National College of Business Administration & Economics Lahore
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National College of Business Administration & Economics Lahore MANAGING THE HEALTH CARE SOLID WASTE IN PUNJAB, PAKISTAN BY JUNAID HABIB-ULLAH DOCTOR OF PHILOSOPHY IN ENVIRONMENTAL MANAGEMENT JANUARY, 2010 NATIONAL COLLEGE OF BUSINESS ADMINISTRATION & ECONOMICS MANAGING THE HEALTHCARE SOLID WASTE IN PUNJAB, PAKISTAN BY JUNAID HABIB-ULLAH A dissertation submitted to School of Business Administration In Partial Fulfillment of the Requirements for the Degree of DOCTOR OF PHILOSOPHY IN ENVIRONMENTAL MANAGEMENT January, 2010 ii IN THE NAME OF ALLAH THE MOST BENEFICENT AND THE MERCIFUL iii NATIONAL COLLEGE OF BUSINESS ADMINISTRATION & ECONOMICS LAHORE MANAGING THE HEALTH CARE SOLID WASTE IN PUNJAB, PAKISTAN BY JUNAID HABIB-ULLAH A dissertation submitted to School of Business Administration, in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY IN ENVIRONMENTAL MANAGEMENT Dissertation Committee: _____________________ Chairman _____________________ Member _____________________ Member ___________________ Rector National College of Business Administration & Economics iv DECLARATION This is to certify that this research work has not been submitted for obtaining similar degree from any other university / college. JUNAID HABIB-ULLAH October, 2011 v DEDICATED TO My Parents Mr. and Mrs. Ch. Habib-Ullah Khan (Late) vi ACKNOWLEDGEMENT In the name of Allah, the most merciful and beneficial, who enabled me to complete this research successfully. I take the opportunity to express my gratitude to all, who helped me throughout this research period. My sincere thanks to the staff of Hospital Waste Management Shalamar Teaching Hospital, Lahore Pakistan especially Javed Iqbal Malik, Imran Yousuf, Zahid Elahi, Naseer-ud-Din and Sajjad Hussain for their constant help during the survey and dissertation writing. I also thank the Medical Superintendents, Deputy Medical Superintendents, paramedical staff and sanitation staff of public and private hospitals including Pathology laboratories, Dental surgery and Pharmaceutical industries of Punjab for giving the accurate data for my study. I specially pay my regards to Dr. Aman Ullah Khan, supervisor of my research work, Dr. Khurshed Ahmad, co-supervisor and Dr Munir Ahmad Rector of National College of Business Administration & Economics, Lahore for their guidance during my studies. I am thankful to my wife, daughter Fizza, sons Jawad and Fawad for their support and encouragement during the preparation of my thesis. vii RESEARCH COMPLETION CERTIFICATE Certified that the research work contained in this thesis entitled “Managing Health Care Solid Waste in Punjab, Pakistan” has been carried out and completed by Junaid Habib-Ullah under my supervision during his Ph.D. Environmental Management Programme. (Prof. Dr. M. Amanullah Khan) (Supervisor) Prof. of Community Medicine FMHS B.Sc., M.B.B.S., DPH, M.P.H & T.M (USA), FCPS, Ph.D. (USA) (Prof. Dr. Khurshed Ahmad) (Co-Supervisor) Environmental Sciences/Management National College of Business Administration & Economics viii SUMMARY Waste generation depends on various factors such as category and type of healthcare facility, level of care provided and extent of re-usable items used in a healthcare facility. This study surveyed the multiple factors related to the handling of the healthcare waste from hospitals, laboratories, dental clinics and the pharmaceutical industry. It was observed that waste generation from healthcare facilities ranged from 0.210 - 0.322 kg/bed, 12.6 - 90.32 kg/day and 326.6 -2348.32 kg/month, with an average in each facility of 0.292, 59.097 and 1544.323, kg/bed, kg/day and kg/month respectively. Regarding the segregation, collection, transportation and disposal of health care waste, 67% of the health care workers had never received any training, 53% of the health care facilities (HCFs) had no central storage area for waste collection, 33% health care facilities (HCFs) did not have post- exposure procedures for injured staff, whereas, 60% did not have any such procedure. 27% of health care facilities did not have budget for disposal of health care waste, whereas 73% generated their funds through patient care cost recovery. Lack of guidelines, waste management plans, awareness of health care waste management, containers for the segregation of waste, record keeping and proper disposal/treatment were the main deficient factors responsible for the poor handling of health care waste. A waste management plan outline and infectious waste management audit form have been developed for initiating a healthcare waste management programme in any health care facility. Emission of the gases produced from incinerator before feeding waste, during & after is now also analyzed. A quality management system for healthcare waste has been proposed, which is cost effective, sustainable and environmentally friendly in an integrated form. The proposed system has been suggested on evidence based exercise during the last nine years at Shalamar Hospital Lahore, Pakistan. ix TABLE OF CONTENTS Page DECLARATION v ACKNOWLEDGEMENT vii RESEARCH COMPLETION CERTIFICATE viii SUMMARY ix Chapter-1: INTRODUCTION 1 1.1 General 1 1.2 Disease Transmission 2 1.3 Hazards 3 1.4 Current Practices of Hospital Waste 4 1.5 Objectives 4 1.6 Operational Definitions 5 1.7 Hypothesis 6 Chapter-2: LITERATURE REVIEW 7 2.1 General Introduction 7 2.2 Identifying Infectious Waste 8 2.3 Category of Infectious Waste 9 2.4 Quantity Of Waste 11 2.5 Waste Handling 13 2.6 Segregation of Waste and Colour Coding Containers 13 2.7 Storage of Waste 14 2.8 Transportation of Waste 15 2.9 Disposal of Waste 15 2.9.1 Incineration of Infectious Waste 15 2.9.2 Destruction Efficiency 16 2.10 Issues and Concerns (Incineration) 17 2.11 Steam Sterilization of Infectious Waste 18 2.12 Emerging Technologies for the Treatment of Medical Waste 18 Chapter-3: MATERIALS AND METHODS 20 3.1 Study Design 20 3.2 Study Area 20 3.3 Selection of Health Care Facilities 20 3.4 Method of Study 20 3.5 Sampling 21 3.6 Data Collection Team 21 3.7 Data Compilation and Presentation 22 x Chapter-4: RESULTS AND DISCUSSIONS 23 4.1 Health Care Facilities (HCFS) Examined 23 4.2 Waste Generation 24 4.3 Awareness and Staff Training 25 4.4 HCW Segregation and Handling 25 4.5 HCW Storage Area 27 4.6 On-Site and Off-Site Transportation 28 4.7 HCW Treatment 28 4.8 Technical Specification & Treatment Process of Equipment 29 (Incinerator) 4.9 HCW Final Disposal 29 4.10 Guidelines at Provincial Level, Plan at Local/Provincial/District 30 Level and Inspection System for Management of HCW 4.11 Policy and Budget 31 4.11.1 Recovery of HCW Management Cost 31 4.12 Discussions 32 4.13 Conclusions 33 Chapter-5: PROPOSED MODEL FOR HEALTH CARE WASTE 35 MANAGEMENT 5.1 Hospital Waste Management Plan-Outline 35 5.2 Steps for the Management Of Hospital Waste 36 5.2.1 Standard Operating Procedures for Segregation of Waste 36 5.2.2 Standard Operating Procedure for Handling and Storage 38 of Waste 5.2.3 Standard Operating Procedure for Transportation of the 39 Waste 5.2.4 Standard Operating Procedure for Disposal of the Waste 40 5.3 Job Descriptions of Waste Management Team 42 5.3.1 Duties and Responsibilities of Medical Superintendent 42 5.3.2 Duties and Responsibilities of Heads of Departments 42 5.3.3 Duties and Responsibilities of Infection Control Officer 43 5.3.4 Duties and Responsibilities of Chief Pharmacist 43 5.3.5 Duties and Responsibilities of Radiology Officer 43 5.3.6 Duties and Responsibilities of Senior Matron and 43 Head of Administration 5.3.7 Duties and Responsibilities of Hospital Engineer 44 5.3.8 Duties and Responsibilities of Waste Management Officer 43 5.4 Proposed Technical Specification of Incinerator 45 5.5 Infectious Waste Management Audit 46 5.6 Cost For Incineration Charges 48 xi 5.7 Proposal for New Incinerator Plant to cover Hundred Health Care 49 Facilities 5.8 Capacity Building 50 5.9 Proposal 2 53 5.10 Proposal 3 Private Public Partnership 53 5.11 Proposal 4 53 5.12 Discussion (about HWM Model) 54 5.13 Indicators For The Proposed Model 56 REFERENCES 57 Annexure-1: Field Questionnaire on Healthcare Waste Management 63 Annexure-2: Healthcare Facilities 69 Annexure-3: Emission Analysis Report 75 xii ABBREVIATIONS AIDS Acquired Immune Deficiency Syndrome CDC Centre for Disease Control CAA Clean Air Act CFR Code of Federal Regulation CO Carbon Monoxide CO2 Carbon Dioxide Cat Category EG Emission Guideline EPA Environment Protection Agency HCW Health Care Waste HCWM Health Care Waste Management HCWMP Health Care Waste Management Programme HCF Health Care Facilities HBV Hepatitis B Virus HCV Hepatitis C Virus HIV Human Immunodeficiency Virus HMIWI Hospital/Medical/Infectious Waste Incinerators HWM Hospital Waste Management JCAHO Joint Commission for Accreditation of Hospital Organization LRBT Leyton Rehmatullah Benevolent Trust MWTA Medical Waste Tracking Act OPD Out Patient Department OT Operation Theaters PCDDs Polychlorinated Dibenzo-p-dioxins PCDFs Polychlorinated Dibenzo-p-furans PM Particulate Matter NOX Nitrogen Oxides POP Persistent Organic Pollutants QMS Quality Management System RCRA Resource Conversation and Recovery Act SCC Sylhet Corporation SOP Standard Operating Procedure SO2 Sulfur Dioxide STCD Segregation Collection Transportation Disposal TB Tuberculosis xiii LIST OF TABLES Table Title Page No. 4.1 Categories, Types and Levels of HCFs 23 4.2 Existence of Infectious Control Team, Availability of 24 Guideline and Plan 4.3 Waste Generation Rates 24 4.4 Associated Risks of HCW 25 4.5 Separate Hazardous and General HCW Storage Area in HCFs 26 4.6 HCW Segregation 26 4.7 Central Storage Area Specification 27 4.8 Means of On-site and Off-site Transportation 28 4.9 On-site Treatment Facility 29 4.10 Disposal of HCW at Municipal Dumping Sites 30 4.11 Record Keeping Arrangement 30 4.12 Inspection System of HCWs 31 4.13 Budget Allocation of HCW 31 xiv LIST OF FIGURES Figure Title Page No.