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Journal of the Academy of Hospital Administration

Knowledge, Attitude and Practices of Bio-Medical Waste Management Amongst Staff of a Tertiary Level Hospital in India

Author(s): S. Saini, S.S. Nagarajan, R.K. Sarma

Vol. 17, No. 2 (2005-01 - 2005-12)

Key Words: Biomedical waste management, KAP study, tertiary Hospital

Key Messages:

  • Medical professionals have tubular vision regarding patient care, and lack attitude for this statutory provision
  • Nurses have better understanding and are more responsible in implementation
  • Paramedical staff have less understanding but better practical application of various aspects
  • Motivation and change of mindset in key function aries like doctor is essential for successful implementation of the BMW management programme

Abstract:

Despite the statutory provision of Biomedical Waste Management, practice in Indian Hospitals has not achieved the desired standard even after seven years of enforcement of the law. In view of this, the present study on Knowledge, Attitude and Practice (KAP) on the subject was carried out in a tertiary level teaching hospital. The hospital under scrutiny for KAP is a 1600 bedded super specialty teaching hospital and research centre with latest facilities. The Institute has a work force of 800 doctors, 1600 nurses and 6000 other support staff. The study is based on a questionnaire designed to understand the KAP of the staff involved in direct patient care facility regarding the Biomedical waste management practices. The KAP study enrolled 156 respondents, representing doctors and nurses from selected patient care areas; Here, a significant gap was observed in the knowledge, attitude and practice of the consultants, residents and scientists with regard to biomedical waste disposal, to their knowledge/understanding on the subject.

The definite apathy of intellectuals towards the operational aspects of the BMW management system can be attributed to the tubular vision of the professionals that is mainly focused on the curative aspects of the patient care services, with lack of understanding towards the role of support services in the overall context of comprehensive health care delivery. Nursing professionals on the other hand, had an edge over the clinicians as far as attitude and practice of BMW mgmt. is concerned although their knowledge on the subject was relatively low. This can be attributed to their accountability and commitment in ward management and the predominance of female workforce, which is by and large more disciplined. The para-medical staff including laboratory and housekeeping staff had least understanding on the subject, but had higher positive attitude with more practical habits, which may be attributed to strict instructions by authorities and fear for any punitive action.

INTRODUCTION

All activities of living thing on earth produce waste in some form or the other. Normally, aerobic and anaerobic process in the environment degrades such products. These wastes, both biodegradable and non-biodegradable hardly had any impact on the environment until the invention of plastics by the modern man. The process of natural degradation could not keep pace with the increase in waste generated by the over increasing population of mankind and its necessities. The air, the water and the land are today becoming disposal sinks for the waste (1).

The last decade witnessed a significant increase of public concern regarding Medical Waste disposal. This was fuelled by reports of “beach washing” of medical waste on the coasts of Florida and Gulf, and the “recycling” of disposable articles in developing countries (2). The reports and figures available from developed countries indicate that approximately 1-5 kg of waste is generated per bed per day, with substantial inter country and inter specialty differences (3). The data available from developing countries also indicate that the( range is essentially similar but the figures are on a lower side with 1-2 kg per day per bed. In India, it is estimated to be 2.0 kg/ bed/ day (4) .The concern regarding the medical waste is mainly due to the presence of pathogenic organisms and organic substances in hospital solid wastes in significantly high concentrations. The substantial number of organisms of human origin in solid waste suggests the presence of virulent strains of viruses and pathogenic bacteria in undetected numbers (5). Therefore improper handling of solid waste in the hospital may increase the airborne pathogenic bacteria, which could adversely effect the hospital environment and community at large. (6) Improper Hospital Waste Management has serious impact on our environment (7). Apart from risk of water, air & soil pollution, it has considerable impact on human health due to aesthetic effects. It is the man behind machines / technology that matters. Therefore, a number of national and local seminars, workshops and symposia have been organized by number of Institutions to develop methodology for BMW mgm and it’s understanding (8). However, ground realities are far from ideal and need a lot of effort and commitment at the top level for effective implementation. The current scenario in the country reveals partial or no segregation at the time of generation, which at times is done by the contractors, or the rag pickers.

The scenario is no different in a metropolitan city of India. Therefore, the Dept. of Hospital administration of a superspecialty tertiary hospital in Delhi designed a Hospital Waste management manual to create awareness amongst the waste generators. To ensure implementation of the waste management system in accordance with the Bio-Medical waste (Management and Handling) rules, 1998, the deptt. of hospital administration circulated manuals and memoranda amongst the concerned staff. However, the improper practice of segregation at the site of origin has been observed which causes mixing of infectious and non-infectious waste. A study was therefore, conducted to understand the awareness amongst the employees as regards to BMW management practices to study the Knowledge, Attitude and Practice of the respondent. The hospital chosen for the study is a premier tertiary level Institute in India . Therefore, the current status of employee’s awareness regarding BMW management will help the authorities to develop the strategy for improving the situation in future.

REVIEW OF LITERATURE

Government of India reacted towards the global concern and notified the Biomedical waste management rules1998 (MINISTRY OF ENVIRONMENT & FORESTS, Notification, New Delhi 20th July 1998). These rules have been framed in exercise of the powers conferred by Sections 6,8 and 25 of Environment (Protection) Act 1986. This is applicable to every hospital and nursing home, veterinary institutions, animal houses or slaughterhouses, which generate, Biomedical waste within a time frame. This law has exempted clinics, dispensaries and laboratories providing treatment or diagnostic facility to less than 1000 patients per month. The Objectives and rationale of BMW management are mainly to reduce waste generation, efficient collection, handling and disposal in such a way that it controls infection and provides safety to employees working in the system and ensure cost effectiveness by avoiding penalties and fines imposed by regulatory authorities. Accordingly, waste is required to be treated and disposed of in accordance with schedules prescribed. The basic elements is to recognize the waste, identify where waste is generated and determine the cause of generation, plan disposal of the waste in a scientific manner so as to render it environmentally non-hazardous and eliminate the source of infection (6).

When the concern is so much about the medical waste there is a need for such a ruling, the health care workers ought to understand what is actually Biomedical waste and the waste connected with the hospital. Hospital waste refers to all waste, biological or non-biological that is discarded, and is not intended for further use in a hospital. According to a WHO report around 85% of the hospital wastes are actually nonhazardous, 10% are infective (hence, hazardous), and the remaining 5% are non infectious but hazardous (chemical), pharmaceutical and radioactive (9).

Bio-medical waste differs from hospital waste in the sense that it is “any solid, fluid or liquid waste, including its container and any intermediate product. These products could be generated during the diagnosis, treatment of immunization of human beings or animals, in research pertaining there to, or in the production or testing of biological and the animal waste from slaughter houses or any other Ilke establishments (10).

METHODOLOGY

This study was conducted in a tertiary level hospital in New Delhi, India. The hospital is a premier research and a referral center in India. This is a 1600 bedded hospital with a work force of 800 doctors, 1600 Nurses and with 6000 other support staff, which includes paramedical staff and house keeping staff as well. The tool used for collection of data was questionnaire which has semi-structured format with a set of 12 items concerning the knowledge, understanding and their behavior on the subject. This was further categorized in three sets with one question each on knowledge, attitude and practice. The questionnaire was given to the 7 categories of staff only in selected high risk areas like operation theatre, laboratories, medicine ward and surgery ward. The staff includes consultants, Residents, Scientists, Nurses, O.T. Staff, Sanitary staff and Laboratory staff and was grouped as Group I to Group VII accordingly. 200 questionnaires were distributed and 156 (78%) were received back out of which 13% are from consultants, 16% from Residents, 14% from Scientists, 13% fromNurses, 14% from O.T. Staff, 14% from Sanitary staff and 16% are Laboratory staff. The answers were analyzed as positive and negative answers and then percentage positive and negative answers per group were calculated and percentage was used to draw statistical status of the groups.

RESULTS AND DISCUSSION

KNOWLEDGE

The results of questionnaire analysis shows that Consultants, Residents and the Scientists respectively have 85%, 81 % and 86% knowledge about the biomedical waste management rule (set-I) Table -1. The knowledge component among the nurses have shown to be 60% and that of Sanitary staff, Operation theatre and Laboratory staff have respectively 14%, 14% and 12% awareness of the subject. ( Fig.- 1) This shows that the people with higher education have more awareness about the environmental issues, national and international activities on Biomedical waste management and the rules prescribed there in.

Table 1: Positive asnwers of questionnaire by staff of different groups (SET-I)

Group I (Consultants) II (Residents) III (Scientists) IV (Nurses) V (OT Staff) VI (Sanitary Staff) VII (Laboratory Staff)
(n = 20) (n = 27) (n = 22) (n = 20) (n = 21) (n = 21) (n = 25)
No. % No. % No. % No. % No. % No. % No. %
Knowledge 17 85 22 81 19 86 12 85 3 14 3 14 3 12
Attitude 16 80 23 85 12 55 20 80 19 90 17 81 14 56
Practice 15 75 24 89 18 82 20 75 19 90 14 67 11 44


Fig. - 1: Group I/Set I/KAP Fig. - II: Groups / Set-II / KAP
Fig. – 1: Group I/Set I/KAP Fig. – II: Groups / Set-II / KAP

Table 2 : Positive asnwers of questionnaire by staff of different groups (SET-II)

Group I (Consultants) II (Residents) III (Scientists) IV (Nurses) V (OT Staff) VI (Sanitary Staff) VII (Laboratory Staff)
(n = 20) (n = 27) (n = 22) (n = 20) (n = 21) (n = 21) (n = 25)
No. % No. % No. % No. % No. % No. % No. %
Knowledge 15 70 22 74 14 64 16 80 19 90 15 71 9 36
Attitude 19 95 26 96 21 95 20 100 20 95 17 81 22 88
Practice 16 80 22 81 16 73 20 100 19 90 19 48 8 32

Table 3: Positive asnwers of questionnaire by staff of different groups (SET-III) in numbers

Group I (Consultants) II (Residents) III (Scientists) IV (Nurses) V (OT Staff) VI (Sanitary Staff) VII (Laboratory Staff)
(n = 20) (n = 27) (n = 22) (n = 20) (n = 21) (n = 21) (n = 25)
No. % No. % No. % No. % No. % No. % No. %
Knowledge 4 20 10 37 6 27 8 40 4 19 3 14 3 12
Attitude 17 85 17 63 13 59 19 95 18 86 16 76 8 32
Practice 13 65 21 78 18 82 20 100 20 95 19 90 16 64

The question that directly indicates the awareness of people on the reasons of making of law on biomedical waste (set-II) Table-2 has best result in Operation Theatre staff having awareness 90%,80% in nurses, 74% in residents, 71% in Sanitary staff, 70% in professors, 64% in scientists group but laboratory staff has only 36% knowledge ratio. It shows (Fig.- II) that functionaries who were involved in direct patient care are relatively more aware than the other groups like scientists and laboratory staff. The functionaries who are least related with the patient care are relatively less aware of the procedures. This may be due to the guidelines of biomedical waste management emphasized in the area where there is about the set III (Table-3) question ofknowledge, where it was asked whether they ever attended any seminar or class regarding BMW. Nurses group has highest percentage of positive response at the rate of 40%. Lowest is found to be 12% in Laboratory staff. This can be substantiated by the fact, which reveal that laboratory people were neither provided with the necessary information nor they were involved in any of the training programs. Consultants, residents, scientists, a.T. staff and sanitary staff have scored 20%,37%,27%,19% and 14% has attended some seminar or class related to the subject and hence, are aware of the concept of scientific waste management procedures respectively. They had attended either seminar or some classes regarding the subject.(Fig.III)

Fig. – III: Groups / Set-III / KAP

Fig. - III: Groups / Set-III / KAP

ATTITUDE

In regard to attitude towards the scientific process Nurses had scored 100% in set- I, 100% in set-II and 95% in set- III in response to the questions on the subject. Similarly, Consultants have scored 80%, 85% and 90%, Residents rated 85%, 96% and 63% and the Scientists rated 55%, 95% and 59% in regards to attitude towards the scientific practice. O.T. staff scored 90%, 95%, 86% whereas sanitary staff have 81 , 81, 76% and Laboratory staff have the rate of 56%,88% and 32% employees on the same count

PRACTICE

In the group of three sets of questionnaire, the findings shown that consultantswere practicing according to BMW rules in the tune of 75%, 80% and 65%. Residents were rated 89%, 81 % and 78% and scientists were at the rate of 82%, 73% and 82% respectively practicing as per rules. In regards to the Nurses it is shown to be the best i.e. 100% of them are practicing according to the rules. O.T staff has 90%, 90% and 95% and sanitary staff with 67%, 48% and 90%, Similar, to the earlier findings in regard to the practice also the laboratory staff has only 44%, 32% and 64% complied with the guidelines and norms listed down in the hospital in regard to Bio-Medical Waste rules.

KNOWLEDGE / ATTITUDE / PRACTICE

The comparison of Knowledge, with Attitude and Practice of groups shows that the people with high education, as consultants, Residents and Scientists though have very good knowledge but relatively low percentage of people having the same kind of attitude and practice habits Table – 1. Fig-I. At the same time if we compare the nurses or Operation Theatre staff, we find that they too have good percentage of people with good knowledge, almost similar in all the three group I, II and III and therefore, attitude and practice percentage is also very high. It has been mainly attributed to the instruction manual and the responsibility given to the nursing staff for implementation of rules by the authorities.

Sanitary staff though has very poor knowledge about the BMW Act and rules, but a good percentage of this category has positive attitude and practice habits. The laboratory staff was found to have recorded lowest in all the three aspects. This indicates that neither authority informed them in the form of instructions nor they supervised their Biomedical waste management practices. While processing further it is observed that the laboratory staff showed least of interest to know more about the system of BMW management and they expressed that it is the responsibility of hospital management providing direct patient care facility only.

The questionnaire also had two questions focused to assess the availability of hospital facility in regard to Biomedical waste management. This when analyzed shows that, 80% of people expressed that hospital has enough infrastructure for proper implementation of Biomedical waste management rules. However, 15% of consultants and 12% Residents are not aware whether hospital provides the proper facilities for segregation and removal of waste and 2% answered that it is not provided. This could be because they did not show any interest to know the facility provided in this regard or the group did not feel that Biomedical waste management is not necessarily a prerequisite for a good patient care service. A small percentage of the respondent expressed that this is not their duty to find out whether such a sensible approach is required and Biomedical waste management is the responsibility of the administration and sanitary staff only and not the doctors. This means they are neither interested to know what is happening around them, nor they have the attitude to contribute towards a system of development for a good patient care activity. 20% scientists expressed thatproper facilities are not provided by the hospital. As per laboratory staff 35% were of the opinion that proper physical facilities for proper implementation of Biomedical waste management rules are not been provided.

Table-4 : Positive asnwers of questionnaire by staff of different groups (Average of three SETS)

Group I (Consultants) II (Residents) III (Scientists) IV (Nurses) V (OT Staff) VI (Sanitary Staff) VII (Laboratory Staff)
(n = 60) (n = 81) (n = 66) (n = 60) (n = 63) (n = 63) (n = 75)
No. % No. % No. % No. % No. % No. % No. %
Knowledge 36 61 53 65 44 61 34 57 26 19 21 33 15 20
Attitude 51 85 66 81 46 70 59 98 57 86 50 79 44 59
Practice 46 76 66 81 51 77 60 100 58 95 44 70 35 47

Fig. - IV: Group / Average-III / KAP

Fig. – IV: Group / Average-III / KAP

While in the column of suggestions almost everyone said that intensive training programs would help increase awareness and practice in the people. Increasing the knowledge as well as the sense of responsibility can attain the promotion of attitude and practice of habits. The publicity of subject through public media as well as departmental programs will definitely help to achieve the desired goal. Some even suggested for strict rules and regulation by authorities with provision of punishment and penalty will serve the purpose.

SUMMARY

In the field of medical practice statutory public health guidelines for Biomedical waste Management and close monitoring of its compliance alone cannot achieve the ultimate goal, if it is not accompanied with social science approach of mass education motivation and change of mind set in all strata of medical practice. Continuous logistic support and user friendly approach is equally important while implementing in the process of any rules, regulations concerning the medical practice other than the core mandate they area are assigned to.

The study has shown a definite apathy of intellectuals towards the operational aspects of the system. The medical professionals have tubular vision on patient care services and pay very little heeds to support services in the overall context of comprehensive patient welfare. Nursing professional are found to have had on edge in the attitude and understanding in the subject and it is found that they are practicing the guidelines in more responsible manner may be due to their accountability and commitment in the patient welfare. Paramedical staff including laboratory staff and housekeeping staff have relatively less understanding on the subject, but has high attitude and more practical habits which may be because of strict instructions by authorities and fear for punitive action.

SOME SUGGESTIONS WHICH WOULD ACT AS REMEDIAL MEASURES INCLUDE

  • Intensive training programs at regular time interval for all the staff with special importance to the new comers.
  • Need for orientation programs for newcomers to understand the hospital function.
  • The entire waste management practices should be a part of total hygiene practice of the society rather thAn confining to hospital and health facility.

Acknowledgments

We acknowledge the AIIMS hospital staff for their cooperative coordination and support during the study.

REFERENCES

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  3. Report of High Power Committee on Urban-Solid Waste Management, Planning Commission, Govt. ofIndia, Hospital waste management. 1995; 35-47.
  4. Grover P.D. Management of Hospital Wastes – An overview. Proceedings of National workshop on Management of Hospital Waste 1998. 16-18.
  5. Wallace L.P., Zaltzman R. and Burchinal lC. Where solid waste comes from; where it goes. Modem hospitals 1972; 121(3): 92-5.
  6. Guidelines for protecting the safety and health of health workers. NIOSH /Health Care Workers guidelines / Chap 6
  7. Li Chin-shan and Jeng Fu-Tien Physical and chemical composition of hospital waste. Infect Control Hosp. Epidemiol, 1993; 14: 145-150.
  8. Rutala WA, Mayhall CG. SHEA Portion paper, 1992, 13:38-48
  9. URL:http//www.hse.gor.uk.ntdir/noframep/agent/pof catefonnent of biological agent according to hared and containment 4thed, 1995; IInd suppl.
  10. Satpathy S, Pandhi RK. Manual for Hospital waste management at AIIMS Hospital, 1998. New Delhi.

S. Saini1, S.S. Nagarajan2, R.K. Sarma3

1 Department of Pediatrics, All India Institute of Medical Sciences, New Delhi-29

2 Manager, Indian Credit Rating Agency (ICRA), New Delhi

3 Prof. R.K. Sarma, Director, NEIGRIHMS, Shillong (Corresponding Author)

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