HOSPITAL WASTE MANAGEMENTTYPES, CHARACTERISTIC, TREATMENT METHOD AND MANAGEMENT

11th May 2009

OUTLINEPotential Hazard of Hospital WasteWaste Management Sources of wasteClassification of Hospital WasteTreatment, Transport and Disposal MethodIncineration of Hospital WasteRegulations

Facts in IndonesiaRS mengolah Limbah = 53%, pengolahan dg IPAL dan septic tank = 51%, sisanya hanya septic tankRS yg melakukan pemeriksaan kualitas limbah 57%, 63% memenuhi syaratPemisahan sampah medis dan non medis 80.7%, 20% dengan pewadahan khusus (warna dan lambang)62.5% insinerator, 14.8% landfill, 22.7% cara lainLimbah toksik, 51.1% insinerator, 15.9% landfill, 33.0% cara lainLimbah radioaktif, hanya 37.1% menyerahkan limbha ke BATAN, sisanya dengan Silo dan cara lainLimbah domestik 98.8% dengan cara landfill

POTENTIAL HAZARDExposed people: ?Patient and medical workersPeople who are contracted working at the hospital (cleaning service etc)Patient (rawat jalan)Visitors

Benefit of Env. ManagementEnvironmental ProtectionBetter Hospital Environmental ManagementHuman Resource DevelopmentContinuous Improvement of Hospital Environment PerformanceMeet Regulation RequirementPart of Total Quality ManagementReduction of ExpensesImprovement of Hospital Public Image

Env. Management ComponentManagement SupportScale and Type match with Env. Impact from Hospital activitiesContinuous improvementMeet the regulation requirementGuideline to prepare and review the objective and goal of Env. ManagementDocumented, applied, maintained and communicated to all Available for all

PlanningIdentification of env. Aspects and ImpactsLegal requirementsEnvironmental Policy and Internal performance criteriaObjectives and goals of env. ManagmeentPlanning and management programStruktur, tanggung jawab, organisasi, kewenangan; proses bisnis management; SDM, skill, budget dan alat; proses untuk mencapai tujuan: prosedur dan pengendalian operasi, pelatihan, sistem pengukuran dan audit, pengkajian manajemen.

ImplementationStructure and responsibilitiesTraining, awareness, competencyCommunicationDocumentation and Env. Management SystemDocument ControlOperational Control Emergency preparednessEvaluationCorrective action

Hospital RegulationPerMenKes RI No 928/Menkes/Per/XI/1995 ttg penyusunan AMDAL bidang kesehatanPedomen teknis penyusunan AMDAL RSPedoman Teknis penyusunan UPL dan UKL RSPerMenKes RI No 986/Menkes/Per/XI/1992 ttg Persyaratan Kesehatan Lingkungan RSKeputusan Dirjen P2M PLP No HK.00.06.6.64, 18 Feb 1993 ttg Persyaratan dan Petunjuk Teknis tentang Tata Cara Penyehatan Lingkungan Rumah SakitPedoman Sanitasi RS IndonesiaPedoman teknis Pengelolaan Makanan dan Infeksi Nosokomial di RSPP no 12/1995 ttg perubahan PP no 19/1994 ttg pengelolaan limbah B3KepMenLH No 58/1995 ttg Baku Mutu Limbah Cair bagi Kegiatan RS

Regulated Env. AspectsEnvironmental Impacts AssessmentNosokomial InfectionChemical and hazardous wasteGas emission, temperature, humidity, nuisance and lighting Effluent quality of waste treatment plantSolid wasteRadioactive wasteMedical waste

Unregulated Env. AspectsManagement structureFacilities, location map of env. controlHistory and Owner of the HospitalHospital General activitiesFlow of Health Treatment ProcedureNosokomial Infection controlHealth and Safety PolicyList of Medical and non medical substanceSistem pengadaan dan jadwal, jml pemakaian, penyimpanan, distribusi dan transportasi bahanAir pollution control

Handling, storage, transportation of domestic, hazardous, chemotherapy waste, disposal procedure and legal letterWater supply, piping, layout, and water consumptionRecording of wastewater effluent qualityWaste water treatment system ( system, facilities and SOP)Sanitation method (pest, microbiology, virus, toxicology)Supply, Layout, consumption of electricityEnvironmental trainingSupplier Consideration of Environmental IssuesMaterial Identification Approach

Environmental Monitoring AspectsWaste productionWaste waterReuse of waste waterEfficiency of Material ConsumptionEnergy consumptionUnplanned disposalRecycle activitiesChemical handlingGas handling Handling of water for cleaning purposes

Medical ActivitiesSupporting activitiesOffice & Social ActivitiesMedical wasteNon Medical WasteIncineratorIPALHospital Activities(sources) ?Waste Generation(solid, liquid, gas) ?Waste Management ?Collection / StorageTransportationTreatmentDisposalWASTE FLOW IN GENERAL

SOURCESMedical ActivitiesSurgical Room, Emergency Room, Policlinic, Dialysis, Delivery Room, treatment of dead body, Chemotherapy, etc.Supporting ActivitiesLaboratories, Radiology, Laundry, Kitchen, Maintenance, PharmacyOffice and Social ActivitiesOffice (administration and accountancy), Medical record, Cafeteria, Mosque, Guest House, Dormitory

CLASSIFICATIONLiquid wasteSolid wasteGas EmissionMedical waste ?Non Medical Waste ?Hospital WasteExcretaToxic chemicalsRadioactive Subs.PathologicalInfectious wasteCitotoxicSharpsPharmalogicalGeneral wasteHazardous wasteChemical waste

CLASSIFICATIONHospital Waste: all wastes that are generated from hospital activities including solid, liquid and gasesLiquid waste: all waste in liquid form from hospital activities including excreta that has possibilities of containing microorganism, toxic chemicals, and radioactive substance.Solid waste: all waste in solid form including medical and non medical waste

Medical waste (limbah medis) (50-60% disposal cost) generated from medical activitiesInfectious waste contains microorganism that may cause disease from surgical room, laboratories, haemodialysisPathological waste human/animal tissue, body part, etcCitotoxic waste material that are/might be contaminated by citotoxic medicine Sharps syringe, scissors, knife, broken glass, nail cutter tertusuk (luka)Pharmacological waste returned medicine, expired or contaminated medicine, spilled medicine, etc.

CLASSIFICATION

Could you explain what are the differences between infectious waste and pathological waste ?

CLASSIFICATIONNon Medical Waste (limbah non medis) mostly generated from hospital supporting activities, office and social activitiesGeneral waste, food, card board, etcHazardous waste toxic, corrosive, flammable, reactive (explosive, reactive to water, shock sensitive)Radioactive solid, liquid or gas contaminated by radionuclide, generated from in-vitro, in-vivo analysis, therapytoxic waste genetoxic (carcinogenic, mutagenic, teratogenic)pressure containers explosive when burnedWaste with high heavy metal concentration Chemical waste disinfection, laboratories, cleaning, may include in hazardous waste categories

Limbah KlinisGolongan A, dressing bedah, swab, dan semua bahan yang tercampur deng bhn tsb, linen dan kasus infeksi, jaringan tubuh, dan hal lain y berkaitan dg swab dan dressingGolongan B, syringe bekas, jarum, catridge, pecahan gelas, dan benda tajam lainnyaGolongan C, limbah dr laboratorium dan post partum kecuali yg termasuk gol AGolongan D, limbah bahan kimia dan bhn farmasi tttGolongan E, plapis bed-pan disposable, urinoir, incontinence-pad, dan stamage-bags

INFECTIOUS WASTEInfectious waste includes the following (EPA): ?Isolation wasteCultures and stocks of infectious agents and associated biologicalsHuman blood or liquid and blood productsPathological waste (tissues, organs, body parts except teeth and hair)Contaminated sharpsMiscellaneous contaminated wastes (animal carcasses)

CHARACTERISTIC of SWEstimate hospital waste generation (US): 4.54 9.08 kg/day per bed6.5 kg/bed per day 11.5 kg/bed per dayBandung (RSHS) = 2.12 kg/bed/dayHospital Medical waste = 10 20 kg/hariImmunization syringe = 66 million/year, total 300 million/yearSolid waste classification system (EPA) based on moisture content, ash content, overall composition heat content incineration purpose

Waste TypeWeight %Heat of combustion J/kgClass 0708500Plastic1519500Class 3104500Class 451000

CLASSIFICATION

ClassPrincipal ComponentsSourcesApprox. Composition, wt %Moisture Content, %Incombustible solids, %Btu value/lb of refuse as fired0Highly combustible waste. Paper, wood, cardboard cartons, and up to 10% treated papers, plastic, or rubber scrapsCommercial, industrial100 trash10585001Combustible waste, paper, cartons, rags, wood scraps, combustible floor sweepingsdomestic, commercial, industrial80 Rubbish 20 garbage251065002Rubbish and garbageresidential50 Rubbish 50 Garbage 50748003Animal and vegetable wastesrestaurants, hotels, markets, institutional, commercial, clubs 35 Rubbish 65 Garbage70525004Carcasses, organs, solid organic wastesHospitals, laboratories, abattoirs, animal pounds, etc.100 animal and human tissue8551000

COMPOSITION

Waste TypeWeight %Generation rate based on 20 kg/bed/dayPathological (non infectious body parts)0.50.10Infectious10.0 15.02.00General/ administrative (noninfectious)50.010.00Food30.06.00Card Board9.51.90

TOXIC & HAZARDOUS WASTEHospital generate 0.056 lb/bed per day toxic and hazardous waste200 bed 336 lb per month hospitals are regulated as generator of hazardous waste

WASTE MANAGEMENT ?Cleaner Production / Waste PreventionWaste Minimization / Source ReductionRecyclingWaste TreatmentWaste DisposalMaterial substitutionLife cycle analysis of productProcess modification, equipment redesignNew productThermal destruction, physical, chemical, biologicalLandfill

WASTE MANAGEMENTRaw MaterialUse of MaterialWaste GenerationWaste Collection/Storage, Transportation and Treatment (On Site)Waste Transportation,Treatment and Disposal (Off site)EnvironmentRecycleReuseWaste tradersWaste traders

PREVETION OF POTENTIAL HAZARDUse safety material or non-hazardous materialUse closed containers for volatile substanceGood ventilation health&safety standardsBody protection (mask, gloves, etc.)Use container with different color for different wasteRegular monitoring for high risk activitiesEpidemiological analysis for high risk activities

ON SITE HANDLING

COLLECTION / STORAGEEPA red bag (operating room waste, blood serums, sharps), white bag (general waste, kitchen waste, boxes)DepKes RI plastic bags colorBlack : general wasteYellow: all waste that must go to incineratorsYellow with black line: all waste that better go to incinerator, but can go to landfill if collected separately Light blue or transparent with dark blue lines: must go to autoclave before next handling

COLLECTION / STORAGEBags or containers should be ? Enough filled so it is easy to be well closed Labeled symbol is given as it is regulatedAble to allow steam to enter during sterilization (if needed) Completed with active date before it can be categorized as general wasteFor syringe : WHO standard (container shape, thickness, material, placing)

TRANSPORTATIONWaste are transported from first collection to temporary storage or to incineratorTransportation means must be cleaned regularly and used only for waste transportIf transported to landfill must not have possibilities to harm the health of transportation personnel Hazardous waste should be transported as regulated in PP 18/1999

HANDLING OF CHEMICAL Non-hazardous chemical should be labeled and handled as general wasteorganic chemical (acetate, amino acid, citric acid, lactic acid, sugar)Inorganic chemical (chloride, fluoride, bromide, sulfate, borate)Hazardous chemical Un reusable chemical incineratordated after used, maximum storage time: 3, 12, 24 monthShock sensitive: diazo substance, metal azide, nitrocellulose, perchloric acid, perchlorate salts, peroxide, picric acid, picrate salts, polynitroaromatic Water reactive: alkaline metal, soil alkaline, lithium alkaline reagent, boron trifluoride solution, grignard solutionOthers: nitrate acid >70%, phosphor (red and white)

DISINFECTION ALTERNATIVESAutoclavingPyrolysis 1200C, vol. reduction 97-98%Fluidized-bed coal technology circulating fluidized bed burning of coalElectron beam technology sterilization of all infectious waste including liquidMicrowave technology not recommendation for pathological and animal waste, + expensiveMechanical-Chemical treatment (Sodium Hypochlorite -NaOCl) pathological Gas/vapor sterilization (ethylene oxide or formaldehyde), not recommendedBiodegradation enzymesSteam sterilization 300 F

COMPARISON

Treatment TechnologyRegulated wastesVol. Reduction (%)Typical Operating Costs $/lb per hrCapital Cost $1000Steam Autoclaveexcept pathological00.05-0.07100 (on site)Autoclave with compactionexcept pathological60-800.03-0.10100Mechanical-chemicalall60-900.0640-350Microwave (with shredder)except pathological and toxics60-900.07-0.10500Incinerationall90-950.07-0.51000 (on site)

DECISION MAKING

INCINERATION ? Infectious, un recover/un recyclable general wasteOperational Parameters: Burning rate (pound/hour), heating value (Btu/pound), heat release value (Btu/cubic feet per hour)Alternatives: Controlled-air incinerators Rotary-kiln incineratorsAir Pollution ControlsWet Scrubbers: impaction of particles with countercurrent flow reactorDry Scrubbers: Reacting particles and gases in spray-dryer section, collection of particles in a baghouse collector

INCINERATORS

INCINERATORS

INCINERATORS

INCINERATORS

What are the differences between controlled air and rotary kiln incinerators ?

AIR POLLUTION CONTROLS

NEW METHODSProblems dioxin carcinogenicDioxin + chlor TCDD (Tetra Chloro Dibenzo para Dioxin) cancerUS many incinerators > regulationJapan 70% world incinerators, high concentration dioxin found in surrounding incinerator 18 from 271 die from cancer> 800 C reduce dioxin but increase heavy metal vaporUsing Sun Light reduce dioxin, reduce cost150C in 20 minutes enough to kill bacteriaLow Thermal DesorbtionInvented by FMIPA UITitanium oxide dioxin reductionIndirect heating with low heat thermolysis drying at low temperature (200-350 C) without oxidation (direct burning)Low pressureNo oxygen reduce vapor point

LIQUID WASTEIndonesia most hospitals use septic tankDirect charge to riverPossibility polluting the surrounding soilUnable degraded by activated sludgeRecommended: OzonizationOzone: oxidation potential 1.7 V radicalOzone in water radical hydroxil (2.8 V)Kill eschericia coli, Salmonella enteriditis, Hepatitis A Virus, etcOxidize organic substance ( fenol, pesticides, atrazine, TNT, etc)

EqualizingReactor(O3)CoagulationFiltration(active carbon)Filter washEnvironment

TOXIC WASTE DISPOSAL

REGULATIONUU No. 23 /1997 Pengelolaan Lingkungan HidupKepMENLH No. 58/1995 Baku mutu limbah cair bagi kegiatan rumah sakitPP No. 18/1999 Pengelolaan limbah B3UU N0. 7/2004 Sumber Daya AirPeraturan Menteri Kesehatan RI No. 1024/2003 Persyaratan Kesehatan Lingkungan RS

REFERENCESHarry M. Freeman, editor (1989) Standard Handbook of Hazardous Waste Treatment and Disposal, McGraw-Hill, Inc., New York.Howard E. Hesketh and Frank L. Cross, Jr. (1995) Engineering Medical Waste-to-Energy Systems, Technomic Publishing Co., Inc., LancesterCRS Handbook of Laboratory Safety 5th edition (A. Keith Furr)Hazardous Waste Management, McGraw-Hill, Inc., New YorkBapedal (2003) Peraturan Lingkungan Hidup, Jilid 1, Bapedal, Jakarta.Wiku Adisasmito, 2007, Sistem Manajemen Lingkungan, PT. Raja Grafindo Persada, Jakarta

ALTERNATIVE METHODS