Managing Medical Waste

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Managing Medical Waste

• Session 5 Infection Control Basics

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Learning Objectives

• Understand that most hospital waste materials are
  not more dangerous than household waste, but
  keeping used sharps and needles from staff and
  public access is a priority
• Learn ways to minimise waste
• Know the criteria for safe management of sharps

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Part I Health Care Waste Overview
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Definitions of Waste

• Health care waste
• All types of waste from all health care
  activities
• Hazardous health care waste
• Waste that presents a health hazard of some kind
• Note Most health care waste is no more hazardous
  than household waste

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Types of Hazards to Consider

• Flammable
• Toxic - mutagenic, cytotoxic, teratogenic, etc
• Reactive
• Allergen, contact sensitiser
• Explosive
• Infectious
• Radioactive
• Corrosive
• Caustic

• Alcohol
• Cancer chemotherapy, tar-based products
• Sulphuric acid, chlorine powder
• Glutaraldehyde
• Picric acid, fertiliser, ammonia
• TB cultures
• Barium enema, X-rays
• Bleach
• Lye

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Hazardous Health Care Waste

• Infectious hazard
• Anatomic waste
• Laboratory cultures
• Sharps
• Live viruses

• Corrosive, teratogenic, reproductive hazard
• Heavy metals
• Pesticides
• Cleaning products
• Pressurised containers
• Mercury
• Cancer therapy

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Is Health Care Waste an Important Source of
Infectious Disease?

• Yes!
• IF needles and syringes are scavenged and
  re-used, then many diseases can be spread
• Keep used sharps and syringes out of public
  access

• No!
• Most medical waste does not have more germs than
  household waste
• It causes visual pollution, generates fear, but
  unless re-use of sharps occurs, medical waste
  causes little disease

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Then Why does this Waste Matter?

• Sharps injuries may harm workers and communities
• Medical waste potentially impacts patients,
  workers, community, and economy because of the
  volume and permanence of waste

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Health Care Institutions Generate about 3.5 kg of
Waste per Bed per Day

• Health care waste may
• Contain infectious organisms, including drug
  resistant ones
• Place cancer causing agents into air or ground
  water
• Cause radiation-related illnesses
• Contribute to global warming harm atmosphere (CFC
  containing refrigerant gas)
• Cause injury (sharps, explosion)
• Cause congenital defects or stillbirth,
  prematurity, infertility

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Which Waste to Address First?

• IC Committees should START with infectious waste,
  especially used sharps and microbiological
  culture waste

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How to Safely Dispose of Infectious Sharps

• Do not recap sharps before disposal
• Dispose of sharps at the point of use in a leak
  proof puncture proof container
• Avoid handling, emptying or transferring used
  sharps between containers
• Autoclave highly infectious waste before disposal
• Control public access to syringes and medical
  equipment
• Shred, encapsulate and bury according to national
  legislation

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For Non-Infectious Hazardous Waste, the Risks
Depend on

• Severity of acute or chronic exposure
• Duration of exposure
• Frequency of exposure
• Concentration agent (1 versus 50)
• Individual vulnerability including pregnancy,
  weight
• Route of exposure (skin, respiratory, oral,
  etc.)
• Steps taken to protect (PPE, relieved from
  immediate contact etc.)

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Who is at Risk?

• Doctors - anesthesiologists, pathologists
• Nurses - oncology nurses, OT, ER
• Hospital support staff - X-ray assistants,
  pharmacy, morgue, and lab staff
• Cleaning staff - those cleaning sewage lines
• General public - those using sharps found in the
  waste

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Common Hazards

• Anesthetic gases
• Glutaraldehyde
• Formaldehyde/formalin
• Cancer therapeutic agents
• Ethylene Oxide
• Radiation
• Asbestos
• Blood contaminated sharps

• Bleach
• Solvents (xylene, toluene, acetone, ethanol)
• Pesticides, fungicides
• Heavy metals (mercury, chronium, cobalt, cadmium,
  arsenic, lead)
• Latex
• Strychnine and cyanide

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12 Steps to Manage Hazardous Wastes before
Disposal

• 1. Know what hazards you have
• 2. Purchase smallest quantity needed, and dont
  purchase hazardous materials if safe alternative
  exists

Use mercury-free thermometers
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12 Steps to Manage Hazardous Wastes (contd)

• 3. Limit use and access to trained persons with
  personal protective gear

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4. Use Engineering Controls such as Ventilation,
Hoods for Select Hazards
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5. Get Rid of Unnecessary Stuff

• Dont accumulate unneeded products
• Dont let peroxides and oxidising agents turn
  into bombs

Photo of bomb robot called into hospital to
dispose of picric acid.
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6. Label with Agent, Concentration and Hazard
Warnings

• Examples of hazard labels

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7. Communicate about Workplace Hazards

• Job description
• Posters on doors
• Labels on hazards
• Give feedback on use of PPE and disposal in
  evaluation
• Role model safe use and disposal
• Contact point who is responsible

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8. Recycle Products When Possible
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(No Transcript)
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Group Discussion Recycling

• Why should recycling be promoted?
• Which products can be safely and cost effectively
  recycled in your facility?

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9. Segregate Hazards at the Source

• Separate sharps and infectious waste where they
  are used
• This prevents injuries that can occur when people
  sort the trash after it is disposed
• Janitors can reinforce separation of sharps waste
  disposal by reporting sharps in garbage to
  Hospital Infection Control Committee members

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10. Have Written Policies on Waste Disposal

• Sharps and infectious waste
• Chemotherapy (cancer)
• Heavy metals (batteries)
• Chemicals
• Post brief, colorful instructions on walls to
  remind workers

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11. Minimise the Handling of Wastes

• Try to eliminate steps that require hazardous
  wastes to be touched, sorted, transferred from
  containers, or handled directly

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12. Conduct Walk-Around Interviews

• Ask about the hazardous substances staff work
  with, how they dispose of them, and what they
  need to be able to dispose of them properly
• Have a no-blame philosophy that strives to solve
  problems, NOT to assign blame

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Part II Waste Management Methods
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Options for Specific Types of Waste

• Pharmaceutical
• Cytotoxic
• Other chemical wastes
• Heavy metals
• Pressurised containers
• Radiation
• Infectious

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Pharmaceutical Waste

• Small amounts
• Disperse in landfill sites, encapsulate or bury
  on site
• Discharge to sewer
• Incinerate
• Large amounts
• Incinerate at high temperatures or encapsulate
• LANDFILL IS NOT RECOMMENDED

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Cytotoxic Waste

• NEVER LANDFILL or DISPOSE TO SEWER
• Disposal Options
• Return to supplier
• Incinerate at high temperature
• Chemical degradation

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Chemical Waste - Further Recommendations

• Keep different hazardous chemicals separate
• Do not dispose into the sewers or street
• Do not encapsulate large amounts of disinfectants
  as they are corrosive and flammable
• Do not bury large amounts of chemicals

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Wastes with Heavy Metals

• Wastes with mercury, cadmium, lead, arsenic,
  strychnine, are poisonous (e.g., thermometers,
  batteries, lead paints, dyes)
• Never incinerate or burn
• Never dispose of in municipal landfills
• Best solution Avoid purchase
• OR
• Recycle in specialised cottage industry or export
  to countries with specialised facilities
• Encapsulation

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Pressurised Gas Containers

• NEVER INCINERATE
• Return undamaged gas cylinders and cartridges to
  the manufacturer for reuse
• Damaged containers empty completely and crush,
  landfill

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Radioactive Waste

• Use requires a national strategy including
• Appropriate legislation
• A competent regulatory organisation
• Trained radiation protection officer to monitor
  exposures
• Return to the manufacturer
• Safe handling and disposal of radioactive waste
  requires a rigorous and relatively complex
  management scheme

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Simple Chemical Disinfection

• Requires shredding of waste
• May introduce strong chemicals into the
  environment (chorine bleach turns into dioxin
  when burned)
• Efficiency varies
• Only the surface is disinfected
• Does not disinfect human tissue
• Special disposal required to avoid pollution

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Waste Disposal Options Include

• Disinfection Autoclaving/ Microwaving,
  treatment, shredding
• Land Disposal
• Burial
• Encapsulation
• Incineration
• Inertisation
• Managed Land-fill
• On-site disposal

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Infectious Waste Autoclaving

• Pressure and temperature
• Holding time
• Sterility indicators
• Type of waste
• Followed by shredding / burial / recycled

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Commercial Disinfection Systems

• Shred waste, treat chemically, encapsulate
• Possible advantages
• Encapsulated residue can be placed in landfill
• Environmentally friendly
• Easy to operate
• Possible disadvantages
• Requires specialised operators
• May be expensive

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Burying Inside Hospital Premises

• Apply the following rules
• Access to the site restricted and controlled
• If waste is retained on site, ensure rapid burial
  to isolate from animal or human contact
• Only hazardous HC Waste to be buried
• Management controls on what is dumped
• Each deposit covered with soil
• Site lined with low permeable material-concrete
• Groundwater pollution must be avoided
• Not recommended for untreated hazardous waste

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Disposal to Land by Encapsulation

• Fill metal or plastic containers to 3/4, add
• plastic foam
• bituminous sand
• cement mortar
• clay material
• When dry, label and seal containers and landfill
• May be used for sharps, chemicals, drugs etc.

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Incineration

• Combustible waste turned to ash at temps gt800 C
• Reduces volume and weight
• Residues are transferred to final disposal site
• Treatment efficiency depends on incineration
  temperature and type of incinerator
• Not all wastes can be incinerated
• Costs vary greatly according to type of
  incinerator
• Produces combustion gases

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Do not Incinerate

• Do not incinerate the following
• Plastics especially halogenated plastics (e.g.
  PVC)
• Pressurised gas containers
• Large amounts of reactive chemical waste
• Radioactive waste
• Silver salts or radiographic waste
• Mercury or cadmium
• Ampoules of heavy metals

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Advantages of Incineration of HC Waste

• Good disinfection efficiency
• Drastic reduction of weight and volume
• Good for chemical pharmaceutical waste

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Disadvantages of Incineration of HC Waste

• Doesnt destroy chemical waste at lower
  temperature for rotary kiln
• Toxic air emissions if no control devices in
  place
• Maintaining temperature levels (and efficiency)
  in field incinerators is difficult, need to
  balance loads with non-hazardous materials
• High costs for high temperature incineration

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Land-fill in Municipal Landfills

• If hazardous health-care waste cannot be treated
  or disposed elsewhere
• Designate a site for hazardous HC Waste
• Limit access to this place
• Bury the waste rapidly to avoid human or animal
  contact
• Investigate more suitable treatment methods

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Because no Disposal Method is Easy or Completely
Safe

• Prevention is best!
• Eliminate purchase by buying safer alternatives
• Recycle
• Use smallest quantities possible, use with
  engineering controls and Personal Protective
  Equipment
• Segregate hazards into separate waste streams at
  source
• Supervise disposal using best available ecologic
  option

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For More Information

• Safe Management of wastes from health-care
  activities. Edited by A Prüss, E Giroult, P
  Rushbrook. Geneva World Health Organisation.
  1999. 228 p. Available online. Includes a
  teachers guide
• www.healthcarewaste.org. A website managed by the
  working group on waste

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More Free References

• http//www.healthcarewaste.org, Health Care Waste
  Management at a Glance
• First, do no harm. WHO/VB/02.26
• Available at www.healthcarewaste.org/linked/online
  docs/4-bd-704.pdf. Contains information about the
  disposal options for sharps

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Thank You!