It has been a growing awareness of the need for safe management of biomedical and healthcare waste all over the world. Biomedical waste and Healthcare wastes which pose the greatest risk to human health are infectious waste (or biomedical waste) which constitutes 15 – 25 percent of total healthcare waste.

There are Infectious wastes it may be include all waste items that are contaminated with or suspected of being contaminated with body fluids such as blood and blood products, used catheters and gloves, cultures and stocks of infectious agents, wound dressings, nappies, discarded diagnostic samples, contaminated materials (swabs, bandages, and gauze), disposal medical devices such as sharps and syringes, contaminated laboratory animals etc. The quantity of waste produced in a hospital depends on the level of national income and the type of facility concerned. A university hospital in a high-income country can produce up to 10 kg of waste per bed per day, all categories combined.

Improper management of healthcare wastes from hospitals, clinics and other facilities pose occupational and public health risks to patients, health workers, waste handlers, haulers and general public. It may also lead to contamination of air, water and soil which may affect all forms of life. In addition, if waste is not disposed of properly, members of the community may have an opportunity to collect disposable medical equipment (particularly syringes) and to resell these materials which may cause dangerous diseases.

When patient care activities are carried out in a healthcare setting, certain waste is produced which has the potential to cause harm to human beings and environment. Such waste includes soiled cotton, bandages, hypodermic needles, syringes, tubings such as intravenous sets, and urinary catheters etc.

Such waste is commonly called as bio-medical waste (BMW) in India, though it is also known by various other names such as clinical waste, medical waste and health-care waste in different parts of world. Such waste constitutes merely 15 to 25% of total waste generated in a hospital, the remaining being general waste such as waste paper, wrapper of drugs, cardboard and left-over food etc .

Methods
Survey method
The study was conducted between December 2009 and April 2010. No sampling was done and all 70 patient care areas of 1100-bedded hospital were included in study. These areas were: Emergency Areas (12 in number), Waste Collection Points of Wards (25 in number), Treatment Rooms of Wards (11 in number), Intensive Care Units (8 in number) and Operation Theatres (14 in number).

Each area was visited on any 3 non-consecutive days in the study period. No visit was made on Sundays and on Public Holidays. Areas were visited during morning hours between 7 am to 10 am and evening hours of the same day between 2 pm and 4 pm. Thus a total of 6 visits were made to each area.

The chosen timings were such when maximum BMW is generated in a patient care area as this was the time when blood samples of patients were taken and medication injections were given. Although medication injections were also given during evening hours and night hours, such time period was excluded from the study due to operational difficulties in collecting data during these timings. All observations were made by same researcher.

Ethical clearance Method
Ethical clearance from institutes ethics committee and permission from Medical Superintendent to collect data from various patient care areas was taken before the study. The study was approved by 'Thesis Review Committee of Post-Graduate Institute of Medical Education and Research (PGIMER), Chandīgarh, India

Data analysis
The score obtained in 6 visits for a particular category of waste management was divided by 6 to obtain the mean score and then percentage mean score was calculated. The score of all observation units in a given area was summated and mean percentage score of the area was calculated. This was done for all categories of waste management and for all areas.

The statistical analysis was carried out using Statistical Package for Social Sciences (SPSS Inc., Chicago, IL, version 15.0 for Windows). All quantitative variables were estimated using measures of central location (mean, median) and measures of dispersion (standard deviation, standard error and 95% confidence interval). Means were compared using One-way ANOVA (analysis of variance) where there were more than two groups and unpaired t-test where there were two area groups. P-value ≤ 0.05 was used as a cut point to determine significance.

Score of each category in Rural
In emergency, the mean score for condition of waste receptacles, segregation of waste, mutilation of recyclable waste and disinfection of waste was 87%, 92%, 85% and 86% respectively. For Central Waste Collection Points of Wards, the score for these categories was 87%, 96%, 90% and 82% respectively; for Treatment Room of wards the score was 85%, 96%, 80% and 63% respectively; for ots, the score was 87%, 96%, 92% and 85% respectively and for icus, the score was 88%, 100%, 92% and 88% respectively.

Scores comparison in different areas of Hospital
The comparison of scores of different areas showed that score related to condition of waste receptacles and segregation of waste was not significantly different amongst various areas i.e. Emergency areas, Central Waste Collection Points of Wards, Treatment Room of Wards, ots and ICU.

The score regarding mutilation of recyclable waste was found significantly different between ots and Treatment Room of wards. The score in ots (n: 13, mean: 92%, 95% CI: 86 to 98%) was significantly higher (p value: 0.033) than that in Treatment Room of Wards (n: 11, mean: 80%, 95% CI: 74 to 86%).

Study tool
Data were recorded on a researcher made checklist covering various aspects of BMW management at source of generation of waste.Primarily, 4 broad functions are carried out at source viz.

1. placement of 4 colour-coded i.e. Black, yellow, red and blue waste bins which are lined on inner side by similarly coloured waste bags;
2. segregation of waste in such waste bags i.e. General waste like waste paper, wrapper of drugs, cardboard, left-over food etc. Is to be put into black; soiled infected waste like dressing material, cotton swabs etc. Is to be put into yellow; plastic waste like plastic syringes, dextrose bottles, intravenous sets, Ryles tubes, urinary catheters etc. Is to be put into red and sharps like hypodermic needles, surgical blades, glass etc. Is to be put into blue bags
3. mutilation of recyclable waste like disposable syringes, plastic dextrose bottles, plastic tubings and hypodermic needles and
4. disinfection of certain categories of waste notably plastics and sharps.

In the hospital, electrically operated needle cutters were used to mutilate hypodermic needles and nozzle (hub) of disposable syringes and scissors were used to cut the plastic tubings and 1% bleaching powder was used to disinfect plastics and sharps. Parameters related to each of the 4 main categories mentioned above were identified and a checklist was prepared .Each desirable observation was assigned 1 mark and each undesirable observation was assigned 0 mark. There were some parameters, observations regarding which could be in part desirable and in part undesirable in a given area, such observation was assigned 0.5 mark.

As an example, if all of the used hypodermic needles in an area were found mutilated (desirable), it was assigned 1 mark; if none of the needles was mutilated (undesirable), it was assigned 0 mark and if some of the needles were mutilated and some not, such observation was assigned 0.5 mark. The checklist was tested in another patient care area of institute not included in the study namely Advanced Pediatrics Centre and parameters which were not feasible to observe were deleted from checklist. In the final score-sheet, there were 16 parameters noted under category condition of waste receptacles, 4 parameters noted under category segregation of waste, 6 parameters noted under category mutilation of recyclable waste and 3 parameters noted under category disinfection of waste. Thus a total of 29 parameters were noted in each study unit

Score of individual parameters
The summated mean percentage score of each of 29 observed parameters showed that it was 100% for placement of waste receptacles and 0% for is cover on waste receptacle foot-operated; for segregation of waste in various waste receptacles, it was from 84.84% to 98.93%; for destruction of used needles and nozzle of syringes, it was 91.21% and 85.73% respectively and for putting of disinfectant solution in blue and red bags, it was 78.97% and 78.68% respectively.

Segregation
Segregation refers to the basic separation of different categories of waste generated at source and thereby reducing the risks as well as cost of handling and disposal. Segregation is the most crucial step in bio-medical waste management. Effective segregation alone can ensure effective bio-medical waste management.

Proper labelling of bins
The bins and bags should carry the biohazard symbol indicating the nature of waste to the patients and public.

Collection
The collection of biomedical waste involves use of different types of container from various sources of biomedical wastes like Operation Theatre, laboratory, wards, kitchen, corridor etc. The containers/ bins should be placed in such a way that 100 % collection is achieved. Sharps must always be kept in puncture-proof containers to avoid injuries and infection to the workers handling them.

Storage
Once collection occurs then biomedical waste is stored in a proper place. Segregated wastes of different categories need to be collected in identifiable containers. The duration of storage should not exceed for 8-10 hrs in big hospitals (more than 250 bedded) and 24 hrs in nursing homes. Each container may be clearly labelled to show the ward or room where it is kept. The reason for this labelling is that it may be necessary to trace the waste back to its source. Besides this, storage area should be marked with a caution sign.

Transportation
The waste should be transported for treatment either in trolleys or in covered wheelbarrow. Manual loading should be avoided as far as for as possible. The bags / Container containing bmws should be tied/ lidded before transportation. Before transporting the bag containing bmws, it should be accompanied with a signed document by Nurse/ Doctor mentioning date, shift, quantity and destination.

Special vehicles must be used so as to prevent access to, and direct contact with, the waste by the transportation operators, the scavengers and the public. The transport containers should be properly enclosed. The effects of traffic accidents should be considered in the design, and the driver must be trained in the procedures he must follow in case of an accidental spillage. It should also be possible to wash the interior of the containers thoroughly.

Personnel safety devices
The use of protective gears should be made mandatory for all the personnel handling waste.

Gloves: Heavy-duty rubber gloves should be used for waste handling by the waste retrievers. This should be bright yellow in colour. After handling the waste, the gloves should be washed twice. The gloves should be washed after every use with carbolic soap and a disinfectant. The size should fit the operator.

Aprons, gowns, suits or other apparels: Apparel is worn to prevent contamination of clothing and protect skin. It could be made of cloth or impermeable material such as plastic. People working in incinerator chambers should have gowns or suits made of non-inflammable material.

Masks: Various types of masks, goggles, and face shields are worn alone or in combination, to provide a protective barrier. It is mandatory for personnel working in the incinerator chamber to wear a mask covering both nose and mouth, preferably a gas mask with filters.

Boots: Leg coverings, boots or shoe-covers provide greater protection to the skin when splashes or large quantities of infected waste have to be handled. The boots should be rubber-soled and anti-skid type. They should cover the leg up to the ankle.

Cleaning devices
Brooms: The broom shall be a minimum of 1.2 m long, such that the worker need not stoop to sweep. The diameter of the broom should be convenient to handle. The brush of the broom shall be soft or hard depending on the type of flooring.

Dustpans: The dustpans should be used to collect the dust from the sweeping operations. They may be either of plastic or enameled metal. They should be free of ribs and should have smooth contours, to prevent dust from sticking to the surface. They should be washed with disinfectants and dried before every use.

Mops: Mops with long handles must be used for swabbing the floor. They shall be of either the cloth or the rubber variety. The mop has to be replaced depending on the wear and tear. The mechanical-screw type of mop is convenient for squeezing out the water.

Vacuum cleaners: Domestic vacuum cleaners or industrial vacuum cleaners can be used depending on the size of the rooms.

Storage Devices
Dustbins:
It is very important to assess the quantity of waste generated at each point. Dustbins should be of such capacity that they do not overflow between each cycle of waste collection. Dustbins should be cleaned after every cycle of clearance of waste with disinfectants. Dustbins can be lined with plastic bags, which are chlorine-free, and colour coded as per the law.

Handling Devices
Trolleys
The use of trolleys will facilitate the removal of infectious waste at the source itself, instead of adding a new category of waste.

Wheel barrows
Wheelbarrows are used to transfer the waste from the point source to the collection centres. There are two types of wheelbarrow – covered and open. Wheelbarrows are made of steel and provided with two wheels and a handle. Care should be taken not to directly dump waste into it. Only packed waste (in plastic bags) should be carried. Care should also be taken not to allow liquid waste from spilling into the wheelbarrow, as it will corrode. These are ideal for transferring debris within the institution. Wheelbarrows also come in various sizes depending on the utility.

Chutes
Chutes are vertical conduits provided for easy transportation of refuse vertically in case of institutions with more than two floors. Chutes should be fabricated from stainless steel. It should have a self-closing lid. These chutes should be fumigated everyday with formaldehyde vapours. The contaminated linen (contaminated with blood and or other body fluids) from each floor should be bundled in soiled linen or in plastic bags before ejecting into the chute.

Alternately, elevators with mechanical winches or electrical winches can be provided to bring down waste containers from each floor. Chutes are necessary to avoid horizontal transport of waste thereby minimizing the routing of the waste within the premises and hence reducing the risk of secondary contamination.

Discussion
Segregation of waste is the most crucial step for proper management of BMW as waste segregated into various color-coded containers is finally taken to different sites for disposal. Presence of a wrong kind of waste in a particular container will obviously nullify the efforts of appropriate disposal of waste. This implies that for proper segregation of waste, the waste bins in appropriate number, at appropriate places and with appropriate colour-code are required to be placed at the source of generation of waste.

The summated score of condition of waste receptacles in all the patient care areas was more than 80%. Various studies have found poor condition of waste receptacles for waste disposal. In a 600-bedded super-specialty corporate hospital of a South Indian city, there were only white receptacles for all types of BMW for aesthetic reasons and since the color of all receptacles or bins was same, following the segregation practices was difficult. In studies in Irbid city of Jordan and UK , waste bins or receptacles were found to be in poor shape.

The high score of condition of waste receptacles in all patient care areas in present study implies that the basic infrastructure for proper segregation of waste at the source of generation of waste was well placed in hospital. However, it was found that almost all waste receptacles were open i.e. Without any lid over them. Waste receptacles should preferably be covered ones having foot-operated lids and so it is desirable to gradually replace the existing open type waste receptacles with the ones having foot-operated lids.

Further analysis of scores of individual parameters that constituted the category mutilation of recyclable waste showed that HCWS do not bend used needles manually; they very rarely re-cap the used needles and generally mutilate the used hypodermic needles. However, they lay less emphasis on mutilation of nozzle of used syringes. They pay even less attention to cutting of used plastic bottles and tubings.

Conclusion
It is concluded that more emphasis needs to be laid on mutilation of recyclable waste and disinfection of waste by hcws especially resident doctors. The present study was done to evaluate the practices of biomedical waste management amongst different patient care areas in tertiary care medical institute of North India using a checklist.

It was found that more emphasis needs to be laid for mutilation of recyclable waste and disinfection of waste especially in Treatment Room of wards which are used exclusively by resident doctors. Hospital administrators may need to formulate and implement a plan for providing appropriate training to hcws especially resident doctors so as to address the deficiencies observed in the study.

References:

1. Pruss A, Cirouit E, Rushbrook P. Safe Management of Wastes From Health-Care Activities. Geneva: WHO; 1999. Definition and Characterization of Health-Care Waste; pp. 2–46.
2. Manual on Solid Waste Management, Ministry of Urban Development, Government of India. http://www.urbanindia.nic.in/publicinfo/swm/swm_manual.htm.
3. Collins CH, Kennedy DA. Microbiological hazards of occupational needle-stick and sharps injuries. J Appl Bacteriol. 1987;62:385–402. [PubMed]
4. Bio-medical Waste (Management and Handling) Rules, 1998, Ministry of Environment and Forests, Government of India. http://cpcb.nic.in/Bio_medical.php.
5. The Environment (Protection) Act, 1986, Ministry of Environment and Forests, Govt. of India. http://envfor.nic.in/legis/env/env1.html.
6. Rao PH. Hospital waste management system – a case study of a south Indian city. Waste Manag Res. 2009;27:313–321. doi: 10.1177/0734242X09104128. [PubMed] [Cross Ref]

Written By: Vinay Kumar Jaynath Dubey (LLM, Criminology)