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Health care waste management project at mbabane government hospital swaziland bongani j. Sigudla


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HEALTH CARE WASTE MANAGEMENT PROJECT AT MBABANE GOVERNMENT HOSPITAL -- SWAZILAND

BONGANI J. SIGUDLA
Co-Authors:

Khanyisile Simelane, Government Hospital, Mbabane

ABOUT THE SPEAKER
Bongani Sigudla from the Ministry of health, Environmental Health Department, hold a Diploma in Environmental Sciences from the University of Swaziland. Started working for the Environmental Health Department from 1992, and was attached in the National Referral Hospital in 2001 to work with a team of consultants in piloting a Health Care Waste Management system.

Bongani is now playing a pivotal-role in the coordination and rollout of the system in the hospital and to other regional health care facilities.



ABSTRACT
The Ministry of Health & Social Welfare (MOHSW) is the principal agency for health Care Risk Waste (HCRW). The Ministry will be the Implementing agency for the HCRW component of the National Solid Waste Management Strategy (NSWMS). MOHSW is responsible for the provision of technical knowledge and capacity development support to public and private hospitals, clinics and other health facilities in both rural and urban areas. The MOHSW undertake their duties on waste management in accordance with the Environment Management Act of 2002, the Waste Regulation 2000 and the EIA Regulations and complementary legislation.

This paper will discuss how Swaziland has started implementing a HCRW system. Focus will be directed at Mbabane Government Hospital, where a pilot project is being implemented. Mbabane Government Hospital is the country’s referral hospital


As part of the National Solid Waste Management Strategy (NSWMS). The Swaziland Environment Authority (SEA) and the MOHSW agreed on the implementation of a Health Care Risk Waste system in the country using the cradle to grave principles. The paper discusses the legal responsibility of the MOHSW on HCRW management. It also discusses in depth the steps that were followed when implementing the project.

The discussion dwells on the routes and activities undertaken in the generation, segregation, characterization storage, transportation and final disposal of HCRW. The paper discusses the future of the project and co-ordination with other sectors such municipalities and private practitioners. The study concludes by saying that the implementation of a HCRW system in Swaziland is possible.



HEALTH CARE WASTE MANAGEMENT PROJECT AT MBABANE GOVERNMENT HOSPITAL -- SWAZILAND

1. INTRODUCTION:

The Swaziland Environmental Authority (SEA) with support of the Danish Government undertook a substantial status quo and need analysis investigation where by specific problems and related needs regarding waste management in Swaziland were identified. A National slid Waste Management Strategy was developed to address all forms of solid waste. The approach applied for the development of the strategy was based on the international hierarchy approach, which includes waste Prevention, Recycling, Collection and Transportation, Treatment and Disposal.


At national level four pilot test projects were negotiated between the SEA and Government ministries to test the strategy, viz.:


  • Health Care Waste Management- Siphofaneni Clinic representing rural clinics and Mbabane Government Hospital representing urban health care institutions.




  • General Solid Waste Management – Kwaluseni Community representing peri-urban communities.

  • Solid Waste recycling – Mbabane City Council

A status quo assessment of health care management in Swaziland was carried in August 2000 and it revealed that there was an urgent need to address the management of Health Care Waste within the health care institutions. Based on that study the following needs were identified:




  • To agree upon the major principals for health care waste: Handling, Storage, Collection and Transportation, Treatment and Disposal.

  • Source segregation of health care waste was compulsory

  • Sound waste management planning that includes data management was essential.

The discussion that follows focuses on the pilot project at Mbabane Government Hospital. The project was carried out with the support of consultants from DANCED.


2. BACKGROUND:
Mbabane Government Hospital has a total of 500 beds with an occupancy rate of 110%. There is a total staff complement of 611 comprising mainly of: 163 staff Nurses,132 Orderlies, 66 Nursing Assistants, 36 Nursing Sisters, 20 Medical Doctors,16 Laundry staff, and administrative staff.
The hospital serves as both a regional and a National referral Hospital providing a basic service to the Mbabane community and the Nation at large. It has 18 units viz.: Medical, Surgical, ICU, High Care, Maternity, Gynaecology, Orthopaedic, Paediatric and Isolation wards. There is also a Theatre, Casualty, OPD, Dental, Laboratory, X-Ray, Kitchen, Dispensary, Laundry, Physiotherapy, Biomedical Engineering Department, Mortuary, Incineration.
The kitchen is contracted out to an independent company. The incinerator is situated some 400 meters on the hill on the south side of the hospital. The road gradient leading to the area is steep and the surface is tarred running only on the south and east sides of the hospital.


  1. SITUATIONAL ANALYSIS

November 2001, the consultants carried out a situational waste management analysis. The objective was to gather baseline information on the current practice and it pointed out on the following discrepancies:



  • No system in place to manage waste

  • Shortage of equipment, lack of understanding and weak supervision resulted in poor segregation of waste

  • No secure storage areas for health care waste awaiting collection and general public were exposed to the potentially harmful properties of health care risk waste.

  • Local incinerator was in poor condition with incomplete combustion and resulting in air pollution.


4. CONSESUS BUILDING
Stakeholders’ forum was organized where information gathered from the site analysis was presented to create a “burning platform” situation and facilitate the HCW process development.
Resolutions emanating from the meeting:
From the discussions it was clear that there was an urgent need to

  • Engage the services of a Health Care Waste Management Specialist/ Consultant.

  • Designate an E.H.O/ Waste Management Officer at the hospital.

  • Develop a Health Care Waste Management System for the hospital




  1. SYSTEM DEVELOPMENT

Three key principles applied in the development of the system are: -


The legal framework presently existing in Swaziland


  • National Solid Waste management Strategy - The strategy required all generators of waste to have a duty of care and be responsible for the hazardous waste generated within their areas. Entrenched in the strategy is the concept of “cradle to grave” management of waste.

  • Environmental Management Act - This act deals with an integrated approach in considering the whole environment and the prevention of pollution. The “precautionary principle, “polluter pays” principle and the duty to care principles are applicable. The minimization of waste is encouraged and waste must be reused, recycled, recovered and disposed safely.

  • Waste Regulation 2000 – it contains regulations on storage, collection and disposal of waste in both urban and rural areas. Aspects covered include carriage of waste, certification and licensing, special waste, recovery of waste, Littering and abandoned vehicles, waste management plans and enforcement.


Multi disciplinary approach with interaction at all levels within the hospital. This framework used includes responsibility, the quality and quantity of staff, the existing skills and the equipment.
Segregation at source is a key requirement in this process. The provision of sufficient colour coded and labeled equipment will ensure that this is carried out as efficiently as possible. The minimum handling of waste will reduce the exposure of workers to infection and injury.


  1. DECISION MAKING PROCESSES

To facilitate the decision-making in the development of the system the following structures were in place:


Health Care Waste Management Steering Committee

Consisted mainly of representatives from SEA, Ministry of Health & Social Welfare, Mbabane City Council, Hospital management, Stores, Biomedical engineering unit, Environmental Health Office, DANCED.


Outputs

  • Waste management system

  • Colour code

  • Intermediate and central holding area for waste

  • Implementation plan for the hospital

  • Test sites

Two smaller task teams were established to implement the new system


HCWM Operational Committee
Committee responsible for implementation of the waste management at unit level. It comprised of unit managers, Matrons, Stores, Senior orderly, Biomedical Engineering and the Hospital administrator who also serves as the Chair.
Outputs

  • Positioning of equipment in units

  • Monitoring tools

  • Code of practice: infection control, hand washing


HCWM Training Task Team;

This committee is responsible for health care waste management training. It comprised of in-service training office staff, Waste management officer and Health education officer. They were to: -



  • Training needs assessment and gaps identification

  • Develop training material: knowledge and skills

  • Develop training programme.

  • Conduct training workshops: formal and awareness programme


7. THE SYSTEM
Classification of waste

The Waste Regulation and WHO requirements were considered when the classification of waste was done.


Health care general waste – the non-hazardous component of health care waste from health

facilities that includes many of the same substances as domestic waste.



Examples:

  • Packaging materials: cardboard boxes, plastic, packaging from needles, syringes and IV lines

  • Kitchen waste: e.g. organic waste etc

  • Office waste: paper, cans, and food wrappings.

Health care risk waste - the hazardous component of health care waste generated within the hospital. HCRW has the potential for creating a number of environmental, health and safety risk, depending on the particular type of risk waste that is handled and the way in which exposure takes place.

Examples of HCRW include:


Infectious Waste: All kind of waste that is likely to contain pathogenic micro-organisms.

Pathological Waste: Parts that are sectioned from the body. (Anatomical)

Sharps: Includes used syringes and needles, surgical blade etc.

Chemicals waste: Includes all kinds of discarded chemicals, including pharmaceuticals that pose a special risk to human health and environment.
Color coding and labeling
Two colors and internationally recognized labeling/ symbols used are

  • Red – Health care risk waste (HCRW)

  • Black -- health care general waste


Equipment
Equipment Design and Specifications:

The equipment is a critical aspect of a good waste management system. When designing the system the following aspect were of key importance:-




  • For the system to be sustainable the consumable items must be readily available to the hospital/facility.

  • The specification for the equipment must be in line with international standards/guidelines.

  • Affordability without compromising the minimum specification

  • Equipment must be robust to withstand rough handling.

Various types of equipment were placed as close as possible to the source of waste generation. The liners specified were limited to three sizes and each size had multiple applications.



The table below shows the various types of equipment introduced by the new system:

Types of Equipment and Specifications

Equipment

Type of Waste

Specification

8 litre sharps


container

Sharps: syringe & needles, surgical blades

Impenetrable, rigid, and leak proof, disposable rectangular polyethylene plastic container with horizontal loading facility and securely fitted lid

10 litre tall sharps

Tro-catheters and other long sharp instruments

Impenetrable, rigid and leak proof long polyethylene plastic container with securely fitted lid.

10 litre tall speci-can

Human Tissue, Blood vials, cultures, stools

Impenetrable, rigid and leak proof long polyethylene plastic container with securely fitted lid.

30 litre Nursing Trolley Bag Holder

Infectious Waste: dressings, used gloves, swabs, etc

470x190 stands with 5mm-wire hook that clips onto the nursing trolley. The stand is made of 6mm hard-drawn wire with a lipped opening of 45 degrees.

30 litre wall mounted stand

With black liner for general waste


With red liner for infectious waste

The same as the above without the lid and it has support bars approximately 125mm from the edges.

85 litre wall mounted stand

With black liner for general waste

With red liner for infectious waste

470x 660x340mm wide stand with mounting brackets fitted to the wall

12 and 20 litre pedal bins

With black liner for general waste

With red liner for infectious waste

Robust metal bin, enamel coated with foot operated lid-lifting device. A handle and chain fixed to the wall




Kick-about trolleys

With red liner for infectious waste in Maternity, ICU and Theatre and Casualty

Stainless steel bowl on a tripod with wheels.

Transportation


Trolleys

For internal use

915x610 with 0,7 meter high mesh with four swivel wheels and low handle for pushing. All the metal components are hot dip galvanized.

Transportation

Trolleys

For external use with risk waste to the incinerator

120 litre wheel-bins


NB: The transportation methods of risk waste to incinerator which is about 400metres away from the hospital remain a challenge to the system

85 litre black bins

With black liner for general waste

Smooth, reusable plastic round dust bin

85 litre white bins

With a red liner for infectious waste

Smooth, reusable plastic round dust bin

43x46cm red liner small

Kick-about trolley, 12 litre pedal bin, 10litre speci-can

Linear low, virgin plastic with a minimum tensile strength of 20 kg.


Welded leak proof seams

Micron thickness: 60


56x 66cm red liner - Medium

Nursing trolleys trolley stand and small wall stand 20litre pedal bin

Linear low, virgin plastic with a minimum tensile strength of 20 kg.


Welded leak proof seams

Micron thickness: 75

75x 90cm red liner - Large

Large wall stands and 85 litre bins

Linear low, virgin plastic with a minimum tensile strength of 20 kg.


Welded leak proof seams

Micron thickness: 90

75x 90 cm black liner

Large

Large wall stands and 85 litre bins

Linear low, virgin plastic with a minimum tensile strength of 20 kg.


Welded leak proof seams

Micron thickness: 60

56x 66cm black liner Medium

Small wall stand and 20 litre pedal bin

Linear low, virgin plastic with a minimum tensile strength of 20 kg. Welded leak proof seams


Micron thickness: 30

Segregation

Segregation at point of generation is critical to the success of the system. HCRW is segregated according to the categories of infection waste, sharps and anatomical waste. Disposal containers are used for sharps and standard re-usable containers of varying sizes are placed at strategic positions to ensure that the waste is contained as soon as possible.


Benefits of segregation:





  • Reduce the risk of exposure

  • More cost effective

  • Reduce the load on the incinerator and the cost.

The system was designed to make container and liners available as close a possible to be source of general so that segregation can be encouraged.
Minimisation and Recycling:
The Minimisation and recycling of waste is a key concept that reduces the volume and consequently the cost of treating the waste. The development plan for the pilot project has not factored these aspects into the plan as it was more important in the initial stages to concentrate on the concept of segregation at source and cradle to grave. This should form part of the continuous improvement cycle after the rollout into the whole hospital has taken place.
Storage
Proper and secured storage of HCW is a necessity in waste management. Three main storage areas are required for safe and environmentally friendly and safe storage of waste

  • Intermediate storage area.

  • Central holding area.

  • Equipment storage area.

Intermediate Storage Areas:


Each unit/ward has its own storage area to store their waste temporally before taken to the central holding area or to the incinerator. Various options are available for intermediate storage areas. A dedicated storage area is recommended but if a since room has sufficient space it can be used. The area must be well ventilated, have sufficient illuminated and easy to clean. It should be secured from unauthorised entry.
Central Holding Area:
Where HCW can be safely accumulated outside the units but within the perimeter of the building for future removal by the municipality or contracted company. The volume of waste accumulated determines size of the storage area. Easy access to the area for large municipality trucks is essential and the area must be secured.
Equipment Storage Area:
A well ventilated easy to clean building with a hard standing and impermeable floor, supplied with running water, good drainage and shelving to stack the waste bags and sharp containers is required.

Transportation
Internal waste transportation trolleys were designed to collect and transport waste from each unit to the central holding area for municipality collection.
A robust HCRW trolley was also designed and put in place for the transportation of risk waste to the incinerator.

Treatment
Treatment method for the HCRW (sharps, infectious waste, and anatomical waste) in the project was incineration. Some other options may be available for instance in rural clinics the pit dumping and burning methods are commonly used but in urban setting only incineration is a viable possible option.
Disposal Options: -
All health care general waste in urban institutions was collected by municipality and disposed off in a sanitary landfill. Arrangement was made with the local authority to collect the ash placed in black bags on regular basis from the hospital.
8. CONSTRAINTS:

The institution depended in funds and warrants from donors and other ministry (SEA) that was piloting the solid waste management projects. The Ministry Health and Social welfare was a recipient of the whole project in terms of funding. There is no separate budget allocation for waste management in institutional and national level within the ministry of health and Social welfare. The new Health Care Waste Management System requires specific equipment more specially the disposable containers, which are imported from South Africa. Resistance in behaviour change among the personnel mostly in the operational level was observed as a major challenge in the implementation and progress of the system. The issue of Health Care Risk Waste treatment remain an environmental challenge. Treatment options/ technology that would meet international environmental standards must be resolved.

9. WAYFORWARD
There is a need for the Ministry of Health and Social welfare to carryout a national health care waste management rapid situational assessment to get baseline information.

To develop national HCWM policy and legislation in consideration of the lesson learnt from the pilot project. This will facilitate the implementation of the system and influence government to allocate a HCWM national budget.



To invest on HCWM treatment technology options and Human Resource development for the implementation and coordination of the system in all health care facilities.


  1. REFERENCES:

        1. Swaziland Environmental Authority: National Solid Waste Management Strategy for Swaziland, September 2001, Fifth Draft, Volume I & II

        2. Swaziland Environmental Authority: National Solid Waste Management Strategy, Status Quo Report, Analysis, 2000, Final Report

        3. World Health Organization Geneva, 1998: Teacher’s Guide, Management of waste from Health –Care activities: A. Pruss, W.K. Townend

        4. Swaziland Environmental Authority (Act 15, 1992): The Waste Regulation 2000, section 18

        5. National Solid Waste Management Strategy: Pilot project on Health Care Risk Waste Management—Mbabane Government Hospital, September- 2003


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