patients producing waste in their own homes should be instructed to contact their Local

Authority or healthcare worker for advice relating to waste collection and disposal.




6. Roles and responsibilities

6.1 Domestic Staff are responsible for the emptying of domestic waste bins, tying the bags

and removal to the relevant waste storage area. Domestic Staff will observe the following

procedures and precautions when handling and moving waste:

Remove from the pedal bins any clinical waste bags that are ¾ full, securing the neck of the bag with a numbered cable tie (if for whatever reason cable ties are not to hand the origin of the waste must be written on the bag with a permanent marker)

Will place the clinical waste bags in the designated wheeled containers or segregated from other waste in the clinical waste disposal room

Will ensure that clinical waste wheeled containers are locked after use.

Will have access to keys for clinical waste wheeled containers.

Will regularly clean the ward/department pedal bins and keep the waste storage areas clean and tidy.

Will ensure that adequate supplies of the numbered cable ties used to identify the origin of waste bags are available at all times.

Will not be permitted to handle sharps bins, medicinal containers or ‘Cytotoxic / Cytostatic bags or containers, this is the responsibility of nursing (or other clinical support) staff.

6.2 Portering Department are responsible for the collection of various waste streams from

wards/departments and for the transportation of these wastes to dedicated storage

compounds. They will observe the following procedures and precautions when handling

and moving waste:

Will not remove any sharps containers or cyto bins which have not been securely sealed and labelled by ward/department staff

Shall not remove any clinical (orange), Cyto (yellow/purple) or domestic waste bags which are split and/or leaking, until the contents have been re-bagged by ward/department staff.

Will have access to bin keys and must ensure that all bins being transported / stored for collection are locked.

Will ensure that the brakes are applied to all bins sited internally or externally.

On delivery of new, clean bins from the clinical/infectious waste contractor(s) the porters will check that all bins can be locked and are generally in good repair. Where this is not the case the bin(s) must be rejected and a “Bin Fault” tag attached.

Will ensure that all clinical waste wheeled containers have the appropriate label attached to the bin to reflect the waste stream they contain, prior to collection of the bin by the waste contractor. A visual check should be made.

Will be responsible for the completion of the waste consignment notes for the removal of all clinical waste; further guidance is provided in the appendix 3. Wastes will not be collected from site by our contractor without a completed hazardous waste consignment for each collection.




Internal waste collections will be carried out on a regular, scheduled basis for clinical and domestic waste streams, although ad hoc collections may be requested where required.

Additional collections will be made for special waste streams such as cytotoxic /

cytostatic waste.

For bulky wastes, such as waste electrical and electronic equipment (WEEE) etc

collections are generally made on an ad hoc request basis by wards/departments

and should be completed as soon as practically possible.

Will be responsible for ensuring that all requests for confidential paper waste red

bins are carried out as soon as possible and all full bins are collected and

transported to the designated collection point.

Will be responsible for ensuring that all requests for non-confidential paper waste

green bins are carried out as soon as possible and all full bins are collected and

transported to the designated collection point.

Will be responsible for ensuring that the waste compound is kept clean, tidy and secure at all times.

Will ensure that the waste compactor is secured when not in use, to prevent unauthorised access.

It is recommended that when the compactor is removed for emptying, porters

should clear the waste compound of any loose waste/litter, etc. It is essential, wherever possible, that the handover of the clinical waste to the

contractor is supervised by a member of the Portering Department.

6.3 Operation of Waste Handling Equipment

All relevant staff will receive training in the operation of waste handling equipment, including vehicles, tugs, trailers, compactors, balers.

Waste handling equipment must not be used by untrained or unauthorised staff.

When not in use, all waste handling equipment must be kept secure.

All relevant staff will receive training in the manual handling of waste and waste containers.

Training records should be maintained for all staff involved in the operation of waste handling equipment.

6.4 All Managers & Staff

6.4.1 Risk Assessments for Waste Management Activities

All managers (or other designated competent persons) must carry out Risk

Assessments to identify and assess the risks to their staff (as well as patients and

the general public) from any waste related duties and activities (including waste

handling, collection, storage, movement and disposal).




These risks should be eliminated where possible and managed and monitored

effectively, with Risk Assessments reviewed on a regular basis.

The frequency for the completion of Risk Assessments will be determined by the

Health and Safety Manager and relevant manager for the area concerned.

Risk Assessments will also be completed after any reported incident involving waste.

Risk Assessments should only be undertaken by staffs who have received appropriate

training. For further information contact the site Health and Safety Adviser.

6.4.2 Accident and Incident Reporting

If an accident occurs involving any waste items, the incident should be reported to the

relevant manager/supervisor immediately.

If an injury has occurred the employee should go to the Occupational Health

Department.

If the injury has occurred out of hours or is an emergency, the employee should go to

the A & E Department for medical attention.

As soon as possible an Incident Report Form should be completed, following internal

procedures.

The Facilities Department and Health and Safety Department will be informed via the

incident reporting system, of any incident involving waste and will take any necessary

measures to investigate the cause of the incident in order to guard against a

recurrence.

6.4.3 Personal Protection

It is the responsibility of all managers to ensure their staff are issued/supplied with appropriate protective clothing, to complete their waste related duties

Managers should also periodically monitor staff to ensure they are wearing appropriate items of protective clothing.

Risk Assessments will indicate the level of protective clothing required depending on the waste duties carried out, and may include; disposable gloves and aprons, heavy duty or sharps proof gloves, overalls/uniform, safety shoes, masks and eye protection.

It is the responsibility of all employees to ensure that protective clothing is worn, as required by their manager and any Risk Assessments, practices and/or procedures.

Staff handling clinical/infectious should be offered immunisation, including hepatitis B and tetanus.

6.4.4 Waste Spillages

All spillages must be regarded as potentially hazardous and dealt with immediately. Under no circumstances shall patients or members of the general public be allowed

to assist or be involved in any way in the clearing or cleaning up of spillages When dealing with spillages, appropriate protective clothing should be worn.




Where required, another member of staff shall assist in keeping the spillage area

safe, until the area can be barricaded off. It is essential that waste produced from dealing with any spillage is packaged and

disposed of appropriately. In the event of spillages of particularly hazardous wastes such as pharmaceuticals

and/or chemicals, the advice and assistance of specialist departments or persons

may be required, e.g. Estates Department, Pharmacy, Pathology Department,

Health and Safety Department. For further, more detailed information in relation to clinical/infectious spillages, please

refer to the Infection Control Manual/Policy where appropriate or to Policy NCPDI001

‘Spillage in the Operating Department’.

6.4.5 Waste Training

The NCA will provide specific training for waste operatives as well as waste training for all staff as part of the mandatory training programme. The NCA is committed to ensuring training provided is accessible for all following disclosure and training packages will be amended to suit the learners needs; the Care Organisation Porter & Waste Managers will be able to assist with this

Mandatory Training can be completed either by attending:

Classroom based sessions accessed via the Training Bulletin

Workplace sessions which should be arranged with the Portering & Waste Managers

The relevant E-learning programme accessed via the Alliance Intranet.

A Waste Management poster presentation

6.5 Portering & Waste Managers

6.5.1 Waste Contracts and Legal Paperwork

Any waste removed from The Northern Care Alliance for disposal must be accompanied by the relevant legal paperwork, i.e. waste transfer or consignment note.

Full details of how to complete a consignment note will be provided by the Portering &

Waste Manager

All hazardous waste consignment notes must be completed in full by relevant, authorised personnel for sections A, B and D.

Regular checks will be made with regard to the accurate completion of this

paperwork, as part of the auditing process.

Records must be kept of all waste transfer notes for 2 years and hazardous waste consignment notes for 3 years.




A Site Register must be maintained by the Portering Department for any

hazardous wastes produced. This should include; copies of consignments notes,

copies of any rejection notes, consignee returns for each hazardous waste

stream.

All specialist departments producing/completing hazardous waste consignment

notes for the disposal of hazardous waste must send a copy of each

consignment note to the Portering & Waste Manager for inclusion in the Site

Register.

The Portering & Waste Managers will ensure that their Care Organisations are

registered as Hazardous Waste Producers, on an annual basis with the

Environment Agency.

Regular reviews will be completed of all waste contracts, with regard to the changing

needs of the sites, legislative compliance, sustainable waste management and value

for money. This process will be undertaken by the Portering & Waste Managers

Provide waste training which is accessible to all and amend training packages

accordingly

Ensure waste bins are labelled to inform the user what waste should be placed in

each bin in patient areas in preparation for PLACE assessments

6.5.2 Auditing

All aspects of waste management across the NCA Care Organisations will be

audited and monitored by the Portering & Waste Managers, with any issues of non-

compliance or poor practice recorded and prioritised in action plans with the

relevant CO General Manager Estates & Facilities

Annual “Duty of Care” checks or audits will be carried out for all waste contractors

employed; this is the responsibility of the Portering & Waste Managers and relevant

specialist departments.

The Infection Control Teams will carry out regular audits which will include aspects

of waste management.

Audits of legal paperwork will be carried out by the Portering & Waste Managers

All departments producing and completing their waste consignment notes for their

wastes must send a copy of each completed note to the Portering & Waste

Managers.

Training records will be monitored by the Education & Training Department and/or

individual departmental managers.

6.6 General Manager Estates & Facilities will




Ensure that all staff within their Care Organisation is aware of and comply with this

procedure and Waste Management Policy.

Be responsible in providing assurances to the Group Deputy Director of Capital,

Estates & Facilities that key employees are trained and competent in waste

management

Ensure sufficient resources are available so that all waste is handled and disposed of

safely and in accordance with the relevant legislation.

Ensure that waste disposal complies with the appropriate codes of practice, e.g.

correct use of coloured bags.

Ensure systems are in place for the accurate identification of wastes, and that all

waste transfer / disposal documentation is maintained and records kept.

Introduce and deliver waste reduction initiatives

6.7 Chief Pharmacist / Head of Pharmacy will

Assist in the formation and implementation of this policy. They, along with the Head of Pharmacy on each site will provide advice and guidance as required on safe procedures for the handling and disposal of pharmaceutical waste materials regarded as clinical or hazardous.

6.8 Procurement Department will

Ensure that all purchases are made bearing in mind the impact of packaging with the aim

to eliminate secondary packaging. The packaging type should be specified on tender

criteria with a view to making suppliers responsible for the removal of their own

packaging where possible and to ensure they are compliant with Packaging Regulations

(essential requirements) 1998.

Ensure that all purchases of electrical and electronic equipment are made bearing in

mind end of life disposal in accordance with the Waste Electrical and Electronic

Equipment Directive 2007 and NHS guidance.

6.9 Waste Contractors

The Facilities Division is responsible for the various contracts for waste collection and

disposal services.

Licensed/permitted contractors are responsible for removing waste and waste containers

from storage locations at each site to licensed/permitted waste disposal, recovery or

treatment sites as required.

They are also responsible for the provision of relevant legal paperwork (i.e. waste

transfer or consignment note) and supplying the Care Organisation with consignee

returns for hazardous waste.




The Portering & Waste Managers or delegate is required to regularly complete waste

transfer and consignment notes for waste movements. Copies of all legal paperwork will

need to be kept for a period not less than 3 years

6.10 Care Organisation Waste Group Meetings

The Waste Group meetings at each Care Organisation provides a forum for discussing any issues relating to the treatment of waste and the implementation and monitoring of this document. Any unresolved issues will be escalated to Group

Discuss initiatives to reduce waste and promote recycling

6.11 Group Deputy Director of Capital, Estates & Facilities has delegated responsibility from the Group Director of Capital, Estates & Facilities for ensuring NCA compliance with regard to the management of all wastes produced on each Care Organisation.

6.12 Group Director of Capital, Estates & Facilities has delegated authority from the Chief Executive to ensure that the NCA complies with relevant waste and environmental legislation with regard to the management of all wastes produced at each Care Organisation.

6.13 Group Chief Executive Officer

The Group Chief Executive Officer has overall responsibility for providing a safe environment for patients and staff and for ensuring the adoption of safe working practices and compliance with relevant legislation

7. Monitoring document effectiveness

Key standards: 100% staff will have completed waste training at the commencement of employment and as and when changes in practice and legislation dictates

Method(s)*: Training and compliance statistics are available on the Organisation mandatory database and are updated regularly. Staff are responsible for ensuring they attend mandatory training

Team responsible for monitoring: Managers shall monitor attendance of their staff

Frequency of monitoring: Managers shall monitor staff attendance at mandatory training monthly

Process for reviewing results and ensuring improvements in performance: The Alliance mandatory training database records attendance and statistics and all staff can access their training records from the intranet

8. Abbreviations and definitions

Clinical waste Waste that is clinical waste as defined by the Controlled Waste Regulations

CO Care Organisation

COSHH Control of Substances Hazardous to Health

Cytotoxic and cytostatic

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.

CQC Care Quality Commission

Hazardous waste Waste classified as hazardous waste by the Hazardous Waste Regulations and the List of Wastes Regulations.

Healthcare waste Relates to waste that is produced by healthcare activities, and of a type specifically associated with such activities.

HTM Health Technical Memorandum

NCA Northern Care Alliance

PAT Pennine Acute Hospitals NHS Trust

PPE Personal Protective Equipment

SOP Standard Operating Procedure

SRFT Salford Royal NHS Foundation Trust

UN United Nations

WEEE Waste Electrical and Electronic Equipment

9. References and Supporting Documents

9.1 References

Department of Health, (2006 and updated 2013). HTM 07-01 ‘Safe Management of

Healthcare Waste’. Crown Copyright, London.

Water UK (April 2011) National Guidance for Healthcare Waste Water Discharges

The Hazardous Waste (England and Wales) Regulations (2005). Crown Copyright,

London.

Environment Agency (2015) Technical Guidance WM3: Hazardous Waste – Interpretation of the definition and classification of hazardous waste. Crown Copyright, London.

The Waste Electrical and Electronic Equipment Regulations (2013). Crown Copyright,

London.

Department of Health (2007) HTM 07-05: The Treatment, Recovery, Recycling and Safe Disposal of Waste Electrical and Electronic Equipment. Crown Copyright, London.

Department of Health (2008 updated 2015) The Health and Social Care Act: Code of practice on the prevention and control of infections and related guidance. Crown Copyright, London.

The Environmental Protection Act (1990). Crown Copyright, London.

The Controlled Waste (England and Wales) Regulations 2012. Crown Copyright,

London.

The Control of Substances Hazardous to Health Regulations (COSHH) (2002 updated 2003, 2004). Crown Copyright, London.

Health and Safety at Work etc. Act 1974. Crown Copyright, London.

Management of Health and Safety at Work Regulations 1992. Crown Copyright, London

The Management of Health and Safety at Work (Amendment) Regulations 2006. Crown

Copyright, London

The Health and Safety (Sharp Instruments in Healthcare) Regulations 2013. Crown

Copyright, London




9.2 Associated Documents NCA

NCAE030(19) Waste Management Policy

Control and Safe Management of Contractors (Estates, Capital & Facilities) Policy

SRFT

TWCG04(15) - Issue No 2 - Disposal of medicines in Intermediate Care

TG21(05) - Issue No 3.2 - Health and Safety Policy

RM10(06) Prevention and Management of Potential Exposure to Blood Borne Viruses

Including Needlestick and Sharps Injuries

PAT

EDQ026 Guidance to Prevent Sharps Injury/Exposure to Blood Borne Viruses

CPDI018 Accidental Inoculation Policy

EDQ007 Health & Safety Policy

CPDI018 Accidental Inoculation Policy

EDQ026 Guidance to Prevent Sharps Injury/Exposure to Blood Borne Viruses

EDC025 Policy for the ordering, storage and administration of Recorded Drugs


Reference Number: NCAE031(19) Version Number: One Issue

Date: of 58


It is the author’s responsibility to ensure that all sections below are completed in relation to this version of the document prior to submission for upload.

Nominated Lead author:

Paul Corr Portering & Waste Manager

Lead author contact details:

0161 778 5182 [email protected]

Lead Author’s Manager:

Name: Nigel Wylie Role: General Manager Estates & Facilities (Oldham CO)

Applies to:

Salford CO Oldham CO North Manchester CO

Bury & Rochdale CO

Northern Care Alliance Group (NCA)

Document developed in consultation with :

Pharmacy Managers Portering & Waste Managers General Managers Estates & Facilities Infection Prevention & Control Medical Devices EBME/MEMS Health & Safety Advisors Group Deputy Director of Capital, Estates & Facilities IM&T

Keywords/ phrases:

Waste, rubbish, bags, yellow, black, clinical, household, Porter, training, PPE, risk assessment, HTM, environment, hazardous, duty of care, WEEE, legislation, recycle, collection

Communication plan:

This policy will be available on the NCA staff web pages of the intranet and will be disseminated to staff via staff meetings. This policy will also be referred to in waste handling training

Document review arrangements:

This document will be reviewed by the author, or a nominated person, at least once every three years or earlier should a change in legislation, best practice or other change in circumstance dictate.

Approval: Add name of Committee and Chairpersons name and role: Rob Jepson, Group Deputy Director of Capital, Estates & Facilities, Estates and Facilities 3P General Managers Mtg

Insert full approval date: 16/07/2019

How approved: Chair’s actions Formal Committee decision

10. Document Control Information



Date: of 58


11. Equality Impact Assessment (EqIA) screening tool Legislation requires that our documents consider the potential to affect groups differently, and eliminate or minimise this where possible. This process helps to reduce health inequalities by identifying where steps can be taken to ensure the same access, experience and outcomes are achieved across all groups of people. This may require you to do things differently for some groups to reduce any potential differences.

1a) Have you undertaken any consultation/ involvement with service users, staff or other groups in relation to this document? If yes, specify what.

Yes – staff and service users

1b) Have any amendments been made as a result? If yes, specify what.

Yes – training packages and signage/labels

2) Does this policy have the potential to affect any of the groups listed below differently? Place an X in the appropriate box: Yes, No or Unsure This may be linked to access, how the process/procedure is experienced, and/or intended outcomes. Prompts for consideration are provided, but are not an exhaustive list.

Protected Group Yes No Unsure

Age (e.g. are specific age groups excluded? Would the same process affect

age groups in different ways?) X

Sex (e.g. is gender neutral language used in the way the policy or

information leaflet is written?) X

Race (e.g. any specific needs identified for certain groups such as dress,

diet, individual care needs? Are interpretation and translation services required and do staff know how to book these?)

X Communication

Religion & Belief (e.g. Jehovah Witness stance on blood transfusions;

dietary needs that may conflict with medication offered.) X

Sexual orientation (e.g. is inclusive language used? Are there different

access/prevalence rates?) X

Pregnancy & Maternity (e.g. are procedures suitable for pregnant and/or

breastfeeding women?) X

Marital status/civil partnership (e.g. would there be any difference

because the individual is/is not married/in a civil partnership?) X

Gender Reassignment (e.g. are there particular tests related to gender? Is

confidentiality of the patient or staff member maintained?) X

Human Rights (e.g. does it uphold the principles of Fairness, Respect,

Equality, Dignity and Autonomy?) X

Carers (e.g. is sufficient notice built in so can take time off work to attend

appointment?) X

Socio/economic (e.g. would there be any requirement or expectation that

may not be able to be met by those on low or limited income, such as costs incurred?)

X

Disability (e.g. are information/questionnaires/consent forms available in

different formats upon request? Are waiting areas suitable?) Includes hearing and/or visual impairments, physical disability, neurodevelopmental impairments e.g. autism, mental health conditions, and long term conditions e.g. cancer.

X Written labels on bins-not all have symbols



Date: of 58


Are there any adjustments that need to be made to ensure that people with disabilities have the same access to and outcomes from the service or employment activities as those without disabilities? (e.g. allow extra time for appointments, allow advocates to be

present in the room, having access to visual aids, removing requirement to wait in unsuitable environments, etc.)

X

3) Where you have identified that there are potential differences, what steps have you taken to mitigate these? The E&F SMT will discuss the format of signage on bins to ensure they meet public sector requirements

for inclusivity. Waste training packages will be amended as and when required to meet learners needs and packages

emailed to learner as required Unsure if standard NHS England colour may affect those with a visual impairment; appropriate training

will be provided to those in need Information only available in English; direction required from E&F SMT and ED&I strategy

4) Where you have identified adjustments would need to be made for those with disabilities, what action has been taken? Escalated to E&F SMT to discuss the way forward for signage, labels and posters etc Waste training packages amended to each learners needs including face to face training, poster training and e-learning

Will this policy require a full impact assessment? Yes / No (a full impact assessment will be required if you are unsure of the potential to affect a group differently, or

if you believe there is a potential for it to affect a group differently and do not know how to mitigate

against this - Please contact the Inclusion and Equality team for advice on [email protected]) Author: Type/sign: Paul Corr Date: 25.04.19

Sign off from Equality Champion: Date: 31/05/19

mailto:[email protected]



Date: of 58


Audit / Monitoring requirement

Method of Audit / Monitoring Responsible person

Frequency of Audit

Monitoring committee

Evidence Location

To monitor waste management activity across all sites in order to ensure that statutory and legislative compliance relating to waste management and handling is being adhered to across all CO premises.

Visual and verbal assessment through site visits to each area across the Alliance that generates waste (i.e. Wards and departments). Discussions with Managers / supervisors of each area will also be required. Walk through the wards / departments looking at individual bin locations ward bays, office areas, toilets, bathrooms, kitchens, etc

Portering & Waste Manager Independent Clinical Waste Auditors

Each waste generating area to be visited at least once every twelve months (annually).

Care Organisation Waste Group

Audits Reports stored centrally All Risks to be reported. All significant risks to be discussed and forwarded as necessary

Audits to be stored electronically and hard copies of reports to be kept by the Portering & Waste Manager

Visual assessment through site visits to each interim storage areas for waste

Each interim waste compound area to be visited at least once every six months

Visual assessment through site visits to each main site storage /collections area for waste and full assessment of waste related paperwork held on site.

Each main waste compound area to be visited at least once every six months.

To monitor waste disposal tonnages and associated financial expenditure against annual budgets.

Assessment of issued tonnages for waste disposal from Care Organisation Data to be provided via waste disposal contractors within the first six working days of each month with data relating to the previous month.

Portering & Waste Manager

Monthly Care Organisation Waste Group Estates & Porter & Waste Managers

Assessment files to be stored centrally

Copies of Waste divisional Budget Statements showing performance to be kept by the Portering & Waste Manager

12. Appendices

Appendix 1 - Monitoring and Review Arrangements



Date: of 58


Duty of Care site visit to contractors waste handling premises.

To visually assess management of NCA waste by contractors is as described in formal SLA & contract documentation. Checks on paperwork and certification to be included within.

Portering & Waste Manager

Each waste handling contractor to be audited at least annually.

Exception reporting to Estates & Facilities General Manager

Documentation and evidence of audit to be written up and stored centrally Any significant risks identified to be escalated

Audits to be stored electronically by Portering & Waste Manager



Date: of 58


Waste management legislation sets out mandatory requirements for the description, packaging and disposal of waste. Each type of waste is given a European Waste Catalogue (EWC) Code which must be used when describing the waste on all relevant documents. There are specific storage and disposal requirements, which will depend on the EWC Code/waste description. It is essential that the NCA complies with these mandatory requirements.

The following table shows the EWC codes, storage, packaging/colour coding and disposal methods that apply to the types of waste likely to be generated by the various wards/departments of the Alliance. All staff produces waste and so all have a legal responsibility to ensure that the waste they produce is disposed of correctly by adhering to the controls and procedures in the NCAE030(19) Waste Management Policy and these Procedures

EWC Code (European waste

catalogue)

Description

Example

Container/ Packaging

Picture

Comments

Disposal Method

20 03 01

(non- hazardous)

Domestic or household waste, similar to the type of waste produced at home.

Packaging, hand towels, food remains / cartons

Clear plastic bag Or Black waste bag

Place in dedicated wheeled domestic waste bins where available or at a designated collection point. Keep separate from all clinical waste streams

Recycling or used as Refuse Derived Fuel (RDF)

20 03 01

(non- hazardous)

Domestic glass containers

Glass jars, bottles, etc.

Cardboard box lined with a clear/black bag

N/A

Must NOT include any medicine bottles.

Recycling or used as Refuse Derived Fuel (RDF)

18 01 03

(hazardous)

Category A pathogen contaminated waste

Anything that has come into contact with a VHF patient

Double bagged in thick yellow plastic bags, placed

inside a yellow rigid plastic container

Complete segregation from other waste streams must be maintained, kept inside isolation area until collected. Follow NCA’s emergency action cards at all times

Incineration only

Appendix 2 Waste Description, Packaging and Disposal Methods



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18 01 03 (hazardous)

Infectious or potentially infectious clinical waste

Soiled dressings, swabs, incontinence pads, gloves, aprons, etc contaminated with blood or body fluids, empty catheter bags, suction tubing.

Orange plastic bag

Must not contain anatomical or pharmaceutical or chemical waste. Keep separate from all other waste streams

Alternative treatment (or incineration)


Infectious or potentially infectious clinical waste In patient’s homes in the COMMUNITY

Soiled dressings, swabs, gloves, aprons etc. contaminated with blood or body fluids, solidified suction canisters / drains.

Orange Infectious Waste BioBin

District Nurse to arrange collection from patient’s home

Alternative treatment (or incineration)


Infectious or potentially infectious clinical waste In patient’s homes in the COMMUNITY

Suction canisters / drains that contain blood / bodily fluids as a liquid.

Yellow Infectious Waste BioBin

District Nurse to arrange collection from patient’s home

Incineration only

18 01 02 / 03 (non-hazardous and/or hazardous)

Non-infectious / infectious anatomical waste

Amputated limbs, placentas, blood bags containing a quantity of blood

Yellow container with red lid.

Keep separate from orange bags and all other waste streams

Incineration only

18 01 03 & 18 01 09 (hazardous)

Sharps (non- cytotoxic/cytostatic)

Needles, scalpels, blades

Yellow sharps container with yellow lid

Keep separate from orange bags and all other waste streams District Nurse to return sharps bins to base for disposal

Incineration only



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18 01 03 & 18 01 09

Medicinally contaminated waste (non-cytotoxic/cytostatic) that contain a sharp.

IV bags, lines, tubing, etc containing a sharp

Yellow sharps container with yellow lid – large aperture

Store with other yellow sharps containers with yellow lids

Incineration only

18 01 08 & 18 01 03 (hazardous)

Sharps and other potentially infectious items contaminated with cytotoxic/cytostatic pharmaceuticals

Needles etc. contaminated with cytotoxic/static pharmaceuticals

Yellow container with purple lid

Keep separate to orange bags and other waste streams. Request separate collection by Portering Department.

Incineration only


Cytotoxic/Cytostatic pharmaceuticals

Cytotoxic/Cytostatic pharmaceuticals including tablets, medicines, etc

Yellow container with purple lid or Cyto BioBin

Keep separate from all other waste streams and request a special collection by the Portering Department.

Incineration only


Cytotoxic/Cytostatic pharmaceuticals Generated by the District Nurse in patients’ homes in the COMMUNITY

Cytotoxic/Cytostatic pharmaceuticals (see list at Appendix B)

Yellow container with purple lid or Cyto BioBin

Patients or their carers / relatives should return waste/medicines no longer required to Christies or their local community pharmacist. District Nurse to return the waste they generate back to base for disposal

Incineration only

18 01 09 (non- hazardous)

Pharmacy general pharmaceuticals

General pharmaceuticals including, tablets, medicines, etc part used, unused and out of date.

Blue rigid container or blue Medicinal BioBin

Packaged into pharmi bins / medicinal BioBins

Incineration only



Date: of 58



Wards / Departments medicines & medicinally contaminated items that are not returned to Pharmacy

Pharmaceuticals including, tablets, medicines, empty infusion bags with no sharps etc


Keep separate to orange bags and all other waste streams.

Incineration only


Medicinally contaminated items that do not contain a sharp. Generated by the District Nurse in patients’ homes in the COMMUNITY

IV lines / bags


Patients or their carers / relatives should return waste/medicines no longer required to their local community pharmacist. District Nurse to return the waste they generate back to base for disposal

Incineration only


Chemically contaminated waste from Path Labs, ESLs and Theatres

Plastic bottles of formalin, soda lime crystals

Yellow rigid container or yellow BioBin

Keep separate to orange bags and all other waste streams.

Incineration only


Amalgam waste

Extracted teeth containing amalgam (from Maxillo Facial Department)

Waste contractor’s white containers

To be disposed of via specialist waste contractor

Specialist recovery

18 01 03 or 20 03 99 (hazardous or non-hazardous)

Mattresses There is an agreement with the Supplier that any mattresses that are not contaminated they take back for disposal

Mattresses from patient care which are infectious

Orange Mattress bag

N/A

A notice must be attached giving reason for disposal before collection by Portering Seek guidance from Infection Control Team, Tissue Viability Nurse or Waste Management Co-ordinator.

Alternative Treatment



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20 01 01

Cardboard

Cardboard boxes and packaging

‘Cardboard Only’ waste bins where provided or Cages

Please ensure that boxes are flattened wherever possible

Recycling - earning revenue


Confidential waste

Any Papers containing staff or patient personal details e.g. patient records, paper diaries, patient lists or potentially sensitive information about the organisation such as; financial records etc.

Confidential waste red bin. Cross cut shredder can be used and the waste put in paper recycling stream.

Contact the Portering Department for collection when full

Securely shredded and then recycled


Confidential waste

Any Non-Paper items containing staff or patient personal details or sensitive information about the organisation, such as; CDs, floppy disks, slides, etc.

N/A.

N/A

Contact the Waste Management Co-ordinator for collection. The items must be kept secure until they are collected.

Securely shredded before disposal to landfill

20 01 01

Paper

Non-confidential paper newspapers, magazines, any cross cut shredded confidential waste

Green bins

Contact the Portering Department for collection when full

Recycling – earning revenue

16 02 14

Waste printer, toner and inkjet cartridges

Various printer cartridges

Collection boxes are provided in designated areas.

Only cartridges, toner - no packaging should be put in the collection boxes

Recycling

20 01 04

Scrap metal

Broken beds (non-electric), filing cabinets

Waste skip / Compound

N/A

Request collection by Porters

Recycling



Date: of 58


Various

Batteries

From general equipment used in wards and departments

Small cardboard box

Batteries should be taken to Estates

Recycling

16 06 01 16 06 02 16 06 03 20 01 33 20 01 33

Batteries: Lead acid (haz) Ni-cad (haz) Mercury containing (haz) Above mixed batteries (haz) Mixed batteries excluding above (may be haz)

Various batteries from vehicles and specialist electronic items and equipment (mainly from Estates and EBME/MEMS/MEMS)

Designated containers in Estates

N/A

Contact Estates.

Specialist disposal

18 01 06 (may be Hazardous) 18 01 07 (non- hazardous)

Chemicals

Chemicals with hazardous properties

Various

N/A

To be disposed of via specialist waste contractor. Contact Waste Management Co-ordinator for advice.

Specialist disposal


Mercury

Mercury waste and items contaminated with mercury.

Various

To be disposed of via a specialist waste contractor. Contact Waste Management Co-ordinator for advice.

Special disposal see COSHH data sheet.


Mixed electric and electrical equipment (not containing hazardous components)

Computers, printers, keyboards

Designated IT Waste Storage Facility

Contact IT to arrange collection – do not leave on corridor

Specialist recovery / recycling



Date: of 58


20 01 36 (non-hazardous)

Mixed electric and electrical equipment (not containing hazardous components)

Fans, microwaves, toasters etc.

Estates WEEE container

N/A

Request collection by Porters – do not leave on corridor



Mixed electric and electrical equipment (containing hazardous components)

TVs, etc


N/A



20 01 23 (may be hazardous)

Discarded equipment containing chlorofluorocarbons (CFCs)

Fridges, freezers and other refrigeration equipment.



Specialist recovery or disposal


Fluorescent tubes

Fluorescent lighting tubes (from Estates & Facilities Department)

Designated container in Estates

Contact site Works Department

Specialist recovery or disposal


Bulky waste

Items such as chairs, tables and other large non- hazardous furniture or equipment

N/A

Do not leave on corridors. Contact Porters for removal. Keep within ward / department whilst awaiting collection.

Reuse, recycling or landfill



Date: of 58


Various (non- hazardous)

Building and engineering wastes

Items such as construction and demolition waste, etc (from Estates Department)

Waste compound

Generated by work carried out by Estates staff. Contractors should have own process for waste disposal.

Specialist recovery and/or disposal

17 06 01 and/or 17 06 05 (may be hazardous)

Insulation material containing asbestos/construction material containing asbestos

Items consisting of or containing asbestos (from Estates & Facilities Department).

Estates waste skip or contractors container

N/A

Generated from work carried out by Estates staff or appointed contractors. Contact site works department.

Specialist disposal


Garden waste

Garden waste for composting

Compost store or open skip

Generated by Grounds & Gardens staff

Composting or landfill



Date: of 58


Appendix 3 Colour Coding of Waste

Title of document; Waste Management Procedures


Date: Leave blank as will be completed upon publication

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Appendix 4 Recognised list of Cytostatic Medicines (November 2015)

The following medicines are classed as cytostatic and are required to be disposed of via the purple waste stream. Staff do not require specific training, as for cytotoxic medicines, to administer cytostatic medicines but should use appropriate PPE as per policy. In addition staff should refer to the summary of product characteristics (SPC) (http://emc.medicines.org.uk/) or package insert for any additional handling instructions. Solid dosage forms of hazardous medicines should not be crushed without seeking advice from pharmacy. The presence of a medicine in the below list does not imply that this medicine is available for use on the North of Tyne Formulary or is stocked in NUTH pharmacies.

Abacavir Estrone Norelgestromin

Abiraterone Estropipate Norethisterone

Acitretin Ethinylestradiol Norgestimate

Adalimumab Ethinylestradiol/desogestrel Obinutuzumab

Afatinib Ethinylestradiol/drospirenone Oestrogens

Aldesleukin Ethinylestradiol/etonogestrel Ofatumumab

Alemtuzumab Ethinylestradiol/gestodene Oxytocin

Alitretinoin Ethinylestradiol/levonorgestrel Panitumumab

Ambrisentan Ethinylestradiol/norelgestronim Pazopanib

Anastrozole Ethinylestradiol/norethisterone Pembrolizumab

Atazanavir Ethinylestradiol/norgestimate Pentamidine

Atripla® Etonogestrel Pertuzumab

Axitinib Etravirine Plerixafor

BCG - connaught Etynodiol Podophyllum

BCG Tice Everolimus Pomalidomide

BCG vaccine Eviplera® Ponatinib

Belimumab Exemestane Raloxifene

Bevacizumab Finasteride Raltegravir

Bexarotene Fingolomod Ranubizumab

Bicalutamide Flutamide Regorafenib

Boceprevir Fosamprenavir Rezolsta®

Bosentan Foscarnet Ribavirin

Bosutinib Fulvestrant Rilpivirine

Buserelin Ganciclovir Riociguat

Cabozantinib Gefitinib Ritonavir

Ceritinib Gemeprost Rituximab

Certolizumab Gestodene Ruxolitinib

Cetrorelix Golimumab Saquinavir

Cetuximab Goserelin Sirolimus

Chloramphenicol Harvoni® Simeprevir




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Ciclosporin Histrelin Sorafenib

Cidofovir Ibrutinib Stavudine

Colchicine Idelalisib Stribild®

Combivir® Imatinib Sunitinib

Crizotinib Ingenol mebutate Tacrolimus

Dabrafenib Indinavir Tamoxifen

Daclatasvir Infliximab (Remicade®/Inflectra® /Remsima®)

Targretin

Darunavir Ipilimumab Telaprevir

Dasatanib Kaletra® Temsirolimus

Defibrotide Kivexa® Tenofovir

Denosumab Lamivudine Teriflunomide

Desogestrel Lapatinib Testosterone

Didanosine Leflunomide Thalidomide

Dimethyl fumarate Lenalidomide Tibilone

Diethylstilbestrol Letrozole Tipranavir

Dinoprostone Leuprorelin Tocilizumab

Doletegravir Levonorgestrel Toremifene

Drosperidone Lopinavir Trametinib

Dutasteride Macitentan Trastuzumab

Dydrogesterone Maraviroc Tretinoin

Eculizumab Medroxyprogesterone Triptorelin

Efavirenz Megestrol Trizivir®

Emtricitabine Menotropins Truvada®

Enzalutamide Mestranol Ulipristal

Ergometrine Mifepristone Valganciclovir

Erlotinib Mycophenolate Vandetinib

Estradiol Nafarelin Vemurafenib

Estradiol/dienogest Nevirapine Viekirax®

Estradiol/nomegestrol Nilotinib Vismodegib

Estrogen-progesterone combinations

Nintedanib Zidovudine

Estrogens, conjugated Nivolumab




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Appendix 5 Recognised list of Cytotoxic medicines (November 2015)

The following medicines are classed as cytotoxic and are required to be disposed of via the purple waste stream. Staff administering cytotoxic medicines should do so accordance with the Anticancer Medicines Policy AND Guidance on the Management of Patients receiving Cytotoxic Chemotherapy for Non Malignant Conditions. Solid dosage forms of cytotoxic medicines should not be crushed. The presence of a medicine in the below list does not imply that this medicine is available for use on the North of Tyne Formulary or is stocked in NUTH pharmacies.

Actinomycin D Dexrazoxane Oxaliplatin

Amsacrine Docetaxel Paclitaxel

Arsenic Trioxide Doxorubicin Peg-asparaginase

Azacitidine Emtricitabine Pegylated Liposomal Doxorubicin

Azathioprine Epirubicin Pemetrexed

Bendmaustine Eribulin Pentostatin

Bleomycin Estramustine Pixantrone

Bortezomib Etoposide Procarbazine

Brentuximab vedotin Fludarabine Raltitrexed

Busulfan Fluorouracil Streptozocin

Cabazitaxel Gemcitabine Tegafur Uracil

Capecitabine Gemtuzumab Temoporfin

Carboplatin Hydroxycarbamide Temozolomide

Carmustine Idarubicin Teniposide

Chlorambucil Ifosfamide Thiotepa

Cisplatin Irinotecan Tioguanine

Cladribine Lomustine Topotecan

Clofarabine Melphalan Trabectedin

Crisantaspase Mercaptopurine Trastuzumab emtansine

Cyclophosphamide Methotrexate Treosulfan

Cytarabine Mitomycin Vinblastine

Dacarbazine Mitotane Vincristine

Dacitabine Mitoxantrone Vindesine

Dactinomycin Nab-Paclitaxel Vinflunine

Daunorubicin Nelarabine Vinorelbine