KNOWLEDGE AND PRACTICES OF NURSES

REGARDING BIOMEDICAL WASTE

MANAGEMENT IN SELECT GOVERNMENT

HOSPITALS

Lt Col Sarvjeet Kaur

Army Hospital (R&R)

India

INTRODUCTION

Anyone, man or animal that takes in food and air and gives off wastes, is a polluter

NOMADIC MAN WAS CLOSE TO NATURE

In olden days, the disposal of waste did not pose significant problems as the population was very small and a vast expanse of land was available for the assimilation of such wastes

• Importance of disposal of solid and liquid waste generated by the people has been recognized by the early civilizations.

• Mohen-jo-daro and Harappa • “Cleanliness is next to Godliness”

• First municipal dump in the western world was in the city of Athens in 500 BC

• Citizens were required to dispose off their waste at least one mile from the city walls.

Hospital waste - A concern for Public Health Administration

DEFINITION OF BMW

According to World Health Organization Healthcare waste includes all the waste generated by healthcare establishments, research facilities, and laboratories

Biomedical waste means any waste which is generated during the diagnosis, treatment or immunization of human beings or animals or in research activities pertaining thereto or in the production or testing of biological (Government of India Gazette 1998, Ministry of Environment and Forests Notification “Bio-Medical Waste (Management and Handling) Rules 1998”).

BMW-A POTENTIAL FOR INFECTION AND INJURY

Biomedical waste

80%

15%1% 1%3%

Gen waste Infec/Anat waste Chemical Radioactive Sharps

BMW- ON THE RISE

• Several surveys done by WHO (1985-2012) have provided an indication of typical healthcare waste generation.

• Generation of healthcare wastes differs not only from country to country but also within a country

SUMMARY OF REVIEW OF LITERATURE

• The United Nations Conference on the Environment and Development (UNCED) (1992) led to the adoption of Agenda 21 as International recommendations for waste management

• Recommendations include– prevention and minimization of waste production– Reuse or recycle – Treat waste by safe & environmentally sound

methods – Disposal of the final residues

SUMMARY OF REVIEW OF LITERATURE

• The World Health Organization (1995) states-– National legislation is the basis for improving

healthcare waste practices in any country– Ministry of environment or national

environmental protection agency may also be involved

SUMMARY OF REVIEW OF LITERATURE

RECOMMENDED COLOUR-CODING FOR HEALTHCARE WASTE

Type of waste Colour of container Type of container markings

Highly infectious waste Yellow

Marked HIGHLY INFECTIOUS or container capable of being autoclaved Strong, leak-proof plastic bag,

Other infectious waste,pathological anatomicalwaste

Yellow Leak-proof plastic bag or container

Sharps Yellow Puncture-proof container “SHARPS”

Chemical andpharmaceutical waste Brown Plastic bag container

Radioactive waste Lead box Labeled with the radioactive symbol

General healthcare Waste Black Plastic bag

Source: WHO, Action plan for the development of national programme for sound management of hospital wastes.

INDIAN SCENARIO

• Limited data available in biomedical waste management in developing countries.

• Government of India, July 20, 1998- ‘Bio-Medical Waste (Management and Handling) Rules.

• Amendments issued in the year 2000 for technology acquisition,

• Health care facilities to take necessary measures for proper segregation, handling and disposal of infectious waste to reduce the hazards of (re)use and disposal.

• The draft rules, namely, the Bio-Medical Waste (Management and Handling)Rules, 2011 were published by the Central Government on 24 th August,2011

• Draft for Bio-Medical Waste(Management and Handling) Rules, 2015 underway

INDIAN SCENARIO

• Waste generated from Medical and surgical wards, labour room, Operating theatres, laboratories etc

• Waste categorized as per their infectivity into ten categories

• Five colour codes-red, yellow, blue, black/green, white

BIOMEDICAL WASTE (BMW)

WASTE SEGREGATION AT POINT OF GENERATION

SCOPE OF THE STUDY• For the present study, the healthcare institutions in a

well established urban city of India were identified through available literature.

• The criterion for selection was based on the bed strength of the hospitals i.e. hospitals above 500 beds

• The biomedical waste management cycle of the three select hospitals were studied.

BMWM cycle in the three hospitals

1, 2, 3, 6

3, 6, 7

4, 7

5, 9, 10

Disposal in secured landfill

AutoclavingMicrowavingChemical treatment and

destruction/ shredding

AutoclavingMicrowavingChemical treatment

IncinerationAutoclavingMicrowaving

Discarded medicines and cytotoxic drugs

Incineration ash Chemical waste

Waste sharpsSolid waste

Soiled waste Solid waste Microbiology tissue

Human anatomical waste Animal waste Microbiology tissue &soiled

waste

Waste Segregation and Disposal

QUANTITY WISE WASTE GENERATION

Terminal treatment modality

Hospital

Hospital (I) Hospital (II) Hospital (III)

Incinerator capacity 10 kilograms/hr 100 kilograms/hr 100 kilograms/hr

Incinerated waste 150+80 kilograms/day*

100kilograms/day 100-120 kilograms/day

Shredder capacity 25 kilograms/hr 25kilograms/hr 25 kilograms/hr

Shredded waste 40kilograms/day 15 kilograms/day 15 kilograms/day

Municipal dump 2000kilograms/day 1000kilograms/day 2000 kilograms/day

OBJECTIVES OF THE STUDY

To assess the knowledge and practices of

biomedical waste management among the

nurses in the three hospitals.

NURSING SERVICE

• The nursing service administration of the three hospitals was vertically positioned at three levels – i.e. at the base level, bedside nurses were involved in

direct patient care and ward administration– At the middle level, head nurses being called as

Senior Sister or Nursing Sister were managing the ward rotations along with intra and inter departmental aspects of administration

– At the top level there were the Nursing Superintendents with the Assistant Nursing Superintendents who supervised the functioning of nursing personnel

• Senior most nurse in the ward was in charge of the ward administration who supervised the biomedical waste management

• There also existed a post of Infection Control Nurse in Hospital (I) and (III); there was no post of Infection Control Nurse in Hospital (II).

NURSING SERVICE

RESEARCH METHODOLOGY

- Descriptive research design

- Both primary and secondary data was used.

Research instrument used in the study were:

• Questionnaire- Semi structured interview schedule with both close ended and open ended questions.

• Observation rating scale - Observation rating scales was prepared (Likert type) to collect information on waste generation, segregation, collection, labeling, transport and disposal

• Non participant observation used to observe methods of waste generation, segregation and waste treatment

RESEARCH METHODOLOGY

• A pilot study of at least 3 per cent of the sample was undertaken to analyze the validity/reliability of the interview schedule.

• Validity and reliability-Content validity was established, test re-test method was utilized for the questionnaires and inter rator reliability for the observation rating scales. The reliability coefficients were found to range between 0.84 to be 0.87 suggesting high reliability in various tools.

• Sampling-Selection of Nurses was done by stratified random sampling from all the wards and departments of the hospital.

• Data Analysis-The primary data analysed using the Statistical Package i.e. Statistical Product for Service Solutions (SPSS). Various statistical formulae like cross-tabulation between the Dependent Variables and the Independent Variables, Chi-Square Test etc.

SAMPLING SAMPLE OF NURSES IN SELECT HOSPITALS

Sample of Nurses in selHospitals

Category Hospital (I) Hospital (II) Hospital (III)

Total Nurses 402 174 65

Sample per cent 17 50 100

Sample 75 75 65

As the hospital waste generation is maximum in the morning hours 80 per cent of the sample was taken from the nurses working in the morning shift, 10 per cent each from the nurses working in the evening and the night shift.

Distribution of the nurses as per their shifts

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Hosp I Hosp II Hosp III

Morning Evening Night

SOCIO-DEMOGRAPHIC PROFILE OF THE NURSES IN SELECT HOSPITALS

Attributes Hospitals

Hospital (I) n=75

Hospital (II)n=75

Hospital (III)n=65

Professional Qualification

GNM 64 (85.3) 68 (90.7) 25 (38.5)

B.Sc. Nursing 11 (14.7) 07 (09.3) 13 (20.0)

Nursing Assts 00.0 00.0 27 (41.5)

EmploymentContract 14 (18.7) 12 (16.0) 00.0

Permanent 61 (81.3) 63 (84.0) 65 (100.0)

Age in years

< 40 61 (81.3) 45 (60.0) 51 (78.5)

41-50 11 (14.7) 14 (18.7) 14 (21.5)

>50 03 (04.0) 16 (21.3) 00.0

Duration of work in years

Below 01 03 (04.0) 07 (09.3) 05 (07.7)

01-05 17 (22.7) 29 (38.6) 59 (90.8)

06-10 24 (32.0) 11 (14.7) 00.0

11-15 22 (29.3) 14 (18.7) 00.0

>15 09 (12.0) 14 (18.7) 01 (01.5)

ANALYSIS OF KNOWLEDGE SCORES OF RESPONDENTS

Knowledge scores Proportion of response (in per cent)

Adequate knowledge 100-80

Partially adequate knowledge 79-60

Inadequate knowledge <60

PROPORTION OF RESPONSES OF RESPONDENTS

Proportion of responses by respondents

Proportion of respondents

Poor 0-20

Fair 21-40Moderate 41-60

Majority 61-80High majority 81-100

KNOWLEDGE OF NURSES REGARDING POLICIES OF BMWM IN THEIR HOSPITALS

AttributesKnowledge

scores

Hospital (I)

n=75

Hospital (II)

n=75

Hospital (III)n=65

χ2 p

Policies

Adequate 21 (28.0) 05 (6.7) 41(63.0)

65.1df=04

<0.001Partially adequate

37 (49.3) 27 (36.0) 12 (18.5)

Inadequate 17 (22.7) 43 (57.3) 12 (18.5)

Waste segregation

Adequate 00.0 00.0 00.0

69.9df=02

<0.001Partially adequate

62 (82.6) 22 (29.3) 58 (89.2)

Inadequate 13 (17.4) 53 (70.7) 07 (10.8)

There was more involvement of nurses in Hospital (III) and (I) in hospital policy formation, implementation and revision

KNOWLEDGE OF NURSES REGARDING POLICIES OF BMWM IN THEIR HOSPITALS

KNOWLEDGE OF NURSES REGARDING TRANSPORT, TREATMENT AND DISPOSAL OF BMWM IN THEIR

HOSPITALS

AttributesKnowledge

scoresHospital (I)

n=75Hospital (II)

n=75Hospital (III)

n=65χ2 p

Waste transport

Adequate 57 (76.0) 74 (98.6) 62 (95.4)

11.1 <0.01Partially adequate

10 (13.3) 01 (1.4) 03 (4.6)

Inadequate 08 (10.7) 00.0 00.0

Waste treatment

Adequate 08 (10.7) 00.0 01 (1.5)

50.5 <0.001Partially adequate

25 (33.3) 01 (1.2) 05 (7.7)

Inadequate 42 (56.0) 74 (98.6) 59 (90.8)

Final disposal of waste

Adequate 00.0 00.0 00.0

108.1 <0.001Partially adequate

05 (6.7) 06 (8.0) 50 (77.0)

Inadequate 70 (93.3) 69 (92.0) 15 (23.0)

FINDINGS

•Nurses were found to have more knowledge regarding segregation and less regarding waste transport•Nurses in all the three hospitals had very low scores on adequate knowledge regarding waste treatment

• Nurses in Hospital (II)&(I) had less knowledge regarding blue container as

doctors were dealing more with plastic waste like syringes, intravenous fluids and drugs

FINDINGS R/T COLOUR CODING

KNOWLEDGE OF NURSES REGARDING USE OF UNIVERSAL PRECAUTIONS AND PERCEIVED RISK

RELATED TO BMWM IN THEIR HOSPITALS

AttributesKnowledge

scoresHospital(I)

n=75Hospital (II)

n=75Hospital(III)

n=65χ2 p

Use of universal

precautions

Adequate 31 (41.3) 20 (26.6) 49 (75.4)

32.1df=2

<0.001Partially adequate

44 (58.7) 51 (68.0) 16 (24.6)

Inadequate 00.0 04 (05.4) 00.0

Perceived risk regarding

BMWM

High risk 06 (08.0) 31 (41.3) 00.0

93.4df=4

<0.001Moderate risk 40 (53.3) 44 (58.7) 21 (32.3)

Low risk 29 (38.7) 00.0 44 (67.7)

No risk 00.0 00.0 00.0

Perception of BMWM as a

health hazard

Always 06 (08.0) 01 (01.3) 00.0

6.9df=2

<0.05Sometimes 37 (49.3) 49 (65.3) 29 (44.6)

Occasionally 32 (42.7) 25 (33.4) 36 (55.4)

Never 00.0 00.0 00.0

RELATIONSHIP BETWEEN USE OF UNIVERSAL PRECAUTIONS AND PERCEIVED RISK AMONG

NURSES IN THREE HOSPITALS

01020304050607080

Hosp I Hosp II Hosp III

No

of n

urse

s

Universal precautions Risk

KNOWLEDGE OF NURSES REGARDING BIOMEDICAL WASTE MANAGEMENT POLICY IN THREE HOSPITALS

Attribute

Knowledge scores of nurses in three hospitals

χ2 pVariables

Hospital (I) n=75 Hospital (II) n=75 Hospital (III) n=65

AdequateNot Adequate

AdequateNot Adequate

AdequateNot Adequate

Employment

Contract 07 (50.0) 07 (50.00) 06 (50.0) 06 (50.0) 00.0 00.0 * *

Permanent

51 (83.6) 10 (16.40) 26 (42.6) 37 (57.4) 53 (81.5) 12 (18.5) 33.4 <0.001

Age in years

<40 44 (72.1) 17 (27.90) 16 (35.5) 29 (64.5) 41 (80.4) 10 (19.6) 23.6 <0.001

41-50 11 (100) 00.0 07 (50.0) 07 (50.0) 12 (85.7) 02 (14.3) * *>50 03 (100) 00.0 09 (56.3) 07 (43.7) 00.0 00.0 * *

Professional

Qualification

GNM 54 (84.4) 10 (15.60) 28 (41.2) 40 (58.8) 25 (100) 00.0 42.2 <0.001

B.Sc. Nursing

04 (36.4) 07 (63.60) 04 (57.1) 03 (42.9) 13 (100) 00.0 * *

Class I,II,III

- - - - 15 (55.5) 12 (44.5) * *

Duration of work in

years

Below 01 00.0 03 (100.00)

03 (42.8) 04 (57.2) 05 (100) 00.0 * *

01-05 15 (88.2) 02 (11.80) 09 (31.0) 20 (69.0) 47 (79.7) 12 (20.3) 24.9 <0.001

06-10 17 (70.8) 07 (29.20) 07 (63.6) 04 (36.4) 00.0 00.0 * *

11-15 17 (77.3) 05 (22.70) 03 (21.4) 11 (78.6) 00.0 00.0 * *

>15 09 (100) 00.0 10 (71.4) 04 (28.6) 01 (100) 00.0 * *

KNOWLEDGE OF NURSES REGARDING BIOMEDICAL WASTE SEGREGATION IN THREE HOSPITALS

Attribute

Knowledge scores of nurses in three hospitals

χ2 pVariables

Hospital (I) n=75

Hospital (II)n=75

Hospital (III)n=65

Adequate Not Adequate

Adequate Not Adequate

Adequate Not Adequate

Employment

Contract 13 (92.8) 01 (7.2) 02 (16.7) 10 (83.3) 00.0 00.0 * *

Permanent 49 (80.3) 12 (19.7) 20 (31.7) 43 (68.3) 58 (89.2) 07 (10.8) 55.0 <0.001

Age in years

<40 55 (90.2) 06 (9.8) 13 (28.9) 32 (71.1) 46 (90.2) 05 (9.8) 60.6 <0.001

41*50 06 (54.5) 05 (45.5) 04 (28.6) 10 (71.4) 12 (85.7) 02 (14.3) * *

>50 01 (33.3) 02 (66.7) 05 (31.2) 11 (68.8) 00.0 00.0 * *

Professional Qualification

GNM 53 (82.8) 11 (17.2) 22 (32.4) 46 (67.6) 23 (92.0) 02 (8.0) 46.9 <0.001

B.Sc. Nursing

09 (81.8) 02 (18.2) 00.0 07 (100) 13 (100) 00.0 * *

Class I,II,III - - - - 22 (81.5) 05 (18.5) * *

Duration of work

Below 01 yr 02 (66.7) 01 (33.3) 01 (14.3) 06 (85.7) 05 (100) 00.0 * *

01*05 yrs 16 (94.1) 01 (5.9) 11 (37.9) 18 (62.1) 52 (88.1) 07 (11.9) 30.2*

<0.001*

06*10 yrs 20 (83.3) 04 (16.7) 03 (27.3) 08 (72.7) 00.0 00.0

11*15 yrs 21 (95.4) 01 (4.6) 04 (28.6) 10 (71.4) 00.0 00.0 * *

>15 yrs 03 (33.3) 06 (66.7) 03 (21.4) 11 (78.6) 01 (100) 00.0 * *

• The permanently employed nurses in Hospital (I) and (III) had better knowledge regarding policies related to BMWM

FINDINGS

• In all the three hospitals, the increase in age was directly proportional to increase in knowledge regarding policies related to biomedical waste i.e. in all the three hospitals, as the age increased, the knowledge regarding BMWM increased.

FINDINGS

• In all the three hospital, nurses with 01-05 years of duration (stay) were found to have better knowledge regarding waste segregation.

FINDINGS

• Nurses of Hospital (III) were found to be completely responsible for BMWM in the hospital and hence score highest on knowledge scores

• Another reason for better waste segregation and management in Hospital (III) was periodic in-service education programmes being conducted in the hospital, almost on monthly basis which was not being conducted in Hospital (I) and (II).

• These nurses had knowledge on indenting for BMWM articles, infrastructure required for waste segregation & standing operative procedures for segregation in ward.

FINDINGS

• The knowledge of waste transport and disposal in Hospital (II) was found more as compared to other two hospitals.

• The reason for this was that in Hospital (II), the nurses were responsible directly to supervise the waste transportation and its feedback to Medical Officer In-Charge of ward and were hence responsible for the same.

FINDINGS

• Another reason was the permanency of the Group D employees in the ward. They were found to be constant in the ward and hence took responsibility for their ward’s waste transport.

• In Hospital (I), this role was completely taken over by Sanitary Inspector and hence nurses did not involve themselves in waste transport and disposal

FINDINGS

• Nurses in all the three hospitals had very low scores on adequate knowledge regarding waste treatment as the nurses were not responsible for treatment or transport

FINDINGS

FINDINGS

• The over all knowledge scores of the nurses regarding final waste disposal was found poor

THREE CONSECUTIVE OBSERVATIONS OF PRACTICES REGARDING BMWM AMONG

NURSES

Attribute

Hospital (I)n=75

Hospital (II)n=75

Hospital(III)n=65

χ2 pNo of observations No of observations No of observations1 2 3 Total 1 2 3 Total 1 2 3 Total

Correct segregati

on

03(4.0)

04(5.4)

04(5.4)

11(4.9)

04(5.4)

03(4.0)

03(4.0)

10(4.4)

10(15.4)

09(13.8)

09(13.8)

28(14.3)

80.7df=4

<0.001

Partially correct

segregation

55(73.3)

57(76.0)

59(78.6)

171(76.0)

40(53.3)

35(46.7)

37(49.3)

112(49.8)

70(93.3)

71(94.7)

71(94.7)

212(94.3)

Waste thrown

anywhere

17(22.7)

14(18.6)

12(16.0)

43(19.1)

31(41.3)

37(49.3)

35(46.7)

103(45.8)

02(3.1)

00.0 02(3.1)

04(2.1)

Total 75 75 75 225 75 75 75 225 65 65 65 195

THREE CONSECUTIVE OBSERVATIONS OF PRACTICES OF BMWM AMONG NURSES

-10

10

30

50

70

90

110

130

150

Hosp I Hosp II Hosp III

No

of n

urse

s

Correct Partially correct Incorrect

FINDINGS

Common procedural errors/issues noted in BMWM segregation practices in select hospitals(sharps)-

• Not burning the needle after use, recapping of needle, discarding needle in needle cutter, container for sharps without disinfectant, Discarding syringe without removing the needle, throwing waste out of container or over the lids of container

• Pilot study conducted in the three hospitals brought out this interesting phenomenon of the patients and patients attendants helping the nurse in waste segregation.

• It was observed on three consecutive occasions that the nurses were being assisted by patients, attendants in their ward’s waste segregation practices

FINDINGS

SCORING OF NURSES FOR BMWM IN SELECT HOSPITALS

BMWM scoring parameters Hospital (I) Hospital (II) Hospital (III)

Policies Inadequate (0.0) Inadequate (0.0) Adequate (1.0)

Waste segregation Adequate (1.0) Inadequate (0.0) Adequate (1.0)

Waste transport Adequate (1.0) Adequate (1.0) Adequate (1.0)

Waste treatment Inadequate (0.0) Inadequate (0.0) Inadequate (0.0)

Final disposal of waste Inadequate (0.0) Inadequate (0.0) Adequate (1.0)

Colour codingRed (Infectious)

Yellow (Infectious)Blue (Plastic)

Black (General)

Adequate (1.0) Adequate (1.0) Adequate (1.0)

Adequate (1.0) Adequate (1.0) Adequate (1.0)

Adequate (1.0) Adequate (1.0) Adequate (1.0)

Adequate (1.0) Adequate (1.0) Adequate (1.0)

Use of universal precautions Inadequate (0.0) Inadequate (0.0) Adequate (1.0)

Perceived risks Low(1.0) High(0.0) Low(1.0)

Practices Correct (1.0) Incorrect (0.0) Correct(1.0)

TOTAL 8/12 5/12 11/12

‘Answers magically appear through incubating and percolating’

Jeanne Sharbuno

• The hospitals in the present study though had a BMWM committee on papers, it was not found active and functional in all aspects of BMWM.

RECOMMENDATIONS

BMW Rules, 1998

The Gazette of India,

Extraordinary, Part II,

Section 3, Subsection (II)

Ministry of Environment

and Forests Notification,

New Delhi, 20 July 1998

• There are no clear policies on Infection Control Committee- It is recommended that an Infection Control Committee which is formulated in the hospitals but remains largely in the papers be made active.

RECOMMENDATIONS

• Pre-vaccination screening and Hepatitis-B vaccination among the staff members and monitoring the health records of all health workers must be made mandatory by the committee.

RECOMMENDATIONS

• The middle level nursing administrators should aim towards implementation of BMWM policy

RECOMMENDATIONS

• Nurses stated that relievers of duty create most problems in BMWM.

• These staff members do not own up any responsibilities for BMWM in the ward and this consecutively affects the BMWM cycle in the ward.

RECOMMENDATIONS

• Operation Theatre nurses felt that Sanitary Inspector should be responsible to see that the segregation was done in proper manner in operation theatre as it was a very busy area and the nurses and doctors had no time to look after BMWM.

• So the operation theatre should have permanent staff.

RECOMMENDATIONS

• The nurses in Hospital (III) lamented that there was a paucity of time to teach the Group D employees about BMWM due to heavy patient load

• Hospital Administrators should organize induction training, periodic on the job training and refresher courses for all grades of employees

RECOMMENDATIONS

• Visit to incinerator, shredder area, pathology laboratory and deep burial sites will improve the practices of health workers

RECOMMENDATIONS

• Each floor or section of the hospital should have a separate sluice room for mop washing and drying

RECOMMENDATIONS

• Establish a ‘Green team’ made up of administrator, nurses and house keeper who are responsible for waste handling.

RECOMMENDATIONS

• Conduct a waste audit –records & reports

RECOMMENDATIONS

• Use the results of the audit to identify wasteful practices and develop a waste management strategy

RECOMMENDATIONS

• There were no hand washing facilities for the Group D employees, same recommended.

RECOMMENDATIONS

Waste transportation methods differed in the hospitals.

• Collection of waste from the wards as per the colour coding by different waste transporters is recommended

RECOMMENDATIONS

• The overall scores for BMWM the hospitals that had outsourced their cleaning were better and hence outsourcing is recommended within the financial constrains of the hospital.

RECOMMENDATIONS

• Senior nurses should be more involved in waste segregation through in- service education programmes and through their participation in Waste Management Committees in the hospitals and in their departments.

RECOMMENDATIONS

Patients should not be involved in helping nurses in waste segregation.

• 3 R’s

RECOMMENDATIONS

Nurses should help make earth a decent rather than deadly inheritance for our children.

THE TIME TO ACT IS ….NOW

Thank You