Waste management in hospital

Waste management in hospital

Guide : Dr. Purwa Patil

• Waste generated in a health care has an inherent potential for dissemination of infection.

• A total of 1-2 kg of waste per bed is generated per day is generated in a hospital.

• Hospital waste can lead to infectious, environmental and aesthetic problems for community.

• Fortunately, only 10% of the waste generated in a health care setting is infectious:

• Hence, segregation is the key to healthcare waste management.

• Medical waste:• Any waste, which is generated in the diagnosis,

treatment or immunization of human beings or animals, in research pertaining thereto, or in the production or testing of biological.

• This definition does not include medical waste resulting from medical care at home.

Classification of Health Care Waste:

• Hospital wastes may be categorized into:• A) Non-hazardous waste • B) Hazardous Wastes

A) Non-hazardous waste• This consists mainly of kitchen waste, general office

waste.

• Kitchen waste can be divided into 2 categories – i) Biodegradable kitchen waste: which includes

peels of fruits and vegetable skin and leftover food, tea, drugs and other natural kitchen wastes.

ii) Non-biodegradable waste: This category of kitchen waste includes wrappings, foils, plastic bags and other material

B) Hazardous WastesPotentially infectious wastes and potentially toxic wastes.

i) Potentially infectious waste from patient care includes – a) Dressings and contaminated swabs b) Laboratory samples, cultures, stocks of infectious agents, laboratory glassware. c) Instruments used in patient care such as endoscopes, ultrasound probes, syringes and needles,

sharps etc.d) Potentially infected materials, placenta, tissues, tumours, organs e) Potentially infected animals used in diagnostic or research studies.

In all these wastes the major concern is to prevent potential accidental transmission of infection.

ii) Potentially toxic wastes include – a) Radioactive waste : These may be solids, liquids and gases used

for analytical procedures, imaging and tumour localization and treatment.

In India, the responsibility for use and disposal of radioactive material is with the Bhabha Atomic Research Centre.

b) Chemical waste: These may be hazardous, toxic, corrosive, inflammable, reactive or genetoxic.

c) Pharmaceutical waste : as a result of surplus stock, spillage, detection of contamination. Should not get recycled or lead to ecologically undesirable side effects.

• The Bio-medical Handling and Management Rules formulated by the Ministry of Environment and Forests(1998) has classified medical waste and suggested a methodology for their handling and disposal

Steps in Waste Management1.segregation

2.Storage

3.Disinfection

4.Transportation

5.Record Keeping

6.Final Disposal

1.Segregation:• Waste should be

segregated at the point of generation.

• Segregation helps to: a.reduce cost b.prevent general waste

from becoming infectious

c.reduce chances of infection in health care workers

Categories of bio- medical waste

Category Category Type of wasteType of waste Treatment & disposal Treatment & disposal optionoption

Category 1Category 1 Human anatomical wastesHuman anatomical wastes Incineration/deep burialIncineration/deep burial

Category 2Category 2 Animal wastesAnimal wastes Incineration/deep burialIncineration/deep burial

Category 3Category 3 Microbiology & bio-technology Microbiology & bio-technology wasteswastes

Local/ autoclaving/ Local/ autoclaving/ microwaving/ incinerationmicrowaving/ incineration

Category 4Category 4 Sharps Sharps Disinfection / autoclave / Disinfection / autoclave / shreddingshredding

Category 5Category 5 Discarded medicines & Discarded medicines & cytotoxic drugs.cytotoxic drugs.

Incineration / destruction Incineration / destruction and land filland land fill

Category 7Category 7 Solid wastes- disposable Solid wastes- disposable itemsitems

Disinfection / autoclaving / Disinfection / autoclaving / shreddingshredding

Category 8Category 8 Incineration ashIncineration ash Municipal land fillsMunicipal land fills

Category 9Category 9 Chemical wastes – used in Chemical wastes – used in biological production, biological production, insecticides.insecticides.

Chemical treatment, Chemical treatment, discharge into drains.discharge into drains.

Category 6 Category 6 Soiled wastes-contaminated Soiled wastes-contaminated with blood / body fluids.with blood / body fluids.

incineration/incineration/autoclaving/ microwavingautoclaving/ microwaving

2.Storage

Table showing Colour coding and containers for disposal of bio-medical wastes

Colour codeColour code Type of Type of containercontainer

Waste categoryWaste category Treatment optionsTreatment options

YellowYellow Plastic bagsPlastic bags Human & animal wastes, Human & animal wastes, Microbial and bio- technologicalMicrobial and bio- technologicalwastes, and soiled wastes (category wastes, and soiled wastes (category 1,2,3 and 6)1,2,3 and 6)

Incineration / Incineration / deep burialdeep burial

RedRed Disinfected Disinfected container / container / plastic plastic bagbag

Microbiological and Microbiological and Biotechnological wastes, Biotechnological wastes, soiled & solid wastesoiled & solid waste(Category – 3, 6 and 7 )(Category – 3, 6 and 7 )

Autoclaving / Autoclaving / microwaving / microwaving / chemical chemical treatmenttreatment

BlueBlue // White White transparenttransparent

Plastic bag / Plastic bag / puncture puncture proof proof containercontainer

Waste sharps and solid wasteWaste sharps and solid waste (category 4 & 7)(category 4 & 7)

Autoclaving / Autoclaving / chemical T. chemical T. destruction and destruction and shreddingshredding

BlackBlack Plastic bag Plastic bag Discarded medicines, cytotoxic Discarded medicines, cytotoxic drugs, incineration ash and drugs, incineration ash and chemical wastes. Category 5, 6 & 9chemical wastes. Category 5, 6 & 9

Secured Secured landfillslandfills..

Segregated in pink/red bags. These are not to be incinerated.

INFECTIOUS PLASTIC ITEMS SHARPSCustom made puncture proof containers.

NON-PLASTIC INFECTIOUS WASTE

Yellow plastic bag is used Items include cotton dressings, anatomical waste.

Choice of bins

• Plastic or metal bins for waste storage can be used to save on the cost and paper work.

• If reusable containers : must be cleaned and disinfected regularly.

• The containers should be smooth and well rounded from inside

• Should be labeled with the Biohazard symbol and the types of waste they have to be used for.

3.Disinfection

• Chemical disinfection of waste is required at source, so that this is no longer the source of pathogenic organisms.

• A good disinfectant is bleach.

• The concentration prescribed by WHO is 10 gm of bleach in 1 litre water.

• Medical wastes that have been chemically disinfected should continue to be treated as hazardous, till careful bacteriological testing has shown disinfection to be complete.

Recommended Dilution of Chlorine Releasing Compounds :

Available chlorineAvailable chlorine ““CleanClean”” condition condition ““DirtyDirty”” condition condition

Required chlorineRequired chlorine 0.1% 1 gm / litre0.1% 1 gm / litre 0.5% 5 gm / litre0.5% 5 gm / litre

Sodium hypochlorite solutionSodium hypochlorite solution5% available chlorine5% available chlorine

20 ml / litre20 ml / litre 100 ml / litre100 ml / litre

Calcium hypochloriteCalcium hypochlorite70% available chlorine70% available chlorine

1.4 gm / litre1.4 gm / litre 7.0 gm / litre7.0 gm / litre

(NaOCI Powder)(NaOCI Powder)Sodium dichlorosocyanurateSodium dichlorosocyanurate

1.7 gm / litre1.7 gm / litre 8.5 gm / litre8.5 gm / litre

(NaOCI Tablets)(NaOCI Tablets)Sodium dichlorosocyanurateSodium dichlorosocyanurate

1 tablet / litre1 tablet / litre 4 tablets / litre4 tablets / litre

Chloramine Chloramine (25% available chlorine)(25% available chlorine)

20 gm / litre20 gm / litre 20 gm / litre20 gm / litre

* Clean condition – after removal of bulk material* Dirty condition – before removal of bulk material

• Other chemical disinfectants that can be used are

• Ethanol 70%• Glutaraldehyde2% for 30mins• Polyvidone iodine 2.5% for 315mins• Hydrogen peroxide 6% for 30mins

• Disposable items :• Items like single use products, syringes, IV bottle, catheters

and rubber gloves. • Procedure: dip them for a minimum of ½ - 1 hour in the

chemical disinfectant or autoclave or micro wave.• They can then be shredded, cut or mutilated. This ensures

that they are not recycled/ used.

• Sharps :• Major portion are the needles, which can be cut by a needle

cutter into a bleaching powder solution or autoclaved or / and shredded or be destroyed by a needle destroyer.

• Sharps should not be left casually on counter tops, food trays or beds as grievous injuries can result.

TRANSPORTATION• Proper filling in containers at regular intervals• Avoid spillage • Identify the bags by labeling of the site of

collection• Transportation by trained personnel, under

supervision and through designated areas• No untreated waste should be kept stored for

> 48hrs.

Do not mix the waste during transportation

Custom made transportation trucks used

Contd……..

• Proper handling of the bags through proper clasping• Do not allow the bags to hit the body of the personnel

Methods for treating biomedical waste

1. Mechanical process2. Thermal process3. Chemical process4. Irradiation process5. Biological process

Mechanical process

• To change the physical form or characteristics of the waste to make further handling easier:

A) compaction: decreases the volume of the waste

B) shredding: granulation, grinding, pulping• Can be used for decontaminated waste

Thermal process

• Use heat to destroy or decontaminate. Is of two types:

1. Low heat systems: temp.< 150°, eg. steam, hot water etc.

2. High heat systems: temp.- 600° - 5500°

Incinerator• Historically most commonly used

by health care

• Involves complete combustion of carbon containing compounds in presence of air and fuel to gases & ash

• Current criteria: at 1200° for > 2 sec.

• Chlorinated plastics should not be incinerated.

• Only low sulphur fuels should be used.

• Combustion efficiency : 99.0%

Advantages: ses vol. & wt. by > 95% - low transportation and disposal cost.Indigenous technology; servicefacilities available.Available in different sizes: > 50 kg/hr.

Disadvantages: air pollution control equipment, lot of fuel: increases

cost.Emission of toxic compounds, gases.If glass present – leads to slagging.Requires skilled operators.liquid waste requires proper treatment before disposal.Faces public and NGOs opposition.

Steam sterilization: a. Autoclave • Destruction of micro organisms at 121°c at 105kPa for 60 mins.

• Cylindrical vessel with provisions for uploading and unloading

• Steam is introduced by either vacuum or gravity displacement

• Steam should penetrate the waste

• Validation test: bacillus steathermophillus spores are used.

• Advantages:

• Appropriate for microbiology, lab waste, blood, fluids, sharps, etc.

• Simple maintenance, low operational costs.• Easily available servicing facilities.• 30% reduction in volume

• Disadvantages:

• Liquid waste needs prior treatment• Less reduction in volume• Patological waste, radioactive waste,

chemicals, should not be treated.• Steam wets the waste se wt

b.Hydroclave• Innovative combination of waste

sterilization, fragmentation, and dehydration.

• Double walled vessel fitted with a motor driven shaft to which are attached powerful fragmenting/mixing arms.

• Steam transmits heat rapidly to fragmented waste

produces steam on its own

• Advantages:• Faster• 6 log bacterial spore reduction• Waste becomes unrecognizable, so suitable for landfill.• Minimal operator training• Low operational cost.• Hydrolysis of organic waste• 80% se in vol.• 50% se in mass• Self unloading

• Disadvantages:• Foreign made.• High capital cost

STAGE ONE - LOADING Bagged waste, in ordinary bags. Sharps containers. Liquid containers. Cardboard containers. Metal objects. Pathological waste.

STAGE TWO - STERILIZINGPowerful rotators mix the waste and breaks it into small pieces. liquid in the waste turns to steam. Needs 20 mins.

STAGE THREE - DEHYDRATIONsterile liquid drained into sanitary sewer. Steam heat and mixing continue until all the liquids are evaporated and the waste is dry.

STAGE FOUR - UNLOADINGThe mixer now rotates in the opposite direction angled blades on the mixer to push the waste out the unloading door. The dry sterile waste is fine-shredded or dropped in a waste disposal bin. The waste is now ready for safe disposal

• Vapoclave:• State of the art• Steam run unit for nonincinerable

waste• Operates at low temp. – 135°c• Level of sterilization ≥ log 6.• Less time needed.• 70% se in vol.• Continuous agitator: good heat

penetration.• No direct human intact.• Treated waste baled fuel for boilers• Destruction is smokeless.• Low operational cost

• Microwave:• High frequency waves

molecules vibrate heat generated from inside.

• Advanced technology.• Microwave radiation kills org.• Waste needs prior shredding and

moistening.• Automatic hoisting bucket• At 94°c for 25 mins.• Appropriate for blood, lab waste,

microbiological waste, fluids, sharps etc.

• Minimal operator training.• Low operational costs.• 80% se in vol.• Compact equipment.• Controlled by computer.• Cost: 12 lakhs – 1.5 crore.

• Plasma systems: material in which temperature is so high that some electrons et separated from atoms.

• Heats waste at very high temp. In oxygen deficient mode glass like residue.

• Gas sterilization: exposure to high concentration of sterilizing gas – ethylene oxide and formaldehyde.

• Both are potential carcinogens.• Costly. Should be used only as a substitute.

• Irradiation: • cobalt 60 / electron beam accelerator gun.• Require post shredding• high capital cost

• Biological process: by using biological enzymes for destruction of all organic waste.

• Biodegradable waste disposal: by biodigestion by bacteria / earth worms.• Can be used as biofertilizer

Deep burial

• Pit / trench: 2 metres deep• Half filled with waste• Covered with lime within 50 cms of surface.• Soil cover.• Animals should not access to the site.• Shallow wells should not be around the pit.• Pits should be distant from the habitation.

Waste reduction and re-use :• More wastes = more expense on waste disposal. • Reuse reduces disposal and procurement cost • Discretion should be applied in selecting disposable and

reusable material depending on the situation, e.g. General Wards and OPD can use mostly reusable items but casualty departments may incorporate more of disposable items.

• The idea behind proper procurement is to find –1) alternative to single use items where possible.2) alternative materials which are more environmentally benign at all stages and even during disposal and ,3) medical kits that do not have much packing and which have longer life cycle

QUANTUM OF HOSPITAL WASTE

• Depends upon the workload of the hospital• Up to 6 Kg/person/year in high income

countries• Difficult to measure in low income countries;

may be about 0.5 to 3.0 Kg /person/year.• CMC produces about 1-1.2 ton of waste /day

SAFETY PRECAUTIONS

• Waste handlers and drivers be trained / educated about waste disposal

• Written protocols be made available• Strict implementation for the use of

protective gears• Awareness programs for the safety of

hospital waste handling

HOSPITAL WASTE

Infectious Non-infectious

Sharp needles, Non-sharp Card Board boxes Kitchen etc. wasteScalpel , blades (B) (C ) (A)

Contaminated waste Laboratory wasteRelated secretionsexcretions (D)

(E) (F) (G) (H) Plastics, PVC, Non Plastic Specimen Pathology Tissues Respiratory equip. Cotton Gauze (Blood & Animal carcass Pipette, PP etc. Linen body fluids) (Soft plastic, bloodbags, I.V. Cath)

puncture proof containers with1% hypochlorite solution

in big boxes or bags

– decontaminate – drain

– autoclave – shred – recycle

Incineration / decontaminate

Microwave/ drain

Incineration

black bags

THE INDIAN SCENARIO

• Poor hospital waste disposal system except in a few hospitals

• In 1998, Government of India laid rules and regulatory laws for proper disposal of waste

• Few private agencies operate in metropolitan cities

In Sassoon…• Only RED bags are used as they are easily available

and easy to use.• Syringes & needles are discarded in separate

containers with 1% sodium hypochlorite solution.• Gloves are also discarded in a container with 1%

medichlor solution. • Cardboard boxes: used for paper waste / non

infectious plastic waste• Waste bins: infectious plastics.• Red bags: infectious material

Disposal in Sassoon• Red bags and kitchen waste: picked up by Image India , a

private company.• Non infectious plastic, infectious plastic after sterilization:

taken by a private company for recycling• Rest of noninfectious waste: picked up by the Pune municipal

corporation for land fill.• Needles & sharps: collection boxes are sealed and given to

the Jamadar for disposal in land fill.• Blood and body fluids: disinfected by adding 1% na.

hypochlorite for minimum of 10 mins and then thrown down the drain.

• Pathology specimens are formalin fixed, so treated as noninfectious: Collected by PMC.

PATHOLOGY

• OPD• CCL• Histopathology • Autopsy

OPD• Lancets, needles,

• Blood, urine, stool, semen samples

• Gauze, cotton• Gloves, plastic

• Store in 10% Na hypochlorite, send to Jamadar• Disinfect with 10 % Na hypochlorite, wash down the drain• Red bag.• Disinfect------

reuse/recycle

CCL• Blood samples, body

fluids, bone marrow

• Glass slides, chambers, test tubes, • Needles, lancets

• Syringe, plastic• Gloves, • Gauze, cotton• paper waste

• Disinfect with 10 % Na hypochlorite, wash down the drain• Treat as above, reuse.

• Store in 10% Na hypochlorite, send to Jamadar

• Disinfect, recycle• Disinfect, reuse/recycle• Red bag• PMC

Histopathology • Tissues and organs – formalin

fixed.• Body fluids, urine, sputum etc.

• Bulbs, test tubes• Blades, needles,

• Infected gauze, cotton, • paper waste• Syringes, gloves, plastic aprons

• PMC collection/ Incinerator• treat with 10% Na hypochlorite for 10 mins, wash down the drain.

• Treat as above, reuse.• Sharps, stored & send to Jamadar • Red bag.• PMC• All disinfected plastic-

recycle/reuse.

Autopsy

• Organs- formalin fixed

• Containers, carry bags• Scalpel blades, gloves,

aprons, • Paper waste

• PMC collection/ Incinerator• PMC collection

• Disinfect, Jamadar• Reuse/recycle• PMC collection.

Biosafety precautions in laboratory• CDC statistics: * HIV through needle stick: 0.25-0.3% * HBV through needle stick: 9-30% * HCV through needle stick: 3-10%• Modes of exposure to blood borne pathogens in the

lab: * During collection * Transfer of specimen * Processing of sample * Cleaning/washing * Disposal of waste * Transport to any other lab

• Universal precautions apply to: Blood, other body fluids• Universal precautions do not apply to: Faeces, nasal secretions, sputum, sweat,

tears, urine, vomitus.• Universal precautions include: Barrier protection, hand washing, safe

techniques, safe handling of sharp items, specimen, blood/body fluids

Handling blood spills

• Cover the contaminated surface with absorbable material, ie. Tissue paper etc.

• Pour 1% Na hypochlorite solution on and round it and keep for > 10 mins.

• Remove paper with gloved hands and throw it in the bin for infectious waste.

• Again clean the area with a mop.• Wear gloves during the entire operation