Management and disposal of clinical waste

The successful completion of this project would be impossible without the assistance and supports from many individuals who have lent me their hands either directly or indirectly. First and foremost, I would like to express my sincere gratitude and appreciation to my supervisor, En Mohd Nor Othman for his endless support, invaluable guidance and critics throughout the project. I would like to express my gratitude to Encik Zulkifli from Department of Engineering Hospital Universiti Kebangsaan Malaysia (HUKM) for giving me the permission to do the reseach in HUKM. Also to Encik Nasyaruddin from Radicare (M) Sdn Berhad (RMSB) branch at for his co-operation on the explanation of clinical waste generation in HUKM. Special thanks to Encik Azman, the Plant Engineer from RMSB incinerator at Teluk Panglima Garang, Selangor for giving me the full explanation on incinerator operation and basic explanation on Kualiti Alam Sdn Bhd operations. Finally, my gratitude goes to my parents and family members who have been most supportive all the times. sisa klinikal di Malaysia yang menggunakan konsep ‘buaian ke kubur' dikawal sepenuhnya oleh Peraturan Kualiti Alam Sekeliling (Sisa Berjadual) 1989. Setiap elemen dalam pengurusan dan perlupusan sisa klinikal melibatkan pihak seperti pengeluar buangan dan kontraktor. Penjanaan sisa klinikal dari hospital memerlukan pengurusan yang lengkap dan tersusun serta memahami tanggungjawab masing-masing. Pengurusan sisa klinikal yang lemah akan menyebabkan peningkatan pendedahan terhadap penyakit-penyakit berjangkit seperti Hepatitis A, Hepatitis B dan AIDS. Adalah penting untuk membezakan sisa klinikal dengan sisa lain. Sumber utama peyakit akibat sisa klinikal adalah kemalangan melibatkan picagari dan alatan tajam. Penggunaan bekas picagari yang diperbuat dari bahan yang kukuh mengurangkan risiko kemalangan. Pengangkutan sisa klinikal samada dalaman atau luaran mempunyai garis panduan tertentu bagi mengurangkan risiko terhadap pekerja, staf hospital dan orang ramai. Kaedah penunuan merupakan kaedah yang terbaik untuk melupuskan sisa klinikal yang dikategorikan sebagai sisa berjangkit. Hasil akhir penunuan iaitu abu (hampas bijih), akan dilupuskan di tapak perlupusan terjamin. ABSTRACT
Management and disposal of clinical waste in Malaysia using ‘cradle-to-grave' concept is controlled by Environmental Quality (Schedule Waste) Regulation 1989. Every element in managing and disposal of clinical waste is dealing with waste generators and contractor. Generation of clinical waste in hospital need complete and arranged management in order to take full responsibility of each job. Poor management can cause high exposure of disease such as Hepatitis A, Hepatitis B, and AIDS. It is important to differentiate clinical waste with other waste. The main source of accident on clinical waste is syringe and blades Using sharp container made from strong material can reduce the risk of accident. Certain guidelines need to be taken into consideration during transportation of clinical waste whether internal or external to reduce risk to porters, hospital staff and publics. Incineration is the best method of disposing clinical waste since it is infectious. End product of incineration is slag (bottom ash), will be sent to secure landfill. TABLE OF CONTENTS
CHAPTER TITLE
DECLARATION
DEDICATION
ACKNOWLEDGEMENT
ABSTRACT
LIST OF TABLE
LIST OF CHART
LIST OF FIGURE
LIST OF APPENDIX
I INTRODUCTION
1.3 Scope of Study 1.3.1 Organization 1.3.4 Temporary Storage System 1.3.5 Internal and External Transportation System 6 1.3.6 Waste Treatment and Disposal System II LITERATURE
Category of Clinical Waste 2.2.12 Waste with high content of heavy metal Background of radioactivity 18 Important element of managing clinical waste 2.4.2 Segregation – including packing, labeling and documentation, transportation and Treatment technique 2.5.1.1 Advantages and Disadvantages III METHODOLOGY
Method of study and getting the information 3.2.1.3 Comment on document IV RESULT
DISCUSSION
4.1.2 Head of Department of each wards and 4.1.4 Radicare (M) Sdn Bhd Supervisor Important element of clinical waste management 4.2.2.1 Yellow clinical waste plastic bags 4.2.2.2 Blue clinical waste plastic bags 4.2.2.3 Method of using clinical waste 4.2.2.4 Sharps container 4.2.2.5 Pedal bin, 15 kg wheeled bin and 54 4.2.2.6 Internal transportation transportation 62 Documentation 64 4.3.1.1 Charge End (Feeding) 4.3.1.3 Heat Recovery stage 4.3.1.4 Pollution Control stage 4.3.2 Disposal of treated waste 4.3.2.1 Kualiti Alam Sdn Bhd 4.3.2.2 Secure Landfill of KASB 4.3.2.3 Method of disposal CONCLUSIONS
REFERENCES
APPENDIX
LIST OF TABLES

TABLE NO.
Most common genotoxic products used in health- Most common gases used in pressure containers Major sources of clinical waste Minor sources of clinical waste Name of wards in HUKM, Cheras Collection frequency of clinical waste in HUKM Clinical waste composition Air Emission Standards for Clinical Waste Incinerator LIST OF CHARTS
Practical category and sources of clinical waste Clinical Waste Management Service for Radicare (M) LIST OF FIGURE
FIGURE NO.
Clinical waste generated in HUKM, Cheras Yellow clinical waste plastic bag Blue clinical waste plastic bags 660 L wheeled bin Small opening for internal transportation of clinical waste The other side of clinical waste small opening Front view of temporary storage The porter taking collected clinical waste to temporary Vehicle loading with clinical waste in 15 kg Side view of vehicle used in external transportations Loading waste in the wheeled bin into Cart Elevator Waste flow in Charge End Process Lime and Activated Carbon Injection area LIST OF APPENDIX
APPENDIX NO.
Equipment used HUKM for clinical waste management Stages of Rotary Kiln incinerator KASB license from Department of Environment Transfer station of schedule waste CHAPTER I
Malaysia has experienced phenomenal economic growth in the last two decades. It has undergone a major structural transformation, moving from agriculture to manufacturing-based economy, with significant social changes. This rapid development has brought about significant impacts to the natural environment. The government has since as early as 1974 taken concrete steps by introducing an enabling legislation called the Environmental Act 1974. The main objective of this act is to prevent, abate and control pollution, and further enhancing the quality of the environment in this country. The Department of Environment has been entrusted to administer this legislation to ensure that Malaysia will continue to enjoy both industrial grow and a healthy living environment. Presently, waste management is one of the most important responsibilities of local authorities in Malaysia where much money is spent in the disposal of waste. Growing affluence and increasing population concentration in urban areas have increased the generation and types of solid waste. A comparison of the increase in waste generation or several urban areas in Malaysia over the last 30 years is shown in Table 1.1. Table 1.1: Estimated Waste Generation
Waste Generation (tonnes/day) 1970 1980 1990 2000 Kuala Terengganu 13.4 45.1 85.2 305.0 14.4 29.1 46.8 368.7 Under the Environmental Quality (Schedule Waste) Regulation 1989, pathogenic and clinical wastes, quarantined materials, discarded drugs except living vaccines and euphoric compounds are categorized as scheduled wastes, hence need to be managed as such. The Ministry of Health (MOH) estimated that the total amount of clinical wastes generated from MOH hospital to be 11500 kg/day or an average of 0.51 kg/occupied bed/ day (Lee, Heng Keng, 2001). Clinical waste is part of waste that generates everyday in hospitals. Clinical waste includes a large component of general waste and a small proportion of hazardous waste. Poor management of clinical waste causes serious diseases in hospital personnel, health workers, patient and the general public. The main source of illness from infectious waste is probably injuries with used needles, which can cause hepatitis and HIV. There are however numerous other diseases which could be transmitted by contact with clinical waste. The hazardous nature of clinical waste may be due to one or more of following characteristic: i) It contains infectious agents ii) It is genotoxic iii) It contains toxic or hazardous chemicals or pharmaceutical iv) It is radioactive v) It contains sharps According to WHO, among the 35 million hospital workers worldwide, about 3 million receive percutaneous exposure to blood borne pathogens each year; 2 million of those to HBV, 0.9 million to HCV and 170 000 to HIV. These injuries may result in 15 000 HCV, 70 000 HBV and 500 HIV infections. More than 90 % of these infections occur in developing countries. This study is done basically to explain the importance of managing the clinical waste in a proper way. As stated above, the act and legislation is to guide the people involved in clinical waste management on doing their work effectively and concerning about the risk to be faced. 1.2 Objectives
The objectives of this project are i) To study the management and disposal of clinical waste at HUKM is in the ii) To study the act and legislation with regards to the procedures of management and disposal of clinical waste. iii) To study the important elements in management and disposal of clinical Scope of study
The scope of study in management and disposal of clinical waste is combined in several systems. Every system has it own scope of work beginning from Organization Structure System to Clinical waste disposal system. 1.3.1 Organization Structure System
Organization is a structure or process where the Director can assign duty to an individual, group or company in order to achieve the objectives. In every department or division, organization chart is important to show the hierarchy and scope of work or duty. Every member in the chart has their own skill depending on the position and function. For example, the officer is the person in charge on directing and controlling the performance for every member in the organization. In this case, he or she will monitor whether the worker take full responsibility in doing their job and follow the guidelines provided because the risk is everywhere. Segregation System
Segregation starts at the place where the clinical waste is generated until at the place it will be disposed, internally or externally. Segregation is also done during the transportation of the waste. In the hospital, every worker who is responsible on waste segregation has to make sure all the clinical wastes were put into yellow bin. For the sharps, it is placed in drum container. The bin and drum container must be tightly covered and when it is three quarter full, it should ready to be disposed. Documentation System
The source of every bin and container must be recognized to trace if there is any spills or over limit of waste. Labeling and documentation is done in certain way. For example, by writing down to the bag or container, using adhesive tag etc. Temporary Storage System
Every hospital must have a temporary storage to minimize the movement of waste in the open from initial storage areas. The storage area should be locked when access is not required and should be accessible only to authorized persons. The importance of having temporary storage is for the convenience of health workers. Every bin and container can be taken out in ‘first in, first out' sequence and load onto the trolley or vehicle used. Internal and External Transportation System
Every single bin and container containing clinical waste will be moved out from where it is generates. Usually, trolley and minivan is used in internal and external waste evacuation. This vehicle shall be reserved only for transportation of clinical waste. It should thoroughly clean and disinfected immediately following any spillage or accidental discharged. Plus, the internal transport routes shall be designed to minimize the passage of waste through patient care areas and other clean areas. Waste Treatment and Disposal System
An evaluation on choosing the right place for disposal and right method for treatment is needed to optimize effectiveness and safety. The evaluation covers some aspect such as technology, environment, economy and geography. Some considerations to be made are: Technology requirement and the importance Treatment process flow Process effectiveness and devices Treatment operation effect to health workers, public and environment. Size of process treatment Operation cost and capital available Site suitability Problem Fact
Clinical waste is a public health issue that attracts attention in both industrialized and developing countries. Improper management of clinical waste may pose health hazard to health workers, public and also environment. Obviously, clinical waste in Malaysia is no longer a simple task. Proper planning and management of hospital or clinical waste generated is crucial, not only in relation to waste disposal but also to various aspects of waste minimization such as environmental education and enforcement of act. The most common problem related to the management and disposal of hospital or clinical waste is money. Just because of budget constraint, the importance of management and disposal of hospital or clinical waste was ignored. Sometimes, lack of awareness also contributes to the problem. The main objectives in this study are to make sure the management and disposal of clinical waste is in good condition plus to fulfill the act that relates to it. Besides that, observation on important elements of management and disposal of hospital or clinical waste is observed. CHAPTER II
LITERATURE REVIEW
Definition of Clinical Waste
For many years, health workers, hospital administrators, and other health related professionals have understood the necessity to protect themselves, their employees/members, and the public from exposure to wastes that might be reservoirs of diseases-transmitting organism. In 1982, the recommendation from Health and Safety Commission London, The Safe Disposal of Clinical Waste, clinical waste is defined as: ‘Waste arising from medical, nursing, dental, veterinary, pharmaceutical or similar practice, investigation, treatment, care, teaching or research which by nature of its toxic, infectious or dangerous content may prove a hazard or give offence unless previously rendered safe and inoffensive. Such waste includes human or animal tissue or excretions, drug and medical products, swabs and dressings, instruments or similar substance or materials'. In other case, Department of Engineering, Ministry of Health include the definition of clinical waste as ‘Any waste that contain swabs, syringes, blood, human or animal tissue, drug and other cleaning devices. It also include any waste from dentistry activity, research, pharmacy, and also veterinary'. For Malaysia, clinical waste is classified as schedule waste from non-specific source under the Environmental Quality (Schedule Wastes) Regulation 1989 that N251 - Discarded drugs except living vaccines and euphoric compounds; N261 - Pathogenic and clinical waste and quarantine materials; N281 - A mixture of scheduled waste N282 - A mixture of scheduled and non-scheduled wastes. Category of Clinical Waste
2.2.1 Infectious waste
Infectious waste is suspected to contain pathogens (bacteria, viruses parasites, or fungi) in sufficient concentration or quantity to cause disease in susceptible hosts. This category includes: Cultures and stocks of infectious agents from laboratory work; Waste from surgery and autopsies on patient with infectious diseases (e.g. tissue, and materials or equipment that have been in contact with blood or other body fluids); Waste from infected patients in isolation ward (e.g. excreta, dressings from infected or surgical wounds, clothes heavily soiled with human blood or other body fluids); Waste that has been in contact with infected patients undergoing haemodialysis (e.g. dialysis equipment such as tubing and filters, disposed towels, gowns, aprons, gloves, and laboratory coats); Infected animals from laboratories; Any other instruments or materials that have been in contact with infected persons or animals. Cultures and stocks of highly infectious agents, waste from autopsies, animal bodies, other waste items that have been inoculated, infected, or in contact with such agents are called highly infectious waste. 2.2.2 Pathological waste
Pathological waste consists of tissues, organs, body parts, human fetuses and animal carcasses, blood and body fluids. Within this category, recognizable human or animal body parts are also called anatomical waste. This category should be considered as a subcategory of infectious waste, even though it may also include healthy body 2.2.3 Sharps
Sharps are items that could cause cuts or puncture wounds, including needles, hypodermic needles, scalpel and other blades, knives, infusion sets, saw, broken glass, and nails. Whether or not they are infected, such items are usually considered as highly hazardous health-care waste. 2.2.4 Pharmaceutical waste
Pharmaceutical waste includes expired, unused, spilt and contaminated pharmaceutical products; drugs and vaccines that are no longer required and need to be disposed of appropriately. The category also includes discarded items used in the handling of pharmaceuticals, such as bottles or boxes with residues, gloves, and mask, connecting tubing and drug vials. 2.2.5 Genotoxic waste
Genotoxic waste is highly hazardous and may mutagenic, teratogenic, or carcinogenic properties. It raises serious safety problems and should be given special attention. Genotoxic waste may include certain cytostatic drugs, chemical, vomit, urine or feaces from patients treated within cytostatic drugs, chemicals, and radioactive Cytotoxic (or antineoplastic) drugs, the principal substance in this category, have the ability to kill or stop the growth of certain living cells and are used in chemotherapy of cancer. They plan an important role in therapy of various neoplastic conditions but are also finding wider application as immunosuppressive agents in organ transplantation and in treating various diseases with an immunological basis. Cytotoxic drugs are most often used in specialized departments such as oncology and radiotherapy units, whose main role is cancer treatment; however, their use in other hospitals departments is increasing and they may also be used outside the hospital
Table 2.1: Most common genotoxic products used in health care premises
Classified as carcinogenic Chemicals: Benzene Cytotoxic and other drugs: Azathioprine, chlorambucil, chlornaphazine, ciclosporin, cyclophosphamide, melphalan, semustine, tamoxifen, thiotepa, treosulfan
Radioative substances
Classified as possibly or probably carcinogenic
Cytostatic and other drugs: Azacitidine, bleomycin, carmustine, chloramphenicol, cisplatin, dacarbazine, daunorubicin, dihydroxymethyfuratrizine (e.g. Panfuran S- no longer in use), doxorubicin, lomustine, methylthyouracil, metronidazole, mitomycin, nafenopin, niridazole, oxazepam, phenacetin, Phenobarbital, phenytoin, procarbazine hydrochloride, progesterone, sarcolysin, streptozocin, trichlormethine Harmful cytostatic drugs can be categorized as follows: Alkylating agents: cause alkalynation of DNA nucleotides, which leads to cross-linking and miscoding of the genetic stocks; Antimetabolities: inhabit the biosynthesis of nucleic acids in the cell; Mitotic inhibitors; prevent cell replication. Cytostatic wastes are generated from several sources and can include the following: Contaminated materials from drug preparation and administration, such as syringes, needles, gauges, vials, packaging; Unwanted drugs, excess (leftover) solutions, drugs returned from the Urine, feaces and vomit from patient, which may contained potentially hazardous amounts of the administered cycostic drugs or of their metabolites and which should be considered genotoxic for at least 48 hours and sometimes up to 1 week after drug administration. 2.2.6 Chemical
Chemical waste consists of discarded solid, liquid and gaseous chemicals, for example from diagnostic and experimental work and from cleaning, housekeeping, and disinfecting procedures. Chemical waste may be hazardous or nonhazardous; in the context of protecting health, it is considered to be hazardous if it has at least one of the following properties: Corrosive (e.g. acids of pH < 2 and bases of pH >12 Reactive (explosive, water reactive, shock-sensitive) Genotoxic (e.g. cycostic drugs) Non-hazardous chemical waste consist of chemical with none of the above properties, such as sugars, amino acids, and certain organic and inorganic salts. 2.2.7 Formaldehyde
Formaldehyde is a significant source of chemical waste in hospitals. It is used to clean and disinfect equipment (e.g. haemodialysis or surgical equipment), to preserve specimen, to disinfect liquid infectious waste, and in pathology, autopsy, dialysis, embalming and nursing units. 2.2.8 Photographic
chemicals
Photographic fixing and developing solutions are used in X-ray department. The fixer usually contains 5-10% hydroquinone, 1-5% potassium hydroxide, and less than 1% silver. The developer contains approximately 45% glutaraldehyde. Acetic acids used in both stop baths and fixer solution. 2.2.9 Solvent
Wastes containing solvent are generated in various departments of hospitals, including pathology and histology laboratories and the engineering departments. Solvent used in hospitals include halogenated compounds, such as methylene chloride, chloroform, trichloroethylene, and refrigerants, and non-halogenated compounds such as xylene, methanol, acetone, isopropanol, toluene, ethyl acetate, and acetonitrile. 2.2.10 Organic chemicals
Waste organic material chemicals generated in hospital facilities include: Disinfecting and cleaning solutions such-as phenol-based chemicals used for scrubbing floors, perchloroethylene used in workshops and Oils such as vacuum-pump oils, used engine oil from vehicles (particularly if there is a vehicle service station on the hospitals Insecticides, rodenticides. 2.2.11 Inorganic chemicals
Waste inorganic chemicals consist mainly of acids and alkalis (e.g. sulfuric, hydrochloric, nitric, and chromic acids, sodium hydroxide and ammonia solution). They also include oxidants, such as potassium permanganate (KMnO4) and potassium dichromate (Kr2Cr2O7) and reducting agents, such as sodium bisulphate (NaHSO3) and sodium sulfite (Na2SO3). 2.2.12 Waste with high content of heavy metals
Wastes with a high heavy-metal content represent a subcategory of hazardous chemical waste, and are usually highly toxic. Mercury waste is typically generated by spillage from broken clinical equipment but their volume is decreasing instruments (thermometers, blood pressure gauge, etc). Whenever possible, spilled drops of mercury should be recovered. Residues from dentistry have high mercury content. Cadmium waste comes from mainly from discarded batteries. Certain "reinforced wood panels" containing lead is still used in radiation proofing of X-ray and diagnostic departments. A number of drugs contain arsenic, but these are treated here as pharmaceutical waste. 2.2.13 Pressurized containers
Many types of gas are used and are often stored in pressurized cylinders, cartridges, and aerosol cans. Many of these, once empty of no further use (although they may contain residues), are reusable, but certain types. Whether inert and potentially harmful, gases in pasteurized containers should always be handled with care; containers may explode if incinerated or accidentally Table 2.2 : Most common gases used in pressure containers
Anaesthetic gases:

Nitrous oxide, volatile halogenated hydrocarbons (such as halothane, isoflurane
and enflurane), which have largely replaced ether and chloroform.)
Application- in hospital operating theaters, during childbirth in maternity hospitals, in ambulance, in general hospitals wards during painful procedure, in dentistry, for sadation, etc.
Ethylene oxide:
Application- for sterilization of surgical equipment and medical devices, in central
supply areas and at times, in operating rooms
Oxygen:
Stored in bulk or cylinders, in gaseous or liquid form, or supplied by central piping.
Application- inhalation supply for patients
Compressed air:

Application- in laboratory work, inhalation therapy equipment, maintenance equipment and environment control system. 2.2.14 Radioactive waste
2.2.14.1 Background on radioactivity
Ionizing radiation cannot be detected by any of the senses and usually cause no immediate effects unless an individual receives a very high dose. The ionizing of radiations of interest in medicine includes the X-rays, α- and β- particles, and γ- rays emitted by radioactive substances. An important practical different between these types of radiation is that X-rays from X-rays tubes are emitted only when generating equipment is switch on whereas radiation from radionuclides can never be switched off and can be avoided only by shielding the material. Radionuclines continuously undergo spontaneously disintegration (known as "radioactive") in which energy is liberated, generally resulting in the formation of new nuclides. The process is accompanied by the emission of one or more types of radiation, such as α- and β- particles, and γ- rays. This cause ionization of intracellular material; radioactives substances are therefore genotoxic. Radioactive waste includes solid, liquid and gaseous materials contaminates with radionuclide. It id produced as a result of procedures such as in-vitro analysis of body tissue and fluids, in-vivo organ imaging and tumors localization, and various investigative and therapeutic practice. Radioactive clinical waste usually contains radionuclides with short half-life, which lose their activity relatively quickly. Certain therapeutic procedures however required the use of radionuclides with longer half-life; these are usually in the form of pins, needles or "seeds" and may be reused on other patient after sterilization. 2.3 Sources of Clinical waste
The sources of clinical waste can be classed as major or minor according to the quantities produced. The major sources are listed in Table 2.1
While minor sources may produce some clinical waste in categories similar to clinical waste and their compositions will be different. For example: They rarely produce radioactive or cytostatic waste Human body parts are generally not included Sharps consist mainly of hypodermic needles Minor sources of clinical waste are listed in Table 2.2
The composition of wastes is often characteristic of the type of source. For example, the different units within a hospital would generate waste with the following Medical wards: mainly infectious waste such as dressings, bandages, sticking plaster, gloves, disposable medical items, used hypodermic needles and intravenous sets, body fluids and excreta, contaminated packaging and meal scraps. Operating theaters and surgical wards: mainly anatomical waste such as tissue, organs, fetuses, and body parts, other infectious waste, and Other health-care units: mostly general waste with small percentage of infectious waste. Laboratories: mainly pathologically (including some anatomical), highly infectious waste, (small pieces of tissue, microbiological cultures, stocks of infectious agents, infected animal carcasses, blood and body fluids), and sharps, plus some radioactive and chemical waste. Pharmaceutical and chemical stores: small quantities of pharmaceutical and chemical wastes, mainly packaging (containing only residues if stores are well managed), and general waste. Supports unit: general waste only Healthcare provided by nurses: mainly infectious waste and many viii) Dental clinics and dentist' offices: mainly infectious waste and sharps, and wastes with high heavy-metal content. ix) Home healthcare (dialysis, insulin injection): mainly infectious waste and Table 2.3 : Major Sources of clinical waste
Hospitals
• University hospitals • General hospitals • District hospitals Other health-care establishments
• Emergency medical care services • Health-care centre and dispensaries • Obstetric and maternity clinics • Outpatient clinics • Dialysis centre • Fist-aid posts and sick bays • Long-term health-care establishments and hospices • Transfusion centre • Military medical services Related laboratories and research centre
Animal research and testing
Blood banks and blood collection services
Nursing homes for the elderly
Table 2.4 : Minor sources of clinical waste
Small health-care establishments
• Physicians' offices • Dental clinics • Acupunctures • Chiropractors Specialized health-care establishments and institutions with low waste generation
• Convalescent nursing homes • Psychiatric hospitals • Disabled persons' institutions Non-health activities involving intravenous or subcutaneous interventions
• Cosmetic ear-piercing and tattoo parlors • Illicit drug user Funeral services
Ambulance services
Home treatment
Chart 2.1 :Practical category and sources of clinical waste
(Kitchen, landscape) half life is over Steam sterilized, shred deep burial encapsulation Clinical waste – from Microbiology lab Steam sterilizes and fluids, secretions contaminated with 2.4 Important elements of managing clinical waste
The objectives of an effective clinical waste management program should be to provide protection to human health and the environment from hazards posed by the waste. Proper management ensures that infectious waste is handled in accordance with established procedures from the time or generation through treatment of the waste (to render it noninfectious and unrecognizable) and its ultimate disposal. In Malaysia, the strategies adopted for the proper management of hazardous wastes are a combination of the following: The ‘cradle-to-grave' concept whereby the waste is managed from its generation to collection, transport and final disposal; Control through legislative and non-legislative means; Provision of proper facilities for the treatment, recovery and final disposal of residue; and Encouragement of waste reduction, reuse and recovery either in-house or at off-site facilities. A clinical waste management should include the following important elements. These elements cover the waste stream from it is generates until disposal. Identification of waste Labeling and documentation, Internal and external transportation Temporary storage Treatment technique Disposal of treated clinical waste 2.4.1 Identification of waste
Every generated waste in hospital must be identified depends on its sources and level of hazards. Basically, two most generated wastes in hospital are clinical waste and kitchen waste. The health-care workers must identify each waste and separate it. This is because each waste needs to be disposed in different ways. 2.4.2 Segregation -including packing, labeling and documentation,
transportation and storage
Segregation is in some ways a minimization of wastes. In fact, it reduces the quantity of wastes, which are hazardous and therefore require special attention and treatment. Segregation is the separation of wastes into the following categories; sharps, infectious non-sharp and non-hazardous waste. Segregation of clinical waste occurs at the time the waste produced, for example, when injection is given, or when packing is Clinical waste should be in package in order to protect waste handlers and the public possible injury and disease that may result from exposure to the waste. In daily practice, the selection of packaging materials is important and appropriate. For example, plastic bags for many types of solid or semisolid waste and puncture-resistant containers for sharps. For liquid-base waste, bottles, flasks, or tanks is used. Labelling can be done in a number of ways such as writing the information on the bag or container, using pre-printed self-adhesive address labels supplied on a peel- off roll, tie-on tag label and self-locking plastics tags. In terms of labeling, all bags and drum containers must be identified at the point of production and should be indelibly and clearly marked with biohazard symbol. An inventory provides an accurate and up- to-date record of quantities and categories of clinical waste being generated, treated and Proper documentation and record is important in order to comply with the Environmental Quality (Schedule Wastes) Regulation 1989, which require an inventory to be kept and a consignment note system to be used for transport of waste from the hospital to an approved facility. 2.5 Treatment technique
Treatment modifies the characteristic of the waste. Treatment of wastes mainly aims at rendering direct exposure to the wastes as less dangerous to human, to recover recyclable materials, and to protect the environment. In 1986 Guide, Environmental Protection Agency (EPA) defined treatment as any method, technique, or process designed to change the biological character or composition of waste. Since landfill operations may cause loss of containment integrity and dispersal of infectious waste, the EPA recommended that all infectious waste be treated prior to disposal. An example of treatment for clinical waste is incineration. 2.5.1 Incineration
Incineration is the combustion of waste in a controlled way in order to destroy it or transform it into less hazardous, less bulky or more controllable constituents. Incineration continues to be a preferred treatment process for clinical waste management. Although incineration is the most effective way, problem will occur such as air pollution as the effect of incineration. Hard metal and toxic waste will assemble in ash. Incineration of clinical waste offers the following advantages or potential Volume reduction, especially for bulky solids with high combustible Detoxification, especially for combustible carcinogens, pathological contaminated material, toxic organic compounds, or biologically active material that would affect sewage treatment plants. iii) Regulatory compliance, especially for fumes containing odourous compounds, photo reactive organics, carbon monoxide, or other combustible materials subject to regulatory emission limitations. Environmental impact mitigation, especially for organic materials that would leach from landfills or create odour nuisance Energy recovery, especially when large quantities of waste are available and reliable markets for by-product fuel or steam are nearby. (Theodore, 1987)
Most modern clinical waste incinerators operate on ‘controlled air' using two chambers. The primary chamber, into which the waste is fed, operates with restricted air flow at 1600 to 1800°F. The waste is pyrolized, and the volatiles move to a secondary chamber where they are combusted at 1800°F or higher temperature. Excess air is provided, in the secondary chamber, to ensure complete combustion. Ash is moved through and exist the primary chamber by the use of hydraulic rams or other 2.5.1.1 Advantages and Disadvantages
• Maximum volume weight • Noncombustibles not reduced in volume (ash, metal, etc) • Sterile residue when operated • Complex operation considering environmental factors • Moderate amount of space • Requires trained operator • Air emission can be controlled • Non-combustibles and ash may pose disposal problems (Frank L.C et al. 1990)
Figure 2.1 : Incinerator
2.5.2 Disposal of treated waste
Disposal refers to the final placement of treated waste on the land, using a sanitary landfill or any other environmentally acceptable method of final storage appropriate to the local conditions. Waste disposal are important for sharps, waste- requiring incineration, waste that not be incinerated and radioactive waste. Incineration of clinical waste will form the formation of CO2, H2O, SOx, POx, HF, HCl, HBr, I2. Also present are metal oxides and traces of unburnt waste. Much attention is directed toward concentrations of oxides of nitrogen (NOx) and sulphur (SOx), hydrogen chloride, particulates, dioxin and furan in the gaseous emissions from clinical waste incinerators (Blenkarn, 1995).
The ash and other residue from the incinerator are to render harmless before final disposal. These wastes are also classified as schedule wastes and have to be managed as stipulated in the Environmental Quality (Scheduled Waste) Regulation 2.6 Act and legislation
In Malaysia, there are some acts related to clinical waste. The Department of environment of Environment (DOE) is empowered under the Environmental Quality Act 1974 to control and prevent pollution and to protect and enhance the quality of the A set of regulations dealing with hazardous waste management which regulates the storage, transport, treatment and disposal of hazardous wastes on May 1989: Environmental Quality (Schedule wastes) Regulation, 1989; Environmental Quality (Prescribed Premises) (Schedule Wastes Treatment and Disposal Facilities) Regulation, 1989; and Environmental Quality (Prescribed Premises) (Schedule Waste Treatment and Disposal Facilities) Order, 1989; The Environmental Quality (Schedule Wastes) Regulation, 1989 prescribed a listing of 107 categories of hazardous wastes defined as "schedule wastes". The wastes are grouped into specific and non-specific sources. Clinical waste is categorized as schedule waste from non-specific source, N261 - "Pathogenic and clinical waste and quarantine materials". The regulations specify the following requirements Scheduled wastes shall as far as practicable, before disposal, be rendered Generation of scheduled wastes shall be reduced using the best practicable means; Waste generators to notify the DOE of any schedule wastes generated and keep up-to-date inventory of scheduled wastes generated, treated and disposed of; Scheduled wastes may be stored, recovered and treated within the premises of a waste generators; Land-farming, incineration, disposal, off-site recovery, off-site storage and off-site treatment shall only be carried out at prescribed premise licensed by the DOE; Use of durable waste containers with clear labels. Storage of wastes shall be proper and adequate; Waste generators shall conform to the requirements of consignment note system when transporting wastes to ensure it reaches the approved destination and are carried out b licenses transporter; Waste generators shall provide information to a transporter regarding the nature of the wastes transported and action to be taken in case of The purpose of this regulation is to control the three specific groups ii) Waste contractors Under the Environmental Quality (Prescribed Premises)(Scheduled Waste Treatment and disposal Facilities) Order 1989, six types of premises are prescribed for which their occupation and use will require a written permission and a licence from DOE. The premises are: Land treatment facilities such as sludge farms; Off site recovery facilities; Off-site treatment facilities such as centralized physical/chemical wastewater treatment; Schedule waste incinerator; Off-site storage facilities incinerators; Off site storage facilities including the transport vehicle; and Secure landfills designated for the disposal of schedule wastes. Three waste generator companies in Malaysia that is the concessionaire appointed by the Ministry of Health and have off-site incinerator including transportation are: Faber Medi-Serve Sdn Bhd (northern region) Radicare (M) Sdn Bhd (central region) Pantai Medivest Sdn Bhd (southern region) CHAPTER III
METHODOLOGY
To achieve the objectives of this study, a variety of method are used. Besides that, to get the best information, one has to experience every step from where the waste is generate to where it will be disposed. Initial Study
Choosing Hospital Universiti Kebangsaan Malaysia (HUKM) as location for case study is done because of some factors. HUKM is one of half privatized hospital in Malaysia where the Government of Malaysia defray half of it expenditure. That is one of the factors because previous studies were done at full privatized and full government hospital. Besides that, HUKM is a new-built hospital and opened on 1 July 1997. In this condition, this study will look for any new and more practical aspect of management and disposal on clinical waste. Therefore the infrastructure, devices, human resource and physical infrastructure will be observed. Method of study and getting the information
Main data
Main data is defined as data from the study done. In order to get the information related to clinical waste, two basic methods are used. 3.2.1.1 Site visit
Department of Engineering HUKM and Radicare (M) Sdn Bhd is the main source of information about management and disposal of clinical waste. Every section of the department has it own specialties. By visiting, data on background of clinical waste management system, number of disposal sites, transportation method, health worker involved can easily found and understood. A visit to Radicare (M) Sdn Bhd incinerator located at Teluk Panglima Garang and waste disposal site at Kualiti Alam Sdn. Bhd. located at Bukit Nenas, Port Dickson, Negeri Sembilan is done. This dispoal sites is the final place for disposal clinical waste in order to practice the safe disposal method. 3.2.1.2 Interview
Interviewing can collect more information on management and disposal of clinical waste. By interviewing, the explanation can give more understanding rather than referring to books. The officers will explain more on every element on managing the clinical waste and the health workers will explain more on technical information on their daily job. All the data of management and disposal of clinical waste is than compared to guidelines and act that relate to it. Interviewing method is used because it is the best method of getting the correct data. Other method such as questionnaire is not appropriate for this study because it is not very effective since number of health-worker in Radicare (M) Sdn Bhd is small. Beside that, by using questionnaire, problem of getting responses can occur. 3.2.1.3 Comment on document
While interviewing, there might be some explanation on some document. This type of document is important in achieving the main objectives on this study. Expected documents are organization chart, forms, scopes of work, safety guidelines and many 3.2.2 Secondary data
Secondary data are data from other studies or from other sources. The data is used to report what other researcher do and the approach they use. It can be divided into two, printed or non-printed data. For printed data, references were taken from journals, research papers, conference papers and collective edition. Non-printed data is an unpublished data, for example the sources from database and Internet. Although Internet is not a reliable sources in long term, but using it to search for other data is good. By using database, plenty of useful e-book is ready to be searched and referred. 3.3 Data analysis
All the data is arranged, processed and analyzed for making some good recommendations on management and disposal of clinical waste. Further more, data analyzing is important to achieve the objectives that were set earlier. Expected results
From the observation and study that will be done later, it is expected that the management and disposal of clinical waste at Hospital Universiti Kebangsaan Malaysia (HUKM) be in good condition. This is because; this newly established hospital is expected to have latest and absolutely efficient technology. The important elements in management and disposal of clinical waste are perfectly practiced without giving bad effect to the health workers, public and It is also believe that HUKM will follow the procedures and guidelines stated in related act discussed in the literature review. CHAPTER IV
RESULTS AND DISCUSSIONS
Privatization of Hospital Support Service in Malaysia started on 1st January 1997 where (3) three major companies were awarded the concession. The concession period is (15) years and each of this company is responsible to provide Hospital Support Service to every hospital in Malaysia according to the region. The objectives of privatization are to improve efficiencies of all hospitals and to provide Quality Health Service to public. Radicare (M) Sdn Bhd (RMSB) is the concessionaire company appointed by Ministry of Health to provide support services to government hospitals in the region of Selangor, Wilayah Persekutuan, Pahang, Terengganu and Kelantan. Besides government hospitals, RMSB also having contacts on (9) nine medical institution on providing support services including Hospital Universiti Kebangsaan Malaysia (HUKM) Pusat Perubatan Universiti Malaya (PPUM) and Hospital Universiti Sains Malaysia (HUSM). RMSB provides hospital support service on clinical waste management, facility engineering maintenance, biomedical engineering maintenance, linen & laundry and cleansing. For this study, case study on management and disposal of clinical waste in HUKM is highlighted. HUKM under Department of Engineering has given every two years of contract for Radicare (M) Sdn Bhd only on clinical waste management. Scopes of service on clinical waste management are: Supply of consumables Wheeled bin for central storage and transportation Collection and transportation of clinical waste on daily basis or as Provide dedicated vehicle Incineration plant Consignment note ORGANIZATION STRUCTURE
HUKM is one of the teaching hospitals in Malaysia that provides secondary and tertiary treatment service. Same as PPUM and HUSM, HUKM also provides the best medical services. Besides, HUKM is one of the first hospitals in Malaysia using information technology approach entirely in its operation. This hospital is complete with the capacity of 1054 bed, 700 medical students and 600 postgraduate students. Located at Jalan Tenteram, Cheras; HUKM is built on 55 acres land is the new campus for Faculty of Medical UKM that replace the old campus at Hospital Kuala In HUKM, a structured organization is developed specially to control and ensure clinical waste management. This organization consists of : Civil Engineering Head of Department Nurse Supervisor Radicare (M) Sdn Bhd Supervisor Radicare (M) Sdn Bhd Porters 4.1.1 HUKM
Director
In this organization, HUKM Director is the officer responsible on hospital administration. He is also responsible to Ministry of Health Malaysia as performance officer to ensure every clinical waste management is properly done every waste disposal procedure is done according to the related act. In Environment Quality Act 1989 (Schedule Waste), it is the Director responsibility on reporting any illegal practices or disobeys the related act on clinical waste management element. 4.1.2 Head of Department of each ward and clinic
Their responsibility in each ward and clinic is to remind the medical personnel, technical personnel and nurses the awareness on managing clinical waste. 4.1.3 Nurse Supervisor
Nurse Supervisor is fully responsible on segregation system and waste storage in the ward. They must make sure the stocks of clinical waste plastic bags and sharps container is enough in 3 days. If it is not enough, a complaint to Radicare (M) Sdn Bhd Supervisor should be made. 4.1.4 Radicare (M) Sdn Bhd Supervisor
Radicare (M) Sdn Bhd Supervisor is the officer send by their company and responsible directly on daily clinical waste management. He must take care on every porters activity on collection, loading to temporary storage. Plus, he is responsible on safety steps taken for any emergencies and ordering ‘consumables' from his company main Chart 4.1 : Clinical Waste Management Service for Radicare (M) Sdn Bhd
IMPORTANT ELEMENT OF CLINICAL WASTE MANAGEMENT
4.2.1 Identification
Identification of clinical waste is the first in activity clinical waste management. Waste identification is important because of hazardous and infectious nature will continue to threaten every person. By identifying the waste, the health workers can continue the activity safely without fear of infectious effect of clinical waste. Radicare (M) Sdn Bhd have categorized clinical waste into 5 (five) groups. Table 4.1: Category of clinical waste
• Soiled surgical dressing, cotton wool, gloves, swabs and all other contaminated waste from treatment areas, plaster and bandaging which have come into contact with blood or wounds, cloth and wiping material used to clean up body fluids and spills of blood. • Material other than linen from cases of infectious disease (e.g. human biopsy material, blood, urine, stools). • All human tissue (whether infected or not), limbs, placenta, animal carcasses and tissue from laboratories and all related swabs and dressings. • "Sharps such as discarded syringes, needles, cartridges, broken glass, scalpel blades, saws and any other sharps instrument that could cause a cut puncture.
• Clinical waste arising from laboratories (e.g. pathology, hematology and blood transfusion, microbiology, histology) and post mortem room waste, other than waste included in Group A. • Pharmaceutical wastes such as expired drugs, vaccines and sera, including expired drugs that have been returned from ward, drugs that have been spilled or contaminated, or are to discarded because they are no longer required. • Cytotoxic drugs • Used disposable bed-pan liner, urine containers, incontinence pads and stoma Table 4.2: Name of wards in HUKM, Cheras
Source : HUKM, Cheras
Pediatric Ward 1, 2 and 3 Ear, Nose and Throat Clinic Oftalmology Clinic Orthopedic Ward Endoscopy Clinic Basically, every ward and clinic in HUKM will generate the same type of waste. The two most generated waste are ordinary clinical waste and household waste. Clinical waste are generated by the health worker such as doctors and nurses. Household waste comes from other sources, for example food waste from patients and visitors who come for the purpose of visiting the patients and food wrappers. Months in 2004
Figure 4.1: Clinical waste generated in HUKM, Cheras
Source : HUKM Cheras
4.2.2 Segregation and Operation
From the interview, it is known that segregation is the most important element in managing clinical waste. By adding the clinical waste and household waste together, the waste status will change to clinical waste and have to be treated exactly as clinical waste. This is stated under Environment Quality Act (Scheduled Waste) 1989. Furthermore, this practice will only increase the fee for the waste treatment. Segregation process started when used clinical equipment are thrown away. The basic clinical wastes generated in every ward and clinic at HUKM are used syringe, cotton, gauze, dressings contaminated with blood, purulent exudates and IV sets. According to RMSB Management Guidelines, standard code of colour is used to every plastic bag and plastic container for clinical waste. Each of the plastics must have biohazard symbol (Figure 4.3) and this action is already stated under
Environment Quality Act (Scheduled Waste) 1989 in Third Schedule, (Regulation 8). Clinical waste to be disposed by incinerator Clinical waste from highly risk disease Figure 4.3: Biohazard Symbol
Yellow plastic bags are not allowed for use for other purposes in any circumstances basically to prevent any confusion in managing clinical waste. It is the same thing to other plastic bags. Light blue plastic will not be provided daily like yellow plastics. For clinical wastes that come from highly risk diseases i.e AIDS, Hepatitis B, Hepatitis C the nurses will contact Radicare (M) Sdn Bhd to provide light blue plastic bags to the ward. It will be sterilized in autoclave machine for 24 hours before disposed to incinerator. Equipment used for clinical waste in wards and clinics is yellow in colour with biohazard logo printed on it. They are pedal bin, wheeled bin, sanitary bin, plastic bag and sharp container. The location of the equipment is different depending on demand and suitability. The effectiveness of segregation starts at the beginning of clinical waste generation. For that, it is the nurses and health-workers full responsibilities. They are responsible to make sure that all clinical waste generated is isolated from household waste and only disposed in the yellow plastic bags provided. They are also responsible to make sure that the clinical waste capacity of each plastic is three quarter full. After that, it is the porter's responsibilities to seal it in a proper way. In manual clinical waste operation, the opening of each the equipment must be in the condition where it is easy to enter the waste. Besides, in any situation, the operation with the equipment must only be done by the handle or neck. Less manual operation on plastic bags of clinical waste is preferred. Every full plastic bags containing clinical waste should be sealed using ordinary plastic band or by usual tie-up. It is forbidden to use stapler for sealing the plastic bags because of the piercing action onto the plastic bags. Plus, it will contribute to odor The main duty of the porters is to carry and collect each of the full plastic bag. After collecting, it is their duty to provide new plastic bags at the bin. Size of the plastics provided varies according to the source of waste generated. The best location for temporary storing is the place nearest to where it is generated. It is a good practice to place clinical waste far from public passages. At HUKM, Radicare (M) Sdn Bhd has provided eight porters consisting of six men and two ladies for this duty at the location according to their daily duty. Collection is done three times a day. They begin carrying and collecting at 8.30 a.m. Then they continue at 2.30 pm and 6.00 pm. Collection frequency depends on the need and Table 4.3 : Collection frequency of clinical waste in HUKM
Source: Radicare (M) Sdn Bhd
Wards/Clinics
Collection Frequency (times)
Pediatric Ward 1, 2 and 3 Medical ward / Emergency Room Orthopedic Ward Ear, Nose and Throat Clinic Endoscopy Clinic 4.2.2.1 Yellow clinical waste plastic bags
The use of plastic bags is considered the most convenience and cheap in clinical waste management. As mention earlier, plastic bags is only for non-sharp waste. The plastic bags used by RMSB fulfill the required standard in BS 6642 : 1985; Specification for Disposable Plastic Bags From Polyethylene Material. Standard of the plastic bags is stated below: a) The plastic bag thickness is at least G 225 (55micron) for less density waste and at least G 100 (25 micron) for higher density waste. b) The plastic bag from ‘high density polyethylene' and not easily punctured. c) The plastic bags must hold to autoclaving process d) The plastic bags must yellow in colour e) For clinical waste that will be disposed using incineration technique, every plastic bag is printed clearly with "SISA KLINIKAL UNTUK DILUPUSKAN MELALUI PENUNUAN/ INCINERATOR" together f) "KEMENTERIAN KESIHATAN MALAYSIA" sign must also be printed clearly. g) Standard infectious/clinical waste sign must also be printed where the
symbol of three crescents arranged overlapping a black circle with white background. The size of every biohazard symbol must not be less than 4.2.2.2 Blue clinical waste plastic bags
The examples of waste that use autoclaving bags are human tissue from surgery ward, placenta from labour room and waste infectious disease treatment. Standard infectious/clinical waste sign must also be printed where the symbol of three crescents arranged overlapping a black circle with white background. The size of every biohazard symbol must not be less than 50mm x 50mm. "KEMENTERIAN KESIHATAN MALAYSIA" sign must also be printed clearly. This bag must in light blue colour and transparent. The thickness of each plastic is 55 micron and can hold out the temperature of 132 degree Celsius and not easily punctured. It will go through autoclaving process. 4.2.2.3 Method of using clinical waste plastic bags
a) The loading for each bags is not more than ¾ full b) The bags are closed by using ordinary plastic band or by usual tie-up. c) The porters then put every full bag into wheeled bin. d) A new plastic bag is provided to the bin. e) Wheeled bin containing full clinical waste will be then taken away to temporary storage.
Figure 4.3 : Yellow clinical waste plastic bag

Figure 4.4 : Blue clinical waste plastic bags
4.2.2.4 Sharps container
Syringes, needles and cartridges should be discarded intact and placed
in suitable sharp containers, which should be sealed when full and enclosed in a yellow clinical waste bag before collection and disposal. Plastics or other fiber material makes sharp container together with plastic lining outside it. It comes with different sizes of Every sharps container must follow these specifications: a) The container must have handle and the location of handle must not interfere when using it. b) The container must have high durability, puncture-proof, and leakage- proof whether in upside down condition. c) Can be taken away without feeling anxious the waste may spill or come out. d) The opening must close tightly and safely when the waste has reached three quarter full of the container as marked outside the container. e) The opening must close tightly during transportation f) The container material can be burned in the incinerator with biohazard logo printed outside it. Figure 4.5 : Sharp container
4.2.2.5 Pedal bins, 15 kg wheeled bins and 660 liter wheeled bins
A pedal bin is a kind of bin where it has foot pedal to open the bin cover. The porter provides the bin with yellow plastics. The (3) three basic pedal bins situated in every HUKM wards and clinics are 20 L bag holder, 50 L bag holder and 20 L sanitary The 15 kg wheeled bins and 660 liter wheeled bins are always used together for transportation purposes. When on duty, every porter will bring 660 liter wheeled bins to the ward and clinics. After it is full, the porter should bring down the bins to Radicare (M) Sdn Bhd situated at HUKM to transfer the collected clinical waste into the 15 kg wheeled bins for weighing process.(APPENDIX A)
Figure 4.6 : 50 L bag holder
Figure 4.7 : 660 L wheeled bin
4.2.3 Internal
The next step of managing clinical waste is transportation. It can be divided into two types, internal transportation and external transportation. External transportation will be discussed later on the next sub-section. Radicare (M) Sdn Bhd has enough equipment for this purpose. The equipment use for internal transportation is 660 liter wheeled bin. This wheeled bin is covered to protect the porters and public from waste spills and smelly odour. The porters are responsible to collect clinical waste from every ward and clinics in HUKM. For example, the collection at pedal bin that is located in every corner of the ward and the clinical equipment store next to the ward. The porter starts their duty by entering every ward or clinic according to their weekly duty rosters. With complete facemask, apron, gloves and shoes, the porter will collect clinical waste in pedal bin and sharp containers. After that, they will gather all yellow plastic bags and sharp containers in one storeroom at the same level of the According to RMSB, it is prohibited for the porters to transport any clinical waste at public passages. To prevent this, the storeroom in every ward and clinic will have a small opening for clinical waste. This opening come complete with inside and outside door and is designed to follow RMSB scope of work and to prevent any disruption by anyone who is not related to clinical waste transportation. The other side of this opening is the public passage where the porter has already placed 660-liter capacity wheeled bin to place the plastic bags and sharp containers. The porter will place every full yellow plastic bag in this opening and close it. After finish collecting and placing the waste in the small opening, they will go out to the public passages to collect back every yellow plastic placed at every small opening. The porter will do the same activity in every floor at HUKM wards. In HUKM, a special elevator is constructed for goods transportation. The porters will use this elevator and bring along the 660 liter wheeled bin with yellow plastic bag containing clinical waste to Radicare (M) Sdn. Bhd branch in HUKM for the next process. Figure 4.8: Small opening for internal transportation of clinical wast
Figure 4.9: The other side of clinical waste small opening
4.2.4 Temporary Storage
After collecting the entire clinical waste generated in HUKM, it is important to provide a proper storage for it. The function of having temporary storage in managing clinical waste is to provide a place where the waste can be stored temporarily, safely and easily for inspection. The storage is placed far from canteen, other stores, and public passage. It also must also have good air circulation. This area must always remain locked when no clinical waste storage activity happen. For transportation purposes, the storage must easily entered by the vehicle that will specially transport it to the incinerator located at Teluk Panglima Garang, Selangor. Before deciding the dimension of temporary storage, there are some factors to be considered. The collection frequency is the most important. In HUKM, Radicare (M) Sdn. Bhd have decided that clinical waste collecting activity starts at 8.30 a.m., 2.30 pm and 6.00 pm daily. Other considerations made on clinical waste temporary storage are number of public holiday weekly and probability of having difficulties in collection. Radicare (M) Sdn. Bhd had provided a large storeroom for this purpose. Storage capacity is for 3 days of collection and minimum of 2 days for storage. The container is locked to make sure that the wheeled bin is safe while waiting for transportation to incinerator. It can store up to 40-wheeled bin with capacity of 15 kg of each bin. In order to prevent bacteria from breeding and odor problem, the container is installed with air conditioned system. The temperature is maintained at 4 to 6 degree Celsius. Outside of the container is marked by biohazard symbol and N-261 as waste category. It is the porter's duty to clean the container weekly. Radicare (M) Sdn Bhd has provided all equipment for cleaning and personal protective equipment (PPE) such as gloves, safety boots, apron and mask if any leakage happened during the storage. Figure 4.10 : Front view of temporary storage

Figure 4.11 : The porter taking collected clinical waste to temporary storage
4.2.5 External Transportation
Well-designed vehicle with suitable criteria is used for external transportation. This vehicle is definitely different from solid waste vehicle. The inner space of the vehicle storage is layered by stainless steel and aluminum to give smooth surface for cleaning purposes. Every hole and pores inside it must be closed to prevent the waste from sticking and left behind when unloading and cleaning process. The vehicle cannot be used for other purposes. It is always provided with all equipment for cleaning and personal protective equipment (PPE) to clean the storage after several processes of loading and unloading the waste. In HUKM, Radicare (M) Sdn Bhd will send a vehicle from the incinerator plant located at Teluk Panglima Garang, Selangor to collect clinical waste daily. The vehicle will come to Radicare (M) Sdn Bhd branch in HUKM at 11.00 am. The driver will bring along empty 15 kg wheeled-bin. After arriving to HUKM, the driver will unload the empty wheeled-bin. After he had finished, the porter unloads the wheeled bin from the temporary storage. The time taken to deliver clinical waste from HUKM to Radicare (M) Sdn Bhd incinerator at Teluk Panglima Garang, Selangor is 45 minutes. There are several guidelines for the driver when delivering the clinical waste. It is estimated that the time for delivering from HUKM to incinerator is 45 minutes, so for any delays, the driver must inform the officer. The driver is prohibited to leave the vehicle used in any circumstances. It must directly send to the incinerator. The contractor must choose safe by avoiding highly population residential area, water bodies and sensitive areas Figure 4.12 : Vehicle loading with clinical waste using 15 kg wheeled bin
Figure 4.13 : Side view of vehicle used in external transportations
4.2.6 Documentation
Clinical waste is one of schedule wastes listed in Environmental Quality (Schedule Waste), Regulation 1989. According to it, every matter of documentation for clinical waste transportation must follow the regulation. It requires an inventory to be kept and a consignment note system to be used for transport of waste from the hospital to an approved facility. Consignment note records the details of the waste generator (HUKM), the rt contractor and the final receiver (Radicare (M) Sdn Bhd) together with the information on the clinical waste being transported. An inventory provides an accurate and up-to-date record of the quantities and categories of clinical wastes being generated, treated and disposed of. The respective parties should retain the record for a period of three years. The consignment note or form is design to record the name of the hospital, e and signature of the officer who responsible in the hospital, quantity of waste generated, name of driver and signature. The steps on consignment note procedure in hospital level are: very collection done by the driver, the clinical waste weight must be calculated and recorded in consignment note. It must be filled in 7 (seven) copies where a copy is kept by HUKM, a copy to Ministry of Health, a copy to Department of Environment and balance of 4 (four) copies are taken by the driver to the incinerator (Radicare (M) Sdn Bhd) After arriving at the incinerator, every information on the consignment written down on the consignment note will be signed by the incinerato operator. The operator should return back a copy to the driver. After all the waste is disposed at Kualiti Alam Sdn Bhd, the operator will send a copy to Department of Engineering at HUKM, De of Environment and a copy for record at the incinerator The information of consignment will be used by Radicare (M) Sdn Bhd to get monthly statistics for annual report or for any future planning. Example of consignment note is in Appendix C.
CLINICAL WASTE TREATMENT AND DISPOSAL
After 45 minutes journey from HUKM, Cheras to Teluk Panglima Garang, Banting; the collected clinical waste is now ready for treatment. Radicare (M) Sdn Bhd only provide incinerator for treatment of clinical waste. Table 4.4 : Clinical waste composition

Waste Type
% WT (Wet Basis)
Miscellaneous 10 (RMSB,2004)
Next, the ash and other residues comprising mainly deformed metallic such blades, scalpel and needles from the incinerator are to render harmless before final disposal. These wastes are also classified as schedule wastes and have to be managed as stipulated in the Environmental Quality (Schedule Waste) Regulation 1989.(Lee, 2001) The incineration system used in Radicare (M) Sdn Bhd in Teluk Panglima Garang is ‘Rotary Kiln with Waste Heat Boiler Incinerator'. It started operation in 1998 with a cost of RM 17.2 million. It is controlled automatically with combustion capacity of 500 kg/hr or 12 ton/day. This total up to 7000-8000 kg of waste treated daily. In daily operation, this incinerator plant is operates 24 hours a day with 3 shift of group worker.(RMSB,2004)
If it is practiced correctly, it can destroy all pathogenic microorganisms and harmful gaseous. It was admitted from the clinical waste disposal practitioner that incineration is the best-disposed method if the plant is well built and operate at very high temperature as suggested. Treatment Technique
Basically, the incinerator in Teluk Panglima Garang has four different stages PPENDIX B)
. Each of the stages is designed to convert solid waste into gaseous, liquid and solid while reducing environmental impact of the incinerator. The stages are: Charge End (Feeding) Pollution Control .3.1.1 Charge End (Feeding)
The first step is where the workers load the 15 kg wheeled bins that contain clinical waste into skip loader. Only two bins can enter in one time. Then, the waste is discharged into hopper. The feed conveyor is then used to move the waste into ram feeder. After that the ram head will push the waste into rotary kiln for incineration. Figure 4.14 : Loading waste in the wheeled bin into Cart Elevator
Figure 4.15 : Waste loaded into Hopper

Figure 4.16 : Waste loaded in Hopper

Figure 4.17 : Waste flow in Charge End Process

4.3.1.2 Thermal Stage
The thermal stage consists of Primary Combustion Chamber (PCC) and Secondary Combustion Chamber (SCC). Major difference between each combustion chamber is the final product. The waste must first enter PCC and then SCC. PCC is using Rotary Kiln for the first incineration stage. The retention time of gas waste is 1 second and solid waste is an hour. Rotary Kiln is insulated with castable or fire brick that can hold the temperature of 760ºC to 900ºC. To complete the combustion, 130% to 150% of excess air is required. This combustion chamber uses diesel as fuel. Final product of PCC is Bottom Ash. It will be send to Kualiti Alam Sdn Bhd (KASB) for final disposal. Waste gas from PCC will be treated through SCC to disperse dioxin and furan at 1000ºC. SCC use Vertical Tower as method of incineration. The function of SCC is to disperse dioxin molecule at 1000 C. The gas retention time is 2.2 seconds with air requirement of 130% to 150%. This tower can hold 982º C to 1149º C of operating temperature. SCC also use diesel to operate. These operating conditions are maintained to ensure complete combustion of the waste material. The final product are Acid gas, Dioxin, Heavy Metal particle etc. Figure 4.18 : Rotary Kiln

Refractory (Castable or fire brick) Solid Phase (Slag) Figure 4.19 : Schematic PCC process

Figure 4.19 : SCC Tower

Temperature = 982 – 1149 deg C Emergency Vent-cap Waste Heat Boiler
Figure 4.20 : SCC flow
4.3.1.3 Heat Recovery Stage
In this stage, hot air from SCC-Down Leg will enter Waste Heat Boiler. Waste Heat Boiler is a cooling media to reduce the temperature of hot air. Radicare (M) Sdn Bhd incinerator uses excess steam from this stage to wash wheeled bins as a waste Figure 4.21 : Waste Heat Boiler
4.3.1.4 Pollution Control stage
Air containing toxic and acid gas from Heat Recovery Stage is treated using powdered lime and carbon. Hydrated powder lime, Ca(OH)2 will neutralized acid gas in recommended reacting temperature of 160ºC to 180ºC. Activated carbon is used to treat heavy metal content. The chemical reaction is stated below 2HCl + Ca(OH)2 CaCl2 + 2H2O
Fly ash is the side product of this stage and the final product is clean gas. The air emission standards imposed by the Department of Environment are shown in Table Table 4.5 : Air Emission Standards for Clinical Waste Incinerator.
Ringleman Chart No. 1 Dioxin and Furan Hydrochloric Acid Source : DOE
All ashes are collected through Bag House Filter before releasing the gas to the atmosphere. The ash produced is considered as schedule wastes and need to be disposed at a licensed facility. Then, the collected ashes are send to Kualiti Alam Sdn Lime and Activated Carbon Injection Figure 4.22 : Pollution Control activities
Cooling Air Injection
Figure 4.23 : Pollution Control area
Figure 4.24 : Lime and Activated Carbon Injection area
Figure 4.24 : Bottom Ash (Slag)

Disposal of treated waste
4.3.2.1 Kualiti Alam Sdn Bhd
Radicare (M) Sdn Bhd (RMSB) has signed an agreement with Kualiti Alam Sdn Bhd (KASB) for disposal of bottom ash (slag) from incinerator. KASB was incorporated on 9 December 1991 and becomes Malaysia's first integrated waste management system centre. The integrated project with the capital cost of RM 300 million will manage variety of hazardous waste including clinical waste in Malaysia. The company is having special rightful authority for 15 years of operation. (APPENDIX D). Some of the facilities in KASB located at Bukit Nenas, Negeri
Sembilan are incinerator, physical-chemical treatment plant, leachate treatment plant, stabilize pond, secured landfill, disposal and movement of schedule waste especially in Malaysia using licensed mechanism and information system of consignment. However, when the system has been fully implemented, it might be feasible both economically and in terms of safety to establish secure landfills in other states. For the collection of wastes from areas futher away from the integrated facility, collection (transfer) stations will be established. The collection stations are located at Johor, Pulau Pinang and Terengganu. By sitting the collection stations in the major toxic waste producing areas, the transport distance from the waste generators to the collection stations will be reduced. (APPENDIX E)
4.3.2.2 Secure Landfill of KASB
The slag or bottom ash arrived from RMSB incinerator at KASB will be disposed at secure landfill. Secure landfill is the final destination for every schedule waste such as metal hydroxide sludge, used catalyst, asbestos waste, mineral sludge, other less dangerous schedule waste, fly ash or residue and slag form incineration. Two types of landfill in KASB are secure landfill and asbestos landfill. Every waste buried here is in solid or semi-solid according to Department of Environment Malaysia. It is well designed to prevent any pollution to water table by using 1 meter thick of compacted clay layer. The compacted clay is layered with Geomembrane High Density Polyethylene (HDPE) and Geonet. The drainpipe system is used to collect leachate to retention pond. Leachate from the retention pond must comply Standard B, Third schedule, Environmental Quality (Sewage and Industrial Effluents) Regulation 4.2.2.3 Method of disposal
Types of ash packaging from RMSB incinerator are plastic bags. Below are the method practiced in KASB for disposal. Stabilized waste is covered with clay after the waste layer reached 2 After each cells became full, it must be covered with geomembrane liner that can prevent infiltrate water. At the top of geomembrane is layered with soil for the purpose of growing herbaceous plant to prevent erosion. Separate drainage system for collecting rain is built around secure Slope landfill area is needed for runoff flowing to retention pond. Leachate at any liner must not exceed 30cm from the liner level. CHAPTER V
CONCLUSIONS AND RECOMMENDATIONS
Conclusions
From the observation made by site visiting, explanation and interview whether from the hospital or incinerator, a conclusion can be made. The management and disposal of clinical waste is good condition. Every personnel that is responsible for clinical waste management know their responsibility and scope of work. They have attended several courses by Radicare (M) Sdn Bhd (RMSB) on handling clinical waste and they must wear apron, gloves, mask and safety shoes while at work. For safety purposes, they are given immunization vaccination on tetanus, hepatitis A, hepatitis B, cholera and polio. Looking on management structure on clinical waste at HUKM, it is well- organized and very systematic. Beginning from HUKM Director to the RMSB porters, they belong to different companies. If there is any disruption or problem on daily routine, one company can make complain to another company. For example, there is a case that happened in one of the wards of HUKM, a trainee nurse have wrongly thrown used syringe into 50-liter bag holder. When the porters comes to ward for clinical waste collection, he had punctured himself accidentally the needle when carrying the yellow plastic bags. In this case, RMSB can complain to HUKM Director and Nurse Observation on identification of waste at HUKM is good and well organized. Every staff knows and understands the purpose of having yellow and black plastic bags. Clear label at each equipment also give useful information to the visitors. In every ward and clinic, segregation activity is clear and well practiced. Usage of sharps container and bag holder is wide because RMSB have provided enough equipment in every ward In terms of clinical waste transportation, RMSB have provided good transportation guidelines that have to be followed by every porter. It is forbidden to bring clinical waste near to anybody in the hospital. A small opening located at every ward is the solution to prevent exposure of clinical waste to public. Another solution is by using special elevator. Besides, the equipment used for this clinical waste management element is made from puncture-proof material. Collected clinical waste from wards and clinics is stored in temporary storage located near RMSB branch office at HUKM. The storage is air conditioned and complete with weighing equipment for clinical waste. It is also complete with cleaning material for any spillage in or outside the temporary storage. It complies with the Ministry of Health regulations. RMSB is applying ‘Manifest System' in documentation system of clinical waste by using consignment note. The main reason of using the system is to make sure all the amount of waste arrived at RMSB incinerator is the same amount of waste generated in HUKM. Information on each consignment note is important for future External transportation system is in good condition for several factors. The RMSB guideline on external transportation is clear on preventing environmental hazard and public health. Steps if spillage or accidental discharge during transportation occurs is understood by the driver and it also fulfill the Act. Disposal of clinical waste generated at HUKM is done at RMSB incinerator located at Teluk Panglima Garang, Banting. It is situated in Teluk Panglima Garang Industrial Area and very far from residential area. The operation is done carefully and systematically. Overall operation of this ‘Rotary Kiln with Waste Heat Boiler Incinerator' is environmentally protected since it is using bag house filter. 5.2 Recommendations
Even though every process on management and disposal of clinical waste is good and very effective, the number of porters in clinical waste collection at HUKM is not enough. Less number of porters will decrease the efficiency of collecting the waste since the waste is infectious and need to be collected more often. Taking legal foreign workers from Indonesia and Bangladesh can solve this problem It will not do any good if the are porters not taking care of their own safety. By observation, most of the porters are not wearing proper mask and shoes. In government hospital, there is a special body in monitoring clinical waste management. Since HUKM is half privatized hospital, no special observation or monitoring is done. It all depends on RMSB guidelines and supervisor. A body or an officer from Department of Engineering, HUKM is needed for this purpose. This case study is done at Hospital Universiti Kebangsaan Malaysia, it means that this case study can cover other half privatized and full-privatized hospital that managed by RMSB. Hence a case study is suggested on Tongkah Medivest Sdn Bhd, a company that manages clinical waste in southern region of Peninsular Malaysia consisting on Negeri Sembilan, Melaka and Johor. A consideration between privatized, half privatized or government hospital in this region is preferred. REFERENCES
Collins C. H.(1991),"Treatment and disposal of clinical and laboratory waste". Medical Laboratory Sciences, 324-331 Frank L. C Jr, Howard E.H and Rykowski P.K (1990), "Infectious Waste Management". Technomic Publishing Co Inc, 18-19 Ibrahim Shafii, (1998), Schedule Waste Management in Malaysia, Seminar Kejuruteraan Awam (SEMKA '98), Jabatan Alam Sekitar, Kuala Lumpur Jamaludin M. J, (1998), Environmental quality management: what the local authorities can do in National Review on Environmental Quality Management: Towards the Next Two Decades, ed. M.N. Hassan, I. Komoo and L.A. Abdullah, Universiti Kebangsaan Malaysia J.I Blenkharn, (1995), The Disposal of Clinical Wastes, Journal of Hospital Infection 1995, Department of Infectious Diseases and Bacteriology, Royal Postgraduate Medical School: 514-520. Kane A, Lloyd J.Zaffran M, Simansen L, Kane M, (1999) Transmission of Hepatitis B, Hepatitis C and human immunodeficiency viruses through unsafe injections in the developing world: model based regional estimates, Bulletin of the World Health Organization, 77(10): 801-807 Lee Heng Keng, (2001), Impak-Quarterly Bulletin of the Department of Environment (DOE), 4/2001, Department of Environment, Malaysia RMSB, (2004), "CWMS Presentation to CEO", Radicare (M) Sdn Bhd.unpublished. Theodore, Louis and Reynolds, Joseph(1987). "Introduction to hazardous waste incineration". John Wiley & Sons APPENDIX A – Equipment used for HUKM for clinical waste
Purposes
Location
Capacity
Equipment
Sharp container - Special container for sharps - Special store - 4 different sizes - Is a disposable container that ward
will burn straight away after it During waste picking-up in from every ward and put in it. Then it goes to - Bin for used sanitary napkins -In toilets - Medium size to - Yellow in colour - Multiple sizes - For disposal of other than every ward and
sharps i.e. cotton, rubber
-Yellow plastic with - 3 different sizes biohazard symbol - A layer to the bins for making it easier to handle - sterilized in autoclave machine for 24 hours before disposed to APPENDIX B – Stages of Rotary Kiln incinerator
Secondary
Combustion
Combustion
Final Product
Air Pollution
Heat Recovery
(Clean Air)
APPENDIX C – Sample of consignment note
APPENDIX D – KASB license from Department of Environment
APPENDIX E – Transfer station of schedule waste

Source: http://www.efka.utm.my/thesis/images/3PSM/2005/4JKAS/Part2/ZaimasturaAA000666d05ttt.pdf.pdf

Acs_ar_ar-2012-00176y 1.9

Lithium Insertion in Nanostructured TiO2(B) ANTHONY G. DYLLA, GRAEME HENKELMAN, AND KEITH J. STEVENSON* Department of Chemistry & Biochemistry, The University of Texas at Austin, Austin, Texas 78712, United States RECEIVED ON JUNE 12, 2012 to become feasible alternatives to current technology, but only if scientists can develop energy storage materialsthat offer high capacity and high rate capabilities. Chemists havestudied anatase, rutile, brookite and TiO2(B) (bronze) in bothbulk and nanostructured forms as potential Li-ion batteryanodes. In most cases, the specific capacity and rate of lithiationand delithiation increases as the materials are nanostructured.Scientists have explained these enhancements in terms of highersurface areas, shorter Liþ diffusion paths and different surfaceenergies for nanostructured materials allowing for more facilelithiation and delithiation. Of the most studied polymorphs,nanostructured TiO2(B) has the highest capacity with promising high rate capabilities. TiO2(B) is able to accommodate 1 Liþ per Ti,giving a capacity of 335 mAh/g for nanotubular and nanoparticulate TiO2(B). The TiO2(B) polymorph, discovered in 1980 by Marchand andco-workers, has been the focus of many recent studies regarding high power and high capacity anode materials with potential applicationsfor electric vehicles and grid storage. This is due to the material's stability over multiple cycles, safer lithiation potential relative to graphite,reasonable capacity, high rate capability, nontoxicity, and low cost (Bruce, P. G.; Scrosati, B.; Tarascon, J.-M. Nanomaterials for RechargeableLithium Batteries. Angew. Chem., Int. Ed. 2008, 47, 2930"2946). One of the most interesting properties of TiO2(B) is that both bulk andnanostructured forms lithiate and delithiate through a surface redox or pseudocapacitive charging mechanism, giving rise to stable high ratecharge/discharge capabilities in the case of nanostructured TiO2(B). When other polymorphs of TiO2 are nanostructured, they still mainlyintercalate lithium through a bulk diffusion-controlled mechanism. TiO2(B) has a unique open crystal structure and low energy Liþ pathwaysfrom surface to subsurface sites, which many chemists believe to contribute to the pseudocapacitive charging.

Microsoft word - 071204 umkchicklin chair position description revised2.doc

University of Missouri - Kansas City Kansas City, Missouri Merl & Muriel Hicklin/Missouri Endowed Chair: Associate/Full Professor, School of Medicine "UMKC is a strong public research university living the values of Education First, Discovery and Innovation; Integrity and Accountability; Diversity, Inclusiveness and Respect; and Energized Collaborative THE SEARCH The Department of Medicine at the University of Missouri – Kansas City (UMKC) School of Medicine invites nominations and applications for the position of the Merl and Muriel Hicklin/Missouri Endowed Chair. The selected candidate must have a passion for teaching, health care delivery, and outcomes research. S/he must have demonstrated the ability to foster collaboration with other academic divisions, sister institutions within UMKC, and local public health organizations. The Department of Medicine is proud of its diverse faculty, and is an equal opportunity employer. Applications from female and minority applicants are welcome. The selected candidate must be a physician at the associate professor level or above with at least 5 years experience and an accomplished investigator and have a record of ongoing grant support in the area of health outcomes research. S/he should also be an effective mentor to junior faculty in the development of outcomes research. THE UNIVERSITY OF MISSOURI -- KANSAS CITY One of the UMKC's major priorities is to lead in the area of Life and Health Sciences. The $35 million Flarsheim Science and Technology Building opened in 2000, and an additional $40 million has been committed to a new health sciences building. Collaborative initiatives, a center for medical research and the drive of public and private partnerships is quickly making the area a national center for science and health research. UMKC is a partner in the Kansas City Life Sciences Institute, a collaborative venture among the metro area's top research institutions and civic groups as well as some Schools and Departments within the University. The University is now moving aggressively to

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