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

Incinerator

Disposal

IPAL

SOURCES

Medical Activities

Supporting Activities

Surgical Room, Emergency Room, Policlinic, Dialysis,

Delivery Room, treatment of dead body,
Chemotherapy, etc.
Laboratories, Radiology, Laundry, Kitchen,
Maintenance, Pharmacy

Office and Social Activities

Office (administration and accountancy), Medical

record, Cafeteria, Mosque, Guest House, Dormitory

CLASSIFICATION
Hospital Waste
Liquid waste

Solid waste

Excreta
Toxic chemicals
Radioactive Subs.

Medical waste ?

Pathological
Infectious waste
Citotoxic
Sharps
Pharmalogical

Gas Emission

Non Medical Waste ?

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

Principal Components

Sources

Approx.
Compositi
on, wt %

Moisture
Content,
%

Incomb
ustible
solids,
%

Btu
value/lb of
refuse as
fired

Highly combustible waste.

Paper, wood, cardboard
cartons, and up to 10%
treated papers, plastic, or
rubber scraps

Commercial,
industrial

100 trash

10

8500

Combustible waste, paper,

cartons, rags, wood scraps,
combustible floor sweepings

domestic,
commercial,
industrial

80 Rubbish
20 garbage

25

10

6500

Rubbish and garbage

residential

50 Rubbish
50 Garbage

50

4800

Animal and vegetable wastes

restaurants,
hotels, markets,
institutional,
commercial,
clubs

35 Rubbish
65 Garbage

70

2500

Carcasses, organs, solid

organic wastes

Hospitals,
laboratories,
abattoirs, animal
pounds, etc.

100 animal
and human
tissue

85

1000

COMPOSITION
Waste Type

Pathological (non
infectious body parts)

Weight
%

Generation rate based on

20 kg/bed/day

0.5

0.10

10.0 15.0

2.00

General/ administrative
(noninfectious)

50.0

10.00

Food

30.0

6.00

Card Board

9.5

1.90

Infectious

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
Waste Treatment
Waste Disposal

New product
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)
Environment

Waste traders

Waste traders

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

Treatment Technology

Regulated
wastes

Vol.
Reduction
(%)

Typical
Operating
Costs $/lb
per hr

Capital
Cost
$1000

Steam Autoclave

except
pathological

0.05-0.07

100 (on
site)

Autoclave with
compaction

except
pathological

60-80

0.03-0.10

100

Mechanical-chemical

all

60-90

0.06

40-350

Microwave (with
shredder)

except
pathological
and toxics

60-90

0.07-0.10

500

Incineration

all

90-95

0.07-0.5

1000 (on
site)

DECISION
MAKING

INCINERATION ?

Infectious, un recover/un recyclable general waste

Operational Parameters:

Alternatives:

Burning rate (pound/hour), heating value (Btu/pound), heat

release value (Btu/cubic feet per hour)
Controlled-air incinerators
Rotary-kiln incinerators

Air Pollution Controls

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

INCINERATORS

INCINERATORS

INCINERATORS

INCINERATORS

 What are the differences between

controlled air and rotary kiln incinerators ?

AIR POLLUTION CONTROLS

NEW METHODS

Problems dioxin carcinogenic

Using Sun Light

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

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

Recommended: Ozonization

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)

Equalizing

Reactor
(O3)

Coagulation

Sedimentation

Filtration
(active carbon)
Filter wash

Environment

TOXIC WASTE DISPOSAL

REGULATION
UU 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

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