SAFHE CONFERENCE 2001, 3 5 October 2001, Sun City

THE IMPORTANCE OF SEGREGATION IN THE PILOT PROJECT: A CASE STUDY

Nobantu Mabel Mpela

Infection Control Nurse, Leratong Hospital

Co-Author:

Janet Magner, Health Care Consultant, Magallan Risk Services

ABOUT THE SPEAKER

Nobantu Mabel Mpela – Speaker: Nobantu is a Registered Nursing Sister with a Diploma in General Nursing (1980) and a Diploma in Midwifery (1982). She started her nursing career in the obstetrical unit at Leratong hospital in June 1982. In 1992 she obtained a Certificate in Infection Control and shortly thereafter opened the Infection Control department at Leratong. In 1999 she completed a Diploma in Community Nursing. In her capacity as head of the Infection Control unit at Leratong, she has co-ordinated many different pilot projects for the institution (e.g. V.C.T., PM.T.C.T and P.E.P.)[1]. It was within her capacity as an Environmental Health and Waste Management Officer at Leratong that she was selected to be managing the health care waste management pilot project at Leratong Hospital and participate in a health care waste management study tour to Cairo, Copenhagen and Manchester in April 2002 to equip her to run the pilot project for Sustainable Health Care Waste Management in Gauteng.

Janet Magner – Co-Author: Janet is an Occupational Health, Safety and Environmental Specialist with a National Diploma in Safety Management (NADSAM) cum laude in 1995. She has completed many NOSA courses, of note attaining the Safety Management Training qualification (SAMTRAC) in 1993. During this same year she also completed the Advanced Risk Management course with the Chamber of Mines. In 1998 she completed an Occupational Hygiene – Legislation course with the Pretoria Technikon.

Janet has had more than 10 years experience in Occupational Health, Safety and Environmental Management in both industry and healthcare. She has specialised in the development and implementation of integrated management systems that cover all aspects of Occupational Health, Safety and Environmental risk management.

Her more recent experiences in development work for projects such as Sustainable Health Care Waste Management in Gauteng and the Solid Waste Management Strategy for Swaziland has given her valuable insight and experience in health care waste management.

ABSTRACT

As part of the project “Sustainable Health Care Waste Management in Gauteng” a pilot study is being run at Leratong Hospital and Itireleng Clinic to test two systems for health care waste management. This paper will cover what the pilot study was able to achieve with regard to improving segregation by the application of better equipment and practices supported by skills training, monitoring and enforcement.

Segregation of health care waste is entrenched within the National Waste Management Strategy where minimization and recycling is recognized as more important than the final treatment and disposal. The importance of proper segregation is reflected in the significant occupational health and safety risks involved as well as in the treatment technologies and cost implications.

Effective segregation is not just a function of improved equipment and technology. It incorporates the synergisms of:

a) the principle of separation at source with the use of strategically placed, colour coded and labelled receptacles for ease of use and quick identification and,

b) people’s attitude that manifests itself into a certain behaviour patterns.

In the pilot project at the two selected Gauteng Health Institutions, the focus was on improving the segregation practices through a planned participative and staff driven process for building capacity and obtaining buy-in. This was achieved through the introduction and correct application of reusable containers with improved technology, the application of operational systems and procedures to support the equipment and a systematic skills development and awareness programme. The process was actively supported by ongoing supervision, monitoring and enforcement to ensure that the standards were maintained.

Significant improvements in the segregation and staff awareness have been achieved resulting in improved occupation health and safety conditions, significant costs savings and empowerment of general assistants who did the collection and transportation. The team work and dedication of all the important parties played an important part in the improved segregation and monitoring of the services.

THE IMPORTANCE OF SEGREGATION IN THE PILOT PROJECT:

A CASE STUDY

INTRODUCTION

Studies conducted as part of the project “Sustainable Health Care Waste Management in Gauteng indicated that for an improved health care system to be sustainable there was a critical need to improve the segregation of waste in health care facilities. The correct segregation of waste is entrenched within the National Waste Management Strategy where minimization and recycling is recognized as more important than the final treatment and disposal. The process outlined in this document supports this in the principles of separation at source and a duty to care. The importance of segregation is also reflected in the potential for significant occupational health and safety risks to nursing, transport, treatment and disposal personnel through mis-segregation. When hazardous health care waste finds its way to the landfill sites, the risks of harm to the public as well as the workers is palpable and has been highlighted by the adverse media reporting that we have experienced. A series of detailed reports and further information is available for download at

BACKGROUND

The project “Sustainable Health Care Waste Management in Gauteng”, hosted by the Department of Agriculture, Environment and Land Affairs (DACEL), assisted by RAMBØLL - a Danish Consulting Company - and co-funded by the Danish Government set out as a main objective to improve the management of health care waste in Gauteng. Two pilot sites were identified, Leratong Hospital in Krugersdorp and Itireleng Clinic in Dobsonville to conduct a pilot test of two health care waste management systems.

Themain objectives of the dual testing of two different systems were to:

1. do a comparative analysis between the two systems
2. inform the tender specifications process for all provincial hospitals and clinics
3. test the assumptions made in the feasibility study
4. test the training and awareness material developed

The results of a feasibility study conducted as part of the project indicated that the familiar single-use cardboard boxes were environmentally unfriendly, costly and unsafe compared to systems based on reusable and puncture resistant containers. The two new systems that were introduced were therefore based on the use of reusable containers.

The wheelie bin / liner system

This system consists of a selection of free-standing stands and wall / trolley mounted baskets, custom fitted with polyethylene liners of varying microns depending on the size. The smaller liners are closed using rubber bands and deposited into the larger liners. 770 litre wheelie bins are used to collect the closed larger liners where they remained for removal to the treatment plant.

The stackable box system

This system consists of 50 and 100 litre reusable polyethylene containers that are designed to stack and nest well for transport. They are lined with plastic liners of lesser microns than that used for the wheelie bin / liner system. The containers are placed at the generation point and when full, the liners are closed with rubber bands and the lids placed onto the containers. A custom designed trolley is used to collect the boxes where the boxes remained for removal to the treatment plant.

The 770 litre wheelie bins, stackable boxes and cage trolleys were cleaned at the treatment plant and returned to the hospital and clinic. Both systems used the same sharps container, pedal bins and kick-about trolleys.

THE IMPORTANCE OF SEGREGATION

The hazards posed by the potential for harm through exposure to health care waste are high. The treatment of the hazardous waste is through burning (incineration) or a non-burn technology (sterilization, electro thermal deactivation, autoclaving) and is more costly than disposal to land. As not all the waste from a health care facility is hazardous a balance must be struck between the cost of treatment and the risks involved.

Significant cost savings can be made by careful segregation of the waste into different categories, which minimises the quantities of hazardous waste that requires expensive treatment and disposal methods. The categories of hazardous waste are by their nature and the form they take different, thus requiring different methods of containerisation, transport, treatment and disposal.

The first stage in the separation of health care waste is into the two main categories of waste that is hazardous and waste that is not hazardous. The World Health Organisation identified [2] these as Health Care Risk Waste and Health Care General Waste.

Health Care General Waste is the non-hazardous part of the waste leaving a health care facility and consists of the normal household waste such as paper, glass, food, cardboard etc. It is this part of the waste where there is further opportunity for minimisation through recycling.

Health Care Risk Waste is the hazardous waste. The World Health Organisation1 has identified nine categories of health care risk waste. Each waste stream requires a different method of containerisation and treatment to protect the workers from exposure and ensure the safe and environmentally friendly destruction.

THE REASONS WHY SEGREGATION IS NOT CARRIED OUT WELL

Segregation is poorly carried out in most of the health care facilities, both government and private in South Africa. The lack of knowledge and understanding of the requirements for good segregation plays a part in this poor performance. However, it has been proved during the pilot test that it is not just a training need. There are many other factors that impact significantly on why waste is not segregated well.

In a survey conducted at the two test-site areas the following factors that impacted negatively on good segregation were identified:

• The inconsistent use of various different coloured liners instead of just two colours (e.g. red and black) caused by poor procurement procedures or poor issuing of equipment create confusion among the workers.
• The liners provided were inappropriately sized with an unknown but thin, micron thickness, leading to overfilling, difficulty with disposing safely, splitting of liners etc.
• Inefficient supply of the correct coloured liners causing the workers to use whatever is available
• Incorrect sizing and placing of containers resulting in over filling and long walking distances to dispose of safely
• Lack of sufficient containers for the categories of waste, particularly with regard to general waste containers forcing the workers to use what is available
• Job performance of health workers is influenced by feelings of being unappreciated and disempowered.
• Lack of a “people” management system to sustain the health care waste system and poor staff morale in the health service.
• The lack of accountability particularly among the medical staff and the general assistants are expected to re-sort the waste during collection
• The lack of regular supervision, mentoring and reinforcement of the standards

THE BASIS FOR SUSTAINABLE SUCCESS IN SEGREGATION

A sustainable success in segregation practices is not only a function of supplying the correct colour coded equipment and the optimal placing of the equipment. A holistic approach with capacity building as a focus is the only way to achieve continuing success. This also requires a combination of the correct and regular supply of equipment, the operational systems/procedures to support the equipment, and a programme of awareness and training.

How to combine all these aspects together was the challenge facing the teams at the pilot sites. A cohesive, well co-ordinated and participative intervention was carried out to address the issues identified during the surveys. These were divided into the following main areas for improvement as follows:

1. Sufficient resource capacity was developed with the establishment of a waste management team, the appointment of a waste management officer with defined roles and responsibilities. Buy-in and involvement obtained of the CEO and the procurement department with regular communication and reporting structures in place.
2. The supply of the correct type, size, quantity and placing of containers, baskets, stands and brackets as close as possible to the point of generation thus simplifying the task for the generators.
3. Operational systems such as ordering of equipment, minimum stock levels, collection and transportation routines etc were devised to ensure that sufficient equipment was provided, correctly placed and finally removed efficiently. A code of practice was introduced to ensure that the equipment was correctly used.
4. All these were combined with a skills development and awareness programme with cascaded training and regular coaching.
5. Regular supervision, monitoring and enforcement programme was embarked upon to reinforce and standards.

THE IMPORTANCE OF GOOD SUPPORT FROM SENIOR MANAGEMENT

The support and involvement of senior management was amply provided during the pilot project. This was displayed many times by the involvement, commitment and support given by the CEO’s and their management teams of the two facilities.

Initially it was believed that the Occupational Health and Safety Committee would form the basic from which the project would be driven. It soon became evident, however, that this committee was not sufficiently grounded and supported into the management structure of the facilities. A separate waste management team was therefore established and a Health Care Waste Management Officer with two Assistants was identified. Although these posts were not dedicated full time to the project, a large portion of their daily task involved waste management, particularly during the planning and implementation phases. A communication network was established where waste was discussed at Senior Management Meetings. This communication was taken down through the line management to the units / departments. The Infection Control Department formed the control centre with the HCWM Officer as the driver of the waste management system. Regular spot checks carried out and information reported back at the Senior Management Meetings.

ROLE OF EQUIPMENT IN GOOD SEGREGATION PRACTICES

The next step in meeting the challenge is to provide the relevant and required equipment at the source of generation. Solving the equipment problems in the pilot project was relatively easy as in the first instance funds were available. The practical application of the hardware to improve segregation was based on the selection of the correct type, the correct size and the optimal placing of the colour coded equipment to encourage and assist the workers to meet the standards required. Nothing is more de-motivating when a person is busy and especially when under pressure, to find that the equipment is inappropriate, too small, far away or missing altogether!

These aspects are discussed separately, with tables in Annexure 1 giving the ‘before’ situation that existed prior to the intervention and ‘after’ situation showing the changes that took place to improve the equipment and hence the segregation practices.

Colour coded and labelling for easy identification

Colour coding and identification markings make for quick and easy identification of the containers and liners for the waste streams thus improving the chances of correct segregation. This is particularly necessary for the identification between the health care risk waste and the health care general waste. Staying true to the colour coding is essential to avoid confusion. In the survey conducted at the pilot sites, transparent liners were used for both the infectious waste and the general waste. This confused the workers and resulted in mis-segregation. To add to the confusion that existed, when supplies of the red liners were not available other colours such as blue and green were used. The colour coding was agreed as red for HCRW and black for HCGW. No other colours were allowed.

Different type of containers for the different categories of waste

Standardization of the containers and liners makes it easier for ordering, positioning and teaching. In the surveys conducted it was found that many different types of containers were used, sometimes with no distinction between the health care risk waste container and the health care general waste container. This compounded the confusion already described by the lack of a consistent colour coding.

The World Health Organisation1 categories of health care risk waste were adopted. In the pilot test, the following categories were used:

• Infectious waste
• Sharps
• Anatomical (Pathological)
• Pharmaceutical

Each one of these categories requires a type of container and/or liner that was not only able to contain and prevent exposure to the worker to the particular hazards posed by the category of waste, but that was also easy to use, readily available, environmentally friendly and cost effective. The specifications for the containers were clearly defined and included being rigid, leak proof, and puncture proof.