An adaptation of current guidelines on the disposal of hospital wastes, as well as improvements in internal safety and hygiene, must be part of an overall plan of hospital waste management that establishes the procedures to follow. This should be done through properly coordinating internal and external services, as well as defining responsibilities in each of the management phases. The main goal of this plan is to protect the health of health care personnel, patients, visitors and the general public both in the hospital and beyond.

At the same time, the health of the people who come in contact with the waste once it leaves the medical centre should not be overlooked, and the risks to them should also be minimized.

Such a plan should be campaigned for and applied according to a global strategy that always keeps in mind the realities of the workplace, as well as the knowledge and the training of the personnel involved.

Stages followed in the implementation of a waste management plan are:

• informing the management of the medical centre

• designating those responsible at the executive level

• creating a committee on hospital wastes made up of personnel from the general services, nursing and medical departments that is chaired by the medical centre’s waste manager.

The group should include personnel from the general services department, personnel from the nursing department and personnel from the medical department. The medical centre’s waste manager should coordinate the committee by:

• putting together a report on the present performance of the centre’s waste management

• putting together an internal plan for advanced management

• creating a training programme for the entire staff of the medical centre, with the collaboration of the human resources department

• launching the plan, with follow-up and control by the waste management committee.

Classification of hospital wastes

Until 1992, following the classical waste management system, the practice was to classify most hospital wastes as hazardous. Since then, applying an advanced management technique, only a very small proportion of the large volume of these wastes is considered hazardous.

The tendency has been to adopt an advanced management technique. This technique classifies wastes starting from the baseline assumption that only a very small percentage of the volume of wastes generated is hazardous.

Wastes should always be classified at the point where they are generated. According to the nature of the wastes and their source, they are classified as follows:

• Group I: those wastes that can be assimilated into urban refuse

• Group II: non-specific hospital wastes

• Group III: specific hospital wastes or hazardous wastes

• Group IV: cytostatic wastes (surplus antineoplastic drugs that are not fit for therapeutic use, as well as the single-use materials that have been in contact with them, e.g., needles, syringes, catheters, gloves and IV set-ups).

According to their physical state, wastes can be classified as follows:

• solids: wastes that contain less than 10% liquid

• liquids: wastes that contain more than 10% liquid

Gaseous wastes, such as CFCs from freezers and refrigerators, are not normally captured (see article “Waste anaesthetic gases”).

By definition, the following wastes are not considered sanitary wastes:

• radioactive wastes that, because of their very nature, are already managed in a specific way by the radiological protection service

• human cadavers and large anatomical parts which are cremated or incinerated according to regulations

• waste water.

Group I Wastes

All wastes generated within the medical centre that are not directly related to sanitary activities are considered solid urban wastes (SUW). According to the local ordinances in Cataluna, Spain, as in most communities, the municipalities must remove these wastes selectively, and it is therefore convenient to facilitate this task for them. The following are considered wastes that can be assimilated to urban refuse according to their point of origin:

Kitchen wastes:

• food wastes

• wastes from leftovers or single-use items

• containers.

Wastes generated by people treated in the hospital and non-medical personnel:

• wastes from cleaning products

• wastes left behind in the rooms (e.g., newspapers, magazines and flowers)

• wastes from gardening and renovations.

Wastes from administrative activities:

• paper and cardboard

• plastics.

Other wastes:

• glass containers

• plastic containers

• packing cartons and other packaging materials

• dated single-use items.

So long as they are not included on other selective removal plans, SUW will be placed in white polyethylene bags that will be removed by janitorial personnel.

Group II Wastes

Group II wastes include all those wastes generated as a by-product of medical activities that do not pose a risk to health or the environment. For reasons of safety and industrial hygiene the type of internal management recommended for this group is different from that recommended for Group I wastes. Depending on where they originate, Group II wastes include:

Wastes derived from hospital activities, such as:

• blood-stained materials

• gauze and materials used in treating non-infectious patients

• used medical equipment

• mattresses

• dead animals or parts thereof, from rearing stables or experimental laboratories, so long as they have not been inoculated with infectious agents.

Group II wastes will be deposited in yellow polyethylene bags that will be removed by janitorial personnel.

Group III Wastes

Group III includes hospital wastes which, due to their nature or their point of origin, could pose risks to health or the environment if several special precautions are not observed during handling and removal.

Group III wastes can be classified in the following way:

Sharp and pointed instruments:

• needles

• scalpels.

Infectious wastes. Group III wastes (including single-use items) generated by the diagnosis and treatment of patients who suffer from one of the infectious diseases are listed in table 1.

Table 1. Infectious diseases and Group III wastes

Laboratory wastes:

• material contaminated with biological wastes

• waste from work with animals inoculated with biohazardous substances.

Wastes of the Group III type will be placed in single-use, rigid, colour-coded polyethylene containers and hermetically sealed (in Cataluna, black containers are required). The containers should be clearly labelled as “Hazardous hospital wastes” and kept in the room until collected by janitorial personnel. Group III wastes should never be compacted.

To facilitate their removal and reduce risks to a minimum, containers should not be filled to capacity so that they can be closed easily. Wastes should never be handled once they are placed in these rigid containers. It is forbidden to dispose of biohazardous wastes by dumping them into the drainage system.

Group IV Wastes

Group IV wastes are surplus antineoplastic drugs that are not fit for therapeutic use, as well as all single-use material that has been in contact with the same (needles, syringes, catheters, gloves, IV set-ups and so on).

Given the danger they pose to persons and the environment, Group IV hospital wastes must be collected in rigid, watertight, sealable single-use, colour-coded containers (in Cataluna, they are blue) which should be clearly labelled “Chemically contaminated material: Cytostatic agents”.

Other Wastes

Guided by environmental concerns and the need to enhance waste management for the community, medical centres, with the cooperation of all personnel, staff and visitors, should encourage and facilitate the selective disposal (i.e., in special containers designated for specific materials) of recyclable materials such as:

• paper and cardboard

• glass

• used oils

• batteries and power cells

• toner cartridges for laser printers

• plastic containers.

The protocol established by the local sanitation department for the collection, transport and disposal of each of these types of materials should be followed.

Disposal of large pieces of equipment, furniture and other materials not covered in these guidelines should follow the directions recommended by the appropriate environmental authorities.

Internal transport and storage of wastes

Internal transport of all the wastes generated within the hospital building should be done by the janitorial personnel, according to established schedules. It is important that the following recommendations be observed when transporting wastes within the hospital:

• The containers and the bags will always be closed during transport.

• The carts used for this purpose will have smooth surfaces and be easy to clean.

• The carts will be used exclusively for transporting waste.

• The carts will be washed daily with water, soap and lye.

• The waste bags or containers should never be dragged on the floor.

• Waste should never be transferred from one receptacle to another.

The hospital must have an area specifically for the storage of wastes; it should conform to current guidelines and fulfil, in particular, the following conditions:

• It should be covered.

• It should be clearly marked by signs.

• It should be built with smooth surfaces that are easy to clean.

• It should have running water.

• It should have drains to remove the possible spillage of waste liquids and the water used for cleaning the storage area.

• It should be provided with a system to protect it against animal pests.

• It should be located far away from windows and from the intake ducts of the ventilation system.

• It should be provided with fire extinguishing systems.

• It should have restricted access.

• It should be used exclusively for the storage of wastes.

All the transport and storage operations that involve hospital wastes must be conducted under conditions of maximum safety and hygiene. In particular, one must remember:

• Direct contact with the wastes must be avoided.

• Bags should not be overfilled so that they may be closed easily.

• Bags should not be emptied into other bags.

Liquid Wastes: Biological and Chemical

Liquid wastes can be classified as biological or chemical.

Liquid biological wastes

Liquid biological wastes can usually be poured directly into the hospital’s drainage system since they do not require any treatment before disposal. The exceptions are the liquid wastes of patients with infectious diseases and the liquid cultures of microbiology laboratories. These should be collected in specific containers and treated before being dumped.

It is important that the waste be dumped directly into the drainage system with no splashing or spraying. If this is not possible and wastes are gathered in disposable containers that are difficult to open, the containers should not be forced open. Instead, the entire container should be disposed of, as with Group III solid wastes. When liquid waste is eliminated like Group III solid waste, it should be taken into consideration that the conditions of work differ for the disinfection of solid and liquid wastes. This must be kept in mind in order to ensure the effectiveness of the treatment.

Liquid chemical wastes

Liquid wastes generated in the hospital (generally in the laboratories) can be classified in three groups:

• liquid wastes that should not be dumped into the drains

• liquid wastes that can be dumped into the drains after being treated

• liquid wastes that can be dumped into the drains without being previously treated.

This classification is based on considerations related to the health and quality of life of the entire community. These include:

• protection of the water supply

• protection of the sewer system

• protection of the waste water purification stations.

Liquid wastes that can pose a serious threat to people or to the environment because they are toxic, noxious, flammable, corrosive or carcinogenic should be separated and collected so that they can subsequently be recovered or destroyed. They should be collected as follows:

• Each type of liquid waste should go into a separate container.

• The container should be labelled with the name of the product or the major component of the waste, by volume.

• Each laboratory, except the pathological anatomy laboratory, should provide its own individual receptacles to collect liquid wastes that are correctly labelled with the material or family of materials it contains. Periodically (at the end of each work day would be most desirable), these should be emptied into specifically labelled containers which are held in the room until collected at appropriate intervals by the assigned waste removal subcontractor.

• Once each receptacle is correctly labelled with the product or the family of products it contains, it should be placed in specific containers in the labs.

• The person responsible for the laboratory, or someone directly delegated by that person, will sign and stamp a control ticket. The subcontractor will then be responsible for delivering the control ticket to the department that supervises safety, hygiene and the environment.

Mixtures of chemical and biological liquid wastes

Treatment of chemical wastes is more aggressive than treatment of biological wastes. Mixtures of these two wastes should be treated using the steps indicated for liquid chemical wastes. Labels on containers should note the presence of biological wastes.

Any liquid or solid materials that are carcinogenic, mutagenic or teratogenic should be disposed of in rigid colour-coded containers specifically designed and labelled for this type of waste.

Dead animals that have been inoculated with biohazardous substances will be disposed of in closed rigid containers, which will be sterilized before being reused.

Disposal of Sharp and Pointed Instruments

Sharp and pointed instruments (e.g., needles and lancets), once used, must be placed in specifically designed, rigid “sharps” containers that have been strategically placed throughout the hospital. These wastes will be disposed of as hazardous wastes even if used on uninfected patients. They must never be disposed of except in the rigid sharps container.

All HCWs must be repeatedly reminded of the danger of accidental cuts or punctures with this type of material, and instructed to report them when they occur, so that appropriate preventive measures may be instituted. They should be specifically instructed not to attempt to recap used hypodermic needles before dropping them into the sharps container.

Whenever possible, needles to be placed in the sharps container without recapping may be separated from the syringes which, without the needle, can generally be disposed of as Group II waste. Many sharps containers have a special fitting for separating the syringe without risk of a needlestick to the worker; this saves space in the sharps containers for more needles. The sharps containers, which should never be opened by hospital personnel, should be removed by designated janitorial personnel and forwarded for appropriate disposal of their contents.

If it is not possible to separate the needle in adequately safe conditions, the whole needle-syringe combination must be considered as biohazardous and must be placed in the rigid sharps containers.

These sharps containers will be removed by the janitorial personnel.

Staff Training

There must be an ongoing training programme in waste management for all hospital personnel aimed at indoctrinating the staff on all levels with the imperative of always following the established guidelines for collecting, storing and disposing wastes of all kinds. It is particularly important that the housekeeping and janitorial staffs be trained in the details of the protocols for recognizing and dealing with the various categories of hazardous waste. The janitorial, security and fire-fighting staff must also be drilled in the correct course of action in the event of an emergency.

It is also important for the janitorial personnel to be informed and trained on the correct course of action in case of an accident.

Particularly when the programme is first launched, the janitorial staff should be instructed to report any problems that may hinder their performance of these assigned duties. They may be given special cards or forms on which to record such findings.

Waste Management Committee

To monitor the performance of the waste management programme and resolve any problems that may arise as it is implemented, a permanent waste management committee should be created and meet regularly, quarterly at a minimum. The committee should be accessible to any member of the hospital staff with a waste disposal problem or concern and should have access as needed to top management.

Implementing the Plan

The way the waste management programme is implemented may well determine whether it succeeds or not.

Since the support and cooperation of the various hospital committees and departments is essential, details of the programme should be presented to such groups as the administrative teams of the hospital, the health and safety committee and the infection control committee. It is necessary also to obtain validation of the programme from such community agencies as the departments of health, environmental protection and sanitation. Each of these may have helpful modifications to suggest, particularly with respect to the way the programme impinges on their areas of responsibility.

Once the programme design has been finalized, a pilot test in a selected area or department should permit rough edges to be polished and any unforeseen problems resolved. When this has been completed and its results analysed, the programme may be implemented progressively throughout the entire medical centre. A presentation, with audio-visual supports and distribution of descriptive literature, can be delivered in each unit or department, followed by delivery of bags and/or containers as required. Following the start-up of the programme, the department or unit should be visited so that any needed revisions may be instituted. In this manner, the participation and support of the entire hospital staff, without which the programme would never succeed, can be earned.

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A hospital is not an isolated social environment; it has, given its mission, very serious intrinsic social responsibilities. A hospital needs to be integrated with its surroundings and should minimize its impact upon them, thus contributing to the welfare of the people who live near it.

From a regulatory perspective, the health industry has never been considered to be on the same level as other industries when they are ranked according to the health risks they pose. The result is that specific legislation in this sphere has been non-existent until recently, although in the last few years this deficiency has been addressed. While in many other kinds of industrial activities, health and safety is an integral part of the organization, most health centres still pay little or no attention to it.

One reason for this could be the attitudes of HCWs themselves, who may be preoccupied more with research and the acquisition of the latest technologies and diagnostic and treatment techniques than with looking into the effects that these advances could have on their own health and on the environment.

New developments in science and health care must be combined with environmental protection, because environmental policies in a hospital affect the quality of life of HCWs within the hospital and those who live outside it.

Integrated Health, Safety and Environmental Programmes

HCWs represent a major group, comparable in size to the large enterprises of the private sector. The number of people who pass through a hospital every day is very large: visitors, inpatients, outpatients, medical and commercial representatives, subcontractors and so on. All of them, to a greater or lesser degree, are exposed to the potential risks posed by the activities of the medical centre and, at the same time, contribute on a certain level to the improvement or the worsening of the safety and the care of the centre’s surroundings.

Strict measures are needed in order to safeguard HCWs, the general public and the surrounding environment from the deleterious effects that may stem from hospital activities. These activities include the use of ever more sophisticated technology, the more frequent use of extremely powerful drugs (the effects of which can have a profound and irreparable impact on the people who prepare or administer them), the too-often uncontrolled use of chemical products and the incidence of infectious diseases, some of which are incurable.

The risks of working in a hospital are many. Some are easy to identify, while others are very hard to detect; the measures to be taken should therefore always be rigorous.

Different groups of health professionals are particularly exposed to risks common to the health care industry in general, as well as to specific risks related to their profession and/or to the activities they perform in the course of their work.

The concept of prevention, therefore, must of necessity be incorporated to the health care field and encompass:

• safety in the broadest sense, including psychosociology and ergonomics as part of the programmes to improve the quality of life in the workplace

• hygiene, minimizing as much as possible any physical, chemical or biological factor that may affect the health of people in the work environment

• environment, following policies to protect nature and people in the surrounding community and decreasing the impact on the environment.

We should be aware that the environment is directly and intimately related to the safety and hygiene in the workplace, because natural resources are consumed at work, and because these resources are later reincorporated into our surroundings. Our quality of life will be good or bad depending on whether we make correct use of these resources and use appropriate technologies.

Everyone’s involvement is necessary in order to contribute to further:

• nature conservancy policies, designed to guarantee the survival of the natural heritage that surrounds us

• environmental improvement policies as well as policies to control indoor and environmental pollution in order to integrate human activity with the environment

• environmental research and training policies to improve working conditions as well as to reduce environmental impact

• planning organizational policies designed to set goals and develop norms and methodology for workers’ health and the environment.

Goals

Such a programme should endeavour to:

• change the culture and habits of health professionals in order to stimulate behaviour more conducive to safeguarding their health

• set goals and develop internal safety, hygiene and environmental guidelines through adequate planning and organization

• improve the methods of work to avoid a negative impact on health and the environment through environmental research and education

• increase the involvement of all personnel and have them take responsibility for health in the workplace

• create an adequate programme to establish and publicize the guidelines as well as to monitor their continued implementation

• correctly classify and manage the waste generated

• optimize costs, avoiding added expenditures that cannot be justified by the increased levels of safety and health or environmental quality.

Plan

A hospital should be conceived as a system that, through a number of processes, generates services. These services are the main goal of the activities performed in a hospital.

For the process to begin, certain commitments of energy, investments and technology are needed, which in turn will generate their own emissions and wastes. Their only aim is to provide service.

In addition to these prerequisites, consideration should be given to the conditions of the areas of the building where these activities will take place, since they have been designed a certain way and built with basic construction materials.

Control, planning and coordination are all necessary for an integrated safety, health and environmental project to succeed.

Methodology

Because of the complexity and the variety of risks in the health care field, multidisciplinary groups are required if solutions to each particular problem are to be found.

It is important for health care workers to be able to collaborate with safety studies, participating in the decisions that will be made to improve their working conditions. This way changes will be seen with a better attitude and the guidelines will be more readily accepted.

The safety, hygiene and environmental service should advise, stimulate and coordinate the programmes developed at the health centre. Responsibility for their implementation should fall upon whoever heads up the service where this programme will be followed. This is the only way to involve the entire organization.

In each particular case, the following will be selected:

• the system involved

• the parameters of the study

• the time needed to carry it out.

The study will consist of:

• an initial diagnosis

• analysis of the risk

• deciding on the course of action.

In order to implement the plan successfully it will always be necessary to:

• educate and inform people of the risks

• improve the management of human resources

• improve the channels of communication.

This type of study may be a global one encompassing the centre as a whole (e.g., internal plan for the disposal of hospital wastes) or partial, encompassing only one concrete area (e.g., where cancer chemotherapeutic drugs are prepared).

The study of these factors will give an idea of the degree to which safety measures are disregarded, as much from the legal as from the scientific point of view. The concept of “legal” here encompasses advances in science and technology as they occur, which requires the constant revision and modification of established norms and guidelines.

It would be convenient indeed if the regulations and the laws by which safety, hygiene and the environment are regulated were the same in all countries, something that would make the installation, management and use of technology or products from other countries much easier.

Results

The following examples show some of the measures that can be taken while following the aforementioned methodology.

Laboratories

An advisory service can be developed involving professionals of the various laboratories and coordinated by the safety and hygiene service of the medical centre. The main goal would be to improve the safety and health of the occupants of all the labs, involving and giving responsibility to the entire professional staff of each and trying at the same time to make sure that these activities do not have a negative impact on public health and the environment.

The measures taken should include:

• instituting the sharing of materials, products and equipment among the different laboratories, in order to optimize resources

• reducing the stocks of chemical products in laboratories

• creating a manual of basic norms of safety and hygiene

• planning courses to educate all laboratory workers on these matters

• training for emergencies.

Mercury

Thermometers, when broken, release mercury into the environment. A pilot project has been started with “unbreakable” thermometers to consider eventually substituting them for the glass thermometers. In some countries, such as the United States, electronic thermometers have replaced mercury thermometers to a very great extent.

Training the workers

The training and the commitment of the workers is the most important part of an integrated safety, health and environment programme. Given enough resources and time, the technicalities of almost any problem can be solved, but a complete solution will not be achieved without informing the workers of the risks and training them to avoid or control them. The training and education must be continuous, integrating health and safety techniques into all the other training programmes in the hospital.

Conclusions

The results that have been achieved so far in applying this work model allow us so far to be optimistic. They have shown that when people are informed about the whys and wherefores, their attitude toward change is very positive.

The response of health care personnel has been very good. They feel more motivated in their work and more valued when they have participated directly in the study and in the decision-making process. This participation, in turn, helps to educate the individual health care worker and to increase the degree of responsibility he or she is willing to accept.

The attainment of the goals of this project is a long-term objective, but the positive effects it generates more than compensate for the effort and the energy invested in it.

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