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ORIGINAL ARTICLE
Year : 2020  |  Volume : 13  |  Issue : 5  |  Page : 546-551  

Nuances of human anatomical waste management in a secondary care government hospital


1 Department of Anatomy, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Obs and Gynae, Government Meddical College, Kathua, Jammu and Kashmir, India
3 Department of Community Medicine, Armed Forces Medical College, Pune, Maharashtra, India

Date of Submission01-Apr-2019
Date of Decision01-Apr-2019
Date of Acceptance03-Sep-2019
Date of Web Publication7-Sep-2020

Correspondence Address:
Shallu Jamwal
Department of Anatomy, Armed Forces Medical College, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_139_18

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  Abstract 


Introduction: The last century has witnessed rapid growth of the health-care institutions in both the public and the private sector as per the demand from the growing population. This has resulted in substantial amount of the biomedical waste (BMW) is generated which presents a health hazard. Objectives: The objective is to study the BMW management (BMWM) practices of the secondary care government hospital and to suggest measures for improvement of the current BMW practices for evolving a better and more efficient system of BMWM. Materials and Methods: The study design was a descriptive study in which various stakeholders and facets of BMWM system in government hospitals were taken into consideration. Samples drawn were purposive, with the objective of studying BMWM in a secondary care hospital. The observations, interviews, and focus group discussions were used for data collection. Results: The various categories of waste generated in a 345 bedded secondary care government hospital and the quantity on a monthly average basis was calculated. Total BMW collected and treated by health-care facility in kg/day is 12 kg, and the same amount is disposed of in a day. Conclusion: There is a dire need for making appropriate technologies, imparting professional training, and allocating adequate financial resources for effective and safe BMW disposal. Public-private partnership and total commitment of the top management will help in proper handling and disposal of BMW.

Keywords: Biomedical waste, government hospital, human anatomical waste


How to cite this article:
Singh Jamwal VD, Jamwal S, Kumar S, Yadav AK. Nuances of human anatomical waste management in a secondary care government hospital. Med J DY Patil Vidyapeeth 2020;13:546-51

How to cite this URL:
Singh Jamwal VD, Jamwal S, Kumar S, Yadav AK. Nuances of human anatomical waste management in a secondary care government hospital. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Oct 21];13:546-51. Available from: https://www.mjdrdypv.org/text.asp?2020/13/5/546/294338




  Introduction Top


The last century has witnessed the rapid growth of the health-care institutions in both the public and the private sector as per the demand from the growing population. This has resulted in a substantial amount of the biomedical waste (BMW) is generated. BMW is any waste, which is generated during the diagnosis, treatment or immunization of human beings or animals or in research activities pertaining thereto or in the production or testing of biologicals, and including categories mentioned in Schedule I. The BMW (management and handling) Rules 1998, prescribed by the Ministry of Environment and Forest, Government of India, came into force on July 20, 1998.[1] The Government Medical Services took the lead in developing BMWM systems across the wide spectrum of its health-care establishments (HCEs) across the country. However, many HCEs lack appropriate systems because of nonavailability of appropriate technologies, lack of professional training, and adequate financial resources, thus becoming health and environment hazard. The existing policy on the BMWM in the government hospitals is being revived.[2]

A system is a group of elements (persons, organizations, equipment, and concepts) that are related in such a way that they influence each other and the behavior of the elements as a whole. System analysis is the examination of various elements of a system with a view to ascertain whether the proposed solution to a problem will fit the system and in turn affect an overall improvement in the system.[3],[4] The time has come to look BMWM as a system.

The vast variety of studies on the BMWM cover varied facets of BMW such as awareness regarding BMW among health-care workers,[5],[6] quantum of waste generated in HCEs,[7] infrastructure of hospitals to handle BMW,[8] environmental and health risks associated with inappropriate and unsafe BMWM and training of health workers, and especially Class IV employee.[9],[10] While these studies are of great help in initiating corrective measures at the local level, but they suffer from an inherent limitation of most quantitative studies namely they view only one particular aspect at one point of time. There are multiple stakeholders at all levels in the management of BMW in the government and private health-care system. Since the holistic picture is not viewed by quantitative research methods, there cannot be an intervention at the level of policy. In such a complex situation, qualitative research tools are often used to analyze the system at a macrolevel to suggest policy interventions. The BMWM system in the government hospitals can be conceptualized as an open-ended system where, on the one hand, the subsystems are in continuous interaction among each other; and on the other hand, these subsystems separately and the system as a whole, are constantly influenced by the external environment. The study design was accordingly formulated based on the above systems approach to review the current BMW disposal in the government hospitals and recommend policy changes to improve it further. Hence the objective was to study the BMWM using system approach in a secondary care government hospital.


  Materials and Methods Top


The study design was a descriptive study in which various stakeholders and facets of BMWM system in government hospitals were taken into consideration. Samples drawn were purposive, with the objective of studying BMWM in a secondary care hospital. For system analysis, we consider the hospital, as system for generation and disposal of wastes. Hence, the process was observed and also interview and focused group discussion were done with all the stakeholders. However, we excluded the training part of the worker from system analysis. The following tools were used for data collection:

  1. Observation


    1. Visit to BMWM facilities in the secondary care government hospital
    2. Assessment of the capacity of various equipment's of BMW disposal
    3. Assessment of the capacity of the category wise BMW generation.


  2. In-depth interview of key personnel


    1. Chief administrator of the hospital
    2. Officer in charge BMWM committee of the hospital.


  3. Focus group discussions: Focus group discussions with Director Health services, Deputy Assistant Director Health (Nodal officers for implementation of BMWM program in his area of responsibility) and faculty members concerned with BMWM of a service medical college.


The study was carried out in a secondary care 345 bedded government hospital prior to the implementation of BMWM rules 2016. The hospital was providing basic health-care facilities and specialized treatment in the form of general medicine, general surgery, obstetrical and gynecology, psychiatry, dermatology, operation theatre, eye, ear nose and throat, and pathology and radiology services. Quantity generated in different waste categories was clubbed into three categories namely Yellow comprising of Cat 1, 2, 3, 5, 6; Red having Cat 7; and Blue Cat 4. The waste generated daily over a period of 1 month was weighed in the presence of the investigator and recorded. Due to the wide variation in the quantity of waste generated, median waste generated was used for analysis. The wide variation was attributed to the variance in the workload, which was directly related to the dependent clientele strength. The capacity of the various equipment for BMW disposal was recorded from the users' manual of the equipment. In key informant and focused group discussion, all aspects of waste management from waste generation to waste disposal were interviewed.


  Results Top


Since this study is a descriptive study to analyze all aspects of BMWM in government hospitals, efforts were made to identify gaps in the existing BMWM system and suggest measures for improvement. During the visit to BMW facility of secondary care government hospital, the collection and disposal of BMW were satisfactory. The BMW was segregated at the source. This is the most effective step which ensures correct routes for disposal, personal safety, and minimal harm to the environment. Segregation was done under the supervision of the department or the ward in charge at the place of generation. This was done for wastes of different categories collected in identifiable containers. Labeling and coding are being done by sorting the waste into color-coded bags or containers.

The transportation of the BMW bags is being done by means of wheeled carts pulled manually by the housekeeping staff from the point of collection to the BMW treatment facility (BMWTF) [Figure 1]. It is pertinent to mention that these wheeled carts were used only for the purpose of transportation of BMW and not for any other purpose. The biohazard symbol was clearly displayed on the carts.
Figure 1: Wheeled cart used for transportation of biomedical waste

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The overall process of segregation, packaging, labeling, transportation, treatment, and final disposal of BMW was satisfactory. However, some key interview informants admitted that there was no backup in case of any failure of the final disposal mechanism due to a mechanical defect or environmental disruptions such as storm, flash floods, and exigencies of service and security reasons. During such times, there will be a problem in disposal of BMW. They were of the unanimous opinion that in case vendors are available for outsourcing the final disposal, all such service hospitals should outsource the same to an approved vendor from their kerb site. Due to security reasons, the collection, segregation, and transportation to kerb site should be the responsibility of the service hospital. They stated that funds need to be earmarked from Annual Contingency Grant for the same by the service hospitals.

The various categories of waste generated in a 345 bedded secondary care government hospital and the quantity on a monthly average basis were calculated [Table 1].
Table 1: Waste generated category wise (monthly average)

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The hospital had a biomedical site facility equipped with an incinerator which is operated by the engineering services [Figure 2] and [Figure 3].
Figure 2: Chimney of the incinerator

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Figure 3: Electronic panel and main body of the incinerator

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Incineration is a waste treatment process that involves the combustion of organic substances in a high-temperature incinerator. Incinerators reduce the solid mass of the original waste by 80%–85% and the volume by 95%–96%, depending on composition and degree of recovery of materials. It significantly reduces the necessary volume for disposal. In simple words, an incinerator is a furnace for burning waste at high temperature.

In addition, BMWTF has a microwave which is operated by the hospital [Figure 4] and [Figure 5]. The microwave is based on the principle of generation of high-frequency waves which cause the particles within the waste material to vibrate, generating heat. This heat generated from within kills all pathogens.
Figure 4: Microwave

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Figure 5: Microwave (with lid open)

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The various types of plastic waste generated by the hospital are mainly disposed of by the plastic shredder. Shredding medical waste in preparation for landfill disposal is a critical part of medical waste management. BMW requires shredding equipment specifically designed to shred plastic waste to an unrecognizable consistency to be disposed of in landfill.

There is no common BMWTF (CBWTF) in operation or under construction for the BMW disposal of this hospital.

Total BMW collected and treated by health-care facility is 12 kg/day, and the same amount is disposed of in a day. Details of on-site treatment equipment's installed by the HCF are shown in [Table 2].
Table 2: Details of on.site treatment equipmentfs installed by the HCF

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The amount of waste generated (category wise kg/day) was calculated and tabulated as [Table 3]. The outsourcing vendor had state-of-the-art facilities for outsourcing at rates approved by the local civic body and state PCB. It charged INR 4.00/bed/day, for collection of BMW from kerb point to final disposal site.[11]
Table 3: The amount of waste generated ( category wise Kg/day)

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Maximum waste generated was from the wards, followed by operation theater and laboratory services. In departments with ʊ beds (Type 5), accident and emergency rooms generated maximum BMW followed by wards.

There was wide variation in the amount of BMW generated per bed across various departments, even having the same number of beds. Therefore, the median values were taken to calculate BMW in each department of hospitals.

There was a facility of one large beehive incinerator in the hospital. Autoclaves, microwaves, and shredders, though adequately scaled, are deficient in a large number of departments. This deficiency could be attributed to the fact that either the equipment has become vintage/obsolete or is unserviceable. The manual destruction of plastics is being done in departments deficient of shredders.


  Discussion Top


Since the past three decades, unregulated handling of BMW is emerging as a serious threat to human health and safety, and many researchers have documented this as a priority area.[12],[13] The concern over HIV/AIDS and other blood-borne infections has led to an increased professional and environmental activism toward this issue.[13] At the global level, 18%–64% of health-care institutions are reported to have unsatisfactory BMWM facilities; predictors include lack of awareness, insufficient resources, and poor disposal mechanisms.[14] We found that the facilities for biomedical waste management including a functional incinerator gave satisfactory results as objectively measured by capacity of equipment used and substantiated by interview of health care providers.

India was one of the first countries to implement BMWM rules.[15] The Ministry of Environment and Forests notified the “BMWM and Handling Rules,” in July 1998 (later amended in the year 2003 and 2011) under the Environment Protection Act, 1986.[16] It enforces the health-care institutions to follow strict segregation, packaging, labeling, and disposal as per BMW rules, 1998. In our analysis, we found that the hospital was complying with BMWM and handling rules; and therefore, no hazardous incidence of BMW was reported in the hospital.

In India, many hospitals lack appropriate technologies of BMW treatment and disposal. Moreover, there is a lack of professional training, adequate financial resources, and above all, lack of commitment at the managerial level. Due to these reasons, Indian hospitals are lacking in proper BMW disposal.[17],[18] However, in our study, we found appropriate technologies were used, and all stakeholders were active in participating in BMW disposal.

The systems approach adopted in this study aims to identify organizational, technical, and social factors involved in the BMW disposal system. All the stakeholders and equipment was available. However, there was no contingency plan in the hospital.

There was wide variation in the amount of BMW generated per bed across the various department with same beds. There is no complaint regarding collection, segregation and transport of BMW to kerb site. The results of a study on government hospitals by Jindal et al.[2] and studies conducted at PGI, Chandigarh and by Passco Environmental Solutions Pvt. Ltd., outsourcing company recognized by Maharashtra Pollution Control Board, on a 1000 bedded hospital in Pune. These have come up with results of 60–250 g/day/bed[19] and 75 g/day/bed,[11] respectively. The wide variation in BMW generated could be due to the confusion in color coding as various categories have multiple options as per BMW rules.[20]

For analysis of the BMW disposal network in the service hospitals, majority of the stakeholders were in favor of outsourcing. With the rapid advancement in health-care industry in the civil, there are now plenty of vendors available who have established CBWTF in most cities. The civil HCEs have by and large reduced their own burden by outsourcing final BMW disposal to these approved vendors. The service hospitals may also consider joining the “civil bandwagon” and thus reduce some of their legal and administrative liabilities.


  Conclusion Top


Basic facilities for biomedical waste management including a functional incinerator gives satisfactory results in a secondary care hospital as objectively measured by capacity of equipment used and substantiated by interview of health care providers. BMW disposal is satisfactory if appropriate technologies are used with the active participation of all stakeholders including hospital administrators. Outsourcing BMW services to a common city agency is the need of hour for government hospitals for effective management of BMW and optimum utilization of resources.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Yadavannavar M, Berad AS, Jagirdar P. Biomedical waste management: A study of knowledge, attitude, and practices in a tertiary health care institution in Bijapur. Indian J Community Med 2010;35:170-1.  Back to cited text no. 6
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Mohankumar S. Hospital waste management and environmental problems in India. Int J Pharm Biol Arch 2011;2:2.  Back to cited text no. 10
    
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Passco Environmental Solutions Private Limited Pune. Available from: http://passco.in. [Last accessed on 2020 Jan 07].  Back to cited text no. 11
    
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Rutala W, Glen M. Medical Waste. SHEA position paper (Society of hospital epidemiology of America). Infect Control Hosp Epidemiol 1992;13:38-48.  Back to cited text no. 13
    
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World Health Organization. Wastes from Health-Care Activities. Factsheet No 253. World Health Organization; November, 2011. Available from: http://www.who.int/mediacentre/factsheets/fs253/en. [Last accessed on 2013 Apr 01].  Back to cited text no. 14
    
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Gupta S, Boojh R, Mishra A, Chandra H. Rules and management of biomedical waste at Vivekananda polyclinic: A case study. Waste Manag 2009;29:812-9.  Back to cited text no. 15
    
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Ministry of Environment and Forests. Government of India. Draft Bio-Medical Waste (Management and Handling) Rules. Ministry of Environment and Forests; 2011. Available from: http://moef.nic.in/downloads/public-information/salient-features- draft-bmwmh.pdf. [Last accessed on 2013 Apr 05].  Back to cited text no. 16
    
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Jahnavi G, Raju PV. Awareness and training need of biomedical waste management among undergraduate students, Andhra Pradesh. Indian J Public Health 2006;50:53-4.  Back to cited text no. 17
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Hanumantha Rao P. Hospital waste management system-a case study of a South Indian city. Waste Manag Res 2009;27:313-21.  Back to cited text no. 18
    
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Singh K, Arora SK, Dhadwal PJ, Singla A, John S. Bio-medical waste management in the U.T. Chandigarh. J Environ Sci Eng 2004;46:55-60.  Back to cited text no. 19
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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