assignment on safe waste disposal of hospital waste

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Health-care waste

• Of the total amount of waste generated by health-care activities, about 85% is general, non-hazardous waste.
• The remaining 15% is considered hazardous material that may be infectious, toxic or radioactive.
• Every year an estimated 16 billion injections are administered worldwide, but not all of the needles and syringes are properly disposed of afterwards.
• Open burning and incineration of health care wastes can, under some circumstances, result in the emission of dioxins, furans, and particulate matter.
• Measures to ensure the safe and environmentally sound management of health care wastes can prevent adverse health and environmental impacts from such waste including the unintended release of chemical or biological hazards, including drug-resistant microorganisms, into the environment thus protecting the health of patients, health workers, and the general public.

Health-care activities protect and restore health and save lives. But what about the waste and by-products they generate?

Of the total amount of waste generated by health-care activities, about 85% is general, non-hazardous waste comparable to domestic waste. The remaining 15% is considered hazardous material that may be infectious, chemical or radioactive.

Types of waste

Waste and by-products cover a diverse range of materials, as the following list illustrates:

• Infectious waste:  waste contaminated with blood and other bodily fluids (e.g. from discarded diagnostic samples), cultures and stocks of infectious agents from laboratory work (e.g. waste from autopsies and infected animals from laboratories), or waste from patients with infections (e.g. swabs, bandages and disposable medical devices);
• Pathological waste:  human tissues, organs or fluids, body parts and contaminated animal carcasses;
• Sharps waste:  syringes, needles, disposable scalpels and blades, etc.;
• Chemical waste:  for example solvents and reagents used for laboratory preparations, disinfectants, sterilants and heavy metals contained in medical devices (e.g. mercury in broken thermometers) and batteries;
• Pharmaceutical waste:  expired, unused and contaminated drugs and vaccines;
• Cytotoxic waste:  waste containing substances with genotoxic properties (i.e. highly hazardous substances that are, mutagenic, teratogenic or carcinogenic), such as cytotoxic drugs used in cancer treatment and their metabolites;
• Radioactive waste:  such as products contaminated by radionuclides including radioactive diagnostic material or radiotherapeutic materials; and
• Non-hazardous or general waste:  waste that does not pose any particular biological, chemical, radioactive or physical hazard.

The major sources of health-care waste are:

• hospitals and other health facilities
• laboratories and research centres
• mortuary and autopsy centres
• animal research and testing laboratories
• blood banks and collection services
• nursing homes for the elderly

High-income countries generate on average up to 0.5 kg of hazardous waste per hospital bed per day; while low-income countries generate on average 0.2 kg. However, health-care waste is often not separated into hazardous or non-hazardous wastes in low-income countries making the real quantity of hazardous waste much higher.

Health risks

Health-care waste contains potentially harmful microorganisms that can infect hospital patients, health workers and the general public. Other potential hazards may include drug-resistant microorganisms which spread from health facilities into the environment.

Adverse health outcomes associated with health care waste and by-products also include:

• sharps-inflicted injuries;
• toxic exposure to pharmaceutical products, in particular, antibiotics and cytotoxic drugs released into the surrounding environment, and to substances such as mercury or dioxins, during the handling or incineration of health care wastes;
• chemical burns arising in the context of disinfection, sterilization or waste treatment activities;
• air pollution arising as a result of the release of particulate matter during medical waste incineration;
• thermal injuries occurring in conjunction with open burning and the operation of medical waste incinerators; and
• radiation burns.

Sharps-related

Worldwide, an estimated 16 billion injections are administered every year. Not all needles and syringes are disposed of safely, creating a risk of injury and infection and opportunities for reuse.

Injections with contaminated needles and syringes in low- and middle-income countries have reduced substantially in recent years, partly due to efforts to reduce reuse of injection devices. Despite this progress, in 2010, unsafe injections were still responsible for as many as 33 800 new HIV infections, 1.7 million hepatitis B infections and 315 000 hepatitis C infections  (1) .

A person who experiences one needle stick injury from a needle used on an infected source patient has risks of 30%, 1.8%, and 0.3% respectively of becoming infected with HBV, HCV and HIV.

Additional hazards occur from scavenging at waste disposal sites and during the handling and manual sorting of hazardous waste from health-care facilities. These practices are common in many regions of the world, especially in low- and middle-income countries. The waste handlers are at immediate risk of needle-stick injuries and exposure to toxic or infectious materials.

In 2015, a joint WHO/UNICEF assessment found that just over half (58%) of sampled facilities from 24 countries had adequate systems in place for the safe disposal of health care waste  (2) .

Environmental Impact

Treatment and disposal of healthcare waste may pose health risks indirectly through the release of pathogens and toxic pollutants into the environment.

• The disposal of untreated health care wastes in landfills can lead to the contamination of drinking, surface, and ground waters if those landfills are not properly constructed.
• The treatment of health care wastes with chemical disinfectants can result in the release of chemical substances into the environment if those substances are not handled, stored and disposed in an environmentally sound manner.
• Incineration of waste has been widely practised, but inadequate incineration or the incineration of unsuitable materials results in the release of pollutants into the air and in the generation of ash residue. Incinerated materials containing or treated with chlorine can generate dioxins and furans, which are human carcinogens and have been associated with a range of adverse health effects. Incineration of heavy metals or materials with high metal content (in particular lead, mercury and cadmium) can lead to the spread of toxic metals in the environment.
• Only modern incinerators operating at 850-1100 °C and fitted with special gas-cleaning equipment are able to comply with the international emission standards for dioxins and furans.
• Alternatives to incineration such as autoclaving, microwaving, steam treatment integrated with internal mixing, which minimize the formation and release of chemicals or hazardous emissions should be given consideration in settings where there are sufficient resources to operate and maintain such systems and dispose of the treated waste.

Waste management: reasons for failure

Lack of awareness about the health hazards related to health-care waste, inadequate training in proper waste management, absence of waste management and disposal systems, insufficient financial and human resources and the low priority given to the topic are the most common problems connected with health-care waste. Many countries either do not have appropriate regulations, or do not enforce them.

The way forward

The management of health-care waste requires increased attention and diligence to avoid adverse health outcomes associated with poor practice, including exposure to infectious agents and toxic substances.

Key elements in improving health-care waste management are:

• promoting practices that reduce the volume of wastes generated and ensure proposer waste segregation;
• developing strategies and systems along with strong oversight and regulation to incrementally improve waste segregation, destruction and disposal practices with the ultimate aim of meeting national and international standards;
• where feasible, favouring the safe and environmentally sound treatment of hazardous health care wastes (e,g, by autoclaving, microwaving, steam treatment integrated with internal mixing, and chemical treatment) over medical waste incineration;
• building a comprehensive system, addressing responsibilities, resource allocation, handling and disposal. This is a long-term process, sustained by gradual improvements;
• raising awareness of the risks related to health-care waste, and of safe practices; and
• selecting safe and environmentally-friendly management options, to protect people from hazards when collecting, handling, storing, transporting, treating or disposing of waste.

Government commitment and support is needed for universal, long-term improvement, although immediate action can be taken locally.

WHO response

WHO developed the first global and comprehensive guidance document,  Safe management of wastes from health-care activities , now in its second edition and more recently a short guide that summarizes the key elements.

• Safe management of wastes from health-care activities

The guide addresses aspects such as regulatory framework, planning issues, waste minimization and recycling, handling, storage and transportation, treatment and disposal options, and training. The document is aimed at managers of hospitals and other health-care facilities, policy makers, public health professionals and managers involved in waste management. In addition, as part of monitoring Sustainable Development Goal 6 on safely managed water and sanitation, the WHO/UNICEF Joint Monitoring Programme will regularly report on safe management of health care waste as part of wider monitoring efforts on water and sanitation in health care facilities.

In collaboration with other partners, WHO also developed a series of training modules on good practices in health-care waste management covering all aspects of waste management activities from identification and classification of wastes to considerations guiding their safe disposal using both non-incineration or incineration strategies.

WHO guidance documents on health-care waste are also available including:

• a monitoring tool;
• a cost assessment tool;
• a rapid assessment tool;
• a policy paper;
• guidance to develop national plans;
• management of waste from injection activities;
• management of waste at primary health care centres;
• management of waste from mass immunization activities; and
• management of waste in emergencies.

In addition, WHO and UNICEF together with partners in 2015 launched a global initiative to ensure that all health care facilities have adequate water, sanitation and hygiene services. This includes addressing health care waste.

(1)  Pépin J, Abou Chakra CN, Pépin E, Nault V, Valiquette L. Evolution of the global burden of viral infections from unsafe medical injections, 2000-2010.PLoSOne. 2014 Jun 9;9(6):e99677.  (2)  WHO/UNICEF,2015. Water, sanitation and hygiene in health care facilities: status in low- and middle-income countries. World Health Organization, Geneva.

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I. Regulated Medical Waste

At a glance.

Guidelines for regulated medical waste from the Guidelines for Environmental Infection Control in Health-Care Facilities (2003).

1. Epidemiology

No epidemiologic evidence suggests that most of the solid- or liquid wastes from hospitals, other healthcare facilities, or clinical/research laboratories is any more infective than residential waste. Several studies have compared the microbial load and the diversity of microorganisms in residential wastes and wastes obtained from a variety of health-care settings. 1399–1402 Although hospital wastes had a greater number of different bacterial species compared with residential waste, wastes from residences were more heavily contaminated. 1397, 1398 Moreover, no epidemiologic evidence suggests that traditional waste-disposal practices of health-care facilities (whereby clinical and microbiological wastes were decontaminated on site before leaving the facility) have caused disease in either the health-care setting or the general community. 1400, 1401 This statement excludes, however, sharps injuries sustained during or immediately after the delivery of patient care before the sharp is "discarded." Therefore, identifying wastes for which handling and disposal precautions are indicated is largely a matter of judgment about the relative risk of disease transmission, because no reasonable standards on which to base these determinations have been developed. Aesthetic and emotional considerations (originating during the early years of the HIV epidemic) have, however, figured into the development of treatment and disposal policies, particularly for pathology and anatomy wastes and sharps. 1402–1405 Public concerns have resulted in the promulgation of federal, state, and local rules and regulations regarding medical waste management and disposal. 1406–1414

2. Categories of Medical Waste

Precisely defining medical waste on the basis of quantity and type of etiologic agents present is virtually impossible. The most practical approach to medical waste management is to identify wastes that represent a sufficient potential risk of causing infection during handling and disposal and for which some precautions likely are prudent. 2 Health-care facility medical wastes targeted for handling and disposal precautions include microbiology laboratory waste (e.g., microbiologic cultures and stocks of microorganisms), pathology and anatomy waste, blood specimens from clinics and laboratories, blood products, and other body-fluid specimens. 2 Moreover, the risk of either injury or infection from certain sharp items (e.g., needles and scalpel blades) contaminated with blood also must be considered. Although any item that has had contact with blood, exudates, or secretions may be potentially infective, treating all such waste as infective is neither practical nor necessary. Federal, state, and local guidelines and regulations specify the categories of medical waste that are subject to regulation and outline the requirements associated with treatment and disposal. The categorization of these wastes has generated the term "regulated medical waste." This term emphasizes the role of regulation in defining the actual material and as an alternative to "infectious waste," given the lack of evidence of this type of waste's infectivity. State regulations also address the degree or amount of contamination (e.g., blood-soaked gauze) that defines the discarded item as a regulated medical waste. The EPA's Manual for Infectious Waste Management identifies and categorizes other specific types of waste generated in health-care facilities with research laboratories that also require handling precautions. 1406

3. Management of Regulated Medical Waste in Health-Care Facilities

Ebola virus disease [august 2014] ‎.

Medical wastes require careful disposal and containment before collection and consolidation for treatment. OSHA has dictated initial measures for discarding regulated medical-waste items. These measures are designed to protect the workers who generate medical wastes and who manage the wastes from point of generation to disposal. 967 A single, leak-resistant biohazard bag is usually adequate for containment of regulated medical wastes, provided the bag is sturdy and the waste can be discarded without contaminating the bag's exterior. The contamination or puncturing of the bag requires placement into a second biohazard bag. All bags should be securely closed for disposal. Puncture-resistant containers located at the point of use (e.g., sharps containers) are used as containment for discarded slides or tubes with small amounts of blood, scalpel blades, needles and syringes, and unused sterile sharps. 967 To prevent needlestick injuries, needles and other contaminated sharps should not be recapped, purposefully bent, or broken by hand. CDC has published general guidelines for handling sharps. 6, 1415 Health-care facilities may need additional precautions to prevent the production of aerosols during the handling of blood-contaminated items for certain rare diseases or conditions (e.g., Lassa fever and Ebola virus infection). 203 Transporting and storing regulated medical wastes within the health-care facility prior to terminal treatment is often necessary. Both federal and state regulations address the safe transport and storage of on- and off-site regulated medical wastes. 1406–1408 Health-care facilities are instructed to dispose medical wastes regularly to avoid accumulation. Medical wastes requiring storage should be kept in labeled, leak-proof, puncture-resistant containers under conditions that minimize or prevent foul odors. The storage area should be well ventilated and be inaccessible to pests. Any facility that generates regulated medical wastes should have a regulated medical waste management plan to ensure health and environmental safety as per federal, state, and local regulations.

Medical wastes require careful disposal and containment before collection and consolidation for treatment. OSHA has dictated initial measures for discarding regulated medical-waste items. These measures are designed to protect the workers who generate medical wastes and who manage the wastes from point of generation to disposal. 967 A single, leak-resistant biohazard bag is usually adequate for containment of regulated medical wastes, provided the bag is sturdy and the waste can be discarded without contaminating the bag's exterior. The contamination or puncturing of the bag requires placement into a second biohazard bag. All bags should be securely closed for disposal. Puncture-resistant containers located at the point of use (e.g., sharps containers) are used as containment for discarded slides or tubes with small amounts of blood, scalpel blades, needles and syringes, and unused sterile sharps. 967 To prevent needlestick injuries, needles and other contaminated sharps should not be recapped, purposefully bent, or broken by hand. CDC has published general guidelines for handling sharps. 6, 1415 Health-care facilities may need additional precautions to prevent the production of aerosols during the handling of blood-contaminated items for certain rare diseases or conditions (e.g., Lassa fever and Ebola virus infection). 203

Transporting and storing regulated medical wastes within the health-care facility prior to terminal treatment is often necessary. Both federal and state regulations address the safe transport and storage of on- and off-site regulated medical wastes. 1406–1408 Health-care facilities are instructed to dispose medical wastes regularly to avoid accumulation. Medical wastes requiring storage should be kept in labeled, leak-proof, puncture-resistant containers under conditions that minimize or prevent foul odors. The storage area should be well ventilated and be inaccessible to pests. Any facility that generates regulated medical wastes should have a regulated medical waste management plan to ensure health and environmental safety as per federal, state, and local regulations.

4. Treatment of Regulated Medical Waste

Regulated medical wastes are treated or decontaminated to reduce the microbial load in or on the waste and to render the by-products safe for further handling and disposal. From a microbiologic standpoint, waste need not be rendered "sterile" because the treated waste will not be deposited in a sterile site. In addition, waste need not be subjected to the same reprocessing standards as are surgical instruments. Historically, treatment methods involved steam-sterilization (i.e., autoclaving), incineration, or interment (for anatomy wastes). Alternative treatment methods developed in recent years include chemical disinfection, grinding/shredding/disinfection methods, energy-based technologies (e.g., microwave or radiowave treatments), and disinfection/encapsulation methods. 1409 State medical waste regulations specify appropriate treatment methods for each category of regulated medical waste.

Of all the categories comprising regulated medical waste, microbiologic wastes (e.g., untreated cultures, stocks, and amplified microbial populations) pose the greatest potential for infectious disease transmission, and sharps pose the greatest risk for injuries. Untreated stocks and cultures of microorganisms are subsets of the clinical laboratory or microbiologic waste stream. If the microorganism must be grown and amplified in culture to high concentration to permit work with the specimen, this item should be considered for on-site decontamination, preferably within the laboratory unit. Historically, this was accomplished effectively by either autoclaving (steam sterilization) or incineration. If steam sterilization in the health-care facility is used for waste treatment, exposure of the waste for up to 90 minutes at 250°F (121°C) in a autoclave (depending on the size of the load and type container) may be necessary to ensure an adequate decontamination cycle. 1416–1418 After steam sterilization, the residue can be safely handled and discarded with all other nonhazardous solid waste in accordance with state solid-waste disposal regulations. On-site incineration is another treatment option for microbiologic, pathologic, and anatomic waste, provided the incinerator is engineered to burn these wastes completely and stay within EPA emissions standards. 1410 Improper incineration of waste with high moisture and low energy content (e.g., pathology waste) can lead to emission problems. State medical-waste regulatory programs identify acceptable methods for inactivating amplified stocks and cultures of microorganisms, some of which may employ technology rather than steam sterilization or incineration.

Concerns have been raised about the ability of modern health-care facilities to inactivate microbiologic wastes on-site, given that many of these institutions have decommissioned their laboratory autoclaves. Current laboratory guidelines for working with infectious microorganisms at biosafety level (BSL) 3 recommend that all laboratory waste be decontaminated before disposal by an approved method, preferably within the laboratory. 1013 These same guidelines recommend that all materials removed from a BSL 4 laboratory (unless they are biological materials that are to remain viable) are to be decontaminated before they leave the laboratory. 1013 Recent federal regulations for laboratories that handle certain biological agents known as "select agents" (i.e., those that have the potential to pose a severe threat to public health and safety) require these agents (and those obtained from a clinical specimen intended for diagnostic, reference, or verification purposes) to be destroyed on-site before disposal. 1412 Although recommendations for laboratory waste disposal from BSL 1 or 2 laboratories (e.g., most health-care clinical and diagnostic laboratories) allow for these materials to be decontaminated off-site before disposal, on-site decontamination by a known effective method is preferred to reduce the potential of exposure during the handling of infectious material.

A recent outbreak of TB among workers in a regional medical-waste treatment facility in the United States demonstrated the hazards associated with aerosolized microbiologic wastes. 1419, 1420 The facility received diagnostic cultures of Mycobacterium tuberculosis from several different health-care facilities before these cultures were chemically disinfected; this facility treated this waste with a grinding/shredding process that generated aerosols from the material. 1419, 1420 Several operational deficiencies facilitated the release of aerosols and exposed workers to airborne M. tuberculosis . Among the suggested control measures was that health-care facilities perform on-site decontamination of laboratory waste containing live cultures of microorganisms before release of the waste to a waste management company. 1419, 1420 This measure is supported by recommendations found in the CDC/NIH guideline for laboratory workers. 1013 This outbreak demonstrates the need to avoid the use of any medical-waste treatment method or technology that can aerosolize pathogens from live cultures and stocks (especially those of airborne microorganisms) unless aerosols can be effectively contained and workers can be equipped with proper PPE. 1419–1421 Safe laboratory practices, including those addressing waste management, have been published. 1013, 1422

In an era when local, state, and federal health-care facilities and laboratories are developing bioterrorism response strategies and capabilities, the need to reinstate in-laboratory capacity to destroy cultures and stocks of microorganisms becomes a relevant issue. 1423 Recent federal regulations require health-care facility laboratories to maintain the capability of destroying discarded cultures and stocks on-site if these laboratories isolate from a clinical specimen any microorganism or toxin identified as a "select agent" from a clinical specimen (Table 27). 1412, 1413 As an alternative, isolated cultures of select agents can be transferred to a facility registered to accept these agents in accordance with federal regulations. 1412 State medical waste regulations can, however, complicate or completely prevent this transfer if these cultures are determined to be medical waste, because most states regulate the inter-facility transfer of untreated medical wastes.

Table 27. Microorganisms and biologicals identified as select agents A

Table 27 A. HHS Non-overlap select agents and toxins (42 CFR Part 73 §73.4) B

• Crimean-Congo hemorrhagic fever virus; Ebola viruses; Cercopithecine herpesvirus 1 (herpes B virus); Lassa fever virus; Marburg virus; monkeypox virus; South American hemorrhagic fever viruses (Junin, Machupo, Sabia, Flexal, Guanarito); tick-borne encephalitis complex (flavi) viruses (Central European tick-borne encephalitis, Far Eastern tick-borne encephalitis [Russian spring and summer encephalitis, Kyasnaur Forest disease, Omsk hemorrhagic fever]); variola major virus (smallpox virus); and variola minor virus (alastrim)
• Exclusions : C Vaccine strain of Junin virus (Candid. #1)
• Rickettsia prowazekii, R. rickettsii, Yersinia pestis
• Coccidioides posadasii
• Abrin; conotoxins; diacetoxyscirpenol; ricin; saxitoxin; Shiga-like ribosome inactivating proteins; tetrodotoxin
• Exclusions C : The following toxins (in purified form or in combinations of pure and impure forms) if the aggregate amount under the control of a principal investigator does not, at any time, exceed the amount specified: 100 mg of abrin; 100 mg of conotoxins; 1,000 mg of diacetoxyscirpenol; 100 mg of ricin; 100 mg of saxitoxin; 100 mg of Shiga-like ribosome inactivating proteins; or 100 mg of tetrodotoxin
• Select agent viral nucleic acids (synthetic or naturally-derived, contiguous or fragmented, in host chromosomes or in expression vectors) that can encode infectious and/or replication competent forms of any of the select agent viruses;
• Nucleic acids (synthetic or naturally-derived) that encode for the functional form(s) of any of the toxins listed in this table if the nucleic acids: are in a vector or host chromosome; can be expressed in vivo or in vitro ; or are in a vector or host chromosome and can be expressed in vivo or in vitro ;
• Viruses, bacteria, fungi, and toxins listed in this table that have been genetically modified.

Table 27 B. High consequence livestock pathogens and toxins/select agents (overlap agents) (42 CFR Part 73 §73.5 and USDA regulation 9 CFR Part 121) B

• Eastern equine encephalitis virus; Nipah and Hendra complex viruses; Rift Valley fever virus; Venezuelan equine encephalitis virus
• Exclusions: C MP-12 vaccine strain of Rift Valley fever virus; TC-83 vaccine strain of Venezuelan equine encephalitis virus
• Bacillus anthracis; Brucella abortus, B. melitensis, B. suis; Burkholderia mallei (formerly Pseudomonas mallei), B. pseudomallei (formerly P. pseudomallei); botulinum neurotoxin- producing species of Clostridium; Coxiella burnetii; Francisella tularensis
• Coccidioides immitis
• Botulinum neurotoxins; Clostridium perfringens epsilon toxin; Shigatoxin; staphylococcal enterotoxins; T-2 toxin
• Exclusions: C The following toxins (in purified form or in combinations of pure and impure forms) if the aggregate amount under the control of a principal investigator does not, at any time, exceed the amount specified: 0.5 mg of botulinum neurotoxins; 100 mg of Clostridium perfringens epsilon toxin; 100 mg of Shigatoxin; 5 mg of staphylococcal enterotoxins; or 1,000 mg of T-2 toxin
• Select agent viral nuclei acids (synthetic or naturally derived, contiguous or fragmented, in host chromosomes or in expression vectors) thatcan encode infectious and/or replication competent forms of any of the select agent viruses;
• Nucleic acids (synthetic or naturally derived) that encode for the functional form(s) of any of the toxins listed in this table if the nucleic acids: are in a vector or host chromosome; can be expressed in vivo or in vitro ; or are in a vector or host chromosome and can be expressed in vivo or in vitro ;

5. Discharging Blood, Fluids to Sanitary Sewers or Septic Tanks

The contents of all vessels that contain more than a few milliliters of blood remaining after laboratory procedures, suction fluids, or bulk blood can either be inactivated in accordance with state-approved treatment technologies or carefully poured down a utility sink drain or toilet. 1414 State regulations may dictate the maximum volume allowable for discharge of blood/body fluids to the sanitary sewer. No evidence indicates that bloodborne diseases have been transmitted from contact with raw or treated sewage. Many bloodborne pathogens, particularly bloodborne viruses, are not stable in the environment for long periods of time; 1425, 1426 therefore, the discharge of small quantities of blood and other body fluids to the sanitary sewer is considered a safe method of disposing of these waste materials. 1414 The following factors increase the likelihood that bloodborne pathogens will be inactivated in the disposal process:

• dilution of the discharged materials with water
• inactivation of pathogens resulting from exposure to cleaning chemicals, disinfectants, and other chemicals in raw sewage; and
• effectiveness of sewage treatment in inactivating any residual bloodborne pathogens that reach the treatment facility.

Small amounts of blood and other body fluids should not affect the functioning of a municipal sewer system. However, large quantities of these fluids, with their high protein content, might interfere with the biological oxygen demand (BOD) of the system. Local municipal sewage treatment restrictions may dictate that an alternative method of bulk fluid disposal be selected. State regulations may dictate what quantity constitutes a small amount of blood or body fluids.

Although concerns have been raised about the discharge of blood and other body fluids to a septic tank system, no evidence suggests that septic tanks have transmitted bloodborne infections. A properly functioning septic system is adequate for inactivating bloodborne pathogens. System manufacturers' instructions specify what materials may be discharged to the septic tank without jeopardizing its proper operation.

6. Medical Waste and CJD

Concerns also have been raised about the need for special handling and treatment procedures for wastes generated during the care of patients with CJD or other transmissible spongiform encephalopathies (TSEs). Prions, the agents that cause TSEs, have significant resistance to inactivation by a variety of physical, chemical, or gaseous methods. 1427 No epidemiologic evidence, however, links acquisition of CJD with medical-waste disposal practices. Although handling neurologic tissue for pathologic examination and autopsy materials with care, using barrier precautions, and following specific procedures for the autopsy are prudent measures, 1197 employing extraordinary measures once the materials are discarded is unnecessary. Regulated medical wastes generated during the care of the CJD patient can be managed using the same strategies as wastes generated during the care of other patients. After decontamination, these wastes may then be disposed in a sanitary landfill or discharged to the sanitary sewer, as appropriate.

• Material in this table is compiled from references 1412, 1413, 1424. Reference 1424 also contains lists of select agents that include plant pathogens and pathogens affecting livestock.
• 42 CFR 73 §§73.4 and 73.5 do not include any select agent or toxin that is in its naturally-occurring environment, provided it has not been intentionally introduced, cultivated, collected, or otherwise extracted from its natural source. These sections also do not include non-viable select agent organisms or nonfunctional toxins. This list of select agents is current as of 3 October 2003 and is subject to change pending the final adoption of 42 CFR Part 73.
• These table entries are listed in reference 1412 and 1413, but were not included in reference 1424.

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Waste Disposal in Hospitals

Last updated on 26th April 2023

In this article

The NHS is Britain’s backbone – propping us up when we need it. It’s a vital resource that’s free at the point of use. However, the NHS does come at a cost – not only to taxpayers but also to the environment. Waste disposal in hospitals is something that not many of us think about.

We visit the nurse for a vaccine or cervical screening appointment, go to Accident and Emergency for a broken limb, or deliver a baby in the maternity unit without so much as a thought for all the hospital waste produced as a result.

According to BRE , the NHS produces a staggering 600,000 tonnes of waste each year. This adds up to over 1% of all domestic waste in the UK. Indeed, it comes as no surprise clinical waste is on the increase , thanks to Covid-19 and the fact that NHS services that were postponed for two years are now resuming.

What is hospital waste?

Hospital waste can also be known as medical waste or clinical waste. Specifically, clinical waste is any waste that poses a risk of contamination or infection. There are many other places besides hospitals that produce similar waste such as dental surgeries, doctors’ surgeries, research laboratories, funeral parlours, veterinary clinics, blood banks and nursing homes.

Other places that do not come under the remit of health practices, such as piercers, tattooists and complementary therapists, may also produce similar waste. Essentially, such waste includes anything that could have come into contact with a person’s body during examination, treatment or research, for example, or as a by-product of such work.

What are the different types of hospital waste?

Hospital waste is essentially categorised in two different ways: whether it is hazardous or non-hazardous.

There are lots of subcategories too that fall into both hazardous and non-hazardous types of hospital waste:

• Infectious waste.
• Anatomical waste.
• Offensive/hygiene waste.
• Chemical waste.
• Pharmaceutical waste.
• Cytotoxic waste.
• Mixed municipal waste.
• Recyclables.

Infectious waste

Infectious waste is any waste that has been contaminated with bodily fluids such as blood, infectious cultures from laboratories and waste from patients who have infections. This includes bandages, swabs, or other medical devices that are disposable.

Anatomical waste

This is sometimes called pathological waste. Essentially, anatomical waste is any waste that contains parts of the anatomy – body tissues. This includes waste such as body parts, organs and fluids such as blood. In a veterinary clinic, animal carcasses would come into this remit too. Anatomical waste is further separated into infectious and non-infectious anatomical waste and is also labelled as to whether it contains any chemicals.

Offensive/Hygiene waste

Offensive waste is anything that is likely to cause an ‘offence’ to the senses and is unpleasant, i.e. due to its smell. This type of waste is not classed as clinical or hazardous waste and it includes things like sanitary protection, nappies and incontinence pads.

As you may have guessed, sharps waste is anything sharp such as needles, syringes, scalpels and blades. However, sharps waste is also separated into subcategories depending on the risk posed.

Sharps containers are specific for sharps that have been contaminated with cytotoxic and cytostatic substances, sharps that have been medically contaminated or non-medically contaminated.  Sharps that are not contaminated with bodily fluids are also categorised differently and are classed as ‘non-hazardous’ waste.

Chemical waste

Chemical waste can be both hazardous and non-hazardous depending on its properties. Most chemical waste in hospitals is considered hazardous. Such waste includes reagents and solvents used in laboratory work as well as X-ray fixers and developers. It also includes cleaning and sterilising agents and batteries.

Pharmaceutical waste

Pharmaceutical waste refers to medication and drug waste and is largely considered non-hazardous with the exception of cytotoxic and cytostatic medications. Hospitals dispose of medication that has expired or has been unused in open containers or packaging.

This also includes prescribed medications that have not been used or medication that belonged to someone who has died or who no longer has use for it.

Cytotoxic and cytostatic waste

Cytotoxic and cytostatic waste is always considered hazardous regardless of whether it has come into contact with a person. This is because it is hazardous due to its ‘genotoxic properties’. This means that the waste may be mutagenic (capable of causing a genetic mutation), carcinogenic (cancer-causing), teratogenic (causing damage to an embryo or foetus) or hazardous for reproduction.

Many hospital departments use products that are cytotoxic as they’re often used in treating cancers and other illnesses. This category includes radioactive wastes that are produced during diagnostic procedures and in radiotherapy.

Mixed municipal waste

Mixed municipal waste is standard domestic waste. Like our homes, hospitals generate a lot of waste that does not pose any risks to those who handle it. This waste comes from the hospital’s general and public bins, office waste, and food and catering waste.

Recyclables

Many items that are used in hospitals are not able to be recycled as they fall into the category of clinical waste or hazardous waste. Some organisations, such as the Waste and Resources Action Programme ( WRAP ), suggest that hospitals do not recycle nearly enough of their waste, with only 7% of healthcare plastic waste being recycled.

However, there are an increasing number of recycling bins for suitable items, particularly cardboard and plastic packaging items. Thanks to specialised shredders, hospitals can recycle paper waste even if it contained sensitive information.

Many of the general public are also unaware of recycling schemes – such as recycling used inhalers for asthma. These contain recyclable plastic and aluminium and can be returned to pharmacies for recycling.

How hospitals dispose of medical waste

It is important to differentiate the types of hospital waste so that hospitals and other medical or laboratory facilities are able to dispose of their waste correctly and safely. This is to protect healthcare workers, refuse workers and the general public.

The Health and Safety Executive and the Department of Health offer guidance and support on how healthcare waste can be managed safely . Hospitals and other establishments dealing with similar waste have a colour system to help waste handlers identify how to dispose of hospital waste correctly.

As is clear, most hospital waste requires incineration with some waste requiring specialist medical incinerators. This is to ensure that all traces of pathogens or infection are destroyed completely.

What are the hazards associated with hospital waste?

Hospital waste contains microorganisms that are potentially harmful and can infect healthcare workers and other patients as well as the public. There is a particular concern surrounding drug-resistant microorganisms that can spread from a hospital to other places. As they are drug-resistant, this makes them hard to treat.

Some of the hazards associated with hospital waste include:

• Injuries caused by sharps.
• Exposure to toxic products such as cytotoxic substances and drugs, whether directly or through the environment during handling or disposing of such waste.
• Burns caused by disinfection protocols and waste treatment.
• Air pollution due to incineration and the particulate matter released in emissions.
• Radiation burns from radioactive substances.
• Injuries associated with disposing of the waste, including burns when operating incinerators.

Sharps-related hazards

The Health and Safety Executive carried out an inspection of NHS organisations in 2015–16 to identify common causes of non-compliance with the Sharps Regulations that are in place to protect staff from the risk of exposure to blood-borne viruses (BBVs). The HSE found that 83% of the organisations failed to comply fully with the regulations.

According to research , sharps injuries are the most common injury that healthcare workers experience. However, the researchers believe that such injuries often go unreported and that the injury occurrence may actually be ten times that of what is reported. Thankfully, the research also notes that confirmed viral transmission due to a needlestick injury has been relatively rare.

The environment

As well as the risk of direct contact with a pathogen, hospital waste also poses health risks by its release into the environment either directly or due to how it is disposed of.

Some of the indirect hazards associated with hospital waste include:

• The incorrect disposal of waste in landfills can contaminate water supplies.
• Chemical wastes can be released into the environment if they are not disposed of correctly.
• Incineration of unsuitable hospital waste can lead to air pollution which includes furans and dioxins. These are harmful carcinogens and have adverse effects on humans. The incineration of metals such as mercury, cadmium and lead can also cause a spread of toxic substances in the environment.

How to manage hospital waste

Hospital waste management is something that must be taken extremely seriously. As outlined, disposing of hospital waste correctly reduces the risks to both people and the environment. It requires diligence and proactivity to prevent adverse risks to health that are often associated with the poor management of waste, including exposure to toxic substances and infectious materials.

According to the HSE , health providers must consider infection control and health and safety legislation, environmental and waste legislation and transport legislation when managing healthcare waste. Particular focus should be on ensuring that hospitals are compliant in how they manage waste by classifying, storing and transporting their waste appropriately as outlined in the Health Technical Memorandum 07-01.

Waste management failure

Unfortunately, hospital waste management is not always done effectively or properly. Often, this is due to a lack of awareness or training of those responsible for disposing of items. However, sometimes a hospital’s waste management systems and protocol are at fault.

They can be overly complicated or too vague, or they may not exist at all. In some cases, waste management is not a priority, often due to insufficient resources – both in terms of staffing and finances. Indeed, some nations do not have regulations regarding hospital waste or, if they do, they do not enforce these regulations.

How hospital waste management could be improved

To improve hospital waste management, organisations should promote practices that not only reduce the amount of waste that they generate but also ensure that waste is segregated appropriately. Hospitals must develop systems that meet all standards, both nationally and internationally.

Alternatives to incineration

The World Health Organization recommends that, where possible, hazardous waste should be treated by methods other than incineration to reduce the risks to the environment and indirect exposure to hazardous substances. These methods can include microwaving, autoclaving, chemical treatments and steaming treatments.

Create a system

Hospitals should ensure that they have the organisation required to dispose of waste correctly. This means that there should be a hierarchy of those responsible at each step in the process when it comes to clinical waste disposal. This system may take time to embed as all staff within a hospital or other care setting must be trained in its proper implementation and use for it to work effectively.

Those responsible for handling healthcare waste must also be made aware of the hazards and risks associated with their role. Full training should be given to all workers in hospitals and other clinical environments to ensure that safe practices are maintained at all times.

This training applies equally to volunteers, hospital café workers and cleaners all the way up to consultants and managers. Those handling substances that are hazardous to health should receive full COSHH training .

Introducing environmentally friendly practices

As mentioned, hospital waste is largely non-recyclable. However, even recyclable waste is often thrown away with municipal waste. For hospitals to manage their waste effectively and become sustainable in a world where climate change is an increasing concern, opting for environmentally friendly practices is paramount. Hospital leaders should investigate potential waste management options that are more sustainable and reduce environmental hazards.

Final thoughts

Hospital waste management and clinical waste disposal pose hazards to people and the environment. And, with almost 600,000 tonnes produced each year, it must be disposed of correctly. Having strong management and systems is the key to handling hospital waste correctly.

With strategies in place and forward-thinking from leaders, hospitals should be able to reduce their waste and find some environmentally friendly alternative to its disposal, at least in part.

Needles and Sharps

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About the author

Laura Allan

Laura is a former Modern Foreign Languages teacher who now works as a writer and translator. She is also acting Chair of Governors at her children’s primary school. Outside of work, Laura enjoys running and performing in amateur productions.

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Safe waste disposal of hospital waste

Hospital waste can also be known as medical waste or clinical waste. Specifically, clinical waste is any waste that poses a risk of contamination or infection. There are many other places besides hospitals that produce similar waste such as dental surgeries, doctors’ surgeries, research laboratories, funeral parlours, veterinary clinics, blood banks and nursing homes.

Proper disposal of hospital waste is critical for maintaining the health and safety of patients, healthcare workers, and the general public. Here are some recommended practices for safe waste disposal of hospital waste:

• Segregation of waste: The first step in safe waste disposal is to segregate different types of waste. This will ensure that each type of waste is treated and disposed of in the appropriate manner. Examples of waste categories include infectious waste, sharps waste, pharmaceutical waste, and hazardous waste.
• Labeling and marking of waste: Each category of waste should be clearly labeled and marked with appropriate color codes and symbols to indicate its contents and level of hazard. This will ensure that the waste is handled and disposed of properly.
• Use of appropriate containers: The use of appropriate containers is crucial for safe waste disposal. Each category of waste should be placed in a designated container that is appropriate for its contents and level of hazard. For example, infectious waste should be placed in leak-proof and puncture-resistant containers, while sharps waste should be placed in puncture-resistant containers.
• Proper transportation: Once the waste is properly segregated, labeled, and placed in appropriate containers, it should be transported to the disposal site using appropriate vehicles and procedures. The transportation process should be carefully planned and monitored to prevent spillage or release of hazardous materials.
• Proper disposal methods: There are various methods of hospital waste disposal, including incineration, autoclaving, chemical treatment, and landfilling. The choice of disposal method should be based on the type and level of hazard of the waste. It is important to follow local regulations and guidelines for safe waste disposal.
• Training of healthcare workers: Healthcare workers should be trained on safe waste disposal practices, including proper segregation, labeling, and handling of waste. They should also be provided with appropriate personal protective equipment (PPE) to prevent exposure to hazardous materials.
• Regular monitoring and auditing: Regular monitoring and auditing of waste disposal practices can help identify areas for improvement and ensure that safe practices are being followed. This can also help to prevent environmental contamination and protect public health.

Table of Contents

Risks Associated with Improper Waste Disposal

Improper waste disposal can have a range of negative effects on both human health and the environment. Some of the risks associated with improper waste disposal include:

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• Pollution of air and water: When waste is not properly disposed of, it can pollute the air and water. For example, burning of waste can release harmful gases and chemicals into the air, while dumping waste in bodies of water can contaminate the water and harm aquatic life.
• Spread of diseases: Improper waste disposal can also contribute to the spread of diseases. For example, discarded medical waste can contain pathogens that can cause infections and spread diseases.
• Soil contamination: Waste that is not properly disposed of can also contaminate the soil, making it unsuitable for agriculture or other uses.
• Hazardous waste exposure: Some types of waste, such as chemicals, batteries, and electronic waste, contain hazardous materials that can be harmful to human health if they are not disposed of properly.
• Climate change: Improper waste disposal can contribute to climate change by releasing greenhouse gases, such as methane, into the atmosphere.
• Wildlife harm: Improper waste disposal can have negative impacts on wildlife as well. For example, animals may ingest plastic waste, which can lead to injury or death.

Overall, proper waste disposal is critical to protecting human health and the environment. It is important to follow appropriate waste management practices and dispose of waste in a safe and responsible manner.

Color-code containers and waste bins

Hospital waste disposal involves the proper identification of the different types of medical waste and each type of medical waste requires a different disposal method. Segregating medical wastes based on their type helps ensure that each waste is discarded, transported, and destroyed properly. Waste bin color coding in hospitals help healthcare staff easily segregate waste and identify which waste goes to which container to help prevent issues arising from random or improper disposal.

Red – anatomical (e.g. blood, organs) Orange – clinical/infectious Yellow – clinical/highly infectious Blue – medicines (e.g. unused drugs) Purple – cytotoxic and/or cytostatic products (e.g. chemotherapy medicines) Black – municipal waste – ie. not clinical or medical waste White – dental

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• Knowledge Center

Why Hospital Waste Management is Important

Each person working in a hospital setting can be impacted by hospital waste management – and each person should be provided with training and education on how healthcare waste handling and disposal processes directly impacts infection control. 

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In this blog we will be covering:

1 /   Hospital Waste Management Definition

2 /   Importance of Waste Management in Hospital

3 /  Hospital Waste Management Tips

4 /  Benefits of Modern Waste Management in Hospitals

5 /  Key Challenges in Hospital Waste Management and Employee Training

6 /  Ensuring Compliance: Your Key Responsibility in Hospital Waste Management  

Hospital waste management definition  

Hospital waste management is defined as the systematic handling, segregation, treatment, and disposal of waste generated in healthcare settings. This includes everything from general waste to more hazardous materials such as sharps, pharmaceuticals, and chemical waste. The goal is to ensure environmental safety, compliance with medical waste regulations, and the protection of healthcare workers and patients.

Importance of waste management in hospitals

Hospital waste management is not a one-size-fits-all solution.

The importance of medical waste management is not to be understated. This is because various types of healthcare waste are generated by every department in a hospital, from the janitorial and housekeeping staff to surgical suites, infectious disease units, and so forth. The same thing can be said about Skilled Nursing communities – each facility has unique needs that vary due to the amount of beds, the procedures performed, and the specialties of healthcare.

Daniels Health takes the time to observe your current processes and complete waste audits before proposing any changes. We meet you where you are and build an improvement plan from there. 

Hospital Waste Management Tips  

Begin with an “inside the four walls” approach.

We work directly with clinical staff to drive better healthcare waste management. Through training, container placement and process improvement within the four walls, we influence safety, alter segregation behaviors, enhance efficiencies and drive substantial cost benefits for our customers.

Our "Inside the Four Walls" approach, used for both acute and non-acute facilities across the US, centers around:

• Safety Infection and Risk Minimization
• Waste Optimization
• Compliance and Education
• Position and Movement
• Storage Optimization   

To learn more about our "Inside the Four Walls" approach, click here.

Education on Hospital Waste Management

We know that education is the key to awareness and proper implementation of healthcare waste segregation and disposal processes inside healthcare facilities. Notable initiatives include recognizing various healthcare waste stream sources and conducting regular healthcare waste audits. These practices are essential components of effective waste management in hospitals, ensuring both safety and compliance.

At Daniels Health, we want to work with you and your staff to ensure everyone feels confident in compliantly disposing of healthcare waste. We are your partner; not just another "bag and a box" medical waste disposal company.

Adopt Simplified Healthcare Waste Management Solutions

We make healthcare waste segregation easy by implementing our bold, reusable containment systems. They are color-coded and optimally placed to help you quickly and safely dispose of healthcare waste. 

Implementing our reusable solutions goes beyond education and enforcement of healthcare waste segregation – by choosing Daniels you are reducing the volume of single-use plastic medical waste or sharps containers going to landfills. You are choosing to move your hospital or healthcare facility in a more sustainable direction.

Benefits of Modern Waste Management in Hospital  

Minimizing touch in hospital waste management.

Nowadays, we are all hyper-aware of how much we are touching any and all surfaces. A modern hospital waste management plan includes solutions that minimize touch. Daniels Health reusable containment systems are either wall-mounted, or on a mobile cart for point-of-use disposal. Our systems should only be touched twice: once placing an empty container in its designated location and secondly when the container is full - permanently locking it to place in a soiled utility room or loading area.

Enhancing Safety 

Not only do we specialize in containers that reduce touch – they are Safety Engineered Devices. Our Sharpsmart alone is peer-reviewed to prevent the risk of container-associated sharps injuries by over 80%!

Healthcare personnel in the US experience over 300,000 needlestick and/or other sharps-related injuries every year. Today the focus is not only on minimizing environmental waste, but increasing worker safety.

Increased Efficiency and Compliance

We know change can be scary and vigilant healthcare waste segregation can feel time-consuming. Nevertheless, enhanced education and improved reporting procedures not only increases efficiency but ensures compliance to federal and state guidelines.

Key Challenger in Hospital Waste Management and Employee Training  

Proper training in waste segregation and effective on-site management of hazardous waste are among the most critical aspects of hospital waste management.

Are your employees confident in the difference between the variety of healthcare waste streams you generate? We're talking:

• Sharps waste
• Biohazard waste  

Are they confident in the safe disposal of medicinal and non medicinal sharps? Have they used point-of-use disposal systems before? Daniels Health emphasizes the “less touches equals less risk” approach. Do your hospital employees know how sharps waste is defined? Sharps don't just reference needles ( ISO standard 23907:2012 ), but include:

• Empty ampoules
• Razor blades
• Suture needles

• Culture slides and dishes

It is up to you to ensure that your Cradle to Grave responsibilities are upheld. As the waste generator, you are legally responsible to properly segregate and dispose of healthcare waste with a management partner of your choice. Daniels Health has proudly supported US healthcare with reliable service for over 30 years – giving many peace of mind that their waste been properly treated.

Improper waste segregation and an overall lack of awareness costs hospitals tens of thousands of dollars a year. This is because some throw away a bulk of their waste into their biohazardous waste stream – even if it's not biohazard waste. One New York City hospital started an aggressive medical waste reduction program and shaved nearly one million dollars annually off their waste disposal costs!

Know the healthcare waste streams

Hospitals, surgery centers, dentists – whatever your size – your facility must be able to follow the trail proper waste segregation to ensure all the streams you generate are treated correctly. This is one of the many reasons why choosing a healthcare partner you can trust is so important – they need to understand your waste at a deep level.

It's essential for hospitals to have policies and procedures in place that regulate the handling and implementation of healthcare waste and the volume and type of waste generated. Just because something is “disposable” doesn't mean that it doesn't have to be handled properly in regard to segregation.

If you are unsure where you can improve your facility's waste management plan – begin with a waste audit. This can be done in-house by your team or in partnership with your healthcare waste services partner. Waste audits are an integral part of healthcare waste management and aid hospitals in determining the difference between clinical waste and non-clinical waste, as well as the proper segregation of waste streams.

Every hospital should have a plan in place to deal with their medical waste. For example, hospitals around the country have implemented best-practices approaches to deal with medical waste. Some of the topics covered include: 

• Biomedical waste management

• Self-auditing for different medical waste streams  

Every department within the hospital - from administration to janitorial - are given specific guidelines and instructions. Washington State created their best-practices guide for medical waste years ago. For example, the anesthesia department is instructed to handle spent charcoal filters as dangerous waste. The clinical research department was mandated to manage their chemicals and waste properly through the use of closed, clearly labeled, and dated containers stored in secured areas.

They took it further and required that secondary containment before proper disposal was needed in certain scenarios. The housekeeping department was provided very specific guidelines on the segregation and storage of solid, biomedical, and dangerous waste as well as recyclables.

Ensuring Compliance: Your Key Responsibility in Hospital Waste Management

The responsibility of adhering to federal and state guidelines for healthcare waste management and disposal belongs to the waste generator. Penalties and fines can be incurred even after medical waste leaves your hospital. Until its final disposition, it's your responsibility.

With over 30 years of experience, we have the expertise to maintain your compliance and be a long-term partner. Our sustainable and efficient hospital waste management solutions put safety of employees and the environment first. Our Safety Engineered Devices are proven to reduce sharps injuries, lower your carbon footprint, and increase efficiency with disposal.

The ever-evolving needs of Hospital healthcare waste management can be daunting, but as your partner, we can tackle it together - and well! To speak to one of our team members about how Daniels can help your hospital, click here.

SPEAK TO AN EXPERT    855 251 2655

Clinical Waste Educator

With 26 years experience working in healthcare, Amy has implemented sustainability initiatives for over 100 hospitals across the United States and brings unique practice and compliance expertise to healthcare waste management.

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• Iran J Nurs Midwifery Res
• v.17(6); Sep-Oct 2012

Function of nurses and other staff to minimize hospital waste in selected hospitals in Isfahan

Maryam maroufi.

Department of Podiatric Nursing, School of Nursing and Midwifery School, Isfahan University of Medical Sciences, Isfahan, Iran

Marzieh Javadi

1 Health Management and Economic Reasearch Center, Isfahan University of Medical Sciences, Isfahan, Iran

Maryam yaghoubi

2 Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran

Saied Karimi

3 Department of Health Services Management, Isfahan University of Medical Sciences, Isfahan, Iran

Medical waste (MW) is all waste materials generated at health care facilities. MW naturally is hazardous for environment and subsequently for human. Waste minimization (WM) is the latest alternative for risk reduction. All hospital staff generally and nurses specially can play an active role through education and the implementation of measures to reduce medical wastage and their environmental effects.

This study is aimed to compare nurses and other staff functions in selected hospitals in Isfahan about waste minimization strategies.

Settings and Design:

This is a descriptive analytical study. The study tool was a researcher -designed questionnaire in five area of waste minimization based on WHO recommendation.

Materials and Methods:

There were 90 nurses and other staff from randomized selected public and private hospitals of Isfahan as the sample of this research. This study was done in 2009.

Statistical Analysis Used:

Data were analyzed by t-test using SPSS 16 .

Nurses mean score of WM performance was 58.16 (12), and others was 58.56 (12.18) (of max 100). There was no significant difference between nurses and others mean score of WM performance according to t-test. There was not significant difference between WM performances of two studied groups in public and private hospitals based on t-test. Comparing between two studied groups mean scores by waste minimization areas indicated that nurses have done significantly better in source reduction area and other staffs have acted better in waste segregation ( P < 0.05).

Conclusions:

All of hospital staff specially, nurses have an important role in qualified waste management practice of hospitals. Totally mean score of WM performance in hospitals (nurses and other) was average. With regard to other countries activities, this result is disappointing. So, it is necessary to plan educational programs for hospital staff, especially nurses.

I NTRODUCTION

Increased standard of living is creating a great risk to the environment by generating a large quantity of waste.[ 1 ] Medical waste (MW) is all waste materials generated at health care facilities, such as hospitals, clinics, physician’s offices and so ondental practices, blood banks, and veterinary hospitals/clinics, as well as medical research facilities and laboratories.[ 2 ]

Today medical waste management is a crucial public health and environmental issue because poor medical waste management unquestionably exposes healthcare workers, waste handlers, and the community to infections, toxic effects, and injuries.[ 3 ] The main portion of MW is non-hazardous.

According to Practice Green health, “the nation’s hospitals generate approximately 6600 tons of waste per year”1 and “as much as 80 to 85% of a healthcare facility’s waste is non-hazardous solid waste-such as paper, cardboard, food waste, metal, glass, and plastics.”[ 4 ] The World Health Organization (WHO) reports similar data and adds that “a smaller portion (10 - 25%) (of health care waste) is infectious/hazardous waste that requires special treatment.[ 5 ]

Although the infectious and hazardous waste have a small portion in MW, improper medical waste management, and mixing infectious waste with the general waste, can lead to the entire bulk of waste becoming potentially hazardous.[ 6 ]

In fact disposing waste is an important problem for health and environment. Many materials are used in health care facilities, such as PVC and mercury, whether incinerated or disposed through other methods such as landfill, can result in the release of hazardous substances into environment.[ 7 , 8 ] The hazards to the human health and to the environment, posed by MW justify a high level of concern with its management.[ 9 ]

The problems of MW incineration, improper waste disposal, and general environmental degradation and the effects of these issues on human health eventually were recognized. Organizations such as the EPA, Environmental Protection Agency, American Nurses Association, HealthCare Without Harm (HCWH), and Hospitals for a Healthy Environment (H2E) have looked for ways to reduce the negative effects of health care practices on the environment.[ 7 ]

Considering all of mentioned problems and according to literature review, the best and most economical way of dealing with waste is to minimize its production.[ 10 ]

Waste minimization means The reduction, to the extent feasible, in the amount of hazardous waste generated prior to any treatment, storage, or disposal of the waste. Because waste minimization efforts eliminate waste before it is generated, disposal costs may be reduced, and the impact on the environment may be lessened.[ 11 ]

WM usually benefits the waste producer: costs for both the purchase of goods and for waste treatment and disposal are reduced and the liabilities associated with the disposal of hazardous waste are lessened.

• Source reduction measures such as purchasing restrictions to ensure the selection of methods or supplies that are less wasteful or generate less hazardous waste.
• Good management and control practices apply to commitment and support of managerial team, set rules and regulations to reduce waste.
• Management in stores of chemicals and pharmaceuticals products apply particularly to the purchasing, keeping, storing, and using of chemicals and pharmaceuticals.
• Waste segregation is careful segregation (separation) of waste matter into different categories, which helps to minimize the quantities of hazardous waste.
• Recyclable products is use of materials that may be recycled, either on-site or off-site.

Waste minimization usually benefits the waste producer: Costs for both the purchase of goods and for waste treatment and disposal are reduced and the liabilities associated with the disposal of hazardous waste are lessened.

In Iran, as many other countries, environmental impacts and hazards of hospital waste have not received sufficient attention. In fact, the management of MW in Iran is struggling with numerous problems.[ 10 ] In a study aimed to investigate waste management in primary healthcare centers of Iran in 2009, the mean of solid waste generation was reported 3.8 kg (bed-day) /1 , respectively.[ 12 ] In another study Sabour investigated the quality and quantity of hospital wastes in Iran, and based on this research Isfahan MW generation were reported 3.14 kg (bed-day /1 .[ 13 ] It is obvious that treating this huge quantity of MW explicitly has a variety of unfavorable effects on the environment. Hence, we should be more responsible about healthy environment. As said before hospital staff specially nurses play important role in waste management.

If we want to improve standards of waste management in hospitals it should be initiated from personnel. In other words all of the hospital personnel are considered as a team for waste management. As WHO said, Good health care waste management in a hospital depends on a dedicated waste management team, good administration, careful planning, sound organization, underpinning legislation, adequate financing, and full participation by trained staff.[ 14 ]

It could be said, using WM strategies is the most appropriate alternative for managing waste anywhere especially in hospitals and all health-service employees, especially nurses, who have direct involvement in a majority of client care, have a role to play in this process. Nurses and other staffs who generate large quantities of hazardous waste in hospitals should therefore be trained in waste minimization and the management of hazardous materials.[ 15 ] Health care personnel should become ecologically sensitive and advocate changes that reduce the quantity of waste generated while maintaining quality patient care and worker safety.[ 16 ]

If the WHO recommended measures implement well by them, it will lead to the proper management of MW and a reduction in the environmental and health problems. So the first step for dealing this issue is, knowing present situation and that how do the hospital personnel act in daily works or to what extent they are sensible about waste reduction? The main objective of the present study was to investigate and regarding critical role of nurses in this process, the waste minimization performance of nurses and other.

M ATERIALS AND M ETHODS

This descriptive cross-sectional study aimed to assess the practice associated with waste minimization (WM) among nurses and the other personnel in selected hospitals of Isfahan in 2009. In order to provide comparability between both private and university hospitals in WM performance, study samples were selected from university and private hospitals. Four university and three private hospitals selected through simple random sampling. The sample size calculated as:

120 person. From which, 30-40 subjects, included auxiliary department directors, such as store, kitchen, pharmacy, housekeeping, and suppliers, which participated in study through the census method. The rest of the sample size (80- 85 persons) included clinical nurses, which were calculated based on their proportional population in each hospital. Selecting nurses within each hospital was done through simple random sampling. Using a list of clinical nurses who have the inclusion criteria of study. The inclusion criterion was full-time employment in the study setting for a minimum of 2 year.

The study tool was a self-designed questionnaire which was derived from WHO guideline about waste minimization in health care facilities.[ 15 ]

It was set into five area of:

1) Source reduction, 2) Good managing and controlling, 3) Managing stores of chemicals and pharmaceuticals products, 4) Waste segregation, 5) Managing recyclable products, as listed in Table 1 . The initial draft was circulated to the members of an expert team, included (three nurses, two academic members and three director in auxiliary departments from hospitals) and modifications were carried out. Finally, the questionnaire set in 39 questions and responses given on a five-point Liker Scale (1 = It is never being done, 5 = It is thoroughly being done).

Questionnaire areas (waste minimization aspects) and definitions

To simplify analyzing and comparing results values of questionnaire were multiplied by 100 and responses were classified as (0-34 = weak performance, 34-67 = average, and 67-100 = good). Content validity of questionnaire was confirmed by experts. Reliability Cronbach’s alpha was calculated for 0.89%, using a sample consisted of 20 randomly selected hospital staff (10 nurses and 10 supportive staff). Reliability Cronbach’s alpha was calculated for each area of questionnaire as:

Source reduction (0.85% 0), good management, and control practices (0.81%) management in stores of chemicals and pharmaceuticals products (0.70%), waste segregation (0.69%), and managing recyclable products (0.75%).

Data gathering was done by observation and interviewing personnel, i.e. all of questions asked from people and complementary information were obtained through observation of daily works and documents in field. In spite of approving this research by research department, all of participants was justified about research objectives and the necessary official permissions were obtained. Descriptive statistics such as mean and standard deviation were employed for calculating participants functions. in order to determine differences between performances mean scores of respondents by job (nurses/ other staff) and by workplace ospital (private/ public) t -test were used. The statistical significance level was considered as P value less than 0.05. Data were analyzed using SPSS 16 software.

This study was aimed to investigate performance of nurses and other staff of selected hospitals in waste minimization strategies. It was carried out in seven randomly selected hospitals (four public and three private) in Isfahan. A total of 89 questionnaires were completed. Respondent rate in clinical nurses was (60%), and in other staff (100%). Totally 51 (57%) of respondents were nurses, and 38 (42%) from other staff. Thirty-nine (43%) were working in private hospitals and fifty (56%) in public hospitals.

Findings showed that the mean score of WM performance in hospitals was 58.33 (12.01 (of max 100) nurses mean score of WM performance was 58.16 (12), and others was 58.56 (12.13) totally. There was no significant difference between nurses and others mean score of WM performance according to t -test ( P = 0.6) [ Table 2 ].

Nurses and other staff Waste minimization performance mean score and SD for all hospitals (out of 100)

Comparing performance mean scores of staff in private and public hospitals showed that, there was not significant difference between WM performances of two studied groups in public and private hospitals based on t -test ( P > 0.05) [ Table 3 ].

Nurses and other staff waste minimization performance mean score and SD for university and private hospitals (out of 100)

Calculating mean score performance of respondents in each area of WM showed that both nurses and other staff had a good or satisfactory practice in the area of management in stores of chemicals and pharmaceuticals products: nurses 91.89 (13.5) and other staff 89.05 (13.2).

For comparing between two studied groups mean scores by waste minimization areas, t -test was performed and indicated significant difference between their performance in two areas: Source reduction ( P = 0.01) and waste segregation ( P = 0.01). Nurses have done significantly better in source reduction area and other staffs have acted better in waste segregation.[ 4 ]

D ISCUSSION

In this study performance of nurses comparing other personnel were investigated. Results showed that nurses’ mean score of WM performance was 58.16 (12), and others’ was 58.56 (12.13). Both group’s scores were at lower average range. There was no significant difference between nurses and others mean score of WM performance according to t -test ( P . v = 0.6). [ Table 2 ]. The deficit in both group performances could be attributed to lack of supervision, weakness in education programs, and specifically in nurses, related to unavailability of waste minimization instructions or booklets to be used as a nursing guide.

This result is consistent with findings of a study aimed to assess the practice related to waste management, among doctors, nurses, and housekeepers in the surgical departments, which stressed that only 18.9% of the nurses, 7.1% of the housekeepers, and none of the doctors had adequate practice.[ 17 ]

As regard to nurses responsibility was defined by ICN: Nurses in clinical care are producers of health care waste and yet are active participants in waste disposal procedures. Nurses in management positions develop policies that deal with the procurement of supplies as well as the production and elimination of health care waste.[ 18 ] The nurses are expected to act better in this field. They must be equipped with the latest information, skills, and practices in waste management.[ 17 ] Nurses, as professionals, need to be aware of the consequences of the health care waste produced by the health sector. Nursing organizations need to: Define and regulate nursing competencies in environmental health and Facilitate nurses’ access to continuing education programs on the subject of health care waste.[ 18 ]

Further, same comparison was done in public and private hospitals and revealed. There was not significant difference between WM performances of two studied groups in public and private hospitals based on t -test ( P > 0.05) [ Table 3 ].

This result is consistent with another study which stressed that there is no evidence that either public or private ownership is a decisive factor for the successful management of health care waste.[ 19 ] In this concern another study carried out in Jordan revealed that the university hospitals, with the lowest amount of waste, have been performed better than others about waste generation.[ 20 ] While private hospitals are expected to do better about wastes because of economic benefits of waste minimization program.

With respect to the mean scores of respondents in each area of WM, the findings revealed that both group of participants had a good or satisfactory practice in the area of management in stores of chemicals and pharmaceuticals products nurses 91.89 (13.5) and other staff 89.05 (13.2). Management in stores of chemicals and pharmaceuticals products apply to issues such as checking of the expiry date of all products at the time of delivery, use of all the contents of each container, or use of the oldest batch of a product first. Considering the content of this area, it could be attributed to high perception of personnel and due to the prominence of chemicals and pharmaceuticals hazards in people’s minds.

Comparing between two studied groups mean scores by waste minimization areas, t -test was performed, and indicated significant difference between their performance in two areas: source reduction ( P = 0.01) and waste segregation ( P = 0.01). Nurses practiced significantly better in source reduction area and other staffs have acted better in waste segregation. In the other areas of WM nurses have obtained higher mean scores [ Table 4 ].

Comparison of nurses and other staff performance by waste minimization areas in all hospitals

Conversely, Mostafa in a study, reported that the percentage of adequate nursing practices related to waste management were low and only 18.9% had adequate practice.[ 17 ] Fortunately, the present study finding is a promising subject; it could be attributed to awareness and knowledge of nurses about their vital role in waste management. Nurses know that a healthy environment impacts the health of people, families, communities, and populations. This knowledge is a foundational element of nursing practice.[ 21 ] They must be equipped with the latest information, skills, and Nurses can become leaders in their work settings by advocating for the implementation of environmental health principles into both nursing. practice and the overall delivery of health care.[ 22 ]

Also comparing between two studied groups mean scores indicated that the other staffs have acted better in waste segregation. As mentioned above, careful segregation (separation) of waste into different categories helps to minimize the quantities of hazardous waste. Although the nurses have a major role to play about waste minimization but all of health services staff in all departments must be sensitive in this concern. Every one in the institution from the top down must be involved and must share the sponsorship of an environmentally sound and sustainable waste management program.[ 23 ]

A CKNOWLEDGMENT

I would like to acknowledge the people who assisted me in doing this research: Firstly managers and executives of hospital for facilitating data gathering and nurses and participant directors of departments for their cooperation in this work.

Source of Support: This Article is derived from Research No 289080 which was funded by the Health Management and Economic Research Center of Isfahan Medical University

Conflict of Interest: None.

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Stary Oskol city, Russia

The city of Belgorod oblast .

Stary Oskol - Overview

Stary Oskol is a city in Russia located in the Belgorod region, standing on the banks of the Oskol River, about 142 km northeast of Belgorod, 632 km south of Moscow.

The population of Stary Oskol is about 222,600 (2022), the area - 134 sq. km.

The phone code - +7 4725, the postal codes - 309500-309518.

Stary Oskol city flag

Stary oskol city coat of arms.

Stary Oskol city map, Russia

History of stary oskol.

In 1300, there was a village called Ugly on the the territory of the present city. Today, it is one of the districts of Stary Oskol. At that time, the village was part of the Grand Duchy of Lithuania and was a border crossing point on the border with the Golden Horde.

The settlement of Oskol was founded by Russian Tsar Fyodor Ioanovich’s order (Ivan’s the Terrible son) to protect the southern borders of the Russian kingdom in 1593. The bulk of the population were peasants and the military.

In 1617, the town was burned by the Poles. In 1625, 1642 and 1677, the Crimean Tatars approached Stary Oskol, but could not capture it. The town was renamed Stary Oskol (meaning Old Oskol) in 1655, when the town of Tsaryov-Alexeyev, located down the river, was renamed Novy Oskol (New Oskol). Fortifications of the town existed until the 18th century.

More Historical Facts…

Gradually, Stary Oskol turned into peaceful, commercial and merchant town - the center of an agricultural district. Industrial production was represented mainly by enterprises on processing agricultural products.

In 1780, the town got its coat of arms. In 1784, Stary Oskol like most Russian towns of that time was rebuilt according to a new plan signed by Empress Catherine II. A large number of brick houses were built, mostly two-story buildings. The historic center of Stary Oskol has been preserved to our time.

In the second half of the 19th century, the town had a wide network of schools, libraries, reading rooms, printing, secondary schools. In 1894, construction of the railway began, trade and industry began to develop rapidly.

Until the 1930s, there were eleven Orthodox churches in Stary Oskol. During the Second World War, Stary Oskol was occupied by the Germans from July 2, 1942 to February 5, 1943. In 1954, the city became part of the newly formed Belgorod region.

In the late 1960s - early 1970s, in connection with the active development of the Kursk Magnetic Anomaly (the most powerful iron ore basin in the world), Stary Oskol became a major center of iron and steel industry.

Stary Oskol was declared a city of three top-priority Komsomol construction projects. The largest enterprises: Lebedinsky Mining and Processing Plant, Stoilensky Mining and Processing Plant, Oskolsky Electrometallurgical Plant became not only the city-forming enterprises, but also the largest industrial enterprises of the country. Stary Oskol experienced a new birth.

Today, Stary Oskol is a rapidly developing city, one of the leading mining and metallurgical centers of Russia.

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Stary Oskol cityscape

Author: Nikolai Ivanov

The fountain on Friendship Boulevard in Stary Oskol

October movie theater in Stary Oskol

Author: Roman Riapolov

Stary Oskol - Features

The coat of arms of Stary Oskol is a shield divided in half diagonally, in the red field there is a rifle, in the green field - a golden plow. It reflects both military and agricultural importance of the town.

Stary Oskol is among Russian cities with the youngest population. The average age of its citizens is about 35 years. The main reason lies in the history of the city. In the second half of the 20th century, a large number of members of the Young Communist League came to Stary Oskol to participate in the construction of large industrial enterprises.

Unique reserves of iron ore, developed industry and infrastructure, high scientific, technical and industrial potential, fertile land form the basis of Stary Oskol economy.

The main branches of local industry are mining, ferrous metallurgy, machine building and metalworking, building materials, food industry. There are more than 140 large and medium industrial enterprises, which employ more than 80 thousand people.

Attractions of Stary Oskol

The city has more than a dozen Orthodox churches and chapels. Alexander Nevsky Cathedral (Tokareva Street, 4/1) is the main church of Stary Oskol. St. Trinity Church (Bolshevistskaya Street, 17/15), built in 1730, is the oldest church in the city.

The Zoo was opened in Stary Oskol in 2008. Bears, lions, tigers, monkeys, wolves, camels, ostriches, and other species of birds and animals live there.

Museum of Local Lore (Lenina Street, 50). The museums, founded in 1923, has exhibitions about the history of Stary Oskol. It is located in a building which is a monument of history and culture of the 19th century once owned by the merchants and brothers Likhutins.

The museum organizes tours of the city and the area including visits to an ancient Russian settlement of Kholki, an underground monastery in Melovy mountains, and a biosphere reserve “Yamskaya steppe”.

Art Museum (Lenina Street, 57). The collection of local masters of folk clay toys (O.M.Goncharova and N.M.Goncharova) is a real pearl of the museum. Stary Oskol folk clay toys production was known from the end of the 18th century.

House Museum of Vasily Yeroshenko (Yeroshenko Street, 15). Yeroshenko’s life is a living legend for blind people not only in Russia but also abroad. He encourages disabled people, supports them with his talent, helps them on their ways to improve techniques. Yeroshenko spoke 12 foreign languages and was the professor of universities in Tokyo and Beijing, he became a classic of Japan literature for children.

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Byl movie theater in Stary Oskol

Friendship Boulevard in Stary Oskol

The Monument to Soviet-Bulgarian friendship in Stary Oskol

Sights of Stary Oskol

The memorial complex Ataman Forest in Stary Oskol

Cannon monument in Stary Oskol

Church of the Nativity in Stary Oskol

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