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RMW Minimization Strategies

While the primary objective of RMW man­agement is to minimize the risk of disease transmission, every facility has an opportu­nity to reduce both risk and cost through improved collection and segregation of RMW. Improved segregation of Regulated Medical Waste (RMW) is considered a “low hanging fruit” in healthcare sustainability, due to its potential for significant cost savings. Many hospitals have let a variety of factors, including lack of ongoing education and retraining.

Step 1: Develop or Review your Facility’s Definition of RMW 

Keep in mind that RMW is defined by each state but hospitals also must be in com­pliance with federal OSHA and DOT regulations. See the Defining RMW page for more specific guidance.

Step 2: Define the Problem and Develop a Cost/Benefit Analysis

There are several steps necessary to define the current state of the organization's RMW program. The first step in improved segregation is the need for a baseline assessment of waste generation rates, to understand how much of the waste stream is currently segregated as RMW.  See Developing a Waste Baseline for more assistance.  A baseline helps to understand the current costs and waste volumes associated with RMW disposal and to identify whether this is an area that deserves focus or not. Be sure to account for fuel surcharges, container rental fees, any turnkey fees for sharps management and separate fees that may be related to special disposal of chemotherapy and pathological waste.

Step 3: Create a Team, Set Goals and Develop an Action Plan

With a good understanding of the amount of RMW your facility generates and the total cost of disposal, the organization is ready to put together the project team and develop the reduction program’s goals and action plan. It is critical that a multi-disciplinary project team be established that includes staff from Environmental Services, Infection Control, Nursing, Safety, Facilities, Employee Education, Employee Health, Laboratory, and clinicians—particularly those from the OR, ED and critical care areas. If you already have a Green Team in place, this project could also live within that team. Highlight manage­ment commitment to the effort.  Delegate a leader and review the processes and departments that are generating the most RMW and target them first for education and reduction.

Step 4: Make Waste Segregation Simple

Provide the proper tools for employees to easily implement waste segregation. First, work with department heads and nurse managers in each area to determine the types and volumes of wastes generated. This will help you determine their container, placement and training needs. Work with Communications to develop edu­cational information including posters, recep­tacle labels, newsletters and employee training.

Step 5: Determine Optimal Container Placement and Use Good Signage

Rule number one- make it easy to do it right! Proper container size, placement and signage are critical to the success of any waste segre­gation program. For greatest success:

  • Red bag containers should be as small as possible for a given area and covered to reduce solid waste that is casually tossed in.
  • Always place a larger, solid waste container beside the regulated waste container.
  • Signage should be clearly posted above and directly on the lid of the receptacle. Use a large font, color and bullet type format, so they are easy to read and understand at a glance. Keep the signage consistent.
  • All RMW containers should display the biohazard label.
  • Remove red bags from underneath sinks, in hallways, restrooms, non-critical care patient rooms and other areas where peo­ple are likely to dispose of their solid waste in RMW containers.
  • Size the container for the appropriate amount of waste generated. The smaller the container, the less likely clinicians will be to throw extraneous items into it. Small, eight gallon containers with step-on lids work well.
  • Ensure solid waste receptacles are emptied in a timely manner so that overfilled cans don’t result in improper use of the red bag.
  • Use multiple languages if necessary for optimal communication.
  • For high use area, consider wheeled recep­tacles or one waste station per several beds.

Step 6: Train, Educate, Repeat

Training is a critical component in an RMW reduction program. Staff requires clear, con­sistent information to understand the reasons for proper segregation: regulations, health and safety impacts, cost implications, and environmental leadership. A few elements organizations should focus on:

  • RMW training must be part of new employee orientation.
  • Re-train current staff on the newly agreed upon definition of RMW.
  • Work with the executive team to hold department heads accountable for their RMW generation and associated disposal costs. The organization must include the OR, which typically generates the most RMW in the entire hospital.
  • Develop incentives or competitions to get people involved.
  • Monitor work areas regularly and consider tracking generation rates.
  • Continue with training on a regular basis, including spot checks, monitoring, report­ing and ongoing training.

Step 7: Review Specialty RMW Streams

Sharps Management

Sharps, including needles and scalpel blades, are singled out for special regulatory provisions by many states. Does the organization have a history of problems with needle sticks or sharps inju­ries due to improper waste handling? The Centers for Disease Control estimates that over 800,000 accidental needle sticks occur each year among healthcare workers.

  • Is the organization still using disposable sharps contain­ers?  
  • Reusable sharps containers are normally emptied and returned by a vendor at about 2/3 full, so they can reduce needle sticks, Typically this program saves money, reduces worker exposure and handling, and can sig­nificantly improve environmental impacts, through reduced plastic sent to landfills and incinerators. 
  • New in 2011 is the ability to recycle the contents of disposable container collection.  Check with group purchasing organizations and talk to other hospitals to see what works best for them and consider piloting options to identify the right choice for the facility.
  • Train staff on the proper use and disposal of sharps, including the imperative to dis­pose of sharps in the right container.
  • Safety is the priority. Assess opportunities to maximize container use by optimizing their size and placement.

Single Use Device Reprocessing

Reprocessing reduces both the purchase and disposal costs of single use devices (SUDs). Instead of treating these items as disposables, they are cleaned and reassem­bled for reuse. Many hospitals have started this type of service for just a few types of equipment, but quickly grow the list when they see the savings roll in. The biggest savings come from buying back reprocessed devices for use at the facility at less than half the original price, in some instances. Hospitals and health systems are saving millions of dollars on this innovative program.

Fluid Managment in the OR

Liquid medical wastes such as suction canis­ters present another unique disposal question. Suction canisters can be responsible for up to 40 percent of infectious waste in the OR . If  adding solidifiers, then dispos­ing of it in red bags, the facility is adding additional chemicals into the mix and could be exposing employees to splashing and spills.

There are now several technologies avail­able to manage fluids in the OR; these sys­tems empty liquid contents of suction can­isters directly into the sanitary sewer, reduc­ing transportation and disposal costs and removing canisters from the waste stream. Canister-free vacuum systems are also avail­able. Work with your local POTW and state regulatory officials to determine your best disposal options.

See the Greening the OR implementation module  and case study on Fluid Management Systems.

Ensure trace chemotherapy waste is NOT disposed of in red bag waste containers, as these are often autoclaved or microwaved, potentially exposing waste management employees.   It is legal to put trace amounts of cytotoxic or chemo agents in a red bag, but ensure that this waste is incinerated, not autoclaved or otherwise treated.

Greening the OR

With its large environmental footprint, the operating room is a common area of focus for EPP, waste and toxicity reduction, energy conservation and more.  Practice Greenhealth has kicked off a Greening the OR initiative. This section provides greater details, case studies and more information about the initiative. 

Step 8: Be Ready to Identify and Solve Problems

Even after program implementation and staff training, facilities may still encounter resis­tance to change and proper segregation. Develop a good working relationship with anyone handling your organization’s waste. Develop a written protocol for any segre­gation issues with waste treatment facilities and landfill operators to have a clear pro­tocol for reporting out on any problems. A response plan is critical, in the event of a contamination or other infraction. Develop a monitoring form, ongoing rounds and a mechanism to report con­cerns and appropriate solutions swiftly back to staff.

Step 9: Consider all Waste Treatment and Hauling Options

RMW must be “disinfected” before it can be disposed of, meaning that the waste must be treated to destroy or kill infectious micro­organisms with a potential to cause disease. Requirements and acceptable treatment meth­ods vary from state to state. RWW treatment technologies rely on two basic approaches to sterilization, excessive heat or chemical agents. Weigh your options and choose wisely.

Practice Greenhealth strongly urges to avoid incineration where possible and to segregate carefully to ensure only true pathological waste and cytotoxic drugs are incinerated.  All other regulated wastes can be treated through nonincineration technology.

Step 10: Track Progress, Report Successes and Reward Staff!

A successful, sustainable program needs a strong leader, good tracking and reporting, and sustained vigilance. To realize full benefits:

  • Track the positive changes in your waste volumes and celebrate these reductions and cost-savings.
  • Reward staff for their efforts.
  • Let the community know about your successes.
  • Inform hospital administrators about any cost-savings.
  • Write a case study of the project’s results to use in the organization's newsletter and as a per­formance improvement indicator for the Joint Commission.
  • Apply for an Environmental Excellence Award with Practice Greenhealth and get recognition for the organization's hard work!

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