BIOMEDICAL WASTE MANAGEMENT

P a g e | 1

2nd INTERNSHIP REPORT

XYZ Hospital, Mumbai .

BIOMEDICAL WASTE MANAGEMENT IN XYZ HOSPITAL – A STUDY .

Dr. Rajesh Kamath

MHA-3rd semester (T.I.S.S.)(2009HO026)

BIOMEDICAL WASTE MANAGEMENT – A STUDY .

P a g e | 2

Objectives of the study: To study the Biomedical waste management procedures in the hospital and assess the deviation from the standard .

Methodology :

Have the standards in hand .

Make an assessment of what is actually happening in the hospital .

Compare with the standards .

Assess the gap in standards and ground realities .

Data collection methods : Observation

Unstructured Interviewing of the Microbiologist, Nurses , Ward boys , Housemen .


P a g e | 3

Introduction :

Proper handling, treatment and disposal of biomedical wastes are important elements of a Hospital infection control programme.

The correct procedures will help protect health care workers, patients and the local community.

If properly designed and applied, waste management can be a relatively effective and an efficient compliance-related practice.

Until fairly recently, medical waste management was not generally considered an issue.

In the 1980s and 1990s, concerns about exposure to human immunodeficiency virus (HIV) and hepatitis B virus (HBV) led to questions about potential risks inherent in medical waste.

Thus hospital waste generation has become a prime concern due to its multidimensional ramifications as a risk factor to the health of patients, hospital staff and extending beyond the boundaries of the medical establishment to the general population.

Hospital waste refers to all waste, biologic or non biologic that is discarded and not intended for further use.

Medical waste is a subset of hospital waste; it refers to the material generated as a result of diagnosis, treatment or immunization of patients and associated biomedical research.

Biomedical waste (BMW) is generated in hospitals, research institutions, health care teaching institutes, clinics, laboratories, blood banks, animal houses and veterinary institutes.

Although very little disease transmission from medical waste has been documented, Experts recommend that medical waste disposal must be carried out


P a g e | 4

in accordance with regulation.

Hospital waste management has been brought into focus in India recently, particularly with the notification of the BMW (Management and Handling) Rules, 1998. This rule makes it mandatory for the health care establishments to segregate, disinfect and dispose their waste in an eco-friendly manner.

Potential implications of Biomedical waste

Risk to healthcare workers and waste handlers:

Improperly contained contaminated sharps pose the greatest infectious risk associated with hospital waste. There is also a theoretical health risk to medical waste handlers from pathogens that may be aerosolized during the compacting, grinding or shredding process that is associated with certain medical waste management or treatment practices. Physical (injury) and health hazards are also associated with the high operating temperatures of incinerators and steam sterilizers and with toxic gases vented into the atmosphere after waste treatment.

Risk to the public :

The Public impact is confined to the aesthetic degradation of the environment from careless disposal and the environmental impact of improperly operated incinerators or other medical waste treatment equipment.

There may be an increased risk of nosocomial infections in patients due to poor waste management. Improper waste management can lead to change in microbial ecology and the spread of antibiotic resistance.


P a g e | 5

Classification

Non-hazardous waste

This constitutes about 85% of the waste generated in most healthcare set-ups. This includes waste comprising of food remnants, fruit peels, wash water, paper cartons, packaging material etc.

Hazardous waste

A) Potentially infectious waste

Over the years different terms for infectious waste have been used in scientific literature, in regulation and in the guidance manuals and standards. These include infectious, infective, medical, biomedical, hazardous, red bag, contaminated, medical infectious, and regulated medical waste. All these terms indicate basically the same type of waste, although the terms used in regulations are usually defined more specifically. It constitutes 10 to 15 %of the total waste and includes:

1. Dressings and swabs contaminated with blood, pus and body fluids.2. Laboratory waste including laboratory culture stocks of infectious agents3. Potentially infected material: Excised tumours and organs, placenta removed

during surgery, extracted teeth etc.4. Potentially infected animals used in diagnostic and research studies.5. Sharps, which include needle, syringes, blades etc.6. Blood and blood products.

B) Potentially toxic waste

1. Radioactive waste: It includes waste contaminated with radionuclide; it may be solid, liquid or gaseous waste. These are generated from in vitro analysis of body fluids and tissue, in vitro imaging and therapeutic procedures.

2. Chemical waste: It includes disinfectants (hypochlorite, gluteraldehyde, iodophors, phenolic derivatives and alcohol based preparations), X-ray processing solutions, monomers and associated reagents, base metal debris (dental amalgam in extracted teeth).


P a g e | 6

Pharmaceutical waste: It includes anesthetics, sedatives, antibiotics, analgesics etc.

Steps in Waste management

Medical waste should be managed according to its type and characteristics. For waste management to be effective, the waste should be managed at every step, from acquisition to disposal. The following are the elements of a comprehensive waste management system:

Waste survey, Segregation, Accumulation and Storage, Transportation, Treatment, Disposal and also Waste minimization.

Waste survey

The survey should differentiate and quantify the waste generated. It should determine the points of generation, the type of waste at each point and the level of generation and disinfection within the hospital. This helps to determine the method of disposal.

Waste segregation

This consists of placing different kinds of wastes in different containers or coded bags at the point of generation . It helps to reduce the bulk of infectious waste as well as treatment costs. Segregation also helps to contain the spread of infection and reduces the chances of infecting other health care workers.

Waste accumulation and storage

Waste accumulation and storage occurs between the point of waste generation and site of waste treatment and disposal. While accumulation refers to the temporary holding of small quantities of waste near the point of generation, storage of waste is characterized by longer holding periods and large waste quantity. Storage areas are usually located near where the waste is treated. Any offsite holding of waste is also considered storage.


P a g e | 7

To contain spills, storage areas should not have floor drains and should be recessed to hold liquids. Floor and walls should be impervious to liquid and easy to clean. They should be disinfected regularly. Refrigeration may be required for prolonged storage of putrifiable and other wastes. Storage area should be posted with 'EXPLICIT' signs.

Waste transportation

When medical waste is not treated on site, untreated waste must be transported from the generation facility to another site for treatment and disposal.

Waste treatment

The term 'treatment' refers to the process that modifies the waste in some way before it is taken to its final resting place. Treatment is mainly required to disinfect or decontaminate the waste, right at source so that it is no longer the source of pathogenic organisms. After such treatment, the residue can be handled safely, transported and stored.

Needles and syringe nozzle - shredded in needle destroyer and syringe cutters

Scalpel blades/ Lancet/ Broken glass should be put in separate containers with bleach, transferred to plastic/ cardboard boxes; sealed to prevent spillage and transported to incubators

Glassware should be disinfected, cleaned and sterilized Culture plates with viable culture should be autoclaved; media are placed in

appropriate bags and disposed off. The plates can be reused after sterilization

Gloves should be shredded / cut / mutilated before disposal. Swabs should be chemically disinfected followed by incineration. If they

contain only a small amount of blood that does not drip, they can be placed in the garbage.

Disposable items are often recycled and have the risk of being used illegally. Dipping in freshly prepared 1% sodium hypochlorite for 30 min. - one hour, followed by mutilation before disposal should be the policy adopted for such items.

Liquid waste generated by the laboratory is either pathological or chemical in nature. Non-infectious waste should be neutralized with reagents.

Liquid infectious waste should be treated with a chemical disinfectant for contamination and then neutralized.


P a g e | 8

Waste disposal

The waste disposal methods vary in their

Capabilities, Cost, Availability and Impacts on the environment.

The various disposal methods include

Incineration, Autoclaving, Chemical methods, Thermal methods (low and high), Ionizing radiation process, Deep burial and Microwaving

Incineration and autoclaving are considered traditional methods.

Untreated medical waste can be disposed off in sanitary landfills. Disposal without treatment is not recommended for human tissues, sharps and culture from clinical laboratories.

Waste minimization

Whereas ordinary solid or liquid waste requires no treatment before disposal, practically all infectious waste must first be treated. The cost for disposal of infectious waste may be ten times the cost for disposal of ordinary solid waste. Any measures that decrease the amount of infectious waste generated will simultaneously decrease the cost of infectious waste disposal.

Cost of biomedical waste management…..The cost of construction, operation and maintenance of a system for managing waste represents a significant part of the overall budget of a hospital if the BMW handling rules have to be implemented in their true spirit. Self-contained on-site treatment methods may be desirable and


P a g e | 9

feasible for large healthcare facilities. They will not be practical or economical for smaller institutes.

An acceptable common system should be in place which will provide A regular supply of color coded bags, Daily collection of infectious waste, Safe transportation of waste to off site treatment facility and Final disposal with suitable technology.

The Bio-Medical Waste (Management and Handling) Rules, 1998.

APPLICATION:

These rules apply to all persons who generate, collect, receive, store, transport, treat, dispose, or handle bio medical waste in any form.

DEFINITIONS: In these rules unless the context otherwise requires

(1) "Act" means the Environment (Protection) Act, 1986 (29 of 1986);

(2) "Animal House" means a place where animals are reared/kept for experiments or testing purposes;

(3) "Authorisation" means permission granted by the prescribed authority for the generation, collection, reception, storage, transportation, treatment, disposal and/or any other form of handling of bio-medical waste in accordance with these rules and any guidelines issued by the Central Government.

(4) "Authorised person" means an occupier or operator authorised by the prescribed authority to generate, collect, receive, store, transport, treat, dispose and/or handle bio-medical waste in accordance with these rules and any guidelines issued by the Central Government;


P a g e | 10

(5) "Bio-medical waste" means any waste, which is generated during the diagnosis, treatment or immunisation of human beings or animals or in research activities pertaining thereto or in the production or testing of biologicals, and including categories mentioned in Schedule I;

(6) "Biologicals" means any preparation made from organisms or micro-organisms or product of metabolism and biochemical reactions intended for use in the diagnosis, immunisation or the treatment of human beings or animals or in research activities pertaining thereto;

(7) "Bio-medical waste treatment facility" means any facility wherein treatment. disposal of bio-medical waste or processes incidental to such treatment or disposal is carried out;

(8) "Occupier" in relation to any institution generating bio-medical waste, which includes a hospital, nursing home, clinic dispensary, veterinary institution, animal house, pathological laboratory, blood bank by whatever name called, means a person who has control over that institution and/or its premises;

(9) "Operator of a bio-medical waste facility" means a person who owns or controls or operates a facility for the collection, reception, storage, transport, treatment, disposal or any other form of handling of bio-medical waste;

(10) "Schedule" means schedule appended to these rules .


P a g e | 11

Standard prescribed Status in the hospital

1. DUTY OF OCCUPIER:It shall be the duty of every occupier of an institution generating bio-medical waste which includes a hospital, nursing home, clinic, dispensary, veterinary institution, animal house, pathological laboratory, blood bank by whatever name called to take all steps to ensure that such waste is handled without any adverse effect to human health and the environment.

2. TREATMENT AND DISPOSAL:(1) Bio-medical waste shall be treated and disposed of in accordance with Schedule I, and in compliance with the standards prescribed in Schedule V.(2) Every occupier, where required, shall set up in accordance with the time-schedule in Schedule VI, requisite bio-medical waste treatment facilities like incinerator, autoclave, microwave system for the treatment of waste, or, ensure requisite treatment of waste at a common waste treatment facility or any other waste treatment facility.

3. SEGREGATION, PACKAGING, TRANSPORTATION AND

The hospital takes all steps to ensure that the waste it produces is handled without any adverse effect to human health and environment .

The hospital has ensured requisite treatment of waste at a common waste treatment facility .

1) The waste in the hospital is categorized into 5 types : 1. Uninfected waste , such as food waste , paper and plastic waste not significant for recycling and medication wrapping . 2 . Infected waste , such as dressings , syringes and gloves .3 . Recyclable waste like i.v. bottles and large plastic covers ,paper and plastic.4. Sharps - Needles , blades , scalpels . The needle tips are burnt in a flame , then cut in a needle cutter . The needle tips and the other sharps are put into a yellow , plastic , puncture proof container .


P a g e | 12

STORAGE:(1) Bio-medical waste shall not be mixed with other wastes.(2) Bio-medical waste shall be segregated into containers/bags at the point of generation in accordance with Schedule II prior to its storage, transportation, treatment and disposal. The containers shall be labeled according to Schedule III.(3) If a container is transported from the premises where bio-medical waste is generated to any waste treatment facility outside the premises, the container shall, apart from the label prescribed in Schedule III, also carry information prescribed in Schedule IV.(4) Notwithstanding anything contained in the Motor Vehicles Act, 1988, or rules thereunder, untreated biomedical waste shall be transported only in such vehicle as may be authorised for the purpose by the competent authority as specified by the government.(5) No untreated bio-medical waste shall be kept stored beyond a period of 48 hoursProvided that if for any reason it becomes necessary to store the waste beyond such period, the authorised person must take permission of the prescribed authority and take measures to ensure that the waste does not adversely affect human health and the environment.

5. The used ampoules are put into a plastic , puncture proof can .6. Tissue specimens sent for Histopathology and Human tissue waste such as the placenta .

This classification is used universally in the hospital in the Segregation and Packaging of Waste .

The uninfected waste , such as food waste , paper and plastic waste not significant for recycling and medication wrapping go into the BLACK BAGS.

The Infected waste , such as dressings , syringes and gloves go into the RED BAGS.Recyclable waste like i.v. bottles and large plastic covers ,paper and plastic go into the GREEN BAG.The needle tips and the other sharps are put into a YELLOW , plastic , puncture proof container .The used ampoules are put into a WHITE , plastic , puncture proof can .The tissue specimens sent for Histopathology and Human tissue waste such as the placenta also go into a YELLOW BAG .

The bags or containers which get filled are taken down to the Waste Temporary storage area .This happens according to the shifts of the Maiters / Maitarnis . The shifts are : 7 a.m. to 3 p.m. , 3 p.m. to 11 p.m. , and 11 p.m. to 7 a.m. Just before the shifts end , the Maiter


P a g e | 13

seals the bags with a cord and takes them down .This waste is picked up by the BMC ( BLACK BAGS ) and SMS Envoclean ( RED and YELLOW BAGS )

The hospital has a Waste Temporary storage area.This is behind the path linking the old building to the new one .This area has storage facilities for both the infected and the non infected waste.These two types of waste are stored separately . The infected waste which is in the red bags is stored in large Green plastic containers . There are 5 such containers in the area.

Adjacent to the place where the Green containers are kept , is the storage space for the Black bags , which contain the uninfected waste or general garbage . This is housed in a shed , and not in closed containers like the red bags , because the black bags contain garbage , which after some time produces a foul smell . Hence an open room is more suited for the temporary storage of this kind of waste .Adjacent to that is the Shed which houses the space for the temporary storage of the green bags.The green bags contain recyclable material .

In this hospital , the YELLOW BAG is supposed to be used in the O.T. ,


P a g e | 14

Histopathology and Laboratory . In the O.T. , the yellow bags are kept in prescribed places , such that they are not easily amenable to misuse . The yellow bags are used for the Placenta and amputated parts . The amputated parts are sometimes claimed by the family members for rituals / cremation / burial. In the case of usage of the yellow bag for the amputated parts , a procedure has to be followed . A form has to be filled in triplicate .The form is named “Requisition for Disposal of body parts”.It has the following information : Patient’s name Reg numberWard/CotSurgeon’s nameAnaesthetist’s name Diagnosis (with brief history )Type of procedure Specimen to be disposed RemarksThe signature of the Surgeon

In case the body part is claimed by the patient’s relatives , then the following information is added, handwritten , on the Requisition form .The body part handed over .The name of the patient’s relative .The Patient’s relative’s signature .The relative’s relation to the patient .It is forwarded to the A.M.D.

One copy of the form goes with the O.T. procedure form .One copy goes to the patient’s file .


P a g e | 15

4. PRESCRIBED AUTHORITY(1) The Government of every State and Union Territory shall establish a prescribed authority with such members

One copy goes with the yellow bag for the records of the occupier involved in the disposal of the part ( Incineration and burial ) .

This form is needed for Medicolegal purposes . If tomorrow a patient or an allegedly aggrieved party alleges that a body part was amputated without consent / needlessly / against sound medical advice / unethically , and that it was disposed off clandestinely , then the Hospital as well as the Occupier concerned with the disposal of the body part have the duly filled Requisition form in their defence .

For the disposal of placentas , no form is required.

The most common contents of the yellow bags are , apart from placentas , gangrenous toes , fingers and limbs .

It was seen that some mixing of the Biomedical waste with other waste happens from time to time. In one instance , there was blood stained cotton in the black bin . The sister asked the maiterni , the maiterni blamed the trainee sister / patients .

The prescribed authority for Mumbai and Maharashtra is the Maharashtra Pollution Control Board ( MPCB )


P a g e | 16

as may be specified for granting authorisation and implementing these rules. If the prescribed authority comprises of more than one member, a chairperson for the authority shall be designated.(2) The prescribed authority for the State or Union Territory shall be appointed within one month of the coming into force of these rules.(3) The prescribed authority shall function under the supervision and control of the respective Government of the State or Union Territory.(4) The prescribed authority shall on receipt of Form 1 make such enquiry as it deems fit and if it is satisfied that the applicant possesses the necessary capacity to handle bio-medical waste in accordance with these rules, grant or renew an authorisation as the case may be.(5) An authorisation shall be granted for a period of three years, including an initial trial period of one year from the date of issue. Thereafter, an application shall be made by the occupier/operator for renewal. All such subsequent authorisation shall be for a period of three years. A provisional authorisation will be granted for the trial period, to enable the occupier/operator to demonstrate the capacity of the facility.(6) The prescribed authority may after giving reasonable opportunity of being heard to the applicant and for reasons thereof to be recorded in writing, refuse to grant or renew authorisation.(7) Every application for authorisation shall be disposed of by the prescribed


P a g e | 17

authority within ninety days from the date of receipt of the application.(8) The prescribed authority may cancel or suspend an authorisation, if for reasons, to be recorded in writing, the occupier/operator has failed to comply with any provision of the Act or these rules :Provided that no authorisation shall be cancelled or suspended without giving a reasonable opportunity to the occupier/operator of being heard.

5. AUTHORISATION(1) Every occupier of an institution generating, collecting, receiving, storing, transporting, treating, disposing and/or handling bio-medical waste in any other manner, except such occupier of clinics, dispensaries, pathological laboratories, blood banks providing treatment/service to less than 1000 (one thousand) patients per month, shall make an application in Form 1 to the prescribed authority for grant of authorisation.(2) Every operator of a bio-medical waste facility shall make an application in Form 1 to the prescribed authority for grant of authorisation.(3) Every application in Form 1 for grant of authorisation shall be accompanied by a fee as may be prescribed by the Government of the State or Union Territory.

6. ADVISORY COMMITTEEThe Government of every State/Union Territory shall constitute an advisory

The hospital has received the requisite authorization .The Hospital pays the Maharashtra Pollution Control Board ( MPCB ) a license fee of Rs.30,000 for 3 years .

Not applicable to the hospital .


P a g e | 18

committee. The committee will include experts in the field of medical and health, animal husbandry and veterinary sciences, environmental management, municipal administration, and any other related department or organisation including non-governmental organisations. The State Pollution Control Board/Pollution Control Committee shall be represented. As and when required, the committee shall advise the Government of the State/Union Territory and the prescribed authority about matters related to the implementation of these rules.

7. ANNUAL REPORTEvery occupier/operator shall submit an annual report to the prescribed authority in Form 11 by 31 January every year, to include information about the categories and quantities of bio-medical wastes handled during the preceding year. The prescribed authority shall send this information in a compiled form to the Central Pollution Control Board by 31 March every year.

8. MAINTENANCE OF RECORDS(1) Every authorised person shall maintain records related to the generation, collection, reception, storage, transporation, treatment, disposal and/or any form of handling of bio-medical waste in accordance with these rules and any guidelines issued.

There is no Annual report written in the hospital regarding the Biomedical waste .

Earlier , registers used to be maintained in the wards recording the dispatch of the waste bags from the wards to the Waste temporary storage area . According to the the I.C. nurse , this was possible then because all the maiter / maiterni staff were permanent , and they followed the procedure of registering . But now , with the advent of contract employees , it was more difficult to ensure compliance , and hence based on the feedback from the nurses , this facility .

Up until about May 2009 , a YELLOW MUSTER card , popularly called the YELLOW CARD , was in use . This was a record of all the RED BAGS , YELLOW BAGS and PUNCTURE


P a g e | 19

(2) All records shall be subject to inspection and verification by the prescribed authority at any time.

PROOF CANS that were lifted by the occupier responsible for the waste disposal . This card contained the following information :The DATE on which the bags were lifted .The NUMBER of bags .The WEIGHT of the bags .The SIGNATURE of the representative of the Occupier for Disposal , when lifting it off the hospital premises .

This card was used by the I.C. sister to cross check the weight claimed to be lifted by the Occupier for Disposal . At the end of the month , the figures on the YELLOW CARD would be tallied with the corresponding figures on the Bill given by the Occupier for Disposal . If there were any discrepancies , the concerned parties would be asked to give suitable explanations .

Around May , 2009 , the contract was renegotiated and the payment to be made was now going to be on a PER BED basis . As the weight being lifted was no longer significant to the payments being made , the maintenance of theYellow muster card was stopped . Hence now there are no records of how the quantity of waste in terms of weight being generated in the hospital. The I.C. sister does not get the Yellow muster cards anymore .

The Black bags too are not weighed . BIOMEDICAL WASTE MANAGEMENT – A STUDY .

P a g e | 20

There are no records as to the quantity of waste in terms of weight being generated in the hospital .

There is no weighing / quantification of the waste generated .

The hospital has a contract with SMS Envoclean Pvt. Lmtd.The contract was signed for 256 beds . The contract is for the Biomedical waste in the Red and Yellow bags .The payment for the Beds 1 to 50 was Rupees 3.40/ bed/day .Above 50 beds , it was Rupees 1.95 /bed/ day .The black bags are lifted by the BMC .

In the morning , generally between 11 a.m. and 12 a.m. , BMC trucks lift the RED BAGS .In the evening , generally between 4.30 p.m. and 5 p.m. , the BMC trucks ( different ones ) pick up the black bags .According to the rates fixed in the contract , the amount would come to :For the first 50 beds ,50 x Rs.3.40 x 30 = Rs.5,100For the remaining 206 beds ,206 x Rs.1.95 x 30 = Rs.12,051Rs.5,100 + Rs.12,051 = Rs. 17,151/ month


P a g e | 21

9. ACCIDENT REPORTINGWhen any accident occurs at any institution or facility or any other site where bio-medical waste is handled or during transportation of such waste, the authorised person shall report the accident in Form Ill to the prescribed authority forthwith.

Accident reporting is done . The proforma for needle stick injuries is with the Infection control sister . If there is an injury , the CMO is informed . The CMO informs the IC sister . The I.C. sister goes to the Casualty with the Proforma for the needle stick injury . The Infectious diseases consultant , in this case H.I.V. specialist Dr. Om Srivastav is informed , who then orders investigations and prescribes medication . Follow up is done with him in the OPD every Thursday at 11 o’clock .The A.M.D.( Assistant Medical Director ) is informed . The routing of the payment and other procedures is through the A.M.D.

The hospital has a Hospital Infection Control Committee (H.I.C.C.) .


P a g e | 22

Dr. Poorva , MD , Microbiology .

2 H.I.C. Nurses . The H.I.C. sisters take rounds three times a day . The first sister takes a round of the entire hospital at 9 in the morning . Then , the first sister takes rounds of one half of the hospital and the second sister the other half of the hospital at 2 p.m. The third round is at 6 p.m. in the evening

Matron

O.T. Nurses - incharge

Pathologist .

The Medical Director .- Chairperson

The Assistant Medical Director .

An Infectious Diseases Consultant .

The Heads of all Clinical Branches .

This H.I.C. meets in the hospital once in three months .

Mumbai has the Hospital Infection Society , Mumbai Forum ( H.I.S.M.F. ) .

It has about 120 members .

They meet every second Tuesday .

H.N. Hospital sends its I.C. Committee members for meetings there.

1. The Infection control ( IC )Nurse has a Hospital infection control ( H.I.C.) file:

In this , they have a check list of all the items to be checked .

The segregation of waste is done in the following manner .

Black bag – Kitchen waste , paper etc.


P a g e | 23

Red bag – Infected gauze pieces , body fluids , contaminated gloves , syringes , dressings ,blood bags etc.

Yellow bag – Only tissues .From O.T. , L.T. , Histopathology .

Green bag – Recycling of uninfected items . I.V. bottles , paper , plastic , glass bottles .

Puncture proof jar for sharp Biomedical waste : Needles , blades ( sharps ) , slides ( from lab )

Recycling puncture proof jar ( ampoules , injection bottles )

2. Needle stick injury file :

For the O.T., the O.T. Sister in charge is responsible for H.I.C. supervision . For the rest of the hospital , it is the H.I.C. sisters .

The Proforma for needle stick injury is with the I.C. sister .

3. Fumigation :

The IC Sister receives handwritten slips , signed by the respective ward incharges that their respective wards have been fumigated on the given date . One copy goes to the fumigation file and one copy is kept in the concerned ward .

The L.T. is fumigated every 15 days .

AKD , Endoscopy , Cath Lab – Every month

All these have fixed days .

The fumigation is done with Bacillocid liquid spray .

The mini O.T. is fumigated every Saturday .

After fumigation , the spaces are kept closed for 1 hour , and then open for another hour before being used.


P a g e | 24

4. Culture and Sensitivity of Aerial count dishes is done in the O.T. , and in all the Intensive care units. This is done once a month .

The strips are taken to the testing areas and kept there for 20 minutes . A control strip is kept in the laboratory environment where culture is going to be grown , so that the relative difference in growth can be estimated .

Reports of this are maintained with the I.C. sister .

5. Microbiological report for drinking water .The overhead water tank and the water from the water tanker are tested for microbiological contamination. Reports are maintained with the I.C. sister .

6. Tanker water which is brought in during periods of shortage like in summer is tested in the laboratory – Before chlorination and After chlorination .

Reports are maintained with the I.C. sister .

7. Patients with Infectious diseases .

The file has U.P. ( Universal Precautions ) written on the top left hand corner of the file .

There is a green wooden tag hung on the door .

There is a red bag under the bed into which all contaminated material can be put immediately .

For H.I.V. , HBsAg , HCV , Open Koch’s , Measles and Pseudomonas infected patients , Universal Precautions (U.P.) have to be taken . These constitute Barrier Nursing Care : Wearing of Gloves , Mask , Gown .

Reports are maintained with the I.C. sister .

8. P.H.C. (Public Health Centre ) File

If there is a case of a notifiable disease , then it is noted in a Public Health Centre file and the B.M.C. ( Municipal Authorities ) are notified , who then take the necessary steps in the area that the patient came from .


P a g e | 25

9. Nurses Vaccination Register .

A record of all the vaccination received is maintained .

HBV – 0 months , 1 month , 6 months , Booster ( after 5 years ) .

10. Educational initiatives for staff were regularly taken .

There were Dramas and skits for the level 4 staff .

An award every month , in the form of a plaque had been instituted for the best ward in Infection control practices .

There are rounds every day in the morning and the afternoon by the two Hospital infection control nurses.

The following things are checked :

1 . General sanitation and hygiene .

2 . Chittle forceps .

It is checked if a new one is issued every day . The date of sterilisation of the forceps will be pasted on the forceps holder .

3 .Hand sanitiser .

Ideally every bed should have one .

Some wards and even ICUs have one for multiple beds .

They should ideally be at the bedside , for each bed , preferably on the right side , because that’s the side used for examining and also for most nursing activities , and hence is the side used more than the left side . The further the Hand sanitiser is from the point of contact with the patient , the lesser the compliance .

4 . The date on the vein flow on each patient is checked . The vein flow has to be changed every 72 hours.

5 . The date on the I.V. tubing is checked . The I.V. tubing has to be changed every 24 hours .


P a g e | 26

6 . The waste bins with the different colour coded bags are checked .

The waste bins should not be overflowing .

The waste must be in the right bags .

PENALTY FOR CONTRAVENTION OF THE PROVISIONS OF THE ACT AND THE RULES, ORDERS AND DIRECTIONS.

(1) Whoever fails to comply with or contravenes any of the provisions of this Act, or the rules made or orders or directions issued there under, shall, in respect of each such failure or contravention, be punishable with imprisonment for a term which may extend to five years or with fine which may extend to one lakh rupees, or with both, and in case the failure or contravention continues, with additional fine which may extend to five thousand rupees for every day during which such failure or contravention continues after the conviction for the first such failure or contravention.

(2) If the failure or contravention referred to in sub-section (1) continues beyond a period of one year after the date of conviction, the offender shall be punishable with imprisonment for a term which may extend to seven years.


P a g e | 27

THE FOLLOWING INFORMATION HAS BEEN INCORPORATED IN THE REPORT AS IT IS A PART OF AND IS REFERRED TO IN THE STANDARDS . IT IS FOR REFERENCE PURPOSE .

SCHEDULE I

CATEGORIES OF BIO-MEDICAL WASTE

------------------------------------------------------------------------------------------------------------------------Option Waste Category------------------------------------------------------------------------------------------------------------------------Category No. 1 Human Anatomical Waste

(human tissues, organs, body parts) Treatment and disposal : incineration@/deep burial*

Category No. 2 Animal Waste(animal tissues, organs, body parts carcasses, bleeding parts, fluid, blood and experimental animals used in research, waste generatedby veterinary hospitals colleges, discharge from hospitals, animalhouses)

Treatment & Disposal : incineration@/deep burial*

Category No 3 Microbiology & Biotechnology Waste(wastes from laboratory cultures, stocks or specimens of micro-Organisms , live or attenuated vaccines , human and animal cellcultures used in research and infectious agents from research


P a g e | 28

and industrial laboratories, wastes from production of biologicals,toxins, dishes and devices used for transfer of cultures)

Treatment & Disposal : Local autoclaving , microwaving , incineration .

Category No 4 Waste sharps(needles, syringes, scalpels, blades, glass, etc. that may cause puncture and cuts. This includes both used and unused sharps)

Treatment and Disposal : Disinfection ( Chemical treatment / autoclaving / microwaving / mutilation /shredding )

Category No 5 Discarded Medicines and Cytotoxic drugs(wastes comprising of outdated, contaminated and discardedmedicines)

Treatment and Disposal : Disinfection (chemical treat ment@01/auto claving / microwaving and mutilation/ shredding .

Category No 6 Solid Waste(Items contaminated with blood, and body fluids including cotton,dressings, soiled plaster casts, lines, beddings, other materialcontaminated with blood)

Treatment and Disposal : incineration@ , autoclaving/microwaving.

Category No. 7 Solid Waste(wastes generated from disposable items other than the waste

sharpssuch as tubings, catheters, intravenous sets etc).


P a g e | 29

Treatment and Disposal : Disinfection by chemical,treatment@@ autoclaving/ microwaving and mutilation/ shredding##

Category No. 8 Liquid Waste(waste generated from laboratory and washing, cleaning, house-keeping and disinfecting activities)

Treatment and Disposal : disinfection by chemical treatment@@ and discharge into drains .

Category No. 9 Incineration Ash (ash from incineration of any bio-medical waste)

Treatment and Disposal : disposal in municipal landfill

Category No. 10 Chemical Waste(chemicals used in production of biologicals, chemicals used indisinfection, as insecticides, etc.)

Treatment and Disposal : chemical treatment@@ and discharge into drains for liquids and secured landfill for solids .

------------------------------------------------------------------------------------------------------------------------

@@ Chemicals treatment using at least 1% hypochlorite solution or any other equivalent chemical reagent. It must be ensured that chemical treatment ensures disinfection.


P a g e | 30

## Multilation/shredding must be such so as to prevent unauthorised reuse.

@ There will be no chemical pretreatment before incineration. Chlorinated plastics shall not be incinerated.

* Deep burial shall be an option available only in towns with population less than five lakhs and in rural areas.

SCHEDULE II

COLOUR CODING AND TYPE OF CONTAINER FOR DISPOSAL OF BIO-MEDICAL WASTES

Colour Conding

Type of Container -I Waste Category Treatment options as per

Schedule I

Yellow Plastic bag Cat. 1, Cat. 2, and Cat. 3,

Cat. 6.

Incineration/deep burial

Red Disinfected container/plastic bag Cat. 3, Cat. 6, Cat.7.

Autoclaving/Microwaving/


P a g e | 31

Chemical Treatment

Blue/White

translucent

Plastic bag/puncture proof Cat. 4, Cat. 7.

Container

Autoclaving/Microwaving/

Chemical Treatment and

destruction/shredding

Black Plastic bag Cat. 5 and Cat. 9 and

Cat. 10. (solid)

Disposal in secured landfill

Notes:

1. Colour coding of waste categories with multiple treatment options as defined in Schedule I, shall be selected depending on treatment option chosen, which shall be as specified in Schedule I.

2. Waste collection bags for waste types needing incineration shall not be made of chlorinated plastics.

3. Categories 8 and 10 (liquid) do not require containers/bags.

4. Category 3 if disinfected locally need not be put in containers/bags.


P a g e | 32

SCHEDULE III

LABEL FOR BIO-MEDICAL WASTE CONTAINERS/BAGS

HANDLE WITH CARE

Note : Label shall be non-washable and prominently visible.


P a g e | 33

SCHEDULE IV

LABEL FOR TRANSPORT OF BIO-MEDICAL WASTE CONTAINERS/BAGS

Day ............ Month ..............Year ...........Date of generation ...................

Waste category No ........Waste classWaste description

Sender's Name & Address Receiver's Name & AddressPhone No ........ Phone No ............... Telex No .... Telex No ............... Fax No ............... Fax No .................Contact Person ........ Contact Person .........In case of emergency please contact Name & Address :

Phone No. Note : Label shall be non-washable and prominently visible.


P a g e | 34

FORM II

ANNUALREPORT

(To be submitted to the prescribed authority by 31 January every year).

1 . Particulars of the applicant:

(i) Name of the authorised person (occupier/operator):

(ii) Name of the institution:

Address

Tel. No

Telex No.

Fax No.

2. Categories of waste generated and quantity on a monthly average basis:

3. Brief details of the treatment facility:

In case of off-site facility:

(i) Name of the operator

(ii) Name and address of the facility:

Tel. No., Telex No., Fax No.

4. Category-wise quantity of waste treated:

5. Mode of treatment with details:


P a g e | 35

6. Any other information:

7. Certified that the above report is for the period from

Date ............................... Signature ...........................................

Place.............................. Designation..........................................

Recommendations

1.The trainee nurses should be impressed upon the knowledge and importance of proper segregation of the waste at the source . A spot survey must be made of ALL ward staff , INCLUDING CLASS IV / CONTRACT EMPLOYEES and education to bridge the gap , if any , must be an ongoing process .

2.After observation of the lifting of the BLACK BAGS by the BMC , it seems that the BLACK BAGS are not sealed properly, because the contents spilled and it was an unpleasant sight with an accompanying unpleasant odour . Some of the bags are VERY HEAVY , my estimate would be 30 to 40 kilos . This becomes very heavy for the BMC employees to lift onto the trucks . Also the sealing ( with short lengths of rope ) comes off more easily with the heavier bags . The BMC workers BIOMEDICAL WASTE MANAGEMENT – A STUDY .

P a g e | 36

do an admirable job of cleaning up the mess that results , but a better sealing system and load limits for bags would make the process better .

3.Labelling is not standardized and entirely random . Most of the bags don’t have the labeling according to the prescribed format . In fact , many of them don’t have any labeling at all . Many have only the colour of the bag written on the tag .

4. There is no weighing / quantification of the waste generated . The rationale given is that the waste treatment charges levied are on a per bed basis . But weighing is recommended , so as to have data regarding the amount of waste generated . Weighing of the bags must be done on a daily basis as and when they are being sent for disposal . Musters must be maintained and a consolidated record must be prepared every month which should then be sent to every member on the Infection control-Biomedical Waste management committee .

5. There is no Annual report written in the hospital regarding the Biomedical waste . Earlier , registers used to be maintained in the wards recording the dispatch of the waste bags from the wards to the Waste temporary storage area . According to the I.C. nurse , this was possible then because all the maiter / maiterni staff were permanent , and they followed the procedure of registering . But now , with the advent of contract employees , it was more difficult to ensure compliance , and hence based on the feedback from the nurses , this practice was terminated .

Also , the practice of maintaining Yellow Muster cards at the security post has been done away with . This must be re-instated so that relevant data is not lost .

6. Hand sanitisers should be kept ideally at the bedside , for each bed , preferably on the right side , because that’s the side used for examining and also for most nursing activities , and hence is the side used more than the left side . The further the Hand sanitiser is from the point of contact with the patient , the lesser the compliance . Hand contact is the most common mode of spread of infection and this needs to be emphasised over and over again to everybody who comes in contact with patients as it was seen that sometimes even Doctors don’t always sanitise their hands between patients , even in the ICCU .

7.The O.T. ward boys and maiternis have no idea about the the use of Yellow bags in the O.T. This led to a lot of confusion in the course of gathering information for


P a g e | 37

this case study / report . It is recommended that they be given the required amount of sensitization towards the goal of knowing the basics of Biomedical waste disposal so that such situations are avoided in the future .


BIOMEDICAL WASTE MANAGEMENT

Documents

Transcript of BIOMEDICAL WASTE MANAGEMENT