Facilities - Waste

Attitudes and Actions

The last decade has witnessed a significant increase of public concern regarding medical waste disposal. This has been fuelled by reports of medical wastes washing up on the coasts of Florida and the Gulf and the 'recycling' of disposable articles in developing countries. The reports and figures available from developed countries indicate a range from 1-5kg/bed/day waste is generated, with substantial inter-country and inter-specialty differences. The meagre data available from developing countries indicate that the range is essentially similar but that the figures are lower (1-2kg/day/patient). In India, it is estimated to be 2.0kg/bed/day.

Pathogenic organisms can be present in hospital solid wastes in significantly high concentrations as well as increased concentrations of organic substrate. Substantial numbers of organisms of human origin have been found, which suggests the presence of virulent pathogenic bacteria and viruses living on solid waste in undetected numbers. The handling of hospital solid waste may increase airborne bacteria if not handled properly and the transmission of viable organisms to other parts of hospital and community is possible.

Improper hospital waste management has a serious impact on the environment. The government of India reacted to global concern and notified the biomedical waste management rules 1998 (Ministry of Environment and Forests, Notification, New Delhi, 20 July 1998). These rules have been framed in exercise of the powers conferred by Sections 6, 8 and 25 of Environment (Protection) Act 1986. This is applicable to every hospital and nursing home, veterinary institution, animal house or slaughterhouse that generates biomedical waste. Exceptions are clinics, dispensaries and laboratories providing treatment or diagnostic facility to less than 1000 patients per month. The objectives and rationale of biomedical waste management are mainly to reduce waste generation and ensure its efficient collection, handling, cost effectiveness and disposal in such a way that it controls infection and provides safety to employees working in the system. The basic elements are to recognise the waste, identify where waste is generated and determine the cause of generation, plan disposal of the waste in a scientific manner so as to render it environmentally non-hazardous and eliminate the source of infection.

Healthcare workers need to understand the difference between biomedical waste and other waste connected with the hospital. Hospital waste refers to all waste, biological or non-biological that is discarded. According to a WHO report, around 85 per cent of hospital waste is non-hazardous, 10 per cent is infective (and hence, hazardous) and the remaining 5 per cent is non-infectious but hazardous - chemical, pharmaceutical or radioactive.

Biomedical waste differs from hospital waste in the sense that it is any solid, fluid or liquid waste, including its container and any intermediate product. These products could be generated during the diagnosis, treatment of immunisation of human beings or animals, in research or in the production or testing of biological and the animal waste from slaughter houses or any other similar establishments.

A number of events have been organised to help to create awareness about hospital waste in India. The harsh realities are, however, far from ideal and it will need a lot of effort and commitment at the highest level for effective implementation. Currently, there is partial or no segregation at the time of generation, which at times was done by contractor, and rag pickers often gain entry to premises.

Clearly, statutory safeguards for biomedical waste management practice in Indian hospitals have still not achieved the desired standards. In view of this, a study on knowledge, attitude and practice on the subject was conducted in a tertiary-level teaching hospital. The All India Institute of Medical Sciences (AIIMS) Hospital has 1600 beds and speciality medical care and research programmes, it also boasts the latest facilities. The AIIMS hospital is a premiere institute, serving as a role model for other hospitals and health facilities. Therefore, understanding employees' current biomedical waste management awareness will help the authorities to develop a strategy to improve biomedical waste management across India in the future.

Pre and Post-Synaptic Effects

The department of hospital administration of AIIMS hospital in Delhi designed a hospital waste management manual to make the waste generator aware of correct practice. Books, manuals and circulars were distributed among staff by the department to encourage a well-organised management system of all potentially infectious and hazardous wastes in accordance with the biomedical waste (management and handling) rules, 1998. However, in practice, it was observed that staff were mixing infectious and non-infectious waste. This is possibly due to improper segregation at the site of origin. A study was, therefore, conducted to gauge employee awareness based on a questionnaire formatted to understand the knowledge, attitude and practice of employees involved in direct patient care regarding biomedical waste management methods.

The questionnaire had a set of 12 items concerning the knowledge, understanding and their behaviour on the subject. This was further categorised in three sets with one question each on knowledge, attitude and practice. This questionnaire was given to seven categories of staff only in selected high-risk areas, including OT, laboratories, medicine and surgery wards. The seven categories of staff were: consultants, residents, scientists, nurses, OT staff, sanitary staff and laboratory staff. They were grouped as Group I to Group VII accordingly. Of the 200 questionnaires distributed, 156 (78 per cent) were received back: 13 per cent were from consultants, 16 per cent from residents, 14 per cent from scientists, 13 per cent from nurses, 14 per cent from OT staff, 14 per cent from sanitary staff and 16 per cent from laboratory staff 16 per cent.

The KAP status of the groups were analysed by using numerical value '1' for a positive answer and '0' for negative answers. Inter- and intra-group differences and p value were calculated by using Chi-square 2xT test.

Knowledge

The results of questionnaire analysis show that consultants, residents and scientists have, respectively, 85, 81 and 86 per cent knowledge of the biomedical waste management rule. The knowledge component among the nurses was shown to be 60 per cent and that of sanitary staff, OT and laboratory staff, respectively, 14, 14 and 12 per cent. This shows that people with a higher level of education have a greater awareness of the environmental issues, national and international activities on biomedical waste management and the rules prescribed therein.

The question that directly indicates people's awareness of the reasons for making a law on biomedical waste was best answered by OT staff, having an awareness level of 90 per cent. There was an 80 per cent awareness level in nurses, 74 per cent in residents, 71 per cent in sanitary staff, 70 per cent in professors and 64 per cent in scientists. Only 36 per cent of laboratory staff had knowledge of the reasons for the law. These results show that those who are involved in direct patient care are relatively more aware of the correct procedures than the other hospital workers. Those who are least related with patient care are relatively less aware of the procedures. This may be due to the guidelines of biomedical waste management being emphasised in the area where there are direct-to-public activities orientated to patient care rather than the hospital process. Or possibly because their activities are overlooked and monitored by supervisory staff of the hospital administration and the decision makers in the hospital.

The results of all the groups are poor where it was asked whether they ever attended any seminar or class regarding biomedical waste. Nurses as a group had highest percentage of positive response at the rate of 40 per cent. Lowest were found to be laboratory staff, with an attendance rate of 12 per cent. This can be substantiated by the fact that laboratory staff were neither provided with the necessary information nor they were involved in any of the training programmes. Consultants, residents, scientists, OT staff and sanitary staff, respectively, scored 20, 37, 27, 19 and 14 per cent. Some have attended a seminar or class related to the subject and, hence, are aware of the concept of scientific waste management procedures.

Attitude

In regard to attitude towards scientific process, nurses scored 100 per cent in set-I, 100 per cent in set-II and 95 per cent in set-III in response to the questions on the subject. Similarly, consultants scored 80, 85 and 90 per cent, residents rated 85, 96 and 63 per cent and scientists 55, 95 and 59 per cent in regards to attitude towards the scientific practice. OT staff scored 90, 95 and 86 per cent, whereas sanitary staff scored 81, 81, 76 per cent. Laboratory staff were markedly lower, scoring 56, 88 and 32 per cent.

Practice

In the group of three sets of questionnaire, the findings shown that consultants were practicing according to biomedical waste rules to the tune of 75, 80 and 65 per cent. Residents were rated 89, 81 and 78 per cent and scientists 82, 73 and 82 per cent, respectively, practicing as per rules. In regards to nurses, it was shown that 100 per cent them were practicing according to the rules. OT staff had 90, 90 and 95 per cent compliance and sanitary staff 67, 48 and 90 per cent. Similar to the earlier findings in regard to practice, laboratory staff showed only 44, 32 and 64 per cent compliance with the guidelines and norms listed down in the hospital in regard to biomedical waste.

Staff Comparison

The comparison of knowledge, with attitude and practice of groups shows that the people with a greater level of education - such as consultants, residents and scientists - have very good knowledge of the rules, but relatively few have the same kind of attitude and practice habits. At the same time if we compare the nurses or OT staff, we find that they too have good percentage of people with good knowledge, however, practice percentage is also very high. This has been mainly attributed to the instruction manual and the responsibility given to the nursing staff for implementation of rules by the authorities.

Sanitary staff, though they have very poor knowledge about the biomedical waste Act and rules, have good percentage of people with positive attitude and practice habits. Laboratory staff were found to have lowest percentage in all categories. This might indicate that laboratory staff were not informed of the legal requirements, perhaps because supervisors were unaware of this group's prime importance in following biomedical waste management. Laboratory staff also showed the least interest in learning about correct procedure, as they felt that it is the responsibility of those providing direct patient care.

The questionnaire also had two questions about the availability of hospital facility in regard to biomedical waste management. This when analysed shows that, 80 per cent of people said that hospital provides enough infrastructures for proper implementation of biomedical waste management rules. However, 15 per cent of consultants and 12 per cent residents do not know whether hospital provides the proper facilities for segregation and removal of waste and 2 per cent answered that it is not provided. This could be because they do not think biomedical waste management as an important prerequisite for a good patient care service. Some also felt that this is not their duty to find out whether or not such a system exists and that biomedical waste management is the responsibility of the administration and sanitary staff not the doctors. Alarmingly, 20 per cent scientists said that proper facilities are not provided by hospital. As per laboratory staff, 35 per cent were not provided with proper physical facilities for proper implementation of biomedical waste management rules.

In suggestions, asked for, almost everyone said that intensive training programmes would help increase awareness and practice. Increasing the knowledge as well as the sense of responsibility of staff members can attain the promotion of attitude and practice habits. It is thought that publicising the subject through the public media as well as through departmental programmes will definitely help to achieve the desired goal. Some respondents even suggested that strict rules and regulation by authorities with provision of punishment and penalty will serve the purpose.