REDUCING NON- SEGREGATED HEALTH CARE WASTE IN WARD 5A & 5AA OF
MULAGO NATIONAL REFERRAL HOSPITAL KAMPALA, UGANDA
By
JOYRINE BIROMUMAISO KASOMA
(BACHELOR OF SCIENCE HEALTH ADMINISTRATION, DIPLOMA NURSING AND
MIDWIFERY) MEDIUM-TERM FELLOW
November, 2013
ii
Table of Content
Table of Content ................................................................................................................................ ii
Declaration ........................................................................................................................................ v
Fellows’ roles in project implementation .......................................................................................... vi
Acknowledgements ..........................................................................................................................vii
Acronyms ........................................................................................................................................ viii
Operational Definitions .....................................................................................................................ix
Abstract ............................................................................................................................................ x
INTRODUCTION ................................................................................................................................. 1
BACKGROUND ................................................................................................................................... 2
LITERATURE REVIEW.......................................................................................................................... 3
2.1 Lack of Segregation Practices .......................................................................................... 3
2.2 Lack of Adequate Facilities ............................................................................................. 4
2.3 Financial Constraints ....................................................................................................... 4
2.4 Inadequate Awareness and Training Programs................................................................. 5
2.5 Lack of Institutional Arrangements.................................................................................. 5
2.6 Reluctance to Change and Adoption ................................................................................ 6
Statement of the problem ................................................................................................................. 7
Justification/ Rationale of the Problem .............................................................................................. 7
CONCEPTUAL FRAMEWORK ............................................................................................................ 10
PROJECT OBJECTIVES ....................................................................................................................... 11
iii
General Objective ............................................................................................................... 11
Specific Objectives: ............................................................................................................ 11
METHODOLOGY .............................................................................................................................. 12
Procuring of pedal waste bins ............................................................................................ 133
PROJECT OUTCOMES ................................................................................................... 155
LESSONS LEARNT ......................................................................................................... 166
CHALLENGES EXPERIENCED AND HOW THEY WERE OVERCOME .................... 166
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS ......................................... 17
Summary…………………………………………………………………………………………………………………………………177
Conclusion ..................................................................................................................................... 177
Recommendation .......................................................................................................................... 177
To host Institutions............................................................................................................ 177
To Maksph CDC ............................................................................................................... 188
Dissemination: .................................................................................................................. 188
Standardization: .................................................................................................................. 18
REFERENCES .................................................................................................................................... 19
APPENDICES ........ ....................................................................................................... 20
List of participant, group 1 in June ...................................................................................... 20
List of participant, group 2 in July ....................................................................................... 21
List of participant, group 3 in July ....................................................................................... 22
List of participants, group 4 in August ................................................................................. 23
iv
List of participant, group 5 in August .................................................................................. 24
List for participants group 6 in August, 2013 ....................................................................... 25
List of participant group 7 in September .............................................................................. 26
List of participant, group 8 in September ............................................................................. 27
Slides of training ............................................................................................................28
Slides of dissemination ..................................................................................................... ...................30
Check List ......................................................................................................................... ..35
List of Figures
Figure 1 Showing Complaint letter from Hill Top a garbage corrector company…………8
Figure 2 Showing photos of mixed medical waste ……………………………..................9
Figure 3 Showing photo of sorting of waste at the storage area ….………………………..9
Figure 4 Bar chart showing mixed medical waste on 5th floor wards……………………..13
Figure 5 Showing Training of hospital staff by the fellow ….……….……...…………... 14
Figure 6 Showing peddled waste bin in different stages of improvement ………....…… 14
Figure 7 Showing 4th
stage: Peddled waste bin with labeled stickers ….………....………15
Figure 8 Showing photos of segregated medical waste ………………………….………..15
v
Declaration
I Joyrine Biromumaiso Kasoma do hereby declare that this end-of-project report entitle Reducing
Non- Segregated Health care waste in ward 5A and 5AA of Mulago National Referral Hospital
Kampala, Uganda has been prepared and submitted in fulfillment of the requirements of the
Medium-Term Fellowship Program at Makerere University School of Public Health and has not
been submitted for any academic or non-academic qualifications.
Signed ………………………………… Date…………………………………..
Joyrine Biromumaiso Kasoma (CQI Medium-term Fellow)
Signed ………………………………… Date…………………………………..
Dr. Katagirya Eric (Institution Supervisor)
Signed …………………………………. Date………………………………
Dr. Ludoviko Zirimenya (Academic Supervisor)
November 2013
vi
Fellows’ roles in project implementation
The following roles were developed and assigned to the fellow:
To organize the daily and weekly segregated waste check list
To work closely with the two resource persons to ensure that all the materials needed are
available and that the training sessions are successful.
To organize monthly CQI team meetings with all the members so that all are aware about
the progress
To work closely and establish communication links with the academic, institutional
supervisors and the MakSPH – CDC fellowship training coordinator.
To work closely with the infection control team and the administration of Mulago
National Referral Hospital to ensure that all the procurement & financial needs for the
project implementation are availed to the CQI team.
To ensure proper accountability of the project resources
To write the project report at the end of the project implementation.
To organize a dissemination program for all Top Hospital Management.
vii
Acknowledgements
MakSPH - CDC Fellowship Program
Academic Mentors
My God, Jesus Christ
Institutional Mentors
Institutional Supervisor
Continuous Quality Improvement Team
Staff of Ward 5A/ 5AA of Mulago National Referral Hospital
Fellow fellows
viii
Acronyms
CQI Continuous Quality Improvement
CDC Centre for Disease Control
GYN Gynaenecology
HCU Health Care Unit
HCWs Health care wastes
IPCD Infection Prevention and Control Department
MakSPH Makerere School of Public Health
MNRH Mulago National Referral Hospital
MoH Ministry of Health
NMS National Medical Stores
OBS Obstetrics
PDCA Plan -Do- Check- Act
SPNO Senior Principal Nursing Officer
WHO World Health Organization
ix
Operational Definitions
Waste: Waste refers to a substance which the owner no longer wants at a given time which has
no current perceived market value. (WHO)
Health Care Waste: This is the total waste generated from hospital during service delivery. It
can be produced in liquid or solid form.
Waste Management: Refers to the generation, minimizing, segregating, collection,
transportation, disposal and monitoring of waste materials.
Waste Segregation: This is the separation of waste generated at the source to its color coded
container as:
Highly infectious waste (anatomical, soiled with blood or body fluids) disposed in a red bin.
Infectious waste (used during the process of health care and is deemed as potentially infectious)
disposed in a yellow bin
Non – infectious waste (paper, packaging plastic containers for in fluids, food lefts etc) disposed
in a black bin
Pharmaceutical waste (drugs maybe cytotoxic (cancerous drugs) non cytotoxic) disposed in a
brown bin
Injection Safety boxes for used sharps and syringes and needles
x
Abstract
Reducing Non- Segregated Health Care Waste in Ward 5A & 5AA of Mulago National Referral
Hospital Kampala, Uganda
Biromumaiso J1, Zirimenya L
2, Matovu J
2 Birabwa D
1
1Mulago National Referral Hospital
2Makerere University School of Public Health CDC
Issues: Health care waste refers to “all wastes produced by health care units (HCU) during
provision of health care services. Proper segregation of medical waste into non infectious and
infection at point of generation is important in infection control. A survey conducted in March
2013 on 5A and 5AA wards of Mulago National Referral Hospital revealed that 90% of the
medical waste generated was not segregated. This posed a high risk to health care workers,
garbage collectors, and the community. This was due to absence of proper waste management
equipment, lack of proper job aids, inadequate knowledge and skills on medical waste
segregation. Mulago Hospital in collaboration with MakSPH CDC implemented interventions to
reduce non segregated medical waste from 90% to 30% within six months
Intervention description: Hospital Staff of ward 5A/5AA were trained, cleaners and garbage
collectors were sensitized, and Job Aids designed and displayed in the clinical practicing area,
basic medium pedal waste bins were procured. Daily check list on waste segregation was used
twice a day for recording bins with mixed waste, totaling to 60 times in a month. Data collected,
managed and analyzed manually.
Out comes: In the period of May to June 2013, proportion of non segregated medical waste on
ward 5A and 5AA reduced from 90% to 70% and 73.3% respectively and by September 2013, it
had reduced to 25% on ward 5A and 26.7% on ward 5AA. This reduced risks of occupational
hazards due to poor waste handling.
Lesson learnt: Introduction of basic medium pedal bins, regular seminar and sensitization are
essential in improving waste segregation practices. Little money provided can lead to significant
improvement. Recommendation: Adoption of medium pedal waste bins by all health institution,
costs for waste management to be included in hospital annual budget, and to adapt new
technology of medical waste machines.
1
INTRODUCTION
Mulago Hospital is a National Referral and Teaching Hospital with a bed capacity of 1500 beds.
It provides speciality services in Surgery, Internal Medicine, Paediatrics, Obstetrics and
Gynaecology, Oncology, Radiology with Computerised Tomography (CT scan), Intensive Care,
Renal Dialysis, Dentistry and Oral Surgery, Orthopaedics including limb fitting, Ear, Nose and
Throat (ENT), Ophthalmology, Dermatology, Genital/ Urinary (Urology), Medicine,
Neurosurgery, Cardiology and Cardiothoracic Surgery, and Accident and Emergency among
others.
Heads of Directorates are Directorate of Surgical Services, Medical services, Obstetrics
Gyneacology, Paediatric Services, Diagnostic & Therapeutics, and Directorate of Administration
& Support Service.
Mulago hospital has an annual in patient turnover of 140,000 In Patients and attends to over
600,000 Out Patients in the Assessment Center, General Out Patient Clinics and Specialist
Clinics and in Accident and Emergency Department annually.
Department of Obstetrics and Gyneacology where the survey on management of medical waste
was conducted, is well established with three fully fledged Maternity and Gynecological
facilities in upper Mulago (Ward 14), Lower Mulago (5th Floor) and Private Patient Wing (Ward
6D & E). The department delivers over 30,000 mothers each year.
The general total hospital In Patient Turn over in year 2011 was 128,345 (17%) and Out Patient
was 629,826 (83%) In year 2012, In Patient was 135,356 (19%) and Out Patient was 577,729
(81%)
Out of the general total hospital patients turn over, Obstetrics and Gynaecology total In Patient in
year 2011 was 40,980 (38%) and Out Patient 67,563 (62%). In year 2012, In Patient was 45,429
(47%) and Out Patient 50,604 (53%).
2
BACKGROUND
Mulago National Referral Hospital provides specialised care and treatment. The service
inevitably generates waste which is hazardous to health if not properly managed.
Waste segregation is the practice of classifying waste, separating and placing it into the
appropriate waste containers immediately after the waste is generated and should be placed in
different color coded bins with bin liners. Failure to segregate infectious from non-infectious
waste means that, all waste is designated as infectious waste.
Waste segregation was still a challenge to Mulago National Referral Hospital, according to the
survey conducted in March 2013 on 5th
floor.
It was observed that, absence of proper waste management equipment, absences of Job Aids in
the clinical practicing area, knowledge inadequacy, poor practice of waste segregation and
disposal are the most critical problem connected with health care waste management. The 90%
of non segregated health care waste identified on gyneacology wards 5A and 5AA respectively
was the basis upon which this project was developed. This project was supported by MakSPH in
conjunction with CDC
3
LITERATURE REVIEW
2.1 Healthcare Waste Management
Hospitals and other healthcare facilities are responsible for the delivery of patient care services.
In the process of delivering, healthcare waste is generated. According to WHO (2000), the
incorrect management of healthcare waste can have direct impacts on the community,
individuals working in health care facilities and natural environment.
The safe management of healthcare waste may be achieved by ensuring care in dealing with the
healthcare waste. Hence it is the ethical responsibility of management of hospitals and healthcare
establishments to have concern for public health. Safe handling, segregation, storage, subsequent
destruction and disposal of healthcare waste ensure mitigation and minimization of the
concerned health risks involved through contact with the potentially hazardous material, and also
in the prevention of environmental contamination.
(www.swlf.ait.ac.th/.../Data/.../4_01%20_Vijaya%20kumar%20Goddu.pd).
2.2 Lack of Segregation Practices
Segregation practice prevents non-infectious waste to get mixed with infectious waste. Lack of
segregation practices significantly increases the quantity of infectious medical waste as mixing
of infectious component with the general non-infectious waste, makes the entire mass potentially
infectious. (Gupta S and Boojh R. Report: Biomedical waste management practices at Balrampur
Hospital, Lucknow, India. Waste Management Research. 2006, 584–591).
There is inadequate practice of segregation of the waste starting from generation to disposal as
seen in Indian hospitals. Even if the segregation of waste at the point of generation is effective,
waste handlers are found mixing it together during the collection and results in loss of ultimate
value of segregation. (Athavale A.V and Dhumale G. B. A Study of Hospital Waste
Management at a Rural Hospital in Maharastra Journal of ISHWM, 2010, 21-31)
4
2.3 Lack of Adequate Facilities
Efforts to provide facilities for storage, collection, treatment and disposal of health care wastes as
well as appropriate technologies have so far been limited in India. Additionally, adequate and
requisite number of sanitary landfills is lacking in India.
Therefore, the biomedical waste are openly dumped into the open bins on the road sides, low
lying area or they are directed into the water bodies; through which severe disease causing agents
are spread into the air, soil and water. (Dwivedi A.K, Pandey S, and Shashi. Fate of hospital
waste in India. Biology and Medicine. 2009, 25-32)
Self contained onsite treatment methods may be desirable and feasible for large healthcare
facilities but are impractical or uneconomical for smaller institutes. An acceptable common
system should be in place which will provide free supply of colour coded bags, daily collection
of infectious waste, and safe transportation of waste to offsite treatment facility and final
disposal with suitable technology. (Rao. S.K.M, Ranyal R.K., Bhatia S.S. and Sharma V.R.
Biomedical Waste Management: An Infrastructural Survey of Hospitals. Medical Journal Armed
Forces India. 2004, 379-382)
2.4 Financial Constraints
With dedicated systems being installed in most of the HCUs, financial provision is necessary for
capital and recurring expenditure including funds for sufficient manpower, disinfectants, devices
and equipment.
Normally, a separate allocation of funds for waste management is not found in Indian hospitals.
It is estimated that INR 3000–4000 (US$ 70–93) per ton of hospital waste is required. (Patil A.D.
and Shekdar A. V. Healthcare waste management in India. Journal of Environmental
Management, 2001, 211–220).
Additionally funds are required for conducting training and awareness programs for health care
staffs. Smaller HCUs ignore waste management practices due to financial constraints (Rao
S.K.M, Ranyal R.K, Bhatia S.S. and Sharma V.R. Biomedical Waste Management. An
Infrastructural Survey of Hospitals. Medical Journal Armed Forces India. 2004, 379-382).
5
2.5 Inadequate Awareness and Training Programs
Awareness of appropriate handling and disposal of health-care wastes among health personnel is
a priority; it is essential that everyone should know the potential health hazards. Regular
programs will help prevent exposure of health-care wastes and related hazards. Poster exhibition,
proper labeling, and explanation by staff are effective methods. Seminars and workshops, and
participation in training courses are also essential. (.Dwivedi A.K, Pandey S. and Shashi. Fate of
hospital waste in India. Biology and Medicine. 2009, 25-32).
Management in most of Indian hospitals is not aware of cost savings achieved due to good waste
management practices. It has also been estimated that disposal savings of between 40% and 70%
could be realized through the implementation of a healthcare waste reduction program. (Tudor
T.L., Noonan C.L. and Jenkin L.E.T. Healthcare waste management: A case study from the
National Health Service in Cornwall, United Kingdom. Waste Management. 2005, 606–615).
2.6 Lack of Institutional Arrangements
Management of health-care waste depends on the input from the administration and active
participation by trained staff in segregation, storage, collection, transportation, treatment and
disposal. In India personnel responsible for these activities are mainly ward attendants and other
supporting staff. (Verma L.K. Managing Hospital Waste is Difficult: How Difficult? Journal of
ISHWM. 2010, 46-50).
A committee consisting of the head of the establishment, all the departmental heads, hospital
superintendents, nursing superintendents and hospital engineers should be formed with a waste
management officer who would be advised by an environmental control advisor and an infection
control advisor is required for proper waste management purposes. (Patil A.D and Shekdar A. V.
Health-care waste management in India. Journal of Environmental Management, 2001, 211–
220).
Studies showed lack of such kind hospital waste management committee or a documented waste
management and disposal policy in Indian hospitals. (Athavale A.V. and Dhumale G.B. A
Study of Hospital Waste Management at a Rural Hospital in Maharastra. Journal of ISHWM.
2010, 21-31).
6
2.7 Reluctance to Change and Adoption
Though now alternative technologies are permitted as per the Biomedical Rules, it takes a long
time to change the mindset of the people. Even now most of the health care providers and
decision making authorities talk of incinerator only although autoclaves and other advanced
waste handling equipments are available. Indiscriminate throwing of the waste is still seen in
most of the hospitals and the waste handlers still are without protective clothing and gears. There
is hardly any change in the applied knowledge and awareness seen in Indian hospitals (Verma
L.K. Managing Hospital Waste is Difficult: How Difficult? Journal of ISHWM. 2010, 46-50).
7
STATEMENT OF THE PROBLEM
According to MOH guide lines, medical waste should be segregated at the source of generation
in its color coded bins with bin liners. However, assessment conducted in March 2013 on ward
5A and 5AA respectively in Mulago hospital showed that, 90% of waste generated was mixed in
one bin without a bin liner, hence posing infection risks to the patients/caretaker, cleaners,
medical workers, Garbage collectors and the community at large. Failure to segregate infectious
from non infectious waste means that, waste generated is all designated as infectious waste and
this has an implication on the costs of disposal, as well as safety.
Justification/ Rationale of the Problem
According to the survey conducted in March 2013 at ward 5A and 5AA, mixture of infectious
and non infectious waste was still a challenge. It was observed that, absence of proper waste
management equipment, poor practice of waste segregation and disposal, absences of Job Aids in
the clinical practicing area, inadequate knowledge and skills on medical waste segregation were
the most critical problem connected with health care waste management. Evidence based of the
complaint letter written to the Director of Mulago hospital dated 12th February 2013 by TOP Hill
Company which is the garbage collection company, photos of mixed waste in one bin, sorting at
the storage site and the bar chart showing percentage of mixed infectious and non infectious
waste was the basis upon the implementation of this project.
Ward 5A and 5AA in OBS and GYN department, during service delivery a lot of medical waste
is generated, if not properly handled it may lead to high risks of infections. The safe and
effective disposal of medical waste starts with the medical practitioner. Poor handling and
disposal of medical waste has potential to morbidity and mortality. Sorting waste at the storage
area exposes workers to occupational hazards
8
Evidence based
Figure 1 showing, Complaint letter from Hill Top a garbage corrector company.
Figure 2 showing photos of mixed medical waste and sorting of waste at the storage area
9
Figure 3: Bar chart showing mixed medical waste on 5th floor wards
Infectious And Non Infectious Medical Waste
Mix
ed M
edic
al w
aste
%
100
90%
90%
80
60
60%
40
30%
20
0
5A
5AA
5B
5C
March. 2013
10
CONCEPTUAL FRAMEWORK
Reduced exposure of
hazardous risk of infection
Reduced non
segregated
medical
waste Segregated
medical waste
Procure ideal
peddled medical
waste containers
Impact knowledge
to hospital staff
on medical waste
management
Developed
Job Aids
Improved practice
in medical waste
segregation
11
PROJECT OBJECTIVES
General Objective
To reduce 90% of non segregated health care waste generated on ward 5A and 5AA by 30%
within 6 months as a way to prevent risks of infection.
Specific Objectives:
1. To improve the practice of medical waste segregation at generation point
2. To reduce non- segregated health care waste from 90% to 30% by September 2013.
12
METHODOLOGY
CQI team was formed at MNRH, comprised of 10 members from different disciplines including:
Dr Birabwa Doreen Male (Deputy Executive Director), Dr. Katagirya Eric (Microbiologist –
Head Infection Control), Nabawanuka Doreen (Head Nurse Infection control), Biromumaiso
Joyrine (CQI fellow), Nkayarwa Jolly (Ag SPNO) Nakubulwa Reginah (In-charge 5A) Lekico
Emilly (In-charge 5AA), Birungi Harriet (CQI member), Namubiru Ruth (CQI member),
Nazziwa Robinah (CQI Member).
With the CQI team, we identified different infection control problems and through multi voting
zeroed down to the problem of mixed medical waste.
At the start of the Project, the CQI team held a one day meeting to share the Project
implementation strategy and designed ways of ensuring that the Project achieves the set targets.
The meeting reviewed management of health care waste in consideration with Ministry of Health
guide lines.
Teaching materials, Job Aids, and check lists used by the supervisors were developed by two
resource persons and 1 fellow
Ideal pedal Medical waste equipments, Presept tablets as a disinfectant and other stationary
materials were procured.
Training of Medical staff for three days, twice in a month from May – September 2013 was
conducted by two resource persons and 1 fellow
Weekly Support Supervision and monitoring of the performance of hospital staff regarding
management of medical waste was carried out by two dedicated supervisors
13
The figure below shows the training of medical staff in different disciplines
Figure 4: Showing Training of hospital staff by the fellow
Sensitizing of garbage collectors and conducting seminars for medical staff by putting more
emphasis on segregation of the health care waste at the generation point. Demonstrating on the
use of different colour coded bins and the video showing challenges of the current waste bins in
the hospital. This instilled in them a need to have the ideal pedal bins to prevent cross infection.
Procuring of pedal waste bins
Procuring basic medium pedal waste bins, in the first stage we painted them in different colour
codes; red for highly infectious waste, yellow for infectious waste, black for non infectious waste
and brown for pharmaceutical waste. However, it was observed after one month that the
practices of waste segregation had not improved!
PDCA was used in the second stage and came out with writings of paper labeling what is to be
put in the each coded bin. It was realized that it needed daily changing as words written by pen
were very small to be read, thus a slight improvement was observed.
We went back on the drawing board and came out with the 3rd
stage; job aids stickers were
developed and plastered on the wall above every stationed bin.
14
In this stage some improvement was observed but it also became difficult for others to follow.
One in-charge reported that, some Health workers were asking her to show them where to put
different type of wastes.
Still with the use of PDCA, the CQI team met and come out with the 4th
stage. In this, labeled
stickers were pasted on the bin covers. A great improvement was observed after the 4th stage
intervention and the set target of 30% was beaten up to 25%
Daily check list on waste segregation was used twice a day for recording bins with mixed waste,
totaling to 60 times in a month. Data collected, managed and analyzed manually.
Figure 5: Showing pedal waste bins procured and their different stages of improvement
1st Stage 2
nd Stage 3
rd Stage
Figure 6: Showing 4th
stage: Pedal waste bins with labeled stickers
15
PROJECT OUTCOMES
On implementation of these strategies, an achievement was realized and reduction of non
segregated medical waste was seen. This is illustrated by the photos and bar chart below.
Figure 7: Showing photos of segregated medical waste
By the month of June 2013, the practice of segregation at the point of generation was not so
specific as only a proportion of segregated medical waste on ward 5A/ 5AA was reduced from
90% to 70% and 73.3% respectively. With PDCA as a measure used in this project, by the end of
September 2013, mixed medical waste had reduced to 25% on ward 5A and 26.7% on ward
5AA. This reduced risks of occupational hazards due to poor waste handling
Figure 8: Showing bar chart showing reduction of non-segregated medical waste in ward 5A/5AA
16
LESSONS LEARNT
How to work with constraint budget and little money invested, can cause a great improvement
Team work and the involvement of Top Hospital Administrators play a big role which is key to
improvement
The value of surveillance
Quality improvement is continuous and gradual
CHALLENGES EXPERIENCED AND HOW THEY WERE OVERCOME
Overwhelming turn up of the trainees, we managed them by dividing them into group and
increasing on the sessions of trainings.
Financial constrain, learnt to budget for the little amount and to priotise what was to benefit the
project
Poor attitude of staff towards health care waste and this was just to keep on training and
sensitizing them.
Resistance to change, continuous sensitization was emphasized
Inadequate supplies, request was forwarded to the Executive Director
Rotation of staff, I spotted another staff and oriented her in the CQI project
17
SUMMARY, CONCLUSIONS AND RECOMMENDATIONS
Summary
Safe and effective waste management and disposal begins with the health practitioner
The effective waste disposal, requires segregation immediately as the different types are handled
differently
Following waste segregation, the waste should be then disposed of to the designated places for
terminal disposal.
Bin should be emptied when they ¾ full, for easy fastening and transportation
During the transportation, the waste should not be mixed up; it should be transported in its bin
liners
Continuous quality improvement is a daily process and gradual, therefore institutions should take
up this strategy, roll it out in the entire organization for the quality of service.
Conclusion
Health care waste management is beneficial to patients, hospital staff and the community as it is
one way of preventing health hazards. This can only be achieved when the practice of
segregation is done at the point of generation.
Recommendation
To host Institutions
These interventions should be applied to all clinical practicing areas
The administration and staff should take time and understand the whole process of continuous
Quality Improvement, the medium term fellowship and not look at it as just benefiting the
fellows since it aims at creating improvement at the host institution
Encourage and support other staff to take up the medium term fellowship as this not only builds
capacity but also creates better project out comes in terms of service delivery
18
To MakSPH CDC
The schedules for the face to face sessions at the School of Public Health should be formally
communicated to the administration of the host institutions to avoid overlapping of activities and
to enable the fellows fully concentrate during these sessions
The funds for project implementation should be released on time to enable faster implementation
Dissemination:
Dissemination of results to the Top hospital senior management was done on 30th
October 2013
and 20 managers were hosted.
Standardization:
Mulago National Referral Hospital in conjunction with African Development Bank (ADB) are
currently running a training of 400 hospital staff in Infection Prevention and Control where waste
management is a course unit.
The management of Mulago National Referral Hospital has take up an initiative to buy the pedal
waste bin for the whole organization as one way of improving on the challenge noticed with the
current waste bins
19
REFERENCES
Athavale A.V. and Dhumale G.B. A Study of Hospital Waste Management at a Rural Hospital
in Maharastra. Journal of ISHWM. 2010, 21-31
Dwivedi A.K, Pandey S. and Shashi. Fate of hospital waste in India. Biology and Medicine.
2009, 25-32
Gupta S and Boojh R. Report: Biomedical waste management practices at Balrampur Hospital,
Lucknow, India. Waste Management Research. 2006, 584–591
Patil A.D and Shekdar A. V. Health-care waste management in India. Journal of Environmental
Management, 2001, 211–220.
Rao S.K.M, Ranyal R.K, Bhatia S.S. and Sharma V.R. Biomedical Waste Management. An
Infrastructural Survey of Hospitals. Medical Journal Armed Forces India. 2004, 379-382
Tudor T.L., Noonan C.L. and Jenkin L.E.T. Healthcare waste management: A case study from
the National Health Service in Cornwall, United Kingdom. Waste Management. 2005, 606–615
Verma L.K. Managing Hospital Waste is Difficult: How Difficult?. Journal of ISHWM. 2010,
46-50.
WHO (2000), the incorrect management of healthcare waste can have direct impacts on the
community, individuals working in health care facilities and natural environment
(www.swlf.ait.ac.th/.../Data/.../4_01%20_Vijaya%20kumar%20Goddu.pd).
20
APPENDICES
List of participant trained in the month of June 2013, Group 1
No Names Cell phone contact Signature
1. Sselugo Muhammed 0788500010
2. Basirika Rebecca 0785214032
3. Nankanja Edith 0702676299
4. Nambooze Betty 0757246573
5. Nalwadda Specioza 0781704520
6. Kemigisha Rose 0783015814
7. Nalugemwa Julie 0772520616
8. Nambi Aisha -
9. Namaato Regina 0704403215
10. Namwesi Shakirah 0704192791
11. Mbabazi Joy 0788774029
12. Lubega Edward 0757354608
13. Munyango Robert 0784539629
14. Mugambwa Javiira 0753699951
15. Nsubuga Noridin
16. Kampulira Fred
17. Lubega Hamuza 0757043452
18. Moses G
19. Muzuguzi 0753890496
20. Sserunjogi Gerard 0773794715
21. Kavuma Livingstone
22. Biromumaiso Joyrine (Facilitator) 0776801219
23. Nabawanuka Doreen (Facilitator) 0712808584
21
List of participant trained in the month of July2013, Group 2
No Names Cadre Cell phone contact Signature
1. Nakirijja Florence 0782920247
2. Kobusingye Maria
3. Zawedde Juliet 0783516707
4. Namuyomba Madina 0775243745
5. Nakayiza Josephine 0782667237
6. Mugga Hadija 0704620338
7. Kamora Doreen 0702520011
8. Birungi Harriet 0772463230
9. Kyompaire Patience 0782500932
10. Nyakato Felista 0774519280
11. Bigambo Harriet 0772697030
12. Namanda Dianah 0782327777
13. Karungi Getrude 0772640514
14 Namanda Agnes 0779588496
15 Babirye Caroline 0772589608
16 Likico Emilly 0772484958
17 Opoti Beatrice 0704910929
18 Nassazi Oliver
19 Nabawanuka Doreen 0712808584
20 Biromumaiso Joyrine 0776801219
21 Awoli Bob
22
List of participant trained in the month of July 2013, Group 3
No Names Ward Cadre Contact Signature
1 Kataike Margaret 3B NO
2 Nakkazi Namisango H PPD NO
3 Najjemba Paskazia Eye Clinic NO
4 Iribagiza M Oliver Oral surgery NO
5 Amon Joyce Ayeko 3BES NO
6 Kyabita Ida Owor 3AN-HDU NO
7 Nambasa Dorothy Main theatre TH A 0754392108
8 Kakooza Charles Main theatre TH A
9 Kirabira Getrude 3B Plastic NO
10 Odoko Enock CAS Records MRA
11 Nassaka Cissy Oral surgery MRA
12 Wasswa Ronald MAC MRA 0774507870
13 Ssozi Saulo SOPD MRA 0752655869
14 Logose Eva Radiotherapy MRA
15 Asio Esther Ruth MOPD MRA
16 Ahimbisibwe Kellen 2C Burns NO 0777081910
17 Omongole James Peter MAC TH A 0774099655
18 Letiru Joyce Eye Theatre NO 0772825427
19 Akampurira Andrew Security Security
20 Nabulya Aminah 2C Burns Th NO
21 Nakagolo Teopista 4A NO
22 Nsiiro Patrick Security Security 0712560975
23 Namuli Muwonge L MFP NO
24 Tino Dorcus CAS NO
25 Opika Diku Enock CAS Theatre TH A
26 Falida Ali MFM NO
27 Ajwang Betty 4C NO
28 Odomoch Jolly Gustell 5C L/S NO
23
List of participants trained in the month of August 2013, Group 4
No Names Ward Cadre Contact Signatures
1. Katusime Gladys F/P EM
2. Birabwa Rosetti Solome Eye TH N/O
3. Auma Joyce A/E NO
4. Nabanda Regina A/E NO
5. Oruya Paskaline A/E TH NO
6. Nansamba Teddy A/E TH NO
7. Kweberawo Sarah Trauma NO
8. Mukiibi Henry A/E MRA
9. Katushabe Beatrice A/E NA
10. Nalubega Jesca Kagwa Oral NO
11. Munyantwari Tom 2C NO
12. Nakayiza Namazzi Rose 6D/E NO
13. Nakirijja Eunice Kisekka 2B Oral NO
14. Nalukenge Nanfuka Cissy 2AGU NO
15. Kubuuza Lydia 5 C L/S EM
16. Nyombi Juliet Kisakye Dental NO
17. Kasoone Namatende Phoebe X-ray NO
18. Nalule Milly 3C/CTs EN
19. Agupio Godfery 3BEM NO
20. Nalukenge Florence 3BES NO
21. Ssanyu Karyowa Harriet 3A HDU NO
22. Nabbanja Ida 3 A ORT NO
23. Namanda Sauda Kasita Main TH TH/ A
24. Lakot Lillian Eye NO
25. Musumba Moses A/E Orth Orth/O
26. Nansubuga I Geraldine 3B Plastic NO
27. Ebitu Richard Records MRA
28. Bweete Anthony Main TH TH/A
24
List of participant trained in the month of August 2013, Group 5
No Names Ward Cadre Contact Signatures
1. Sentongo Getrude F/P EM
2. Kyalimpa Allen Eye Ward N/O
3. Acakala Marie A/E NO
4. MababaziJanet A/E NO
5. Bulega Hanah A/E TH NO
6. Birungi Sarah A/E TH NO
7. Nabulime Josephine Trauma NO
8. Namubiru Florence A/E MRA
9. Kabagame James A/E NA
10. Bamwenda Wilson Trauma NO
11. Namulindwa Juliet 2C NO
12. Namukasa Teddy 3 AOrth N/A
13. Nasimbwa Lydia 2B Oral NO
14. Anyango Stella 3C CTS NO
15. Kawala Florence 3BEM NO
16. Kajobe Margaret Dental NO
17. Ajakot Magadarena 2A NO
18. Mugerwa Sam A/E Orth Orth
19. Gonza Leo 3BEM NO
20. Natta Christine 3BES NO
21. Nalwoga Rose ENT NO
22. Nampewo Rose 3 A ORT NO
23. Naigaga Nubu Main TH TH/ A
24. Nzabona Sarah Kigono Eye Rec MRA
25. Asekenya Merab 2C Burns NO
26. Namatovu Zubeda 3B Plastic NO
27. Nyangoma Grace Records MRA
25
List for participants trained in the month of August 2013, Group 6
No Names Ward Cadre Tel Contact Signature
1. Mugarra Thereza F/P NO
2. Nabukeera Rosemary Eye Cl N/O
3. Fiona chardiru ENT NO
4. Nantumbwe Ruth 3D ICU NO
5. Salamuka Nancy A/E TH NO
6. Namulondo Jalia A/E TH NO
7. Mbonimpa Nelson Trauma NO
8. Eloulu Peter A/E MRA
9. Hanyurwa Arison A/E NA
10. Achen Lillian Grace Trauma NO
11. Ngamita Jumanywal Grace 2C NO
12. Namwabivu Jesca 2C Ho NO
13. Achio Betty 2B Oral NO
14. Nakandi Rebecca 3C CTS NO
15. Bonabana Catherine 3BEM NO
16. Nassimbwa Lydia 2 B Oral NO
17. Banura Constance Dental NO
18. Nankya Prossy Luwanga A/E Orth Orth
19. Nalubega Mary CSSD Mech/O
20. Nawamwena Janet 3BES NO
21. Akulia Proscovia ENT NO
22. Zawedde Grace 3 A ORT NO
23. Taaka Anne Eye Clinic NO
24. Nabuufu Rehema MFM/ 5C NO
25. Elasu Akello Hellen Records MRA
26. Namatovu Olivia 2 A GU NO
27. Mugisha Dennis Oler Records MRA
26
List of participant trained in the month September 2013, Group 7
No Names Cadre Contact Signature
1 Nayanga Jometha NA 0782740225
2 Nakintu Harriet NO
3 Wakyaya Peter Dobbi
4 Namiiro Proscovia NO 0775914061
5 Namigadde Christine NO
6 Nasozi Joyce T/A
7 Tegulwa Miriam NO 0772675063
8 Abinen Innocent Lab T 0782798072
9 Bigambo Harriet NO 0772697030
10 Nabulya Ritah NO
11 Atenge Josephine NA
12 Amulen Hellen Nyaripo NO
13 Najjuma Grace NO 0782887261
14 Pido Florence NO 0712316767
15 Pande Saul Dobbi
16 Nyangoma Sarah NO
17 Nabagala Margaret NO 0772615893
18 Olwa Sarah NO 0782711800
19 Odwong Rosemary Acayoto NO 0712865669
20 Lutaaya Phoebe NO
21 Nyafwono Winnifred Record 0715068881
22 Bulime Ruth NO 0712836865
23 Nakalema Beatrice NO 0772306260
24 Ondoru NO 0703895594
25 Aisu Jessica Lab T 0772457900
26 Andru Monicah NO 0772690877
27 Namasoga Esther NO 0751348619
27
List of participant trained in the month of September 2013, Group 8
No Names Cadre Contact Signature
1 Alupo Martha NO
2 Namukasa Teddy NA
3 Ochendi Tom Dobbi
4 Nabuufu Rehema NO
5 Atucungwire Judith NO
6 Anyango Stella NO
7 Nagadya Ramulah NO
8 Bisaso Esther NO
9 Birungi Harriet NO
10 Nakirija Florence NO
11 Oyella Mildred Mysie NO
12 Akello Esther NO
13 Buhule Beatrice NO
14 Mukambwe Moses NO
15 Swai Samson Dobbi
16 Mukiibi Janat Nabatanzi NO
17 Birabwa Mary NO
18 Naboosa Julliet NO
19 Nalugwa Gladys EN
20 Wadembere Mary NO
21 Opio Maureen Record
22 Mukakizima Margaret NA
23 Twinomuhangi Sulphine NO
24 Jjemba Immaculate NO
25 Laloka Rosemary Lab Tech
26 Agondeze Sandra Lab Tech
27 Namataka Hellen NO
28
SLIDES OF TRAINING
Management of Health care waste.
Joyrine Biromumaiso Kasoma
Infection Prevention and Control Dept
Continuous Quality Improvement Fellow
Definitons • Waste: Waste refers to a substance which the owner
no longer wants at a given time which has no current perceived market value.
• Health care waste: This is the total waste generated from hospital during service delivery. It can be produced in liquid or solid form.
• Waste management: Refers to the generation, minimizing, segregating, collection, transportation, disposal and monitoring of waste materials.
Waste segregationWaste segregation is the practice of classifying ,
separating waste and placing it into the appropriate waste containers immediately after the waste is generated and should be placed in different color coded bins with bin liners.
Recommended methods/categories of segregation are as follows; highly infectious, infectious, non infectious, pharmaceutical with the corresponding bin liners, and sharps
Type of waste Bin colour
Highly infectious Red Sputum container, used test tubesAll anatomical waste, pathological waste used blood giving sets, heavily oozing with blood gauze, Extracted teeth, etc
infectious yellow Used cotton, gauze, gloves, used Iv Fluid line.
sharps yellow Used syringes and Needles, used blades , used scalpels, and used carnulars
pharmaceutical Brown/grey Empty vials and expired drugs
Non - infectious Black Discarded paper, packaging material, empty bottles or cans, food peeling and lefts
The safe and effective disposal of health care waste starts with the health practitioner
• Waste has a potential to pollute land, air and water irrespective of the disposal method.
• Poor handling of waste has the potential to cause mobility and mortality. Many cases of HIV, HBV, HCV infections have been seen within the health care setting due to poor handling of waste.
Disposal of waste has a cost implication. Generation, disposal of waste requires resources, materials, staff, time as well as space.
Failure to segregate infectious from non infectious waste means that the waste is all designated as infectious waste – this has an implication on the costs of disposal, as well as safety.
Sorting waste at the storage area exposes workers at high risk of infection as well as the environment.
29
Young boy sorting mixed waste
Infectious waste and injection safety
boxes
Pharmaceutical waste
Designated storage area at
the hospital
Disinfection of empty vials
Taken to Kiteezi
dumping area by KCCA
Taken to Nakasongola by
NMS for crushing
Medical Pit for burying
Incineration by burning
Nature of health care
waste
Non infectious
health care waste
toxicNon
Medical waste flow chart
Highly infectious
waste (anatomical
NO
Yes
• Following waste segregation, the waste should be then disposed of to the designated places for terminal disposal.
• Bin should be emptied when they ¾ full, for easy fastening and transportation
• During the transportation, the waste should not be mixed up, it should be transported in its bin liners
In summary;• Safe and effective waste management and disposal
begins with the health practitioner
• The effective waste disposal, requires segregation immediately as the different types are handled differently
• Colour coded bins and bin liners are important for the segregation, as well as the storage.
• Waste should be transported in containers or carts, so that the liners don’t get torn and waste is littered
30
SLIDES OF DISSEMINATION
Reducing Non- Segregated Health care waste in ward 5A /5AA of
Mulago National Referral Hospital Kampala, Uganda
Joyrine Biromumaiso KasomaCQI Fellow
Dr. Ludoviko Zirimenya Dr Katagirya EricAcademic supervisor Institutional Supervisor
Background
• Mulago is a National Referral hospital
• While providing services creates waste
Which itself may be dangerous
Introduction
• Waste segregation is separating waste
• Place it immediately in bin after generation
• Failure to segregate medical waste means
that sorting has to be done at the storage
area
Infectious waste and injection safety
boxes
Pharmaceutical waste
Designated storage area at
the hospital
Disinfection of empty vials
Taken to Kiteezi
dumping area by KCCA
Taken to Nakasongola by
NMS for crushing
Medical Pit for burying
Non infectious
health care waste
toxicNon
Highly infectious
waste (anatomical
NO
Yes
incineration for burning
Nature of health care
waste
Medical waste flow chart
•MOH guide lines, medical waste should besegregated at the source of generation
Assessment conducted in March 2013 on ward 5Aand 5AA showed medical waste generated wasmixed
Problem statement
How the problem was identified
• Complaint
letter
addressed to
the Director
of Mulago
Hospital
dated 12th
February
2013 from
the TOP Hill
company
which is the
garbage
transportation
company.
31
INFECTIOUS AND NON INFECTIOUS MEDICAL WASTE
Mix
Me
dic
al
wa
ste %
March,2013
100 90% 90%
80
60 60%
40
30%
20
0
5A 5AA 5B 5C
Video portraying Challenges with current Bins
General objective
General objective
Reducing 90% of medical waste on 5A/5AA
Specific objective
Segregation of medical waste at generation point
Countermeasures
• Conducting seminars for Hospital staff
• Sensitizing of Cleaners and garbage collectors
• Incorporate 5S in infection control measures
• Designing of Job Aids and displaying
• Procuring basic medium peddled waste equipments
• Daily checklist, Weekly Monitoring and supervision
32
Colour coded bins painted in there different colours
Labeling of bins using written papers
DISPLAYED JOB AID
Stickers indicating what to be put in the bins
0
10
20
30
40
50
60
70
80
90
100
JUNE JULY AUGUST SEPTEMBER
5A Ward
5AA Ward
Bar chart showing the reduction of non segregated medical waste in ward 5A and 5AA
Perc
en
tage (%
)
Month (2013)
70%
28.3%26.7%
55%53.3%
73.3%
26.7%25%
33
Challenges and lesson learnt so farChallenges
• Overwhelming turn up of the trainees
• Financial constrain
• Poor attitude of staff towards medical waste
• Resistance to change and Rotation of staff
• Inadequate supplies
Lesson leant
• How to work with constraint budget
• Team work leads to improvement
• The value of a surveillance
• Quality improvement is continuous and gradual
• Positive outcome every after intervention
Standardization plan
• Mulago Hospital/ADB to train 400 staff
• Management of MNRH to procure pedal bins
34
Project time table
No Planned activity Time frame Resource person Input
Ap
r
May
Jun
e
July
Au
g
Sep
t
Oct
1 Holding first meeting with CQI team to review MOH waste management protocol.
CQI team and fellow Communication Meeting facilitation cost
2 Three days of developing training material ,Job Aids and check list to be used by supervisors and cleaners
Resource person and fellow
Venue Facilitation Fee Meeting facilitation cost
2 Training hospital staff in different discipline e.g. Nurses, interns, students doctor, cleaners and garbage collectors
3 Resource persons and 20 participants each session
Communication Meeting facilitation cost, stationary, pens, books and Facilitators fee
3 Purchasing of medical waste equipment, Presept tablets and other stationary
2 CQI members and 1 Driver
Fuel, Facilitation fee Cost for items
4 Meeting with the cleaner/garbage collector to monitor the progress every after two months
2 Infection Control Nurses
Meeting facilitation cost Time
5 Monthly Support supervision on waste segregation practices and monitoring of project progress
2 Infection Control Nurses
Check list, Stationary
6 Monthly Meeting for the CQI team to review and monitor the progress of project
CQI team members Meeting Facilitation cost, Communication
9 Dissemination of result to staff and hospital top management and Final report writing
Fellow Venue, Meeting Facilitation cost, Communication
35
Check List
Daily check list for Quality improvement on segregation of Medical waste On Ward 5A/5AA t
1st week of July 2013 ward …………….. Name…………………………
Date Day Time Black Yellow Red Brown Remarks
Yes No Yes No Yes No Yes No
29/06/2013 Saturday AM
PM
30/06/2013 Sunday AM
PM
01/07/2013 Monday AM
PM
02/07/2013 Tuesday AM
PM
03/07/2013 Wednesday AM
PM
04/07/2013 Thursday AM
PM
05/07/2013 Friday AM
PM
Key: Yes – Not Mixed No - Mixed