PRIRU^NIK DOBRE PRAKSE UPRAVLJANJA MEDICINSKIM OTPADOM

Projekat finansiraEvropska unija

Projekat implementira Dru{tvo za istraživanje i

razvoj Tuzla

Projekat “NVO i medicinski otpad”

Novembar, 2012.

PRIRUČNIK DOBREPRAKSE UPRAVLJANJA MEDICINSKIM OTPADOM

Izdavač: Društvo za istraživanje i razvoj

Džafer mahala 66 75000 Tuzla, Bosna i Hercegovina tel/ fax: +387 35 277 254 društvo.razvoj@bihnet.ba www.istraz.org

Radna grupa za izradu Priručnika:

dr Amer Ćustović, JZU Univerzitetsko klinički centar Tuzla dr Sadeta Hadžić, JZU Univerzitetsko klinički centar Tuzla mr.Esad Arnautović , DIR Tuzla dr Mustafa Burgić, DIR Tuzla, stručni saradnik za okoliš Emir Arpadžić, DIR Tuzla, stručni saradnik za okoliš Amila Šećerkadić, DIR Tuzla, stručni saradnik Jasmina Ovčina, CISP, stručni saradnik

Radna grupa za podršku pri izradi Priručnika:

JKP Regionalni centar za upravljanje otpadom Kemis – BH d.o.o Lukavac JZU Univerzitetsko klinički centar Tuzla JZU Dom zdravlja Tuzla JZU Dom zdravlja Gračanica JZU Dom zdravlja Banovići CEETZ Tuzla EKOPOT Tuzla Udruga Hrvatska žena Tuzla CISP NVO Etno Klub Kicelj Tuzla UG “ Klub potrošača” Tuzla Crveni križ TK

Štampa: Papir karton, Tuzla

Tiraž: 1000 primjeraka

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Akronimi:

NVO Nevladina organizacijaBiH Bosna i HercegovinaEU Evropska unija TK Tuzlanski kantonJU Javna ustanovaFBIH Federacija Bosne i Hercegovine WHO Svjetska zdravstvena organizacija RS Republika Srpska LZO lična zaštitna oprema

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SADRŽAJ

Akronimi .................................................................................................................................................................................... 31. UVOD ........................................................................................................................................................................... 52. MEDICINSKI OTPAD ................................................................................................................................................. 62.1. Osnovni principi upravljanja medicinskim otpadom .................................................................................................... 62.2. Definicija i podjela medicinskog otpada ....................................................................................................................... 62.3. Kategorije medicinskog otpada ..................................................................................................................................... 72.3.1. Opasan medicinski otpad .............................................................................................................................................. 83. ZDRAVSTVENI RIZICI OD MEDICINSKOG OTPADA .......................................................................................... 103.1. Profesionalni i javno zdrastveni rizici ........................................................................................................................... 103.1.1. Rizik od infektivnog otpada .......................................................................................................................................... 113.1.2. Rizik od hemijskog i farmaceutskog otpada ................................................................................................................. 134. PROCJENA RIZIKA .................................................................................................................................................... 144.1. Procjena rizika u kontekstu medicinskog otpada .......................................................................................................... 144.2. Pet koraka u proceni rizika ........................................................................................................................................... 145. ZAKONSKA REGULATIVA ....................................................................................................................................... 185.1. Zakonski okvir upravljanja medicinskim otpadom u BiH ............................................................................................ 185.2. Međunarodno zakonodavstvo ....................................................................................................................................... 185.2.1. EU direktive .................................................................................................................................................................. 185.2.2. Bazelska konvencija ...................................................................................................................................................... 195.2.3. Prilagođavanje međunarodnom zakonodavstvu ........................................................................................................... 196. UPRAVLJANJE MEDICINSKIM OTPADOM U ZDRAVSTVENIM USTANOVAMA ........................................... 206.1. Učesnici u procesu zbrinjavanja medicinskog otpada .................................................................................................. 206.2. Odgovorne osobe i tijela za organizaciju i unutrašnji nadzor ....................................................................................... 206.3. Upravljačka struktura, povezanost i odgovornosti ........................................................................................................ 216.4. Izrada Plana za upravljanje otpadom ............................................................................................................................ 227. OBUKA I EDUKACIJA ............................................................................................................................................... 237.1. Stavovi o upravljanju otpadom ..................................................................................................................................... 237.2. Identifikovanje potreba za obukom i obuka zaposlenih ............................................................................................... 238. PRAĆENJE KVALITETA UPRAVLJANJA OTPADOM ............................................................................................ 259. RUKOVANJE MEDICINSKIM OTPADOM .............................................................................................................. 299.1. Razdvajanje medicinskog otpada ................................................................................................................................ 299.2. Odlaganje i obilježavanje medicinskog otpada ............................................................................................................. 309.3. Unutrašnji transport i skladištenje opasnog medicinskog otpada ................................................................................. 329.4. Odlaganje, transport i skladištenje pojedinih vrsta otpada u zdravstvenoj ustanovi .................................................... 339.4.1. Odlaganje i transport oštrog otpada .............................................................................................................................. 339.4.2. Odlaganje i transport infektivnog otpada ...................................................................................................................... 349.4.3. Odlaganje i transport patološkog otpada ....................................................................................................................... 359.4.4. Odlaganje i transport farmaceutskog otpada ................................................................................................................. 369.4.5. Odlaganje i transport hemijskog otpada ....................................................................................................................... 379.4.6. Odlaganje i transport citotoksičnog i citostatičkog otpada ........................................................................................... 389.4.7. Odlaganje radioaktivnog otpada .................................................................................................................................. 389.5. Prostorija za centralno skladištenje u ustanovi ............................................................................................................. 3910. KONAČNA OBRADA I ODLAGANJE MEDICINSKOG OTPADA ........................................................................ 4010.1. Opcije za konačnu obradu i dlaganje otpada ................................................................................................................ 4010.2. Odlaganje otpada na deponiju ...................................................................................................................................... 4010.3. Obrada infektivnog otpada pomoću sterilizacije parom (u autoklavu) ......................................................................... 4110.4. Spaljivanje ..................................................................................................................................................................... 42

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1. UVOD

Priručnik dobre prakse upravljanja medicinskim otpadom“ nastao je kao rezultat rada Radne grupe Društva za istraživanje i razvoj Tuzla u okviru aktivnosti: Zbrinjavanje medicinskog otpada u odabranim zdravstvenim institucijama projekta „NVO i medicinski otpad“ koji finansira Evropska unija. Namijenjen je svim zdravstvenim ustanovama i svim ostalim interesnim stranama koje učestvuju u implementaciji ovog pro-jekta u smislu uspostavljanja jedinstvenog sistema upravljanja medicinskim otpadom u zdravstvenim ustano-vama Tuzlanskog kantona. Predstavlja dobar izvor informacija i stručnih preporuka za zbrinjavanje medicin-skog otpada, u skladu sa domaćom zakonskom regulativom i primjenom dobre prakse i najboljih raspoloživih tehnika EU za upravljanje medicinskim otpadom.

Cilj Priručnika je da pruži osnovne informacije koje će doprinijeti smanjenju količine medicinskog otpada u zdravstvenim ustanovama, razdvajanjem otpada na osnovne kategorije na mjestu nastanka, pravilno pako-vanje istog, obilježavanje i odlaganje, izdvajanje sekundarnih sirovina iz otpada, reciklaža, kao i korištenje čistijih tehnologija za sterilizaciju odnosno dekontaminaciju infektivnog medicinskog otpada. Krajnji cilj je doprinos zaštiti okoliša i unapređenju zdravlja građana TK i BiH

Primjenom Priručnika u svakodnevom radu prije svega zdravstvenih ustanova, a potom i svih ustanova u kojima se pruža zdravstvena zaštita, daće se doprinos u:

• iznalaženju jedinstvenog pristupa u upravljanju medicinskim otpadom i uspotstavljanju bezbjednog sistema upravljanja medicinskim otpadom,

• povećanju bezbijednosti u radu zaposlenih,• unapređenju bezbjednosti korisnika zdravstvene zaštite,• smanjenju rizika od širenja zaraznih bolesti • smanjenju drugih štetnih rizika od svih vrsta medicinskog otpada• smanjenju količine medicinskog otpada • unapređenju stanja okoliša.

Priručnik dobre prakse sadrži informacije i preporuke koje se odnose na:

• Definiciju medicinskog otpada• Klasifikaciju medicinskog otpada• Zdravstveni rizici i procjena rizika od medicinskog otpada• Zakonska regulativa u BiH i međunarodno zakonodavstvo • Upravljanje medicinskim otpadom u zdravstvenim ustanovama • Obuka i edukacija • Praćenje kvaliteta upravljanja otpadom • Rukovanje medicinskim otpadom • Konačna obrada i odlaganje medicinskog otpada

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2. MEDICINSKI OTPAD

Otpad nastaje kao posljedica svake ljudske djelatnosti, pa tako i zdravstvene. Razvoj zdravstvene tehnologi-je promijenio je količine i sastav medicinskog otpada. U zdravstvenim ustanovama nastaje medicinski i komu-nalni otpad. Komunalni otpad nastaje u bolesničkim sobama, kuhinji, administraciji i sadrži: papir, kartonsku ambalažu, staklo, limenke, ostatke hrane i slično. Medicinski otpad nastaje pružanjem medicinskih usluga i predstavlja rizik za zdravlje i okolinu. Zato je obaveza zdravstvenih ustanova i kompletne društvene zajednice da se medicinski otpad adekvatno zbrinjava od mjesta njegovog nastanka do krajnjeg zbrinjavanja.

2.1. Osnovni principi upravljanja medicinskim otpadom

Osnovni principi upravljanja medicinskim otpadom su:• Smanjivanje proizvodnje i količine medicinskog otpada;• Uspostavljanje procesa razdvajanja/prema načinima prerade i odlaganja; • Pravilno upravljanje otpadom koji ugrožava zdravlje ljudi• Planiranje aktivnosti u vezi sa upravljanjem medicinskim otpadom (izrada plana upravljanja medicin-

skim otpadom za svaku zdravstvenu instituciju. • Upravljanje otpadom kojim se ne ugrožava zdravlje ljudi i okoliša;• Organizovanje prerade i odlaganja otpada na najpogodniji način u okviru različitih tokova otpada;• Priprema ili sanacija neuređenih privremenih ili trajnih skladišta otpada;• Vođenje evidencije i dokumentacije o aktivnostima u vezi sa upravljanjem medicinskim otpadom;• Praćenje pokazatelja u vezi sa razdvajanjem, odlaganjem i tretmanom otpada;• Preduzimanje korektivnih mjera u planiranju aktivnosti na godišnjem nivou;• Obuka zaposlenih za poslove razdvajanja, obilježavanja, pakovanja, odlaganja i tretmana medicinskog

otpada;• Motivisanje zaposlenih za efikasno upravljanje medicinskim otpadom;• Razvoj svijesti o upravljanju medicinskim otpadom;• Multidisciplinarna saradnja u cilju uređivanja sistema upravljanja medicinskim otpadom, kako na nivou

zdravstvene ustanove, tako i na teritoriji administrativnog okruga.

Za dobru praksu upravljanja otpadom od ključnog je značaja da zdravstveni radnici i saradnici tačno znaju šta se od njih očekuje u vezi sa razdvajanjem otpada, da budu motivisani i propisno obučeni za navedene ak-tivnosti, kao i da imaju adekvatnu saradnju sa upravom zdravstvene ustanove po pomenutim pitanjima.

2.2. Definicija i podjela medicinskog otpada

Prema Pravilniku o upravljanju medicinskim otpadom FBiH, medicinski otpad je otpad koji se proizvodi u zdravstvenim ustanovama i koji je obuhvaćen Pravilnikom o kategorijama otpada sa listama. To je otpad koji nastaje kod zaštite zdravlja ljudi i životinja i/ili srodnih istraživanja (isključujući otpad iz domaćinstava i restorana koji ne potiče iz neposredne zdravstvene zaštite) otpad od njege novorođenčadi, dijagnosticiranja, liječenja ili prevencije bolesti kod ljudi.

U Evropskom katalogu otpada prema EU Direktivi broj 75/442/EEC, otpad se definiše na osnovu slijedeća tri kriterijuma:

1. Porijeklo otpada tj. definisanje industrijske grane ili sektora iz koga potiče otpad (prva dva broja – zdravstveni sektor – 18).

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2. Proces tokom kojeg nastaje otpad (druga dva broja – otpad koji nastaje pri pružanju zdravstvenih usluga u porodilištima, iz dijagnostike, liječenja ili prevencije bolesti kod ljudi – 18 01).

3. Tip otpada (treći par brojeva – neinfektivni otpad – otpad čije sakupljanje i odlaganje ne podliježe posebnim zahtjevima za sprječavanja infekcija, 18 01 04).

Prema Evropskom katalogu otpada, svaki tip otpada posjeduje klasifikacioni broj ili sopstveni kod koji se sastoji od 6 cifara (primjer, 18 01 03). Ukoliko izvjesne kategorije otpada pored klasifikacionog broja sa 6 cifara posjeduju i zvjezdicu koja stoji iza brojeva, zvjezdica označava da taj otpad spada u opasan otpad (primjer: 18 01 03*, Infektivni otpad).

2.3. Kategorije medicinskog otpada

Kategorije medicinskog otpada koje se koriste u BiH baziraju se na kategorizaciji iz Evropskog kataloga otpada EU Direktiva broj 75/442/EEC. Bosna i Hercegovina je potpisnica direktive, te je prema istoj definisala kriterijume i katalog otpada. Katalog otpada je sistematizovani pregled naziva otpada prema osobinama i djelatnostima iz kojih otpad potiče i sastavni je dio Pravilnika o kategorijama otpada sa listama. Prema Evropskom katalogu otpada medicinski otpad definisan je kao otpad koji nastaje pri pružanju zdravstvene zaštite u medicini i veterini (ljudima i životinjama) i/ili srodnim istraživanjima i zaveden je pod brojem 18 00 00 sa podskupovima.

Otpad prema Direktivi (Kontrolisani otpad)

Otpad koji potpada pod odredbe Okvirne direktive Evropske unije br. 75/442/EEC i na koji se odnose kasnije usvojeni amandmani naziva se „Otpad prema Direktivi”. „Otpad prema Direktivi” obuhvata:

1. Komunalni čvrsti otpad (kućni otpad ili otpad iz domaćinstva)2. Komercijalni otpad (otpad iz komercijalnih ustanova, radnji, kancelarija itd)3. Industrijski otpad (otpad iz industrijskih djelatnosti )4. Otpad od izgradnje/rušenja (potiče iz građevinarstva i predstavlja najveći pojedinačni izvor kontrolisanog

otpada)5. Opasan otpad spada u kontrolisani otpad koji se smatra opasnim ili teškim za čuvanje, preradu ili

odlaganje.

Klasifikacija medicinskog otpada prema Evropskom katalogu otpada

Odjeljak br. 18: otpad koji nastaje kod zaštite zdravlja ljudi i životinja i/ili srodnih istraživanja (isključujući otpad iz domaćinstava i restorana koji ne potiče iz neposredne zdravstvene zaštite) zaveden je pod brojem 18 00 00 sa pododeljcima.

Pododjeljak br. 18 01: otpad od njege novorođenčadi, dijagnosticiranja, liječenja ili prevencije bolesti kod ljudi.

Pododjeljak 18 02: Otpad koji nastaje pri pružanju zdravstvene zaštite u veterini (otpad iz istraživanja, dijagnostike, liječenja ili prevencije bolesti u veterini).

U tabeli 1 je data Standardna klasifikacija otpada u skladu sa Direktivom 75/442/EEC (Izvod iz Kataloga otpada sa opisanim kategorijama otpada Pravilnika o kategorijama otpada sa listama, Službene novine FBiH broj 9/05).

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2.3.1. Opasni medicinski otpad

Svjetska zdravstvena organizacija (WHO), klasificirala je opasni medicinski otpad na klinički i neklinički. Klinički otpad dijeli se na 7 različitih grupa: patološki, infektivni, farmaceutski, hemijski, oštre predmete, aerosole i posude pod pritiskom i radioaktivni otpad.

Opasan medicinski otpad sadrži toksične, štetne, kancerogene i infektivne materije Otpad iz ustanova u kojima se pruža zdravstvena zaštita obavezno se razvrstava na mjestu stvaranja na opasan i neopasan medicin-ski otpad i prema osobinama i mjestu nastanka dijeli se na: patološki otpad, infektivni otpad, oštre predmete, farmaceutski otpad, hemijski otpad, posude pod pritiskom i radioaktivni otpad tabela 2 ).

Slika 1: Klasifikacija medicinskog otpada Svjetske zdravstvene organizacije

Klasifikacioni br. Vrste, osobine i djelatnost iz koje otpad potiče18 01 Otpad pri pružanju zdravstvenih usluga u porodilištima, iz dijagnostike, liječenja ili prevencije bolesti kod ljudi

18 01 01 oštri predmeti (osim 18 01 03)18 01 02 dijelovi ljudskog tijela i organi, vrećice i konzerve krvi (osim 18 01 03)18 01 03* ostali otpad čije je sakupljanje i odlaganje podvrgnuto specijalnim zahtjevima radi prevencije infekcije

18 01 04 otpad čije sakupljanje i odlaganje nije podvrgnuto specijalnim zahtjevima radi prevencije infekcije (npr. rublje, zavoji od gipsa, posteljina, odjeća za jednokratnu primjenu, platno, pelene...)

18 01 06* hemikalije koje se sastoje od ili sadrže opasne materije18 01 07 hemikalije koje nisu navedene pod 18 01 0618 01 08* citotoksici i citostatici18 01 09 lijekovi koji nisu navedeni pod 18 01 0818 01 10* amalgamski otpad iz stomatološke zaštite

18 02 Otpad od istraživanja, dijagnosticiranja, liječenja ili prevencije bolesti u životinja18 02 01 oštri predmeti (osim 18 02 02)18 02 02* ostali otpad čije sakupljanje i odlaganje podliježe specijalnim zahtjevima radi prevencije infekcije18 02 03 otpad čije sakupljanje i odlaganje ne podliježe specijalnim zahtjevima radi prevencije infekcije18 02 05* hemikalije koje se sastoje od ili sadrže opasne materije18 01 06 hemikalije koje nisu navedene pod 18 02 0518 02 07* citotoksici i citostatici18 02 08 lijekovi koji nisu navedeni pod 18 02 07

Tabela 1: Klasifikacija medicinskog otpada prema Evropskom katalogu otpada

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Tabela 2. Kategorije medicinskog otpada

Kategorije medicinskog otpada Opis

Infektivni Laboratorijske kulture, izlučevine, materijal i oprema u kontaktu sa zaraženim pacijentima

Patološki Krv, i druge tjelesne tekućine, dijelovi tijela, fetusiOštri predmeti Igle, skalpeli, noževi, slomljeno stakloFarmaceutski LijekoviGenotoksični Citostatici, genotoksične hemikalijeHemijski Otapala, laboratorijski reagensi, dezinficijensiTeški metali Baterije, tlakomjeri, termometriPosude pod pritiskom Plinske boce, metalni spremnici

Radioaktivni otpad Tekućine koje se koriste u radioterapiji, urin i izlučevine bole-snika liječenih radio-nuklidima

Infektivni otpad sadržava patogene biološke agense koji zbog svog tipa, koncentracije ili broja mogu ugro-ziti zdravlje ljudi. Ova vrsta otpada uključuje kulture i pribor iz mikrobioloških laboratorija, materijal i pribor koji je došao u dodir sa krvlju ili izlučevina infektivnih bolesnika ili je oslobođena tokom hirurških zahvata, previjanja rana ili obdukcijama, ili otpad iz odjela za izolaciju bolesnika, otpad iz jedinica za hemodijalizu, sistema za infuziju, rukavice i drugi pribor za jednokratnu upotrebu, te otpad koji je došao udodir sa pokusnim životinjama kojima je inokuliran zarazni materijal.

Patološki otpad čine dijelovi ljudskog tijela, amputati, tkiva i organi odstranjeni tokom hirurških zahvata, tkiva uzeta u dijagnostičke svrhe, placente i fetusi te pokusne životinje i njihovi dijelovi.

Oštri predmeti uključuju igle, lancete, štrcaljke, skalpele i ostale predmete koji mogu izazvati ubod ili pos-jekotinu.

Farmaceutski otpad uključuje farmaceutske proizvode, lijekove i hemjske supstance koji su vraćeni s odje-la gdje su bili proliveni, rasipani, pripremljeni a neupotrebljeni, ili im je istekao rok upotrebe ili se trebaju baciti iz bilo kojeg razloga.

Hemijski otpad čine odbačene čvrste, tekuće ili gasovite hemijske materije koje se upotrebljavaju pri medicinskim, dijagnostičkim ili eksperimentalnim postupcima, čišćenju i dezinfekciji. Dijeli se na opasni sa osobinama toksičnosti, korozivnosti, zapaljivosti, reaktivnosti i genotoksičnosti, te inertni hemijski otpad koji nema navedena svojstva.

Posude pod pritiskom čine bočice koje sadrže gasove pod pritiskom s različitim materijamaantibiotik, dezinficijens, insekticid i drugi, a koje se apliciraju u obliku aerosola. Pri izlaganju višoj tem-

peraturi mogu eksplodirati.

Radioaktivni otpad predstavlja čvrsti i tekući otpad kontaminiran radionuklidima iz in vitro laboratorijskih analiza tkiva i tjelesnih tekućina te iz in vivo dijagnostičkih i terapeutskih zahvata koji se uglavnom izvode na odjelima za nuklearnu medicinu. Ova kategorija otpada podliježe posebnim propisima (Pruss i sar., 1999).

Prema definiciji Svjetske zdravstvene organizacije gore navedenoj podjeli opasnog medicinskog otpada pridodate su još dvije kategorije: genotoksični otpad i otpad sa visokom koncentracijiom teških metala.

Genotoksični otpad ima mutageno, teratogeno i kancerogeno djelovanje. Ova skupina otpada uključuje citostatike koji se najčešće koriste u onkologiji u hemoterapiji karcinoma, kao imunosupresori u transplantaci-jama, radioterapiji i drugim granama medicine. U ovu grupu spadaju ostale genotoksične hemikalije i radio-aktivni materijal, ambalaža i ostali kontaminirani materijal, kao i tjelesne izlučevine (urin, fekalije, povraćeni sadržaj) bolesnika liječenoh citostaticima. U specijaliziranim onkološkim bolnicama ova vrsta otpada može činiti čak i do 1% od ukupne količine nastalog medicinskog otpada (Pruss i sar; 1999).

Otpad s visokom koncentracijom teških metala predstavlja podkategoriju opasnog hemijskog otpada. U ovaj otpad ubrajamo živu, koja se najčešće generira iz amalgamskih blombi- otpad stomatoloških ordinacija i/ili razbijene medicinske opreme. U baterijama koje se odlažu na otpad nalaze se kadmij, olovo i arsen.

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3. ZDRAVSTVENI RIZICI OD MEDICINSKOG OTPADA

Zagađenje koje dolazi iz zdravstvenih ustanova je specifično i može da bude veoma opasno, kako po zdravlje ljudi koji rade u zdravstvenim ustanovama, tako i po zdravlje okoline, odnosno stanovništva i eko-sistema u kojem se taj otpad skladišti. Najveći proizvođači medicinskog otpada su velike zdravstvene ustan-ove odnosno, klinike, domovi zdravlja, stacionari, dijagnostičke laboratorije, centri za transfuziju i dijalizu. Manji proizvođači su manje zdravstvene jedinice kao što su ambulante porodične medicine specijalističke i stomatološke ambulante.

Sve osobe koje mogu doći u kontakt sa medicinskim otpadom izložene su potencijalnom riziku po zdrav-lje i to:

• medicinsko osoblje: ljekari, medicinske sestre, ostali medicinski i nemedicinski radnici u zdravstvenim ustanovama;

• pacijenti u i van zdravstvenih ustanova i njihovi posjetioci;• zaposleni u javno komunalnim preduzećima koji rukuju i prevoze otpad;• zaposleni na deponijama i osobe koje pretražuju otpad;• stanovništvo a posebno djeca ukoliko se igraju sa predmetima koje se mogu naći u otpadu van

zdravstvenih ustanova.

Uvođenjem i implementacijom adekvatnih procedura za minimiziranje rizika od medicinskog otpada u pr-vom redu štiti se zdravlje stanovništva i smanjuje uticaj na životnu sredinu. Prvi korak u sistemu menadžmenta je da se identifikuju potencijalni rizici. Mogući putevi prenošenja bolesti su:

• Direktni kontakt• Kontakt sa vektorima• Aerobna transmisija• Zagađena voda• Zagađen okoliš

3.1. Profesionalni i javno zdravstveni rizici

U postupku rukovanja medicinskim otpadom, medicinski i nemedicinski radnici, izloženi su riziku i to prvenstveno od povređivanja ukoliko upotrebljeni oštri predmeti nisu bezbjedno upakovani. Svjetska zdravs-tvena organizacija procijenjuje da se zbog neadekvatnog rukovanja medicinskim otpadom, godišnje u svijetu zarazi hepatitisom B, C i HIV-om oko 20 miliona osoba. Tom riziku su izloženi i oni koji pretražuju otpad u kontejnerima i na deponijama. Stanovništvo može biti izloženo riziku od medicinskog otpada na direktan i indirektan način, različitim putevima kontaminacije:

• inhalacijom,• penetracijom kroz kožu• ingestijom

Odlaganje medicinskog otapada ne smije se vršiti na nekontrolisan način u životnu sredinu, jer može imati direktan negativan efekat na zemljište i podzemne vode. Jedan od glavnih zadataka upravljanja medicinskim otpadom je identifikacija opasnosti po javno zdravlje i životnu sredinu. Na slici broj 2. prikazane su relacije između uzroka i posljedica neadekvatnog upravljanja medicinskim otpadom.

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3.1.1. Rizik od infektivnog otpada

Upravljanje medicinskim otpadom je integralni dio bolničke higijene i kontrole infekcija. Medicinski ot-pad treba smatrati rezervoarom patogenih mikroorganizama, sa koga se oni, ukoliko se otpadom neadekvatno rukuje, mogu dalje prenijeti i kod osjetljivih osoba izazvati kolonizaciju, a i infekciju. Putevi prenošenja su direktni kontakt, vazduh ili različiti vektori. Na ovaj način, infektivni medicinski otpad predstavlja rizik za nastanak bolničkih (nozokomijalnih, intrahospitalnih) infekcija kako kod zdravstvenog osoblja, tako i kod pacijenata.

Oko 80% opasnog medicinskog otpada je infektivni tj. opasan medicinski otpad koji sadrži i/ili može sadržati mikroorganizme koji mogu izazvati obolijevanja ljudi i životinja, a čine ga kulture i pribor iz mikrobioloških laboratorija, oprema, materijal i pribor koji je bio u kontaktu s krvlju i ostalim izlučevinama infektivnih bolesnika, otpad od dijalize, te iz svih ostalih zahvata na pacijentima. Ovaj otpad može biti iz-vor svih vrsta infekcija (respiratornih, kožnih, gastrointestinalnih, urinarnih, infekcija koje se mogu prenijeti putem krvi i drugih tjelesnih tečnosti).

Rizik koji nose krv i druge tjelesne tečnosti

Pravilno rukovanje medicinskim otpadom je od posebnog značaja za nastanak infekcija koje se mogu prenijeti putem krvi i drugih tjelesnih tečnosti. U riziku za nastanak ovog tipa infekcija nastalih u zdravs-tvenim ustanovama su, prije svih medicinski radnici, kao i drugi uposlenici u ovim ustanovama, ali mogu biti i pacijenti. Rizični kontakt osobe osjetljive na infekcije koje se prenose krvlju i telesnim tečnostima koje

Slika 2. Relacije između uzroka i posljedica neadekvatnog upravljanja medicinskim otpadom

OSNOVNIUSLOVI

NEISPUNJENIUSLOVI

PRAKTIČNAINPLIKACIJA

IZLOŽENOST EFEKTI NAZDRAVLJE

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je sadrže, predstavlja svaki kontakt kože osjetljive osobe koja nema kontinuitet (ubod iglom, posjekotina) i sluzokože (oči, usta, nos) sa krvlju i tjelesnim tečnostima koje sadrže mikroorganizme.

Pored direktnog kontakta sa inficiranom osobom i njenim tjelesnim tečnostima, od posebnog je značaja indirektan kontakt sa predmetima, prije svega različitom medicinskom opremom kontaminiranom krvlju i drugim tjelesnim tečnostima. Jedan od najrizičnijih indirektnih kontakta jesu i perkutane povrede (PP). Pod perkutanim povredama se podrazumjevaju 2 osnovne vrste povreda: povrede na igle koje se koriste u terapiji i dijagnostici i povrede na oštre predmete (skalpeli, staklo itd.).

Po svojoj učestalosti, kao i po riziku koji svakodnevno prijeti u zdrastvenim ustanovama od širenja in-fekcija PP, najznačajniji su infekcije uzrokovane sa 3 mikroorganizma: virusom hepatitisa B (HBV), C (HCV) i HIV-a. Rizik za sticanje infekcija koje oni izazivaju u zdravstvenim ustanovama zavisi kako od primjene preporučenih efektivnih mjera prevencije, tako i od prevalencije infekcija u populaciji i verovatnoće inoku-lacije mikroorganizma tokom rizičnog kontakta.

Virus hepatitisa B

Iako je danas prevencija hepatitisa B u većini zemalja svjeta zakonski regulisana obaveznom vakcinacijom uposlenih u zdravstvenim ustanovama, treba naglasiti da postoji dio osoba koje i dalje odbijaju da primjene ovu mjeru prevencije hepatitisa B, pa su u riziku za infekciju. Ovo je veoma kontagiozna infekcija, zbog vi-soke koncentracije HBV u perifernoj krvi kod inficiranih osoba. Pored krvi, tjelesne tečnosti sa kojima kontakt nosi visoki rizik za infekciju su: pljuvačka (posebno u toku stomatoloških procedura), cerebrospinalana, peri-tonelana, pleuralna, perikardijalna, amnionska, sinovijalna tečnost, sperma, vaginalna tečnost i bilo koja druga koja sadrži vidljivu krv, kao i organi i tkiva koja nisu na odgovarajući način pripremeljena za patohistološki pregled. Neadekvatno odlaganje i tretiranje ovih tjelesnih tečnosti i tkiva kao medicinskog otpada, povećava rizik za infekciju HBV-om, kako zaposlenih u zdravstvenim ustanovama, tako i pacijenata, pa čak i za epi-demijsko širenje bolesti u obje populacije.

Izlaganje urinu, fecesu, nosnom sekretu, suzama, sputumu ili povraćenom sadržaju nose minimalan rizik za infekciju, ukoliko nisu kontaminirane krvlju. HBV je stabilan i do 7 dana u osušenim kapljicama krvi, tako da kontakt sa neživom sredinom kontaminiranom krvlju koja sadrži HBV takođe je rizičan za infekciju, što je tipično za jedinice za hemodijalizu. Rizik za infekciju osjetljivih zaposlenih u zdravstvenim ustanovama nakon perkutanog izlaganja krvi bolesnika zaraženih HBV-om, koji su HBSAg pozitivni je 6-30%, a najviši je u slučaju da je bolesnik i HbeAg pozitivan, pod uslovom da se ne primijeni postekspozicijska profilaksa.

Virus hepatitisa C

Virus hepatitisa C se prenosi jednokratnim izlaganjem velikim količinama krvi inficiranih osoba (primjena transfuzija netestirane krvi i produkata krvi), ili pri ponovljenim direktnim perkutanim ekspozicijama manjim količinama krvi inficiranih, kao u slučaju intravenskih korisnika droge. Opisane su i infekcije nastale preko pluvačke (ekspozicija tokom ugriza), kao i ekspzicijom konjuktiva krvlju inficiranih osoba. Podaci iz različitih dijelova svijeta ukazuju da prokuženost osoba zaposlenih u zdravstvenim ustanovama prati prevalenciju pop-ulacije u regionu. Tako je u SAD-u 1% zdravstevnih radnika inficirano HCV-om. Prospektivne studije ukazuju da je rizik za infekciju nakon perkutane povrede (PP) na HCV pozitivan izvor 1.8% (0-7%). Za nastanak HCV infekcije ističe se i značaj povređivanja na igle sa haloom (šupljinom).

Virus humane imunodeficijencije

Prvi slučaj prenošenja ovog virusa sa pacijenta na zdravstvenog radnika zabilježen je 1986. godine. Do decembra 2001. godine CDC je registrovao, na dobrovoljnom principu prijavljivanja, 57 dokumentovanih i

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138 vjerovatnih infekcija HIV-om zaposlenih u zdravstvenim ustanovama u SAD-u. HIV je 100 puta manje kontagiozan od HBV. Nakon perkutane povrede (PP) kod zaposlenih u zdravstvenim ustanovama, prospek-tivne studije su pokazale da je rizik za nastanak infekcije 0.3%. Retrospektivna anamnestička studija sprove-dena na zdravstvenim radnicima koji su imali perkutane povrede (PP) na HIV pozitivne izvore, je pokazala da su faktori rizika za nastank infekcije bili: dubina povrede, prisustvo krvi na igli, procedure koje obuhvataju plasiranje igle u arteriju ili venu i terminalna bolest pacijenta koji je izvor. Ekspozicija mukoznih membrana krvlju i tjelesnim tečnostima udružena je sa rizikom od nastanka HIV infekcije od 0.09%.

Epidemiologija perkutanih povreda Podaci dobijeni na osnovu nadzora nad povredama zaposlenih u zdravstvenom sistemu SAD-a (National

Surveillance System for Health Care Workers – NaSH) opisuju epidemiologiju perkutane povrede (PP). U najvećem riziku za perkutane povrede (PP) su medicinske sestre, a samim tim i za infekcije koje se prenose ovim putem. U riziku su i zaposleni u zdravstvenim ustanovama koji su uključeni u njegu i terapiju pacijenta (doktori medicine i drugi medicinski tehničari), osoblje koje radi u biomedicinskim laboratorijama i oso-blje koje pruža logističku podršku dijagnostici i liječenju (npr. službe za održavanje higijene u zdravstvenim ustanovama). To su ciljne grupe za edukaciju u oblasti pravilnog rukovanja medicinskim otpadom. Pravilnosti se uočavaju i u odnosu na mjesto dešavanja perkutane povrede (PP). Iako se one mogu dešavati u svim di-jelovima zdravstvenih ustanova, većina, oko 40%, se dogodi u onim dijelovima gde se odvija terapija i njega oboljelih, prije svega, u 21% slučajeva na odeljenjima gde su pacijenti hospitalizovani, a u 13% u jedinicama intenzivne njege i terapije. U operacionim salama dogodi se 25% perkutanih povreda (PP). Podaci CDC-a ukazuju da prema vremenu javljanja do perkutane povrede PP najčešće dolazi neposredno nakon upotrebe i prije odlaganja igala i oštrih predmeta (41%), tokom neposrednog izvođenja određene procedure (39%) i tokom i nakon njihovog odlaganja (16%). Iz svega navedenog proizilazi da je rizik za nastanak infekcija koje se prenose putem krvi i tjelesnih tečnosti u direktnoj vezi sa rukovanjem medicinskim otpadom u zdravst-venim ustanovama, te bi mjere prevencije ovih infekcija trebalo zasnovati na definisanju svih procedura u ovoj oblasti.

3.1.2. Rizik od hemijskog i farmaceutskog otpada

Mnoge od hemikalija i faramaceutskih preparata koji se upotrebljavaju u zdravstvenoj zaštiti mogu biti rizične po zdravlje (toksičnost, genotoksičnost, kancerogenost i sl.) Zaposleni u apotekama, anesteziji i labo-ratorijama, izloženi su riziku od respiratornih i kožnih bolesti usled izlaganja gasovima, aerosolima i rast-vorima. Sporadični slučajevi ranjavanja ili trovanja hemikalijama i farmaceutskim preparatima uglavnom su posledica neadekvatnog rukovanja, pa se preporučuje upotreba manje toksičnih preparata, strogo poštovanje procedura za upotrebu i adekvatne zaštitne mjere. Poseban rizik pretstavljaju citotoksične supstance, pa su zdravtsvene ustanove koje ih koriste dužne sačiniti posebna uputstva za rukovanje otpadom koji sadrži tragove tih supstanci. Mnogi citostatici su ekstremno iritantni i mogu imati lokalni efekat pri direktnom kontaktu sa kožom ili očima. Oni mogu takođe uzrokovati vrtoglavice, glavobolju ili dermatitis.

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4. PROCJENA RIZIKA

Procjena rizika je veoma važan faktor kod određivanja potencijalne opasnosti od medicinskog otpada. Up-ravljanje rizikom znači preduzimanje preventivnih mjera i procedura, pripremu za incident i za reagovanje na njega, kao i poboljšavanje sadašnje situacije s ciljem smanjivanja rizika i stvaranja uslova pod kojima je rizik prihvatljiv. Samo rizik kojim se može upravljati predstavlja prihvatljiv rizik, to jest rizik koji podrazumjeva da se moguće posledice po ljudsko zdravlje i materijalna dobra nalaze u okvirima prihvatljivog. U okviru zakon-ske regulative, kako u domenu zdravstva i medicine, tako i u oblasti zaštite okoliša, postoji potreba za izradom procjene rizika od strane svih subjekata koji se bave upravljanjem medicinskim otpadom.

4.1. Procjena rizika u kontekstu medicinskog otpada

Svrha sprovođenja postupka Procjene rizika je da pomogne u iznalaženju razumnih odluka sa ciljem zaštite okoliša i zdravlja stanovništva. Važno je da se procjena vrši aktivno i uz razmišljanje, umjesto da se jednostav-no zaokružuju dati odgovori. Za Procjenu rizika neophodno je uzeti u obzir kako opasnosti, tako i rizike.

OPASNOST (HAZARD) je nešto što potencijalno može da izazove štetu.PRIJETNJA koju donosi opasnost opisuje PRIRODU ŠTETE koja može da nastane.RIZIK predstavlja kombinaciju procjene ozbiljnosti prijetnje i vjerovatnoće (stepena do koga je vjero-

vatno) da će se ove prijetnje realizovati.

Prema tome, procjena rizika je proces u kome se:

• Identifikuju opasnosti;• Identifikuju i procjenjuju prijetnje koje su sa tim povezane;• Procjenjuju rizici;• Procjenjuje značaj tih rizika u okolnostima o kojima se raspravlja.• Rezultati procjene rizika treba da budu redovno bilježeni, tj. da budu evidentirani.

4.2. Pet koraka u procjeni rizika

Pri procjeni rizika, preduzima se slijedećih pet koraka:

KORAK BR.1: Identifikovati opasnosti;KORAK BR. 2: Utvrditi ko/šta bi moglo biti oštećeno/povrijeđeno i kako;KORAK BR. 3: Procjeniti rizike i odlučiti da li su postojeće mjere predostrožnosti adekvatne ili bi trebalo preduzeti dodatne mjere;KORAK BR. 4: Zabilježiti zaključke i rezultate procjene;KORAK BR. 5: Provjeriti napravljene procjene

Korak br. 1: Identifikovanje opasnosti (hazards)

• Identifikovati koje su supstance ili oblici bioloških agenasa prisutni;• Identifikovati sve prisutne biološke opasnosti;• Identifikovati potrebne kategorije ograničavanja;

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• Procjeniti postojeće mjere za ograničavanje opasnosti;• Sakupiti informacije o karakteristikama opasnosti.

U opasnosti (hazard) od medicinskog otpada spada:

• infektivna priroda otpada;• oštri predmeti ili sječiva, staklene boce itd.;• agresivna priroda otpada.

Korak br. 2: Utvrđivanje ko/šta može biti oštećeno ili povrijeđeno i na koji način

Različite grupe lica mogu biti potencijalno izložene opasnostima. Njih čine:

• mladi i neiskusni radnici, pripravnici, majke po povratku sa porodiljskog odsustva i trudnice,• osoblje u laboratorijama, fizički radnici koji prenose otpad,• pomoćni radnici koji manipulišu otpadom, radnici na deponijama, opšta populacija, okoliša uopšte;• čistači, posjetioci, radnici u službi održavanja koji nisu stalno na radnim mjestima;• ostali.

Važno je naglasiti da svi koji se mogu naći u zdravstvenim ustanovama gdje se stvara medicinski otpad nemaju odgovarajuća znanja o potencijalnim opasnostima istog, niti će se sva ta lica ponašati na isti način. Na primjer, među pripadnicima opšte populacije koji imaju pristup otpadu mogu da se nađu ljudi sa posebnim potrebama, koji imaju teškoće u primanju novih informacija, kao i pacijenti koji pate od narkomanije i mogu da se ponašaju na drugačiji način.

Korak br. 3: Procjena rizika i odlučivanje o tome da li su postojeće mjere predostrožnosti odgovarajuće ili je potrebno preduzeti dodatne mjere

Kvantitativna procjena rizika može da se dobije određivanjem vjerovatnoće odvijanja za svaku pojedinačnu opasnost, a potom množenjem dobijene vrijednosti sa mjerom ozbiljnosti vjerovatnih posljedica. Ovi faktori mogu da se izraze kvantitativno (brojčanim vrijednostima) ili kvalitativno (opisno), kako je prikazano u tab-elama 3.4. i 5. u nastavku.

Ocjena Kvalitativni opis Ozbiljnost

1. NeznatneNema povreda ili štete, samo za

slučajeve u kojima je šteta jedva izbjeg-nuta.

2. Umjerene Povrede koje se saniraju prvom pomoći, manje ozbiljne bolesti i mali gubici.

3. Ozbiljne Povreda ili bolest koja zahtijeva kratko bolovanje. Značajna šteta ili gubici.

4. Veoma ozbiljne Veoma ozbiljni nesrećni slučajevi, hen-dikepiranost, velika šteta ili gubici.

5. Katastrofalne Jedna ili više ljudskih žrtava, katostrofalni gubici

Rezultati procjene rizika mogu da pokažu da je određeni rizik neprihvatljiv te da ga je neophodno smanjiti primenom metoda kontrole, prije nastavka daljih aktivnosti.

Tabela 3. Tabela ozbiljnosti

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Tabela 4. Matrica rizika1

1 Boje korištene u ovoj tabeli ne odgovaraju šemi boja po kojoj se obilježavaju tokovi medicinskog otpada.

Vjerovatnoća Ozbiljnost1 2 3 4 5

5 Sigurna 5 10 15 20 254 Izrazito vjerovatna 4 8 12 16 203 Vjerovatna 3 6 9 12 152 Malo vjerovatna 2 4 6 8 101 Izrazito malo vjerovatna 1 2 3 4 5

Prioritetni rizik Opis Ocjena rizika

Nedopustiv rizik

Rad ne treba da počne, ili, ukoliko je već započet, treba ga odmah zaustaviti. Uko-liko je ovaj rizik nemoguće smanjiti čak i uz neograničena materijalna sredstva, rad mora da bude trajno zabranjen.

VISOK

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Značajan rizik

Rad ne bi trebalo da počne dok se rizik ne smanji. Moguće je da će, za smanjivanje rizika, biti neophodno da se odvoje značajna sredstva. Ukoliko je rad u toku, razmotrite zaustavljanje svih aktivnosti bez odlaganja.

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Umjeren rizik

Pokušajte da dalje smanjite rizik, ali troškovi sprečavanja treba da budu odmereni i ograničeni. Sve mere za smanjivanje rizika trebalo bi da budu primenjene u tačno defin-isanom roku.

SREDNJI

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Umjeren rizik

U slučajevima u kojima je rizik povezan sa izrazito štetnim posljedicama, neophodna je dalja procjena, kako bi se preciznije utvrdila verovatnoća da će doći do štete, kao osnov za određivanje da li ima potrebe za poboljšanjem kontrole.

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Podnošljiv rizik

Nije neophodna dodatna kontrola. Razmotrite rešenja koja sufinansijski isplativija i efikasnija, ili mjere za poboljšanje koje ne zahtijevaju dodatne troškove. Nastavite sa praćenjem da biste osigurali da se mjere kontrole sprovode.

NIZAK2-6

Trivijalan rizik Ne zahtijeva nikakve mjere 0-1

Prilikom kontrole rizika potrebno je primjenjivati sljedeće principe:• Odabrati opcije koje nose manji rizik (u potpunosti odstraniti rizik, primjer: koristiti bezbjedonosne igle

sa samozaštitom);• Spriječiti pristup izvoru opasnosti (obezbjeđenje skladišta za opasni otpad (radioaktivni, infektivan,

hemijski, citostatski medicinski otpad);• Organizovati radne aktivnosti tako da se smanji izloženost opasnosti (npr. koristiti kontejnere sa

točkićima za infektivni medicinski otpad, spriječiti pristup ljudi koji ne dobijaju zdravstvene usluge u dijelovima zdravstvene ustanove gdje se pružaju zdravstvene usluge);

• Obezbijediti korištenje opreme za ličnu zaštitu;• Obezbijediti olakšice (na primjer: opremu za pranje kontejnera u cilju uklanjanja kontaminacije, prvu

pomoć itd.).

Tabela 5.

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• Vakcinacija zaposlenih protiv Hepatitisa B, postekspozicijska profilaksa i druge mjere za sprječavanje nastanka krvlju prenosivih bolesti.

Korak br. 4: Bilježenje postupaka i aktivnosti

Mada zaključak iz procjene rizika može da bude zasnovan na stručnom mišljenju osoba koje rade samu procjenu, važno je istaći da se svaka procjena bazira na dokazima i evidenciji o adekvatno sprovedenoj procjeni rizika. Procedure i evidencija treba da budu veoma jednostavne, tako da obezbijede pisani trag koji je lako pra-titi. Odgovarajući način vođenja pisanih bilješki je onaj koji omogućava licu koje sa treće strane vrši procjenu da prati proces donošenja odluka. Procjenu rizika treba da vrše ljudi koji posjeduju odgovarajuće kvalifikacije i iskustvo, odnosno tim sastavljen od takvih lica.

Korak br. 5: Provjeriti sopstvenu procjenu i revidirati je ukoliko je to potrebno

Neophodno je provjeriti procjene rizika u sljedećim slučajevima:• ukoliko nove supstance, oprema ili procedure izazivaju nove opasnosti;• ukoliko dođe do značajne izmjene prirode posla ili načina na koji se vrše procedure;• periodično, da bi se obezbijedilo da su postojeće procedure i dalje efikasne.

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5. ZAKONSKA REGULATIVA

5.1. Zakonski okvir upravljanja medicinskim otpadom u BiH

Upravljanje medicinskim otpadom, koji po svojim osobinama može biti opasan i/ili inertan, u BiH je regulirano entitetskim i kantonalnim Zakonima i podzakonskim aktima. Oba entitetska okvirna Zakona o up-ravljanju otpadom (Republike Srpske i Federacije BiH) nalažu da je tretman medicinskog otpada prioritetna stavka.

U skladu sa Pravilnicima u RS i FBiH o upravljanju medicinskim otpadom postoji potreba za:

• Razdvajanjem medicinskog od ostalih vrsta otpada,• Razdvojenim i kontrolisanim odlaganjem otpada,• Propisnim pakovanjem, obilježavanjem i predajom otpadnog materijala ovlaštenom prevozniku,• Tretiranjem i odlaganjem u cilju eliminisanja opasnosti, i• Prikupljanjem podataka o vrstama i količinama proizvedenog medicinskog otpada.

Legislativa ima za cilj da osigura:

1. Da se opasni otpad tretira i odlaže na zakonski i ekološki prihvatljiv način, i2. Da se umanji rizik po ljudsko zdravlje.

Zakonodavstvo upravljanja otpadom u FBiH čine: Zakon o zaštiti okoliša (Sl. novine FBiH 33/03), Zakon o upravljanju otpadom (Sl. novine FBiH 33/03), Pravilnik koji određuje postupanje sa opasnim otpadom koji se ne nalazi na listi otpada ili čiji je sadržaj nepoznat (Sl. novine FBiH 33/03), Pravilnik o upravljanju medicinskim otpadom (Sl. novine FBiH 7/08),

Pravilnik o kategorijama otpada sa listama (Sl. novine FBiH 9/05), Pravilnik o potrebnim uslovima za prenos obaveza sa proizvođača i prodavača na operatera sistema za prikupljanje otpada (Sl. novine FBiH 9/05), Pravilnik o sadržaju plana prilagođavanja upravljanja otpadom za postojeća postrojenja za tretman ili odlaganje otpada i aktivnostima koje preduzima nadležni organ (Sl. novine FBiH 9/05), Pravilnik koji određuje postupanje sa opasnim otpadom koji se ne nalazi na listi otpada ili čiji je sadržaj nepoznat, Pravilnik o upravljanju ambalažom i ambalažnim otpadom, Pravilnik o obrascu, sadržaju i postupku obavještavanja o važnim karakteristikama proizvoda i ambalaže od strane proizvođača (Sl. novine FBiH 8/08), Uredba koja reguliše obavezu izvještavanja operatora i proizvođača otpada o sprovođenju programa nadzora, monitoringa i vođenja evidencije prema uslovima iz dozvole (Sl. Novine FBiH 31/06), Uredba o finansijskim garancijama kojima se može osigurati prekogranični promet otpada (Sl. novine FBiH 41/05).

5.2. Međunarodno zakonodavstvo

5.2.1.EU direktive

Osnovi politike upravljanja otpadom u Evropskoj uniji sadržani su u Rezoluciji Vijeća Evrope o strategiji upravljanja otpadom (97/C76/01) koja se bazira na Okvirnoj direktivi o otpadu (75/442/EEC) i ostalim propi-sima o upravljanju otpadom u EU.

Utvrđeno je pet osnovnih načela:

• hijerarhija upravljanja otpadom,• samoodrživa postrojenja za odlaganje,

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• najbolja dostupna tehnologija,• blizina odlaganja otpada i• odgovornost proizvođača.

Uz navedena nastoje se ostvariti i sljedeća načela: zajednička definicija otpada u svim državama članicama, podsticanje čistije proizvodnje i korištenja čistih proizvoda, podsticanje korištenja ekonomskih instrumenata, regulisanje transporta otpada, kao i zaštita okoliša i unutrašnje tržište.

EU zakonodavni okvir koji obuhvata bezbjedno upravljanje otpadom i zaštitu zdravlja i bezbjednosti defin-isan je sljedećim propisima:

1. Direktiva 75/442/EEC o otpadu (Okvirna direktiva)2. Direktiva 99/31/EC o deponijama otpada3. Direktiva 94/62/EC o ambalaži i ambalažnom otpadu4. Direktiva 96/61/EEC o integralnoj prevenciji i kontroli zagađenja5. Direktiva 97/11/EC o procjeni uticaja određenih javnih i privatnih projekata na okoliš kojom se mijenja

i dopunjuje Direktiva 87/337/EEC6. Direktiva 2001/42/EC o procjeni uticaja određenih planova i programa na okoliš7. Direktiva 91/689/EEC o opasnom otpadu izmijenjena direktivom 94/31/EC8. Direktiva 2000/76/EC o spaljivanju otpada9. Direktiva 94/67/EC o spaljivanju opasnog otpada10. Direktiva 89/369/EEC o redukciji zagađenja iz novih gradskih postrojenja za spaljivanje otpada i Di-

rektiva 89/429/EEC o redukciji zagađenja iz postojećih gradskih postrojenja za spaljivanje otpada11. Direktiva 2004/37/EC o zaštiti radnika od rizika povezanih sa izlaganjem karcinogenima ili muta-

genima na radnom mjestu12. Direktiva 2000/54/EC o zaštiti radnika od rizika povezanih sa izlaganjem biološkim sredstvima na

radnom mjestu13. Direktiva 98/24/EC o zaštiti zdravlja i bezbjednosti radnika izloženih rizicima od hemijskih sredstava

na radnom mjestu14. Uredba 259/93/EEC o nadzoru i kontroli isporuka otpada unutar zemalja EZ, kao i pri ulasku i izlasku

iz njih.15. Uredba 2150/2002 o statistici otpada

5.2.2. Bazelska konvencija

Bazelska konvencija o kontroli prekograničnog kretanja opasnog otpada injegovog odlaganja (1989) je jedan od najvažnijih međunarodno prihvaćenih pravnih akata u oblasti upravljanja opasnim otpadom, koji, između ostalog, reguliše i prekogranično kretanje i odlaganje medicinskog otpada (kao vrste opasnog otpada). Sporazum je potpisalo preko 100 zemalja, koje su prihvatile princip da je jedini legitimni transport opasnog otpada, izvoz iz zemalja koje nemaju postrojenja ili stručni kadara za pouzdano odlaganje otpad, u zemlje koje imaju i postrojenja i stručni kadar.

5.2.3. Prilagođavanje međunarodnom zakonodavstvu

Postojeća zakonska regulativa ne obuhvata sve aspekte upravljanja medicinskim otpadom i ne daje preporuke za tretman posebnih tokova otpada, što predstavlja i medicinski otpad. Neophodno je njeno usaglašavanje sa evropskim direktivama i međunarodnim standardima, što podrazumeva jasno definisanje opasnog medicin-skog otpada i njegovih različitih kategorija, uvođenje sistema integralnog upravljanja (razdvajanje, sakupl-janje, skladištenje, postupanje, tretman, odlaganje, transport), sistema evidencije, principa pravne i finansijske odgovornosti generatora otpada, inspekcijskog sistema koji će obezbediti efikasno sprovođenje zakona, kao i kaznenih odredbi. Takođe, upravljanje medicinskim otpadom mora biti usaglašeno sa ostalim relevantnim za-konima koji se odnose na upravljanje otpadom generalno, uticaje na javno zdravlje i okoliš, kvalitet vazduha, prevenciju i kontrolu infektivnih bolesti i upravljanje radioaktivnim materijama.

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6. UPRAVLJANJE MEDICINSKIM OTPADOM U ZDRAVSTVENIM USTANOVAMA

Pravilno upravljanje medicinskim otpadom uveliko ovisi o dobroj upravi i organizaciji, ali zahtijeva i odgovarajuće zakonodavstvo i finansije, kao i aktivno sudjelovanje od strane obučenog i informisanog osoblja. Zdravstvene ustanove uspostavljaju svoj menadžment za upravljanje otpadom koji sadrži četiri osnovna as-pekta: pravni, ekonomski, organizacioni i tehnološki.

6.1. Učesnici u procesu zbrinjavanja medicinskog otpada

• Zdravstveni uposlenici iz direktnog procesa rada u dijelu identificiranja, razvrstavanja, odlaganja i pako-vanja otpada na mjestu nastanka (ljekari, medicinski tehničari, medicinske sestre-tehničari, laboratori-jski tehničari, farmaceutski tehničari i sl.);

• Spremačice i uposlenik na transportu u dijelu postupaka oko prikupljanja i transporta otpada do mjesta sekundarnog skladištenja, te u dijelu čišćenja i dezinfekcije prostora inicijalnog i sekundarnog skladišta i višekratne ambalaže za prikupljanje otpada;

• Tehničko osoblje za tehnologiju prerade i tretmana otpada unutar ustanove;• Ustanove koje na osnovu ugovora preuzimaju otpad radi krajnjeg zbrinjavanja

6.2. Odgovorne osobe i tijela za organizaciju i unutrašnji nadzor

• Odgovorne osobe i tijela za organizaciju i unutrašnji nadzor nad zbrinjavanjem medicinskog otpada u ustanovi su:

• Direktor/ Rukovodilac ustanove za obezbjeđenje uslova za zaštitu uposlenika i okoliša i za provedbu cjelokupnog Plana upravljanja medicinskim otpadom;

• Referent, (tehničar medicinskog otpada, rukovodilac za medicinski otpad ili menadžer medicinskog ot-pada, u zavisnosti od ustanove) za upravljanje otpadom za obaveze utvrđene Pravilnikom o upravljanju medicinskim otpadom;

• Odbor za upravljanje medicinskim otpadom za obaveze utvrđene Pravilnikom o upravljanju medicin-skim otpadom;

• Komisija za kontrolu infekcija i tim za kontrolu infekcija za nadzor nad zbrinjavanjem medicinskog otpada (infektivni, patološki i oštri otpad);

• Higijensko epidemiološke službe za higijensko epidemiološki nadzor nad svim postupcima sa otpadom na osnovu Plana upravljanja medicinskim otpadom, kontrolu kvaliteta, prikupljanje i analizu podataka i izvještavanje.

• Glavne medicinske sestre-tehničari klinika/poliklinika, glavni farmaceutski tehničar bolničke apoteke za periodični nadzor;

• Odgovorne medicinske sestre-tehničari odjeljenja i farmaceutski tehničari kliničkih apoteka za organi-zaciju sakupljanja, odvajanja, odlaganja otpada i kontinuirani nadzor.

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6.3. Upravljačka struktura, povezanost i odgovornosti

Rukovodilac zdravstvene ustanove imenuje referenta za upravljanje otpadom i formira odbor/ tim koji treba da izradi Plan upravljanja otpadom. Prema Pravilniku o upravljanju medicinskim otpadom, rukovodilac zdravs-tvene ustanove koja zapošljava više od 50 uposlenika dužan je uspostaviti odbor za upravljanje otpadom. U od-bor za upravljanje otpadom obavezno se imenuju rukovodilac zdravstvene ustanove, referent za upravljanje ot-padom i referent za sprečavanje nastanka infekcija. Veće zdravstvene ustanove treba da imaju veći broj članova u Odboru. Sastav odbora je odraz djelatnosti ustanove. U sastavu Odbora za upravljanje otpadom trebaju biti: direktor ustanove, šefovi odjeljenja, referent za kontrolu infekcije, šef apoteke, referenta za zračenje, glavna sestra, zdravstveni menadžer, sanitarno-ekološki inženjer, šef finansija, inženjer zaštite na radu, referent za up-ravljanje otpadom kao i druge osobe ovisno o veličini zdravstvene ustanove i vrstama djelatnosti. Ova struktura može biti prilagođena svakoj zdravstvenoj ustanovi. U manjoj zdravstvenoj ustanovi jedna osoba može obavlja-ti više odgovornosti ali će se primijeniti isti princip. Odbor za upravljanje otpadom odgovoran je za upravljanje medicinskim otpadom u zdravstvenoj ustanovi u skladu sa Pravilnikom. Odbor za upravljanje otpadom sastaje se najmanje jedanput u šest mjeseci radi razmatranja primjene sistema za upravljanje medicinskim otpadom u skladu sa Pravilnikom i preduzimanja potrebnih aktivnosti.

Odbor za upravljanje medicinskim otpadom ima slijedeća ovlaštenja i odgovornosti:

1. identificirati i klasificirati sav medicinski otpad2. pripremiti Plan upravljanja otpadom3. organizirati odlaganje otpada u posebne kontejnere i skladištenje u privremeni skladišni prostor4. obezbijediti odgovarajuće zbrinjavanje otpada5. organizirati zbrinjavanje otpada što bliže mjestu nastanka6. poduzimati najviše sigurnosne mjere u slučaju potrebe

Rukovodilac zdravstvene ustanove imenuje referenta za upravljanje otpadom koji će nadzirati i koordinira-ti Plan upravljanja otpadom. Referent za upravljanje otpadom odgovara za izvršenje svojih obaveza odboru za upravljanje otpadom odnosno rukovodiocu zdravstvene ustanove. Ime referenta za upravljanje otpadom dostavlja se ministru zdravstva kantona na čijem se teritoriju zdravstvena ustanova nalazi. Obaveze referenta za upravljanje otpadom su:

• izrada i prilagođavanje Plana upravljanja medicinskim otpadom u ustanovi;• nadzor nad primjenom Plana upravljanja i odredaba Pravilnika;• da obezbijedi obučavanje radnika zdravstvene ustanove za upravljanje medicinskim otpadom• organiziranje prevoza, odlaganja ili obnavljanja otpada koji zadovoljava potrebe upravljanja otpadom

proizvedenog u zdravstvenoj ustanovi;• vođenje evidencije o upravljanju medicinskim otpadom;• pokretanje inicijativa za smanjenje količine proizvedenog otpada.

Pokazalo se da je dobra praksa, za sve zdravstvene ustanove koje proizvode više od 500 kg opasnog ot-pada godišnje, da postave najmanje jedno lice odgovorno za upravljanje otpadom. U svakom odijeljenju/službi zdravstvene ustanove potrebno je imenovati osoblje odgovorno za upravljanje medicinskim otpadom, koje bi pomagalo licu odgovornom za upravljanje medicinskim otpadom. Ta lica će svakodnevno vršiti nadzor i izvještavati o upravljanju otpadom na odjeljenju.

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6.4 . Izrada Plana za upravljanje otpadom

Na osnovu člana 3. Zakona o upravljanju otpadom (“Službene novine Federacije BiH”, broj 33/03 i 72/09) i Pravilnika o upravljanju medicinskim otpadom (“Službene novine Federacije BiH”, broj 77/08) člana 5. Pravilnika o upravljanju medicinskim otpadom vrši se na osnovu Plana upravljanja otpadom. Zdravstvena ustanova dužna je donijeti Plan upravljanja medicinskim otpadom u roku od dvije godine od dana stupanja na snagu Pravilnika. Plan upravljanja medicinskim otpadom mora biti usklađen sa Planom upravljanja otpadom kantona. Plan upravljanja medicinskim otpadom odobrava kantonalno ministarstvo okoliša. Prema članu 11. Pravilniku o upravljanju medicinskim otpadom (”Službene novine FBiH” 77/08), svaka zdravstvena ustanova treba da izradi plan upravljanja medicinskim otpadom koji mora sadržavati:

1. opis različitih vrsta otpada u skladu sa kategorijama otpada koji se proizvodi u zdravstvenoj ustanovi; 2. listu dijelova zdravstvene ustanove u kojima može nastati medicinski otpad; 3. za svaki dio ustanove, dati opis vrste medicinskog otpada a za svaku vrstu otpada navesti procedure koje

se trebaju slijediti u vezi sa: - detaljnim opisom kontejnera u koje će se odložiti otpad uključujući materijal i boju kontejnera, poklopac

i obilježja i - detaljima o odlaganju kontejnera u postrojenje za tretman medicinskog otpada unutar zdravstvene

ustanove; 4. procedure premještanja otpada iz postrojenja za tretman do centralnog skladišta otpada; 5. procedure skladištenja u centralnom skladištu otpada; 6. vanredne procedure u slučaju prosipanja otpada.

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7. OBUKA I EDUKACIJA

Rukovodilac zdravstvene ustanove dužan je da obezbijedi da svaki radnik zdravstvene ustanove bude uključen u program obuke i edukacije sa ciljem podizanja svijesti o tretmanu medicinskog otpada, i upozna-vanja sa principima i praksama sistema za upravljanje medicinskim otpadom u zdravstvenoj ustanovi.

7.1. Stavovi o upravljanju otpadom

Promjena stepena informisanosti, znanja, vještina i stavova o rukovanju medicinskim otpadom je predus-lov za kvaliteno rukovanje i zbrinjavanje medicinskog otpada. Unapređenje odgovarajućeg rukovanja i odla-ganja medicinskog otpada je put očuvanja i unaprijeđenja javnog zdravlja i svaki član zajednice ima pravo da bude obavješten o mogućim opasnostima za zdravlje.

Ciljevi javnog obrazovanja o medicinskom otpadu su slijedeći:

1. Spriječiti izlaganje medicinskom otpadu i izlaganje opasnostima po zdravlje.2. Stvoriti svijest i podstaći odgovornost među pacijentima i posjetiocima zdravstvenih ustanova u vezi sa

higijenom i upravljanjem medicinskim otpadom. 3. Obavjestiti javnost o rizicima vezanim sa medicinskim otpadom fokusirajući se na ljude koji žive u

neposrednoj blizini, ili posjećuju zdravstvene ustanove, porodice pacijenata koji se liječe kod kuće, i skupljače otpada na deponijama otpada.

Veoma važan cilj informisanja o medicinskom otpadu je motivisanje medicinskog osoblja da usvoji dobar praktični pristup u upravljanju otpadom. Zaposlene treba ohrabriti i podstaknuti da slijede dobru praksu u up-ravljanju otpadom na taj način što će ona biti prikazivana u pozitivnom svijetlu i kao doprinos kvalitetnijem i bezbjednijem radnom okruženju. Pozitivni i negativni stavovi u odnosu na dobru praksu upravljanja otpadom uvijek su pod snažnim uticajem onih ljudi koji se nalaze na rukovodećim položajima i koji definišu politiku upravljanja otpadom jedne zdravstvene ustanove, odnosno koji odlučuju o raspodjeli resursa. Prema tome, treba istaći da zaposlenima na svim nivoima treba upućivati isključivo koncizne i relevantne informacije koje se odnose na upravljanje medicinskim otpadom. Adekvatna obuka je neophodna za sva lica odgovorna za upravljanje otpadom u svakoj zdravstvenoj ustanovi.

7.2. Identifikovanje potreba za obukom i obuka zaposlenih

Priroda i domet obuke i treninga osoblja u vezi sa upravljanjem otpadom očigledno će biti različiti i zavisiće od položaja i nadležnosti pojedinaca o kojima je riječ. U nekim slučajevima, uputstva treba samo da utiču na zaposlene da postanu svjesni svojih odgovornosti u nadgledanju upravljanja otpadom, dok će u drugim slučajevima, uputstva biti praktična i usmjerena na specifične zadatke. S obzirom da većina zaposlenih na upravljanje otpadom gleda kao na neku manje važnu aktivnost, obuka i obrazovanje tih zaposlenih treba da budu usmjereni na praktične savjete koji obuhvataju slijedeće:

1. odgovornosti i zadaci – šta se od njih očekuje;2. gdje mogu da dobiju savjet i pomoć; 3. šta je potrebno da učine za sopstvenu bezbjednost i bezbjednost pacijenata, ostalog osoblja, kao i za

bezbjednost okoliša.

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Obuka treba da obuhvati:

a. rukovodioce u ovom poslu na nekoliko nivoa, direktore, uključujući i tehničke rukovodioce; b. ljekare, medicinske sestre i zaposlene u mikrobiloškim i biohemijskim laboratorijama;c. medicinsko osoblje koje radi u terenskoj službi; d. stomatologe i pomoćno stomatološko osoblje; e. osoblje angažovano u transportu otpada u okviru zdravstvenih ustanova, kao i između zdravstvenih

ustanova i pogona za obradu ili odlaganje otpada;f. zaposlene koji se bave prikupljanjem i odlaganjem otpada.

Broj zaposlenih koji će biti uključeni u obuku može da oteža prenos i pružanje informacija. Štampani ma-terijal (slika 3. ) u vidu preporuka za razdvajanje otpada (poster) je veoma koristan podsjetnik za sprovođenje dobre prakse u svakodnevnom radu na segregaciji otpada. Direktori i rukovodioci za upravljanje medicinskim otpadom treba da podstiču i zahtevaju odgovarajuće oblike obuke o upravljanju medicinskim otpadom od zvaničnih institucija. Obuku i edukaciju o upravljanju medicinskim i komunalnim otpadom provodi multi-disciplinarni tim po programu koji odredi Odbor za upravljanje otpadom. Za provođenje obuka određenih kategorija uposlenika mogu biti angažovane i firme koje preuzimaju otpad iz ustanove, ako postavljaju svoju ambalažu. Prilikom provođenja obuke, evidentira se prisustvo, a na kraju svake provedene obuke, izvrši se provjera usvojenih znanja testiranjem.

Program obuka i edukacija :

1. Menadžment za upravljanje medicinskim otpadom, zakonske osnove, obaveze i odgovornost .2. Vrste medicinskog otpada, definicija u skladu sa kategorijama otpada koji se proizvodi u zdravstvenoj

ustanov3. Razdvajanje, obilježavanje, odlaganje na mjestu nastanka, i evidencije otpada.4. Transport, privremeno skladištenje i krajnje zbrinjavanje medicinskog otpada.5. Zdravstveni rizici od medicinskog otpada6. Upravljanje rizikom krvlju prenosivim bolestima.7. Praćenje kvaliteta, prikupljanje podataka, analiza i izvještavanje 8. Novi svjetski trendovi u zbrinjavanju medicinskog otpada

Slika 3 Štampani materijali za informisanje osoblja

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8. PRAĆENJE KVALITETA UPRAVLJANJA OTPADOM

Nakon usvajanja Plana upravljanja otpadom i njegove implementacije u zdravstvenoj ustanovi, pristupa se kontroli i ocjeni kvaliteta upravljanja otpadom.

Ova vrsta kontrole će obuhvati :

1. Nadzor menadžmenta za upravljanje otpadom2. Ocjenu kvaliteta razvrstavanja medicinskog otpada3. Ocjenu kvaliteta unutrašnjeg transporta4. Ocjenu mjesta decentralnog i centralnog skladištenja otpada

Kontrola i ocjena kvaliteta provodi se korištenjem formulara koji se satoje od tabela koje su prikazane u nastavku na tabelama 6 i 7.

Dokumentacija i uprava Komentari DostupniPlan upravljanja otpadom Da/NeStrategiju upravljanja otpadom Da/NeProcedure za pojedine vrste otpada Da/NeUgovore sa firmama koje preuzimaju otpad Da/NeEvidencije i izvještaji o vrstama i količinama otpada Da/Ne

Vođenje evidencije o ubodnim akcidentima Da/NeFormulari za prijavljivanje slučaja ubodom iglom Da/Ne

Datum posljednjeg zabilježenog akcidenta Da/NeFormulari za prijavljivanjeakcidenata i nesretnih slučajeva Da/Ne

Protokol, procedura i izvještaji ovakcinaciji protiv hepatitisa Da/Ne

Postoji li budžet za potrošni materijal (kese, kontejneri za oštre predmete itd)? Da/Ne

Da li je uvedena procedura za naručivanje i raspodjelu potrošnog materijala Da/Ne

Tabela 6. Nadzor menadžmenta za upravljanje otpadom

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Sakupljanje i razvrstavanje medicinskog otpada Komentari Ocjena

Da li se otpad pravilno razvrstava na mjestu nastanka? 0 1 2 3 4

Da li je ambalaža adekvatno postavljena na mjesta nastanka otpada? 0 1 2 3 4

Da li se koristi ambalaža sa odgovarajućom bojom i oznakama opasnosti za pojedine vrste otpada (oštre predmete infektivni otpad, farmaceutski, hemijski, citostatski)?

0 1 2 3 4

Da li se primopredaja otpada evidentira? 0 1 2 3 4Da li su identifikovana i uspostavljena mjesta sakupljanja otpada? 0 1 2 3 4

Da li su mjesta sakupljanja dobro obilježena i organizirana i da li su kontejneri dobro označeni?

0 1 2 3 4

Da li su mjesta sakupljanja rizičnog otpada izvan domašaja opće populacije? 0 1 2 3 4

Da li se na mjestima za sakupljanje otpada koristi sistem sakupljanja otpada u ambalažu sa odgovarajućom bojom za pojedine vrste otpada?

0 1 2 3 4

Da li uposleni koji rukuju sa otpadom nose ličnu zaštitnu opremu 0 1 2 3 4

Da li su uposlenici koji rukuju sa otpadom upoznati sa procedurama u slučaju prosi-panja otpada?

0 1 2 3 4

Da li su uposlenici koji rukuju otpadom up-oznati sa rizikom od povrede otpadnim oštrim predmetima?

0 1 2 3 4

Da li su kontejneri čisti i da li je uspostavljen sistem održavanja? 0 1 2 3 4

Za ocjenu kvaliteta skupljanja i razvrstavanja otpada koriste se pitanja iz Tabele 7, te se kvalitet ocjenjuje ocjenom od 0 do 4.

Za ocjenu kvaliteta sakupljanja i razvrstavanja otpada koriste se pravila iz tabela 8:

Potpunausaglašenost

(100%)

Skoro potpunausaglašenost

(80%)

Uopćenoprihvatljivo - neki

problemi su uočeni(60%)

Uočljivo velikiproblemi,

neophodnepromjene

Neprihvatljivostanje, neophodno

je bez odlaganjapreduzeti mjere

4 3 2 1 0Potpuno

razvrstavanje ivisok kvalitetrazvrstavanja

Mali problemi –otpad se pravilno

razvrstava

Otpad se uglavnomdobro razvrstava

Osnovnorazdvajanje na

rizičan i nerizičanotpad

Osnovnorazdvajanje, ali

postoje greške urazvrstavanju

Tabela 7. Ocjena kvaliteta razvrstavanja medicinskog otpada

Tabela 8. Ocjena kvaliteta sakupljanja i razvrstavanja otpada

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Tabela 9. Ocjena kvaliteta unutrašnjeg transporta

Unutrašnji transport Komentari OcjenaKako se opasni medicinski otpad

transportuje od mjesta sakupljanja do mjesta privremenog ili konačnog

skladištenja?

0 1 2 3 4

Da li uposleni koji obavljaju ovufunkciju nose ličnu zaštitnu opremu? 0 1 2 3 4

Da li su uposleni koji obavljaju ovu funkciju upoznati sa procedurama u

slučaju izlivanja?0 1 2 3 4

Da li su uposleni koji obavljaju ovu funkciju svjesni rizika od otpada od

oštrih predmeta?0 1 2 3 4

Za ocjenu kvaliteta unutrašnjeg transporta otpada koriste se pitanja iz Tabele 9, te se kvalitet ocjenjuje ocjenom od 0 do 4. Za ocjenu kvaliteta koriste se sljedeća pravila:

Ocjena 4 - Potpuna usaglašenost (100%) - Upotreba odgovarajuće LZO, adekvatna transportna ambalaža, pridržavanje propisanih uputstava prilikom transporta, obilježavanje odgovarajućom bojom i oznakom.

Ocjena 3 - Skoro potpuna usaglašenost (80%), mali problemi – Upotreba odgovarajuće LZO, adekvatna transportna ambalaža, pridržavanje propisanih uputstava prilikom transporta, obilježavanje odgovarajućom bojom ali bez oznaka.

Ocjena 2 - Uopćeno prihvatljivo (60%), neki problemi su uočeni – Upotreba odgovarajuće LZO, adek-vatna transportna ambalaža, pridržavanje propisanih uputstava prilikom transporta, ne postoji obilježavanje odgovarajućom bojom i ne postoje oznaka.

Ocjena 1 - Uočljivo veliki problemi, neophodne promjene – Nema plana, nema jasnih uputstava, loša praksa.

Ocjena 0 - Neprihvatljivo stanje, neophodno odmah preduze mjere – Slab ili nepostojeći unutrašnji trans-port sa slabom opremom i infrastrukturom.

28

Skladištenje Komentari OcjenaDa li su mjesta decentralnog skladištenja jasno označena? 0 1 2 3 4

Da li mjesta decentralnog i central-nog skladištenja odgovaraju nam-jeni (da li se lako dezinfikuju, ima li

dovoljno prostora itd?)

0 1 2 3 4

Da li kontejneri u decentralnom i cen-tralnom skladištu odgovaraju datoj

namjeni (da li su određeni bojom, da li su označeni,

odgovarajuće konstrukcije itd?)

0 1 2 3 4

Da li se mjesto decentralnog i cen-tralnog skladištenja redovno čiste i dezinfikuje? Da li o tome postoje

odgovarajući dokazi?

0 1 2 3 4

Koja je učestalost sakupljanja otpada iz mjesta decentralnog u centralno

skladište? 0 1 2 3 4

Da li uposleni koji obavljaju ovu funkciju nose ličnu zaštitnu opremu? 0 1 2 3 4

Da li su uposleni koji obavljaju ovu funkciju upoznati sa protokolima za

slučaj izlijevanja? 0 1 2 3 4

Da li su uposleni koji obavljaju ovu funkciju svjesni rizika od otpada od

oštrih predmeta? 0 1 2 3 4

Za ocjenu kvaliteta mjesta decentralnog i centralnog skladištenja otpada koriste se pitanja iz Tabele 10, te se kvalitet ocjenjuje ocjenom od 0 do 4. Za ocjenu kvaliteta koriste se sljedeća pravila:

Ocjena 4 - Potpuna usaglašenost (100%) -Potpuno razdvajanje i visokokvalitetno razvrstavanje uz us-postavljanje mjesta decentralnog i centralnog skladišta koja su osigurana, označena i čista

Ocjena 3 - Skoro potpuna usaglašenost (80%), mali problemi – Otpad se pravilno razvrstava uz uspostav-ljanje mjesta decentralnog i centralnog skladišta koja su osigurana, označena i čista

Ocjena 2 - Uopćeno prihvatljivo (60%), neki problemi su uočeni – Otpad se uglavnom razvrstava, konte-jneri mogu da budu puni, a mjesto decentralnog i centralnog skladišta mogu da djeluju neuredno.

Ocjena 1 - Uočljivo veliki problemi, neophodne promjene – Osnovno razvrstavanje uz slabo održavanje mjesta skladišta.

Ocjena 0 - Neprihvatljivo stanje, neophodno odmah preduzeti mjere – Ne postoji mjesto decentralnog i/ili centralnog skladišta.

Tabela 10. Ocjena mjesta decentralnog i centralnog skladištenja

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9. RUKOVANJE MEDICINSKIM OTPADOM

Po obavljenoj identifikaciji određene kategorije otpada i obavljenoj procjeni rizika, neophodno je sa ot-padom postupati na ispravan i bezbjedan način. Svi uposlenici koji rukuju otpadom, obavezno nose zaštitnu opremu i moraju biti educirani o medicinskom otpadu i mjerama sigurnosti prilikom prolijevanja ili drugih akcidenata. U skladu sa tim, potrebno je obezbjediti neophodnu obuku i ličnu zaštitnu opremu za sva lica koja neposredno rukuju medicinskim otpadom, kako bi im se omogućilo da obave svoj posao bezbjedno i odgo-vorno.

9.1. Razdvajanje medicinskog otpada

Efikasno upravljanje medicinskim otpadom se zasniva na ključnoj aktivnosti koju čine razdvanje (seg-regacija) i obilježavanje otpada. Odgovarajuće rukovanje, obrada i odlaganje otpada prema kategoriji otpada sprečava zagađenje životne sredine, smanjuje troškove i pomaže očuvanju i zaštiti javnog zdravlja.

30

Razdvajanje uvijek mora da bude odgovornost proizvođača ili stvaraoca otpada. Razdvajanje medicinskog otpada treba obaviti što je moguće bliže mjestu njegovog nastanka. Ključni dogovor koji definiše uniformnost u upravljanju medicinskim otpadom je sistem razdvajanja medicinskog otpada i obilježavanja istog dogo-vorenim bojama prema kategorijama, a koji se primenjuje u svim zdravstvenim ustanovama, državnog i pri-vatnog sektora. Najpogodniji način razdvajanja medicinskog otpada na različite kategorije je razdvanje otpada u plastične vreće ili posude različite boje. Imajući u vidu raspoloživu tehnologiju za tretman određenih katego-rija medicinskog otpada i ljudske resurse, predloženi sistem razdvajanja medicinskog otpada i obilježavanja različitim bojama, predstavlja primjer preporučene prakse u upravljanju medicinskim otpadom za primjenu u BiH (FBiH).

Uopšteno govoreći, hladne boje kao što su crna, zelena i plava dodeljene su kategorijama otpada koje nisu opasne: na primjer, komunalni otpad, otpad koji može da se reciklira itd. Opasan otpad obično se označava toplim bojama u kodu boja, kao što su žuta, i crvena: na primjer, infektivni otpad (crvena boja), hemijski otpad (žuta boja) i slično.

Kako bi se osiguralo sigurno rukovanje, razdvajanje otpada uključuje različite aktivnosti:

• Sakupljanje u adekvatnu ambalažu• Primjena jednoobraznog sistema kodiranja po bojama• Etiketiranje i označavanje simbolima

9.2. Odlaganje i obilježavanje medicinskog otpada

Zdravstveni uposlenici u procesu rada postavljaju i označavaju kontejnere za pojedine vrste medicinskog otpada na mjestu njihovog nastanka. U toku rada, kada nastane otpad, oni ga identificiraju, razdvajaju i odlažu u adekvatnu ambalažu. Nakon razdvajanja otpad se odlaže u posebne kontejnere i plastične kese koji su različitih boja određenih za različite vrste otpada, što omogućava prepoznavanje vrste otpada. Namjenska ambalaža mora biti adekvatno postavljena na svim mjestima u službi gdje se stvara medicinski otpad i mora biti izrađena tako da svojim karakteristikama (boja, oblik, veličina) omogućava i olakšava razvrstavanje opas-nog medicinskog otpada na mjestu nastanka. Na nju se postavlja i ispuni naljepnica i za tu vrstu otpada.

Prema važećem Pravilniku o upravljanju medicinskim otpadom u FBiH (Sl. novine FBiH 77/08), za infek-tivni otpad je određena ambalaža crvene boje.

Slika 4 Ambalaža za medicinski otpad

31

Boja ambalaže za medicinski otpad (FBiH) :

1. Oštri otpad (crvena), 2. Infektivni otpad (crvena),3. Patološki otpad (Crvena sa crnim pojasom),4. Hemijski otpad (žuta),5. Farmaceutski otpad (zelena),6. Komunalni otpad (crna i plava).

Ambalaža za odlaganje i skladištenje mora biti označena natpisom “opas-ni medicinski otpad”, s naznakom o vrsti otpada, nepropusna za tekućine (ne postoji mogućnost ispadanja i/ ili prolijevanja njihovog sadržaja), imati poklopce koji onemogućavaju neovlašteno otvaranje posuda i kontejnera

pri daljem postupanju ili obrađivanju i da pri obrađivanju ne zagađuje okoliš.Ambalaža sa infektivnim otpa-dom mora biti označena međunarodnim simbolom za obilježavanje otpada koji predstavlja biološku opasnost.

Ovisno o vrsti rizika od hemijskog otpada vrši se označavanje hemijskog otpada. (Slika 6)

Kad je kontejner napunjen do predviđenog nivoa, medicinska sestra ga zatvara, i predaje uposleniku koji vrši transport otpada u zdravstvenoj ustanovi. Primopredaju evidentira u obrasce primopredaje otpada.

Uloga zdravstvenih uposlenika je u provjeri da li su po obavljenom prikupljanju medicinskog otpada kese čvrsto zatvorene i da li se u okviru njihove službe kese pune do 2/3 njihove zapremine. Ukoliko se pomiješaju opasni i bezopasni otpad, takav otpad se mora smatrati opasnim otpadom. Nadzor razdvajanja medicinskog otpada na odjeljenjima vrši osoblje koje je u ljestvici odgovornosti zaduženo da nadzire rad osoblja pri čijem radu nastaje medicinski otpad.

Slika 5 Međunarodni znak za otpad koji predstavlja biološku opasnost

Toksičan Iritantan Štetan za zdravlje

Korozivan

Zapaljiv Eksplozivan Oksidirajući agens Opasan za okoliš

Slika 6 Označavanje hemijskog rizika

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9.3. Unutrašnji transport i skladištenje opasnog medicinskog otpada

Infektivni i oštri otpad se privremeno skladište u prostoriji za decentralno skladištenje na odjeljenju, a kasnije se transportuju u prostoriju za centralno skladištenje u ustanovi. Decentralno skladištenje omogućava osoblju da bude efikasnije i omogućava češće sakupljanje otpada sa lokacijom za razdvajanje otpada. Nji-hovom primjenom se izbjegavaju duži transporti malih količina otpada i smanjuje učestalost transporta do centralnog skladišta. Kontejneri i kese propisno obilježeni i zatvoreni, odnose se iz službe kada se napune 2/3 njihove zapremine i u njima ne smije biti nikakve tekućine. Prije odnošenja otpada medicinsko osoblje izvrši primopredaju otpada uposleniku za transport otpada i popunjavaju evidenciju. Kese sa otpadom ne treba nositi u ruci na bilo kakve veće udaljenosti, jer to povećava rizik od ozljede oštrim predmetima. Uposlenik za trans-port otpada ne smije ispravljati pogreške u razdvajanju otpada tako što će artikle prebacivati iz jedne kese u drugu, odnosno iz jednog kontejnera u drugi. Potrebno je isplanirati specifične puteve kretanja otpada, kako bi se spriječilo izlaganje osoblja i pacijenata potencijalnim rizicima i kako bi se minimiziralo kretanje otpada kroz područja u kojima borave pacijenti i kroz druga čista područja

Otpad iz službi i odjeljenja odnosi uposlenik zadužen za transport otpada u kontejnerima ili kolicima za transport medicinskog otpada koji garantuju da neće doći do prosipanja otpada prilikom transporta. Kolica za transport medicinskog otpada treba da budu označena sa međunarodnim znakom za biološku opasnost i treba ih koristiti samo za medicinski otpad. Odvoz treba vršiti redovno i on treba da odražava dinamiku proizvodnje otpada i skupljanja na lokacijama za privremeno skladištenje. Veoma važan parametar kvaliteta prikupljanja infektivnog medicinskog otpada je i to što se nikada ne smije dozvoliti da se otpad nagomilava na mjestu nastanka. Rutinski program i dinamika za skupljanje otpada mora da bude ustanovljena od strane zaduženog lica u zdravstvenoj ustanovi, odnosno od strane zdravstvene ustanove. Dinamika odnošenja i prikupljanja in-fektivnog medicinskog otpada u zdravstvenoj ustanovi je dio plana upravljanja medicinskim otpadom zdravst-vene ustanove. Određene preporuke se moraju poštovati i od strane pomoćnih radnika zaduženih za skupljanje otpada, što takođe mora biti obezbeđeno u svakoj zdravstvenoj ustanovi. Transport treba da se odvija tokom perioda smanjenog intenziteta aktivnosti i to samo duž fiksno određenih ruta. Kolica koja se koriste za interni prevoz infektivnog otpada treba da budu:

• jednostavna za utovar i istovar (niska platforma za utovar);• bez oštrih rubova (oni mogu da oštete kese ili kontejnere);• jednostavna za čišćenje i dezinfekciju;• izrađena od materijala koji može da izdrži redovno izlaganje uobičajenim sredstvima za čišćenje i dez-

infekciju;• očišćena i dezinficirana nakon transporta;• preporučuje se upotreba zatvorenih kolica sa poklopcem.

Putevi za sakupljanje i transport treba da budu odvojeni prostorno i vremenski od ostalih puteva u zdravst-venoj ustanovi, a naročito od onih gdje se nalaze sterilni materijali i gdje se pružaju zdravstvene usluge. Trans-

Slika 7 Preuzimanje medicinskog otpada i tabela evidencije

33

port medicinskog otpada do centralnog prostora za privremeno odlaganje vrši se najmanje jedan puta dnevno, a po mogućnosti jedan puta u smjeni. Transport patološkog otpada obavlja se u transportnim kontejnerima ili kolicima za transport otpada koja su označena adekvatno za tu vrstu otpada. Nakon transporta kontejner se pere i dezinfikuje.

Dobra praksa zahtjeva da se vozila koja se koriste za otpad koriste samo za tu namjenu, to jest samo za transport infektivnog medicinskog otpada (iz zdravstvenih ambulanti do centralne zgrade doma zdravlja), posebnu pažnju treba posvetiti zaštiti osoblja koje vozi automobil ili onog koje se istim prevozi. To uključuje i posebne mjere za dodatno sekundarno pakovanje infektivnog medicinskog otpada za potrebe transporta i bezbjednosti, kao i mjere za redovno provjetravanje vozila i čišćenje i dezinfekciju.

9.4. Odlaganje, transport i skladištenje pojedinih vrsta otpada u zdravstvenoj ustanovi

9.4.1. Odlaganje i transport oštrog otpada

• Sav oštri otpad (izuzev radioaktivnog i citostatskogoštrog otpada) nastao na odjeljenju (igle, skalpeli, lancete, itd.) odlaže se na mjestu nastanka direktno u kontejner za oštri otpad, nesmiju se poklopci vraćati na iglu.

• Kontejner za oštri otpad postavlja se na svim mjestima gdje nastaje oštri otpad, od krute plastike je ne-probojan za sadržaj i napravljen tako da ga oštri otpad ne može probiti i da je onemogućeno ispadanje sadržaja ili ozljeđivanje i prijenos infekcija na osobe koje upotrebljavaju posudu ili rukuju s otpadom i

Slika 8 Posude za sakupljanje oštrih predmeta

34

označen oznakama za ovu vrstu otpada (crvena boja za kontejner, naljepnica za oštri otpad).• Svaki kontejner je označen sa etiketom za oštri otpad koja sadrži podatke: izvor otpada (služba), datum,

vrijeme, ime osobe koja popunjava deklaraciju, kategoriju otpada i šifru iz Kataloga otpada i oznaka opasnosti za oštri otpad.

• Medicinska sestra-tehničar priprema kontejnere za oštri otpad i vrši njihovo obilježavanje etiketama.• Igle i drugi oštri otpad odlažu se u kontejner tako da ne smiju viriti izvan kontejnera. Kontejner se smije

napuniti samo do dvije trećine njegove zapremine.

Transport oštrog otpada

• U planom predviđeno vrijeme prikupljanja otpada ili kad je napunjen do 2/3 kontejner se čvrsto zatvara i predaje radniku za transport otpada.

• Primopredaja otpada se evidentira u obrascu za primopredaju medicinskog otpada. • Transport otpada sa odjeljenja vrši se u transportnom kontejneru crvene boje ili pomoću kolica za trans-

port otpada koji su označeni oznakama za oštri otpad. • Uposlenik zadužen za transport otpada, vrši transport otpada do prostorije za sterilizaciju otpada, ako

se otpad steriliše u ustanovi ili do prostorije za privremeno skladištenje otpada u ustanovi kada otpad preuzima firma za krajnje zbrinjavanje.

• Oštri otpad se predaje uposleniku koji vrši sterilizaciju a primopredaja se evidentira u protokol sterili-zacije, što se potvrđuje potpisom.

• Nakon završene sterilizacije provjeri se uspješnost sterilizacije te evidentira.• Ako je sterilizacija uspješna otpad se odlaže kao komunalni otpad. • Ako otpad preuzima firma onda se primopredaja evidentira putem otpremnice.

9.4.2. Odlaganje i transport infektivnog otpada

• Čvrsti infektivni otpad se na mjestu nastanka odlaže u crvenu vreću postav-ljenu u kantu/kontejner za infektivni otpad.

• Na vreću ili kantu medicinska sestra/tehničar postavlja naljepnicu za infektiv-ni otpad i upisuje sledeće podatke: izvor otpada (služba), datum, vrijeme, ime osobe koja popunjava deklaraciju, kategoriju otpada i šifru iz Kataloga otpada. Ambalaža za infektivni otpad označen je međunarodnim znakom za biološku opasnost i crvenom bojom.

• Veoma infektivan otpad (otpad koji sadrži uzročnike infekcije Hepatitis B, Hepatitis C, HIV, MRSA i sl.) zahtjeva toplotnu ili hemijsku sterilizaciju u području gdje nastaje, te se takav ne predaje ustanovi na krajnje zbrinjavanje.

• Kulture i pribor iz mikrobiološkog laboratorija laboratorijski tehničar ili drugo medicinsko osoblje odmah nakon upotrebe odlaže u plastične kese ili kontej-nere koji su označeni oznakom za infektivni otpad i namijenjeni i kompatibilni sa procesom sterilizacije.

Slika 9 Ambalaža i naljepnica za infektivni otpad

Slika 10 Ambalaža za transport infektivnog otpada

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Transport infektivnog otpada

• Zatvorenu kantu ili vreću sa infektivnim otpadom medicinska sestra tehničar predaje spremačici ili up-osleniku za transport otpada. Otpad se odlaže u kontejner za transport infektivnog otpada. Primopredaja otpada evidentira se u obrazac primopredaje.

• Uposlenik za transport otpada, vrši transport otpada do prostorije za sterilizaciju otpada, ako se otpad steriliše u ustanovi ili do prostorije za privremeno skladištenje otpada u ustanovi kada otpad preuzima firma za krajnje zbrinjavanje.

• Otpad preuzima zaduženi uposlenik na sterilizaciji otpada, evidentira otpad u svesku uz obavezne pot-pise.

• Ako otpad preuzima firma, uposlenik za transport otpada odlaže otpad u prostoriju za privremeno odla-ganje infektivnog i oštrog otpada u ustanovi, i evidentira ga u svesku evidencije.

• Nakon sterilizacije provjere se kontrolni parametri i ako su zadovoljavajući otpad se odlaže kao komu-nalni.

• Ugovorena firma preuzima otpad iz prostorije za privremeno odlaganje prema utvrđenom rasporedu pod nadzorom odgovornog uposlenika i primopredaja se evidentira putem otpremnice i arhivira u ustanovi.

9.4.3. Odlaganje i transport patološkog otpada

• Patološki otpad se na mjestu nastanka odlaže u plastične kese (crvene boje sa crnom trakom), koje su postavljene u plastične kante crvene boje i označene oznakom za patološki otpad. Medicinska sestra/tehničar postavlja kesu u kontejner za patološki otpad stavlja odgovarajuću naljepnicu i upisuje datum i vrijeme, naziv odjeljenja, i potpiše se.

• Kad se vreća napuni do 2/3 ona se zatvara vezivanjem i postavlja u transportnu ambalažu• Patološki otpad se što kraće zadržava na mjestu nastanka. • Medicinska sestra-tehničar predaje upakovan i obilježen otpad uposleniku za transport otpada. Primo-

predaja otpada evidentira se u obrazac primopredaje.

Transport patološkog otpada

• Transport patološkog otpada obavlja se u adekvatnom transportnom kontejneru. Kontejner za transport patološkog otpada ima odgovarajuće oznake za tu vrstu otpada.

• Uposlenik za transport otpada odmah vrši transport patološkog otpada u prostoriju za privremeno odla-

Slika 11 Ambalaža i naljepnica za patološki otpad

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ganje patološkog otpada, gdje je smješten zamrzivač namijenjen isključivo za zamrzavanje patološko-biološkog otpada, odloži ga u zamrzivač i evidentira odlaganje.

• Krajnje zbrinjavanje patološkog otpada vrši ovlaštena firma na osnovu ugovora sa zdravstvenom ustanovom.

9.4.4. Odlaganje i transport farmaceutskog otpada

Odmah po utvrđivanju neispravnosti lijeka ili farmaceutske supstance zdravstveni uposlenik obavještava medicinsku sestru/tehničara ili farmaceutskog tehničara zaduženog za priručnu apoteku, koji odlaže otpad u odgovarajudu ambalažu (plastične kese, kartonske kutije, plastična ili metalna burad i sl.) koja je prilagođena svojstvima otpada i označena oznakom

“Opasnost! Opasan farmaceutski otpad”. Otpad treba označiti i odgovarajudom deklaracijom koja sadrži:

◊ Datum i vrijeme: ◊ Izvor otpada: ◊ Naziv lijeka /Šifra EU kataloga otpada: ◊ Ime osobe koja popunjava deklaraciju:

Otpad se na odjeljenju evidentira u „Listu evidencije farmaceutskog otpada“ na odjeljenju. Lista sadrži: 1. redni broj 2. naziv lijeka 3. oblik i količinu lijeka 4. datum odlaganja otpada 5. ime i prezime zaposlenog koji je predao otpad 6. datum i vrijeme preuzimanja otpada 7. ime i prezime zaposlenog zaduženog za privremeno odlaganje otpada

Transport farmaceutskog otpada

• Klasifikovan, obilježen, upakovan, evidentiran i odložen farmaceutski otpad, upućuje se u apoteku is-tog dana po utvrđivanju neispravnosti.

• Evidencija otpada u apoteci se vrši upisom podataka u „Listu evidencije farmaceutskog otpada“ koja sadrži iste podatke kao i lista evidencije na odjeljenju.

Slika 12 Ambalaža i naljepnica za farmaceutski otpad

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Slika 13 Odlaganje farmaceutskog otpada

• Farmaceutski otpad se čuva u privremenom skladištu za farmaceutski otpad koji se nalazi u blizini magacina apoteke izdvojeno i obilježeno oznakom “FARMACEUTSKI OTPAD“ i zaključano.

• Farmaceutski otpad preuzima firma koja ima dozvolu za zbrinjavanje farmaceutskog otpada na osnovu ugovora sa zdravstvenom ustanovom.

• Lijekovi koji se nabavljaju putem ugovora kojim se dozvoljava povrat lijekova sa isteklim rokom upotrebe, predaju se dostavljaču

Ugovorom o nabavci lijekova, zdravstvena ustanova treba osigurati besplatan povrat lijekova sa isteklim rokom proizvođaču ili dostavljaču.

9.4.5. Odlaganje i transport hemijskog otpada

• Hemijski otpad u biohemijskom laboratoriju nastaje manuelnim analiziranjem uzoraka. Koriste se reagensi koji sadrže kiseline, baze, indikatore pa se otpad koji nastaje anliziranjem ovih analiza tretira kao hemijski otpad, i odlaže se u kontejnere za hemijski otpad koji su postavljeni na mjestu nastanka otpada i označeni oznakama za hemijski otpad.

• Pune kontejnere laboratorijski tehničar zatvori, zalijepi naljepnicu za hemijski otpad s podacima izvor otpada (služba), datum, vrijeme, ime osobe koja popunjava deklaraciju, kategoriju otpada i šifru iz Kataloga otpada i predaje ih osoblju koje vrši transport medicinskog otpada do prostorije za privremeno skladištenje hemijskog otpada. Primopredaja se evidentira u obrazac primopredaje.

• Krajnje zbrinjavanje ovog otpada vrši firma na osnovu ugovora sa zdravstvenom ustanovom.• Hemijsko-biološki otpad u biohemijskom laboratoriju nastaje nakon obrade uzorka na biohemijskim

analizatorima i hematološkim analizatorima. Svi analizatori imaju plastične kontejnere za tečni otpad koji u sebi sadrže obrađeni biološki materijal pomješan s reagensima za određivanje pojedinih analiza koji sadrže hemijske komponente. Ovaj se otpad tretira kao hemijski otpad.

Slika 14 Ambalaža i naljepnica za hemijski otpad

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• Napunjene plastične kontejnere odgovorna osoba za održavanje aparata (laboratorijski tehničar) odvoji od aparata po propisanom pravilu za odvajanje kontejnera za otpad ( svaki analizator u svom programu ima proceduru za odvajanje punog kontejnera za otpad) zatvori čepom, nalijepi naljepnicu za hemijski otpad s podacima: izvor otpada (služba), datum, vrijeme, ime osobe koja popunjava deklaraciju, kat-egoriju otpada i šifru iz Kataloga otpada.

• Zapakovane kontejnere laboratorijski tehničar predaje uposleniku zaduženom za transport otpada koji postavlja otpad u transportna kolica i odvozi u prostoriju za odlaganje hemijskog otpada. Primopredaja se evidentira.

• Krajnje zbrinjavanje hemijskog otpada vrši ovlaštena firma na osnovu ugovora sa zdravstvenom ustano-vom.

9.4.6. Odlaganje i transport citotoksičnog i citostatičkog otpada

Postojećim propisima u BiH nije definisana boja za citostatski otpad, dok se u nekim evropskim zemljama koristi ljubičasta boja za označavanje ove vrste otpada.

• Citostatski otpad na mjestu nastanka odlaže medicinska sestra-tehničar i farmaceutski tehničar u kon-tejner za citostatski otpad.

• Kontejner mora biti označen sa etiketom koja sadrži podatke: izvor otpada (služba), datum, vrijeme, ime osobe koja popunjava deklaraciju, kategoriju otpada i šifru iz Kataloga otpada. Kontejner je označen i simbolom “Štetan za zdravlje“.

• Označene i zapakovane kontejnere medicinska sestra predaje spremačici koja vrši transport do pros-torije za privremeno skladištenje citostatskog otpada.

• Primopredaja medicinskog otpada evidentira se u obrazac za primopredaju medicinskog otpada. • Citostatski otpad iz prostorije za privremeno skladištenje preuzima firma koja vrši krajnje zbrinjavanje

na osnovu ugovora. Potvrda o preuzimanju citostatskog otpada čuva se u ustanovi.

9.4.7. Odlaganje radioaktivnog otpada

Pakiranje: u namjenske olovne kontejnere za radioak vni otpadEtiketiranje: ◊ “Oprez ! Radioaktivni otpad”◊ Vrsta radionukleida

Slika 15 Ambalaža i naljepnica za radioaktivni otpad

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◊ Zračenje na naznačeni datum (vrijeme početka skladištenja)◊ Obavezno navođenje perioda skladištenja◊ Za eksterni transport: informacije u skladu sa preporukama UN

9.5. Prostorija za centralno skladištenje u ustanovi

U članu 10. Pravilnika o upravljanju medicinskim otpadom (”Službene novine FBiH” 77/08), određeni su uslovi koje treba da ispunjava zdravstvena ustanova u pogledu prostorija za centralno skladištenje medicin-skog otpada. Prema tom pravilniku lokacija mora biti zatvorena prostorija koja ispunjava slijedeće uvjete:

• da je pod nadzorom referenta za upravljanje otpadom;• da je dovoljno prostrana za prijem maksimalno predviđene količine otpada različitih kategorija koje

moraju biti razdvojeno uskladištene;• da je onemogućen fizički pristup neovlaštenim licima i štetočinama;• da ima obezbijeđen odgovarajući rashladni odjel za otpad koji zahtijeva skladištenje u hladnim pros-

torijama• da je opremljena uređajima za gašenje požara i inertnim absorbirajućim materijalom za lokaliziranje

eventualno prosutih tečnosti (hemikalija).

Slika 16 Centralno skladište

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10. KONAČNA OBRADA I ODLAGANJE MEDICINSKOG OTPADA

Krajnje zbrinjavanje medicinskog otpada može se vršiti u samoj zdravstvenoj ustanovi ukoliko je ona opremljena za to, ili to mogu vršiti firme koje su ovlaštene za zbrinjavanje pojedinih vrsta otpada. Zbrinja-vanje se vrši na osnovu ugovora koji zdravstvena ustanova sklopi sa takvim firmama u skladu sa Pravilnikom o prenosu obaveza sa proizvođača i prodavaća na operatera sistema za upravljanje otpadom („Službene novine Federacije BiH“, br.9/05) U BiH postoji više firmi koje su ovlaštene za preuzimanje ili zbrinjavanje pojedinih vrsta otpada.

10.1. Opcije za konačnu obradu i dlaganje otpada

Prilikom izbora načina konačne obrade i odlaganja medicinskog otpada, uprava zdravstvene ustanove treba da ima u vidu sledeće kriterijume:

• Poštovanje važeće zakonske regulative;• Ponašanje u skladu sa prihvaćenim preporukama Priručnika dobre prakse za upravljanje medicinskim

otpadom,• Korištenje sredstava i tehnologija koje su, pored toga što zadovoljavaju prethodna dva uslova, ujedno

i ekonomski isplativa.

Prilikom pravljenja takvog izbora, ključnu ulogu u tom procesu će igrati stručno i komercijalno rasuđivanje, kao i znanje o tome šta je usklađeno sa zakonskom regulativom i sa preporukama dobre prakse. Dužnost svih rukovodilaca i svih uposlenika u zdravstvenim ustanovama je da svaki otpad odlazi u pravi tok otpada.

Slučajne ili namjerne greške u sistemu mogu dovesti do značajnog povećanja opasnosti i rizika koji su pov-ezani s upravljanjem medicinskim otpadom. Najuže rukovodstvo zdravstvene ustanove bi, naravno, trebalo da ima jasno definisane ciljeve u vezi upravljanja infektivnim medicinskim otpadom, a ti ciljevi treba da budu sastavni dio dokumenta koji se zove Politika o upravljanju otpadom date zdravstvene ustanove.

10.2. Odlaganje otpada na deponiju Deponije predstavljaju mesto za konačno odlaganje ostataka iz procesa sterilizacije parom infektivnog

medicinskog otpada. To znači da se sav otpad koji je tretiran u autoklavima u ustanovama u kojima se nalaze ova postrojenja, po završenoj obradi, odlaže kao komunalni otpad na lokalnim deponijama. Rukovodioci odgovorni za upravljanje medicinskim otpadom, trebalo bi da budu sigurni da je proces sterilizacije tehnički adekvatan za tu svrhu i da postoji odgovarajući nadzor nad tim procesom, kako neadekvtno tretirani otpad ne bi bio ponovno upoterebljen, recikliran ili odložen na deponiju. Neophodo je da se odlaganje otpada na deponiju vrši u skladu sa direktivama evropske unije i postojećim propisima o deponijama.

Direktivom Evropske unije br. 1999/31/EC od 26. aprila 1999. godine („Direktiva o deponijama”) koja se odnosi na sve deponije u koje se odlaže otpad poslije 16. jula 2001. godine uključuje:

• progresivno smanjivanje količina biorazgradljivog komunalnog otpada koji se smije odlagati u de-ponije tokom pet, osam i petnaest godina;

• zabranu odlaganja u deponije infektivnog otpada koji potiče iz medicinskih ustanova i veterinarskih stanica, tečnosti, guma i otpada koji je eksplozivan, rđajući, oksidirajući ili koji je zapaljiv;

• zahtjev da se sav otpad obradi prije odlaganja na deponiju;• klasifikaciju mjesta za odlaganje otpada na inertne, one koji nisu opasni ili opasne;

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• testiranje otpada prije prihvatanja obaveze zadovoljavanja kriterijuma prihvaćenih širom Evrope o tome šta se može prihvatiti kao mjesto za odlaganje otpada u okviru svake klasifikacije.

Odlaganje medicinskog otpada koji potiče iz medicinskih ustanova a koji se definiše kao „infektivan”, na deponije, je zabranjeno.

10.3. Obrada infektivnog otpada pomoću sterilizacije parom (u autoklavu)

Infektivni medicinski otpad može biti opasan po ljude koji dolaze u dodir sa njim i koji njime manipulišu. Glavni cilj obrade ove kategorije medicinskog otpada je sterilizacija, putem koje se medicinski otpad pretvara u bezopasni komunalni otpad. Ukoliko se infektivni medicinski otpad najprije steriliše, a zatim i tako usitni

da se ne može prepoznati kao otpad koji je medicinskog porijekla, tada se on može odložiti na deponijama. Aparat u kome se vrši sterilizacija otpada parom (autoklav) ne smije da nosi rizik za osoblje koje radi na nje-mu, za osoblje koje se bavi upravljanjem otpadom ili za opštu populaciju. Osnovni zahtjev je da proces steri-lizacije autoklaviranjem dovede do potpunog uništenja bioloških agenasa u otpadu. Taj zahtjev podrazumjeva da i operativni uslovi, na primjer, temperatura, kao i period tokom koga se ta temperatura održava, moraju biti ispoštovani i da otpad mora da bude u takvom obliku da u cjelini tj. svakim svojim dijelom, dostigne naznačene uslove.

U skladu s tim, slijedeće kategorije otpada mogu se obrađivati putem sterilizacije parom u postrojenjima koja imaju odgovarajuću dozvolu za ovaj proces;

a. upotrebljeni opštri predmeti, špricevi, cjevčice i ampule od upotrebljenih lijekova/ukoliko lijekovi nisu citotoksični

42

b. slomljeno staklo, manji polomljeni predmeti iz zdravstvenih ustanovac. krv i kontaminirane tečnosti, stabilizovane radi sprečavanja curenja iz kesa ili cijevi.d. neprepoznatiljivo tkivo iz dijagnostičkih procedura, nehirurškihe. otpad nastao iz hemodijalize i peritonealne dijalizef. zavojni materijal i tupferi, umrljani krvlju i drugim telesnim sekretima i ekskretima;g. ulošci, pelene umrljane tjelesnim tečnostima i/ili ekskretom;h. klinički otpad iz kliničkih laboratorija (izuzev Krojcfeld-Jakobove bolesti – Creutzfeldt-Jakob Dis-

ease)Postoji širok spektar različitih sistema tretmana infektivnog otpada. Uopšteno posmatrano, alternativni sis-

temi tretmana mogu da se podijele na sisteme koji rade na bazi vodene pare, sisteme koji rade na bazi toplog vazduha (suhe toplote ), kao i sisteme koji rade na bazi hemijskih sredstava i na bazi zračenja. Najpoznatija tehnologija za alternativni tretman infektivnog medicinskog otpada je primjena autoklava za tretman ili de-kontaminaciju pomenute kategorije otpada. Zastupljenost ove tehnologije u pomenutom procesu je od 80 do 90%. Efikasnost procesa autoklaviranja zavisi od faktora koji utiču na temperaturu unutar prostora obrade, penetraciju pare kroz otpad i vremena obrade. Prednosti ove metode su: niska investicija, redukcija zapremine, jednostavno rukovanje, jednostavna kontrola procesa.

Nedostaci: nije za sve vrste otpada, efikasnost nije 100% u koliko otpad nije usitnjen do određenje veličine čestice i mogućnost emisije u vazduh i otpadne vode.

10.4. Spaljivanje

Spaljivanje(insineracija) predstavlja odgovarajući način eliminacije većine medicinskog otpada uključujući tu i neke vrste hemijskog otpada, ali ne i radioaktivni otpad. Svaka spalionica treba da zadovoljava uslove za postrojenje za spaljivanje, u skladu sa zakonom, i svaka spalionica se posmatra posebno. Postrojenja za spaljivanje treba da funkcionišu prema principima iz Okvirne direktive Evropske komisije o otpadu i Na-cionalne strategije BiH u vezi sa otpadom putem usvajanja tehnologije stvaranja energije iz otpada. U pro-cesu spaljivanja (inseneracije) medicinski otpad sagorijeva, proizvodeći gasove i nesagorivi ostatak (pepeo). Izdvojeni gasovi se moraju tretirati prije ispuštanja u vazduh, dok se pepeo odlaže na deponije (za opasan ili neopasan otpad). Najčešći korišćeni tipovi inseneratora za tretman medicinskog otpada su: plazma tehnologi-ja; višekomorni insenerator za patološki otpad; inseneratori sa kontrolisanim vazduhom; rotacione peći i jednokomorni insenerator sa statičkom rešetkom. Prednosti ove tehnologije su: drastična redukcija mase i zapremine otpada, neprepoznatljivo porijeklo nakon tretmana, prihvatljiva za sve vrste otpada (osim: radio-aktivnog i otpada sa teškim metalima, PVC, soli srebra i fotografski otpad, posude pod pritiskom i reaktivne hemikalije) od čega zavisi izbor tipa inseleratora, može se koristiti proizvedena toplota i nema otpadnih voda. Nedostaci su: visoke investicije, visoki troškovi održavanja, moguća emisija štetnih gasova.

U skladu sa zakonskim propisima slijedeće kategorije otpada mogu biti spaljene u postrojenjima koja imaju odgovarajuću dozvolu za rad:

1. sav medicinski otpad „visoko infektivne” prirode, to jest, od pacijenata koji su u strogoj izolaciji i boluju od poznate infektivne bolesti ili sa sumnjom na neko infektivno oboljenje (na primjer, Lassa, Ebola i virusi hemoragične groznice, itd);

2. sav medicinski otpad koji potiče od pružanja zdravstvenih usluga pacijentima oboljelim od oboljenja Creutzfeldt-Jakob (CJD) kao i medicinski otpad koji potiče od istraživanja u vezi sa ovom bolešću;

3. sve mikrobiološke kulture koje nisu prošle sterilizaciju u autoklavu 4. zagađeni veći metalni predmeti (na primjer: proteze, igle, hirurški instrumenti za jednokratnu upotrebu

itd);5. inficirana krv, stabilizovana da bi se izbjeglo izlivanje (uključujući kese i epruvete)6. svi prepoznatljivi dijelovi tijela posle hirurških intervencija iz hirurških sala ili drugih hirurških pros-

tora, sala za autopsiju i iz laboratorija;

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7. fetalno tkivo i placenta iz porodilišta i ginekoloških ordinacija;8. sav opasni otpad, na primjer, citotoksični otpad, farmaceutski otpad, uključujući farmaceutske hemika-

lije, barijum, kadmijum, kobalt, olovo, živu (uključujući amalgam), nikl, srebro i mnoge druge kompo-nente itd. (ali ne i barijum sulfat).

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GOOD PRACTICE HANDBOOK ON MEDICAL WASTE MANAGEMENT

Project funded by the European Union

Project implemented byAssociation for Research and Development Tuzla

“NVO and medical waste” Project

GOOD PRACTICE HANDBOOK ON MEDICAL WASTE MANAGEMENT

November, 2012.

Publisher:Društvo za istraživanje i razvoj(Association for Research and Development)

Džafer mahala 66 75000 Tuzla, Bosna i Hercegovina tel/ fax: +387 35 277 254 društvo.razvoj@bihnet.ba www.istraz.org

Working group for production of the Handbook:

dr Amer Ćustović, JZU Univerzitetsko klinički centar Tuzla dr Sadeta Hadžić, JZU Univerzitetsko klinički centar Tuzla mr.Esad Arnautović , DIR Tuzla dr Mustafa Burgić, DIR Tuzla, stručni saradnik za okoliš Emir Arpadžić, DIR Tuzla, stručni saradnik za okoliš Amila Šećerkadić, DIR Tuzla, stručni saradnik Jasmina Ovčina, CISP, stručni saradnik

Working group that supported the production of the Handbook:

JKP Regionalni centar za upravljanje otpadom Kemis – BH d.o.o Lukavac JZU Univerzitetsko klinički centar Tuzla JZU Dom zdravlja Tuzla JZU Dom zdravlja Gračanica JZU Dom zdravlja Banovići CEETZ Tuzla EKOPOT Tuzla Udruga Hrvatska žena Tuzla CISP NVO Etno Klub Kicelj Tuzla UG “ Klub potrošača” Tuzla Crveni križ TK

Print: Papir karton, Tuzla

Printing: 1000 copies

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Acronyms:

NGO Non-governmental organizationB&H Bosnia and HerzegovinaEU European UnionTC Tuzla CantonJU Public InstitutionFB&H Federation of Bosnia and HerzegovinaWHO World Health OrganizationRS Republika SrpskaPPE Personal protective equipment

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CONTENTS

Acronyms ................................................................................................................................................................................... 31. INTRODUCTION ........................................................................................................................................................ 52. MEDICAL WASTE ...................................................................................................................................................... 62.1. Basic principles of medical waste management ........................................................................................................... 62.2. Definition and classification of medical waste ............................................................................................................. 62.3. Categories of medical waste ......................................................................................................................................... 72.3.1. Hazardous medical waste .............................................................................................................................................. 83. HEALTH RISKS OF MEDICAL WASTE ................................................................................................................... 103.1. Professional and public health risks .............................................................................................................................. 103.1.1. Risk of infectious waste ................................................................................................................................................ 113.1.2. Risk of chemical and pharmaceutical waste ................................................................................................................. 134. RISK ASSESSMENT ................................................................................................................................................... 144.1. Risk assessment in the context of medical waste .......................................................................................................... 144.2. Five steps in risk assessment ........................................................................................................................................ 145. LEGISLATION ........................................................................................................................................................... 185.1. Legal framework of medical waste management in B&H .......................................................................................... 185.2. International legislation ............................................................................................................................................... 185.2.1. Basel Convention ......................................................................................................................................................... 185.2.2. Adjustment to international legislation ......................................................................................................................... 195.2.3. Adjustment to the international law .............................................................................................................................. 196. MEDICAL WASTE MANAGEMENT IN HEALTH INSTITUTIONS ...................................................................... 206.1. Participants in the process of disposing of medical waste ........................................................................................... 206.2. Responsible persons and bodies for organization and internal control ........................................................................ 206.3. Administrative structure, correlation andresponsibilities ............................................................................................. 216.4 . Development of the Plan for the waste management .................................................................................................... 227. TRAINING AND EDUCATION .................................................................................................................................. 237.1. Attitudes on waste management ................................................................................................................................... 237.2. Identification of the training needs and the training of employees ............................................................................... 238. MONITORING THE QUALITY OF WASTE MANAGEMENT ............................................................................... 259. HANDLING THE MEDICAL WASTE ....................................................................................................................... 299.1. Separation of medical waste ......................................................................................................................................... 299.2. Disposal of the medical waste and marking ................................................................................................................. 309.3. Internal transport and disposal of hazardous medical waste ........................................................................................ 329.4. Disposal, transport and storage of certain types of waste in helth institution .............................................................. 339.4.1. Sharp waste disposal and transport .............................................................................................................................. 339.4.2. Infectious waste disposal and transport ...................................................................................................................... 349.4.3. Pathological waste disposal and transport ................................................................................................................... 359.4.4. Pharmaceutical waste disposal and transport ............................................................................................................... 369.4.5. Chemical waste disposal and transport ....................................................................................................................... 379.4.6. Cytotoxic and citostatic disposal and transport ........................................................................................................... 389.4.7. Radioactive waste disposal .......................................................................................................................................... 389.5. The room for the central storage in the institution ....................................................................................................... 3910. FINAL ANALYSIS AND DISPOSAL OF MEDICAL WASTE ................................................................................. 4010.1. Options for the final analysis and disposal of waste ..................................................................................................... 4010.2. Disposal of waste to landfill .......................................................................................................................................... 4010.3. Treatment of infectious waste by steam sterilization .................................................................................................... 4110.4. Incineration ................................................................................................................................................................... 42

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1. INTRODUCTION

„Good Practice Handbook On Medical Waste Disposal“ was created as a result of the working group „Društva za istraživanje i razvoj“ Tuzla („Association for Research and Development“ Tuzla) within the framework of the activity called Disposal of medical waste in selected health care institutions of the project „NGO and Medical Waste“ financed by the European Union. It is designed for all health care institutions and all other interested parties which take part in the implementation of this project in terms of establishing the unique system of medical waste management in health care institutions of Tuzla Canton. Furthermore, it presents the good source of information and professional recommendations for the medical waste disposal in accordance with the domestic legislation and the implementation of good practice and the best available EU techniques for medical waste management.

The goal of this Handbook is to offer basic information which will help carrying out the activities to reduce the amount of medical waste in health care institutions and the classification of waste to basic categories at the location of waste generation. Also, it will helpto carry out the proper packaging, marking and disposal as well as the use of cleaner technologies for the treatment of infectious medical waste and the proper final disposal of all waste categories. The ultimate goal is to contribute to environmental protection and to improve the health of the citizens of TC and B&H.

The application of Handbook in every day work of, primarily, health care institutionsand then all other institutions which provide health care, will give the contribution to:

Finding a unified approach to medical waste management and the establishment of safe system for medical waste management

• Improving the safety of health care users• Reducing the risks of spreading the infectious diseases• Reducing the other harmful risks from all types of medical waste • Reducing the amount of medical waste• Improving the environmental situation.

Good Practice Handbook provides information and recommendations related to:

• Definition of medical waste• Classification of medical waste• Health risks and risk assessment of medical waste• Legislation in B&H and International Legislation• Medical waste management in health care institutions• Training and education• Monitoring the quality of waste management• Handling of medical waste• The final treatment and disposal of medical waste

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2. MEDICAL WASTE

Waste is generated as a result of any human activity, including medical. The development of medical tech-nology has changed the amount and composition of medical waste. Medical and municipal waste is generated in health care institutions. Municipal waste is generated in patients’ rooms, kitchen and administration offices and contains: paper, carton, glass, cans, food leftovers and similar. Medical waste is generated from providing the medical services and presents a risk to health and environment. Therefore, the obligation of health care institutions and the entire community is to properly dispose the medical waste from the place of its generation to the final disposal.

2.1. Basic principles of medical waste management

The basic principles of medical waste management are:• Reducing the generation and amounts of medical waste;• Establishing the process of classification according to the ways of processing and disposing;• Proper management of the waste that threatens the human health;• Planning the activities related to medical waste management (making plan for medical waste manage-

ment for each health care institution);Managing the waste which does not endanger human health and the environment;• Organizing the processing and disposal of waste in the most appropriate manner in the framework of

the different waste processes;• Preparing or recovering the unarranged temporary or permanent waste storages;• Record keeping and documenting the activities related to medical waste management;• Monitoring indicators related to classification, disposal and treatment of waste;• Taking corrective measures in planning the activities on annual level;• Training employees for the jobs of separating, marking, packaging, disposing and treating medical

waste;• Motivating employees for the efficient medical waste management;• Raising awareness about the medical waste management;• Multidisciplinary collaboration for the purpose of editing systems for medical waste management, both

at the level of health care institution and on the territory of administrative county;

For good waste management practice it is vital that medical workers and associates know exactly what is expected of them in terms of waste classification. Also, they should be motivated and properly trained for these activities, as well as to have adequate cooperation with the administration of the health care institution on such matters.

2.2. Definition and classification of medical waste

According to the Regulations on medical waste management of the FB&H, medical waste is a waste gen-erated in health care institutions and covered by the Regulations on Waste Categories with lists. It is a waste generated in human and animal health protection and/or related research (excluding the waste from house-holds and restaurants which does not originate from immediate health care). Also, it is a waste generated in newborns’ care, diagnosing, treating or preventing diseases in humans.

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According to the EU Directive number 75/442/EEC in the European Waste Catalogue, waste is defined on the basis of the following three criteria:

1. Origin of the waste, i.e. defining industries or sectors from which the waste has generated (the first two numbers-the medical sector-18)

2. Process during which the waste is generated (the second two numbers-the waste generated in the provision of health services in maternity hospitals, diagnosing, treating or preventing diseases in humans-18 01)

3. Type of waste (the third pair of numbers-non-infectious waste-the waste whose collection and disposal is not subject to special requirements for preventing infections, 18 01 04).

According to the European Waste Catalogue, each type of waste has a classification number or its own code that consists of 6 digits (for example, 18 01 03). If certain categories of waste have an asterisk after the 6 digits, the asterisk indicates that this waste is hazardous waste (for example, 18 01 03*, infectious waste).

2.3. Categories of medical waste

Categories of medical waste used in B&H are based on the categorization form the European Waste Catalogue of EU Directive number 75/442/EEC. Bosnia and Herzegovina has signed the directive and defined by it the criteria and the catalogue of waste. The waste catalogue is a systematic review of the names of waste according to the characteristics and activities from which the waste originates and is an integral part of the Regulations on waste categories with lists. According to the European Waste Catalogue, medical waste is defined as a waste generated in the provision of health care in medicine and veterinary medicine (humans and animals) and/or related research and is filed under the number 18 00 00 with subsections.

Waste according to Directive (Controlled waste)

Waste that falls under the provisions of the Framework Directive of the European Union number 75/442/EEC and to which the later adopted amendments are related is called “Waste according to Directive”. “Waste according to Directive” includes:

1. Municipal solid waste (house waste or waste from households)2. Commercial waste (waste from commercial institutions, shops, offices, etc.)3. Industrial waste (waste from industrial activities)4. Waste from construction/demolition (originating from construction and represents the largest indi-

vidual source of controlled waste)5. Hazardous waste falls under the controlled waste which is considerate hazardous or difficult for stor-

age, processing or disposal.

Classification of medical waste according to the European Waste Catalogue

Section 18: waste generated in human and animal health protection and /or related research (excluding the waste from households and restaurants which does not originate from immediate health care) is filed under the number 18 00 00 with subsections.

Subsection 18 01: waste generated in newborns’ care, diagnosing, treating or preventing diseases in hu-mans.

Subsection 18 02: waste generated in provision of health care in veterinary medicine (waste from research, diagnosis, treatment or prevention of diseases in veterinary medicine).

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2.3.1. Hazardous Medical Waste

World Health Organization (WHO), has classified the hazardous medical waste in clinical and nonclinical. Clinical waste is divided into 7 different groups: pathological, infectious, pharmaceutical, chemical, sharp objects, aerosols and pressure vessels, and radioactive waste (Figure 1).

Hazardous medical waste contains toxic, harmful, carcinogenic and infectious substances. The waste from the institutions where healthcare is provided must be classified,at the point of generation, into hazardous and non-hazardous. Then, according to the characteristics and the place of origin it is divided into: pathological waste, infectious waste, sharp objects, pharmaceutical waste, chemical waste, pressure vessels and radioactive waste (Table 2).

FIGURE1. Classification of medical waste by World Health Organization

In Table 1, the Standard Classification of waste in accordance with Directive 75/442/EEC (Excerpt from the Waste Catalogue with described waste categories form the Regulations on Waste Categories with Lists, Official Gazette No. 9/05) is given:

Classification number Types, characteristics and activities from which the waste originates

18 01 Waste generated in the provision of health services in maternity hospitals, the diagnosis, treatment or prevention of diseases in humans

18 01 01 Sharp objects (except for 18 01 03)18 01 02 Body parts and organs, blood bags and blood cans (except for18 01 03)18 01 03* Waste whose collection and disposal is subject to special requirements to prevent infections.

18 01 04 Waste whose collection and disposal in not subject to special requirements to prevent infections (e.g.laundry, plaster bandages,linen, disposable clothing, diapers, cloth...)

18 01 06* Chemicals consisting of or containing hazardous substances18 01 07 Chemicals that are not listed under 18 01 0618 01 08* Citotoxics and cytostatics18 01 09 Medicines that are not listed under 18 01 0818 01 10* Amalgam waste from dental care

18 02 Waste from research, diagnosing, treatment and prevention of diseases in animals.18 02 01 Sharp objects(except for18 02 02)18 02 02* Waste whose collection and disposal is subject to special requirements to

prevent infections.18 02 03 Waste whose collection and disposal in not subject to special requirements to prevent infections.18 02 05* Chemicals consisting of or containing hazardous substances.18 01 06 Chemicals that are not listed under 18 02 05.18 02 07* Citotoxics and cytostatics.18 02 08 Medicines that are not listed under 18 02 07

Table1.Classification of medical waste according to the European Waste Catalogue

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Table 2. Categories of medical waste

Categories of medical waste Description

Infectious Laboratory cultures, fluids, materials and equipment in contact with infected patients

Pathological Blood and other body fluids, body parts, fetusesSharp objects Needles, scalpels, knives, broken glassPharmaceutical MedicinesGenotoxic Cytostatic, genotoxic chemicalsChemical Solvents, laboratory reagents, disinfectantsHeavy metals Batteries, blood pressure monitors, thermometersPressure vessels Gas bottles, metal containers

Radioactive waste Liquids used in radiotherapy, urine and excreta of patients treated with radio-nuclide.

Infectious waste contains pathogenic biological agents that, due to their type, concentration or number, may endanger human health. This type of waste includes culture and equipment from microbiological labo-ratories, also materials and equipment that came into contact with the blood or excreta of infectious patients or has been exempt during surgical procedures, bandaging wounds or autopsies. It also includes waste from the department for the isolation of patients, waste from the hemodialysis units, infusion systems, gloves and other disposable equipment, and also the waste that came into contact with experimental animals which were inoculated with infectious material.

Pathological waste consists of parts of the human body, amputates, tissues and organs removed during the surgical procedure, tissues taken for diagnostic purposes, placentas and fetuses, and the experimental animals and their body parts.

Sharp objects include needles, lancets, syringes, scalpels and other objects that may cause a puncture or a cut.

Pharmaceutical waste includes pharmaceutical products, medicines and chemical substances that have been returned from the department where they were spilled, squandered, prepared but unused or the expiration date has expired or they should be thrown out for any reason.

Chemical waste consists of discarded solids, liquids or gaseous chemical substances that are used in medi-cal, diagnostic or experimental procedures, cleaning and disinfection. It is dividedinto Hazardous with prop-erties of toxicity, corrosivity, flammability, reactivity and genotoxicity, and Inert Chemical Waste that has no listed properties.

Pressure vessels are bottles containing gases under pressure with different substances like antibiotic, dis-infectant, insecticide and otherswhich are applied in the form of aerosols. They may explode when exposed to higher temperature.

Radioactive waste is a solid and liquid waste contaminated with radionuclides from in vitro laboratory analysis of tissues and body fluids and also from in vivo diagnostic and therapeutic procedures that are gener-ally performed at the Departments of Nuclear Medicine. This category of waste is subject to special regula-tions. According to the World Health Organization’s definition, two more categories have been added to the above mentioned division of Hazardous medical waste: genotoxic waste and waste with high concentration of heavy metals.

Genotoxic waste has mutagenic, teratogenic and carcinogenic effects. This group of waste includes cyto-static which is mostly used in Oncology, in cancer chemotherapy, as immunosuppressant in transplantations, radiotherapy and other branches of medical science. This group also includes other genotoxic chemicals and radioactive materials, packaging and other contaminated materials, as well as the body fluids (urine, feces, vomit) of patients treated with chemotherapy. In specialized oncology hospitals this type of waste can even make up to 1% of the total amount of generated medical waste.

Waste with high concentration of heavy metals is a subcategory of Hazardous medical waste. This waste includes mercury mostly generated from amalgam filling-the waste from dental ordinations and/or broken medical equipment. In the disposed batteries there are cadmium, lead and arsenic.

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3. HEALTH RISKS OF MEDICAL WASTE

The contamination that comes from health care institutions is specific and can be very dangerous both to the health of people who work in health care institutions and to the health of the environment, i.e. the popula-tion and ecosystem where the waste is stored. The largest producers of medical waste are major health care institutions, i.e. clinics, health centers, in-patient clinics, diagnostic laboratories, centers for transfusion and dialysis. Smaller producers are smaller health care units such as family medicine clinics, specialist clinics and dental clinics.

All persons who may come into contact with medical waste are exposed to potential health risks, namely:

• Medical personnel: doctors, nurses, other medical and non-medical workers in health care institutions;• Patients in and out of health care institutions and their visitors;• Employees of public community utilities that handle and transport the waste;• Employees in landfills and people searching through waste;• The population and especially children if they play with objects that can be found in the trash outside

of health care institutions.

By introducing and implementing the adequate procedures to minimize the risks of medical waste, the population’s health is protected and the impact on the environment is reduced. The first step in the manage-ment system is to identify potential risks. Possible routes of transmission are:

• Direct contact• Contact with the vectors• Aerobic transmission• Polluted water• Polluted environment

3.1. Professional and Public Health Risks

In the process of handling the medical waste, medical and non-medical workers are exposed to the risks, primarily of harming themselves if the used sharp objects are not safely packed. World Health Organization estimates that, due to inadequate handling of medical waste, around 20 million people per year get infected with hepatitis B or C and HIV. Also, those who search through the wastes in containers and in the landfills are exposed to these risks. Population may be exposed to the risks of medical waste in a direct and indirect man-ner, through different ways of contamination:

• Inhalation• Penetration through the skin• Ingestion

Disposal of the medical waste in the environment should not be conducted in unsupervised manner, be-cause it can have a direct negative effect on the soil and underground waters. One of the main tasks of medical waste management is the identification of risks to public health and the environment. Figure 2 shows the rela-tions between the cause and consequences of inadequate medical waste management.

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Figure2. Relations between the cause and consequences of inadequate medical waste management

BASICCONDITIONS

FULFIELLDCONDITIONS

PRACTICALIMPLICATION

EXPOSURE EFECT ONHEALTH

3.1.1. Risk of infectious waste

Medical waste management is an integral part of hospital hygiene and infection control. The medical waste should be considered as a reservoir of pathogenic microorganisms, from which they could, if waste is handled inadequately, be further transmitted and causecolonization or even infection in sensitive persons. Routes of transmission are direct contact, air or different vectors. In this way, the infectious medical waste presents a risk for the development of hospital infections (nosocomial, intrahospital) in both, health care professionals and patients.

Around 80% of hazardous medical waste is infectious, i.e. hazardous medical waste which contains and/or may contain microorganisms that can cause illness in humans and animals. It is consisted of cultures and items from microbiological laboratories, equipment, materials and equipment that have been in contact with blood and other fluids of infectious patients, and also dialysis waste and waste from all other interventions on patients. This waste can be a source of all kinds of infections (respiratory, skin, gastrointestinal, urinary, and also infections that can be transmitted through blood and other body fluids).

Risks coming from blood and other body fluids

The proper handling of medical waste is of a particular importance for the development of infections that can be transmitted through blood and other body fluids. At risk of developing this type of infections generated in health care institutions are, first of all, medical workers as well as other employees in these institutions, but also the patients. The risk contact for the infections transmitted through blood and other body fluidsis every contact of the sensitive person’s skin which has no continuity (needle stick, laceration) and mucous membrane (eyes, mouth, nose) with blood and body fluids containing microorganisms.

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In addition to the direct contact with an infected person and his/her body fluids, the indirect contact with objects, primarily different medical equipment contaminated with blood and other body fluids, is also very important. One of the most risky indirect contacts is percutaneous injury (PI). Percutaneous injuries include two basic types of injuries: injuries by needles used in the treatment and diagnosis, and injuries on sharp ob-jects (scalpels, glass, etc.).

According to the frequency and risks of spreading the infections caused by percutaneous injuries (PI) that daily threaten the health care institutions, the most important infections are caused by three microorganisms: hepatitis B (HBV), C (HCV) and HIV. The risk of getting the infections that they cause in health care institu-tions depends on both, the application of recommended effective measures of prevention, and the prevalence of infections in the population and the probability of inoculation of microorganisms during the risky contact.

The Hepatitis B Virus (HBV)

Even though the prevention of Hepatitis B in most countries of the world is nowadays legally regulated by obligatory vaccination of employees in health care institutions, it should be noted that there is still a number of people who refuse to apply this measure of prevention of Hepatitis B, so they are at risk of infection. This is a highly contagious infection because of the high concentration of HBV in peripheral blood of infected persons. Besides blood, the contact with these body fluids carries a high risk for infection, and those are: saliva (es-pecially during the dental procedure), cerebrospinal, peritoneal, pleural, pericardial, amniotic, synovial fluid, sperm, vaginal fluid and any other fluid that contains visible blood, as well as the organs and tissues which have not been appropriately prepared for pathohistological examination. Inadequate disposal and treatment of these body fluids and tissues as medical waste, increases the risk of HBV infection to both, employees in health care institutions and to patients, but also increases the risk for epidemic spread of the disease in both populations.

Exposure to urine, feces, nasal secretions, tears, sputum or vomit, carries a minimal risk of infection if they are not contaminated with blood. HBV is stable up to 7 days in dried drops of blood, therefore the contact with inanimate environment contaminated with blood containing HBV is also a risk of infection, and it is typical of the hemodialysis units. The risk of infection of sensitive employees in health care institutions after the per-cutaneous exposure to the blood of HBV infected patients who are HBsAg positive is 6 to 30% and the risk is highest in the case that the patient is HBeAg positive providing that post-exposure prophylaxis is not applied.

The Hepatitis C Virus (HCV)

The hepatitis C virus is transmitted by single exposure to large quantities of infected persons’ blood (the transfusion by untested blood and blood products), or by repeated direct percutaneous exposures to smaller quantities of infected persons’ blood, as in the case of intravenous drug users. Furthermore, the infection through saliva (exposure in the bite) and through the exposure toconjunctiva of blood of infected persons are described. Data from different parts of the world indicate that seroprevalence of persons employed in health care institutions follows the prevalence of the population in the region. Therefore, in the USA, 1 % of medi-cal workers are infected with HCV. Prospective studies indicate that the risk of infection after a percutaneous injury (PI) on HCV positive source is 1.8% (0-7%). For the occurrence of HCV infection, the importance of injury on needles with the hole is emphasized.

Human Immunodeficiency Virus

The first case of transmission of this virus from the patient to the medical worker was recorded in 1986. To December 2001CDC has registered, on a basis of voluntary reporting, 57 documented and 138 probable infections with HIV in employees of health care institutions in the USA. HIV is 100 times less contagious than

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HBV. After the percutaneous injury (PI) of those employed in health care institutions, the prospective studies have shown that the risk of infection development is 0.3%. The retrospective anamnestic study conducted on medical workers who had percutaneous injuries (PI) on HIV positive sources, has shown that the risk factors for development of infection were: depth of injury, the presence of blood on the needle, the procedures involv-ing the placement of a needle into an artery or vein, and the terminal disease of a patient who is the source. Exposure of mucous membranes to blood and body fluids is associated with the risk of developing HIV infec-tion from 0.09%.

Percutaneous injury epidemiology

Data obtained on the basis of injury surveillance of employees in the health care system of the USA (Na-tional Surveillance System for Health Care Workers-NaSH) describe the epidemiology of percutaneous injury (PI). At the greatest risk for percutaneous injury (PI) are nurses, and therefore for the infections transmitted this way. Also, at risk are the employees in health care institutions who are involved in the care and treatment of patients (medical doctors and other medical technicians), the staff working in biomedical laboratories and the staff providing logistical support to diagnosis and treatment (e.g. services responsible for hygiene in health care institutions). These are the target groups for training in the area of proper handling of medical waste. Regularities are also observed in relation to the place of occurrence of percutaneous injuries (PI). Although they can occur in all parts of health care institutions, the majority, about 40%, occur in those parts where treat-ment and care of patients are provided, 21% in the departments where patients were hospitalizes and 13 % in the departments of intensive care and treatment. 25% of percutaneous injuries (PI) happen in the operating rooms. CDC data indicate that, according to the time of occurrence, percutaneous injuries (PI) usually occur immediately after the use and before the disposal of needles and sharp objects (41%), then during the immedi-ate performing of a certain procedure (39%) and during and after its disposal (16%). All the above mentioned indicates that the risk of development of infections transmitted through blood and body fluids is in direct con-nection with the medical waste handling in health care institutions. Therefore, the measures to prevent these infections should be established on defining all the procedures in this area.

3.1.2. The risk of chemical and pharmaceutical waste

Many of the chemicals and pharmaceutical products used in health care can be of risk to health (toxicity, genotoxicity, carcinogenicity, etc.). Employed in pharmacies, laboratories and anesthesiology departments are at the risk of respiratory and skin diseases due to exposure to gases, aerosols and solvents. Sporadic cases of injury or poisoning by chemicals and pharmaceutical products are mainly the consequences of inadequate handling, so the use of less toxic products, the strict compliance of the procedures for use and the adequate protective measures are recommended. Cytotoxic substances present a special risk, so the health care institu-tions that use them are obligated to make special instructions for handling the waste containing traces of these substances. Many cytotoxic substances are extremely irritating and can have a local effect in direct contact with the skin or eyes. They can also cause dizziness, headaches or dermatitis.

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4. RISK ASSESSMENT

The risk assessment is a very important factor in determining the potential dangers of medical waste. Risk management means taking preventive measures and procedures, also the preparation for the incident and the response to it, as well as improving the current situation in order to reduce the risk and to create the conditions under which the risk is acceptable. Only the risk that can be managed is an acceptable risk, i.e. the risk which implies that the possible consequences to human health and material goods are within the limits of acceptable. Within legislation, both in the domain of health and medicine and in the domain of environmental protection, there is a need for a risk assessment by all parties involved in the management of medical waste.

4.1. Risk assessment in the context of medical waste

The purpose of conducting the Risk assessment procedure is to help finding rational decisions with a goal to protect the environment and public health. It is important that the assessment is done actively and with re-flection, instead of merely circling the given answers. In order to conduct the risk assessment it is necessary to take into consideration the hazards as well as the risks.

HAZARD is something that could potentially cause damage.THE THREAT caused by hazard describesTHE NATURE OF THE DEMAGE that could occur. RISK presents the combination of the assessment of threat severity and the probability (the degree to which

it is probable) that these threats will be realized.

Therefore, the risk assessment is a process in which:• Hazards are identified;• The threats associated with it are identified and assessed;• Risks are assessed;• The importance of these risks in the discussed circumstances is assessed;• The results of the risk assessment should be regularly noted, i.e. recorded.

4.2. Five steps in risk assessment

The following five steps are taken when assessing the risk:

STEP No1: Identify hazards.STEP No2: Determine who/what might be damaged/injured and how;STEP No3: Assess the risks and decide whether the existing measures of precaution are adequate oradditional measures should be taken;STEP No4: Record the conclusions and results of the assessment;STEP No5: Check the assessments made.

Step No1: Identify hazards

• Identify which substances or forms of biological agents are present;• Identify all present biological hazards;

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Table 3. The table of seriousness

• Identify the required categories of restriction;• Assess the existing measures for limiting the hazards;• Collect information about the characteristics of the hazards.

The hazards of medical waste include:• The infectious nature of waste;• Sharp objects or blades, glass bottles, etc.• The aggressive nature of waste.

Step No2: Determine who/what might be damaged or injured and how

Different groups of individuals might be potentially exposed to the hazards. Those groups include:• Young and inexperienced workers, interns, mothers after returning from maternity leave and pregnant

women;• Personnel in laboratories, workers who transport the waste;• Auxiliary workers who handle the waste, workers at landfills, the general population, the environment

in general;• Cleaners, visitors, workers in maintenance services who are not constantly at their work places;• And the others.

It is important to emphasize that not everyone found in the health care institutions where medical waste is generated, has the adequate knowledge of the potential dangers of it, nor will any such person act in the same way. For example, among the members of the general population who have access to the waste, one can find people with special needs who have difficulties in receiving new information, as well as patients who suffer from drug addiction and therefore may behave in different way.

Step No3: Assess the risks and decide whether the existing measures of precaution are adequate or additional measures should be taken

Quantitative risk assessment may be obtained by determining the probability of occurrence for each indi-vidual hazard, and then multiplying the obtained value with the measure of seriousness of probable conse-quences. These factors can be expressed quantitatively (numerical values) or qualitatively (descriptive), as shown below in Tables 3, 4 and 5.

Assessment Qualitative description Seriousness

1. InsignificantNo injuries or damages; Only for the

cases in which the damage was narrowly averted.

2. ModerateInjuries that can be sanitized by first aid; Less serious illnesses and small number

of losses.

3. Serious Injury or illness that requires the short sick leave. Significant damage or losses.

4. Very serious Very serious accidents; disability, big damages or losses.

5. Catastrophic One or more casualties; catastrophic losses.

The results of the risk assessment may show that a particular risk is unacceptable and that it is necessary to reduce it by applying the methods of control before proceeding further activities.

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Table 4. The risk matrix1

1 Colors used in this table do not match the color scheme which marks the flows of the medical waste.

Probability Seriousness1 2 3 4 5

5 Certain 5 10 15 20 254 Highly likely 4 8 12 16 203 Probable/Likely 3 6 9 12 152 Unlikely 2 4 6 8 101 Almost Certainly Not 1 2 3 4 5

Priority risk Description Risk assess-ment

Unacceptable risk

Work should not begin or if it has already begun, it should be stopped immediately. If this risk is impos-sible to reduce even with unlimited resources, the work must be permanently banned.

HIGH

25

Significant risk

Work should not begin until the risk is reduced. It is possible that in order to reduce the risk the signifi-cant resources would be required. If the work is in progress, consider stopping all the activities without delay.

20

Moderate risk

Try to reduce the risk, but the cost of prevention should be measured and limited. All measures for reducing the risk should be applied within defined period of time.

MEDIUM

13-16

Moderate risk

In the cases where the risk is associated with ex-tremely harmful consequences, further assessment is necessary in order to accurately determine the probability that there will be a hazard as a basis for determining whether there is a need for improved control.

8-12

Tolerable risk

No need for additional control. Consider solutions which are cost effective and efficient, or measures for improvement that do not require additional costs. Continue monitoring to ensure that the con-trol measures are implemented.

LOW2-6

Trivial risk Does not require any action. 0-1

During risk control it is necessary to apply the following principles:• Select the options that carry a lower risk (completely remove the risk, e.g. use the safe needles with

self-protection).• Prevent access to the source of hazard (providing the storage facilities for hazardous waste-radioactive,

infectious, chemical, cytostatic medical waste);• Organize work activities so as to reduce the exposure to hazards (e.g. use the containers with wheels

for infectious waste, prevent access to people who do not receive health care services in areas of health care institutions where health care is provided);

• Ensure the use of personal protective equipment;• Provide incentives (for example: equipment for washing containers in order to eliminate contamination,

then first aid, etc.);• Vaccination of employees against Hepatitis B, post-exposure prophylaxis and other measures for the

prevention of diseases transmitted through blood.

Table 5.

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Step No4: Recording procedures and activities

Although the conclusion of the risk assessment can be based on the professional opinion of the persons con-ducting the assessment, it is important to emphasize that each assessment is based on evidence and records on adequately conducted risk assessment. Procedures and records should be very simple in order to provide the written notes easy to follow. The appropriate manner of keeping the written notes is the one which allows the person who conducts the assessment from a third side/party to follow the decision-making process. The risk assessment should be conducted by people with the right qualifications and experience, i.e. a team consisted of such persons.

Step No5: Check the self-assessment and revise it if necessary

It is necessary to check the risk assessment in the following cases:• If new substances, equipment or procedures cause new hazards;• If there are significant changes in the nature of work or in the way the procedures are conducted;• Periodically to ensure that the existing procedures are still effective.

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5. LEGISLATION

5.1. Legal framework of medical waste management in B&H

Management of medical waste which by its characteristics can be hazardous and/or inert is, in B&H, regu-lated by entity and cantonal laws and sub law acts. Both Entity Framework Laws on Waste Management (of Republika Srpska and the Federation of Bosnia and Herzegovina) require the treatment of medical waste as a priority.

In accordance with the Regulations of RS and of the FB&H on medical waste management, there is a need for:

• Separation of medical from other types of waste,• Separated and supervised disposal of waste• Proper packaging, marking and handing over of the waste materials to authorized carrier,• Treatment and disposal in order to eliminate hazards, and• Collecting data about types and amounts of produced medical waste.

The legislation aims to ensure that:1. The hazardous waste is treated and disposed in a legal and environmentally accepted manner, and2. To reduce the risks to human health.

The Legislation for waste management in FB&H consists of: the Law on Environmental Protection (Offi-cial Gazette of FB&H 33/03), the Law on Waste Management (Official Gazette of FB&H 33/03), Regulations which determine the handling of hazardous waste not found on the list of waste or whose content is unknown (Official Gazette FB&H 33/03), Regulations on medical waste management (Official Gazette FB&H 33/03), Regulations on waste categories with lists (Official Gazette FB&H 9/05),Regulations on the necessary condi-tions for the transfer of obligations from the producers and sellers on the system operator for the collection of waste (Official Gazette FB&H 9/05), Regulations on the content of the adaptation plan for waste management for the existing treatment facilities or waste disposal and activities undertaken by the competent authority (Of-ficial Gazette FB&H 9/05), Regulations specifying the handling of hazardous waste that is not found on the list of waste or whose content is unknown, Regulations on the management of packaging and packaging waste, Regulations on the form, content and the process of notifying of the relevant characteristics of the product and packaging by the manufacturer (Official Gazette FB&H 8/08), Rules that regulate the reporting obligation of operators and manufacturers of waste on the implementation of the programs of supervision, monitoring and record keeping according to the conditions of permit (Official Gazette FB&H 31/06) and the Rules on finan-cial guarantees which can ensure the trans-border movement of waste (Official Gazette FB&H 41/05).

5.2. International legislation

5.2.1. The EU Directive

The basis of the politics of waste management in the European Union are found in the European Coun-cil Resolution on the waste management strategy (97/C76/01) based on the Framework Directive on waste (75/442/EEC) and other Regulations on waste management in the EU.

Five basic principles have been determined and those are:• Hierarchy of waste management• Self-sustaining facilities for disposal• Best available technology• Proximity of waste disposal and• Responsibility of producers.

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Alongside the mentioned, certain attempts are made to the following principles: a common definition of waste in all countries members of the EU, encouraging the cleaner production and the use of cleaner products, encouraging the use of economic instruments, regulation of waste transportation, as well as the environmental protection and internal market.

The EU legislative framework which includes safe waste management and health protection and safety is defined by the following rules:

1. Directive 75/442/EEC on waste (Framework Directive)2. Directive 99/31/EC on waste landfills3. Directive 94/62/EC on packaging and packaging waste4. Directive 96/61/EEC on integrated prevention and control of pollution5. Directive 97/11/EC on the assessment of the effects of certain public and private projects on the envi-

ronment which amends the Directive 87/337/EEC6. Directive 2001/42/EC on the assessment of the effects of certain plans and programs on the environ-

ment7. Directive 91/689/EEC on hazardous waste amended by Directive 94/31/EC8. Directive 2000/76/EC on waste incineration9. Directive 94/67/EC on hazardous waste incineration10. Directive 89/369/EEC on the reduction of pollution from new municipal facilities for waste incinera-

tion and Directive 89/429/EEC on the reduction of pollution from the existing municipal facilities for waste incineration

11. Directive 2004/37/EC on the protection of workers from the risks related to the exposure to carcinogens or mutagens at work place

12. Directive 2000/54/EC on the protection of workers from the risks related to the exposure to biological substances at work place

13. Directive98/24/EC on the protection of the health and safety of workers exposed to risks of chemical substances at work place

14. Regulation 259/93/EEC on the supervision and control of waste shipments within the countries mem-bers of the EU, and also when entering and exiting those countries

15. Regulation 2150/2002 on waste statistics

5.2.2. Basel Convention

Basel Convention on the Control of Trans-border Movement of Hazardous Waste and Its Disposal (1989) is one of the most important internationally accepted legal acts in the field of hazardous waste management, which, among other things, regulates the trans-border movement and disposal of medical waste (as a type of hazardous waste). The agreement was signed by over 100 countries, which have accepted the principle that the only legitimate transport of hazardous waste is the export from the countries which do not have facilities or qualified personnel for reliable waste disposal to the countries which have both, the facilities and the quali-fied personnel.

5.2.3. Adjustment to the International law

Existing legislation does not cover all aspects of medical waste management and does not give the recom-mendations for the treatment of specific waste streams, which is also the medical waste. Its compliance with the European Directive and international standards is necessary and it implies a clear defining of hazardous medical waste and its different categories, the introduction of the system of integrated management (separation, col-lection, storage, handling, treatment, disposal, transport), and also the record system, the principle of legal and financial responsibility of waste generators, and the inspection system which will ensure the effective imple-mentation of the law and penalty provisions. Furthermore, medical waste management must be in compliance with other relevant laws relating to waste management in general, the impacts on public health and the environ-ment, air quality, prevention and control of infectious diseases and the management of radioactive substances.

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6. MEDICAL WASTE MANAGEMENT IN HEALTH CARE INSTITUTIONS

Proper medical waste management largely depends on the good administration and organization, but also requires appropriate legislation and finances, as well as the active participation of trained and informed per-sonnel. Health care institutions impose their own waste management which contains four basic aspects: legal, economic, organizational and technological.

6.1. Participants in the process of medical waste disposal

• Medical employees in direct work process of identifying, classifying, disposing and packaging of waste at the place of generation (doctors, medical technicians, nurses-technicians, laboratory technicians, phar-maceutical technicians, etc.);

• Maids and the employees working on transport in the part of the procedure when waste is collected and transported to the place of the secondary storage, and in the part of the procedure when the initial and the secondary storages and reusable containers for waste collection are cleaned and disinfected;

• Technical staff for the technology of processing and treating the waste within the institutions;• Facilities that take waste for the final disposal on the basis of the contract.

6.2. Persons and bodies responsible for the organization and internal supervision

Persons and bodies responsible for the organization and internal supervision over medical waste disposal in the institutions are:

• Director/Head of the institution providing conditions for the protection of employees and the environ-ment and for the implementation of the whole Plan of medical waste management;

• Personnel officer (medical waste technician, supervisor for medical waste or medical waste manager, depending on the institution) for waste management and the obligations regulated by the Regulation on medical waste management;

• Committee for medical waste management and the obligations regulated by the Regulations on medical waste management;

• Commission for the infection control and the team for the infection control andmonitoringof a disposal of medical waste (infectious. pathological and sharp objects);

• Hygienic and epidemiological services for the hygienic and epidemiological monitoring over all proce-dures with waste on the basis of the Plan for medical waste management, quality control, collection and analysis of data and reporting;

• Head nurses-clinical/polyclinic technicians, the Head pharmaceutical technician of the hospital phar-macy for periodic monitoring;

• Responsible nurses-department technicians and pharmaceutical technicians of clinical pharmacies for organizing the collection, classification, disposal of waste and continuous monitoring.

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6.3. Management structure, coherence and responsibilities

Head of the health care institution appoints the personnel officer for waste management and forms a com-mittee/team which should make a plan for waste management. According to the Regulations on medical waste management, the head of the health care institution which employees more than 50 employees is obligated to appoint committee for waste management. The head of the health care institution, the personnel officer for waste management and personnel officer for the prevention of infections must be appointed in the Committee for waste management. Larger health care institutions should have a larger number of members in the Com-mittee. The structure of the Committee reflects the actions of the institutions. Members of the Committee for waste management should be: director of the institution, heads of departments, personnel officer for infec-tion control, head of the pharmacy, personnel officer for radiation, head nurse, health care manager, sanitary and environmental engineer, head of finance, health and safety engineersat their workplace, personnel officer for waste management as well as other persons depending on the size of the health care institution and types of health care activities. This structure can be adapted to any health care institution. In smaller health care institution one person can carry more responsibilities but the same principle will be applied. The Committee for waste management is responsible for medical waste management in health care institution according to the Regulations. The Committee for waste management meets at least once every six months to review the application of the systems for medical waste management in accordance with the Regulations and in order to undertake necessary actions.

The Committee for medical waste management has the following authorizations and responsibilities:

1. Identify and classify all the medical waste2. Prepare a Plan for waste management3. Organize the disposal of waste in special containers and to storage it in a temporary storage area. 4. Ensure the proper waste disposal5. Organize waste disposal as closer to the place of generation as possible6. Take the highest security measures in case of a need.

Head of the heath care institution appoints a personnel officer for the waste management who will moni-tor and coordinate the Plan for waste management. Personnel officer for waste management responds for the conduction of his/her obligations to the Committee for waste management i.e. to the Head of health care institution. Name of the personnel officer for the waste management is given to the Minister of Health of the Canton on which territory the health care institution is located. The obligations of the personnel officer for the waste management are:

• Preparation and adaptation of the Plan for medical waste management in the institution;• Supervising the implementation of the Plan for waste management and the points of Regulations;• Provide training for medical workers of the health care institution for the medical waste management;• Organize the transport, disposal or recycling of the waste that meets the needs of the management of

waste produced in the health care institution;• Keeping records on medical waste management;• Launching initiatives to reduce the amount of waste produced.

It has been proved as a good practice, for all the health care institutions which produce more than 500 kilo-grams of hazardous waste per year, to appoint at least one person responsible for the waste management. In any department/service of a health care institution it is necessary to appoint personnel responsible for medical waste management, in order to help the person responsible for the medical waste management. Those persons will regularly monitor and report on waste management in a department.

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6.4. Development of the Plan for waste management

On the basis of Article 3 of the Law on Waste Management (“Official Gazette of FB&H”, No 33/03 and 72/03) and the Regulations on medical waste management (“Official Gazette of FB&H”, No 77/08) Article 5 of the Regulations for medical waste management is conducted on the basis of the Plan for waste management. The health care institution is obligated to develop a Plan for medical waste management within two years from the date when Regulations entry into force. The Plan for medical waste management must be in compliance with the Cantonal Plan of waste management. Plan for medical waste management is approved by the Can-tonal Ministry of Environment. According to the Article 11 of the Regulations on medical waste management (“Official Gazette of FB&H” 77/08), each health care institution should develop a plan for medical waste management which must contain:

1. Description of different types of waste in accordance with the waste categories produced in a health care institution;

2. List of departments of health care institutions where medical waste can generate;3. Give a description of the type of medical waste for each department of the institution and for each type

of waste specify the procedures to be followed in relation to:- Detailed description of containers where waste will be disposed, including the color of the container,

cover and characteristics, and- Details of the disposal of containers at the facilities for medical waste treatment within the health care

institution.4. Procedures for moving waste from the treatment facilities to the central waste storage;5. Procedures for storing the waste in the central waste storage;6. Emergency procedures in case of waste spillage.

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7. TRAINING AND EDUCATION

Head of the health care institution is obligated to ensure that every worker of the health care institution is included in the training and education program with the aim of raising awareness about the medical waste treatment, and familiarization with the principles and practices of the systems for medical waste management in the health care institution.

7.1. Attitudes about waste management

Changing the level of information, knowledge, skills and attitudes about handling medical waste is a condi-tion for quality handling and disposal of medical waste. Improving the proper handling and disposal of medi-cal waste is a way of preserving and improving public health and every member of community has a right to be informed about potential risks to health.

The goals of public education on medical waste are as follows:

1. Prevent exposure to medical waste and exposure to health risks2. Raise awareness and encourage responsibility among patients and visitors of health care institutions in

relation to hygiene and medical waste disposal.3. Inform the public about the risks related to medical waste by focusing on people who live nearby or who

visit the health care institution, and also families of the patients treated at home and the collectors of waste at landfills.

One very important goal of informing about medical waste is the motivation of medical personnel to adapt a good practical approach to waste management. Employees should be encouraged and stimulated to follow the good practiceof waste management in the way that it will be presented in a positive manner and as a con-tribution to more qualitative and safer working environment. Positive and negative attitudes in relation to good practice of waste management are always under strong influence of those people in positions and who define the politics of waste management of one health care institution, i.e. who decide how to allocate the resources. Therefore, it should be noted that employees at all levels should be given only concise and relevant informa-tion relating the medical waste management. Adequate training is necessary for all personnel responsible for waste management in each health care institution.

7.2. Identifying the needs for training and education of employees

The nature and scope of training and education of personnel regarding the waste management will evident-ly be different and will depend on the position and responsibilities of individuals concerned. In some cases, the instructions should only affect the employees to become aware of their responsibilities in monitoring the waste management, while in other cases, the instructions will be practical and focused on specific tasks. Given that the majority of employees sees the waste management as some less important activity, the training and education of those employees should be focused on practical advice that include the following:

1. Responsibilities and tasks-what is expected of them;2. Where they can get advice and help;3. What they need to do for their own safety and the safety of patients, other personnel and of the environ-

ment.

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Training should include:

a. Managers in this business on several levels, directors, including also technical managers;b. Doctors, nurses and employees of microbiological and biochemical laboratories;c. Medical personnel working in field service;d. Dentists and auxiliary dental personnel.e. Personnel engaged in the transport of waste within the health care institutions, as well as between the

health care institutions and treatment facilities or waste disposal,f. Employees working on collecting and disposing the waste.

The number of employees involved in the training may make the transfer of information a bit difficult. Printed material (Figure3) in the form of recommendations for waste separation (a poster) is a very useful reminder of good practice in every day work on the segregation of the waste. Doctors and heads for medical waste management should encourage and require appropriate forms of training on medical waste management from official institutions. Training and education on medical and municipal waste management is conducted by multidisciplinary team by the program determined by the Committee for waste management. To conduct the training of certain categories of employees, firms that take waste form the institutions may be engaged if they set their packaging. The presence at the trainings is recorded and at the end of each training in order to assess the acquired knowledge employees do a test.

Program of training and education:

1. Management of medical waste management, legislation, responsibilities and obligations.2. Types of medical waste, definition in accordance to the categories of waste produced in health care insti-

tution.3. Classificatio, marking, disposal at the place of generation and the records of disposal.4. Transport, temporary storing and final disposal of medical waste.5. Health risks of medical waste6. Risk management of diseases transmitted by blood.7. Monitoring the quality, collecting data, analysis and reporting.8. New global trends in the medical waste management.

Slika 3 Štampani materijali za informisanje osoblja

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8. MONITORING THE QUALITY OF WASTE MANAGEMENT

After the adoption of the Plan for waste management and its implementation in health care institutions, the next step is the control and assessment of the quality of waste management.

This type of control will include:

1. Supervision of the management for waste management2. Assessment of the quality of medical waste classification.3. Assessment of the quality of internal transport.4. Assessment of the place of decentralized and central storing of waste.

Control and assessment of quality is conducted by using forms consisting of tables shown in the following Tables 6 and 7.

Documentation and administration Comments Available

Waste management plan YES/NOWaste management strategy YES/NOProcedures for certain types of waste YES/NOContracts with companies that take over the waste YES/NORecords and reports on the types and quantities of waste YES/NOKeeping record on accidental stabs YES/NOForms for reporting the cases of needle stabs YES/NODate of the last recorded accident YES/NOForms for reporting the accidents and unfortunate accidents YES/NO

Protocol, procedure and reports on vaccination against Hepatitis YES/NO

Is there a budget for disposable materials(bags, contain-ers for sharp objects,etc.)? YES/NO

Is the procedure for ordering and distributing the dispos-able materials determined? YES/NO

Table6. Supervision of the management for managing the waste

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Collection and separation of medical waste Comments AssessmentIs waste properly classified at source? 0 1 2 3 4Is the packaging adequatively placed at the point of generation of waste? 0 1 2 3 4

Is the packaging with the proper color and hazard markings for certain types of waste (sharp objects, infectious waste, pharmaceu-tical, chemical, cytostatic) used?

0 1 2 3 4

Is the transfer of waste recorded? 0 1 2 3 4Are the places of collection of the waste identified and organized? 0 1 2 3 4

Are the places of collection of the waste well marked and organized and are the containers well marked?

0 1 2 3 4

Are the places of collection of hazardous waste out of the reach of the general popula-tion?

0 1 2 3 4

Is the system for collection of waste in the packaging with the appropriate color for certain types of waste used at the places of collection?

0 1 2 3 4

Are employees who handle the waste carry-ing the personal protective equipment? 0 1 2 3 4

Are the employees who handle the waste familiar wih the procedure in case of the waste spillage?

0 1 2 3 4

Are the employees who handle the waste familiar with the risks of injuries by sharp objects?

0 1 2 3 4

Are the containers clean and is the system for maintenance established? 0 1 2 3 4

To assess the quality of the collection and classification of waste the questions from the Table7 are used and the quality is assessed with grades from 0 to 4.

To assess the quality of the collection and sorting of waste, the rules from Table 8 are used:

Table 7. Assessment of the quality of medical waste classification

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Complete compatibility (100%)

Almost complete compatibility (80%)

Generally accepta-ble-some problems

identified (60%)

Noticeably large problems, changes

necessary

Unacceptable con-dition, necessary to take measures

without delay4 3 2 1 0

Complete classification and a

high quality of sorting

Small problems-waste is properly

sorted.

Waste is generally well sorted.

The basic classification to risky and risk-free waste.

The basic classifica-tion, but there are errors in sorting.

Internal transport Comments AssessmentHow is the hazarodus waste trans-ported from the place of collection to the place of temporary or final

storage?

0 1 2 3 4

Do employees who carry out this function wear personal protective

equipment?0 1 2 3 4

Are employees who carry out this function familiar with the procedures

in case of spillage?0 1 2 3 4

Are employees who carry out this function aware of the risks of sharp

objects?0 1 2 3 4

The questions from the Table 9 are usedto assess the quality of internal transport of waste, and the quality is graded from 0 to 4. For the quality assessment the following rules are used:

Grade 4 - Complete compatibility (100%)- The use of proper PPE, the adequate transport packaging, com-plience with the regulatory instructions during the transport, marking with proper color and label.

Grade 3 - Almost complete compatibility (80%), small problems- the use of proper PPE, the adequate transport packaging, complience with the regulatory instructions during the transport, marking with the proper color but without label.

Grade 2 - Generally acceptable-some problems identified (60%)- the use of proper PPE, the adequate transport packaging, complience with the regulatory instructions during the transport, but there is no color mark of the label.

Grade 1 - Noticeably large problems, changes necessary- No plan, no clear instructions, bad practice.

Grade 0 - Unacceptable condition, necessary to take measures without delay- Weak or nonexisting internal transport with poor equipment and infrastructure.

Table 8. Assessment of the quality of collection and sorting of waste

Table 9. Assessment of the quality of internal transportation

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Storing Comments AssessmentAre the places of decentralized stor-

ing clearly marked? 0 1 2 3 4

Do places of decentralized and central storing meet the purpose

(are they easily disinfected, is there enough space, etc)?

0 1 2 3 4

Do containers in decentralized and central storages meet the purpose (are they marked by color, are they

labeled, do they have corresponding structure, etc)?

0 1 2 3 4

Is the place of decentralized and central storing regularly cleaned

and disinfected? Is there adequate evidence about that?

0 1 2 3 4

What is the frequence of waste col-lection from the decentralized into

central place of storing? 0 1 2 3 4

Do employees perfoming this func-tion wear personal protective equip-

ment?0 1 2 3 4

Are the employees perfoming this function familiar with the protocols in

case of spillage?0 1 2 3 4

Are the employees performing this function aware of the risk od sharp

objects?0 1 2 3 4

Questions from the Table 10 are used to assess the quality of the place of decentralized and centralstor-ing, and the quality is graded with 0 to 4. For the assessment of the quality the following rules are used:

Grade 4 - Complete compatibility (100%)- Complete separation and a high quality classification with es-tablishement of decentralized and central storages that are secured, labled and cleaned.

Grade 3 - Almost complete compatibility (80%), small problems – waste is properly sorted with establishe-ment of decentralized and central storages that are secured, labeled and cleaned.

Grade 2 - Generally acceptable-some problems identified (60%) – Waste is mostly classified, containers may be filled, and the decentralized and central storages may seem untidy.

Grade 1 - Noticeably large problems, changes necessary- Basic classification with weak maintenance of the storages.

Grade 0 - Unacceptable condition, necessary to take measures without delay- There are no decentralized and central storages.

Table10. Assessment of the place of decentralized and central storing

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9. HANDLING THE MEDICAL WASTE

It is necessary to treat waste in a proper and safe manner once that identification of certain waste category and risk assessment are conducted. All the employees handling the waste must wear the protective equipment and must be educated about medical waste and the security measures in case of spillage or other accidents. Accordingly, it is necessary to provide the needed training and personal protective equipment for all the people handling the medical waste in order to enable them to do their jobs safely and responsibly.

9.1. Classification of medical waste

The effective medical waste management is based on the key activity that includes segregation and labeling the waste. The proper handling, treatment and disposal of waste by waste categories prevent the contamination of the environment, help reduce costs and help preserve and protect the public health.

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The classification must always be the responsibility of the manufacturer or producer of waste. Medical waste classification should be conducted as close as possible to the place of it generation. The key agree-ment which defines uniformity in medical waste management is the system of medical waste classification and labeling the same with determined colors according to the categories which are applied in all health care institutions of both public and private sector. The most convenient method of medical waste classification in different categories is to separate the waste in plastic bags or containers of different colors. Considering the available technologies for the treatment of certain categories of medical waste and the human resources, the proposed system for medical waste classification and labeling with different colors presents an example of recommended practice in medical waste management to use in B&H (FB&H).

In general, cool colors such as black, green and blue are assigned to the categories of waste which are not dangerous, for example: municipal waste, waste that can be recycled, etc. Hazardous waste is usually labeled with warm colors in the code of colors, such as yellow and red, for example: infectious waste (red color), chemical waste (yellow color) and so on.

In order to ensure the safe handling, the waste classification includes different activities:• Collection in the adequate packaging• Use of a unified coding system by colors• Labeling and marking with symbols

9.2. Disposal and labeling of medical waste

Medical workers in the working process set up and label containers for certain types of medical waste at the place of its generation. During work, when the waste is generated, they identify it, classify and dispose in the adequate packaging. After the classification waste is disposed in the special containers and plastic bags which are in different colors for the different types of waste thus allowing the identification of the waste type. Proper packaging must be adequately placed at all locations in departments where medical waste is generated and must be constructed so that its characteristics (color, shape, size) facilitate and enable the classification of hazardous medical waste at the place of its generation. Special sticker is placed on that packaging and labeled for that type of waste.

According to the Regulations on medical waste management in the FB&H (Official Gazette of FB&H 77/08), the red color packaging is assigned for the infectious waste.

Figure 4. Packaging of medical waste

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The color of packaging for medical waste (FB&H):

1. Sharp waste (red)2. Infectious waste (red)3. Pathological waste (red with black belt)4. Chemical waste (yellow)5. Pharmaceutical waste (green)6. Municipal waste (black and blue)

The packaging for disposal and storing must be clearly labeled with “hazardous medical waste”. Also, it must have the label specifying the type of waste which is impermeable to liquids (no possibility of falling off and/or the spillage of its content). The lids must prevent the unauthorized open-

ing of containers during further treatment or processing and also it must not pollute the environment while treated. The packaging with infectious waste must be labeled with the international symbol for labeling the waste which presents biological risk.

Labeling of the chemical waste depends on the type of risk of chemical waste. (Firgure6)

When container is filled to the required level, nurse closes it and handles it to the employee who does the transport of waste in that health care institution. Handover is recorded in the forms for the waste transfer.

The role of the medical employees is in checking whether the bags are tightly closed after the completed collection of medical waste and whether the bags are filled to 2/3 of their capacity during their shift. If hazard-ous and non-hazardous waste gets mixed, that waste must be considered hazardous. The monitoring of medi-cal waste classification at departments is conducted by personnel responsible for monitoring the work of other staff during whose work the medical waste is generated.

Figure 5. International symbol for the waste which presents biological risk

Toxic Iritating Risk to health Corrosive

Flammable Explosive Oxidizing agent Dangerous to the environment

Figure 6. Labeling the chemical risk

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9.3. Internal transport and storing of hazardous medical waste

Infectious and sharp wastes are temporarily stored in the room for decentralized storing at the department, and later transported to the room for central storing in the institution. Decentralized storing allows the person-nel to be efficient and also allows more frequent collection of waste with the location of waste classification. Their application helps avoid the longer transports of smaller amounts of waste and reduces the frequency of transport to the central storage. The containers and begs properly labeled and closed are transported from the department when 2/3 of their capacity is filled and there can be no liquid in them. Before the transportation of the waste medical personnel perform handover to the employee responsible for the transport of waste and they fill in the record form. Bags with the waste should not be carried in hands to any greater distance, because it increases the risk of injury on sharp objects. The employee responsible for the transport must not correct the errors made in classification of the waste by shifting items from one bag into the other, i.e. from one container into the other. It is necessary to plan the specific ways for waste transport in order to prevent the exposure of staff and patients to potential risks and in order to minimize the movement of waste through the areas where there are patients and through other clean areas.

Waste from the departments and services is carried by the employee responsible for the transport of waste in containers or carts for transport of medical waste which guarantee that there will be no spillage of waste during transport. Carts for the transport of medical waste should be labeled with the international symbol for biological hazard and they should be used only for medical waste. The transport should be done regularly and it should reflect the dynamics of waste production and collection on locations for temporary storing. A very important parameter of quality of infectious medical waste collection is the fact that piling up of the waste at the place of generation should never be allowed. Routine program and the dynamics for waste collection must be determined by the responsible person in health care institution, i.e. by the health care institution. Dynamics of transporting and collecting the infectious medical waste in the health care institution is a part of the plan for medical waste management of the health care institution. Certain recommendations must be respected even by the auxiliary workers responsible for waste collection which also should be provided in each health care institution. Transport should be done during periods of reduced intensity of activities and only along certain fixed routes. Carts used for the internal transport of infectious waste should be:

• Easy to load and unload (low platform for loading)• Without sharp edges (they can damage the bags or containers)• Easy to clean and disinfection;• Made of materials which can withstand the regular exposure to usual means for cleaning and disinfec-

tion;• Cleaned and disinfected after the transport;• The use of lid closed carts is recommended.

Figure 7. Taking over the medical waste and the table of records

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Routs for collection and transport should be separated in space and time by other routes in health care insti-tutions and especially from those where sterile materials are and where health services are provided. Transport of medical waste to the centralized room for temporary storage is conducted at least once a day, and preferably once per shift. Transport of pathological waste is done in transporting containers or carts for transport which are adequately labeled for that type of waste. After the transport containers are cleaned and disinfected.

Good practice requires that vehicles used for transport of waste are used only for that purpose, i.e. only for the transport of infectious medical waste (from health clinics to central building of the health center). Also, special attention should be paid to the protection of personnel driving the vehicle or the one driving in the same. It also includes special measures for additional secondary packaging of infectious medical waste for the needs of transport and safety, as well as the measures for regular ventilation of the vehicle and cleaning and disinfecting.

9.4. Disposal, transport and storage of certain types of waste in health care institutions

9.4.1. Disposal and transport of sharp waste

• All sharp waste (except radioactive and cytostatic sharp waste) generated in the department (needles, scalpels, lancets, etc.) is deposited at the place of generation directly into the containers for sharp waste. One must not put the lids back on the needles!

• Containers for sharp waste are placed in all places where the sharp waste is generated. They are made

Figure 8. Containers for the collection of sharp objects

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of rigid plastic impervious for the content and made so that the sharp waste cannot penetrate it. Also, the falling out of the content is disabled or injuries and transmission of infections on the persons who use the container or handle the waste. It is also labeled with symbols for this type of waste (red color for the container, and sticker for the sharp waste).

• Each container is marked with a label for the sharp waste which contains the following data: source of waste (department), date, time, name of the person completing the declaration, the category of waste and the code from the Waste Catalogue and the symbol for the hazards of sharp waste.

• Nurse-technician prepares the containers for sharp waste and conducts its marking with labels. • Needles and other sharp wastes are disposed in the containers in the way that they do not protrude be-

yond the container. Containers should be filled only up to two thirds of their capacity. Transport of sharp waste:

• Container is tightly closed and handed over to the employee responsible for the transport of waste within the determined time of waste collection or when the container is filled up to 2/3 of its capacity,

• The transfer of waste is recorded in the form for the transfer of medical waste• Transport of waste from the departments is done in the red transport containers or using the cart for

waste transport that are marked by labels for sharp waste• Employee responsible for the waste transport conducts the transport of waste to the room for steriliza-

tion of waste if the waste is sterilized in the institution or to the premises for the temporary storage of waste in the institution when it is then taken over by the firm for the final disposal.

• Sharp waste is handed over to the employee who performs the sterilization and the transfer is recorded in the protocol of sterilization, which is confirmed by signature.

• After the conducted sterilization the success of sterilization Is checked and recorded.• If the sterilization is successful, waste is disposed as a municipal waste• If the waste is taken over by the firm then the transfer is recorded by dispatch note.

9.4.2. Disposal and transport of infectious waste

• At the place of its generation, solid infectious waste is disposed in the red bag put in a bucket/container for infectious waste.

• Nurs/medical technician puts a label on the bag or bucket containing the follow-ing data: the source of waste (department), time and date, the name of the person who completes the declaration, the category of waste and also the code from the Waste Catalogue. The packaging for infectious waste is marked by the interna-tional symbol for biological hazards and with red color.

• Highly infectious waste (the waste containing the causes for Hepatitis B, Hepa-titis C, HIV, MRSA, etc. infections) requires thermal or chemical sterilization in the area of its generation, and, it is not handed over to the facility for the final

Figure 9. Packaging and label for infectious waste

Figure 10. Packaging for transport of infectious waste

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disposal if found in those conditions.• Immediately after the use nurses or other medical personnel dispose cultures and equipment from mi-

crobiological laboratory into plastic bags or containers marked for infectious waste and designed for and compatible with the process of sterilization.

Transport of infectious waste

• Nurse/medical technician hands over the closed bucket or bag with infectious waste to the maid or to the employee responsible for transport of waste. Waste is disposed into containers for transport of infec-tious waste. The handover is recorded into the transfer form.

• The employee responsible for the transport of waste transports the waste to the room for the sterilization if the waste is sterilized in the institution or to the room for temporary disposal of waste in the institu-tion until the waste is taken over by the firm responsible for the final disposal.

• The waste is taken over by the employee responsible for the waste sterilization. He/she records the taken waste in the notebook with required signatures.

• If the waste is taken over by the firm, the employee responsible for the transport disposes the waste in the room for the temporary disposal of infectious and sharps waste in the institution. The employee also records it in the records notebook.

• After the sterilization, the control parameters are checked and if satisfactory, the waste is disposed as municipal waste.

• The contracted firm takes over the waste from the room for temporary disposal in the arranged schedule under the supervision of a responsible employee and the transfer is recorded through the dispatch note and archived at the institution.

9.4.3. Disposal and transport of pathological waste

At the place where it generated pathological waste is disposed in the plastic bags (red bags with black stripe) which are placed in red plastic buckets and labeled with a symbol for pathological waste. Nurse/techni-cian places a beg in the container for the pathological waste, puts the proper label and writes time and date, the name of the department and signs it.

• When bag is filled up to 2/3, it is closed by binding and put into the transport packaging• Pathological waste is as short as possible keep at the place of generation• Nurse/technician hands over the packaged and labeled waste to the employee responsible for the waste

transport. The transfer of the waste is recorded in the form transfer form.

Figure 11. The packaging and the label for pathological waste

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Transport of pathological waste

• Transport of pathological waste is done in the appropriate transport containers. Containers for transport of pathological waste have appropriate labels for that type of waste.

• The employee responsible for the waste transport immediately transports the pathological waste in the room for the temporary pathological waste disposal where there is a freezer intended only for freezing the pathological and biological waste. The employee puts it in the freezer and makes a record.

• The final disposal of pathological waste is done by the licensed firm under contract with the health care institution.

9.4.4. Disposal and transport of pharmaceutical waste

Immediately after determining the defective drug or pharmaceutical substance, the medical worker notifies the nurse/technician of pharmaceutical technician responsible for the pharmacy who then disposes the waste in the proper packaging (plastic bags, cardboard boxes, plastic or metal barrels, etc.) that is adapted to the properties of waste and marked “Danger! Hazardous pharmaceutical waste!”

Waste should be marked also with a proper declaration containing:

◊ Date and time◊ Source of waste◊ Name of the drug/Code of the EU waste catalogue ◊ The name of the person completing the declaration.

Waste is recorded in the “List of records of pharmaceutical waste” in the department. The list contains:1. Ordinal number2. Name of the drug/medicine3. Form and the amount of drug/medicine4. Date of waste disposal5. Name and surname of the employee who handed the waste6. Date and time of taking over the waste7. Name and surname of the employee responsible for temporary waste disposal

Figure 12. The packaging and the label for pharmaceutical waste

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Figure 13. Disposal of pharmaceutical waste

Transport of pharmaceutical waste• Classified, labeled, packaged, recorded and disposed pharmaceutical waste is taken to the pharmacy on

the same day of finding the drug defective.• Records of waste in the pharmacy are done by entering the data in the “List of records of pharmaceuti-

cal waste” which contains the same data as the list of records in the department.• Pharmaceutical waste is kept in the temporary storage for pharmaceutical waste located near the phar-

macy warehouse. It is singled out and labeled “PHARMACEUTICAL WASTE” and locked. • Pharmaceutical waste takes over the licensed firm for disposal of pharmaceutical waste under contract

with the health care institution.• Drugs/medicines procured under contract allowing the return of drugs/medicines with expired date are

handed over to the supplier.

The health care institution with the contract on procurement of drugs/medicines should ensure the free return of the drugs with expired date to the manufacturer or supplier.

9.4.5. Disposal and transport of chemical waste

• Chemical waste in biochemical laboratory is generated by manual analysis of the samples. Reagents containing acids, bases and indicators are used so the waste generated by doing these analyses is treated as chemical waste. It is disposed in the containers for chemical waste put on the place where the waste generated and labeled with the symbols for chemical waste.

• Laboratory technicians close the filled containers, put the label for chemical waste with data of waste source (department), date and time, name of the person completing the declaration, the category of waste and the code from the Catalogue of waste, It is then handed over to the employees responsible

Figure 14. The packaging and the label for chemical waste

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for the medical waste transport to the room for temporary storage of chemical waste. The handover is recorded in the transfer form.

• The final disposal of this waste is done by the firm under contract with the health care institution • Chemical and biological waste is generated in the biochemical laboratory after the analysis of the sam-

ple on biochemical and hematology analyzers. All analyzers have plastic containers for liquid waste containing certain processed biological substance mixed with reagents for the determination of certain analysis that contain chemical components. This waste is treated as chemical waste.

• Person responsible for the maintenance of appliances (the laboratory technician) separates the filled plastic containers from the appliances according to the prescribed rule for the separation of waste con-tainers (each analyzer has in its program the procedure for the separation of filled waste container). She/he then closes it with the cap, puts a label for chemical waste with following data: source of waste (department), time and date, name of the person completing the declaration, category of the waste and the code from the Catalogue of waste.

• The laboratory technician hands over the sealed containers to the employee responsible for the waste transport who then puts the waste in the transport carts and takes it to the room for chemical waste dis-posal. The handover is recorded.

• The final disposal is done by the licensed firm under contract with the health care institution.

9.4.6. Disposal and transport of cytotoxic and cytostatic waste

The existing Regulation in B/H did not define the color for cytostatic waste , while some European coun-tries use purple color for marking this type of waste.

• Cytostatic waste is disposed on the place of its generation by the nurse-pharmaceutical technician in the containers for cytostatic waste.

• Containers must be labeled with the following data: the source of waste (department), time and date, the name of the person completing the declaration, the category of waste and the code from the Catalogue of waste. Container is also marked with the symbol “Harmful to health“.

• Marked and sealed containers nurse gives to the maid who transports it to the room for temporary stor-age of cytostatic waste.

• The transfer of medical waste is recorded in the transfer form for the handover of medical waste.• Cytostatic waste from the room for temporary storage is taken over by the firm which performs the final

disposal on the basis of a contract. The certificate on taking the cytostatic waste is kept in the institution.

9.4.7. Disposal of radioactive waste

Packaging: in particular lead containers for radioactive waste.Labeling:◊ “Caution! Radioactive waste”◊ Type of radionuclides

Figure 15. Packaging and the label for radioactive waste

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◊ Radiation on the specified date (the start time of storing)◊ Obligatory indication of the storage period◊ For external transport: the information in accordance with the UN recommendations.

9.5. Room for the central storage in the institution

In Article 10 of the Regulations on medical waste management (“Official Gazette” 77/08), certain condi-tions which need to be fulfilled by the health care institution in terms of the rooms for central storage of medi-cal waste are determined. According to that Regulations the location must be a closed room which meets the following requirements:

• Being under supervision of personnel officer responsible for waste management• Specious enough to receive the maximum predicted amount of waste of different categories which have

to be separately stored. • Disabled physical access by unauthorized persons and pests• To have adequate cooling department for the waste requiring storage in cold rooms.• Being equipped with the fire extinguisher and inert absorbing material for localizing the possibly spilled

liquids (chemicals).

Figure 16. Central storage

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10. FINAL PROCESSING AND DISPOSAL OF MEDICAL WASTE

The final disposal of medical waste can be done in the health care institution if it is equipped for that, or it can be done by the firms licensed for the disposal of certain types of waste. Disposal is conducted under a contract which a health care institution signs with such firms in accordance to the Regulations on the transfer of obligations from the manufacturer and seller to the operator of the system for waste management (“Official Gazette of FB&H”, No 9/05). There are several firms in B&H that are licensed for taking over or disposal of certain types of waste.

10.1. Options for the final treatment and disposal of waste

When selecting the mode of the final treatment and disposal of medical waste, the management of health care institutions should have in mind the following criteria:

• Compliance with the legislation• Conduct in accordance with the accepted recommendations from the Handbook of Good Practice of

medical waste management• Use of resources and technologies which are, in addition to meeting the two previous conditions, also

economically viable.

When making the choice, the key role in that process has professional and commercial reasoning, as well as the knowledge on what is in compliance with the legislation and with the recommendations of good practice. The obligation of all managers and all employees in the health care institutions is to make sure that any waste goes to a proper waste stream.

Unintentional or intentional errors in the system can lead to a significant increase of hazards and risks re-lated to medical waste management. The immediate management of health institutions should, of course, have clearly defined goals relating the medical waste management, and those goals should be an integral part of the document called the Politics on waste management of the given health care institution.

10.2. Disposal of waste to landfills

Landfills are the place for the final disposal of residues form the process of steam sterilization of infectious medical waste. It means that all waste treated in autoclaves in the institutions where these facilities are located, is after the completion of treatment disposed as a municipal waste on local landfills. Managers responsible for the medical waste management should be sure that the process of sterilization is technically adequate for that purpose and that there is adequate supervision over that process so that inadequately treated waste would not be reused, recycled or disposed on the landfill. It is necessary that the disposal of waste on the landfill is done in accordance with the European Union Directives and with the existing Regulations on landfills.

European Union Directive No 1999/31/EC from 26 April 1999 (the “Directive on the landfills”) regarding all landfills for waste disposal after 16 July 2001, includes:

• Progressively reducing the amount of biodegradable municipal waste which can be disposed in landfills in five, eight and fifteen years.

• Prohibition of disposal of infectious waste which comes from the medical institutions and veterinary

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stations, also of fluids, tires and waste which is explosive, rusting, oxidizing or flammable• Request that all waste should be processed prior to disposal on landfills• Classification of the place for waste disposal on inert, and on hazardous and non-hazardous• Testing the waste before accepting the obligation of meeting the criteria accepted throughout Europe

about what can be accepted as a place for waste disposal within each classification.

Disposal of a medical waste coming from the medical institutions and defined as “infectious” on landfills is prohibited.

10.3. Treatment of infectious waste by steam sterilization (in autoclave)

Infectious medical waste can be hazard to people who come in contact with it and who manipulate it. The main goal of the treatment of this type of medical waste is the sterilization through which the medical waste is

converted into harmless municipal waste. In case that infectious medical waste is first sterilized and then frag-mented in a way that it cannot be identified as a waste of medical origin, then it cannot be disposed on landfills. Apparatus in which the steam sterilization of waste is performed (autoclave) cannot be of risk to personnel working on it and for the personnel responsible for the waste management or for the general population. The basic request is that the process of sterilization by autoclaving leads to a complete destruction of biological agents in the waste. This request requires that operating conditions for example, temperature, as well as the period of keeping that temperature, must be completed and that waste must be in such a form that as a whole, i.e. with each its part reaches specified conditions.

In accordance with that, the following categories of waste can be treated by steam sterilization in facilities that have the appropriate license for this process:

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a. Used sharp objects, syringes, tubes and ampoules of used medicines/if medicines are not cytotoxicb. Broken glass, smaller broken objects from health care institutionsc. Blood and contaminated fluids stabilized in order to prevent leakage from bags or tubes.d. Unrecognizable tissue from nonsurgical diagnostic procedurese. Waste generated from hemodialysis and peritoneal dialysisf. Bandages and cotton balls stained with blood and other body fluids and excretionsg. Panty liners and diapers stained by body fluids and/or excretionsh. Clinical waste from clinical laboratories (except for Creutzfeldt-Jakob Disease).

There is a wide range of different systems for treatment of infectious waste. Generally speaking, the alter-native systems of treatment can be divided into systems that work on the basis of aerated water, systems that work on the basis of hot air (dry heat), and the systems that work on the basis of chemical substances and on the basis of radiation. The best known alternative treatment technology of infectious waste is the use of auto-clave for the treatment or decontamination of mentioned category of waste. The use of this technology in the above mentioned process is 80 to 90%. The efficiency of the autoclaving process depends on the factors that influence the temperature of the treatment facility, the steam penetration through waste and the period of treat-ment. The advantages of this method are: low investment, reduction of volume, simple operation, and easy control of the process.

Disadvantages: not suitable for all types of waste, the efficiency is not 100% if the waste is not fragmented to the certain size of particles and the possibility of air emissions and waste waters.

10.4. Incineration

Incineration is an appropriate way of eliminating the majority of medical waste including some types of chemical waste, but not radioactive waste. Each incinerator must meet the requirements for incineration facil-ity in accordance with the law and each incinerator is considered separately. The incineration facilities should function by the principles of the Framework Directive of the European Commission for Waste and National strategy of B&H in relation to waste through the acceptance of technologies which generate energy from waste. In the process of incineration the medical waste is burned, producing gases and inflammable residue (ash). Secluded gases must be tested before being discharged into air, while the ash is disposed on landfills (for hazardous or non-hazardous waste). The most frequently used types of incinerators for the treatment of medical waste are: Plasma Technology, multichamber incinerator for pathological waste, incinerators with controlled air, rotary kiln and Single chamber incinerator with static grid. The advantages of this technology are: drastic reduction of mass and volume of waste, unrecognizable origin after the treatment, suitable for all types of waste (except for radioactive and waste with heavy metals, PVC, silver salts and photographic waste, pressure vessels and reactive chemicals) of which depends the choice of incinerator, and also the produced heat can be used and there are no waste waters. Disadvantages are: high investments, high maintenance costs and the possible emission of harmful gasses.

In accordance with the legislation the following category of waste can be incinerated in the facilities with the appropriate license to operate:

1. All medical waste of “highly infectious” nature, i.e. from the patients who are in strict isolation and suffer from known infectious disease or suspected to have some infectious disease (for example, Lassa, Ebola, and viruses of hemorrhagic fever, etc.),

2. All medical waste coming from the provision of health care to patients suffering from Creutzfeldt-Jakob Disease (CJD) and medical waste coming from the research related to this disease,

3. All microbiological cultures which have not passed the sterilization in the autoclave4. Polluted larger metal objects (for example: dentures, needles, surgical instruments for single use, etc.),

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5. Infected blood stabilized to avoid spillage (including the bags and test tubes)6. All recognizable body parts after surgical interventions from surgical rooms or other surgical spaces,

autopsy rooms and from laboratories,7. Fetal tissue and placenta from the Maternity and gynecological surgeries,8. All hazardous material, for example, cytotoxic waste, pharmaceutical waste including pharmaceutical

chemicals :barium, cadmium, cobalt, lead, mercury (including amalgam), nickel, silver and many other components, etc. (but not barium sulfate),

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