No part of waste management has been studied, debated, codified and monitored as much as the safe disposal of biomedical waste. Its rules predate those for other streams of waste and its guidelines are crystal clear. Or are they?
While the rules framers may have had the best of intentions, there is many a slip between the cup and the lip. Do the rules take into account the reality of healthcare in India today? Have they translated into capacity building for more effective biomedical waste management? Do they cover the hundreds of ifs and buts that permeate healthcare? Two infection control specialists weigh in.
Dr Abhimanyu Bishnu, Chief Executive Officer, Innovhealth Services & Chief Quality & Excellence Officer, Health City Hospital, Guwahati plots the ground reality of biomedical waste management in India today against a timeline of how the rules have evolved over the years.
Rules vs reality
Two decades ago, the concept of biomedical waste segregation and management didn’t really exist. The Environmental Protection Act took care of only part of the problem, because biomedical waste is very different from the rest of domestic waste: a hotel or a factory, for example, may generate waste that is toxic but not infectious, which is the nature of biomedical waste.
Finally, in 1998, the Bio Medical Waste (Management and Handling) Rules were brought into force, but even today, if you go to a Tier III city or the outskirts of a Tier I city, you will find mixing and open disposal of biomedical waste. I have seen this with my own eyes. Even after introducing regulations and many interventions, this problem persists.
Over the years, the rules have been modified, re-tuned and made more streamlined, with certain punitive aspects thrown in. Things have improved to a large extent but the importance of biomedical waste management has not been really understood by many hospitals, even those that are accredited.
Very often, the last area to get attention is biomedical waste. In a typical assessment, more often than not, we find deficiencies in biomedical waste practices. The importance of implementing the rules is not reflected by hospital managements as well. But if we look at the epidemiology of hospital acquired infections, waste generation, waste segregation and waste disposal is a triad that forms one of the most important pillars of infection control.
In 2016, the biomedical waste management rules were revised further. One of the concerns of the hospital staff handling this waste was that they were not able to understand in which category to dispose of which stream of waste. With 10 different sub-streams, things became confusing.
In the revised rules, all these categories were done away with, and four basic categories of biomedical waste were retained. It became easier for the end-user to segregate waste. Additionally, a provision was introduced which stipulated that a common biomedical treatment centre had to be present within 75 kilometres of a healthcare facility.
This looked very good on paper. But in West Bengal, where I come from, there are only 6-7 biomedical waste management agencies available for 25 districts. Clearly, this 75 km formula is not working.
The new rules also provided for barcode tagging of biomedical waste, which has only partially been implemented. When we assess hospitals, we usually find that they have not introduced this.
The rules emphasised training and vaccination of biomedical waste handlers, since they are vulnerable to needlestick injuries and needlestick infections, which can lead to infectious disease transmission. It laid emphasis on voluntary reporting of adverse events related to biomedical waste management, and submission of annual reports of biomedical waste ‘returns’ which must be published on the hospital’s website. Many hospitals that are pursuing NABH certification are following these.
A provision was introduced which stipulated that a common biomedical treatment centre had to be present within 75km of a healthcare facility. But in West Bengal, there are only 6-7 biomedical waste management agencies available for 25 districts.
Dr Anusha Rohit, Head of Department of Microbiology and Sr. Consultant, Chair-Infection Control, Madras Medical Mission, Chennai shines a spotlight on the situations for which the rules may not have a definitive answer.
Yellow or green?
One of the changes that came about with the Biomedical Waste Management Rules 2016 was getting rid of the black covers that used to be used for cytotoxic drugs, disinfectants etc., which later on got added into the yellow bag. One of the problems we face is that according to the rules, empty disinfectant or hand rub bottles, which are just plain plastic, still need to go into yellow bags. An empty plastic bottle is actually not biomedical waste at all…should it go into the green bin instead?
Plastic or cardboard?
According to the 2016 rules, for waste sharps, a puncture-proof container should be used, because even glass can puncture through plastic. Most hospitals stuck to blue plastic containers. When we had our NABH audit, we were reminded that we had to use a puncture-proof container, so we shifted from plastic to a cardboard container.
The problem with a cardboard container is that as it starts getting full, it begins to get wet and the cardboard becomes very soft. When it is three-fourths full, for example, the weight of the glass inside may be so much that it can puncture and break through the base of the cardboard box.
At our hospital, we are debating what option to go for. The cost factor is very important; how should a smaller hospital handle this?
For ‘long’ waste, what?
We are a cardiac specialty hospital and have a large number of cardiology patients; the long trocars or piercing wires are much longer than the largest puncture-proof container. They used to stick out and sometimes fall out of small containers, and our staff would have to pick them up and put them back. We specifically ordered for large containers, but in certain cases, the trocar is still sticking right out, and there is a chance of injury to patients. How can one deal with this?
What I plan to do in my setup is a cost analysis between the practice that we were doing earlier to what we’re doing now to see if there is a cost benefit; otherwise, we need to rethink on solutions that could possibly be utilised in these kinds of conditions. It’s important that we talk with data; without this, the hospital management cannot be convinced to go in for a change. The data has to be authentic; when change is evidence-based, we end up having better solutions at hand.