U.S. healthcare facilities faced an unexpected dilemma during the international outbreak of West Ebola Virus Disease (EBV) from 2014-2016: hospitals were unprepared and often overwhelmed as they struggled to manage the waste from protective isolation materials, patient care items such as soiled sheets and used syringes.
For example, Emory University Hospital in Atlanta was suddenly forced to manage as many as 40 bags of regulated medical waste (RMW) per day that was generated during while caring for just four patients with EBV in its special isolation unit. The hospital was forced to store the waste onsite in a special quarantined area in 32-gallon waste containers for six days until an agreement could be reached with Stericycle, the waste hauler, to pick up the waste.
The staff at Emory fortunately handled their infectious medical waste appropriately and prevented any exposure to other staff. The U.S. Centers for Disease Control subsequently issued stricter guidelines for the safe storage and disposal of Ebola-contaminated waste.
Even though the Ebola outbreak was eventually contained, the possibility of future outbreaks of this or other highly contagious diseases remains a challenge to all healthcare facilities. These challenges include a host of tough questions. What is the best and safest way to dispose of RMW to mitigate the risks of transmission to patients and staff? What if a greater number of patients with EBV or infection with other hemorrhagic viruses or highly antibiotic resistant bacteria entered the U.S. healthcare system in the future, leading to more widespread risk of transmission because of an inability to safely handle large volumes of infectious medical waste?
Outdated RMW disposal methods
Most U.S. hospitals, outpatient facilities and clinics currently store and dispose of RMW using antiquated methods. RMW waste is typically collected in red biohazard bags and stored in a designated area onsite for up to a week, before being picked up by a certified hauler to be taken to an off-site incinerator.
This creates two significant challenges for facilities. First, the further RMW, including used needles and syringes, is transported from the point of generation to storage and disposal the greater the potential opportunity for inadvertent exposure to staff. Healthcare workers are most often accidentally exposed to injuries from used needles after the needle has been used and before disposal. Even well-trained staff make mistakes. The World Health Organization estimates that two million healthcare workers worldwide experience avoidable needle stick injuries each year, which place them at risk of acquiring Hepatitis B and C and HIV.
Second, all healthcare facilities have “cradle to grave” responsibility for proper and expedient medical waste treatment and disposal. This means that facilities are liable for harm caused by that medical waste from its source of generation to safe disposal. For example, if a truck carrying medical waste crashes en route to an incinerator, the healthcare facility is responsible for mitigation and liable to litigation if humans are exposed to their cargo.
Every state has specific regulations for treatment and handling RMW. The state’s local environmental protection agency usually oversees enforcement of the local regulations. Many states have expanded their definition of RMW to include non-human tissue and even plant waste in recent years. This has placed added responsibility and costs on many healthcare systems and medical research facilities. When additional RMW is stored temporarily onsite and disposed of by a commercial waste disposal company, the risk of unanticipated exposure of patients and staff to RMW increases.
The preceding risks and logistical problems in safe waste disposal have become more difficult to mitigate as healthcare has progressively become more decentralized. Patients are receiving care in small, outpatient facilities such as ambulatory surgery centers, long-term care facilities, dialysis and infusion centers, and outpatient clinics rather than in hospitals. Most small facilities lack the resources to invest in conventional autoclave technology to sterilize RMW. This means they are forced to spend money and time developing systems to safely collect, package, store and then transport RMW in order to follow CDC, OSHA, DOT, DHS and state protocols and best practice guidelines. Failure to follow such protocols subjects each facility to risks and costs from accidental injuries or exposures of employees and fines from regulatory agencies when lapses occur. Such lapses are common. One study showed that 17 percent of waste disposal handlers don’t follow proper protocols.
New innovative approaches needed
To reduce the risk of environmental transmission of pathogens via contaminated surfaces and via exposure to infectious medical waste, facilities need to be open to new approaches for safe disposal. The most effective approaches enable RMW to be remediated onsite, at the point of care, reducing the risk of exposure to staff and patients.
Nobody knows when the next outbreak of Ebola or other highly infectious diseases will occur. Ongoing risks associated with environmental transmission of “ordinary” endemic viral and bacterial pathogens are often handled in cumbersome, expensive and sometimes inadequate ways. New technologies for environmental decontamination and disposal of RMW are being developed that can reduce risk to patients and staff, simplify or largely eliminate the complexity and risks of its collection, packaging, storage, transportation and disposal while simultaneously saving money and time.
Written by Daniel J Sexton, M.D. FIDSA, Professor of Medicine, Duke University Medical Center; advisory board member, Sterilis, LLC