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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 45  |  Issue : 3  |  Page : 146-154

Assessment of hospital waste management in Tanta University


Public Health and Community Medicine Department, Faculty of Medicine, Tanta University, Tanta, Egypt

Date of Submission21-Feb-2017
Date of Acceptance16-Jul-2017
Date of Web Publication29-Nov-2017

Correspondence Address:
Amira K. El-Dawla Mokhtar El-Shinawey
Demonstrator, Public Health and Community Medicine Department, Faculty of Medicine, Tanta University, Tanta, Gharbia Governorate, 31511
Egypt
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DOI: 10.4103/tmj.tmj_19_17

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  Abstract 


Background Healthcare waste represents one of the most important environmental problems in the world because of the potential environmental hazards and public health risks, and its management is an integral part of infection control programs.
Aim The aim of this study was to assess hospital waste management in Tanta University, Tanta, Gharbia Governorate, Egypt.
Study design This is a cross-sectional descriptive study.
Patients and methods This study was carried out in Tanta University Hospitals. Its target included eight hospitals and 14 outpatient clinics affiliated to Tanta University with a healthcare waste management team in them. Observational checklist was the tool used and was filled by the researcher.
Results The study revealed that the application of administrative aspects was insufficient in 16.4% of departments. Concerning minimization and transport of waste, 96.7% of departments had insufficient level. Sufficient level was found among only 18 and 13.1% as regards sorting and collection of waste, respectively. Treatment and final disposal of waste was insufficient in 91.8% of departments. In all departments, personal protective equipment (PPEs) were insufficient while training was sufficient in more than one-fourth of the departments (26.2%).
Conclusion The departments did not perform the sufficient level of health care waste management (HCWM), except in sorting and collection of waste (18 and 13.1% of the departments, respectively).

Keywords: Egypt, Gharbia Governorate, healthcare waste, management


How to cite this article:
El-Shinawey AK, Atalla AA, Abbas KM, Atlam SA. Assessment of hospital waste management in Tanta University. Tanta Med J 2017;45:146-54

How to cite this URL:
El-Shinawey AK, Atalla AA, Abbas KM, Atlam SA. Assessment of hospital waste management in Tanta University. Tanta Med J [serial online] 2017 [cited 2018 Feb 25];45:146-54. Available from: http://www.tdj.eg.net/text.asp?2017/45/3/146/219437




  Introduction Top


Healthcare waste has become a critical issue and has taken a central place in the national health polices of many countries [1]. Its management is an integral part of infection control and hygiene programs in healthcare settings. Healthcare waste represents a relatively small portion of the total waste generated in a community [2],[3],[4].

According to the United States Environmental Protection Agency, healthcare wastes contain all waste generated by healthcare facilities (HCF), such as hospitals, clinics, physician’s offices, dental practices, blood banks, and veterinary hospitals/clinics, as well as at medical research facilities and laboratories that can include a wide range of materials, such as used needles and syringes, soiled dressings, body parts, diagnostic samples, blood, chemicals, pharmaceuticals, medical devices, and radioactive materials [5],[6].

Good healthcare waste management in a hospital depends on a dedicated waste management team, good administration, careful planning, sound organization, underpinning legislation, adequate financing, full participation by trained staff, the use of appropriate techniques for disposal, an internal management system and training program for related personnel, the waste generated, and a national regularly framework [7],[8]. Safe and reliable methods for waste handling are essential, and hence due emphasis has been placed on segregation, safe collection, storage, and treatment and final disposal at the site to minimize the health hazard [9].

In Egypt, waste disposal is governed by laws of the Ministry of Environmental Affairs and the Ministry of Health and Population. Regulations classify the waste from healthcare settings to be hazardous [10]. Assessment of the overall hospital waste management procedure is greatly needed. This is why this work was conducted.

The aim of this work was to assess hospital waste management in Tanta University Hospitals. The objectives of this study were to identify the current waste management operating procedures in Tanta University Hospitals and determine gaps and pitfalls in the current operating procedures in accordance with standard guidelines.


  Patients and methods Top


Study design and settings

It is a cross-sectional descriptive study that was carried out at Tanta University Hospitals, as they are the main referral hospitals in Mid-Delta where all types of medical activities are practiced. The capacity of the hospitals includes 1097 beds distributed in eight hospitals. In all, 14 outpatient clinics were affiliated to these hospitals. These beds were served by 1441 physicians, 3643 nurses and head nurses, in addition to 70 technicians and 539 workers. The total number of admitted and attendant patients during the year 2014 was 524 418.

Tool of the study

An observational check list derived and adapted from The International Committee of The Red Cross Hospital waste management form was used [11],[12],[13]. It included the following items that represent waste management steps: general issues or administrative aspects, minimization, sorting waste, collection and storage, transport, treatment and final disposal, staff protection measures, and training. The observations were answered with ‘yes’, ‘to some extent’ or ‘no’. ‘Yes’ meant total fulfillment of the observation, ‘to some extent’ meant partial fulfillment of the observation, and ‘no’ meant nonfulfilment of the observation. The checklist items were given scores. Each positive answer was given a score of 2, the answer of ‘to some extent’ was given a score of 1, and each negative answer was given a score of 0. The total score was measured for the tool used, and the score ranged from 0 up to 138 according to the number of items in each element of the tool. The department or section that achieved more than or equal to 75% of the total score was considered to have level 1 (sufficient), those that achieved more than 50–75% were considered to have level 2 (somewhat sufficient), and those that achieved one half or less (≤50%) were considered to have level 3 (insufficient).

Manipulation of data

Coding of the checklist was done for the purpose of data entry into an Excel spreadsheet and then the data were exported to statistical package for the social sciences, version 21 (SPSS-V21). Sorting, tabulation, and analysis of data were performed. The data were presented as frequencies (number and percentage). Significance was tested whenever needed. Fisher’s exact test was the most appropriate test for this study (expected values were <5). P value of less than 0.05 was adopted as the level of significance.

Administrative consideration

Dean of Tanta Faculty of Medicine was approached to obtain official permission to conduct the study; meetings were held with heads of the hospitals and relevant personnel in each hospital for orientation about objectives and procedures of the study and to get their cooperation and support throughout the execution of this study.

Ethical considerations

Research ethics rules applied in Tanta Faculty of Medicine were taken into consideration throughout the implementation of this study.


  Results Top


Administrative tools were available for healthcare waste management according to the provided services in Tanta University Hospitals.

In all the visited departments and units, there was a policy and assigned working groups for waste management. The duties of each member were updated (either completely or to some extent) in 83.6% of the studied departments. All the departments were not correctly reporting waste quantities. Resources for healthcare waste management were available (either completely or to some extent) in the entire medical, surgical, and laboratory departments ([Table 1]).
Table 1 Availability of the administrative tools for healthcare waste management according to the provided services in Tanta University Hospitals

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Availability of the items needed for waste sorting in the studied departments of Tanta University Hospitals is shown in [Table 2]. It shows that containers and bags were available (either completely or to some extent) at the site of waste production in 97.1% of the medical departments, 95.6% of the surgical departments, and 100% of the studied laboratory departments. Sharps containers were available (either completely or to some extent) in 97.1% of the medical departments compared with 100% of the surgical and laboratory departments. Bags were suitable for their desired purpose in 88.2% of the medical departments compared with 78.3 and 50.0% of the surgical and laboratory departments, respectively. The criteria of sharps containers were suitable in all the studied departments. Stocks of bags and sharps containers were observed in 94.1–100.0% of the studied departments. Clear identification of each type of waste by a color code or system was observed in all the studied departments.
Table 2 Availability of the items needed for waste sorting in the studied departments of Tanta University Hospitals

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Practices during sorting and collection of healthcare waste

Waste was collected (either completely or to some extent) regularly in 91.2% of the medical departments compared with 95.6 and 75.0% of the surgical and laboratory departments, respectively. Bags and sharps containers were closed when two-thirds full in 26.5% of the medical departments and 39.1% of the surgical departments compared with none of the laboratory departments. They are grasped from the top in all the studied departments. Nonpiling of bags was observed in 73.5 and 78.3% of the medical and the surgical departments compared with 100% of the laboratory departments. None emptying of bags was observed in 76.5 and 87.0% of the medical and the surgical departments, respectively. Bags and sharps containers were taken after closure in 59.0% of the studied departments. Full bags were replaced immediately with new ones in all departments. There were no suitable storage facilities for waste in all the studied departments ([Table 3]).
Table 3 Practices during sorting and collection of healthcare waste according to the provided services in Tanta University Hospitals

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Training of healthcare waste management personnel

[Table 4] displays training of healthcare waste management personnel according to the provided services in Tanta University Hospitals. It shows that waste management training was set for workers in 88.2% of the medical departments, 87.0% of the surgical departments, and 100% of the studied laboratory departments. In all the studied departments, not all the workers were trained. Courses were held for new staff in 70.6–100% of the studied departments. Content of the training was to some extent adjusted to suit each category of the staff in 76.5 and 87.0% of the medical and surgical departments, respectively, compared with 100% of the laboratory departments.
Table 4 Training of healthcare waste management personnel according the provided services in Tanta University Hospitals

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Overall percentages of the frequency of the main items of healthcare waste management in Tanta University Hospitals are as follows:

[Table 5] shows the mean percentages of the frequency of the main items of healthcare waste management in Tanta University Hospitals. It shows that collection and storage had the highest mean percentage followed by sorting of waste and general issues: 59.0, 55.2, and 43.3%, respectively. Transport had the least mean percentage, 5.9%, followed by that of the personal protective equipment (PPE), 23.9%.
Table 5 Mean percentage of the frequency of the main items of healthcare waste management in Tanta University Hospitals

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Levels of achievement of healthcare waste management

As regards general issues, 83.6% of departments were to some extent sufficient, 17.6% of the medical departments were insufficient compared with 13% of the surgical and 25% of the laboratory departments, and the rest were insufficient. Minimization of waste in all departments was insufficient, except in 3.3% of departments, which were two surgical departments; it was to some extent sufficient. Sorting of waste was sufficient in 0.0–26.1% of the studied departments. Collection and storage of waste was sufficient in 14.7% of the medical departments compared with 8.7% in the surgical departments and 25.0% of the laboratory departments. Transport of waste was insufficient in 96.7% of the studied departments. Treatment and final disposal was insufficient in 91.2 and 91.3% of the medical and surgical departments, respectively, compared with 100% of the laboratory departments. PPE was insufficient in all of the studied departments. Training was to some extent sufficient in 67.6 and 78.3% of the medical and surgical departments compared with 100% of the laboratory departments ([Table 6]).
Table 6 Levels of achievement of healthcare waste management according to the provided services in Tanta University Hospitals

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Total levels of achievement of healthcare waste management according to the provided services in Tanta University Hospitals are displayed in [Table 7]. In all, 91.2% of the medical departments and 82.6% of the surgical departments had insufficient level of achievement and the rest of them had to some extent sufficient level. All the laboratory departments had insufficient level of achievement.
Table 7 Total levels of achievement of healthcare waste management according to the provided services in Tanta University Hospitals

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  Discussion Top


Healthcare waste management has become a critical issue and has taken a central place in national health polices of many countries [1]. Healthcare waste management is a major problem in most of the countries and the appearance of disposable needles, syringes, and other similar items has increased the difficulties in healthcare waste disposal [14]. This study was conducted to assess hospital waste management in Tanta University Hospitals through identifying the current waste management operating procedures and determining gaps and pitfalls in the current operating procedures in accordance with standard guidelines. Health care waste (HCW) generation depends on numerous factors such as type of HCF, hospital specialization, available waste segregation options, seasonal variation, the number of hospital beds, and proportion of patients treated on a daily basis [15]. According to the study of Komilis et al. [16] in Greece, there was a positive correlation between the total healthcare waste generation rates (kg/day) and the number of beds. Odette et al. [17] reported in their study in HCFs in Madagascar that about half of the surveyed HCFs did not have waste management plan or procedure of internal HCW. Ahmed et al. [18] in their study in Khartoum State Hospitals, Soudan, showed lack of comprehensive waste disposal plans. There was no plan for healthcare waste management in 80% of the visited hospitals (Federal Hospitals, State Hospitals, University Hospitals, and Private Hospitals). He observed also lack of proper guidelines, legislations, regulations, and instructions on healthcare waste management, particularly issues covering segregation, collection, and disposal of various categories of wastes in a suitable manner to render it harmless [18]. A study by Moreira and Gunther [19] at a Primary Healthcare Center in Sao Paulos, Brazil, found that most of the legal requirements for managing healthcare waste were unknown to managers and healthcare workers, and this resulted in many noncompliance episodes detected. In contrast to this, the present work revealed that there was a policy for waste management.

Marincovic et al. [20] reported that the healthcare waste generation rate does not depend upon the size and the type of the medical institution, but also differs from country to country based on the level of economic development.

Correct reporting of waste quantities should be determined by the amount of waste per bed or patient in order to allocate the resources needed [21]. This was not in place in the studied departments or units of Tanta University Hospitals. There was no tool available to detect the weight of healthcare waste, and instead of this quantification efforts were in the form of recording the number of red and black bags. In the present study, the appropriateness of allocated resources could not be directly judged. It could be roughly estimated from the number of beds, patients turnover, and practiced activities, which might not be accurate.

This was in agreement with the results obtained in a study by Odette et al. [17] in Madagascar, which goes hand-in-hand with the study by Abor and Bouwer [22] in South Africa, who found that there was a lack of reliable data on hospital waste quantification.

According to WHO [23], the proper sorting of healthcare wastes before their ultimate distribution or disposal is the most crucial element of any waste management program. Bags or sharps containers should be replaced when they are three-fourths full. According to Abd El-Salam [24] in El Beheira Governorate, Egypt, who implemented a similar study, less than two-thirds (62.5%) of surveyed HCFs were following these recommendations. In the present study, fewer proportions of the studied departments of Tanta University Hospitals closed the bags and sharps containers while two-thirds (29.5%) full only.

The present study reported that clear identification of each type of waste by a color code or system was available in all departments and units. This was in concordance with the study by Kumari et al. [25], who reported appropriate segregation and labeling of healthcare waste storage receptacles at the studied hospital in China, and a bar-coded tracking system for healthcare waste is under construction. A study in Jordan also revealed that all studied hospitals used color-coded receptacles to store healthcare waste [8].

In contrast to this study, Alagöz and Kocasoy [21] in Istanbul found that most of the healthcare institutions did not have appropriate color-coded bags or containers for sorting the different types of waste. In addition, Shinee et al. [26] reported that in Mongolia most of the healthcare institutions do not have appropriate color-coded receptacles for sorting the different types of waste.

The present study revealed availability of supplies needed for sorting waste in Tanta University Hospitals. This was in agreement with studies conducted in South Africa and India, which reported that about 97 and 67%, respectively, of HCFs segregated HCW into readily available waste bins [27],[28]. A survey conducted in China showed that 73% of the hospitals used segregation in collection of HCW for all medical waste [29].

In this study, the used bags were suitable for their desired purpose in 82% of departments; however, 18% of these bags were not suitable to the containers and the containers were not covered all the time. The criteria of sharps containers were suitable in all departments. In contrast to Coker et al. [30], who found that some healthcare centers in Nigeria reported the use of inappropriate receptacles like any plastic bags, paper bags, or cardboard to collect clinical waste.

The present study showed that the total achievement of segregation as one item of waste management was sufficient only in 14.8% of the studied departments of Tanta University Hospitals. Despite the observed defects in the total achievement of waste segregation (18.0%), it was still higher compared with the findings of similar studies held in different countries including Egypt [4],[20],[31],[32],[33],[34],[35],[36],[37]. This may be attributed to the national legalizations and guidelines applied in Tanta University Hospitals.

Collection of waste in Tanta University Hospitals was done regularly. The same was also observed in a study conducted by Bdour et al. [1] in Jordan, which revealed that collection is done regularly by a private company at the beginning of each shift. However, in Ibadan, Nigeria, the studied HCFs had no definite or regular collection time, and medical waste was always over spilling from receptacles because of not being collected [30].

The present study revealed that there was no storage area for the produced waste and the storage containers are located at the shoulder of the street outside the hospital building and the area is fully accessible to animals and people. In agreement with this, Alagöz and Kocasoy [21] in Ibn Nafis Hospital in Istanbul, Turkey, reported unsecure location of storage sites and that storage containers are located at the shoulder of the street outside the hospital building. This also goes hand-in-hand with a study conducted by Coker et al. [30], who reported unsecure location of storage of healthcare waste in Nigeria and that most of the hospitals have no special place for storage of healthcare waste before disposal. Taru and Kuvarega [38] reported the absence of proper storage in Harare, Zimbabwe, which attracted rats and flies and resulted in risks to the health. The study conducted by Soliman and Ahmed [10] in Egypt revealed that some departments stored their healthcare waste inside the utility rooms such as surgical, medical, laboratory, and ICUs, whereas labor rooms, operating rooms, and dialysis units do not store healthcare waste in the department, but the waste is immediately transported to the general storage area of the hospital, which was located on the basement floor near to the exit door or near the incinerator. Birpinar et al. [39] in Istanbul, Turkey, found that 63% of the hospitals have temporary storage sites and 94% of these satisfy WHO requirements.

Training of healthcare waste management personnel in Tanta University Hospitals was to some extent sufficient in about two-thirds (73.8%) of the studied departments. The study showed that waste management training was set for workers in 88.5% of the departments, but not all the workers were involved. Courses were held for new staff in 75.4% of the departments. Content of the training courses implemented in each department was adjusted to suit each category of the staff in 82.0% of them. In agreement with the present study, Birpinar et al. [39] found that in Istanbul, Turkey, 98% of HCFs organize training courses for collection personnel and training is carried out twice a year. Also, Kumari et al. [25] in China found that regular and updated training and awareness programs were conducted in every department. On the other hand, several other studies reported that healthcare workers were not educated enough in management of healthcare waste and that most of them have not had any special training on management of healthcare waste [6],[37],[40],[41]. Abor [42] reported that members of the medical staff in the studied HCF have not yet received any formal training with regard to healthcare waste management and are consequently unaware of environmental health impacts of healthcare waste.

The overall achievement of transportation of waste as an important step in the process of healthcare waste management in Tanta University Hospitals was insufficient in 96.7% of the studied departments. According to Alam et al. [43], who conducted a similar study in Bangladesh, the transport of waste was insufficient. The same was also obtained by Dehghani et al. [44] in Iran. This was also documented by Bdour et al. [1] on the basis of his findings in a study carried out in Jordan.

The level of achievement of waste minimization was insufficient in most of the studied departments of Tanta University Hospitals (96.7%). In contrast to these findings, hospitals in developed countries recycling programs are in action to recycle uncontaminated solid waste materials such as office paper, cardboard, metal cans, and selected glass [45].

Acknowledgements

The authors thank the Head of Public Health and Community Medicine, Faculty of Medicine, Tanta University for his general support.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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