1. Module 13: On-site Transport and Storage of Healthcare Waste

2. Module Overview Present the basic principles of waste transport Present equipment specifications and describe appropriate equipment for waste transport Describe routing plans Describe specifications for storage areas Describe the requirements for storage of different kinds of wastes

3. Learning Objectives Define the essential elements of on-site transport equipment Evaluate and improve on transport equipment designs Explain the basic requirements for central storage Develop a plan for safe routing of different kinds of waste Write procedures for cleaning and disinfection of on-site transport equipment

4. Steps in Healthcare Waste Management Waste classification Waste segregation Waste minimization Handling and collection On-site transport and storage Treatment and disposal

5. Types of Waste Transport There are two types of waste transport: –Internal Transport (on-site or in-house transport) refers to the transport of waste inside the healthcare facility, such as Transport from points of generation to interim storage areas to a central storage to an on-site treatment site. Transport from points of generation to interim storage areas to a central storage pending external transport to an off-site treatment facility –External Transport (or off-site transport) refers to the transport of wastes from healthcare facilities to off-site storage areas and to off-site treatment facilities

6. General Principles of On-Site Transport Movement of waste should take place during low activity times whenever possible Regular transport routes and collection times should be fixed and reliable Specific routes should be planned to prevent exposure to staff and patients –Minimize the passage of loaded carts through patient care and other clean areas –Avoid pathways used for patients and the public – use separate floors, stairways, or elevators if possible

7. Example of a Healthcare Facility Site Plan Showing Collection Points GROUND FLOOR Ward 1 Stairs Reception Medical Records X-ray Pharmacy Cafeteria & Kitchen Outpatient Department Waiting Area Infectious Waste Storage Entrance Chemical Waste Storage Infectious Waste Chemical Waste Regular Waste sharps

8. General Principles of On-Site Transport Waste transport staff should wear adequate personal protective equipment like gloves, strong closed shoes, overalls and masks All waste bag seals should be in place and intact at the end of transportation There should be separate, secured, storage rooms to maintain segregation of: –Infectious waste –Chemical, pharmaceutical and other wastes –General waste

9. On-site Transport Equipment Healthcare waste should be transported within the healthcare facility by means of wheeled trolleys, carts or bins Equipment used to transport waste should not be used for any other purpose Transporting waste by hand should be minimized due to the risk of accidents and injuries from infectious materials or improperly disposed sharps The use of waste chutes in a healthcare facility is not recommended because of the difficulty of decontaminating chutes and the increased risk of transmitting airborne infections

10. On-site Transport Equipment Segregation should be maintained during transport Infectious waste/sharps –can be transported together (depending on the final treatment / disposal) –should not be transported with other hazardous waste unless there are separate compartments –Should be transported in color-coded trolleys that are labeled with the biohazard symbol and the words “Danger: Infectious Waste” General waste –Should be transported in trolleys of a different color (e.g., black) Other hazardous waste (chemical and pharmaceutical) –should be transported separately to their respective storage areas

11. Waste Transport Requires the use of proper PPE

12. Waste Transport Requires good body mechanics to protect the body from injury. Examples of bad and good body mechanics when lifting WRONG RIGHT

13. Equipment Specifications Trolleys, carts and wheeled bins should be: –Easy to load and unload –Designed without sharp edges that could damage waste bags or containers –Easy to clean –Lidded and labeled –Easy to clean with a drainage hole and a plug for large bins –Easy to push and pull –Not too high so that the view of staff transporting waste is not restricted –Easily identifiable for each waste stream –Appropriately sized according to the volumes of waste generated at the facility

14. Typical Infectious Waste Trolley Hard plastic container with a lid and push bar Durable and easy to clean Leak-proof Wheeled Color-coded, marked with the biohazard symbol and text Large capacity

15. Typical General Waste Trolley Hard plastic container with a lid and push bar Durable and easy to clean Leak-proof Wheeled Different color from the infectious waste cart Large capacity

16. Example of an Infectious Waste Trolley This trolley at a hospital in Lebanon has separate compartments for infectious waste (red), soiled linens (blue), and sharps containers. It also has compartments for cleaning and disinfecting solutions, and supplies of color-coded bags.

17. Example of an Infectious Waste Trolley In settings where no color- coded trolleys are available, a standard wheeled trolley could be used with color-coded bags by affixing a biohazard label with text on the outside of the wheeled trolley.

18. Examples of Wheeled Bins to Transport Larger Amounts of Infectious Waste

19. In settings where no color-coded bins are available, a standard wheeled bin could be used with color-coded bags by affixing a biohazard label with text on the outside of the bin. Example of a Wheeled Bin to Transport Larger Amounts of Infectious Waste

20. Push-carts for Low-Resource Settings Ideally made up of robustly constructed stainless steel with good, durable castors Mainly used to remove or transfer one or two bins/containers of waste from the storage room or treatment room to the garbage trolley outside the ward Image courtesy of WHO.int

21. Example of a Push-cart Push-cart used in India with separate compartments for different color-coded waste bins or containers Image courtesy of rajswasthya.nic.in

22. Push-carts for Low-Resource Settings A leak-proof and covered trolley made of stainless steel with wheels and a handle on one side A leak-proof and covered wheelbarrow to collect general waste from hospital premises Image courtesy of WHO.int

23. Example of a Wheeled Bin for Chemical Waste This wheeled bin (bottom photo) has a lid (not shown) and a sloped bottom with a plugged hole for drainage and cleaning. It is used with trays (top photo) to hold cytotoxic and other chemical wastes. The bin is made of chemically- resistant stainless steel.

24. Cleaning Transport Equipment Transport equipment should be cleaned and disinfected daily with an appropriate disinfectant

25. Example of a Cart Cleaning Station This cart cleaning station at a hospital uses sodium hypochlorite solution for disinfection followed by rinsing with a pressure hose to clean infectious waste wheeled bins. The station has a local exhaust vent and sewer drain. It is located next to the central storage area where infectious waste is picked up by an external transporter for treatment at an off-site autoclave treatment plan.

26. Routing Waste collection has to be carried out from “clean to dirty” Starting from the most hygienically sensitive medical areas, a fixed route needs to be planned around other areas and interim storage sites The frequency of collection has to be carefully planned to ensure there are no overflowing waste containers Cross contamination with other transported items should be avoided

27. Routing Plan The routing plan will depend on: –Waste volume and number of bags –Waste type –Capacity of ward storage area –Capacity of the transport equipment –Transport distances and times between collection points

28. On-site/Interim Storage Interim storage is the place within a department or floor of a healthcare facility where waste is stored temporarily before being brought to the central storage area Waste generated on the wards could be stored in dirty utility rooms or closets used for storing cleaning equipment, dirty linen, and other waste If dirty utility rooms are not available, then the waste can be stored in the wards at designated and labeled areas away from patients

29. On-site/Central Storage Central storage is the place within a healthcare facility where waste should be brought for safe retention until it is treated or collected for transport off-site

30. General Requirements for Storage Areas The storage area should: have an impermeable, hard-standing floor with good drainage be easy to clean and disinfect (a tiled floor and walls are recommended) have facility to keep general waste separated from infectious and other hazardous waste have a water supply for cleaning purposes have easy access for staff in charge of handling the waste have a lock to prevent access by unauthorized persons have easy access for waste-collection vehicles be protected from the sun, rain or snow be inaccessible to animals, insects, and birds

31. General Requirements for Central Storage Areas The storage area should: have good lighting and at least passive ventilation not be situated near fresh food stores and food preparation areas have a supply of cleaning equipment, protective clothing, and waste bags or containers have a washing basin with running tap water and soap for the staff be cleaned regularly at least once a week have a capacity appropriate to the volumes of waste generated be labelled in accordance with the hazardous level of the stored waste

32. Labels for Central Storage Areas

33. Example of a Central Storage Area at a Hospital

35. Storage of Infectious Waste and Sharps The storage area should have a biohazard sign Regular inspection and cleanup (at least weekly) of storage areas should be part of HCWM plans Workers should be trained in site spillage procedures Sharps can be stored without problems, but other infectious wastes must be kept cool if storage times are exceeded, or refrigerated at a temperature of 3°C to 8°C if stored for more than a week

36. Storage Times for Infectious Waste Storage times for infectious waste (e.g. the time gap between generation and treatment) should not exceed the following if the storage area is not cooled: Temperate climate  72 hours in winter  48 hours in summer Warm climate  48 hours during the cool season  24 hours during the hot season

37. Pathological Wastes Storage Considered as biologically active waste –Expect gas formation and pathogen growth Storage should be air-conditioned or refrigerated (e.g. in the morgue) and should be stored at a temperature of 3°C to 8°C In some cultures, body parts are given to the family for ritual procedures or are buried in designated places

38. Pharmaceutical Wastes Storage Classification (WHO, 1999) –Non-hazardous waste which can be stored in the non- hazardous storage area: Ampoules with non-hazardous content (e.g. vitamins) Fluids with non-hazardous contents like vitamins, salts (NaCl), amino salts… Solids, semi-solids like tablets, capsules, granules, powders for injection, mixtures, creams, lotions, gels, suppositories, etc. Aerosols, including propellant-driven sprays and inhalers

39. Pharmaceutical Waste Storage Hazardous wastes that should be stored in accordance with their chemical characteristics or specific requirements for disposal: –Controlled drugs (should be stored under government supervision) –Disinfectants & antiseptics –Anti-infective drugs, like antibiotics –Genotoxic drugs (genotoxic waste) –Ampoules with antibiotics

40. Chemical Wastes Storage Consider characteristics of the different chemicals to be stored and disposed –inflammable, corrosive, explosive Spillage kits, PPE and first aid equipment (eye-shower, etc.) should be available Should have adequate lighting and good ventilation; constructed of materials suitable to withstand explosion or leakage Storing liquid chemicals –storage should be equipped with a liquid and chemical proof sump or catch- containers under the storage containers

41. Chemical Wastes storage Storage compartments should be labelled in accordance to their hazardous class Liquid and solid waste should be stored separately If possible the original packaging should be used for storage Labels should have the following: –Hazard Symbol(s), Waste classification, Date, Point of generation (if applicable).

42. Examples of Chemical Waste Storage Images from the WHO Blue Book Safety cabinet for flammable substances Flammable substances inside the safety cabinet Liquid chemicals on a chemical-resistant plastic container

43. Radioactive Wastes Storage Should be stored in containers that prevent dispersion Should be labelled with the type of radionuclide, the date, and details of required storage conditions Waste with > 90 days half-life time has to be collected and stored externally in accordance to local regulations

44. Radioactive Wastes Storage Storage must be equipped with sufficient shielding material, such as lead shielding walls or as movable shielding material Should be flameproof and have surfaces easy to decontaminate Area must be clearly marked with “RADIOACTIVE WASTE” and the international hazard label should be placed on the door Radiation levels outside the storage should not exceed 2.5 µSv/hr.

45. What is Wrong With This Picture? Note: The yellow bag is infectious waste.

46. What is Wrong With This Picture? Note: Yellow is the color code for infectious waste.

47. What is Wrong With This Picture? Note: Yellow is the color code for infectious waste.

48. Country- Specific Requirements Add your country specific requirements or guidelines for transport and storage of HCW on- site.

49. Pictures You may add pictures of carts, equipment, and storage areas in the current facility or other facilities in the country.

50. Discussion How does your facility store and transport wastes? Are there written guidelines for properly storing and transporting the wastes? Are different types of wastes kept separate during transport and storage? What are some alternative methods for dealing with these wastes that may or may not be practiced in your facility? Are safety procedures or practices in place to ensure that staff members and the public are not exposed during the processes? Do you know about your country’s or region’s regulations regarding waste transport and storage? What are the advantages and disadvantages of different healthcare waste transport systems? Do some seem to be safer and more effective than others? What about storage procedures? How does the storage setup in your facility compare with some of the general requirements given in this presentation? Any weaknesses or barriers?