By Michael Roshko, PharmD

The challenges that led Thomas Jefferson University Hospitals (TJUH) to seek external assistance for pharmaceutical waste disposal compliance were common enough. Most hospitals are concerned with EPA and The Joint Commission (TJC) compliance, as well as the liability of potential harm to patients, staff, visitors, and the environment. At TJUH—which includes the main campus with 750 beds, Methodist Hospital with 250 beds, and Jefferson Hospital for Neuroscience with 120 beds—the pharmacy operation is decentralized to meet the needs of each facility. We wanted our pharmaceutical waste program to effectively do the same.

While the initiation of a pharmaceutical waste program was led by our environmental services (EVS) and pharmacy departments, the process involved a multi-departmental “pharmaceutical work group.” This group—consisting of representatives from nursing, nurse education, accreditation, facilities, risk management, safety and health, infection control, information systems, and sustainability—was collectively excited about the various benefits of such a program. Their cooperation was integral to the successful implementation.

In-house vs. Outsource

We wanted to get ahead of the compliance curve by initiating a program that linked our organization’s goals with TJC standards and regulatory requirements. Given the complexity and sensitivity of TJC’s 21 hospital standards, we knew  a comprehensive turnkey solution was necessary.

The first step in this process was to determine which pharmaceuticals were hazardous and if proper disposal could be managed in-house. We also considered non-hazardous drugs that are damaging to the environment. We decided that the potential cost and risk to staff was such that an outsourced provider would be our best option. We wanted a service that could provide a waste characterization that segregated the formulary by EPA and DOT waste streams and identified the compatibility of hazardous and non-hazardous pharmaceuticals based on chemical content.

Finding the Right Vendor

Some vendors we reviewed had program plans and characterization capabilities, others focused on hazardous waste disposal only. We wanted a vendor with national experience that could share best practices and coordinate cost containment strategies with us. We chose Stericycle’s pharmaceutical waste compliance program in part because it uses a system of checks and balances to assess where we are and where we need to be. Implementing the program involved a four-phase approach:

Identification of formulary characterization and waste coding: Stericycle provided the characterization within one week of submitting our formulary, and continues to provide updates as we add new products. Additionally, Stericycle provides us with a comprehensive annual report. TJUH identifies drugs on patient labels and in ADCs using simple codes on each container, thereby ensuring proper disposal.

• On-site education of pharmacy, nursing, and EVS staff: Staff were educated on how to properly interpret the simple waste codes with a particular focus on proper disposal of partial IVs with instilled medication. Continued drain disposal of “plain” IVs (electrolytes, saline, and dextrose) and proper disposal of controlled substances also was reinforced.
• Implementation of color-coded, reusable containers: Having a variety of container sizes and mounting options (wall brackets, floor dollies, etc) allowed us to address challenges related to space.
• Transportation and destruction: Stericycle technicians collect and bring full containers to a central accumulation area a few times each week where they pack the waste. The fully packed containers are picked up from this location on a weekly basis. The pharmaceutical work group identified an adequate waste storage area and enlisted administrative support in raising awareness and acceptance of the program.

TJUH’s main campus began this process in November 2008 with mandatory training for anyone handling hazardous waste. The training process took just two days. Later, new employee orientation and employee yearly competency reviews were added.

Results

Our six-month pilot phase at TJUH included 150 beds and all inpatient pharmacies. With effective training, waste coding of all pharmaceuticals, and the use of color- coded containers, in its first year, the fully implemented program dramatically minimized disposal costs, as only 3,000 pounds of the roughly 75,000 pounds of pharmaceutical waste collected was RCRA hazardous. The response from staff also has been quite positive, with high visibility to the CEO and executive suite. Thus far, we have had success in meeting our goals, which included exceeding the standards for regulatory compliance, mitigating costs, keeping harmful pharmaceuticals out of the public water supply, and focusing on the safety and health of our staff, patients, visitors, and the communities we serve.

Michael Roshko, PharmD, is the operations manager for Thomas Jefferson University Hospital in Philadelphia, Pennsylvania. He is responsible for all inpatient pharmacy services.

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