Policies

Regulated Medical Waste Management

Policy Purpose

To establish policies, work practices, and systematic procedures for the handling, packaging, collection, transportation and disposal of Regulated Medical Waste (RMW). The goal is to minimize waste generation and ensure safe and efficient handling of all RMW at Farmingdale State College (FSC). In addition, this policy ensures compliance with federal, state and local regulations on proper handling of regulated medical waste.

Persons Affected

Faculty, Staff, Students, Third-Parties

Policy Statement

All RMW generated at FSC shall be handled, packaged, collected, transported and disposed of in such a manner as to protect health and safety, assure compliance with environmental regulations and law, promote effective utilization of resources and contribute to and support the mission of the College. The College also supports and will strive to meet or exceed established regulated medical waste minimization objectives and similar initiatives.

Procedures

1.1. General RMW Handling Methods

1.1.1. RMW as defined must be placed in a properly labeled red bag or puncture resistant container. Waste which has a strong potential for leakage must be placed into double bags of which at least the outer bag is red in color. Items such as I.V. tubing or containers which contain small amounts (<20 cc) of fluids (blood) may be disposed of in this manner. Large amounts of fluids (>20 cc) cannot be disposed of in this manner.

1.1.2. The red bags must be tied or otherwise secured so as to prevent leakage during storage, handling and transport. The red bags will be placed into RMW boxes, sealed with tape and stored in a restricted area. Boxes, bags, tape and labels will be supplied by either an authorized RMW waste contractor or by the Office of EH&S. Containers of RMW will be picked up by the Physical Plant following receipt of a Work Order request. The Office of EH&S will make arrangements with an authorized RMW contractor to collect the RMW boxes on a regular basis or as the need arises. Contact the EH&S Office with any related questions.

1.1.3. Employees handling RMW will wear personal protective equipment including nitrile gloves and safety glasses.

1.1.4. Employees handling RMW will have spill clean-up material made available when doing so.

1.1.5. All red bags, infectious agents or other RMW will be collected and disposed of as RMW. All waste is subject to scrutiny to insure proper packaging and disposal (i.e. general refuse free of potentially infectious waste material).

1.1.6. Any general waste that is found to contain RMW will be placed into a red bag and disposed of as RMW.

1.1.7. As part of regular laboratory inspections, notification will be given to the area supervisor when a violation of policy is identified by EH&S. Employees will be expected to review the incident and develop a "plan of correction" and submit it to the Office of EH&S.

1.1.8. Copies of the inspection report will be sent to the effected employee(s) and their immediate supervisor.

1.1.9. The RMW is either treated in a New York State certified and permitted autoclave prior to disposal as non-hazardous or removed from the facility by an authorized RMW contractor for treatment offsite. Since FSC does not have any certified or permitted autoclaves, all waste passed through an autoclave unit at the College must still be discarded as RMW if it met the definition of RMW prior to autoclaving it. Note: There are no certified or permitted autoclaves on campus.

1.2. Handling Methods for Sharps

1.2.1. All sharps must be disposed of in appropriately labeled puncture resistant sharps containers.

1.2.2. Sharps containers may then be placed inside properly packaged RMW boxes when full and disposed of as RMW.1.2.3. All uncontaminated or clean disposable glass and rigid plastic-ware should be disposed of in an appropriate puncture resistant regular trash container.

1.2.4. Dispose of regulated sharps contaminated with <15 cc of fluids in a regular/standard sharps container. Contact EH&S for guidance on disposal of regulated sharps contaminated with >15 cc of fluids.

1.3. Disposal Methods for Liquid Waste

1.3.1. Liquid medical waste, including blood and body fluids, will be disposed of through the sanitary sewer system (i.e. toilet or hopper, but not the hand washing sink). Body fluids greater than 20 cc in containers which are not easily emptied (i.e. pleuravac or 1-liter evacuated bottles), or may cause unnecessary exposure to employees when poured, are to be segregated from other RMW. If possible, place the containers in a red bag, and then inside a box. Label the box as "BIOHAZARD.” Free liquids must not be disposed of in red bags. Contact the Office of EH&S for further instruction.

1.4. Handling Methods for Pathological Waste

1.4.1. All pathological animal or human tissue and anatomical parts will be placed into leak-proof red bags, labeled with the generator’s name and address and placed in a fiber drum or other approved RMW container. The outer container also needs to be labeled with the generator’s name and address, sealed and stored in a restricted area. Properly packaged containers will be brought to the RMW storage facility following a Work Order request submitted to the Physical Plant. The Office of EH&S will make arrangements with an authorized RMW contractor to collect the RMW containers on a regular basis or as the need arises.

1.5. RMW mixed with General Nonhazardous Waste

1.5.1. Any general waste that is found to also contain RMW, after transportation to a refuse disposal site, will be handled as RMW.

1.5.2. The waste transporter will immediately provide notification to the Office of EH&S or to as appropriate.

1.5.3. An authorized RMW contractor will be contacted by either the Office of Environmental Health and Safety or the Physical Plant to remove and properly dispose of the regulated medical waste.

1.5.4. If it can be determined which building, area/unit or laboratory generated the medical waste, immediate notification will be given to the area supervisor. These employees will be expected to review the incident and enact whatever may be necessary to assist in prevention of similar problems in the future. With this in mind, the area/unit will be required to develop a "plan of correction" and submit it to the Office of EH&S.

1.6. Decontamination of Objectionable Waste

1.6.1. Objectionable waste is any biological waste material that is not RMW that can be rendered non-objectionable by a chemical process or through autoclaving.

1.6.2. Liquid objectionable material may be autoclaved and poured down a drain.

1.6.3. Liquid objectionable material may also be treated with a 10% bleach solution or other disinfectant and poured down the drain.

1.6.4. Autoclave semi-solid objectionable media in an appropriate autoclave bag and check that the indicator on the bag changed color.

1.6.5. Autoclaved semi-solid or solid objectionable media may be discarded to the regular trash.

1.7. Microbiological Specimens

1.7.1. All non-infectious fungal, bacterial and virus cultures that have not been used in the diagnosis, treatment, or immunization of human beings or animals, in the research pertaining thereto, or in the testing of biologicals, can be autoclaved in an appropriate autoclave bag and disposed of to the regular trash. Check that the indicator on the bag changed color.

1.7.2. All infectious fungal, bacterial and virus cultures or those that have been used in the diagnosis, treatment, or immunization of human beings or animals, in the research pertaining thereto, or in the testing of biologicals, can be autoclaved in an appropriate autoclave bag but must still be disposed of as RMW. Alternatively, unless deemed necessary, the waste need not be autoclaved and may be directly packaged and disposed of as RMW.

1.7.3. To avoid the misplacement of autoclaved bags destined for disposal as RMW, the following steps must be followed:

- Place the autoclave bag into a Red Regulated Medical Waste bag and then place the bag into a RMW box.

- Seal the RMW box and submit a Work Order to request a waste pickup when needed.

1.8. Special Disposal

1.8.1. Alternate methods of special infectious waste disposal will be directed by the Office of EH&S.

1.9. General Non-Hazardous Waste

1.9.1. Any discarded solid items that are not known or suspected to be contaminated with potentially hazardous materials.

1.9.2. Collection - General, non-hazardous waste is routinely collected by the custodial or housekeeping staff and disposed into trash receptacles for disposal.

1.9.3. If the following items have not come in contact with infectious materials, they may be disposed of as municipal waste:

- diapers

- feminine hygiene products

1.10. Medical Waste Tracking Forms (Manifests) Process

1.10.1. All Medical Waste Tracking Forms (Manifests) must be signed and dated by the transporter and the generator.

1.10.2. All employees signing regulated medical waste manifests must be DOT Hazmat Trained.

1.10.3. The generator or staff member signing the manifest must check over items 1 through 14 on the tracking form, for purposes of verifying its accuracy.

1.10.4. After a thorough review of items 1 through 14, the generator must then sign the tracking form in item 15.

1.10.5. After the RMW transporter has also signed-off in item 16, a copy of the tracking form will be given to the authorized FSC manifest signer who will then forward to the EH&S Officer.

1.10.6. Copy 1 of the RMW tracking form will be mailed back to the EH&S Officer after the RMW is received by the disposal facility and after a disposal facility representative signs-off in item 22. Alternatively, the signed facility copy may only be available through electronic means. If this is the case, the digital copy must be downloaded and filed with all other associated paperwork.

1.10.7. Both copies of the tracking form must be maintained by the Office of EH&S/generation site for at least three years from the date the waste was accepted by the RMW transporter.

1.10.8. Both copies of manifest (the original and TSDF-signed copy) will be put into the RMW manifest binder maintained in the Office of EH&S.

1.10.9. If the signed Treatment, Storage and Disposal Facility (TSDF) copy of manifest is not received within 30 days of shipped date, a phone call to TSDF will be made to request a copy of TSDF-signed copy.

1.10.10. If the TSDF signed copy of manifest is not received within 45 days of shipped date, a formal exception letter must be sent to the NYSDEC and to the TSDF facility.

Definitions

Other Potentially Infectious Materials (OPIM) - OPIM refers to any bodily fluid identified as potentially capable of transmitting a communicable disease.

Regulated Medical Waste (NYS DOH definition) - Any waste which is generated in the diagnosis, treatment or immunization of human beings or animals, in research pertaining thereto, or in the production or testing of biologicals, when listed by the Department of Environmental Conservation (see Section 27-1501 – 27-1519 of the Environmental Conservation Law), provided, however, that RMW shall not include any hazardous waste identified or listed by the Department of Environmental Conservation.

Regulated Medical Waste (OSHA definition) - Regulated Waste means liquid or semi-liquid blood or contaminated items that would release blood or Other Potentially Infectious Materials (OPIM) in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other OPIM and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.

Types of RMW: Six (6) subcategories exist within the general definitions of regulated medical waste.

1. Cultures and Stocks: Cultures and stocks of agents infectious to humans, and associated biologicals, cultures from medical or pathological laboratories, cultures and stocks of infectious agents from research laboratories, wastes from the production of biologicals, discarded live and attenuated vaccines, and culture dishes and devices used to transfer, inoculate, or mix cultures, nutrient agars, gels, broths (including those utilizing human blood and blood products), human and primate cell lines, animal cell lines known or likely to be infected or contaminated with human microbes or agents classified as bloodborne pathogens.
   
   2. Human Pathological Wastes: This waste shall include tissues, organs, body parts (except teeth and contiguous areas of bone and gum) and body fluids that are removed during surgery or autopsy or other medical procedures, or specimens of body fluids and their containers and discarded material saturated with such body fluids other than urine. This waste shall not include urine or fecal materials submitted for other than diagnosis of infectious diseases.
   
   3. Human Blood and Blood Products: Discarded waste human blood or blood components, including serum and plasma, containers with free-flowing blood or blood components or discarded saturated material containing free flowing blood or blood components; and materials saturated to the point of dripping with blood or blood products.
   
   4. Sharps: Unused sharps and sharps used in animal or human patient care, medical research, or in clinical or pharmaceutical laboratories, including hypodermic, intravenous, or other medical needles, hypodermic or intravenous syringes to which a needle or other sharp is still attached, Pasteur pipettes, scalpel blades, or blood vials, and broken or unbroken glass (including slides and cover slips) in contact with infectious agents.
   
   5. Infectious Agents: Organisms that cause disease or an adverse health impact to humans and listed in section 2.1 of the State Sanitary Code and those found in Biosafety Levels 2 through 4 of the Centers for Disease Control's Manual for Biosafety in Microbiological and Biomedical Laboratories. Other organisms defined as infectious by the Office of EH&S may also be included.
   
   6. Animal Waste: Discarded materials including carcasses, body parts, body fluids, blood, or animal bedding contaminated with infectious agents or from animals inoculated during research, production of biologicals, or pharmaceutical testing with infectious agents.

Related Documents

https://www.dec.ny.gov/chemical/8789.html

https://www.health.ny.gov/facilities/waste/

https://newyork.public.law/laws/n.y._environmental_conservation_law_section_27-1501

https://govt.westlaw.com/nycrr/Document/I4eacc3f8cd1711dda432a117e6e0f345?viewType=FullText&originationContext=documenttoc&transitionType=CategoryPageItem&contextData=(sc.Default)&bhcp=1

https://www.cdc.gov/labs/pdf/SF__19_308133-A_BMBL6_00-BOOK-WEB-final-3.pdf

FSC Bio Waste Safety Guide (farmingdale.edu)

Responsible Office

Office of Environmental Health and Safety