An Evaluation of Health Care Waste Management in Base Hospitals of Colombo District

Health Care Waste Management (HCWM) is an integral part of hygiene and infection control within a health care facility and a proper management of waste helps in controlling nosocomial infections (2). All individuals exposed to improperly managed HCWM are potentially at risk of being injured or infected. The most vulnerable groups include medical staff namely, doctors, nurses, sanitary staff and hospital maintenance personnel. Patients receiving treatment in the health care facility, their visitors and the general public are also at risk of being


Introduction
Improper disposal of health care waste poses a great risk to humans, worldwide.It contaminates the natural environment (air, water, soil, fauna and flora) and the manmade environment, thereby affecting the wellbeing and health of humans.All over the world there is evidence of major health effects related to improper disposal of healthcare waste (1).
Health Care Waste Management (HCWM) is an integral part of hygiene and infection control within a health care facility and a proper management of waste helps in controlling nosocomial infections (2).All individuals exposed to improperly managed HCWM are potentially at risk of being injured or infected.The most vulnerable groups include medical staff namely, doctors, nurses, sanitary staff and hospital maintenance personnel.Patients receiving treatment in the health care facility, their visitors and the general public are also at risk of being

Introduction
Current Health Care Waste Management (HCWM) situation in Sri Lanka needs drastic improvement in order to reduce the direct/indirect adverse health impacts to health personnel and public.

Objective
The study aimed at evaluating HCWM of the two base hospitals in Colombo district.

Methodology
In a hospital based descriptive cross-sectional study in both base hospitals in the Colombo district, processes followed in relation to HCWM and availability of facilities for HCWM were assessed using an observation checklist and knowledge, attitude and practices of nursing officers (n=328) were studied using a self-administered questionnaire.

Results
A majority of nursing officers (97.8%) were females.Though a majority (57.9%) had >10 years working experience, only 36.9% had received a formal training in HCWM.Overall knowledge regarding HCWM was 'poor' in 59.5%.A majority of study population had favourable attitudes in implementing HCWM and 'good' practices related to HCWM (74.8%).

Conclusion
Many gaps were identified in both hospitals in processes followed in relation to HCWM and facilities needed for effective HCWM.
HCWM in both hospitals need improvement.Processes related to HCWM need to be regularized and facilities should be provided.Knowledge gaps among nursing officers need to be bridged by educational programmes to sustain the favourable attitudes and to further improve practices.

Key words:
Evaluation waste management, health care units injured or infected through health care waste (HCW) (2).
The National Environment Act (NEA) of No. 47 of 1980 with its amendments is the basic legal documents that regulate the management of hazardous waste in Sri Lanka (3).Further to these st legal provisions, on 1 of February 2008 a Gazette notification announced the necessity for all health institutions in the country to obtain a license for health waste management even though, organized safe HCWM systems were scarce in health institutions of the country at that time.Realizing this deficiency, Ministry of Health jointly with Central Environment Authority has taken the initiative to implement HCWM plans in all the health institutions in the country commencing from central and provincial institutions.This initiation has given recognition to the significant role played by the nurses to ensure an effective process of HCWM from the point of waste production to transport of waste out of the wards to the central storage.Hence, improving knowledge attitudes and practices of health care workers especially nursing officers has been included as an integral part of HCWM plans.However, existing levels of knowledge, attitudes and practices regarding HCWM has not been assessed in detail in Base Hospitals in the country (4).
This study aimed at evaluating HCWM of the base hospitals in Colombo districts by assessing the processes these institutions followed in relation to HCWM and availability of facilities for HCWM.Description of knowledge, attitude and practices of nursing officers in these institutes was also aimed as a part of the evaluation.Since this evaluation in November 2008 to January 2009, no formal HCWM project has been implemented in these two base hospitals up to May 2011, indicating that the situation remains same.

Methodology
This descriptive cross-sectional study was conducted at two base hospitals in the district of Colombo at Avissawella and Homagama.Data collection period was November 2008 to January 2009.
Evaluation of HCWM included three different aspects.A description of knowledge, attitude and practices of nursing officers, an assessment of the processes these institutions followed in relation to HCWM and an assessment of availability of facilities for HCWM were these three aspects.
A pre-tested structured self-administered questionnaire was used to assess knowledge, attitude and practices of nursing officers in these institutes regarding HCWM.The study planned to include all the nursing officers in both hospitals (n=343) on duty, in the assessment.A list of all the nursing officers on the duty roster of the Medical, Surgical, Gynaecology and Obstetrics, Paediatrics, Eye and Ear, Nose and Throat wards at the time of the survey was obtained from the data base of administration units of both hospitals.Principal investigator obtained informed verbal consent and recruited all the nursing officers attached to each ward by visiting each of these wards on several occasions.A pretested self administered questionnaire was the tool used to obtain data.During most of the occasions the principal investigator met the nursing officers by appointments and distributed and collected the filled questionnaires at the same time.Care was taken to avoid discussions among nurses when responding to the questionnaire.On few occasions that this could not be done, they were collected after allowing the shortest time interval as possible.
A pre-tested structured observation checklist developed based on the standards of National Guidelines of HCWM in Sri Lanka was used to assess processes each ward of the two hospitals followed in relation to HCWM and availability of facilities for HCWM in each ward of the two hospitals.
Principal investigator did all the observations.The data were analyzed using software package of SPSS Version 10.Knowledge related to colour coded segregation, infectious waste management and sharp waste management was assessed using a comprehensive set of questions.Each question related to these aspects was assigned a weighted score in which high weights were assigned to the items related to core knowledge that is accepted as requirement to implement a HCWM properly.Based on the score study units were categorized as having 'good' or 'poor' knowledge related to that aspect of HCWM.Further, an 'overall knowledge' score was also calculated for each study unit by combining scores of all aspects of knowledge.Based on this 'overall knowledge' score participant were categorized into two levels of overall knowledge on HCWM as 'poor' and 'good'.
The study also inquired into different aspects of attitudes in related to HCWM.
Practices related to colour coded segregation, infectious waste management and sharp waste management was also assessed using a comprehensive set of questions.Each question related to these aspects was assigned a weighted score in which high weights were assigned to the items related to basic practices that is accepted as essential to implement a HCWM properly.Based on the score for each aspects study units were categorized as having 'good' or 'poor' practices related to that aspect of HCWM.
Ethical clearance was obtained from the Ethical Review Committee of the Faculty of Medical Sciences, University of Sri Jayawardenapura and administrative approval was obtained from Provincial Director of Health Services of Western Province, Regional Director of Health Services of Colombo, District and from relevant Medical Superintendents of the hospitals.

Results
Study included 328 of 343 eligible nurses with a response rate of 95.6%.A majority nursing officers (321/328, 97.8%) were females.Of the nursing officers, 12.8% had a Diploma qualification.In grade seniority approximately half (46.6%) were in 'Grade 2A'.A majority (57.9%) had >10 years working experience (Table 1).Different aspects of attitudes in related to HCWM were inquired into.A majority of the nursing officers had favourable attitudes related to HCWM as indicated by the pattern of responses to all the statements in Table 2.

Waste transport
Dedicated trolleys or wheeled containers to transport waste available ü ü In assessing the practices of nursing officers regarding different aspects of HCWM, based on a weighted score obtained for a series of questions it was shown that 85.7% of nursing officers had 'good' practices regarding colour coded disaggregation of waste.The proportions of nursing officers who had 'good' practices regarding sharp waste management was 78.7% while the corresponding proportion regarding 'infectious waste management' was 71%.
In categorization based on the 'overall practice' 74.8% was shown to have 'good' overall practice while 25.2% had 'poor' overall practice regarding HCWM.
The information gathered though observation checklist revealed that none of the hospitals had a functioning 'waste management committee' nor a 'waste management plan' which are requirements under the national guidelines.Information related to processes of waste segregation, storage and transport processes in the wards of the two hospitals gathered by the observation checklist is shown in Table 3.
Of the processes observed, only 'separating waste into at least 3 categories' met the recommended standard in all wards of the hospital I. Other than this requirement, all wards in hospital II used 'recommended colour code in segregation' and had 'separate containers to satire hazardous waste'.
Also the observation checklist was used to assess the procedures followed and facilities available for final treatment and disposal of infectious waste and sharp wastes in the two hospitals.
None of the two hospitals had incinerators with standards recommended by the national guidelines.None of the two hospitals used autoclave to disinfect infectious waste.Open air burning/burning in a substandard incinerator of sharp waste and open air burning, burying in pits and handing over to municipality waste collection system were the methods adopted for infectious waste.

Discussion
Findings of this study can be considered as a comprehensive evaluation of the HCWM situation of the two hospitals as it assessed the processes and facilities as well as the relevant knowledge, attitude and behaviours among nursing officers who would be the key health care personnel in implementing the HCWM process once it is established.(13).
In the present study majority had favourable attitudes.This indicates that HCWM when initiated would provide productive outcomes in both health care institutions included in the survey.
In this study practices of selected aspects were assessed and it was found that a majority reported correct practice.The ideal technique to assess practices would be through observations (9).However, in this study assessment of practices was through self report due to logistics difficulties conducting interviews.The possibility of overestimates by the respondents should be considered.
According to the evaluation through the checklist both hospitals lacked waste management plans and waste management committee which are essential to initiate a HCWM process in the institution.Regarding waste segregation, storage and transport most of aspects did not meet the required standard in all wards or was not practiced at all.Incineration and autoclaving the most efficient way of final treatment of waste and infectious waste were not available within both institutions and method used were not recommended under national guidelines.These findings need to be considered in implementing HCWM projects in these institutions.

Conclusions and Recommendations
All aspects of HCWM in both hospitals need much improvement.Processes related to HCWM need to be regularized.Both institutions need provision of essential facilities.Knowledge gaps among nursing officers need to be bridged by educational programmes.Educational programmes need to focus on technical details specific to HCWM.Mechanisms to sustain the favourable attitudes and correct practices related to HCWM needs to be adopted.