GUIDE for SUSTAINABLE WASTE MANAGEMENT in the HEALTH-CARE SECTOR

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1 LIFE ENVIRONMENT EMAS AND INFORMATION TECHNOLOGY IN HOSPITALS LIFE04 ENV/GR/ GUIDE for SUSTAINABLE WASTE MANAGEMENT in the HEALTH-CARE SECTOR Developed by: EPTA Ltd. 15, Olofytou Str, Athens, Greece DECEMBER 2006

2 Guidance on Health-Care Waste Management Categories and Definition of health-care waste According to the Greek legislative framework (Ministerial Decision 37591/2031/2003: Measures for the Management of Health-care waste), medical waste is being classified to the following categories: α) Non Hazardous Medical Waste-Characteristics Similar to Municipal Solid Wastes (MW-MC) β) Hazardous Medical Waste (HMW) β.1) Infectious Waste (HMW-IC) β.2) Toxical and Infectious Waste (HMW-TIC) β.3) Toxical Waste (HMW- ΤC) γ. Other Medical Waste (OMW): Radioactive waste, batteries, used oils etc κ.ά. Classification of hazardous health-care waste is summarized and described in more detail in the following tables Table 1. Non Hazardous medical waste-characteristics Similar to Municipal Solid Wastes (MW-MC) Waste deriving from food preparation areas (kitchens etc) Food waste (excluding waste from patients with infectious diseases) Paper, Plastic, Metals, Packaging materials Waste from cleaning activities Clothing Waste other then those mentioned in Table 2 Waste from gardening activities Pads, nappies, diapers, plaster etc that cannot be classified as infectious waste of Table 2 Infectious Waste (HMW-IC) that has been effectively treated (sterilisation etc) and can be

3 safely disposed to Landfills Table 2 Infectious Waste (HMW-IC) Waste that their collection and disposal necessitate special requirements regarding the risk of infection Body tissues and human organs Waste that derives from sources where there is danger of infection (e.g. rooms for patients with infectious diseases etc). Infectious waste is suspected to contain pathogens (bacteria, viruses, parasites, or fungi) in sufficient concentration or quantity to cause disease in susceptible hosts. In general it is waste that has been in contact with: α)blood in such a quantity that it is visible β) urine and excreta from patients that suffer from diseases that can me transmitted through excreta γ)sperm, Cerebrospinal fluid, synovial fluid, vagina fluid etc Waste from veterinary activities that: α)have been infected with pathogens for human and animals β)have come in contact with biological fluids (blood, urine etc) γ)animal parts, tissues, animal carcasses, organs Examples Needles, infusion sets, scalpels, knives, blades, tubing and filters, gloves, surgical clothing, syringes, infusion sets, transfusion sets, gauge bandages, adhesive dressings disposable towels, gowns, aprons, gloves, and laboratory coats etc Table 3 Toxical and Infectious Waste (HMW-TIC) Waste from R&D, laboratories and biochemical-microbiology tests Anatomical Waste Unidentified body parts, tissues, animals experimentation Waste from pathological units, chemotherapy activities

4 Table 4 Toxical Waste (HMW- ΤC) Waste with high content of heavy metals Expired pharmaceuticals including cytotoxic drugs Oils from vacuum pumps Insulation materials that comprise asbestos Chemical substances that comprise hazardous materials Cytotoxic and cytostatic pharmaceutical waste Dental amalgam Table 5 Other Medical Waste (OMW) Radioactive waste Batteries, Aerosol containers etc Health and Environmental Impacts of Health-Care Waste If health-care waste is not managed properly it proves to be harmful to the environment. It not only poses a threat to the employees working in the hospital, but also to the people surrounding that area. All individuals exposed to hazardous health-care waste are potentially at risk, including those within health-care establishments that generate hazardous waste, and those outside these sources who either handle such waste or are exposed to it as a consequence of careless management. Possible hazards from health care waste are the following: PHYSICAL HAZARDS: E.g. Physical contact with sharp objects, noise exposure, physical injuries from waste collection and handling etc CHEMICAL HAZARDS: Although chemical and pharmaceutical products may be found in small quantities in health care waste, these substances are hazardous. They may cause intoxication, either by acute or by chronic exposure, and injuries, including burns. Intoxication can result from absorption of a chemical or pharmaceutical substance through the skin or the mucous membranes, or from inhalation or ingestion. Injuries to the skin, the eyes, or the mucous membranes of the airways can be caused by contact

5 with flammable, corrosive, or reactive chemicals (e.g. formaldehyde and other volatile substances). It should be stated that the most common injuries are burns. BIOLOGICAL HAZARDS: Infectious waste may contain any of a great variety of pathogenic microorganisms. These viruses are generally transmitted through injuries from syringe needles contaminated by human blood. There is particular concern about infection with human immunodeficiency virus (HIV) and hepatitis viruses B and C, for which there is strong evidence of transmission via health-care waste. According to the official data from WHO, 25 million people have been infected with hepatitis viruses C and with HIV, because of the inappropriate management of health-care waste. It is estimated that one infection take place in blood transfusions. ENVIRONMENTAL HAZARDS : Apart from the risk to the patients and health care personnel, consideration must be given to the impact of health care waste to the general public and the environment. In particular, attention should be paid to the possible pollution of the air, water and soil including the aesthetic aspects. If medical waste are not segregated efficiently, hazardous waste fractions will be disposed to landfill together with non hazardous medical waste. This entails high risk of fire/ explosion at landfill site, pollution and public health. Special attention must be given in order to impose limits on the discharge of hazardous liquids to sewers. Principles Regarding the Collection of Health-Care Waste The effective management of health care waste considers the basic elements of waste minimization, segregation and proper identification of the waste. Different types of medical wastes should be collected separately according to their characteristics, as depicted in Table 6:

6 Table 6: Collection Principles regarding Health-care waste Collection Type of Health-care waste (according to treatment process) Non Hazardous Container Type Plastic bag Color and Labeling Color: Black No labeling Infectious waste (sterilization) Container (hospital box) with inert double plastic bag (strong, leak proof, Puncture proof) Color: Yellow Labeling: Hazardous medical Waste, sign of Bilogical Hazard, date and source of waste generation Infectious Waste (incineration) Container (hospital box) with inert double plastic bag (strong, leak proof, Puncture proof) Color: Red Labeling: Hazardous medical Waste, sign of Bilogical Hazard, date and source of waste generation Infectious and toxical waste (incineration) Container (hospital box) with inert double plastic bag (strong, leak proof, Puncture proof) Color: Red Labeling: Hazardous medical Waste, sign of Bilogical Hazard, date and source of waste generation Sharps Puncture-proof container with lid Color: Yellow Labeling: Hazardous medical Waste, sign of Bilogical Hazard, date and source of waste generation

7 Picture 1 Picture 2 Picture 3 Hazardous Waste Hazardous Waste Container for sharp objects (Sterilization) Incineration Management of Other medical waste fractions (pharmaceutical, radioactive, batteries etc) Large quantities of obsolete or expired pharmaceuticals stored in hospital wards or departments should be returned to the pharmacy for disposal. Other pharmaceutical waste generated at this level, such as expired drugs or packaging containing drug residues should not be returned because of the risk of contaminating the pharmacy. It should be deposited in the specified container at the point of generation. In particular expired pharmaceuticals and Cytotoxic waste should be collected in strong, leak-proof containers, labeled with the date and the source of waste generation. The entity responsible for the management of radioactive waste (treatment, import, export, disposal) is the Greek Atomic Energy Commission is an independent civil service, supervised by the General Secretariat of Research and Technology (GSRT) under the Ministry of Development. Health care Facilities should

8 implement the Joint Ministerial Order 1014 (FOR) 94, Official Gazette No 216/B/ , "Radiation Protection Regulations". Used Batteries should collected separately in special containers and delivered to the certified management system AFIS S.A. Used oils from vacuum pumps and engines oils should be collected separately and delivered for special treatment. Aerosol containers may be collected with non hazardous health care waste once they are completely empty. Aerosol containers should not be burnt or incinerated. Waste with a high content of heavy metals (e.g. cadmium or mercury) should be collected separately in strong, leak proof containers and the identity of the chemicals should be clearly marked on the containers. What are the specifications of temporary storage areas for hazardous medical waste? Που μπορώ να αποθηκεύσω προσωρινά τα ιατρικά απόβλητα? Storage areas for hazardous medical waste should have necessary capacity and environmental conditions that prevent the modification of physical and chemical characteristics of the wastes. The site should be clearly labelled with the biological hazard sign and have at least the following specifications: The storage area should allow easy access for staff in charge of handling the waste, Easy access for waste collection vehicle is essential Floors, walls, and ceilings of the storage area must be kept clean in accordance to established procedures, which at a minimum should include daily cleaning of floors There should be good lighting and adequate ventilation

9 The site should be protected from sun, rain, strong winds, floods, etc and been connected to wastewater sewage system. The storage area should have an impermeable, hard-standing floor with good drainage and should be easy to clean and disinfect. It should be possible to lock the storage area to prevent access by unauthorized persons The storage area should not be situated in the proximity of fresh food stores or food preparation areas Floors, walls, and ceilings of the storage area must be kept clean in accordance to established procedures, which at a minimum should include daily cleaning of floors A supply of cleaning equipment, protective clothing, and waste bags or containers should be located conveniently close to the storage area Should have fire protection equipment (fire prevention measures) The infectious waste should be temporarily stored in special areas inside the health care facility or the treatment facility in temperature < 5 0 C and no longer than 5 days. In case of quantities less than 500 lt, infectious waste can be stored for a maximum period of 30 days and in temperature 0 0 C. Toxical waste should be temporarily stored in special areas inside the health care facility for no longer than 2 years. Which are the specifications of the vehicle that transfers health care waste? Collection vehicles used for the transport of health care wastes should not be used for the transport of any other material. The vehicle should have an enclosed leak proof body and capable of being locked to secure the waste. The vehicle should be able to store the waste in temperature <=8 0 C and be easy to clean. It should also carry suitable

10 protective clothing and cleaning equipment. The vehicle must be marked with the international hazard sign, have fixed equipment for the measurement of the weight of wastes and automated load platform. Health care waste should be accompanied by consignment note (type of waste, source, weight) in order to be transferred. It must be mentioned that the vehicle should not be equipped with compaction mechanism. Which are the common methods for the treatment of health care wastes? According to the Greek legislative framework, infectious waste can be treated with sterilization while all the other hazardous waste categories must be incinerated. Incineration is a high-temperature dry oxidation process that reduces organic and combustible waste to inorganic, incombustible matter and results in a very significant reduction of waste volume and weight. This process is usually selected to treat wastes that cannot be recycled, reused, or disposed of in a landfill site. Wet thermal or steam disinfection is based on exposure of shredded infectious waste to high-temperature, high-pressure steam, and is similar to the autoclave sterilization process. It inactivates most types of microorganisms if temperature and contact time are sufficient. The following Figures depict the Basic Steps in Health Care Waste Handling.

11

12 Figure 1: Basic steps in health care waste management Protective clothing for health-care waste transportation

13 Table 3 : Protective clothing Protective clothing Helmets, with or without visors (depending on the operation) Face masks (depending on operation) Eye protectors (safety goggles) depending on operation. Overalls (coveralls) obligatory Industrial aprons obligatory Leg protectors and/or industrial boots obligatory Disposable gloves (medical staff) or heavy-duty gloves (waste workers obligatory. Industrial boots and heavy-duty gloves are particularly important for waste workers. The thick soles of the boots offer protection in the storage area, as a precaution from spilled sharps, and where floors are slippery. If segregation is inadequate, needles or other sharp items may have been placed in plastic bags; such items may also pierce thinwalled or weak plastic containers. If it is likely that health-care waste bags will come into contact with workers legs during handling, leg protectors may also need to be worn. Operators of manually loaded incinerators should wear protective face visors and helmets. During ash and slag removal and other operations that create dust, dust masks should be provided for operators.

14 Figure 3: Recommended protective clothing for health-care waste transportation Which are the basic measures for waste minimization? Following are ideas that promote waste reduction opportunities at a health care facility: Formulate an integrated plan for waste minimization/prevention (e.g. set targets, responsibilities, inspections) Purchase products with minimal environmental impacts, buy in bulk whenever possible Choose physical methods of disinfection instead of chemical on the condition that public health protection is being assured Firstly use the products that will expire earlier Audit chemical supplies and use inventory control for chemical substances: Improve ordering practices so perishable products don't become outdated and unusable Replace mercury thermometers with electrical ones Replace paper towels with air dryers Reduce waste from Offices, segregate recyclables

15 Compost kitchen and food waste Train your employees when they are first hired and annually thereafter in waste minimization concepts Place the containers for the hazardous medical waste only near their generation source Consider switching from disposable to reusable medical instruments (e.g., stainless steel trays, laparoscopic instruments) Use washable plates, eating utensils, glasses, and cups for cafeteria and patient service Increase double-sided copying in central copy areas, Usage of recycled paper Assess need for photocopies and print only what is needed Eliminate unused items from custom surgical packs (once a pack is opened, unused items are discarded).

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