REDUCING NON- SEGREGATED HEALTH CARE WASTE IN WARD 5A & 5AA OF

MULAGO NATIONAL REFERRAL HOSPITAL KAMPALA, UGANDA

By

JOYRINE BIROMUMAISO KASOMA

(BACHELOR OF SCIENCE HEALTH ADMINISTRATION, DIPLOMA NURSING AND

MIDWIFERY) MEDIUM-TERM FELLOW

November, 2013

ii

Table of Content

Table of Content ................................................................................................................................ ii

Declaration ........................................................................................................................................ v

Fellows’ roles in project implementation .......................................................................................... vi

Acknowledgements ..........................................................................................................................vii

Acronyms ........................................................................................................................................ viii

Operational Definitions .....................................................................................................................ix

Abstract ............................................................................................................................................ x

INTRODUCTION ................................................................................................................................. 1

BACKGROUND ................................................................................................................................... 2

LITERATURE REVIEW.......................................................................................................................... 3

2.1 Lack of Segregation Practices .......................................................................................... 3

2.2 Lack of Adequate Facilities ............................................................................................. 4

2.3 Financial Constraints ....................................................................................................... 4

2.4 Inadequate Awareness and Training Programs................................................................. 5

2.5 Lack of Institutional Arrangements.................................................................................. 5

2.6 Reluctance to Change and Adoption ................................................................................ 6

Statement of the problem ................................................................................................................. 7

Justification/ Rationale of the Problem .............................................................................................. 7

CONCEPTUAL FRAMEWORK ............................................................................................................ 10

PROJECT OBJECTIVES ....................................................................................................................... 11

iii

General Objective ............................................................................................................... 11

Specific Objectives: ............................................................................................................ 11

METHODOLOGY .............................................................................................................................. 12

Procuring of pedal waste bins ............................................................................................ 133

PROJECT OUTCOMES ................................................................................................... 155

LESSONS LEARNT ......................................................................................................... 166

CHALLENGES EXPERIENCED AND HOW THEY WERE OVERCOME .................... 166

SUMMARY, CONCLUSIONS AND RECOMMENDATIONS ......................................... 17

Summary…………………………………………………………………………………………………………………………………177

Conclusion ..................................................................................................................................... 177

Recommendation .......................................................................................................................... 177

To host Institutions............................................................................................................ 177

To Maksph CDC ............................................................................................................... 188

Dissemination: .................................................................................................................. 188

Standardization: .................................................................................................................. 18

REFERENCES .................................................................................................................................... 19

APPENDICES ........ ....................................................................................................... 20

List of participant, group 1 in June ...................................................................................... 20

List of participant, group 2 in July ....................................................................................... 21

List of participant, group 3 in July ....................................................................................... 22

List of participants, group 4 in August ................................................................................. 23

iv

List of participant, group 5 in August .................................................................................. 24

List for participants group 6 in August, 2013 ....................................................................... 25

List of participant group 7 in September .............................................................................. 26

List of participant, group 8 in September ............................................................................. 27

Slides of training ............................................................................................................28

Slides of dissemination ..................................................................................................... ...................30

Check List ......................................................................................................................... ..35

List of Figures

Figure 1 Showing Complaint letter from Hill Top a garbage corrector company…………8

Figure 2 Showing photos of mixed medical waste ……………………………..................9

Figure 3 Showing photo of sorting of waste at the storage area ….………………………..9

Figure 4 Bar chart showing mixed medical waste on 5th floor wards……………………..13

Figure 5 Showing Training of hospital staff by the fellow ….……….……...…………... 14

Figure 6 Showing peddled waste bin in different stages of improvement ………....…… 14

Figure 7 Showing 4th

stage: Peddled waste bin with labeled stickers ….………....………15

Figure 8 Showing photos of segregated medical waste ………………………….………..15

v

Declaration

I Joyrine Biromumaiso Kasoma do hereby declare that this end-of-project report entitle Reducing

Non- Segregated Health care waste in ward 5A and 5AA of Mulago National Referral Hospital

Kampala, Uganda has been prepared and submitted in fulfillment of the requirements of the

Medium-Term Fellowship Program at Makerere University School of Public Health and has not

been submitted for any academic or non-academic qualifications.

Signed ………………………………… Date…………………………………..

Joyrine Biromumaiso Kasoma (CQI Medium-term Fellow)

Signed ………………………………… Date…………………………………..

Dr. Katagirya Eric (Institution Supervisor)

Signed …………………………………. Date………………………………

Dr. Ludoviko Zirimenya (Academic Supervisor)

November 2013

vi

Fellows’ roles in project implementation

The following roles were developed and assigned to the fellow:

To organize the daily and weekly segregated waste check list

To work closely with the two resource persons to ensure that all the materials needed are

available and that the training sessions are successful.

To organize monthly CQI team meetings with all the members so that all are aware about

the progress

To work closely and establish communication links with the academic, institutional

supervisors and the MakSPH – CDC fellowship training coordinator.

To work closely with the infection control team and the administration of Mulago

National Referral Hospital to ensure that all the procurement & financial needs for the

project implementation are availed to the CQI team.

To ensure proper accountability of the project resources

To write the project report at the end of the project implementation.

To organize a dissemination program for all Top Hospital Management.

vii

Acknowledgements

MakSPH - CDC Fellowship Program

Academic Mentors

My God, Jesus Christ

Institutional Mentors

Institutional Supervisor

Continuous Quality Improvement Team

Staff of Ward 5A/ 5AA of Mulago National Referral Hospital

Fellow fellows

viii

Acronyms

CQI Continuous Quality Improvement

CDC Centre for Disease Control

GYN Gynaenecology

HCU Health Care Unit

HCWs Health care wastes

IPCD Infection Prevention and Control Department

MakSPH Makerere School of Public Health

MNRH Mulago National Referral Hospital

MoH Ministry of Health

NMS National Medical Stores

OBS Obstetrics

PDCA Plan -Do- Check- Act

SPNO Senior Principal Nursing Officer

WHO World Health Organization

ix

Operational Definitions

Waste: Waste refers to a substance which the owner no longer wants at a given time which has

no current perceived market value. (WHO)

Health Care Waste: This is the total waste generated from hospital during service delivery. It

can be produced in liquid or solid form.

Waste Management: Refers to the generation, minimizing, segregating, collection,

transportation, disposal and monitoring of waste materials.

Waste Segregation: This is the separation of waste generated at the source to its color coded

container as:

Highly infectious waste (anatomical, soiled with blood or body fluids) disposed in a red bin.

Infectious waste (used during the process of health care and is deemed as potentially infectious)

disposed in a yellow bin

Non – infectious waste (paper, packaging plastic containers for in fluids, food lefts etc) disposed

in a black bin

Pharmaceutical waste (drugs maybe cytotoxic (cancerous drugs) non cytotoxic) disposed in a

brown bin

Injection Safety boxes for used sharps and syringes and needles

x

Abstract

Reducing Non- Segregated Health Care Waste in Ward 5A & 5AA of Mulago National Referral

Hospital Kampala, Uganda

Biromumaiso J1, Zirimenya L

2, Matovu J

2 Birabwa D

1

1Mulago National Referral Hospital

2Makerere University School of Public Health CDC

Issues: Health care waste refers to “all wastes produced by health care units (HCU) during

provision of health care services. Proper segregation of medical waste into non infectious and

infection at point of generation is important in infection control. A survey conducted in March

2013 on 5A and 5AA wards of Mulago National Referral Hospital revealed that 90% of the

medical waste generated was not segregated. This posed a high risk to health care workers,

garbage collectors, and the community. This was due to absence of proper waste management

equipment, lack of proper job aids, inadequate knowledge and skills on medical waste

segregation. Mulago Hospital in collaboration with MakSPH CDC implemented interventions to

reduce non segregated medical waste from 90% to 30% within six months

Intervention description: Hospital Staff of ward 5A/5AA were trained, cleaners and garbage

collectors were sensitized, and Job Aids designed and displayed in the clinical practicing area,

basic medium pedal waste bins were procured. Daily check list on waste segregation was used

twice a day for recording bins with mixed waste, totaling to 60 times in a month. Data collected,

managed and analyzed manually.

Out comes: In the period of May to June 2013, proportion of non segregated medical waste on

ward 5A and 5AA reduced from 90% to 70% and 73.3% respectively and by September 2013, it

had reduced to 25% on ward 5A and 26.7% on ward 5AA. This reduced risks of occupational

hazards due to poor waste handling.

Lesson learnt: Introduction of basic medium pedal bins, regular seminar and sensitization are

essential in improving waste segregation practices. Little money provided can lead to significant

improvement. Recommendation: Adoption of medium pedal waste bins by all health institution,

costs for waste management to be included in hospital annual budget, and to adapt new

technology of medical waste machines.

1

INTRODUCTION

Mulago Hospital is a National Referral and Teaching Hospital with a bed capacity of 1500 beds.

It provides speciality services in Surgery, Internal Medicine, Paediatrics, Obstetrics and

Gynaecology, Oncology, Radiology with Computerised Tomography (CT scan), Intensive Care,

Renal Dialysis, Dentistry and Oral Surgery, Orthopaedics including limb fitting, Ear, Nose and

Throat (ENT), Ophthalmology, Dermatology, Genital/ Urinary (Urology), Medicine,

Neurosurgery, Cardiology and Cardiothoracic Surgery, and Accident and Emergency among

others.

Heads of Directorates are Directorate of Surgical Services, Medical services, Obstetrics

Gyneacology, Paediatric Services, Diagnostic & Therapeutics, and Directorate of Administration

& Support Service.

Mulago hospital has an annual in patient turnover of 140,000 In Patients and attends to over

600,000 Out Patients in the Assessment Center, General Out Patient Clinics and Specialist

Clinics and in Accident and Emergency Department annually.

Department of Obstetrics and Gyneacology where the survey on management of medical waste

was conducted, is well established with three fully fledged Maternity and Gynecological

facilities in upper Mulago (Ward 14), Lower Mulago (5th Floor) and Private Patient Wing (Ward

6D & E). The department delivers over 30,000 mothers each year.

The general total hospital In Patient Turn over in year 2011 was 128,345 (17%) and Out Patient

was 629,826 (83%) In year 2012, In Patient was 135,356 (19%) and Out Patient was 577,729

(81%)

Out of the general total hospital patients turn over, Obstetrics and Gynaecology total In Patient in

year 2011 was 40,980 (38%) and Out Patient 67,563 (62%). In year 2012, In Patient was 45,429

(47%) and Out Patient 50,604 (53%).

2

BACKGROUND

Mulago National Referral Hospital provides specialised care and treatment. The service

inevitably generates waste which is hazardous to health if not properly managed.

Waste segregation is the practice of classifying waste, separating and placing it into the

appropriate waste containers immediately after the waste is generated and should be placed in

different color coded bins with bin liners. Failure to segregate infectious from non-infectious

waste means that, all waste is designated as infectious waste.

Waste segregation was still a challenge to Mulago National Referral Hospital, according to the

survey conducted in March 2013 on 5th

floor.

It was observed that, absence of proper waste management equipment, absences of Job Aids in

the clinical practicing area, knowledge inadequacy, poor practice of waste segregation and

disposal are the most critical problem connected with health care waste management. The 90%

of non segregated health care waste identified on gyneacology wards 5A and 5AA respectively

was the basis upon which this project was developed. This project was supported by MakSPH in

conjunction with CDC

3

LITERATURE REVIEW

2.1 Healthcare Waste Management

Hospitals and other healthcare facilities are responsible for the delivery of patient care services.

In the process of delivering, healthcare waste is generated. According to WHO (2000), the

incorrect management of healthcare waste can have direct impacts on the community,

individuals working in health care facilities and natural environment.

The safe management of healthcare waste may be achieved by ensuring care in dealing with the

healthcare waste. Hence it is the ethical responsibility of management of hospitals and healthcare

establishments to have concern for public health. Safe handling, segregation, storage, subsequent

destruction and disposal of healthcare waste ensure mitigation and minimization of the

concerned health risks involved through contact with the potentially hazardous material, and also

in the prevention of environmental contamination.

(www.swlf.ait.ac.th/.../Data/.../4_01%20_Vijaya%20kumar%20Goddu.pd).

2.2 Lack of Segregation Practices

Segregation practice prevents non-infectious waste to get mixed with infectious waste. Lack of

segregation practices significantly increases the quantity of infectious medical waste as mixing

of infectious component with the general non-infectious waste, makes the entire mass potentially

infectious. (Gupta S and Boojh R. Report: Biomedical waste management practices at Balrampur

Hospital, Lucknow, India. Waste Management Research. 2006, 584–591).

There is inadequate practice of segregation of the waste starting from generation to disposal as

seen in Indian hospitals. Even if the segregation of waste at the point of generation is effective,

waste handlers are found mixing it together during the collection and results in loss of ultimate

value of segregation. (Athavale A.V and Dhumale G. B. A Study of Hospital Waste

Management at a Rural Hospital in Maharastra Journal of ISHWM, 2010, 21-31)

4

2.3 Lack of Adequate Facilities

Efforts to provide facilities for storage, collection, treatment and disposal of health care wastes as

well as appropriate technologies have so far been limited in India. Additionally, adequate and

requisite number of sanitary landfills is lacking in India.

Therefore, the biomedical waste are openly dumped into the open bins on the road sides, low

lying area or they are directed into the water bodies; through which severe disease causing agents

are spread into the air, soil and water. (Dwivedi A.K, Pandey S, and Shashi. Fate of hospital

waste in India. Biology and Medicine. 2009, 25-32)

Self contained onsite treatment methods may be desirable and feasible for large healthcare

facilities but are impractical or uneconomical for smaller institutes. An acceptable common

system should be in place which will provide free supply of colour coded bags, daily collection

of infectious waste, and safe transportation of waste to offsite treatment facility and final

disposal with suitable technology. (Rao. S.K.M, Ranyal R.K., Bhatia S.S. and Sharma V.R.

Biomedical Waste Management: An Infrastructural Survey of Hospitals. Medical Journal Armed

Forces India. 2004, 379-382)

2.4 Financial Constraints

With dedicated systems being installed in most of the HCUs, financial provision is necessary for

capital and recurring expenditure including funds for sufficient manpower, disinfectants, devices

and equipment.

Normally, a separate allocation of funds for waste management is not found in Indian hospitals.

It is estimated that INR 3000–4000 (US$ 70–93) per ton of hospital waste is required. (Patil A.D.

and Shekdar A. V. Healthcare waste management in India. Journal of Environmental

Management, 2001, 211–220).

Additionally funds are required for conducting training and awareness programs for health care

staffs. Smaller HCUs ignore waste management practices due to financial constraints (Rao

S.K.M, Ranyal R.K, Bhatia S.S. and Sharma V.R. Biomedical Waste Management. An

Infrastructural Survey of Hospitals. Medical Journal Armed Forces India. 2004, 379-382).

5

2.5 Inadequate Awareness and Training Programs

Awareness of appropriate handling and disposal of health-care wastes among health personnel is

a priority; it is essential that everyone should know the potential health hazards. Regular

programs will help prevent exposure of health-care wastes and related hazards. Poster exhibition,

proper labeling, and explanation by staff are effective methods. Seminars and workshops, and

participation in training courses are also essential. (.Dwivedi A.K, Pandey S. and Shashi. Fate of

hospital waste in India. Biology and Medicine. 2009, 25-32).

Management in most of Indian hospitals is not aware of cost savings achieved due to good waste

management practices. It has also been estimated that disposal savings of between 40% and 70%

could be realized through the implementation of a healthcare waste reduction program. (Tudor

T.L., Noonan C.L. and Jenkin L.E.T. Healthcare waste management: A case study from the

National Health Service in Cornwall, United Kingdom. Waste Management. 2005, 606–615).

2.6 Lack of Institutional Arrangements

Management of health-care waste depends on the input from the administration and active

participation by trained staff in segregation, storage, collection, transportation, treatment and

disposal. In India personnel responsible for these activities are mainly ward attendants and other

supporting staff. (Verma L.K. Managing Hospital Waste is Difficult: How Difficult? Journal of

ISHWM. 2010, 46-50).

A committee consisting of the head of the establishment, all the departmental heads, hospital

superintendents, nursing superintendents and hospital engineers should be formed with a waste

management officer who would be advised by an environmental control advisor and an infection

control advisor is required for proper waste management purposes. (Patil A.D and Shekdar A. V.

Health-care waste management in India. Journal of Environmental Management, 2001, 211–

220).

Studies showed lack of such kind hospital waste management committee or a documented waste

management and disposal policy in Indian hospitals. (Athavale A.V. and Dhumale G.B. A

Study of Hospital Waste Management at a Rural Hospital in Maharastra. Journal of ISHWM.

2010, 21-31).

6

2.7 Reluctance to Change and Adoption

Though now alternative technologies are permitted as per the Biomedical Rules, it takes a long

time to change the mindset of the people. Even now most of the health care providers and

decision making authorities talk of incinerator only although autoclaves and other advanced

waste handling equipments are available. Indiscriminate throwing of the waste is still seen in

most of the hospitals and the waste handlers still are without protective clothing and gears. There

is hardly any change in the applied knowledge and awareness seen in Indian hospitals (Verma

L.K. Managing Hospital Waste is Difficult: How Difficult? Journal of ISHWM. 2010, 46-50).

7

STATEMENT OF THE PROBLEM

According to MOH guide lines, medical waste should be segregated at the source of generation

in its color coded bins with bin liners. However, assessment conducted in March 2013 on ward

5A and 5AA respectively in Mulago hospital showed that, 90% of waste generated was mixed in

one bin without a bin liner, hence posing infection risks to the patients/caretaker, cleaners,

medical workers, Garbage collectors and the community at large. Failure to segregate infectious

from non infectious waste means that, waste generated is all designated as infectious waste and

this has an implication on the costs of disposal, as well as safety.

Justification/ Rationale of the Problem

According to the survey conducted in March 2013 at ward 5A and 5AA, mixture of infectious

and non infectious waste was still a challenge. It was observed that, absence of proper waste

management equipment, poor practice of waste segregation and disposal, absences of Job Aids in

the clinical practicing area, inadequate knowledge and skills on medical waste segregation were

the most critical problem connected with health care waste management. Evidence based of the

complaint letter written to the Director of Mulago hospital dated 12th February 2013 by TOP Hill

Company which is the garbage collection company, photos of mixed waste in one bin, sorting at

the storage site and the bar chart showing percentage of mixed infectious and non infectious

waste was the basis upon the implementation of this project.

Ward 5A and 5AA in OBS and GYN department, during service delivery a lot of medical waste

is generated, if not properly handled it may lead to high risks of infections. The safe and

effective disposal of medical waste starts with the medical practitioner. Poor handling and

disposal of medical waste has potential to morbidity and mortality. Sorting waste at the storage

area exposes workers to occupational hazards

8

Evidence based

Figure 1 showing, Complaint letter from Hill Top a garbage corrector company.

Figure 2 showing photos of mixed medical waste and sorting of waste at the storage area

9

Figure 3: Bar chart showing mixed medical waste on 5th floor wards

Infectious And Non Infectious Medical Waste

Mix

ed M

edic

al w

aste

%

100

90%

90%

80

60

60%

40

30%

20

0

5A

5AA

5B

5C

March. 2013

10

CONCEPTUAL FRAMEWORK

Reduced exposure of

hazardous risk of infection

Reduced non

segregated

medical

waste Segregated

medical waste

Procure ideal

peddled medical

waste containers

Impact knowledge

to hospital staff

on medical waste

management

Developed

Job Aids

Improved practice

in medical waste

segregation

11

PROJECT OBJECTIVES

General Objective

To reduce 90% of non segregated health care waste generated on ward 5A and 5AA by 30%

within 6 months as a way to prevent risks of infection.

Specific Objectives:

1. To improve the practice of medical waste segregation at generation point

2. To reduce non- segregated health care waste from 90% to 30% by September 2013.

12

METHODOLOGY

CQI team was formed at MNRH, comprised of 10 members from different disciplines including:

Dr Birabwa Doreen Male (Deputy Executive Director), Dr. Katagirya Eric (Microbiologist –

Head Infection Control), Nabawanuka Doreen (Head Nurse Infection control), Biromumaiso

Joyrine (CQI fellow), Nkayarwa Jolly (Ag SPNO) Nakubulwa Reginah (In-charge 5A) Lekico

Emilly (In-charge 5AA), Birungi Harriet (CQI member), Namubiru Ruth (CQI member),

Nazziwa Robinah (CQI Member).

With the CQI team, we identified different infection control problems and through multi voting

zeroed down to the problem of mixed medical waste.

At the start of the Project, the CQI team held a one day meeting to share the Project

implementation strategy and designed ways of ensuring that the Project achieves the set targets.

The meeting reviewed management of health care waste in consideration with Ministry of Health

guide lines.

Teaching materials, Job Aids, and check lists used by the supervisors were developed by two

resource persons and 1 fellow

Ideal pedal Medical waste equipments, Presept tablets as a disinfectant and other stationary

materials were procured.

Training of Medical staff for three days, twice in a month from May – September 2013 was

conducted by two resource persons and 1 fellow

Weekly Support Supervision and monitoring of the performance of hospital staff regarding

management of medical waste was carried out by two dedicated supervisors

13

The figure below shows the training of medical staff in different disciplines

Figure 4: Showing Training of hospital staff by the fellow

Sensitizing of garbage collectors and conducting seminars for medical staff by putting more

emphasis on segregation of the health care waste at the generation point. Demonstrating on the

use of different colour coded bins and the video showing challenges of the current waste bins in

the hospital. This instilled in them a need to have the ideal pedal bins to prevent cross infection.

Procuring of pedal waste bins

Procuring basic medium pedal waste bins, in the first stage we painted them in different colour

codes; red for highly infectious waste, yellow for infectious waste, black for non infectious waste

and brown for pharmaceutical waste. However, it was observed after one month that the

practices of waste segregation had not improved!

PDCA was used in the second stage and came out with writings of paper labeling what is to be

put in the each coded bin. It was realized that it needed daily changing as words written by pen

were very small to be read, thus a slight improvement was observed.

We went back on the drawing board and came out with the 3rd

stage; job aids stickers were

developed and plastered on the wall above every stationed bin.

14

In this stage some improvement was observed but it also became difficult for others to follow.

One in-charge reported that, some Health workers were asking her to show them where to put

different type of wastes.

Still with the use of PDCA, the CQI team met and come out with the 4th

stage. In this, labeled

stickers were pasted on the bin covers. A great improvement was observed after the 4th stage

intervention and the set target of 30% was beaten up to 25%

Daily check list on waste segregation was used twice a day for recording bins with mixed waste,

totaling to 60 times in a month. Data collected, managed and analyzed manually.

Figure 5: Showing pedal waste bins procured and their different stages of improvement

1st Stage 2

nd Stage 3

rd Stage

Figure 6: Showing 4th

stage: Pedal waste bins with labeled stickers

15

PROJECT OUTCOMES

On implementation of these strategies, an achievement was realized and reduction of non

segregated medical waste was seen. This is illustrated by the photos and bar chart below.

Figure 7: Showing photos of segregated medical waste

By the month of June 2013, the practice of segregation at the point of generation was not so

specific as only a proportion of segregated medical waste on ward 5A/ 5AA was reduced from

90% to 70% and 73.3% respectively. With PDCA as a measure used in this project, by the end of

September 2013, mixed medical waste had reduced to 25% on ward 5A and 26.7% on ward

5AA. This reduced risks of occupational hazards due to poor waste handling

Figure 8: Showing bar chart showing reduction of non-segregated medical waste in ward 5A/5AA

16

LESSONS LEARNT

How to work with constraint budget and little money invested, can cause a great improvement

Team work and the involvement of Top Hospital Administrators play a big role which is key to

improvement

The value of surveillance

Quality improvement is continuous and gradual

CHALLENGES EXPERIENCED AND HOW THEY WERE OVERCOME

Overwhelming turn up of the trainees, we managed them by dividing them into group and

increasing on the sessions of trainings.

Financial constrain, learnt to budget for the little amount and to priotise what was to benefit the

project

Poor attitude of staff towards health care waste and this was just to keep on training and

sensitizing them.

Resistance to change, continuous sensitization was emphasized

Inadequate supplies, request was forwarded to the Executive Director

Rotation of staff, I spotted another staff and oriented her in the CQI project

17

SUMMARY, CONCLUSIONS AND RECOMMENDATIONS

Summary

Safe and effective waste management and disposal begins with the health practitioner

The effective waste disposal, requires segregation immediately as the different types are handled

differently

Following waste segregation, the waste should be then disposed of to the designated places for

terminal disposal.

Bin should be emptied when they ¾ full, for easy fastening and transportation

During the transportation, the waste should not be mixed up; it should be transported in its bin

liners

Continuous quality improvement is a daily process and gradual, therefore institutions should take

up this strategy, roll it out in the entire organization for the quality of service.

Conclusion

Health care waste management is beneficial to patients, hospital staff and the community as it is

one way of preventing health hazards. This can only be achieved when the practice of

segregation is done at the point of generation.

Recommendation

To host Institutions

These interventions should be applied to all clinical practicing areas

The administration and staff should take time and understand the whole process of continuous

Quality Improvement, the medium term fellowship and not look at it as just benefiting the

fellows since it aims at creating improvement at the host institution

Encourage and support other staff to take up the medium term fellowship as this not only builds

capacity but also creates better project out comes in terms of service delivery

18

To MakSPH CDC

The schedules for the face to face sessions at the School of Public Health should be formally

communicated to the administration of the host institutions to avoid overlapping of activities and

to enable the fellows fully concentrate during these sessions

The funds for project implementation should be released on time to enable faster implementation

Dissemination:

Dissemination of results to the Top hospital senior management was done on 30th

October 2013

and 20 managers were hosted.

Standardization:

Mulago National Referral Hospital in conjunction with African Development Bank (ADB) are

currently running a training of 400 hospital staff in Infection Prevention and Control where waste

management is a course unit.

The management of Mulago National Referral Hospital has take up an initiative to buy the pedal

waste bin for the whole organization as one way of improving on the challenge noticed with the

current waste bins

19

REFERENCES

Athavale A.V. and Dhumale G.B. A Study of Hospital Waste Management at a Rural Hospital

in Maharastra. Journal of ISHWM. 2010, 21-31

Dwivedi A.K, Pandey S. and Shashi. Fate of hospital waste in India. Biology and Medicine.

2009, 25-32

Gupta S and Boojh R. Report: Biomedical waste management practices at Balrampur Hospital,

Lucknow, India. Waste Management Research. 2006, 584–591

Patil A.D and Shekdar A. V. Health-care waste management in India. Journal of Environmental

Management, 2001, 211–220.

Rao S.K.M, Ranyal R.K, Bhatia S.S. and Sharma V.R. Biomedical Waste Management. An

Infrastructural Survey of Hospitals. Medical Journal Armed Forces India. 2004, 379-382

Tudor T.L., Noonan C.L. and Jenkin L.E.T. Healthcare waste management: A case study from

the National Health Service in Cornwall, United Kingdom. Waste Management. 2005, 606–615

Verma L.K. Managing Hospital Waste is Difficult: How Difficult?. Journal of ISHWM. 2010,

46-50.

WHO (2000), the incorrect management of healthcare waste can have direct impacts on the

community, individuals working in health care facilities and natural environment

(www.swlf.ait.ac.th/.../Data/.../4_01%20_Vijaya%20kumar%20Goddu.pd).

20

APPENDICES

List of participant trained in the month of June 2013, Group 1

No Names Cell phone contact Signature

1. Sselugo Muhammed 0788500010

2. Basirika Rebecca 0785214032

3. Nankanja Edith 0702676299

4. Nambooze Betty 0757246573

5. Nalwadda Specioza 0781704520

6. Kemigisha Rose 0783015814

7. Nalugemwa Julie 0772520616

8. Nambi Aisha -

9. Namaato Regina 0704403215

10. Namwesi Shakirah 0704192791

11. Mbabazi Joy 0788774029

12. Lubega Edward 0757354608

13. Munyango Robert 0784539629

14. Mugambwa Javiira 0753699951

15. Nsubuga Noridin

16. Kampulira Fred

17. Lubega Hamuza 0757043452

18. Moses G

19. Muzuguzi 0753890496

20. Sserunjogi Gerard 0773794715

21. Kavuma Livingstone

22. Biromumaiso Joyrine (Facilitator) 0776801219

23. Nabawanuka Doreen (Facilitator) 0712808584

21

List of participant trained in the month of July2013, Group 2

No Names Cadre Cell phone contact Signature

1. Nakirijja Florence 0782920247

2. Kobusingye Maria

3. Zawedde Juliet 0783516707

4. Namuyomba Madina 0775243745

5. Nakayiza Josephine 0782667237

6. Mugga Hadija 0704620338

7. Kamora Doreen 0702520011

8. Birungi Harriet 0772463230

9. Kyompaire Patience 0782500932

10. Nyakato Felista 0774519280

11. Bigambo Harriet 0772697030

12. Namanda Dianah 0782327777

13. Karungi Getrude 0772640514

14 Namanda Agnes 0779588496

15 Babirye Caroline 0772589608

16 Likico Emilly 0772484958

17 Opoti Beatrice 0704910929

18 Nassazi Oliver

19 Nabawanuka Doreen 0712808584

20 Biromumaiso Joyrine 0776801219

21 Awoli Bob

22

List of participant trained in the month of July 2013, Group 3

No Names Ward Cadre Contact Signature

1 Kataike Margaret 3B NO

2 Nakkazi Namisango H PPD NO

3 Najjemba Paskazia Eye Clinic NO

4 Iribagiza M Oliver Oral surgery NO

5 Amon Joyce Ayeko 3BES NO

6 Kyabita Ida Owor 3AN-HDU NO

7 Nambasa Dorothy Main theatre TH A 0754392108

8 Kakooza Charles Main theatre TH A

9 Kirabira Getrude 3B Plastic NO

10 Odoko Enock CAS Records MRA

11 Nassaka Cissy Oral surgery MRA

12 Wasswa Ronald MAC MRA 0774507870

13 Ssozi Saulo SOPD MRA 0752655869

14 Logose Eva Radiotherapy MRA

15 Asio Esther Ruth MOPD MRA

16 Ahimbisibwe Kellen 2C Burns NO 0777081910

17 Omongole James Peter MAC TH A 0774099655

18 Letiru Joyce Eye Theatre NO 0772825427

19 Akampurira Andrew Security Security

20 Nabulya Aminah 2C Burns Th NO

21 Nakagolo Teopista 4A NO

22 Nsiiro Patrick Security Security 0712560975

23 Namuli Muwonge L MFP NO

24 Tino Dorcus CAS NO

25 Opika Diku Enock CAS Theatre TH A

26 Falida Ali MFM NO

27 Ajwang Betty 4C NO

28 Odomoch Jolly Gustell 5C L/S NO

23

List of participants trained in the month of August 2013, Group 4

No Names Ward Cadre Contact Signatures

1. Katusime Gladys F/P EM

2. Birabwa Rosetti Solome Eye TH N/O

3. Auma Joyce A/E NO

4. Nabanda Regina A/E NO

5. Oruya Paskaline A/E TH NO

6. Nansamba Teddy A/E TH NO

7. Kweberawo Sarah Trauma NO

8. Mukiibi Henry A/E MRA

9. Katushabe Beatrice A/E NA

10. Nalubega Jesca Kagwa Oral NO

11. Munyantwari Tom 2C NO

12. Nakayiza Namazzi Rose 6D/E NO

13. Nakirijja Eunice Kisekka 2B Oral NO

14. Nalukenge Nanfuka Cissy 2AGU NO

15. Kubuuza Lydia 5 C L/S EM

16. Nyombi Juliet Kisakye Dental NO

17. Kasoone Namatende Phoebe X-ray NO

18. Nalule Milly 3C/CTs EN

19. Agupio Godfery 3BEM NO

20. Nalukenge Florence 3BES NO

21. Ssanyu Karyowa Harriet 3A HDU NO

22. Nabbanja Ida 3 A ORT NO

23. Namanda Sauda Kasita Main TH TH/ A

24. Lakot Lillian Eye NO

25. Musumba Moses A/E Orth Orth/O

26. Nansubuga I Geraldine 3B Plastic NO

27. Ebitu Richard Records MRA

28. Bweete Anthony Main TH TH/A

24

List of participant trained in the month of August 2013, Group 5

No Names Ward Cadre Contact Signatures

1. Sentongo Getrude F/P EM

2. Kyalimpa Allen Eye Ward N/O

3. Acakala Marie A/E NO

4. MababaziJanet A/E NO

5. Bulega Hanah A/E TH NO

6. Birungi Sarah A/E TH NO

7. Nabulime Josephine Trauma NO

8. Namubiru Florence A/E MRA

9. Kabagame James A/E NA

10. Bamwenda Wilson Trauma NO

11. Namulindwa Juliet 2C NO

12. Namukasa Teddy 3 AOrth N/A

13. Nasimbwa Lydia 2B Oral NO

14. Anyango Stella 3C CTS NO

15. Kawala Florence 3BEM NO

16. Kajobe Margaret Dental NO

17. Ajakot Magadarena 2A NO

18. Mugerwa Sam A/E Orth Orth

19. Gonza Leo 3BEM NO

20. Natta Christine 3BES NO

21. Nalwoga Rose ENT NO

22. Nampewo Rose 3 A ORT NO

23. Naigaga Nubu Main TH TH/ A

24. Nzabona Sarah Kigono Eye Rec MRA

25. Asekenya Merab 2C Burns NO

26. Namatovu Zubeda 3B Plastic NO

27. Nyangoma Grace Records MRA

25

List for participants trained in the month of August 2013, Group 6

No Names Ward Cadre Tel Contact Signature

1. Mugarra Thereza F/P NO

2. Nabukeera Rosemary Eye Cl N/O

3. Fiona chardiru ENT NO

4. Nantumbwe Ruth 3D ICU NO

5. Salamuka Nancy A/E TH NO

6. Namulondo Jalia A/E TH NO

7. Mbonimpa Nelson Trauma NO

8. Eloulu Peter A/E MRA

9. Hanyurwa Arison A/E NA

10. Achen Lillian Grace Trauma NO

11. Ngamita Jumanywal Grace 2C NO

12. Namwabivu Jesca 2C Ho NO

13. Achio Betty 2B Oral NO

14. Nakandi Rebecca 3C CTS NO

15. Bonabana Catherine 3BEM NO

16. Nassimbwa Lydia 2 B Oral NO

17. Banura Constance Dental NO

18. Nankya Prossy Luwanga A/E Orth Orth

19. Nalubega Mary CSSD Mech/O

20. Nawamwena Janet 3BES NO

21. Akulia Proscovia ENT NO

22. Zawedde Grace 3 A ORT NO

23. Taaka Anne Eye Clinic NO

24. Nabuufu Rehema MFM/ 5C NO

25. Elasu Akello Hellen Records MRA

26. Namatovu Olivia 2 A GU NO

27. Mugisha Dennis Oler Records MRA

26

List of participant trained in the month September 2013, Group 7

No Names Cadre Contact Signature

1 Nayanga Jometha NA 0782740225

2 Nakintu Harriet NO

3 Wakyaya Peter Dobbi

4 Namiiro Proscovia NO 0775914061

5 Namigadde Christine NO

6 Nasozi Joyce T/A

7 Tegulwa Miriam NO 0772675063

8 Abinen Innocent Lab T 0782798072

9 Bigambo Harriet NO 0772697030

10 Nabulya Ritah NO

11 Atenge Josephine NA

12 Amulen Hellen Nyaripo NO

13 Najjuma Grace NO 0782887261

14 Pido Florence NO 0712316767

15 Pande Saul Dobbi

16 Nyangoma Sarah NO

17 Nabagala Margaret NO 0772615893

18 Olwa Sarah NO 0782711800

19 Odwong Rosemary Acayoto NO 0712865669

20 Lutaaya Phoebe NO

21 Nyafwono Winnifred Record 0715068881

22 Bulime Ruth NO 0712836865

23 Nakalema Beatrice NO 0772306260

24 Ondoru NO 0703895594

25 Aisu Jessica Lab T 0772457900

26 Andru Monicah NO 0772690877

27 Namasoga Esther NO 0751348619

27

List of participant trained in the month of September 2013, Group 8

No Names Cadre Contact Signature

1 Alupo Martha NO

2 Namukasa Teddy NA

3 Ochendi Tom Dobbi

4 Nabuufu Rehema NO

5 Atucungwire Judith NO

6 Anyango Stella NO

7 Nagadya Ramulah NO

8 Bisaso Esther NO

9 Birungi Harriet NO

10 Nakirija Florence NO

11 Oyella Mildred Mysie NO

12 Akello Esther NO

13 Buhule Beatrice NO

14 Mukambwe Moses NO

15 Swai Samson Dobbi

16 Mukiibi Janat Nabatanzi NO

17 Birabwa Mary NO

18 Naboosa Julliet NO

19 Nalugwa Gladys EN

20 Wadembere Mary NO

21 Opio Maureen Record

22 Mukakizima Margaret NA

23 Twinomuhangi Sulphine NO

24 Jjemba Immaculate NO

25 Laloka Rosemary Lab Tech

26 Agondeze Sandra Lab Tech

27 Namataka Hellen NO

28

SLIDES OF TRAINING

Management of Health care waste.

Joyrine Biromumaiso Kasoma

Infection Prevention and Control Dept

Continuous Quality Improvement Fellow

Definitons • Waste: Waste refers to a substance which the owner

no longer wants at a given time which has no current perceived market value.

• Health care waste: This is the total waste generated from hospital during service delivery. It can be produced in liquid or solid form.

• Waste management: Refers to the generation, minimizing, segregating, collection, transportation, disposal and monitoring of waste materials.

Waste segregationWaste segregation is the practice of classifying ,

separating waste and placing it into the appropriate waste containers immediately after the waste is generated and should be placed in different color coded bins with bin liners.

Recommended methods/categories of segregation are as follows; highly infectious, infectious, non infectious, pharmaceutical with the corresponding bin liners, and sharps

Type of waste Bin colour

Highly infectious Red Sputum container, used test tubesAll anatomical waste, pathological waste used blood giving sets, heavily oozing with blood gauze, Extracted teeth, etc

infectious yellow Used cotton, gauze, gloves, used Iv Fluid line.

sharps yellow Used syringes and Needles, used blades , used scalpels, and used carnulars

pharmaceutical Brown/grey Empty vials and expired drugs

Non - infectious Black Discarded paper, packaging material, empty bottles or cans, food peeling and lefts

The safe and effective disposal of health care waste starts with the health practitioner

• Waste has a potential to pollute land, air and water irrespective of the disposal method.

• Poor handling of waste has the potential to cause mobility and mortality. Many cases of HIV, HBV, HCV infections have been seen within the health care setting due to poor handling of waste.

Disposal of waste has a cost implication. Generation, disposal of waste requires resources, materials, staff, time as well as space.

Failure to segregate infectious from non infectious waste means that the waste is all designated as infectious waste – this has an implication on the costs of disposal, as well as safety.

Sorting waste at the storage area exposes workers at high risk of infection as well as the environment.

29

Young boy sorting mixed waste

Infectious waste and injection safety

boxes

Pharmaceutical waste

Designated storage area at

the hospital

Disinfection of empty vials

Taken to Kiteezi

dumping area by KCCA

Taken to Nakasongola by

NMS for crushing

Medical Pit for burying

Incineration by burning

Nature of health care

waste

Non infectious

health care waste

toxicNon

Medical waste flow chart

Highly infectious

waste (anatomical

NO

Yes

• Following waste segregation, the waste should be then disposed of to the designated places for terminal disposal.

• Bin should be emptied when they ¾ full, for easy fastening and transportation

• During the transportation, the waste should not be mixed up, it should be transported in its bin liners

In summary;• Safe and effective waste management and disposal

begins with the health practitioner

• The effective waste disposal, requires segregation immediately as the different types are handled differently

• Colour coded bins and bin liners are important for the segregation, as well as the storage.

• Waste should be transported in containers or carts, so that the liners don’t get torn and waste is littered

30

SLIDES OF DISSEMINATION

Reducing Non- Segregated Health care waste in ward 5A /5AA of

Mulago National Referral Hospital Kampala, Uganda

Joyrine Biromumaiso KasomaCQI Fellow

Dr. Ludoviko Zirimenya Dr Katagirya EricAcademic supervisor Institutional Supervisor

Background

• Mulago is a National Referral hospital

• While providing services creates waste

Which itself may be dangerous

Introduction

• Waste segregation is separating waste

• Place it immediately in bin after generation

• Failure to segregate medical waste means

that sorting has to be done at the storage

area

Infectious waste and injection safety

boxes

Pharmaceutical waste

Designated storage area at

the hospital

Disinfection of empty vials

Taken to Kiteezi

dumping area by KCCA

Taken to Nakasongola by

NMS for crushing

Medical Pit for burying

Non infectious

health care waste

toxicNon

Highly infectious

waste (anatomical

NO

Yes

incineration for burning

Nature of health care

waste

Medical waste flow chart

•MOH guide lines, medical waste should besegregated at the source of generation

Assessment conducted in March 2013 on ward 5Aand 5AA showed medical waste generated wasmixed

Problem statement

How the problem was identified

• Complaint

letter

addressed to

the Director

of Mulago

Hospital

dated 12th

February

2013 from

the TOP Hill

company

which is the

garbage

transportation

company.

31

INFECTIOUS AND NON INFECTIOUS MEDICAL WASTE

Mix

Me

dic

al

wa

ste %

March,2013

100 90% 90%

80

60 60%

40

30%

20

0

5A 5AA 5B 5C

Video portraying Challenges with current Bins

General objective

General objective

Reducing 90% of medical waste on 5A/5AA

Specific objective

Segregation of medical waste at generation point

Countermeasures

• Conducting seminars for Hospital staff

• Sensitizing of Cleaners and garbage collectors

• Incorporate 5S in infection control measures

• Designing of Job Aids and displaying

• Procuring basic medium peddled waste equipments

• Daily checklist, Weekly Monitoring and supervision

32

Colour coded bins painted in there different colours

Labeling of bins using written papers

DISPLAYED JOB AID

Stickers indicating what to be put in the bins

0

10

20

30

40

50

60

70

80

90

100

JUNE JULY AUGUST SEPTEMBER

5A Ward

5AA Ward

Bar chart showing the reduction of non segregated medical waste in ward 5A and 5AA

Perc

en

tage (%

)

Month (2013)

70%

28.3%26.7%

55%53.3%

73.3%

26.7%25%

33

Challenges and lesson learnt so farChallenges

• Overwhelming turn up of the trainees

• Financial constrain

• Poor attitude of staff towards medical waste

• Resistance to change and Rotation of staff

• Inadequate supplies

Lesson leant

• How to work with constraint budget

• Team work leads to improvement

• The value of a surveillance

• Quality improvement is continuous and gradual

• Positive outcome every after intervention

Standardization plan

• Mulago Hospital/ADB to train 400 staff

• Management of MNRH to procure pedal bins

34

Project time table

No Planned activity Time frame Resource person Input

Ap

r

May

Jun

e

July

Au

g

Sep

t

Oct

1 Holding first meeting with CQI team to review MOH waste management protocol.

CQI team and fellow Communication Meeting facilitation cost

2 Three days of developing training material ,Job Aids and check list to be used by supervisors and cleaners

Resource person and fellow

Venue Facilitation Fee Meeting facilitation cost

2 Training hospital staff in different discipline e.g. Nurses, interns, students doctor, cleaners and garbage collectors

3 Resource persons and 20 participants each session

Communication Meeting facilitation cost, stationary, pens, books and Facilitators fee

3 Purchasing of medical waste equipment, Presept tablets and other stationary

2 CQI members and 1 Driver

Fuel, Facilitation fee Cost for items

4 Meeting with the cleaner/garbage collector to monitor the progress every after two months

2 Infection Control Nurses

Meeting facilitation cost Time

5 Monthly Support supervision on waste segregation practices and monitoring of project progress

2 Infection Control Nurses

Check list, Stationary

6 Monthly Meeting for the CQI team to review and monitor the progress of project

CQI team members Meeting Facilitation cost, Communication

9 Dissemination of result to staff and hospital top management and Final report writing

Fellow Venue, Meeting Facilitation cost, Communication

35

Check List

Daily check list for Quality improvement on segregation of Medical waste On Ward 5A/5AA t

1st week of July 2013 ward …………….. Name…………………………

Date Day Time Black Yellow Red Brown Remarks

Yes No Yes No Yes No Yes No

29/06/2013 Saturday AM

PM

30/06/2013 Sunday AM

PM

01/07/2013 Monday AM

PM

02/07/2013 Tuesday AM

PM

03/07/2013 Wednesday AM

PM

04/07/2013 Thursday AM

PM

05/07/2013 Friday AM

PM

Key: Yes – Not Mixed No - Mixed