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Disposal of Clinical Wastes: Tata Memorial Hospital Experience

Disposal of Clinical Wastes: Tata Memorial Hospital Experience. Dr Rohini Kelkar M.D., D.P.B. Professor & Head, Dept of Microbiology Tata Memorial Hospital, Mumbai. “No one was ever really taught. Each has to teach himself.” Swami Vivekananda. The Reality Ignorance

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Disposal of Clinical Wastes: Tata Memorial Hospital Experience

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  1. Disposal of Clinical Wastes: Tata Memorial Hospital Experience Dr Rohini Kelkar M.D., D.P.B. Professor & Head, Dept of Microbiology Tata Memorial Hospital, Mumbai

  2. “No one was ever really taught. Each has to teach himself.” Swami Vivekananda • The Reality • Ignorance • Commercialization of science • Apathy • The Concerns • Occupational • Public health • Environmental

  3. The Science • The only documented risk of transmission of infections from waste to healthcare workers is through sharps • There is however a potential for transmission of several microbial infections due to dumping of untreated wastes by healthcare facilities. • Mixing of a small quantity of infectious waste with municipal garbage converts the entire waste to “ infectious” • Segregation of wastes at source followed by appropriate treatment is the key to the success of a waste management strategy

  4. Hospital waste Hazardous Non-hazardous Noninfectious Infectious Kitchen Recyclables Cytotoxic drugs Toxic Chemicals Radioactive Sharps: needles, scalpel blades, scalp veins, glass contaminated with blood Non-sharps Patient contaminated waste Laboratory waste Specimens Anatomical Plastics Non-plastics contaminated cotton waste, gauze, linen PVC, PE PET, PS Equipment

  5. The Social Issue: Ragpickers

  6. The TMH Pathway • Closure of the incinerator • Awareness programs for all the staff • Refashioning the storage area • Street play • Posters

  7. Incinerator circa 1994 1. CLEARLY DEFINE THE PROBLEM

  8. Segregation at source into defined categories using a simplified system. 2. FOCUS ON SEGREGATION FIRST Appropriate placement of Colour Coded Bins Radioactive Waste

  9. Sharps Disposal 3. INSTITUTE A SHARPS MANAGEMENT SYSTEM

  10. Waste Audit 4. KEEP FOCUS ON REDUCTION

  11. About Sharps: • The only documented transmission of infection from waste to HCWs is through sharp injuries. Thus safe disposal of sharps is the first priority. • Sharp injuries: • Before or during use (17%) • After Use but before disposal (70%) • During or after disposal (13%) • (Our Experience: Majority of sharp injuries occur due to improper disposal and waste handlers are the victims) 5. ENSURE WORKER SAFETY THROUGH EDUCATION, TRAINING AND PROPER PERSONAL PROTECTIVE EQUIPMENT Safe Disposal of Sharps: Do not recap needles. If essential learn the right way to do so.

  12. Collection network. . 6. PROVIDE SECURE COLLECTION AND TRANSPORTATION

  13. Waste management Strategy: • Reduce Risks and Liabilities: This should be detailed through written policies and continuing training and education of hospital staff. • Control Costs: Audit of current practices, search for waste minimization practices is a continuing process. • Plan for Future: Look for alternative technologies, co-operative facilities and means of diversification. • Commitment towards protecting Human Health and the Environment 7. DEVELOP PLANS AND POLICIES

  14. Infection Awareness Week 8. INVEST IN TRAINING Street Play

  15. 9. DEVELOP THE INFRASTRUCTURE

  16. 10. Evaluation of Technologies

  17. Evaluation of Non Burn Technologies for Medical Waste Treatment

  18. 1. Demonstrated Performance

  19. 2. Technical & Performance Criteria

  20. 3. Vendor Qualifications

  21. 4. Environmental & Permitting Issues

  22. 5. Occupational Health & Safety Issues

  23. 6. Facility: & Infrastructural Requirements

  24. 7. Economics

  25. Inauguration of Tata Memorial Hospital waste treatment facility On September 10, 1999, well before the first dead line set by the Ministry of Environment and Forest, 31 December 1999.

  26. Selection of Technology and Implementation is not the setting sun Evaluation is a continuous process

  27. TMH Waste Audit Nov. 1999 to Dec. 2007 Total infectious waste treated – 614 tonnes.  83,511 kg. in 2007.  Cost of treatment = Rs. 14.86 / kg.

  28. TMH Infectious Waste Audit 2008 - 2009 Total infectious waste treated 2000-2009= 800 tonnes. Cost of treatment = Rs. 14 / kg.

  29. TMH Waste Management • Waste is Sterilized, Dehumidified, Shredded and reduced in terms of Weight and Volume by 75%. • It is not recognizable as Medical Waste

  30. Hazardous Waste

  31. Environment News On 15 April, 2005, a 51 year-old asbestos laden ship, Kong Fredrick IX was on its way to Alang ship breaking yard, Gujarat for scrapping. The ship's new owners Jupiter Ship Management, a Mumbai based company, had renamed it to 'MV Riky'. Connie Hedegaard, Denmark's environment minister alerted the Indian environment minister saying, "I believe our interests are joint - and I call on you to co-operate in this case by denying the ship to be dismantled in India - and refer the ship to return to Denmark to be stripped of the hazardous waste."

  32. India’s significant economic growth and rise in industrialization coupled by lax government enforcement of anti-pollution laws and regulations have had a detrimental effect on India’s natural environment. Hazardous waste from industrial processes, medical waste and India’s thriving scrap recycling businesses pollutes Indian air, soils and waterways.

  33. India is a signatory to the three conventions on hazardous chemicals and waste: The Basel Convention on the Control of Trans-boundary Movement of Hazardous Waste and their Disposal, The Rotterdam Convention on the Prior Informed Consent Procedure for Certain Hazardous Chemicals and Pesticides in International Trade and The Stockholm Convention of Persistent Organic Pollutants.

  34. The Hazardous Substances Management Division (HSM) of the Ministry of Environment and Forests (MoEF) has the responsibility for promoting safe management and use of hazardous substances, including hazardous waste. The HSM has established three sets of rules: The Hazardous Wastes (Management and Handling) Rules (1989, amended in 2003), The Bio-medial Wastes (Management and Handling) Rules (1998/2000), and The Batteries (Management and Handling) Rules (2001).

  35. The HSM relies primarily on the The Central Pollution Control Board (CPCB), The State Pollution Control Boards (SPCBs) or State Pollution Control Committees (SPCCs), and The environmental departments in India’s 25 states to implement, monitor and prosecute.

  36. Approximately 5 million tonnes of hazardous waste is produced annually in India. According to a 2003 report, Indian industries in the following five states had generated over 80% of the country’s hazardous waste: Andhra Pradesh, Gujarat, Karnataka, Maharashtra and Tamil Nadu.

  37. European Commission focus on waste management Pitfalls of the currently available technologies for managing wastes

  38. European Commission focus on waste management Pitfalls of the currently available technologies for managing wastes

  39. E-wasteHow green is your Apple?Aug 25th 2006From The Economist print edition

  40. God proposes, man disposes Waste and taste Dec 11th 2006From Economist.com The rubbish tip as cultural artefact FRESH Kills landfill in New York, until recently the biggest rubbish tip on earth, was said to be one of the very few man-made objects visible from space, along with the Great Wall of China.

  41. LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS Class AConcentration limit: 50 mg/kgA1 Antimony and antimony compoundsA2 Arsenic and arsenic compoundsA3 beryllium and cadmium compoundsA4 Cadmium and beryllium compoundsA5 Chromium (VI) compoundsA6 Mercury and mercury compoundsA7 Selenium and selenium compoundsA8 Tellurium and tellurium compoundsA9 Thallium and thallium compoundsA10 Inorganic cyanide compounds (cyanides)A11 Metal carbonylsA12 NapthaleneA13 AnthraceneA14 PhenanthreneA15 Chrysene, benzo(a) anthracene, fluoranthene, benzo(a) pyrene, benzo(K)fluoranthene, indeno(1, 2, 3-ed) pyrene and benzo(ghi)peryleneA16 Halogenated fused aromatic rings, e.g. polychlorobiphenyls plus derivativesA17 Halogenated aromatic compoundsA18 BenzeneA19 Dieldrin, aldrin, and endrinA20 Organotin compounds Ministry of Environment & Forests: Hazardous Wastes (Management and Handling) Amendment Rules, 2002

  42. Class B Concentration limit: 5,000 mg/kgB1 Chromium (III) compoundsB2 Cobalt compoundsB3 Copper compoundsB4 Lead and lead compoundsB5 Molybdenum compoundsB6 Nickel compoundsB7 Tin compoundsB8 Vanadium compoundsB9 Tungsten compoundsB10 Silver compoundsB11 Organic halogen compoundsB12 Organic phosphorus compoundsB13 Organic peroxidesB14 Organic nitro-and nitroso-compoundsB15 Organic azo-and azo-oxy compoundsB16 NitrilesB17 AminesB18 (Iso-and thio-) cyanatesB19 Phenol and phenolic compoundsB20 MerceptansB21 AsbestosB22 Drilling, cutting, grinding and rolling oil or emulsions thereofB23 Halogen-silanesB24 Hydrazine(s)B25 FluorineB26 ChlorineB27 BromineB28 White phosphorusB29 Ferro-silicon and alloysB30 Manganese-siliconB31 Halogen-containing substances which produce acidic vapours on contact with damp air or water, e.g. silicon tetrachloride, aluminum chloride, titanium tetrachloride LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS Ministry of Environment & Forests: Hazardous Wastes (Management and Handling) Amendment Rules, 2002

  43. LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS Class C Concentration limit: 20,000 mg/kg C1 Ammonia and ammonium compoundsC2 Inorganic peroxidesC3 Barium compounds, except barium sulphateC4 Fluorine compoundsC5 Phosphorus compounds, except the phosphates of aluminum, calcium and ironC6 Bromates, (hypo)bromitesC7 Chlorates, (hypo)chloritesC8 Aromatic compoundsC9 Organic silicon compoundsC10 Organic sulphur compoundsC11 IodatesC12 Nitrates, nitritesC13 SulphidesC14 Zinc compoundsC15 Salts of per-acidsC16 Acid halides, acid amidesC17 Acid anhydrides Ministry of Environment & Forests: Hazardous Wastes (Management and Handling) Amendment Rules, 2002

  44. LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS Ministry of Environment & Forests: Hazardous Wastes (Management and Handling) Amendment Rules, 2002 Class D Concentration limit: 50,000 mg/kgD1 SulphurD2 Inorganic acidsD3 Metal bisulphatesD4 Oxides and hydroxides except those of: hydrogen, carbon, silicon, iron, aluminum, titanium, manganese, magnesium, calciumD5 Aliphatic and napthenic hydrocarbonsD6 Organic oxygen compoundsD7 Organic nitrogen compoundsD8 NitridesD9 Hydrides

  45. LIST OF WASTE SUBSTANCES WITH CONCENTRATION LIMITS Ministry of Environment & Forests: Hazardous Wastes (Management and Handling) Amendment Rules, 2002 Class E Regardless of concentration limit E.1 Highly flammable substancesE.2 Substances which generate dangerous quantities of highly flammbale gases on contact with water or damp air.

  46. LIST OF PROCESSES GENERATING HAZARDOUS WASTES Ministry of Environment & Forests Hazardous Wastes (Management and Handling) Amendment Rules, 2003

  47. LIST OF PROCESSES GENERATING HAZARDOUS WASTES Ministry of Environment & Forests Hazardous Wastes (Management and Handling) Amendment Rules, 2003

  48. LIST OF PROCESSES GENERATING HAZARDOUS WASTES Ministry of Environment & Forests Hazardous Wastes (Management and Handling) Amendment Rules, 2003

  49. REPORT ON CLINICAL WASTE AUDIT 2005

  50. Hazardous liquid waste / month:

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