1. Pharmaceutical Waste – Ambulatory Care Sites Christina Schmelzer August 6, 2013

2. 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

3. 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

4. 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

5. 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

6. Which drugs go into blue bins?

7. 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

8. Which medications go into the blue bins?

9. Blue Bin Collection Containers 5.4 Quart Bin 3 Gallon Bin

10. What do the bins look like? Blue top Blue Sticker

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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 DateNumber of containers Container Contents Description Amount (volume or weight of container)

17. 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

18. 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

19. 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

20. Online Waste Tracking System

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

27. 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

28. Recent statistics (June 2012 – April 2013) Total pounds hazardous materials – 944 Total pounds non-hazardous materials – 268 Pickup Frequency Per Month

29. 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

30. 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

31. 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

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