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PRIYANKA SHARMAMODERATOR- DR. SANDEEP DOGRA

STRATEGIES IN HOSPITAL WASTE MANAGEMENT

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BMW Definition The BMW Act/RegulationBMW Act recent changesClassification of BMWSteps in waste managementStandardsBWM @ GMCHreferences

OVERVIEW

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DEFINITIONS

Biomedical Waste:Biomedical waste comprises human & animal anatomical

waste, treatment apparatus like needles, syringes and other materials used in health care facilities in the process of treatment and research.  This waste is generated during diagnosis, treatment or immunization in hospitals, nursing homes, pathological laboratories, blood bank, etc. (Ministry of Environment and Forests)

Any waste, which is generated during the diagnosis, treatment or immunization of human beings or animals or in research or in the production or testing of biological products (WHO)

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Cont..

“handling” The generation, sorting, segregation, collection, storage, packaging, loading, transportation, unloading, processing, treatment, destruction, conversion, or offering for sale, transfer, disposal of such waste

“health care facility” Means a place where diagnosis, treatment or immunization of human beings or animals is provided irrespective of type and size of health treatment system, and research activity

“prescribed authority” Means the State Pollution Control Board in respect of a State and Pollution Control Committees

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THE ACT

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Major salient features

The ambit of the rules has been expanded to include vaccination camps, blood donation camps, surgical camps or any other healthcare activity;

Phase-out the use of chlorinated plastic bags, gloves and blood bags within two years;

Pre-treatment of the laboratory waste, microbiological waste, blood samples and blood bags through disinfection or sterilization on-site in the manner as prescribed by WHO or NACO;

Provide training to all its health care workers and immunize all health workers regularly;

Establish a Bar-Code System for bags or containers containing bio-medical waste for disposal;

Report  major accidents;

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Major salient features (contd.)

Bio-medical waste has been classified in to 4 categories instead 10 to improve the segregation of waste at source;

Procedure to get authorization simplified. One time Authorization

The new rules prescribe more stringent standards for incinerator to reduce the emission of pollutants in environment;

State Government to provide land for setting up common bio-medical waste treatment and disposal facility;

No occupier shall establish on-site treatment and disposal facility, if a service of `common bio-medical waste treatment facility is available at a distance of seventy-five kilometer.

Operator of a common bio-medical waste treatment and disposal facility to ensure the  timely collection of bio-medical waste from the HCFs and assist the HCFs in conduct of training

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New Biomedical Waste Categories

Category

type of waste Type of bag Treatment and Disposal options

Yellow (a)Human Anatomical Waste: Human tissues, organs, body parts and fetus below the viability period (as per the Medical Termination of Pregnancy Act 1971

(b)Animal Anatomical Waste : Experimental animal carcasses, body parts, organs, tissues, including the waste generated from animals used in experiments or testing in veterinary hospitals or colleges or animal houses.

Yellow colored non-chlorinated plastic bags

Incineration or deep burial

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Category

type of waste Type of bag

Treatment and Disposal options

c) Soiled Waste: Items contaminated with blood, body fluids like dressings, plaster casts, cotton swabs and bags containing residual or discarded blood and blood components.

Incineration or deep burial*

In absence of above facilities, autoclaving or micro-waving/ hydroclaving .

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Category

type of waste Type of bag

Treatment and Disposal options

(d) Expired or Discarded Medicines: Pharmaceutical waste like antibiotics

including all items contaminated with cytotoxic drugs along with glass or plastic ampoules, vials etc

Yellow coloured non-chlorinated plastic bags or containers

•Expired `cytotoxic drugs and items contaminated with cytotoxic drugs to be returned back to the manufacturer or supplier for incineration at temperature >1200 0C or

• to common bio-medical waste treatment facility for incineration

• All other discarded medicines shall be either sent back to manufacturer or disposed by incineration.

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(e) Chemical Waste: Chemicals used in production of biological and used or discarded disinfectants.

Yellow colored containers or non-chlorinated plastic bags

Disposed of by incineration o

(f) Chemical Liquid Waste : Liquid waste generated X-ray film developing liquid, discarded Formalin, infected secretions, aspirated body fluids, liquid from laboratories and floor washings, cleaning

Separate collection system leading to effluent treatment system

chemical liquid waste should be pre-treated before mixing with other waste water.

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g) Discarded linen, mattresses, beddings contaminated with blood or body fluid

Non-chlorinated yellow plastic bags

•Non- chlorinated chemical disinfection followed by incineration

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(h) Microbiology, Biotechnology and other clinical laboratory waste: Blood bags, Laboratory cultures, vaccines, human and animal cell cultures used in research, production of biological, residual toxins, dishes and devices used for cultures.

Autoclave safe plastic bags or containers

Pre-treat to sterilize with nonchlorinated chemicals on-site as per National AIDS Control Organization or World Health Organization guidelines thereafter for Incineration.

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Category

type of waste Type of bag Treatment and Disposal options

red Contaminated Waste (Recyclable)

(a) Wastes generated from disposable items such as tubing, bottles, intravenous tubes and sets, catheters, urine bags, syringes (without needles and needle syringes) and gloves.

Red colored non-chlorinated plastic bags or containers

•Autoclaving or micro-waving/ hydroclaving followed by shredding •Treated waste to be sent to registered or authorized recyclers or plastics to diesel or fuel oil or for road making, whichever is possible. •Plastic waste should not be sent to landfill sites

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Whitetranslucent

Waste sharps including Metals: Needles, syringes with fixed needles, needles from needle tip cutter or burner, scalpels, blades, or any other contaminated sharp object that may cause puncture and cuts. This includes both used, discarded and contaminated metal sharps

Puncture proof, Leak proof, containers

Autoclaving or Dry Heat Sterilization followed by shredding; and sent for final disposal to iron foundries (having consent to operate from the State Pollution Control Boards or Pollution Control Committees) or sanitary landfill or designated concrete waste sharp pit.

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blue (a) Glassware: Broken or discarded and contaminated glass including medicine vials and ampoules except those contaminated with cytotoxic wastes.

Cardboard boxes with blue colored marking

Disinfection (by soaking the washed glass waste after cleaning with detergent and Sodium Hypochlorite treatment) or through autoclaving or microwaving or hydroclaving and then sent for recycling

(b) Metallic Body Implants

Cardboard boxes with blue colored marking

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Statistics

Total bio-medical waste generation in the country is 484 TPD from 1,68,869 healthcare facilities (HCF), out of which 447 TPD is treated. MoHFW The quantum of waste generated in India is estimated to be 1-2 kg per bed per day in a hospital and 600 gm per day per bed in a clinic.

85% of the hospital waste is non-hazardous, 15% is infectious/hazardous.

Every year an estimated 16 billion injections are administered worldwide, but not all of the needles and syringes are properly disposed of afterwards.

In 2010, unsafe injections were still responsible for as many as 33 800 new HIV infections, 1.7 million hepatitis B infections and 315 000 hepatitis C infections

A person who experiences one needle stick injury from a needle used on an infected source patient has risks of 30%, 1.8%, and 0.3% respectively of becoming infected with HBV, HCV and HIV

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SOURCES OF BIOMEDICAL WASTE

MAJOR SOURCESGovt. hospitals/private hospitals/nursing

homesDispensaries/PHC/CHC/SDHMedical, dental and nursing

colleges/institutes Veterinary colleges/research centers.Blood banks/mortuaries

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•Physicians/dentist clinics•Blood donation camps.•Vaccination centers.•cosmetic piercing.

MINOR SOURCES

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Types of BMW

Non-hazardous (85%)Hazardous (15%)

Infectious (10%) Non-Infectious (5%)

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INFECTIOUS WASTE Lab cultures plate Human tissues or fluids Body parts BloodBody fluidsFoetusSharps-NeedlesScalpelsKnivesBladesBroken glass

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NON-INFECTIOUS WASTEDrugs expiredLab reagentsExpired DisinfectantsBatteriesBroken ThermometerRadioactive waste

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Hospital Waste Management involves: collection segregation transportation treatment disposal

STEPS IN WASTE MANAGEMENT

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COLLECTION AT SOURCE

Red – contaminated waste(RECYCLABLE)like plastic bag,

catheter , intravenous stes

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LABELS

)

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SEGREGATION AT SOURCE

reduces the amount of waste needing special handling

and treatment

prevents mixture of medical waste like sharps with general waste.

Prevents illegal reuse

Of the general waste, biodegradable waste can be composted within hospital premises and can be used for gardening purposes

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STORAGE

Once collection occurs then biomedical waste is stored in a dedicated place.

The duration of storage should not exceed 24 hrs. Each container must be clearly labeled to show the ward or room where it is kept-may be necessary to trace the waste back to its source.

Besides this, storage area should be marked with a BMW hazard sign.

28 TRANSPORTATION

Locally transported for treatment either in trolleys or in covered wheelbarrow.

The bags / Container containing BMWs should be tied/ lidded before transportation.

Biohazard symbol

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PROTECTION oF HCW

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PERSONNEL SAFETY DEVICES

Mandatory for all the personnel handling waste.Gloves:  rubber gloves The size should fit the operator.Aprons, gowns, suits: Aprons is worn to prevent contamination of

clothing and protect skin. It should be made of cloth or impermeable material such as plastic.

People working in incinerator chambers should have gowns or suits made of non-inflammable material.

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Cont..

Masks:  working in the incinerator chamber to wear a

mask covering both nose and mouth

Boots:  Leg coverings, boots or shoe-covers -protection to

splashing anti-skid type. should cover leg up to ankle.

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HELMET EYE PROTECTORS

FACE MASK

PLASTIC APRON

RUBBER GLOVES

BOOTS

33TREATMENT OF BMW

Chemical processes Thermal processes Mechanical processes

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CHEMICAL PROCESS

Sodium hypochlorite 10,000 ppm for spillage, 2500 ppm for discard container 1000 ppm for cleaning

Suitable for Liquid waste treatment, blood, urine, stool.

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THERMAL PROCESS

These processes utilize heat Depending on the temperature they operate, it is been grouped into two categories

•Low-heat systemsAutoclave & Microwave

•High-heat systemsIncinerator & Hydroclaving

36Low-heat systems 

i. Autoclaving is a low heat thermal process and it uses steam for disinfection of waste.

ii. Microwaving is a process which disinfects the waste by moist heat and steam generated by microwave energy.

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AUTOCLAVE

PRINCIPLE

•Steam penetrates objects in the autoclave•Moist heat kills microorganisms via coagulation of proteins• temperature of not less than 121°C and pressure of 15 pounds per cycle for not less than 60 minutes• use - For microbiological waste, blood & blood products, body fluids, used sharps.

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MICROWAVING

LOADING DEVICE -transfers the waste into shredder

SHREDDER - Break into small piecesShredded waste mixed with water – subjected to

microwavesWater in waste heated by microwave.Heat waste to temp. of 97-100 C . Cycle time- 40

to 45 minInfectious components destroyed by heat

conduction.Finally passed to landfill.

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ardous or radioactive waste, contaminated animal parts and large metal parts

No Microwaving to be done for:

•Cytotoxic /Radioactive waste.

•Contaminated body parts, tissues.

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INCINERATOR

PRINCIPLE : High temperature, dry oxidation process that reduces

organic & combustible waste to inorganic & incombustible waste

Converts the waste into ash,  gas, and heat.

Gases are cleaned of gaseous and particulate pollutants before they are dispersed into the atmosphere

Wastes to be incinerated shall not be chemically treated with any chlorinated disinfectants.

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TYPES OF INCINERATORS

DOUBLE CHAMBEREDSINGLE CHAMBERED

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Double- chamber pyrolytic incinerators

2 Chambers

Pyrolytic chamber/primary chamber---800 CPost combustion/secondary chamber---1000

CChimney

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USES

Infectious wastePathological wastePharmaceuticals

NOT TO BE INCINERATEDbroken thermometers, used batteries or ampoules containing heavy metals

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HYDROCLAVE – Stage oneMedical Waste is deposited in the Hydroclave vessel.

The Hydroclave can process:Pathological waste, Sharps containers Liquid containerMetal objects

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Stage two The waste fragmentation and sterilization

A. Powerful rotators mix the waste and breaks it into small pieces.

B. Steam fills the vessel and heats the vessel interior.

C. The liquids in the waste turn to steam.

D. After 20 minutes the waste and liquids are sterile.

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Stage three Vessel venting and dehydration

A. The vent is opened, and the vessel de-pressurizes.

B. Steam heat and mixing continue until all the liquids are evaporated and the waste is dry.

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Stage four Unloading the Waste

A. The unloading door is opened.

B. The mixer now rotates in the opposite direction, so angled blades on the mixer can push the waste out the unloading door.

C. The dry, sterile waste can be fine-shredded further or dropped in a waste disposal bin.

The waste is now ready for safe disposal!

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ADVANTAGES

Dry waste,Low odor, due to the dryness.Volume reduction to 85%Weight reduction to 70%Accepted as harmless waste.

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HydroclaveNo pre-shredding of

infectious wasteHigh level of sterilityLow operating costby steam

Microwave

Must pre-shredLow levelHigh operating costExpensive

electricity

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MECHANICAL PROCESSES

Change physical form or characteristics of the waste either to facilitate waste handling or to process the waste in conjunction with other treatment steps.

SHREDDING - used to destroy plastic and paper waste to prevent their reuse. Only the disinfected waste can be used in a shredder.

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SHREDDERS

For plastic -only after autoclaving

After autoclaving-send to shredders

sold to authorized plastic molder unit

Have set of revolving blades that cut waste into small pieces

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DISPOSAL

ASH – To land fillRECYCLABLE WASTE - To registered or authorized

recyclers or plastics to diesel or fuel oil or for road making, whichever is possible.

METALS - Sent for final disposal to iron foundries to produce metal castings

NEEDLES - Pits or encapsulation

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STANDARDS IN BMW

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INCINERATORS

Should meet the following operating and emission standards:

A. Operating StandardsCombustion efficiency (CE) shall be at least 99.00%The temperature of the primary chamber should be

minimum of 800 degree C and the secondary chamber shall be minimum of 1050 degree C + or - 500C

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Parameter Limiting concentration in mg Nm3 (milligrams per cubic metre) unless stated

Mercury and its compounds 0.005Nitrogen oxides 400HCl 50

B . EMISSION STANDARDS

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AUTOCLAVING

1.Biological indicator –Geobacillus stearothermophilus spores using vials or spore Strips;

once in every week records - maintained.

2.chemical strip or tape- changes color when certain temperature is reached

during autoclaving of each cycle

3.RECORDING OF OPERATIONAL PARAMETERS: Should have computer recording devices- automatically and

continuously monitor and record dates, time of day, load identification number and operating parameters throughout the entire length of the autoclave cycle.

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MICROWAVING

Biological indicators for microwave shall be Bacillus atrophaeus spores using vials or

spore strips with at least 1 x 104 spores per detachable strip.

The biological indicator should be placed with waste and exposed to same conditions as the waste during a normal treatment cycle

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DEEP BURIAL

A pit or trench should be dug about two meters deep.

It should be half filled with waste, then covered with lime within 50 cm of the surface, before filling the rest of the pit with soil

It must be ensured that animals do not have any access to burial sites. Covers of iron or wire meshes may be used.

On each occasion, when wastes are added to the pit, a layer of 10 cm of soil shall be added to cover the wastes.

The deep burial site should be relatively impermeable and no shallow well should be close to the site.

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CONT..

The pits should be distant from habitation, and located so as to ensure that no contamination occurs to surface water or ground water. The area should not be prone to flooding or erosion.

The location of the deep burial site shall be authorized by the prescribed authority.

The ground water table level should be a minimum of six meters below the lower level of deep burial pit.

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EFFICACY OF CHEMICAL DISINFECTION

Microbial inactivation efficacy is equated to “Log10 kill” which is defined as the difference between the logarithms of number of test microorganisms before and after chemical treatment.

4 Log10 reduction or greater for Bacillus Subtilis (ATCC 19659) in chemical treatment systems.

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STANDARDS FOR LIQUID WASTE

PARAMETERS PERMISSIBLE LIMITS Suspended solids 100 mg/l pH 6.5-9.0 Oil and grease 10 mg/l BOD 30 mg/l COD 250 mg/l

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BMW @ GMCH, Jammu

Three types of color bags used in wards for BMW collection and seggregation

Black, blue & yellow

For general waste- BLACK bagsFor infectious waste- YELLOW bagsFor sharps – BLUE bags

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Disposal of used Syringes/needles/broken vials

After administering injection, needle destroyed using a needle destroyer / cutter

Followed by cutting of the plastic hub of the syringe without detaching the needle from the syringe.

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Transport & Disposal

Transport: Trolleys To BMW shed at the backside of hospital

Disposal: Incinerator – Not used General waste collected by municipality truck BMW collected by state BMW agency for disposal in

BMW plant at Udhampur

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BMW at Dept. of Microbiology, GMC, Jammu

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SPECIMEN RECEIVED

Blood, Urine,Stool, Peritoneal fluid,Pleural fluid,Synovial fluid, CSF, pus, sputum

Tissues, Vaginal, Throat, Wound swabs

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SLIDES

Slides immersed in discarding jar containing 1% sodium hypochlorite in water is generally effective.

Left for overnight.Jars emptied down the discard sink.

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CULTURE PLATES AND TUBESCulture plates, drug sensitivity plates, culture

material with bacterial growth in liquid or solid media in tubes, bottles and plates .

Directly loaded in to autoclave

Melted media and liquids poured down the drain. The containers are washed and reused.

70HOSPITAL WASTE MANAGEMENT COMMITTEE AND IT’S FUNCTION

It functions under the Chairmanship of the Medical Superintendent.

It is a broad based committee with representative from various departments like microbiology dept.,

including Medical store, sanitation, Nursing and engineering Depts.

FUNCTION OF THE COMMITTEE : Implementation of the Bio-Medical Waste (Management )

Rules published in gazette of India Monitor and ensure effective, hospital waste management

in the Hospital. Organize proper and timely; training program for all

categories of workers.

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REFERENCES

Biomedical waste management rules,2016 by Dept. of environment, forest and climate change-GOVT. OF INDIA

WHO guidelines on BMW management

Parks Textbook of Preventive and Social Medicine

Guidelines on safe disposal of Used Needles andSyringes in the Context of Targeted Intervention forInjecting Drug Users.

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