Impact of intervention on healthcare waste management practices in a tertiary care governmental hospital of Nepal

Healthcare waste is produced from various therapeutic procedures in hospitals, such as chemotherapy, dialysis, surgery, delivery, resection of gangrenous organs, autopsy, biopsy, injections, etc. These result in the production of non-hazardous waste (75–95%) and hazardous waste (10–25%), such as sharps, infectious, chemical, pharmaceutical, radioactive waste, pressurized containers (e.g., inhaler cans) [1‐12]. Non-hazardous wastes, from healthcare settings, are comparable to household waste, in regards to their risk to both human health and the environment. Similar disposal processes can be applied to both household waste and non-hazardous healthcare waste [3, 8, 13, 14]. If non-hazardous waste is mixed with hazardous waste, disposal should be employed as per regulations for hazardous waste [3]. Improved segregation of waste would thus minimize the burden of total hazardous waste [14].

Improper healthcare waste management causes environmental pollution, and infectious waste may lead to the transmission of more than 30 significant pathogens, including typhoid, hepatitis B, hepatitis C, HIV, Escherichia coli, Staphylococcus aureus, and Pseudomonas aeruginosa [1, 2, 4, 5, 11‐21]. When healthcare waste is placed in landfills or buried, contamination of ground water may occur, which may result in the spread of E. coli. Pathogens, present in waste, can also enter and remain in the air for a long period, in the form of spores or pathogens. Hence, healthcare establishments should enhance the practice of waste segregation, sorting and resource recycling and recovery [22]. Furthermore, proper waste treatment methods not only decrease the weight, and volume of the waste but also the infectivity and organic compounds in the waste [9].

Poor healthcare waste management (HCWM) practices may result in patients, staff, waste handlers and the community being exposed to the unnecessary health risks of the waste [19]. In developing countries, HCWM has not gained much momentum, and healthcare waste is frequently disposed along with domestic waste [5, 13, 23]. Improper HCWM practice is alarming in developing countries because resources are inadequate to manage wastes, and waste management is often delegated to poorly educated and untrained laborers, who perform without proper guidance or adequate protection [11, 16].

Many studies have focused on healthcare waste management practices in Jordan, Iran, Egypt, Saudi Arabia, Kuwait, Tanzania, Mauritius, Netherlands, Finland, Korea, Turkey, Brazil, Mongolia, Greece, USA, UK, China, Bangladesh and India. In Bangladesh, Nigeria, Iran, Jordan, Libya, Botswana and India, there is a lack of legal provisions, rules and regulations regarding healthcare waste management, suitable waste treatment facilities, protective measures and efficient training [1, 5, 7, 12, 18, 20, 24]. Our study is the first study in Nepal to evaluate the impact of pre- and post-test HCWM interventions and will help policy makers devise effective waste management regulations to protect both the people and environment of Nepal.

The pre-intervention evaluation showed that the hospital had not allocated budget for proper waste management practices. The waste was transported away from the patients’ areas, and other clean areas. The hospital had incinerator in a location accessible to the waste handlers, but not to the public. The hospital did not have HCWM Committee, policy, standard operating procedure (SOP) and proper color coding system for waste segregation, collection, transportation and storage, as well as the specific well-trained waste handlers.

The post-intervention evaluation showed that waste water was still not treated by the hospital. The HCWM policy and SOP were developed, after interventions, and they were consistent with the national and international laws and regulations. The committee developed a plan for recycling or waste minimization. Health professionals, such as doctors, nurses and waste handlers, were provided training on HCWM practices. The training programs included segregation, collection and handling, transportation, treatment and disposal of the waste, as well as occupational health and safety issues. The committee developed a plan for treatment and disposal of chemical and pharmaceutical waste.

The pre-intervention evaluation showed that outcome of the study was poor (score 26%). The post-intervention evaluation revealed that outcome of the intervention was excellent (score 86%).

The pre-intervention evaluation showed the poor status of waste management practices. This might be due to the lack of environment-friendly technology and the principle of ‘reduce, reuse and recycle policy’. The committee adopted the practice of collecting and storing all healthcare wastes in a temporary waste storage area, within the premises, until they were transported to the waste treatment area [1, 5]. The waste treatment area was isolated from the patients’ treatment area, and was not accessible to the public. The treatment area consisted of waste segregation area, separate incinerator area, cytotoxic waste collection area, autoclave area, and mercury collection house. The committee organized training programs for nurses, and committee members regarding the impact of mercury and importance of its safe disposal. The used needles were cut by the needle cutter, attached with the procedure trolley. The cut portions of needle, and other sharp wastes, were kept in a bucket, half filled with 0.5% sodium hypochlorite, for 24 hours. Then they were collected in sharp pit, near waste treatment area. The committee also developed instructive posters regarding proper waste management technique to make the public aware of the effective segregation of waste. These were inexpensive, but impressive methods of gaining public support for waste management activities, and could be achieved within short period, with the limited resources available [15].

The committee adopted the system of segregation of waste at source, into suitable colour-coded high density polyethylene bags and bins, for the easy identification and segregation of infectious and non-infectious wastes. Infectious waste was packaged to protect the waste handlers and the public from the potential injury and the spread of disease [5]. Waste minimization and disposal system, including the principle of ‘reduce, reuse and recycle’, was developed, by the committee, to maintain clean environment in the hospital premises. The committee selected one focal nurse from each ward, every month, on rotation basis. The nurse was given HCWM related specific job descriptions of counseling each caregiver of patient regarding proper waste management technique. The nurse was suggested to document all counseling sessions, and provide patient information leaflet, developed by the committee. The nurse also presented the progress report and any problems, in each meeting of the committee. The committee revised the waste management policy and SOP once, and organized refresher training for all health professionals till date, and this would be continued every year.

Full set of personal protective equipment (PPE), with gloves, mask, shoes and apron, was provided to the waste handlers because lack of sufficient PPE, and knowledge regarding correct usage and benefits of using PPE, might expose them to infections and injury [2]. The waste handlers, nurses and all healthcare workers were immunized against hepatitis B thrice (initially, on first month, and after six months), and then 2–3 months later, screening for seroconversion. The booster dose would be given after 5 years. Tetanus vaccination was given twice (initially, and on first month), keeping in consideration of allergic responses to it. Hospital documented all the immunization records and distributed the immunization cards.

The committee adopted the policy of incinerating hazardous waste for the interim period, until they would be subjected to the alternative waste management techniques, such as microwaving with shredding, full range of autoclaving or chemical sterilization. If the incinerator was operated properly (high and continuous temperature, filtration of particulate emission), it would not incur excessive risks [5]. However, after incineration, combustible components of the wastes would be converted into the gaseous byproducts (carbon dioxide, carbon monooxide, dioxin, furan), and the non-combustible components would remain as solid byproduct, namely ash [16]. Moreover, the incinerator ash would be hazardous due to the presence of needles and sharps, non-destroyed pathogens, and the hazardous substances. There would also be the risk of direct inhalation by the hospital staff and patients up to a distance of 20–50 m of incinerator. Canada, USA, and Greece ceased the use of the hospital waste incinerators due to the risk of air pollution, and adopted the alternative waste disposal techniques, such as autoclaving and microwave sterilization [11].

In the long-term, the committee adopted the policy of partial cost recovery from the proper waste management. At the end of eight months of waste management practices, the committee gained partial success towards this. The committee expanded waste management practices in the whole hospital within 13.5 months of the commencement of HCWM program. The committee would start measuring the infectious and the total waste produced in kilogram per procedure per day, for their better quantification.

After the implementation of HCWM program, changes were documented via same IRAT form, which was used during pre-intervention period. The encouraging result of the post-intervention evaluation might be due to the regular monitoring and evaluation, because good HCWM depended on the dedicated waste management team, good administration, careful planning, sound organization, adequate budget allocation and the enthusiastic participation by the trained staff [17, 25]. All these shifted the poor outcome of the pre-intervention period (26% score) to the excellent outcome during post-intervention period (86% score) (Table 2).

The results of the research emphasized that wastes should have been properly segregated at source, according to different categories, to minimize the burden of the infectious and the hazardous waste. The workers, who collected, transported and treated waste, should have been provided with the proper personal protection equipment (gloves, shoes or boots, and aprons). The health workers and the waste handlers should have been given hepatitis and tetanus vaccinations.

During pre-intervention period, hospital did not have HCWM Committee, policy, standard operating procedure, and proper color coding system, for waste segregation, collection, transportation and storage, as well as the specific well-trained waste handlers. The HCWM policy and SOP were developed, after interventions, and they were consistent with the national and international laws and regulations. Health professionals, such as doctors, nurses and waste handlers, were trained on HCWM practices. The pretest and posttest evaluation of healthcare waste management practices, at the hospital, showed that poor outcome of the pre-intervention study (26% score) was converted to the excellent outcome during post-intervention period (86% score).