POLICY DESCRIPTION: Environmental –
Hazardous Waste Management
REPLACES POLICY DATED: 1/12/99, 7/21/99,
11/1/05 (DC.010)
EFFECTIVE DATE: May 1, 2007
PROCEDURE NUMBER: ENV.010
APPROVED BY: Ethics and Compliance Policy Committee
DEPARTMENT: Engineering and Facility
Management
PAGE: 1 of 5
SCOPE: All Company-affiliated subsidiaries including, but not limited to hospitals, ambulatory
surgery centers, outpatient imaging centers, physician practices, Corporate Departments, Groups, and
Divisions, and on-site subcontractors.
PURPOSE: To require each facility to handle and dispose of hazardous waste in accordance with
applicable Environmental Protection Agency (EPA) regulations.
POLICY:
1.
This procedure addresses federal regulatory requirements. State laws or regulations may
impose additional requirements. Each facility should consult with the Corporate Engineering
and Facility Management Department and the facility’s Operations Counsel to identify and
comply with any additional requirements.
2.
If a facility generates hazardous waste, the facility must determine its generator status. If
necessary, the facility must register with EPA as a generator and comply with generator
requirements. A list of hazardous waste commonly generated from a health care operation is
attached and includes antineoplastics (chemotherapy) waste.
3.
A site specific hazardous waste separation, recycling, and waste minimization program must be
developed to minimize the hazardous waste generation.
4.
Hazardous waste generated by non-HCA sources must not be accepted.
5.
A facility must use an EPA/Department of Transportation (DOT) certified hazardous waste
transporter to remove the waste and dispose of it at an EPA registered treatment or disposal site.
The hazardous waste disposal contract must be reviewed by the HCA Legal Department. Avoid
those facilities with poor operating records, too many violations, or listed as uncontrolled site.
PROCEDURE:
Registration and Analytical Testing
1. A facility must determine if it generates hazardous waste.
2. A facility must determine if a waste material is classified as hazardous waste.
3. Also, the facility must determine how much hazardous waste will be generated so that the facility
can determine if it is a conditionally exempt generator, a limited quantity generator, or a generator
before it registers with EPA. A limited quantity generator is not required to annually report to
State/EPA.
4. An EPA certified hazardous waste disposal facility requires a waste profile before the hazardous
waste can be accepted for disposal. If a facility generates a new type of hazardous waste, either from
4/2007
POLICY DESCRIPTION: Environmental –
Hazardous Waste Management
REPLACES POLICY DATED: 1/12/99, 7/21/99,
11/1/05 (DC.010)
EFFECTIVE DATE: May 1, 2007
PROCEDURE NUMBER: ENV.010
APPROVED BY: Ethics and Compliance Policy Committee
DEPARTMENT: Engineering and Facility
Management
PAGE: 2 of 5
specific projects or routine health care operations, the characteristics of the waste must be
determined by sampling and analysis. A facility should ask for a copy of the analytical test results
and keep it on file.
5. If a facility needs assistance, contact the Corporate Engineering and Facility Management
Department Manager.
Handling
1. Never mix hazardous and non-hazardous wastes. Hazardous waste must not be disposed of with
regular trash.
2. Each hazardous waste stream must be segregated according to the nature of the hazard. Never mix
hazardous waste with other types of waste materials (such as regular trash or medical waste.)
3. Stored hazardous waste must be kept locked at all times.
4. Hazardous waste containers must be properly labeled and tagged with appropriate warnings.
5. Secondary containment should be provided for all hazardous waste storage/holding.
6. Do not store filled containers of hazardous waste more than 180 days. If the facility is a large
quantity generator, the maximum storage time is 90 days.
7. Weekly visual inspection of hazardous waste storage is required.
Handling Antineoplastic Waste
1. Containers holding any amount of free liquid must be managed as hazardous waste. Place container
(e.g., vials, syringes, IV bags) into the bulk hazardous waste container for proper disposal. Typical
Antineoplastic materials include; Chlorambucil, Cyclophosphamide, Daunomycin,
Diethylstilbestrol, Melphalan, Mitomycin C, and Streptozotocin.
2. Gowns, goggles, gloves or other materials such as those used for spill clean up (rags, wipes, towels,
pads, etc.) which are contaminated with antineoplastic agents must be managed as hazardous waste.
Place these items into the bulk hazardous waste container for proper disposal.
3. Needles used with antineoplastics must be placed in a designated chemo sharps container for
incineration as regulated medical waste.
4. Completely empty vials, syringes, IV bags, etc. as well as soft materials (e.g., gowns, goggles,
gloves, tubing, and wipes) that have no overtly contaminate (no visible liquid) antineoplastic agent
are considered trace chemotherapy waste. These should be placed in separate (often yellow)
regulated medical waste containers for incineration/disposal.
4/2007
POLICY DESCRIPTION: Environmental –
Hazardous Waste Management
REPLACES POLICY DATED: 1/12/99, 7/21/99,
11/1/05 (DC.010)
EFFECTIVE DATE: May 1, 2007
PROCEDURE NUMBER: ENV.010
APPROVED BY: Ethics and Compliance Policy Committee
DEPARTMENT: Engineering and Facility
Management
PAGE: 3 of 5
5. Special Handling
a. Epinephrine: In health care settings, waste epinephrine (Waste Code P042) is by far the most
common hazardous waste drug generated.
Epinephrine Syringe Interpretation: After the proper dose has been injected, EPA considers
residues remaining in a syringe to have been used for their intended purpose. Therefore, the
syringe containing residue epinephrine is not a hazardous waste and can be discarded as
regulated medical waste in a sharps container.
b. Toxicity: Many formulations containing the following chemicals are likely to be characterized as
hazardous waste, even at 1% or less concentrations.
 Arsenic
 Barium
 Cadmium
 Chloroform
 Chromium
 Lindane
 M-cresol
 Mercury (Thimerosal)
 Selenium
 Silver
If there is any doubt as to the proper hazardous waste characterization of these solutions,
analysis must be conducted to determine whether the solution meets the EPA’s toxicity
limits.
c. Controlled Substances: Outdated and / or waste drugs must be destroyed so that they are beyond
reclamation and two health care professionals must document the destruction. Another option
for disposal is through your hazardous waste vendor.
i. Schedule I includes drugs that have no accepted medical use, such as heroin.
ii. Schedule II drugs are used medically, but have high abuse potential, such as morphine,
and their purchase, storage, and use requirements are very strictly monitored.
iii. Schedules III through V are drugs with decreasing abuse potential, including sedatives,
tranquilizers, and cough suppressants, such as codeine.
d. Thimerosal: All drugs containing thimerosal fail the EPA criteria for mercury toxicity; therefore,
manage all drugs containing thimerosal as hazardous waste. Wherever possible, minimize waste
by purchasing alternative products that do not contain thimerosal.
Transportation
1. Any hazardous waste must be packaged in a DOT approved container with proper label and warning.
2. It is not acceptable for facility personnel to transport hazardous wastes.
4/2007
POLICY DESCRIPTION: Environmental –
Hazardous Waste Management
REPLACES POLICY DATED: 1/12/99, 7/21/99,
11/1/05 (DC.010)
EFFECTIVE DATE: May 1, 2007
PROCEDURE NUMBER: ENV.010
APPROVED BY: Ethics and Compliance Policy Committee
DEPARTMENT: Engineering and Facility
Management
PAGE: 4 of 5
3. Each facility should verify the registration (DOT and State Environmental Agency) of the hazardous
waste transporter, and have the transporter sign the manifest for each removal.
4. Each shipment of hazardous waste must be accompanied by a properly executed EPA hazardous
waste manifest and applicable land ban notification forms. A facility should keep a copy of
manifest.
Disposal
1. The facility must dispose of hazardous waste at an EPA registered treatment or disposal site. The
facility should verify that the disposal site is properly operated in accordance with all applicable state
and federal requirements by performing an audit or surveillance.
2. After a shipment of hazardous waste is removed, the manifest, signed by the transporter and the
ultimate disposal facility, should be returned to the facility within 30 days. This manifest should be
kept forever. If a complete hazardous waste manifest has not been returned to the facility within 45
days, the facility is required to contact the disposal facility, write an “exception report” with
explanation, and attach the file copy of the manifest.
3. Reverse distributors are not Waste Management Services. “Reverse distribution” is a process
whereby some unused, but potentially usable pharmaceuticals can be returned to the manufacturer
for credit. The EPA did not intend for reverse distribution to relieve responsibility as a generator for
making hazardous waste determinations. Reverse distributors cannot be used as waste management
services. The following should NEVER be returned to a reverse distributor since they are NEVER
creditable:
 Unused compounded IVs
 Partial or empty vials
 Used ointments
 Bulk chemicals or materials
 Outdated samples
 Outdated Pharmacy re-packs
 Waste-controlled substances unless the reverse distributor has a solid waste permit and the
technical ability to report the transaction to the Automation of Reports and Consolidated
Orders System (ARCOS).
RECORDKEEPING:
A complete records file should include:
 A list of wastes for off-site hauling (waste profile),
 Original EPA (or state) notification form for hazardous waste generator registration and all
subsequent amendments,
4/2007
POLICY DESCRIPTION: Environmental –
Hazardous Waste Management
REPLACES POLICY DATED: 1/12/99, 7/21/99,
11/1/05 (DC.010)
EFFECTIVE DATE: May 1, 2007
PROCEDURE NUMBER: ENV.010
APPROVED BY: Ethics and Compliance Policy Committee
DEPARTMENT: Engineering and Facility
Management
PAGE: 5 of 5
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A copy of the permit from each hazardous waste transporter and disposal facility which provides
services for the property,
Agency visit/inspection records,
Any annual reports to EPA,
Waste pickup logs,
All manifests, receipts, certificates of disposal/destruction, or equivalent documents (never
destroy these records),
Weekly inspection (by facility personnel) logs, and
Personnel training records.
REFERENCES:
Federal Regulation 40 CFR 261-266
Federal Regulation CFR 1910.1030, OSHA Bloodborne Pathogens
4/2007
LIST OF TYPICAL HAZARDOUS WASTES FROM A HEALTHCARE FACILITY
Waste Substance*
Hazardous Waste Code
Formaldehyde
Xylene
Acetone
Chloroform
Toluene
Carbon Tetrachloride
Benzene
Methylene Chloride
Freon
Mixed Solvents
Silver Containing Wastes
Barium
Mercury Containing Wastes
Lead Containing Wastes
Ethylene Oxide
Phenol
Waste Acids (sulfuric acid, nitric acid, etc.)
Waste Oil
Waste Paints
Picric Acid (solid or semi-solid)
U122
U239
U002
U044 or D022 (mixture)
U220
U211
U019
U080
R-11(U121), R-12 (U075)
F001, F002, F003 depending on chemicals
D011
D005
D009
D008
U115
U188
D002 or depending on chemicals
D001
Depending on chemicals
D003
HAZARDOUS WATES AT FACILITIES INCLUDE THESE ANTINEOPLASTIC
(CHEMOTHERAPY) SUBSTANCES:
Chlorambucil
U035
Cyclophosphamide
U058
Daunomycin
U059
Melphalan
U150
Mitomycin C
U010
Streptozocin
U206
Uracil Mustard
U237
Arsenic Trioxide
P012
*Not reclaimed or burnt for energy recovery
2/2007
Attachment to Policy ENV.010