HAZARDOUS WASTE MANAGEMENT AT HEALTHCARE FACILITIES

HAZARDOUS WASTE MANAGEMENT AT HEALTHCARE FACILITIES *Dr. D. Shreedevi *Associate Professor, Apollo Institute of Hospital Administration, Apollo Health City, Jubilee Hills, Hyderabad 500096. (M) 9441885258 (O) 040-23543269 e-mail dsridevi72@yahoo.com, dsridevi93@gmail.com Abstract Health care waste is a source of generation of hazardous biomedical waste. According to WHO Fact Sheet, of the total waste generated by healthcare activities, about 80% is general waste. The remaining 20% is considered hazardous that may be infectious, toxic or radioactive. It is necessary to design proper policies to avoid the spread of infection through waste and illegal reuse of the waste material. Policies should provide specification for handling waste for generation, segregation, collection, storage, transportation and treatment. This study is conducted to compare the biomedical waste management policies of Apollo Hospital with Delhi Pollution Control Committee (DPCC) guidelines. Policies of Environment Protection Agency (EPA) of USA and National Health care Services (NHS) of UK were studied to perform comparative analysis of global standard. A structured checklist was used to assess the accuracy of handling in compliance with DPCC guidelines. The policies of the hospital are framed in compliance with the guidelines provided with DPCC. Due to negligence and lack of supervision loopholes in the procedure was observed during the stages of storage and transportation. Key words: DPCC, EPA, health care waste, hazardous waste, NHS, WHO Introduction Biomedical waste management is an important aspect of any healthcare organization. With the increase in the consumption of utilities per bed, there is a tremendous rise in production of biomedical waste, disposal or further handling of which has gather concern of all. The biomedical waste is the waste that is generated during the diagnosis, treatment or immunization of human beings or animals or in research activities pertaining thereto, or in the production or testing of biological components. According to Bio-medical waste (Management and Handling) rules 1998, waste can be categorized into the following categories. Waste categories Category 1 Category 2 Category 3 Category 4 Type of waste Human Anatomical Waste Animal Waste Microbiology and Biotechnology Waste Waste Sharps 1

Category 5 Category 6 Category 7 Category 8 Category 9 Category 10 Discarded Medicines and Cytotoxic drugs Solid Waste Solid Waste from disposable items Liquid Waste Incineration Ash Chemical Waste Source: Delhi Pollution Control Committee guidelines Objectives of the Study To study the management of hazardous waste in healthcare facilities To know the biomedical waste management procedure of global standards viz. UK and USA To compare and analyze the shortcomings in the waste management procedure of Apollo Hospital in comparison to above mentioned standards. Methodology The initial part of the study involved observation of the process flow and functioning of various departments of the hospitals. A structured checklist was used to assess the accuracy of handling in compliance with DPCC guidelines. The hospital was divided into floors and floors were further divided into towers. Following this division the data was collected by observing each set of bins and taking personal interview of people associated with waste handling procedure. Policies formulated by DPCC, UK and USA were also studied. Two separate checklists were prepared by keeping in mind the guidelines of DPCC and global standards. Data was collected by observation of all the areas associated with storage, transportation and treatment of the waste. Housekeeping staff were interviewed for procedure related information. The study was done by taking both primary and secondary data. Sources of waste generation The sources of health-care waste can be classified as major or minor according to the quantities produced. 2

Hazardous Waste Related to Bio Medical Waste Healthcare waste includes a large component of general waste and smaller proportion of hazardous waste. Exposure to hazardous healthcare waste can result in disease or injury. The hazardous nature of healthcare waste may be due to one or more of the following characteristics: it contains infectious agent; it is genotoxic; it contains toxic or hazardous chemical or pharmaceuticals; it is radioactive; it contains sharps; All individual exposed to hazardous healthcare waste are potentially at risk, including those within healthcare establishments that generate hazardous waste and those outside these sources who either handle such waste or are exposed to it as consequence of careless management. Management of Biomedical Waste: Biomedical waste management is including four major steps. These steps help in achieving effective waste management only when followed accurately and routinely. The steps are as follows. Generation of Biomedical Waste: 3

Medical activities generate waste that should always be discarded at the point of use by the person who used the item. The quantity of HCW generated should always be minimized and precautions must be taken during their handling. 1. Environment Protection Agency (United States of America) Medical Waste Tracking Act 1988 requires U.S. Environment Protection Agency to formulate policies and find alternative means for disposal of biomedical Waste. A lot of emphasis is given to public education regarding waste disposal and waste minimization. The policies can be categorized in following manner: 1. Waste Categorization: Proper waste categorization avoids cross contamination of general waste from infectious 4

or hazardous waste. It helps in providing effective treatment to a better categorized waste. 2. Generation: Types of generators are: Hospitals, Intermediate care facilities, Clinics, Physician Offices, Dental Offices, Laboratories, Funeral Home, Veterinarian, Blood banks, Animal Care, Emergency Care, Hospices, Home Healthcare, Illicit Drug users. All these areas are concerned as potential biomedical waste generators and are supposed to follow the guidelines formulated by EPA. A lot of stress is given on waste minimization which helps in reducing the cost of material used per bed and treatment cost of waste is also reduced. Collection, Handling and Storage to be done by trained waste handlers. Containers should have bio-hazards signs. Bins should be non-corrosive and bags should be heavy plastic material. Storage area should be durable and easily cleansable. It should be protected from wind, rain, vermin & vector and should be maintain in odorless state. Floor should be impermeable to liquid with perimeter curve. 3. Transportation: Trollies and vehicle used for outside transport should be designed to facilitate least damage to structural integrity of waste. Waste should be transported only through the designed route. The waste handlers should use protection equipments. Procedures to be undertaken in case of fire should be well designed. (Out-house transportation). Proper documentation of the type and quantity of waste being transported should be maintained. Authorized personnel should only be allowed for transportation to avoid illegal reuse of needles and other kind of waste. 4. Treatment, Destruction and Disposal: S.No. Type of Waste Treatment Procedure 1. Sharps 2. Culture and Stock Steam sterilisation or incineration or thermal/chemical deactivation 3. Blood & blood products Discharge to sanitary sewer system or approved septic system. 4. Pathological Stream sterilisation or incineration or thermal/chemical deactivation. 5. Isolation waste Steam sterilisation or incineration. 6. Animal Waste Incineration 7. Unused Sharps Sealed in hard-to-open container then chemical disinfection or steam sterilization or incineration. 8. Low level radioactive substance Chemical decontamination. Never steam sterilize 9. Antineoplastic waste Chemical decontamination and never steam sterilize. 10. Small Volume of Chemical hazardous Waste Same as above. 2. National Health Care Services (United Kingdom) 1. Healthcare Waste Generation: Healthcare waste is generated during the course of patient treatment. Waste generated from treatment processes may be clinical, hazardous or household at the final point of disposal. Hazardous waste is any waste that displays one or more of hazardous properties H1-14 set out in the Hazardous Waste (England and Wales) Regulations, 2005. 2. Segregation To comply with the Duty of Care requirements, different types of controlled waste (some of which may also be hazardous) need to be kept separate (not mixed) and may also require specialized 5

containment in order to reduce contamination potential. 3. Containment Containment of all wastes must be appropriate to the level of risk. Wastes considered dangerous for transport on the road e.g. some clinical and hazardous wastes, require UN (United Nations) approved packaging and containment. Each waste type affected by this legislation is also assigned an individual UN number, e.g. most clinical waste is classified as UN3291. This code is displayed on all UN approved packaging designed to contain clinical waste bags, boxes. Sharps bins must display the British Standard kite mark and the code BS 7230 4. Decontamination Aims to prevent or minimize exposure to potentially hazardous substances or pathogens from bodily fluids, cultures etc. by cleaning equipment using a disinfecting or sterilising agent suitable to the level of risk. This procedure must be undertaken for reusable equipment prior to being sent for repair to Biomedical Engineering. Completion of a decontamination/decommissioning certificate once cleaning has been undertaken informs staff that the equipment they are removing is free from contamination and therefore safe for handling or disposal. A completed decontamination / decommissioning certificate must be attached to the equipment prior to removal for repair or disposal 5. Decommissioning Decommissioning of equipment is removal from use. The equipment may be broken, obsolete or due for replacement. Decommissioned equipment needs to be made safe prior to disposal. 6. Collection and Transport All clinical and household waste left in disposal areas will be removed from all internal departments at least daily as a minimum requirement. Where appropriate wheelie bins are supplied to contain waste in disposal areas. Portering or support staff removes waste from internal disposal areas to external storage. Service staffs remove bins from external units to the waste compound. All clinical waste must be bagged or placed in a rigid container before placing into Euro type /wheelie bin. 7. Storage of Clinical Waste awaiting collection Containers must be kept secure from unauthorized persons, entry by animals and free from infestation by rodents and insects while on site. Clinical waste bins must be kept locked at all times. Clinical waste stores must be kept locked when unattended or outside normal working hours in order to prevent escape of waste. Gap Analysis: It is the comparison between the Current Practices of Apollo Hospitals and Guidelines recommended by Delhi Pollution Control Committee. For this analysis, the guidelines were divided into four categories: 1. Basic Requirement 2. Generation & Segregation 3. Collection & Storage 4. Transportation 5. Treatment 6

ANALYTICAL COMPARISON WITH GLOBAL STANDARDS 1. Generation and Segregation EPA NHS DPCC Apollo 7

1. Segregated broadly on basis of solid, liquid & sharps. 1. Segregation at point of generation. 1. Segregation at the point of generation. 1. Segregation at point of generation. 2. Segregated according to treatment method. 2. Segregation based on method of treatment. 2. Segregation according to treatment method. 2. Colour coding as directed by DPCC. 3. No colour coding followed. 3. Six colour coded bins for effective segregation. 3. Four colour coded bins for effective segregation. 3. Separate container for needles, blades, scalpel, etc. 4. Classified under 10 heads on basis of infectivity & toxicity. 4. Sharps should be immediately disposed after use. 4. Sharps to be disposed in Sharps bin puncture proof white container. 2. Collection EPA NHS DPCC Apollo 1. To be done by trained waste 1. Waste handlers 1. Use of PPE by waste 1. Waste handler use PPE. handlers. should use PPE. handler. 2. Regular disinfection of trolleys 2. Waste should be filled 2. Seal the bags by cable 2. Bags sealed with cable. & restrict the use of trolleys for only up to 3/4th of the before transferring to central waste handling only. bag. storage. 3. Containers should have bio- 3. Latex/Nitrile gloves 3. Bio-hazard sign should 3. Biohazard sign displayed on hazards signs used for handling sharps. be displayed on every bin the bins. 4. Bins should be non-corrosive 4. Heavy & Medium duty & bags should be heavy plastic plastic bags should be material. used. 5. If bags get contaminated from outside cover it with fresh bag before transporting. 6. Place antineoplastic drug waste in bag on 4-mil polyethylene or 2-mil thick polypropylene 3. Storage 8

EPS NHS DPCC Apollo 1. Storage area should be 1. Waste should be 1. The bins should not be 1. Waste should not be stored for durable & easily cleansable stored secure from allowed to fill more than more than 48 hrs. unauthorized person. 3/4th. 2. It should be protected from 2. It should be secured 2. No entry for 2. Bags should not be allowed to wind, rain, vermin & vector and from rain water, animals & unauthorized persons in fill more than 3/4th of the bag. should be maintain in odourless wind. storage area. state. 3. Floor should be impermeable 3. Central storage should 3. The containers should 3. Common room to store all to liquid with perimeter curve. be spacious enough to have lid to cover the waste types of waste in central storage. store different waste in the storage. separately. 4. Provide storage area with 4. Designed by special 4. Waste should not be proper ventilator. team in accordance with stored for more than 48 the requirement. hrs. 5. It should have access to only 5. Bins should be authorized personnel & should disinfected regularly. have bio-hazard sign displayed. 4. Transportation EPA NHS DPCC Apollo 1. Trolleys and vehicle used for 1. Wheelie bins should be 1. Colour coded trolleys to 1. Wheelie bins used to outside transport should be used for convenient be used to transport the transfer the waste. designed to facilitate least transportation. waste. damage to structural integrity of waste. 2. The waste handlers should 2. Specific route should be 2. Waste should be 2. Only 2 different colour use protection equipments. designed for in-house transported via designated trolleys used to transport the transportation route only. waste. 9

3. Procedures to be undertaken 3. Before out-house 3. Waste should not cross 3. Labelling is done before in case of fire should be well transportation all the public areas. carrying it to central storage. designed. (Out-house documentation should be transportation) done. 4. Label on the waste 4. Closed lid trolleys used to should contain all the transport. details. 5. The waste should not 5. Before handing the waste come in contact with outer to vendors proper environment while documentation is done. transporting. 5. Treatment EPA NHS DPCC Apollo 1. Sharps: 1. Anatomical Waste: Incineration. Refer Table 1. Sharps: Autoclaved then shredded & sent for landfills. 2. Culture & stock: Steam sterilization or incineration or thermal/chemical deactivation. 2. Radioactive Waste: Incineration. 2. General Waste: Handed over to municipal corporation for further disposal. 3. Blood & blood products: Discharge to sanitary sewer system or approved septic system. 3. Cytotoxic Waste: Incineration. 3. All other waste is handed over to vendors as authorized by the DPCC. 4. Pathological: Stream sterilization or incineration or thermal/chemical deactivation. 4. Confidential waste: Shredding and landfill. 5. Isolation waste: Steam sterilization or incineration. 6. Animal Waste: Incineration 7. Unused Sharps: sealed in hard-to-open 10

container then chemical disinfection or steam sterilization or incineration. 8. Low level radioactive substance: Chemical decontamination. Never steam sterilize 9. Antineoplastic waste: Chemical decontamination and never steam sterilize. 10. Small Volume of Chemical hazardous Waste: Same as above. Comparison with global standards infers inclusion of few more aspects like: There can be policies regarding handling of solid and liquid waste separately. There can be policies referring to handling of broken glasses & metallic sharps. Policy can be made specifying the type of plastic bags used for waste storage. Design specification of central storage area can be included in policy framework. In case of fire, flood or other such emergency, method of handling biomedical waste can be specified in the policy. Specific route can be designed and included in policy. Conclusion To conclude, the policy framework of the hospital is found to be appropriate in most of the aspects. Gap analysis performed between the current practices and DPCC guidelines reveals that staff was found to be aware of the correct means and methods of dealing with biomedical waste. However, housekeeping staff was found to be unaware of waste transportation route. Central Storage area was found to be very poorly organized. Strict supervision should be done to check on segregation practices. Separate body of supervision can be framed who can supervise the disposal station every now and then. References 1. Bekir Onursal, Health Care Waste Management in India - The World Bank October, 2003. 2. Best Management Practices for Hospital Waste, Washington State Department of Ecology, December, 2005. 3. Bio-Medical Waste (Management and Handling) Rules, 1998. 4. Central Pollution Control Board Manual 5. Delhi Pollution Control Committee manual 6. Environment Protection Agency (USA): Model guidelines for State Medical Waste Management 7. Hazardous Waste Management at Health Care Facilities NCDENR Division of Waste Management. 11

8. Hema Chandra, Hospital Waste An Environmental Hazard and its Management. ISEB Vol. 5. No.3 July 1999. 9. National Health Services (UK): Waste Policy and Procedure. 10. Patil AD, Shekdar AV (2001), Health care waste Management in India, pubmed 11. Safe Management of Wastes from Health Care Activities - WHO, Geneva, 1999. 12. World Health Organization: http://www.healthcarewaste.org 12