This program describes the procedures and methods for the management of medical, biohazard or pharmaceutical wastes.
I. Purpose/Scope
- Purpose: The production of medical waste materials at California State University, Northridge (CSUN) creates a variety of potential safety and environmental compliance issues. The purpose of this Procedure is to ensure that applicable compliance issues are considered and addressed before storing and disposing of such material.
- Scope: This procedure applies to all faculty, staff and students who generate medical waste materials that will be handled or stored on campus.
II. Definitions
- Biohazard Bag: A disposable bag that is impervious to moisture and has a strength sufficient to preclude ripping, tearing, or bursting under normal conditions of usage and handling of the waste-filled bag as prescribed by the American Society for Testing Materials (ASTM) D1922 and D1709. The color of the bag shall be red, except when yellow bags are used to segregate trace chemotherapy waste. The biohazard bag shall be marked with the international biohazard symbol.
- Biohazardous Waste:
- Regulated medical waste, clinical waste, or biomedical waste that is a waste or material derived from the medical treatment of a human or animal that is suspected of being infected with a pathogen that is also infectious to humans, which includes diagnosis and immunizations; or form biomedical research, which includes the production and testing of biological products.
- Cultures and stocks of infectious agents from research and instructional laboratories.
- Human surgery specimens, tissues or animal parts, fluids, or carcasses suspected of being contaminated with infectious agents suspected or known to be contagious to humans.
- Waste containing discarded materials contaminated with excretion, exudate, or secretions from humans or animals that are required to be isolated to protect others from highly communicable diseases or diseases of animals that are highly communicable to humans.
- Waste which is hazardous only because it is comprised of human surgery specimens or tissues which have been fixed in formaldehyde or other fixatives, or only because the waste is contaminated through contact with, or having previously contained, chemotherapeutic agents, including, but not limited to, gloves, disposable gowns, towels, and intravenous solution bags and attached tubing which are empty.
- Infectious agent: A type of microorganism, bacteria, mold, parasite, or virus, including, but not limited to, organisms managed as Biosafety Level II, III, or IV by the federal Centers for Disease Control and Prevention, that normally causes, or significantly contributes to the cause of, increased morbidity or mortality of human beings.
- Medical Waste: Any biohazardous, pathology, pharmaceutical, or trace chemotherapy waste that is not regulated by the federal Resource Conservation and Recovery Act of 1976; sharps and trace chemotherapy wastes generated in the diagnosis, treatment, immunization, or care of humans or animals; waste generated in research using human or animal pathogens.
- Pharmaceutical: A prescription or over-the-counter human or veterinary drug.
- RCRA Hazardous Waste: Wastes that exhibit certain characteristics regulated by RCRA (Resource Conservation and Recovery Act). A waste may be considered hazardous if it is ignitable (i.e., burns readily), corrosive, or reactive (e.g., explosive). Waste may also be considered hazardous if it contains certain amounts of toxic chemicals. In addition to these characteristic wastes, Hazardous waste takes many physical forms and may be solid, semi-solid, or even liquid.
- Sharps Container: A rigid puncture-resistant container that, when sealed, is leak resistant and cannot be reopened without great difficulty.
- Trauma Scene: A location soiled by, or contaminated with, human blood, human body fluids, or other residues from the scene of a serious human injury, illness, or death.
- Treatment: Any method, technique, or process designed to change the biological character or composition of any medical waste so as to eliminate its potential for causing disease, as specified in Chapter 8 (commencing with Section 118215).
III. Facility Information
- Facility Description: CSUN is a registered a large quantity generator (Registration #19-29) and is located at:
California State University, Northridge
18111 Nordhoff Street
Northridge, CA 91330-8284
Telephone- (818) 677-2401
Emergency Telephone (818) 677-2111
- Two (2) departments on campus generate are the primary generators of regulated medical wastes:
- Biology/Science Departments - average medical waste generation per month: 742 pounds
- Student Health Center - average medical waste generation per month: 112 pounds
- Person Responsible for Implementation of the Plan:
Environmental Compliance Specialist
Telephone: (818) 677-2401
Fax: (818) 677-5853
IV. Medical Waste Management
- Laboratory Wastes: Specimen or microbiological cultures, stocks of potentially infectious agents, and culture media.
- Blood or Body Fluids: Liquid blood elements or other regulated bodily fluids, or articles contaminated with blood or bodily fluids.
- Sharps: Syringes, needles, blades, broken glass.
- Surgical Specimens: Human (unrecognizable) or animal parts or tissues removed surgically or by autopsy.
- Pharmaceutical Waste
No medical waste is discharged to sewers. No mixed radioactive/medical waste is generated. CSU Northridge conducts no infectious disease research using live animals.
V. Medical Waste Management Company
- Waste Collection & Transportation: The Facility has contracted with Veolia North America and Clean Harbors Environmental Services as it's Medical Waste Management Companies. The Contractors provide the following services:
- Waste Pick-Up
- Waste Transportation
- Waste Disposal
Medical Waste Management Companies:
Veolia North America:
241 W. Laurel Street
Colton, CA 92324
Telephone: (909) 370-0730
Clean Harbors Environmental Services
2500 E. Victoria St.
Compton, CA 90220
Telephone (310) 764-5851
- Waste Treatment: Our medical waste treatment contractor treats all medical waste off site. The Environmental Health and Safety Office maintains tracking documents for transport and treatment of medical waste for a minimum of three (3) years.
- There is no onsite treatment of medical waste.
VI. Procedures
- Student Health Center, Biology and Chemistry
- Collection:
Medical waste is collected at the point of generation in rigid containers lined with red biohazard bags. The containers are labeled with the words "Biohazardous Waste" or "Biohazard" and the international biohazard symbol, such that the labels can be seen from all sides. Medical waste is segregated from other types of waste at the point of generation.
Sharps wastes are collected at the point of generation in "no cut" rigid walled, puncture resistant single use containers.
- Transportation:
Medical Waste – Rigid containers with lids are used to transport Medical Waste to one of the approved Medical Waste Storage Areas. The biohazard bag is removed from the container and tied with a gooseneck knot. The container is cleaned and sanitized if necessary, lined with a new red biohazard bag and returned to service.
Sharps containers –Full Sharps containers are closed securely and transported to one of the approved medical waste storage areas.
- Storage:
There are two (2) approved medical waste storage areas. They are located at:
- Student Health Center
- Citrus Hall (Science 3), Room 3200A
The storage areas are secured (locked) except when waste is added or removed. The single door is marked with a sign that reads (in English and in Spanish)
"CAUTION - BIOHAZARDOUS WASTE STORAGE AREA - UNAUTHORIZED PERSONS KEEP OUT".
The waste is stored inside heavy duty, covered, plastic containers until picked up by one of the approved medical waste management companies. Storage containers are supplied by the medical waste management company and are exchanged for clean sanitized containers after each waste pickup. The storage takes place at room temperature (approximately 68 - 77 F) and never exceeds seven (7) days in duration due to a prearranged, regular waste pick up schedule.
- All other areas on Campus generating Medical Waste
Contact Environmental Health and Safety (extension 2401) to assistance and guidance.
- Guidance Documents
- Acceptable Containers, Transportation and Storage
- Securing Red Bags
- Unacceptable Practices
- PHARMACEUTICAL WASTE (Student Health Center):
- Collection & Segregation: Waste pharmaceuticals are segregated into three categories:
- · Regularly packaged (manufacturer / distributor): These materials are managed by Reverse Distribution through the Student Health Center. Reverse Distribution is when unwanted pharmaceuticals are returned to the manufacturer for a credit or for those materials a manufacturer will not accept destroyed by thermal incineration.
- · Open packages and individual doses: Pharmaceutical disposal program through the medical waste management company, whereby we are supplied with 2-gallon containers which we fill with unusable products. These containers are placed in the medical waste storage are picked up by the medical waste disposal company and destroyed by thermal incineration.
- · Pharmaceutical chemicals: Waste pharmaceuticals chemicals are segregated into “RCRA hazardous” and non-hazardous wastes at the point of generation. RCRA hazardous waste is placed in a compatible container with a conforming label and the label is completed.
Pharmaceutical Reverse Distribution Company:
Inmar Inc /Exp Pharmaceutical Services Corp
4332 Empire Rd
Fort Worth, TX 76155
Telephone (800) 350-0397
- Storage: To avoid unauthorized access to waste pharmaceuticals chemicals during the accumulation process it is recommended that drugs be rendered unrecognizable or otherwise unmarketable by commingling, removal of doses from blister packs or vials, or by otherwise adulterating the drugs.
RCRA hazardous waste is disposed by calling the Environmental Health and Safety Office (X-2401) for disposal at intervals not to exceed 90 days.
Other waste pharmaceuticals can accumulate for up to one year if the generation rate is less than 10 pounds per year. If the generation rate exceeds 10 pounds per year the pickup interval is 90 days.
VII. Emergency Action Plan
- Medical waste is stored only in secured labeled areas. Waste is then transported, treated and disposed by our medical waste management company. In the event that our primary medical waste management company (TCI) is incapable of transporting medical waste in a timely manner, our secondary medical waste management company (Clean Harbors Environmental Services) will provide these services.
Clean Harbors Environmental Services
(310) 764-5851
24 – hour emergency telephone number (800) 645-8265
- In the event of a spill of bio-hazardous materials, the Campus has a variety of capabilities and plans to mitigate any adverse effects. The Campus has a round-the-clock police department and an on-call hazardous materials emergency response team. The Campus also maintains both a general emergency response plan/emergency operations center and a hazardous materials emergency response plan. Members of these teams participate in both training and drills. Furthermore, as a backup, our hazardous waste disposal contractor has emergency response capability and can respond to hazardous materials emergencies.
- Clean-Up Procedures: In the case of a spill of medical waste, clean up may be done by rinsing or immersion for three minutes using one of the following chemical sanitizers. The concentrations listed below are minimum concentrations; stronger solutions are, of course, more effective.
- Chlorine: Commercially available bleach contains about 5% (five percent) sodium hypochlorite. A dilution of one part of the commercial product to 49 (forty-nine) parts water produces a solution of approximately 1000 (one thousand) parts per million (equivalent to 0.1% active ingredient)
- Dry calcium hypochlorite tablets for pools: (Pulsar Plus Briquettes) will contain approximately 65% (sixty-five percent) available chlorine. A mixture of 1.5 pounds of Pulsar Plus Briquettes to 1 gallon of water will produce a solution of approximately 1000 (one thousand) parts per million available chlorine.
- Ammonia: Commercially available ammonia solutions each contain about 5% (five percent) quaternary ammonia. A dilution of one part of the commercial product to 49 (forty-nine) parts water produces a solution of approximately 1000 (one thousand) parts per million (equivalent to 0.1% active ingredient) Note: Chlorine (bleach) and ammonia should never be mixed together.
- Phenolic solutions of 500 parts per million (0.05%) of the active agent.
- Iodoform solutions of 100 parts per million (0.01%) of the active agent.
- Trauma Clean-Up:
- Trauma Scene: “Trauma scene” means a location soiled by, or contaminated with, human blood, human body fluids, or other residues from the scene of a serious human injury, illness, or death.
- Trauma Scene Waste Management Practitioner: “Trauma scene waste management practitioner” means a person who undertakes as a commercial activity the removal of human blood, human body fluids, and other associated residues from the scene of a serious human injury, illness, or death, and who is registered with the department health services.
Registered Trauma Scene Management Practitioner for CSUN:
ServPro of Burbank, California
Department of Health Services Registration number 196
24-hour telephone number (818) 842-1400
Contact Name: Heidy Beltran
Alliance Environmental Group, LLC
Department of Health Services Registration number 209
24-hour telephone number (626) 626-633-3500 / (877)858-6220
Contact Name: Armando Delgadillo
VIII. References
IX. Certification
I hereby certify that to the best of my knowledge and belief the statements made herein are correct and true.
Name: Anthony J Pepe Date: March 15, 2018
Signature: ___________________________________
X. Revision Record
| REVISION | CHANGES | DATE |
| Revision 7.51 | Reviewed | March 2014 |
| Revision 7.52 | Update Hazardous Waste Contractor Name | January 2015 |
| Revision 7.53 | Updated quantity of Medical Waste generated per month | June 2017 |
| Revision 7.54 | Updated
| March 2018 |
| Revision 7.55 | Review and update | November 2022 |