Disposal of epinephrine; shellfish and iodine allergies; fires caused by hair gel; patient jewelry; vaginal use of chlorhexidine gluconate

AORN Journal, Feb, 2006 by Eric Briesemeister, Byron L. Burlingame

QUESTION: Recently, I heard that outdated vials of epinephrine and epinephrine pens require special disposal because epinephrine is a hazardous substance. If this is true, what should I do with outdated epinephrine-containing products in the OR?

ANSWER: Epinephrine is a regulated hazardous waste that must be disposed of according to the Environmental Protection Agency's (EPA's) Resource Conservation and Recovery Act (RCRA) regulations. (1) Although, these rules were created in the mid 1970s, health care facilities were not required to adhere to them until recently. Approximately four years ago, the EPA began inspecting hospitals and assessing fines for RCRA violations. For example, one large hospital on the East Coast was fined $214,420 (2) and another was fined $372,254 (3) for hazardous-waste disposal violations.

In the RCRA regulations, chemicals are considered regulated or nonregulated rather than hazardous or nonhazardous. The EPA defines regulated waste as being either characteristic waste or listed waste. According to EPA definitions, characteristic wastes are those that are ignitable, reactive, corrosive, or toxic. Listed waste chemicals are placed in one of four lists: F, K, U, or P. (4)

* F-listed wastes are generic process wastes from nonspecific sources. (5)

* K-listed wastes are industry-specific wastes from specific sources. (6)

* U- and P-listed wastes are discarded commercial chemical products. (7,8)

Epinephrine is a P-listed waste, meaning that it is considered a highly toxic or acute hazardous waste. All P-listed wastes are wastes in which the sole active ingredient is the listed chemical. This is the only EPA waste type for which empty containers also must be treated as hazardous waste. If the P-listed chemical is not the sole active ingredient, then the chemical does not require special disposal. For example, in the medication lidocaine with epinephrine, both the lidocaine and the epinephrine have active purposes; therefore, epinephrine is not the sole active ingredient, and the substance is not regulated as hazardous waste. The rules apply to

* unused, discarded commercial chemical products (eg, outdated never-opened vials of epinephrine);

* off-specification chemicals (eg, epinephrine that contains impurities);

* container residue (eg, empty original containers, although the EPA has specifically exempted residues left in a syringe or other dispensing instrument (9)); and

* spill residues.

A multidisciplinary team should be formed to determine what types of epinephrine are present throughout the facility. This team may consist of representatives from surgery, nursing, anesthesia, pharmacy, and the department responsible for waste management. The team should

* list all products containing epinephrine that are used in the facility,

* determine whether epinephrine is the sole active ingredient in all the products on the list,

* label all epinephrine containers to indicate the need for special disposal,

* create policies and procedures to include lists of regulated hazardous wastes and directions for handling them, and

* provide required annual training for all health care workers regarding regulated hazardous wastes and proper handling of the wastes. (10)

Other hazardous wastes exist in the OR in addition to epinephrine. All chemicals in a facility, including medications, should be evaluated to determine whether they are characteristic or listed wastes. Disposal requirements may differ depending on the classification (ie, characteristic; F-, K-, U- or P-listed). A list of some of the more common items in the OR that may be hazardous and the reasons why they are considered hazardous waste are listed in Table 1.

Hazardous waste should be collected and consolidated into an approved leak-proof container labeled "hazardous waste." These containers should be inspected weekly for leakage. A licensed, hazardous-waste disposal company must be used to remove all hazardous wastes. For more information, see

* "Laws and regulations," Environmental Protection Agency, http://www.epa.gov/docs/epacfr40/chapt-I.info/;

* "Region 2 Compliance; Healthcare," Environmental Protection Agency, http://www.epa.gov/region02/healthcare/; and

* "Wastes," Environmental Protection Agency, http://www.epa.gov/epaoswer/osw/.

Specific state requirements for disposal of epinephrine may be more restrictive than the federal RCRA. Check with your state environmental protection division for any rule differences.

ERIC BRIESEMEISTER

MS

SAFETY MANAGER

UNIVERSITY OF TOWA HOSPITALS AND CLINICS, IOWA CITY

The author thanks Jim Pyrz, University of Iowa environmental programs manager, and Victoria Steelman, RN, PhD, CNOR, advanced practice nurse, at the University of Iowa Hospitals and Clinics, Iowa City for their time and assistance.

QUESTION: It was brought to my attention recently that a shellfish allergy does not have any true relationship to an iodine, povidone-iodine, or x-ray dye allergy. Is this information accurate?

ANSWER: Studies have shown that there is no evidence to support a link between shellfish allergies and an allergy to iodine, povidone-iodine, or x-ray dye. (11-13) A connection between a shellfish allergy and iodine products was assumed based on the iodine content in fish. (13) A person with a shellfish allergy actually reacts to tropomyosins (ie, proteins) in the fish and not to the iodine. (11,13)