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HAZARDOUS WASTE MANAGEMENT AT HEALTHCARE FACILITIES

*Dr. D. Shreedevi

*Associate Professor, Apollo Institute of Hospital Administration, Apollo Health City, Jubilee Hills,

Hyderabad – 500096. (M) 9441885258 (O) 040-23543269

e-mail dsridevi72@yahoo.com, dsridevi93@gmail.com

Abstract

Health care waste is a source of generation of hazardous biomedical waste. According to WHO Fact

Sheet, of the total waste generated by healthcare activities, about 80% is general waste. The remaining

20% is considered hazardous that may be infectious, toxic or radioactive. It is necessary to design proper

policies to avoid the spread of infection through waste and illegal reuse of the waste material. Policies

should provide specification for handling waste for generation, segregation, collection, storage,

transportation and treatment.

This study is conducted to compare the biomedical waste management policies of Apollo Hospital with

Delhi Pollution Control Committee (DPCC) guidelines. Policies of Environment Protection Agency (EPA)

of USA and National Health care Services (NHS) of UK were studied to perform comparative analysis of

global standard. A structured checklist was used to assess the accuracy of handling in compliance with

DPCC guidelines. The policies of the hospital are framed in compliance with the guidelines provided with

DPCC. Due to negligence and lack of supervision loopholes in the procedure was observed during the

stages of storage and transportation.

Key words: DPCC, EPA, health care waste, hazardous waste, NHS, WHO

Introduction

Biomedical waste management is an important aspect of any healthcare organization. With the increase in the consumption of utilities per bed, there is a tremendous rise in production of biomedical waste, disposal or further handling of which has gather concern of all. The biomedical waste is the waste that is generated during the diagnosis, treatment or immunization of human beings or animals or in research activities pertaining thereto, or in the production or testing of biological components. According to Bio-medical waste (Management and Handling) rules 1998, waste can be categorized into the following categories.

Waste categories Type of waste

Category 1 Human Anatomical Waste

Category 2 Animal Waste

Category 3 Microbiology and Biotechnology Waste

Category 4 Waste Sharps

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Category 5 Discarded Medicines and Cytotoxic drugs

Category 6 Solid Waste

Category 7 Solid Waste from disposable items

Category 8 Liquid Waste

Category 9 Incineration Ash

Category 10 Chemical Waste

Source: Delhi Pollution Control Committee guidelines

Objectives of the Study

To study the management of hazardous waste in healthcare facilities

To know the biomedical waste management procedure of global standards viz. UK and USA

To compare and analyze the shortcomings in the waste management procedure of Apollo Hospital in comparison to above mentioned standards.

Methodology

The initial part of the study involved observation of the process flow and functioning of various departments of the hospitals. A structured checklist was used to assess the accuracy of handling in compliance with DPCC guidelines. The hospital was divided into floors and floors were further divided into towers. Following this division the data was collected by observing each set of bins and taking personal interview of people associated with waste handling procedure. Policies formulated by DPCC, UK and USA were also studied. Two separate checklists were prepared by keeping in mind the guidelines of DPCC and global standards. Data was collected by observation of all the areas associated with storage, transportation and treatment of the waste. Housekeeping staff were interviewed for procedure related information. The study was done by taking both primary and secondary data.

Sources of waste generation

The sources of health-care waste can be classified as major or minor according to the quantities produced.

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Hazardous Waste Related to Bio Medical Waste

Healthcare waste includes a large component of general waste and smaller proportion of hazardous waste. Exposure to hazardous healthcare waste can result in disease or injury. The hazardous nature of healthcare waste may be due to one or more of the following characteristics:

it contains infectious agent;

it is genotoxic;

it contains toxic or hazardous chemical or pharmaceuticals;

it is radioactive;

it contains sharps;

All individual exposed to hazardous healthcare waste are potentially at risk, including those within healthcare establishments that generate hazardous waste and those outside these sources who either handle such waste or are exposed to it as consequence of careless management.

Management of Biomedical Waste: Biomedical waste management is including four major steps. These steps help in achieving effective waste management only when followed accurately and routinely. The steps are as follows.

Generation of Biomedical Waste:

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Medical activities generate waste that should always be discarded at the point of use by the person who used the item. The quantity of HCW generated should always be minimized and precautions must be taken during their handling.

1. Environment Protection Agency (United States of America)

Medical Waste Tracking Act 1988 requires U.S. Environment Protection Agency to formulate policies and find alternative means for disposal of biomedical Waste. A lot of emphasis is given to public education regarding waste disposal and waste minimization. The policies can be categorized in following manner:

1. Waste Categorization: Proper waste categorization avoids cross contamination of general waste from infectious

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or hazardous waste. It helps in providing effective treatment to a better categorized waste. 2. Generation: Types of generators are: Hospitals, Intermediate care facilities, Clinics, Physician Offices, Dental Offices, Laboratories, Funeral Home, Veterinarian, Blood banks, Animal Care, Emergency Care, Hospices, Home Healthcare, Illicit Drug users. All these areas are concerned as potential biomedical waste generators and are supposed to follow the guidelines formulated by EPA. A lot of stress is given on waste minimization which helps in reducing the cost of material used per bed and treatment cost of waste is also reduced. Collection, Handling and Storage to be done by trained waste handlers. Containers should have bio-hazards signs. Bins should be non-corrosive and bags should be heavy plastic material. Storage area should be durable and easily cleansable. It should be protected from wind, rain, vermin & vector and should be maintain in odorless state. Floor should be impermeable to liquid with perimeter curve.

3. Transportation: Trollies and vehicle used for outside transport should be designed to facilitate least damage to structural integrity of waste. Waste should be transported only through the designed route. The waste handlers should use protection equipments. Procedures to be undertaken in case of fire should be well designed. (Out-house transportation). Proper documentation of the type and quantity of waste being transported should be maintained. Authorized personnel should only be allowed for transportation to avoid illegal reuse of needles and other kind of waste.

4. Treatment, Destruction and Disposal:

S.No. Type of Waste Treatment Procedure

1. Sharps

2. Culture and Stock Steam sterilisation or incineration or thermal/chemical deactivation

3. Blood & blood products Discharge to sanitary sewer system or approved septic system.

4. Pathological Stream sterilisation or incineration or thermal/chemical deactivation.

5. Isolation waste Steam sterilisation or incineration.

6. Animal Waste Incineration

7. Unused Sharps Sealed in hard-to-open container then chemical disinfection or steam sterilization or incineration.

8. Low level radioactive substance

Chemical decontamination. Never steam sterilize

9. Antineoplastic waste Chemical decontamination and never steam sterilize.

10. Small Volume of Chemical hazardous Waste

Same as above.

2. National Health Care Services (United Kingdom)

1. Healthcare Waste Generation: Healthcare waste is generated during the course of patient treatment.

Waste generated from treatment processes may be clinical, hazardous or household at the final point of

disposal. Hazardous waste is any waste that displays one or more of hazardous properties H1-14 set out

in the Hazardous Waste (England and Wales) Regulations, 2005.

2. Segregation

To comply with the Duty of Care requirements, different types of controlled waste (some of

which may also be hazardous) need to be kept separate (not mixed) and may also require specialized

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containment in order to reduce contamination potential.

3. Containment

Containment of all wastes must be appropriate to the level of risk. Wastes considered dangerous

for transport on the road e.g. some clinical and hazardous wastes, require UN (United Nations) approved

packaging and containment. Each waste type affected by this legislation is also assigned an individual

UN number, e.g. most clinical waste is classified as UN3291. This code is displayed on all UN approved

packaging designed to contain clinical waste – bags, boxes. Sharps bins must display the British

Standard kite mark and the code BS 7230

4. Decontamination

Aims to prevent or minimize exposure to potentially hazardous substances or pathogens from

bodily fluids, cultures etc. by cleaning equipment using a disinfecting or sterilising agent suitable to the

level of risk. This procedure must be undertaken for reusable equipment prior to being sent for repair to

Biomedical Engineering.

Completion of a decontamination/decommissioning certificate once cleaning has been

undertaken informs staff that the equipment they are removing is free from contamination and therefore

safe for handling or disposal. A completed decontamination / decommissioning certificate must be

attached to the equipment prior to removal for repair or disposal

5. Decommissioning

Decommissioning of equipment is removal from use. The equipment may be broken, obsolete or

due for replacement. Decommissioned equipment needs to be made safe prior to disposal.

6. Collection and Transport

All clinical and household waste left in disposal areas will be removed from all internal

departments at least daily as a minimum requirement. Where appropriate wheelie bins are supplied to

contain waste in disposal areas. Portering or support staff removes waste from internal disposal areas to

external storage. Service staffs remove bins from external units to the waste compound. All clinical waste

must be bagged or placed in a rigid container before placing into Euro type /wheelie bin.

7. Storage of Clinical Waste awaiting collection

Containers must be kept secure from unauthorized persons, entry by animals and free from

infestation by rodents and insects while on site. Clinical waste bins must be kept locked at all times.

Clinical waste stores must be kept locked when unattended or outside normal working hours in order to

prevent escape of waste.

Gap Analysis: It is the comparison between the Current Practices of Apollo Hospitals and Guidelines recommended by Delhi Pollution Control Committee. For this analysis, the guidelines were divided into four categories:

1. Basic Requirement 2. Generation & Segregation 3. Collection & Storage 4. Transportation 5. Treatment

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ANALYTICAL COMPARISON WITH GLOBAL STANDARDS

1. Generation and Segregation

EPA NHS DPCC Apollo

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1. Segregated broadly on basis of solid, liquid & sharps.

1. Segregation at point of generation.

1. Segregation at the point of generation.

1. Segregation at point of generation.

2. Segregated according to treatment method.

2. Segregation based on method of treatment.

2. Segregation according to treatment method.

2. Colour coding as directed by DPCC.

3. No colour coding followed. 3. Six colour coded bins for

effective segregation.

3. Four colour coded bins

for effective segregation.

3. Separate container for

needles, blades, scalpel,

etc.

4. Classified under 10 heads on

basis of infectivity & toxicity.

4. Sharps should be

immediately disposed after

use.

4. Sharps to be disposed in

Sharps bin puncture proof

white container.

2. Collection

EPA NHS DPCC Apollo

1. To be done by trained waste

handlers.

1. Waste handlers

should use PPE.

1. Use of PPE by waste

handler.

1. Waste handler use PPE.

2. Regular disinfection of trolleys

& restrict the use of trolleys for

waste handling only.

2. Waste should be filled

only up to 3/4th of the

bag.

2. Seal the bags by cable

before transferring to central

storage.

2. Bags sealed with cable.

3. Containers should have bio-

hazards signs

3. Latex/Nitrile gloves

used for handling sharps.

3. Bio-hazard sign should

be displayed on every bin

3. Biohazard sign displayed on

the bins.

4. Bins should be non-corrosive

& bags should be heavy plastic

material.

4. Heavy & Medium duty

plastic bags should be

used.

5. If bags get contaminated from

outside cover it with fresh bag

before transporting.

6. Place antineoplastic drug

waste in bag on 4-mil

polyethylene or 2-mil thick

polypropylene

3. Storage

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EPS NHS DPCC Apollo

1. Storage area should be

durable & easily cleansable

1. Waste should be

stored secure from

unauthorized person.

1. The bins should not be

allowed to fill more than

3/4th.

1. Waste should not be stored for

more than 48 hrs.

2. It should be protected from

wind, rain, vermin & vector and

should be maintain in odourless

state.

2. It should be secured

from rain water, animals &

wind.

2. No entry for

unauthorized persons in

storage area.

2. Bags should not be allowed to

fill more than 3/4th of the bag.

3. Floor should be impermeable

to liquid with perimeter curve.

3. Central storage should

be spacious enough to

store different waste

separately.

3. The containers should

have lid to cover the waste

in the storage.

3. Common room to store all

types of waste in central storage.

4. Provide storage area with

proper ventilator.

4. Designed by special

team in accordance with

the requirement.

4. Waste should not be

stored for more than 48

hrs.

5. It should have access to only

authorized personnel & should

have bio-hazard sign displayed.

5. Bins should be

disinfected regularly.

4. Transportation

EPA NHS DPCC Apollo

1. Trolleys and vehicle used for

outside transport should be

designed to facilitate least

damage to structural integrity of

waste.

1. Wheelie bins should be

used for convenient

transportation.

1. Colour coded trolleys to

be used to transport the

waste.

1. Wheelie bins used to

transfer the waste.

2. The waste handlers should

use protection equipments.

2. Specific route should be

designed for in-house

transportation

2. Waste should be

transported via designated

route only.

2. Only 2 different colour

trolleys used to transport the

waste.

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3. Procedures to be undertaken

in case of fire should be well

designed. (Out-house

transportation)

3. Before out-house

transportation all the

documentation should be

done.

3. Waste should not cross

public areas.

3. Labelling is done before

carrying it to central storage.

4. Label on the waste

should contain all the

details.

4. Closed lid trolleys used to

transport.

5. The waste should not

come in contact with outer

environment while

transporting.

5. Before handing the waste

to vendors proper

documentation is done.

5. Treatment

EPA NHS DPCC Apollo

1. Sharps: 1. Anatomical Waste:

Incineration.

Refer Table 1. Sharps: Autoclaved then

shredded & sent for landfills.

2. Culture & stock: Steam sterilization or

incineration or thermal/chemical

deactivation.

2. Radioactive Waste:

Incineration.

2. General Waste: Handed over to

municipal corporation for further

disposal.

3. Blood & blood products: Discharge to

sanitary sewer system or approved septic

system.

3. Cytotoxic Waste:

Incineration.

3. All other waste is handed over to

vendors as authorized by the

DPCC.

4. Pathological: Stream sterilization or

incineration or thermal/chemical

deactivation.

4. Confidential waste:

Shredding and landfill.

5. Isolation waste: Steam sterilization or

incineration.

6. Animal Waste: Incineration

7. Unused Sharps: sealed in hard-to-open

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Comparison with global standards infers inclusion of few more aspects like:

There can be policies regarding handling of solid and liquid waste separately.

There can be policies referring to handling of broken glasses & metallic sharps.

Policy can be made specifying the type of plastic bags used for waste storage.

Design specification of central storage area can be included in policy framework.

In case of fire, flood or other such emergency, method of handling biomedical waste can be specified in the policy.

Specific route can be designed and included in policy.

Conclusion

To conclude, the policy framework of the hospital is found to be appropriate in most of the aspects.

Gap analysis performed between the current practices and DPCC guidelines reveals that staff was

found to be aware of the correct means and methods of dealing with biomedical waste. However,

housekeeping staff was found to be unaware of waste transportation route. Central Storage area was

found to be very poorly organized. Strict supervision should be done to check on segregation

practices. Separate body of supervision can be framed who can supervise the disposal station every

now and then.

References

1. Bekir Onursal, “Health Care Waste Management in India” - The World Bank October, 2003. 2. Best Management Practices for Hospital Waste, Washington State Department of Ecology,

December, 2005. 3. Bio-Medical Waste (Management and Handling) Rules, 1998. 4. Central Pollution Control Board Manual 5. Delhi Pollution Control Committee manual 6. Environment Protection Agency (USA): Model guidelines for State Medical Waste Management 7. Hazardous Waste Management at Health Care Facilities – NCDENR – Division of Waste

Management.

container then chemical disinfection or

steam sterilization or incineration.

8. Low level radioactive substance:

Chemical decontamination. Never steam

sterilize

9. Antineoplastic waste: Chemical

decontamination and never steam sterilize.

10. Small Volume of Chemical hazardous

Waste: Same as above.

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8. Hema Chandra, Hospital Waste – An Environmental Hazard and its Management. ISEB Vol. 5. No.3 – July 1999.

9. National Health Services (UK): Waste Policy and Procedure. 10. Patil AD, Shekdar AV (2001), “Health care waste Management in India, pubmed 11. “Safe Management of Wastes from Health Care Activities”- WHO, Geneva, 1999. 12. World Health Organization: http://www.healthcarewaste.org