Ensuring safety in Hospitals
According to World Health Organization, 80-85% of total amount of waste generated by healthcare activities is the general waste. Only 15-20% waste is considered hazardous which may be infectious, injurious, toxic or radioactive. Poor management of healthcare waste exposes healthcare workers, waste handlers and the community to infections, toxic effects and injuries. Lack of awareness about the health hazards related to healthcare waste, inadequate training in proper waste management, absence of waste management and disposal systems, insufficient financial and human resources and the low priority given to the subject are the most common problems connected with healthcare waste management.
Biomedical Waste Management Policy of Apollo Hospitals International Limited, Ahmedabad, gives clear direction about the waste disposal process, provides practical guidance to hospital staff on safety at all stages of waste handling to avoid nosocomial infections and physical injuries and encourages safe working practices among healthcare workers.
Hazards Related to Biomedical Waste
Potential risks of biomedical waste are well known to all healthcare workers and include sharp inoculation injuries, transmission of infections either through infected blood/tissues, airborne transfer or skin contact. Hepatitis-B, Hepatitis-C, HIV and other viruses may be transmitted through infected blood. Chemical & pharmaceutical wastes can affect the body through inhalation of dust or aerosols, skin absorption, ingestion of accidentally contaminated food, ingestion through bad practice of mouth pipetting or from contact with chemotherapy patients’ body fluids. Cytotoxic compounds could be extremely irritant to skin and eyes and
also has genotoxic, mutagenic effects. Radioactive wastes can be a potential carcinogenic hazard. The effect of an exposure ranges from minor symptoms like headache, dizziness and vomiting to most serious adverse effects on genetic material.
Classification of Healthcare Waste
Classifying biomedical waste is another important aspect for effective handling and further disposal. Healthcare waste may be classified into clinical waste, sharps, chemical waste, pharmaceutical waste, radioactive waste, laboratory waste, cytotoxic/genotoxic waste, food & general waste etc. Each category of waste has to be treated and further be disposed off in different ways.
Healthcare Waste Management
Segregation
Segregating biomedical waste at the point of generation is critical to the safe management of biomedical wastes, which facilitates further collection, handling, storage, transportation and disposal and reduces the handling costs of these wastes. It is very important to see that there is no mixing of infectious andnon-infectious wastes. Responsibility of proper segregation primarily lies with all the staff generating the waste during clinical or non-clinical operations. Central Pollution Control Board (CPCB) has published the guidelines for the healthcare organizations which recommend the colour coded bins/containers/sacks/ receptacles to be provided for easy identification and effective sorting. They are placed as close to the point of waste generation as possible.
Hospital should display the segregation guidelines for clear identification & sorting of the types of the waste and place appropriately color coded/labeled waste bins, containers & trolleys. It is important not to allow bins/containers to be filled more than 3/4th level, to avoid spillage. Sharps are discarded in puncture proof auto-locked containers which are usually filled up with 1% Sodium Hypochlorite solution upto 3/4th level. Disposables and plastic items are mutilated and glass vials/bottles are emptied before throwing in waste bins.
Collection
As biomedical waste gets accumulated in small quantities in clinical areas, it needs to be collected as soon as possible. The interval between subsequent collections should be as short as reasonably practicable. With regard to infectious and foul smelling waste, the collection period should even be shorter. As a routine practice, it is advisable to collect waste not later than every two and four hours from ICUs and wards/other areas respectively. Tying and lifting the waste bag on top without getting it compressed is very important consideration during waste collection. Handlers must wear PPE and take all precautions to prevent sharp injury or body fluid exposure. Waste bins must be regularly washed and disinfected.
Local Storage
If it is not possible to frequently transport the waste from operational areas directly to central storage site; it is preferred to have local storage areas on each floor. Waste can temporarily be stored here securely in labeled color coded containers/polythene bags without littering the surrounding. Such local storage areas are located slightly away from the patient care areas and public spaces. Waste handlers must take all precautions to avoid mixing of infectious and non-infectious waste in local storage. Different wastes in the same storage area should be clearly demarcated. Storage area should be properly tiled for ease in cleaning and to prevent entry of rodents. Waste should be transported from local storage area to central storage area at the earliest possible. Daily cleaning of these storages must be done.
Trasnportaion to Central Sotrage
Transportation of waste from local to central storage area is one of the important links in the waste management process. Central storage areas are generally situated separately within the hosptial premises. Waste is transported in close air-tight color-coded container trolleys at scheduled time interval through predefined route. Scheduling and route of transportation should be such that there is no crossing over with food trolleys or sterile areas. Few salient points pertaining to central storage areas are as under:
- Reserved for biomedical waste only
- Located away from kitchen, material stores and from public routes
- Adequetely lit and ventilated rooms/ cubicles with impervious tough flooring
- Restricted entry, colour-coded selfclosing doors, kept locked when not in use
- Secured from animal entry and free from insects or rodent infestations
- Availability of washing facilities, appropriate PPE, first-aid kit for waste handlers
- Availability of fire extinguishers
- Scheduled washing and disinfection of central storage areas
Transportation to Final Disposal Site, Treatment & Disposal
In India, most of the healthcare facilities are outsourcing these activities to Common Biomedical Waste Treatment Facility (Pollution Control Board Authorized CBWTF). Waste transportation to final disposal site is done daily in close cart/ vehicle with smooth & impermeable surfaces. Thumb rule here is that no waste must be kept stored in the hospital beyond the period of 48 hours. Infectious wastes, in particular, start decomposing after few hours and become more hazardous if stored beyond 48 hours. Weighing of the outgoing waste is usually done to monitor waste generation per bed per day. Indian healthcare facilities generate 1-2 kgs waste per bed. Since it is expected to keep increasing in coming years, it is very essential to keep a tight watch on waste generation. Hospital’s Infection Control Officer visits the final disposal site periodically to see the proper disposal process.
Few points for consideration for treatment and disposal:
- The waste is mutilated and disinfected before its final disposal to prevent the re-use and infections.
- Syringes are cut and chemically disinfected with 1% bleaching powder solution before the final disposal into sharps pit.
- Infected plastics are also chemically di
sinfected or autoclaved, shredded and recycled and sent for final disposal into municipal dumps. - General waste is transported to municipal waste dumps for final disposal without any treatment.
Handling Accidents & Incidents
Healthcare organization should have structured procedures for dealing with accidents or incidents involving clinical waste which may put employees or others at risk. Employees should be able to report to Emergency Department Staff Clinic at earliest upon exposure or injury. Immediate first-aid measures must be made available in case of any injury and post-exposure prophylaxis be given to affected handlers on case to case basis. Any deviations in defined process or related incidents are to be promptly reported to Quality Assurance/Infection Control Dept where they are thoroughly investigated and root-cause-analysis is carried out to establish the exact cause. Accordingly, corrective and preventive actions are initiated to prevent recurrences in the future.
Personnel Protection and Safety
The waste handlers and other staff who are involved directly or indirectly in this process are adversely affected and their health and safety must be protected at all the times.
Following personal protective equipment (PPE) should be freely available for their use to prevent injuries and exposure. Appropriate cleaning, maintenance and checking of all the protective equipment must be ensured from time to time.
- Disposable gloves & heavy-duty gloves when handling waste containers.
- Industrial aprons / leg protectors: if the risk of bodily contact with waste sacks/containers.
- Face shields/glasses to protect employees from potential splashing.
- Sturdy industrial boots to protect the feet against the risk of heavy containers being accidentally dropped. The soles of such boots will also offer some protection in the storage area against spillage, sharps and where floors become slippery.
- Helmets and strong industrial PPE in high risk areas.
- Masks and respiratory protectors for protection against toxic dust.
- Standard PPE (approved by BARC) for protection against radioactive wastes.
Protective immunization i.e. Hepatitis-B, Tetanus etc are highly recommended for all staff handling healthcare wastes. Washing facilities at storage and disposal facilities must be made available and handlers must be educated on correct hand washing practices for their safety. All the waste handlers are medically examined at specific time interval and training on occupational safety is imparted frequently. Work SoPs at all working areas are displayed as ready reference and to avoid any confusion. Beside PPE, spillage kits, mercury kits, HAZMAT kits, first aid kits and fire lighting equipment are provided to concerned staff.
Education & Training
Since training and awareness is the powerful tool to ensure optimal compliance to defined work-flows and to prevent any mishap, waste management training is imparted to all staff on joining itself and is an integral component of orientation program for all new employees. Focused group training sessions are also conducted at regular intervals by Infection Control Department on handling the waste & adhering to the established policy. Upon revision of any policy/ procedure, retraining is also conducted. Such trainings cover awareness about occupational risks involved in healthcare waste management, hazard recognition and measures to mitigate besides colorcoding, labelling, route marking, special problems related to disposal of sharps etc. They are also taught on modes of pathogen transmission, personal safety, cleaning and disinfection procedures, use of protective clothing/equipment and how-to-deal-with spillage and other incidents at work area. Trainings on hand hygiene, first aid, fire safety are mandatory to all staff. Mock Drills and practical demonstrations are also conducted periodically wherein staff can see and learn the correct practices.
Quality Assurance
Continuous monitoring of the established protocols and practices is of paramount importance in sustaining the efforts. At Apollo Hospitals, Infection Control Officer takes the onus of overseeing the biomedical waste management processes, with the help of House Keeping In-charge. Biomedical waste management has been one of the permanent agenda in monthly Infection Control Committee Meetings. Needle stick injuries and all waste related incidents are reviewed in these meetings besides hospital acquired infections and hand hygiene compliance. Periodic process audits are carried out by Quality Assurance Department to see the
adherence and compliance to SoPs and reports deviations, if any, to Infection Control Committee. Cross departmental audits are also done wherein seniors
staff of one area audits the process of segregation, labeling and transportation of another area/department. Department wise waste volume is closely pursued every month.
Major (Dr) Sanjay Dalsania,
Chief Quality Officer,
Apollo Hospitals International Limited,
Ahmedabad
Dr. Mahesh Patel,
Quality and Patient Safety Officer,
Apollo Hospitals International Limited,
Ahmedabad