Planning for HCWM SAFHE April 2014

By: Janet Magner Magner Risk Services

Acknowledgement: Infrastructure Unit Support Systems (IUSS) Project dated 04/10/2013; Development Draft 1.0

Set the Scene

�  What is HCW?

�  Basic principles: �  Waste Management Hierarchy

�  Integrated waste management

�  7 Steps of Cradle-to-Grave Process

Category

Class No. as per SANS 10228 and Annex D of

SANS 10248*

Hazard Type as per SANS

10228*

Hazard Rating as per DWAF

Minimum Requirements** and Annex

D of SANS 10248

Sub-category as per SANS 10248***

/Examples

Colour Coding for packaging

as per S.7 Table 1 of

SANS 10248***

Hazard Label as per Annex D of SANS

10248***

Human body parts Red Infectious hazard labelAnimal body parts Orange Infectious hazard label

Non-infectious animal anatomical Blue

Infectious non-anatomical 6,2 infectious 1

Includes all material contaminated with material suspected to contain pathogens

Red Infectious hazard label

Sharps 6,2 Infectious 1

Needles, Blades, needles with or without tubing, broken clinical glass, blood vials, ampoules

Yellow"Danger" "Contaminated Sharps" and the Infectious hazard label

6,1 Gas 1 Danger hazard label3 Flammable 1-4 Flammable hazard label5 Oxidising 1-4 Oxidising hazard label

6,1 Toxic 1 Cytoxic Hazard label8 Corrosive Corrosive hazard label

Radioactive 7 Ionising radiation 1 Nuclear medicine, oncology None Radioactive hazard label

* South African National Standards (SANS) 10228:2006 Fourth Edition ; The identification of dangerious goods for transport** Department of Water Affairs (DWAF) Minimum requirements for the handling, classification and disposal of hazardous waste; Waste management series; Second Edition 1998

*** South African National Standards (SANS) 10248-1:2008 First Edition; Management of Healthcare waste: Part 1 Management of health care waste for healthcare facilities

Categories of Health Care Risk Waste

Dark Green

6,2 1Infectious

Pharmaceutical, cytotoxic pharmaceutical and various chemicals

Chemical and Pharmaceutical

Infectious Anatomical

©  Icando  &  Magallan  Risk  Services  

Avoid waste first

Minimise through reuse and recycling

Treat

Landfill

Energy Recovery Treat

Disposal

Hierarchy of waste management O

rder

of

incr

easi

ng i

mpor

tanc

e

The 7 Steps

Step 7: Treatment and Disposal

Cradle to Grave Process Integrated Health Care Waste Management

Storage of consumable items Green Procurement and procurement of equipment and consumables for HCWM

Steps 1-3: Generation, segregation,

containerisation and Interim

Storage

Step 4: Internal transport

Step 5: Central Storage

Step 6: External Transport

Internal transport for the of HCGW categories

Internal transport for the categories of

HCRW

Health Care Waste

Reuse Recycle Remaining HCGW Categories of

HCRW (Solid) Categories of

HCRW (Liquid)

Health Care Risk Waste

Non-Hazardous Health Care General

Waste

Other Hazardous Waste

External collection and Transport by

contracted Service Provider

External collection and

transport Municipality

- Infectious/highly infectious (solid & liquid) - Anatomical - Sharps - Pathological (Lab) - Pharmaceutical - Radiocative - Cytotoxic/Genotoxic Some items

require a system for

cleaning e.g. reusable

containers.

Non-clinical glass Paper Cardboard Containers

Reuse

Bottles, Paper Cardboard Tins Plastic bottles etc

Recycle

remaining items of HCGW (including food for disposal

Remaining HCGW - Mercury

- Silver - Asbestos - flurorescent tubes - Chemicals - Grease - Oil - Paints - Solvents - Batteries - Electronic waste

External collection and transport by

contracted SP

External collection and transport by contracted SP

Disposal of residue of treatment to a

hazardous (H:H or H:h) landfill site.

Disposal of HCGW to a non-

hazardous Landfill site.

To sewer Disposal of residues of treatment and/or disposal to a H:H or

H:h landfill site.

Treatment through burn or non-burn

technologies

Reprocessing of recycled materials.

Only that with a pH values >6 to

<10

Some reprocessing for recycling

Some for disposal

Where is the HCWM Industry at present?

�  Focus on Illegal dumping

�  Focus on Treatment Facilities

�  Focus on good segregation

�  Focus on training

Historical focus on Segregation

�  Continual focus on good segregation

�  The results research conducted in two projects:

�  National Solid Waste Management Strategy for Swaziland - Mbabane Hospital (2000 – 2001)

�  Sustainable health care waste management in Gauteng - Leratong and Itireleng (2000 – 2003)

Result of the research on segregation

1.  Insufficient containers and / or liners at point of generation

2.  Inconsistent colour coding

3.  No disposable containers

4.  Incorrect type, sizes of containers used

5.  Incorrect placing of equipment

6.  Poor inter-relations between departments

7.  Poor job performance

8.  Non-adherence to colour coding

9.  lack of people management and accountability

10.  lack of regular monitoring and supervision

Historical focus on Training

�  Training frequently considered as the panacea for all the ails the industry

�  Training cannot be effective in isolation

So, what are the critical shifts?

1.  Impact that procurement has on all the 7 steps

2.  Impact that poor storage facilities at dispatch has on ability to plan and provide containers at source

3.  Impact that poor segregation has on internal and external collection, transport and treatment

4.  Impact that lack of adequate interim storage has on internal transport and within the hospital environment

5.  Impact of inadequate internal transportation systems

6.  Impact that the Central Storage has on the hospital environment and external collection and transportation

1. Impact of Procurement on 7 steps of cradle-to-grave

�  Correct containers for the type of waste

�  Supplied at the right time

�  Types of containers purchased impacts on placement

�  Interim storage requirements are determined by the type of size of containers (or vice versa)

�  Internal transport needs are determined by the type of containers used

�  The types and sizes of containers used to store the waste will impact on the size of the Central Storage area

�  External transport needs to cater for the type of container

�  The containers (whether single use or reusable) impact on how treatment is carried out

Procurement needs

�  Knowledge of the types, sizes and colours of containers required

�  Budget to purchase the necessary items

�  Good stock control system in place to maintain a consistent supply and order before stock runs out

�  Sufficient stock for emergency situations

�  Ordering routines set up in accordance with usage, size of the facility and delivery delays

2. Impact of poor storage facilities at dispatch store

�  Inadequate storage for new items resulting in the need to keep small quantities of consumable items

�  Ordering required to be done on more frequent intervals

�  Poor security at storage areas

• Uncontrolled stock levels in units

• Stores not aware of the impact of shortages

Before: After:

• Sufficient  stock  for  levels  in  the  central  warehouse  

Regular  supply  and  good  stock  control

Storage needs at dispatch store

�  Storage needs for consumable items planned.

�  Size determined by quantities generated

�  Access for delivery vehicle with sufficient space for turning circles

�  Storage space sufficient in size to accommodate 2 – 3 months supply

�  Storage requirements for new reusable containers awaiting distribution.

�  Secure store, sufficient venitlation, good lighting, protection from the elements, (closed brick building)

1

10

100

1,000

0 1,000 2,000 3,000 4,000 5,000 6,000 7,000

Stor

age

area

requ

ired

-m2

(loga

rithm

ic s

cale

)

Daily HCRW mass generation - kgs

180

120

90

60

30

Stock-holding (days):

Storage area required for consumable HCRW containers at hospitals and MOUs

120180

9060

30

3. Impact of poor segregation

�  Injury to collection and transport staff

�  Additional expense incurred due to larger quantities required to be incinerated

�  Larger items such as gas cylinders thrown into the waste

�  Dumping of HCRW on landfill as HCGW

�  Access of children to infectious waste and sharps

Support needs for good segregation

�  Supply of sufficient containers for all categories of HCW generated

�  Correct placing for easy access on walls and floor �  Brackets on walls, baskets or containers on floors, dressing

trolleys and/or other means for getting the waste containers to source

�  Sufficient height where containers are safe and not accessible to children

�  Small autoclaves in laboratories provided to reduce highly infectious waste

�  Space for wheelie bins or trolleys to maneuver during internal transport

�  Regular removal of full containers with frequency determined by the quantities of HCW generated

4. Impact of lack of adequate interim storage

�  Build-up of HCRW within the wards

�  Exposure to patients and visitors

�  Infection control compromised

Interim storage needs �  Temporary storage of the size to accommodate the

generation of 2 – 3 days of HCRW (over weekends or when the internal collection does not happen)

�  Sufficient in size to accommodate both HCRW and HCGW.

�  Able to accommodate the containers for each category of waste generated in the HC Facility. (Plastic boxes in smaller units, wheelie bins in larger units)

�  Space for refrigeration of anatomical waste if the need to store for longer than 24 hours.

�  Space required for the storage of pathological in laboratories and pharmaceutical waste in pharmacies

�  Well ventilated, adequate light, smooth surfaces, good ventilation

5. Impact of poor internal collection and transport

�  Exposure of HCRW to patients and visitors

�  Exposure to staff transporting

�  Infection Control principles compromised

Needs for Internal Transport

�  HCRW and HCGW transported separately

�  Larger HC Facilities can have a separate service route/lifts

�  Routes and lifts large enough to allow for size of containers and turning circles

�  Trolleys provided sufficient support

�  Ramps/slopes provided instead of steps

�  Provision made for motorised transport in larger hospitals

6. Impact of poor central storage facilities

�  Accumulation of HCW in all different areas of the HC Facility

�  More frequent collections required

�  Access to HCRW by patients and visitors

�  Infection control principles compromised

�  Injury to staff and transporters

�  Cleaning of reusable containers not carried out regularly

Central Storage Area needs

�  Size of the storage area determined by the quantities of waste generated over a given period and the specified frequency of collection

�  Space requirements are also determined by the size of the reusable bins (wheelie bins in larger facilities or plastic boxes in smaller facilities)

�  Freezer or cold room (2 degrees C or less) required for the storage of anatomic al waste if stored for longer than 24 hours

�  .

-

500

1,000

1,500

2,000

2,500

3,000 0 1,000 2,000 3,000 4,000 5,000 6,000 7,000

Usa

ble

beds

Daily HCRW mass generation (kg)

Central Hospital

60%

80%

100%

Bed occupancy:

0

200

400

600

800

1,000

1,200

1,400

0 1,000 2,000 3,000 4,000 5,000 6,000 7,000

Stor

age

area

requ

ired

m2

301697543

Collection interval (days):

Storage area required for full 100 Lre-usable box containers

3

7

5

4

16

9

30

0

200

400

600

800

1,000

1,200

1,400

1,600

0 1,000 2,000 3,000 4,000 5,000 6,000 7,000

Stor

age

area

requ

ired

m2

301697543

Collection interval (days):

Storage area required for full 770 L wheelie-bins

7

5

3

9

4

1630

Central Storage Area needs

�  Both HCGW and HCRW is required to be stored for periods of time

�  Ideal to have an area that can accommodate the full spectrum of HCW (including recycling)

�  Reduction of HCGW can be achieved by having waste compactors on site in the larger hospitals

�  Provision for clean and dirty areas

�  Provision for scales

�  Provision made for the storage of oil, grease, thinners, paint etc.

�  Provision made for the storing and collection of recycled items

Central Storage Area needs

�  Provision made for good ventilation and lighting, easy cleaning and drainage, emergency lighting, access control, signage.

�  Easy access to the area for wheelie bins, and vehicles of different sizes

�  Provision made for cleaning of reusable containers

Summary

The nursing staff are the proverbial ham in the sandwich where HCWM is concerned.

They cannot effectively operate without:

�  Proper procurement and dispatching facilities and procedures for the regular supply of containers

�  The full support of hospital services for the provision of adequate facilities and systems