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HOSPITAL WASTE

MANAGEMENT
TYPES, CHARACTERISTIC,
TREATMENT METHOD AND
MANAGEMENT

11
th
May 2009
OUTLINE
Potential Hazard of Hospital Waste
Waste Management
Sources of waste
Classification of Hospital Waste
Treatment, Transport and Disposal
Method
Incineration of Hospital Waste
Regulations



Facts in Indonesia
RS mengolah Limbah = 53%, pengolahan dg IPAL dan
septic tank = 51%, sisanya hanya septic tank
RS yg melakukan pemeriksaan kualitas limbah 57%,
63% memenuhi syarat
Pemisahan sampah medis dan non medis 80.7%, 20%
dengan pewadahan khusus (warna dan lambang)
62.5% insinerator, 14.8% landfill, 22.7% cara lain
Limbah toksik, 51.1% insinerator, 15.9% landfill, 33.0%
cara lain
Limbah radioaktif, hanya 37.1% menyerahkan limbha ke
BATAN, sisanya dengan Silo dan cara lain
Limbah domestik 98.8% dengan cara landfill


POTENTIAL HAZARD
Exposed people: ?
Patient and medical workers
People who are contracted working at the
hospital (cleaning service etc)
Patient (rawat jalan)
Visitors

Benefit of Env. Management
Environmental Protection
Better Hospital Environmental Management
Human Resource Development
Continuous Improvement of Hospital
Environment Performance
Meet Regulation Requirement
Part of Total Quality Management
Reduction of Expenses
Improvement of Hospital Public Image


Env. Management Component
Management Support
Scale and Type match with Env. Impact from
Hospital activities
Continuous improvement
Meet the regulation requirement
Guideline to prepare and review the objective
and goal of Env. Management
Documented, applied, maintained and
communicated to all
Available for all
Planning
Identification of env. Aspects and Impacts
Legal requirements
Environmental Policy and Internal performance
criteria
Objectives and goals of env. Managmeent
Planning and management program
Struktur, tanggung jawab, organisasi, kewenangan; proses
bisnis management; SDM, skill, budget dan alat; proses
untuk mencapai tujuan: prosedur dan pengendalian operasi,
pelatihan, sistem pengukuran dan audit, pengkajian
manajemen.

Implementation
Structure and responsibilities
Training, awareness, competency
Communication
Documentation and Env. Management System
Document Control
Operational Control
Emergency preparedness
Evaluation
Corrective action

Hospital Regulation
PerMenKes RI No 928/Menkes/Per/XI/1995 ttg penyusunan AMDAL
bidang kesehatan
Pedomen teknis penyusunan AMDAL RS
Pedoman Teknis penyusunan UPL dan UKL RS
PerMenKes RI No 986/Menkes/Per/XI/1992 ttg Persyaratan
Kesehatan Lingkungan RS
Keputusan Dirjen P2M PLP No HK.00.06.6.64, 18 Feb 1993 ttg
Persyaratan dan Petunjuk Teknis tentang Tata Cara Penyehatan
Lingkungan Rumah Sakit
Pedoman Sanitasi RS Indonesia
Pedoman teknis Pengelolaan Makanan dan Infeksi Nosokomial di
RS
PP no 12/1995 ttg perubahan PP no 19/1994 ttg pengelolaan limbah
B3
KepMenLH No 58/1995 ttg Baku Mutu Limbah Cair bagi Kegiatan
RS

Regulated Env. Aspects
Environmental Impacts Assessment
Nosokomial Infection
Chemical and hazardous waste
Gas emission, temperature, humidity, nuisance
and lighting
Effluent quality of waste treatment plant
Solid waste
Radioactive waste
Medical waste
Unregulated Env. Aspects
Management structure
Facilities, location map of env. control
History and Owner of the Hospital
Hospital General activities
Flow of Health Treatment Procedure
Nosokomial Infection control
Health and Safety Policy
List of Medical and non medical substance
Sistem pengadaan dan jadwal, jml pemakaian,
penyimpanan, distribusi dan transportasi bahan
Air pollution control
Handling, storage, transportation of domestic,
hazardous, chemotherapy waste, disposal procedure
and legal letter
Water supply, piping, layout, and water consumption
Recording of wastewater effluent quality
Waste water treatment system ( system, facilities and
SOP)
Sanitation method (pest, microbiology, virus, toxicology)
Supply, Layout, consumption of electricity
Environmental training
Supplier Consideration of Environmental Issues
Material Identification Approach
Environmental Monitoring Aspects
Waste production
Waste water
Reuse of waste water
Efficiency of Material Consumption
Energy consumption
Unplanned disposal
Recycle activities
Chemical handling
Gas handling
Handling of water for cleaning purposes
Medical Activities
Supporting activities Office & Social Activities
Medical waste Non Medical Waste
Incinerator IPAL
Hospital Activities
(sources) ?
Waste Generation
(solid, liquid, gas) ?
Waste Management ?
Collection / Storage Transportation Treatment Disposal
WASTE FLOW IN GENERAL
SOURCES
Medical Activities
Surgical Room, Emergency Room, Policlinic, Dialysis,
Delivery Room, treatment of dead body,
Chemotherapy, etc.
Supporting Activities
Laboratories, Radiology, Laundry, Kitchen,
Maintenance, Pharmacy
Office and Social Activities
Office (administration and accountancy), Medical
record, Cafeteria, Mosque, Guest House, Dormitory
CLASSIFICATION
Liquid waste Solid waste Gas Emission
Medical waste ? Non Medical Waste ?
Hospital Waste
Excreta
Toxic chemicals
Radioactive Subs.
Pathological
Infectious waste
Citotoxic
Sharps
Pharmalogical
General waste
Hazardous waste
Chemical waste

CLASSIFICATION
Hospital Waste: all wastes that are generated
from hospital activities including solid, liquid
and gases
Liquid waste: all waste in liquid form from
hospital activities including excreta that has
possibilities of containing microorganism, toxic
chemicals, and radioactive substance.
Solid waste: all waste in solid form including
medical and non medical waste
Medical waste (limbah medis) (50-60% disposal cost)
generated from medical activities
Infectious waste contains microorganism that may
cause disease from surgical room, laboratories,
haemodialysis
Pathological waste human/animal tissue, body
part, etc
Citotoxic waste material that are/might be
contaminated by citotoxic medicine
Sharps syringe, scissors, knife, broken glass, nail
cutter tertusuk (luka)
Pharmacological waste returned medicine, expired or
contaminated medicine, spilled medicine, etc.


CLASSIFICATION
Could you explain what are the differences
between infectious waste and pathological
waste ?
CLASSIFICATION
Non Medical Waste (limbah non medis) mostly
generated from hospital supporting activities, office and
social activities
General waste, food, card board, etc
Hazardous waste toxic, corrosive, flammable, reactive
(explosive, reactive to water, shock sensitive)
Radioactive solid, liquid or gas contaminated by radionuclide,
generated from in-vitro, in-vivo analysis, therapy
toxic waste genetoxic (carcinogenic, mutagenic, teratogenic)
pressure containers explosive when burned
Waste with high heavy metal concentration
Chemical waste disinfection, laboratories, cleaning, may
include in hazardous waste categories
Limbah Klinis
Golongan A, dressing bedah, swab, dan semua
bahan yang tercampur deng bhn tsb, linen dan kasus
infeksi, jaringan tubuh, dan hal lain y berkaitan dg
swab dan dressing
Golongan B, syringe bekas, jarum, catridge, pecahan
gelas, dan benda tajam lainnya
Golongan C, limbah dr laboratorium dan post partum
kecuali yg termasuk gol A
Golongan D, limbah bahan kimia dan bhn farmasi ttt
Golongan E, plapis bed-pan disposable, urinoir,
incontinence-pad, dan stamage-bags
INFECTIOUS WASTE
Infectious waste includes the following (EPA): ?
Isolation waste
Cultures and stocks of infectious agents and
associated biologicals
Human blood or liquid and blood products
Pathological waste (tissues, organs, body parts
except teeth and hair)
Contaminated sharps
Miscellaneous contaminated wastes (animal
carcasses)
CHARACTERISTIC of SW
Waste
Type
Weight
%
Heat of
combustion
J/kg
Class 0 70 8500
Plastic 15 19500
Class 3 10 4500
Class 4 5 1000
Estimate hospital waste generation (US):
4.54 9.08 kg/day per bed

6.5 kg/bed per day 11.5 kg/bed per day

Bandung (RSHS) = 2.12 kg/bed/day
Hospital Medical waste = 10 20 kg/hari
Immunization syringe = 66 million/year, total 300
million/year
Solid waste classification
system (EPA) based on
moisture content, ash
content, overall composition
heat content
incineration purpose

CLASSIFICATION
Class Principal Components Sources
Approx.
Compositi
on, wt %
Moisture
Content,
%
Incomb
ustible
solids,
%
Btu
value/lb of
refuse as
fired
0 Highly combustible waste.
Paper, wood, cardboard
cartons, and up to 10%
treated papers, plastic, or
rubber scraps
Commercial,
industrial
100 trash 10 5 8500
1 Combustible waste, paper,
cartons, rags, wood scraps,
combustible floor sweepings
domestic,
commercial,
industrial
80 Rubbish
20 garbage
25 10 6500
2 Rubbish and garbage residential 50 Rubbish
50 Garbage
50 7 4800
3 Animal and vegetable wastes restaurants,
hotels, markets,
institutional,
commercial,
clubs
35 Rubbish
65 Garbage
70 5 2500
4 Carcasses, organs, solid
organic wastes
Hospitals,
laboratories,
abattoirs, animal
pounds, etc.
100 animal
and human
tissue
85 5 1000
COMPOSITION
Waste Type Weight
%
Generation rate based on
20 kg/bed/day
Pathological (non
infectious body parts)
0.5 0.10
Infectious 10.0 15.0 2.00
General/ administrative
(noninfectious)
50.0 10.00
Food 30.0 6.00
Card Board 9.5 1.90
TOXIC & HAZARDOUS WASTE
Hospital generate 0.056 lb/bed per day
toxic and hazardous waste
200 bed 336 lb per month hospitals
are regulated as generator of hazardous
waste
WASTE MANAGEMENT ?
Cleaner Production /
Waste Prevention
Waste Minimization /
Source Reduction
Recycling
Waste Treatment
Waste Disposal
Material substitution
Life cycle analysis of product
Process modification,
equipment redesign
New product
Thermal destruction,
physical, chemical, biological
Landfill
WASTE MANAGEMENT
Raw Material
Use of Material
Waste Generation
Waste Collection/Storage,
Transportation and
Treatment (On Site)
Waste Transportation,
Treatment and
Disposal (Off site)
Environment
Recycle
Reuse
Waste traders
Waste traders
PREVETION OF POTENTIAL
HAZARD
Use safety material or non-hazardous
material
Use closed containers for volatile substance
Good ventilation health&safety standards
Body protection (mask, gloves, etc.)
Use container with different color for different
waste
Regular monitoring for high risk activities
Epidemiological analysis for high risk activities
ON SITE
HANDLING
COLLECTION / STORAGE
EPA red bag (operating room waste, blood
serums, sharps), white bag (general waste,
kitchen waste, boxes)
DepKes RI plastic bags color
Black : general waste
Yellow: all waste that must go to incinerators
Yellow with black line: all waste that better go to
incinerator, but can go to landfill if collected
separately
Light blue or transparent with dark blue lines: must go
to autoclave before next handling
COLLECTION / STORAGE
Bags or containers should be ?
Enough filled so it is easy to be well closed
Labeled symbol is given as it is regulated
Able to allow steam to enter during
sterilization (if needed)
Completed with active date before it can be
categorized as general waste
For syringe : WHO standard (container shape,
thickness, material, placing)

TRANSPORTATION
Waste are transported from first collection
to temporary storage or to incinerator
Transportation means must be cleaned
regularly and used only for waste transport
If transported to landfill must not have
possibilities to harm the health of
transportation personnel
Hazardous waste should be transported
as regulated in PP 18/1999
HANDLING OF CHEMICAL
Non-hazardous chemical should be labeled and handled
as general waste
organic chemical (acetate, amino acid, citric acid, lactic acid,
sugar)
Inorganic chemical (chloride, fluoride, bromide, sulfate, borate)
Hazardous chemical
Un reusable chemical incinerator
dated after used, maximum storage time: 3, 12, 24 month
Shock sensitive: diazo substance, metal azide, nitrocellulose,
perchloric acid, perchlorate salts, peroxide, picric acid, picrate
salts, polynitroaromatic
Water reactive: alkaline metal, soil alkaline, lithium alkaline
reagent, boron trifluoride solution, grignard solution
Others: nitrate acid >70%, phosphor (red and white)
DISINFECTION ALTERNATIVES
Autoclaving
Pyrolysis 1200C, vol. reduction 97-98%
Fluidized-bed coal technology circulating fluidized bed
burning of coal
Electron beam technology sterilization of all infectious
waste including liquid
Microwave technology not recommendation for
pathological and animal waste, + expensive
Mechanical-Chemical treatment (Sodium Hypochlorite -
NaOCl) pathological
Gas/vapor sterilization (ethylene oxide or formaldehyde), not
recommended
Biodegradation enzymes
Steam sterilization 300 F

COMPARISON
Treatment Technology
Regulated
wastes
Vol.
Reduction
(%)
Typical
Operating
Costs $/lb
per hr
Capital
Cost
$1000
Steam Autoclave except
pathological
0 0.05-0.07 100 (on
site)
Autoclave with
compaction
except
pathological
60-80 0.03-0.10 100
Mechanical-chemical all 60-90 0.06 40-350
Microwave (with
shredder)
except
pathological
and toxics
60-90 0.07-0.10 500
Incineration all 90-95 0.07-0.5 1000 (on
site)
DECISION
MAKING
INCINERATION ?
Infectious, un recover/un recyclable general waste
Operational Parameters:
Burning rate (pound/hour), heating value (Btu/pound), heat
release value (Btu/cubic feet per hour)
Alternatives:
Controlled-air incinerators
Rotary-kiln incinerators
Air Pollution Controls
Wet Scrubbers: impaction of particles with countercurrent flow
reactor
Dry Scrubbers: Reacting particles and gases in spray-dryer
section, collection of particles in a baghouse collector


INCINERATORS
INCINERATORS
INCINERATORS
INCINERATORS
What are the differences between
controlled air and rotary kiln incinerators ?
AIR POLLUTION CONTROLS
NEW METHODS
Problems dioxin carcinogenic
Dioxin + chlor TCDD (Tetra Chloro Dibenzo para Dioxin)
cancer
US many incinerators > regulation
Japan 70% world incinerators, high concentration dioxin
found in surrounding incinerator 18 from 271 die from cancer
> 800 C reduce dioxin but increase heavy metal vapor
Using Sun Light
reduce dioxin, reduce cost
150C in 20 minutes enough to kill bacteria
Low Thermal Desorbtion
Invented by FMIPA UI
Titanium oxide dioxin reduction
Indirect heating with low heat thermolysis drying at low
temperature (200-350 C) without oxidation (direct burning)
Low pressure
No oxygen reduce vapor point


LIQUID WASTE
Indonesia most hospitals use septic tank
Direct charge to river
Possibility polluting the surrounding soil
Unable degraded by activated sludge
Recommended: Ozonization
Ozone: oxidation potential 1.7 V radical
Ozone in water radical hydroxil (2.8 V)
Kill eschericia coli, Salmonella enteriditis, Hepatitis A Virus, etc
Oxidize organic substance ( fenol, pesticides, atrazine, TNT, etc)

Equalizing
Reactor
(O
3
)
Coagulation Sedimentation
Filtration
(active carbon)
Filter wash
E
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v
i
r
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n
m
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TOXIC WASTE DISPOSAL
REGULATION
UU No. 23 /1997 Pengelolaan
Lingkungan Hidup
KepMENLH No. 58/1995 Baku mutu
limbah cair bagi kegiatan rumah sakit
PP No. 18/1999 Pengelolaan limbah B3
UU N0. 7/2004 Sumber Daya Air
Peraturan Menteri Kesehatan RI No.
1024/2003 Persyaratan Kesehatan
Lingkungan RS
REFERENCES
Harry M. Freeman, editor (1989) Standard Handbook of
Hazardous Waste Treatment and Disposal, McGraw-Hill,
Inc., New York.
Howard E. Hesketh and Frank L. Cross, Jr. (1995)
Engineering Medical Waste-to-Energy Systems,
Technomic Publishing Co., Inc., Lancester
CRS Handbook of Laboratory Safety 5
th
edition (A. Keith
Furr)
Hazardous Waste Management, McGraw-Hill, Inc., New
York
Bapedal (2003) Peraturan Lingkungan Hidup, Jilid 1,
Bapedal, Jakarta.
Wiku Adisasmito, 2007, Sistem Manajemen Lingkungan,
PT. Raja Grafindo Persada, Jakarta


ALTERNATIVE METHODS