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Healt, Cano Waste, Management ee @ INTENDED LEARNING OUTCOMES ‘At the end of the lesson, the students should be able to: 1. discuss the importance of proper waste management in health care facilities; examine the laws and regulations governing health care waste management; and 3. describe the proper identification, segregation, collection, storage, transport, treatment, and disposal of health care wastes.Health Care Waste i, ment 189 0 pRE-TEST [a ——— cane east ee ee ee Scores ' Rig ka section! ——— ar ee Date: eee ee ions: Choose the letter that correspond: instructions ponds to the correct answer ite it a ied T and write it on the __=_}- Majority ofthe wastes produced by health care facilities are a. pharmaceutical wastes ©. radioactive wastes b. non-hazardous wastes d. infectious wastes ——? Asyringe used for the injection of an antineoplastic drug is classified under this type of waste. a. pharmaceutical waste c. chemical waste 4. sharps . Which of the following is a halogenated disinfectant? a. Methylene chloride b. infectious waste c. Sodium hypochlorite b. Hydrogen peroxide d. Potassium permanganate DOH Administrative Order No. 2008-0021 mandated the phaseout of equipment containing this metal. a. lead c. mercury b.. silver d. chromium . This law prohibited the use of incineration as a method of disposal for biomedical ‘wastes. a RA. 4226 c. RA.8749 b. R.A. 6969 d. R.A. 9275 - The most important step in the proper management of health care wastes is a. waste reuse c. waste recycling inimization b. waste recovery d. waste miiPrinelples of Medical Laboratory Science 1 iner with a black band is used for this type of waste, cc. chemical waste 4. allof the above 7. Ayellow plastic li a. pharmaceutical wastes b. cytotoxic waste . What is the meaning of the symbol below? 2 a. reactive b. explosive c. flammable solid d. flammable liquid 9. This method of waste treatment uses moist heat at 121 °C at 15 psi for 15-30 minutes. a. pyrolysis c. microwave b. autoclave d. inertization 10. This is an engineered site designed to keep the waste isolated from the environment and is tightly regulated by the DENR. a. landfill c. inertization b. safe burial 4. encapsulationa Health Care Waste Mar aq Health Care Wastes pefiningd The disposal of wastes generated by health care facilities has become a growing concern in try and around the world. In 2015, a joint WHO/UNICEF assessment found that just our (98%) of sampled facilities from 24 eountries had adequate systems in place for the over gisposal of health care wastes. This issue is given special attention as the wastes generated ae povich care industry may be hazardous to nature and are detrimental to a person's bythe ao the environment. As such, all health care facilities are tasked to ensure that there neath and health effects and environmental consequences resulting from their generation, collection, storage, transport, treatment, and disposal of health care wastes. ne coun reno a segregation, Health care wastes refer to all solid or liquid wastes generated by any of the following activities: 1. diagnosis, treatment, and immunization of humans; research pertaining to diagnosis, treatment, and immunization of humans; research using laboratory animals geared towards improvement of human health; ep __ production and testing of biological products; and 5. other activities performed by a health care facility that generates wastes. ‘According to WHO, between 75 and 90 percent of wastes generated by health care activities on average are non-hazardous. The remaining 10 to 25 percent is considered hazardous and may be infectious, toxic, or radioactive. High-income countries typically generating larger volumes of health care wastes produce 0.5 kg of hazardous waste per hospital bed per day while low-income countries generate 0.2 kg on average. However, proper segregation of hazardous and non-hazardous wastes in low-income countries tends to be less implemented, thus making the real quantity of hazardous wastes much higher. In the Philippines, 30.7 percent of wastes from health care facilities are hazardous while the remaining 69.63 percent afe general wastes. Philippine hospitals generate an average of 0.34 kg of infectious sharps and pathological wastes and 0.39 kg of general wastes per bed per day. All health care facilities, institutions, business establishments, and other spaces where health care services are offered with activities or work processes that generate health care wastes are called health care waste generators. These include 1. hospitals and medical centers 2. infirmaries 3. birthing homes 4. clinics and other health-related facilities a. medical b. ambulatory c. dialysis192 Principies ot Medical Laboratory Science 1 a e. f & h. health care centers and dispensaries . surgical alternative medicine dental veterinary 5. laboratories and research centers a s Boe em & medical and biomedical laboratories medical research centers blood banks and blood collection services dental prosthetic laboratories nuclear medicine laboratories biotechnology laboratories animal research and testing drug testing laboratories HIV testing laboratories 6. drug manufacturers institutions a. a & d. e. f & drug rehabilitation centers training centers for embalmers medical technology internship training centers schools of Radiologic Technology medical schools nursing homes dental schools 8. mortuary and autopsy centers Categories of Health Care Wastes Health care wastes generated by health care facilities are categorized into seven” infectious waste, pathological and anatomical waste, sharps, chemical waste, pharmaceuti waste, radioactive waste, and non-hazardous or general waste. 1. Infectious Waste refers to all wastes suspected to contain pathogen! in sufficient concentration that may cause disease to a susceptible host. It in discarded materials or equipment used for diagnosis, treatment, and management of patients with infectious diseases. Examples include discarded mict solid wastes with infections such as dressings, sputum cups, urine containers, 9 robial cultures: 1s or toxins cludes.Health Care Waste Management blood bags, liquid wastes with infections such as blood, urine, vomitus, and other pody secretions, and food wastes (liquid or solid) coming from patients with highly rrrectious diseases. pathological and Anatomical Waste refers to tissue sections and body fluids or organs derived from biopsies, autopsies, or surgical procedures sent to the jaboratory for examination. Examples include internal organs and tissues used for histopathological examinations. Anatomical waste is a subgroup of pathological waste that refers to recognizable body parts usually from amputation procedures. . Sharps refer to waste items that can cause cuts, pricks, or puncture wounds. They are considered the most dangerous health care waste because of their potential to cause both injury and infection. Examples include used syringes in phlebotomy, blood lancets, surgical knives, and broken glasswares. Chemical Waste refers to discarded chemicals (solid, liquid, or gaseous) generated during disinfection and sterilization procedures. It also includes wastes with high content of heavy metals and their derivatives. Common examples of this type of waste are laboratory reagents, X-ray film developing solutions, disinfectants and soaking solutions, used batteries, concentrated ammonia solutions, concentrated hydrogen peroxide, chlorine, and mercury from broken thermometers and sphygmomanomieters. Chemicals are considered hazardous when they are + toxic (with health and environment hazards), * corrosive (acid of pH<2.0 and bases of pH>12.0) + flammable (with a flash point below 60 °C) + reactive (explosive with water) Examples of common chemical wastes found in health care facilities are shown in the table below. Table 11.1 Common chemical waste in health care facilities Ad Smee \ acetic, chromic, hydrochloric, nitric, sulfuric | Alcohols, ethanol, isopropanol, phenols | Aldehydes. formaldehyde, glutaraldehyde, ortho-phthalaldehyde | Bases ‘ammonium hydroxide, potassium hydroxide, sodium hydroxide, sodium bicarbonate | Halogenated calcium hypochlorite, chlorine dioxide, iodine solutions, iodophors, | disinfectants sodium dichloroisocyanurate, sodium hypochlorite (bleach) | Halogenated chloroform, methylene chloride, perchloroethylene, refrigerants, | solvents, trichloroethylene arsenic, cadmium, chromium, lead, mercury, silver ‘acetone, acetonitrile, ethanol, ethyl acetate, formaldehyde, 5 isopropanol, methanol, toluene, xylenes. |Non-halogenated _ | | solvents 193194 Principles of Medical Laboratory Science 1 So Other disinfectants | hydrogen peroxide, peroxyacetic acid, quaternary amines hydrogen peroxide, potassium dichromate, potassium permanganate Reducers sodium bisulfite, sodium sulfite anesthetic gases, asbestos, ethylene oxide, herbicides, paints, pesticides, waste oils Oxidizers Miscellaneous Pharmaceutical Waste refers to expired, spilt, and contaminated pharmaceutical products, drugs, and vaccines including discarded items used in handling pharmaceuticals. It includes antineoplastic, cytotoxic, and genotoxic wastes such as drugs used in oncology or radiotherapy, and biological fluids froth patients treated with the said drugs. Examples include empty drug vials, medicine bottles, and containers of cytotoxic drugs including materials used for their preparation and administration such as syringes, needles, and vials. Radioactive Waste refers to wastes exposed to radionuclides including radioactive diagnostic materials or radiotherapeutic materials. Residues from shipment of radioactive materials and unwanted solutions of radionuclides intended for diagnostic or therapeutic use are examples of radioactive wastes as well as liquids, gases, and solids contaminated with radionuclides whose ionizing radiations have genotoxic effects, In the hospital, usual examples of radioactive wastes include cobalt (Co 90), technetium (99 Te), iodine (131 I) and iridium (192 In), irradiated blood products and contaminated waste, patient's excretion, and all materials used by patients exposed to radionuclides within 48 hours. Non-hazardous or General Waste refers to wastes that have not been in contact with communicable or infectious agents, hazardous chemicals, or radioactive substances, and do not pose a hazard. Examples include plastic bottles, used paper products, office wastes, scrap wood, and food waste of non-infectious patients. This type of waste can be further classified as a. Recyclable wastes in health care facilities such as + paper products such as used office paper, computer printouts, and corrugated cardboard boxes + aluminum from beverage cans and other aluminum containers + pressurized gas containers such as oxygen tanks + plastic products including polyethylene terephthalate (PET) plastic water bottles, plastie milk containers, and polypropylene plastic bottles for saline solutions and irrigation fluids + glass such as used vials for sterile solutions + wood such as scrap wood and used wood shipping palletsHealth Care Waste M: agement «durable goods such as used furniture and furnishings «electronic devices such as used computer equipment and print cartridges b. Biodegradable health care wastes such as left-over food from non-infectious patients and garden wastes such as grass trimmings and tree cuttings «. Non-recyclable/non-biodegradable health care wastes that cannot be classified into either of the first two categories impact of Health Care Wastes Individuals exposed to health care wastes such as the medical staff (doctors, nurses, medical technologists, etc.), in- and out-patients, visitors, caregivers, support staff, waste haulers, garbage pickers, and the general public are potentially at risk of being injured or infected. Other potential hazards may include drug-resistant microorganisms that can spread ian health facilities into the environment. Exposure of the general population can be mainly thyough chronic exposure (for prolonged periods in minute quantities) or acute exposure (for short periods in large quantities). Adverse health outcomes associated with health care wastes and by-products also include « sharps-inflicted injuries + toxic exposure to pharmaceutical products, in particular, antibiotics and cytotoxic drugs released into the surrounding environment, and to substances such as mercury or dioxins, during the handling or incineration of health care wastes « chemical burns from disinfection, sterilization, or waste treatment activities «air pollution arising as a result of the release of particulate matter during medical waste incineration + thermal injuries occurring in conjunction with open burning and the operation of medical waste incinerators + radiation burns ‘Treatment and disposal of health care wastes may pose health risks indirectly through the release of pathogens and toxic pollutants into the environment. Following are some guidelines in the treatement and disposal of health care wastes + The disposal of untreated health care wastes in landfills can lead to the contamination of drinking, surface, and ground waters if those landfills are not properly constructed. + The treatment of health care wastes with chemical disinfectants can result in the release of chemical substances into the environment if those substances are not handled, stored, and disposed in an environmentally-sound manner, ced, but’ inadequate incineration or the + Incineration of waste is widely practi Its in the release of pollutants into the air incineration of unsuitable materials rest! 195TSG Principies of Medica! Laboratory Science 1 neinerated materials containing or treated yj rans, which are human carcinogens and hay health effects. Incineration of heavy metal, particular lead, mercury, and cadmium) cay and in the generation of ash residue. I chlorine can generate dioxins and fw been associated with a range of adverse or materials with high metal content (in lead to the spread of toxic metals in the environment. * Only modern incinerators operating at 850°C to 1100°C and fitted with special gag. cleaning equipment are able to comply with the international emission standards for dioxins and furans. It should be noted that disposal of health care wastes by incineration is not allowed in the Philippines. + Alternatives to incineration such as autoclaving, microwaving, and steam treatment integrated with internal mixing, which minimize the formation and release of chemicals or hazardous emissions should be given consideration in settings where there are sufficient resources to operate and maintain such systems and disposal of the treated waste. The following are the benefits achieved through proper and strict compliance with standards on the management of health care wastes: + protection of patients, health workers, and the general population from the adverse effects of health care wastes to human health; + contribution to the collaborative efforts around the world to protect the environment from pollution and contamination caused by health care wastes; + increased compliance of health care institutions to the laws, regulations, and guidelines on health care wastes; and + prevention of long-term liabilities and loss of reputation caused by violations to the laws, regulations, and guidelines on health care wastes. Legislation, Policies, and Guidelines Governing Health Care Wastes Health care facilities should be familiar with the laws and regulations regarding the generation, collection, storage, transport, treatment, and disposal of health care wastes. This will ensure that each facility will be able to develop a sound health care waste management system that adheres to established standards. International agreements pertaining to health care waste management 1. The Montreal Protocol on Substances that Deplete the Ozone Layer (1987) WS adopted in Montreal, Canada on September 16, 1987 and came into force, as agreed upon, on January 1, 1989. It sets the final objective of the Protocol to eliminate 0z0n® depleting substances in the environment.Health Care Waste Management Basel Convention on a“ the Control of the Transboundary Movements of a ie jardous Wastes and Their Disposal (1989) is concerned with the transboundary ovements of hazardous waste. The countries that signed the Convention accepted the m nciple that only legitimate transboundary shipments of hazardous waste are exported Pin countries that lack the facilities or expertise to safely dispose certain wastes to other fro tries that have both facilites and expertise. 4, The United Nations Framework Convention on Climate Change (1992) includes a legally non-binding pledge that by the year 2000, major industrialized nations would oluntarily reduce their greenhouse gas emissions to 1990 levels. ‘The Stockholm Convention on Persistent Organic Pollutants (2001) is a global treaty £ health and the envi fro i S to protect human environment from persistent organic pollutants (POPs). pOPs are chemicals that (1) remain unchanged in the environment for long periods of time; (2) accumulate in the fatty tissues of living organisms; and (3) are toxic to both humans and wildlife. . The ASEAN Framework Agreement on the Facilitation of Goods in Transit (1998) is acore instrument that provides nine high level protocols that set out generic standards to be put into place for the implementation of an international transit system. Specifically, the framework agreement includes Protocol 9 on Dangerous Goods which provides provisions on the transport of toxic and infectious substances. National laws and policies on health care waste management 1. Republic Act No. 4226 “Hospital Licensure Act” (1965) is an act that requires the registration and licensure of all hospitals in the country and mandates the DOH to provide guidelines for hospital technical standards as to personnel, equipment, and physical facilities. a. DOH Administrative Order No. 70-A series of 2002 “Revised Rules and Regulations Governing the Registration, Licensure, and Operation of Hospitals and Other Health Facilities in the Philippines” - includes the application or renewal of license, submission of plans, and other design requirements under the Code of Sanitation of the Philippines, National Plumbing Code of the Philippines, Revised Fire Code of the Philippines, and National Building Code of the Philippines. The Manuals on Hospital Waste Management and Health Facilities Maintenance are also required for submission for verification by the DOH- Bureau of Health Facilities and Services (BHFs). DOH Administrative Order No. 2005-0029 dated December 12, 2005 “Amendment to Administrative Order No. 70-A series of 2002 re: Revised Rules and Regulations Governing the Registration, Licensure and Operation of Hospitals and Other Health Facilities in the Philippines” - requires the HCF to submit a health care waste Management Plan to BHFS as one of its requirements for the issuance of license to operate.198 Prine Tinciples of Medical Laboratory Science 1 ©. DOH Administrative Order No. 2007-0027 dated August 22, 2007 “Revised p, and Regulations Governing the Licensure and Regulation of Clinical Labbe in the Philippines” ~ requires written procedures for the proper disposal cone te care waste and other hazardous substances and required written policy guidelines = biosafety and biosecurity. 2. Republic Act No. 6969 “An Act to Control Substances and Hazardous and Nucleg, Wastes” (1990) requires the registration of waste generators, waste transporters, ang operators of toxic and hazardous waste treatment facilities with the EMB. The Waste generators are required to ensure that their hazardous wastes are properly collecte, , transported, treated, and disposed in a sanitary landfill. a. DENR Administrative Order No. 36, Series of 2004 “Revising DENR Administrative Order No. 29, Series of 1992, to Further Strengthen the Implementation of Republic Act 6969 and Prescribing the Use of the Procedural Manual” the Procedural Manual requires a comprehensive documentation on the legal and technical requirements of hazardous waste management. The Manual does not include provisions regarding the management of nuclear wastes. It is composed of ten sections that discuss the (1) classification of hazardous wastes, (2) waste generators, (3) waste transporters, (4) storage and labelling, (5) Treatment, Storage, and Disposal (TSD) facilities, (6) manifest system, (7) monitoring, (8) prohibited acts, (9) schedule of fees, and (10) import of recyclable materials containing hazardous substances and export of hazardous waste. b. DOH-DENR Joint Administrative Order No. 02 series of 2005 dated August 24, 2005 entitled “Policies and Guidelines on Effective and Proper Handling, Collection, tment, Storage, and Disposal of HCW” - aims to (a) provide guidelines to generators, transporters, and operators/owners of TSD Facilities on the proper handling, collection, transport, storage, treatment, and disposal of health care, wastes (HCW); (b) clarify the jurisdiction, authority, and responsibility of DENR and DOH with regard to health care waste management (HCWM); and (c) harmonize the efforts of DENR and DOH on HCWM. DOH Administrative Order 2007-0014 “Guidelines on the Issuance of Certificate of Product Registration for Equipment or Devices Used for Treating Sharps, Pathological and Infectious Waste” ~ requires the manufacturers, importers, and distributors, including generators of HCW that sell and/or use equipment and pathological, and infectious waste to secure a Certificate evices and Transport, Treat devices in treating sharps, of Product Registration (CPR) from DOH through the Bureau of Health D Technology. Republic Act No. 8749 “The Philippine Clean Air Act of 1999” prohibits the incineration of bio-medical wastes effective July 17, 2003. It promotes the use of state- of-the-art, environmentally-sound, and safe non-burn technologies for the handling, treatment, thermal destruction, utilization, and disposal of sorted, unrecy'e® biomedical, and hazardous wastes.Health Care Waste Management 199 epublic Act No. 9008 “Ecological Solid Waste Management Act of 2000” mandates na Uvregation of solid wastes atthe sources including households and institutions like hospitals by using a separate container for each type of waste. republic ‘Act 9275 “The Philippine Clean Water Act of 2004” pursues a policy of ; Monomic growth in a manner consistent with the protection, preservation, and revival of the quality of the country’s fresh, brackish, and marine waters. presidential Decree 813 (1975) and Executive Order 927 (1983) “Strengthening rie Funetions of Laguna Lake Development Authority (LLDA)” which further mengthens the powers and functions of the LLDA to include environmental protection and jurisdiction over surface waters of the Laguna Lake basin. Through £0. 927, the LLDA is empowered to issue permits for the use of surface waters within Laguna de Bay. ._ presidential Decree 856 “The Code on Sanitation of the Philippines ~ Chapter XVII on Sewage Collection and Exereta Disposal” (1998) requires the approval of DOH in terms of the following: (a) constructions of any approved type of toilet in every house and community which may be allowed for a group of small houses of light material or temporary in nature; (b) plans of individual sewage or sewage system and the sub-surface absorption system or other treatment device; (c) location of any toilet or sewage disposal .ystem in relation to a source of water supply; (4) the discharge of untreated effluent from septic tanks and/or sewage treatment plants to bodies of water; (e) manufacture of septic tanks; and (f) method of disposal of sludge from septic tanks or other treatment plants. a. Rules and Regulations Governing the Collection, Handling, Transport, Treatment, and Disposal of Domestic Sludge and Septage, (2004), a “Supplement to the IRR of Chapter XVII on Sewage Collection and Disposal and Excreta Disposal and Drainage of 1998” ~ require individuals, firms, public and private operators, owners, and administrators engaged in desludging, collection, handling and transport, treatment, and disposal of domestic sewage treatment plants/facilities and septage from house septic tanks to secure environmental sanitation clearances from DOH. b. Chapter XVIII of Presidential Decree 856 “The Code on Sanitation of the Philippines” on Refuse Disposal (1998) ~ requires cities and municipalities to provide an adequate and efficient system of collecting, transporting, and disposing refuse in their areas of jurisdiction. They also require occupants of buildings, institutions such as hospitals and residences to provide a sufficient number of receptacles for refuse. ©. Operation Manual on the Rules and Regulations Governing Domestic Sludge and Septage (June 2008) - provides detailed procedures and forms which need to comply with the IRR governing the collection, handling, transport, treatment, and disposal of domestic sludge and septage. It is designed to guide private and public service Providers, as well as government regulators, towards effective sludge and septage management program in the country.200 Principies of Medical Laboratory Science 1 8. Presidential Decree No. 984 “Revised Implementing Rules and Regulations ippines, Chapter XXI on Disposal of Deag 4 a new restriction on open viewing op d. Administrative Order 2010-0033 c Of PD 856 Code on Sanitation of the Phil Persons” (December 2010) ~ implement Z § remains when the individual's death was caused by certaln communicable diseases, Te explicitly states, “The remains sball be placed in.a Plastic coaavek RAK or other durable airtight container at the point of death and a biohazard tag attached, provided that, this container shall not be opened for viewing OF SOY other purpose prior to burial or cremation.” “providing for the Revision of Republic Act No, 3931, Commonly known as the Pollution Control Law, and for Other Purposes” (1976) governs the discharge of potentially polluting substances to air and water 1 provides the basis for the DENR regulations on water pollution through its IRR, DENR ‘Adrainistrative Order Nos. 64 and 35. The IRR for air emissions was mitally set by DENR Administrative Order No. 14, but was later replaced by the Clean Air Act of 199g (R.A. 8749). a. DENR Administrative Order No. 34, Series of 1990 “Revised Water Usage and Classification/Water Quality Criteria Amending Section Nos. 68 and 69, Chapter III of the 1978 National Pollution Control Commission (NPCC now EMB) Rules and Regulations” classified bodies of water according to their designated uses and did not preclude use of the bodies of water for other purposes that are lower than the classification, provided that, such use does not prejudice quality required for such waters. b. DENR Administrative Order No. 35, Series of 1990, “Effluent Regulations” - lists the effluent regulations for the different levels of pollutants according to their water category/class. DENR Administrative Order No. 26, Series of 1992, ‘Amending Memorandum Circular No. 02, Series of 1981: Appointment/Designation of Pollution Control Officers” ~ requires the appointment/designation of a Pollution Control Officer (PCO) and lists the qualifications, reporting requirements, and duties and responsibilities of accredited PCOs. |. Presidential Decree No. 1586 “Environmental Impact Statement (EIS) System” (1978) requires projects, like the construction of new hospital buildings or expansion of existing hospitals, to secure an Environmental Compliance Commitment (formerly Environmental Compliance) Certificate (ECC) prior to the construction and operation of the facility. An ECC is required for the installation and operation of. HCW treatment systems like pyrolysis, autoclave, microwave, and other treatment technology including landfills. . Executive Order No. 301 “Establishing a Green Procurement Program for ‘All Departments, Bureaus, Offices, and Agencies of the Executive Branch o} Government” (2004) aims to (a) promote the culture of making environmentallyHealth Care Waste Management informed decisigne ig the Sore sespegially in the purchase and use of different roductss (D) include environmental criteria in public tenders, whenever possible and practicables © establish the specifications and requirements for products or services to ne considered environmentally advantageous; and (d) develop incentive programs for suppliers of environmentally advantageous products or services, poH Administrative Order No. 2008-0021 dated July 30, 2008 “Gradual Phaseout of Mercury in all Philippine Health Care Facilities and Institutions” requires all health care facilities (HCF) to gradually phaseout the use of mercury-containing devices and equipment. The initial targets of the phaseout are mercury thermometers and sphygmomanometers in the health care facility. a. Department Memorandum No. 2011-0145, “Guidelines for the Temporary Storage of Mercury Wastes in HCF in Accordance with AO No. 0021, s. 2008 on the Gradual Phaseout of Mercury in All Philippine health care Facilities and Institutions” - provides the detailed guidelines on the temporary storage of mercury-containing devices and the management of mercury spills to enhance patient safety measures in HCF, to protect health care workers from potential hazards from mercury exposures, and to minimize the accumulation of mercury in the environment. . DOH Administrative Order No. 2008-0023 dated July 30, 2008 “National Policy on Patient Safety” requires the establishment and maintenance of a culture of patient safety in the HCF as the responsibility of its leaders. As such, HCF shall ensure that an enabling mechanism/strategy is in place to ensure patient safety. The key priority areas in patient safety include, but are not limited to, proper patient identification, assurance of blood safety, safe clinical and surgical procedures, provision and maintenance of safe quality drugs and technology, strengthening infection control standards, maintenance of the environment of care standards, and energy and waste management standards. . DOH “Manual on Health Care Waste Management” in 2011 (Revising the 2007 Health Care Waste Management Manual) serves as a reference for HCF administrators in the implementation of an effective and efficient waste management program. The requirements for doing such are provided in the manual by listing the standards of performance, defining the mandatory requirements, providing new concepts, and citing examples and tools. The Manual is designed to be used by all workers within the HCF. Philhealth Benchbook for Quality Assurance in health care (2006) includes health care waste management as one of its parameters in the quality assurance of healthcare. BFAD Memorandum Circular No. 22, Series of 1994, “Inventory, Proper Disposal, and/or Destruction of Used Vials or Bottles” and BFAD Bureau Circular No. 16, Series of 1999: “Amending BFAD MC No. 22 dated September 8, 1994, Regarding Inventory, Proper Disposal, and/or Destruction of Used Vials or Bottles” - these circulars are released to prevent the proliferation of adulterated, misbranded, and counterfeit drugs brought about by the recycling of used pharmaceutical bottles and vials. It contains the guidelines on the proper inventory and destruction of bottles and vials. 201202 Principles of Medical Laboratory Science 1 Health Care Waste Manageme health care facilit nt System ies generally follow a well-defined flow by Health care wastes generated by and disposal. In the health care waste from the point of generation down to their treatment : management hierarchy, it is highly preferable to prevent the generation of wastes and to reduce the quantity of generated wastes by using different methods of reusing, recycling, and recovering wastes. soo ree kV Via hoot Resource Development it eo ie o Treat Dispose End of Pipe Least Preferable Figure 11.1 Health Care Waste Management Hierarchy The most important step in the proper management of health care wastes is waste minimization using an approach known as the Green Procurement Policy. This policy involves two aspects—waste prevention and waste reduction. Through proper procurement planning wastes are minimized even before their generation. Health care facilities are encouraged to vail of services that are the least harmful to the environment and to purchase less polluting products. Also, waste reduction from the source is implemented by encouraging proper waste segregation to determine the nature and volume of generated wastes to allow efficient waste management at the least cost. Safely reusing, recycling, and recovering wastes are collectively termed as resource development. Reusing refers to either finding a new application for a used material or using for the same application repeatedly. Safety and efficiency, however, should the same product oratory glassware be considered when reusing medical items and devices. For example, lab like glass culture tubes can be used repeatedly after decontamination. Recycling refers to the processing of used materials into new products. Computer printouts from the hospital, for example, can be sold and recycled into new paper products. The recovery of waste, on the other hand, is defined in two ways: (1) energy recovery, whereby waste is converted to fuel for generating electricity or for direct heating of premises and (2) as a term. used to encompass three subsets of waste recovery: recycling, composting, and energy recovery.alth Care Waste Management 203 at cannot be safely reused, recycled, or for we ‘This approach to health care waste aes aie ie mple™ and disposal. Waste treatment is the process of changing the Haed ‘ ae ‘ paracteristios Of WASTE 1D ama its potential to cause harm. Waste eee e sl Meters to discharging, depositing placing or releasing any health ae peo! ands OF water. Not all types of wastes require treatment. For example ea ee ain tie nts can be disposed of through composting without the need for esac ym PA me materials need to be treated first before disposal. Effluent aes evel ws ospitals for example, needs to undergo sewage treatment prior to its release to the sovirorrent on, Collection, Storage, egati greg port of Health Care Wastes and Trans| seatth care facilities are tasked to ensure that generated wastes are properly and safely aged. To ensure this, health care wastes must be segregated, collected, stored, and Mepeported While considering risk and occupational safety and compliance with existing laws, polices, and guidelines. Hazardous wastes must never be mixed with general wastes and there must be a waste management officer responsible for the management of the health care wastes ofa facility. the effective management of health care wastes considers the basic elements of waste minimization, identification, and segregation. Segregation at the source of waste generation thould be the responsibility of the waste generator. Segregation is the process of separating different types of waste at the point of generation until their final disposal. To improve the efficiency of the segregation and minimize the incorrect use of bins; proper placement, labelling of waste bins, and use of color-coded plastic liners must be strictly implemented. The purpose of color coding is to make it easier for personnel in a health care facility to put waste into correct bins and maintain segregation during collection, storage, transport, treatment, and disposal. ‘mani Table 11.2 Guidelines for the proper labelling, marking, and color coding for waste segregation in health care facilities ‘Type of Waste ered Infectious Waste | BIN e eet Strong leak-proof bin with cover labelled “Infectious” with biohazard symbol z UNER Yellow plastic that can withstand autoclaving with 0.009 mm and labelled “Infectious Waste” with a tag indicating source ¢ : of waste and date of collection; may or may not have b204 Principies of Medical Laboratory Science 1 Saka ification Sharps Pathological ai BIN ' Anatomical Wastes | sion jeak:proot bin wih cover labelled “Pathological/Anatomical Waste" with biohazard symbol LINER withstand autoclaving with 0.009 mm thickness. siogieal/Anatomical Waste" with a tag indicating dd date of collection. Biohazard symbol is Yellow plastic that can and labelled “Pathological/A’ source and weight of waste an optional. BIN Puncture-proof container with wi with biohazard symbol LINER Not applicable ide mouth and cover labelled “Sharps" Chemical Waste BIN Labelled “Chemical Waste’; For liquid chemical waste, inside the bin is a disposal bottle made of amber-colored glass with at least 4 liters capacity that is strong, chemical-resistant, and leak-proof. LINER Yellow with black band plastic with 0.009 mm thickness and labelled “Chemical Waste" with a tag indicating source and weight of waste and date of collection Pharmaceutical Waste BIN ‘Strong leak-proof bin with cover labelled “Pharmaceutical Waste” for expired drugs and drug containers and “Cytotoxic Waste" for cytotoxic, genotoxic, and antineoplastic waste LINER Yellow with black band plastic with 0.009 mm thickness and labelled “Pharmaceutical Waste” with a tag indicating source and weight of waste and date of collection Radioactive Waste BIN Radiation proof repositories, leak-proof, and lead-lined container labelled with name of radionuclide and date of deposition with radioactive symbol LINER Orange plastic with 0.009 mm thickness and labelled “Radioactive” with a tag indicating name of radionuclide and date of deposition General Waste BIN Optional recycle symbol for recyclable non-hazardous wastes; varying sizes depending on the volume of waste. LINER Black or colorless plastic for non-biodegradable and green for biodegradable with a thickness of 0.009 mm with a tag indicating source, weight of waste, and date of collection; Health Care Waste Management 205 the implementation ofa color-coding system fc E aa for health care wastes, the following i 1. Highly infectious waste must be disinfected at Source, 5, Anatomical waste including recognizable ~ should be disposed through safe burial or body parts, placenta eee waste, and organs . Pathological waste must be refrigerated if not collected or treated within 24 hi Sharps must be shredded or crushed before they are transported to the ae Chemical and pharmaceutical wastes shall be ; Wastes with high content of heavy me e © ‘Segregated and collected I irae except mercury, should be collected nt facilit = be collected separately. Hazardous chemical suuneenn a down the drain but shall be stored in strong chemical Tesistant leak-proof containers or amber disposal bottles. Expired and discolored pharmaceuticals should be returned to the pharmacy for temporary storage to be returned to the manufacturer/ supplier. Pharmaceuticals shall be kept in their original packaging for proper identification and prevention of possible reaction with other chemicals. . Radioactive waste has to be decayed to background radiation levels. If it has reached the background radiation level and is not mixed with infectious or chemical waste, the radioactive waste is considered as regular non-infectious waste. 7. Allwaste bins must be properly covered to prevent cross contamination. 8. Aerosol containers can be collected with the general waste. Aside from the information placed on the tag, yellow plastic liners should also be labelled with symbols appropriate for the types of waste they contain. The following are the symbols used by the DENR Environmental Management Bureau together with other universally accepted hazard symbols. Oe Snore W Biohazard ani tt Symbol Symbol ‘e New Radiation Symbol Explosive Ionizing Sear Radiation Sign Reactive Cytotoxic Infectious e Symbol & Symbol slice Def Old Radiation Symbol @ Poison/ Toxic Symbol Flammable Solid Symbol Flammable Liquid Symbol206 —Principios of Medical Laboratory Science 1 Health care facilities should have storage areas for general wastes, recyclable materials hazardous wastes, and phased-out mercury devices. Cytotoxic wastes must be stored separately from other wastes in a designated secured location while radioactive wastes must be stored in containers that can prevent dispersion of radiation during the period that their radionuclide contents are being allowed to decay. Proper collection and transport of health care wastes are important components in health care waste management. Their implementation requires commitment and cooperation among all the workers in the health care facility. There must be a regular on-site collection of wastes and these must be transported using designated trolleys to the facility's waste treatment area | or waste storage facility. During on-site collection and transport, the personnel hauling the wastes must be properly trained and should wear appropriate personal protective equipment (PPE) to minimize the risk of infection and injury. For off-site transport of health care wastes, only accredited DENR transporters and official waste collectors are allowed to transport | wastes from the health care facility to a Treatment/Storage/Disposal (TSD) facility or to the final disposal site. Proper waste treatment is necessary to ensure that health care wastes do not pose harm to the people and the environment. The manner of waste treatment usually varies and largely depends on the type of waste that needs to be inactivated and its potential impact. Health care wastes can be decontaminated either by sterilization or disinfection. Sterilization kills all microorganisms while disinfection reduces the level of microorganisms present in the material. Listed below are the acceptable technologies and methods used in the treatment of health care wastes. 1. Pyrolysis is the thermal decomposition of health care wastes in the absence of supplied molecular oxygen in the destruction chamber where the said waste js converted into gaseous, liquid, or solid form. This can handle the full range of health care wastes. Waste residues may be in the form of greasy aggregates or slugs, recoverable metals, or carbon black. These residues are disposed in a landfill. 2, Autoclave is the use of steam sterilization to render waste harmless and is an efficient wet thermal disinfection process. This method of using pressure and heat is widely used and the usual setting is at 121 °C with a pressure of 15 psi | for 15 to 30 minutes. Indicators such as color-changing tapes or biological test i ampules containing bacterial spores can be used to check the validity of the i : j Treatment and Disposal of Health Care Wastes i sterilization. 3. Microwave is a technology that typically incorporates some type of size reduction device. Shredding of wastes is done before disinfection. In this process, waste is exposed to microwaves that raise the temperature to 100 °C (237.6 °F) for atJeast 30 minutes. Microorganisms are destroyed by moist h coagulates and denatures enzymes and structural proteins. fe chemical disinfection, chemicals like sodi i » oxide, peroxyacetic acid, and heated alkali a ane eer ite, hydrogen kill or inactivate present pathogens. Itis recommended that Ababa iy wastes to (bleach) with @ concentration of 5 percent be used for chemical Sees This method, however, generates chemical wastes from the us ae fection. disinfectants. ed chemical which irreversibly md Biological process uses an enzyme mixture to decontami 3 s z aminate healt wastes. The resulting by-product is put through an extruder to remove aon wastewater disposal, The technology is suited for large applications and is also being developed for possible use in the agricultural sector. ¢, Encapsulation involves the filling of containers with waste, adding and immobilizing material, and sealing the containers. The process uses either cubic boxes made of high-density polyethylene or metallic drums, that are three-quarters filled with sharps, or chemicals or pharmaceutical residues, The containers or boxes are then filled up with a medium such as plastic foam, bituminous sand, and cement mortar. After the medium has dried, the containers are sealed and disposed in a landfill. 7. Inertization is especially suitable for pharmaceutical waste that involves the mixing of waste with cement and other substances before disposal. For the inertization of pharmaceutical waste, the packaging shall be removed, the pharmaceuticals ground and a mixture of water, lime, and cement will be added. The homogenous mass produced can be transported to a suitable storage site. Alternatively, the homogeneous mixture can be transported in liquid state to a landfill and poured into municipal waste. The process is relatively inexpensive and can be performed using relatively unsophisticated equipment. After treatment, health care wastes are usually disposed in landfills. A landfill is an engineered site designed to keep waste isolated from the environment. This site must secure Proper permits from DENR before it can accept wastes. Health care wastes that are properly treated can be mixed with general wastes provided that it is certified by the DOH that the organisms in the waste products are inert and cannot regenerate. For health care facilities in far-flung areas with no access to landfills, disposal is usually through safe burial. As a disposal method, safe burial is only applicable to treated infectious wastes, sharps, pathological and anatomical wastes, small quantities of encapsulated/inertisized solid chemical and Pharmaceutical wastes and only allowed in health care facilities located in remote areas, Used sharps and syringes can also be disposed using septic or conerete vaults if the health care facility has no access to a TSD facility. Health Care Waste Management 207208 Principles of Medical Laboratory Science 1 @ KEY POINTS e activities performed by a health care facility. Health care wastes are by-products of th amounts of wastes and the environment. with designated colors, labels, markings, Health care facilities generate large which can be harmful to patients, health personnel, the general population, There are seven categories of health care wastes and specifications for their disposal. ‘There must be a proper procedure for the generation, segregation, collection, storage, transport, treatment, and disposal of health care wastes. lth care wastes should focus primarily on waste The proper management of he minimization. tems depends on the adherence of ‘The success of health care waste management sys all the personnel of a health care facility on the existing laws, guidelines and policies regarding health care wastes.Health Care Waste Management 209 0 acTIVITY SHEET Score: Ne co eee Date: io SSS Mai Ee ctions: Reflect on the importance of proper waste mani struc 7 Ins Write your realizations about it. ‘agement in the health care setting. 1Health Care Waste Management 2n 0 posT-TEST Name: TS SS Se cen I Se eee ae gection: — Date: ak ca ae 1, instructions: Read each statement and evaluate whether itis TRUE or FALSE, Write Tif itis true and F if not, pee: The amount of hazardous wastes generated by health care facilities in the Philippines is higher than the average volume generated by low-income countries. Implementation of a “Green Procurement Policy” can help in the waste minimization of health care facilities. All items that can cause cuts or puncture wounds such as syringes are collectively categorized as “sharps” regardless of how they were used in the health care facility. Health care wastes have the potential to cause harm to the people and the environment. . Chemical wastes should be stored for extended periods to allow their active components to biologically decay and thus prevent their dispersion to the environment. . Sterilization refers to the killing of all microorganisms present in a material while disinfection only reduces the microbial load of inanimate objects. ___7. Abin used for infectious waste should be yellow and Properly labelled with its waste designation and a biohazard symbol with a yellow plastic liner. All health care facilities can opt to use safe burial as a method of waste disposal instead of using a landfill. i stes. —_9. Encapsulation is an ideal method of treatment of pharmaceutical wast i ical wastes containin; Wastes containing mercury can be jncluded with other chemical w: ct iB heavy metals.212 Principles of Medical Laboratory Science 1 IL. Instructions: Match each waste to the container’s color by writing the corresponding letter on the space provided. Waste ———1. Vomitus of a patient undergoing chemotherapy —— 2. Blood lancet used for random glucose testing —— 3. Aused bottle for sterile saline solution Leftover food from the party in the children’s ward 5. An evacuated tube containing blood used for CBC Color of Container/Bag a b. ic da . orange black green yellow yellow with black band redHealth Care Waste Management 213, Q _ENHANCEMENT/REINFORCEMENT OF LEARNING crea ? * Pa proper segregation of wastes is essential in health care waste management. To improve tive Activity jc liteney of seavegation, color coding, and standard labelling are usually implemented in f ) pealth care facilities including clinical laboratories. ‘Tasks L Design an information poster intended to be distributed to clinical laboratories in your locale. The poster size should be A3 (297 x 420 mm). Furthermore, the poster should incorporate the following concepts: a. categories of health care waste; b. examples of the different categories of health care wastes; ¢. color coding scheme for health care waste segregation; and 4. standard labels, markings, and specifications for health care waste segregation. Present your poster to the class and to the faculty-in-charge for critiquing and editing. . Distribute your edited information posters to the clinical laboratories in your locale. Document your distribution of the posters and submit your documentation to the faculty-in-charge.
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