It has been a growing awareness of the need for safe management of biomedical
and healthcare waste all over the world. Biomedical waste and Healthcare wastes
which pose the greatest risk to human health are infectious waste (or biomedical
waste) which constitutes 15 – 25 percent of total healthcare waste.
There are Infectious wastes it may be include all waste items that are
contaminated with or suspected of being contaminated with body fluids such as
blood and blood products, used catheters and gloves, cultures and stocks of
infectious agents, wound dressings, nappies, discarded diagnostic samples,
contaminated materials (swabs, bandages, and gauze), disposal medical devices
such as sharps and syringes, contaminated laboratory animals etc. The quantity
of waste produced in a hospital depends on the level of national income and the
type of facility concerned. A university hospital in a high-income country can
produce up to 10 kg of waste per bed per day, all categories combined.
Improper management of healthcare wastes from hospitals, clinics and other
facilities pose occupational and public health risks to patients, health
workers, waste handlers, haulers and general public. It may also lead to
contamination of air, water and soil which may affect all forms of life. In
addition, if waste is not disposed of properly, members of the community may
have an opportunity to collect disposable medical equipment (particularly
syringes) and to resell these materials which may cause dangerous diseases.
When patient care activities are carried out in a healthcare setting, certain
waste is produced which has the potential to cause harm to human beings and
environment. Such waste includes soiled cotton, bandages, hypodermic needles,
syringes, tubings such as intravenous sets, and urinary catheters etc.
waste is commonly called as bio-medical waste (BMW) in India, though it is also
known by various other names such as clinical waste, medical waste and
health-care waste in different parts of world. Such waste constitutes merely 15
to 25% of total waste generated in a hospital, the remaining being general waste
such as waste paper, wrapper of drugs, cardboard and left-over food etc .
The study was conducted between December 2009 and April 2010. No sampling was
done and all 70 patient care areas of 1100-bedded hospital were included in
study. These areas were: Emergency Areas (12 in number), Waste Collection Points
of Wards (25 in number), Treatment Rooms of Wards (11 in number), Intensive Care
Units (8 in number) and Operation Theatres (14 in number).
Each area was visited on any 3 non-consecutive days in the study period. No
visit was made on Sundays and on Public Holidays. Areas were visited during
morning hours between 7 am to 10 am and evening hours of the same day between
2 pm and 4 pm. Thus a total of 6 visits were made to each area.
timings were such when maximum BMW is generated in a patient care area as this
was the time when blood samples of patients were taken and medication injections
were given. Although medication injections were also given during evening hours
and night hours, such time period was excluded from the study due to operational
difficulties in collecting data during these timings. All observations were made
by same researcher.
Ethical clearance Method
Ethical clearance from institutes ethics committee and permission from Medical
Superintendent to collect data from various patient care areas was taken before
the study. The study was approved by 'Thesis Review Committee of Post-Graduate
Institute of Medical Education and Research (PGIMER), Chandīgarh, India
The score obtained in 6 visits for a particular category of waste management was
divided by 6 to obtain the mean score and then percentage mean score was
calculated. The score of all observation units in a given area was summated and
mean percentage score of the area was calculated. This was done for all
categories of waste management and for all areas.
The statistical analysis was carried out using Statistical Package for Social
Sciences (SPSS Inc., Chicago, IL, version 15.0 for Windows). All quantitative
variables were estimated using measures of central location (mean, median) and
measures of dispersion (standard deviation, standard error and 95% confidence
interval). Means were compared using One-way ANOVA (analysis of variance) where
there were more than two groups and unpaired t-test where there were two area
groups. P-value ≤ 0.05 was used as a cut point to determine significance.
Score of each category in Rural
In emergency, the mean score for condition of waste receptacles, segregation
of waste, mutilation of recyclable waste and disinfection of waste was 87%,
92%, 85% and 86% respectively. For Central Waste Collection Points of Wards, the
score for these categories was 87%, 96%, 90% and 82% respectively; for Treatment
Room of wards the score was 85%, 96%, 80% and 63% respectively; for ots, the
score was 87%, 96%, 92% and 85% respectively and for icus, the score was 88%,
100%, 92% and 88% respectively.
Scores comparison in different areas of Hospital
The comparison of scores of different areas showed that score related to
condition of waste receptacles and segregation of waste was not
significantly different amongst various areas i.e. Emergency areas, Central
Waste Collection Points of Wards, Treatment Room of Wards, ots and ICU.
The score regarding mutilation of recyclable waste was found significantly
different between ots and Treatment Room of wards. The score in ots (n: 13,
mean: 92%, 95% CI: 86 to 98%) was significantly higher (p value: 0.033) than
that in Treatment Room of Wards (n: 11, mean: 80%, 95% CI: 74 to 86%).
Data were recorded on a researcher made checklist covering various aspects of
BMW management at source of generation of waste.Primarily, 4 broad functions are
carried out at source viz.
- placement of 4 colour-coded i.e. Black, yellow,
red and blue waste bins which are lined on inner side by similarly coloured
- segregation of waste in such waste bags i.e. General waste like waste
paper, wrapper of drugs, cardboard, left-over food etc. Is to be put into
black; soiled infected waste like dressing material, cotton swabs etc. Is to
be put into yellow; plastic waste like plastic syringes, dextrose bottles,
intravenous sets, Ryles tubes, urinary catheters etc. Is to be put into red
and sharps like hypodermic needles, surgical blades, glass etc. Is to be put
into blue bags
- mutilation of recyclable waste like disposable syringes, plastic
dextrose bottles, plastic tubings and hypodermic needles and
- disinfection of certain categories of waste notably plastics and sharps.
In the hospital,
electrically operated needle cutters were used to mutilate hypodermic needles
and nozzle (hub) of disposable syringes and scissors were used to cut the
plastic tubings and 1% bleaching powder was used to disinfect plastics and
sharps. Parameters related to each of the 4 main categories mentioned above were
identified and a checklist was prepared .Each desirable observation was assigned
1 mark and each undesirable observation was assigned 0 mark. There were some
parameters, observations regarding which could be in part desirable and in part
undesirable in a given area, such observation was assigned 0.5 mark.
example, if all of the used hypodermic needles in an area were found mutilated
(desirable), it was assigned 1 mark; if none of the needles was mutilated
(undesirable), it was assigned 0 mark and if some of the needles were
mutilated and some not, such observation was assigned 0.5 mark. The checklist
was tested in another patient care area of institute not included in the study
namely Advanced Pediatrics Centre and parameters which were not feasible to
observe were deleted from checklist. In the final score-sheet, there were 16
parameters noted under category condition of waste receptacles, 4 parameters
noted under category segregation of waste, 6 parameters noted under category mutilation of recyclable waste and 3 parameters noted under category disinfection of waste. Thus a total of 29 parameters were noted in each study
Score of individual parameters
The summated mean percentage score of each of 29 observed parameters showed that
it was 100% for placement of waste receptacles and 0% for is cover on waste
receptacle foot-operated; for segregation of waste in various waste
receptacles, it was from 84.84% to 98.93%; for destruction of used needles and
nozzle of syringes, it was 91.21% and 85.73% respectively and for putting of
disinfectant solution in blue and red bags, it was 78.97% and 78.68%
Segregation refers to the basic separation of different categories of waste
generated at source and thereby reducing the risks as well as cost of handling
and disposal. Segregation is the most crucial step in bio-medical waste
management. Effective segregation alone can ensure effective bio-medical waste
Proper labelling of bins
The bins and bags should carry the biohazard symbol indicating the nature of
waste to the patients and public.
The collection of biomedical waste involves use of different types of container
from various sources of biomedical wastes like Operation Theatre, laboratory,
wards, kitchen, corridor etc. The containers/ bins should be placed in such a
way that 100 % collection is achieved. Sharps must always be kept in
puncture-proof containers to avoid injuries and infection to the workers
Once collection occurs then biomedical waste is stored in a proper place.
Segregated wastes of different categories need to be collected in identifiable
containers. The duration of storage should not exceed for 8-10 hrs in big
hospitals (more than 250 bedded) and 24 hrs in nursing homes. Each container may
be clearly labelled to show the ward or room where it is kept. The reason for
this labelling is that it may be necessary to trace the waste back to its
source. Besides this, storage area should be marked with a caution sign.
The waste should be transported for treatment either in trolleys or in covered
wheelbarrow. Manual loading should be avoided as far as for as possible. The
bags / Container containing bmws should be tied/ lidded before transportation.
Before transporting the bag containing bmws, it should be accompanied with a
signed document by Nurse/ Doctor mentioning date, shift, quantity and
Special vehicles must be used so as to prevent access to, and direct contact
with, the waste by the transportation operators, the scavengers and the public.
The transport containers should be properly enclosed. The effects of traffic
accidents should be considered in the design, and the driver must be trained in
the procedures he must follow in case of an accidental spillage. It should also
be possible to wash the interior of the containers thoroughly.
Personnel safety devices
The use of protective gears should be made mandatory for all the personnel
Gloves: Heavy-duty rubber gloves should be used for waste handling by the waste
retrievers. This should be bright yellow in colour. After handling the waste,
the gloves should be washed twice. The gloves should be washed after every use
with carbolic soap and a disinfectant. The size should fit the operator.
Aprons, gowns, suits or other apparels: Apparel is worn to prevent contamination
of clothing and protect skin. It could be made of cloth or impermeable material
such as plastic. People working in incinerator chambers should have gowns or
suits made of non-inflammable material.
Masks: Various types of masks, goggles, and face shields are worn alone or in
combination, to provide a protective barrier. It is mandatory for personnel
working in the incinerator chamber to wear a mask covering both nose and mouth,
preferably a gas mask with filters.
Boots: Leg coverings, boots or shoe-covers provide greater protection to the
skin when splashes or large quantities of infected waste have to be handled. The
boots should be rubber-soled and anti-skid type. They should cover the leg up to
Brooms: The broom shall be a minimum of 1.2 m long, such that the worker need
not stoop to sweep. The diameter of the broom should be convenient to handle.
The brush of the broom shall be soft or hard depending on the type of flooring.
Dustpans: The dustpans should be used to collect the dust from the sweeping
operations. They may be either of plastic or enameled metal. They should be free
of ribs and should have smooth contours, to prevent dust from sticking to the
surface. They should be washed with disinfectants and dried before every use.
Mops: Mops with long handles must be used for swabbing the floor. They shall be
of either the cloth or the rubber variety. The mop has to be replaced depending
on the wear and tear. The mechanical-screw type of mop is convenient for
squeezing out the water.
Vacuum cleaners: Domestic vacuum cleaners or industrial vacuum cleaners can be
used depending on the size of the rooms.
It is very important to assess the quantity of waste generated at each point.
Dustbins should be of such capacity that they do not overflow between each cycle
of waste collection. Dustbins should be cleaned after every cycle of clearance
of waste with disinfectants. Dustbins can be lined with plastic bags, which are
chlorine-free, and colour coded as per the law.
The use of trolleys will facilitate the removal of infectious waste at the
source itself, instead of adding a new category of waste.
Wheelbarrows are used to transfer the waste from the point source to the
collection centres. There are two types of wheelbarrow – covered and open.
Wheelbarrows are made of steel and provided with two wheels and a handle. Care
should be taken not to directly dump waste into it. Only packed waste (in
plastic bags) should be carried. Care should also be taken not to allow liquid
waste from spilling into the wheelbarrow, as it will corrode. These are ideal
for transferring debris within the institution. Wheelbarrows also come in
various sizes depending on the utility.
Chutes are vertical conduits provided for easy transportation of refuse
vertically in case of institutions with more than two floors. Chutes should be
fabricated from stainless steel. It should have a self-closing lid. These chutes
should be fumigated everyday with formaldehyde vapours. The contaminated linen
(contaminated with blood and or other body fluids) from each floor should be
bundled in soiled linen or in plastic bags before ejecting into the chute.
Alternately, elevators with mechanical winches or electrical winches can be
provided to bring down waste containers from each floor. Chutes are necessary to
avoid horizontal transport of waste thereby minimizing the routing of the waste
within the premises and hence reducing the risk of secondary contamination.
Segregation of waste is the most crucial step for proper management of BMW as
waste segregated into various color-coded containers is finally taken to
different sites for disposal. Presence of a wrong kind of waste in a particular
container will obviously nullify the efforts of appropriate disposal of waste.
This implies that for proper segregation of waste, the waste bins in appropriate
number, at appropriate places and with appropriate colour-code are required to
be placed at the source of generation of waste.
The summated score of condition of waste receptacles in all the patient care
areas was more than 80%. Various studies have found poor condition of waste
receptacles for waste disposal. In a 600-bedded super-specialty corporate
hospital of a South Indian city, there were only white receptacles for all types
of BMW for aesthetic reasons and since the color of all receptacles or bins was
same, following the segregation practices was difficult. In studies in Irbid
city of Jordan and UK , waste bins or receptacles were found to be in poor
The high score of condition of waste receptacles in all patient care areas in
present study implies that the basic infrastructure for proper segregation of
waste at the source of generation of waste was well placed in hospital. However,
it was found that almost all waste receptacles were open i.e. Without any lid
over them. Waste receptacles should preferably be covered ones having
foot-operated lids and so it is desirable to gradually replace the existing
open type waste receptacles with the ones having foot-operated lids.
Further analysis of scores of individual parameters that constituted the
category mutilation of recyclable waste showed that HCWS do not bend
used needles manually; they very rarely re-cap the used needles and generally
mutilate the used hypodermic needles. However, they lay less emphasis on
mutilation of nozzle of used syringes. They pay even less attention to cutting
of used plastic bottles and tubings.
It is concluded that more emphasis needs to be laid on mutilation of
recyclable waste and disinfection of waste by hcws especially
resident doctors. The present study was done to evaluate the practices of
biomedical waste management amongst different patient care areas in tertiary
care medical institute of North India using a checklist.
It was found that more emphasis needs to be laid for mutilation of recyclable
waste and disinfection of waste especially in Treatment Room of wards which
are used exclusively by resident doctors. Hospital administrators may need to
formulate and implement a plan for providing appropriate training to hcws
especially resident doctors so as to address the deficiencies observed in the
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Written By: Vinay Kumar Jaynath Dubey (LLM, Criminology)