1. Human Waste Management
Lunch & Learn – May 2014
Anne Augustin MLT, CIC
Network Coordinator – Central West

2. Human Waste Management
Goal: To be able to critically assess human waste management in one’s organization and provide recommendations as required.
Objectives
Describe three risks associated with the management of human waste in the health care setting.
Discuss the impact of toilet flushing on contamination of the environment.
State four options for disposal of human waste in the health care setting.
Describe the pros and cons for each of the four options of human waste disposal in the health care setting.

3. Risks Associated with Human Waste Management?
Decanting human waste
Dumping urine, feces, vomit into the toilet or hopper (sluice)
Toilet flushing
Use of spray wands to rinse receptacles (i.e., bedpans)
Disperses droplets of the fluids into the immediate area of the toilet
Image: Public Health Ontario

4. Aerosols Generated by Flushing
Position of settle plates
Toilet was seeded
Serratia marcescens
MS-2 bacteriophage
Untreated toilet
Treated toilet
sodium hypochlorite at 5000 ppm
neutralized
Flushed
1 min.
30 min.
60 min.
Barker and Jones in their 2005 paper describe how the measured the “spray” (aerosol formation and surface contamination) created by a domestic toilet
This slide shows the position of the settle plates
They seeded the toilet with pigmented Serratia marcescens and a bacterial phage
The inoculum was applied with a 50-ml syringe
directly to sidewalls of the toilet bowl
an even coating of organisms on the toilet.
Reason – to simulate the splashing like you would have with diarrhea.
Was allowed to sit for 5 minutes …. Started toilet flushing
Barker J and Jones MV 2005

5. Aerosols Generated by Flushing
Review slide…
Authors conclude:
Formed stool – very little risk of dissemination of bacteria as easily flushed away
Viral diarrhea such as norovirus:
Multiple trips to the toilet
Ongoing contamination of the toilet bowel and sides
Each flush – sends aerosols into the air that can be breathed in (norovirus) and deposited on surfaces – contact (fecal/oral) transmission
Bacterial diarrhea - Each flush – sends aerosols into the air that can be deposited on surfaces – contact (fecal/oral) transmission
Formed stool – very little risk of dissemination of bacteria
Viral diarrhea – dissemination by aerosols (breathing in airborne particles) and contact
Bacterial diarrhea – dissemination by aerosols contaminating touch surfaces
Barker J and Jones MV 2005

6. Clostridium difficile and Toilets
Does flushing the toilet (lid up) cause widespread contamination of Clostridium difficile?
Human fecal suspensions containing standardized C. difficile load
suspension was poured into the toilet bowl and applied to the sides to mimic the diarrhea
Toilets:
Cleaned inside and out with 1000 ppm of free available chlorine and then neutralized
Agar Plates
Top of the tank, right and left hand side of toilet, on the floor, and on top of the lid (for the closed lid experiment)
Many of us have dealt with outbreaks of C. difficile in our facilities.
We have used:
contact precautions (gloves and gown),
increased cleaning with a sporocidal agent,
hand hygiene, and
trying to ensure the affected patient or resident has their own toilet facilities.
Yet, sometimes the outbreaks or transmission continues…. So is there something about the toilet and flushing it? Does this cause widespread contamination of the environment?
This is the question Best, Sandoe and Wilcox asked in their paper…”Potential for aerosolization of Clostridium diffiicile after flushing toiltes: the role of toilet lids in reducing environmental contamination risk.”
In this paper, the feces of healthy C. difficile negative elderly volunteers were treated to give smooth fecal suspensions to which standardized suspensions of C. difficile was added just before testing – this was poured into the toilet bowel and on the sides to mimic the splash created when someone with diarrhea uses the toilet.
The toilets were cleaned inside and out with a solution of 1000 ppm of free chlorine
Then agar plates for C. difficile were placed around the toilet:
top of the tank
on the right-hand left-hand side of the toilet seat
(located on top of the lid for lid-closed tests)
and three on the floor (15 cm in front of the toilet, on the left- and right-hand sides of the toilet).
Best EL, Sadoe JAT, Wilcox MH 2011

7. Clostridium difficile and Toilets
Settle plates – during the 90 minutes after flushing:
Large droplets are released
Contaminate the immediate environment.
Floor, tank and toilet seat
Closing the toilet seat lid - decreased dissemination
Surfaces become rapidly seeded with C. difficile after toilet flushing
Frequent cleaning needed to remove environmental contamination - especially with repeated toilet use
C. difficile was recovered on settle plates placed on the floor, toilet tank, seat during the 90 min after flushing.
The authors state this demonstrates that:
large droplets are released when the toilet is flushed and these then contaminate the immediate environment.
Closing the toilet seat lid prevents large droplet aerosolization
The majority of the C. difficile recovered on the settle plates was due to relatively quick deposition of C. difficile spores following flushing.
Surfaces can become rapidly contaminated with C. difficile after toilet flushing (without a closed lid).
Due to the fact that spores can survive in the environment for prolonged periods of time - very frequent cleaning needs to be done to mitigate the contamination
Since I read these two articles… I NEVER flush the toilet without closing the lid!
Best EL, Sadoe JAT, Wilcox MH 2011

8. Contamination Contaminates items in close proximity to the toilet
Can spray human waste on healthcare providers
Increases the risk of transmission to patients/residents/clients and healthcare providers

9. Human Waste Management
Protect the Environment
Protect the Patient and Residents
Protect the Staff
Provide a Safe Environment
So what can we do ….. We want to protect the environment from becoming contaminated…. This will help us to protect our patients and residents so they do not become ill, and also protect our staff who provide care – ultimately providing a safe environment to receive care and provide care.
Well we do have options….

10. Options….Dumping of Human Waste into Toilet or Sluice
Blop, blop, splish, splash
Dumping into toilet, sluice or use of spray wand
CSA Z8000 – no spray wands
Controls at the health care provider
Least effective
Use of personal protective equipment (PPE)
Gloves
Gown
Mask
Eye protection
Hand hygiene – before and after
Thinking about the hierarchy of controls ……
Environmental controls – removal of the hazardous risk – most effective
Administrative controls – policies and procedures
Controls at the health care provider – least effective
Up to each individual to execute the control each and every time…
Image: Microsoft Clip Art

11. Options….Dumping of Human Waste into Toilet or Sluice
PPE donned every time human waste is dumped
This is the least desirable option
Patient/resident at risk
Contaminating the environment
Health care provider at risk
Contaminating the health care worker and the environment
This control would be the use of hand hygiene prior to donning personal protective equipment (gloves, gown, mask and eye protection). The PPE would have to be worn each time the human waste was dumped into the toilet, hopper, sluice, rimmed flushing sink
Review slide…..
Image: Microsoft Clip Art

12. Break the Transmission Human Waste Management
Bag-type Liner
Lines a bedpan or commode
Disposed into the regular waste stream
Macerator
Mechanical chopping and water
Disposable receptacle
Disposed into the sanitary sewer
Washer Disinfector
Removes soil and cleans medical equipment
Provides low-level disinfection
Noncritical medical equipment/devices that do not require high-level disinfection or sterilization may be reprocessed in a washer-disinfector (e.g., bedpans).
There are other options which help to mitigate the exposure of the health care worker and the patient or resident to contamination – contamination of self and or the environment
So let’s review each of these options…

13. Technical Requirements
Bag-type Liner
Pros
Gels liquid waste making transport safer
Regular waste stream
Not flushable
No additional plumbing required
Not affected by power outages
Cons
Consumable – ongoing operating cost and need for storage of product
Adds to solid stream waste
Needs a support (e.g. bedpan or commode)
Transport to disposal
Contingency plan in case of outbreak.
Technical Requirements
None
Review slide….
Bag-type liner can be used with a bed-pan or a commode – which ever is best for the patient/resident
After the patient/resident is done – pull the “strings” and tie closed….
Pros
A gel in the liner gels the liquid so there is sloshing to the waste.
Can be disposed of into the regular waste stream
You do not flush this product so there is no need for additional plumbing requirements
Not affected by power outages.
Cons
You need a liner each time the patient/resident uses the bed-pan commode…. Although some vendors say you can use up to 3 times… may get a bit stinky….Consumable – ongoing operating cost and need for storage of product
Adds to solid stream waste
Needs a support (e.g. bedpan or commode)
Transport to disposal
Contingency plan in case of outbreak…… some way to order and quickly receive more product than you would normally use should you go into an outbreak
There are no technical requirements

14. Technical Requirements
Macerator
Pros
Disposable paper based receptacle with or without support
May contain a solidifying gel
No dumping
Waste slurry directly into sanitary sewer
Macerator lid seals
Cons
Consumables – ongoing operating costs and storage of product
Transport receptacle to macerator.
Process for spill clean up
Plumbing and sanitary sewer systems must be sufficient.
Backup process for power outage
Increased water and power usage
Preventative maintenance and repairs
Sufficient number of macerators
Significant capital investment
Technical Requirements
Adequate water supply – volume required is macerator specific
Drain with sufficient diameter
Access to an electric supply
Review slide…..
Pros
Disposable paper based receptacle with or without support
May contain a solidifying gel
No dumping – this is very good for staff and patients/residents…. Less exposure to potential contamination
Waste slurry directly into sanitary sewer
Macerator lid seals
Cons
Consumables – ongoing operating costs and storage of product and again – need to have a contingency if you go into outbreak that you can have sufficient number of supplies on hand/delivered on a timely basis
Transport receptacle to macerator.
Process for spill clean up – need to carry the waste to the macerator…. Might spill so you need a documented process regarding how to clean up potential messes….
Plumbing and sanitary sewer systems must be sufficient – this needs to be assessed by your facilities staff and there may need to be conversation with the waste water people in your town or city
Backup process for power outage – consider putting on emergency power… could be a back up in the dirty utility room…. Stinky!
Increased water and power usage – increased operating costs
Preventative maintenance and repairs – increased operating costs
Sufficient number of macerators – this will be dependent on your organization – the lay out, # of residents/patients
Significant capital investment
Technical Requirements – as with any design or renovation you will have to work with your facilities people, the manager of the affected area and administration to decide where the macerators will be placed, how many you need and to ensure that the technical requirements are met……..
Adequate water supply – volume required is macerator specific
Drain with sufficient diameter – macerator specific
Access to an electric supply

15. Technical Requirements
Washer Disinfectors
Pros
Use re-usable bedpans, urinals, basins.
No dumping of waste into toilets
Door which seals so there is no aerosolization of waste.
Cons
Adequate storage and convenient access to bedpans.
Transport receptacle to washer disinfector.
Process for spill clean up.
Back up for power outage
Preventative maintenance and repairs
Sufficient number of washer disinfectors
Significant capital investment
Alkaline detergent
Thermal Conditions
Technical Requirements
Disinfector is large enough to hold re-usable items
Adequate water supply
Drain with sufficient diameter
Access to an electric supply
Review slides…..
Pros
Use re-usable bedpans, urinals, basins – do need a process to ensure the bed-pan goes back to the person to whom it belongs.
No dumping of waste into toilets – the new washer disinfectors - no longer need you dump and then put into the washer disinfector….but you must be very careful that items that can’t go in, don’t go in – for example, wipes, faceclothes, hand towels…. This will cause big issues with the washer disinfector. This will require education…. Ongoing education
Door which seals so there is no aerosolization of waste.
Cons
Adequate storage and convenient access to bedpans.
Transport receptacle to washer disinfector – would be rare to have one washer disinfector in every room, so staff will have to walk the bed pan/commode bucket to where the washer disinfector is located
Process for spill clean up – just in case spills happen
Back up for power outage – again – consider having some of your washer disinfectors on emergency power
Preventative maintenance and repairs – important to avoid down times
Sufficient number of washer disinfectors – this will depend on your patient/resident population, building configuration
Significant capital investment
Alkaline detergent…. Your choice in detergent is important to help ensure you are …..in an article by Dr. Michelle Alfa, published in AJIC 2013… she noted that “hospital ward washer disinfectors cannot achieve thermal conditions that are sufficient to kill C. difficile spores. The use of validated cycle plus alkaline detergent is clearly and important factor for eradication of spores from bedpans.”
Thermal Conditions – need to ensure your washer disinfector is properly set up and is meeting the parameters required…. In an article by Dr. Elizabeth Bryce, published in AJIC 2011, it was stated…”Users should thoroughly evaluate in-use efficacy of bedpan decontaminators…….forced function and compliance features for correct loading of machines, detergent, and rinse agent dispensing, and ability to operate the machine only when the detergent is present should be integral to the bedpan disinfector design.”
Technical Requirements – as discussed with the macerator – need to work with facilities, area affected and admininstration at a minimum to ensure the correct device is chosen and adequate education is provided to the staff.
Disinfector is large enough to hold re-usable items
Adequate water supply
Drain with sufficient diameter
Access to an electric supply

16. Conclusion Human waste management There are options
Safe
Effective
Efficient
There are options
Dumping into toilet or sluice while wearing PPE – least effective and poses greatest risk to the patient/resident and health care provider
Bag-type liners
Macerators
Washer Disinfectors
Each system has its pros and cons
The three things we can say for certain when it comes to human waste management are:
Needs to be safe
Safe for the staff – on spraying/splashing self or environment – putting self at risk
Safe for the patient/resident – not contaminating environment and therefore a risk for transmission
Needs to be effective
There is no time for re-work
Needs to be efficient
In many health care facilities, many patients/residents need help or are completely dependent on others with respect to their toileting needs
Health care providers need to be able to take care of these efficiently to meet workload demands
There are also options…. Review the 4 options.

17. References
Barker J, Jones MV. The potential spread of infection caused by aerosol contamination of surfaces after flushing a domestic toilet. J Appl Microbiol 2005;99:339–347.
Best EL, Sandoe JAT, Wilcox MH. Potential for aerosolization of Clostridium difficile after flushing toilets: the role of toilet lids in reducing environmental contamination risk. Journal of Hospital Infection 2012;80:1-5
Canadian Standards Association. Canadian health care facilities, Z , c2011
Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee (PIDAC). Best Practices for Cleaning, Disinfection and Sterilization in All Health Care Settings. Toronto, ON: Queen’s Printer for Ontario; 2013
PublicHealthOntario.ca

18. References
Canadian Standards Association. Handling of waste materials in health care facilities and veterinary health care facilities Z c2009
Alfa M, Olson N, Buelow-Smith L and Murray BL, Alkaline detergent combined with a routine ward bedpan washer disinfector cycle eradicates Clostridium difficile spores from the surface of plastic bedpans. AJIC 2013;41:381-3
Public Health Agency of Canada, Clostridium Difficile Infection, Infection Prevention and Control Guidance for Management in Acute Care Settings [cited 2013 Aug 20] Available from: aspc.gc.ca/nois-sinp/guide/c-dif-acs-esa/index-eng.php#a13

19. References
Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee (PIDAC). Annex C: Testing, Surveillance and Management of Clostridium difficile In All Health Care Settings. Toronto, ON: Queen’s Printer for Ontario; 2013
Bryce E, Lamsdale A, Forrester L, Dempster L, Scharf S, McAuley M, Clearie I, Stapleton S, Browning S. Bedpan washer disinfectors: an in-use evaluation of cleaning and disinfection. Am J Infect Control 2011 Sept. Vol. 39 (7) pp
Agence d’évaluation des technologies et des modes d’intervention en santé (AETMIS). Comparative Analysis of Bedpan Processing Equipment. Technical note prepared by Christine Lobè. (AETMIS 09-04) Montréal, 2009.