18. The Waste Audit The Waste Audit is the first step for the implementation of an economical and ecological waste management system. Before actions towards a modern waste management can be done, a detailed picture of the current situation of the existing waste management must be available. The goal of a Waste Audit is to conduct a survey of the waste streams in a hospital and to learn where, how and why the waste is generated, this in dependence of the different sectors and sub-sectors of a hospital. With these researched data and information, it will be possible to set up a waste management concept to minimize the waste streams and to determine which actions will be most beneficial, as well as to identify potential areas for improvement of the current waste management. Additional, these data will be the base to control the efficiency and the developments of the waste management in the future. 18.1 The steps of the Waste Audit 18.1.1 The planning of the Waste Audit Before the waste audit can start, a basic research structure must be worked out to ensure a smooth and successful investigation. Following points should be cleared before starting a waste audit: Agreement by the board of directors Definition of the to be researched hospital areas Definition of the to be researched information Definition of the to be researched kind of waste Definition of research period Definition of the expected results Calculation of the needed time Calculation of the needed materials Calculation of the supported staff Set up of a Master plan and a mile-stone planning for the waste audit 18.1.2 Information gathering The first step of the Waste Audit is to collect necessary information about the current waste management in the hospital. This will include information about: The kinds of waste generated in each department 1
Segregation, collection, transportation, storage, disposal, documentation of the different waste groups Recycling and reuse of materials Level of awareness and knowledge among the staff about the waste hazards Occupational safety Information of the expected waste generation, based on existing disposal documentation or based on purchasing records and experience Information on disposal costs and income from recyclable materials Information on ongoing or planned waste initiatives The information can be collected during visits to the different departments based on an in forehand prepared list. The responsible staff of the departments should be met and interviewed based on this standardised questionnaire. Furthermore, information about the waste generation can be found in the purchasing records (material input = waste output). Moreover inspection and analysis of the existing documentation of the waste disposal is a source for information about the generated waste amounts in the hospital. Nurses, cleaners, transportation workers should be interviewed in the terms of occupational safety and the needle stick problem. Existing waste management equipment such as bins, bags, containers, trolleys, incinerator, as well as protective clothing should be investigated and recorded in an inventory list. 18.1.3 Waste stream analysis Often it can be noticed that the available data are not sufficient, not trustable or completely missing. Especially if a waste management system will be introduced for the first time, hard data are missing. To find out this kind of data, often the only possibility is to conduct a waste stream analysis. Waste stream analysis means to analyse a defined waste stream in practice, to collect information on the quality and quantity of the waste stream by practical but scientifically investigation. The needed work of a waste stream analysis should never be underestimated and due to the often missing awareness of the hospital workers, it must be permanently supervised and controlled by a responsible person. As this kind of work often will be seen as dirty, dangerous and useless, it often will not be carried out in a professional way or not at all. This leads to the set up of waste management plans based on wrong data and ends in wrong investments, missing or oversized equipment and the set up of worse waste management action plans. To get a trustable data basis for the decision on to be carried out next steps, for an analysis period of not less than 1 3 weeks ( at least 7 days per + 1 trial day = 8 days = data of one complete week 24 hours per day) the complete, defined waste stream must be measured. To do: Controlled measurement of quantity (volume, weight) and quality (segregation, etc.) of the specified waste streams from the specified areas 2
Daily documentation of the results of the carried our research (Per stream and area: Volume, weight, quality, date) Documentation of the research area (Number of patients, occupation rate of the beds, etc.) Evaluation and analysis of the collected data per research area. How to carry of the measurement of the waste: Measurement of the volume: Filling of the collected waste in containers with a defined volume (if unknown filling with water to find out) Measurement of the weight: Filled containers will be weight (Waste weight = Total weight -Container weight) Quality inspection: Opening of the waste bags under observation of work security, inspection of the segregation quality How to evaluate the results: Calculation of the waste production on Patient-day basis, if possible divided in in-patients and out-patients (e.g. 69 in-patients, 123 kg waste = 1,78 kg/patient-day, 230 out-patients, 89 kg waste = 0,39 kg/out-patient) Calculation of the density (Kg/m³) for the planning of the segregation point bin capacities (e.g. 69 kg/0,61 m³ = 113 Kg/m³) 3
18.2 Sample guide Waste Audit Step 1: Set up of the research plan 1.1 Organisation of the waste audit: Who will be responsible for the waste audit? Who will take part and work on the waste audit? What will be the task of everybody involved (Job description)? Who must be informed? Who will take the decision if a waste audit will be carried out? 1.2 Target planning waste audit: Which information and data shall be available after the waste audit? Why are they needed? Which waste streams will be investigated? Which departments shall be investigated? Who must be interviewed? Which information and data will be necessary? When must the waste audit be finished? How must the results be evaluated and presented? 1.3 Resources planning: What kind of equipment will be needed during the waste audit? Will this equipment be available or must it be purchased? How much time will everybody involved in the waste audit need (in hours)? How much time will be needed for interviews, etc.? 1.4 Project planning: Start of the waste audit? Set up of a time schedule for the duration of the waste audit Division and sub-division of the different task to be carried out Task planning for everybody involved in the project (Who is doing what till when) Set up of a mile-stone planning 1.5 Presentation of the research plan and decision by the board of directors 4
Step 2: Information gathering 2.1 Analysing the structure and organisation of the hospital: Set up of an organisation diagram List of all existing medical departments, function of the department, name and telephone number of the head of the department (e.g. maternity, oncology, etc.) List of all existing supporting departments, function of the department, name and telephone number of the head of the department (e.g. laboratory, pathology, X-ray department, etc.) List of all existing non-medical departments with function of the department, name and telephone number of the head of the department (e.g. administration, laundry, kitchen, store and logistics, etc.) List of all existing committees with a description of the task of the committee, name and telephone number of the head of the committee (e.g. infectious control committee, housing committee, etc.) Clearance of the pathways of decision making divided in different levels: o For personal matters o For purchasing and investments o For organisational matters 2.2 Input analysis of the hospital: How many people are working in the hospital? What kind of hazardous goods are purchased and used? How much water and energy is consummated per year? How many beds does the hospital have in total? 2.3 Output analysis of the hospital: Medical Services: o How many patients are treated in the hospital per year (In-patients, Outpatiens)? o How many total treatment days (Duration of the stay per patient) o What are the top 15 treated diseases in the hospital? o How many cases of infectious diseases (e.g. Meningitis, Tuberculosis, Hepatitis, Haemorrhagic fevers, HIV, Herpes, etc.)? o Quantity of other medical services? (e.g. laboratory researches, etc.?) Other Services: o How many meals (breakfast, lunch, dinner) are served per year? o How many clothes are washed per year? o Quantity of other, other services? (e.g. cleaning, etc, etc.?) Waste production: o How much waste (separated in waste categories) is produced per year? o How much waste water? 5
2.3 Analysis waste management: Organisation of the waste management: o Who is momentary responsible for the waste management (Department, Head of the department)? o Which persons are strategically involved in the waste management, what are their tasks (name, task description)? o Which persons are operationally involved in the waste management, what are their tasks (name, job description)? o What are the top 15 treated diseases in the hospital? o Who is responsible for the purchasing of needed equipment and services for the waste management? o Does a waste management plan and a waste management team exist? o Does any internal policy, etc. for the waste management exist? o Does any external guideline, regulation, etc. for the waste management exist? o Are important data in regard to the waste management recorded? (Waste management planning, waste generation, incidents, waste manifests, etc.) o What kind of equipment is available for the segregation, collection, transport, storage and disposal of waste? o Are any training programs (awareness programs, etc.) being given to the hospital staff in regard to the waste management, the needle stick problem, nosocomial infections? o Are any proceedings regarding waste management available? o Is protection equipment for the waste worker available? If yes, which kind of equipment? o Did the waste worker get any vaccination (e.g. hepatitis, tetanus, etc.)? o Is there a special training program for the waste worker existing? Momentary proceeding in waste management o How is the non-hazardous waste (household waste, disposables, plastic, paper, glass, metal, etc.) handled during the steps: segregation, collection, transportation, storage and disposal? o How is the hazardous waste (for each waste group, e.g. infectious waste, pharmaceutical waste, chemical waste, radioactive waste, cytotoxic waste, etc.) handled during the steps: segregation, collection, transportation, storage and disposal? o How often is the hazardous and non-hazardous waste collected at the wards, how often is the waste disposed of? o Are any data regarding the waste generation available? 2.4 Analysis of the departments (for each department): Description of the organisation of the department How many people are working in the department? (Divided by specialisation) 6
Description of the services carried out by the department (How many beds, how many treatment days, which kind of services, etc.) What kind of hazardous materials are used in the department? Who is responsible for cleaning and the waste disposal? Description of the momentary waste management in the department What kinds of waste are generated in the department? How are the different waste groups segregated and collected? Does the staff got any training for the waste management? Are guidelines and proceedings available regarding waste management? Momentary main points of problem regarding the existing waste management How often does an accident with waste (e.g. needle stick, spillages, etc.) occur in the department What kind of equipment is available for the waste management and disposal? Is valuable waste recycled and sold? If yes how much waste per week or month, what are the prices per kg they get? 2.5 Evaluation of the gathered data 7
Step 3: Waste stream analysis 3.1 Planning and preparation of the waste stream analysis: Fixing the start and the end time of the analysis (>7 days + 1 trial day in a row), fixing the time schedule for the involved worker Fixing the kind of waste streams which will be investigated Fixing the research area (which departments), information of the departments about the background of the waste stream analysis Information of the research area about to be carried out work by them (labelling, etc.) Organisation and reservation of the already available and needed equipment (e.g. scale, containers, etc.) Purchasing of the necessary, further equipment (bags, labels, etc.) Preparation of needed data list, etc. Planning of waste collection points, information of the waste collection staff about the temporary changed way of collection in the research area Kick-off meeting with the department and other involved people 3.2 Carrying out the waste stream analysis: Collection of the waste from the research area and transportation to a fixed storage point, separate from the normal storage places Measuring of the different waste streams by volume and by weight, (once per 24 hours fixed measurement time for the complete research period) Quality control of the segregation praxis by ocular check (obtaining of the occupational safety during the inspection of hazardous waste!!!) Record keeping of the investigated data Investigation of the performance data of the research area (e.g. patients treated per day, number of X-rays carried out, number of researches carried out, amount of laundry washed, number of meals prepared, etc.) 3.3 Evaluation of the data from the analysis 8