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Medical Waste Management Plan


​Purpose

The purpose of this Medical Waste Management Plan (The Plan) is to ensure that the University of the Pacific complies with all requirements set forth in the 2017 California Medical Waste Management Act. This plan describes the processes necessary to safely manage the University’s generated medical waste and defines the responsibilities of all aspects of the plan.

Policy Details

University has the following medical waste streams:

  1. Animal tissue, body parts, etc. This waste stream is generated from teaching and/or research activity and can be managed as medical waste.
  2. Preserved animal body parts or tissue and human tissue will be managed as pathology medical waste.
  3. Sharps will be managed as medical waste.
  4. Pharmaceuticals (expired or patient returned, etc.) and active ingredients of pharmaceuticals will be managed as medical waste.

Scope

The scope of this plan encompasses all University facilities in the City of Stockton.

Applicability

This policy applies to all full time and part-time university employees, faculty, programs and volunteers regardless of the funding source and dollar value.

General Information

Name and Address

 

University of the Pacific
3601 Pacific Avenue
Stockton, CA 95211
Type of BusinessSchool of Higher Education

Medical Waste Transport and Disposal

 

Ingenium is the primary contractor to transport and dispose of medical waste.

Ingenium Contact Information

 

Sacramento Office 

6063 Foodlink St 

Sacramento 95828

(916) 668-6798

Medical Waste Definition

The following Materials are to be considered medical waste for the purpose of disposal;

  1. Cultures and broths from medical and pathological laboratories known to contain human pathogenic or virulent organisms.
  2. Discarded live or attenuated vaccines as well as the devices and culture dishes used to transfer, inoculate, and mix these vaccines.
  3. Animal parts, fluids, tissues, or carcasses inspected by the attending veterinarian suspected of being contaminated with infectious agents known to be contagious to humans.
  4. Devices that contain human fluid blood and blood products.
  5. Microorganisms or materials contaminated with microorganism that are classified as Biosafety IV. (Note, this does not include organisms that cause common cold, influenza, and other diseases not representing a significant danger to nonimmunocompromised persons.)
  6. Infectious agents that cause a significant increase in morbidity or mortality of human beings.
  7. Medical sharps, including syringes with/without needles and all other needles of medical devices without regard for use.
  8. Other medical equipment, including pipettes and vials, only if they contained virulent organisms or human blood.
  9. Industrial sharps (i.e., razor blades) only if they come in contact with infectious materials.
  10. Pharmaceutical Waste, including expired, spent, partials, out dated or patient returns.

Responsibilities

Managers and Supervisors

 

  1. Must ensure that all medical wastes are properly disposed of in accordance with this procedure.
  2. Must ensure that all affected personnel have been trained on this procedure.
  3. Must ensure that required Bloodborne Pathogen requirements are met pursuant to OSHA's universal precautions.

Environmental Health and Safety (EH&S)

 

  1. Maintains and distributes this plan and any updates.
  2. Manages contract(s) with outside medical waste vendors and coordinate waste pickups.
  3. Assist Managers and Supervisors as needed for implementation of this procedure.

Controlled Substances

Pharmaceutical waste classified by the federal Drug Enforcement Agency (DEA) as “controlled substances” are disposed of in compliance with the DEA requirements with being logged and in dual control, and disposed of by our medical waste hauler.

Generation and Storage Procedures

All medical waste must be accumulated separately from other wastes in compliant red containers clearly labeled "BIOHAZARD". These containers will be labeled on the top and sides as required by Section Health & Safety Code 118280.

Red plastic biohazard bags will be utilized for non-sharps waste accumulation and tied to prevent leakage of contents prior to transferring to a container for storage. Sharps must be collected in a rigid puncture resistant container. These sharps containers can be combined with non-sharps waste in biohazard containers only if the waste will be transferred off-site by a licensed bio hazardous waste vendor.

University of the Pacific generates an estimated 345 pounds of medical waste per month, therefore all medical waste sharps (full containers) and non-sharps must be treated within 7 days unless waste is stored below 32° F. If the waste is maintained below 32° F it may be stored for up to 90 days before treatment or off-site disposal by a licensed medical waste hauler.

The storage areas are located in the Pharmacy Building Basement and The Biological Sciences building and are secured (locked) except when waste is added or removed and. The doors are marked with a sign that reads, "CAUTION - BIOHAZARDOUS WASTE STORAGE AREA - UNAUTHORIZED PERSONS KEEP OUT", in both English and Spanish.

Onsite Treatment Procedures

Non-sharps medical waste will be treated by steam sterilization in the Biological Sciences Department and Pharmacy Building Basement.

Disposal Procedures

Once treatment has been completed, non-sharps waste may be disposed in standard solid waste dumpsters. Sharps waste must not be placed into a solid waste dumpster, even it treated. It must be transferred to the accumulation drum located in Pharmacy Basement Freezer, and then be transported and disposed of by our medical waste hauler.

Emergency Action Plan

In the event that the autoclaves in the Biology Department and/or in the Pharmacy Building basement become inoperable and the primary hauler is unavailable. University of the Pacific has identified an emergency backup hauler the following medical waste transporter to collect medical waste as needed:

Stericycle
30542 San Antonio St
Hayward, CA 94544
(510) 471-0918

In the event of a biohazardous spill, the follow precautions must be followed:

  • Universal precautions must be utilized by trained personnel; including the use of protective gloves, goggles and other PPE as necessary to prevent potential exposure.
  • All biohazardous materials must be removed from affected surfaces.
  • Affected surfaces must be decontaminated by immersing the surfaces in a chemical sanitizer for a minimum of (3) three minutes.

The sanitizer must contain one of the following:

  1. Hyperchlorite solution (500 ppm available chlorine)
  2. Phenolic solution (500 ppm active agents
  3. Iodoform solution (100 ppm available iodine)
  4. Quaternary ammonium solution (400 ppm active agent)

All waste generated, including PPE and items used in decontamination must be disposed of in a compliant red biohazardous waste bag or compliant sharps containers as necessary. The bags or containers must be conspicuously labeled with the international biohazard label and marked as "Biohazard" or "Biohazardous Waste".

Closure Plan

A closure plan for the termination of treatment at the facility using, at a minimum, one of the methods of decontamination specified in subdivision (a) or (b) of Section 118295 (also listed under the Emergency Action Plan), thereby rendering the property to an acceptable sanitary condition following the completion of treatment services at the site.

Recordkeeping

All records associated with the treatment and disposal of medical waste will be maintained by the treating department and/or EH&S for a minimum of three years. All pink waste tracking forms must be maintained by EH&S.

Violations

Staff and faculty failing to abide by these policies may be subject to corrective action up to and including, dismissal, and/or legal action by the University.  


About This Policy
Last Updated
3/14/2018
Original Issue Date
5/18/2016

Responsible Department
Enterprise Risk Management