COMPLIANCE
Because compliance with local and federal regulations for biohazardous waste management is of critical importance to our university, the surrounding community and others upon whom it may impact, noncompliance must be considered a serious breach of university policy.
Departmental safety officers shall inspect all biohazardous waste generators and facilities as often as necessary to assure enforcement of provisions of the Nonclinical Biohazardous Waste Disposal Program.
The chain of possession and responsibility for biohazardous waste is as follows:
1. At the point of biohazardous waste generation, the laboratory Supervisor is responsible for its proper storage, transport, transfer and disposal, whether performed by the Supervisor of his or her designee.
2. The Department shall assure that an assigned Department Safety Officer oversees biohazardous waste holding, transport and storage at its centralized biohazardous waste storage site(s).
3. Physical Facilities refuse transport personnel who perform biohazardous waste pick-up and transfer shall be responsible for accepting only properly packaged waste and for assuring its proper handling, transport and transfer to hospital biohazardous waste personnel.
4. Hospital Safety personnel accepting nonclinical biohazardous waste shall assure that all nonclinical biohazardous waste received meets local and federal biohazardous waste packaging requirements and that its final transport and disposal meets Environmental Protection Agency compliance standards.
All individuals who generate, transfer, transport, treat or dispose of biohazardous waste in violation of these provisions shall be subject to disciplinary action as outlined in the Howard University Handbook ("Progressive Steps of Discipline") in accordance with applicable collective bargaining agreements. Safety officers shall conduct an investigation of infractions and shall submit a written report to the Departmental Biosafety Committee. The committee shall then impose necessary administrative sanctions it deems appropriate based on the severity of threat to university and/or public health.
APPENDIX: AUTOCLAVE USE AND TESTING PROCEDURES
1. Autoclaving Biohazardous Waste
a. Follow proper segregation procedures to assure that all waste has been properly separated by category.
b. Place chemical or biological indicator with load or autoclave tape on outside of container as means of verifying effectiveness of sterilization.
c. Use the recommended temperature, pressure and time:
i. Temperature: 1210C to 1230C (2500F to 2540F)
ii. Pressure: 15 psi.
iii. Time: Minimum of 30 minutes or more at the recommended temperature.
d. Assure effective sterilization or decontamination:
i. Make sure that steam is able to contact all areas of the load:
(1) Uncover or open containers or bag to be autoclaved to enable steam contact with all parts of waste.
(2) Load must not exceed the effective capacity of the autoclave chamber.
(3) Make sure steam supply to autoclave is adequate and that there are no air pockets present in steam line.
(4) Water can be added to containers if added moisture is needed.
(5) Use SLOW EXHAUST for liquids.
(6) Use FAST EXHAUST for nonliquids.
e. Observe autoclave safety rules to prevent injury such as burns:
i. Use proper protective equipment (lab coat and heat-resistant gloves) to prevent biohazard exposure and to prevent burns.
ii. Make sure that autoclave door is properly sealed.
iii. Do not open door while the chamber is still pressurized.
iv. DO NOT put sealed items in the autoclave: NOTE: A large long-necked bottle which has been over-filled with liquid may behave like a sealed container.
v. DO NOT autoclave biohazards containing more than a TRACE of solvents, volatile or corrosive chemicals (phenol, ether, chloroform, TCA). DO NOT autoclave any radioactive material unless sanctioned to do so by Radiation Safety.
vi. Allow autoclave to cool down before opening door (Safety interlock usually prevents this) DO NOT stand in front of door when opening it.
vii. Because liquids which are removed too soon tend to boil, avoid the risk of burns by not overfilling containers and by allowing liquids to cool down properly before removal from the autoclave.
f. After sterilization and when bag or box has cooled sufficiently, close and seal bag or place lid on box. Confirm by inspection of the heat indicator that sterilization has been successfully carried out. Write ADECONTAMINATED@ on bag or box.
g. Follow disposal procedures outlined for decontaminated nonsharps or sharps (or decontaminated chemical or radioactive waste if applicable)..
2. Steam Sterilization:
a. The biological indicator recommended for use for steam sterilization is Bacillus stearothermophilus spores.
b. Use spore strips or ampules rated at 104 to 106 organisms.
c. The spores should be killed at 2500 F in 30 minutes.
3. Dry Heat Sterilization:
a. The biological indicator recommended for use for dry sterilization is Bacillus subtilis spores.
b. Use spore strips or ampules rated at 106 organisms.
4. Spore Testing Procedure
a. Place the recommended spore strips (see above) in the autoclave with the load, distributing them inside and outside of packs, etc.
b. Operate autoclave as per routine use.
c. Record chamber temperature. Date entry.
d. Fast exhaust autoclave after completion of the cycle.
e. Perform spore viability analysis as recommended by spore strip manufacturer and record results.
f. In instances of failure of sterilizer repeat test and assure that overload was not the cause of test failure.
g. If repeat test verifies autoclave failure take unit out of service. Execute repair order and post unit against use until problem is corrected.
5. Chemical Disinfection for Use when it is not feasible to autoclave or for Liquids > 1 gallon:
a. Soak contaminated glassware in a freshly made (less than 24 hours old) 1:10 dilution of household bleach to water.
b. Liquids: Treat with a 1:10 dilution of household bleach to liquid waste (not recommended in this program for blood or plasma or serum). Add absorbent sufficient to soak up liquid.
