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Understanding Medical Waste: What you Ought to Know

Understanding Medical Waste: What you Ought to Know

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When the all are healed, what happen to what helps them healed?

When we go to the hospital for our general check-ups, we may see labels such as ‘medical waste’ or ‘not for medical waste’ on different rubbish bins around the premises. Although the meaning of the term medical waste may sound easy to know what it means intuitively, the real question might be: what makes a waste a medical one? Furthermore, we may also ask what differentiates medical waste from other types of waste like industrial waste; thus, how should each type of medical waste be treated for a safe disposal procedure? 

In Understanding Medical Waste, we will try to dissect each question’s answer to provide some coverage on what we can broadly understand with the term medical/clinical/hospital/healthcare waste. Firstly, we will start by understanding what medical waste is, including its definition, types and facilities that produce them. Next, we will also see how to manage healthcare waste through its basic principle and broad (universal) process.

What is a medical waste?

The principle of all waste management is to prevent harm to human or the environment, from creation to disposal

Amy Wolff (2018:171)

The International Committee of the Red Cross (ICRC) defines the term medical waste as a kind of waste that is “produced in health-care or diagnostic activities” (p. 12). However, this definition may be too broad when we try to apply it to different countries’ understanding of what it consists of—especially when it comes to the different procedures for its disposal. For example, according to the Regulation of the Ministry of Health of Indonesia number 18 of 2020 Article 1 (PERMENKES No. 18 Tahun 2020 Pasal 1), medical waste is produced from health care’s medical services activities[1]. Thus, under this board definition, World Health Organization (WHO)[2] lists several kinds of medical wastes, include:

  • Infectious waste: waste contaminated with blood and other bodily fluids (e.g. from discarded diagnostic samples), cultures and stocks of infectious agents from laboratory work (e.g. waste from autopsies and infected animals from laboratories), or waste from patients with infections (e.g. swabs, bandages and disposable medical devices);
  • Pathological waste: human tissues, organs or fluids, body parts and contaminated animal carcasses;
  • Sharps waste: syringes, needles, disposable scalpels and blades, etc;
  • Chemical waste: for example solvents and reagents used for laboratory preparations, disinfectants, sterilants and heavy metals contained in medical devices (e.g. mercury in broken thermometers) and batteries;
  • Pharmaceutical waste: expired, unused and contaminated drugs and vaccines;
  • Cytotoxic waste: waste containing substances with genotoxic properties (i.e. highly hazardous substances that are, mutagenic, teratogenic or carcinogenic), such as cytotoxic drugs used in cancer treatment and their metabolites;
  • Radioactive waste: such as products contaminated by radionuclides including radioactive diagnostic material or radiotherapeutic materials; and
  • Non-hazardous or general waste: waste that does not pose any particular biological, chemical, radioactive or physical hazard.

To note, Non-hazardous or General Waste is also sometimes called household waste. These waste types are mainly produced from non-clinical activities essential in healthcare service provision. These activities include general admission activity, medical administration, outpatient department, and such. 

Of the total amount of waste generated by health-care activities, about 85% is general or non-hazardous waste, […] the remaining 15% is considered hazardous material that maybe be infectious, chemical or radioactive.”

WHO, 2018

This classification of various types of medical waste is used to help categorize handling procedures to avoid contamination between different waste types with another or its environment. Particularly for the latter, the environment possible to get contaminated includes anyone who handles the waste management procedure and those who live within the disposal area, which may affect their likelihood. Therefore, only official healthcare facilities can contribute to the production procedures of medical waste, and only official waste management businesses to operate disposal procedures.

What counts as health-care facilities?

The Ministry of Health also defines health-care facilities as a tool and/or venue used to provide medical services/aids—whether promotive, preventative, curative or rehabilitative—performed by the central government, regional government and/or individual/private[3]. For instance, some health-care facilities under this definition include[4]:

  1. Tempat praktik mandari tenaga kesehatan (private healthcare provider centres);
  2. pusat kesehatan masyarakat;
  3. klinik (clinical centres);
  4. rumah sakit (hospitals);
  5. apotek (apothecaries/pharmacies);
  6. unit transfusi darah (blood transfusion points);
  7. laboratorium kesehatan (medical/healthcare-related laboratories);
  8. optikal (optics/eye centres);
  9. fasilitas pelayanan kedokteran untuk kepentingan hukum; and
  10. fasilitas pelayanan kesehatan tradisional.

Managing waste

The main goal of elaborate and specific methodologies provided for different waste types is to protect humans and the environment from any health hazard produced by contributing to the healthcare waste creation to its disposal (Wolff, 2018). A concept called “the circular economy” (The Waste and Resources Action Programme (WRAP), 2016), which pushes initiatives for handling waste will be safely re-integrated back into the production cycle. This understanding of waste disposal management would help further aspiration to acquire better and improved future methodologies.

Understanding the principle of medical waste management

To elaborate, according to Wolff (2018:171-2) the basic principles of safe healthcare waste handling strategy is proceeded as such:

  • The use of “waste hierarchy” to decide the best possible management method: When the standard reduce, reuse, recycle method fails, recovering it is deemed the next possible option (usually for waste processing via incinerator). Lastly, disposing it is supposed to be the last option of waste management (i.e., by burying it in a landfill).
  • All those who handle waste have a “duty of care”[5] to prevent it from causing harm: to ensure the safety of anyone who contributes to the process of waste management, proper and valid documentation of authorization to manage[6]
  • Categorizing various wastes is essential to ensure lower risk during the handling process to identify proper transport facility and further treatment of each waste: contamination, leakage, and other risks from waste management can cause severe effects to those who handle them or the environment if not treated as they should be treated. Categorization helps simplify the process and minimize the risk of handling them in the long run. 
  • Proper transport and packaging to ensure waste producers, handlers, the environment, and the public from harm: Official regulations should be sufficient for precise and consistent recommendations for development in the waste management industry. In Indonesia, under UU No. 32 of 2009, it is written that Government Regulation specifies such requirements in detail[7].
  • Additional containment measures are required for the use of biological agents or genetically modified organisms: To prevent diseases and toxic contamination through biological agents.
  • Treatment/recovery and disposal routes should be appropriate for the waste type: particularly for medical waste; we will elaborate more on the broad understanding of the whole process below.
  • All waste treatment, recovery, and disposal sites should be able to handle waste without posing risk of harm to human health and the environment: PP No. 101 of 2014 Article 198 clauses (a) and (b) as well as Article 199 clauses (a) and (b) pose specific requirements in which anyone who contributes at any point of the production up to the disposal of waste management must be able to perform proper treatment, recovery and disposal process to prevent any environmental damage. Further information on Article 200 from the same Government Regulation paper[8].

Understanding medical waste management in a broader sense

Truthfully, to understand how to manage waste—even when the job only consists of managing medical waste—there are more complexities under the recommended methods regulated by the government. However, as the United Nation’s Human Rights charter rights of clean, safe, and healthy environment to live as a part of fundamental human rights, so does the Indonesian government. Thus, it is essential to know that some international regulations bind countries on the base of acknowledging the importance of good air, water, soil, and other environmental pillars in that country’s likeliness to succeed economically.

Therefore, we will only discuss several steps of hospital waste management as a broad topic instead of going per each waste category. Below are the steps reported by the ICRC (2011:45-61)[9]:

1. Sorting, Receptacles and Handling

In short, this step is identifying wastes.

  • Waste sorting is the responsibility of the nursing staff at every healthcare facilities, which must be done at the closest proximity to where the waste was produced. This is to ensure minimization of contamination and infection risk.
  • Sorting wastes that undergo the same treatment procedure is not needed[10] except for sharp wastes that has to always be separated from other wastes at all times.
  • Any non-hazardous waste when already placed in the same waste container as other hazardous and toxic wastes will automatically categorized as the latter.
  • When handling bags, once it reaches 2/3 of full capacity of the bag, staff must close them immediately while wearing gloves and other appropriate protective attributes when necessary. Moreover, it is important to NOT PILE as well as NOT EMPTY the bags.
2. Collecting and Storage
  • (Most) wastes can be stored for around a week when placed in a refrigerated environment of 3o to 8oC. However, when not in a refrigerated area, the wastes can only be stored for:
    • In temperate climate: 72 hours in Winter or 48 hours in Summer;
    • In hot climate: 48 hours in cool season or 24 hours in hot season.
  • Infectious wastes must not stored in areas that are exposed or can be commonly accessed by the public.
  • There are several specific criteria in accordance to the WHO (2017), such as[11]:
    • It must be closed, and access must be restricted to authorized persons only;
    • it must be separate from any food store;
    • it must be covered and sheltered from the sun;
    • the flooring must be waterproof with good drainage;
    • it must be easy to clean;
    • it must be protected from rodents, birds and other animals;
    • there must be easy access for on-site and off-site means of transport;
    • it must be well aired and well lit;
    • it must be compartmented (so that the various types of waste can be sorted);
    • it must be near the incinerator, if incineration is the treatment method used;
    • it must be wash basins nearby;
    • the entrance must be marked with a sign (“No unauthorized accesse”, “Toxic”, or “Risk of infection”)
3. Transport
Vehicles and means of conveyance
  • According to the ICRC, here are some requirements must be met for the means of conveyance:
    • they must be easy to load and unload;
    • they must not have any sharp corners or edges that might tear the bags or damage the containers;
    • they must be easy to clean; (with a 5% active chlorine solution);
    • they must be clearly marked.
  • Moreover, off-site means requirements for transit of waste include:
    • they must be closed in order to avoid any spilling on the road;
    • they must be equipped with a safe loading system (to prevent any spilling inside or outside the vehicle);
    • they must be marked according to the legislation in force if the load exceeds 333 kg
  • The vehicles and means of conveyance must be cleaned daily.
  • Here are some types of means of conveyance recognized by the Basel Convention:
    • On-site transport: some use different means of conveyance including those used indoor—examples include: wheelbarrows and carts. Because it is used inside of the facility, it must only be transported during slacker periods where it is cleaned everyday to avoid hazardous effects.
    • Off-side transport: also called external transport. This means that healthcare facilities who produce wastes require external (off-site) storage and treatment facilities to manage their wastes.
    • Cross-border transport
4. Treatment and Disposal

The most complex part of waste management lies significantly on this step.

To choose which treatment would be ideal to which waste depends on the quantity and characteristic of the waste type, availability of waste treatment site in close proximity to the healthcare facility, the cultural acceptance of treatment methods, whether reliable transit methods are available, whether space for waste storage is available at the healthcare facility, material and human resources, a regular electricity supply for the process’ availability, local and national legislation, etc. This is to show that there is no one-fit-for-all method in managing waste.

Type of waste/techniques1. Sharps2a. Waste entailing risk of contamination2b. Anatomical waste2c. Infectious waste3a. Medicinal waste3d. Chemical waste
Rotary kilin 900-1200°Cyesyesyesyesyesyes
Pyrolytic or dual-chamber incinerator >800°Cyesyesyesyesnono
Single-chamber incinerator 300°-400°Cyesyesyesyesnono
Chemical disinfectionyesyesnoyesnono
Autoclaveyesyesnoyesnono
Encapsulationyesnononoyesyes
On-site burial pityesyesyesyesyesno
Needle pityesnononoyesno
Off-site sanitary landfillsyesyesnoyesnono
Table 1: Suitability of treatment techniques by type of waste [ICRC, 2011]

In general, hazardous and toxic medical wastes go through more complex methods of waste management like what was shown above. On the other hand, non-hazardous ones like general wastes go through similar process as other kinds of general waste that are produced outside hospital/healthcare facilities. Therefore, to understand more about medical waste disposal processes, we would recommend reading Manajemen Rumah Sakit by Dr. Suparto Adikoesoemo[12].

Conclusion

In conclusion, medical waste is a type of waste produced by healthcare facilities; it is a sub-type of hospital waste with the other is general/non-hazardous hospital waste. Under the term medical waste, there are several more specific categories such as: infectious waste, pathological waste, sharp waste, chemical waste, pharmaceutical waste, cytotoxic waste, and radioactive waste. This categorical system of waste helps further simplifying the activity to choose which management operation deemed proper for each waste’s characteristics to prevent harm to those who manage them, the environment and the public.


Footnotes

[1] Regulation of the Ministry of Health of the Republic of Indonesia No. 18 of 2020 article 1 clause (1) states: “Limbah Medis adalah hasil buangan dari aktifitas medis pelayanan kesehatan.” See Permenkes Nomor 18 Tahun 2020 https://peraturan.bpk.go.id/Home/Details/152561/permenkes-no-18-tahun-2020

[2] See the World Health Organization 2015 https://www.who.int/news-room/fact-sheets/detail/health-care-waste

[3] Regulation of the Ministry of Health of the Republic of Indonesia No. 18 of 2020 article 1 clause (3) states: “Fasilitas Pelayanan Kesehatan adalah suatu alat dan/atau tempat yang digunakan untuk menyelenggarakan upaya pelayanan kesehatan, baik promotif, preventif, kuratif maupun rehabilitatif yang dilakukan oleh pemerintah pusat, pemerintah daerah, dan/atau masyarakat” See Pemerkes No. 18 Tahun 2020 Pasal 1 ayat (3) https://peraturan.bpk.go.id/Home/Details/152561/permenkes-no-18-tahun-2020

[4] See Peraturan Pemerintah No. 47 Tahun 2016 tentang Fasilitas Pelayanan Kesehatan https://rsud.purbalinggakab.go.id/wp-content/uploads/2018/05/PP_NO_47_2016.pdf

[5] “Duty of Care” is the duty of a fiduciary to be responsible for making company decisions that are ethical, legal and by being open-minded with governance and law development to ensure the effectiveness of that decision for the company. See Kenton, W. (2021) Duty of Care. New York: Investopedia. Available at: <https://www.investopedia.com/terms/d/duty-care.asp#toc-what-is-duty-of-care>

[6] Peraturan Menteri LHK No. 6 Tahun 2021 tentang  Tata Cara dan Persyaratan Pengelolaan Limbah B3 Pasal 44 states: “Setiap orang yang melakukan pemanfaatan limbah B3 yang telah ditetapkan sebagai produk samping, dikecualikan dari kewajiban memiliki persetujuan teknis PLB3.”

[7] For further reading in specific recommendation in the transport for waste management, see: Peraturan Pemerintah No. 101 Tahun 2014 tentang Pengelolaan Limbah B3. Available at: https://drive.google.com/open?id=0Bwsvlo7c-gOuTkFTd2F5OUVVSDQ

[8] Ibid.

[9] See International Committee of the Red Cross (ICRC), Medical Waste Management. Available at https://www.icrc.org/en/doc/assets/files/publications/icrc-002-4032.pdf

[10] See World Health Organization (WHO), INSTRUCTOR GUIDE MODULE 9: CLASSIFICATION OF HEALTHCARE WASTE and MODULE 10: SEGREGATION OF HEALTHCARE WASTE. Available at https://cdn.who.int/media/docs/default-source/wash-documents/wash-in-hcf/training-modules-in-health-care-waste-management/module-9_and_10-instructor.pdf?sfvrsn=ec11ccd1_7

[11] See World Health Organization (WHO), Safe Management of Waste from Health-care Activities available at https://apps.who.int/iris/bitstream/handle/10665/259491/WHO-FWC-WSH-17.05-eng.pdf

[12] Dr Adikoesoemo elaborates on each waste type’s management methodologies as well as other managerial work related to the hospital business. Chapter XIII on Pengelolaan Rumah Sakit focuses on hospital management including its definitions and mechanical terms used to understand more about the whole process. See PerPusNas for offline access of the work at https://opac.perpusnas.go.id/DetailOpac.aspx?id=123677

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Refrences:

Adikoesoemo, S., 2017. Manajemen Rumah Sakit. 6th ed. Jakarta: Pustaka Sinar Harapan, pp.125-30.

Direktorat Jenderal Pengelolaan Sampah, Limbah dan B3 Kementrian Lingkungan Hidup, 2009. UNDANG-UNDANG REPUBLIK INDONESIA NOMOR 32 TAHUN 2009 TENTANG PERLINDUNGAN DAN PENGELOLAAN LINGKUNGAN HIDUP. Jakarta: www.hukumonline.com. Available at: <https://pslb3.menlhk.go.id/portal/uploads/laporan/1548333565_UU_NO_32_2009.pdf >[Accessed: 11 August 2022].

Who.int. 2015. Health-care waste. [online] Available at: <https://www.who.int/news-room/fact-sheets/detail/health-care-waste> [Accessed 11 August 2022].

Kementerian Lingkungan Hidup dan Kehutanan, 2021. Peraturan Menteri LIngkungan HIdup dan Kehutanan No. 6 Tahun 2021 tentang Tata Cara dan Persyaratan Pengelolaan Limbah Bahan Berbahaya dan Beracun. Jakarta: Kementerian Lingkungan Hidup dan Kehutanan. Available at: <https://drive.google.com/drive/folders/0Bwsvlo7c-gOuMFY4dW5ZYUdVX2c?resourcekey=0-vVYJf3WM6fZaa9PKu84UPw&usp=sharing> [Accessed: 14 August 2022].

Kementrian Kesehatan Republik Indonesia, 2020. PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA NOMOR 18 TAHUN 2020 TENTANG PENGELOLAAN LIMBAH MEDIS FASILITAS PELAYANAN KESEHATAN BERBASIS WILAYAH. Jakarta: Kementerian Kesehatan. Available at: <https://peraturan.bpk.go.id/Home/Details/152561/permenkes-no-18-tahun-2020#:~:text=Nomor%2018%20Tahun-,2020,-.pdf > [Accessed: 12 August 2022].

Kenton, W., 2021. Duty of Care. [online] Investopedia. Available at: <https://www.investopedia.com/legal-4768893#editorial-policy> [Accessed 16 August 2022].

2011. Medical Waste Management. [ebook] Geneva, Switzerland: International Committee of the Red Cross. Available at: <https://www.icrc.org/en/doc/assets/files/publications/icrc-002-4032.pdf> [Accessed 12 August 2022].

Pemerintah Republik Indonesia, 2016. PERATURAN PEMERINTAH REPUBLIK INDONESIA NOMOR 47 TAHUN 2016 TENTANG FASILITAS PELAYANAN KESEHATAN. Jakarta: www.hukumonline.com. Available at: <https://rsud.purbalinggakab.go.id/wp-content/uploads/2018/05/PP_NO_47_2016.pdf> [Accessed: 12 August 2022].

Pizzi, R., 2013. Module 14: Off-site Transport and Storage of Healthcare Waste. Available at: <https://cdn.who.int/media/docs/default-source/wash-documents/wash-in-hcf/training-modules-in-health-care-waste-management/module-14—off-site-transport-and-storage-of-health-care-waste.pdf?sfvrsn=db4f438a_2> [Accessed: 15 August 2022].

Wolff, A., 2017. Chapter 10: Management of Waste from the Health-care Sector. In: A. Boxall and R. Kookana, ed., Health Care and Environmental Contamination. [online] Marrickville: Elsevier, pp.167-97. Available at: <https://doi-org.ezproxy.is.ed.ac.uk/10.1016/B978-0-444-63857-1.00010-3> [Accessed 11 August 2022].

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