HOSPITAL WASTE MANAGEMENT

1. HOSPITAL WASTE MANAGEMENT TYPES, CHARACTERISTIC, TREATMENT METHOD AND MANAGEMENT 11th May 2009

2. OUTLINE Potential Hazard of Hospital Waste Waste Management Sources of waste Classification of Hospital Waste Treatment, Transport and Disposal Method Incineration of Hospital Waste Regulations

3. Facts in Indonesia RS mengolah Limbah = 53%, pengolahan dg IPAL dan septic tank = 51%, sisanya hanya septic tank RS yg melakukan pemeriksaan kualitas limbah 57%, 63% memenuhi syarat Pemisahan sampah medis dan non medis 80.7%, 20% dengan pewadahan khusus (warna dan lambang) 62.5% insinerator, 14.8% landfill, 22.7% cara lain Limbah toksik, 51.1% insinerator, 15.9% landfill, 33.0% cara lain Limbah radioaktif, hanya 37.1% menyerahkan limbha ke BATAN, sisanya dengan Silo dan cara lain Limbah domestik 98.8% dengan cara landfill

4. POTENTIAL HAZARD Exposed people: ? Patient and medical workers People who are contracted working at the hospital (cleaning service etc) Patient (rawat jalan) Visitors

5. Benefit of Env. Management Environmental Protection Better Hospital Environmental Management Human Resource Development Continuous Improvement of Hospital Environment Performance Meet Regulation Requirement Part of Total Quality Management Reduction of Expenses Improvement of Hospital Public Image

6. Env. Management Component Management Support Scale and Type match with Env. Impact from Hospital activities Continuous improvement Meet the regulation requirement Guideline to prepare and review the objective and goal of Env. Management Documented, applied, maintained and communicated to all Available for all

7. Planning Identification of env. Aspects and Impacts Legal requirements Environmental Policy and Internal performance criteria Objectives and goals of env. Managmeent Planning and management program Struktur, tanggung jawab, organisasi, kewenangan; proses bisnis management; SDM, skill, budget dan alat; proses untuk mencapai tujuan: prosedur dan pengendalian operasi, pelatihan, sistem pengukuran dan audit, pengkajian manajemen.

8. Implementation Structure and responsibilities Training, awareness, competency Communication Documentation and Env. Management System Document Control Operational Control Emergency preparedness Evaluation Corrective action

9. Hospital Regulation PerMenKes RI No 928/Menkes/Per/XI/1995 ttg penyusunan AMDAL bidang kesehatan Pedomen teknis penyusunan AMDAL RS Pedoman Teknis penyusunan UPL dan UKL RS PerMenKes RI No 986/Menkes/Per/XI/1992 ttg Persyaratan Kesehatan Lingkungan RS Keputusan Dirjen P2M PLP No HK.00.06.6.64, 18 Feb 1993 ttg Persyaratan dan Petunjuk Teknis tentang Tata Cara Penyehatan Lingkungan Rumah Sakit Pedoman Sanitasi RS Indonesia Pedoman teknis Pengelolaan Makanan dan Infeksi Nosokomial di RS PP no 12/1995 ttg perubahan PP no 19/1994 ttg pengelolaan limbah B3 KepMenLH No 58/1995 ttg Baku Mutu Limbah Cair bagi Kegiatan RS

10. Regulated Env. Aspects Environmental Impacts Assessment Nosokomial Infection Chemical and hazardous waste Gas emission, temperature, humidity, nuisance and lighting Effluent quality of waste treatment plant Solid waste Radioactive waste Medical waste

11. Unregulated Env. Aspects Management structure Facilities, location map of env. control History and Owner of the Hospital Hospital General activities Flow of Health Treatment Procedure Nosokomial Infection control Health and Safety Policy List of Medical and non medical substance Sistem pengadaan dan jadwal, jml pemakaian, penyimpanan, distribusi dan transportasi bahan Air pollution control

12. Handling, storage, transportation of domestic, hazardous, chemotherapy waste, disposal procedure and legal letter Water supply, piping, layout, and water consumption Recording of wastewater effluent quality Waste water treatment system ( system, facilities and SOP) Sanitation method (pest, microbiology, virus, toxicology) Supply, Layout, consumption of electricity Environmental training Supplier Consideration of Environmental Issues Material Identification Approach

13. Environmental Monitoring Aspects Waste production Waste water Reuse of waste water Efficiency of Material Consumption Energy consumption Unplanned disposal Recycle activities Chemical handling Gas handling Handling of water for cleaning purposes

14. WASTE FLOW IN GENERAL

15. SOURCES Medical Activities Surgical Room, Emergency Room, Policlinic, Dialysis, Delivery Room, treatment of dead body, Chemotherapy, etc. Supporting Activities Laboratories, Radiology, Laundry, Kitchen, Maintenance, Pharmacy Office and Social Activities Office (administration and accountancy), Medical record, Cafeteria, Mosque, Guest House, Dormitory

17. CLASSIFICATION Hospital Waste: all wastes that are generated from hospital activities including solid, liquid and gases Liquid waste: all waste in liquid form from hospital activities including excreta that has possibilities of containing microorganism, toxic chemicals, and radioactive substance. Solid waste: all waste in solid form including medical and non medical waste

18. Medical waste (limbah medis) (50-60% disposal cost)? generated from medical activities Infectious waste ? contains microorganism that may cause disease from surgical room, laboratories, haemodialysis Pathological waste ? human/animal tissue, body part, etc Citotoxic waste ? material that are/might be contaminated by citotoxic medicine Sharps ? syringe, scissors, knife, broken glass, nail cutter ? tertusuk (luka) Pharmacological waste ?returned medicine, expired or contaminated medicine, spilled medicine, etc. CLASSIFICATION

19. Could you explain what are the differences between infectious waste and pathological waste ?

20. CLASSIFICATION Non Medical Waste (limbah non medis) ? mostly generated from hospital supporting activities, office and social activities General waste, food, card board, etc Hazardous waste ? toxic, corrosive, flammable, reactive (explosive, reactive to water, shock sensitive) Radioactive ? solid, liquid or gas contaminated by radionuclide, generated from in-vitro, in-vivo analysis, therapy toxic waste ? genetoxic (carcinogenic, mutagenic, teratogenic) pressure containers ? explosive when burned Waste with high heavy metal concentration Chemical waste ? disinfection, laboratories, cleaning, may include in hazardous waste categories

21. Limbah Klinis Golongan A, dressing bedah, swab, dan semua bahan yang tercampur deng bhn tsb, linen dan kasus infeksi, jaringan tubuh, dan hal lain y berkaitan dg swab dan dressing Golongan B, syringe bekas, jarum, catridge, pecahan gelas, dan benda tajam lainnya Golongan C, limbah dr laboratorium dan post partum kecuali yg termasuk gol A Golongan D, limbah bahan kimia dan bhn farmasi ttt Golongan E, plapis bed-pan disposable, urinoir, incontinence-pad, dan stamage-bags

22. INFECTIOUS WASTE Infectious waste includes the following (EPA): ? Isolation waste Cultures and stocks of infectious agents and associated biologicals Human blood or liquid and blood products Pathological waste (tissues, organs, body parts except teeth and hair) Contaminated sharps Miscellaneous contaminated wastes (animal carcasses)

24. CHARACTERISTIC of SW

25. CLASSIFICATION

26. COMPOSITION

27. TOXIC & HAZARDOUS WASTE Hospital generate 0.056 lb/bed per day toxic and hazardous waste 200 bed ? 336 lb per month ? hospitals are regulated as generator of hazardous waste

28. WASTE MANAGEMENT ?

29. WASTE MANAGEMENT

30. PREVETION OF POTENTIAL HAZARD Use safety material or non-hazardous material Use closed containers for volatile substance Good ventilation ? health&safety standards Body protection (mask, gloves, etc.) Use container with different color for different waste Regular monitoring for high risk activities Epidemiological analysis for high risk activities

31. ON SITE HANDLING

32. COLLECTION / STORAGE EPA ? red bag (operating room waste, blood serums, sharps), white bag (general waste, kitchen waste, boxes) DepKes RI ? plastic bag’s color Black : general waste Yellow: all waste that must go to incinerators Yellow with black line: all waste that better go to incinerator, but can go to landfill if collected separately Light blue or transparent with dark blue lines: must go to autoclave before next handling

33. COLLECTION / STORAGE Bags or containers should be ? Enough filled so it is easy to be well closed Labeled ? symbol is given as it is regulated Able to allow steam to enter during sterilization (if needed) Completed with active date before it can be categorized as general waste For syringe : WHO standard (container shape, thickness, material, placing)

34. TRANSPORTATION Waste are transported from first collection to temporary storage or to incinerator Transportation means must be cleaned regularly and used only for waste transport If transported to landfill must not have possibilities to harm the health of transportation personnel Hazardous waste should be transported as regulated in PP 18/1999

35. HANDLING OF CHEMICAL Non-hazardous chemical should be labeled and handled as general waste organic chemical (acetate, amino acid, citric acid, lactic acid, sugar) Inorganic chemical (chloride, fluoride, bromide, sulfate, borate) Hazardous chemical Un reusable chemical? incinerator dated after used, maximum storage time: 3, 12, 24 month Shock sensitive: diazo substance, metal azide, nitrocellulose, perchloric acid, perchlorate salts, peroxide, picric acid, picrate salts, polynitroaromatic Water reactive: alkaline metal, soil alkaline, lithium alkaline reagent, boron trifluoride solution, grignard solution Others: nitrate acid >70%, phosphor (red and white)

36. DISINFECTION ALTERNATIVES Autoclaving Pyrolysis ? 1200?C, vol. reduction 97-98% Fluidized-bed coal technology ? circulating fluidized bed burning of coal Electron beam technology ? sterilization of all infectious waste including liquid Microwave technology ? not recommendation for pathological and animal waste, + expensive Mechanical-Chemical treatment (Sodium Hypochlorite -NaOCl) ? pathological Gas/vapor sterilization (ethylene oxide or formaldehyde), not recommended Biodegradation ? enzymes Steam sterilization ? 300 ?F

37. COMPARISON

38. DECISION MAKING

39. INCINERATION ? Infectious, un recover/un recyclable general waste Operational Parameters: Burning rate (pound/hour), heating value (Btu/pound), heat release value (Btu/cubic feet per hour) Alternatives: Controlled-air incinerators Rotary-kiln incinerators Air Pollution Controls Wet Scrubbers: impaction of particles with countercurrent flow reactor Dry Scrubbers: Reacting particles and gases in spray-dryer section, collection of particles in a baghouse collector

40. INCINERATORS

41. INCINERATORS

43. INCINERATORS

44. What are the differences between controlled air and rotary kiln incinerators ?

45. AIR POLLUTION CONTROLS

46. NEW METHODS Problems ? dioxin ? carcinogenic Dioxin + chlor ? TCDD (Tetra Chloro Dibenzo para Dioxin) ? cancer US ? many incinerators > regulation Japan ? 70% world incinerators, high concentration dioxin found in surrounding incinerator ? 18 from 271 die from cancer > 800 ?C ? reduce dioxin but increase heavy metal vapor Using Sun Light reduce dioxin, reduce cost 150?C in 20 minutes ? enough to kill bacteria Low Thermal Desorbtion Invented by FMIPA UI Titanium oxide ? dioxin reduction Indirect heating with low heat thermolysis ? drying at low temperature (200-350 ?C) without oxidation (direct burning) Low pressure No oxygen ? reduce vapor point

47. LIQUID WASTE Indonesia ? most hospitals use septic tank Direct charge to river Possibility polluting the surrounding soil Unable degraded by activated sludge Recommended: Ozonization Ozone: oxidation potential 1.7 V ? radical Ozone in water ? radical hydroxil (2.8 V) Kill eschericia coli, Salmonella enteriditis, Hepatitis A Virus, etc Oxidize organic substance ( fenol, pesticides, atrazine, TNT, etc)

48. TOXIC WASTE DISPOSAL

49. REGULATION UU No. 23 /1997 ? Pengelolaan Lingkungan Hidup KepMENLH No. 58/1995 ? Baku mutu limbah cair bagi kegiatan rumah sakit PP No. 18/1999 ? Pengelolaan limbah B3 UU N0. 7/2004 ? Sumber Daya Air Peraturan Menteri Kesehatan RI No. 1024/2003 ? Persyaratan Kesehatan Lingkungan RS

50. REFERENCES Harry M. Freeman, editor (1989) Standard Handbook of Hazardous Waste Treatment and Disposal, McGraw-Hill, Inc., New York. Howard E. Hesketh and Frank L. Cross, Jr. (1995) Engineering Medical Waste-to-Energy Systems, Technomic Publishing Co., Inc., Lancester CRS Handbook of Laboratory Safety 5th edition (A. Keith Furr) Hazardous Waste Management, McGraw-Hill, Inc., New York Bapedal (2003) Peraturan Lingkungan Hidup, Jilid 1, Bapedal, Jakarta. Wiku Adisasmito, 2007, Sistem Manajemen Lingkungan, PT. Raja Grafindo Persada, Jakarta

51. ALTERNATIVE METHODS