nghiên cứu về quản lý chất thải y tế tại bệnh viện đại học Norwich và Norfolk Pudussery kevin 2011

nghiên cứu về thực trạng quản lý chất thải y tế tại bệnh viện đại học norwich và norfolk. do Kenvin Paul Pudussery thực hiện năm 2011. Luận án tập trung chủ yếu về quản lý chất thải y tế tại NNUH. Chương 1 là phần giới thiệu và nhằm mục đích để cung cấp cho một thông tin cơ bản liên quan đến quản lý chất thải y tế và biện minh cho chủ đề. Chương 2 tài liệu hiện hành về quản lý chất thải y tế. Các phương pháp được sử dụng để đạt được các mục tiêu và mục đích của dự án này được giải thích trong chương 3. Các kết quả dự án được đưa ra trong chương 4 và kết quả được trình bày trong chương 5 với so sánh nó với các tài liệu hiện tại và mục tiêu ban đầu. Chương 6 kết thúc các nghiên cứu đưa ra một số khuyến nghị để cải thiện việc quản lý chất thải y tế tại NNUH.

A STUDY ON THE MEDICAL WASTE MANAGEMENT AT THE NORFOLK AND NORWICH

UNIVERSITY HOSPITAL

by

KEVIN PAUL PUDUSSERY

(4905822)

Thesis presented in part-fulfilment of the degree of Master of Science

in accordance with the regulations of the

University of East Anglia

School of Environmental Sciences

University of East Anglia

University Plain

Norwich

NR4 7TJ September 2011

© 2011 Kevin Paul Pudussery

This copy of the dissertation has been supplied on condition that anyone who consults it is understood to recognise that its copyright rests with the author and that no quotation from the dissertation, nor any information derived there from, may be published without the author‘s prior consent Moreover, it is supplied on the understanding that it represents an internal University document and that neither the University nor the author are responsible for the factual or interpretative correctness of the dissertation

ABSTRACT

The high generation rate of medical waste in UK is a proof that medical waste management

in UK is problematic Based on a case study undertaken at Norfolk and Norwich University Hospital (NNUH) this research looks in to the various issues in the field of medical waste management The research explores the staff‘s perception towards the medical waste management The study aims to examine the knowledge level and attitude and role of health care workers towards the medical waste management The NHS has set a 10% carbon reduction target to be met by 2015 (NHS, 2009), as part of the strategy to meet the UK Government‘s Climate Change Act The study examines whether the hospital could reduce its carbon foot print by improving the medical waste management

The study looks in to the various medical waste treatment technologies available and choose the best available technology for the on site treatment of medical waste A multi criteria decision analysis is used for the same

The results of the study show that the health care workers have a critical role in achieving efficient medical waste management The study shows that hospital could highly benefit from

an on site incinerator coupled with an effective waste management programme geared to waste minimization This will help hospital to reduce carbon foot print and hence towards sustainability

ACKNOWLEDGEMENT

I would like to thank first and foremost Dr David Benson for his invaluable academic supervision and enthusiasm throughout this dissertation, as well as for the support and confidence he gave me from every meeting and point of contact that occurred from start to finish

I would also like to thank Dr Matt Cashmore who is the course director and other MSc course staff, especially Dr Alan Bond for their advice and guidance throughout the year Further thanks go to Chris Paul, Graham Corke, for allowing me to conduct this study at Norwich and Norfolk University Hospital Thanks must also go to the people who agreed to undertake the surveys, without which the study would have seriously have been compromised

Finally, thanks must go to all my friends and family for their continual support and enthusiasm towards this study, for having confidence in my ability throughout the duration of the course

ABBREVIATIONS

NNUH: Norfolk and Norwich University Hospital

UEA : University of East Anglia

WHO : World Health Organization

DoH : Department of Health

NHS: National Health Service

RCN: Royal College of Nursing

UK: United Kingdom

DEFRA: Department of Environment food and Rural Affairs AoDM Association of Domestic Managers

HCW: Health care waste

EU: European Union

BAT: Best Available Technology

3Rs Reduce, Reuse and Recycle

TABLE OF CONTENTS

I ABSTRACT……… ii

II ACKNOWLEDGMENT ……….…iii

III ABBREVIATION………iv

TABLE OF CONTENTS 5

LIST OF TABLES 8

LIST OF FIGURES 9

CHAPTER 1: INTRODUCTION 10

1.1) Definition and Classification of Medical Waste 10

1.2) Waste policies and legislations in UK that applies to medical waste management 11

1.3) Medical waste Management in United Kingdom (UK) and associated problems 13

1.4) Why Medical Waste Management at NNUH: Justification 13

1.5) Overall Objective and Specific Aims 14

1.6) Organisation of study 16

2.1) Medical waste management in UK 17

2.2) Best Practices for Hospital Waste Management 19

2.3) Hazardous waste transportation 20

2.4) Medical waste treatment technologies 21

CHAPTER 3: METHODOLOGY 24

3.1) Introduction to methodology 24

3.2) Interview with the Waste Management Officer at NNUH 25

3.3) Participant Observation 27

3.4) A Questionnaire survey about the waste management practices of Staffs at NNUH hospital 29

3.4.1) Identifying what information is needed 29

3.4.1) Deciding what sort of questionnaire to use 29

3.4.2) Framing the questions 30

3.4.3) Designing of the Self-completion Questionnaire 30

3.4.4) Creating the first draft, editing and revising 31

3.4.5) Sampling and revising 31

3.4.6) Conducting the survey 32

3.5) Questionnaire survey to understand the public perception about medical waste treatment technologies: 32

3.5.1) Framing the questions: 32

3.5.2) Analysis of the result 33

3.6) Comparison of different medical waste treatment technologies 33

3.6.1) Selection of Alternative technologies 34

3.6.2) Selection of the evaluation criteria, and analysis of possible actions 34

3.6.3) Determination of the significant coefficients (Ranking and weighting) 35

3.6.4) Analysis of the results and selection of best technology 36

CHAPTER 4: RESULTS 38

4.1) Primary Data Analysis 38

4.1.1) Medical waste management policy and plan at the NNUH 38

4.1.2) Details of medical waste generated at NNUH 39

4.1.3) GHG emissions from transportation of medical waste: 41

4.2) Health care workers perception on Medical waste and its management 43

4.2.2) Perceptions about the Constituents of medical waste: 44

4.2.3) Employees perception towards Current waste management practice 45

4.2.4) Attitude towards training 48

4.2.5) Perception towards best treatment technology 49

4.3) Consideration of alternatives:- 49

4.3.1) Capital Investment and Operational cost (C1) 49

4.3.3) Volume and Mass reduction of medical waste(C3) 51

4.3.4) Environmental Impacts of the proposed technology(C4) 51

4.3.5) Public acceptance (C5) 53

4.3.6) Training and operational requirements(C6) 54

4.3.7) Occupational Health and safety including needle stick prevention(C7) 54

4.3.8) Analysis of the result: 54

4.4) Public Perception about Medical waste treatment technologies 56

4.4.1) Demographic data 56

4.3.2) Public perception about medical waste treatment technologies 57

CHAPTER 5: DISCUSSION 59

5.1) Waste management policy, plans and practice 59

5.2) Practitioner‘s perception towards medical waste management 60

5.3) Alternatives for medical waste treatment and selection of Best Available Technology 63

5.4) Public perception about various medical waste treatment technologies 64

5.4) Limitations of the study 64

6.1) Conclusion 66

6.2) Recommendations 67

Reference 69

APPENDIX………..67

LIST OF TABLES

Table 1.1: Types of medical waste ……….5

Table 2.1: Health care waste generation in selected countries ……….12

Table 3.1: Methodology of research……… 20

Table: 3.2: Sampling size of the surv ………26

Table 3.3: MCDA matrix ……… 29

Table.3.4: Criteria‘s for the selection of best treatment technology ………30

Table 4.1: Waste segregation at NNUH……… 32

Table 4.2: Comparison of the RCN guidance and NNUH waste management policy… 33 Table 4.3: Calculations of GHG emissions from medical waste transportation ……… 36

Table 4.4: demographic data of the people surveyed ………37

Table: 4.5: knowledge of employees about the constituents of medical waste …………38

Table 4.6: Ranking: Capital cost……… 44

Table 4.7: Ranking: On types of waste treated ……… 45

Table: 4.8: Ranking: Volume and mass reduction ……….45

Table: 4.9:Environmental impacts of various technologies……… 47

Table 4.10: Ranking: Environmental impacts……… 47

Table 4.11: Ranking: Public acceptance ……….47

Table: 4.12: Ranking: Training and operational requirements ……… 48

Table: 4.13: Ranking: Occupational health and safety:……… 48

Table: 4.14: MCDA matrix ………49

Table: 5.15: Demographic data of public survey ……… 50

LIST OF FIGURES

Figure: 1.1: The overall objective of the project……….10 Figure: 3.1: Flow chart showing the various processes involved in an Interview ………….21 Figure: 4.1: Composition of health care waste at NNUH ……….34 Figure 4.2: Employees attitude towards medical waste management for different age

groups at NNUH ……… 38 Figure: 4.3: Knowledge about the hazardous nature of medical waste ……… 39 Figure: 4.4: Frequency of waste going to wrong bin ………40 Figure: 4.5: Problems faced by employees during segregation of medical waste………….40

Figure: 4.6: Problems faced by employees during segregation of medical waste ………41 Figure: 4.7: Knowledge of the employees as if when the medical waste bin should be sealed … 41

Figure: 4.8: Importance of training in waste management ……… 42

Figure: 4.9: Perception of workers towards various treatment Technologies ……….43

Figure: 5.10: Figure showing the perception of people about medical waste……… 51

Figure: 4.11: Public perception towards various medical waste treatment technologies… 52

CHAPTER 1: INTRODUCTION

Great strides have been made in the field of health care system over the years Ironically, along with restoring and maintaining community health, health care settings also threaten their well-being The health of public, patients and professionals alike are affected by poor waste management practices (Shinee et al, 2008) In addition to this, it also contributes to environmental degradation In 1983, a meeting was held at Bergen, Norway The meeting was convened by the World Health Organization (WHO) regional office for Europe The Biomedical waste management issue was first discussed during this meeting The ―beach wash-ups‖ of summer 1988 bought this issue to the limelight (Lee et al,1996).Now, years later, this has turned into a global humanitarian issue

All the wastes generated by medical activities come under Health-care waste They are involved in diagnostic activities and preventive, curative and palliative treatments in both the human and veterinary fields of medicine In short, health-care waste is all the waste produced by a medical institution (public or private), a medical research facility or a laboratory (Graikos et al 2010) There are two types of health care waste as shown in table 1.1

1) Hazardous

waste

Clinical/Infectious/medical waste, cytotoxic and cytostatic medicines, batteries, health are chemicals and hazardous properties, radioactive substances, X ray photo chemicals

2) Non- Hazardous

waste

Offensive/hygiene waste, non cyto-toxic and cyto-static medicines, domestic waste, packaging waste, recyclable waste food waste

Table 1.1: Types of medical waste (Source: The safe management of health care waste, RCN, 2007)

Clinical waste is divided in to two categories:

I Infectious waste: - It is defined under the Controlled Waste Regulations 1992 and controlled by Section 34 of the Environmental Protection Act 1990 as (DOE 1990a):

( a)‖ Any waste which consists wholly or partly of human or animal tissue, blood or body fluids, excretions, drugs or other pharmaceutical products, swabs or dressings or syringes, needles or other sharp instruments, being waste which unless rendered safe may prove hazardous (including microbial (infectious), pharmacological and /or physical [e.g sharps] dangers) to any person coming into contact with it‖

(b) ―Any other waste arising from medical, nursing, dental, veterinary, pharmaceutical or similar practice, investigation, treatment, care, teaching or research, or the collection of blood for transfusion being waste, which may cause infection to any person coming into contact with it‖

II Medicinal waste

Medicines other than cytotoxic and cytostatic medicines come under medicinal waste (The safe management of health care waste, RCN; DoH, 2006)

Some health care waste fall under ―dangerous goods‖ The producers and consignors of these are obliged under the Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations for ensuring suitable categorization and identification, packaging, marking, labeling and documentation of the waste (DfT, 2007; Tudor et al 2009)

The Health and Safety at Work Act and Control of Substances Hazardous to Human Health COSHH) Regulations requires the health care providers to perform risk assessments for determining and minimizing any subsequent risks to staff, patients and the environment New standards for incineration were also introduced by EPA The European Union Incineration Directive (EU 2000) caused many of these plants to close due to the increased stringency of the emission limits to air and water The NHS and Community Care Act (DoH 1990) made the segregation of clinical and non clinical waste mandatory In addition, EPA assigned local authorities for providing collection services for clinical waste generated through treatment at homes or other residential settings

The Special Waste Regulations (DoE 1996), the Hazardous Waste (England and Wales) Regulations 2005 and the List of Waste (England) Regulations 2005, guided partly by the EU Waste Codes caused more health care waste to be classified as hazardous and thus creating a need for them to be appropriately consigned Waste Incineration Directive compliance is a criterion for new incinerators So some categories of waste will need to undergo alternative treatment and will have high-temperature treatment or incinerations

as its only option (Tudor 2009) Environmental permits issued either under the requirements of the former Pollution Prevention and Control or the new Environmental Protection Regulations give exact specifications on the amount and types of wastes that can be treated at a facility Under the Special Waste Regulations and the Hazardous Waste Regulations, there should be no mixing of hazardous and non-hazardous waste and so proper methods for segregating different streams are necessary

1.3) Medical waste Management in United Kingdom (UK) and

associated problems

As a largest employer and organization in UK NHS is responsible for most of the medical waste in UK It employs more than 1.3 million peoplew3 and runs 259 NHS trusts The role of sustainability in the practices of the NHS is limited, as per the studies conducted

in the UK (Tudor 2004) In the year 2005 – 06, NHS produced 118383.22 tonnes of clinical waste and £ 73 million was spent for the disposal The average clinical waste per day per patient is very high compared to other developed countries like France and Germany (Hutchins 2009) These high generations of medical waste have been a problem

in UK for a quite long time The quantities of healthcare waste in England and Wales have recorded an increase of 20% between 2001- 2004 But accurate regional level figures are limited as the number of formal systems for tracking waste quantities within the organization is very few (woolridge et al 2005; Tudor 2005) Hence, medical waste still continues to be a problem in the field of waste management in UK

1.4) Why Medical Waste Management at NNUH: Justification

The Norfolk Norwich University Hospital (NNUH) is a general acute hospital, which was opened to patients in November 2000 The hospital is built by Octagon Healthcare Limited, managed by NHS Trust staff and the nonclinical services are managed by Serco

As a health care institution Norfolk and Norwich hospital produces a lot of medical and surgical waste The institutions of health care have enormous opportunity to do good or bad to the natural environment and to increase or diminish carbon emissions (Coote, 2006) Being an environmental friendly organization, NNUH wants to decrease their carbon foot print by improving their waste management practice Currently, NHS is responsible for more than 3% of all GHG emissions in England (Cole, 2009)

Hence, there is a urgent need in NHS hospital to reduce their carbon emissions In order

to achieve significant and long term reduction in carbon foot prints the organization should first assess the various opportunities for carbon reduction and should develop a structured master plan for the same (WHO, 2008)

The various ways to reduce the carbon foot print in hospitals are by making the right procurement choices, introducing green travel plans, improving the waste management,

by implementing energy saving strategies (WHO, 2008; Michael 2006, Barrat et al, 2004; Environmental health nursing, 2010) In regard to issues in waste management, higher generation rates of medical waste due to improper segregation and waste disposal are the key areas of concern Waste transportation and end disposal is the area of concern in medical waste management Hence a study on the medical waste management is essential

to provide a structured master plan to reduce carbon emissions and hence towards sustainability

Health care facilities can decrease their green house gas contribution by (Environmental Health Nursing, 2010)

 Recycling and buying recycling products

 Reducing/preventing the waste generation

 On site treatment of waste The argument her is that the waste management policy should target more on waste minimization Also, the perception of health care staff is highly critical towards waste minimization This study looks on the possibility of reducing carbon emissions by reducing the medical waste generated and also by avoiding the unnecessary transport of medical waste by building an onsite waste treatment plant.

Since one of the objective is to consider an on-site waste treatment plant at NNUH, the public concern their perception towards various technology cannot be neglected Hence a study is also done to understand the public perception towards various technologies

1.5) Overall Objective and Specific Aims

The overall objective of this project is to perform a study on the current medical waste management at NNUH and to aims find out how hospital can benefit from improving medical waste management practices The various aspects of medical waste management discussed in this study are shown in the figure 1.1

The aims of the project are:

 To analyze the current medical waste management legislations, policies and practices at NNUH

 To Understand the perception of staffs at NNUH towards the medical waste management and to analyze how it affects the waste generation at NNUH

 To investigate the reasons behind higher generation of medical waste at NNUH

 To find out the best suitable waste treatment technology for the on site treatment of medical waste

 To understand the public perception towards various waste management technologies

Fig: 1.1: The overall objective of the project

Medical waste management

emissions and otherproblems associated withthe transport of edicalwaste

3) Public perception

medical waste treatmenttechnologies

1.6) Organisation of study

The dissertation is heavily concentrated on the medical waste management at NNUH Chapter 1 is the introduction and aims to give a basic background information‘s regarding medical waste management and the justification for the topic Chapter 2 looks

in to the current literature about medical waste management The methodology used to achieve the objectives and aims of the project is explained in chapter 3 The results of the project are given in chapter 4 and the results are discussed in chapter 5 with comparing it with the current literature and initial objectives Chapter 6 concludes the research giving some recommendations to improve the medical waste management at NNUH

CHAPTER 2: LITERATURE REVIEW

2.1) Medical waste management in UK

United Kingdom is the largest producer of health care waste in Europe In 2007-08 hospitals

in UK produced approximately 190 000 tonnes of Health Care Waste (HCW) In addition to that a lot of HCW is generated from the 20 000 care homes and 40 000 beauticians operating around the country (Tudor et al, 2009) Table 1 below shows that hospitals in UK, on an average generate 5.5 kg of medical waste per person per day, which is very high when compared to the other developed countries

Table 2.1: Healthcare waste generation in selected countries

Netherlands 0.6 Germany 0.4 Source: (krisiunas et al, 2000; Chung and Lo, 2003)

The medical waste disposal in UK has become very expensive and it is estimated that UK spends more than £125 million for the treatment of Health Care Waste (Tudor et al, 2009) Hence, there has been a growing interest among the various hospitals to find out different strategies to reduce the amount of medical waste generated Also, there has been increase in the development of recycling programs for health care wastes in recent years (Wen and Eaves, 2003; Da Silva et al, 2005; NHS Estates, 2002) Although there are many literatures available on the Medical Waste management in general, only limited studies have been done

to find out the exact reasons for higher generation and patterns of medical wastes in UK

(Tudor 2009) One reason might be that the waste generation pattern will be different for different hospitals depending on the facilities and services it offer ( Ferraz et al, 2000; Madeira 1995; ) The concept of sustainability is lacking in the health care systems in England (Jochelson et al, 2004 Tudor, 2006) According to Tudor (2009), in UK there is a lack of research and accurate data about the generation patterns of health care waste in order

to provide an evidence base for future decision making The various reasons towards the poor waste management practises around the globe are (WHO fact sheet N°253, 2007):

 The absence of waste management

 Lack of awareness about the health hazards

 Insufficient financial and human resources and poor control of waste disposal

 Lack of strict and appropriate regulations

 The clear attribution of responsibility of appropriate handling and disposal of waste

 According to the 'polluter pays' principle, this responsibility lies with the waste producer, usually being the health-care provider, or the establishment involved in related activities (WHO fact sheet N°253, 2007)

The technology, regulations, education and training, waste management policies in developed countries are at an advanced stage than in developing countries There are strict legislations at the local, regional and national levels which are geared towards the proper management of hazardous clinical waste generated in developing countries (WHO, 2007) The healthcare industries in United Kingdom are generally operated under strict legislations, licenses and code of practices, along with environment health and safety regulations (Blenkharn 2005; WHO fact sheet N°253, 2007) The stringent environmental controls and legislation on medical waste in UK has ensured high standards of clinical waste disposal but failed to decrease the amount of medical waste generated in UK (NHS Estates 2000, NHS Estates 2002; Tudor, 2005; Salkin 2003) Safe handling and storage of medical waste is still a problem in UK despite the strict regulations (Audit Scotland, 2005; Blenkharn 2005)Also, most of the literature on medical waste management concentrates on the developing nations rather than developed nation, one of the reason being poor waste management legislations and practices in developing countries In order to understand the reason behind higher generation of medical waste in UK and the problems in Health Care Waste (HWM) management at the hospitals, we need to know about the best practise for HWM in UK

2.2) Best Practices for Hospital Waste Management

Major changes have been made in the management of hazardous waste so that the requirements of the European Hazardous Waste Directive are met In accordance with this, there has been a revision of the guidance document Safe Disposal of Clinical Waste by NHS Estates On the basis of this, the department of Health revised the joint-agency guidance and it‘s publishing its final form as a 119-page document was done on the 30th November 2006, under the gateway reference 6874 (Department of health, 2006) As far as the best practice of hospital waste is concerned, this document is the latest reference from the government‘s end Moreover, it is very details and gives information regarding all aspects of waste management

It also gives the mandatory and optional settings This document actually replaces the Health Services Advisory Committee‘s guidance document ‗Safe disposal of clinical waste‘ (The Management of Health and Safety, 1999) Revision and updating of the 1999-guidance was done so that we can take into consideration, the changes in legislation regulating the management of waste, its storage, transportation, treatment and disposal, and health and safety (Tudor 2009)

On the basis of this, concise 17-page guidance on healthcare waste had been published by the Royal College of Nursing This guidance is widely used in UK as the best management practice The RCN guidance include guidelines about the definition and classification of medical waste, waste segregation, waste assessments, waste audits, Accidents and incidents, training and competence and community nursing A national colour coded system is now used for the segregation of waste and is linked to an appropriate disposal path (DoH, 2006, RCN guidance on health care waste) Staffs are provided with different colour coded receptacles and sack holders which should be positioned in locations close to the point of waste production and should be replaced when ¾th full, securely tied and appropriately labeled (DoH 2006) The argument here is that although this system helps in separating different types of waste, it doesn‘t actually reduce the amount of waste produced In fact it has created some confusion among the workers to put which waste in which bin Hence there

is every chance that the waste ends up in a wrong bin especially when the bins are kept together In a study conducted by Saini et al(2005), they found that there is a significant gap

of knowledge, attitude and practices among the health care employees at the hospital

WHO has identified that the percentage of infectious waste in health care wastes is between

10 – 25% (Pruss, 1999) The various studies show that the amount of wastes which require special attention is just a fraction of total health care waste generated (Blenkharn , 2005; Jang

et al, 2006; Lee et al, 2004; Ozbek and Sainin , 2004; Park and Jeong, 2001; Patil and Shekdar, 2001; Tsakona, et al; 2007 ) These studies argue that reusing and recycling programmes and an effective segregation of wastes can be a means of reducing rising quantities of waste generation and disposal cost If the waste can be reduced or recycled it can not only reduce the disposal cost, but also return money by selling recyclable materials (Cheng et al, 2009; Lee et al, 2002; Lee et al, 2004) Studies by Tudor (2006) the percentage

of hazardous waste in various hospitals in UK is as high as 40 – 60% A few researches have shown that the percentage of non-hazardous waste disposed of in the hazardous/clinical waste stream can often be 50–90% (Zafar & Butler 2000, AoDM 2003, Woolridge et al 2005).Rayner (2003) demonstrated that more than 25% of the clinical wastes can be classified as domestic waste

In a study conducted by Saini et al (2005), they found that by the careful segregation of items like paper, card boards, plastics and bio degradable wastes the medical waste stream can be reduced by 60% The literature shows that the lack of knowledge and inefficient waste management practices are the reasons for high generation of wastes

2.3) Hazardous waste transportation

Unless treated using an on-site treatment technology, the clinical waste need to be transported securely to a suitable treatment plant which has the license to treat clinical waste The waste transportation of hazardous waste has to comply with the strict regulations associated with it Due to this reason clinical waste transportation and disposal in UK is really costly (Blenkharn 2005; Tudor 2009) There is a significant amount of waste transport across UK and it is the comparatively higher in England It is a matter of high health and safety concerns Also, in addition to that it has various environmental impacts like Green House Gas (GHG) emissions (Tudor et al, 2005) The estimated figures for greenhouse emissions from waste transfer station to disposal/management site is 4.3kgCO2eq/ tonne of waste.( Smith et al, 2001) The literature shows that it is advantageous to avoid the hazardous waste wherever possible By

treating the waste on-site the wastes are confined to a limited space, there by making it more convenient and minimize the risk to public health and environment

2.4) Medical waste treatment technologies

Literature review s on waste disposal/ waste treatment technologies are rather contradictory Some of the most common technologies include incinerators, sterilization or autoclave, irradiation, sterilization, microwave, chemical disinfection and secured landfill According to previous studies (Park and Jeong, 2001; Lee et al., 2004), about 49–60% of medical waste is treated by various incinerations, 20–37% by autoclave sterilization, and 4–5% by other methods Incineration and steam autoclave sterilization are the main methods currently being used and are considered mature technologies Each of the technologies mentioned above has some advantages and some disadvantages

Incineration utilizes thermal energy to decline waste materials to non combustible residue or ash and exhaust gases (Dursun et al, 2011) The Fly and bottom residues produced after medical waste incineration contain high level of heavy metal like Pb, Cd, Ni, Cr, Cu and Zn Medical waste aHigh values of metal leachability prohibit the land filling of these ashes as imposed by EU directives (Gotsis 2008) Medical waste is the 3rd largest sources of dioxin air emission However, despite of public concerns about incinerators, it is the most frequently used option, due to its advantages regarding the sterilization of pathological and anatomic waste, volume and mass reduction, and energy recovery (Zhao et al 2008)

Autoclaving/sterilization is the second most commonly used waste disposal technology The process involves steaming the waste materials at lethal temperatures to penetrate and potentially kill pathogens (Armstrong et al 2010) Autoclave is viewed as a more costly method than incineration (Jang et a,(2006) One of the major disadvantages of autoclave pointed out is that it doesn‘t reduce the size of waste fed in to the system The treated waste then has to go to the landfill sites which again cause many environmental threats Many studies shows that a shredder incorporated with an autooclave can be the best option to treat the medical waste (Armstrong et al, 2010; Brenda et al 2010)

The microwave process utilizes the radiant energy to kill infectious agents by convering radiant energy to heat and pressure Shredding is usually combined with microwave

technology A combined on site Microwave - small scale incinerator technology is the most cost effective and environmental friendly treatment technology (Lee et al 2003) The disinfection efficiency of microwave can be a performance issue for microwave (Path, 2005)

In chemical treatments, chemicals like chlorine, formaldehyde, ethylene oxide etcetera are used as disinfectants Again the effectiveness of disinfection is questioned as it is dependent

on the temperature, pH and surface area (Path 2005)

The above literatures show the contradictory views regarding the medical waste treatment One thing to be noted in these literatures is the difference in the type of waste they have examined The compositions of wastes they have examined vary which shows that the best treatment should be selected depending on the characteristics of the waste Also with the proper reduction of waste and preventing the waste containing chlorine a mercury entering to the incinerator can reduce the environmental impacts of medical waste incinerators While none of the alternative technologies are totally risk free, they can be combined with an effective program of waste reduction and segregation to reduce the environmental impacts and financial cost of medical waste disposal

The criteria‘s used to evaluate technological option should consider environmental, health and economic factors (Batterman 2004) The best technology for the medical waste treatment will be different for different hospitals It may depend on the local conditions and the requirement of the hospital However WHO gives a list of factors to guide the selection of best technology for treating medical waste (Pruss 1999) They are: -

 Disinfection efficiency

 Volume and mass reduction

 Quantity of wastes for treatment

 Infrastructure requirements

 Options available for final disposal

 Operation and maintanence consideration

 Location and surroundings of the treatment site and disposal facility

 Public acceptability

 Available space

 Investment and operating cost

 Health and environmental considerations

 Types of waste for treatment and disposal

 Regulatory requirement

 Occupational health and safety considerations

 Training requirements

Hence, it can be interpreted from the literature that, medical waste management is an area

of high concern due to the high generation of medical waste, improper segregation and also due contradictory views about the various technologies Medical waste management

is an area which needs more research and study to gear iit towards sustainability

CHAPTER 3: METHODOLOGY

3.1) Introduction to methodology

The methods chosen specifically relate to the aims and objectives of the research study It is shown in table 3.1 Here, qualitative interview and participant observation data was combined with quantitative survey material to test the arguments that

To collect primary data‘s

and understand the current

waste management policies

and practices at NNUH

 Interview with waste manager

 Site visits/

Participant observation

 Current waste management policy

 The waste generation data

 Information about medical waste disposal

To understand the

perception of staff towards

medical waste management

 Participant Observation

 Quantitative survey

 Follow up Questions

 Employees interest towards medical waste management

 Level of comfortableness towards current segregation practice

 Difficulties faced by workers towards current segregation system

 Attitude towards training and improving waste management

 Employees perception towards various treatment Technologies

To choose the best available

technology for waste

treatment

 Linear additive model Multi criteria decision analysis

 Selection of technology

To understand the public

perception towards medical

waste management

 Questionnaire survey  Peoples knowledge

and views towards various treatment technologies

Table: 3.1: Methodology for the research

I The waste management policies should target more on waste minimization

II The health care workers perspective towards medical waste management is

critical towards efficient segregation and waste minimization

Also a multi criteria decision analysis is used to find out the best treatment technology A quantitative public survey is also used to find out the perception of public towards the waste treatment technologies

The methodology is explained in detail in the following sections

3.2) Interview with the Waste Management Officer at NNUH

The purpose of the interview with the waste management officer at NNUH was to collect the primary data and background information about the waste management practices at the hospital The data‘s and information‘s collected formed the basis for this research An interview protocol was initially developed to cover qualitative data collection that included interview technique, sampling, ethical issues and data analysis

Semi-structured interview - This approach is meant to assure that the some general areas of

information are collected from each interviewee; this provides more focus than the conversational approach, but still allows a degree of freedom and adaptability in getting the information from the interviewee

The interviews were scheduled and conducted at a time appropriate for the interviewee (medical waste manager at NNUH) and the interviews were undertaken in the interviewee‘s office Interviewer developed a rapport with interviewee as it is important in collecting accurate and true data‘s It was done through an initial set of questions to put the respondent

at ease The issue of confidentiality was addressed as good interviewing techniques often elicit personal data (Payne, 1999)

Bryman (2008) lists some of the basic elements which should be considered while preparing interview questions They are:

 Create a certain amount of order on the topic areas, so that your questions about them flow reasonably well, but be prepared to alter the order of questions during the actual interview

 The interview questions should not be too specific, but should be formulated such that it will help you to answer your research questions

 Comprehensible and relatively simple language should be used while you are interviewing people

 Do not ask leading questions

 The information you collect, be it a general data (like age, gender) or specific data (like position in company, numerical data), make sure that you ask or record ‗factsheet‘s these information is useful for contextualizing peoples answer

Questions

Finalized guide

Interview Topics

Formulating Interview Questions Review/ Revise questions

The interview was focussed on questions related to various aspects of medical waste management (fig 1.1) covered in this research They are:

 The general details about the hospital trust

 Medical waste management plan/policy at the NNUH

 The organizational structure of the waste management at the hospital

 Classification of medical waste

 Segregation of medical waste and colour coding system

 Storage, transportation and current disposal method of the medical waste

 Records of medical waste generated

The Face to face Interview helped in gathering data‘s about the internal waste management policies at the hospital and the waste generation data The appropriate date and time for the site visits were fixed during the interview The data‘s about the waste transportation and the off-site treatment plant was also collected A copy of the waste management policy of NNUH was collected and other data‘s were recorded for the analysis A request to visit the Off-site treatment plant and the emission data‘s from medical waste was placed to the respective company through the waste management officer at NNUH, but was rejected

2010 Guidelines to Defra / DECC's GHG Conversion Factors for Company Reporting (Defra 2010) was used to find the green house gas emissions from the transportation of medical waste.See appendix 4 for details

3.3) Participant Observation

The site visit or participant observation will enable the investigator to understand the exact nature of activities and associated activity associated with a process (Zobel and Burman, 2004) It will also help in creating good relationships with staff and facilitate the release of internal documents during the research period

An initial walk over of the site was undertaken to become familiar with the layout and internal activities in the hospital NNUH is a 1010 cute bed hospital with 27 operation theatres and 27 wards Series of site visits were made to collect data by observing and talking

to people The observations were carried out 2 times during June to August The observations were carried out along with the waste management team while they were

collecting medical waste from the wards Yellow bins and black bins are placed at every ward and other places like operation theatres, in-patient room‘s etcetera where medical wastes are produced The producers of waste, in this case health care workers are responsible for the proper segregation of waste The general infectious waste bags are taken by the cleaners to the disposal hold rooms In total there are 58 hold rooms in the hospital Each hold room contains at least one 770 litre yellow bin and another 770 litre black bin The special wastes are disposed in appropriate waste bins by the staffs directly The waste collection team collect the waste from the hold rooms and take it to the common storage area for the clinical waste The bins are later taken by the waste incinerator company A consignment note was given at the end which is signed by both the hospital waste manager and the company staff This gave

an understanding of how waste stream are generated, segregated, collected and transported in practice The site visits gave an exposure of what actually happens in offices and the organisational culture of staff members During the site visits, it was noted that attitude of health care workers towards waste segregation is really important in medical waste management The whole practise was observed and recorded to compare the observed practise with practise mentioned in the policy

Fig: 3.1a: Picture showing the storage area for medical waste

3.4) A Questionnaire survey about the waste management practices of

Staffs at NNUH hospital

Questionnaires surveys are one of the best methods to collect primary data from health care workers and is often conducted for the same (McColl, 2001) It can produce valid, reliable, unbiased and discriminatory data from a sample of people The survey results can be error prone and biased from a range of sources However, close attention to issues of questionnaire design and survey administration can reduce these errors

The main steps in preparing a questionnaire survey are:-

1 Identifying what information is needed

2 Deciding what sort of questionnaire to use

3 Framing the questions

4 Designing the questionnaire

5 Creating the first draft ,editing and revising

6 Sampling and revising

7 Conducting the survey

8 Analyzing the result

3.4.1) Identifying what information is needed

The core aim of this survey is to analyse the practitioner‘s perspective towards medical waste management

3.4.1) Deciding what sort of questionnaire to use

A close ended, self completed questionnaire method was employed to analyse the practitioner‘s perspective towards medical waste management In this method, the respondents answered the questions by completing the questionnaire themselves, i.e self administered These questions provided specific answer choices although there may be an

"other" value with brief space for adding an additional value

3.4.2) Framing the questions

The questionnaire survey questions were formulated in such a way that they aimed at: understanding workers general knowledge about medical waste in terms of constituents, hazards and diseases that could be transmitted thorough improper management of medical

wastes

The first few questions (questions 1-4) were general and aimed to understand the age group; gender; the background of the health worker; and his/her attitude towards medical waste management The questions 5 and 6 were formulated in such a way that they aimed to understand the participant‘s knowledge about the constituents and knowledge of the hazard category of infectious waste Questions 7 – 14 were about the waste segregation practices They aimed to understand the practitioner‘s views and attitude towards the current segregation practice and also the practical difficulties and problems faced by them during waste segregation Question 15 examined on the awareness about the occupational health hazards which arise due to improper management of infectious waste The purpose of questions 16 – 17 was to find out participant‘s attitude towards training on waste management Question 18 is to find out which treatment technology does the practitioner think as the best way to dispose medical waste Also it incurs the practitioner‘s opinion about building an on-site treatment plant at NNUH The final question aimed at finding out whether the workers at the hospital are satisfied with the current waste management practices

An open question was also included asking for suggestions to improvise the current waste management practice at the hospital Questionnaire is given as Appendix 2

3.4.3) Designing of the Self-completion Questionnaire

Designing the questionnaire is a very important step especially in social science research Dilman (1983) points out that clear instructions and an attractive layout can improve the response rate whereas steps like making a questionnaire shorter than it really is - such as reducing margins and spaces – make it look cramped and thereby attractive The total appearance can be enhanced by using a variety of print styles like different print size, bold,

italics and capitals By using one font style for general instructions, one for headings, one for specific instructions, one for questions and one for closed answers can make it more attractive (Bryman 2008) The evidence from the available literature suggest that when ordering the questions, general questions should precede specific questions (McColl, 2001)

3.4.4) Creating the first draft, editing and revising

A draft of the questionnaire survey is made, which is then edited and revised based on the design criteria mentioned in previous section

3.4.5) Sampling and revising

De Vaus, (2002) suggests that pre-testing should be conducted with people who match those whom the questionnaire will finally be given The basic aim of sampling is to check whether the survey questions operate to function as a research instrument for the project (Bryman, 2004)

Since the area of research and the people that needed to be interviewed were already decided, the next step was to decide the sampling size The bigger the sample size, the more precisely

it reflects the target group A quota is a sample size for a sub-group The quota and the sampling size for this survey are as follows

The responses from the pilot were analysed and the questions were reviewed before sending out the questionnaires

3.4.6) Conducting the survey

The questionnaire was distributed among the hospital staff: Doctors, nurses, paramedical staff and ancillary workers Survey was conducted in wards and staff restaurants in the evenings

when most of the employees are less busy

Analyzing the result

Analysis of the questions was to produce comments, figures and tables and to allow the answers of the questionnaires by visualisation and interpretation It followed the procedures

below:

 Introduced tables in Microsoft Excel;

 Entered responses of each questionnaire in the appropriate rows and columns created;

 Charts, tables and graphs were drawn based on the data collected

Along with the Questionnaire survey, the participants were also asked about the other obstacles they faced, coordination problems within the various departments and suggestions

to improve the medical waste management at the hospital Some of them were asked questions based on the answers they gave in the survey

3.5) Questionnaire survey to understand the public perception about

medical waste treatment technologies:

If the hospital want to built an on site waste treatment plant, its important to know the public perception towards various technology There has been various public protests towards various treatment technologies in the past A method similar to the above survey is used in this section with some changes A closed end, self completed survey is used

3.5.1) Framing the questions:

The first few questions were general which aimed to understand the age group, gender and the professional background of the person The following question was focused to understand his/her interest towards waste management The 5th question examined whether he/she knows the difference between normal municipal waste and medical waste It also examined people‘s awareness about the risk associated with the medical waste The next question was aimed to interpret which technology does him/she considers as the best way to treat medical waste The 7th question was to find out whether the people are willing to take part in a public meeting if any medical waste treatment plant is planned to be built in their nearby locality

Sampling and the obtained results were analyzed before distributing the final questionnaires

3.5.2) Analysis of the result

Analysis of the questions was to produce comments, figures and tables and to allow the answers of the questionnaires by visualization and interpretation The results were tabulated

in Microsoft Excel and were analyzed using graphs and tables

Extra care was taken in the introductory note to make people understand that it is just a part

of the academic study and there is no plan in reality, to build any waste treatment plants in the nearby locality For the same reason, the NNUH was never mentioned in the questionnaire survey, although the survey was conducted within 5 miles of NNUH The explanation for the technical terms was given prior to the questionnaire section The questionnaire can be found in appendix 3

3.6) Comparison of different medical waste treatment technologies

"Best Practicable Environmental Option" (BPEO) is defined as that option that provides the most benefit or causes the least damage to the environment as a whole, at a cost acceptable to society, in the long term as well as in the short term.‖ (Dec et al; 2007;) The five main factors

to be considered according to the above act are: human health; economy; environment; society; and cultural heritage A Multi Criteria Decision analysis (MCDA) was used to determine the best treatment technology currently available (Dursun et al, 2011)

MCDA is a structured approach used to determine overall preferences between different options, on the basis of various objectives which the decision making body has already identified Measurable criteria were developed in order to assess the extent to which the objectives have been achieved If it can either be proved, or reasonably assumed, that the criteria are preferentially independent of each other and if uncertainty is not formally built into the MCA model, then the simple linear additive evaluation model is applicable (Dec et

al, 2007)

Three components of a typical MCDA Assessment are illustrated in the matrix shown in Figure 1 It includes

1) The various available technologies (row 1)

2) The criteria‘s on which each alternative is measured (column 1)

3) The measured value (R11 to R84) for each criterion for each option (Rows 3 to 4 and columns 2 to 4)

The Various steps in the MCDA analysis are:-

3.6.1) Selection of Alternative technologies

a) Incineration with energy recovery

b) Autoclaving with shredding

c) Chemical treatment

d) Micro wave

3.6.2) Selection of the evaluation criteria, and analysis of possible actions

The various technologies were evaluated by considering various health, environment and economic criteria People doing research and working in the hospital waste management are consulted for the same It is assumed that the criteria are preferentially independent of each other One thing to be noted in the research is that this method aim to find out the best technology for the on-site medical waste treatment at the NNUH and not in general Hence the criteria are selected accordingly and the criteria with which various technologies will be compared are (Batterman, 2004; Pruss 1999):

1) Capital Investment and Operational cost (C1) 2) Types of Waste treated(C2)

3) Volume and Mass reduction of medical waste(C3) 4) Environmental Impacts of the proposed technology(C4)

5) Public Acceptance(C5) 6) Training and operational requirements(C6) 7) Occupational Health and safety including needle stick prevention(C7)

3.6.3) Determination of the significant coefficients (Ranking and weighting)

 Ranking:

All the treatment technologies were assessed on each of the above mentioned criteria A vast study on the available literature is done to obtain the data‘s required for the analysis The capital investment is estimated from the literature review The best technology is given a value score of 4 and the least viable technology is given a score of 1

Table 3.3: MCDA matrix

Technology Incineration Autoclaving Microwave Chemical

treatment Criteria

acceptance is really important because some of the technology like incineration has faced

public opposition in the past The criteria and weightage is shown in the figure below

Table.3.4: Criteria‘s for the selection of best treatment technology

3.6.4) Analysis of the results and selection of best technology

The overall score for each alternative was found by multiplying the value score on each

criterion by the weight of that criterion, and then adding all those weighted scores

together

Overall score for incineration =

R11×WC1+ R21 × WC2 + R31 × WC3 + R41 × WC4 +

R51 × WC5 + R61 × WC6 + R71 × WC7 ………… (1)

Similarly overall score for all the alternatives were found out and the alternative with the highest score was determined as the best technology available for an onsite treatment of medical waste for NNUH.

CHAPTER 4: RESULTS 4.1) Primary Data Analysis

4.1.1) Medical waste management policy and plan at the NNUH.

The clinical waste management policy at NNUH contains

i Classification of Clinical waste:-

The infectious waste is defined and classified according to the DH guidance and the guidance on health care waste published by Royal college of Nursing 2007 (The Department of Health, 2006; The Royal college of Nursing, 2007)

ii Segregation of medical waste and colour coding system

The segregation at NNUH is done through the following colour coding system as shown in table 5.1

Table 4.1: Waste segregation at NNUH (NNUH waste management policy document, 2009)

Colour of the bin Waste category Yellow

Wastes which requires

permitted or licensed facility

Cytotoxic and cytostatic waste

Clear/ Black

Minimum treatment/disposal

required is landfil

Domestic/ Municipal waste

White Amalgam waste for recovery

Green Recyclable wastes

iii Storage, transportation and current disposal method of the medical waste

The guidance was in accordance with the DH guidance and the guidance on health care waste published by Royal college of Nursing 2007 (The Department of Health, 2006; The Royal college of Nursing, 2007))

The table 5.2 shows the comparison of RCN guidance on health care waste and waste management policy with the various steps in waste management hierarchy

Guidance on RCN guidance on health

care waste (Royal college of Nursing, 2007)

Waste Management Policy at NNUH

Table 4.2: Comparison of the RCN guidance and NNUH waste management policy

The RCN guidance doesn‘t mention anything about the waste minimization Even though recycling was mentioned in the waste management policy of the hospital, in practice the recycling practices were very limited Most of the disposal holds rooms don‘t have space for the green bins There are two or at least one 770 litres yellow wheelie clinical waste bins and one black 770 litres wheelie bins at every hold rooms

4.1.2) Details of medical waste generated at NNUH

The Fig 5.1 shows the composition of the waste generated at NNUH 49.03% of the total waste generated is clinical waste Only 19.35% of the waste is recycled and remaining 31.62% is domestic waste The clinical waste generation data at the NNUH hospital for the year 2010 is shown in Appendix 1 of the report

Total quantity of domestic waste produced in the year 2010 = 558.14 Tonnes

Total quantity of Recyclable wastes produced in the year 2010 = 341 56 Tonnes Total quantity of clinical waste produced in the year 2010 = 865.4069 Tonnes

Fig: 4.1: Composition of health care waste at NNUH

Total quantity of special clinical waste produced in the year 2010 = 59.2237 Tonnes Total general clinical waste generated at the hospital for the year 2010 = 816.8618 Tonnes

From above data‘s, the average quantity of clinical waste generated per day can be calculated by dividing the above quantities by 365

Quantity of general clinical waste generated = 2.3275 Tonnes/day

Quantity of special clinical waste generated = 0.16226 Tonnes/day

Total clinical waste generated at the hospital in a day = 2.4901 Tonnes/day

These data‘s are important in later stages of the research to decide the capacity of the onsite treatment technology

Average money spend for the treatment of clinical waste = £ 500/ tonnes