best practices waste mgmt philippines

E x a m p l e s f r o m F o u r P h i l i p p i n e H o s p i t a l s

B E S T P R A C T I C E S I N H E A L T H C A R E W A S T E M A N A G E M E N T


BEST PRACTICESinHEALTH CARE WASTE MANAGEMENT

Examples from Four Philippine Hospitals

Health Care Without Harm AsiaFebruary 2007

Metro Manila, Philippines


Health Care Without Harm (HCWH) is aninternational coalition of over 440 organizationsin more than 50 countries, working to transformthe health care industry so it is no longer a sourceof harm to people and the environment.

In the Philippines, HCWH Asia has laid thegroundwork for promoting its three main issueson environmental responsibility in health care:best practices in health care waste management,mercury-free health care, and alternativetechnologies to incineration of medical wastes.

In the four years that HCWH Asia has been in thecountry, it has done high profile projects such asthe documentation of the proper disposal ofneedles and syringes used in the DOH PhilippineMeasles Eradication Campaign in 2004 and thehosting of the first ever Southeast AsianConference on Mercury in Health Care in early2006.

HCWH Asia has been visibly promoting its causesthrough seminars, conferences, and trainingprograms, and has made several contributions tovarious published material concerning its keyenvironmental issues. Most notably, HCWH iscited as one of the contributors to the creation ofthe Philippine Department of Health’s Health CareWaste Management Manual.

A B O U T


N o t i c e

This report was written in adherence to anagreement HCWH made to not reveal theidentities of the four hospitals. Recentdevelopments, however, now allow us to revealthe identities of three of the four hospitals:

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Recent developments however, now allow us toreveal the identities of three of the four hospitals.

Hospital A: Philippine Heart CenterQuezon City

Hospital C: Philippine Children’s Medical CenterQuezon City

Hospital D: San Lazaro HospitalCity of Manila

Hospital B has opted to retain its anonymity.


Health Care Without Harm would like to thank thefour hospitals who participated in this study. Ourdeepest gratitude is extended to the hospitalmanagement for their interest and support,without which this study would not have beenpossible. We also want to thank all the nurses,housekeeping staff, and other personnel whoshared their precious time, knowledge, andexperiences towards the completion of this study.

Ludgerio D. Torres, M.D.Executive DirectorPhilippine Heart Center (PHC)

Julius A. Lecciones, MD, MHSA, MPMExecutive DirectorPhilippine Children’s Medical Center (PCMC)

Vivian Lee, M.D.Executive Director (time of study), PCMC

Corazon D. Rivera, MDDeputy Director for Hospital Support Services,PCMC

Arturo Cabanban, M.D., MPHChief of Hospital, San Lazaro Hospital (SLH)

Eleonorita ReyesAdministrative Officer, San Lazaro Hospital (SLH)

A C K N O W L E D G E M E N T S


Key contributors from the four hospitals:

Ms. Ester A. BorjaHead, Auxilliary Services Department, PHC

Mercy Rosalina C. Del Rosario, RN, MHSAActing Deputy Director for Nursing Services, PCMC

Engr. Aida CalmaEngineer III, SLH

Consultants:

Jorge Emmanuel, Ph.DUNDP Global Environmental Facility Project

Glen McRae, Ph.DCGH Environmental Strategies, Inc.

Firuzeh MahmoudiUNDP Global Environmental Facility Project

Ratna SinghToxics link

Laura BrannenHospitals for a Healthy Environment (H2E)

Janet BrownHospitals for a Healthy Environment (H2E)


The Philippine Department of Health

Dr. Francisco T. Duque IIISecretary, Philippine Department of Health

Dr. Ethelyn NietoUndersecetary, Philippine Department of Health

Arch. Rebecca M. PenafielDirector III, National Center for Health Facility Development

Dr. Criselda G. AbesamisDirector IV, National Center for Health Facility Development

ResearchersMaria Cristina Carganilla-Paruñgao, RMTMichellie Ann Damazo-SabandoMarc MascariñaDino Alberto Subingsubing

Health Care Without Harm-South East AsiaMerci V. Ferrer, CoordinatorFaye V. Ferrer, Mercury in Health Care Program OfficerRonnel Lim, Anti-Incineration Program Officer

Editorial Consultant: Jet Damazo


C O N T E N T SIntroduction

The Problem with Health Care WastesHealth Care Without Harm and the

Promotion of Best PracticesThe Philippine CaseAddressing the ProblemBest Practices in the Philippines

Health Care Waste Assessment ofFour Teritary Hospitals in Metro Manila

Best Practices of the Four HospitalsBest Practices in the Administrative and

Policy-making LevelCase Study: Hospital A - Leadership Counts

Best Practices in Health Care Waste Minimization:Waste Reduction ActivtiesCase Study: Hospital B - Small Steps Go a Long WayCase Study: Hospital C - Getting Evryone Involved

Best Practices in Health Care Waste ProcessingCase Study: Hospital D - Effective Systems in Place

Best Practices in Health Care Waste Disposal

Conclusion

An Assessment is the First Step

A n n e x e sIIIIII

Health Care Without Harm Global AccomplishmentsTypes of Health Care WastesService Providers of Alternative Technologies

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3456

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1216

182732364042

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ADBDOHHWAPHCWHHCWMUNEPUS EPAWHOWMC

A B B R E V I A T I O N S

Asian Development Bank(Philippine) Department of HealthHealth Care Waste Assessment ProjectHealth Care Without HarmHealth Care Waste ManagementUnited Nations Environment ProgrammeUnited States Environmental Protection AgencyWorld Health OrganizationWaste Management Committee


Over the past few years, public concern has been growingover the disposal of wastes produced by health carefacilities in the Philippines. Several reports have citedlarge, albeit inconsistent, figures of the amount ofinfectious waste hospitals in Metro Manila produce daily,and little information is available on what is done withthese wastes, especially after the banning of incinerationin the country.

More recently, these concerns have been fueled by reportsthat some of these wastes end up in our open dumpsitesand in some cases, in rivers, leading some sectors to callfor the allowing of incineration once again.

Health Care Without Harm (HCWH) believes that healthcare waste can be managed properly without the use ofincinerators that produce toxic air pollutants that posethreat to human health and environment. To begin with,not all of the wastes produced by hospitals are infectiousor hazardous. With proper management and the use ofwell-known solid waste management tools such assegregation and recycling, the portion of a hospital’s wastestream that poses risk to human and environmentalhealth need not be cause of public fear.

This publication is the result of a study made by HCWHon the waste management practices of four tertiaryhospitals in Metro Manila. A compilation of best practices,this report highlights how four hospitals in a developingcountry where an incineration ban is in place have been

I n t r o d u c t i o n

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According to the World HealthOrganization (WHO), in 2000, 21million people all over the world wereinfected with the hepatitis B virus dueto injections with contaminatedsyringes. Another 2 million people wereinfected with the hepatitis C virus dueto the same cause, and about 260,000were infected with HIV.

Ironically, all these people acquireddiseases as a result of the practices ofthe very institutions that should beprotecting their health. The sheer nature

of providing health care, unfortunately, creates wastes thatcan pose serious environmental and health risks to healthcare workers, waste handlers, and even waste pickers.

This, however, is the case only if the wastes produced byhealth care facilities are not managed properly.

In 2002, though, a WHO assessment conducted in 22developing countries showed that 18% to 64% of health carefacilities do not use proper waste disposal methods. Whilemost of the waste produced by health care facilities is notany more dangerous than regular household waste, some typesdo represent a higher risk to health. According to the WHO,these include infectious waste (15% to 25% of total health-care waste), among which are sharps waste (1%), body partwaste (1%), chemical or pharmaceutical waste (3%), and

I N T R O D U C T I O N

The Problem with Health Care Wastes

able to manage, minimize and properly dispose of theirwaste. Through their example, other health care facilities canhopefully adopt measures and policies that will ensure thatthey truly do no harm.

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radioactive and cytotoxic waste or broken thermometers(less than 1%). Improperly managed and disposed, thesewastes can expose health care workers and the public torisk of infections.

(Data from WHO Policy Paper on Health Care Waste)

Health Care Without Harm andthe Promotion of Best Practices

HCWH believes that, in order to fulfill the medical ethicto “first do no harm”, the health care industry has aresponsibility to manage waste in ways that protect boththe public and the environment. Thus, HCWH works toeliminate the dangerous practice of incineration, as wellas to minimize the amount and toxicity of all wastegenerated by the health care sector.

A key factor in achieving these goals is the promotion ofbest practices in health care waste management (HCWM),including by reducing the amount of waste producedthrough segregation, source reduction, and resourcerecovery and recycling. These practices do not only protectthe environment and minimize the risk/prevent the spreadof disease, they, in fact, make good business sense forhealth care facilities as they save substantial amounts ofmoney that can be used to further improve the facilities’waste management.

Over the past decade, there has been a significant increasein the popularity of these practices, as the health careindustry worldwide moves towards reducing pollution intheir respective backyards. The rapid growth of HCWH’scampaign and the many accomplishments it has made ina short time mean only one thing: environmentalawareness among hospitals is growing (refer to Annex I:HCWH’s Major Achievements).


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Available Figures on Hospital Waste Generated in Metro Manila*

Metro Manila Development Authority (MMDA)(2000)

Japan International Cooperation Agency ( JICA)(2001)

Asian Development Bank (ADB)(2003)

9 tons infectious waste/day60 tons total waste/day

17 tons infectious waste/day

27 tons infectious waste/day47 tons total waste/day

The market for cost-effective alternative technologies that aresafer and cleaner than incineration and just as effective atrendering medical waste harmless is also increasing,consequently driving down prices and making them moreaffordable.

All these show that safe health care is not only a worthygoal, but a realistic one. Moreover, hospitals, as providers ofhealth care, should take a leadership role in this issue becausepromoting best practices in health care waste managementis, in essence, promoting health.

The Philippine Case

Until the Philippine Clean Air Act was passed in 1999, healthcare facilities in the Philippines relied heavily on incinerationto dispose of their waste. Philippine hospitals are estimatedto generate up to 10,290 tons of waste each year.

The common practice in the past was to simply dump allforms of waste together, from reception-area trash tooperating-room waste, and burn them in incinerators. Whileburning of wastes seems convenient, its downside is theproduction of highly toxic pollutants, such as dioxins andfurans, both in the form of gas released during the burningprocess and as components of the ash that remainsafterwards.


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Addressing the ProblemThe issue of properly managing infectious and hazardoushealth care waste is indeed a pressing one that needs tobe addressed to ensure that health care facilities do notbring harm to the communities in which they operate.The situation is even more pressing in the country wherenot all hospitals have access to alternative technologiesthat can be used to safely and effectively dispose harmfulwastes.

While no recent publicly available data exists on howhospitals today dispose of their infectious and hazardouswastes, some studies provide an indication of where theseused to go. According to JICA, 47% of the 158 facilitiesthey surveyed then disposed of their infectious wastesthrough incineration. The more recent ADB studyestimates that only 5 tons of infectious wastes per dayare disposed of through autoclave, microwave orincineration, and approximately 22 tons per day are eitherburied on-site or discarded along with the rest of the wastecollected by the municipal waste collection service.

Another study on waste management practices of hospitalsin Metro Manila conducted by Victorio Molina for theDepartment of Health (DOH) revealed thatalthough most of the hospitals perform waste segregation,less than 50% of the 144 hospitals studied did not havethe proper mechanisms for proper waste handling andsegregation. Incineration and landfill were used for finaldisposal of wastes. Only two out of five hospitals had anexisting waste management committee and a separatebudget allocation for waste management program

As such, while the Philippine Clean Air Act was heraldedas a landmark legislation, the question of what is nowbeing done with the voluminous infectious wastesgenerated begs to be asked.


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In 2001, the Department of Health (DOH), through itscollaboration with different organizations and agencies,revised its Health Care Waste Management Manual to followthe policies stipulated under the Philippine Clean Air Act andthe Ecological Solid Waste Management Act of 2000. Themanual provides health care facilities with practical guidelinesin establishing Health Care Waste Management Programs, andpromotes the use of alternative technologies for the disposalof health care wastes.

To demonstrate how medical waste can be disposed of safelyin the country without incineration, in February 2004, HCWH,in coordination with the DOH, documented the safe handlingand disposal of 19.5 million syringes used to vaccinatechildren nationwide under the Philippine Follow-Up MeaslesElimination Campaign. The used syringes were collected in5-liter safety boxes, and treated and disposed of usingautoclave facility, microwave, septic vault encapsulation, orseptic burial.

A sample of a labeled burial pitused during the PMEC Campaign

If the proper disposal of theseinfectious wastes can be done insuch a massive scale in thePhilippines (in rural areas, noless), then proper wastemanagement and disposal ispossible for hospitals.

Best Practices in the Philippines

In the wake of all these developments, in February of 2005,HCWH Asia launched a project entitled Health Care WasteAssessment of Four Tertiary Hospitals in Metro Manila.


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Beginning with a thorough four-step health care wasteassessment, the study sought to document the goodpractices of four tertiary hospitals in Metro Manila inmanaging their health care waste in order to serve as amodel or guide to other hospitals.

The advantage of piloting the study in the Philippines istwo-fold:

(1) It is an opportunity to show that best practices inhealthcare waste management can flourish even in adeveloping country; and

(2) In a country where incineration is banned, hospitalsare able to successfully employ alternative methods andtechniques to effectively minimize, manage and disposeof their waste.

The results and recommendations from the study willhopefully serve as guide for other hospitals in thePhilippines so that they can adopt the necessary systemsand procedures for their own health care wastemanagement programs.


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Health Care Waste Assessment of FourTertiary Hospitals in Metro Manila

The primary goal of HCWH’s study is to draw up baselinedata on good health care waste management practices fromfour tertiary care hospitals with different cases and specialtiesin Metro Manila, described briefly below:

A DOH-retained 302-bed specialty hospital with an averageof 370 admissions per day, it has over 1,800 personnel, mainlycomposed of professional staff (medical doctors, surgeons,nurses, pharmacists, etc.), management, and technical staff.

A small government hospital managed by a non-stock, non-partisan, non-profit foundation located in the southern partof Metro Manila, this hospital has 149 beds with a 29.9-averagebed occupancy per day and 6,685 admissions in 2004.

A 200-bed goverment hospital specializing in pediatric care,this hospital had an average yearly admission of 9,369patients from 2000-2004. Patient consultations in the out-patient department and emergency room average 45,246 peryear.

A government hospital mandated by the DOH as the referralcenter for infectious diseases, this hospital has a 900-bedcapacity, with an average admission of 316 patients per dayin 2004. The institution was regarded as the “National

Hospital A

Hospital B

Hospital C

Hospital D

H E A L T H C A R E W A S T E A S S E S S M E N T O F F O U R T E R T I A R Y H O S P I T A L S I N M E T R O M A N I L A

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reference Laboratory for different types of infectiousdiseases such as sexually transmitted infections (STIs),Hepatitis and HIV/ AIDS.”

To achieve the study’s objectives, the project wasimplemented through a four-step health care wasteassessment. This process can give valuable insights intohow health care wastes are produced, handled, anddisposed of.

The project was done in four stages:

Reviewing documents related to the hospital’s wastemanagement system and policies helped to gauge howrigorous the hospitals’ systems are and showed howbest to proceed with the project.

People in charge of managing the hospital wastesystem, such as key members of the administrationand waste management committees, were interviewedto learn more about actual waste managementpractices.

Through discussions with select groups of hospital stafffrom different departments (nursing, housekeeping,janitorial, etc.), the information gathered from the firsttwo steps is validated and the level of awarenesshospital staff have on waste management issues andpolicies is revealed.

An observation tour of the waste flow in the hospital,the walk-through allowed the documentation of actualpractices performed by the different departments ofthe hospital.

1. Document Review

2. Key Informant Interview

3. Focus Group Discussions

4. Walk-through Assessment


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This four-step process enabled the team to document theexisting practices of the four hospitals, analyze theireffectiveness, recommend ways to improve them, and, finally,determine the factors that contribute to the success of a wastemanagement system.


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Best Practices of the Four Hospitals

The proper management of health care waste need not betoo complicated nor unaffordable exercise. As thefollowing sections will show, the four tertiary hospitalsstudied employed simple tools, enhanced by theirinnovativeness, to come up with “best practices” thatcontributed to reducing the volume of waste they produceand safely disposing of infectious and hazardous wastes.

Basic waste management principles apply. First, anassessment of the volume, type, and source of wasteshould be conducted. Then, at the administrative level,rules and policies should be set clearly to guide andencourage the staff to handle waste properly. Wasteminimization strategies can then be employed to reducethe quantity of health care wastes, so that the ultimategoal of safely and properly disposing infectious andhazardous wastes can be achieved even withoutincineration.

In fact, according to the ADB study, if waste minimizationstrategies are implemented, the estimated volume ofhealth care waste by 2010 of 55 tons per day can bereduced to a more manageable 18.5 tons per day.

The following pages will describe the “best practices” inhospital waste management and how four tertiaryhospitals as documented by HCWH’s Health Care WasteAssessment Project (HWAP) have successfully been ableto adopt them.

B E S T P R A C T I C E S O F T H E F O U R H O S P I T A L S

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Best Practices in the Administrative andPolicy Making Level

Appropriate health care waste management practices dependlargely on the administration and organization and requireadequate legislative and financial report as well as the activeparticipation by trained and informed staff. (DOH Manual)

A prerequisite to a successful waste management system isthe establishment of a dedicated Waste ManagementCommittee.

In the hospitals studied, the following factors have beenobserved to contribute to the overall effectiveness of thecommittees:

A. Formation of a Health Care Waste Management Committee (HCWMC)

Health care waste includes all wastes generated orproduced as a result of diagnosis, treatment orimmunization of both human beings and animals; researchor production of biologicals and waste originating fromminor or scattered sources. Health care facilities such ashospitals, research laboratories, medical and dental clinics,nursing homes, ambulance, mortuary and autopsy centers,etc. produce varying levels of health care wastes.

Health care wastes are categorized into: general, infectious,pathological, sharps, pharmaceutical, genotoxic, chemical,radioactive, and wastes which contain high amounts ofheavy metals. While general wastes do not require specialhandling, the improper handling of others, collectivelyreferred to as hazardous and infectious wastes, may causepotential harm to health personnel, patients in health careestablishments and even the general public.


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(1) Recognition of the committee as an integral part of thehospital organization

(2) Presence of active members representing keydepartments of the hospital

(3) Visible and tangible support from the administration,such as through funding, policy support, resourceavailability, and event participation.

(4) Regularity of meetings(5) A dedicated waste management officer or waste

management committee member

The study consistently learned through interviews andfocus group discussions of how the cooperation ofhospital staff in the waste management programs islargely due to the visibility of and vigilance of thecommittee, as well as the support they receive from theadministration. In Hospital C, a hospital issuance backingan innovative incentive program - a sign of strongadministration support - is partly credited for its success.

Once a committee isformed, an efficient wastemanagement systembased on a solid wastemanagement plan iscreated.

The DOH HCWM is anexcellent guide in creating this, and other managementprinciples and strategies can also be applied. Hospital A,for example, uses the 5S system, which refers to fiveJapanese words that describe standardized cleanup oftentranslated as "Sort, Straighten, Shine, Systemise andSustain." A sixth S for "safety" is often added.

B. Developing and Updating the Facility's Waste Management Plan


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A primary function of a HCWMC:Establish baseline data and developthe facility’s health care wastemanagement plan which shouldinclude a minimization plan,training, and written guidelines onwaste management. (DOH Manual)


Waste minimizations programs, or in the case of Hospital A,a Zero Waste Program, are integral parts of the four hospitals'waste management systems as they reduce the overall riskof exposure health workers deal with. Documented wasteminimization activities of the four hospitals are discussed inmore detail in the succeeding sections.

Being responsible for the overall safety of the people involvedin implementing the waste management system of thehospital, the waste management committees set policies thatensure occupational safety and overall health of these workers.

In some of the studied hospitals, a policy that all wastehandlers should have Hepatitis B and Anti-Tetanusvaccinations exists. When personnel are accidentally prickedby misplaced needles, they are immediately sent to theinfirmary where they are usually given anti-tetanus shots.

The level of awareness of the hospital staff on the committeesprograms and policies greatly contribute to the success ofthe waste management system.

The four hospitals employ several methods in communicatingthe importance of proper waste management to their staff.These are summarized into three basic activities:

(1) ORIENTATION of staff through training programs,workshops, lectures, and seminars;

(2) Printed INFORMATION MATERIALS, such as posters,brochures and leaflets. One hospital (Hospital D) even has adedicated bulletin board for this; and

(3) EVENTS that promote waste management issues andactivities. Hospital A holds an annual Waste management andinfection control week and monthly clean-up days for eachdepartment.

C. Sample Policies and Programs

D. Communications and Training


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The four hospitals' waste management committees useseveral activities to monitor the following areas:

(1) Compliance to the waste processing procedures(2) Amount, types and sources of waste generated(3) Disposal costs and savings(4) Success of waste minimization activties(5) Awareness and compliance(6) Incidents/accidents related to waste handling

E. Monitoring


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Hospital A: Leadership Counts

In a DOH-retained 302-bed specialty hospital, most, if notall, of the 1,800 people that collectively make up theirstaff are actively involved in implementing wastemanagement programs.

For example, once every two months, the staff of each ofthe nursing departments comes together to sort out itemsearmarked for disposal and identify those that can bereused. The holiday season then sees nurses bringing outtheir creative sides in producing Christmas decorationsfrom recycled materials.

The key to all this is strong leadership of a very visiblewaste management committee, and the strong support itreceives from the hospital administration.

A regular orientation on the hospital’s waste segregationand waste management policies is given to patients andnew staff. They also hold monthly meetings to discuss andaddress issues related to waste management, with updateson waste management disseminated through thesupervisors/managers of each department and discussed totheir members. Once every year, a Waste ManagementWeek and an Infection Control Week is held.

The committee keeps itself up-to-date with the trends inwaste management and environmental health awareness,and the roles hospitals can play in promoting it. Armedwith all this knowledge, they have developed a systemthat integrates different techniques taken not only fromtraditional waste management styles, but also from otherpopular management styles. The committee is also

C A S E S T U D Y

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excellent at developing out-of-the-box solutions forcommon problems.

It conducts random hospital rounds to monitor the properwaste disposal, including segregation and recyclingpractices, of every department, with particular attentionpaid to the top five infectious waste generators in thehospital.

If there are violations of the waste disposal policy, incidentreports are prepared and submitted to them. A verbalreprimand is given on the first instance, and a writtenwarning that is attached to personnel records follows ifrepeated.

The dedication and visibility of the committee ensures thathospital personnel are not only aware of the issue, theyunderstand the importance of and wisdom behind makingsure that waste is safely and properly disposed of.

This sign posted at thehospital’s pathologydepartment says itright: Proper HospitalWaste Disposal isEveryone’s Concern

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Source reduction, in its simplestexplanation, involves not creatingwaste in the first place. However, itinvolves sophisticated riskmanagement, liaison withmanufacturers, and consultationswith staff. A careful re-evaluation ofa hospital’s purchasing practices,

product choices, and operating procedures can reveal severalopportunities for waste reduction.

Kaiser Permanente, one of the largest health care providersin the US, sets a good example: in their efforts to minimizetheir waste, Kaiser Permanente purchasing staff in Oregoncollaborated with manufacturers to reduce excess packagingin a variety of products. For instance, they requestedmanufacturers to shift to recyclable packaging such ascorrugated cardboard, thus reducing the size of the packageand requiring less packaging. Purchasing supplies in bulkfurther reduced packaging and handling costs.

Purchasing policies such as these that create opportunitiesfor waste reduction, and showing a clear preference forsuppliers that share the same concern is a good start forhospitals that want to have a waste minimization program.

II. Best Practices in Health Care WasteMinimization: Waste Reduction Activities

Source reductioninvolves measures thateither completelyeliminate the use of amaterial to generate lesswaste. (DOH Manual)

By not allowing the entry of unnecessary materials in theirfacilities in the first place, they were able to reduce theirpotential waste stream.

A. Reduction at Source


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Locally, one of the participant hospitals in HCWH’s studyheavily discourages the use and entry of polystyrene foamproducts (more commonly known by the trademark nameStyrofoam) in its facility. Styrofoam products, as a solidwaste material, are particularly problematic because oftheir being non-biodegradable and the lack of optionsavailable in the country for reusing or recycling it.

Hospitals personnel, patients and visitors are asked touse reusable or more environment-friendly disposableitems whenever applicable. From the main entry point ofthe hospital, for example, visitors are already advised tonot bring in food contained in Styrofoam packaging.

Before the advent ofdisposables, hospitals usedvarious reusable products intheir facilities. It is only in thepast two decades that wehave seen a sharp rise in theuse of disposables in healthcare facilities.

Hospitals adopting “re-use”as a waste reduction strategymake a return to the use ofsome reusable materials,which is a sensible option

especially with new technologies for disinfection andsterilization readily available. However, careful proceduresand safety standards should be established.

In the U.S. and in other parts of the world, the demandfor reusable supplies and supplies that have refillablepackaging has seen a significant increase. This is notsurprising because apart from environmental benefits, theuse of these types of products can produce enormousfinancial benefits.


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Re-use is not only findinganother use for a product but,more importantly, reusing theproduct over and over again for agiven function as intended.Promoting re-use entails theselection of reusable rather thandisposable products wheneverpossible. Re-use will also entailsetting reliable standards fordisinfection and sterilization ofequipment and materials for use.(DOH Manual)

B. Re-use


The Medical Center Hospital of Vermont, for example, hasbenefited financially from waste reduction through reuse.The hospital invested in reusable resuscitation bags andventilator circuit tubings which led to annual savings of about$40,000 (about P2 million).

Another hospital in the US reported annual savings of$70,000 (P3.5 miliion) in disposal costs and a reduction of22,000 pounds (11 tons) of waste just by switching toreusable underpads.

Although reusable items initially cost more than disposables,the long term benefits are clear. Not only do hospitals andpatients get savings from the costs of disposable items, lesshealth care waste produced also means savings from disposalcosts.

In the case of our four hospitals, they adopted this conceptmainly though finding uses for various materials that wouldotherwise be considered as waste. A tour of the study’s fourparticipant hospitals revealed how this strategy is appliedby different departments in their facilities.

Offices and ClinicsIn hospital offices and clinics, the simple reuse of the backof used bond papers for memos, laboratory print outs,running bills or monthly reports significantly reduces theneed for fresh stocks of bond paper. Used folders andenvelopes are reused for filing patient’s records and as filedividers.

Printer ink cartridges are collected and are either sold torecyclers or taken to refilling stations. In each office, a pointperson is assigned to monitor and ensure the propercollection of used ink cartridges and the collection of emptycartridges upon the release of new cartridges.


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In other cases, used paper also find its way into centralsupply rooms to serve as wrapping paper for items to beautoclaved.

Central Supply and PharmacyThe packaging materials hospitals get from medical andpharmaceutical supply deliveries are reused in a varietyof ways. Thick cartons and boxes are cut into strips to

resemble splints, (see image left)wrapped in paper, and then sterilized.Boxes that are about just the right sizeare crafted into improvised trays formedicines. During rainy days, sheets ofcarton are used as mats. Some are re-used as receptacles for used syringesand vials.

Re-usable materials and equipments are sterilized usingthe hospital’s autoclave. Inlaboratories, glassware and vials arecleaned, sterilized, and reused asspecimen collection bottles forlaboratory examinations. (see imageright)

Unused medical supplies or thosewith expired sterilization are re-sterilized and re-packed for futureuse.

Slightly used latex gloves from treatment rooms arewashed, sterilized, and packaged for one-time re-use.Other gloves are sterilized and re-used as hot or coldwater compress.

Intravenous fluid (IVF) bottles are re-used as drainagebottles and as containers for distilled or sterile waterand dietary supplements. They are also sometimes usedas urine collectors.


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In one innovative hospital, some medical items have evenfound their way to the housekeeping department, whereexpired and unused tubings are used as clothes lines.

Dietary / Cafeterias

The cafeterias and dietary departments of the four hospitalsuse mostly reusable dishware and utensils.

Used cooking oil aluminum containers are used as additionaltrash cans.

Plastic bottles of mineral water are re-used as improvisedcontainers for used syringes, while glass soda bottles of arere-used as suction collecting bottle.

Housekeeping

Old or stained linens are recycled into flat sheets, mortuarysheets, and cleaning rugs, and old curtains are turned intotelephone and cabinet linings. Old blankets and towels arerecycled into doormats, table rugs, and hand towels.

Used and properly washed disinfectant containers are re-usedas water storage containers for the hospital’s comfort rooms.

Broken trash bins are re-used as plant receptacles in thehospital’s garden.

Pictures of some of the hospitals’ autoclaves.

‘


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In Hanoi, Vietnam, most hospitals practice some form ofwaste segregation to recover recyclable materials. Paperand cardboard are recycled, plastic wastes, such astransfusion bottles and syringes, are sold to junkshopsand recyclers, and old x-ray films are sold to jewelers forelectrolytic extraction of silver.

In Bogotá, Colombia, three hospitals were able to generatea total revenue of Colombian $10,600,000 (US$ 4,735.62or Php 229,149.03)) out of recycled materials fromhospital waste.

In Manila, the efficiency of the study’s participanthospitals in collecting recyclable items from the wastethey produce and the sale of these generate significantamounts of profit. In 2004, the highest income generatedamong the four amounted to P379,971.58 (US$ 7,852.55)- enough to cover the annual the salaries of two additionalwaste management personnel. On the other hand, thelowest income generated still totaled P152,788.20 (US$3,157.54), enough to cover the annual wage of anemployee or purchase at least 65 mercury-free infraredear thermometers (each can cost about US$ 45.46 or Php2,200.00).

Wherever effective waste segregation systems andmonitoring of proper waste disposal are carried out byhospital waste management committees, there isincreasing income from the sale of recyclable materials.Profits from the sale of recyclables go to any of the threedocumented beneficiaries:

C. Recycling


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Recycling is collecting waste and processing it into somethingnew. Many items in the hospital can be recycled. Items such asorganics, plastic, paper, glass and metal can be recycled easily.(DOH Manual)


(1) Housekeeping Department: profits are used for purchasingcleaning agents, additional trash bins, trash liners, doormats,etc. The generated income from recycling covers some of thehousekeeping department’s expenses, and is sometimes usedfor emergency purchases of housekeeping materials.

(2) Hospital General Fund: profits are added to the hospital’stotal profit.

(3) Employees: Profits become part of the employee’sbenefits.

The recyclable items often collected and sold by theparticipant hospitals include the following:

Offices and ClinicsBoxes and CartonsPapers - Old Newspapers andMagazines, Used Papers, Shredded papers, Old PhoneDirectoriesInk Cartridges

Central Supply and PharmacyBoxes and CartonsIVF BottlesAssorted PlasticsGlass Bottles

Dietary / CafeteriaBoxes and CartonsUsed Kitchen OilEmpty cans of cooking oilDietary SlopsAssorted PlasticsPlastic Bottles Glass Bottles

Other items that cannot be sold to recyclers are used in craftsand other livelihood projects. For example, hospital personneland staff are highly encouraged to participate in contests

HousekeepingBoxes and CartonsPlastic Bottles

EngineeringBoxes and CartonsCar batteriesAssorted MetalsAssorted Tin CansScrap Wood


24


held by some of the hospitals, usuallyduring the holidays, where the bestChristmas decorations fashioned outof recycled materials are rewarded.Hospital D even has a dedicated abulletin board for decorations andprojects made from recycled items.

Other examples of recycling activitiesinclude empty juice containers/ tetra packs turned intobags that are displayed or sold during fairs, and parts ofthe old cribs and bedstransformed into fences andtrolleys used for wastetransport and aluminum oilcans transformed into dustpans.

Although the burden ofcollecting recycling materialscommonly falls on the wastehandlers and janitors, hospitals can employ otherstrategies to make their recycling program moreeffective. Hospital D, for example, strategically locatesdedicated recyclable waste receptacles along thehallways. These are labeled accordingly and encouragepeople to throw the listed items in these bins.


25


D. Segregation

Segregation is the process of separating different types ofwaste at the point of generation and keeping them isolatedfrom each other. Appropriate resource recovery and recyclingtechnique can be applied to each separate waste stream.Moreover the amount of hazardous waste that needs to betreated will be minimized or reduced subsequentlyprolonging the operational life of the disposal facility andmay gain benefit in terms of conservation of resources. (DOHManual)

As an example: Mt. Sinai Medical Center located in New YorkCity, USA, provides one of the best examples of the economicbenefits of a waste reduction activity. The hospital was ableto develop a waste segregation program that generated savingsof more than US$ 1 million per year. This was achieved bytraining nurses and housekeepers to distinguish the red bag(red bags in the US are for infectious waste) items frommunicipal solid waste (MSW), and by withdrawing red-bagcontainers to centralized locations such as: medication rooms,examination/ treatment and soiled utility rooms.

Proper segregation of their waste also revealed that 80% ofthe waste produced in the operating room (OR) is frompackaging, and is usually generated before the patient’sarrival in the room, thus reducing the amount of waste to beclassified as “infectious”.

In the case of the four participant hospitals, propersegregation has been a key factor in the success of their wastemanagement and minimization programs. Waste segregationbenefited our participant hospitals in two ways:

(1) Proper segregation significantly reduced the amount ofinfectious waste and thereby directly reduced the cost ofwaste disposal.Key practices that contributed to this include:

(a) Placement of yellow trash cans only in areaswhere infectious waste is generated


26


Hospital B: Small Steps Go a Long WayC A S E S T U D Y

Despite being the smallest of the four hospitals in terms ofboth size and number of patient admissions, Hospital B didnot use these as an excuse to not have a good waste man-agement system.

A government hospital managed by a non-stock, non-partisan, non-profit foundation located in the southernpart of Metro Manila, Hospital B established a WasteManagement Committee in 2001.

Faced with limited financial resources, the hospital decidedto augment its waste management budget with incomegenerated from the sale of its recyclable materials, such asnewspapers, ink cartridges, aluminum cans, and plasticbottles. The housekeeping department regularly reports themonthly income generated from the recyclables to theaccounting division.

The income helps the hospital cover the expenses incurredby the housekeeping department. The money is kept by thehousekeeping department for emergency purchases ofhousekeeping materials, such as cleaning agents, additionaltrash bins, trash liners, doormats, etc.

In addition, because of the efficiency of the hospital'swaste segregation system, their infectious waste showed adecreasing trend both in the actual weight and the cost ofwaste treatment. In January 2004, the hospital spentP17,600 (US$ 363.72) to treat about 490 kilograms ofinfectious waste. By December of the same year, it paid itswaste treater a mere P3,400 (US$ 70.26) for about 95kilograms of infectious waste.

27

B E S T P R A C T I C E S I N H E A L T H C A R E W A S T E M A N A G E M E N T28

(b) Placement of puncture proof sharps containersin nurses stations and treatment rooms

(c) Proper labeling of the yellow trash cans and otherhazardous waste containers.

(2) Efficient waste segregation as the foundation of for otherwaste minimization activities such as recycling andcomposting.

Segregated recyclable waste has made some of our hospitalssignificant profits as discussed in the previous section. Otherdocumented effective practices include:

Color-coded and properly labeledtrash bins are readily available andstrategically placed in most of theareas of the hospital encouragingproper segregation at source.

Jan 2004 April 2005

Php 20,000

Chart showing the decrease in Hospital B’s infectiouswaste stream

Green and black trash cans areplaced in general areas and inoffices (Hospital A)



Fluorescent LampsNot all waste items should be sold. Fluorescent lamps, inparticular, should not be sold to unaccredited “lamprecyclers” because they contain some amount of mercuryand the mishandling of these can lead to serious healthrisks and environmental pollution. A joint administrativeorder signed by the DOH and Department of Environmentand Natural Resources clearly states that wastes containingany amount of mercury should be handled only byaccredited waste transporters and treaters.

Research by HCWH, however, has revealed that there are noproper mercury waste recyclers in the country. Anyoneclaiming to be a mercury waste recycler should be dulyaccredited first before dealing with hospitals.

Hospitals are therefore advised to properly store spentfluorescent bulbs in individual boxes (preferably in thepackaging they came in)to prevent breakage and in storethem in an area dedicated to the storage of mercury-containing waste, until they can be collected or transferredby an accredited hazardous waste transporter.

Another option is to talk to the supplier and inquire aboutthem taking back used fluorescent bulbs.

Vials

Selling vials to the wrong person can promote theproliferation of fake drugs. This is especially true for emptyvials of expensive 3rd or 4th generation drugs. One hospitalcrushes these vials to ensure that they cannot be refilledwith fake medicine.

What Not to Sell

29


Left: Clear labels for the containers of used needles abd syringes at Hospital B;Right: Sign at Hospital D placed on above infectious waste trash bins.

Left: Spacious storage facility for recyclables at Hospital D; Right: Storage forrecylables at Hospital B, photo shows collected cartons ready for selling.


30

Posters on proper waste segregation and disposal are placed abovetrash bins.

Dedication of ample storage space for collected recyclables.Recyclables are easier to sell when sold in bulk.

Left: Three colored trash bins are available in most patient areas at Hospital C.;Right: Hospital A places a box to collect recyclable items (like IVF Bottles)beside the standard three trash cans in wards. They use foot operated trashbins for its ease of use.


Recylables such as plastic bottles and cups, aluminum cansand other plastics are washed prior to transport to thestorage area

The success of the hospitals’ segregation programs as wasteminimization activities were found to rely heavily on thefollowing:

(1) Cooperation of the waste producers and handlers(2) The dedication and leadership of the hospital administration(3) Information materials of the hospital on proper waste segregation(4) System of segregation(5) Incentive system


31


Hospital C: Getting Everyone Involved

In this government hospital, staff members, which areoften overloaded with taking care of over 9,000 admittedpatients every year, are all mindful of how they disposeof their wastes. Some even go as far as washing their usedcups, soda cans and bottles, plastics, and other recyclablewastes before neatly placing them in the trash cans.

This level of cooperation and involvement is the result,not of the usual awareness campaigns and informationmaterials, but of the incentive program the hospital hasput in place.

A profit-sharing scheme for the sale of hospital domesticwastes was employed, wherein people were rewarded fortheir waste segregation efforts. Staff directly involved inwaste segregation received incentives from the sale ofthe food wastes. Free annual checkups (Tetanus andHepatitis B immunization) were also provided to preventstaff from contracting diseases.

Coming from a situation where housekeeping staffdisplayed high resistance to segregating domesticwastes from non-domestic wastes, and where pilferageof food and non-food wastes was frequent, the effectof the new incentive program in 2003, backed by ahospital issuance, was remarkable. (source: “Earn ExtraIncome from Waste” available at www.csc.gov.ph)

Because the hospital staff now knows where the moneyfrom the sale of recyclables goes to, waste minimizationhas become a hospital-wide community affair. Thus, in

C A S E S T U D Y

E x a m p l e s f r o m F o u r P h i l i p p i n e H o s p i t a l s 33

2003, hospital earned P346, 698.07 (US$ 7,164.91) fromthe sale of recyclable non-biodegradable wastes, In2004, they earned P368,537.70 (US$ 7,616.25) from thesame, and an additional P11,433.88 (US$ 236.29) fromthe sale of dietary slops.

Photos from the hospital’s storagearea for recyclables andunservicable equipment. Fromtop: different types of waste paperare stored in different boxes;unservicable equipment like oldcribs, tables, etc.; plastic bottlesare grouped according to type andsize


E. Composting

Two of the study’s participanthospitals employ thisstrategy in different ways.One hospital composts yardwastes for the hospital’sbackyard garden, where theygrow plants that they use tolandscape the hospital. Theother one uses food scrapsand other kitchen wastes.

Using a makeshift compostpit out of large rubber pots,the second hospital producescompost material that isused as fertilizer for theirvegetable garden. Thiscompost activity andvegetable garden is thebrainchild and project of ahospital employee, agraduate of the hospital’swaste management trainingprogram.

Composting is anotherimportant strategy to minimizewaste such as food discards,kitchen waste, cardboard andyard waste. Some hospitals inother countries have alsosuccessfully compostedplacenta waste. Sufficient landspace for on-site composting farenough from patient care andpublic access area would beneeded. Food scraps can providemost of the nitrogen whilebulking agents commonly foundin hospitals such as cardboardand wooden chips could providecarbon. Composting techniquesranges from simple un-aeratedstatic piles to aerated windrowsto vermin-composting. Theresulting rich compost can besold or donated to local farmersand gardeners or used for plantsaround the health care facilitygrounds. (DOH Manual)

Hospital C and Hospital D’s compost gardens.


34


All of the four hospitals sell all, or at least someportion, of their food discards to piggery owners, withHospital C reportedly earning PHP 11,433.88 (US$236.29) in 2004 from the sale of dietary slops alone.

Although the success of any type of waste managementand minimization program is largely dependent on thecooperation of the actual waste producers (in this case,the patients, visitors and hospital staff) and the wastehandlers, the contribution of waste reduction strategiesmade at the policy making level has a huge impact onthe success or failure of the entire waste managementsystem.

In purchasing departments of the participant hospitals,for example, a “take-back policy” is usually stipulatedin contracts with private medical/pharmaceuticalsuppliers. The return policy provides the hospital withthe option to return products near their expirationdates. This practice alone has contributed heavily to thesharp decline of the volume of pharmaceutical wastesof the hospitals.

Well-organized and effective inventory systems forcentral supply offices have proven extremely helpful inavoiding the creation of unnecessary waste like expiredproducts.

Monitoring the rate of consumption of different typesof medical supplies by the different departments toreveal important insights as to how purchasingschedules can be improved. Implementing a strict “firstin, first out” (FIFO) policy for both medical supplies andpharmaceutical products and regular monitoring ofexpiration dates of stock supplies/materials are goodexamples of an effective waste minimization policiespracticed by the four hospitals.

F. Policies


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III. Best Practices in Health Care WasteProcessing

Along with implementation of waste minimization practices,hospitals should exert effort to ensure the safety of peoplewho handle or encounter the waste materials. Within thefacility, hospital staff, patients, visitors, and waste handlersand transporters are at risk of acquiring infections fromimproperly kept needles or poorly segregated infectiouswastes, for example. Outside the hospital, waste pickers whoscour through mounds of unsorted trash, as well as the publicin general, are also at risk.

Waste Segregation and StorageTo prevent unwanted infections from health care waste, anumber of practices have shown to be effective. Propersegregation at source by the waste producer is foremostamong these. Segregation should take place as close aspossible to where the waste is generated and should bemaintained in storage areas during transport.

The most appropriate way of identifying categories of healthcare waste is by sorting the waste into color-coded plasticbags or containers. Recommended color-coding scheme forhealth care waste follows:

All individuals exposed to hazardous health care waste arepotentially at risk, including those within the health careestablishments that generate hazardous waste, and those outsidethese sources who either handle such waste or are exposed to it asa consequence of careless management. (DOH Manual)


36


A Color Coding Scheme for Health Care Waste

Color

BlackGreenYellowYellow with black bandOrangeRed

Type of Waste

Non-infectious dry wasteNon infectious wet waste (kitchen, dietary, etc.)Infectious and Pathological WasteChemical waste including those w/ heavy metalsRadioactive wasteSharps and pressurized containers


37

Waste handlers follow regularly-spaced collectionschedules from hospital rooms and departments.Trolleys are used for this, along with other wastecollection gear as shown below:

All of the hospitals provide personal protective equip-ment/gears such as latex gloves, tongs/ forceps andmasks to their waste handlers/ collectors during actualwaste collection and transport.

All departments of the four hospitals practice wastesegregation following the color coding scheme prescribedby the DOH HCWM Manual. The use of color-coded trashcans and trash liners is observed to keep the wastesegregated during waste collection until final disposal.

Pictures ofwaste collectorsof Hospital Aand Hospital C.



38

Collection involves taking the filled bags and replacing thetrash bins with new ones. The collected bags are placed incorresponding color coded receptacles (or in some caseslarger trash bags) on the waste collector’s trolleys.

Other good practices observed are:

Appropriatecontainers forsharps are alsoused by thehospitals.

The storage areas have designated areas for different typesof waste, ensuring that waste is segregated until finaldisposal. Well-designed storage areas are spacious, easy toclean, located far from patient areas and secured by gatesand locks. For some hospitals, the storage areas are openedonly in accordance to the collection schedules.

Photos show the waste storage area of Hospital D for generaland infectious waste and the storage area of Hospital A forinfectious waste.

One hospital hasa needle de-stroyer/ burner in every ward, thus, possibility of needlestick injury is minimized. Reduction of sharps from thetotal infectious waste was facilitated by this instrument.



For some hospitals, waste collectors follow waste flowdiagrams designed by the hospitals’ waste managementcommittees. These diagrams show how waste is to bemoved from the points of generation to the storageareas, making sure that the waste is kept away frompublic areas and routes.

For hazardous wastes like nuclear wastes from thenuclear medicine department, these are placed in a“delay to decay lead insulated cabinet”. After completenuclear decay, the wastes are temporarily stored ingarbage holding area to be scheduled for on-sitetreatment.

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Hospital D: Effective Systems in Place

The largest of the four hospitals studied, this facility's wastemanagement system stands out as an example of howlarge-scale waste management is possible. Composed ofseveral buildings situated on a large, expansive compound,the hospital's ability to create and implement effectivesystems given its sheer size is remarkable.

For a hospital of this size, a key factor in the success of itswaste management system was having effective systemsin place.

To begin with, its Waste Management Committee draftedits own healthcare waste management manual, based onthe standards set by the DOH. Then it developed a "HealthCare Waste Management and Ecological AwarenessProgram" with three subprograms, namely: 3Rs (reduce,re-use, and recycle) and Livelihood program, Complianceand Monitoring program, and Health Education program.Each subprogram has its own team with its own work andfinancial plans approved by the chairperson of thecommittee and/ or the Medical Center Chief II.

For hospital staff, a five-day waste management trainingprogram is held every quarter. Aside from the usual lectureson proper waste handling, the training program includesecological tours in landfills and facilities of known wastetreaters. Evaluations are also conducted before and afterthe program to assess the level of awareness and knowledgehospital staff have on waste management. Selectparticipants who successfully complete the training courseare further trained to become trainers or facilitators infuture trainings.

C A S E S T U D Y

40


Patient education sessions are also regularly conductedto inform and educate patients, as well as visitingstudents, on proper waste disposal.

Monitoring of compliance is conducted throughrandom inspections by committee members. Reportsfrom this activity are collated a monthly basis andreported to the chairperson of the program. Thecommittee also meets regularly to assess the existingprograms and further systematize health care wastemanagement in the hospital.

Waste flow diagrams arealso posted strategicallythroughout the compoundto guide the wastehandlers accordingly.

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After waste minimization strategies have been carried outto reduce the volume of waste produced, the final step inwaste management is proper end-disposal of the remainingwastes.

While general wastes are collected by the hospitals' respec-tive city governments, each of the four hospitals has had tocontract the service of a private waste treater that uses anon-burn technology (for two hospitals, their treater usesspecifically Microwave Disinfection), in the treatment ofinfectious wastes. Microwave disinfection is essentially asteam-based process, where disinfection occurs through theaction of moist heat and steam generated by microwaveenergy.

Infectious wastes are collected by the waste treaters fromthe hospitals regularly (twice per week on average), and theresulting treated wastes are placed in controlled dumpsites.

IV. Best Practices in Health Care Waste Disposal

A list of waste treaters in the Philippines that use alternative non-burn technologies in treating and disposing of hospital wastefound at the end of this report. (Annex III)

Photos from ac-tual collectionprocess of infec-tious wastes bya private alter-native technol-ogy providerfrom Hospital C.The green bins

in the second picture are being weighed in the presence of a waste manage-ment committee representative. The weight of each bin, whichc contains seg-regated infectious wastes, are recorded by the hospital guard, the WMC repre-sentative and the collector.



ConclusionIn the issue of waste management, hospitals, asproviders of health care, are given the opportunity totake proactive measures towards protecting publichealth. These actions are not unreasonably difficult; infact, they are manageable, as the four hospitalsfeatured in this report have proven. They, along withtheir documented best practices, are a testament tothe old adage: if there’s a will, there’s a way.

Because of their commitment to environmentalresponsibility and safe health care, the hospitals wereable to rise up to the different challenges they facedto become examples of facilities with best practices inhealth care waste management

For Hospital A, all it took was the enthusiasm anddedication of strong leaders to create a hospital-wideculture for proper waste management. Hospital Bshowed that no matter how preliminary, goodpractices are important to laying the groundwork forproper waste management. They also showed that thesize of the health care facility or the volume of wasteproduced is no excuse to not taking action. Hospital C,on the other hand, has shown that a single innovativepolicy can make all the difference. And Hospital Dshowed how proper waste management on a largescale is not impossible with proper systems in place.

Perhaps, more importantly, these four hospitalsshowed that there is no one waste managementsystem, guide or specific set of practices, that areapplicable to all.

C O N C L U S I O N


Each facility has to determine and develop a wastemanagement plan, adopt practices that are suited to theirfacility, and create corresponding programs and policiesthat works for them.

The goal of this report is not to serve as a manual; rather,by sharing the commitment and practices of thesehospitals, it aims to inspire other to join the campaign forproper waste management, and to find practices bestsuited to their own facilities. By taking part in the study,these hospitals did not only take steps to better their ownfacilities and share what they knew, they also showed howhospitals should be at the forefront of promoting theseissues.

HCWH would like to end this report with an invitation forother hospitals to take the first step towards improvingtheir waste management systems through conductinghealth care waste assessments in their facilities.

The next page gives a brief introduction to health carewaste assessments and more resource files on the topic areincluded in the CD that comes with this report. We hopeyou will find them useful in your own campaign forenvironmentally responsible health care.

44

C O N C L U S I O N


An assessment is the first stepIn developing a waste minimization program or improving anexisting waste management system, a health care wasteassessment is the first step. There is a lot of sense in knowingwhat the actual situation is before any major changes to anexisting system. What is important is to understand first howthings are done and why things are done the way they are.

Knowing what is being generated, who is generating it and whohas the responsibility for collection and disposal, how it is beingcollected and disposed, and why the management decisionscreating the system was made.

Knowing WHAT is being generated can lead to a specific recyclingand waste reduction strategies

Knowing WHERE wastes are generated determines thecollection procedure, especially those that need special handling

Knowing WHO or what section of the hospital generatesparticular kinds of wastes can assist management in identifyingand tapping necessary resource people in designing the wastemanagement system.

It also allows management to explore waste reductiontechniques and alternative materials that may fit better into thesystem.

Knowing HOW involves the current waste management systemsand procedures of the hospital, and how this can be betterimproved.


Health Care Without HarmMajor Achievements

A n n e x I

Health Care Without Harm (HCWH) was founded in1996 to solve a disturbing pollution problem in thehealth care industry: the US Environmental ProtectionAgency (US EPA) had identified medical wasteincinerators as the single largest source of dioxin, apotent carcinogen. In response, 28 organizationsformed HCWH on the premise that the health careindustry has a duty to fulfill its creed to “first, do noharm.” Today, HCWH has 443 member organizationsin 52 countries working to reduce pollution in thehealth care industry, with offices in North America,Europe, Asia, and Latin America. Here’s a look back atmajor achievements of the past decade:

* More than 5,000 medical waste incinerators haveclosed in the US, and hundreds have closed acrossEurope, as hospitals have switched to safer, non-burnwaste treatment technologies. Today, there are lessthan 100 medical waste incinerators remaining in theUS.

* The market for mercury thermometers has beenvirtually eliminated in the US as most hospitals andall major pharmacies have switched to safer non-mercury devices. Fourteen states and 20 cities in theUS have passed laws to ban or limit the sale ofmercury-containing medical devices, and the EuropeanUnion has taken the first step toward banning theexport of mercury-containing products.

* 5,548 facilities in the US have joined Hospitals for aHealthy Environment, a joint program of US EPA,


American Hospital Association, American Nurses Associationand HCWH. These hospitals are eliminating mercury entirely,and have agreed to reduce waste by 50% and reduce use oftoxic, persistent chemicals.

* The first health-based green building system for hospitals,the Green Guide for Health Care, has 84 pilot projectsrepresenting more than 20 million square feet of construction.These hospitals are being built with less-toxic materials andhealing design elements.

* Major hospital systems are phasing out PVC medical devicesdue to concerns about the health impact of toxic additives.The world’s leading medical device manufacturers havepledged to develop PVC-free product lines.

* The top group purchasing organizations in the US –representing more than 70% of buying power for the nation’shealth care industry — have committed to take mercuryproducts off contracts, list DEHP-free/ PVC-free medicaldevices in catalogues, identify products that containbrominated flame retardants, and educate their customersabout environmentally preferable purchasing.

* More than 50 cities, states, and medical societies in the UShave passed resolutions to reduce PVC, dioxin, mercury, ormedical waste incineration.

* HCWH has organized nurses to be leading advocates forenvironmental responsibility in the health care industry. Readabout nurses who are driving change in their facilities atwww.theluminaryproject.org

* Under a newly developed food program, hospitals areadvocating for antibiotic-free meat and pesticide-free foods.They are serving organic, locally grown food, and are plantinggardens on site. Kaiser Permanente now has 25 farmer’smarkets serving locally grown organic food at their medicalfacilities across the US.


* With support of health care professionals andinstitutions across Europe, the European Union passed amajor reform of chemicals policy, which will providehealth and safety data for thousands of chemicals andhelp move the market toward safer alternatives.

* In collaboration with the United Nations DevelopmentProgram and the WHO, HCWH is implementing a globalproject to demonstrate sustainable health care wastemanagement in Argentina, Latvia, Lebanon, India, thePhilippines, Senegal, and Vietnam.

* In 2004, the WHO modified its health care wastemanagement policy to include health risks associated withincineration. Strategies include selecting PVC-free medicaldevices and promoting non-incineration waste disposaltechnologies. In 2005, the WHO developed a non-mercurypolicy for the health care sector.

* To make safe, low-cost waste treatment optionsavailable worldwide, HCWH launched an internationalcontest to find innovative non-burn waste treatmenttechnologies. Winning designs are posted at:www.medwastecontest.org

* HCWH’s flagship event, CleanMed, has become theworld’s largest health care conference on environmentallypreferable medical products and green building. Registertoday for CleanMed US or CleanMed Europe:www.cleanmed.org


Comparable to domestic waste, this type ofwaste does not pose special handling problemor hazard to human health or the environment-Comes mostly from administrative andhousekeeping functions

Waste that contains pathogens, (bacteria,viruses, parasites or fungi) in sufficientconcentration or quantity to cause disease insusceptible hosts. This includes:

• Cultures and stocks of infectious agentsfrom laboratory work

• Waste from surgery and autopsies onpatients with infectious diseases

• Waste from infected patients inisolation wards

• Waste that has been in contact withinfected patients undergoinghaemodialysis

• Infected animals from laboratories; andAny other instruments or materials that

have been in contact with infectedpersons or animals

Consists of tissues, organs, body parts, humanfetus and animal carcasses, blood and bodyfluids; Should be considered a subcategory ofinfectious waste, even though it may alsoinclude healthy body parts

Types of Health Care Wastes

A n n e x II

General Waste(Black and Green)

InfectiousWaste(Yellow)

PathologicalWaste(Yellow)

(From the DOH HCWM Manual, with color coding scheme)


Includes needles, syringes, scalpels, saws,blades, broken glass, infusion sets, knives,nails and any other items that can cause a cutor puncture wounds. Whether or not they areinfected, such items are usually considered ashighly hazardous health care waste.

Includes expired, unused, spilt, and contami-nated pharmaceutical products, drugs, vaccinesand sera that are no longer required and needto be disposed of appropriately. This categoryalso includes discarded items used in handlingof pharmaceuticals such as bottles withresidues, gloves, masks, connecting tubing anddrug vials.

Genotoxic waste may include certain cytostaticdrugs, vomit, urine or feces from patientstreated with cytostatic drugs, chemicals andradioactive materials. This type of waste ishighly hazardous and may have mutagenic,teratogenic or carcinogenic properties.

Cytotoxic wastes are generated from severalsources including contaminated materials fromdrug preparation and administration, such assyringes, needles, gauges, vials, packaging;outdated drugs, excess (left over) solutionsand drugs returned from wards.

Chemical waste consists of discarded solid,liquid, and gaseous chemicals, for examplefrom diagnostic and experimental work andfrom cleaning, housekeeping and disinfectingprocedures.

Sharps(Red)

PharmaceuticalWaste(Yellow withblack band?)

GenotoxicWaste(Orange?)

ChemicalWaste(Yellow withblack band)


Chemical waste is considered hazardous if ithas at least one of the following properties:

• Toxic• Corrosive (e.g. acids of pH < 2 and bases

of pH > 12)• Flammable• Reactive (explosive, water-reactive,

shock sensitive)• Genotoxic (e.g. cytostatic drugs)

Represents a sub-category of hazardous chemi-cal waste and are usually highly toxic. (e.g.mercury from thermometers, cadmium fromdiscarded batteries, and lead)

Many types of gases are used in health careand are often stored in pressurized cylinders,cartridges, and aerosol cans. Many of theseonce empty or of no further use (although theymay still contain residues) are reusable, butcertain types notably aerosol cans, must bedisposed of. Whether inert or potentiallyharmful, gases in pressurized containers shouldalways be handled with care; containers mayexplode if incinerated or accidentally punc-tured.

Includes disused sealed radiation sources,liquid and gaseous materials contaminatedwith radioactivity, excreta of patients whounderwent radionuclide diagnostic and thera-peutic applications, paper cups, straws, needlesand syringes, test tubes, and tap water wash-ings of such paraphernalia.

ChemicalWaste-continued(Yellow with blackband)

Waste w/ highcontent of heavymetals (Yellow withblack band)

PressurizedContainers(Red)

RadioactiveWaste(Orange)


Chevalier Enviro Services (CESI)Autoclave/steam sterilizer

Address Km 17 West Service Road Cervantes St.,Bormaheco Compound, South SuperHighway, Sucat, Paranaque City

PHONE +632-823-3659+632-823-4245

FAX +632-823-3599+632-776-7042

EMAIL [email protected] www.chevalier.com/business/cel.htm

Cleanway Technology CorporationAutoclave/steam sterilizer

(Office Address) Herma Building, 94 Scout RallosStreet, Quezon City, Philippines

(Plant) Cleanway Cavite Plant, Blk 4, Lot 2,4-8, Meridian Industrial Park II,Maguyam Road, Silang, Cavite,Philippines

PHONE +632 922-3421FAX +632 929-5306

PAE Environmental IncorporatedAutoclave/steam sterilizer

(Office Address) 908 ALPAP II Building Trade St. cornerInvestment Drive Madrigal Business Park,Alabang, Muntinlupa

(Plant) General Emilio Aguinaldo MemorialHospital CompoundTrece Martires, Cavite

Service Providers of Alternative Technologies

A n n e x III


PHONE +632-842-7087+632-842-7177

FAX +632-842-7154

Pollution Abatement Systems Specialists, Inc.Autoclave/steam sterilizer, shredder/grinder

Address 2nd Level, Waterfront Hotel, KahugSalinas Drive, Cebu City, Philippines

PHONE +632 32 2342519+632 32 2342517+632 32 2342515

FAX +632 32 2342523

SafeWaste Inc.Autoclave/steam sterilizer

Address 3 Pallosapis St., Greenville, City ofSan Fernando, Pampanga 2000,Philippines

PHONE +63 45 - 963 22 19FAX +63 45 - 963 22 19EMAIL [email protected] www.safewasteasia.com

HCWH does not endorse any particular company orwaste treater. For more information on alternativetechnologies, a report is available at www.noharm.org


Asian Development Bank and DENR, Metro ManilaSolid Waste Management Report (TA-3848-PHI),September 2003 available at http://www.asiandevbank.org.

Department of Health, Health Care WasteManagement Manual, Department of Health,Manila, Philippines, 2004.

Molina, Victorio, Waste Management Practices ofHospitals in Metro Manila, College of PublicHealth, University of the Philippines.

Ahmed, Reham, Hospital Waste Management inPakistan, August 1997.

California Department of Health Services andCalifornia Healthcare Association, Self-Assessment Manual for Proper Management ofMedical Waste, second edition, March 1999.

F. Daschner, Reduction and Utilization of HospitalWaste with the Focus on Hazardous, Toxic andInfectious Waste, Institute for EnvironmentalMedicine and Hospital Hygiene, August 2000.

Department of Health Services, A Guide toMercury Assessment and Elimination in HealthCare Facilities, Medical Waste Management

R E F E R E N C E S


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Health Care Without Harm Asia is interested in finding more bestpractices in health care waste management. If you think yourfacility has best practices and would like to share them, pleasecontact us, we will more than happy to hear your story.

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