Waste regulation and risk management?

Waste regulation, particularly that concerning biohazardous wastes, tends to be prescriptive.

That approach is, in some part, the foundation of all regulation though perhaps there is need for a real shift in direction.

The Environment Agency is in a position to understand the value and application of risk assessment, but largely fails to apply that knowledge in its regulatory activities. With clinical wastes, for example, hazards can be safely mitigated by risk management. If contact with clinical wastes can be eliminated as it passes along the disposal chain, then the risk of infection and of other pollution incidents is low and overall the risk will be negligible. Can this be permitted to relax the prescriptive rules governing waste handling?

Always to expect the unexpected, spillages or a torn bag  and other exposures might occur and minimum standards of containment are undoubtedly required. In this context, reliance on plastic bags might be questioned but prohibition of formal compaction and use of rigid UN-approved containers goes some way to managing the remaining risk that must be measured against the risk of managing of clearing and spillage that does occur.

Further along the disposal chain, the requirement to process and treat clinical wastes to the n’th degree, to provide non-burn treatments that provide high sterility assurance levels or to employ high temperature incineration may seem like overkill. Once incineration has been chosen as the disposal option, the chemistry of incineration requires that incineration must be performed to the highest standard as it itself can be a pollution risk unless performed with great care. The cost of treatment, carbon footprint and environmental impact can be profound.

With teh ATT or non-burn technologies, high sterility assurance levels are less meaningful. When and where, and how, will anyone come into contact with the treatment residues? They wont. Does this mean that the real risk is low and an environmentally sound, and less energy-expensive process, can be substituted since the risk of downstream pollution or contact is low?  That would be the logical conclusion.

Regulators have been happy to permit risk assessment for process selection of wastes that may or may not contain  pharmaceutical residues, but go further that waste audit and composition analysis to demand complex environmental assessments that place the hurdle so high that it cannot reasonable be met let alone exceeded. In this context, risk assessment becomes devalued, used more as a weapon that a tool to the discredit of those who seek to hide behind it.

Somewhat surprisingly, risk assessment pops up elsewhere. As clinical waste items are to be discarded, risk assessment is proposed to encourage producers to pick through the detritus of clinical care, segregating at source based on the perceived risk of infection individual items for separate disposal. That requirement is not working, though it enables several boxes to be ticked.

As those segregated wastes pass along the disposal chain they will be aggregated with other wastes to create a viable waste output sent for treatment. So what is the unit of risk assessment? Per waste item or per patient? Per ward or clinical department? Per cart full or truck-load, or per producer site? This mis-match between source segregation and processing or waste outputs denigrates the entire process, wastes time, effort and money, and devalues the entire process of risk assessment.

That would be bad enough if those charged with that responsibility were properly equipped with such information. Which items are hazardous by risk of infection? That assessment requires some knowledge of the patient’s condition including perhaps their carriage of certain infectious agents that might be unknown or unrecognised, and unrelated to the present condition. For example, a patient attending the A&E department after a road accident may spend weeks in hospital after resuscitation and trauma surgery. Who knows that the patient is positive for Hepatitis B or Hepatitis C, or even HIV? There may be no need to ask and no foundation for routine precautionary testing. The patient may be entirely unaware, or simply choose not to tell.

Within the clinical environment based on the CDC Universal and Standard Precautions reminds healthcare workers of the risks of infection and the importance of its prevention in the care of both patients and staff. A competent risk assessment at the point of care and disposal must entail consideration also of the disposal chain and possible exposures that might occur as wastes pass along that chain. This cannot be achieved and the risk assessment as expected in disposal becomes something of a nonsense. The decisions of waste producers will not carry through to site-wide operations where broad generalisation is necessary. But the pretense continues and we maintain some degree of waste segregation though its application varies tremendously. Despite much strutting, that aspect of the disposal chain is left alone by regulators and is not effectively policed, though elsewhere they seek to apply tight control.

We are left with a rather meaningless compromise. Risk assessment of wastes at source is uncertain and largely ineffective. In contradicts the CDC Universal and Standard Precautions that are central to the training and performance of all  professions. That universality is ignored completely, with professional judgement and ‘choice’ in source segregation removed in support of site-wide operation or cost-driven decisions forged between a site waste manager and contractor. Still other constraints are created by problems of space availability in the healthcare environment that results in that vast majority of healthcare delivered in 100-year old hospital buildings that do not have space sufficient to accommodate a range of different waste receptacles.

Once wastes are uploaded for transfer to a treatment facility, the realities of risk assessment are set aside, at least until the treatment process has been selected. If wastes are considered non-hazardous by risk of infection then those wastes can be considered as sanitary or offensive wastes. Landfill becomes permissible, or processing for some material  or resource recovery though barriers still exist. If wastes are to be treated by one of the licensed ATT processes, risk assessment once again applies, though this time the assessment is more apparent than real and regulators set the barrier artificially high without the sound scientific foundation and clarity of thought that should be a central part of risk assessment.

Risk assessment is waste management requires a trustworthy commercial sector guaranteed not to cut corners or be swayed by opportunities to reduce expenditure at the expense of a properly risk managed operation. Regulators, in their part, must use risk assessment properly and not as a largely artificial barrier that is little more than a pretence to sound regulation and quietly ignored when the practicalities simply do not, and can not, fit with the ideology, only after to use that same risk assessment to impede waste treatment operations that can be further advanced by reduction in carbon footprint and supplementary materials recovery operations.

Risk assessment is an invaluable tool. Sadly, it is widely mis-used resulting in a succession of contradictions in the clinical waste disposal chain. While these contradictions are permitted to remain, and in some circumstances actively encouraged, through a failure to consider the realities of waste handling, and of infection risk, carbon footprints and disposal costs will remain unnecessarily high. That cannot be right.

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