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Journal of the Academy of Hospital Administration

"Sharps"(Biomedical Waste) management - A model for Implementation (An experimental study)

Author(s): Hem Chandra*, Sunil Shishoo**

Vol. 13, No. 1 (2001-01 - 2001-06)

Abstract : Biomedical waste consists only 10 -15% of total waste generated in the hospital. Among ten categories of biomedical waste, "SHARPS" are most vulnerable, as they transmit infection directly into the body by puncture. Disinfection at the source of generation is the best treatment for sharps. The simplest method of disinfection at source is by 2% hypochlorite solution. Health care providers (HCP) are responsible for generation and disinfection of sharps. Knowledge, attitude and practices (KAP) followed by control mechanism is the ideal method of implementation. The model for sharps disposal developed at SGPGIMS revealed that the practices are difficult, but not impossible. A check list consisting of 12 mistakes, which could be committed by HCP while implementing the practices of Sharps disposal shows that S. No. 1 (needle should not be recapped), 2 (do not put gauze, cotton and piston of syringe.) are the common mistakes committed by all the wards. MICU, Cardiology wards have committed minimum numbers of mistakes and have shown good sign of improvement in practices in future. All wards have committed all mistakes except S. No. 7 (number of syringes is less than number of needles) and 12 (quantity of syringes destroyed in bucket has gone down from previous month). Mistakes No. 1, 2 and 3 were difficult to improve. Urology wards committed maximum mistakes. The study also revealed that by implementation of sharps disposal model, majority of HCP gradually developed the practices and over all only 0.20% mistakes was committed by wards. This shows that by implementation of practices, 99.80% risk of developing the infection through SHARPS has been eliminated by HCP. The model made for sharp disposal proved effective and efficient.

Keywords : Biomedical waste; sharps;

Introduction

Though hospitals make relatively insignificant contribution to the total garbage mountain, they have an obligation to deal with Bio-Medical Waste in an effective and safe manner being hazardous and infectious in nature. Because of its composition, there are significant risks associated with hospital waste. Infections are the most common health hazards associated with poor hospital waste management, which has been magnified with the advent of AIDS and Hepatitis B virus infections and increase in the prevalence of disease in the health care providers (HCP). Good collection, handling, transport, treatment and ultimate disposal procedures are essential for well being of patients, hospital staff, the community and the environment. Although, the risk posed by Bio-Medical Waste can never be totally eradicated, it can be significantly reduced by careful planning. An effective programme of hospital waste management can have distinct economic benefits such as cost saving linked to waste reduction and improved purchasing power.

Ministry of Environment and Forest, Government of India, notified the rules for management and handling of bio-medical waste called Bio-medical waste (Management and Handling) Rules 1998. These rules apply to all hospitals who generate, collect, receive, store, transport, treat, dispose or handle bio-medical waste in any form. From amongst all categories of waste, the "SHARPS", which includes syringe, needle, canula, glass, ampoules etc. have the highest disease transmission potential. Almost 85% sharps injuries are caused during their usage and subsequent disposal; and more than 20% of those who handle them encounter "stick " injuries. Although sharps comprise of a relatively small portion of the total hazardous waste generated in any hospital, they have maximum propensity and potential for causing needle stick injuries and hence can cause infection. Therefore these require maximum precautions.

It is extremely unfortunate that medical waste regulation has never before focussed on the immediate and extremely high risk faced by the hospital workers and waste handlers. There is no mention of worker's safety, procedure, training and operation and monitoring the activities. Now, hospital waste management is one of the thrust areas which is drawing the attention of health authorities and the government.

Sanjay Gandhi, PGI, a super specialty, 600 bedded hospital, is also bound and committed to follow the guide lines as prescribed by Ministry of Environment and Forest and C.P.C.B. In view of above, it has been decided to adopt the healthy practice of Hospital Waste Management in SGPGI, hospital. The implementation was thought in the phased manner. A pilot project for disinfection of "sharps" waste at generation point and central disposal of these sharps was planned with following aim and objectives.

Aim:- Implementation of Biomedical Waste Management practices with special reference to "sharps" waste category at SGPGI Hospital, Lucknow.

Objectives:

  1. To identify and segregate hospital waste sharps at the source of generation.
  2. To disinfect these sharps at the source of generation and destroy it centrally to minimise the spread of infection.
  3. To promote and improve the health and safety of health care providers.
  4. To develop and implement a healthy practice of waste management for "SHARPS" category of waste.

Methodology:

Following activities were planned.

1. Awareness development - Awareness about the hospital infection, hospital waste and ill effects to the health care providers/ visitors of the hospital/community/environment due to improper hospital waste management was developed among health care providers (employee) by massive training programme (IEC followed by KAP).

2. Supportive measures - Supportive measures required such as space, man power, bleaching powder, weighing machine, needle destroyers, money etc. to implement the programme were arranged.

3. Model preparation - The model of centrally supervised sharps waste segregation, collection, disinfection, transportation, accounting and disposal at central waste disposal unit (CWDU) was made.

4. Demonstration - The whole procedure was demonstrated one by one to health care providers of the respective wards.

5. Pilot study - Initially two wards ware identified for pilot study and later on after the positive results were achieved, the facilities was extended to 10 wards

6. Implementation - The complete programme was implemented in 10 wards and is being continued till date.

7. Evaluation - The implementation of the programme at the level of health care providers (HCP) was continuously monitored, evaluated by physical inspection and 12 point check list.

Steps for implementation:

1. Initially two wards were identified to carry out the pilot study for segregation, collection, transportation, treatment and final disposal of SHARPS category of waste, but later on, the system was extended to 10 wards.

2. The procedure of "sharps" waste management was demonstrated to all sister I/C of all 10 wards and she wasinstructed to train rest of the staff of the ward.

3. 2% sodium hypochlorite solution was prepared from bleaching powder at Central Waste Disposal Unit (CWDU) daily in the morning and evening and the same was transported in puncture proof plastic buckets (withlid) of 5 liter capacity to each ward twice in a day.

4. All ward staff (Doctors, Nurses, helpers etc.) were instructed that after using the syringes/sharps, they are tobe disposed into the bucket with 2% hypochlorite solution without any further manipulation and those should always remain dipped in the solution.

5. Syringes, needle sharps were collected from the wards in the bucket, were counted daily by the CWDU staff and recorded in a register for number, type and other material in it.

6. After recording, the syringes and needles were destroyed with the syringe/needle cutter or destroyer and other like ampoule, blade etc. were destroyed accordingly.

7. The waste collected after disinfection and destruction was packed in large bags and finally disposed off. Syringes having more than 5-10c.c. capacity were retained to recycle in future after ETO sterilization.

8. Control (monitoring, measurement, evaluation and correction) over the process was done by the following ways.

  1. Correct measurement of Hypochlorite solution at central point and its distribution to the user points (ward) twice in a day.
  2. Inspection and measurement of used Hypochlorite solution and contents available in it such as syringe, needle etc. at ward level and CWDU level. Data for mistakes/deficiencies was recorded daily.
  3. Twelve points instructions check list (criterias/norms) showing probable mistakes/deficiencies committedby the users was prepared and data for mistakes/deficiencies was recorded daily after inspecting the used hypochlorite solution.
  4. Based on observations, respective ward in charges were periodically informed about the mistake committed by the users in implementing the sharp disposal and directed to improve the habit in future (evaluation and feed back).
  5. Continuous monitoring by above mentioned methods was done for 10 wards for nine months till such time, when minimum number of mistakes were noticed (correction).
  6. Gradual improvement in the implementation by minimizing the mistakes was observed for 9 months. (CQM).

List of Deficiency / Mistakes - check list

  1. Needles should not be recapped.
  2. Do not put Gauze, Cotton, waste paper, in the bucket container.
  3. Please leave air gap between barrel and piston of syringe.
  4. Do not put medicine wrappers, I.V. sets etc. into the bucket.
  5. Do not put syringes packing material into the bucket.
  6. Number of needles is less than Number of syringes.
  7. Number of syringes is less than Number of Needles.
  8. Do not throw fruit peel and other food waste in the bucket.
  9. There were no syringes in the bucket during morning evening shift dated.
  10. Blood/fluid was left in the syringe.
  11. Do not bend the needles.
  12. Quantity of syringes destroyed in bucket has gone down beyond 10% level from previous week.

Requirements (Central Waste Disposal Unit)

A Location: A large room with proper ventilation, water supply and sink.

B Manpower: Supervisor - 01

  • Safai Karamachari - 03
  • Man power was immunized against Tetanus and Hepatitis B.

C Material:

  1. Bleaching Power- 6 bags/month (25kg. Bag)
  2. Industrial gloves - 25 pairs/month
  3. Weighting balance- 01
  4. Plastic buckets- 30 ( 5-10 Ltrs.) for wards
  5. Plastic Containers- 02 No. (100 Ltrs.) for making Hypochlorite solution in CWTU.
  6. Mug- 10
  7. Stationery- As per requirement.

D Machine: Syringe and Needle cutter-05

E Money: For initial investment and recurring expenses.

The initial expenditure on material was approx Rs. 15,000/-; and Rs. 15,000/- for purchase of needle cutters/destroyer (Total Rs. 30,000/- only). On an average Rs. 5000.00 Per month was incurred in purchase of bleaching powder, gloves, and maintenance of needle destroyer etc.

Advantages of central waste disposal unit:

  1. Centrally supervised disinfection at the source, but disposal of sharps ensures the chances of infection to health care workers/providers are minimized to the maximum possible.
  2. The procedure is cost effective due to:
    1. Only 5 needle destroyers were needed for the entire wards instead of allowing one for each ward area 10 and two as spare.
    2. Proper supervision, operation and care reduced the maintenance cost and increased the life of equipment.
    3. The supervision is better in central system, which maintains the quality control.
  3. By calculating the number of needle and syringes received from ward, it helps in assessing the implementation of waste disposal process at the ward level.
  4. Syringes of 5c.c. and above capacity can be recycled after ETO sterilization as it is cost effective.

Observations

Ten wards were identified initially for implementation of sharps disposal systems with the intention to extend the facilities in all patient care areas in future. Following are the observations.

1. (a) Nature and types of waste received:

  1. Needle - Cotton and bandages
  2. Syringe - Wrappers
  3. Used ampoule - peel of fruits
  4. scalpel - Blade
  5. Paper

(b) Average waste generated

  1. Average number of needle, per ward, per day - 20 Number of syringes per ward, per day.- 20
  2. Average weight of syringe and needle, per ward, per day -150gm.

2. Deficiency Measurement

A- Comparative distribution of deficiencies month wise.

Check Point S. No. March April May June July Aug Sep Oct. Nov. Total
1. 10 9 09 6 8 6 6 3 1 43
2. 04 06 07 3 7 4 4 7 2 37
3. 10 8 9 3 7 7 3 3 2 49
4. 03 2 NIL NIL 1 NIL 1 1 1 6
5. 01 1 NIL 1 NIL 2 1 3 NIL 08
6. 02 1 NIL NIL NIL NIL NIL 3 2 07
7. NIL NIL NIL NIL NIL NIL NIL NIL 1 NIL
8. 01 NIL NIL 1 NIL 1 1 1 NIL 04
9. 02 1 03 05 3 NIL 4 2 1 20
10 1 NIL NIL 1 NIL NIL NIL 3 NIL 04
11. 01 NIL 01 2 1 2 2 1 NIL 07
12. NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
Total

35 28 29 22 27 22 22 28 9  

B- Comparative distribution of deficiencies month and ward wise

No. Ward March . April May June July Aug Sep Oct Nov Total
1 Endo Medicine 4 3 4 2 4 4 2 4 1 32
2 Emergency 3 2 4 4 4 2 4 3 1 33
3 MICU 3 3 nil 1 nil 1 1 3 nil 12
4 Cardiology 6 4 nil 2 nil 1 2 2 2 19
5 CVTS A 1 1 3 2 3 3 2 3 1 21
6 CVTS B 1 1 4 1 1 2 1 5 nil 18
7 Nephro A 1 1 3 1 6 3 1 nil 2 22
8 Nephro B 4 3 4 2 5 20 2 2 nil 28
9 Urology A 6 5 nil 5 nil - 5 2 nil 31
10 Urology B 6 5 7 2 4 4 2 4 2 43
  Total 35 28 29 22 27 22 28 28 9  

C- Deficiencies, ward and month distribution

Deficiency No. - No. of ward involved
S. No. . March July Sep Nov
1 10 5 4 2
2 4 5 2 1
3 10 4 3 2
4 3 nil 1 nil
5 1 nil nil nil
6 2 nil nil 1
7 nil nil nil nil
8 1 3 4 1
9 2 nil nil 1
10 1 nil nil nil
11 1 nil nil nil
12 nil nil nil nil

3 Check points

(A) Deficiencies

  1. Except S. No. 7 and 12 all types of mistakes were committed by all the wards.
  2. Maximum common mistakes/deficiencies committed by the wards for S.No. 1, 2 and 3.
  3. Minimum mistakes/deficiencies committed by the wards for S.No.10 and 6.
  4. Mistakes/deficiencies not committed by the wards at all - 7 and 12.
  5. Mistakes/deficiencies easy to improve by the wards - 4, 5, 6, 8, 10 and 11.
  6. Mistakes/deficiencies difficult to improve - 1, 2 and 3 but gradual improvement observed.

(B) Wards

  1. Almost all the wards have high number of deficiency in the first month of implementation i.e. Mar.2000.
  2. Wards having maximum deficiency (over all) -- Urology B, Urology A, Endo Medicine, Emergency.
  3. Wards having minimum deficiency---(over all)- MICU and Cardiology.
  4. Ward which have shown good response and steady position -MICU and Cardiology.

Inferences

  1. Sharp category is easily distinguished from other categories and can be disinfected at the source.
  2. Though the process and implementation is tough, but possible.
  3. Information, Education and Communication followed by knowledge, attitude and practical applications are the essential components of implementation.
  4. Future directed control over the system is one of the essential prerequisite for the implementation.
  5. Absolute planning based on management principles is required for the project.
  6. The implementation is resource consuming process. Traditional method can not achieve the results.
  7. Equal response is not shown by all the wards but have shown gradual improvements.
  8. Category 1, 2 and 3 mistakes are very common while implementing he system. Therefore special emphasis is to be given for correction of these mistakes.
  9. The mistake No. 1, 2, and 3 are difficult to improve but can be gradually with vigorous efforts.
  10. Approx. 600 (20 x 30 days) syringes are used per ward per month and total 54,000 (600 x 10 x 9) in 9 months by all 10 wards). Assuming minimum one mistake per syringe, the total mistakes which could be committed by HCP of all wards for 9 months is 54,000. In comparison to this, only 110 mistake were committed by all 10 wards in 9 months for seven categories i.e. category No. 1, 3, 6, 7, 10, 11 and 12 mistake, which are bio hazardous in real sense. It means that only 0.20% mistakes/deficiencies were committed by health care providers (HCP). Therefore 0.20% risk is still prevalent in population of HCP to develop the infection through sharps.
  11. Study reveals that majority of HCP (99.80%) are protected against sharps transmitted diseased and injury by implementing the healthy sharps disposal practices. Rest of HCP (0.20%) can also be covered by strengthening the programme and eliminating the risk.

Conclusion

Biomedical waste is generated by the health care providers. Therefore, it becomes the responsibility of this group to segregate and manage the waste in such a way, that it is no longer hazard for them, public and environment. Among ten categories of biomedical waste, sharps are the most vulnerable as they transmit the infection directly by body puncture. The methods of SHARPS disposal are difficult to implement but not impossible. The Information, Education and Communication (IEC) approach is followed by enhanced knowledge, changed attitude and safe practices ; which can achieve the desired objectives. It is essential to make norms/criteria/specification for monitoring and evaluation of the practices. The study conducted at SGPGIMS has shown the measures to be adopted to implement a system, a control process and gradual improvement in the habit of the health care providers. The observations based on 12 points check list proved to be an ideal control process for accomplishment of verifiable, tangible and measurable objectives. Based on above, the model made for sharps disposal proved effective and efficient.

Recommendations:

  1. The programme should be extended to other patient care areas of the hospital.
  2. Strict continuous control and supervision is required over the system.
  3. Programme to be strengthened to achieve 100% success and protection.
  4. Similar programmes to be chacked out for treatment and disposal of other categories of waste.
  5. IEC programme followed by KAP for all categories of HCP about infection control and waste management to be conducted regularly.

References

  1. Anand R C, Satpathy S. Hospital waste management a holistic approach. 2nd edn. New Delhi; Jaypee Brothers Medical publishers (P) Ltd.; 2000:p11.
  2. Biomedical waste (handling and management) rules 1998; Ministry of Forest and Environment, Government of India.
  3. Nobel JJ; Waste disposal unit : sharps Paediatrics Emergency Care, April 1995, 11 (2); 118-20.
  4. Branson M; Hazards of Sharps disposal: British Journal of Nursing, Feb-Mar 1995, 4(4): 193-5.
  5. Agarwal; Medical waste - Protect and involve and workers: Proceedings of national workshop on anagement of hospital waste, April 16-18, Jaipur 1998; 37-38.

* Medical Superintendent and Incharge Hospital Administration
** Asstt. Superintendent (CSSD and Laundry) Sanjay Gandhi P.G.I.M.S. Lucknow (U.P.)

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