Assessment of medical wastes management protocolsin Jordanian healthcare institutions

Thakir D. AlMomani*

Department of Biomedical Engineering,College of Engineering, The Hashemite University,3036 Engineering Building, Zarqa 13115, Jordan*Corresponding author

Loay A. Al-Zube

Department of Biomedical Engineering,College of Engineering, The Hashemite University,3032 Engineering Building, Zarqa 13115, JordanE-mail: alzube@hu.edu.jo

Osama M. Al-Bataineh

Department of Biomedical Engineering,College of Engineering, The Hashemite University,3033 Engineering Building, Zarqa 13115, JordanE-mail: omabio@hu.edu.jo

Abstract: Successful and effective medical waste management strategyrequires adopting clear and distinct protocols that will guarantee the

appropriate and correct execution of this strategy. This study presentsthe results of a survey that has been conducted among the nursing staffworking in different Jordanian hospitals in the northern, middle and

southern parts of Jordan. The survey contained questions about medicalwaste administrative procedures and collection protocols. The resultsshowed that the southern part of Jordan has the least proper way of

administrative procedures and collection protocols of medical waste.However, other parts still need more attention to reach safe handling andtreatment of medical wastes.

Keywords: Jordan; medical waste; management; collection.

Reference to this paper should be made as follows: AlMomani, T.D., Al-Zube, L.A. and Al-Bataineh, O.M. (2013) ‘Assessment of medical wastesmanagement protocols in Jordanian healthcare institutions’, Int. J.

Environment and Waste Management, Vol. 11, No. 3, pp.323–334.

Biographical notes: Dr. Thakir AlMomani had received Ph.D. degree inBiomedical engineering from the University of Iowa in 2007. He is

currently an Assistant Professor in the Biomedical EngineeringDepartment at the Hashemite University (Jordan). His research focuseson bio-fluids, biomechanics, and medical waste management. He

published many articles in micro-scale modeling of RBC / platelet

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Int. J. Environment and Waste Management, Vol. 11, No. 3, 2013

interaction. Beside his focus on mechanical interaction of blood cells, Dr.AlMomani has studied medical waste management in Jordan. Heparticipated in many local, regional, and international conferences to

share ideas with other scientists in his field around the world.

Dr. Loay Al-Zube received his PhD from the University of Medicine andDentistry of New Jersey. He is currently an assistant professor at the

Hashemite University in JORDAN. Dr. Al-Zube has contributed greatlyto the understanding of impaired bone healing in the presence ofDiabetes Miletus. He is involved in the development of local drug

delivery systems for specific growth factors and cytokines important forosseous repair. Dr. Al-Zube has published several journal articles. Hispublications reflect his research interests in osseous repair, biostatistics,and medical wastes. He is also the founder and president of the

Jordanian Biomedical Engineering Society.

Dr. Osama Al-Bataineh had received Ph.D. degree in Bioengineering fromthe Pennsylvania State University in 2005. He is currently an Assistant

Professor in the Biomedical Engineering Department at the HashemiteUniversity (Jordan). His research focuses on therapeutic applications ofultrasound transducers and medical wastes. He published many articles

in ultrasound induced hyperthermia and tissue ablation for noninvasivecancer treatments. Beside to that, Dr. Al-Bataineh has participated inwriting book chapter in the area of medical waste management. Heparticipated in many local, regional, and international conferences to

share ideas with other scientists in his field around the world.

1 Introduction

Owing to medical wastes potential environmental hazard and public health risks, itsmanagement has gained great importance worldwide (Dehghani et al., 2008). Medicalwastes were often mixed with municipal wastes and disposed inappropriately indomestic waste landfills (Dehghani et al., 2008). In 1999, the World HealthOrganization (WHO) announced that health wastes should be handled anddisposed separately from municipal wastes. As WHO recommended, medical wasteswere categorised into: high infectious pathological and anatomical wastes, sharps,chemical and pharmaceutical wastes, radioactive wastes, wastes with high contentof heavy metals and general healthcare wastes.

Infectious medical wastes can spread diseases to healthy subjects owing tocontamination with blood or body fluids from sick patients. As an example, grimyneedles and other sharps cause injury as well as disease spreading. Dangerouschemical wastes are poisonous to water supplies, soil and air. Because of previousrisks, proper handling of medical wastes is essential to provide protection to publichealth and environment. Consequently, good medical waste management systemshould include designation of waste handling, emergency plans and staff training.Fully implemented and documented medical waste management is essential foreffective results. The whole system should be managed by professional person whoenforces the provisions of the management plan. As part of successful plan,

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medical wastes should be separated from other domestic wastes to ensure the propertreatment and handling to protect public health and environment and at the sametime reduce the cost of handling and processing.

Many recent studies had been performed worldwide to assess and evaluate medicalwaste management protocols and its environmental impact. Dehghani et al. (2008)had performed a study that aimed to characterise solid wastes generated indifferent Iranian healthcare facilities. The study concluded that Iran healthcarefacilities had no clear or efficient rules and regulations regarding the treatment andhandling of medical wastes. In Brazil, Vieira et al. (2009) also showed that therewas a deficiency in medical waste treatment and disposal in Brazilian healthinstitutions participated in the study. Furthermore, Bendjoudi et al. (2009)indicated that hospitals in Algeria were not following the proper protocols ofmedical waste management. The outputs of incinerators were higher than theinternational standard, which might have a direct effect on the neighbouringresidents of the incinerators. Similar results and conclusions were found in aLibyan (Sawalem et al., 2009) and China’s studies (Young et al., 2009).

Jordan, as most of the developing countries, is facing a serious challenge in thesubject of medical waste management in its healthcare institutions. In October 2001,the Jordan Minister of Health (MOH) issued a new version of medical wastemanagement regulations that aim to regulate medical waste administrativeprocedures and disposal protocols. These regulations involved the following maincriteria: the definition of the medical wastes, the administrative procedures of medicalwaste inside the healthcare facility, the domain that produces medical wastes,segregation, collection and transportation, storing and disposal of medical wastes.

According to these regulations, different healthcare facilities should follow a clearand distinct process of medical waste disposal that guarantees the least possiblehazardous effects of medical waste on both humans and environment. However,recent studies that had been accomplished to assess medical wastes management inJordan had all agreed that there was a lack in the process of handling and disposingof medical wastes in different regions of Jordan. Furthermore, all of these studieswere accomplished in either the northern or the middle part of Jordan; few of themhave studied the medical wastes in the southern part of Jordan (Abdulla et al., 2008).

In Jordan, public healthcare facilities are considered the largest producers ofmedical wastes compared with private healthcare facilities. According to theMOH’s latest annual report (2008), Jordan can be divided into three main parts,the northern, middle (that includes Amman city) and the southern part. Theseparts include 30 public hospitals and 1427 public medical centres directed byMOH. These facilities produce about 3350 kg of medical wastes yearly (MOH,2008). MOH has signed an agreement with King Abdallah University Hospital(KAUH) (located in the Jordan University of Science and Technology (JUST)campus) to dispose medical wastes produced from public healthcare facilities ofnorthern regions of Jordan (Irbid, Jerash, Mafraq and Ajloun cities). KAUH hastwo working incinerators with a daily capacity of 5.5 tons. A new loan from theSwedish government was issued to build a third incinerator in KAUH and tomaintain the working ones to provide the least possible pollution to theenvironment (MOH, 2008). The middle regions of Jordan (Amman, Zarqa,AlBalqa and Madaba cities) have 13 hospitals and 541 medical centres. Some ofthese hospitals have their own impaired incinerators that lead to improper disposal

Assessment of medical wastes management protocols 325

of large quantities of medical wastes (MOH, 2008). The southern parts of Jordan(AlKarak, AlTafilah, Ma’an and Alaqaba cities) have only four public hospitalsand 310 public medical centres. Medical waste disposal in this part suffers frominefficient incineration owing to technical problems to local incineration facilities,such as the lack of maintenance and the smaller capacity incinerators comparedwith produced wastes. Moreover, the transportation to incineration facilities inmiddle and northern regions is costly. MOH has put forward many suggestionsand plans to apply most updated techniques and standards for safe handling anddisposal of medical wastes depending on previous deficiencies in the wholeJordanian public medical waste management system.

Previous researchers tried to report and to address sporadic information regardingmedical waste management system among Jordanian healthcare sectors. Table 1summarises published articles since 1988. Articles are arranged depending on thetargeted region of the study. The attention was focused on the northern region ofJordan and partially to Amman city’s hospitals. Different aspects of managementissues of medical wastes were addressed including handling, disposing andgenerated amounts. Generated wastes were estimated from 0.5 to 2.5 kg=bed=dayfor northern hospitals whereas in Amman hospitals the reported quantity was3.4 kg=bed=day. Handling of medical wastes showed inadequate management in thenorthern hospitals. Inefficient disposal of liquid and solid wastes was reported inboth northern hospitals and Amman city hospitals as well. Depending on reportedarticles, more information is required to address the management of medical wastesin distanced regions away from the capital of Jordan. It seems that northern regionhas benefited from the JUST active researchers in Ramtha city owing to shortdistance from the university to most hospitals in the region. However, southernand middle regions of Jordan require more attention from researchers concerningmedical waste practices and management.

The analysis presented in this project aimed to investigate knowledge andimplementation of the primary stages of medical waste management in Jordanianhealthcare facilities. It is hypothesised that these stages are well defined and explainedto the nursing staff, whom they are in direct contact with patients and medical

Table 1 Published articles that address medical waste issues in Jordan

Research Target Conclusion

JES 1999 All hospitals . 32% of hospitals use incineration for disposal

Alnatsheh et al. 2004 Public hospitals . Generation: 3500 kg=day (public) 1700 kg=day(private)

Qusous 1988 Amman . Generation: 3.4 kg=bed=dayOweis et al. 2005 Amman hospitals . Disposal of medical waste is not optimal

Obeidat et al. 1994 Northern region . Generation: 0.776 kg=bed=dayAbu Qdais et al. 2007 Northern region . Insufficient segregation in some hospitalsBdour et al. 2007 Northern region . Inadequate handling and disposing

Abdulla et al. 2008 Northern region . Inefficient incinerators. Inefficient liquid disposal. Generation: 0.5–2.5 kg=bed=day(90% infectious waste)

326 T.D. AlMomani et al.

wastes. Any deficiency or misunderstanding of these rules and regulations is expected tocause major challenges such as the spread of infectious diseases among patients andhazard materials into the environment. Furthermore, it is hypothesised that there willbe no major differences in the staff responses among the participated hospitals. Byselecting the nursing staff, this study aimed to:

i) inspect the degree of awareness (by asking questions that are related to theadministrative procedures aspects) among the people who are supposed to behighly qualified and in direct touch with patients, devices, medication and wastes.

ii) The observations of those people about the first stage (i.e., the collection stage)of waste handling.

2 Materials and method

2.1 The survey (the questionnaire)

This study involves a questionnaire that has been prepared by the investigatorswith careful attentions to the medical waste management regulations issued by theMOH in 2001. The questionnaire consisted of two parts (Tables 2 and 3), the first part

Table 2 Investigating the knowledge and implementation of the general medical wasteadministrative procedures

No. Question

1 Medical wastes are very important to fulfil your duties2 Your department has signs that warn you about the dangerous of the medical wastes3 In the case of emergency, your department has a clear plan for medical waste pollution

4 Training and lectures are periodically held to point out the importance of medical wastes5 There is specific temporal programme for medical waste removal6 Each medical waste container has a label that includes all information about the content of

this container7 There is an immunisation record for the medical staff and employees8 There is special record for injuries that are related to medical wastes9 There is a daily record that shows the types and quantities of medical wastes

Table 3 Investigating the knowledge and implementation of the medical waste collectionprotocols

No. Question

1 In your department, medical wastes are treated in the right way2 The person, who takes the medical wastes away from your department, is a qualified

person who wears special dress

3 Medical wastes are classified and separated in their bags according to colours andcapacities

4 Specified collecting tools and bags are always available in your department5 The transporting containers are cleaned every day

6 Special storages are available for the medical wastes, so they are completely separatedfrom other wastes

Assessment of medical wastes management protocols 327

was designed to investigate the knowledge and implementation of the general medicalwaste administrative procedures. The second part intended to investigate theknowledge and implementation of the medical waste collection protocols. Thequestionnaire was given to a representative sample of nursing staff in different hospitalsfrom northern, middle and southern parts of Jordan. The questionnaire was written inboth Arabic and English, however it was presented to the participants in Arabic.

Different hospitals had been selected in this study; these hospitals were consideredas a representative sample for the Jordanian healthcare facilities. Hospitals inNorthern, middle and southern parts of Jordan were selected. Most of the previousstudies that were accomplished in Jordan to date were performed whether inAmman, the middle, or the northern parts of Jordan. And, few of them wereconducted in the southern part of Jordan. AlKarak hospital is considered as agood representative of southern-part hospitals. It is located in AlKarak city with apopulation of about 250,000. AlKarak hospital is the major hospital in this citywith 147 beds. As a result of that, by picking this hospital, a good idea can beextracted for the southern part of Jordan.

The hospitals that were covered in this survey were AlRamtha hospital (Ramthacity, northern part of Jordan), AlHussain Hospital or AlSalt Hospital (AlSalt City,middle part of Jordan), Prince Hamzah Hospital (Amman city, middle part ofJordan), Amman Hospital (Amman city, middle part of Jordan) and AlKarakHospital (AlKarak city, southern part of Jordan). The survey was accomplishedbetween October 2008 and April 2009.

2.2 Questionnaire answer options

Each nursing staff has five options for the answers, so he=she can mark the mostappropriate answer. These answers can be divided in two groups:

i) positive answers: this group involves ‘agree’ and ‘strongly agree’ answers

ii) negative answers: this group involves ‘disagree’, ‘strongly disagree’ and ‘neutral’answers.

All questions are established in one manner, so that the positive answers indicate goodknowledge, appreciation and implementation of the person for the content of thisquestion, whereas negative answers indicate otherwise. Furthermore, lack ofknowledge for the implementation of medical waste protocols leads to wrongpractices of medical waste management and potential increase of hazardous risks.Consequently, the neutral answers considered as negative ones.

2.3 Statistical analysis

Two quantitative methodologies were used to analyse the questionnaire results. Thefirst method was a comparison between the positive answers (strongly agree andagree) and the negative answers (strongly disagree, disagree and neutral). Theadditive sums of positive or negative answers for each hospital were calculated forall questions. The results of this comparison intended to point out a comprehensivelook at the differences between the participated hospitals. It is considered a goodsign if the survey showed a high number of positive answers.

328 T.D. AlMomani et al.

The second method contained a detailed quantitative comparison of thequestionnaire answered from each hospital. Analysis of Variance (ANOVA) wasperformed followed by Holm-Sidak post hoc tests to identify differences betweentreatment groups (SigmaStat 3.0, SPSS Inc., Chicago, IL). Significance wasestablished at p� 0.05. To compare the questionnaire answers between differenthospitals, the data was normalised by dividing the total number of answers for eachanswer option by the total number of participants of each hospital. Normalisationwas used to minimise variability owing to differences in the sample size of each hospital.

3 Results

3.1 Method I results

Figure 1 shows the results of the survey for different hospitals that are concerning with theadministrative procedures of the medical wastes management. This figure summarises theadditive positive (Sum (positive answers)=(total number of answers)), and additivenegative (Sum (negative answers)=(total number of answers)) responses. Differenthospitals show different responses to the questions of the survey, AlHussain hospital(middle of Jordan) showed the highest positive value with a positive average of 0.69, whilethe worst responses were found in AlKarak Hospital (southern Jordan) with a negativeaverage value of 0.60. The other three hospitals were shown close results. This means thatthe middle and northern regions of Jordan have more awareness than the healthcarefacilities located in the southern part of Jordan. Those results were not necessarilyagreeing with results collected for the collection questions that are presented in Figure 2.In this figure, it can be seen that AlRamtha hospital has better collection method with apositive average value of 0.58, and AlKarak Hospital has the worst collection methodwith a negative average value of 0.63. To have more accurate ideas about the medicalwaste administrative procedures in these hospitals, in the following section the results willbe statistically analysed to predict the significant differences between different answers.

Figure 1 Management questions, additive sums of: (a) blue: positive answers and(b) red: negative answers (see online version for colours)

Assessment of medical wastes management protocols 329

3.2. Method II results

3.2.1 Administrative procedures

The results of this study show no significant differences in the administrativeprocedure steps for the ‘agree’ and ‘neutral’ answers. The significant differenceshave only appeared in ‘strongly agree’, ‘disagree’ and ‘strongly disagree answers’(as shown in Figure 3 and Table 4). By comparing the calculated p-value for allhospitals, it can be clearly seen that there is a significant difference betweenAlHusein (or AlSalt) hospital, from the one side, and AlKarak, AlRamtha andAmman hospitals, from the other side, respectively. For the ‘disagree’ answer,significant differences are found between AlKarak Hospital and Amman,AlRamtha and Prince Hamzah Hospitals. Moreover, significant differences areobserved between Prince Hamzah hospital and AlHusein (or AlSalt) and Ammanhospitals. For the ‘strongly disagree’ answer, significant differences were observedbetween Amman Hospital and AlKarak, AlHusein (or AlSalt), AlRamtha andPrince Hamzah hospitals. Furthermore, AlKarak hospital vs. AlRamtha and PrinceHamzah hospitals are showing significant difference with p-values less than 0.05.

3.2.2 Collection protocols

For the collection questions, disagree and strongly disagree answers are the onlyanswers that showed significant differences between the hospitals (Figure 4 andTable 5). Significant difference was found between Amman hospital vs. AlKarak,AlHusein (or AlSalt), Prince Hamzah and AlRamtha Hospital, respectively.AlKarak hospital has also shown significant difference when comparedwith AlRamtha and Prince Hamzah hospitals. With respect to the ‘disagree’ answer,significant difference is noticed between Amman hospital and AlKarak, AlRamthaand AlHusein (or AlSalt) hospitals. AlKarak also showed significant difference whencompared with AlHusein (or AlSalt); Prince Hamzah and AlRamtha hospitals.

Figure 2 Collection questions, additive sums of: (a) blue: positive answers and(b) red: negative answers (see online version for colours)

330 T.D. AlMomani et al.

Figure 3 Responses by nursing staff to the questionnaire as a ratio from the total numberof responses, management part: (questions 1–9) (see online version for colours)

Table 4 Comparisons for factors (management)

Hospital name

Strongly agree Disagree Strongly disagree

P-value Significant P-value Significant P-value Significant

AlHussain vs. ALKarak 0.001 Yes 0.001 Yes 0.114 NoAlHussain vs. AlRamtha 0.043 Yes 0.056 No 0.156 NoAlHussain vs. Amman 0.49 Yes 0.942 No 0.001 Yes

AlHussain vs. P. Hamzeh 0.077 No 0.013 Yes 0.379 NoP. Hamzeh vs. ALKarak 0.111 No 0.001 Yes 0.016 YesAmman vs. AlKarak 0.165 No 0.001 Yes 0.001 Yes

AlRamtha vs. AlKarak 0.184 No 0.001 Yes 0.004 YesP. Hamzeh vs. Alramtha 0.781 No No 0.58 NoP. Hamzeh vs. Amman 0.829 No 0.015 Yes 0.013 YesAmman vs. AlRamtha 0.951 No 0.065 No 0.048 Yes

Assessment of medical wastes management protocols 331

0.524

4 Discussion and conclusion

This current study involves a survey that covered different hospitals in northern,middle and southern parts of Jordan. The survey was conducted according to theregulations of MOH. This survey tried to cover two main criteria among thosementioned in the MOH regulations issued in 2001. These criteria are:administrative procedures and collection protocols.

The results of this study showed that all hospitals have real shortages in themedical waste management. Even though the results of the hospitals in the middleand the northern parts are more satisfactory than those in the southern part ofJordan, this does not mean that these healthcare facilities are following the right andthe most appropriate ways of medical waste administrative procedures and collectionprotocols. Because of the importance and the dangerous of the medical wastes on

Figure 4 Responses by nursing staff to questionnaire as a ratio from the total number ofresponses, collection part (questions 1–6) (see online version for colours)

332 T.D. AlMomani et al.

both human and environment, the nursing staff should be highly qualified and welltrained in this area. The numbers in Figures 1 and 2 are in the range of 50% positiveresponse or even less than that, which means that the other 50% of the staff has noidea or less information about medical waste management and the importance of thissubject (this can be concluded from the average results of the managerial questions),or that they have bad or negative observation regarding the habits and ways that arefollowed in the collection process of the medical wastes inside the hospitals.

Using the one-way ANOVA, the results are analysed and compared for differenthospitals. Differences between questionnaire answers are clearly observed. In themanagement area, significant differences have only appeared in ‘strongly agree’,‘disagree’ and ‘strongly disagree’ answers. While in collection questions, ‘disagree’and ‘strongly disagree’ answers are the only answer options that show significantdifferences between different hospitals. Considering the management answers, andby observing the ‘strongly agree’ and ‘disagree’ answer options (Figure 3), AlKarakhospital showed the most negative responses to these two answer options, whichdoes not agree with the ‘strongly disagree’ option in which Amman hospitalshowed the most negative response for this option. This implies that even inAmman city (which is the capital city of Jordan), the medical waste management isstill not moving in the right direction, and the staff there is still not satisfied aboutthe management steps followed by the hospitals to reduce the effects of the medicalwastes. In collection part, the people in AlKarak and Amman hospitals areshowing the least acceptance level in this area. For ‘disagree’ answer, AlKarakshow that the collection process is still not appropriate in this hospital (Figure 4),while Amman hospital has the worst collection process, and this can be concludedfrom Figure 4.

Consequently, the process of managing and processing of medical wastes is stillnot efficient in Jordan. Even though the Jordanian government is giving thissubject a great attention, people working with this kind of wastes are notrecognising the real effects of these wastes. And, the administration of thesefacilities should give more attention for the handling and disposing of the medicalwastes in all levels. In future, more comprehensive studies are still needed. In whichthe amounts of medical wastes produced in different medical facilities arecalculated. Different types of pollutants are also needed to be estimated.

Table 5 Comparisons for factors (collection)

Hospital name

Disagree Strongly disagree

P-value Significant P-value Significant

AlKarak vs. Amman 0.001 Yes 0.001 YesAlKarak vs. AlRamtha 0.001 Yes 0.025 YesAlKarak vs. AlHussain 0.011 Yes 0.023 Yes

AlKarak vs. P. Hamzeh 0.018 Yes 0.008 YesP.Hamzeh vs. Amman 0.033 Yes 0.106 NoAlHussain vs. Amman 0.051 No 0.042 Yes

P. Hamzeh vs. AlRamtha 0.177 No 0.604 NoAlHussain vs. AlRamtha 0.249 No 0.956 NoAlRamtha vs. Amman 0.394 No 0.037 YesP. Hamzeh vs. AlHussain 0.836 No 0.643 No

Assessment of medical wastes management protocols 333

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