Proper disposal in the SICU

Trauma Columnist · Jul 13, 2013

PEritoneal dialysis fluid can be disposed of in the toilet. It is considered waste products and can be disposed of in the toilet or in a hopper. Not usually in a sink.

jennycRN · Jul 13, 2013

Good questions! If you have a good relationship with your preceptor, you can ask her the rationale for these actions. You have questions and want to learn, the conversation doesn't need to be confrontational. The hospital likely has policies which apply to these practices, and a little research might inform you whether her practices are in line with hospital policy.

For example, propofol is not a controlled substance. So we don't 'waste' partially filled bottles. Since they are glass, I throw them, along with the tubing into the sharps bin, where in theory they aren't much at risk of being diverted.

My experience disposing of effluent is limited to peritoneal fluid and I have heard arguments for both the biohazard bin and the dirty utility sink. One educator told me it is similar in nature to urine and can be disposed of as urine would be. I don't know how potentially infectious it could be.

If you waste a controlled substance like fentanyl, it should be disposed of on the spot. Some nurses do carry the rest 'just in case' but this has the potential to create a discrepancy if the number of vials withdrawn doesn't match the number of doses given (our pharmacy audits this). In the interest of protecting my license, I wouldn't want to do anything that could give anyone reason to suspect I was diverting narcotics.

Just my perspective, hope it is helpful! Good luck!

Altra, BSN, RN · Jul 13, 2013

Any measurable volume of liquid should not go into the garbage - regardless of the color bag. That is just asking for liquid to splash the next time something is tossed, or the bag to break during transfer/cleaning. Please, please treat your environmental services team with courtesy and do not do this. Institutional garbage removal is also priced by weight -- still think that you should be tossing liquids into the trash?

Propofol is not controlled, nor "highly abused". You probably remember one high profile case -- an anomaly.

And while your hospital's policies regarding waste procedures should be followed to the letter by all staff ... yes, there is indeed a Fentanyl shortage.

Dodongo, APRN, NP · Jul 13, 2013

The ultrafiltrate line from our CRRT goes into the sink or toilet. Just like urine or feces (if you have a flexiseal/rectal trumpet). Diprivan isn't a controlled substance in the same way benzos or narcs are. It does not need to be wasted. I do put it in a large sharps container because it is a glass vial. As for the fentanyl scenario, that is very suspect. I would say something to her. Do it in a respectful way, but that is a big concern for me.

MunoRN, RN · Jul 13, 2013

Although it's been proposed, propofol is not a scheduled narcotic according to the DEA (state health departments may differ), so it's not typically wasted with a witness.

Affluent drainage bags are essentially urine, and the toilet is the preferred disposal route for urine as well as other forms of human waste such as feces. Blood products and other tissues go in a biohazard bag.

The fentanyl is based on facility protocols. The DEA, FDA, ISMP, etc, all suggest that it's acceptable to save "extra" medication for subsequent use so long as it is labelled properly, facility policies may limit this, but many facility policies approve of drawing up an entire vial and giving it in divided doses so long as the med is appropriately labelled, handled, and stored.

Biffbradford · Jul 13, 2013

^^ Agree.

As far as the Fentanyl, I think if you go back and officially 'waste' the Fentanyl, you get it co-signed and then just throw it away. Be it a partial ampule or an IV bag. I normally would draw up the whole ampule into a syringe and save the rest in case that same patient needed more later. At the end of the shift, I would then either officially waste it out right, or save it for the next nurse (usually asking "do you want it or should I waste it?"). It depends on who was following me. Sometimes it's simpler to just waste it and be done with it, get home faster!

JonM_RN · Jul 13, 2013

1. Dialysis effluent is not red bin waste and can safely be disposed of in the sink and/or toilet. Red bin waste typically applies to only grossly bloody items that theoretically if you were to hold in your hand and squeeze and blood drips out, then it can go in the red bin.

2. Propofol is neither a controlled substance nor highly abused. You are thinking of the late Michael Jackson's death. Remember, his cardiologist purchased the drug to administer to him. You cannot get it outside of a hospital, and it is not a narcotic. There is nothing addictive about it, you can't get high off it it.

3. Here's where your preceptor is wrong. The amount of Fentanyl dose ordered should have been drawn up and administered with the remainder properly wasted at the time the medication was first drawn up. Although what your preceptor did is practiced among some nurses, it is not only a bad habit, but unethical. Many nurses do this because they feel bad wasting half or more of a vial of drug, but all that aside your are still carrying around medication in your pocket that you previously documented as a wasted product.

rort · Jul 14, 2013

Thank you everyone for your replies. I really appreciate it. I think, as a student, I am overly cautious. I prefer the thought of disposing of the effluent waste in a toilet rather than the sink where we wash our hands, but it sounds like either way is fine. I like the idea of putting the propofol in the sharps container since it is glass, but it's good to be assured that the regular garbage is fine. Finally, I do see that as of 7/3, there is a Fentanyl shortage, but I should note the Fentanyl incidence happened mid June, when there was not, so that was no reason to hold onto the extra drug. It still seems improper to me to carry it around. I appreciate feedback from all of you experienced ICU nurses. Thank you!

MunoRN, RN · Jul 14, 2013

3. Here's where your preceptor is wrong. The amount of Fentanyl dose ordered should have been drawn up and administered with the remainder properly wasted at the time the medication was first drawn up. Although what your preceptor did is practiced among some nurses, it is not only a bad habit, but unethical. Many nurses do this because they feel bad wasting half or more of a vial of drug, but all that aside your are still carrying around medication in your pocket that you previously documented as a wasted product.

I think you're over-generalizing there a bit. I'm not sure where you got the idea that a Nurse with remaining fentanyl has already been "previously documented as a wasted product", but I'm guessing it comes from how many Pyxis dispensers are set up. A facility can chose to require that any amount of medication beyond a single dose be wasted in the same log-in as it is pulled, which usually produces the "dose= x amount, do you plan on administering xx amount?" If you answer that you plan on giving less and that you are going to waste the rest (which requires a witness long-in anyway, then you are correct, carrying the supposedly wasted drug around is bad practice.

Not all facilities follow that method however, mine actually requires that you save the extra medication, this is specifically to deter drug diversion (you can divert much more using the practice of "wasting" 75 mcg of fentanyl out of every 100mcg vial). It should be properly handled (not carried around in a pocket) and properly stored (we use locked medication storage in every room), but to say it's unethical as a general rule is incorrect, it totally depends on your facility policies.

JonM_RN · Jul 14, 2013

My apologizes for not being specific. At my facility, the first scenario you described is how we practice, and actually, I work at two different hospitals and they both practice controlled waste disposal this way. When withdrawing medication from the pyxis and the dose is less than what is in the dispensed vial, a witness is required at the time of withdrawal from the pyxis with an amount to be given and an amount to be wasted documented at the time of removal from pyxis. So yes, if someone continues to carry around medication that they just documented as "wasted" then it is unethical. However I was not taking into account other methods, such as the one described at your facility. My mistake for generalizing.

BellionRN · Jul 14, 2013

I have to agree with most of the replies!

When I worked in MSICU, the fluid from dialysis was actually filtered right into the sink by the dialysis nurses (the hose was put directly in the sink) and afterward it was just asked of us to run ample amounts of water through the drain to dilute and rinse the sink. I figure it's all sterile, so what's the harm in washing my hands there after? :)

Propofol as was mentioned isn't controlled, so I always chuck it in the sharps :) much of the time we go through so much in 12 hours that I only change the tubing because the med itself is almost or practically new!

I always draw up my entire syringe for narcotics, etc., label it for the patient, the concentration and the drug and put it on my desk for later. The amount of drugs I have to push and sometimes the rapidity in which I need to sedate the patient is too much to have to run to the Pyxis, ask a nurse to discard, draw up and administer. If I'm drawing up morph and versed for my patient, I have 10mg/10ml (so 1:1) syringes for each and I almost never have any left over. Also, if you're going off the unit for something (Anglo, CT, Scope), it's necessary to have drugs "just in case".

I've only been out a little over 2 years, I still remember some of the things that horrified me initially!