MODULE 12: Labeling, Handling and Collection of Healthcare Waste The training modules are part of the United Nations Development Programme-supported, Global Environment Facility-funded Project on Healthcare Waste, in cooperation with the World Health Organization and Health Care Without Harm. The modules were completed in 2012 by Preethi Pratap, PhD, and Leslie Nickels, PhD, of the University of Illinois at Chicago School of Public Health, and Jorge Emmanuel, PhD, Chief Technical Advisor of the UNDP GEF Project, with input from Yves Chartier (WHO), Mohammad-Ali Hamandi, MPH, Ashley Iwanaga, MPH, Glenn McRae, PhD, Megha Rathi, PhD, Ruth Stringer (Health Care Without Harm), and Emily Warren, MSES. This module may be used as a resource to improve healthcare waste management. The module is copyrighted but may be reproduced in its original unaltered form without permission for advocacy, campaigning and teaching purposes. Reproduction and distribution for commercial resale is strictly prohibited. UNDP GEF does not warrant that the information contained in this document is complete and correct and shall not be liable for any damages incurred as a result of its use.

Module Overview Describe appropriate labeling, handling and collection procedures for wastes, particularly infectious and sharps wastes Present the steps in developing a collection system Describe methods of bag closure Describe ways for handling common problems

Learning Objectives Describe the requirements for labeling Describe the requirements for handling and collection of different types of waste Know the steps in developing a collection system Demonstrate proper methods of bag closure, handling and collection Demonstrate procedures for dealing with common problems This module should be adapted for different participants depending on how responsibilities are divided. For example, the slides on proper bag closure are appropriate for the waste generators (health professionals such as nurses and doctors) and/or the waste workers, depending on who has the responsibility for sealing the bags. Slides that relate to segregation and labeling are appropriate for the waste generators. Slides on waste handling are appropriate for the waste workers and their supervisors. In general, slides on waste collection are appropriate for both waste generators and waste workers. The slides on the steps in developing a collection system is appropriate for the department supervisors, supervisors of the waste workers, and healthcare waste management committee. The slides on handling common problems should be used for all participants in order to sensitive everyone about the problems.

Steps in Healthcare Waste Management Waste classification Waste segregation Waste minimization Handling and collection On-site transport and storage Treatment and disposal

Waste Labeling Should be established as part of a healthcare waste management plan Recommended waste label content: Date Type of waste Point of generation (to allow tracking) Weight should be routinely recorded, where possible. Infectious Waste Date __________ Department _________________ Contact ____________________ AB Hospital, City A routine program for infectious waste labeling should be established as part of a healthcare waste management plan. Ideally, waste bags bags and containers should be labelled with the date, type of waste and point of generation to allow it to be tracked through to disposal. Where possible, weight should also be routinely recorded. Anomalies between departments with similar medical services or over time at one location can show up differences in recycling opportunities or problems such as poor segregation and diversion of waste for unauthorized reuse.

Waste Handling Should be established as part of a healthcare waste management plan Waste handling Requires use of proper PPE Requires use of good body mechanics A routine program for waste handling should be established as part of a healthcare waste management plan.

Waste Handling Body mechanics The way we move when conducting activities Good body mechanics could protect the body from injury. Examples of bad and good body mechanics when lifting Body mechanics refers to the way we move during every day activities. Good body mechanics may also protect your body, especially your back, from pain and injury. Using good body mechanics is important. Having your body in the right position helps protect your back and allows you to use your body in a safe way. Injury to the spine may cause problems such as a loss of feeling, movement, and strength, and could also lead to loss of body functions. When lifting an object: Test the weight. Get in a stable position by having your feet apart in a standing position. Your back should be kept straight. Lower your body to get close to the object by bending from your hips and knees. DO NOT bend at the waist. Keeping your knees bent and your back straight, lift the object using your arm and leg muscles. Do not use your back muscles. Tighten your stomach muscles when lifting. Do not bend and twist your body at the same time. When turning, rotate your whole body, not just your back. Repeat the same movements when setting the object down. For heavy objects, use wheeled carts, safety belts and other equipment to help you move the object or ask another person to help you. Source of image: http://www.vcu.edu/oehs/fire/safetytech.html WRONG RIGHT

Waste Collection Should be established as part of a healthcare waste management plan Waste collection Should ensure that waste from each area is collected at least daily (except for sharps) Should ensure that containers are not overfilled Should ensure segregation is maintained Sharp waste should be collected when the box is 3/4th filled A routine program for infectious waste collection should be established as part of a healthcare waste management plan. General, non-hazardous wastes should not be collected at the same time or in the same trolley as infectious or other hazardous wastes

Steps for Developing a Waste Collection System Identify the points of generation of different types of wastes within the healthcare facility Quantify the amounts of wastes and calculate optimum container sizes for each area Evaluate how quickly the containers fill Set up fixed collection times so infectious waste containers are removed when 3/4th full; set up a notification procedure for whenever waste needs to be removed sooner Resupply bags or containers during removal Conduct continuous monitoring and improvement The first step towards effective waste management is identification of sources producing the waste within hospital premises. This is required both at the macro level, where the community of regulating boards identify institutions that generate healthcare waste, and within the institutions, where the administration identifies activities and points that generate such waste. This identification helps the managers to focus their resources and efforts for effective waste management. Within the healthcare organization, waste may be produced in the wards, laboratories, injection room, outpatient departments, offices of the medical practitioners, pharmacy, radiology department and any other place where any diagnostic, therapeutic or research activity are undertaken. Appropriate containers or bag holders should be placed in all locations where particular categories of waste may be generated. Collection should be daily for most wastes with collection timed to fit with the pattern of waste generation at each location. Instructions on waste separation and identification should be posted at each waste collection point to remind staff of the procedures.

Some Considerations When Scheduling Collection Times Match collection times with the regular pattern of waste generation during the day Examples: In medical areas where the morning routine begins with the changing of dressings – collect infectious waste mid- morning to prevent accumulation of soiled bandages In facilities with set visiting hours – collect general and recyclable waste after visitors have departed Collect infectious waste from surgical theaters according to the schedule of operations

Infectious Waste Containers Ideal infectious waste containers are those that have Lids that remain closed except when waste is discarded Pedal-operated devices to open the lids Color-coded bags inside the containers

Infectious Waste Collection Wastes should be transported to the designated central or interim storage area Waste bags and containers should be labeled with the date, type of waste, and point of generation so that it can be correctly and easily tracked through to disposal Do not redistribute the waste contents by shaking the bag as this could cause liquids or aerosols to be released. Where possible, waste generated on the wards should be stored in dirty utility rooms, which are designated for cleaning equipment, dirty linen, and waste. From here the waste can be collected and transported to the central storage facility. If dirty utility rooms are not available, then the waste can be stored in the wards at designated and labeled areas in the ward.

Proper Bag Closure Staff should ensure that waste bags are tightly closed or sealed when they are about ¾ full Bags should not be closed by stapling (which can cause tears) A plastic tag or tie can be used Light-gauge bags can be closed by tying the neck Heavy-gauge bags may require a plastic sealing tag of the self-locking type

Proper Bag Closure Examples of bag tying methods Simple knot Goose-neck or swan-neck method Self-locking tag Twist the open end and tie the end into one knot. (Do not tie alternate corners into knots. This will not appropriately close the bag.)Photo: https://www.ouhsc.edu/ehso/training/bbplesson3.html Swan-neck method: Twist the open end and then fold it over into a “gooseneck” or swan-neck, and then seal over the neck using a twist-tie or tape. Source: http://www.biosch.hku.hk/clinicalwaste/clinicalwaste.html Self-locking or twist ties: Seal tightly when using self-locking twist ties. Be careful of loose twist ties which can slide off when the bag is carried.

Bag Removal and Replacement The bags or containers should be replaced immediately with new ones of the same type A supply of fresh collection bags or containers should be readily available at all locations where waste is produced

Collection of Sharps Safety boxes should not be more than ¾ full when closing and sealing them. Overfilling increases the risk of needle-stick injuries. If a cardboard safety box has a broken handle, check all sides and bottom to make sure there are no protruding needles before removing the container. Heavy-duty gloves should be used when handling sharps containers.

Chemical Waste Collection Chemical wastes should never be mixed or disposed of down the drain but stored in strong leak-proof containers All chemicals should be clearly labeled type of waste name of the major chemicals any necessary hazard labels, e.g. corrosive, flammable, explosive, or toxic

Pharmaceutical Waste Collection Unused pharmaceuticals should go back to the pharmacy for return to the manufacturers or dispatched to specialist waste treatment contractors Spilled and contaminated pharmaceuticals should go directly from the point of generation to the facility waste storage Pharmaceuticals should be kept in their original packaging to aid identification and prevent reaction between incompatible chemicals

Radioactive Waste Collection Where specialist disposal services exist, they should collect and handle radioactive wastes. Otherwise, waste may be stored in radiation- proof repositories (leak-proof, lead-lined, and clearly labeled with name of radionuclide and date of deposition) where it can decay naturally

Discussion What is your facility’s protocol for different types of wastes? How do you collect…? Non-infectious wastes Chemical waste Mercury (broken thermometer) Pharmaceutical wastes Cytotoxic drugs Radioactive wastes

How to Handle Improperly Segregated Waste Poorly segregated waste should never be sorted, but instead treated as the most hazardous type of waste in the container Corrective action must be taken to ensure that the waste is segregated properly in the future

How to Handle Leaking Bags or Containers Leaking bags or sharps containers should be placed in a secondary container (e.g., another plastic bag) with the same color code and label.

How to Handle Overfilled Bags Do not attempt to transfer portions of the waste to another bag or container Two workers with proper PPE are needed With one worker holding open a larger secondary container (e.g., a larger plastic bag of the same color code), another worker should carefully place the overfilled bag or container into the secondary container putting the overflowing waste in first Affix a special label on the outside container if it is not color-coded; follow clean-up procedures if there is a spill Report the overfilled bag to your supervisor

How to Handle an Overfilled Sharps Container Do not attempt to transfer portions of the waste to another container Using long heavy-duty gloves that protect the arms, carefully place the overfilled container into a larger secondary container that is puncture-resistant (e.g., a thick hard cardboard box or plastic box) Affix a special label on the outside container if it is not labeled and follow clean-up procedures if there is a spill Report the overfilled container to your supervisor

Overfilling Waste Container Why does this happen? How can it be prevented?

Overfilling Sharps Container Why does this happen? How can it be prevented?

Country-Specific Requirements Add information here about the country specific guidelines or requirements for labeling, handling, and collection of healthcare wastes.

Discussion What are some procedures and protocols in place in your facility for handling and collecting wastes? Are there different guidelines set up for different types of wastes – infectious, chemical, etc.? Do you know about country-specific guidelines for handling and collection? How does your facility deal with the removal of wastes? What labeling process do you follow? What are some of the weaknesses and strengths of your current system? How can existing practices be improved?