Chapter One

INTRODUCTION

Background of the Study

An old saying says “Cleanliness is next to Godliness”. The essence of this was aptly

captured by Dravidians, who in 5000 BC gave due emphasis to immaculate town

planning and safe and effective sewerage systems who got rid of all solid and liquid

wastes generated by the pollution. They were indeed the pioneers as far as scientific

waste management is concerned; which is borne out from excavation of Mohanje-Dora

and Harapa.

The modern hospitals and health care institutions including research centers use a

wide variety of drugs including antibiotics, cytotoxics, corrosive chemicals, radioactive

substances, which ultimately become part of hospital waste. The advent of disposables

in the hospitals has brought in it’s wake attendant, ills i.e inappropriate recycling,

unauthorized and illegal re-use and increase in the quantum of waste. All round

technological progress has lead to increased availability of health related consumer

goods, which have the propensity for production of increased wastes.

In this study, the researcher is interested to know the health care waste management

on selected hospitals in the province of Cavite. Health care waste management

(HCWM) is a process to help ensure proper hospital hygiene and safety of health care

workers and communities. It includes planning and procurement, construction, staff

training and behavior, proper use of tools, machines and pharmaceuticals, proper

disposal methods inside and outside the hospital, and evaluation. Its many dimensions

require a broader focus than the traditional health specialist or engineering point of view.

Healthcare waste (HCW) is a by-product of healthcare that includes sharps,

non-sharps, blood, body parts, chemicals, pharmaceuticals, medical devices and

radioactive materials. Poor management of HCW exposes healthcare workers, waste

handlers and the community to infections, toxic effects and injuries.

WHO Programme activities include developing technical guidance materials for

assessing the quantities and types of waste produced in different facilities, creating

national action plans, developing national healthcare waste management (HCWM)

guidelines and building capacity at national level to enhance the way HCW is dealt

with in low income countries.

A Hospital Waste Management Committee has been established in each of the

associated hospitals with a view to improve and streamline Hospital Waste Management

and for proper implementation of Bio-Medical Waste Management Rules ’98 under the

chairmanship of the Medical Superintendents. It is a broad based committee with

representative from hospital administration, clinical departments, pathology and

microbiology departments and has powers to take decisions on all matters related to

bio-Medical Waste Management in the respective hospitals. This smaller core group is

responsible for implementation of these rules. The responsibilities of the various

categories of the staff involved in the generation, collection, transportation and disposal
of wastes is formulated and implemented by this committee.

Three (3) tertiary hospitals are selected on this study. These are Metrosouth Medical

Center, Emilio Aguinaldo College Medical Center and Cavite Medical Center . All are

Located in the province of Cavite. Each

hospital averages about 150 beds. The indoor complexes of the hospitals has 1 to 15

wards (Surgery, Medicine, Eye, Ortho & RT). The specialized nursing care units like

ICU, CCU, dialysis Unit are also available. All hospitals have major operation theatres

and minor operation theatres.

The Emergency Department of the hospitals run round the clock with almost more than

400 patients attending the Casualty of the hospital every day. The facilities of

Emergency lab. X-ray, ultrasound, ECG, CT Scan and Blood Bank are available 24 hours

in the emergency. Each hospital has its own CSSD, Laundry, Kitchen, Mortuary and

hospital stores.

Theoretical Framework

This study was based on the theory of Florence Nightingale which emphasizes the

need for manipulating the physical environment in order to hasten the recovery of a

client. Nightingale believed that in nurturing the environment through providing

nutrition, hygiene, light, comfort, appropriate noise, socialization and hope, the body

could repair itself (Udan, 2004). This study, although not directly concerned with the

effect of environment to recovery, recognizes the importance of maintaining a clean

physical environment to help prevent the onset of illness. We have heard of so many
instances of people getting sick due to unsanitary conditions. Scientific studies proved

that inhaling, ingesting or having skin contact with chemical wastes can result to cancer,

birth defects and damage to the nervous system. As long as hospital wastes are not

properly handled and dispose, these will always pose health risks.

Research Paradigm

Statement of the Problem

This study aims to determine the Healthcare Waste Management of Selected

Hospitals in Molino, Bacoor Cavite .

This study will answer the following questions:

1. What is the profile of the respondents according to:

1.1 Demographic Profile

- Age
- Gender
- Educational Attainment
- Occupational Status
2. What is the significant relationship between the compliance on Health Care Waste

Management of selected hospitals in the province of Cavite?

3. Is thee a significant difference between the level of knowledge and the

respondent’s profile as to their age, gender, educational attainment and

occupational status?
Null Hypothesis

1. There is no significant relationship between demographic profiles.

2. There is no significant relationship between the compliance on Health Care Waste

Management of selected hospitals in the province of Cavite.

3. There is no significant difference between the level of knowledge and the

respondent’s profile as to their age, gender, educational attainment and

occupational status.

Significance of the Study

This study aims to determine the significance of the healthcare waste management of

selected hospitals in the province of Cavite. This study will also make practitioners and

other hospital staff be awared of their roles in the prevention and control of infection as

well as their responsibilities in protecting their patients from the risk of exposing to

pathogenic microorganisms. The results will be beneficial to the following:

Patients

This study will provide them the knowledge regarding hospital waste management.

Staff Nurses

As health care practitioners, this study will provide them knowledge on proper

hospital waste segregation in order to prevent spread of pathologic microorganisms.

Hospital Personnel Staff

This study will provide them the knowledge on the basic aspects of handling hospital

wastes thus minimizing the possibilities of risks of exposing themselves to its toxic
effects and the community to infection.

Future Researcher

This study will serve as a reference when similar studies are conducted in the future.

Scope and Delimitation

This study focus on the compliance of selected hospitals on Health Care Waste

Management in the province of Cavite.

The subjects of the study are hospitals based in Cavite- Metrosouth Medical Center,

Emilio Aguinaldo College Medical Center and Cavite Medical Center. The respondents

are the staff nurses and the personnel of the different selected hospitals in the province of

Cavite.

The study will be conducted on July 2011 using data gathering through

questionnaires.

Definition of Terms

The following terms were defined operationally within the context of this study.

Bio-Medical Waste- May be defined as “any solid, fluid or liquid waste, including its

container and any intermediate product, which is generated during its diagnosis,

treatment or immunization of human beings or animals, in research pertaining thereto, or

in the production or testing of biologicals and the animal waste from slaughter houses or

any other like establishments.”

Medical Waste- is a term used to describe “any waste that is generated in the diagnosis,

treatment or immunization of human beings or animals, in research pertaining thereto, or

in the production or testing of biologicals.”

Clinical Waste- is defined as “any waste coming out of medical care provided in

hospitals or other medical care establishments, but does not include waste generated at

home.”

Hospital Waste- refers to all waste, biological or non-biological that is generated from a

hospital, and is not intended for further use.

Pathological Waste- is defined as “waste removed during surgery/autopsy or other

medical procedures including human tissues, organ, body parts, body fluids and

specimens along with their containers.”

Infectious Waste- refers to that portion of Bio_Medical Waste which may transmit viral,

Bacterial or parasitic diseases, if concentration and virulence of pathogenic organisms is

sufficiently high.

Hazardous Waste- refers to that portion of Bio-Medical Waste which has a potential to

cause hazards to health and life of human being.

Radioactive Waste- includes waste contaminated with radionuclides, it may be solid,

liquid or gaseous waste. These are generated from in-vitro analysis of body fluids and

tissues, in-vitro imaging and other therapeutic procedures.

Pressurized Waste- include compressed gas cylinders, aerosol cans and disposable

compressed gas containers.

General Waste- includes general domestic type waste from offices, public areas, stores,

catering areas, comprising of newspapers, letters, documents, cardboard containers,

metal cans, floor sweepings and also includes kitchen wastes.

 Chapter Two

REVIEW OF LITERATURE AND RELATED STUDIES

This chapter includes related readings, local and international investigated researches/

studies and literature taken from medical and nursing journals, articles, books, and on-

line resources that have been organized and presented according to the theme of

healthcare waste management on different hospitals been selected.

Studies carried out have indicated that about 2 Kg. of wastes are generated per bed

per day which gives an idea about the tremendous volume of waste generated on a day

today basis.

Segregation or the separation of different types (categories) of waste by sorting at the

Point of generation has been considered as the “key” for the entire process as it allows

Special attention to be given to the relatively small quantities of infections and hazardous

waste, thus reducing the risks and cost of waste management. Conversely small errors at

this stage can create lot of subsequent problems.

It is now universally accepted that segregation is the responsibility of the generator of

wastes i.e the doctor, nurse or para-medical personnel. However, in reality, this job is

always relegated to the sanitation staff, and it becomes a truly Herculean task to

segregate or sort out various categories once they have been mixed up.

Health care wastes are in the form of solid and liquid wastes generated in the

diagnosis , treatment or immunization of human beings or animals; in medical research

or in production of vaccines or other substances produced from living organisms. They

are commonly generated by hospitals, medical or research laboratories, clinics offices of

physicians and dentists, veterinarians, long term-care facilities (for example, nursing

homes) and funeral homes. These wastes represent a relatively small portion of the total

solid waste stream, and are simple to identify, to separate and to treat properly. Hospital

wastes include sharps (for example hypodermic syringes, glass slide, and scalpels),

human or animal tissue of excretion, medical products (including swabs and dressings),

etc.

According to the Department of Health (Environmental Health Service), hospital

wastes are classified and promulgated as guidelines (Manual on Hospital Waste

Management) for all hospitals and other health care facilities.

1. Pathological wastes consists of tissues, organs, body parts, human fetuses and

animal carcasses; and most blood and body fluids.

2. Infectious waste contains pathogens in sufficient concentration or quantity that

exposure to it could result in disease. This category includes cultures and stock

of infectious agents from laboratory work, waste from surgery and autopsies on

patients with infectious diseases, waste from infected patients undergoing

Hemodialysis, waste from infected patients in isolation wards and waste that has

been in contact with animals inoculated with an infectious agent or suffering from

an infectious disease.

3. Sharps include needles, syringes, scalpels, saws, blades, broken glass, nails and

other items that could cause a cut or puncture.

4. Pharmaceutical wastes include pharmaceutical products, drugs, and chemicals

have been returned from wards, have been spilled, are outdated or contaminated,

or are to be discarded because they are no longer required.

 5. Radioactive wastes include solid, liquid and gaseous waste contaminated with

radionuclides generated from vitro analysis of body tissues and fluids, in vivo

body organ imaging and tumor localization, and therapeutic procedures.

6. Chemical wastes comprise discarded, solid, liquid and gaseous chemicals, for

example from diagnostic and experimental work, and cleaning, housekeeping and

disinfecting procedures. Chemical waste may be hazardous or non-hazardous.

According to Department of Health (DOH) Administrative Order No 68-A, series

of 1989, hospitals are categorized according to service capabilities offered:

a. Primary Hospital- equipped with the service capabilities needed to support

licensed physicians rendering services in medicine, pediatrics, obstetrics, and minor

surgery.

b. Secondary Hospital- equipped with the service capabilities needed to support

licensed physicians rendering services in the field of medicine, pediatrics, obstetrics and

gynecology, general surgery and other ancillary services.

c. Tertiary Hospital- is fully departmentalized and equipped with the service

capabilities needed to support certified medical specialists and other licensed physicians

rendering services in the field of medicine, pediatrics, obstetrics and gynecology,

surgery and their sub-specialties and ancillary services.

Laws and Policies on Hospital Waste is primarily regulated by three (3) laws, namely,

the Metropolitan Manila Authority (MMA) Ordinance No. 16, Hospital Licensure Law

(Republic Act No. 4226) and The Toxic Substances and Hazardous and Nuclear Waste

control Act of 1990 (Republic Act No. 6969).

Metropolitan Manila Authority Ordinance No. 16. This ordinance (Appendix 3) was
passed in 1991 by the Metropolitan Manila Council (now called as Metro Manila

Development Authority), a political body covering Metro Manila. The objectives of

Ordinance are to (1) prevent hospital acquired infection; (2) environmental protection;

(3) protection of hospital personnel and visitors, garbage collectors, scavengers and the

community at large. The ordinance classifies hospital waste and prescribes the use of a

color coding of waste bags to identify the types of wastes. It provides for the standard

storage procedures and the alternative disposal system such as enclosed burning pit,

ground pits and the sewage disposal system for hospital waste. It also provides that all

hospitals shall be required to earmark specific amount necessary for the implementation

of the ordinance. It further provides for the payment of a special garbage fee for hospital

waste and the penalties in cases of violation of the ordinance. The implementing agency

is the Health Operation Center of MMA. The highlight of this ordinance is the provision

obliging all hospitals in Metro Manila to use four (4) types of trash bags for easy

identification of waste. These are the following; (1) black trash bag for non-infectious

dry waste; (2) green trash bags for non-infecious wet waste; (3) yellow trash bags for

dry and wet chemical and other potentially infectious waste, pathological waste,

chemical waste and sharps contained in punctured proof containers covered with solution

of lime; and (4) orange trash bags with trefoil sign for radioactive waste that will be

stored in the hospital until rendered as inactive and/or disposed in accordance with the

prescribed rules and regulations of the Philippine Nuclear Research Institute.

Hospital Licensure Law (Republic Act No. 4226) The authority to license all

hospitals in the Philippines is vested under Hospital Licensure Law. Upon the

reorganization of DOH, this authority is now under the Bureau of Licensing and
Regulations that took over the function from the defunct BMS. Under the law, hospitals

are categorized as government or private hospitals. However, the BLR through

Administrative Order (AO) No. 68-A series of 1989 further classified hospitals into the

following;

1. Government or private hospital

4. General or special hospital

5. Primary, secondary or tertiary hospitals according to the service capabilities

Offered

6. Training or non-training hospitals

In addition, the Administrative Order covers also the revised rules and regulations

governing the registration, licensure and operation of hospitals in the Philippines. It

specifies the needed physical facilities of a hospital for solid waste management such as

the physical plant, hospital equipment and maintenance of these physical facilities.

Toxic and Hazardous and Nuclear Wastes Control Act of 1990. This law covers the

importation, manufacture, processing, handling, storage, transportation, sale, distribution,

use and disposal of all unregulated chemical substances and mixtures in the Philippines.

It also covers the entry, even in transit, as well the storage and disposal of hazardous and

nuclear wastes into the country for whatever purposes. Under this law, pathogenic and

infectious wastes are considered hazardous and therefore covered by this law. This law

provides that the Department of Environment and Natural Resources is responsible for

the implementation by providing the powers to confiscate or impound the materials if

prima facie evidence is present that said materials present unreasonable risk or injury to

health or the environment. The law also defines the prohibited acts and provides for
administrative and criminal penalties.

Three agencies are primarily responsible for managing and regulating hospital waste

in Metro Manila. These are the following: Metro Manila Development Authority

(MMDA)- The MMDA is currently responsible for managing Municipal Solid Waste

(MSW) landfills for Metro Manila. In principle, collection is the responsibility of the

LGU’s although the smaller LGU’s depend on the MMDA to collect the MSW. MMA

Ordinance No. 16 prohibits disposal of regulated hospital wastes to any MMA landfills.

the Health Operations Center (HOC) in MMDA has the responsibility for

implementation, monitoring and enforcement of MMA Ordinance No. 16. Department of

Health (DOH). The DOH has several responsibilities for regulating hospitals in the

Philippines and in addition operates 45 hospitals in Metro Manila. In principle, DOH

inspectors have some responsibility for ensuring proper waste management and disposal.

The DOH is monitoring the management of hospital wastes through the following health

services; Environmental Health Services, Hospital Operation and Management Services,

Hospital Maintenance Services, Health Infrastructure Services, Radiation Health Service,

and Bureau of Licensing and Regulations.

DOH through the Bureau of Licensing and Regulations has the power to withhold or

revoke licenses of hospitals in cases of violations of its orders, policies or guidelines.

Department of Environment and Natural Resources (DENR). This agency regulates

certain categories of hospital wastes under Republic Act No. 6969, Therefore the DENR

is responsible for regulating incinerators (design, operations, air emissions, and residue

disposal). In principle, the DENR inspects hospital sites (and hospital incinerators) to

Ensure compliance with regulations promulgated under Republic Act No. 6969.
 There appears to be no safe way of managing all the hazardous medical wastes that are

currently produced in Metro Manila. A private incinerator operated by International

Waste management Inc. (IWMI) has no flue gas treatment on either of its 2 incinerators.

It has been found that 13 hospitals in Metro Manila have “incinerators”, however, most

of them are no more than an uncontrolled burning boxes with stacks and do not meet

Philippine and international standards for incineration of infectious waste and for safe

handling system. Most are not in operation at present. None appear to have adequate

control of emissions, post combustion, or adequate temperature control. A large volume

of infectious wastes is disposed in burial pits located at hospital sites, and in municipal

landfills, both practices of which pose significant risks to humans, including direct

contact and contamination of surface water or groundwater. Furthermore, previous

studies and current studies showed that majority of the hospitals is not practicing pre-

treatment procedures for their infectious waste and not adhering to color-coded system

required by MMDA Ordinance No. 16. Hazardous hospital wastes are being mixed with

with general medical waste in black plastic bags (which should only contain non-

infectious solid wastes). The black bags are designated for delivery to municipal

landfills.

Based on the study entitled “Hazardous Hospital Waste Management in Metro

Manila” undertaken by the Pasig River Rehabilitation Program (PRRP), infectious waste

(hazardous waste) generation for the surveyed 55 hospitals has reached a value

corresponding to 0.38 kg per patient-per-day. Based on the average expected bed

occupancy in the NCR of 12,120 patients per day, the present average hospital infectious

waste generation will be 4,600 kg/day. Presently, the infectious waste are either
landfilled, incinerated in simple incinerators, burned in the open, dumped inside or

outside the hospital compound, buried or composted.

Proper on site handling and storage of infectious hospital wastes are very important in

the reduction of risks to health and the environment posed by these wastes. In the PRRP

study, pre-treatment of these wastes is also practiced with 80% using chemical

disinfectants and 40% using both chemical disinfectants and autoclaves. Common

storage containers are plastic bags, and glass jars with temporary storage facilities such as

bins, pits and rooms. In the same study, the most common facilities used for storage of

infectious waste are plastic bags, covered bins/trash cans, and glass jars with covers. The

use of plastic bags is more popular in private hospitals than in government. The

differences between government and private hospitals could reflect different levels of

financial resources available.

Most (78%) existing collection points are within the services departments of the

hospital as was discovered in the PRRP study. There are however collection points

outside the buildings (53%) as well as in alleys and streets (15%). Waste collection

frequencies are varied with most (78%) hospitals having collection once to three times a

day using pushcarts for transport. Most transportation of hospital waste is carried out by

use of traditional dump trucks often together with municipal solid waste. However,

during 1992 an increasing number of private hospitals have contracted, the Integrated

Waste Management Incorporated (IWMI). This company supplies the plastic containers

(0.20 cubic meter) to their clients and hauls them to their incinerators.

Most hospitals in the NCR avail themselves of the collection service offered by

MMA. However, because of the Local Government Code, the respective LGU’s are now
responsible for the collection of solid waste. Due to MMA Ordinance No. 16 which

mandates waste segregation and color coding, hospitals are presently separating and

color coding their hospital solid waste prior to collection for final disposal. However,

the degree of compliance varies greatly among the hospitals. No special disposal

service for the hospital waste is presently being provided for by the MMA. Comparison

between the governmental and private hospital shows that the governmental hospital in

general have a significantly higher frequency of low cost and high risk infectious waste

disposal as open burning, burying, and composting compared to private hospitals.

Source reduction, in its simplest explanation, involves not creating waste in the first

place. However, it involves sophisticated risk management, liaison with manufacturers,

and consultations with staff. A careful re-evaluation of a hospital’s purchasing practices,

product choices, and operating procedures can reveal several opportunities for waste

reduction. Hospital personnel, patients and visitors are asked to use reusable or more

environment-friendly disposable items whenever applicable. From the man entry point

of the hospital, for example, visitors are already advised not to bring in food contained

in Styrofoam packaging.

Before the advent of disposables, hospitals used various reusable products in their

facilities. It is only in the past two decades that we have seen a sharp rise in the use of

disposables in health care facilities. Hospitals adopting “re-use” as a waste reduction

strategy makes a return to the use of some reusable materials which is a sensible option

especially with new technologies for disinfection and sterilization readily available.

However, careful procedures and safety standards should be established. In the U.S. and

in other parts of the world, the demand for reusable supplies and supplies that have
refillable packaging has seen a significant increase. This is not surprising because apart

from environmental benefits, the use of these types of products can produce enormous

financial benefits. In other cases, used paper also find its way into central supply rooms

serve as wrapping paper for items to be autoclaved.

The packaging materials hospitals get from medical and pharmaceutical supply

deliveries are reused in a variety of ways. Thick cartons and boxes are cut into strips to

resemble splints wrapped in paper, and then sterilized. Boxes that are about just the

right size are crafted into improvised trays for medicines. During rainy days, sheets of

carton are used as mats. Some are reused as receptacles for used syringes and vials.

re-usable materials and equipments are sterilized using the hospital’s autoclave. In

laboratories, glassware and vials are cleaned, sterilized and reused as specimen

collection bottles for laboratory examinations. Unused medical supplies or those with

expired sterilization are resterilized and repacked for future use. Slightly used latex

gloves from treatment rooms are washed, sterilized and packaged for one-time re-use.

Other gloves are sterilized and re-used as hot or cold water compress. Intravenous fluid

(IVF) bottles are re-used as drainage bottles as containers for distilled or sterile water and

dietary supplements. They are also sometimes used as urine collectors. In one

innovative hospital, some medical items have been found their way to the housekeeping
department, where expired and unused tubings are used as clothes lines. Other items that

cannot be sold to recyclers are used in crafts and other livelihood projects. For example,

hospital personnel and staff are highly encouraged to participate in contests held by some

of the hospitals, usually during the holidays, where the best Christmas decorations

fashioned out of recycled materials are rewarded. Other examples of recycling activities

include empty juice containers/ tetra packs turned into bags that are displayed or sold
during fairs, and parts of the old cribs and beds transformed into fences and trolleys used

for waste transport and aluminum oil cans transformed into dust pans.

Proper segregation significantly reduced the amount of infectious waste and thereby

directly reduced the cost of waste disposal. Key practices that contributed to this

include: placement of yellow trash cans only in areas where infectious waste is

generated, placement of puncture proof sharps containers in nurses stations and treatment

rooms, proper labeling of the yellow trash cans and other hazardous waste containers.

Efficient waste segregation as the foundation for other waste minimization activities such

as recycling and composting.

The success of any type of waste management and minimization program is largely

dependent on the cooperation of the actual waste producers and the waste handlers, the

contribution of waste reduction strategies made at the policy making level has a huge

impact on the success or failure of the entire waste management system. In purchasing

departments of different hospitals, a “take-back” policy is usually stipulated in contracts

with private medical/pharmaceutical suppliers. The return policy provides the hospital

with the option to return products near their expiration dates. This practice alone has

contributed heavily to the sharp decline of the volume of pharmaceutical wastes of the

hospitals. Well organized and effective inventory systems for central supply offices have

proven extremely helpful in avoiding the creation of unnecessary waste like expired

products.
.

Chapter Three

METHODOLOGY

This chapter discusses the methods and procedures that were utilized and observed in

the study. It covers the following areas of concern: a) research design b) population

and sampling c) research instrument d) validity and reliability of the instrument

e) data gathering procedures and (f) statistical treatment of the data.

Research Design

In this study, the researcher used a descriptive type of research. This study is

concerned primarily to obtain an accurate and significant description of the phenomenon

being studied.

Descriptive research involves the collection of data in order to test the hypothesis or

answer particular questions regarding the current status of the main concept of the study.

As defined by Venzon (2004), it describes and interprets what is and reveals

conditions and relationships that exist or do not exist, practices that prevail, beliefs or

points of view or attitudes that are held or not held, procedures that are continuing or

otherwise, effects that are being felt or trends that are developing.

In this study, the researcher attempted to determine the compliance on health care

waste management of selected hospitals in the province of Cavite.