Managing flow of waste and materials in hospitals

Adequate storage should be available for reusable, noncritical care equipment to avoid high-risk practices such as leaving equipment in unit hallways with no means of identifying if it is clean or dirty.

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Transmission of infection or infectious agents is a complex process. Multiple modes or mechanisms of transmission require multiple prevention strategies. 

Some strategies involve designing the health care environment to support optimal practice by designing the built environment in ways that facilitate ease of cleaning and disinfection to limit opportunities for transmission. As staff members on the front lines of infection prevention, environmental services (EVS) professionals are well qualified to help inform these design decisions during new construction and renovation projects. 

The following overview was excerpted and edited from the chapter on “Flow of Patients, Personnel, Equipment and Waste” in the book, Using the Health Care Physical Environment to Prevent and Control Infection — A Best Practice Guide to Help Health Care Organizations Create Safe, Healing Environments, to provide EVS professionals with an overview of some of the strategies. 

It omits extensive discussions of supply chain and infrastructure considerations, and patient and staff flow and isolation, that are also covered in the chapter but are less relevant to EVS professionals. Readers are encouraged to access the entire publication, which also has a chapter on selecting cleanable surfaces, via the box on page 49.

Managing waste

Both regulated medical waste and general waste can be a reservoir for pathogens and a potential source of health care personnel exposure to infectious diseases such as bloodborne pathogens. If waste is not contained and separated from clean areas, pathogens can potentially be transmitted via direct or indirect contact either by vectors, including insects and rodents, by fomites (e.g., contaminated surfaces or equipment) or on the hands of health care personnel. For these reasons, management of waste in health facilities is regulated.

There are requirements for segregation and containment of biohazardous waste in accordance with the Occupational Safety and Health Administration’s bloodborne pathogens standard. In addition to these federal regulations, local public health regulations for transport and disposal of waste are in place. The overall importance of preventing contamination of the health care environment is codified by the Centers for Medicare & Medicaid Services in the following Condition of Participation 482.42: “The hospital must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases.”

Safe disposal of human waste and bodily fluids remains a challenge in health care facilities. Ensuring that capabilities for disposing of waste are readily accessible to patient rooms addresses the transport of waste long distances through hospital corridors; however, it does not address the contamination of surfaces in the patient bathroom or shared toilet room resulting from the flushing of waste in a toilet or a flush rim clinical sink, also known as a “hopper.” Ample evidence suggests that this activity results in surface contamination. 

A third concern, also not addressed by direct access to a toilet room, is the potential for contamination of health care personnel clothing when emptying and manually cleaning a soiled bedpan. Health care personnel uniforms are frequently contaminated with potentially pathogenic bacteria; however, the role of health care attire in the spread of health care-associated infections (HAIs) has not been clearly established.

New construction

Ensuring a design promotes optimal flow of materials and waste with a goal of reducing the risk of HAIs is just one of many goals faced by health care construction teams. The process begins with a functional program and completion of an infection control risk assessment (ICRA). During this planning phase, a multidisciplinary team meets to develop and agree on the future state of the facility. At a minimum, the design plans should meet standards for the built environment as set forth by local regulatory authorities. 

Many spaces in health care facilities are designated as “clean areas.” However, among these are a range of protective requirements based on the function of the area. For example, a clean equipment room where patient care items such as IV poles, walkers and commodes are stored need only be a finished room with cleanable surfaces, sized to accommodate the volume of equipment intended to be stored there. 

In contrast, a clean and sterile supply room requires positive airflow and a minimum number of air changes per hour. An even higher level of protection is required in central sterile supply where sterilized, wrapped or containerized surgical instruments and supplies are stored.  

In addition to ensuring that clean supply areas are designed correctly in terms of HVAC requirements and finishes, many other questions need to be answered by the planning and design team to ensure that supplies are managed in a way that protects from contamination.

Pharmacy compounding rooms are another clean space that need protection from dust, moisture and other contaminants. Requirements for these rooms are detailed in the United States Pharmacopeia Standard 797. These design requirements include specifics for surfaces, airflow filtration and layout. Consideration should also be given to where this specialized area is located within the overall layout of the facility so the access to the pharmacy is from a clean corridor. 

Protected environment (PE) rooms and operating rooms are also considered clean spaces and are designed to protect specific groups of patients from environmental sources of contamination. PE rooms are positively pressurized with HEPA-filtered supply air at a prescribed rate to minimize the risk of exposure to airborne fungi such as Aspergillus. Potential sources of fungi in the hospital environment include clothing of staff and visitors, fresh flowers and plants, external shipping containers, wet or moldy building materials or construction dust, and poorly maintained or compromised HVAC systems. 

Maintaining separation between clean and dirty functions is fundamental to infection prevention in health care and includes basic practices such as ensuring that patient care unit design includes space for accumulation and holding of regular and medical waste. 

These areas must be adequately sized to the needs of the unit and be located away from the flow of patients, personnel and supplies. These soiled holding locations also must be designed to have negative airflow to contain odors and contaminants. This is consistent with the overarching infection control principle of ensuring that air flows from clean to less-clean areas.

Bulk waste storage carts are common in hospitals and are used in the collection and removal of clinical wastes. They are sometimes staged in common areas within hospital buildings to receive waste from clinical departments. The risk of cross-contamination from these types of carts is significant; if used, such carts should be stored in an area separated from patient care, in a dedicated soiled holding room with negative airflow.

Maintaining separation between clean and dirty functions is also true for loading docks, where supplies are delivered and waste is picked up. Thoughtful planning is required to ensure that delivery of clean materials is separated from the process of waste removal to prevent potential cross-contamination that can eventually make its way into hospital patient care areas. 

These processes should be done in areas that are also separate from the usual travel paths of staff and patients. Decisions will need to be made about space for unboxing and transport of medical supplies to clean areas of the hospital. This is especially true for supplies being delivered to the surgical suite. Clean and sterile items being delivered to the surgical suite should be transported in a manner that preserves package integrity and protects items from contamination along the route.

Because external cardboard shipping containers collect and generate dust and are exposed to dirt and insects in warehouses and in transport vehicles, supplies must be removed from these boxes before being brought to the surgical suite. Ideally, all supplies should be removed from external cardboard shipping boxes prior to being transported to any patient care area. If this is not possible, supplies must be removed from these boxes before being placed into clean and sterile supply rooms on patient care units, in clinics or other ambulatory care locations. 

Cardboard shipping boxes then must be removed from the unit. Failure to provide space for this activity on the loading dock or on the patient care units can result in dirty external shipping containers and pallets finding their way into clean and sterile storage areas.

In addition, adequate storage should be available on patient care units for reusable, noncritical patient care equipment such as IV pumps, mobility devices, commodes and IV poles. Questions that need to be asked for these items include:

• Where will this equipment be cleaned and disinfected between uses, and by whom?
• Where will it be stored once cleaned?
• How will staff know when equipment is clean and patient ready?

While these basic design features might seem to be fundamental, space and budgetary constraints often result in compromises during the design phase and spaces intended for this type of storage are repurposed for additional clinical space or offices. These decisions can result in high-risk practices such as storing clean, reusable patient care equipment in a soiled holding room or soiled workroom or leaving it in unit hallways with no means of identifying if it is clean or dirty. 

Design should include either dedicated space or procedural mechanisms for removing clean supplies from external shipping containers. If equipment will be unit owned and managed, they will need a soiled workroom or soiled utility room where equipment can be taken to be cleaned and disinfected and then moved to a clean space for storage. 

Another approach is for this equipment to be managed centrally. In this model, used equipment is aggregated in a soiled holding room or soiled utility room and then transported, preferably on a covered cart, to a central location for cleaning and disinfection and then placed back into use. Other opportunities for cross-contamination related to equipment that must be considered include the reprocessing of reusable instruments or devices that are frequently used in patient care areas. 

Separation of clean and dirty functions within the patient room also presents a significant challenge. The patient room is considered inherently contaminated, as this is where the patient spends the majority of their time, and it is well established that surfaces in the patient care environment rapidly become colonized with the patient’s flora. 

Providing stable, cleanable, horizontal work surfaces, such as carts or countertops separated from water sources, can provide these necessary surfaces. In the absence of dedicated work surfaces, staff will use overbed tables or even the bed itself for these purposes. While overbed tables are able to be cleaned and disinfected before use, they may not be cleared or cleaned adequately to safely use for clean or sterile procedures.

Consideration should also be given to adequate storage space for patient belongings such as shelves or cabinets to minimize clutter on surfaces and facilitate ease of cleaning.

Safe management of human waste is a challenge both within the patient room bathroom (toilet with bedpan sprayer) and within a soiled utility or toilet room (flush rim sink/hopper). 

Current methods of waste disposal and bedpan cleaning in many hospitals can result in contamination of both the environment and health care personnel clothing. Some newer approaches to bedpan management can potentially reduce this risk. These methods include:

• The use of disposable, odor blocking sleeve-type bedpan covers to contain and dispose of the waste in regular trash.
• Point-of-care automated bedpan cleaning devices installed in the patient bathroom, where the waste is discharged directly into the sanitary sewer followed by a cleaning and disinfection cycle.
• Single-use paper-based bedpans or urinals coupled with a macerator disposal system.
• Placement of lids or barrier shields on flush rim sinks/hoppers if used.
• Currently, little evidence in the literature demonstrates that these approaches to waste disposal reduce HAIs. However, ample evidence demonstrates the role of surface contamination in the spread of infection and the impact of effective surface cleaning and disinfection in reducing these infections. Thus, it follows that other methods of reducing surface contamination could also contribute. 

Renovation projects

Renovation of existing spaces provides an opportunity to update facility infrastructure and improve existing design to incorporate new best practices for infection prevention. When renovating an existing unit or department, the project team may consider the following:

• Complete a critical review of existing workflows. 
• Analyze tasks in clinical areas to determine if some design features are barriers to compliance with infection prevention practices and modify if possible.
• If supplies must necessarily be stored next to a sink, install splash guard barriers between sinks and clean supplies.
• If health care personnel persist in storing clean supplies under sinks, replace “drop in” sinks and cabinets with wall-hung sinks or remove cabinet doors and install a panel that is screwed in place that prevents storage but still allows access to plumbing.
• Include an infection preventionist in the design discussions. 
• Evaluate current practice for storage of items such as crutches, IV poles and clean commodes. 
• If existing conditions don’t allow for the addition of clean equipment storage space, protocols should be developed for identifying clean equipment that is stored in hallways, or a shower room could be renovated into an acceptable clean equipment storage room.

Best practices

Best practices related to infection prevention and the flow of materials and waste will ensure the separation of clean and dirty health care functions to prevent cross-contamination and maintain a sanitary environment, including:

• Providing space for accumulation/holding of regular and medical waste, adequately sized to the needs of the unit, located away from flow of staff/patients. 
• Keeping bulk waste storage carts clean and stored in an area separated from patient care in a dedicated soiled holding room.  
• Ensuring the delivery of clean materials (e.g., medical supplies and clean linen) is separated from the process of waste removal on the loading dock.  
• Providing space for removal of supplies from external shipping boxes (e.g., on the loading dock or other dedicated space) prior to being transported to any patient area and ensuring items delivered to the surgical suite are transported in a manner that preserves package integrity and protects items from contamination.  
• Ensuring adequate storage on patient units for reusable care equipment (e.g., IV pumps, mobility devices and commodes) and determining where equipment will be cleaned/disinfected and by whom, and where it will be stored.  
• Exploring new technology or simple containment approaches for the disposal of human waste. 

Paula J. Wright, R.N., CIC, was project manager in the infection control unit at Massachusetts General Hospital when she wrote the chapter in the book Using the Health Care Physical Environment to Prevent and Control Infection — A Best Practice Guide to Health Care Organizations from which this was excerpted.