ETLog Health Consulting GmbH Am Kanal 16 16766 Kremmen Germany Tel.: ++ 49 (0)30 44 31 87 30 Fax: ++ 49 (0)30 44 31 87 49 E-Mail: pieper@etlog-health.de Web: www.etlog-health.de International experiences Healthcare Waste Mangement
ETLog Health GmbH Over the past years, ETLog Health has been appointed to conduct consulting services for nearly 100 internationally recognized healthcare waste projects in more than 40 countries, mainly in Europe, Africa, the Middle East, Caribbean and Asia.
Content 1. International Experiences 2. Logistical Aspects 3. Treatment methods 4. Waste Management Plans 5. Training and Monitoring / Inspection
Why healthcare waste management? Healthcare waste is an integrative part of infection control Improper handling, treatment and disposal methods of healthcare waste can cause nosocomial infections, occupational accidents, and environment pollution; it might result in an increase of the costs. The establishment of a safe waste handling system will increase safety and health for personal and public.
Overview Classification Non-hazardous waste Infectious waste General waste Recyclable and reusable materials Highly infectious waste Infectious waste Healthcare waste Sharps waste Pathological waste Hazardous waste Pharmaceutical waste Chemical waste Radioactive waste Cytotoxic waste Other hazardous pharmaceutical waste Pressurized container Waste with high content of heavy metals Other hazardous chemical waste
Types of risks The main risks associated with healthcare wastes are: Physical risks Chemical risks Microbiological risks Radiological risks Environmental risks
Exemplary Logistic Pattern Non- hazardous waste Potential infecious Highly infetious waste Chemical waste General Waste Recycling Waste Infectious Waste Sharp Waste Pathologicanatomical Waste Autoclaving on site Incineration ash Recycling Autoclaving Hazardous Waste Incineration Cremation Hazardous Waste Treatment ash ash Non-hazardous Waste landfill Hazardous Waste Landfill Burial / Cemetery
Points of action (internal) Generation Segregation De-central storage Identification following the classification system Packaging and labelling Transport Bringing together of small amounts (On-site treatment) Central storage Transport Reduction of the hazardousness Interim storage and set ready for external disposal
Points of action (external) Central storage External transport (Off-site treatment) (Recycling) Final disposal Reduction of the hazardousness Reduction of energy consumption and use of raw materials
Example: Logistic for Bishkek Central and de-central solutions are envisaged De-central Tuberculosis and Infectious disease hospitals are mandatory to receive a treatment system Healthcare facilities which can not be clustered because of their location Central solutions Bigger Hospitals are equipped with a treatment system and the waste from other facilities is collected and transported to the central facility
Centralised Concept Example Serbia
CONCEPT IN PRACTICE HCW Generator: Transfer Point (Pick up) Central Treatment Point Empty & cleaned Containers Registration of uplifted container Municipal Landfill Unloading & weighing of waste Documentation Treatment of Waste Non- Hazardous Waste
Incineration Incineration and incineration can often not be easily compared. A clear distinction must be made between simple field incinerators and high-tech, central household waste or special hazardous waste incinerators. De-Montfort Incinerator Waste treatment center, Augsburg with houshold waste and special waste incinerator.
Incineration II Three main factors for the incineration process - 3 T's : Time waste remains in the combustion chamber, Temperature of incineration, Turbulence of air and gasses in the combustion chamber. Primary combustion (primary chamber) Decomposition of all combustibles Gasification / partial combustion Burning of carbon Post combustion (secondary chamber) Complete combustion of all unburned and partially burnt waste into gas form Destruction of pathogens
Incineration IV Operation problems
Alternative treatment systems Basel Convention: Steam treatment by autoclaving is listed as the PREFERRED METHOD for the treatment of healthcare waste But: Steam treatment is not equal steam treatment the quality highly depends on the process cycle, the equipment and the user. Steam treatment is only for infectious waste including sharps!! Note: High temperature steam is still the safest and most common agent for the sterilization of medical supplies in health facilities.
Process cycle - gravity autoclave: Non-vacuum systems Steam is inserted until air is removed, Air is removed via valves due to the density difference of air and steam, Needs long treatment time due to still existent cold islands, Long process time (norm. >2h) due to long pre-heat and cool down phase. >45 min Temperature waste Temperature chamber
Pre-vacuum systems 2 bar I n s i d e 1 bar - P r e s s u r e Process cycle: Air is mechanically removed by a vacuum-pump. By working with a single pre-vacuum cycle, still some air will remain in the autoclave and can act as an isolator. To minimize this problems longer treatment times are required. In some countries this cycle is not accepted. 0,1 bar Vacuum Steam injection Treatment Time Air is more heavy then steam and will settle at the ground
Pressure [p] Fractionated systems 2000 1800 Phase I VSV-Cycle Phase II Sterilization Phase III Drying; Un/Loading Phase I Phase II Phase III 1600 1400 1200 1000 800 600 400 200 Chamber pressure 0 0 20 40 60 80 100 120 140 160 180 Time t [min] Through a fractioned vacuum-steam cycle, a steam atmosphere of 99 % can be guaranteed (Phase 1). During the disinfection (Phase 2) hospital waste is treated by saturated steam under pressure (Temperature >130 C).
Planning and Implementation of HcWM Systems 1. Assessment 2. General framework I. Obligatory waste policy / strategy II. III. Development of Laws / by laws Financing of investment and operation costs 3. Detailed implementation & cost plan 4. Implementation of the system Phased / Parallel / Pilot implementation Equipment, Infrastructure, Guidelines & SOP, Education / Training system 5. Post-check of the implemented system
Challenge clear interfaces of responsibility Inside of the healthcare facility External Classification Segregation Collection Transport Storage External Transport Treatment Landfill Defined clear responsibilities available?
Internal: Responsible Person for HCWM Introduction and supervision of waste segregation Data recording Regarding medical waste Supervision of final disposal Supervision of storage rooms Safe methods in the handling of hazardous waste Observing the legal regulations
Setting up of a hcwm pilot Way forward? Identification of a pilot hospital Planning of Logistic / Infrastructure / Equipment Tendering / Delivery / Implementation Development of an internal guideline & SOP Information / Education / Communication Education Insertion of HcWM education system into existing health education / outsourcing of performances to private entities Training of relevant authorities on monitoring Development of a monitoring system Expending of system