AIIMS Bio-Medical Waste Management Manual PDF

ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI AIIMS Bio-medical Waste Management Manual Dedication: For sure, to AIIMS we dedicate this document, but to...

ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI AIIMS Bio-medical Waste Management Manual Dedication: For sure, to AIIMS we dedicate this document, but to those as well, who serve and breath life into the monument: 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 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI It is indeed a matter of great collective pride for the staff at AII India Institute of Medical Sciences, New Delhi that we are the first tertiary Hospital to be provided the authorization under the Bio-medical Waste Management Rules 2016 as well as Consent to Operate under Air and Water Act. The rules describe the Director as the Occupier; for an Institution as large as AIIMS, the role brings with it the responsibility and accountability to implement the mandatory rules effectively. I find this manual, timely and essential. Though rules define practices, their implementation is always a challenge and institutional adaptability and adjustment needs a ready guide. The Department of Hospital Administration has effectively and efficiently implemented all the aspects of the rules, the authorization being the validation. The AIIMS manual for Bio Medical Waste management completes the picture. I am aware of challenges that Bio-medical Waste Management entails; need for constant reiteration, turnover of staff, to a few, a fringe element in clinical care, covert ill effects of poor practices and a large hospital with varied cadre of staff are all a reality. Thus, against such a backdrop, I am confident that this manual will be very handy. I am delighted by the ready-reckoner-like feel of the manual, with illustrations, diagrams and fact bubbles. I am also happy to observe that all cadre of staff have been addressed since segregation involves all the staff at AIIMS. AIIMS through its Clean & Green AIIMS campaign and guideline booklet has always been a torch bearer of Sanitation. The awards and accolades have helped it to strive for even greater heights. Bio medical waste management is an important key result area of the campaign and I am sure that this manual is another feather in its already crowded cap. Prof. Randeep Guleria Director AIIMS Page 1 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI From the Desk of the Medical Superintendent: A Foreword on an afterthought: The Bio-medical Waste Management Rules 2016 has been a long-awaited updated version of the 1998 rules; the mushrooming of health care industry within the milieu of the country coinciding with the drift towards greater environmental consciousness and greater accountability. The new rules bring in several significant changes, primarily at reducing errors (by decreasing the number of categories from 10 to 4), increasing the accountability of both the occupier and the common Bio Medical Waste treatment facility operator and bringing the concept of reduce, recycle & reuse to the fore. Some of the significant changes include phasing out of chlorinated material, training, immunization, bar-coding of waste, pre-treatment of laboratory waste and stricter norms for treatment and disposal. Occupational safety finds its rightful place in these rules as also accountability through bar-coding systems, web-site based reporting and a well-defined section of Occupier & CBTFW operators’ responsibilities. A much-needed thrust to environmental protection has been provided through a section that elucidate such standards in disposal through incinerators and autoclaves to be followed by the common Bio Medical Waste treatment and disposal facility operators. In a significant development, the consent to operate has been linked to the Bio Medical Waste Rules thereby viewing the healthcare organization as a single entity from the prospective of the pollution control board. However, this makes procedures such as authorization, renewals and consent to operate a bit more challenging with Bio Medical Waste linked to functioning of the sewage treatment plant, effluent treatment facilities as well as the operation of equipment such as diesel generator and boilers. Due importance has been given laboratory waste by mandating onsite treatment. Cytotoxic waste, an important issue in the content versus container debate, has also been addressed. This is what makes this manual a contemporary requirement to a hospital as vast as AIIMS. It is with a certain sense of pride that I wish to state that AIIMS is the first public hospital in India to have obtained its consent to operate and the renewal of Bio-medical Waste authorization under the new rules. The paradigm shift brought about by the new rules makes this manual an important ready reckoner for all the health care workers of the hospital. Indeed, this manual is designed in a format to help all cadre of Healthcare workers at AIIMS. Page 2 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI The manual thus progresses from a topical view of AIIMS from the perspective of BMW mgmt to the salient features of the rules and its implication to AIIMS. The next chapter deals with the subtler processes and procedures unique to Bio medical waste management AIIMS. An illustrative guide is an easy way for a lay reader to under the most important part of the rules-segregation. The section for sanitation staff is drafted appropriately, in Hindi. Finally, the last chapter delineates clearly the roles and responsibilities of each cadre of healthcare worker, including sanitation staff, infection control nurses and Hospital Administrators. Bio Medical Waste is often considered as an afterthought, an overlooked by product of healthcare, physically and metaphorically relegated to the sidelines. However, I am confident that this manual will significantly contribute to the greater visibility brought about by the new rules by assigning bio medical waste management its rightful place, as an important facet of effective patient care management with far reaching healthcare and legal implications. As the Medical Superintendent of a premier healthcare organisation, I am aware that appropriate Bio Medical Waste management practice need constant reiteration to move it from the realm of practice to the zone of a habit. I am confident that this Bio Medical Waste manual would be an effective tool to that end. Dr. D.K. Sharma Medical Superintendent Page 3 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Acknowledgement Drafting the acknowledgement section of any document is often a risky preposition, fraught with the danger of excluding the names of people whose contribution has been significant and deserves a mention. Thus a disclaimer is an order. However, a manual of this nature would remain incomplete without a note of gratitude. The authors are indebted to the Director, AIIMS for lending his guiding hand in implementation of the rules. We are indeed delighted that this manual is being released by the Director, AIIMS in the capacity of the occupier, and we hope the manual has shaped up to his expectations. The Medical Superintendent as a key stakeholder in implementation of the Bio-medical Waste Management Rules 2016 had first conceived the idea of a manual as a handbook for all AIIMS staff. Thus we are grateful to him for not only sowing the seeds of the idea in our minds, but also helping us nurture it. Personifying an ideal boss, he has allowed ideas to be generated and empowered his subordinates to implement the rules and positively influencing its outcome, this manual. The faculty and residents of Department of Hospital Administration have always been at the forefront of effective implementation of practices. Needless to say, this manual is a culmination of their efforts in implementation of the rules. To that end, this manual, is a documented testimony to the correct practices that are already in place. These practice are thus a reflection of the efforts of the department. Thus, Bio Medical Waste management practices have been honed, corrected, reiterated, improved and implemented over several years of hard work. Therefore, gratitude should also be expressed to the Officer In-Charges of Bio-medical Waste Management in the past for passing on a better and more refined baton to their successors. We would like to express our gratitude to Officers – in-charge Bio-medical Waste Management. in the years gone by, Prof. Sidhartha Satpathy, Prof. Sanjay Arya and Dr. Amit Lathwal for having handled Bio Medical Waste management adroitly at some of the crucial stages of implementation resulting in the current status of Bio Medical Waste management culminating in this manual. We thank the infection control committee and in particular, the infection control nurses who are an important stakeholder of the implementation structure and have made valuable contribution to this manual. Finally, we also like to express our gratitude to all the healthcare workers at AIIMS who have made this manual a reality and to whom this manual is dedicated as an intended reading and handy companion. Page 4 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI FIRST AMONG EQUALS!! AIIMS, New Delhi is the first public hospital in India to be authorized under the Bio-medical Waste Management Rules-2016 ! Page 5 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Index 1 Chapter I: 7 The Bio-medical Waste Management manual: A sneak preview….. 2 Chapter II: 10 Introduction 3 Chapter III: 15 Bio-medical Waste Management rules 2016, salient features and its implication on AIIMS 4 Chapter IV: 26 Bio-medical Waste Management at AIIMS 5 Chapter V: 35 Segregation : An illustrative guide 6 Chapter VI: 40 Bio-medical Waste Management in Hindi 7 Chapter VII: 46 Roles and Responsibilities of Stake holders 8 Annexure: 51 a. Authorisation of AIIMS under Bio-medical Waste Management rules b. Consent to Operate under the Air (Prevention & Control of Pollution) Act 1981, and Water (Prevention & Control of Pollution)1974 c. Complete list of bio medical wastes (area wise) and the appropriate disposal bag/container Page 6 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Chapter I: The Bio-medical Bio medical waste Wastemanagement Managementmanual: manual:AAsneak sneakpreview preview “ A sneak preview should be like a good book review, generating enough curiosity to read the book without giving the plot away! “ A manual on Bio-medical Waste Management must tread the fine path of not becoming a text book while imparting knowledge in a ready- to-use customized manner and manage to keep the reader engaged. Thus, not all portions are relevant for all cadre of staff , though staff such as residents of Deptt. of Hospital Admn., and Infections control nurses must be aware of all the aspects on the manual. A brief preview will aid the reader:- Chapter II: Introduction The first Chapter provides a brief introduction to AIIMS and gives global perspective on Bio-medical Waste and its burden. An organogram from the perspective of BMW mgmt. provides a visual understanding the reporting channel under the Occupier–the AIIMS Director. The important aspect of Environmental impact and legal implications of Bio medical waste is briefly touched upon to lay emphasis on these important aspects. Chapter III: Bio-medical Waste Management rules 2016, salient features and its implication on AIIMS As the Bio-medical Waste Management rules 2016 are bedrock of correct practices, this chapter enumerates the salient features of rules 2016 and its implication on AIIMS. Thus, clauses such as change in colour, cardboard boxes of glassware, hub cutter, bar coding, lab waste mgmt, and linking of Consent to Operate & Bio-medical Management have a far reaching impact as well as are a challenge in implementation. Chapter IV: BMW management at AIIMS This chapter elucidates the Institutional machinery. A illustrative flow diagram of generation to disposal schema intends to provide a snapshot of the system. Laboratory waste management needing onsite treatment is described. The Sewage Treatment Plant is related to both Consent to Operate as well as liquid waste management and the features of STP at AIIMS is briefly described. Chapter V: Segregation: An illustrative guide Possibly the most important component in the manual, this entirely illustrative chapter deals exclusively with the biggest challenge of effective Bio medical waste management – segregation, in a simple what –goes-where format. Page 7 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Chapter VI: Bio-medical Waste Management in Hindi, directly addresses an important cadre of staff, the sanitation workers and supervisors. Chapter VII: Roles and Responsibilities of Stake holders Though essentially the most important role of most stakeholders including doctors, nurses and technicians is restricted to effective segregation, specific roles a needed to be enumerated. For examples Heads of Department have an important leadership and administrative role, while nurses need to maintain records of quantum of waste collection & needle stick injury, supervision, procurement etc.. They are of course responsible for overall correct practices. Similarly, hospital administrators, Infection Control nurses and Karamcharies have specific roles that need to be elucidated. The section for Karamcharis is in Hindi for their convenience. Page 8 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Reduce, recycle, reuse; for, one man’s trash is another’s treasure…. Did you know? - As per the new rules no hospital can establish on-site treatment and disposal facility, if a service of common Bio-medical Waste treatment facility is available within at a distance of 75 kilometer. Thus bio medical waste management at AIIMS is outsourced! - Using modern technology only 5% of incinerable waste is converted to ash that goes to landfills ! - Infected plastic waste is sterilized and nearly 50% is brought back into circulation after treatment. These are first converted to plastic granule and transformed to newer plastics such as bags!! - About 60 % of sharp waste are melted in furnaces and reused as part of stainless steel products! - Nearly all glass waste are recycled after treatment and melting in foundries! Page 9 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Chapter II: “ AIIMS:- An edifice with a reputation to uphold, its lanes replete stories new and old, a brighter future beckoning post-haste, and not a moment “ there is to waste What you can expect to learn from this chapter s !))-3 ITS MISSION AND CHALLENGES IN "IO MEDICAL 7ASTE -ANAGEMENT s (OSPITAL 7ASTE MGMT VIEWED FROM A GLOBAL PERSPECTIVE AS A SINGLE CONNECTED MONOLITH s 4HE LEGAL ANGLE OF "IO MEDICAL 7ASTE -ANAGEMENT s )MPLICATIONS OF NON COMPLIANCE s 4HE INSTITUTIONAL ORGANOGRAM FROM THE PERSPECTIVE OF "IO MEDICAL 7ASTE -ANAGEMENT AIIMS: A brief overview The All India Institute of Medical Sciences, New Delhi established through an act of parliament in 1956 is a premiere medical institution of National importance with a trinity of mission of teaching, research and patient care; the last component initially envisaged to support to the first two. However, over the past half a century of rendering equitable, accessible and affordable healthcare, the unintended brand building has resulted in a substantial tilt towards patient care component. The Centres with various super-specialities at AIIMS are another adaptive response to the specialization and sub specialisation in medicine and is under the functional and administrative control of the Chief with the Director being the overall Head of the Institute. Likewise, the administrative, functional and operational authority of the AIIMS (main) hospital is vested upon the Medical Superintendent. The various hospital/centers presently in AIIMS are: 1. AIIMS Main Hospital 2. Cardio Thoracic Center 3. Neuro Sciences Center 4. Dr. B.R.Ambedkar Institute Rotary Cancer Hospital 5. Jai Prakash Narayan Apex Trauma Center 6. National Drug De-addiction &Treatment Centre, Ghaziabad 7. Dr. Rajendra Prasad Center for Ophthalmic Sciences 8. Center for Dental Education and Research Page 10 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI AIIMS continues to take rapid strides to cater to a growing and diverse demography. Several specialty blocks, National Cancer Institute, Trauma II projects are on the anvil and are a major step in bridging the gap. There is an essential duality in the nature of AIIMS; at one level, a general hospital for many patients from Delhi and at another, a tertiary care referral hospital for a large section of Indian population. An adaptive change has been a rise in the number of beds from 750 in early 1970s to a total bed capacity of 2412 beds in 2017. The bed occupancy is nearly 90% and about 10,000 patients visit the Out-Patient Department daily. The Emergency wards have around 650 patients visiting it per day. The hospital has nearly 14,000 staff including many outsourced workers. An even larger patient and their attendant clientele thronging its premises raises the footfall to about 50,000 a day. It is evident that such a ‘city unto itself’ is bound to generate enormous hospital waste and effective handling of this bio medical waste is a major challenge to the Hospital administration of the institute. Hospital/Bio-medical Waste Management: A global perspective The proper management of Hospital/Healthcare/Biomedical waste has become a topic of enormous concern having global implications and attention. It is of course well known and documented that Hospital waste is a potential health hazard to the health care workers, public, flora and fauna of the area.A 1990 report by the U.S. Agency for Toxic Substances and Disease Registry concluded that biomedical waste from health care settings may pose an injury and exposure risks via occupational contact with medical waste for doctors, nurses, and janitorial, laundry and refuse workers. Hence, Biomedical waste must be properly managed and disposed off to protect the environment, general public and workers, especially healthcare and sanitation workers who are at risk of exposure to biomedical waste as an occupational hazard. Steps in the management of biomedical waste include generation, accumulation, handling, storage, treatment, transport and disposal. Bio-medical Waste Management: A Legal Requirement: The Environment Protection Act 1986, the Bio Medical Waste (Management and Handling) Rules in July 1998, subsequently revised in 2011and now the “Bio-medical Waste Management Rules, 2016” are an attestation to the commitment of the Govt of India. The law works on a simple “the polluter pays principle” The responsibility of hospital administrator as regards to proper handling and disposal of Biomedical waste had become a statutory requirement with the promulgation of Government of India (Min of Environment, Forests& climate change) gazette notification no. 460 dated 27 Jul 1998 & notification of the Bio-medical Waste (Management and Handling) Rules in July 1998 & subsequently revised in 2011.“Bio-medical Waste Management Rules, 2016” came into force in supersession of the 1998 rules with gazette notification no. G.S.R. 343(E) dated 28thMarch 2016. The Central Pollution Control Board and the State Pollution Control Committees have the authority to cancel the Consent to Operate and the Authorization of Healthcare Institutions and under the Bio-medical Waste Management Rules 2016 for non-compliant Hospitals. Indeed there have been such instances in India. Page 11 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI It is therefore essential that all officials concerned with the administration of hospitals and other health care echelons take all steps to adhere to the laid down directives to ensure that waste generated is handled without any adverse effect to human health and environment. It is equally important that all medical, dental, nursing officers, other paramedical staff and waste handlers such as safaikarmacharis, Hospital attendants & Sanitation attendants be well oriented to the basic requirements of handling and management of biomedical waste. It is with this objective of providing such basic information that this manual is envisaged. From the ethical perspective, needle stick injury endured by a Healthcare workers due to incorrect Bio medical waste management practices are liable for legal suits besides being ethically incorrect. Failure to comply with the provisions of the Rules, will attract penal action as per the provisions of the Environment (Protection) Act, 1986, which includes imprisonment for a period of 5 years or a fine of Rs.1 lakh or both. Page 12 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI AIIMS ORGANOGRAM : BIO-MEDICAL WASTE (BMW) MANAGEMENT PERSPECTIVE Director Chiefs of Dy.Dir Medical Centres (Admn.) Superintendent Infection Control S.E. committee Addl. M.S. Offr. i/C BMW Management Sr. Sanitation Officer Sanitation Officer Infection Control nurses Page 13 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Did you know? - According to WHO, nearly 85% of all waste generated by hospitals in general waste - About 10 % is Bio-medical Waste - And only 5% is other wastes such as radioactive and chemical wastes - In a large tertiary care hospital such as AIIMS, the Bio medical waste generated is about 1.5kg/bed/day as against 2.8kg/bed/day from a similar sized hospital in USA Page 14 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Chapter III: I: BIO-MEDICAL WASTE MANAGEMENT RULES 2016: Salient features and its implication on AIIMS “ Rules are not necessarily sacred, principles are. “ What you can expect to learn from this chapter s 7HAT IS "IO MEDICAL 7ASTE s 7HAT TYPES OF WASTE DO NOT CONSTITUTE "IO MEDICAL 7ASTE  s &EATURES OF "-7 MANAGEMENT 2ULES  EVERYONE SHOULD KNOW s 7HAT ARE THE DUTIES OF !))-3 AS PER "-7 MANAGEMENT 2ULES   s 7HAT ARE THE DUTIES OF THE VENDOR COLLECTING "IO MEDICAL 7ASTE FROM !))-3 s 7HAT RECORDS NEED TO BE MAINTAINED  s 7HAT HAPPENS IF THERE IS AN ACCIDENT s 7HAT ARE THE CATEGORIES OF "IO MEDICAL 7ASTE AND WHAT GOES INTO WHAT s (OW IS LIQUID WASTE HANDLED 3EWAGE 4REATMENT 0LANTS Definition of Bio-medical Waste: “Bio-medical waste" means any waste, which is generated during the diagnosis, treatment or immunization of human beings or animals or research activities pertaining thereto or in the production or testing of biological or in health camps. The Bio-medical Waste Management rules are applicable to all persons who generate, collect, receive, store, transport, treat, dispose, or handle bio medical waste in any form. Bio-Medical Waste rules 2016 doesn’t apply to the following types of wastes as they are covered under different acts enumerated below: Radioactive wastes Municipal Solid Wastes Hazardous chemicals Hazardous microorganisms, genetically engineered Lead acid batteries microorganisms and cells Hazardous wastes E-Waste Page 15 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI The major Chapter I: salient features of BMW Management Rules, 2016 include the following: (a) The scope of the rules has been expanded to include vaccination camps, blood donation camps, surgical camps or any other healthcare activity; (b) Phase-out the use of chlorinated plastic bags, gloves and blood bags within two years (c) Pre-treatment of the laboratory waste, microbiological waste, blood samples and blood bags through disinfection sterilization on-site in the manner as prescribed by WHO or NACO (d) Provide training to all its health care workers and immunize all health workers regularly; (e) Establish a Bar-Code System for bags or containers containing bio-medical waste for disposal; Page 16 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI (f) Report major accidents; (g) Existing incinerators to achieve the standards for retention time in secondary chamber and Dioxin and Furans within two years; (h) Bio-medical waste has been classified in to 4 categories instead of 10 to improve the segregation of waste at source; Cat. Type of Bag/ Type of Waste Treatment/Disposal Container used options Yellow non-chlorinated a) Human Anatomical Waste Incineration or Plasma plastic bags b) Animal Anatomical Waste pyrolysis or deep burial* C) Soiled Waste d) Expired or Discarded Separate collection Medicines system leading to e) Chemical Waste effluent f) Micro, Bio-t and other clinical treatment system lab waste g) Chemical Liquid Waste Red non-chlorinated Contaminated Waste (Recyclable) Autoclaving/microwaving plastic bags or tubing, bottles, intravenous tubes /hydroclaving and containers and then sent for recyling sets, catheters, urine bags, not be sent to landfill syringes (without needles) and gloves White (Translucent) Waste sharps including Metals Auto or Dry Heat Puncture, Leak, Sterilization tamper proof followed by shredding or containers mutiation or encapsulation Blue Cardboard boxes Glassware Disinfection or autoclaving, with blue colored microwaving, hydroclaving marking and then sent for recycling Page 17 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI (i) Procedure to get authorization simplified. The validity of authorization synchronized with validity of consent orders for Bedded HCFs. (j) The new rules prescribe more stringent standards for incinerator to reduce the emission of pollutants in environment; (k) Inclusion of emissions limits for Dioxin and furans; (l) No occupier shall establish on-site treatment and disposal facility, if a service of `common bio-medical waste treatment facility is available at seventy-five kilometers. (n) Operator of a common bio-medical waste treatment and disposal facility to ensure the timely collection of bio-medical waste from the Health Care Facility and assist the Health Care Facility in conduct of training. DUTIES OF OCCUPIER: 1. To provide a safe, ventilated and secured location for storage of segregated BMW within premises. 2. Phase out use of chlorinated plastic bags, gloves and blood bags within two years from the date of notification of these rules. 3. Provide training to all its health care workers and others involved in handling of bio medical waste. Page 18 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI 4. Immunization against Hepatitis B and tetanus for workers. 5. Establish a Bar-Code System for bags or containers containing bio-medical waste to be sent out of the premises. DUTIES OF OPERATOR: 1. Report major accidents and remedial measures to SPCB 2. Ensure timely collection of BMW from healthcare facilities 3. Handing over of recyclable waste to after treatment by autoclaving and incineration 4. Establish bar coding and GPS for handling within one year Page 19 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI 5.Assist health care facilities in training of workers 6. Upgradation of existing incinerators and achievement of standards for secondary chamber TREATMENT AND DISPOSAL: 1. No healthcare facility shall setup onsite BMW treatment facilities if a CBMWTF exists within 75 kms of distance. SEGREGATION, PACKING STORAGE AND TRANSPORT: 1. Bio-medical waste classified into 4 categories based on treatment options. 2. No untreated bio-medical waste shall be kept stored beyond a period of 48 hours 3. If required to store beyond 48 hours, the occupier shall ensure that it affect human health and inform the SPCB with reason. AUTHORIZATION: 1. One time Authorization for Non-bedded HCFs. 2. The validity of authorization shall be synchronized with validity of consent orders for Bedded HCFs MONITORING OF IMPLEMENTATION OF THE RULES: ANNUAL REPORT: 1. Every occupier shall submit an annual report to the prescribed authority by 30th of June every year 2. The prescribed authority shall compile, review, analyze and report to the Central Pollution Control Board (CPCB) by 31st July every year 3. The CPCB shall submit a report on the same to the Ministry of Environment, Forest & climate change by 31st August every year 4. The Annual reports shall be available on the websites of the occupier, State Pollution Control Board (SPCB) and the CPCB Page 20 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI MAINTENANCE OF RECORDS: 1. Records in relation to generation, collection, reception, storage, transportation, treatment and disposal shall be maintained as per rules For 5 years 2. Biomedical waste management website ACCIDENT REPORTING: 1. In case of major accident-intimate immediately and submit a report within 24 hours SCHEDULES: There are 4 schedules (or parts) in the Bio-Medical Waste rules 2016: Schedule 1: Categorization and Management Schedule 2: Standards for treatment and disposal of BMW Schedule 3: Prescribed Authority and duties Schedule 4: Label of containers, bags and transportation of Bio-Medical waste Schedule 1 of Bio-medical Waste Management Rules 2016 contains details of Bio-medical Waste categories and their segregation, collection, treatment, processing and disposal options. Bio-medical waste classified in to 4 categories based on treatment options Page 21 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Page 22 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI BMW Rules 2016 Implication SEGREGATION, PACKING STORAGE AND TRANSPORT Bio-medical waste classified in to 4 categories Will improve the segregation of waste at source based on treatment options instead of 10 channelize proper treatment and disposal categories based on type of waste as per previous rules. No untreated bio-medical waste shall be kept Reiteration of older rules to ensure HAI is stored beyond a period of 48 hours prevented If required to store beyond 48 hours, the Difficulty of obtaining permission within 48 hours occupier shall ensure that it affect human health is eliminated. and inform the SPCB with reason. TREATMENT AND DISPOSAL Pre-treatment of the laboratory waste, This is to prevent the possible microbial microbiological waste, blood samples and blood contamination. Logistical and administrative bags through disinfection or sterilization on-site issues abound especially if biomedical waste in the manner as prescribed by WHO or NACO mgmt. is outsourced. AUTHORIZATION One-time Authorization for Non-bedded HCFs. Application and consent can be given together The validity of authorization shall be synchronized SPCB can make single inspection with validity of consent orders for Bedded HCFs AUTHORIZATION provide training to all its health care workers and Will improve the management of BMW including others involved in handling of bio medical waste collection, segregation Immunization against Hepatitis B and tetanus for Will ensure protection of workers handling BMW workers Establish a Bar-Code System for bags or Improve segregation/transport containers containing bio-medical waste to be Prevent pilferage sent out of the premises Report major accidents and remedial measures Help monitor and improve management to SPCB Page 23 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI BMW Rules 2016 Implication MONITORING OF IMPLEMENTATION OF THE RULES: ANNUAL REPORT Every occupier shall submit an annual report to The Institutions are now compelled to retain the prescribed authority by 30th of June every documents in a different format. year The prescribed authority shall compile, review, - analyze and report to the CPCB by 31stJuly every year The CPCB shall submit a report on the same to - the MoEFCC by 31st August every year The Annual reports shall be available on the HCF become more transparent and accountable websites of the occupier, SPCB and the CPCB MAINTENANCE OF RECORDS Records in relation to generation, collection, Improve accountability reception, storage, transportation, treatment and disposal shall be maintained as per rules For 5 Generate data on the amount and type of years biomedical waste generated. ACCIDENT REPORTING Any major accident-intimate immediately and Risk analysis and mitigation improved submit a report within 24 hours Implementation: Efficient implementation of the bio-medical waste management pivots on orientation, training and involvement of all the staff in the facility. Ensuring proper disposal and segregation at source is the most important step as this is the limiting factor for most organizations. Continuous training and committees to monitor the implementation can be of help. Page 24 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Remember: 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 !!! Page 25 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Chapter IV: Bio-medical Waste Management at AIIMS: “ There are parallel stories running everywhere, And here’s one to share.. Patients whom we treat and manage Generate waste for others to treat and manage.. What you can expect to learn from this chapter “ s (OW IS "IO MEDICAL 7ASTE -ANAGEMENT AT !))-3 COORDINATED  s 4HE LIFE CYCLE OF A "IO MEDICAL 7ASTE UP TO THE POINT OF DISPOSAL s /N SITE TREATMENT OF LABORATORY WASTE s 7HAT HAPPENS AT THE #OMMON "IO MEDICAL 7ASTE TREATMENT FACILITY s ! BRIEF ON THE !))-3 3EWAGE 4REATMENT 0LANT For practical purposes, the whole system of Bio-Medical Waste and General waste Management in the hospital is be divided into the following segments First Segment Middle Segment Last Segment Segregation and Collection of 1. Collection and transportation of Transportation of waste at the site of generation biomedical waste from the collection Bio-medical waste from the (ward / lab /Blood bank / user points to Central temporary collection Central temporary areas etc.) and transportation to and storage facility collection and storage the Collection points i.e sluice area/ center, treatment and room/common corridor etc). 2. Collection and transportation of final disposal. This This service is carried out by biomedical waste from the collection segment of service is being outsourced sanitation firms. points at laboratories and blood rendered by the DPCC banks and microwaving of these authorized CBWTF wastes. Subsequently these wastes operator M/S Biotic Pvt. are transported to Central temporary Limited collection and storage facility 3. Transportation of general wastes from Collection points to NDMC central collection facility. These services are also carried out by outsourced sanitation firms Page 26 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Generation to Disposal Process – An illustrative journey ! Step -1 BMW is collected from various sites in appropriate location Step -2 waste is collected from colour coded bins and the bags are loaded on to trolleys Step -3 Trolleys from all over the hospital transport the waste and is storage in the Temporary Storage facility (for less than 48hrs) Page 27 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Step -4 Bags are weighed and bar coded Step -5 All Collected Bags are loaded on to special Bio Medical Waste Trucks and are transported to common BMW Treatment facility (Outsourced vendor approved by DPCC) Page 28 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI SPECIAL HANDLING OF LAB WASTE- PRE- TREATMENT ON SITE BEFORE DISPOSAL 1. BIO-MEDICAL WASTE GENERATED FROM THE VARIOUS LABOROTORIES 3. THE BAGS CONTAINING LAB WASTE ARE THEN TRANSPORTED TO THE TEMPORARY STORAGE FACILITY TO BE DISPOSED OFF ALONG WITH 2. OTHER BIO MEDICAL WASTE FROM THE BAGS ARE OTHER AREAS OF THE HOSPITAL LOADED IN A MICROWAVE AND ARE PRE- TREATED AS PER SPECIFIED GUIDELINES Page 29 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI FLOW CHART SHOWING PROCESS FOR DISPOSAL OF BIO-MEDICAL WASTE AT COMMON TREATMENT SITE (Courtesy – Biotic Waste Solutions Pvt. Ltd, New Delhi) TREATMENT PROCEDURE Collection of Bio-medical Waste in Leak Proof TSDF/LANDFILL closed Vehicles FACILTIY Final Disposal INCINERATION ASH ST A C K Incinerable Waste Flue Gases CBWTF INCINERATION AIR POLLUTION CONTROL DEVICE Autoclavable Waste AUTOCLAVING SHREDDING AUTHORISED RECYCLER Final Disposal E.T.P TREATED WATER VEHICLE WASHING REUSED IN CLEANING ETC. SCRUBBING & GREEN BELT, ETC. GLASS CHEMICAL ETP SLUDGE DISINFECTION STORED IN LEAK PROOF CONTAINERS AN ISOLATED PLACE AUTHORIZED RECYCLER Page 30 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Common Bio-medical Waste Treatment Facility (CBWTF) Collection of Bio Medical Waste from hospital at common treatment facility of Biotic Waste Solution (outside the hospital) Collection of Bio Medical Waste from hospital at common treatment facility of Biotic Waste Solution (outside the hospital) The yellow colour bags are put into the ROTARY KILN INCINERATOR for disposal by burning Page 31 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Biotic Waste Solution Pvt.Ltd.: Authorised Common Bio-medical Waste Treatment Facility Operator for AIIMS (CBWTF) Glassware recycled after treatment AUTOCLAVE- contents of RED Bags are autoclaved The contents from the RED are put into autoclave for sterilisation and then they are shredded before reuse. Page 32 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI SEWAGE TREATMENT PLANT OF AIIMS, NEW DELH a. Sewage Treatment Plant b. Chemical Liquid waste: Separate Collection system to STP c. STP being inspected by Kaya Kalp Inspection team: AIIMS, New Delhi was adjudicated first among all central govt.hospitals Page 33 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Did you know? That as of 2018, in a month, - AIIMS produces 24000 kgs of yellow waste, - 23,500 kgs of plastic and rubber waste - 500 kgs of sharps and 26,200 kgs of glass waste! - That is a colossal 74,500kgs a month or nearly 2500 kgs of Bio-medical waste a day!!! - Imagine if it doesn’t get segregated, transported, treated and disposed off correctly!!! Page 34 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Chapter V: “ Segregation: An Illustrative Guide : “ Segregation is knowing what goes where, and is as important as patient care! Page 35 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Page 36 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Page 37 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI WHITE CONTAINER PUNCTURE PROOF, LEAK & TAMPER PROOF FOR SHARPS ALL INFECTED SHARPS WASTE BIOHAZARD White Container: All infected sharps waste s 7ASTE 3HARPS INCLUDING -ETALS s.EEDLES s 3YRINGES WITH FIXED.EEDLES s.EEDLES FROM.EEDLE 4IP #UTTER OR "URNER s 3CALPELS s "LADES s #ONTAMINATED 3HARP OBJECTS Designed Under Guidance by: Department of Hospital Administration - AIIMS, New Delhi Page 38 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Page 39 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI                 ! 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K8N8 J K> \>" n"*o 8 av  56 &7(89 " ,:&;'' gY 8 7g\*  0* " 70= 8 2"  @3 Q7*" )*   7"&K K> KL @3 &n' *K U:"'8"* "F @ + 8" :Q " +"5 &* ;gj8 (8." 5"*" 7"&KZ &*.@ 8 8"."Fa.* @3 @Q R!S K> @Q R S'n" '" ="T 8H \Q&@8" @9:QJF Z6 =8"8 J A \ '" ="T 50 \ 56 &7(89 " ,:&;:8F @3 U' [ Va3 ==* =0† 0+ l]]m K> :  ="+W= 2 l‡ m 8 =8"8 J !* 7"&KZ. %9.8 8".F8'"F8 "ˆ. 8"F @3 )5F 0!"Z Page 44 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Page 45 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Chapter VII: Roles and Responsibilities of Stake holders: Though the knowledge of correct segregation practices is the most facet of the practices for all stakeholders including doctors, nurses and technicians, specific roles a needed to be enumerated. “ “ Here's an opportunity for all of us to play a crucial role, a responsibility to the nation and world as whole! 1. Heads of Department:- a) Primary leadership role, ensuring all staff understand the importance of bio medical waste mgmt.., follow correct practices, nurses feel empowered to correct erring residents and vice versa. b) Ensuring that all the consultants & residents are trained in adopting correct segregation practices and make regular inspections to see that they are followed by all consultants, the residents & nurses posted in their labs, wards, ICU’s & OT’s. c) Root cause analysis & corrective and preventive action of accident reporting as per BMW rules. d) Ensuring that nurses procure all the requisite items for bio medical waste management. 2. Consultants &Residents: a) Appropriate Segregation b) Vaccination c) Annual health check-up 3. Hospital Administrators: a) Compliance with all sections of the Bio medical waste management Rules -2016. b) Application, authorization & Renewal of Authorization. c) Submitting monthly & annual audit reports to statutory authority like DPCC. d) Procurement of all equipment/ items and ensure use across the hospital to aid in correct implementation of rules. e) Supervision & auditing at frequent intervals. f) Constitution of Bio medical waste management committee & holding regular meetings. g) Preparation of tenders & entering agreement regarding transportation of waste from source of generation to common waste collection area & from there to disposal. h) Coord. with Engineering service to ensure proper functioning of STP. Page 46 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI 4. Staff Nurses : a) Proper segregation b) Supervision of house keeping c) Senior nurses should audit the practices adopted by residents & all their subordinate staff including Hospital & sanitary attendants. d) Incident reporting e) Indenting & maintaining logistics required for BMW handling in ward, lab, ICU & OT’s. f) Ensuring that SA’s take proper precautions while handling waste. g) Post exposure prophylaxis to be ensured in case on needle stick injuries 5. Infection Control Nurses : a. Creating SOP’s of complete BMW handling. b. Maintaining data records & reporting. c. Regular rounds and audits d. Supervision of vaccination & health status of health care workers. e. Training of all health care staff in adopting corrects practices. 6. Hospital /Sanitary Attendants: Page 47 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI 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 ! Page 48 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Annexure-I SEGREGATION LIST OF COMMON ITEMS IN HOSPITAL AS PER BIO-MEDICAL WASTE MANAGEMENT RULES 2016: Yellow bin: 1. Human anatomical waste: A. Tissues, organs, body parts B. Foetus, Umbilical stump, placenta 2. Animal anatomical waste: Tissues, organs, body parts 3. Soiled waste: items contaminated with blood and body fluids A. Dressings , sponges, gauze B. Plaster casts C. Cotton swabs D. Blood bags E. Infected gowns, mask, shoe covers, cap 4. Expired or discarded medicines including antibiotics (except cytotoxic) 5. All yellow waste that are generated from labs 6. Chemical waste A. Discarded disinfectants, Cleaning agents B. X-ray film developing liquid, Infected secretions C. Aspirated body fluids, Liquid from laboratories Yellow bin with cytotoxic label: 1. Used, discarded and expired cytotoxic drugs whether in plastic vaccutainers, syringes , glass vials, ampoules, glass bottles.The container is not the determining factor in the case of segregation of cytotoxic wastes. 2. All items used during preparation and administration of cytotoxic drugs (eg: glass and plastic bottles, ampoules, vials, iv sets, gloves, syringes without needle, dressing, cotton swabs, etc.) Red bin: All infected plastic recyclable waste: A. Waste generated from tubings, I. Et/tt tubes, Ng tubes B. Plastic i/v bottles, (normal saline, J. Transparent dressing sheet (eg: tegaderm) DNS, Ringer lactate etc, etc) K. Ventilator/ nebulizer tubing’s C. IV tubes /BT sets, central line, PICC line L. Ostomy bags D. Gloves M. Tracheal tubes E. Urine bags, Catheters N. Suction/ oxygen tubing’s F. Drains O. Diagnostic kits G. Syringes without needles P. All plastic and rubber infected waste H. Vaccutainers without needles generated from laboratories* Page 49 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Sharp containers (puncture proof, tamper proof and leak proof) A. Needles without cap B. Pre-filled glass syringe with fixed needles C. Scalpel, blades D. Biopsy needles E. Guide wires F. Suture needles G. Cannula and biopsy needle stilette H. All sharps generated from laboratories* Blue marked cardboard box 1. Broken, discarded and contaminated glassware including slides, vials and ampoules (except cytotoxic waste) 2. Metallic body implants 3. Disposable laparoscopic instruments 4. All glassware generated from, laboratories * *All laboratory waste is first treated on site by microwaving before final disposal Black bin: 1. General waste including food, paper waste etc 2. Uninfected plastic wastes such a mineral water bottles 3. Uninfected disposable towel 4. Uninfected gowns, shoe covers, cap, masks 5. Covers of sterile items such as syringes etc 6. Sterillium used bottle 7. Bacillol or any other uninfected used bottle. Page 50 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Annexure-II Authorization of AIIMS under the BMW Management Rules 2016 Page 51 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT  ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI Annexure-III Consent to Operate under the Air (Prevention & Control of Pollution) Act 1981 and Water (Prevention & Control of Pollution) Act 1974 Page 52 MANUAL FOR BIO MEDICAL WASTE MANAGEMENT ALL INDIA INSTITUTE OF MEDICAL SCIENCES, NEW DELHI