PRE-ACCEPTANCE HEALTHCARE WASTE SELF-AUDIT TOOL

This self-audit tool has been produced to support nursing only care homes, and is designed to assist in completing the pre-acceptance requirements for waste disposal.

Many legally authorised clinical waste disposal facilities, including both incinerators and treatment plants, are now required to obtain this information from their customers before they can accept your waste.  You should complete this form to assist your waste contractor in disposing of your waste. Disposal sites are required to obtain this information from nursing care homes, before July 2013.

The tool asks a number of questions to help determine the most appropriate way to dispose of your waste. These are not intended to be trick questions so you should answer the questions honestly. Some questions are supported by brief explanatory notes, which in certain cases may assist you in identifying potential problems.

How do I do it?

The most effective way is to do all of the following:

•	Check each room of your home and see what waste containers are present;
•	Look in each in use waste container to see what is actually in them (this should be done visually, without putting your hands inside the containers);
•	Question your staff about how they would dispose of different items (understanding and practice can vary);
•	It is also worthwhile checking your storerooms and cupboards to see if there are any pieces of equipment or reagents that you may not have considered.

You should send the completed audit to your waste contractor. They will assess the information and use this information to advise you on completion of waste documentation, ensure that your waste is disposed of appropriately, and provide additional advice on some aspects of your waste practices if necessary.

What happens to me if the audit shows that I am doing something wrong?

The main purpose of this tool is to enable you and your waste contractor to identify the appropriate way to manage your waste. If you are doing something seriously wrong either:

•	This audit tool will identify it, or
•	Your waste contractor may contact you with advice.

Appropriate waste segregation has been a legal requirement since 2005. However, no waste segregation system operates perfectly all the time. Regularly auditing your procedures enables you to identify and address issues. The fact that you have undertaken this audit and subsequently address any issues identified is very positive. 

Once completed, future audits will only need to take place every 5 years or if you subsequently amend your segregation practices. 

Audit findings – [Insert Care Home Name] Information

Date and description of audit and the procedures employed.
	
[Insert date]

Visit to each area and the storage area – and observation and discussion with staff

Details of person conducting the audit and their qualifications and competencies.

Details of the home waste producer.

Process from which waste derives	
[Insert details, eg care home manager] 

[care home, 1 High Street, New Town, The Shire  W2P 4XZ]

Nursing care	

A list of the functional areas included within the audit (which should encompass the entire home). 
	
[treatment and support rooms examined] 

The estimated quantity of each waste stream produced on the premises.

[per collection / insert frequency]
	
Hazardous (amend or add to as necessary)
sharps boxes 
[x]  yellow lid
[x]  orange lid
[x]  purple lid

[x] orange bags
[x] medicinal receptacles

Non-hazardous 
[x] offensive waste containers  
[x] municipal waste (black) bags
 	
Date of production of the waste and waste storage and preservation techniques used before collection 
	[Insert dates] 

[For example, stored in cool outhouse area]	

Audit Findings – Waste Containers
Please indicate waste container types in use (and complete on report  and summary sheets)	
Type	Colour(s)	In Use (Y/N)?	Size(s)	Label details	Number and location	
Sharps Boxes	Yellow – purple lid	
				
	Yellow – yellow lid	
				
	Yellow – orange lid	
				
	Other (please specify)
………………………..					
Medicine Bins	Yellow – blue lid
					
	Other (please specify)
………………………..					
Waste Bags	Clinical waste – orange
					
	Offensive waste ‘Tiger bag’ – 					
	Domestic -Black bags
					
Confidential paper

	Other (please specify)
					
Other (eg batteries,  chemicals, fluorescent bulbs etc)

Audit Findings - Composition Questions

The following section contains a number of questions. It serves two purposes:

•	Firstly to help you identify current segregation practices by asking relevant questions, and
•	Secondly as a result to assist you in classifying and describing your waste.

You should answer each element of the questions and write the European Waste Catalogue (EWC) classification code(s) and descriptions elements provided on the report sheet for the relevant container and room. Once the report sheets have been completed for each area of the practice, these can be combined onto a single summary sheet.

1: Cytotoxic and Cytostatic Medicines
It is likely that some nursing homes administer a small number of cytotoxic and cytostatic medicines. 

Does you nursing home have any of the medicines in appendix A (Yes/No)

If yes, 

a)	Into which container do you dispose of solid waste medicines?

b)	What container(s) do you dispose of liquid waste medicines in?

c)	What container(s) do you dispose of outer cardboard packaging from these medicines in? (ie do you discard them with the medicines)?

If any of these cytotoxic and cytostatic medicines are administered by injection,
Into which waste containers(s) do you place the contaminated items arising? 

d)	Needles or syringes

e)	Syringe bodies (if separated)

f)	Cartridges or other medicine vials/ampoules or bottles used to charge the syringe

(Note that this includes any syringes that are fully discharged).

	

Yes/No

(a and b) Classification:
18 01 08*

Description: Cytotoxic and cytostatic medicines

(c) Classification:20 01 01

Description: cardboard packaging

(d and e) Classification: 18 01 03* and 18 01 08*
Description: Cytotoxic and cytostatic contaminated sharps

(f) Classification:
18 01 08*

Description: Cytotoxic and cytostatic medicines

2 : Other Medicinally Contaminated Sharps 
Into which waste containers(s) do you place the medicinally contaminated items arising from injections of medicines? 
a) Needles or syringes

b) Syringe bodies (if separated)

c) Cartridges or other medicine vials/ampoules or bottles used to charge the syringe

(Note that this includes any syringes that are fully discharged).

 .................................................

 .................................................

.................................................	

(a and b) Classification: 18 01 03* and 18 01 09
Description: Medicinally contaminated sharps (not cytotoxic and cytostatic)

(c) Classification: 
18 01 09
Description: Medicines (not cytotoxic or cytostatic)	

3: Non- medicinally contaminated sharps 
Do you produce any waste needles, syringes, or other sharp instruments that are not used in the administration of medicines? Eg phlebotomy
a)	Into which container do you place them?

Yes/No

.................................................	

Classification: 18 01 03* 
Description: Non-medicinally contaminated sharps	

4: Medicines (non cytotoxic and cytostatic)
Other than those identified in Question 1

a)	What container(s) do you dispose of solid waste medicines in?

b)	What container(s) do you dispose of liquid waste medicines in?

c)	What container(s) do you dispose of outer cardboard packaging from these medicines in? (I.e. do you discard them with the medicines)?

Note: waste medicines may possess hazardous properties (e.g. flammable) that may affect their handling and disposal. You should make your waste contractor aware of such properties.

.................................................

.................................................

................................................

.................................................

	

(a and b) Classification: 18 01 09
Description: Medicines (not cytotoxic or cytostatic)

(c)Classification: 20 01 01
Description: Cardboard packaging

	

5: Municipal wastes, office and packaging wastes 
Which container(s) are each of the following discarded in?
a)	Newspapers/magazines etc 

b)	Cardboard packaging  (eg glove boxes)

c)	Drink or food packaging, cartons or cans

d)	Sterile packaging from medical items/equipment

e)	Patient records or other documents (including or restricted to confidential)

.................................................

  .................................................

.................................................

.................................................

.................................................	
Unless segregated and recycled use:

Classification: 20 03 01 
Description: Mixed municipal waste

6: Offensive Wastes - Municipal 
a)	Do you have a bin for the disposal of continence products in the care home toilets?

b)	What container(s) is used for this waste?

Y/N

.................................................	

Classification: 20 01 99
Description: Municipal offensive hygiene waste

7: Other Clinical and Offensive Wastes 
What type of container(s) do you dispose of each of the following in?
a)	Personal Protective Equipment (PPE), e.g. gloves, gowns, facemasks etc contaminated with potentially infectious body fluids (e.g. blood/saliva)

b)	Swabs or tissues or other soft items contaminated with potentially infectious body fluids

c)	Other non-sharp blood contaminated items (please specify)

Do you segregate offensive healthcare waste (other than those wastes identified in question 7) from clinical waste

What type of container(s) do you dispose of each of the following in?
a)	PPE (gloves, gowns, facemasks etc)  NOT contaminated with potentially infectious body fluids (e.g. blood)

b)	Swabs, tissues, or other soft items NOT contaminated with potentially infectious body fluids.

c)	Unused medical items (not sharps) e.g. an unused swab dropped on the floor

…..............................................

.................................................

................................................

................................................

Y/N

.................................................

.................................................

.................................................	

(a,b,c)Classification: 18 01 03*
Description: clinical waste, infectious

Classification: 18 01 04*
Description: offensive hygiene waste from healthcare

8: Chemicals 
Do you use or produce any of the following, and if so what containers do you dispose of them in?
a)	Diagnostic kits including chemical reagents

b)	Chemical disinfectants

c)	Handgels

	

................................................

................................................

................................................

................................................

If containers are rinsed and cleaned before disposal:

Classification: 15 01 02
Description: plastic packaging

If containers are discarded without rinsing:

Classification: 18 01 06* or 18 01 07 (depends on chemical – 18 01 06 if hazardous)

9: Waste Storage 
Are your waste containers, and particularly your clinical waste containers, segregated by container type in your waste store? (i.e. are you putting sharps boxes, medicines bins, and clinical waste bags in the same wheeled cart?) a resume of how waste is stored prior to collection

Y / N	

Audit Report Sheet  - Waste classification and composition - (complete a new sheet for each area eg bedrooms, treatment rooms, bathrooms etc)

Container Type
	
Example : Yellow lidded sharps box				
Coding and description elements from Questions

	2(a and b)  18 01 03 and 18 01 09
Medicinally contaminated sharps (not cytoxic or cytostatic).
2(c)  18 01 09 Medicines (not cytotoxic and cytostatic) .
3(a)  18 01 03* Non-medicinally contaminated sharps.
				
Any other constituents identified during audit 	
none				

Container Type
					
Coding and description elements from Questions
					
Any other constituents identified during audit

Audit Summary Sheet  - (composite of report sheets for each area)

Container Type
	
Example : 				
Coding and description elements from Questions

				
Any other constituents identified during audit					

Container Type
					
Coding and description elements from Questions

				
Any other constituents identified during audit					

The waste classification, description and disposal options for the contents of each waste stream (derived from summary report)
	
Waste Stream	Classification	Description	Hazards	Disposal Options	
Example: Yellow lidded sharps box	18 01 03* and 18 01 09	Clinical waste, mixed medicinally contaminated sharps and medicines (non-cytotoxic and cytostatic) 
	Infectious (H9)	Incineration only	
Example: Orange bag 
	18 01 03*	Clinical waste, infectious
		Alternative Treatment 
	
Example: Purple lidded rigid container	18 01 08*	Cytotoxic and Cytostatic medicines

		Incineration	

					

Explanatory notes

Clinical waste alternative treatment: suitable for clinical wastes that do not contain offensive wastes, medicines, chemicals, municipal wastes etc. From a care home only those wastes classified as 18 01 03* alone should be disposed in this way (orange bags). 

Clinical waste incineration: usually suitable for all types of clinical waste and offensive wastes from care homes. It is normally the only means to dispose of clinical wastes contaminated with medicines / chemicals or containing anatomical wastes.

Recycling or Recovery: paper, cardboard may be recycled (seek advice from your waste collection company).

Appendix A : Cytotoxic and cytostatic medicines – ‘Ready Reckoner’.

The definition of cytotoxic and cytostatic medicines is wide, and is based on chemical properties rather than usage. Any medicine that is carcinogenic, mutagenic, toxic for reproduction, or toxic is classified as a ‘cytotoxic and cytostatic’ medicine. As a result this classification will include many hormonal preparations, oncology drugs, immunosuppressants, a vaccine, and a number of antivirals/antibiotics.

Examples in community care might include, for example, chloramphenicol, BCG vaccine, Methotrexate, and Methoxyprogesterone (Depo provera), Oxytocin (Syntometrine, Syntocinon).

The chemical properties of a medicine can normally be determined by consulting its material safety data sheet and looking for the following chemical risk phrases or their descriptions

Table 1: Chemical risk phrases and their descriptions related to the definition of Cytotoxic and Cytostatic	
Risk Phrase	Description	Related Hazardous Property	
R23
R24
R25	Toxic by inhalation
Toxic by contact with skin
Toxic if swallowed	H6 Toxic	
R26
R27
R28	Very toxic by inhalation
Very toxic by contact with skin
Very toxic if swallowed		
R40	Limited evidence of carcinogenic effect	H7 Carcinogenic	
R45
R49	May cause cancer
May cause cancer by inhalation		
R60	May impair fertility	H10 Toxic for reproduction	
R61	May cause harm to the unborn child		
R62	Possible risk of impaired fertility		
R63	Possible risk of harm to the unborn child		
R46	May cause heritable genetic damage	H11 Mutagenic	
Muta.Cat 3 with R68	Possible risk of irreversible effects