Hospital waste management system in Kermanshah: challenges, future and sustainable management with circular economy
Hospital waste generation and influence factors
To develop hospital waste management knowing the correct generation waste rate is essential13. The comparison of seven hospitals in number of beds, total waste generation, and medical and general segregation percent was shown in Table 1. The results show that the average waste generation in educational hospitals in Kermanshah was 3.6 kg/day per occupied bed. The highest and lowest waste generation were in H6 and H7, respectively. The results of systemic reviews in Iran have shown hospital waste generation rates were 3.5 kg/ bed /day on average and 2.67–4.80 kg/bed/day14,15. It was determined medical and general waste segregation rates were 50.96% and 49.04%, respectively. According to WHO guidelines about 10–25% of hospital waste, and segregation rate in studied hospitals need more attention. Other studies have shown inappropriate hazardous and nonhazardous waste segregation in hospitals16.
On the other hand, it was concluded the mean medical and general waste segregation rates in public hospitals were 50.15 and 49.85, respectively. In specialized hospitals, medical and generation rates were 48.09% and 51.91%, too. The medical to general waste ratio were estimated at 44.56% and 37.63% in public and specialized hospitals by Jafaari’s (2015) study17. The data comparison shows a significant difference between the present study and Jafaari’s study in specialized hospitals, and also similar results was seen in public hospitals.
The percent of Kind of hospital waste generated in hospital
As can be observed in Fig. 2 medical waste is categorized into infectious, pathological, pharmaceutical, and sharp waste in 41.76, 4.86, 2.58, and 1.77, respectively. Other studies in Iran show sharp waste generation rates, of 1–2% in specialized and public hospitals17 and 0.76-15% of total hospital waste generation. In a study, by examination of 49 articles, the pathological and pharmaceutical waste rates were concluded 0.1–1.1% and 1.3–21%, respectively14.
Table 2 summarizes general, infectious, and pharmaceutical waste in hospitals of Kermanshah in detail. Sampling performed three times. The average density of the general, infectious, and pharmaceutical wastes was 0.11, 0.10, and 0.35, respectively.
Hospital waste composition in hospitals of Kermanshah in average
Figure 3 indicates general, infectious, and pharmaceutical waste composition in selected hospitals. As it is seen, paper, cardboard, and “others “make up the most important part of general waste. The most of “others” were food residences. Paper and cardboard by 32% were the top. Field searching, it is resulted that most paper and cardboard generated a culture of visiting and care patients with pastry and juice. The greatest part of infectious and pharmaceutical wastes were plastic and textile (35%), and glass (85%), too. In a study of the quality of general and infectious waste in Abadan city, the same result, the percentage of the production rate of food waste and textiles and plastics was higher18. The results of Taghipour and Mosaferi indicated food waste and plastics were the most sections of generated general and infectious waste in 10 selected hospitals in Tabriz19. Oduro-Kwarteng (2021) in Ghana shows the major part of infectious waste was textile, plastic, and paper. In this study, food waste was the highest part of general waste20.
The size of the healthcare-occupied bed, type of healthcare facility, and services can affect the medical waste generation rate21. In the current study, the relationship between hospital waste generation and several factors including hospital specialty, occupied bed percent, inpatient admission, total surgical operation, total outpatient admission in clinics, total emergency ward admission, and total personnel was investigated.
The analysis shows the relation between total and infectious waste with occupied beds is significant (P = 0.865 and 0.849 0.750 – Sig = 0.12 and 0.16 at the 0.05 level). A study carried out in Addis Ababa, Ethiopia indicated similar results to the current study22. Other correlations didn’t estimate significance. The results showed no correlation between hospital waste and or total inpatient admission, or total outpatient admission in clinics but the correlation was significant in total personnel with total waste (rs = 0.821, Sig = 0.023) and general waste (rs = 0.873, Sig = 0.01) and at the 0.05 level. A study done by Debere (2015) demonstrated no significant relation between hospital waste generation to the number of outpatient flow22.
Segregation, labeling, collection and handling
Segregation is the most important step to decrease medical waste8,23, it is done by healthcare personnel23. According to national standards in Iran, in all selected hospitals, hospital wastes were categorized by color-coded bags. Proper segregation and infectious waste reduction can be implemented by the colored standard method14. General waste, infectious waste, sharp waste and pharmaceutical, and cytotoxic waste were collected in blue bins with black bags, yellow bins with yellow bags, safety boxes, and white bins with white bags, respectively. The pathological wastes were collected separately to transfer to the grave by religious instructions.
By filling 3/4 bins, all kinds of waste are collected. There were labeling systems according to national standards to determine the type of waste in all hospitals. However, the labeling level in all selected hospitals was about 60% on average. Inappropriate labeling can induce increased medical waste generation and increased HCWM costs21. In all selected hospitals, all kinds of waste after collection were handled by one or a maximum of two plastic trolleys without any separated color code to temporal storage.
Handling hospital waste in two systems included central handling at three hospitals and non-central handling at four hospitals. Besides one hospital without a specific time, another hospital handling time was 3–4 times in 24 h. In all selected hospitals, the trolley disinfection, and waste bins were Sodium hypochlorite. In all hospitals, there aren’t specific trolleys and also specific paths to handle waste, and this is demonstrated by the hazard to healthcare and visitors during transfer16. Due to the health risks of waste handling, healthcare service staff training is vital but they do not receive adequate training on occupational health and safety related to the handling of medical wastes22. Notwithstanding, the results show the employing process didn’t by learning ability. In addition, specific training modules weren’t in all selected hospitals. Besides face-to-face education, recorded educations were carried out 1–2 times every trimester.
Temporal storage and treatment
Iranian guidelines advise the temporal storage site should have impermeable floors and walls to protect pests with suitable drainage, strong exhaust, and separate places for medical and general waste which is to WHO guidelines24. As shown in Fig. 4, the temporal storage site condition in all selected hospitals was surveyed according to national medical waste in Iran and it was 73.26% on average. The evaluation scores were in the range of 56.4–84.6%. Two hospitals obtained lower than 70% scores. Overall, the range was good but the results show strong exhaust far away healthcare personnel and visitors weren’t existing in these hospitals. In none of them, the hospital wastewater system with optimal performance was seen.
The temporal site statues in Kermanshah’s hospitals
Keeping in view Article 7 of the Waste Management Law of Iran, it is the responsibility of every producer to execute special waste management. Along this line, it is vital to ensure that medical waste is handled without any unfavorable effect on human health and the environment.
The results of the current study were shown in all studied hospitals general, infectious and sharp waste after treatment transfer to a final disposal site. Pharmaceutical waste in four hospitals to implement special treatment taken to specified companies and the rest of the hospitals disposed of crushed pharmaceutical to infection waste.
Based on the data garnered from the research, the treatment system was based on steam- (autoclave and hydroclave). As mentioned in other studies, steam-based methods was seen in most Iranian hospitals14. The beginning of the COVID-19 pandemic caused to increase the patient and hospitalization. Then, excessive waste generation happened25. Therefore, the need to support a management system, especially on-site treatment critical situations becomes clearer. After this experience, in all educational hospitals of Kermanshah supporting or extra treatment devices launched.
To know the quantity and quality of wastes is the base to determine available and needed facilities, to do effective waste management. In all hospitals, total waste generation by general, infectious, sharp, and pharmaceutical was entitled although, according to national standards, to weigh waste generation based on ward separation is necessary only at one selected hospital was implemented. It is surveyed in other studies and contrasts with the current results24. It helps to monitor waste generation and more effective waste planning.
Improper hospital waste transfer as a one of the waste management hierarchy can cause diseases and spread infection in the environment and it is studied in many studies by detailed and new approaches26. Collection and treatment a pivotal step to hospital waste management providing any shortage can spread epidemic disease in the community. So, the application new design method including reverse logistics networks can reduce the adverse effect on health and in addition handling costs1,27. The two selected companies transported the safe infectious waste collected to a landfill site. The municipality transported the segregated general waste collected in black bags for suitable disposal.
Furthermore, establishing standard hospital waste management facilities requires training and awareness upgrades in the healthcare personnel and medical students. The number and how-to train were investigated in the studied hospital. There were 3–4 public classes for healthcare personnel and 4–10 classes for healthcare workers. But there weren’t specific planning and modules for doing so. On the other hand, a significant fraction of servicing is done by medical students in educational hospitals, no specific consideration in hospital waste management training is given for these parts of hospitals. The importance of hospital waste management training was studied in many studies28,29,30. In the study of Azami-Aghdash et al., the effect of the action plan technique on waste management was investigated and it was demonstrated systematic training can be effective in segregation, total and medical waste reduction, and improvement in the health, economic, and environmental condition31.
Estimation of HCW generation in Kermanshah province
The results of Minoglou et al. work demonstrated certain socio-economic and environmental indices per country can be used to mathematically predict HCW generation and it can be more beneficial than direct HCW weight measurements. A positive correlation between HCW generation and HDI, LE, SCH_Y, and CO2 emission was observed32,33. In this study, the mentioned criteria, by the Human Develop Reports (2021) from the United Nations Development Programme for Iran were attained. Then by application of these data, the HCW generation (kg/bed/day) in 2030 was estimated. The estimated HCW generation is shown in Fig. 5. The estimated HCW generation of S1 and S2 were about the same but in S3 was higher.
The temporal site statues in Kermanshah’s hospitals
By estimating a 1.5% annual increase in Kermanshah’s population (1.2 million) and three beds for 1,000 people in 2030, it will generate about 11-ton HCW. Given the improper HCWM, half of the estimated HCW will be hazardous waste. However, it is necessary to implement exact HCWM to increase medical waste generation to WHO recommendations and integrate HCWM. Segregation is the first and vital hospital waste management. It could minimize health and environment risk34. So, it is obvious that with no change in the current laws of HCW for sustainable HCWM, the increase in segregation will reduce health and environmental risks.
Circular economy: scopes and recommendation and future view
The concept of the circular economy is based on the transition from the traditional model (takeaway) to the loop-closed model to conserve energy and natural resources through waste and to create local opportunities to work35. Proper waste management plays a vital role in transit and achieving CE strategy36. View of hospital waste management national standards and the importance of a sustainable environment in Iran, but there isn’t a comprehensive view of hospital waste management. Reviewing the laws regarding separation to reach a kind of disposal based on economic and environmental principles is necessary. It is used by other countries to segregate waste to minimize the impact environment. In developed countries, waste was segregated to have green disposal including autoclave and recycling, incineration and energy, and finally landfill. There are many samples of the 3Rs strategy implementation but academic information shortage is seen1.
Reducing, reusing and recycling are the basic approaches in healthcare management24, but according to the national standard of Iran, any recycling of hospital waste is forbidden. In example, reusing surgical gowns and the end use in other industrial applications, such as insulation can have environmental and economy benefit37. Recycling of general waste and also disinfected medical waste needs to be emphasized and it needs to be updated in the latest guideline of the Ministry of Health and Medical Education of Iran according to the 3Rs policy of waste reduction and national environmental policy. Every innovation in hospital waste management practices is not accepted easily however the improving countries are forced to implement because of extensive health and environmental challenges38. To start, reducing the healthcare system can be implemented by creating purchase strategies based on higher quality and durable products35.
On the other hand, the healthcare sector is one of the biggest industries in the world, producing much medical waste that was allocated to environmental destruction39. Applying the 3Rs policy can improve the natural environment. The 3Rs strategy should be merged with CE and sustainable environment to protect the environment and save money1. The circular economy starts by making the green team. Then, it tracks waste minimization, safe reuse, recycling, and reprocessing2. As is noticed, autoclaving can be the first step to recycling infectious waste, while in Kermanshah, all infectious waste is sent to landfills. Some kind of autoclavable plastic, or glass after disinfection and washing can be reused. Other plastics and glasses can be shredded to recycle.
It is demonstrated that proper hospital waste management needs to insist on financial support40, and it should be considered to determine a stable budget. The exact CE policy implementation by reducing reusing and also recycling produced waste can have cost recovery in the long term. An integrated solid waste management based on the 3E strategy (economy, environment, and energy) was investigated in some studies41,42. As mentioned, hospitals as one most the fastest growing services by producing the most medical waste need a new approach including 3E to integrate solid waste and it is recommended by national leaders.
On the other hand, with the steady flow of infectious waste, including body tissues and contaminated materials with blood and other body fluids, it is not currently possible to establish CE strategies because there are no recycling options and it might require a lot of energy. So, they still have to rely on the traditional disposal methods2.
Recommended approach to hospital waste management (by authors)
It is reported that ten times the cost of medical waste in return general waste1, so the simplest method to minimize medical waste, segregation was neglected. Therefore, although the implementation of the circular economy strategy requires the revision of laws at the national level, at the local level, to make a green management team and the use new of methods of training along with power supervising according to the new approach must be noticed in segregation. Also, Plan, Do, Check, and Act to improve the segregation, training, and other elements of hospital waste management were noticed8,43,44. Figure 6 shows the recommended approach to hospital waste management.
This study has some strengths, including a comprehensive assessment of HCWM in hospitals of Kermanshah, the use of a prediction model to survey the increase in hospital waste, and the importance of revising the current HCWM system. Also, it clarifies the importance of a new sustainable approach to decrease environmental issues. One inherent weakness of this study is its restricted theoretical section, so it is recommended field study in future studies.
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