HOSPITAL GENERATED WASTE: A PLAN FOR ITS PROPER MANAGEMENT
Salih H.M. Aljabre, PhD, King Fahd Hospitalof the University, Al-Khobar, Saudi Arabia
إن المستشفيات مصادر هامة للنفايات الضارة وكل مستشفى له طابعه الخاص في انتاج النفايات وأسلوب نقلها و من المهم إدارتها بطريقة سليمة للوقاية من مضارها الصحية و البيئية.
يوضح هذا التقرير خطه للإدارة الآمنة للنفايات الطبية تم وضعها من قبل لجنة إدارة النفايات الطبية بمستشفي الملك فهد الجامعي بالخبر. وضمت هذه الخطة عدة مراحل منها جمع البيانات المطلوبة والتعرف على حجم المشكلة ومن ثم تطبيق برنامج لفصل وجمع ونقل النفايات الطبية داخل المستشفي. وتم تقييم العمل بهذه الخطة لتلافي المشاكل التي تواجه التطبيق الأمثل لهذه الخطة.
ويمكن الاستفادة من هذه التجربة في المنشآت الطبية المشابهة لما أثبتته من فعالية في التعامل اللآمن مع النفايات الطبية وكذا جدواها الاقتصادية.
الكلمات المرجعية:نفايات المستشفى، النفايات الطبية، نفايات الرعاية الصحية، إدارة المستشفيات، الخدمات البيئية
Hospitals are important sites for the generation of hazardous waste. Each hospital has its own profile for the generation and transportion of waste according to its location. It is extremely important to manage hospital generated waste properly in order to avoid health and environmental risks.
This article reports the plan designed and used by the hospital waste management committee in King Fahad Hospital of the University , Alhkobar, Saudi Arabia, for the safe management of hospital generated waste starting from the collection areas to the final disposal procedure. The plan was in four stages: background information, identification of problems, intervention and monitoring. The possible solutions for problems encountered are suggested.
This plan which was efficient and cost effective can be used in other medical establishments.
Key Words: Hospital waste, healthcare waste, medical waste, hospital management, environmental services.
Hospitals are important sites for the generation of waste. Every department in the hospital generates waste and the overall product is waste of different kinds; healthcare, household and administrative
Dr. Salih H.M. Aljabre, P.O. Box 10011, Dammam 31433, Saudi Arabia
waste. Healthcare waste includes infectious, chemical, expired pharmaceutical and radioactive items and sharps. These items can be pathogenic and environmentallyadverse. They are referred to in this article as hazardous healthcare waste. Other waste items generated through healthcare but not hazardous include medication boxes, the packaging of medical items and food, remains of food, and waste from offices.
The management of hospital generated waste is not only the responsibility of the hospital administration but also of every department and every healthcare providing personnel in the hospital. It is a process that should begin at the site of generation where medical waste has to be properly collected and segregated from other non-hazardous waste in specific color-coded receptacles. Transportation of hazardous healthcare waste should be well mapped in the hospital and conveyed by special carts. Storage should be carried out in utility rooms specially prepared for this purpose. Various methods, on-site or off-site are available for the final treatment of hazardous healthcare waste.1,2 The work force handling this kind of waste should be thoroughly trained.
There are reports of programs directed at the reduction of hazardous healthcare waste and the control of the cost of disposal.3 Evaluating the individual hospital profile of generation and flow of hazardous healthcare waste is a necessary primary step required for initiating effective management of hospital generated waste. This article reports the plan designed and used by the hospital waste management committee in King Fahd Hospital of the University (KFHU), Alkhobar, Saudi Arabia, to upgrade the management of hospital waste. This plan which is efficient, cost-effective and that requires no extra human resources can also be used in other hospitals.
The committee was composed of the director of the hospital, associate director of nursing, infection control nurses and the director of housekeeping.
The plan was in four phases: background information, identification of problems, intervention and monitoring.
A. Background information
The following are the requirements: (1) Test of the awareness of the healthcare staff of the hospital generated waste. (2) Review of the items of medical supplies used by the hospital. (3) Determination of the weight of the generated hospital waste. (4) Review of policy and procedure on the handling of healthcare waste and lists of items designated as hazardous healthcare or other types of waste. (5) Assessment of the number, location, condition, proper color coding and content of the means of collection. (6) Mapping and inspection of the storage areas and the route of transportation.
B. Identification of problems
The following are the possible problems envisaged: (1) Change of contracted housekeepers and/or environmental cleaning services. (2) Lack of awareness of healthcare staff. (3) Inaccurate disposal of waste items in the designated receptacles. (4) Failed means of collection, transporting or storage. (5) Injuries resulting from inaccurate disposal of hazardous healthcare waste items such as needles and glassware.
The following actions are recommended: (1) Launching of educational and orientation campaign. (2) Amendment of the policy and procedure on the handling of healthcare waste. (3) Modification of the means of collection, transportation systems and storage areas in accordance with the setting and layout of the hospital. (4) Appointment of inspectors to oversee the handling of waste. (5) Establishment of management plans for individual departments with the active participation of the departmental chiefs, head nurses or chief technicians. (6) Establishment of contingency plans to deal with spills of hazardous healthcare waste and the possible failure of the final treatment method.
The following measures are suggested: (1) Regular inspection of the means of collection, transportation and storage. (2) Feed-back from the departments. (3) Assessment of the weight of healthcare waste. (4) Re-testing the awareness of the healthcare staff of the generation of waste in hospitals. (5) Auditing the upgraded management.
The flow of hazardous healthcare waste should be well controlled from the sources of generation to the final treatment. The plan presented here is an important step for the proper managment of hazardous healthcare waste. It provides an appraisal of the profile of generation, collection, transportation and storage of healthcare waste in a hospital.
Having a policy and a set of procedures that regulate the handling of healthcare waste is essential for the implementation of an effective plan of management. The policy and procedure ought to take into consideration the peculiar setting of the hospital. The classification of waste items generated by the individual hospital as hazardous healthcare or other wastes should be very clear and precise.4,5 There should be no problems with any staff attitude on the disposal of waste items.6,7 Measures to deal with spillage of waste and the failure of the on-site final treatment method should be dealt with in the policy and procedure.
Healthcare waste is viewed as a defect of the healthcare provision.8 With the expansion of the use of disposable medical items, this defect has also expanded.9 Healthcare providers should be educated on the generation of waste in the course of providing healthcare and encouraged to utilize medical items rationally. Orientation on the way the hospital handles healthcare waste should be made part of all in-service training and education programs. All hospital staff regardless of status, medical students and cleaners not excepted, should be responsible for the proper handling of healthcare waste.10 It is vital to motivate the healthcare staff to follow the policy and procedure paying particular attention to the correct disposal of waste items into the proper receptacles. Contracted house keepers and/or environmental services should be well-acquainted with the layout of the hospital and comprehend thoroughly the policy and procedure of that hospital on the management of waste in order to use the proper methods of disposal.
The means of collection, transportation and storage sites should be efficient and meet the necessary standards required by the regulatory body.11,12 The location of these areas should take into consideration the peculiar setting of individual departments, the flow of patients in ambulatory services, bed locations and number in wards. Access to these areas should be restricted to healthcare staff only and be off bounds to patients and visitors.
The type and weight of healthcare waste can be determined and planned for in advance by reviewing the inventory of the medical supplies purchased . It is wise to bear in mind the waste potential of these supplies when making an order. Recycling practices are set up by hospitals to reduce healthcare waste, protect the environment and save money.13,14 The weight of healthcare waste is related to the items considered as medical waste. It is also related, in the long run, to the level of the healthcare provided by a hospital and in the short run, to the daily clinical work and bed occupancy. We recommend that an assessment of the weight of hospital wastes be made; hazardous and other kinds of waste with base line figures. The amount of waste per bed or patient can be calculated and the cost of disposal of hazardous healthcare waste estimated.3,9
There should be close monitoring of follow-up measures taken and regular inspections. Central to any plan is the proper maintenance of the physical line of handling hazardous healthcare waste i.e., the means of collection, transportation and storage. The means of collection, i.e., collection receptacles must be particularly scrutinized for the kind of waste items disposed in them. Hazardous healthcare waste disposed of in the wrong receptacles would not be given the proper final treatment required. This is one source of injury to workers particularly from needles and broken glassware.15 Conversely, non-hazardous healthcare waste items collected with hazardous healthcare waste creates an overload in the transportation and storage as well as an unnecessary disposal by the final treatment method. Increase or decrease in the weight of hazardous healthcare waste, therefore, should be interpreted cautiously in conjunction with the inspection of the means of collection. Violations have to be recorded and brought to the attention of the department chiefs and head nurses. Feedback from the staff on all aspects of the plan should be encouraged. Total quality management should be used to evaluate the performance of the plan at a later time.16,17 Finally, the result of the proper monitoring of hazardous healthcare waste would be the handling of a controlled amount of waste leading to cost-effective and risk-free management.
I would like to thank the head nurses and chairmen of the hospital clinical departments, supervisors of allied medical services and housekeeping for their cooperation and support for the project. I also deeply appreciate the assistance and collaboration of the chief of administration and purchasing, Mr Fahd Alshobian; the head of the medical education and in-service teaching and total quality management, Mr Ahmad Alkuwaitty, and the chief engineer of the Maintenance Department, Nabil Abbas.
1. Turnberg M. Biohazardous waste: risk assessment, policy and management. New York: John Wiley and Sons, 1996.
2. Culikova H, Polansky J, Bencko V. Hospital waste- the current and future treatment and disposal trends. Cent Eur J public Health 1995; 3:199-201.
3. Garcia R. Effective cost reduction strategies in the management of regulated medical waste. Am J Infect Control 1999; 27:165-75.
4. Rutala WA, Weber DJ. Infectious waste- mismatch between science and policy. New EnglandJ Med 1991; 325:578-82.
5. Klangsin P, Harding AK. Medical waste treatment and disposal methods used by hospitals in Oregon, Washingtonand idaho. J Air Waste Manag Assoc 1998; 48:516-26.
6. Issues involved in hospital waste management- an experience from a large teaching institution. J Acad Hosp Adm 1995; 7-8:79-83.
7. Farmer GM, Stankiewicz N, Michael B, et al. Audit of waste collected over one week from ten dental practices. A pilot study. Aust Dent J 1997;42:114-7.
8. Kerly FR, Nissly BE. Total quality management and statistical quality control: practical applications to waste stream management. Hosp Mater Manage 1992; 14:40-59.
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10. Messing K. Hospital trash: cleaners speak of their role in disease prevention. Med Anthropol Q 1998; 12:168-87
11. Alzahrani MA, Alshanshouri MA, Fakhri ZI. Guide of healthcare waste management. Riyadh( Saudi Arabia): Ministry of Health; 1998.
12. Guide to the management of medical waste in eastern region. Eastern Province ( Saudi Arabia): General Directorate of Health Affairs; 1998.
13. Kirkby G. Waste management: three R’s (reduce, reuse, recycle) reduce waste, safe money. Leadersh Health Serv 1993; 2:30-3.
14. Hooper DM. One hospital’s road to waste minimization. Med Waste Anal 1994; 8:3-5.
15. Richard VS, Kenneth J, Ramaprabha P, et al. Impact of introduction of sharps containers and of education programs on the pattern of needle stick injuries in a tertiary care centre in India. J Hosp Infect 2001; 47:163-5.
16. Studnicki J. The medical waste audit. A framework for hospitals to appraise options and financial implications. Health Program 1992; 73:68-74.
17. Escaf M, Shurtleff S. A program for reducing waste: the Wellesyley Hospitalexperience. Can J Infect Control 1996; 11:7-11.
THE FUTURE OF THE CURRICULUM OF ALLIED (APPLIED) HEALTH SCIENCES IN SAUDI ARABIA
Abdulaziz A. Al-Mulhim, JBO&G, Ahmed Al-Kuwaiti, MA, DHCPS
College of Applied Medical Sciences, King Faisal University, Dammam, Saudi Arabia
خــلفــيه:هنالك حاجة ماســة للأشخاص اللذين يعملون في مجال العلوم الصحية والتطبيقية في المملكة العربية السعودية ، ولذلك فمن الضروري أن يتم إعداد المناهج والخطط الدراسـية بصورة تفي بالاحتياجات الصحية للمجتمع السعودي وبما يتناسب مع الأمراض الشائعه في المملكه .
هدف الدراسة:إن الهدف من هذه الورقة هو إبراز أهمية تغيير محتوى ومضمون منهج العلوم الصحية في المملكة العربية السعودية . ويجب أن يكون هذا التغيير مبنياً على الحاجات الصحية الآنية والمتغيرة لهذا المجتمع. ويجب أن يفي هذا التغيير بالمتطلبات الصحية للمجتمع السعودي ويعكس واقع ممارساته الصحية. بالإضافة إلى إبراز كيفية تطبيق وتنفيذ هذا التغيير.
ومن أجل وضع هذا التغيير موضع التنفيذ، اقترحت الدراسة أن تأخذ كليات العلوم الصحية والتطبيقية بالآتي :- (1) أن يكون هذا التغيير مبنياً على الاحتياجات المرحلية للمجتمع السعودي . ( 2 ) تلبية المتطلبات والاحتياجات الصحية للمجتمع السعودي مثلما هو الواقع لتطبيق هذه الممارسات الصحية.
توصــيات:توصي هذه الورقة بإلقاء نظرة فاحصة طويلة الأجل على المناهج وجعل عملية إعادة تطوير وتقويم المناهج عملية مستمرة متجددة مع كل المستجدات الطبية واستهداف عملية تطوير الكلية بشكل عام وعملية تقييم الخريجين بشكل دائم .
كلمات مرجعية:العلوم الصحية والتطبيقية ، التعليم النموذجي المبني على الأدوار ، التقييم المسـتمر للبرامج .
Background: Despite the dearth of allied health professionals in the Kingdom of Saudi Arabia (KSA), the demand for them has increased. Like any other geographic location, KSA, has its own pattern of diseases. Therefore, the curriculum of the health professionals should be appropriately designed to meet the health needs of hospitals and clinics.
Objectives: To demonstrate that changes in the curriculum of Allied (Applied) Health Sciences in KSA are necessary, and how these changes should be implemented. This paper also recommends that these changes must: (1) be based on the current needs of the community, (2) satisfy the health requirements of the Saudi community as well as the realities of its health practices. The Allied Health Colleges must: (1) undertake a long-term review of the curriculum, (2) ensure that the curriculum reform is continuous, (3) target faculty development, (4) target student evaluation.
Key Words: Allied (Applied) Health, Format of teaching, Continuous evaluation .
Dr. Abdulaziz Al-Mulhim, P.O. Box 40093, Al-Khobar 31952, Saudi ArabiaINTRODUCTION
Both the Ministry of Health and the Ministry of Higher Education have evolved a strategy for developing the Saudi human element in the field of health by planning the necessary programs for training Saudi nationals in different specialties of the health profession. The Ministry of Health (MOH) started planning the establishment of health institutions during the fifth development plan (1410-1415). By 1418, there were 32 health institutions which had graduated 272 students. The MOH had already established 13 health colleges and the graduates in that year was numbered 478.1 Similar institutions have been established by the medical services in the Armed Forces and in the National Guard and student intake has increased over the years.
The Ministry of Higher Education established the first College of Applied Medical Sciences in King Saud University in the year 1402. After that, a similar college was opened in King Abdul Aziz University, and in 1415, colleges were opened in each of King Faisal and Um Al-Qura universities.
It has been estimated that the needs of the Kingdom for the allied medical health professionals is about 130,000, but only 30% of this number is currently Saudi. It is obvious from these facts that there is a need for more allied health colleges and institutions to meet the current as well as the future demands for these health professionals. Moreover, it is also important to restructure the curricula of the existing institutions and design new ones to meet changing health requirements of the population.
Educators must endeavor to understand that certain changes in the society’s view of health and diseases, in the organization, as well as in the delivery of healthcare services have re-shaped their expectations.2,3 There have been remarkable achievements in the field of applied health sciences within the last few decades.4
It is being proposed, that Health Colleges and Institutes should be in the forefront of the development and improvement of healthcare services in the Kingdom. They should play an active role in the implementation of the government’s policy of ensuring that Saudis are trained and recruited into all areas of the health professions. These institutes should be instrumental in encouraging Saudi students to enroll in the different specialties in the fields of the allied health professions.
The increased demand for allied health professionals such as physiotherapist, respiratory therapists and nursing personnel has prompted medical and health institutes to attract Saudi nationals into various allied health programs. The idea is to provide these graduates with the necessary knowledge and expertise in order to take over from the expatriates who have been running these services. The curriculum and training must be tailored to Islamic values and equip the graduates to meet the professional challenges that lie ahead.
In this paper we are trying to demonstrate that changes in the curriculum of Allied (Applied) Health Sciences in Saudi Arabia are necessary, and to demonstrate how these changes should be implemented.REQUIREMENTS FOR CHANGE
One means of meeting the challenges of the allied health professions is to base the reform of both the content and the context of the curriculum on the current and changing needs of the society. This change should satisfy the requirements of the Saudi community, as well as the realities of its health practices.5 All reports identifying problems, claim that reform is essential and urgently needed, and prescribe similar solutions.6 Many of these reports focus on two elements: reform of curricular content and instruction, and the internal restructuring of Health Colleges and Institutes. Barriers to change and reform have also been repeatedly identified in literature and commented on by different researchers. It is necessary, therefore, to devise strategies that would remove or minimize these obstacles, and provide a plan necessary for implementing the required changes.6
Other health professionals have been very supportive of the desire for change, and have initiated much of the dialogue and studies needed.6 Such areas as teaching, curricular design and content, as well as the teaching environment–affiliated organizati-ons, and the community have been special areas of concern. However, Coles (1985) has written about formal, informal, and hidden curricula, and has noted that a great deal of what is taught and most of what is learned, takes place within the hidden curriculum defined as the set of influences that function at the level of organizational structure and culture.7
ROLES FOR ALLIED HEALTH PROFESSIONALS
In order to find the best means of educating the Allied Health Professionals and respond to their educational needs, the following new roles and four major attributes based on previous studies and the views of scholars of contemporary Saudi medical education have been identified.6,8,9 These are important characteristics needed to meet the expectations of the Saudi community. They outline learning objectives for students that would promote the acquisition of these attributes.9 To ensure they can and will adequately attend to all aspects of health care, the allied health professional must be altruistic, knowledgeable, competent and conscientious.
The educational objectives of the colleges and the definition of the roles should provide an excellent framework for the creation of curricula that will satisfy the needs of the community.10,11 As pointed out earlier, the demand for change is neither complex nor novel. The difficulty is in ensuring that those changes are properly executed. However, to train a new kind of Health Sciences professional, capable of meeting the challenges of the 21st century, there are certain vital requirements.
It is important that the identified specialist roles be incorporated into the continuum of their education–undergraduate, postgraduate and beyond. While it is appropriate that undergraduate educators take the lead in defining and implementing the necessary changes, similar changes in graduate education should be made and, indeed, in continuing education in the later years in the practice of the profession. One of the reasons for the failure of reforms highlighted in literature is the unwillingness or inability to incorporate the necessary changes in the continuum of education and later practice.9
Role Model Teaching
Role model teaching is not the ‘main thing’ that influences others, it is the ‘only thing’. The inculcation of ethical values and professionalism is a critical element in the process of education.7,4 The behavior of faculty members, in demonstrating – or failing to demonstrate – the desired roles, is critical to any reform process. Since much of Saudi undergraduate Allied Health Education depends upon experiential learning in numerous settings, the power of role models cannot be overemphasized.11 In many undergraduate curricula at present, clinical experience is part of the early training in allied health college.
Requirements for changing students’ evaluation and assessment
Two essential strategies required for change deal with faculty development and student evaluation. It is widely acknowledged that student behavior to a large extent is model-dependent. There are numerous opportunities for developing and using methods that provide greater scope for evaluating a wider range of skills and performance of the student. Faculty members need a deeper understanding of the educational sciences and their application to learner motivation. In addition, they need effective teaching and mentoring strategies in order to make the best of all opportunities currently available.4 Moreover, they need to understand the essential elements of an effective learning environment and the interrelatedness of learning – teaching – supervision – and evaluation.2,7 Simply put, faculty members must be trained to be more effective teachers. Besides, evaluation models must be created to measure the achievement of educational objectives linked to the newly defined roles of Allied (Applied) Health.
It must be remembered that professionals of the Health Sciences do not work in isolation, but as part of the larger community they are committed to serve. The need to recognize and support the essential role of educators in preparing allied health professionals for the future should be paramount if the current and evolving expectations of the Saudi society are to be met. The appointment of faculty members who are committed to the promotion of Health Science Education as a profession, their subsequent academic advancement, and rewards for outstanding teaching achievements are important aspects that Health Colleges must not overlook.
Leadership is important, and so the role of deans and department chairpersons in this regard is critical. People in authority must do their utmost to engender in their colleagues the importance of incorporating the modeling of roles into their teaching and continuum of education and practice. The leader’s interest and commitment is critical for the success of the current effort to advance the prospects of Allied (Applied) Health Education in Saudi Arabia.
RECOMMENDATIONS FOR THE FUTURE
(1) Promote continuing education to maintain and improve the competence of all allied health professionals engaged in healthcare delivery. (2) Establish a resource center to provide up-to-date information for allied health professionals in the Kingdom. (3) Provide graduates of the allied (applied) health professions with the necessary clinical experience in a setting of supervised clinical responsibility in order to consolidate their knowledge and basic skills for the practice of the profession. (4) Ensure that graduates develop the appropriate professional attitude and ethics in accordance with the highest acceptable standards. (5) Enhance coordination and collaboration of all Health Colleges in the Kingdom. (6) Create a council to oversee the quality of graduates of the allied (applied) health professions in the Kingdom.
1. Ministry of Health Annual Report. Riyadh: MOH; 1418.
2. Magzoub ME. Studies in Community Based Education. Maastricht, The Netherlands: Network of Community-Oriented Educational Institutions for Health Sciences; 1994.
3. World Federation for Medical Education. Proceedings of the World Summiton Medical Education. Medical Education (Supplement) 1993; 28:140-9.
4. Harden RM, Laidlaw jm, Ker JS, Mitchell HE. AMEE Medical Education Guide Number 7. Task Based Learning: An Educational Strategy for Undergraduate, Postgraduate and Continuing Medical Education, Part. 2. Medical Teacher 1996; 18(2): 91-8.
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6. Al-Muhanna F. The Process of Strategic Changes of the Undergraduate Curriculum at the Collegeof Medicineand Medical Sciences, King Faisal University. Advancing Horizons in Medical Education. Proceeding of the First GCC Conference of Faculties of Medicine in the GCC Countries. Kuwait. April 26-28, 1999.
7. Coles C. A Study of the Relationship Between Curriculum and Learning in Undergraduate Medical Education, Ph.D. Dissertation / School of Education, University of South Southampton, United Kingdom, 1985.
8. Al-Sibai MH, Al-Freihi HM, Lutfi AM, Al-Mahaya SA, Magbool G, El-Mouzan ML. Evolution of the Undergraduate Curriculum at the College of Medicine, King Faisal University. Annals of Saudi Medicine 1989; 9:64-71.
9. Al-Gindan Y, Al-Sulaiman AA. Undergraduate Curriculum Reform in Saudi Medical Schools, Needed or Not? Saudi Medical Journal 1998; 19(3):229-31.
10. Harden RM, Core and Option. In: Walton H (Ed), Proceedings of the World Summiton Medical Education. Medical Education 1994; 28 (Suppl 1):112-3.
11. Miles R. Experiential Learning in the Classroom. In: Allan P, Jolley M, editors. The Curriculum in Nursing Education, London: Croom Helm; 1987.