UNIVERSITY GUIDANCE
THE DISPOSAL OF CLINICAL WASTE
Document No:
Date:
Area Applicable:
Review Year
CU/14/CW/1.0
September 2014
Cardiff University Main Campus, Heath Campus
University outer buildings
2016
Document History
Author(s)
Revision
Number
.1
Date
Katrina A Henderson
Date
Amendment
Name
September
2014
Approved by
1.0 Introduction/Principle Objectives of the Guidance
It is the University’s responsibility to limit the amount of clinical waste
production through its activities, as far as is reasonably and economically
practicable. This is to be achieved by careful consideration of the disposal
implications of all purchases and by products.
Where the production of clinical waste is unavoidable then it is the
University’s responsibility to ensure the safe segregation, handling, disposal
of waste and that all persons handling any such waste will exercise care to
avoid injury or risk of harm to themselves or others, including the general
public. It is the producers’ responsibility to ensure that all waste is disposed
of in the correct manner.
This Guidance covers all clinical waste produced in the University, main
campus and stand alone buildings on the Heath campus; namely Infectious
Biological/Clinical waste, [University Schools and Departments based within
shared buildings on hospital based sites must follow the relevant NHS Policy.
A copy of the Cardiff and Vale Hazardous Waste Policy can be found at
www.cf.ac.uk/osheu/cvpolicies/index.html
2.0
Legal Requirements
2.1 Hazardous Waste Regulations
The University is required to register all sites generating hazardous waste
with Natural Resources Wales. The hazardous waste codes for the
University are listed at:
http://www.cardiff.ac.uk/osheu/environment/waste/envwaste.html
Where special consignments are being made reference to these codes must
be made available to the contractor.
All clinical waste must be disposed of in such a manner, as to protect
anyone working with, or near, or handling articles or substances which are
wastes and which constitute a reasonably foreseeable risk of injury, or may
cause ill health. Any accidents/injuries involving waste must be reported
immediately in accordance with the University’s procedures for the reporting
of accidents and untoward incidents.
3.0 Responsibilities
3.1 Managers and Supervisors
Managers and supervisors should ensure that:
(i) all wastes under their control are disposed of appropriately
(ii) adequate emergency response and spillages equipment is in place
(iii) consignment notes are completed
(iv) consideration is given to the disposal of clinical waste when
undertaking a risk assessment
(v) staff /students under their control are informed of the appropriate
disposal procedures for clinical waste
(vi) consideration has been given to adopting the process/procedure with
least environmental impact
3.2 Staff and students
All staff should:
(i) Ensure that they dispose of clinical wastes appropriately.
3.3 Health, Safety and Environment Committee
(i) Regularly reviewing the University’s safety, health and environmental
performance, and agreeing any necessary action plans.
3.4 Occupational Safety, Health and Environment Unit (OSHEU)
OSHEU is responsible for the provision of advice and guidance on clinical
waste streams and for undertaking duty of care audits. In addition OSHEU is
responsible for monitoring statutory compliance through audit of Schools
and Departments.
4.0 Identification, Description and Segregation of Waste
4.1 Description of Waste
The producer of the clinical waste must be able to describe the waste for
disposal. The description should include: a. The name of the hazardous waste.
e.g. Clinical; offensive etc
b. Where did the waste arise?
E.g. The location – Room/Laboratory and School/Directorate
Where waste is identified as problematical, it is the producer’s duty to
establish what special precautions for handling and transporting of that
hazardous waste are required, and to ensure that the clinical waste is
bagged securely, tied with the appropriate tie and labelled clearly with the
place of origin.
4.2 Segregation of Waste
The following clinical waste streams require specific safe segregation: -
Waste Container
Waste Stream
Final disposal
Yellow bag
Yellow-stream infectious waste
requires disposal by incineration in
a suitably licensed or permitted
facility. This waste stream includes
anatomical waste and may include
other types of waste which require
incineration
to
comply
with
national
or
regional
policy,
including unautoclaved waste from
clinical laboratories.
Waste
which
requires 18 01 03 / 18 01 09
disposal by incineration
Indicative
treatment/disposal
required is incineration in a
suitably permitted or licensed
facility.
On rare occasions, microbiological
cultures and other infectious waste
classified as Category A infectious
substances in ADR (high risk) may
require disposal off-site. In such
instances the waste should be
placed in appropriate yellow
Unapproved packages for this type
of waste (these may differ from
other yellow containers used in
hospitals). Wherever possible,
Category A infectious substances
(including waste) should be
treated on site (using an autoclave
or equivalent) before being
transported for disposal.
Infectious Biological/Clinical waste
for incineration
EWC Codes
Orange bag
Yellow Sharps box
potentially infectious waste may be Waste
which
may
be 18 01 03 / 18 02 02
treated to render it safe prior to “treated”
final disposal.
Indicative
treatment/disposal
required is to be “rendered
Orange-stream infectious waste is safe” in a suitably permitted or
waste known or suspected to licensed
facility,
usually
contain pathogens classified in alternative treatment plants
Category B as specified in the (ATPs)). However this waste
Carriage Regulations.
may
e.g. discarded clinical specimens; also be disposed of by
gloves, pipette tips, liquid & solid incineration.
cultures
yellow-lidded sharps receptacles Waste
which
requires 18 01 03
should contain waste that requires disposal by incineration
20 01 99 (non medicinal)
disposal by incineration only, such Indicative
treatment/disposal
as sharps containing a quantity of required is incineration in a
medicinal product (for example suitably permitted or licensed
undischarged sharps or partially facility.
discharged
sharps);Needles,
scalpels, sharp items originating
from laboratory / healthcare areas
Yellow rigid container
Carcasses / human tissue, items Waste
which
requires 18 01 03 / 18 01 09 / 18 01
that are likely to leak
04
disposal by incineration
Indicative
treatment/disposal
required is incineration in a
suitably permitted or licensed
facility.
Tiger bag
non-infectious and which does not
require specialist treatment or
disposal, but which may cause
18 01 04 / 20 01 99 / 18 02
Offensive/hygiene waste*
Indicative
treatment/disposal 03
required is landfill in a suitably
offence to those coming into
contact with it. Offensive/hygiene
waste includes animal bedding,
nappies, and autoclaved lab waste
and does not need to be classified
for transport.
permitted or
licensed site. This waste should
not
be
compacted
in
unlicensed/permitted
facilities.
Orange lidded sharps
orange-lidded sharps receptacles
should be used for waste that can
be subjected to alternative
treatment such as plastic singleuse instruments and nonmedicinally contaminated sharps.
In some cases (dependent on
authorisation type and regulator),
this may extend to fully discharged
medicinally (other than cytotoxic
and cytostatic) contaminated
sharps.
Waste
which
may
be 18 01 03
“treated”
Indicative
treatment/disposal
required is to be “rendered
safe” in a suitably permitted or
licensed
facility,
usually
alternative treatment plants
(ATPs)). However this waste
may
also be disposed of by
incineration.
Purple lidded sharps
purple-lidded sharps receptacles
should be used for waste that is
contaminated with cytotoxic and
cytostatic medicinal products.
Cytotoxic
and
cytostatic 18 01 08
waste
Indicative
treatment/disposal
required is incineration in a
suitably permitted or licensed
facility.
Blue lidded rigid container
Pharmaceutical
incineration.
waste
for Waste
which
requires 18 01 09
disposal by incineration
Indicative
treatment/disposal
required is incineration in a
suitably permitted or licensed
facility.
Biobins
Waste
which
may
be
“treated”
Indicative
treatment/disposal
required is to be “rendered
safe” in a suitably permitted or
licensed
facility,
usually
alternative treatment plants
(ATPs)). However this waste
may
also be disposed of by
incineration.
 Sharps may be treated to render them safe in suitably licensed or permitted facilities prior to final disposal. However, if the sharps are
contaminated with cytotoxic or cytostatic products, they should be placed in suitably coloured receptacles (yellow/ purple) and disposed
of in suitably authorised incineration facilities.
For sharps to be considered for alternative treatments, the producer must demonstrate that they have robust segregation procedures in
place to separate those sharps that require incineration from those suitable for alternative treatment. Where robust segregation of
sharps contaminated with cytotoxic or cytostatic products cannot be guaranteed, all sharps waste should be incinerated.
 Offensive wastes: A Departmental Risk Assessment has to be carried out to determine any possible residual toxins/carcinogens
etc. In their absence this material can be treated as Offensive Waste which is required to be disposed of via deep landfill.
 Producers of clinical and biological waste must also read the University guidance on Autoclaving and waste disposal
CU Autoclaving and Waste Disposal
5.0 Storage of Hazardous Waste
All clinical/biological wastes must be stored securely prior to collection for disposal.
It is considered best practice for all clinical waste to be stored in adequate secure
(locked) facilities within the School / department. It is not acceptable to store waste
in unsecured locations. Where clinical wastes are stored outside they must be
protected from the weather i.e. clinical waste should be stored in lockable yellow
trolleys.
6.0 Collection and Disposal
6.1
Clinical / Biological / Offensive
Infectious Clinical / biological Laboratory waste is collected weekly from
departmental storage areas by a specialist disposal contractor. Waste should
be brought to the collection area at the agreed time of the collection. It is not
acceptable to leave hazardous clinical waste unattended.
The disposal contractor is entitled to refuse any waste which they deem to be
inadequately or improperly packed. It is a legal duty of any person producing
clinical wastes to ensure, as far as is reasonably practicable, that any
subsequent handler of that waste is not put at risk and this “duty of care”
continues right up to the final disposal or destruction of the waste.
DISPOSAL OF HUMAN TISSUE MUST BE IN ACCORDANCE WITH THE
HUMAN TISSUE AUTHORITY CODE OF PRACTICE – THE REMOVAL,
STORAGE AND DISPOSAL OF HUMAN ORGANS AND TISSUE
http://www.hta.gov.uk/_db/_documents/2006-07-04_Approved_by_Parliament__Code_of_Practice_5_-_Removal.pdf
7.0
Consignment notes
All hazardous waste consigned to the specialist waste contractor must be
signed for before the waste leaves Cardiff University property. Where the
hazardous waste is coordinated centrally then the consignment note will be
retained centrally by the coordinating department. Where the hazardous
waste collection has been arranged directly by the School/Department then
the School/Department must retain a copy of the consignment note.
Records must be kept for a minimum of 3 years. (Appendix 1 – Completion
of consignment notes)
8.0
Duty of Care Visits
As part of the compliance process, duty of care visits must be carried out on
the hazardous waste produced within the University following from the point
of production to the ultimate disposal. Duty of care visits will be carried out
where reasonably practical on a biannual basis. It is the responsibility of the
department managing the hazardous waste stream to undertake the duty of
care audit: -
9.0
Hazardous waste minimisation
The University actively encourages Schools and Departments to minimise
their clinical waste production where reasonably practicable i.e. investment
in new technologies where clinical waste is reduced
Appendix 1 Completion of Consignment notes
Section A Notification Details
This section must include the building/area that the waste is to be collected from. It
must also contain the correct premises code (see Appendix 1). Details of where the
waste is to be taken must also be included.
Section B Description of the waste
Section C Carrier’s Certificate
This section must be completed by the specialist waste contractor (usually the
driver). Ensure the name, carrier registration, vehicle registration, date and time are
completed
Section D Consignor’s Certificate
A University representative must sign this section.
Section E Consignee’s Certificate
ALL HAZARDOUS WASTE CONSIGNMENT NOTES MUST BE RETAINED BY
THE UNIVERSITY FOR 3 YEARS1 – THIS IS A LEGAL REQUIREMENT
Hazardous waste contractors are required to provide quarterly returns to the
hazardous waste producer. For Clinical waste these are retained by OSHEU at
Cathays campus and at individual sites for Heath campus.
Hazardous Waste (England and Wales) Regulations 2005 and the Hazardous Waste (Wales) Regulations
2005.
1