Pharmaceutical Waste Management

1. Pharmaceutical Waste Management

2. Agenda Why does my facility need an Rx Waste Program? Environment Regulations What is Rx Waste? Elements of a Full Service Rx Waste Program Waste characterization Waste collection & segregation Waste transportation & disposal

3. The Growing Concern- Environmental & Regulatory Impact USGS (US Geological Survey) Water Survey Organic Wastewater Contaminants (OWCs) found in 80% of streams tested 33% of OWCs detected were pharmaceuticals in Minnesota alone EPA Regulatory Activity October 2007 four hospitals visited unannounced by EPA Region I (Boston Area) Warnings issued Re-visit 1Q08 looking for Rx Waste implementation plan The Joint Commission (TJC) Standards involving Medication Management, Environment of Care, and Leadership

4. Who is Involved Environmental Protection Agency (EPA) Department of Transportation (DOT) The Joint Commission (TJC) Drug Enforcement Agency (DEA) Local & State Regulators The primary regulatory agencies are the EPA-who define hazardous waste, DOT-who regulate shipping, packaging and manifesting and JCAHO- Joint Commission on Accreditation of Healthcare. It is the local POTW that determines what can or cannot be sewered based on the capabilities of the local water treatment system. The primary regulatory agencies are the EPA-who define hazardous waste, DOT-who regulate shipping, packaging and manifesting and JCAHO- Joint Commission on Accreditation of Healthcare. It is the local POTW that determines what can or cannot be sewered based on the capabilities of the local water treatment system.

5. RX Waste Compliance Program EPA Regulations Managing hazardous materials inside a facility

6. RCRA Enacted 1976 - targeted hazardous industrial waste Applies to chemicals (pharmaceuticals) Defines EPA RCRA hazardous waste Generator must: determine if waste is RCRA hazardous waste determine their waste generator status

7. RCRA Hazardous Drug Categories Listed Waste P – Listed (epinephrine and nitroglycerin) U – Listed (chemotherapy drugs) Characteristic Waste - 4 characteristics Ignitability, Corrosively, Reactivity, Toxicity Hazardous Waste is Compatible or Non-Compatible Compatible – can be placed in container without danger of reaction Non-Compatible – potential for chemical reaction if co-mingled

8. Characteristic Waste Thresholds Ignitability - Aqueous Solution containing 24% alcohol or more by volume & flash point<140° F., D001 Waste. Corrosivity - An aqueous solution having a pH <= 2 or >= to 12.5, D002 Waste. Reactivity – Must meet eight separate criteria identifying certain explosive and water reactive wastes. D003 waste. Nitroglycerin formulations are excluded federally from the P081 listing as non-reactive as of August 14, 2001 under FR: May 16, 2001. Some states have adopted the exclusion. Toxicity - Approximately 40 chemicals which meet specific leaching concentrations. Examples of potential toxic pharmaceuticals: Arsenic, Barium, Mercury ,Cadmium, Chloroform, Selenium, Chromium, Silver Infectious waste—      (i)   General. Municipal and residual waste which is generated in the diagnosis, treatment, immunization or autopsy of human beings or animals, in research pertaining thereto, in the preparation of human or animal remains for interment or cremation, or in the production or testing of biologicals, and which falls under one or more of the following categories:        (A)   Cultures and stocks. Cultures and stocks of infectious agents and associated biologicals, including the following: cultures from medical and pathological laboratories; cultures and stocks of infectious agents from research and industrial laboratories; wastes from the production of biologicals; discarded live and attenuated vaccines except for residue in emptied containers; and culture dishes, assemblies and devices used to conduct diagnostic tests or to transfer, innoculate and mix cultures.        (B)   Pathological wastes. Human pathological wastes, including tissues, organs and body parts and body fluids that are removed during surgery, autopsy, other medical procedures or laboratory procedures. The term does not include hair, nails or extracted teeth.        (C)   Human blood and body fluid waste.          (I)   Liquid waste human blood.          (II)   Blood products.          (III)   Items saturated or dripping with human blood.          (IV)   Items that were saturated or dripping with human blood that are now caked with dried human blood, including serum, plasma and other blood components, which were used or intended for use in patient care, specimen testing or the development of pharmaceuticals.          (V)   Intravenous bags that have been used for blood transfusions.           (VI)   Items, including dialysate, that have been in contact with the blood of patients undergoing hemodialysis at hospitals or independent treatment centers.          (VII)   Items saturated or dripping with body fluids or caked with dried body fluids from persons during surgery, autopsy, other medical procedures or laboratory procedures.          (VIII)   Specimens of blood products or body fluids, and their containers.        (D)   Animal wastes. Contaminated animal carcasses, body parts, blood, blood products, secretions, excretions and bedding of animals that were known to have been exposed to zoonotic infectious agents or nonzoonotic human pathogens during research (including research in veterinary schools and hospitals), production of biologicals or testing of pharmaceuticals.        (E)   Isolation wastes. Biological wastes and waste contaminated with blood, excretion, exudates or secretions from:          (I)   Humans who are isolated to protect others from highly virulent diseases.          (II)   Isolated animals known or suspected to be infected with highly virulent diseases.        (F)   Used sharps. Sharps that have been in contact with infectious agents or that have been used in animal or human patient care or treatment, at medical, research or industrial laboratories.      (ii)   Mixtures.        (A)   The term also includes materials identified under subparagraph (i) that are mixed with municipal and residual waste, including disposable containers.        (B)   The term also includes mixtures of materials identified in subparagraph (i) with quantities of radioactive waste not subject to regulation.      (iii)   Exceptions. The term does not include the following:        (A)   Wastes generated as a result of home self-care.        (B)   Human corpses, remains and anatomical parts that are intended for interment or cremation, or are donated and used for scientific or medical education, research or treatment.        (C)   Etiologic agents being transported for purposes other than waste processing or disposal pursuant to the requirements of the United States Department of Transportation (49 CFR 171.1—190), the Department of Transportation (67 Pa. Code Part I) and other applicable shipping requirements.        (D)   Samples of infectious waste transported offsite by Commonwealth or United States government enforcement personnel during an enforcement proceeding.        (E)   Body fluids or biologicals which are being transported to or stored at a laboratory prior to laboratory testing.        (F)   Ash residue from the incineration of materials identified in subparagraphs (i) and (ii) if the incineration was conducted in accordance with §  283.402 (relating to infectious waste monitoring requirements). The ash residue shall be managed as special handling municipal waste.        (G)   Reusable or recyclable containers or other nondisposable materials, if they are cleaned and disinfected, or if there has been no direct contact between the surface of the container and materials identified in subparagraph (i). Laundry or medical equipment shall be cleaned and disinfected in accordance with the United States Occupational Safety and Health Administration Requirements in 29 CFR 1910.1030 (relating to bloodborne pathogens).        (H)   Soiled diapers which do not contain materials identified in subparagraph (i).        (I)   Mixtures of hazardous waste subject to Article VII (relating to hazardous waste management) and materials identified in subparagraph (i) shall be managed as hazardous waste and not infectious waste.        (J)   Mixtures of materials identified in subparagraph (i) and regulated radioactive waste shall be managed as radioactive waste in accordance with applicable Commonwealth and Federal statutes and regulations, including, but not limited to, §  236.521 (relating to minimum requirements for classes of waste).        (K)   Mixtures of materials identified in subparagraph (i) and chemotherapeutic waste shall be managed as chemotherapeutic waste in accordance with this article.  Infectious waste—      (i)   General. Municipal and residual waste which is generated in the diagnosis, treatment, immunization or autopsy of human beings or animals, in research pertaining thereto, in the preparation of human or animal remains for interment or cremation, or in the production or testing of biologicals, and which falls under one or more of the following categories:        (A)   Cultures and stocks. Cultures and stocks of infectious agents and associated biologicals, including the following: cultures from medical and pathological laboratories; cultures and stocks of infectious agents from research and industrial laboratories; wastes from the production of biologicals; discarded live and attenuated vaccines except for residue in emptied containers; and culture dishes, assemblies and devices used to conduct diagnostic tests or to transfer, innoculate and mix cultures.        (B)   Pathological wastes. Human pathological wastes, including tissues, organs and body parts and body fluids that are removed during surgery, autopsy, other medical procedures or laboratory procedures. The term does not include hair, nails or extracted teeth.        (C)   Human blood and body fluid waste.          (I)   Liquid waste human blood.          (II)   Blood products.          (III)   Items saturated or dripping with human blood.          (IV)   Items that were saturated or dripping with human blood that are now caked with dried human blood, including serum, plasma and other blood components, which were used or intended for use in patient care, specimen testing or the development of pharmaceuticals.          (V)   Intravenous bags that have been used for blood transfusions.          (VI)   Items, including dialysate, that have been in contact with the blood of patients undergoing hemodialysis at hospitals or independent treatment centers.          (VII)   Items saturated or dripping with body fluids or caked with dried body fluids from persons during surgery, autopsy, other medical procedures or laboratory procedures.          (VIII)   Specimens of blood products or body fluids, and their containers.        (D)   Animal wastes. Contaminated animal carcasses, body parts, blood, blood products, secretions, excretions and bedding of animals that were known to have been exposed to zoonotic infectious agents or nonzoonotic human pathogens during research (including research in veterinary schools and hospitals), production of biologicals or testing of pharmaceuticals.        (E)   Isolation wastes. Biological wastes and waste contaminated with blood, excretion, exudates or secretions from:          (I)   Humans who are isolated to protect others from highly virulent diseases.          (II)   Isolated animals known or suspected to be infected with highly virulent diseases.        (F)   Used sharps. Sharps that have been in contact with infectious agents or that have been used in animal or human patient care or treatment, at medical, research or industrial laboratories.      (ii)   Mixtures.        (A)   The term also includes materials identified under subparagraph (i) that are mixed with municipal and residual waste, including disposable containers.        (B)   The term also includes mixtures of materials identified in subparagraph (i) with quantities of radioactive waste not subject to regulation.      (iii)   Exceptions. The term does not include the following:        (A)   Wastes generated as a result of home self-care.        (B)   Human corpses, remains and anatomical parts that are intended for interment or cremation, or are donated and used for scientific or medical education, research or treatment.        (C)   Etiologic agents being transported for purposes other than waste processing or disposal pursuant to the requirements of the United States Department of Transportation (49 CFR 171.1—190), the Department of Transportation (67 Pa. Code Part I) and other applicable shipping requirements.        (D)   Samples of infectious waste transported offsite by Commonwealth or United States government enforcement personnel during an enforcement proceeding.        (E)   Body fluids or biologicals which are being transported to or stored at a laboratory prior to laboratory testing.        (F)   Ash residue from the incineration of materials identified in subparagraphs (i) and (ii) if the incineration was conducted in accordance with §  283.402 (relating to infectious waste monitoring requirements). The ash residue shall be managed as special handling municipal waste.        (G)   Reusable or recyclable containers or other nondisposable materials, if they are cleaned and disinfected, or if there has been no direct contact between the surface of the container and materials identified in subparagraph (i). Laundry or medical equipment shall be cleaned and disinfected in accordance with the United States Occupational Safety and Health Administration Requirements in 29 CFR 1910.1030 (relating to bloodborne pathogens).        (H)   Soiled diapers which do not contain materials identified in subparagraph (i).        (I)   Mixtures of hazardous waste subject to Article VII (relating to hazardous waste management) and materials identified in subparagraph (i) shall be managed as hazardous waste and not infectious waste.        (J)   Mixtures of materials identified in subparagraph (i) and regulated radioactive waste shall be managed as radioactive waste in accordance with applicable Commonwealth and Federal statutes and regulations, including, but not limited to, §  236.521 (relating to minimum requirements for classes of waste).        (K)   Mixtures of materials identified in subparagraph (i) and chemotherapeutic waste shall be managed as chemotherapeutic waste in accordance with this article.

9. Formulary Analysis # NDC’s % NDC’s 2,615 100.0% Total Characterized 196 7.5% RCRA Hazardous 2,419 92.5% Non-Hazardous

10. P Listed Waste Acutely Hazardous Includes Epinephrine, Nicotine, Nitroglycerin, Phentermine, Physostigmine, Warfarin, Arsenic trioxide (chemo drug) Empty containers (except for used syringes) are hazardous waste – not RMW P-listed waste containers are not “RCRA empty”, unless they are triple rinsed (resulting rinsate must be discarded as hazardous waste).

11. Epinephrine Exclusion A 1994 EPA Hotline interpretation, not an EPA regulation or law Allows disposal of “used” Epinephrine syringes with residue as regulated medical waste. Only applies to “used syringes” – does not apply to vials, IV bags or other Epi containers Exclusion must be accepted at State level NH has accepted

12. Epinephrine Salts EPA has declared non-hazardous those pharmaceuticals in which the sole active ingredient is epinephrine salts Pharmaceuticals in which the sole active ingredient is epinephrine base are hazardous. Exclusion must be accepted at State level

13. U-Listed Hazardous Waste Toxic Chemo drugs Empty U–listed drug containers can be disposed of as RMW if: All contents have been removed using normal means AND No more than 3% by weight remains If BOTH conditions are not met, empty U-listed drug containers must be treated as hazardous waste.

14. Chemo Waste Bulk chemo is RCRA hazardous waste U-Listed P-Listed (Arsenic Trioxide) Non-RCRA Hazardous (best practice treat as haz) Trace chemo is RMW “RCRA Empty” Containers (not for p-listed) PPE

15. Common Chemotherapeutic/Antineoplastic Wastes Chlorambucil [Leukeran] U035 Cyclophosphamide [Cytoxan, CTX, Neosar] U058 Daunomycin [Daunorubicin, Cerubidine) U059 Melphalan [Alkeran, L-PAM] U150 Mitomycin C [Mitomycin, Mutamycin] U010 Streptozotocin, Chlornaphazine [Zanosar] U206 Uracil Mustard U237 Ethyl Carbamate U238 Azaserine U015 3-Methylcholanthrene U157 Arsenic Trioxide (Trisenox) P012 Bevacizumab (Avastin) Non-RCRA Hazardous Carmustine (Bicnu) Non-RCRA Hazardous Irinotecan Hydrochloride (Campostar) Non-RCRA Hazardous Doxorubicin Hydrochloride (Doxil) Non-RCRA Hazardous Oxaliplatin (Eloxatin) Non-RCRA Hazardous Common Chemo Wastes

16. Chemo Waste Disposal

17. Chemo Waste Disposal

18. Industry “Best Practices” Both the NIOSH Drug Alert & ASHP Guidelines acknowledge: EPA & DOT compliance required for hazardous waste disposal Non-RCRA hazardous chemo drugs mimic hazardous drugs & should be handled and disposed of as hazardous

19. Rx Waste Categories

20. Hazardous waste determinations not done or incorrect Labeling of hazardous waste not done or incorrect Throwing HW down the drain Improper disposal of chemotherapy drugs Inadequate training for employees in HW management Not conducting proper weekly inspections of HW storage No or inadequate HW manifests Improper management of expired pharmaceuticals Lack of emergency contingency plan “Identification and Management of Regulated Hazardous Waste” – EPA Region 2 Common EPA Inspection Violations Common EPA Identified Issues. In light of EPA and DOT regulations, consider these common EPA identified issues: •HW determinations and labeling that is incorrect or not done – remember, HW labeling must meet U.S. DOT requirements •Pouring HW down the drain •Improper disposal of chemo waste •Inadequate or no HW management employee training •Not performing weekly inspections of HW accumulation areas •Lack of or inadequate HW manifests •Poor/improper management of expired/outdated pharmaceuticals •No Emergency Contingency Plan •Failure to determine/identify RCRA HW Common EPA Identified Issues. In light of EPA and DOT regulations, consider these common EPA identified issues: •HW determinations and labeling that is incorrect or not done – remember, HW labeling must meet U.S. DOT requirements •Pouring HW down the drain •Improper disposal of chemo waste •Inadequate or no HW management employee training •Not performing weekly inspections of HW accumulation areas •Lack of or inadequate HW manifests •Poor/improper management of expired/outdated pharmaceuticals •No Emergency Contingency Plan •Failure to determine/identify RCRA HW

21. Waste Generator Status Amount of P-listed waste generated monthly, hospital wide, can determine EPA hazardous waste status. Small Quantity Generator More than 100kg (220.4lbs) but less than 1000kg (2204lbs) of hazardous waste or less than 1 kg (2.2 lbs) of acute hazardous (P-listed) waste per calendar month. Large Quantity Generator More than 1000kg (2204 lbs) of hazardous waste or more than 1kg/month (2.2 lbs) of acute hazardous (P-listed) waste per calendar month. NOTE: 1 liter of water weighs 2.204 lbs.

22. RX Waste Compliance Program DOT Regulations Safely transporting hazardous materials

23. U.S. DOT Regulations DOT regulations involve 4 basic requirements: 1.Classification, description, and packaging 2.Proper marking and labeling 3.Segregation into proper streams 4.Training   Hazmat Implementation Act Recently, the fine section was rewritten to raise fines. Currently fines average $30,000 per violation but can range up to $100,000.     US DOT HM229 If a generator i.e. hospital ships Hazmat without proper documentation the carrier must report it or the carrier can be prosecuted with the shipperDOT regulations involve 4 basic requirements: 1.Classification, description, and packaging 2.Proper marking and labeling 3.Segregation into proper streams 4.Training   Hazmat Implementation Act Recently, the fine section was rewritten to raise fines. Currently fines average $30,000 per violation but can range up to $100,000.     US DOT HM229 If a generator i.e. hospital ships Hazmat without proper documentation the carrier must report it or the carrier can be prosecuted with the shipper

24. Compatibility & DOT Waste Streams Waste medicine liquid flammable toxic Compatible Waste flammable liquids Compatible Waste medicine liquid toxic Compatible Waste flammable solid inorganic Compatible Waste corrosive liquids acidic organic Non-Compatible Waste organic peroxides Non-Compatible Waste oxidizing liquid Non-Compatible

25. RX Waste Compliance Program The Joint Commission Accreditation not Regulation

26. TJC Accreditation Issue The EPA has awarded a grant to H2E (Hospitals for a Healthy Environment) to train JCAHO inspectors on hazardous materials, which includes pharmaceuticals. Many believe that this will become an increasing area of focus on JCAHO surveys. Tracer methodology is being used to track pharmaceuticals from dispensing to disposal.The EPA has awarded a grant to H2E (Hospitals for a Healthy Environment) to train JCAHO inspectors on hazardous materials, which includes pharmaceuticals. Many believe that this will become an increasing area of focus on JCAHO surveys. Tracer methodology is being used to track pharmaceuticals from dispensing to disposal.

27. State of New Hampshire The EPA has awarded a grant to H2E (Hospitals for a Healthy Environment) to train JCAHO inspectors on hazardous materials, which includes pharmaceuticals. Many believe that this will become an increasing area of focus on JCAHO surveys. Tracer methodology is being used to track pharmaceuticals from dispensing to disposal.The EPA has awarded a grant to H2E (Hospitals for a Healthy Environment) to train JCAHO inspectors on hazardous materials, which includes pharmaceuticals. Many believe that this will become an increasing area of focus on JCAHO surveys. Tracer methodology is being used to track pharmaceuticals from dispensing to disposal.

28. RX Waste Compliance Program What is Pharmaceutical Waste

29. Examples of Pharmaceutical Waste Pharmaceutical Waste Partial vials (safety caps removed) Un-dispensed, pre-instilled IV’s Pre-filled syringes Partial syringes Discontinued meds Un-administered meds Patient prescriptions Characteristic Hazardous Lantus Humalog Humulin N Humulin R Centrum Silver Flovent Taxol Witch Hazel Benzamycin P – Listed Epinephrine* Nitroglycerin** Coumadin/Warfarin*** U – Listed Chemotherapy drugs Cytoxan Mutamycin

31. RX Waste Disposal Assessment  Blood Saturated Materials

32. How Rx Waste Will be Managed

33. All Hospital Waste Streams Blood Saturated Materials

34. Major Program Steps Waste Characterization of hospital formulary Identify hazardous pharmaceuticals Waste collection & segregation Place waste in appropriate container Transportation & Disposal Comply with DOT regulations for transportation Comply with EPA regulations for disposal

35. RX Formulary Characterization

36. Waste Collection EPA requirements for hazardous waste collection At or near point of generation Under generator’s control Locations Pharmacy Patient-care areas Pyxis Stations Med Carts Med rooms Soiled utility rooms

37. Waste Segregation At point of generation hospital staff places waste into appropriate containers Non-RCRA into one container RCRA hazardous in multiple containers In HW Accumulation Area trained technicians segregate waste that was collected in one or two containers Non-RCRA into one container RCRA hazardous into multiple containers Over classify all waste as hazardous waste Segregate into multiple hazardous waste containers At point of generation or in HW accumulation area

38. Segregation SLIDE 25 – Industry Initiatives As I have already mentioned, Abbott Northwestern Hospital and the Allina Health Group are pioneers in implementing a pharmaceutical waste management initiative. H2E has also launched a pharmaceutical waste management initiative with a hospital in the northeast. As I mentioned earlier, Stericycle has launched pharmaceutical medical waste management initiatives with multiple hospitals including a 5 member hospital group in South Florida, a hospital in Minnesota and a hospital in Indiana. There are additional on-going discussions with hospitals in NY, CA and WVA. GO TO SLIDE 26 GO TO SLIDE 26SLIDE 25 – Industry Initiatives As I have already mentioned, Abbott Northwestern Hospital and the Allina Health Group are pioneers in implementing a pharmaceutical waste management initiative. H2E has also launched a pharmaceutical waste management initiative with a hospital in the northeast. As I mentioned earlier, Stericycle has launched pharmaceutical medical waste management initiatives with multiple hospitals including a 5 member hospital group in South Florida, a hospital in Minnesota and a hospital in Indiana. There are additional on-going discussions with hospitals in NY, CA and WVA. GO TO SLIDE 26 GO TO SLIDE 26

39. Pharmacy SLIDE 25 – Industry Initiatives As I have already mentioned, Abbott Northwestern Hospital and the Allina Health Group are pioneers in implementing a pharmaceutical waste management initiative. H2E has also launched a pharmaceutical waste management initiative with a hospital in the northeast. As I mentioned earlier, Stericycle has launched pharmaceutical medical waste management initiatives with multiple hospitals including a 5 member hospital group in South Florida, a hospital in Minnesota and a hospital in Indiana. There are additional on-going discussions with hospitals in NY, CA and WVA. GO TO SLIDE 26 GO TO SLIDE 26SLIDE 25 – Industry Initiatives As I have already mentioned, Abbott Northwestern Hospital and the Allina Health Group are pioneers in implementing a pharmaceutical waste management initiative. H2E has also launched a pharmaceutical waste management initiative with a hospital in the northeast. As I mentioned earlier, Stericycle has launched pharmaceutical medical waste management initiatives with multiple hospitals including a 5 member hospital group in South Florida, a hospital in Minnesota and a hospital in Indiana. There are additional on-going discussions with hospitals in NY, CA and WVA. GO TO SLIDE 26 GO TO SLIDE 26

40. Patient Care Areas SLIDE 25 – Industry Initiatives As I have already mentioned, Abbott Northwestern Hospital and the Allina Health Group are pioneers in implementing a pharmaceutical waste management initiative. H2E has also launched a pharmaceutical waste management initiative with a hospital in the northeast. As I mentioned earlier, Stericycle has launched pharmaceutical medical waste management initiatives with multiple hospitals including a 5 member hospital group in South Florida, a hospital in Minnesota and a hospital in Indiana. There are additional on-going discussions with hospitals in NY, CA and WVA. GO TO SLIDE 26 GO TO SLIDE 26SLIDE 25 – Industry Initiatives As I have already mentioned, Abbott Northwestern Hospital and the Allina Health Group are pioneers in implementing a pharmaceutical waste management initiative. H2E has also launched a pharmaceutical waste management initiative with a hospital in the northeast. As I mentioned earlier, Stericycle has launched pharmaceutical medical waste management initiatives with multiple hospitals including a 5 member hospital group in South Florida, a hospital in Minnesota and a hospital in Indiana. There are additional on-going discussions with hospitals in NY, CA and WVA. GO TO SLIDE 26 GO TO SLIDE 26

41. SLIDE 25 – Industry Initiatives As I have already mentioned, Abbott Northwestern Hospital and the Allina Health Group are pioneers in implementing a pharmaceutical waste management initiative. H2E has also launched a pharmaceutical waste management initiative with a hospital in the northeast. As I mentioned earlier, Stericycle has launched pharmaceutical medical waste management initiatives with multiple hospitals including a 5 member hospital group in South Florida, a hospital in Minnesota and a hospital in Indiana. There are additional on-going discussions with hospitals in NY, CA and WVA. GO TO SLIDE 26 GO TO SLIDE 26SLIDE 25 – Industry Initiatives As I have already mentioned, Abbott Northwestern Hospital and the Allina Health Group are pioneers in implementing a pharmaceutical waste management initiative. H2E has also launched a pharmaceutical waste management initiative with a hospital in the northeast. As I mentioned earlier, Stericycle has launched pharmaceutical medical waste management initiatives with multiple hospitals including a 5 member hospital group in South Florida, a hospital in Minnesota and a hospital in Indiana. There are additional on-going discussions with hospitals in NY, CA and WVA. GO TO SLIDE 26 GO TO SLIDE 26

42. Transportation & Disposal Non-RCRA waste is transported to an RMW facility RCRA hazardous is transported by a licensed hazardous waste hauler to a hazardous waste facility All waste is incinerated Non-RCRA at an RMW incinerator RCRA at Hazardous waste incinerator

43. Implementation Training for staff Pharmacy Clinicians EVS Train all shifts Topics Program implementation consulting Regulations Program Details Containers Segregation Transportation & Disposal

44. On-going Support Continuous support to ensure on-going compliance Rx waste characterization of new drugs added to formulary Annual Audit to ensure compliance Manifests Accumulation Area weekly inspections Proper segregation Annual training

45. Program Goals Reduces Risk associated with hazardous waste compliance Helps meet TJC standards Helps stay in compliance with EPA, DOT and state regulations

46. RX Waste Compliance Program Questions? Tmartinez@stericycle.com (559) 351-8945