Waste Management in hospitals <br />Egyptian guidelines perspective<br />With a special thanks to Environmental department in Alexandria High institute of public health<br />By Dr Mohamed ABORAS<br />Alexandria medical school, MBA, Master of hospital administration<br />Tel 0020122176434<br />firstname.lastname@example.org<br />
Introduction:<br />Health-care medical waste is a by-product of health care facility.<br />Examples: sharps, non-sharps, blood, body parts, chemicals, pharmaceuticals as drugs, medical devices,<br />
Why should we manage our hospital waste?<br />1-Increasing number of hospitals and their wastes volumes due to increasing number of patients. <br />2- Increasing number of oncology departments and centers creating highly toxic and radio-active wastes.<br />3- Highly infective bio-hazardous wastes are mis- used and reused illegally.<br />4- Burning of dumpsites creates highly hazardous emissions from clinical wastes.<br />5- Household similar garbage is a source of income if properly segregated.<br />6- Cost of disposal of medical waste more 10 times than cost of disposal of non medical waste.<br />
Poor management of health care waste:<br />1- may expose health care personnel, waste handlers, and the community to infectious agents, to toxic materials, and to an increased risk of injury.<br /> 2- It may also damage the environment (e.g., contamination of water, air, and food). <br />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. <br />
هل تمثل تلك النفايات أي خطورة على الصحة العامة؟<br />مخاطر خارج المنشأة <br />(مخاطر بيئية)<br /><ul><li>الأطباء والممرضين ومساعديهم.
العاملين فى نقل النفايات أو معالجتها ( عند التعقيم مثلا )</li></ul>مخاطر داخل المنشأة <br />تشير منظمة الصحة العالمية إلى أنه في عام 2000 تسببت المحاقن الملوثة في:<br /><ul><li>21 مليون عدوى HBV (32%)
نفايات مشعة</li></li></ul><li>AGREEMENTS AND PRICIPLES GOVERNING <br />MANAGEMENT OF HCHCW<br />
Magnitude of Medical Waste in Egypt<br /> Egypt generates an average of 24,600 tons of hazardous or infectious waste daily from private, governmental hospitals ( excluding military hospitals).<br />
DEFINITIONS AND REGULATIONS<br />Hazardous Health Care Waste HCHW<br />Waste that requires special treatment or handling (Includes contaminated sharps, blood products, laboratory wastes, chemicals used in dialysis, chemotherapy, expired drugs, photographic chemicals, solvents..etc).<br />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)<br />Regulations govern labeling, handling, treatment, transport, storage, and disposal of hazardous chemical waste, include:<br /><ul><li>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 handling
Ministry of Health regulations for handling controlled substances
Traffic rules for transportation of hazardous chemicals</li></li></ul><li>المواد والنفايات الخطرة<br />( مادة 29 ) يحظر تداول المواد و النفايات الخطرة بغير ترخيص من الإدارة المختصة 0 و تبين اللائحة التنفيذية لهذا القانون إجراءات و شروط منح الترخيص و الجهة المختصة بإصداره 0 <br /> و يصدر الوزراء - كل في نطاق اختصاصه – بالتنسيق مع وزير الصحة و جهاز شئون البيئة جدولا بالمواد و النفايات الخطرة المشار إليها في الفقرة الأولي من هذه المادة 0 <br />( مادة 30 ) تخضع إدارة النفايات الخطرة للقيودو الإجراءات الواردة باللائحة التنفيذية لهذا القانون 0 <br /> وتحدد اللائحة المذكورة الجهة المختصة بوضع جداول للنفايات الخطرة التي تخضع لأحكامه و ذلك بعد أخذ رأي جهاز شئون البيئة 0 <br />( مادة 31 ) يحظر إقامة أي منشآت بغرض معالجة النفايات الخطرة إلا بترخيص من الجهة المختصة بعد أخذ رأي جهاز شئون البيئة و يكون التخلص من النفايات الخطرة طبقا للشروط والمعايير التي تحددها اللائحة التنفيذية 0 <br />( مادة 33 ) علي القائمين علي إنتاج أو تداول المواد الخطرة سواء كانت في حالتها الغازية أو السائلة أو الصلبة أن يتخذوا جميع الاحتياطات بما يتضمن عدم حدوث أي أضرار بالبيئة 0 و علي صاحب المنشأة التي ينتج عن نشاطها مخلفات خطرة طبقا لأحكام هذا القانون الاحتفاظ بسجل هذه المخلفات و كيفية التخلص منها و كذلك الجهات المتعاقد معها لتسلم هذه المخلفات 0 وتبين اللائحة التنفيذية البيانات التي تسجل في هذا السجل و يختص جهاز شئون البيئة بمتابعة السجل للتأكد من مطابقة البيانات للواقع 0 <br />حماية البيئة الهوائية من التلوث<br />( مادة 34 ) يشترط أن يكون الموقع الذي يقام عليه المشروع مناسبا لنشاط المنشأة بما يتضمن عدم تجاوز الحدود المسموح بها لملوثات الهواء ، وأن تكون جملة التلوث الناتج عن مجموع المنشآت في منطقة واحدة في الحدود المصرح بها 0 وتحدد اللائحة التنفيذية لهذا القانون المنشآت الخاضعة لأحكامه و الجهة المختصة بالموافقة علي ملاءمة الموقع و الحدود المسموح بها لملوثات الهواء و الضوضاء في المنطقة التي تقام بها المنشأة 0 <br />( مادة 35 ) تلتزم المنشآت الخاضعة لأحكام هذا القانون في ممارستها لأنشطتها بعدم انبعاث أو تسرب ملوثات للهواء بما يجاوز الحدود القصوى المسموح بها في القوانين و القرارات السارية و ما تحدده اللائحة التنفيذية لهذا القانون 0 <br />
General Principles of Waste Management<br />1- A clear facility policy for waste management should be available for proper implementation of integratedwaste 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.<br />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. <br />
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.<br />4- Facility managers should ensure that this plan is in place, with adequate budget and personnel to implement it.<br />5-Implementation of the healthcare waste management plan and routine monitoring should be carried out in parallel with the information/training program.<br />
6- The waste management plan should be presented in simple terms and displayed in a diagram at all points of waste generation. <br />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.<br /> <br />
9- Waste management plan should address four components of waste management .<br />8-Hands-on staff training in the details of the waste management plan is optimal. Training should<br />include:<br />· Basic information about HCW and the risks of bad management of HCW.<br />· Basic information on the facility’s waste management plan.<br />· Each employee’s responsibility and role in healthcare waste management.<br />· Technical instruction on application of the practices described in the waste management plan.<br />
Sorting and Segregation<br />Sorting the waste at the point at which it is generated.<br /> Separate containers should be used for disposing of general and medical waste. <br />The person who generates it should segregate the waste by type. <br />Colored plastic bags should be used to help distinguish between general- and medical-waste containers. <br />A three-bin system for waste sorting should be established<br />
Bio-hazardous wastes containers in rooms, wards, laboratories, ICU, OT areas<br />
General Information<br /><ul><li>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</li></li></ul><li>
ملاحظات عند القيام بفصل النفايات<br />يجب أن يكون الفصل عند المنبع.<br />تملأ الأوعية حتى 4/3 حجمها.<br />يجب تمييز جميع أنواع العبوات التي سوف تستخدم لتعبئة ونقل نفايات الرعاية الصحية كالآتى:<br /> اللون – الرمز المميز – عبارة ”نفايات طبية“ – اسم المنشأة والقسم المولد للنفايات وتاريخ التحميل والمسئول عن الجمع والنقل.<br />
Handling<br />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.<br />
Importanttips in Handling<br /><ul><li>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</li></li></ul><li>All handling segregated wastes should be tightly closed specially while mobilizing them through different areas and different floors in hospitals and medical care centers<br />Hospitals should have a cleaning and drying facility for the reused mobilizing containers<br />
Open hazardous waste containers and unidentified bags should be completely avoided<br />
Staff who is handling the waste should be well protected and their clothing daily washed in hospital laundry to insure its disinfection<br />
ON-SITE STORAGE AND LARGE TRANSPORTATION CONTAINERS FOR HCW<br />Bar fenced Trolley<br />
Interim storage<br />Waste should be transported at the end of every shift. WHY??<br /> - To reduce the risk of infection and of injury<br /> - To minimize the amount of time waste is stored at the health care facility. <br />
Waste should be stored in containers with lids to minimize the potential for insect, rodent, or other animal infestation, and to minimize the smell.</li></li></ul><li>Bio-hazardous wastes must be stored in securely closed cooled rooms <br />Storage areas floors should be covered with impermeable material as epoxy <br />
Environmental and law regulations including those derived from the ratification of global binding.</li></li></ul><li>Methods to Control Medical waste<br />Should be adjusted with a comprehensive waste management plan <br />
ALTERNATIVES FOR CONTROL OF HCHCW<br />4Rs<br /><ul><li>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. </li></li></ul><li>مقياس حرارة ومقياس ضغط بدون زئبق:<br />
Objectives of final treatment <br />Effective reduction of the infectious hazards of health-care waste and prevent scavenging. Which means transforming infectious waste into non risk waste.<br />At the same time reduce the bad environmental outcome of the treatment method.<br />
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<br />
Incineration<br />Three basic kinds of incineration technology are of interest for treating health-care waste:<br />• double-chamber pyrolytic incinerators, which may be especially designed to burn infectious health-care waste;<br />• single-chamber furnaces with static grate, which should be used only if pyrolytic incinerators are not affordable;<br />• rotary kilns operating at high temperature, capable of causing decomposition of genotoxic substances and heat-resistant chemicals.<br />
Egyptian Experience with Incinerators<br />Egypt with foreign donations has installed more than 80 incinerators for household and clinical wastes<br />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<br />Hospital environment were badly Affected <br />
Burning and high temperature Exposures were a main concern<br />Storage areas for incinerators fuel were always contaminated with oils and formed a hazardous site very hard to decontaminate after scraping the incinerators. <br />Formed ash has to be disposed as hazardous material because of its high content of heavy metals <br />
<ul><li>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. </li></ul>In order to bury medical waste in Egypt, a facility must apply for a license. <br />
Shredding of waste before disinfection<br />Shredding of solid health-care waste before disinfection ( chemical or thermal) is essential for the following reasons:<br />• to increase the extent of contact between waste and disinfectant by increasing the surface area and eliminating any enclosed spaces;<br />• to render any body parts unrecognizable to avoid any adverse visual impact on disposal;<br />• to reduce the volume of waste.<br />
Introduction<br /> - “Sharps” refers to any object that can cut or puncture the skin including, but not limited to, needles,scalpels, lancets, broken vials or glass<br />- The primary cause of occupational exposure to blood-borne pathogens in all health care personnel (HCP) is needle sticks injury or other sharp objects.<br /> - At least 20 pathogens have been known to be transmitted following percutaneous exposure to blood. <br />. <br />
Introduction- Cont<br />- The most important of these pathogens are hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV.<br />- Infections with each of these pathogens are potentially life threatening – and preventable<br />
Frequency and Causes of Needle stick Injuries in Egypt<br /> - Almost 70% of all HCP have been exposed over their lifetime to needle stick injuries.<br /> - Needle stick and sharps injuries (NSSI) rate of 33 per 1000 HCP.<br />- The highest proportion of exposures was to nurses at the point of use. <br />
Most needle stick injuries occur during the following activities: <br />
One-hand Recapping (“Scoop”) Technique <br />To safely recap needles use “the one-hand” technique:<br />Step 1<br />Place the cap on a flat surface, then remove your hand from the cap.<br />Step 2<br />With one hand, hold the syringe and use the needle to “scoop up” the cap.<br />Step 3<br />When 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). <br />
Tips for performance criteria of sharps containers<br />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. <br />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. <br />
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.<br />4- Accommodation: Container designs should be convenient, environmentally sound, and easy to store. <br />