PANJAB UNIVERSITY

COMPLIANCE RATE STUDY OF BIO-MEDICAL WASTE IVY HOSPITAL, MOHALI SEGREGATION AT SOURCE IN THE PATIENT CARE AREAS OF IVY HOSPITAL, MOHALI SUBMITTED BY: Dr. Jaspreet Kaur Ishar REGISTRATION No: 09-UIM-92 A project report submitted in partial fulfillment of the requirements for the degree of Master of Business Administration in Hospital Management to University Institute of Applied Management Sciences Panjab University, Chandigarh, (India)

PANJAB UNIVERSITY CHANDIGARH INDIA-160014

DECLARATION

I hereby declare that the project report titled COMPLIANCE RATE STUDY OF BIO-MEDICAL WASTE SEGREGATION AT SOURCE IN THE PATIENT CARE AREAS OF IVY HOSPITAL, MOHALI

Submitted in partial fulfillment of the requirements for the degree of Master of Business Administration in Hospital Management to U.I.A.M.S, Punjab University, is my original work and not submitted for the award of any other degree, diploma, fellowship, or any other similar title or prizes

Place: Mohali Date : July 2010

Dr. Jaspreet Kaur Ishar Registration No: 09UIM-92

This is to certify that the project report titled COMPLIANCE RATE STUDY OF BIO-MEDICAL WASTE SEGREGATION AT SOURCE IN THE PATIENT CARE AREAS OF Ivy Hospital, Mohali

Submitted in partial fulfillment of the requirements for the degree of Master of Business Administration in Kaur Ishar Hospital Management from U.I.A.M.S, Panjab University

Registration No:

Dr.Jaspreet Kaur Ishar Registration No: 09-UIM-92 has worked under my supervision and guidance and that no part of this report has been submitted for the award of any other degree, diploma, fellowship or other similar titles or prizes and that the work has not been published in any journal or Magazine.

(Shweta Kapoor) Master in Healthcare Administration

ACKNOWLEDGMENT

I would like to express my sincere thanks to Ivy Hospital, for giving me an opportunity for working on the project and for extending all the possible support and guidance required for the successful completion of the project and the learning which came along with the entire process. All this would not have been fruitful without contribution of various people to whom I would like to express my gratitude. First of all, I would like to thank my guide and mentor Mrs. Shweta Kapoor (NABH coordinator), Quality Cell whose guidance and constructive feedback helped me improve my quality of work to a great extent. I would like to express my gratitude to Mr. Nehchal Singh (Adm.Co-ordinator)for his valuable suggestions while doing the project work. I would also like to thank Mr.Gurtej Singh, CEO, Ivy hospital, who gave me the chance to pursue my summer internship here. Furthermore, I want to thank Mrs.Rupinder Kaur, Head of HR department who guided me in completing my tasks

Finally, I would like to sincerely thank all the supporting departments and faculty members of Ivy hospital for their assistance and for providing me all the relevant information that assisted me to accomplish successful completion of my project.

Dr. JASPREET KAUR ISHAR M.B.A HOSPITAL MANAGEMENT

IVY HOSPITAL MOHALI

OVERVIEW OF THE ORGANIZATION

Ivy Hospital is a landmark tertiary care health destination promoted by a team of professionals. The Multi-Specialty Hospital cum Cancer Research Institute with Modern Diagnostic Centre and a capacity of 180 Beds has the state-of-the-art technology over virtually all specialties. The technology advantage is complemented by the man power excellence providing sophisticated and specialized medical care at affordable cost. The expert team of doctors and support staff ensure the best care is delivered at all time with utmost dedication. It is their sacrament to enrich and preserve valuable human lives. From the moment you arrive, you will notice that our hospital is unique. Our team is dedicated to bringing you a world of care with every visit. World-class medical care, friendly, devoted service and affordability are the key features in our every touch. We have achieved laurels for being one of the best-organized multi-specialty hospitals. The highly competent experts in various disciplines taking charge of patient care give the double advantage of safety and mental peace for the patients .We emphasize on humane approach in patient care, which is obvious in every staffs activities. Early detection and timely intervention is our mantra and no undue delay is observed during administering treatment. Together with the technology to match world-class standards and support services like pharmacy, laboratory and cafeteria we pledge to make your stay at the hospital peaceful and comfortable.

VISION To be World Class Super Specialty health Provider in North India MISSION To be the Largest healthcare provider in North India by 2012 Available, Accessible &Affordable Healthcare Care &Cure with Compassion & Commitment Ensure Excellence in Healthcare Provide Healthcare Service by adhering to ethical code of conduct.

VALUES Integrity We are committed to the highest ethical standards in our conduct. Service Excellence We are committed to our standards of service excellence and dedicated to exceeding the expectations to those we serve. Responsibility We accept personal accountability for the work we do. Teamwork We will foster work environment that encourages new ideas and creativity. Professionalism We will uphold public trust in the healthcare profession by our conduct, standard of service and quality of medical care. Innovation We are committed to a supportive environment that encourages new ideas and creativity. Quality We are consistently striving to provide the highest quality and safe patient care. Safety We are dedicated to creating the safest hospital for all.

HOSPITAL PROFILE
The Ivy Hospital is a brand new state of the art multi specialty hospital, the brain child of Mr. Gurtej Singh (CEO) & Dr Kanwaldeep Kaur. The hospital opened on 26 November 2007.It is strategically located at a prime location in sector 71, Mohali. The First Phase of the SuperSpecialty hospital is now operational and the following departments are functional:

Anesthesiology and critical care Cardiology Cardiovascular & Thoracic Surgery Dentistry Dermatology and Cosmetology Endocrinology ENT Gynecology & Obst. Internal Medicine Medical Oncology Nephrology Neurosurgery Neurology Neurotherapy

Orthopedics Pathology Pediatrics Pediatric Surgery Pain Management Centre Physiotherapy Plastic and Cosmetic Surgery Psychiatry Radiation Oncology Radiology Renal (Kidney) Transplant Surgery Surgical Oncology Urology & Laparoscopic Surgery Vascular Surgery

Ivy hospital has a dedicated Quality cell. Its functions include framing Policies, SOPs, Manuals, implementation of all policies, training of staff and auditing etc. Ivy Hospital is empanelled with more than 95 organizations & TPAs including ECHS, ESI, RBI, SBI, NHPC & FCI. In its constant drive to achieve the best quality of care, Ivy Hospital has set up a special division to look after the needs of International Patients and make their stay comfortable and feel at home. Services offered at the department of International patient care are:

Medical Tourism Distant Consultation (Through telemedicine / phone / e-mail) Assistance at the Airport Emergency Medical Evaluation Co-ordination of doctor's appointments Local Travel Arrangements Accommodation for relatives and attendants 8

Key features of the hospital are:

Fully Air conditioned building state of-the-art laminar flow Air conditioning in Operation Theaters & ICUs.

7 Operation Theaters and 180 beds including advanced ICU & CCU. Highly qualified and experienced team of doctors, Para medical staff and other professionals to run various departments of the hospital.

Departments equipped with advanced and sophisticated equipment to provide world class healthcare.

Liver-kidney transplant in the Chandigarh region

Fall

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CONTENTS
Page no. ACKNOWLEDGMENT AN OVERVIEW OF THE ORGANIZATION HOSPITAL PROFILE LIST OF TABLES EXECUTIVE SUMMARY Chapter 1 2 3 4 5 6 7 Title INTRODUCTION REVIEW OF LITERATURE METHODOLOGY RESULTS AND ANALYSIS CONCLUSION AND RECOMMENDATIONS BIBLIOGRAPHY ANNEXURES a) ANNEXURE I Survey Questionnaire for Hospital waste segregation b) ANNEXURE II Questionnaires filled by hospital staff 3 4 7 10 10 12 Page no. 13 18 29 32 38 41

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LIST OF TABLES

Table no.
I II

Title
Treatment & disposal of Bio-Medical Waste

Page No. 2

Color coding and type of container for disposal 2 of B.M.W according to the BIO-MEDICAL WASTE 3
(MANAGEMENT & HANDLING RULES 1998)

III

Color coding and type of container for disposal of BIO-MEDICAL WASTE at Ivy Hospital

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IV

Compliance rate and subsequent findings regarding 34 the B.M.W segregation practices in the patient care areas of Ivy Hospital

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ABSTRACT
Issues of improving the management of bio-medical wastes are receiving attention throughout the world since healthcare institutions generate tons of biomedical waste each year. The key to minimization and effective management of biomedical waste is segregation (separation) and identification of the waste. Improper segregation leads to mixing of hazardous and nonhazardous waste and dumping of hazardous waste outside the hospital. This is a hazard to community as it can lead to many infectious diseases such as hepatitis, tetanus and HIV. The rag pickers who pick up discarded materials from such areas often use contaminated needles and sharp objects causing infection. So it is necessary to properly segregate the bio-medical waste at the point of generation only. In the present study an attempt is made to determine the compliance rate of bio-medical waste segregation at source in patient care areas of Ivy hospital and reasons for non-compliance. Recommendations are also provided to improve the compliance rate. The topic includes the literature regarding the bio-medical waste segregation and also covers the bio-medical waste act. The method adopted for the present study was observation method. The data was collected through direct observations and data was than statistically analyzed. From the analysis data it was found out that there has been non-compliance in few departments of the hospital due to some reasons which are given in the report. Recommendations are also provided.

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EXECUTIVE SUMMARY

Background: Segregation is an essential part of the bio-medical waste management process. Improper segregation at source is a hazard to the community leading to many infectious diseases such as tetanus, hepatitis, HIV etc. So it is necessary to properly segregate the biomedical waste at the point of generation only. The present study was performed to know the compliance rate of bio-medical waste segregation at source in Ivy hospital. Method: Direct observations were used in the study. Results: The results of the study show that there was non-compliance in some departments. ICU and Cath lab had the worse compliance rate. Data analysis: Various analytical techniques were used such as Percentage estimation chart, fish bone analysis. A comparative analysis of different departments was also done. Reasons and recommendations: The reasons for non-compliance were known. Some of the reasons were lack of knowledge, careless attitude of staff etc. Recommendations are also provided for improving the compliance rate. Conclusions: After analyzing the results it is felt that there is non-compliance in the segregation of waste at source which can be hazard to the community. Immediate measures must be taken to improve the compliance rate.

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CHAPTER I INTRODUCTION

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1. INTRODUCTION
1.1 INTRODUCTION
Hospital is one of the complex institutions which is frequented by people from every walk of life in the society without any distinction between age, sex, race and religion. This is over and above the normal inhabitants of hospital i.e patients and staff. All of them produce waste which is increasing in its amount and type due to advances in scientific knowledge and is creating its impact. The hospital waste, in addition to the risk for patients and personnel who handle these wastes poses a threat to public health and environment. Keeping in view inappropriate biomedical waste management, the Ministry of Environment and Forests notified the Biomedical Waste (management and handling) Rules, 1998 in July 1998. In accordance with these Rules (Rule 4), it is the duty of every occupier i.e a person who has the control over the institution and or its premises, to take all steps to ensure that waste generated is handled without any adverse effect to human health and environment. The hospitals, nursing homes, clinic, dispensary, animal house, pathological lab etc., are therefore required to set in place the biological waste treatment facilities.

1.2 BIO-MEDICAL WASTE MANAGEMENT PROCESS

Handling, segregation, mutilation, disinfection, storage, transportation and final disposal are vital steps for safe and scientific management of bio-medical waste in any establishment. The key to minimization and effective management of biomedical waste is segregation (separation) and identification of the waste.

1.3 TOPIC OF THE PROJECT

Compliance rate study of bio-medical waste segregation at source in the patient care areas of Ivy hospital.

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1.4 GOAL OF THE PROJECT

To know the compliance rate of bio-medical waste segregation at source and to identify the areas which provide an opportunity to improve the compliance rate and recommend effectual and practical measures to it.

1.5

NEED AND SIGNIFICANCE

The key to minimization and effective management of biomedical waste is segregation (separation) and identification of the waste. Proper segregation reduces the amount of waste needs special handling and treatment, prevents the mixture of medical waste like sharps with the general municipal waste, prevents illegal reuse of certain components of medical waste like used syringes, needles and other plastics, provides an opportunity for recycling certain components of medical waste like plastics after proper and thorough disinfection, Recycled plastic material can be used for non-food grade applications, of the general waste, the biodegradable waste can be composted within the hospital premises and can be used for gardening purposes, reduces the cost of treatment and disposal (80 per cent of a hospitals waste is general waste, which does not require special treatment, provided it is not contaminated with other infectious waste).So Segregation is the essence of waste management and should be done at the source of generation of Bio-medical waste e.g. all patient care activity areas, diagnostic services areas, operation theaters, labor rooms, treatment rooms etc. The responsibility of segregation should be with the generator of biomedical waste i.e. doctors, nurses, technicians etc. (medical and paramedical personnel).

1.6 STATEMENT OF THE PROBLEM

Only 10 - 15% of hospital waste i.e. "Biomedical waste" is hazardous. But when hazardous waste is not segregated at the source of generation and mixed with non-hazardous waste, then 100% waste becomes hazardous. Hence, improper bio-medical waste segregation at source is risk to healthcare workers, waste handlers and the community. The objective of the project is to check out the compliance rate of bio-medical segregation at source in the patient care areas of Ivy hospital and to improve this compliance rate. 16

1.7 DEFINITION OF KEY TERMS

1.7.1 BIO-MEDICAL WASTE - Bio-medical waste means 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. 1.7.2 SEGREGATION AT SOURCE - Segregation at source means to dispose off non hazardous waste and hazardous waste separately in different containers at the point of generation only . Different types of hazardous waste must also be dispose off separately in different containers. Proper color coding should be followed.

1.8 WHY SEGREGATION AT SOURCE IS NECESSARY ?

In fact only 10 - 15% of hospital waste i.e. "Biomedical waste" is hazardous, not the complete. But when hazardous waste is not segregated at the source of generation and mixed with nonhazardous waste, then 100% waste becomes hazardous. The non hazardous waste is dumped outside the hospitals at waste dump sites. This leads to Dumping of heaps of hazardous medical wastes consisting of bandages, syringes, plastic and aluminum equipment etc. along with nonhazardous waste outside the hospitals, creating a lot of health problems. At the waste dump sites there are several rag pickers trying to salvage any discarded material to sell them and make a living. These rag pickers are exposed to the risk of injuries from contaminated needles and other sharp objects and to various infectious diseases. The biomedical waste (BMW) also emits a foul smell during the rainy season. The stagnant waste and unsanitary conditions are potential breeding ground for flies, Mosquitoes, rodents and insects, which maintain the already existing disease cycle. Due to these acts, diseases like hepatitis, tetanus and dengue fever, HIV infection, etc. generally spread. So Segregation is the essence of waste management and should be done at the source of generation of Bio-medical waste e.g. all patient care activity areas, diagnostic services areas, operation theaters, labour rooms, treatment rooms etc. The responsibility of segregation should be with the generator of biomedical waste i.e. doctors, nurses, technicians etc. (medical and paramedical personnel).

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1.9 OBJECTIVE OF PROJECT

To find out the compliance rate of bio-medical waste segregation at source in all patient care areas of the Ivy hospital. To know the factors responsible for non- compliance and to improve them. To compare the compliance rate of various departments. To know the knowledge of the staff.

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CHAPTER II REVIEW OF LITERATURE

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2. REVIEW OF LITERATURE

2.1 BIO-MEDICAL WASTE:Bio Medical Waste means 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 biological including containers. Bio-medical waste means any solid and/or liquid waste including its container and any intermediate product, which is generated during the diagnosis, treatment or immunization of human beings or animals.

2.2 COMPONENTS OF BIO-MEDICAL WASTE

Human anatomical waste (tissues, organs, body parts etc.). Animal waste (as above, generated during research/experimentation, from veterinary hospitals etc.). Microbiology and biotechnology waste, such as, laboratory cultures, micro-organisms, human and animal cell cultures, toxins etc. Waste sharps, such as, hypodermic needles, syringes, scalpels, broken glass etc. Discarded medicines and cyto-toxic drugs. Soiled waste, such as dressing, bandages, plaster casts, material contaminated with blood etc. Solid waste (disposable items like tubes, catheters etc. excluding sharps). Liquid waste generated from any of the infected areas. Incineration ash Chemical waste

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2.3 SOURCES OF BMW

The major sources of health-care waste are hospitals and other health-care establishments, laboratories and research centers, mortuary and autopsy centers, animal research and testing laboratories, blood banks and collection services, and nursing homes for the elderly.

2.4 QUANTITY OF BMW

Hospitals and other health care facilities generate lots of waste which can transmit infections, particularly HIV, Hepatitis B & C and Tetanus, to the people who handle it or come in contact with it. High-income countries can generate up to 6 kg of hazardous waste per person per year. In the majority of low-income countries, health-care waste is usually not separated into hazardous or non-hazardous waste. In these countries, the total healthcare waste per person per year is anywhere from 0.5 to 3 kg.

2.5

BIO- MEDICAL WASTE MANAGEMENT ACT BIOMEDICAL WASTE (MANAGEMENT & HANDLING) RULES 1998
Amended on 2000

The Bio medical waste (Management and handling) Rules 1998 were notified under the Environment Protection Act, 1986 (29 of 1986) by the Ministry of Environment and Forest, Govt of India on 20th July, 1986. The guidelines have been prepared to enable each hospital to implement the said rules, by developing comprehensive plan for hospital waste management, in terms of segregation, collection, treatment, transportation and disposal of hospital waste.

The BMW Rules are applicable to every occupier of an institution generating biomedical waste which includes a hospital, nursing homes, clinic, dispensary, veterinary institutions, animal houses, pathological lab, blood bank by whatever name called, the rules are applicable to even.

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 Under the BMWR, segregation of bio-medical waste is mandated as the key basic step

to proper waste management. (1) Bio-medical waste shall not be mixed with other wastes. (2) Bio-medical waste shall be segregated into containers/bags at the point of generation in accordance with Schedule II prior to its transportation, treatment and disposal. The containers shall be labeled according to Schedule III.

CATEGORIES OF BIO-MEDICAL WASTE Schedule I (Rule 5)

WASTE CATEGORY Category No. 1 Category No. 2

TYPE OF WASTE Human Anatomical Waste (Human tissues, organs, body parts)

TREATMENT DISPOSAL OPTION Incineration@ / deep burial*

AND

Animal Waste (Animal tissues, organs, body parts, carcasses, bleeding parts, fluid, blood and experimental animals used in research, waste generated by Incineration@ / deep burial* veterinary hospitals and colleges, discharge from hospitals, animal houses) Microbiology & Biotechnology Waste (Wastes from laboratory cultures, stocks or specimen of live micro organisms or attenuated vaccines, human and animal Local autoclaving/ microwaving / cell cultures used in research and infectious agents from research and industrial incineration@ laboratories, wastes from production of biologicals, toxins and devices used for transfer of cultures) Disinfecting (chemical Waste Sharps (Needles, syringes, scalpels, blades, glass, etc. that may cause treatment@@ / autoclaving / puncture and cuts. This includes both used and unused sharps) microwaving and mutilation / shredding## Discarded Medicine and Cytotoxic drugs (Wastes comprising of outdated, Incineration@ / destruction and contaminated and discarded medicines) drugs disposal in secured landfills Soiled Waste (Items contaminated with body fluids including cotton, dressings, Incineration@ soiled plaster casts, lines, bedding and other materials contaminated with blood.) microwaving Solid Waste (Waste generated from disposable items other than the waste sharps such as tubing, catheters, intravenous sets, etc.) / autoclaving /

Category No. 3

Category No. 4

Category No. 5

Category No. 6

Category No. 7

Disinfecting by chemical treatment@@ / autoclaving / microwaving and mutilation / shredding# # Disinfecting drains by chemical

Category No. 8 Category No. 9 Category No.10

Liquid Waste (Waste generated from the laboratory and washing, cleaning, housekeeping and disinfecting activities) Incineration Ash (Ash from incineration of any biomedical waste)

treatment@@ and discharge into Disposal in municipal landfill

Chemical treatment @@ and 22 Chemical Waste (Chemicals used in production of biologicals, chemicals used discharge into drains for liquids and in disinfecting, as insecticides, etc.) secured landfill for solids.

@@ Chemical treatment using at least 1% Sodium hypochlorite solution or any other equivalent chemical reagent. It must be ensured that chemical treatment ensures disinfection. ** Mutilations / Shredding must be such as to prevent unauthorized reuse. @ There will be no chemical pre-treatment before incineration. Chlorinated plastics shall not be incinerated. * Deep burial shall be an option available only in towns with population less than five and in rural areas lakh

SCHEDULE II (Rule 6) COLOUR CODING AND TYPE OF CONTAINER FOR DISPOSAL OF BIO-MEDICAL WASTE
TABLE II Color coding Yellow Blue Type of container Plastic bag Plastic Bag/Disinfected White container Puncture bag Plastic bag Plastic bag proof Cat 4 Waste category Cat 1,2,3,6 Cat 7 Treatment options as per schedule I Incineration/deep burial Autoclaving/microwaving/chemical treatment Autoclaving/microwaving/chemical treatment & mutilation Cat 5,10 ( Solid) Disposal in secured Landfill General paper recyclable waste

container/Plastic Green Green

Notes:

Color coding of waste categories with multiple treatment options as defined in Schedule I, shall be selected depending on treatment option chosen, which shall be specified in Schedule I.

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Waste collection bags for waste types needing incineration shall not be made of chlorinated plastics. Category 3 if disinfected locally need not be put in containers/bags.

SCHEDULE III (See Rule 6) LABEL FOR BIO-MEDICAL WASTE CONTAINERS/BAGS

2.6 BIO- MEDICAL WASTE SEGREGATION

Segregation means the separation of the entire waste generated in a hospital in defined, different waste groups according to the specific treatment and disposal requirements. Only a segregation system can ensure that the waste will be treated according to the hazards of the waste and that the correct disposal routes are taken and that the correct transportation equipment will be used. Segregation is the key to any effective waste management. Without effective segregation system, the complete waste stream must be considered as hazardous.

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Occupational safety can only be maintained if the risks from the materials are defined, identifiable and the resulting counter measures are taken. By this, the risk of injury and incidents can be minimized in a cost effective waste.

Recycling can be only carried out if recyclable materials are separated from the hazardous waste (contaminated materials are excluded from any recycling activity and must be treated as mixed hazardous waste). To guarantee a high quality of the recycling materials it must be collected in a sort pure way. Mixed waste will decrease the possible income.

The separate handling, treatment, and disposal of different kind of hazardous and nonhazardous waste in different ways will reduce dramatically costs. Only the different kind of hazardous waste will be treated and disposed in a costly way instead of the entire waste stream in a hospital.

Conversely small errors at this stage can create lot of subsequent problems. It is now universally accepted that segregation is the responsibility of the generator of wastes i.e. the doctor, nurse or Para-medical personnel. However, in reality, this job is always relegated to the sanitation staff; and it becomes a truly Herculean task to segregate or sort out various categories, once they have been mixed up.

The hospital waste needs to be segregated collected and disinfected at source itself final disposal, so that the unscrupulous traders do not get any scope to reuse this material, which might cause highly infectious diseases. Several things affect the degree of segregation:

1) All bins should be preferably easy to use, in terms of their use and design and placement. There are instances when mixing of waste was directly linked to the poor access of particular bin .All decisions regarding bins should be taken in consultation with the personnel.

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2) The bins should be kept clean and should be covered and foot-pressed. This will eliminate the hesitation to approach a bin due to its appearance. 3) The number of each bin type should be optimized. As each bin directly translates into a liner (bag), economically it makes sense to use bins intelligently. The bins and bags should be of the same size to minimize wastage.

2.7 THE PRINCIPLES OF SEGREGATION

The correct segregation is the clear responsibility of every waste generator, independent of the organizational position of the generator (Duty of care principle). In case of doubts regarding the waste group, the precautionary principle must be followed, that means if a classification of the waste unclear or not recognizable, the waste must be classified in the highest to be expected risk gro The segregation should be carried out by the producer and close as possible to the place of generation, that means segregation must take place at source, e.g. on the ward, at the bedside, operation theatre, laboratory, etc. and must be carried out by the person generating the waste e.g. nurse, physician (proximity principle).

The segregation must be applied from the point of generation, during collection, transport, storage and final disposal. Every place of generation should have the necessary equipment for the types of wastes that are generated at that place like bags, bag holder, container, etc.

Segregation and identification instructions should be placed at each waste collection point.

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Segregated waste should not be mixed during transport and storage. If hazardous and non hazardous wastes are mixed, the entire mixture must be considered and treated as hazardous waste.

Correct segregation will only be achieved through a rigorous training of all hospital staff and waste generators inside the hospital (this includes patients and visitors).

The segregation should be carried out first under the polluter pay principle and second under the precautionary principle. This means the generator must segregate as good as possible and shall only in unclear situ.

2.8 COLOR CODING OF THE SEGREGATED WASTE

Color coding means to combine different waste groups with similar hazards in one main group and to identify this main group in a fast and easy way by a fixed color .The different waste groups have different colors for the containers and bags for the identification according to the hazards and applied throughout the complete disposal chain (segregation, collection, storage, transport, disposal): Warning colors for hazardous waste (Red, yellow, orange) Positive colors for recycling (Blue, green, etc.) Neutral colors for normal waste (Black, etc.)

IVY HOSPITAL BIOMEDICAL WASTE

27

Colorcode
Yellow bag

Type of waste
Body parts, soiled cottons, dressings,plaster, other material contaminatedwith blood,fluids. Used tubings, catheters,IV sets, and other used plastic material

Blue bag

White bag

All glass bottlesand other glass materialbut not broken

Greenbag

Generalwaste ( Paper,Disposableglasses)

Black bag

Kitchenwaste

Sharp container

Mutilatedneedles,scalpels,blades,sharps,brokenglass etc

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CHAPTER III RESEARCH METHODOLOGY

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3.1 STUDY AREA

Ivy Hospital, Mohali, Punjab

3.2 STUDY PERIOD

May-June 2010

3.3 STUDY DESIGN

Observational study

3.4

STUDY TOOLS

1. Observation of Bio-medical waste segregation & handling in the Hospital. 2. Self assessment on Bio-medical waste (management &handling) Rules 1998.

3.5 STUDY TECHNIQUE

The first step was the primary data collection which was done on the following departments H.D.U, Triage, I.C.U-1, General ward-1, 2, 3, &4, Dialysis, Cath Lab. The segregation practices being followed in these departments were closely observed from 9.30 to 6.00pm daily. Data regarding the no of errors made in the segregation practices and type of bins were noted/ recorded. According to the Bio- Medical Waste Management and Handling Rules 1998 Bio-Medical Waste shall not be mixed with other wastes and shall be segregated into containers/bags at the point of generation in accordance with Schedule II prior to its storage, transportation, treatment and disposal. Any deviation has been considered as an error. The various reasons for the error were found. The various statistical tools were used with graphical representation to analyze them and needful recommendations have been given for the respective reasons.

3.6 TYPES OF ANALYSIS

Quantitative analysis

3.7 ANALYTICAL TOOLS

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The following analytical tools were used: I. Percentage estimation chart II. Fish bone analysis

3.8 SCOPE OF THE STUDY

The present study attempts to determine awareness of health care personnel in Ivy hospital and to assess their attitude towards it. The study tries to know and improve bio-medical waste segregation at source in Ivy hospital. The scope of this study is limited to Ivy hospital only.

3.9 LIMITATION OF THE STUDY

Doctors not willing to attend the awareness classes conducted by Quality cell. Some critical areas such as ICU-2 could not be included in the study due to less no of patients. Low attendance of the nursing staff during the awareness classes conducted by quality cell.

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CHAPTER IV RESULTS AND ANALYSIS

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4.1 COMPLIANCE RATE CHART

After taking observations at the various departments under study the following results were obtained.

COMPLIANCE RATE (Before the implementation of corrective measures)

6% 0

57%

5% 3
5% 0 4% 0 3% 0

4% 8 4% 5 3% 7 2% 7 2% 0

g a t n c r e P

2% 0 1% 0 0 %

16%

May-2010

Data analysis
I.C.U-1 has the lowest compliance rate (16%) followed by Cath Lab (20%) G.W-2 has the highest compliance rate of 57% followed by G.W-1 (53%) Compliance rate of G.W-3 is 45% Compliance rate of Dialysis unit is 27% 33

 Compliance rate of H.D.U is 48% Compliance rate of Triage is 37% Compliance rate of Cath lab is 20%

Table depicting the compliance rate and subsequent findings regarding the B.M.W segregation practices in the patient care areas of Ivy hospital

TABLE IV
G.W -1,2,3
G .W-1 ,2 SEGREGATION (Good G .W -3

I.C.U -1

DIALYSIS

H.D.U

TRIAGE

Cathab l

Poor Poor Average Average Poor segregation) segregationsegregation segregation segregation segregation (Average segregation)

Specific findings

Kidney trays less Blue and Errors m ade byBlue and Errors m ade by in no. yellow bins patients yellow bins patients Needle cutter not present not present Errors m ade by not Errors m ade by available patient relatives Errors m ade by patient relatives Kidney trays patients less in no. Errors m ade by The attitude of Needle cutter patient relatives the professionals not available for w hom it is Blue and yellow not part of their bins not present job is an in G.W -3 im portant finding

Com m on Lack of training findings Lack of supervision

Lack of attitude Lack of know ledge about m ethods/ guidelines of segregation and its importance

Carelessness

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Criteria for rating:

0-25% - Poor segregation 25-50%-Average segregation 50-75%-Good segregation 75-100%- Excellent segregation

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MEASURES TAKEN Awareness classes were conducted by the Quality cell to educate nurses and G.D.As regarding the importance of B.M.W Segregation at source . Extra bins were provided in the departments ( wherever required) Checking/ Observation / Monitoring of the various departments

COMPLIANCE RATE (After the implementation of the corrective measures)

10 0% 9% 0 8% 0 7% 0 6% 0 5% 0

9% 0

8% 7

9% 0

8% 7 7% 0

8% 9 8% 0

9% 1

g a t n c r e P

4% 0 3% 0 2% 0 1% 0 0 %

Data Analysis

JUNE -2010

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 Lot of improvement has occurred and waste mixing has reduced to a great extent. I.C.U-1 and Dialysis Unit has shown maximum improvement.

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4.4 FISH BONE ANALYSIS

RESOURCES

HUM AN
(Doctors, Nurses, G.D.As ,Patients, Patient relatives, )Visitors M AN Bins less in no.
Carelessness Lack of knowledge Lack Shortage of of supervision plastic bags Lack of training

Kidney trays less in no.

Lack of attitude

IM PROPER BM W SEGREGATION
Govt ules R

Lack of space ( for additional bins)

INFRASTRUCTURE

EXTERNAL

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Effects of Improper Bio-medical Waste Segregation

Infections waste mixed with non-infectious waste will increase the treatment and disposal cost. Recycling can be only carried out if recyclable materials are separated from the hazardous waste (contaminated materials are excluded from any recycling activity and must be treated as mixed hazardous waste). Mixed waste will decrease the possible income. Risk of air, water and soil pollution directly due to waste, or due to defective incineration emissions and ash. Injuries from sharps leading to infection to all categories of hospital personnel and waste handler. Nosocomial infections in patients from poor infection control practices and poor waste management. Risk of infection outside hospital for waste handlers and scavengers and at time general public living in the vicinity of hospitals. Risk associated with hazardous chemicals, drugs to persons handling wastes at all levels. Disposable being repacked and sold by unscrupulous elements without even being washed. Drugs which have been disposed off, being repacked and sold off to unsuspecting buyers.

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CHAPTER V CONCLUSIONS AND RECOMMENDATIONS

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5. CONCLUSIONS & RECOMMENDATIONS

5.1 SUMMARY
Bio-medical waste segregation at source is an essential part of bio-medical waste management process. Segregation means mixing of non-hazardous and hazardous waste which leads to dumping of hazardous waste outside the hospital, which is a hazard to the community. So it is necessary to properly segregate the bio-medical waste. A study was performed regarding the bio-medical waste segregation at source in the Ivy hospital to know the compliance rate of the segregation at source. Observations were taken in different departments that were under study. The compliance rates of various departments were known and comparative analysis was done of different departments. Non-compliance was found out in all the departments. Different types of analytical tools were used to give a better picture. Analytical tools such as Percentage estimation chart, fish bone analysis were used. There were many reasons that were responsible for showing non-compliance that have been discussed in results.

5.2 CONCLUSION
From the following, it was analyzed that there is non-compliance regarding bio-medical waste segregation at source in the Ivy Hospital. All the departments under study show noncompliance of bio-medical waste. The reasons for non-compliance have been discussed earlier in the report. The following are the recommendations to improve the segregation at source: 1. Every week, a nurse should be given additional responsibility to see that the segregation is proper in their departments and to give the weekly report regarding the segregation to the nursing head. Different nurses should be appointed for different shifts. 2. A strict action must be taken against the staff who is not following the instructions. Punishments such as Censure or for habitual offenders deduction of the salary for the day, on which that person was found not segregating properly, will help in improving the compliance rate. 41

3. After every month, a 15 minute written test must be conducted for medical staff in which there are questions regarding the bio-medical waste and its segregation. The results should be displayed on the notice board containing the scores of each individual. This will help in increasing the knowledge of the staff and would help the management to know about the individual performance. 4. Covered bins should be provided in the patient care areas. They offer an aesthetic advantage, are much safer in cases of accidents (to minimize spillage) and also prevent the spread of infection. 5. Bio-hazard symbol should be there on the containers containing hazardous waste along with instruction Do not throw general waste. This will help in reducing errors made by relatives of the patients in areas such as general ward. 6. Proper instructions chart having information regarding the color coding and different containers used for disposal of bio-medical waste must be provided to each nurse, technician and helpers individually so that they can go through the charts regularly even if they are not in the hospital. This will help them in remembering the instructions.

BIBLIOGRAPHY REFERENCES

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Gordon JG, Rein Hardt PA, Denys GA (2004): Medical waste management. In: Mayhall CG (ed). Hospital epidemiology and infection control, (3 Williams and Wilkins publication. Pages: 1773-85.
rd

). Lippincott

Rutala WA, Weber DJ (2005). Disinfection, sterilization and control of hospital waste. In: Mandell, Douglas and Bennett's Principles and practice of infectious diseases (6 th ed.). Elsevier Churchill Livingstone Publication. Pages: 3331-47

Rao SK, Ranyal RK, Bhatia SS, Sharma VR (2004): Biomedical waste management: An infrastructural survey of hospitals, MJAFI, Vol. 60

Sharma M (2002): Hospital waste management and its monitoring, (1 st ed.), Jaypee Brothers Medical Publication.

Cocchiarella L, Scott Deitchman D, Young D (2000): Biohazardous waste management: What the physicians need to know, Arch Fam Med, 9: 26-9

The Gazette of India. Biomedical Waste (Management & Handling) Rule 1998. No 460 July 27th 1998 and Amended No. 375, June 2nd 2000

Jugal Kishore. Joshi TK. Biomedical Waste Management. Employment News 2000. Govt of India. Feb 19-25.

Rao SKM, Garg RK. A study of Hospital Waste Disposal System in Service Hospital. Journal of Academy of Hospital Administration July 1994; 6(2):27-31. Singh IB, Sarma RK. Hospital Waste Disposal System and Technology. Journal of Academy of Hospital Administration, July 1996; 8(2):44-8. Acharya DB, Singh Meeta. The book of Hospital Waste Management. Minerva Press, New Delhi 2000; 15, 47. Srivastava JN. Hospital Waste Management project at Command Hospital, Air Force, Bangalore. National Seminar on Hospital waste Management: a report 27 May 2000. A study of Hospital Waste Management System in Command Hospital (Southern Command), Pune; a dissertation submitted to University of Pune. Wg Cdr RK Ranyal 43

Dec 2001;page 37.

WEBSITES
www.google.com

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ANNEXURE - I

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ANNEXURE I

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SURVEY QUESTIONNAIRE FOR HOSPITAL WASTE SEGREGATION

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ANNEXURE-II

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ANNEXURE - II
QUESTIONNAIRES FILLED BY HOSPITAL STAFF

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