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1 Health Care Waste production: measures and estimates in “V. Cervello” Hospital, Palermo, Italy Salvatore Nicosia*, Placido A. Lanza, Antonina Lima and.

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Presentation on theme: "1 Health Care Waste production: measures and estimates in “V. Cervello” Hospital, Palermo, Italy Salvatore Nicosia*, Placido A. Lanza, Antonina Lima and."— Presentation transcript:

1 1 Health Care Waste production: measures and estimates in “V. Cervello” Hospital, Palermo, Italy Salvatore Nicosia*, Placido A. Lanza, Antonina Lima and Marco Mosca Salvatore Nicosia, Assoc. Prof. in Environmental Engineering DIIAA, Dipartimento di Ingegneria Idraulica ed Applicazioni Ambientali, Università di Palermo Viale delle Scienze, 90128 Palermo (nicosia@idra.unipa.it) Dubrovnik (HR), Sept. 30 – Oct. 3, 2009

2 2 Are sustainability criteria relevant for Health Care activities?  Inasmuch they deal with health hospitals, physician’s clinics, etc. are commonly thought of as overriding any other concern.  However, all of these institutions and structures actually produce wastes, whose management may be susceptible of improvements of economical and ecological nature.

3 3 Classes of sanitary wastes after the European Regulations The main and most relevant waste classes in EWC – European Waste Catalogue: 18 00 00 Wastes from human or animal health care and/or related research (except kitchen and restaurant wastes not arising from immediate health care) but also 15 00 00 Waste packaging; absorbents, wiping cloths, filter materials and protective clothing not otherwise specified 09 00 00Wastes from the photographic industry.

4 4 Source and nature of the risks from medical waste (EU) Risk Waste class or type Infec_ tious Chemi_ cal None 09 01 01* to 05* Developer solutions etc 15 01 01 to 08*(*) 18 01 01 Unused sharps 18 01 03 Pathogenic culture plates. Tissues, organs and non-recognizable parts. Sharps. Gloves. Catheters and probes. Bandages. Dialysis filters. Bags with drainages, faeces… 18 01 04 Non-contaminated dressings, …, linen, disposable clothing, diapers 18 01 06* Chemicals … dangerous substances 18 01 07 Chemicals, other 18 01 08* Cytotoxic and cytostatic medicines 18 01 09 Medicines other than 18 01 08! (*) provided that cannulae and needles have been removed and that bags have been cleared of organic liquids. Containers of anti-blastic or radioactive medicines excluded. Under the general condition that they do not originate from isolation wards.

5 5 Generation Rates, 1 – What they depend on primarily, on the nature of the medical cares that are given; strongly, also, on the manner in which staff handle and make up the waste. Necessary questions:   Do the wastes that are dropped and sealed in the special bins really belong all to the type 18 01 03* (= infectious)?   Is it sure that it is not being added any non-infectious waste such as Waste … not subject to special requirements … or Medicines other than … 18 01 08?   Maybe also Plastic and Glass packaging are being un- necessarily associated to supposed infectious waste?   How much do the wastes really weigh?

6 6 Generation Rates, 2 – Unit Production Indexes  PU 1 is the Unit Production Index referred to occupied sleeping accommodation: where M R is the quantity of waste produced in one year (kg/year)  PU 1 represents the quantity of waste produced daily per sleeping accommodation on duty (year average).  PU 2 is the Unit Production Index referred to number of hospitalisations: where R is the number of hospitalisations in one year (or any given time span)  PU 2 represents the average quantity of waste produced per patient admitted.

7 7 Generation Rates, 3 – an overview (after WHO, 1999 – rearranged)

8 8 Generation Rates, 4 – National data from Italy (APAT)

9 9 Methods for surveying and monitoring Generally speaking, distinct records should be kept of: a) municipal-like HCW; b) Non-Hazardous HCW; c) Hazardous – Non Infectious HCW and d) Hazardous – Infectious HCW. From the recorded data, Unit Production Indexes can be calculated. (  slide 6)  Caution: distribute over the whole park of beds on duty - or over the total medical services given - the amount of waste generated by the labs, divided and associated to similar types produced in the Departments.

10 10 Case study: a survey carried out in Palermo In order to obtain detailed information on generation rates a monitoring work was recently carried out in two major Hospitals in Palermo, let them be A and B. The monitoring work consisted in weighing the labelled “hazardous waste” containers coming from medical care filled up in Departments purposely chosen for 15 days. The Departments selected were 4 per hospital, and the same in both hospitals: General and Emergency Surgery (Hospital A and B) 1 st Resuscitation (as above) Emergency Room Oncological DH (= Haematology for Hospital B).

11 11 The survey in selected hospitals, 1 – the method Procedure followed in this work for HCW production, year 2007 HCW estimates and extrapolation to 1 year Extrapolation of monitored data to 1 year Comparison of monitored HCW data vs. estimates Monitoring for 2 weeks in 4 Departments Data of Hospital’s purchases in Jan.- Apr. ‘07 Selected list of purchased products Physical properties assumed Mass estimates (amount and composition)

12 12 The survey, 2- some results Some results were rather surprising Table 1 - HCW production: quantities and classes. 91,71 8,25 0,04 133.921 Hospital B (year 2006) 93,9 4,0 2,1 424.766 Hospital A (year 2005) Infectious Non-Infectious HCW-H [%] HCW-NH [%] HCW Production [kg] Hospitals Wastes labelled as Non- Hazardous are the least of all the fractions! Nearly all Wastes labelled as Hazardous are supposed to be Infectious!

13 13 The survey, 3- other results Other results for infectious waste are aligned with national statistics Source Character Liberti et al., 1994 Nicosia et al., 2006-07 APAT (I), 2008 Apparent Density 0.110.10 – 0.13( ) Production Index per bed on duty 0,440.8 – 1.4; exception_ ally 3.1 1.4 per bed; 1.7 per conventional day of stay (*) (*) relevant for Day Hospital / Day Surgery Departments

14 14 Why are the apparent densities of Infectious Waste so low? Reasonable values would be (as experimentally determined by APAT, Italy): Type of wasteEWC codeDensity, kg/m 3 Hazardous, infectious (general) 18 01 02 - 03300 Hazardous, infectious (anatomical parts) 18 01 02 - 03900 Municipal-like15 01 06; 18 01 04600 (!) Non-hazardous18 01 01 – 04 -05300 Liquidall1 000

15 15 We must suppose that insufficient care is often put by personnel in filling up the bags and cans. 60 dm 3 capacity 1/3 full; real waste density 300;  apparent density 100!

16 16 Are we able to verify the results? A material balance helps. Containers cannot be inspected So we must make resort to indirect measures and calculations. Hospital’s Pharmacy or Procurement Office Medicines, remedies etc. Liquids exchange Departments, Laboratories Sorted Wastes to treatment and disposal

17 17 How can we predict the amount and composition of waste? Two examples A catheter bag weighs 100 g at the purchase When completely full, it weighs  500 + 100 g Expected amount of plastics (kg) = N pieces x 0.1 Expected amount of liquids (kg) = N pieces x 0.5 An infusion bag weighs 560 g at the purchase When completely empty, it weighs 60 g Expected amount of plastics (kg) = N pieces x 0.06 Expected amount of liquids (kg) = 0 Of course the personnel need clear directions to dispose of used medical devices in the right box distinguishing among them the infectious / non infectious ones!

18 18 A common spreadsheet, once entered the data, makes the calculations for us. See results  slide 20. Example: the Hospital “V. Cervello”, here called “B”.

19 19 NOTE: Among the hundreds of items purchased by Hospitals, diapers are critical - for their enormous number in hospital use - for the big gain in water content  increased weight after use (+ 60% and more) - for the high probability that they are dropped in the infectious waste bag even when not prescribed.

20 20 Example of composition of assumed infectious waste when no source - separated collection of glass and plastics is made Including liquids Without liquids

21 21 Correspondence between experimental weighings and predictions on the short period (a few months) is likely not to be perfect

22 22 Concluding remarks Actually, Health Care Wastes are not huge amounts and are not all infectious There are enormous margins for a sound management of them; container labelling, staff training etc are the premise for a proper, affordable, sustainable disposal Glass separation at the source gives the benefits of recycle (if there are factories for it in the Country!) and of reduction of the amounts in weight and in volume Plastics separation gives similar benefits, but subtracts Thermal Value to the waste. Therefore, when infectious waste – which is humid - is to be incinerated, aux. fuel is required Incidentally, in the ongoing debate about incineration of HCW in USA, Canada, Australia, plastics separation is claimed, although no chlorinated polymers are involved in medical devices.

23 23 Thank you for interest!

24 24 APPENDIX

25 25 Classes after the European Regulations - 2 EWC – European Waste Catalogue – Abstract CLASS 15 - WASTE PACKAGING; ABSORBENTS, WIPING CLOTHS, FILTER MATERIALS AND PROTECTIVE CLOTHING NOT OTHERWISE SPECIFIED 15 01 Packaging 15 01 02 Plastic packaging 15 01 03 Wooden packaging 15 01 04 Metallic packaging 15 01 05 Composite packaging 15 01 06 Mixed packaging 15 01 07 Glass packaging 15 01 08* Packaging containing residues of - or contaminated by - dangerous substances 15 02 Absorbents, …, wiping cloths and protective clothing 15 02 02* Absorbents, …, wiping cloths, protective clothing contaminated by dangerous substances 15 02 03 Absorbents, …, wiping cloths and protective clothing other than those mentioned in 15 02 02

26 26 Classes after the European Regulations - 3 EWC – European Waste Catalogue – Abstract CLASS 18 - WASTES FROM HUMAN OR ANIMAL HEALTH CARE AND/OR RELATED RESEARCH (except kitchen and restaurant wastes not arising from immediate health care) 18 01 Wastes from natal care, diagnosis, treatment or prevention of disease in humans 18 01 01 Sharps (except 18 01 03) 18 01 02 Body parts and organs including blood bags and blood preserves (except 18 01 03) 18 01 03* Waste whose collection and disposal is subject to special requirements in view of the prevention of infection 18 01 04 Waste … not subject to special requirements … (e.g. dressings, …, linen, disposable clothing, diapers) 18 01 06* Chemicals consisting of, or containing, dangerous substances 18 01 07 Chemicals other than those mentioned in 18 01 06 18 01 08* Cytotoxic and cytostatic medicines 18 01 09 Medicines other than those mentioned in 18 01 08 18 01 10* Amalgam waste from dental care (!)

27 27 Classes after the European Regulations - 4 EWC – European Waste Catalogue – Abstract CLASS 18 - WASTES FROM HUMAN OR ANIMAL HEALTH CARE AND/OR RELATED RESEARCH (except kitchen and restaurant wastes not arising from immediate health care) 18 02 Wastes from research, diagnosis, treatment or prevention of disease involving animals (much as above) CLASS 09 - WASTES FROM THE PHOTOGRAPHIC INDUSTRY 09 01 Wastes from the photographic industry 09 01 01* Water-based developer and activator solutions 09 01 03* Solvent-based developer solutions 09 01 04* Fixer solutions 09 01 05* Bleach solutions and bleach fixer solutions

28 28 A possible correspondence between WHO and EU definitions Type of wasteWHO DefinitionUE Infectious Waste suspected to contain pathogens e.g. lab cultures; waste from isolation wards; tissues (swabs), materials … that have been in contact with infected patients; excreta 15 02 02 Pathological Human tissues or fluids e.g. body parts; blood and other body fluids; foeti 18 01 02 Sharps Sharp waste, e.g. needles; infusion sets; scalpels; knives; blades; broken glass 18 01 03* Pharmaceutical Waste containing pharmaceuticals, e.g. expired or no longer needed; items contaminated by or containing pharmaceuticals (bottles, boxes) 18 01 08*, 09 Genotoxic Waste containing substances with genotoxic properties e.g. cytostatic drugs (often used in cancer therapy)… 18 01 08* Chemical Waste containing chemical substances e.g. laboratory reagents; film developer; disinfectants that are expired or no longer needed; solvents 18 01 06*, 07 With high content of heavy metals Batteries; broken thermometers; blood-pressure gauges; etc. 18 01 06* Pressur. containers Gas cylinders; gas cartridges; aerosol cans Radioactive waste Waste containing radioactive substances e.g. unused liquids; contamin. glassware, packages, or paper; urine and excreta from patients treated or tested with radio-nuclides; sealed sources


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