HOSPITAL WASTE MANAGEMENT

TYPES, CHARACTERISTIC, TREATMENT METHOD AND MANAGEMENT

11th May 2009

OUTLINE
Potential

Hazard of Hospital Waste Waste Management Sources of waste Classification of Hospital Waste Treatment, Transport and Disposal Method Incineration of Hospital Waste Regulations

Facts in Indonesia

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

POTENTIAL HAZARD
Exposed

people: ?

Patient and medical workers People who are contracted working at the hospital (cleaning service etc) Patient (rawat jalan) Visitors

Benefit of Env. Management

Environmental Protection Better Hospital Environmental Management Human Resource Development Continuous Improvement of Hospital Environment Performance Meet Regulation Requirement Part of Total Quality Management Reduction of Expenses Improvement of Hospital Public Image

Env. Management Component

Management

Support

Scale and Type match with Env. Impact from Hospital activities Continuous improvement Meet the regulation requirement Guideline to prepare and review the objective and goal of Env. Management Documented, applied, maintained and communicated to all Available for all

Planning

Identification of env. Aspects and Impacts Legal requirements Environmental Policy and Internal performance criteria Objectives and goals of env. Managmeent Planning and management program
Struktur, tanggung jawab, organisasi, kewenangan; proses bisnis management; SDM, skill, budget dan alat; proses untuk mencapai tujuan: prosedur dan pengendalian operasi, pelatihan, sistem pengukuran dan audit, pengkajian manajemen.

Implementation

Structure and responsibilities Training, awareness, competency Communication Documentation and Env. Management System Document Control Operational Control Emergency preparedness

Evaluation Corrective action

Hospital Regulation

PerMenKes RI No 928/Menkes/Per/XI/1995 ttg penyusunan AMDAL bidang kesehatan Pedomen teknis penyusunan AMDAL RS Pedoman Teknis penyusunan UPL dan UKL RS PerMenKes RI No 986/Menkes/Per/XI/1992 ttg Persyaratan Kesehatan Lingkungan RS Keputusan Dirjen P2M PLP No HK.00.06.6.64, 18 Feb 1993 ttg Persyaratan dan Petunjuk Teknis tentang Tata Cara Penyehatan Lingkungan Rumah Sakit Pedoman Sanitasi RS Indonesia Pedoman teknis Pengelolaan Makanan dan Infeksi Nosokomial di RS PP no 12/1995 ttg perubahan PP no 19/1994 ttg pengelolaan limbah B3 KepMenLH No 58/1995 ttg Baku Mutu Limbah Cair bagi Kegiatan RS

Regulated Env. Aspects

Environmental Impacts Assessment Nosokomial Infection Chemical and hazardous waste Gas emission, temperature, humidity, nuisance and lighting Effluent quality of waste treatment plant Solid waste Radioactive waste Medical waste

Unregulated Env. Aspects

Management structure Facilities, location map of env. control History and Owner of the Hospital Hospital General activities Flow of Health Treatment Procedure Nosokomial Infection control Health and Safety Policy List of Medical and non medical substance

Sistem pengadaan dan jadwal, jml pemakaian, penyimpanan, distribusi dan transportasi bahan

Air pollution control

Handling, storage, transportation of domestic, hazardous, chemotherapy waste, disposal procedure and legal letter Water supply, piping, layout, and water consumption Recording of wastewater effluent quality Waste water treatment system ( system, facilities and SOP) Sanitation method (pest, microbiology, virus, toxicology) Supply, Layout, consumption of electricity Environmental training Supplier Consideration of Environmental Issues Material Identification Approach

Environmental Monitoring Aspects

Waste production Waste water Reuse of waste water Efficiency of Material Consumption Energy consumption Unplanned disposal Recycle activities Chemical handling Gas handling Handling of water for cleaning purposes

WASTE FLOW IN GENERAL

Hospital Activities (sources) ?
Medical Activities Supporting activities Office & Social Activities

Waste Generation (solid, liquid, gas) ?

Medical waste Non Medical Waste

Waste Management ?
Collection / Storage Transportation Treatment Disposal

Incinerator

IPAL

SOURCES

Medical Activities

Surgical Room, Emergency Room, Policlinic, Dialysis, Delivery Room, treatment of dead body, Chemotherapy, etc.
Laboratories, Radiology, Laundry, Kitchen, Maintenance, Pharmacy Office (administration and accountancy), Medical record, Cafeteria, Mosque, Guest House, Dormitory

Supporting Activities

Office and Social Activities

CLASSIFICATION
Hospital Waste
Liquid waste Solid waste Gas Emission

Excreta Toxic chemicals Radioactive Subs.

Medical waste ?

Non Medical Waste ?

Pathological Infectious waste Citotoxic Sharps Pharmalogical

General waste Hazardous waste Chemical waste

CLASSIFICATION

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

CLASSIFICATION

Medical waste (limbah medis) (50-60% disposal cost) generated from medical activities Infectious waste contains microorganism that may cause disease from surgical room, laboratories, haemodialysis Pathological waste human/animal tissue, body part, etc Citotoxic waste material that are/might be contaminated by citotoxic medicine Sharps syringe, scissors, knife, broken glass, nail cutter tertusuk (luka)

Pharmacological waste returned medicine, expired or contaminated medicine, spilled medicine, etc.

 Could

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

CLASSIFICATION

Non Medical Waste (limbah non medis) mostly generated from hospital supporting activities, office and social activities

General waste, food, card board, etc Hazardous waste toxic, corrosive, flammable, reactive (explosive, reactive to water, shock sensitive)
Radioactive solid, liquid or gas contaminated by radionuclide, generated from in-vitro, in-vivo analysis, therapy toxic waste genetoxic (carcinogenic, mutagenic, teratogenic) pressure containers explosive when burned Waste with high heavy metal concentration

Chemical waste disinfection, laboratories, cleaning, may include in hazardous waste categories

Limbah Klinis

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

INFECTIOUS WASTE

Infectious waste includes the following (EPA): ?

Isolation waste Cultures and stocks of infectious agents and associated biologicals Human blood or liquid and blood products Pathological waste (tissues, organs, body parts except teeth and hair) Contaminated sharps Miscellaneous contaminated wastes (animal carcasses)

CHARACTERISTIC of SW

Estimate hospital waste generation (US):

4.54 9.08 kg/day per bed 6.5 kg/bed per day 11.5 kg/bed per day

Bandung (RSHS) = 2.12 kg/bed/day Hospital Medical waste = 10 20 kg/hari Immunization syringe = 66 million/year, total 300 million/year Waste Weight Type % Solid waste classification system (EPA) based on Class 0 70 moisture content, ash Plastic 15 content, overall composition Class 3 10 heat content incineration purpose Class 4 5

Heat of combustion J/kg 8500 19500 4500 1000

CLASSIFICATION
Class
0

Principal Components Highly combustible waste. Paper, wood, cardboard cartons, and up to 10% treated papers, plastic, or rubber scraps Combustible waste, paper, cartons, rags, wood scraps, combustible floor sweepings Rubbish and garbage Animal and vegetable wastes

Sources Commercial, industrial

Approx. Compositi on, wt %

100 trash

Moisture Content, %
10

Incomb ustible solids, %

5

Btu value/lb of refuse as fired

8500

domestic, commercial, industrial residential restaurants, hotels, markets, institutional, commercial, clubs

80 Rubbish 20 garbage 50 Rubbish 50 Garbage 35 Rubbish 65 Garbage

25

10

6500

2 3

50 70

7 5

4800 2500

Carcasses, organs, solid organic wastes

Hospitals, laboratories, abattoirs, animal pounds, etc.

100 animal and human tissue

85

1000

COMPOSITION
Waste Type Weight % 0.5 10.0 15.0 Generation rate based on 20 kg/bed/day 0.10 2.00

Pathological (non infectious body parts) Infectious

General/ administrative (noninfectious)

Food Card Board

50.0

10.00

30.0 9.5

6.00 1.90

TOXIC & HAZARDOUS WASTE

Hospital

generate 0.056 lb/bed per day toxic and hazardous waste 200 bed 336 lb per month hospitals are regulated as generator of hazardous waste

WASTE MANAGEMENT ?
Cleaner Production / Waste Prevention
Material substitution Life cycle analysis of product

Waste Minimization / Source Reduction

Process modification, equipment redesign

Recycling

New product

Waste Treatment
Waste Disposal

Thermal destruction, physical, chemical, biological

Landfill

WASTE MANAGEMENT
Raw Material

Use of Material
Reuse Recycle Waste Generation Waste Collection/Storage, Transportation and Treatment (On Site) Waste Transportation, Treatment and Disposal (Off site)

Waste traders

Waste traders

Environment

PREVETION OF POTENTIAL HAZARD

Use safety material or non-hazardous material Use closed containers for volatile substance Good ventilation health&safety standards Body protection (mask, gloves, etc.) Use container with different color for different waste Regular monitoring for high risk activities Epidemiological analysis for high risk activities

ON SITE HANDLING

COLLECTION / STORAGE
EPA red bag (operating room waste, blood serums, sharps), white bag (general waste, kitchen waste, boxes) DepKes RI plastic bags color

Black : general waste Yellow: all waste that must go to incinerators Yellow with black line: all waste that better go to incinerator, but can go to landfill if collected separately Light blue or transparent with dark blue lines: must go to autoclave before next handling

COLLECTION / STORAGE
Bags

or containers should be ?

Enough filled so it is easy to be well closed Labeled symbol is given as it is regulated Able to allow steam to enter during sterilization (if needed) Completed with active date before it can be categorized as general waste For syringe : WHO standard (container shape, thickness, material, placing)

TRANSPORTATION
Waste

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

HANDLING OF CHEMICAL

Non-hazardous chemical should be labeled and handled as general waste

organic chemical (acetate, amino acid, citric acid, lactic acid, sugar) Inorganic chemical (chloride, fluoride, bromide, sulfate, borate)

Hazardous chemical

Un reusable chemical incinerator dated after used, maximum storage time: 3, 12, 24 month Shock sensitive: diazo substance, metal azide, nitrocellulose, perchloric acid, perchlorate salts, peroxide, picric acid, picrate salts, polynitroaromatic Water reactive: alkaline metal, soil alkaline, lithium alkaline reagent, boron trifluoride solution, grignard solution Others: nitrate acid >70%, phosphor (red and white)

DISINFECTION ALTERNATIVES

Autoclaving Pyrolysis 1200C, vol. reduction 97-98% Fluidized-bed coal technology circulating fluidized bed burning of coal Electron beam technology sterilization of all infectious waste including liquid Microwave technology not recommendation for pathological and animal waste, + expensive Mechanical-Chemical treatment (Sodium Hypochlorite NaOCl) pathological Gas/vapor sterilization (ethylene oxide or formaldehyde), not recommended Biodegradation enzymes Steam sterilization 300 F

COMPARISON
Regulated wastes except pathological Vol. Reduction (%) 0 Typical Operating Costs $/lb per hr 0.05-0.07 Capital Cost $1000 100 (on site)

Treatment Technology
Steam Autoclave

Autoclave with compaction

Mechanical-chemical Microwave (with shredder) Incineration

except pathological
all except pathological and toxics all

60-80
60-90 60-90

0.03-0.10
0.06 0.07-0.10

100
40-350 500

90-95

0.07-0.5

1000 (on site)

DECISION MAKING

INCINERATION ?

Infectious, un recover/un recyclable general waste Operational Parameters:

Burning rate (pound/hour), heating value (Btu/pound), heat release value (Btu/cubic feet per hour) Controlled-air incinerators Rotary-kiln incinerators Wet Scrubbers: impaction of particles with countercurrent flow reactor Dry Scrubbers: Reacting particles and gases in spray-dryer section, collection of particles in a baghouse collector

Alternatives:

Air Pollution Controls

INCINERATORS

INCINERATORS

INCINERATORS

INCINERATORS

 What

are the differences between controlled air and rotary kiln incinerators ?

AIR POLLUTION CONTROLS

NEW METHODS

Problems dioxin carcinogenic

Dioxin + chlor TCDD (Tetra Chloro Dibenzo para Dioxin) cancer US many incinerators > regulation Japan 70% world incinerators, high concentration dioxin found in surrounding incinerator 18 from 271 die from cancer > 800 C reduce dioxin but increase heavy metal vapor reduce dioxin, reduce cost 150C in 20 minutes enough to kill bacteria

Using Sun Light

Low Thermal Desorbtion

Invented by FMIPA UI Titanium oxide dioxin reduction Indirect heating with low heat thermolysis drying at low temperature (200-350 C) without oxidation (direct burning) Low pressure No oxygen reduce vapor point

LIQUID WASTE

Indonesia most hospitals use septic tank

Direct charge to river Possibility polluting the surrounding soil Unable degraded by activated sludge
Ozone: oxidation potential 1.7 V radical Ozone in water radical hydroxil (2.8 V) Kill eschericia coli, Salmonella enteriditis, Hepatitis A Virus, etc Oxidize organic substance ( fenol, pesticides, atrazine, TNT, etc)
Reactor (O3) Filtration (active carbon) Filter wash Environment

Recommended: Ozonization

Equalizing

Coagulation

Sedimentation

TOXIC WASTE DISPOSAL

REGULATION
No. 23 /1997 Pengelolaan Lingkungan Hidup KepMENLH No. 58/1995 Baku mutu limbah cair bagi kegiatan rumah sakit PP No. 18/1999 Pengelolaan limbah B3 UU N0. 7/2004 Sumber Daya Air Peraturan Menteri Kesehatan RI No. 1024/2003 Persyaratan Kesehatan Lingkungan RS
UU

REFERENCES

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

ALTERNATIVE METHODS