The business of waste — specifically, the business of off-site management of hazardous and non-hazardous medical waste — is big. The global medical waste management industry is so large, in fact, that market analysts expect it to grow to more than $560 billion by 2020.
Several factors are driving these predictions, including “highly stringent regulations governing disposal of medical waste” such as sharps and infectious and pathological waste, according to a recent Transparency Market Research report.
Skilled nursing facilities are considered small- to medium-sized medical waste generators, but they are still fully subject to the growing body of regulations and bureaucracy. Not knowing what to do, or how to do it properly, can cost big bucks.
Medical waste must be managed in accordance with myriad requirements established by federal, state and local governing bodies. Tracking, disposing and storing medical waste can be a confusing and complicated endeavor for already overworked SNF operators, says Jan Harris, director of regulatory compliance with Sharps Compliance Inc., a company that provides comprehensive waste management services to healthcare facilities.
“Clinical staff should be just that, clinical staff,” she says. “Having to figure out safest and most cost-effective management of waste, training, policies and regulations can take away from resident care.”
Indeed, the list of governing bodies alone is dizzying, even for a veteran SNF administrator or director of nursing. The Centers for Medicare & Medicaid Services, Occupational Safety and Health Administration, Environmental Protection Agency, Centers for Disease Control and Prevention, U.S. Department of Transportation, state and county health departments and environmental agencies, and even the U.S. Postal Service all have a hand in how medical waste is handled, stored, disposed of and transported.
Harris, who has been working in medical waste compliance for more than 25 years, notes that when she works with SNFs and other senior living settings, she focuses first on regulations that apply to that building or campus.
“We need to know how to assist customers in compliance in all 50 states. We service customers from one location in one state, to those with 8,000 locations in all states as well as territories,” she says.
As one might imagine, compliance is a substantial concern for SNFs, especially when it comes to infection prevention and control.
“What comes up a lot in long-term care is the disposal of items that are put in isolation containers,” says Harris. “It’s not unusual for nurses and other direct care staff to put everything into the red bag, even medical waste that is not bio-hazardous.”
The 15% minority
Harris recounts a story of assessing a SNF for the first time and finding nine full tubs that were designated for medical waste.
“I went through all of it, and what started as nine 40-gallon tubs was reduced down to one-third of one tub of actual medical waste,” she says. “This demonstrates how much trash is thrown in that tub.”
If facility staff were educated about what medical waste is, “the SNF would save a lot of time and money,” Harris explains.
In the hierarchy of medical waste, Harris says that most of what’s put in the red bag [a red-colored bag that holds bio-hazardous waste], is not actually bio-hazardous. In fact, only 10% to 15% of waste in any healthcare facility is actual infectious waste, according to the World Health Organization, which says that of the total amount of waste generated by healthcare activities, about 85% of it is general, non-hazardous waste. The remaining 15% is considered hazardous material that may be infectious, toxic or radioactive.
Staff might deposit everything — gowns, gloves, non-bloody dressings — into the red bag due to an overabundance of caution or because that bag is within closest reach of the caregiver, Harris says.
“That’s not necessary. Unless it’s bloody, it can be taken to the dumpster. I’ve seen many SNFs put everything that comes out of the isolation room into the red bag.”
In defense of direct care staff, Lisa Sweet, chief clinical officer for the National Association of Health Care Assistants, admits that CNAs may often toss gloves and protective gowns into the red bags for several reasons, the most prevalent of which relates directly to their jobs.
“A lot of it boils down to the fact that sometimes CNAs are stretched so thin that they take shortcuts in the direction of being overly cautious,” she says. “I’m sure there is probably a need for more education and retraining when it comes to knowledge of waste management. It really makes you realize how important it is to have adequate training and education.”
Sweet emphasizes that when a CNA provides hygiene for an incontinent resident, for example, “who may potentially have infectious waste or feces that could kill someone else such as C. Diff [Clostridium difficile], it shows the extent of influence they have and the importance of their work.”
Research has found no epidemiologic evidence to indicate that traditional waste-disposal practices of healthcare facilities — whereby clinical and microbiological wastes were decontaminated on site before leaving the facility — have caused disease in either the healthcare setting or the general community.
The CDC does note that the statement excludes sharps injuries sustained during or immediately after the delivery of patient care before the sharp is discarded.
“Therefore, identifying wastes for which handling and disposal precautions are indicated is largely a matter of judgment about the relative risk of disease transmission, because no reasonable standards on which to base these determinations have been developed.”
Training and education
Harris explains that, in her experience within a hospital setting, the infection preventionist or IP department are also those responsible for medical waste management.
“Nursing homes don’t have that [yet] and so it’s sometimes more difficult to stay on top of education and training with regard to proper waste management,” she speculates. “In addition, the high turnover among staff adds to this complication.”
In an effort to alleviate this issue for clients, Sharps provides its clients with a training and education portal on its site. The trainings are aimed at helping staff put processes in place that will help to ensure better compliance, Harris notes.
CMS training course
All SNFs soon should have infection control specialists in place, thanks to the CMS final rule on requirements of participation. The agency announced recently that it is collaborating with the CDC on the development of a training course on infection control and prevention for nursing home staff. Slated to be available in spring 2019 as an online on demand course, it will be free of charge, the agency said in a memo in March.
It will take approximately 16 to 20 hours and will include a certificate of completion following the online exam.
The announcement comes in the midst of the implementation of CMS’ new infection control and prevention requirements for SNFs, the deadline for which to have them in place is November 2019.
Although the already vague requirements do not make changes to the current requirements for medical waste management, all SNFs must have in place an infection preventionist who works at least part-time on staff. While there are some specific requirements outlined, they do not directly address medical waste management.
However, as both Harris and Sweet note, having a designated infection preventionist along with more prescriptive infection prevention and control programs and trainings in place may be helpful in getting SNF staff to more clearly identify and separate hazardous and non-hazardous waste.
CDC weighs in on waste
Defining what is medical, what is hazardous, and what is not hazardous is not easy, and it’s not the same in every state.
The Centers for Disease Control and Prevention’s website notes that the “most practical approach to medical waste management is to identify wastes that represent a sufficient potential risk of causing infection during handling and disposal and for which some precautions likely are prudent.”
While some regulations address the degree or amount of contamination, such as blood-soaked gauze, that defines the discarded item as a regulated medical waste, the Environmental Protection Agency’s “Manual for Infectious Waste Management” identifies and categorizes other specific types of waste generated in healthcare facilities that also require handling precautions.
Even the CDC admits “precisely defining medical waste on the basis of quantity and type of etiologic agents present is virtually impossible.”