At the Greenville Hospital System in South Carolina, we have been in the process of developing a comprehensive pharmaceutical waste management plan for quite a while. Given the unclear and often conflicting regulations, one could make the argument that it would be easier to wait on a universal waste ruling. However, we did not believe we could be responsible to our community and the environment without having a plan in place to conscientiously manage our pharmaceutical waste. Thus began a long process of working with consultants to assess our inventory, reviewing the different disposal options, and examining points of weakness such as controlled substance disposal in an effort to adopt a comprehensive waste management solution. 

In assessing the various options, we adopted a guiding principle of designing a program that would be as simple as possible for both nursing and pharmacy staff, yet effective enough to capture the vast majority of our pharmaceutical waste. Aware that a successful program would require interdisciplinary collaboration, we included pharmacy, nursing, environmental services, and the hazardous materials handling manager in the process, as well as representation from each clinical department that would be impacted. While pharmacy was tasked with determining and implementing the solution, the other players involved had to be on board as well: nursing as the main program utilizers, environmental services as the container collectors, and hazardous materials as the storage and containment providers. 

Building a Comprehensive Program
Ultimately we chose to ensure that none of our pharmaceutical waste would be placed in a landfill by managing all of this waste as hazardous, relying on a vendor who manages it through high-temperature incineration. This approach is quite simple to manage in practice; a 3-gallon blue top container resides on each medication cart or nursing unit, allowing nurses to dispose of the majority of waste at the point of generation, while larger black containers are placed in the utility rooms for the disposal of large volume IV bags. By simplifying the process, we eliminated the need for pharmacy to develop and manage an identification and labeling system for every RCRA-hazardous product, and decreased the prospect that we would receive numerous calls from nursing should they be unclear about following a sticker-driven sorting process. From nursing’s perspective, the addition of a single waste stream was a straightforward method that addressed their environmental concerns, so they were pleased to embrace it. 

Of course this approach results in higher disposal costs, but administration is clear that we are also avoiding the staff costs--and frustrations--associated with a complicated sorting program. Perhaps most importantly, we are confident that this is the most responsible approach for the environment. Should the EPA implement a universal waste regulation in the future, we will be in an excellent position to deescalate the program if necessary; escalating a program once it is in place is a much more difficult challenge.

Addressing Controlled Substance Waste
Despite our improvements to pharmaceutical waste management, there was one glaring area that remained unaddressed; like many facilities, our controlled substances were being disposed of via the sewer, directly into the waste water system. Not only did this not meet our health system’s goal of responsible environmental stewardship, but also staff members from both pharmacy and nursing were concerned about their direct roles in adding potentially harmful substances to our community’s environment. This widespread concern was a motivating factor to find a better solution and was also a key selling point in convincing our staff members to take part in testing a new system. 

Time and Motion Study
Fortuitously, a controlled substance containment system that renders this waste nonrecoverable recently entered the market and after investigating its ease of use—it is a smart canister system without mechanical components requiring maintenance—we chose to do an in-house evaluation of the Cactus Smart Sink. To compare the effectiveness of the new product against our existing system of wasting via the sewer, we created a time and motion study based on scientifically valid observational methods. Three units with high levels of controlled substance waste (a medical oncology unit, an orthopedic surgery unit, and a general surgical unit) were chosen for the study to determine the time nurses spent disposing of controlled substances via the traditional sewer system method versus wasting via the canister system. In addition to their high level of waste generation, the nurses on these three units had to walk a considerable distance to follow our policy on controlled substance disposal. 

Because all of our controlled substances are stored in automated dispensing cabinets (ADCs), time to disposal was measured from removal of the drug at the ADC until the actual time of drug wastage. Pharmacy observers recorded these times as they observed the process. We measured time to disposal for one month via the traditional method and for one month via the new canister system. Of note, there was some effect on the study due to its observational nature. In the first phase when we measured time to disposal via the traditional method, we noted that nursing staff, aware that they were being timed, looked for the fastest method of disposal. On one unit, rather than walking the distance to the usual utility room for disposal, they began using a closer sink located in a locked food station that was not intended for this purpose. 

In phase two, we mounted the canister systems on the walls adjacent to the ADCs, a location that was recommended and approved by the nurses on each unit. Again, the time to waste was recorded for one month. At the conclusion of the study, we ran a statistical analysis to determine the differing effects of the two systems. The time saved with disposal via the canister system was statistically significant (P<0.05), with an average savings of 15 to 20 seconds per drug (see Figure 1). Given nursing’s observed practice of shortening disposal times during the initial study phase, it is possible that the time savings could be even higher. Notably, during the second phase of the study using the canister system, nurses on that unit noticed a high number of patients and visitors freely accessing the newly unlocked food station, which prompted them to relock the station and follow correct procedure.

Our goal in testing the canister system was to determine if it was compatible with nursing practice and if it made the job easier. To that end, we followed up the time and motion study with an opinion survey sent to every nurse involved in the study, which they were to complete anonymously and return to pharmacy. Of the 100 surveys sent out, 35 were returned. The survey questioned nursing on their usual practices, their satisfaction with these practices, their experience with the canister system, and their satisfaction with using the canister system in practice. The surveys confirmed our belief that nursing often circumvented our controlled substance policy and commonly wasted these products in trash cans and sharps containers, making it clear that a more effective policy was necessary. The surveys demonstrated that nursing found the canister system convenient and appreciated a nonrecoverable waste option that gave them an environmentally responsible waste option (see Figures 2 and 3).

Click here to view a larger version of these Figures

Conclusion
Given the positive results from our study of the canister system, we are moving ahead with implementing this solution in our academic medical center as a component of the overall waste management program. This is an ongoing project that will continue into 2012 as we work with the individual nursing units to determine the best locations for the canisters. We will continue to roll out our comprehensive waste management program into our procedural units and other patient care areas that administer medications. Once we have fine-tuned the process on our main campus, we will roll it out to our community hospitals as well. 

Having  the support of administration and the front line staff contributed to the success of the development and implementation of this effective, environmentally responsible program. This support made it possible to be one of the first hospitals in the country to implement such a complete solution to the common challenge of managing all pharmaceutical waste, including controlled substances, from cradle to grave. 

Fred Bender, PharmD, FASHP, has worked as the director of pharmacy services for the Greenville Hospital System since 2004. He also serves as the clinical education administrator for the Greenville Hospital System/South Carolina College of Pharmacy program. Dr. Bender received his bachelor of science and doctor of pharmacy degrees from Duquesne University School of Pharmacy.