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

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.

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

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

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

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

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

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

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….

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

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

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…

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

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

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

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.

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, Z8000- 11, 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

References Canadian Standards Association. Handling of waste materials in health care facilities and veterinary health care facilities Z317.10-09 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. 2009 [cited 2013 Aug 20] Available from: http://www.phac- aspc.gc.ca/nois-sinp/guide/c-dif-acs-esa/index-eng.php#a13

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 566-70 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.