Waste mangment

Waste Management in hospitals

Egyptian guidelines perspective

With a special thanks to Environmental department in Alexandria High institute of public health

By Dr Mohamed ABORASAlexandria medical school, MBA, Master of hospital

administrationTel [email protected]

Introduction:Health-care medical waste is a by-product of health care facility.

Examples: sharps, non-sharps, blood, body parts, chemicals, pharmaceuticals as drugs, medical devices,

Why should we manage our hospital waste?

1- Increasing number of hospitals and their wastes volumes due to increasing number of patients. 2- Increasing number of oncology departments and centers creating highly toxic and radio-active wastes.3- Highly infective bio-hazardous wastes are mis- used and reused illegally.4- Burning of dumpsites creates highly hazardous emissions from clinical wastes.5- Household similar garbage is a source of income if properly segregated.6- Cost of disposal of medical waste more 10 times than cost of disposal of non medical waste.

Poor management of health care waste:1- may expose health care personnel, waste handlers, and the community to infectious agents, to toxic materials, and to an increased risk of injury. 2- It may also damage the environment (e.g., contamination of water, air, and food). 3- In addition, if waste is not disposed of properly, members of the community may have an opportunity to collect disposable medical equipment (particularly syringes) and to resell these materials. Medical waste can potentially be reused without sterilization. This reuse of unsterilized waste material causes a large portion of the diseases that develop due to poor waste management.

خطورة أي النفايات تلك تمثل هلالعامة؟ الصحة على

مخاطر داخل

المنشأة

خارج مخاطر المنشأة

( بيئية (مخاطر

والممرضين األطباء.ومساعديهمالمرضى. للمنشأة .الزائرين النظافة عمال) المغسلة) . نقل فى العاملينمعالجتها أو النفايات

ال) مثال (تعقيمعند

الصحة منظمة تشيرفي أنه إلى العالمية

تسببت 2000عام في الملوثة :المحاقن

- عدوى 21 HBV مليون(32%)

- عدوى 2 HCV مليون(40%)

- HIV عدوى 260,000(5%)

على خطورة أي النفايات تلك تمثل هلالعامة؟ الصحة

مؤذي - منظرالقمامة - نباشو

الصرف - بشبكة تضر آكلة نفاياتوالمياه - البحرية بالبيئة يضر زئبق

الجوفيةالمجاري - تلوث للجينات سامة أدوية

المائيةمشعة - نفايات

INTERNATIONAL AGREEMENTS

The Basel Convention: HCHCW is one of the categories of hazardous wastes covered by the Convention

to minimize the generation of hazardous wastes in terms of quantity and hazardousness;

to dispose of them as close to the source of generation as possible;

to reduce the movement of hazardous wastes.

.2. The Stockholm Convention on Persistent Organic Pollutants

This Convention is a global treaty to protect human health and the environment from persistent organic pollutants (POPs).  POPs are chemicals that remain intact in the environment for long periods, become widely distributed geographically and are toxic to humans and wildlife

PRINCIPLES GOVERNING HCWM

1. Duty of care principle: Entities that generates waste has a duty to dispose it safely.

2. Polluter pays principle: All waste producers are legally and financially responsible for the safe handling and environmentally sound disposal of the waste they produce.

3. Precautionary principle: waste is hazardous until shown to be safe. This means that where it is unknown what the hazard may be, it is important to take all the necessary precautions.

4. Proximity principle: Treatment and disposal of hazardous waste should take place at the closest possible location to its source in order to minimize the risks involved in its transport..

AGREEMENTS AND PRICIPLES GOVERNING MANAGEMENT OF HCHCW

Magnitude of Medical Waste in Egypt

Egypt generates an average of 24,600 tons of hazardous or infectious waste daily from private, governmental hospitals ( excluding military hospitals).

Hazardous Health Care Waste HCHWWaste that requires special treatment or handling (Includes contaminated sharps, blood products, laboratory wastes, chemicals used in dialysis, chemotherapy, expired drugs, photographic chemicals, solvents..etc).

DEFINITIONS AND REGULATIONS

Regulations govern labeling, handling, treatment, transport, storage, and disposal of hazardous chemical waste, include:Egyptian Environmental Law 4/94 which regulates air emissions; and governs the management of hazardous materials and wastes. WHO guidelines for worker safety, waste labeling and handling; Nuclear Safety Commission (NSC) for radioactive waste handlingMinistry of Health regulations for handling controlled substancesTraffic rules for transportation of hazardous chemicals

NO special law on HCWM exists in Egypt. Such law is needed to establish legal controls and to enforce relevant regulations by the national agencies responsible for HCW M (EEAA, MOH, NSC)

الخطرة والنفايات المواد29مادة ) المختصة يحظر ( اإلدارة من ترخيص بغير الخطرة النفايات و المواد 0تداولالمختصة الجهة و الترخيص منح شروط و إجراءات القانون لهذا التنفيذية الالئحة تبين و

0بإصداره - اختصاصه نطاق في كل الوزراء يصدر شئون –و جهاز و الصحة وزير مع بالتنسيق

المpادة هpذه من األولي الفقpرة في إليهpا المشpار الخطpرة النفايpات و بpالمواد جpدوال 0البيئpة 30مادة ) للق تخضع ( الخطرة النفايات اإلجراءات وديإدارة بالالئحة و الواردة

القانون لهذا 0التنفيذية تخضع التي الخطرة للنفايات جداول بوضع المختصة الجهة المذكورة الالئحة وتحدد

البيئة شئون جهاز رأي أخذ بعد ذلك و 0ألحكامه 31مادة ) من ( بترخيص إال الخطرة النفايات معالجة بغرض منشآت أي إقامة يحظر

المختصة الخطرة الجهة النفايات من التخلص يكون و البيئة شئون جهاز رأي أخذ بعدالتنفيذية الالئحة تحددها التي والمعايير للشروط 0طبقا

33مادة ) حالتها ( في كانت سواء الخطرة المواد تداول أو إنتاج علي القائمين عليأي حدوث عدم يتضمن بما االحتياطات جميع يتخذوا أن الصلبة أو السائلة أو الغازية

بالبيئة طبقا 0أضرار خطرة مخلفات نشاطها عن ينتج التي المنشأة صاحب علي واالحتفاظ القانون هذا كذلك ألحكام و منها التخلص كيفية و المخلفات هذه بسجل

المخلفات هذه لتسلم معها المتعاقد التي 0الجهات البيانات التنفيذية الالئحة وتبينمطابقة من للتأكد السجل بمتابعة البيئة شئون جهاز يختص و السجل هذا في تسجل

للواقع 0البيانات التلوث من الهوائية البيئة حماية34مادة ) يكون ( أن المنشأة يشترط لنشاط مناسبا المشروع عليه يقام الذي الموقع

الهواء لملوثات بها المسموح الحدود تجاوز عدم يتضمن الناتج بما التلوث جملة تكون وأن ،بها المصرح الحدود في واحدة منطقة في المنشآت مجموع التنفيذية 0عن الالئحة وتحدد

و الموقع مالءمة علي بالموافقة المختصة الجهة و ألحكامه الخاضعة المنشآت القانون لهذاالمنشأة بها تقام التي المنطقة في الضوضاء و الهواء لملوثات بها المسموح 0الحدود

35مادة ) ألنشطتها ( ممارستها في القانون هذا ألحكام الخاضعة المنشآت بعدم تلتزمبها المسموح القصوى الحدود يجاوز بما للهواء ملوثات تسرب أو و انبعاث القوانين في

القانون لهذا التنفيذية الالئحة تحدده ما و السارية 0القرارات

COMPOSTION AND QUANTITY OF HCW IN EGYPT

General Principles of Waste Management1- A clear facility policy for waste management should be available for proper implementation of integrated waste management plan. The policy should describe in detail the methods of waste segregation, collection, storage, and disposal, according to the resources available in each health facility.2- Roles and responsibilities of the different team members responsible for waste management should be clarified. One main person should be assigned to be responsible for waste management in each facility.

3- All healthcare staff should be aware of the facility’s basic healthcare waste management plan and their role in the plan. This includes management and regulatory staff, medical doctors, nurses and nursing assistants, cleaners, waste handlers, and visitors to the facility.

4- Facility managers should ensure that this plan is in place, with adequate budget and personnel to implement it.

5-Implementation of the healthcare waste management plan and routine monitoring should be carried out in parallel with the information/training program.

6- The waste management plan should be presented in simple terms and displayed in a diagram at all points of waste generation.

7- Better health and environmental working conditions for waste handlers should be addressed in planning resources for waste management. This includes (but is not limited to ) the use of protective clothing and specialized equipment to ensure worker safety as well as safety for the general public.

9- Waste management plan should address four components of waste management .

8- Hands-on staff training in the details of the waste management plan is optimal. Training shouldinclude:· Basic information about HCW and the risks of bad management of HCW.· Basic information on the facility’s waste management plan.· Each employee’s responsibility and role in healthcare waste management.· Technical instruction on application of the practices described in the waste management plan.

Step Definition

Sorting

Sorting is separating waste by type (e.g.,

infectious waste, pharmaceutical waste) into color coded bags at the place where it is

generated

HandlingHandling is

collecting and transporting

waste within the facility.

Step Definition

Interim Storage

Interim storage is storing waste within

the facility until it can be transported for final

treatment , disposal.

Final treatment and disposal

Final disposal is the elimination of solid medical waste, liquid medical waste,

sharps, and hazardous chemical waste from the

health facility.

Sorting and Segregation

Sorting the waste at the point at which it is generated. Separate containers should be used for disposing of general and medical waste. The person who generates it should segregate the waste by type. Colored plastic bags should be used to help distinguish between general- and medical-waste containers. A three-bin system for waste sorting should be established

Type of waste Segregation and sortingGeneral non medical waste Black bags

Solid medical waste( Infectious and anatomic)

Red Bags

Sharp waste Sharp container puncture resistant and leak proof as tin

cans with lid or bottles

Radioactive waste Yellow bags

Important tips

- Sort at the site of generation.- The person who generate is responsible for

segregation.- Should be cleaned by disinfectant every

day.- Sharp container must be in a convenient

place.

Hazardous Wastes Containers

Bio-hazardous wastes bags and trolleys units

Sharps and needles containers

• Bio-hazardous wastes containers in rooms, wards, laboratories, ICU, OT areas

General Information

•Hazardous clinical wastes are 10% - 20% of the total hospital waste

•Hazardous wastes has to be weighted for better control after being segregated at the several clinical units in the hospital in order to control the process

•Keeping good records is important to monitor its security

بفصل القيام عند مالحظاتالنفايات

المنبع • عند الفصل يكون أن .يجبحتى • األوعية .حجمها 4/3تمألالتي • العبوات أنواع جميع تمييز يجب

نفايات ونقل لتعبئة تستخدم سوف: كاآلتى الصحية الرعاية

” – – نفايات عبارة المميز الرمز اللون – المولد“ والقسم المنشأة اسم طبية

التحميل للنفايات عن وتاريخ والمسئول. والنقل الجمع

الرموز

القمامة سلة في مرمية وحقن إبر الصورة في يرىالخاصة العيادات بأحد

Handling

Medical waste should be handled as little as possible before disposal. Medical waste should not be collected from patient-care areas by emptying it into open carts; this may lead to contamination of the surroundings and to scavenging of waste as well as to an increase in the risk of injury to staff, clients and visitors.

Important tips in Handling

• Handle medical waste as little as possible.• Medical waste and sharps containers should be discarded when they are three quarters full or at least once per day or per shift.

• Never put hands into a container that holds medical waste.

• Do not empty medical waste into open carts because this increases the risk of injury to staff, patients, and visitors, and may lead to spills and to environmental contamination

• All handling segregated wastes should be tightly closed specially while mobilizing them through different areas and different floors in hospitals and medical care centers

• Hospitals should have a cleaning and drying facility for the reused mobilizing containers

Larger Mobilization Containers Tightly Covered

Open hazardous waste containers and unidentified bags should be completely

avoided

• Staff who is handling the waste should be well protected and their clothing daily washed in hospital laundry to insure its disinfection

Bar fenced Trolley

ON-SITE STORAGE AND LARGE TRANSPORTATION CONTAINERS FOR HCW

Interim storage

Waste should be transported at the end of every shift. WHY??

- To reduce the risk of infection and of injury - To minimize the amount of time waste is stored at the health care facility.

Interim storage

Waste should be stored in an area of controlled access that is minimally trafficked by staff, clients, and visitors. Interim storage time should not exceed two days. It is preferable to have a room to store waste in on each floor of the facility, but, if this is difficult, one central storage room should be designated.

• Never store medical waste in open containers.

• Never throw waste into an open pile.

•Waste should be stored in containers with lids to minimize the potential for insect, rodent, or other animal infestation, and to minimize the smell.

Important tips for storage

Bio-hazardous wastes must be stored in securely closed cooled rooms

Storage areas floors should be covered with impermeable material as epoxy

SHREDDING AND SECURED STORAGE OF HCW

Final treatment

CONSIDERATIONS FOR SELECTION OF HCHCWTREATMENT TECHNOLOGIES•Quantities and types of waste produced;

•Availability of sites for waste treatment and disposal (space on HCF premises and distance to the nearest residential areas);

•Social acceptance of treatment and disposal method

•Possibility of treatment in a central facility with a HCW treatment system within reasonable distance;

•Existence of reliable transportation services

•Availability of human, financial and material resources

•Existence of a reliable power supply;

•Environmental and law regulations including those derived from the ratification of global binding.

Methods to Control Medical waste

• Should be adjusted with a comprehensive waste management plan

Waste Reduction and Recycling: One way to reduce the need to burn hazardous waste is by reducing waste generation. Much of the waste which is burned can be recycled and remade into new items instead.

Autoclaving: Some waste can be superheated and sterilized so it can be harmlessly buried in landfills. Switching to an on-site autoclave saves 50%. Using Nontoxic Equipment Alternatives: Many medical items are available which do not contain dioxin and mercury. For example, hospitals can use thermometers that contain no mercury and non-PVC plastic items that contain no dioxin or chlorine.

4Rs

ALTERNATIVES FOR CONTROL OF HCHCW

بدون ضغط ومقياس حرارة مقياس:زئبق

Objectives of final treatment

• Effective reduction of the infectious hazards of health-care waste and prevent scavenging. Which means transforming infectious waste into non risk waste.

• At the same time reduce the bad environmental outcome of the treatment method.

Hospital hazardous wastes should not reach dump sites

or solid sanitary landfill without shredding and

sterilization to prevent their illegal and health hazardous

reuse of reusable components

Treatment method Definition

Incineration

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

Chemical disinfectant

Chemicals are added to waste to kill or inactivate the pathogens it contains; this treatment usually results in disinfection rather than sterilization.

Wet and dry thermal treatment

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; a minimum temperature of 121°C is needed.

Microwave irradiation

Microorganisms are destroyed by microwaves of a frequency of 2450 MHz and a wavelength of 12.24cm. is rapidly heated by the microwaves and the infectious components are destroyed by heat conduction

Land disposal and burying

Which can be done inside the hospital premises or outside.

Encapsulation Pretreatment method before disposal.

Inertization ( stabilization)

Mixing waste with cement and other substances before disposal in order to minimize the risk of toxic substances contained in the waste migrating into surface water orGroundwater.

Discharge to sewer

Incineration

Three basic kinds of incineration technology are of interest for treating health-care waste:

• double-chamber pyrolytic incinerators, which may be especially designed to burn infectious health-care waste;

• single-chamber furnaces with static grate, which should be used only if pyrolytic incinerators are not affordable;

• rotary kilns operating at high temperature, capable of causing decomposition of genotoxic substances and heat-resistant chemicals.

Egyptian Experience with Incinerators

• Egypt with foreign donations has installed more than 80 incinerators for household and clinical wastes

• All of them did not operate as stated and were highly rejected by the surrounding communities and finally stopped because of their severe air pollution

• Hospital environment were badly Affected

• Burning and high temperature Exposures were a main concern

• Storage areas for incinerators fuel were always contaminated with oils and formed a hazardous site very hard to decontaminate after scraping the incinerators.

• Formed ash has to be disposed as hazardous material because of its high content of heavy metals

OPEN BURNING OF HCHCW

INCINERATION OF HCW

Medical waste incinerator in USA placed within green areas to absorb the generated toxic gases. Do we have this privilege in our country areas?

Land disposal

BURIAL PIT FOR HCW

• Burial should be at least 50 meters from the nearest water source, located downhill from any wells, free of standing water, and in an area that does not flood. • Burial pit should be 1-2 meters wide and 2-5 meters deep. The bottom of the pit should be at least 1.8 meters above the water table. • Erect a fence or a wall around the site to keep out animals. • Every time solid medical waste is added to the pit, cover it with 10-30 cm of dirt. • When the level of waste reaches to within 30-50 cm of ground level, fill the pit with dirt, seal it with concrete, and dig a new pit.

In order to bury medical waste in Egypt, a facility must apply for a license.

Landfill Cover

Shredding of waste before disinfection

Shredding of solid health-care waste before disinfection ( chemical or thermal) is essential for the following reasons:

• to increase the extent of contact between waste and disinfectant by increasing the surface area and eliminating any enclosed spaces;

• to render any body parts unrecognizable to avoid any adverse visual impact on disposal;

• to reduce the volume of waste.

Waste Management II: Safe Sharps Disposal

Introduction

- “Sharps” refers to any object that can cut or puncture the skin including, but not limited to, needles, scalpels, lancets, broken vials or glass - The primary cause of occupational exposure to blood-borne pathogens in all health care personnel (HCP) is needle sticks injury or other sharp objects.

- At least 20 pathogens have been known to be transmitted following percutaneous exposure to blood.

.

Introduction- Cont

- The most important of these pathogens are hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV.

- Infections with each of these pathogens are potentially life threatening – and preventable

Frequency and Causes of Needle stick Injuries in Egypt

- Almost 70% of all HCP have been exposed over their lifetime to needle stick injuries.

- Needle stick and sharps injuries (NSSI) rate of 33 per 1000 HCP.

- The highest proportion of exposures was to nurses at the point of use.

Recapping, bending, or breaking needles; Inserting a needle into a test tube or specimen

container and missing the target; Injury from a person carrying unprotected sharps; Sharps that are present in unexpected places, like

linens; During complex surgical procedures; Handling or disposing of waste that contains used

sharps, and; Patients moving suddenly during injections

Most needle stick injuries occur during the following activities:

One-hand Recapping (“Scoop”) Technique

To safely recap needles use “the one-hand” technique:Step 1Place the cap on a flat surface, then remove your hand from the cap.Step 2With one hand, hold the syringe and use the needle to “scoop up” the cap.Step 3When the cap covers the needle completely, use the other hand to secure the cap on the needle hub. Be careful to handle the cap at the bottom only (near the hub).

Hands-free Technique for Passing Sharps

The assistant puts the sharp in a sterile kidney basin or other “safe zone” in the sterile field.

The assistant tells the service provider that the sharp is in the safe zone.

The provider picks up the sharp item, uses it, and returns it to the safe zone.

Tips for performance criteria of sharps containers

1- Functionality: Containers should remain in a good state during their entire usage. They should be leak resistant on their sides and bottoms, and puncture resistant until final disposal. Individual containers should have adequate volume and safe access to the opening.

2- Accessibility: Containers should be accessible to all workers who use, maintain, or dispose of sharp devices. Containers should be placed in all areas where sharps are used and, if necessary, portable within the workplace.

3- Visibility: Containers should be plainly visible to the workers who use them. Workers should be able to see the degree to which the container is full and proper warning labels.

4- Accommodation: Container designs should be convenient, environmentally sound, and easy to store.

Thank you for listening