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OUTLINE. Potential Hazard of Hospital WasteWaste Management Sources of wasteClassification of Hospital WasteTreatment, Transport and Disposal MethodIncineration of Hospital WasteRegulations. Facts in Indonesia. RS mengolah Limbah = 53%, pengolahan dg IPAL dan septic tank = 51%, sisanya hany
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1. HOSPITAL WASTE MANAGEMENT TYPES, CHARACTERISTIC, TREATMENT METHOD AND MANAGEMENT
11th May 2009
2. OUTLINE Potential Hazard of Hospital Waste
Waste Management
Sources of waste
Classification of Hospital Waste
Treatment, Transport and Disposal Method
Incineration of Hospital Waste
Regulations
3. Facts in Indonesia RS mengolah Limbah = 53%, pengolahan dg IPAL dan septic tank = 51%, sisanya hanya septic tank
RS yg melakukan pemeriksaan kualitas limbah 57%, 63% memenuhi syarat
Pemisahan sampah medis dan non medis 80.7%, 20% dengan pewadahan khusus (warna dan lambang)
62.5% insinerator, 14.8% landfill, 22.7% cara lain
Limbah toksik, 51.1% insinerator, 15.9% landfill, 33.0% cara lain
Limbah radioaktif, hanya 37.1% menyerahkan limbha ke BATAN, sisanya dengan Silo dan cara lain
Limbah domestik 98.8% dengan cara landfill
4. POTENTIAL HAZARD Exposed people: ?
Patient and medical workers
People who are contracted working at the hospital (cleaning service etc)
Patient (rawat jalan)
Visitors
5. Benefit of Env. Management Environmental Protection
Better Hospital Environmental Management
Human Resource Development
Continuous Improvement of Hospital Environment Performance
Meet Regulation Requirement
Part of Total Quality Management
Reduction of Expenses
Improvement of Hospital Public Image
6. Env. Management Component Management Support
Scale and Type match with Env. Impact from Hospital activities
Continuous improvement
Meet the regulation requirement
Guideline to prepare and review the objective and goal of Env. Management
Documented, applied, maintained and communicated to all
Available for all
7. Planning
Identification of env. Aspects and Impacts
Legal requirements
Environmental Policy and Internal performance criteria
Objectives and goals of env. Managmeent
Planning and management program
Struktur, tanggung jawab, organisasi, kewenangan; proses bisnis management; SDM, skill, budget dan alat; proses untuk mencapai tujuan: prosedur dan pengendalian operasi, pelatihan, sistem pengukuran dan audit, pengkajian manajemen.
8. Implementation
Structure and responsibilities
Training, awareness, competency
Communication
Documentation and Env. Management System
Document Control
Operational Control
Emergency preparedness
Evaluation
Corrective action
9. Hospital Regulation PerMenKes RI No 928/Menkes/Per/XI/1995 ttg penyusunan AMDAL bidang kesehatan
Pedomen teknis penyusunan AMDAL RS
Pedoman Teknis penyusunan UPL dan UKL RS
PerMenKes RI No 986/Menkes/Per/XI/1992 ttg Persyaratan Kesehatan Lingkungan RS
Keputusan Dirjen P2M PLP No HK.00.06.6.64, 18 Feb 1993 ttg Persyaratan dan Petunjuk Teknis tentang Tata Cara Penyehatan Lingkungan Rumah Sakit
Pedoman Sanitasi RS Indonesia
Pedoman teknis Pengelolaan Makanan dan Infeksi Nosokomial di RS
PP no 12/1995 ttg perubahan PP no 19/1994 ttg pengelolaan limbah B3
KepMenLH No 58/1995 ttg Baku Mutu Limbah Cair bagi Kegiatan RS
10. Regulated Env. Aspects Environmental Impacts Assessment
Nosokomial Infection
Chemical and hazardous waste
Gas emission, temperature, humidity, nuisance and lighting
Effluent quality of waste treatment plant
Solid waste
Radioactive waste
Medical waste
11. Unregulated Env. Aspects Management structure
Facilities, location map of env. control
History and Owner of the Hospital
Hospital General activities
Flow of Health Treatment Procedure
Nosokomial Infection control
Health and Safety Policy
List of Medical and non medical substance
Sistem pengadaan dan jadwal, jml pemakaian, penyimpanan, distribusi dan transportasi bahan
Air pollution control
12. Handling, storage, transportation of domestic, hazardous, chemotherapy waste, disposal procedure and legal letter
Water supply, piping, layout, and water consumption
Recording of wastewater effluent quality
Waste water treatment system ( system, facilities and SOP)
Sanitation method (pest, microbiology, virus, toxicology)
Supply, Layout, consumption of electricity
Environmental training
Supplier Consideration of Environmental Issues
Material Identification Approach
13. Environmental Monitoring Aspects Waste production
Waste water
Reuse of waste water
Efficiency of Material Consumption
Energy consumption
Unplanned disposal
Recycle activities
Chemical handling
Gas handling
Handling of water for cleaning purposes
14. WASTE FLOW IN GENERAL
15. SOURCES Medical Activities
Surgical Room, Emergency Room, Policlinic, Dialysis, Delivery Room, treatment of dead body, Chemotherapy, etc.
Supporting Activities
Laboratories, Radiology, Laundry, Kitchen, Maintenance, Pharmacy
Office and Social Activities
Office (administration and accountancy), Medical record, Cafeteria, Mosque, Guest House, Dormitory
17. CLASSIFICATION Hospital Waste: all wastes that are generated from hospital activities including solid, liquid and gases
Liquid waste: all waste in liquid form from hospital activities including excreta that has possibilities of containing microorganism, toxic chemicals, and radioactive substance.
Solid waste: all waste in solid form including medical and non medical waste
18. Medical waste (limbah medis) (50-60% disposal cost)? generated from medical activities
Infectious waste ? contains microorganism that may cause disease from surgical room, laboratories, haemodialysis
Pathological waste ? human/animal tissue, body part, etc
Citotoxic waste ? material that are/might be contaminated by citotoxic medicine
Sharps ? syringe, scissors, knife, broken glass, nail cutter ? tertusuk (luka)
Pharmacological waste ?returned medicine, expired or contaminated medicine, spilled medicine, etc.
CLASSIFICATION
19. Could you explain what are the differences between infectious waste and pathological waste ?
20. CLASSIFICATION Non Medical Waste (limbah non medis) ? mostly generated from hospital supporting activities, office and social activities
General waste, food, card board, etc
Hazardous waste ? toxic, corrosive, flammable, reactive (explosive, reactive to water, shock sensitive)
Radioactive ? solid, liquid or gas contaminated by radionuclide, generated from in-vitro, in-vivo analysis, therapy
toxic waste ? genetoxic (carcinogenic, mutagenic, teratogenic)
pressure containers ? explosive when burned
Waste with high heavy metal concentration
Chemical waste ? disinfection, laboratories, cleaning, may include in hazardous waste categories
21. Limbah Klinis
Golongan A, dressing bedah, swab, dan semua bahan yang tercampur deng bhn tsb, linen dan kasus infeksi, jaringan tubuh, dan hal lain y berkaitan dg swab dan dressing
Golongan B, syringe bekas, jarum, catridge, pecahan gelas, dan benda tajam lainnya
Golongan C, limbah dr laboratorium dan post partum kecuali yg termasuk gol A
Golongan D, limbah bahan kimia dan bhn farmasi ttt
Golongan E, plapis bed-pan disposable, urinoir, incontinence-pad, dan stamage-bags
22. INFECTIOUS WASTE Infectious waste includes the following (EPA): ?
Isolation waste
Cultures and stocks of infectious agents and associated biologicals
Human blood or liquid and blood products
Pathological waste (tissues, organs, body parts except teeth and hair)
Contaminated sharps
Miscellaneous contaminated wastes (animal carcasses)
24. CHARACTERISTIC of SW
25. CLASSIFICATION
26. COMPOSITION
27. TOXIC & HAZARDOUS WASTE Hospital generate 0.056 lb/bed per day toxic and hazardous waste
200 bed ? 336 lb per month ? hospitals are regulated as generator of hazardous waste
28. WASTE MANAGEMENT ?
29. WASTE MANAGEMENT
30. PREVETION OF POTENTIAL HAZARD Use safety material or non-hazardous material
Use closed containers for volatile substance
Good ventilation ? health&safety standards
Body protection (mask, gloves, etc.)
Use container with different color for different waste
Regular monitoring for high risk activities
Epidemiological analysis for high risk activities
31. ON SITE HANDLING
32. COLLECTION / STORAGE EPA ? red bag (operating room waste, blood serums, sharps), white bag (general waste, kitchen waste, boxes)
DepKes RI ? plastic bag’s color
Black : general waste
Yellow: all waste that must go to incinerators
Yellow with black line: all waste that better go to incinerator, but can go to landfill if collected separately
Light blue or transparent with dark blue lines: must go to autoclave before next handling
33. COLLECTION / STORAGE Bags or containers should be ?
Enough filled so it is easy to be well closed
Labeled ? symbol is given as it is regulated
Able to allow steam to enter during sterilization (if needed)
Completed with active date before it can be categorized as general waste
For syringe : WHO standard (container shape, thickness, material, placing)
34. TRANSPORTATION Waste are transported from first collection to temporary storage or to incinerator
Transportation means must be cleaned regularly and used only for waste transport
If transported to landfill must not have possibilities to harm the health of transportation personnel
Hazardous waste should be transported as regulated in PP 18/1999
35. HANDLING OF CHEMICAL Non-hazardous chemical should be labeled and handled as general waste
organic chemical (acetate, amino acid, citric acid, lactic acid, sugar)
Inorganic chemical (chloride, fluoride, bromide, sulfate, borate)
Hazardous chemical
Un reusable chemical? incinerator
dated after used, maximum storage time: 3, 12, 24 month
Shock sensitive: diazo substance, metal azide, nitrocellulose, perchloric acid, perchlorate salts, peroxide, picric acid, picrate salts, polynitroaromatic
Water reactive: alkaline metal, soil alkaline, lithium alkaline reagent, boron trifluoride solution, grignard solution
Others: nitrate acid >70%, phosphor (red and white)
36. DISINFECTION ALTERNATIVES Autoclaving
Pyrolysis ? 1200?C, vol. reduction 97-98%
Fluidized-bed coal technology ? circulating fluidized bed burning of coal
Electron beam technology ? sterilization of all infectious waste including liquid
Microwave technology ? not recommendation for pathological and animal waste, + expensive
Mechanical-Chemical treatment (Sodium Hypochlorite -NaOCl) ? pathological
Gas/vapor sterilization (ethylene oxide or formaldehyde), not recommended
Biodegradation ? enzymes
Steam sterilization ? 300 ?F
37. COMPARISON
38. DECISION MAKING
39. INCINERATION ? Infectious, un recover/un recyclable general waste
Operational Parameters:
Burning rate (pound/hour), heating value (Btu/pound), heat release value (Btu/cubic feet per hour)
Alternatives:
Controlled-air incinerators
Rotary-kiln incinerators
Air Pollution Controls
Wet Scrubbers: impaction of particles with countercurrent flow reactor
Dry Scrubbers: Reacting particles and gases in spray-dryer section, collection of particles in a baghouse collector
40. INCINERATORS
41. INCINERATORS
43. INCINERATORS
44. What are the differences between controlled air and rotary kiln incinerators ?
45. AIR POLLUTION CONTROLS
46. NEW METHODS Problems ? dioxin ? carcinogenic
Dioxin + chlor ? TCDD (Tetra Chloro Dibenzo para Dioxin) ? cancer
US ? many incinerators > regulation
Japan ? 70% world incinerators, high concentration dioxin found in surrounding incinerator ? 18 from 271 die from cancer
> 800 ?C ? reduce dioxin but increase heavy metal vapor
Using Sun Light
reduce dioxin, reduce cost
150?C in 20 minutes ? enough to kill bacteria
Low Thermal Desorbtion
Invented by FMIPA UI
Titanium oxide ? dioxin reduction
Indirect heating with low heat thermolysis ? drying at low temperature (200-350 ?C) without oxidation (direct burning)
Low pressure
No oxygen ? reduce vapor point
47. LIQUID WASTE Indonesia ? most hospitals use septic tank
Direct charge to river
Possibility polluting the surrounding soil
Unable degraded by activated sludge
Recommended: Ozonization
Ozone: oxidation potential 1.7 V ? radical
Ozone in water ? radical hydroxil (2.8 V)
Kill eschericia coli, Salmonella enteriditis, Hepatitis A Virus, etc
Oxidize organic substance ( fenol, pesticides, atrazine, TNT, etc)
48. TOXIC WASTE DISPOSAL
49. REGULATION UU No. 23 /1997 ? Pengelolaan Lingkungan Hidup
KepMENLH No. 58/1995 ? Baku mutu limbah cair bagi kegiatan rumah sakit
PP No. 18/1999 ? Pengelolaan limbah B3
UU N0. 7/2004 ? Sumber Daya Air
Peraturan Menteri Kesehatan RI No. 1024/2003 ? Persyaratan Kesehatan Lingkungan RS
50. REFERENCES Harry M. Freeman, editor (1989) Standard Handbook of Hazardous Waste Treatment and Disposal, McGraw-Hill, Inc., New York.
Howard E. Hesketh and Frank L. Cross, Jr. (1995) Engineering Medical Waste-to-Energy Systems, Technomic Publishing Co., Inc., Lancester
CRS Handbook of Laboratory Safety 5th edition (A. Keith Furr)
Hazardous Waste Management, McGraw-Hill, Inc., New York
Bapedal (2003) Peraturan Lingkungan Hidup, Jilid 1, Bapedal, Jakarta.
Wiku Adisasmito, 2007, Sistem Manajemen Lingkungan, PT. Raja Grafindo Persada, Jakarta
51. ALTERNATIVE METHODS