The purpose of the infectious waste policy is to establish  infectious waste management procedures in the university community to protect the health and safety of employees and to enhance the environment and natural resources. This guide provides procedures to ensure infectious wastes are properly handled. The Commonwealth of Virginia issued regulations governing infectious waste management under the Regulated Medical Waste Management Regulations, (VR 672-40-01:1, June 29, 1994) which authorizes the Department of Environmental Quality to enforce such regulations. It is the intent of Virginia Commonwealth University (VCU) to comply with all state and federal regulations regarding management of infectious wastes. In this regard, generators of infectious wastes are responsible for proper handling, storage and disposal of wastes. Contract management of the program is provided by the Physical Plant Department. Guidance and compliance monitoring is provided by the Office of Environmental Health & Safety (OEHS), Chemical & Biological Safety Section.
 

DEFINITION OF INFECTIOUS WASTES

In general, infectious waste (regulated medical waste) is considered capable of producing an infectious disease in humans. Any agent whose virulence is unknown should be considered to be infectious. Specific categories of regulated medical waste, as outlined by DEQ are:

Cultures and Stocks of Microorganisms and Biologicals. --- Discarded cultures, stocks, specimens, vaccines and associated items that may be pathogenic to humans. Discarded etiologic agents are infectious waste. Waste from the production of biologicals and antibiotics that may have been contaminated by organisms pathogenic to humans are considered infectious.

Blood and Blood Products. --- Wastes consisting of human blood, human blood products (includes serum, plasma, etc.) and items contaminated by free-flowing human blood are infectious waste.

Pathologic Wastes. --- All pathological wastes and other wastes that are human tissues, organs, body parts, or body fluids are infectious waste.

Sharps. --- Used hypodermic needles, syringes, scalpel blades, pasteur pipettes, broken glass and similar devices likely to be contaminated with organisms that are pathogenic to healthy humans and all sharps used in patient care are infectious waste.

Animal carcasses, body parts, bedding and related wastes. --- Animal carcasses, body parts, bedding and related wastes exposed to organisms that may be pathogenic to humans are infectious waste.

Miscellaneous waste. --- Residue from the clean-up of a spill of any infectious waste is also subject to this guideline.

Any solid waste contaminated by or mixed with an infectious waste.

NOTE: The following wastes are not subject to this guide and may be discarded in the general trash.

used personal hygiene products, such as diapers, facial tissues and sanitary napkins.

material, not including sharps, containing small amounts of blood or body fluids, and no free flowing or unabsorbed liquid.

Disposal of Infectious Wastes - Regulated medical waste should be disposed of in red biohazard bags for off-site treatment. Instructions regarding packaging, labeling, and pick-up can be found below. If in-house treatment (steam sterilization or chlorination) will occur, the DEQ regulations as outlined below must be followed.

ORANGE BAG WASTE
Waste that will be sterilized on-site in either an autoclave or by chlorination must be handled as infectious waste prior to sterilization, but can be disposed of as solid waste following sterilization.

TREATMENT METHODS FOR ORANGE BAG WASTE

AUTOCLAVING - Infectious waste treated in an autoclave must be subjected to one of the following temperature/pressure conditions:

Temperature of not less than 250⁰F for 90 minutes at 15 psi of gauge pressure,
Temperature of not less than 272⁰F for 45 minutes at 27 psi of gauge pressure,
Temperature of not less than 320⁰F for 16 minutes at 80 psi of gauge pressure.

Autoclave Controls and Record keeping

Daily  Requirements

1.    Each package of waste sterilized must have indicator tape which demonstrates if the sterilization temperature was achieved. Note that it is the individual operator's responsibility to ensure that the load was sterilized for the correct amount of time. Autoclave tape only demonstrates if the correct temperature was achieved.
Waste is not satisfactorily sterilized if the indicator fails to demonstrate that the proper temperature was achieved during autoclaving.

2.    A log book shall be used to record the date, time and operator for each load and the type and amount of waste treated. This log book shall also be used to document calibration dates and results and the dates and results of efficacy testing. The log book shall be kept for 3 years.

Monthly Requirements

1.     Efficacy testing must be performed monthly under full loading conditions. The test agent is spores of B. stearthermophilus. The dates and test results must be maintained in the log book.

Once infectious waste has been steam sterilized (autoclaved), it should be in an orange plastic bag. A tag or label must be securely bound to bag, with the following information:

Download this label
 

Virginia Commonwealth University - OEHS  Box 980112 Richmond, Virginia 23298-0112 Date Autoclaved:____________________ Responsible Person:__________________ Phone Number:______________________ The generator certifies that this waste has been treated in accordance with the Virginia Regulated Medical Waste Management Regulations and is no longer regulated medical waste.

CHLORINATION- Although chlorination for laboratory-generated infectious materials is not specifically recognized by DEQ as an acceptable method of sterilization, it has been recognized as a safe, standard laboratory procedure for many years and in some instances, is excluded from regulation. Please contact OEHS, Chemical & Biological Safety Section (8-4866) to determine if this is an acceptable option for your laboratory setting. In some instances, this method requires less handling, is safer and less costly than alternatives. One example: discarding blood or blood products down the drain (sanitary sewer). Since this is a legal practice under DEQ regulations, the addition of a dilute bleach solution to the container adds a measure of workplace safety to this disposal method. If chlorination is utilized, contact time must be minimum of 25 minutes in a 5 to 10% bleach solution.
 

PACKAGING AND LABELING - Infectious Waste

General. --- Waste generators are responsible for ensuring that infectious waste (red bag) is discarded directly into clearly identifiable containers and labeled as described below. Infectious waste must be packaged and labeled before it is stored, treated, transported or disposed. Persons packaging infectious waste shall wear heavy gloves of neoprene or equivalent material and other protective equipment consistent with the level of hazard.

Packaging --- refers to waste prepared for transportation to the disposal facility. Infectious waste must be packaged in either 2 highly leak-resistant, red plastic bags (each capable of passing the ASTM 125 # drop test) or 1 bag inside a rigid, leak-proof container. Currently, the university is utilizing one ASTM 125# rated bag with a double-walled cardboard box.

Sharps --- must be placed directly into rigid puncture-resistant containers at the point of generation and labeled as specified below.

Labeling --- All infectious waste must be labeled immediately after packaging. The label must contain at least the following information:

Name, address, telephone number of the University and/or Hospital, and the date on which the waste was discarded.

The words "REGULATED MEDICAL WASTE" in large print.

The words "PATHOLOGICAL WASTE", if pathological waste is included.

The name, address and business telephone number of the contracted waste transporter.

The Biological Hazard symbol.

DO NOT USE RED BAGS FOR DISPOSAL OF ANY WASTE OTHER THAN INFECTIOUS.
 

STORAGE

Storing small quantities of infectious waste awaiting transportation to a collection area for disposal site is permissible as long as the packaging and labeling requirements are met. Areas designated for storage must have controlled access (i.e., locked rooms). Carpets and floor coverings with seams cannot be used in storage areas. Infectious waste stored for more than 7 days must be refrigerated (stored in an ambient temperature between 35-45 ⁰F). No infectious waste can be stored for more than 7 consecutive days after generation, unless it is frozen within 72 hours of generation and remains frozen during the entire period of storage. No infectious waste can be stored for more than 30 days, even if frozen.
 

TRANSPORTATION AND DISPOSAL

The Physical Plant Department contracts with an approved transporter to dispose of infectious waste on a regular schedule. Generators of infectious waste should make appointments through Customer Service Center: 828-9444 to have their waste picked-up by the contractor. Please keep in mind that Physical Plant employees are not directly responsible for infectious waste pick-ups (except for the Woods/Lyons Building).
 

TRAINING

Clinics and laboratories at VCU must instruct assigned personnel in packaging, labeling, storage and disposal requirements of this guide. Additionally, individuals assigned to treat infectious waste by autoclaving must be aware of autoclave temperature, pressure, time, performance testing and record keeping requirements. Records of training must be maintained by each department for verification.
 
 
 

INFECTIOUS WASTE SPILLS

To provide initial containment, clinics and laboratories must maintain a supply of materials as follows:

Material designed to absorb liquids, such as absorbent pads, vermiculite or disposable towels.

One gallon of hospital-grade disinfectant effective against mycobacteria, with a spray bottle capable of discharging its content in a mist or stream.

Neoprene (or similar) gloves, and N-95 respirators.

Red plastic bags, sealing tape and biohazard labels or tags.

Spill Containment and Clean-up:Upon spilling infectious materials, prevent spreading by establishing a barrier around the material - then take the following steps:

1. Leave the area until the aerosol settles (Few minutes).

2. Don appropriate personal protective equipment (PPE) and secure spill area.

3. Spray the broken/damaged containers of infectious waste with disinfectant.

4. Place broken containers and spillage in labeled, red bags. Sharps must be recovered using forceps.

5. Disinfect the area.

6. Clean and disinfect nondisposable items.

7. Place disposable PPE items in red waste bag.

8. Replenish containment and cleanup kit.

9. Prepare a report documenting the date, location, nature of infectious waste involved, and describe the incident, clean-up procedures and disposition of wastes. Forward one copy OEHS.

: 828-1392