Pharmaceutical Waste – Ambulatory Care SitesChristina SchmelzerAugust 6, 2013

Introduction• Why?• Locations• Process• Will cover (1) selection of discarded drugs, (2) method of collection,

(3) segregation, packing, and disposal, and (4) scheduling pick-ups• Training: Which drugs do we collect?• Recordkeeping• Manifesting• Logs• Waste Tracking System for Off-site Pharmacy Waste

• Billing• Statistics • Improvements and Continued Struggles

Why?• Certain discarded drugs are hazardous waste• University Policy• Prevent the discharge of waste drugs into streams, lakes, etc.• Prevent the diversion of waste drugs for unintended use

Locations• Types of locations:• Private Diagnostic Clinics (PDC)

• Duke owned clinics• Community Private Diagnostic Clinics (CPDC)

• Duke affiliated clinics• Duke Primary Care (DPC)

• Primary care, urgent care, etc.• Hospital Based Clinics (HBC)

• Oncology, etc. *Higher drug amounts administered generally*• University Clinics (Uclinics)

• Student Health• Other clinics

• Health and Fitness

The Numbers• As of July 15, 2013• PDCs – 41• CPDCs – 41• DPCs – 38• HBCs – 46• Uclinics – 3• Other clinics – 1

• Duke is constantly adding new clinics, whether through acquiring existing clinics, or opening new clinics

Which drugs go into blue bins?

How was this list determined?• Over 60 clinics were inventoried• Pharm Ecology - Pharm E Wizard• Used to identify those drugs that are regulated

• Met with Duke Pharmacy to confirm proper terminology and titles for each drug on the list

Which medications go into the blue bins?

Blue Bin Collection Containers

5.4 Quart Bin

3 Gallon Bin

What do the bins look like? Blue top

Blue Sticker

Items that DO NOT go into the blue bin:

These items should NOT be placed in blue bins (they should be placed in red bags or sharps boxes). Scissors Sharps Empty syringes with needles/glass bottles/blood bags (any

container in which the medicine was completely administered to the patient)

Butterfly needles Sodium Chloride Needles Tweezers

Items that DO NOT go into the blue bin (continued):

These items should NOT be placed in blue bins (they should be placed in the regular trash) Used gloves/gowns Empty syringes without needles/non-glass bottles

Controlled substances are NOT included

Training • Who?• Currently optional, offered to all staff, especially those who work

with those regulated drugs• Topics covered• What drugs go in, including items that do not• How to maintain records of bin (log)• Why do we collect these drugs?• Cost

• Two types offered• In-Clinic• Online

Online versus In-Clinic Training• In-Clinic• Positives

• Answer questions immediately• Put a face with a program• Verify correct set-up

• Negatives• VERY time-intensive, usually only performed once• Details can be forgotten

• Online• Positives

• Follows job titles from person to person, so turnover is less of a factor• Quick and easy to update• Use of photos, text, and quizzes

• Negatives• Right now training is NOT required• Details can be forgotten

Recordkeeping

1. Waste Manifest The contractor collecting the waste will complete a Waste

Manifest based on the contents of the container The “Responsible person” at each location must sign the manifest

and retain the top copy A “completed manifest” signed by the disposal facility will be

returned to each location Both the signed top copy and the completed manifest should be

filed together with a “Certificate of Destruction” that will be sent from the disposal site to each location.

Clinics will maintain all copies for three years

Recordkeeping, continued

2. Hazardous Waste Log The clinic also must maintain a log of all medications placed into

the blue bins. Log should be filed when bin is collected. Example:

Medication Disposal Log Sheet

Date Number of containers

Container Contents Description

Amount (volume or weight of container)

Who performs the work?• Hired a contractor to:• Schedule pick-ups• Add 4 digit code to manifest• Segregate hazardous from non-hazardous discarded drugs• Repack and ship to permitted TSDF• Bill directly to clinics

Scheduling Pick-ups• For the first year• Infrequent, unknown pick-up frequency

• For the second year• Infrequent, more well-known frequency

• For the third year• Frequent, scheduled pick-ups

• In future years• Frequent, scheduled pick-ups on a once-a-month basis• Other pick-ups based on contractor schedule and convenience

Tracking, Organization• Organization was necessary for reporting purposes. Using a 4

digit code allows for quick knowledge of each location and ease of reporting frequency (# of pickups per bin).

• All off-campus clinics have a 4 digit code• First digit indicates clinic type

• 1 – PDC (i.e. 1001)• 2 – CPDC (i.e. 2001)• 3 – DPC (i.e. 3001)• 4 – HBC (i.e. 4001) *most have barcodes• 5 – University clinics (i.e. 5001)

• Codes are attached to bracket• Assists in tracking bins • Helps connect manifest to bin

Online Waste Tracking System

Online Waste Tracking System

Online Waste Tracking System

Online Waste Tracking System

Online Waste Tracking System

Online Waste Tracking System

Billing/Payments• Contractor bills clinics directly• Copy of invoice to Duke• Follow-up of non-payment checked /tracked down by Duke

Current Billing• Clinics pay 1 stop fee + disposal costs + bin replacement costs• If multiple bins were collected at one time, each location could

share the stop fee to reduce costs• Multiple bins may all be located in one clinic, or may be

located in multiple clinics in one building• Clinics were provided with an approximation of cost based on

a bin with all correct items in it• Bins with other items such as biological materials or sharps likely

maintain a different cost based on the change in disposal fee

Recent statistics (June 2012 – April 2013)

• Total pounds hazardous materials – 944• Total pounds non-hazardous materials – 268• Pickup Frequency Per Month

0

0.5

1

1.5

2

2.5

3

3.5

4

JuneJulyAugustSeptOctNovDecJanFebMarchApril

Month

No.

of B

ins

Improvements since implementation• Billing/payment issues no longer reach 90 day late payment

deadline• Set schedule reduces work hours for scheduling, allows for

more work hours for program improvement• 4 digit code allows for better tracking of bins, from clinics

moving to how many bins exist in one area

Negatives to the process• Large work hours for small amount of waste• Several weeks turnaround time for pickups• Hard to audit for compliance due to distance• Difficult to determine whether the correct drugs are being

collected or not • Quality Control Audit

• High level of turnover makes training a challenge• New clinics result in new inventories that are not considered

until the next poster update

Summary• Since implementation of the program in 2010, the program

has grown in the following ways:• Added ~40 new clinics• Performed 65+ pickups • In 2012-2013, picked up 944 lbs. of hazardous material, otherwise to

go to the trash or biohazard

Questions?Contact me!Christina Schmelzer• Duke Occupational and Environmental Safety Office• (919) 684-2794• christina.schmelzer@duke.edu