Bio-medical Waste Disposal Processes

• This manual focuses on bio-medical waste management at the All India Institute of Medical Sciences (AIIMS), New Delhi.
• It dedicates itself to AIIMS and those who work there.

Authors

• Dr. Parmeshwar Kumar, Assistant Professor, Department of Hospital Administration.
• Dr. K.Vamsi Krishna Reddy, Senior Resident, Department of Hospital Administration.
• Dr. Siddharth Mishra, Junior Resident, Department of Hospital Administration.

Director's Message

• AIIMS New Delhi is the first tertiary hospital authorized under the Bio-Medical Waste Management Rules 2016, and the Air and Water Act.
• The rules designate the Director as the Occupier, giving them the accountability to implement these rules.
• The manual is designed to be a ready guide for adapting to the challenges of bio-medical waste management and its implementation.
• The Clean & Green campaign at AIIMS strives for better sanitation, with bio-medical waste management being key to these goals.

Medical Superintendent's Foreword

• The Bio-medical Waste Management Rules 2016 are an updated version of the 1998 rules.
• The new rules reduce error by decreasing the number of categories (from 10 to 4).
• The new rules increase accountability for both the facility operator and the occupier.
• Reduce, recycle, and reuse concepts are brought to the forefront.
• Significant changes include phasing out chlorinated material, training, immunization, bar-coding of waste, pre-treatment of laboratory waste, and stricter treatment and disposal norms.
• Occupational safety is addressed through bar-coding, web-based reporting, and defined responsibilities for Occupier & CBTFW operators.
• Environmental protection is emphasized through disposal standards for incinerators and autoclaves.
• Consent to operate is linked to the Bio-Medical Waste Rules, viewing healthcare organizations as a single entity from a pollution control board perspective.
• AIIMS is the first public hospital in India to obtain consent to operate and renewal of Bio-medical Waste authorization under the new rules.

Acknowledgements

• The manual is made with gratitude to the Director of AIIMS.
• The Medical Superintendent conceived the idea of the manual as a handbook for staff.
• Thanks is given to the faculty, residents of the Department of Hospital Administration, the Officer In-Charges of Bio-medical Waste Management, infection control committee, infection control nurses, and all healthcare workers at AIIMS.

First Among Equals

• AIIMS, New Delhi is the first public hospital in India to be authorized under the Bio-medical Waste Management Rules-2016.

Index of the Manual

• Chapter I: Sneak preview of the Bio-medical Waste Management manual.
• Chapter II: Introduction to Bio-medical Waste management.
• Chapter III: Bio-medical Waste Management rules 2016, salient features and implications on AIIMS.
• Chapter IV: Bio-medical Waste Management at AIIMS.
• Chapter V: Segregation : An illustrative guide.
• Chapter VI: Bio-medical Waste Management in Hindi for sanitation staff.
• Chapter VII: Roles and Responsibilities of Stake holders.
• Annexure: Including AIIMS authorization, consent to operate, and a list of bio medical wastes with disposal bag/container.

Chapter I: The Bio-medical Waste Management Manual - A Sneak Preview

• The manual is user-friendly and written for all levels of staff.

Chapter II: Introduction

• Provides a brief introduction to AIIMS with a Bio-medical Waste global perspective.
• Provides an organogram from the perspective of BMW management, and the reporting channel under the Occupier-the AIIMS Director.
• Touches on Environmental impact, and legal implications of Bio medical waste.

Chapter III: Bio-medical Waste Management Rules 2016, Salient Features and Its Implication on AIIMS

• Enumerates the Waste Management Rules and their implications on AIIMS.
• Clauses include changes in color, cardboard boxes for glassware, hub cutter, bar coding, lab waste management, and linking Consent to Operate & Bio-medical Management.

Chapter IV: BMW Management at AIIMS

• Explains AIIMS institutional machinery and its illustrative flow diagram of generation to disposal.
• The Sewage Treatment Plant is related to Consent to Operate and liquid waste management.

Chapter V: Segregation: An Illustrative Guide

• Deals with the challenge of effective Bio-medical waste management and segregation.

Chapter VI: जैव चिकित्सा अपशिष्ट प्रबंधन

• Addresses sanitation workers and supervisors directly in Hindi.

Chapter VII: Roles and Responsibilities of Stake Holders

• Enumerates the roles of stakeholders, like doctors, nurses and technicians.
• Heads of Department need leadership skills, while nurses maintain records of waste collection & needle stick injuries.

Reduce, Recycle, Reuse

• New rules restrict on-site treatment and disposal facilities if a Bio-medical Waste treatment facility is within 75 km.
• AIIMS outsources its bio medical waste management.
• Modern technology converts only 5% of incinerable waste into landfill ash.
• Infected plastic waste is sterilized, and about 50% is brought back into use.
• About 60% of sharp waste is melted in furnaces and reused as stainless steel.
• Almost all glass is recycled after treatment and melting.

Chapter II: Introduction

• The chapter will cover AIIMS' mission and challenges in Bio-medical Waste Management, and legal implications.

AIIMS Overview

• All India Institute of Medical Sciences, New Delhi was established in 1956
• There is a trinity of mission of teaching, research and patient care.
• AIIMS has a bed capacity of 2412 beds in 2017.
• Bed occupancy is nearly 90%, with 10,000 daily outpatients.
• Emergency has about 650 patients a day
• There is ≈14,000 staff, including outsourced workers.
• Footfall raises to 50,000 a day.

Hospital/Bio-medical Waste Management: A Global Perspective

• Hospital waste is a potential health hazard to healthcare workers.
• Steps in waste management include generation, accumulation, handling, storage, treatment, transport, and disposal.

Bio-medical Waste Legal Requirements

• The Environment Protection Act 1986 and "Bio-medical Waste Management Rules, 2016" show India's commitment to the environment.
• The law works on the "polluter pays principle".
• The Central Pollution Control Board and State Pollution Control Committees can cancel the Consent to Operate and Authorization of Healthcare Institutions in non-compliant hospitals.

Ethical Perspective

• It is essential that all concerned officials adhere to directives to ensure that generated waste is handled properly.
• Healthcare workers enduring needle stick injuries resulting from incorrect Bio medical waste management are liable for lawsuits.
• Failure to comply with the Rules will attract action as per the provisions of The Environment Act, 1986, including imprisonment (5 years) or a fine (Rs. 1 lakh), or both.

AIIMS Organogram: Bio-Medical Waste (BMW) Management Perspective

• The director is at the top.
• Then there is: chiefs of centres, deputy director (administration), and medical superintendent.
• The next tier is: additional MS, SE, and infection control committee.
• The lowest tier is: senior sanitation officer, officer i/c BMW management, sanitation officer, and infection control nurses.

Did You Know?

• According to WHO, nearly 85% of all waste generated by hospitals is general waste.
• 10% is Bio-medical Waste.
• 5% constitutes radioactive and chemical wastes.
• Bio medical waste generated is about 1.5kg/bed/day in a large tertiary care hospital like AIIMS.

Chapter III: Bio-Medical Waste Management Rules 2016 Includes

• Expanding the scope of rules to include medical activities like vaccination camps.
• Phase out of chlorinated plastic items within two years.
• Laboratory and blood samples pre-treatment.
• Provide required training regularly for all health care workers and immunize them.
• Bar-Code systems for tracking wastes.
• Report major accidents.
• Existing incinerators must achieve standards.
• Bio-medical waste is classified into 4 categories instead of 10.

Waste Categories and Treatment Options

• Yellow bags are for Human/Animal Anatomical Waste, Soiled Waste, Expired Medicines, most lab waste, and Chemical Liquid Waste, and undergo incineration/plasma pyrolysis/deep burial.
• Red bags are for Contaminated Recyclable Waste (tubing, bottles etc.), and undergo autoclaving/microwaving/hydroclaving followed by recycling.
• White containers are for Waste sharps including Metals, and undergo Auto or Dry Heat Sterilization followed by shredding or encapsulation.
• Blue cardboard boxes are for Glassware and undergo disinfection/autoclaving, and then are recycled.

Additional Rules

• Simplified authorization procedure.
• More stringent standards for incinerators with lowered emissions.
• Emission limits for Dioxin/furans.
• No on-site treatment facility allowed if a common bio-medical waste treatment facility is available within 75 kilometers.
• Operator to ensure timely bio-medical waste collection, along with training assistance.

Duties of Occupier

• Provide safe, ventilated location for storage of segregated BMW within premises.
• Phase out use of chlorinated plastic bags, gloves and blood bags within two years.
• Provide waste handling training to all health care workers.
• Immunization against Hepatitis B and tetanus.
• Establish a Bar-Code System for bags/containers with bio-medical waste which goes outside of the premises for disposal.

Duties of Operator

• Report any major accidents and come up with remedial measures.
• Ensure BMW is collected in a timely manner.
• Handing over of recyclable waste after treatment.
• Establish bar coding and GPS for handling within one year.
• Assist health care facilities in training.
• Implement the upgrades needed of existing incinerators.

Treatment and Disposal

• No healthcare facility can setup an on-site BMW treatment facility if a common treatment facility exists within 75 kms.

Segregation, Packing, Storage and Transport

• Bio-medical waste is classified into 4 categories based on treatment options.
• Do not store untreated waste for over 48 hours
• If needed, the occupier must ensure their is no harm to human health.

Authorization

• There is one time authorization offered for non-bedded HCFs.
• Consent orders are synchronized with validity of authorization.

Monitoring Implementation of the Rules

• Annual report: Every occupier is to submit one by June 30 each year to the correct authority, this organization will then compile data, review, analyze and report the data to the Central Pollution Control Board (CPCB) around July 31 each year
• The CPCB shall submit a report to the Ministry of Environment, Forest & climate change by August 31.
• Annual reports accessible on websites of the occupier, State Pollution Control Board (SPCB) and the CPCB

Maintenance of Records

• Records are to be maintained for 5 years related to generation, collection, reception, storage, transportation, treatment and disposal.
• Biomedical waste has its own website.

Accident Reporting

• In the event of a major accident-intimate immediately and file a report within 24 hours

Schedules of the Bio-Medical Waste Rules 2016

• There are four.
• Schedule 1: Categorization and Management.
• Schedule 2: Standards for BMW treatment/disposal.
• Schedule 3: Authority and duties.
• Schedule 4: Bags, containers and transportation labels.

Points About Implementation

• BMW improves if: Proper disposal and distribution at the facility is used.
• Segregation is the most important first event.
• Continuous training and committees should be available

Bio Medical Waste Segregation Tips

• "YELLOW has blood and tissues dead, Infected plastics and rubber go in RED, Sharps in Containers lockable &white, Blue Card boards for Glassware, that's right, The colour Black for general waste Don't forget this in your haste !!!"

Chapter IV: Bio-medical Waste Coordination

• How is Bio-medical Waste Management at AIIMS coordinated? Has a life cycle.

Points of Disposal for Bio-Medical Waste

• Laboratory waste is to be treated on site.
• What happens in the common place?
• Brief: AIIMS Sewage Treatment Plant

AIIMS Segmentation

• Steps: -Segregation
• Collection
• Transportation -Outsourced Sanition
• Collection and transmission of center Bio medical wastes
• Labs, blood banks, microwaving/transmission to storage center.

Management of Bio Medical Wastes

• This is done through outside organizations, which transport bio-medical waste, treat the area and finaliz
• Bio-medical Wastes are stored for < 46 hrs only.
• Bags are then weighed/ bar coded/ sent for disposal.

Lab Waste Handling

• 1. BIO-MEDICAL WASTE GENERATED FROM THE VARIOUS LABORATORIES
• 2. Pre-treated through microwaving.

Common Treatment Site Disposal Flowchart

• Collection of Bio-medical Waste in Leak Proof closed Vehicles -> TSDF/LANDFILL FACILTIY (Final Disposal)
• Incinerable Waste -> INCINERATION (Flue Gases) -> AIR POLLUTION CONTROL DEVICE
• Autoclavable Waste -> AUTOCLAVING -> SHREDDING -> AUTHORISED RECYCLER (Final Disposal)

• VEHICLE WASHING CLEANING ETC. -> E.T.P.-> TREATED WATER REUSED IN SCRUBBING & GREEN BELT, ETC. GLASS

• CHEMICAL DISINFECTION -> AUTHORIZED RECYCLER
• ETP SLUDGE STORED IN LEAK PROOF CONTAINERS AN ISOLATED PLACE

Bio-medical Waste Treatment (CBWTF)

• It is put into the ROTARY KILN INCINERATOR For Burning
• The glassware is reused.
• Red Bags are to be autoclaved.
• The contents of RED are heated, sterilized, reused, and shredded.

AIIMS Waste Amounts

• As of 2018:
• 24,000Kgs is yellow waste.
• 23,500Kgs is plastic/rubber waste.
• 500Kgs is sharps while 26,200Kgs is glass wastes.
• These factors are 74,500Kgs monthly or 2500Kgs a day.
• This does not take into account the wastes properly being transported/treated.

All Waste is Colour-Coded in AIIMS:

• Red Bin: All infected plastic recyclable waste
• Waste from tubs, bottles, lines, gloves ETC. Follow Guidelines
• Yellow Bin:Follow Gidelines
• Human/Animal Anatomical and Soiled Waste
• Tissues Organ Body Parts & Blood
• Blue Bin
• Broken/Contaminated Glasswares Only
• White Container
• " Sharps Only Black bin: Non-Infectious

CHAPTER VI

• This Chapter:
• Talks of Management of Bio Medical Wastes based on 2016's rules.
• These rules have guidelines in sanitation.
• The staff need to correctly manage
• Wastes are sectioned into four colors.

Chapter VII: Stakeholder Responsibilities

• Key points: Correctly distribute the wastes which need doctor's input's
• "Here's an opportunity for all of us to play a crucial role, a responsibility to the nation and world as whole!"
• Head of Departments are required to ensure that staff and nurses understand importance of BMW mgmt, follow correct practices, and feel empowered to correct erring residents and vice versa.

Nurse's Staff Responsibilities

• Perform: Supervision, reporting, corrections properly/correctly, handle waste carefully, and ensure correct needle stick injuries.

General Waste Guidelines

• Perform: Proper segregation, report anything strange. Contact Nurse supervisor.

Proper Container Usage

• Red Bag:
• Tubing
• Stoppers
• NG Tubes
• Yellow Bag
• Animal or human waste
• bandages
• drapes
• Blue Bins
• Glass.

Important Tip!!

• "The responsibility of what we generate, Doesn't end just at our gate, Some of it must burn, Into smoke and ash it will turn But recycling of much of what we segregate.. Must be ensured, for that's its exalted fate !"

Explains the disposal methods for yellow and red bio-medical waste bags at Biotic Waste Solution facility. It also looks at the purpose of the ETP and the destination for incineration ash produced by the Common Bio-medical Waste Treatment Facility.