Pharmaceutical Waste Management Program

1. Pharmaceutical Waste Management Program University of Chicago Medical Center

2. Introduction • University of Chicago Medical Center (UCMC) will be implementing a program to collect Pharmaceutical (Rx) waste throughout the hospital. • The program has been designed to collect and manage this waste using Best Management Procedures. • Training Module: • This training module is designed to explain the requirements, describe the identification process, and show how pharmaceuticals will be identified by the Pharmacy and collected in various containers in all departments of the hospital.

3. Introduction • Program Overview • Pharmacy evaluates the hospital formulary and develops a quick and easy way (through identifiers) to indicate where to place the waste. • Staff administers the Pharmaceutical and looks for the identifier(s) to determine where to dispose of waste. • Staff disposes of the Pharmaceutical waste in containers placed strategically in their Unit. • Staff will be required to know where to dispose of each type of Pharmaceutical waste. • Staff will not be required to memorize what to do with each Pharmaceutical waste. • Stericycle (third party) staff will be responsible for Pharmaceutical waste container service and transport.

4. Who to Contact With Questions • If there are any questions regarding this new program, please see the educational postings in each unit or contact the following individuals: • Jennifer Palombizio, Manager of Safety Office and Environmental Compliance, 2-3363, 5-SAFE or jennifer.palombizio@uchospitals.edu • Judd Johnson, Assoc. Dir – FD&C, 2-8259 or jjohnson@bsd.uchicago.edu • If the above individuals are not available, the Pharmacy Director can be contacted

5. Regulatory Environment • In addition to promoting Environmental Stewardship, there are regulations that apply to the management and disposal of pharmaceutical wastes • What are healthcare facilities required to do? • Manage all identified Hazardous Waste generated within the facility (Pharmaceuticals, Lab Wastes, Engineering, Solvents, etc.). This program concentrates on the Pharmaceutical Wastes • Some Pharmaceuticals are considered hazardous to the Environment and therefore UCMC will manage accordingly • Rules and Regulations (EPA, IL EPA, DOT, The Joint Commission) • Federal: US Environmental Protection Agency • Rules developed in 1976, recently began looking at Healthcare • State: Illinois Environmental Protection Agency • Additional Regulations – Department of Transportation (when shipping), Sewered Waste (drain disposal), The Joint Commission – Environment of Care

6. Current Rx Waste Practices Rx waste is currently being disposed of in a variety of non-compliant ways. The table below shows some common locations where Rx waste is being disposed, what can continue to go into those containers, and what cannot.

7. Processes Not Changing • Controlled Substances Handling • Still must witness and waste to drain per DEA guidance and written procedures • Radioactive Rx and Nuclear Medicine Procedures • Follow existing procedures with half life decay, etc. • Regulated Medical Waste • Sharps (needles, etc.) = Sharps Container • Red bag wastes = Red Bag/Infectious Waste Container • IV Draining • Can still cut and drain non-pharmaceuticals to the drain and bags to the garbage • Maintenance IVs and Fluids (saline, potassium, sodium chloride, D5W, etc.) • If Pharmaceutical is added, then manage as it is identified

8. Examples of Rx Waste To Collect The rules apply not only to the Rx in various forms and doses, but also applies to some containers that held the Rx. Examples of items to collect: • Vials • IVs and tubing • Doesn’t Include Maintenance IVs (Saline, LRs, Dextrose, KCl, Na Bicarb) • Oral Medications • Partial syringes • Unit dose packaging • Specifically - Coumadin unit dose packaging, nicotine patch and backing • Patient prescriptions • Left from patients and families

9. Categories of Rx Waste • Rx can be either Hazardous or Non-hazardous to the Environment (different from OSHA Hazardous or Bio-Hazardous definitions) • Hazardous Rx Waste – About 6% of formulary • Rx might be identified as hazardous to the environment because it is specifically listed (Warfarin, Nicotine) • Some Rx is hazardous because the Rx has something in it • Rx with Alcohol is Ignitable; Some Rx are Corrosive • Some Rx contain preservatives (Thimerisol) that make them hazardous • Non-Hazardous Rx Waste – About 93% of the formulary • Most Rx are not hazardous according to EPA definitions but many of these Rx may still adversely affect the environment • As a best management practice, UCMC will also collect all non-hazardous Rx and dispose through incineration

10. Identifying Rx Waste Streams • How to Identify Pharmaceuticals: • A Formulary Analysis has been completed by the Pharmacy to identify what Rx need to be managed in which container • Pharmacy will Identify the Hazardous Rx for disposal in Black containers • AcuDose or EPIC MAR notification for those that are distributed through the AcuDose System • “Dispose in Black Container” • “For Disposal Return to Pharmacy” • Rx that has no AcuDose or MAR message or label, is Non-Hazardous and is disposed of in the BLUE Container

11. WHAT ARE THE DIFFERENT TYPES OF RX WASTE? Sewerable Wastes Compatible Hazardous Waste Incompatible Hazardous Waste (Separate) Chemotherapy Wastes Non-Hazardous Waste

12. Pharmaceutical Waste Stream Management Labeled or Identified as Hazardous / Incompatible Rx by Pharmacy Sewer System Hazardous Rx Waste “Place in BLACK Container” Incompatible Rx Waste “Return to Pharmacy” Potentially Infectious & Hazardous Rx Waste “Return to Pharmacy” Bulk & Trace Chemotherapy Rx Waste Non-Hazardous Rx Waste No Messaging • Items that can be cut and poured down the drain • Plain IV Solutions • Solutions containing additives, such as: • Potassium chloride • Potassium phosphate • Sodium phosphate • Calcium • Sodium bicarbonate • Controlled Substances • Items identified with a message or black dot • Examples • Insulin • Some Vaccines • Trace elements • Coumadin • Nicotine • Miscellaneous • Rx Spill Cleanup Debris • Rx in Syringe – Discharge into gauze, gauze in container, syringe to SHARPS • Incompatible Rx Wastes Require Segregation to Meet DOT, Safety & Disposal Requirements • Place in zip lock bag • Aerosols • Inhalers with canister • Oxidizers (Examples) • Unused Silver Nitrate • Corrosives (Examples) • L-cysteine (in pediatric TPN) • Corrosives (Examples) • Botox • Chemotherapy Rx and containers that ARE empty • Empty Syringes • Gowns with chemo small amount of contamination • Gloves • Goggles • Wipes • Empty IVs / Tubing • Vials • Chemotherapy Rx and containers that are NOT empty • Chemo Agents • IVs with Residual Chemo Agents • Chemo Spill Cleanup Debris • Vials with Residual Chemo Agents • Tablets, caps etc. • Not Labeled or Identified as • Non-Hazardous Rx by Pharmacy • Examples • Antibiotics • Lidocaine • Marcaine • Heparin • Miscellaneous • Full/partially filled syringe – expel into gauze, gauze in container, empty syringe in SHARPS • A Combination of Infectious Waste & Hazardous Rx Waste • Examples • Must meet by the Hazardous and Infectious Waste Definitions • Managed like a spill response Place into BLACK CONTAINER Cut and Discharge to Drain Place into a BAGGIE and RETURN TO PHARMACY Call EVS for PURPLE CONTAINER Place into BLACK CONTAINER Place into BLUE CONTAINER Place into YELLOW CONTAINER • SHARPS • Needles • Empty syringes (See Above) • Empty controlled substance containers • REGULAR TRASH • Outside packaging and overwrap that did not contact Rx • Regular Trash • Shipping packaging

13. Sewer System • Items that can be cut and poured down the drain • Plain IV Solutions • Solutions containing additives, such as: • Potassium chloride • Potassium phosphate • Sodium phosphate • Calcium • Sodium bicarbonate • Controlled Substances SEWERABLE WASTES Plain IV Solutions Controlled Substances Cut and Discharge to Drain

14. Plain IV Solutions • Plain IV Solutions are those prepackaged items that did not have Rx added to it • Continue to drain Plain IV Solutions to the drain and the bags then go to the Garbage • These Plain IV Solutions Include: • Saline • Lactated Ringers • Potassium chloride • Potassium phosphate • Sodium phosphate • Calcium • Sodium bicarbonate

15. Controlled Substances • Continue to follow DEA witness/waste requirements per your Hospital’s Policy • Witness and waste to the drain, sink, toilet • Do NOT dispose controlled substances: • In RMW containers • In Hazardous Rx waste containers • In Non-hazardous Rx waste containers, or • In Trash • Once empty, the containers can be placed into the Sharps container or Blue Non-hazardous Rx waste container

16. Hazardous Rx Waste “Place in BLACK Container” • Items identified with a message or black dot • Examples • Insulin • Some Vaccines • Trace elements • Coumadin • Nicotine • Miscellaneous • Rx Spill Cleanup Debris • Rx in Syringe – Discharge into gauze, gauze in container, syringe to SHARPS COMPATIBLE HAZARDOUS RX WASTES Place into BLACK CONTAINER

17. Compatible Hazardous Rx Waste “Place in BLACK Container” • Identified with the AcuDose message or MAR message in the Label Comments, and/or on the label • The Rx and containers having contact with Rx (vials, IVs & Tubing, etc.) placed into container (full, partials or empty) • Specifically includes Coumadin and NicotineWaste and Packaging • Place in BLACK Container

18. Incompatible Rx Waste “For Disposal Return to Pharmacy” • Incompatible Rx Wastes Require Segregation to Meet DOT, Safety & Disposal Requirements • Place in zip lock bag • Aerosols • Inhalers with canister • Oxidizers (Examples) • Unused Silver Nitrate • Corrosives (Examples) • L-cysteine (in pediatric TPN) • Corrosives (Examples) • Botox INCOMPATIBLE HAZARDOUSRX WASTES Place into a BAGGIE and RETURN TO PHARMACY

19. Incompatible Hazardous Rx Waste Place in Baggie “For Disposal Return to Pharmacy ” • Identified with the AcuDose message or MAR message in the Label Comments, and/or on the label • Rx Waste that cannot be collected in the same container due to EPA and DOT regulations • Examples: Aerosols (mouthpiece removed), Corrosives (Robinul), Oxidizers (unused silver nitrate sticks), Toxins (Botox) • Bag and place in Incompatible Container

20. Bulk & Trace Chemotherapy Rx Waste • A Chemotherapy Rx and containers that are NOT empty • Chemo Agents • IVs with Residual Chemo Agents • Chemo Spill Cleanup Debris • Vials with Residual Chemo Agents • Tablets, caps etc • Chemotherapy Rx and containers that ARE empty • Empty Syringes • Gowns with chemo small amount of contamination • Gloves • Goggles • Wipes • Empty IVs / Tubing • Empty Vials Chemotherapy Waste Bulk Chemotherapy Waste (Black) Trace Chemotherapy Waste (Yellow) Place into BLACK CONTAINER Place into YELLOW CONTAINER

21. TRACE Chemotherapy • “Trace” Chemotherapy Waste is any EMPTY Chemotherapy Container (YELLOW) • Empty IVs and tubing • Syringes • Non-contaminated PPE • Gowns, Goggles, Gloves • Wipes • Place these items into the YELLOW Container that is currently being used • Yellow Containers will be located on units that consistently use Chemotherapy items

22. BULK Chemotherapy • “Bulk” Chemotherapy Waste is any chemotherapy Rx that is NOT empty • Non-empty containers holding free liquid (vial, IV bag, tubing) • Oral medications – Patient refused, medication dropped, etc. • Discontinued Rx – Patient reaction, partial IV • Overtly contaminated garments and spill clean up material • Gowns, Goggles, Gloves • Spill cleanup (Rags, Wipes, Towels) • Place into BLACK Container

23. Non-Hazardous Rx Waste No Messaging • Not Labeled or Identified as • Non-Hazardous Rx by Pharmacy • Collect Full and Partially Full Rx Containers • Examples • Antibiotics • Lidocaine • Marcaine • Heparin • Miscellaneous Non-hazardous RX Waste Place into BLUE CONTAINER

24. Non-Hazardous Rx Waste NO LABEL or IDENTIFIER • Identified with the AcuDose message or MAR message in the Label Comments, and/or on the label • Managed by placing waste into BLUE Container • Majority of Rx will be Non-hazardous - therefore no label

25. Regular Trash • Items that can be disposed of in the regular Trash include: • Outside packaging and package inserts • Cardboard • Plain IVs and Tubing

26. GENERAL REQUIREMENTS Containers – Closed and Labeled Movement of Full Containers Spill Response

27. Container Requirements PHARMACEUTICAL HAZARDOUS WASTE START DATE _____________________________ CONTAINER FULL DATE ___________________ PHARMACEUTICAL HAZARDOUS WASTE START DATE _____________________________ CONTAINER FULL DATE ___________________ • The hazardous waste containers (Black) must be stored in a closed and labeled • Close the containers when not using them • The label must have at least the words “Hazardous Waste”, a description of the contents, and the date that the container was filled (completed by Stericycle)

28. Movement of Containers • Rx Waste Containers must be under the control of the staff; therefore they will be generally located in centralized areas in each unit such as the Soiled Utility Rooms or in or near Med Rooms or Procedure Rooms • The full containers will be managed like the Sharps Containers and picked up by Stericycle Technician

29. Spill Response • Refer to facility Spill Response Policy, which includes the following: • Call Spill Team • Secure Area • Identify Material & get MSDS • Contain and Clean-up as directed by Spill Team • Spill Kits, Absorbents • Dispose of Hazardous Clean-up Materials Properly • Hazardous Waste Container