Bio-Hazard Waste Holding Room

Q: Our facility has a soiled utility room near the main laundry that also holds bagged, sealed, boxed, then sealed again bio-hazardous wasted awaiting removal by the contractor. Is this room required to have a dedicated air exhaust ventilation system to the outside of the building?

A: Yes… I believe it is required to have a dedicated air exhaust system to the outdoors. This is a requirement based on multiple entities. According to the FGI Guidelines, a soiled holing room is required to have the following:

  • Negative air pressure
  • 2 ACH minimum for outside air
  • 10 ACH minimum total
  • Room must exhaust directly to outdoors
  • No room unit ventilator air recirculation

In addition, according to the OSHA Bloodborne Pathogen standard 1910.1030(e)(4), if the storage area is also a HIV and HBV production area, then the room is required to have a dedicated exhaust system. So, it appears to me that the room is required to have a system that exhausts the air directly to the outdoors.

Waste Containers

Q: The 2012 Life Safety Code allows for 96 gallon containers outside a hazardous area for clean waste.  Unfortunately, our vendor that handles recycling does not have a 96 gallon container that meets the fire rating to take advantage of the LSC specifications (FM Approval 6921 labeling).  Hence, how many 32 gallon containers can be stored in an area and is there a requirement to space them apart?

A: The Life Safety Code does address this issue. The 2012 LSC, section limits soiled linen and trash containers to 32 gallons capacity. Mobile containers that exceed 32 gallon capacity are required to be stored in a room designed as a hazardous area when not attended. An aggregate of containers with a total accumulated capacity of 32 gallons must not exceed a 64 square foot area. So, technically, you could have many 32 gallon containers as long as they are in their own 64 square foot area.

Section of the 2012 LSC has the additional provision of allowing the 96 gallon container used for recycling clean waste and patient records waiting destruction are excluded from the conditions in provided the container does not exceed 96 gallons capacity and are labeled and listed as meeting the requirements of FM Approval standard 6921. If your container does not meet the FM Approval standard 6921 (or comparable listing) then you do not qualify for section You would then have to follow section

Containers Used for Patient Records Awaiting Destruction

Q: Are bins holding patient records waiting to be shredded required to have a FM fire rating in a hospital?

 A: Yes. Section of the 2012 edition of the Life Safety Code says containers used solely for recycling clean waste or for patient records awaiting destruction shall be permitted to be excluded from having to be stored in a hazardous room, provided all of the following are met:

  • Each container is limited to 96 gallons capacity, or they must be located in a room designated as a hazardous area;
  • Container size shall not be limited in hazardous areas;
  • Containers for combustibles shall be labeled and listed as meeting the requirements of FM Approval Standard 6921, or other approved listing agencies.

So, to answer your question… Yes; According to the 2012 edition of the LSC, containers used for patient records waiting to be destroyed are required to meet FM Approval Standard 6921; however, other trash containers used for purposes other than recycling clean waste and/or patient records awaiting destruction are not required to meet the FM Approval Standard 6921.

FM Approval on Waste Containers

Q: In the fine print of the new 2012 Life Safety Code, under sections 18/ for containers used solely for recycling clean waste or for patient medical records awaiting destruction, the following is noted:

(4) Containers for combustibles shall be labeled and listed as meeting the requirements of FM Approval Standard 6921, Containers for Combustible Waste; however, such testing, listing, and labeling shall not be limited to FM Approvals.

My question is: Does this in reality become a hard burden to prove? Are other hospital facility managers unwilling to utilize the CMS waiver for this for fear that they will have difficulty proving compliance?

A: I have not heard of any facility manager not using the CMS categorical waiver based on the reluctance to be able to prove that the containers meet the requirements listed. It is a real possibility, but I can’t say I am aware of anyone with this concern.

It sounds like you must have checked your own containers to see if they comply with this FM Approval listing requirement. If so, I assume you found some that did not meet the requirements. I do know that some manufacturers do meet this requirement and therefore there are containers out there for clean recyclables and patient records waiting for shredding that do meet this requirement.

I would suggest you make it a condition with the shredding company to provide FM Approval listed containers if they continue to want your business.